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Tobacco fight must continue

Tobacco takes an enormous toll on the health of the public as the cause of 440,000 deaths annually in the United States and 4.8 million deaths worldwide.

An estimated 8.6 million persons in the United States have serious smoking-related illness. The World Health Organization projects that by the year 2030 the use of tobacco will kill 10 million persons annually —including 7 million in developing countries— which will make tobacco use the world’s leading cause of preventable death.

In 2001, the prevalence of smoking in the United States stood at 25.5% among men and 21.5% among women, down from the peaks of 57% among men in 1955 and 34% among women in 1965.5 Rates of smoking have plateaued, however, since 1990.5 The prevalence varies by state, ranging from 31% in Kentucky to 13% in Utah, and it is increasingly concentrated in populations that have relatively little education and low incomes.

Smoking rates are declining in all age groups, except among persons 18 to 24 years of age, among whom the prevalence rose from 23% in 1991 to 27% in 2000.

Mental illness and smoking have been closely linked. For example, smoking rates have been reported to be over 80% among persons who have schizophrenia, 50 to 60% among persons with depression, 55 to 80% among those who have alcoholism, and 50 to 66% among those who have substance-abuse problems.

One study estimated that smokers with coexisting psychiatric or substance-abuse disorders account for 44% of all cigarettes smoked in the United States, a percentage that reflects both the high prevalence of smoking in connection with these conditions and the fact that patients with these disorders are very heavy smokers.

Worldwide, it is estimated that 47% of men but only 12% of women smoke. As compared with smoking rates among men in other countries, in the United States the rate ranks in the lowest fifth, but it is higher than in Australia, Sweden, and many of the developing countries. By contrast, smoking rates among women in the United States are in the highest third for women worldwide.

Globally, smoking rates among men are highest in Asia (e.g., 67% in China, 65% in Korea, and 53% in Japan), but the rates are also high in Russia (63%), Yugoslavia (52%), and Mexico (51%). In almost all nations, women are much less likely to smoke than men; among women, the smoking rate is a mere 4% in China and in Korea (and the rate is even lower in most Arab countries) but is about 33% in Argentina and Norway.

In the relatively few countries that have anti-tobacco policies, government has provided the essential leadership; the exception is the United States, where grassroots action and litigation by citizens have generated most of the changes, including changes that were mediated by laws and regulations.

In the face of an aggressive tobacco industry that in 2001 spent $11.2 billion on advertising and promotion in the United States alone. Effective control of the use of tobacco requires multiple policy strategies. Most of the promising approaches have not been fully implemented.

In this Special Report I review the landmark $209 billion Master Settlement Agreement (MSA) of 1998 between 46 states and the U.S. tobacco industry and, after a brief history of the MSA, assess its strengths and limitations as an instrument of tobacco control. Current U.S. tobacco-control policies at the federal, state, and local levels are summarized, with an emphasis on recent developments in the area of policy.
Resource: NEJM ©2004
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