摘要：Tobacco use in the United States has declined dramatically over the past 50 years, with the prevalence of cigarette smoking falling from about 42% of all adults to less than 20% by 2007. If this rate of decline continues, smoking could be eliminated in the United States by 2047. Framed in military parlance, we may be halfway through a 100-year war against the leading public health killer of our time. We describe factors that have contributed to progress over the last 50 years and identify policy and other initiatives that can contribute to the elimination of tobacco use in the United States. Among the public health successes of the 20th century, the decline in tobacco use since the early 1960s has been a historic achievement. As shown in Figure 1 , adult smoking in the United States has fallen from a rate of about 42% a half century ago to less than 20% today. Framed in military parlance, we may be at the halfway point in a “100-year war” against tobacco addiction. This framing raises the question of what can be done to shorten this war. In essence, how can we steal a march in the 21st century in the battle against tobacco use and the tobacco industry? We review strategies that have worked thus far and recommend additional steps to further reduce tobacco use and dependence. Open in a separate window FIGURE 1 Smoking prevalence among adults aged 18 years and older: United States, 1965-2007, with projections to 2047. Note. Projections assume that the average percentage point rate of decline per year observed from the 1960s to 2007 will continue. Actual annual rates of decline between the 1960s and 2007 have varied. Numerous observers have claimed over time that tobacco use has plateaued and that progress against its use has stalled. 1 – 3 However, the remarkable decline in rates of tobacco use since the 1960s ( Figure 1 ) belies this claim and underscores the remarkable success of tobacco control efforts to date. A review of smoking prevalence data from the Centers for Disease Control and Prevention shows that adult smoking between 1965 and 2007 declined by an average of about 0.5 percentage point per year (from 42% to 20%; Figure 1 ), although the actual annual declines have varied over these four decades. Extrapolation of these data reveals that, if this rate of decline continues, smoking will be essentially eliminated in the United States by about 2047. Fine-grained analyses of the declines suggest that the overall pattern of decreases was caused by the progressive enactment of new and stronger policies and interventions. 4 – 14 Continued innovation of tobacco control efforts and continued attention to tobacco industry tactics (e.g., price discounting, increased marketing of smokeless tobacco products) will be needed to maintain this rate of decline into the future. What strategies have been most effective in spurring declines in prevalence? There is no doubt that release of information about the health hazards of tobacco drove down use. The surgeon general's report on the health effects of smoking released in 1964 presaged a burst of prevention and cessation activities. 15 Additionally, the late 1960s demonstrated the power of public health countermarketing, 16 – 18 and this was amplified by later public health campaigns. 4 , 18 – 21 Moreover, evidence that secondhand smoke is a significant cause of mortality 22 and that tobacco is addictive 23 fostered both the acceptance of clean indoor air policies and the development of evidence-based clinical treatments. 24 – 26 Finally, given the cost-sensitive nature of tobacco use, increasing the cost of cigarettes through tobacco excise taxes reliably led to drops in consumption and prevalence. 5 , 27 – 29 Formal modeling analyses suggest that the reductions in prevalence observed over the last 40 years are a result of such policy changes and interventions as tax increases, clean indoor air laws, advertising restrictions, product labeling laws, youth access laws, mass media campaigns, and increased availability of cessation programs. 4 – 14
