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The end of the "tobacco and cancer" century.

Envision our society without tobacco addiction: cleaner lungs breathing cleaner air and rare, if any, lung cancer; heart disease deaths plummeting to a shadow of their current level and virtually no emphysema; and children having a fighting chance to reach their full potential for health. Contrast that dream with the current nightmare we have come to endure as our national cancer profile. Tobacco, packaged in all its different shapes and sizes, has condemned our nation to a grimy sea of preventable cancer. As a society, we have been forced to accept the unacceptable and to tolerate the intolerable. The exhaustive annual report to the nation by Wingo et al. (1) in this issue of the Journal documents again that lung cancer, whose meteoric rise was triggered by the introduction of cigarettes into U.S. society at the turn of the 20th century, continues its dominance as the premier cancer killer. In the late 1980s, the rise of lung cancer to surpass breast cancer as the number one cancer killing women marked a dismal national milestone. Lung cancer now contributes to more than one fourth of all cancerrelated deaths each year (1). Future medical historians will undoubtedly recall the 1900s as the “tobacco and cancer” century. To complicate matters further, Boffetta et al. (2) conclude from a pooled analysis of seven case–control studies that European cigars, cigarillos, and pipe tobacco carry lung cancer risks comparable to those of cigarettes. Since the elevated odds ratios that they documented are greater than those previously reported (3), these troubling conclusions clearly need confirmation in follow-up studies. If confirmed, the European results have international ramifications. Of note, cigar consumption in the United States (which had steadily declined from the mid-1970s to the early 1990s) has surged again, prompting calls for warning labels(4) and other control measures. Current trends in youth tobacco use portend an even more ominous future. It is astonishing that almost half of all high school-age children in the United States currently use some form of tobacco(1,5,6). National cigarette smoking rates for high school students have recently risen by an astronomical 32% (from 1991 through 1997). Overt and covert marketing by the tobacco industry successfully lures droves of new adolescent customers to replace the nearly 2 million customers lost each year, to death or quitting(7,8).Capitalizing on the vulnerability of adolescence, the industry dangles smoking as a forbidden fruit to serve as a badge of rugged independence. The end result, of course, is the exact opposite—preventable illness and, ultimately, total dependence on our health care system. In this way, our children are being systematically seduced and abandoned. The silver lining in this report card is that cancer incidence and mortality rates have turned the corner (1). Overall, incidence rates that peaked in 1992 are now decreasing (by about 2% a year), predominantly for men (around 4% a year). Male lung cancer incidence has been dropping steadily since 1984 (1). Resisting a decline is cutaneous melanoma (9), another thoroughly preventable cancer. Cancer death rates for all 10 leading sites have also begun a decline, except for non-Hodgkin’s lymphoma and female lung cancer. While these declines certainly reflect steady advances in cancer research and treatment, the halving of male smoking rates over the past three decades and the resultant drop in male lung cancer incidence and mortality show that cancer prevention works. We need, but so far have not s en, a similar decline in lung cancer deaths for women. Further declines will only come from acceleration of national antitobacco efforts that are finally changing the social norm. National strategies that previously focused solely on smoking cessation for individuals now stress the power of prevention for populations(10). These themes include preventing minors’ access to tobacco, reducing environmental tobacco smoke exposure, raising prices to serve as an economic disincentive, and product regulation(10). On the national level, a core question swirls around the fundamental authority of the U.S. Food and Drug Administration to regulate tobacco (11), an issue that should soon reach the U.S. Supreme Court. While these federal discussions continue, states have galvanized public health action at the local level. In the past decade, health coalitions in four states—California (1988), Massachusetts (1992), Arizona (1994), and Oregon (1996)—successfully passed citizen-backed tobacco tax initiatives that have served to deter consumption while generating millions of new dollars to fund tobacco control programs (7,12). Such programs include smoking education as part of school health programs, commuity and workplace smoking cessation and prevention efforts, and statewide smoking cessation quitlines. Also, new antitobacco counteradvertising on television and radio denormalizes and deglamorizes the addiction, to reveal it for what it is— “slow-motion suicide.” The states’ programs have produced stunning results: California now boasts the second lowest adult smoking prevalence in the country (1,13),while Massachusetts’ and Oregon’s adult per capita cigarette consumption has dropped many times faster than the national decline (14,15). The 1998 blockbuster national tobacco settlement presents a once-in-a-lifetime opportunity. This multistate master settlement agreement (MSA) ended an avalanche of state attorney general lawsuits initially launched to recoup Medicaid dollars spent for smoking-related illness. Public health advocates had hoped that these lawsuits would land a knockout blow to the tobacco industry. They had to settle for an industry bruised (16) but that remains essentially intact to proceed with business as usual. Nevertheless, the tobacco industry must now provide $246 billion over the next 25 years to all 50 states and some cities and territories(17). It is unclear whether the federal government will waive some (or all) of their claims to the settlement dollars, but state lawmakers must decide now how to spend the windfall.