Tobacco: Our Biggest Health Foe

Howard Markel, MD, PhD


June 24, 2005

Every Thursday evening, I spend a few hours counseling teenagers about substance abuse. Use of marijuana and alcohol abuse are the 2 most frequently discussed problems. But also discussed is the use of other dangerous substances such as cocaine, prescription drugs, opiates, amphetamines, Ecstasy, LSD, and hallucinogenic mushrooms. Almost like clockwork, at the end of every session, many of these teens leave the clinic to take a cigarette break before going home. Ironically, nicotine is the one substance of abuse we never seem to talk about at these group meetings.

To be sure, there are a lot of dangerous substances out there harming the health of Americans. But it is hardly hyperbole to declare that the title of public health enemy number 1e rests securely upon the consumption of tobacco -- be it smoked, chewed, or simply blown onto the breathing space of others.

No wonder, then, that a recent Centers for Disease Control and Prevention (CDC) study found that smoking and exposure to secondhand smoke accounted for 435,000 or 18.1% of the total number of US deaths in 2000. To put it in better perspective, this number is greater than the number of people who died of poor diet and physical inactivity (400,000 deaths, or 16.6% of total US deaths), alcohol consumption (85,000 deaths or 3.5%), infections (75,000 deaths), toxic agents (55,000 deaths), automobile accidents (43,000 deaths), firearms (29,000 deaths), sexual behaviors (20,000 deaths), and illicit drug use (17,000 deaths).[1] Smoking is also a contributing factor for spontaneous abortions, low birth weight, stillborn births, and sudden infant death syndrome.

In 1998, the tobacco companies made a historic legal settlement with all of the 50 states and the District of Columbia. It called for them to make annual payments to the state governments, in perpetuity. The payments over the first 25 years alone were estimated at $246 billion and were intended to finance tobacco prevention programs aimed at youngsters, programs to help smokers quit, and a public campaign to minimize teen exposure to tobacco marketing programs. But as I write this column, the US Justice Department is negotiating with the tobacco companies to sharply curtail an additional proposed penalty of $130 billion to create a cigarette recovery program for every smoker in the United States to only $10 billion.

Alas, it is not only legal wrangling that is draining the pool of resources that ought to go to these life-saving efforts. Even the millions of dollars that have thus far been collected are not always used to keep our kids away from cigarettes, let alone to help older smokers to kick the habit. Sadly, many of the most cash-strapped states spend the majority of these funds on other purposes, ranging from paving roads to funding college scholarships. This year, all of the states will spend about $538 million on tobacco prevention programs or about one third of the CDC's minimum recommendation of $1.6 billion.

Only 3 states currently fund tobacco prevention programs at the minimum levels recommended by the CDC -- Delaware, Maine, and Mississippi; 10 others are funding these programs at about half that level and 32 states at less than half of these recommended levels. Worse, 5 states (Michigan, Missouri, New Hampshire, South Carolina, and Tennessee) and the District of Columbia allocate no significant funds for tobacco prevention.

During the same period when states have cut funding for tobacco prevention, the tobacco industry has increased its marketing and advertising budgets by 84%. Since the historic settlement of 1998, big tobacco spent $12.7 billion a year or $34.8 million a day -- and much of this marketing remains targeted at youngsters. This means that the tobacco companies spend more money marketing their products in 1 day than 46 states and the District of Columbia spend in an entire year to prevent smoking.[2]

But the saddest statistics have to do with our children. More than 5 million kids alive today, or about 33% of all youth smokers, will die prematurely from smoking-related illnesses. Or breaking it down to just 1 year, 322,423 kids became regular smokers in 2005; 103,175 of them will die prematurely because of this insidious addiction. Nearly 90% of all adults who smoke cigarettes took their first puff before age 18.[3,4,5,6,7]

Every day, more than 4000 kids try their first cigarette and every day another 2000 youngsters become new, regular, daily smokers. Twenty-five percent of all children are regular cigarette smokers by the time they cross the stage in their high school auditoriums to pick up their diplomas.

Eighty-two percent of young smokers aged 12-17 prefer Marlboro, Camel, and Newport cigarettes. Not surprisingly, these 3 represent the most heavily advertised brands and their campaigns are shamelessly targeted at youth. Marlboro, the most heavily marketed brand, makes up about 50% of the youth cigarette market with only 38% of those smokers older than 25 years. And, don't forget that smoking during youth has also been associated with an increased likelihood of using illegal drugs.[7]

As pediatricians and other clinicians providing healthcare to children, we spend a lot of time learning about and trying to prevent or, at least, treat a wide number of deleterious conditions. Yet none looms larger than those produced by these seemingly simple packs of cigarettes. It is, without question, the public health dilemma of our era, and we need to do so much more in terms of research, innovative prevention efforts to keep kids away from tobacco, and the development of programs that help smokers quit smoking.

One can only wonder how future generations of healthcare providers -- and patients -- will judge our efforts over the past few decades to thwart this enemy. But I would not recommend holding one's breath for a favorable report.


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