Acting Surgeon General Boris Lushniak is the latest in a long line of surgeons general who have tried to pound the final nails into the coffin of America's smoking habit.
Smoking's persistence isn't for lack of evidence about the harms it causes. The latest report, which tops 900 pages, contains an impressive list of disorders newly deemed to be caused by smoking. They include diabetes, facial deformities in babies born to smoking mothers, liver and colorectal cancer, age-related macular degeneration, ectopic pregnancy, rheumatoid arthritis and erectile dysfunction, to name a few.
The newly recognized harms aren't limited to smokers. Secondhand smoke raises the risk of stroke by up to 30 percent.
"Smoking really is even worse than we knew," Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, tells Shots. Half of all long-term smokers will die from a smoking-related disease, with the annual toll now about 480,000 people.
Frieden says smoking is more lethal than it used to be. "Even though the Americans who smoke are smoking fewer cigarettes, the risk of dying among smokers is increasing," he notes, quoting the new report.
The trend is striking. Between 1959 and 2010, the risk of lung cancer among women jumped from about three times that of those who never smoked to 26 times. Among men who smoke, the lung cancer rate more than doubled, from 12 times to 25 times the risk of never-smokers.
The CDC says changes in cigarette design and composition since the 1950s have shifted the pattern of lung cancers from a type called squamous cell carcinomas to adenocarcinomas. That's one reason why smoking has become more deadly.
"However, the pattern of changes in risk and death rates in other diseases caused by smoking make it difficult to sort out what specific aspects of smoking are most responsible for increased risk of dying prematurely due to smoking," CDC spokesman Joel London writes in an email.
Whatever the reason, the report conveys a new sense of urgency.
"If we don't act now," Frieden says, "5.6 million of our children will be killed by tobacco," based on current rates of smoking among adolescents and young adults. And 3 1/2 million children in middle and high school now smoke, according to the new report; 3,200 youths start smoking every day.
About 43 million U.S. adults are smokers, or 18 percent. That's progress compared with 42 percent at the time of the first surgeon general's report in 1964, but it's not going down fast enough to meet a 2020 goal of 12 percent.
Many of the anti-smoking actions proposed in the report are familiar: raise cigarette taxes, fund more public education, increase the legal age for buying cigarettes from 18 to 21.
But there's one new wrinkle. Behavioral psychologist David Abrams says this report makes a significant distinction between the harmfulness of burning tobacco and less harmful ways of delivering the nicotine that keeps people addicted.
The report concludes that "cigarettes and other combusted tobacco products" should be eliminated.
"That is new because it implies that less harmful forms of getting one's nicotine — especially if one cannot quit smoking cigarettes — may be acceptable," Abrams tells Shots.
E-cigarettes are electronic cigarettelike devices that don't burn tobacco. They release nicotine in a vapor that doesn't contain the toxic chemicals that cause most of smoking's harm.
Abrams helped write the report's last chapter on "the changing landscape of tobacco control." He works for Legacy for Health, an anti-tobacco group set up as part of a 1998 legal settlement with the tobacco industry.
Abrams thinks e-cigarettes could help wean millions away from cigarettes. "For the first time in a century," he says, "we have an appealing alternative way to give addicted current smokers a satisfying way to give up their combusted products."
He calls this a harm-reduction strategy that would be a big change from the total-abstinence approach of current tobacco control efforts. It's sort of like condoms or clean-needle exchanges to prevent HIV infection.
And it promises to be equally controversial.
The CDC's Frieden, for one, is a skeptic. "It might be possible that things like e-cigarettes in the future will have a positive role," he says. "As they're being rolled out now, I have grave concerns that they're doing more harm than good."
RENEE MONTAGNE, HOST:
It's MORNING EDITION, from NPR News. I'm Renee Montagne.
STEVE INSKEEP, HOST:
And I'm Steve Inskeep. Good morning. This month marks the 50th anniversary of the surgeon general's report that linked cigarette smoking to lung cancer, a landmark report and the catalyst for a massive national anti-smoking campaign.
It's started a decades-long conversation about smoking, as a matter of public health and as a matter of personal choice. That conversation continues. Today, the surgeon general released a new report on smoking, the 32nd time the office has spoken out over the years.
NPR's Richard Knox says the report identifies new risks to smoking, and breaks new ground on e-cigarettes.
RICHARD KNOX, BYLINE: Acting Surgeon General Boris Lushniak is the latest in a long line of surgeons general who've tried to pound the last nails in the coffin of America's smoking habit. There's no reason to think his 900-page report will do the trick. But it's not for lack of trying.
THOMAS FRIEDEN: Smoking really is even worse than we knew.
KNOX: That's Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention. He ticks off an impressive list of disorders the report now finds are caused by smoking.
FRIEDEN: Diabetes, birth defects and stroke in people who are exposed to second-hand smoke.
KNOX: Also: Liver cancer, colorectal cancer, age-related macular degeneration, ectopic pregnancy, rheumatoid arthritis, erectile dysfunction and more. Frieden says smoking not only causes more diseases, it's more lethal than it used to be.
FRIEDEN: Even though the Americans who smoke are smoking fewer cigarettes, the risk of dying from smoking among smokers is increasing.
KNOX: Maybe because companies have re-engineered cigarettes in recent decades, changing the way people inhale and increasing the toxic components of smoke. Whatever the reason, the report conveys a new sense of urgency.
FRIEDEN: If we don't act now, 5.6 million of our children will be killed by tobacco.
KNOX: Many of the proposed actions are familiar: raise cigarette taxes, do more public education, increase the legal age for buying cigarettes. But there's one new wrinkle. Behavioral psychologist David Abrams says this report makes a distinction between the harmfulness of burning tobacco and less-harmful ways of delivering the nicotine that keeps people addicted.
DAVID ABRAMS: That is new because it implies that less-harmful forms of getting one's nicotine - especially if one cannot quit smoking cigarettes - may be acceptable.
KNOX: That includes e-cigarettes - electronic, cigarette-like devices that don't burn tobacco. They release nicotine in a vapor that doesn't contain the toxic chemicals that cause most of the harm.
Abrams helped write the new report's last chapter on the changing landscape of tobacco control. He's with Legacy for Health, an anti-tobacco group set up as part of past legal settlements against the industry. He thinks e-cigarettes could help wean millions away from cigarettes.
ABRAMS: For the first time in a century, we have an appealing, alternative way to give addicted current smokers a satisfying way to give up their combusted products.
KNOX: Abrams calls this a harm-reduction strategy rather than a total abstinence approach. It's sort of like condoms or clean-needle exchanges to prevent AIDS. And it might be equally controversial.
Dr. Frieden, the CDC director, is a skeptic.
FRIEDEN: It might be possible that things like e-cigarettes, in the future, will have a positive role. As they're being rolled out now, I have grave concerns that they're doing more harm than good.
KNOX: Among other things, Frieden worries e-cigarettes will addict many adolescents and young adults to nicotine, and then they'll take up conventional cigarettes with all their dangers.
FRIEDEN: We know that nearly 2 million American kids have now used e-cigarettes. That's a problem.
KNOX: Frieden says strict regulation is needed to prevent companies from marketing e-cigarettes to young people.
FRIEDEN: Including things like bubble-gum and cotton-candy flavors; marketing over the Internet, where kids can get them; free samples; and the kind of advertising that re-glamorizes the act of smoking.
KNOX: Advocates are waiting for word from the Obama administration on whether the Food and Drug Administration has the ability to regulate e-cigarettes under the Tobacco Control Act of 2009.
Richard Knox, NPR News. Transcript provided by NPR, Copyright NPR.