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. 1 , 2 An estimated 8.6 million persons in the United States have serious smoking-related illness. 3 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. 4
In 2001, the prevalence of smoking in the United States stood at 25.5 percent among men and 21.5 percent among women, down from the peaks of 57 percent among men in 1955 and 34 percent among women in 1965. 5 Rates of smoking have plateaued, however, since 1990. 5 The prevalence varies by state, ranging from 31 percent in Kentucky to 13 percent in Utah, and it is increasingly concentrated in populations that have relatively little education and low incomes. 6 Smoking rates are declining in all age groups, except among persons 18 to 24 years of age, among whom the prevalence rose from 23 percent in 1991 to 27 percent in 2000. 7
Mental illness and smoking have been closely linked. For example, smoking rates have been reported to be over 80 percent among persons who have schizophrenia, 8 , 9 50 to 60 percent among persons with depression, 10 55 to 80 percent among those who have alcoholism, 11 , 12 and 50 to 66 percent among those who have substance-abuse problems. 12 , 13 One study estimated that smokers with coexisting psychiatric or substance-abuse disorders account for 44 percent 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. 12
Worldwide, it is estimated that 47 percent of men but only 12 percent of women smoke. 14 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 percent in China, 65 percent in Korea, and 53 percent in Japan), but the rates are also high in Russia (63 percent), Yugoslavia (52 percent), and Mexico (51 percent). In almost all nations, women are much less likely to smoke than men; among women, the smoking rate is a mere 4 percent in China and in Korea (and the rate is even lower in most Arab countries) but is about 33 percent in Argentina and Norway. 4
In the relatively few countries that have antitobacco 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. 15 In the face of an aggressive tobacco industry that in 2001 spent $11.2 billion on advertising and promotion in the United States alone, 16 effective control of the use of tobacco requires multiple policy strategies. Most of the promising approaches have not been fully implemented. 17 , 18 , 19 , 20
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.
There are four key ingredients of successful public health efforts — highly credible scientific evidence, passionate advocates, media campaigns, and law and regulation, usually at the federal level. 77 In the battle against the harmful effects of tobacco use, the scientific evidence came first, almost 50 years ago, and since then advocates of tobacco control have engaged in a four-decade battle against the U.S. tobacco industry. 15 Except for a two-year national media campaign against tobacco use in the late 1960s, there was little counteradvertising about tobacco until the mid-1990s, and initially it was run in only a few states until the recent MSA-funded American Legacy Foundation's campaign. At the same time, government initiatives, particularly federal antitobacco efforts, have been relatively weak. In addition to the 440,000 Americans who die each year from smoking, another 8.6 million suffer from serious tobacco-induced illness. 3 Although U.S. smoking rates are slowly declining, progress toward that end would be faster if federal policymaking matched both the rigor of the scientific evidence against tobacco use and the resolve of antitobacco advocates.
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