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Lyndon Haviland, DrPH

Correspondence: Requests for reprints should be sent to Lyndon Haviland, DrPH, American Legacy Foundation, 2030 M St NW, Suite 600, Washington, DC 20036 (e-mail: lhaviland{at}americanlegacy.org).

	INTRODUCTION

TOP INTRODUCTION THE FACTS THE SHAPE OF OUR... SMOKING AS A STIGMATIZED... SILENCE IN THE GOVERNMENT PUBLIC HEALTH References

 
Tobacco-related disease kills 178 000 women each year in the United States,¹ yet a search for the public discourse on this fact reveals a profound silence. As a nation, we have failed to mount and support an organized public response to the ongoing public health tragedy of tobacco use. The public health community must find a way to give voice to the thousands of families who will experience the premature loss of a loved one because of tobacco use. In creative new ways, we must engage a broad range of partners, both public and private, and help them raise their voices to demand comprehensive action.

Although many of us are activists and many are working to counteract tobacco’s harm, the public remains largely silent, its lack of outrage evident in the daily news, in the public debate on smoking bans, and in the lack of pressure on our government to protect workers, families, and children. There is so little public demand for action. We must find ways to spark a national movement to demand the funding and implementation of comprehensive tobacco control programs. We must overcome apathy and public silence. Tobacco control advocates must learn from the AIDS activists that silence equals a continuing saga of disease, suffering, and death.

How can we as public health practitioners change this silence into a public demand for comprehensive tobacco control that includes prevention, cessation, and regulation? How can we join together to give voice to the women and men who die each year in America of tobacco-related diseases? How can we prevent the needless suffering of families across the nation that results from tobacco use?

	THE FACTS

TOP INTRODUCTION THE FACTS THE SHAPE OF OUR... SMOKING AS A STIGMATIZED... SILENCE IN THE GOVERNMENT PUBLIC HEALTH References

 
As public health practitioners, we begin planning tobacco prevention and control programs with a review of the inarguable facts. Tobacco remains the leading cause of preventable death in the United States, killing more people each year than AIDS, suicide, murder, car accidents, and drugs combined.² It is the only product that when used as directed kills approximately one third of its users.³ Indeed, the facts are hard to believe—for example, passive smoking (exposure to environmental tobacco smoke) kills 53 000 people each year in the United States and puts thousands more at risk.⁴ The World Bank predicts that by 2030, tobacco-related illnesses will cause 10 million deaths per year, more than any other cause,⁵ yet the recently passed Framework Convention on Tobacco Control negotiated among 193 countries has been signed by 76 participants and ratified by only 3 (Matt Barry, Campaign for Tobacco-Free Kids, oral communication, November 5, 2003).

Given the facts about the harmfulness of tobacco, why is public silence so deafening? Why does the tobacco control community confront apathy, silence, and seemingly insurmountable barriers when implementing scientifically sound programs designed to prevent or reduce tobacco use in the United States? Nicotine is highly addictive, yet the marketing, production, and sale of products that contain nicotine are not regulated by the Food and Drug Administration.

	THE SHAPE OF OUR EPIDEMIC

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Lung cancer is the leading cause of cancer death among men and women,² and the majority of its victims die within one year of diagnosis.⁶ Although it has been debated by the tobacco industry for decades, the scientific evidence of tobacco’s impact on health is clear and well accepted. Tobacco use is implicated in a wide range of medical conditions, both adult and pediatric, including cardiovascular diseases, pulmonary conditions, a multitude of cancers, and reproductive health outcomes.⁷ Perhaps the sheer magnitude of the diverse negative health consequences precludes a targeted demand for action.

An additional reason for the silence is the shape and the face of the current epidemic of tobacco use in the United States. Tobacco is not an equal opportunity killer. It is the poorest and least educated Americans who smoke at the highest rates⁸ and who bear a disproportionate burden of death and disease as a result of their tobacco use.⁹ There is evidence that sexual minorities smoke at much higher rates than the national average, but because there are no national data for this population, the full extent of the problem—and thus the means to address it—remains unclear.¹⁰ And while racial and ethnic minorities smoke at lower rates than White Americans, tobacco takes a dramatic toll on their communities because they have poorer access to medical care.¹¹

To find our voice as a movement, we must confront the social and class dimensions of tobacco use. A national movement to eradicate tobacco use must encourage participation at all levels and within all communities. A successful movement must have diversity in its leadership and must manifest a commitment to identify, train, and support the diverse communities most affected by tobacco use. Diverse leadership, vision, and voice will help us win the fight against disparities in access to prevention and cessation messages as well as access to the health care services necessary to treat tobacco-related illnesses.

	SMOKING AS A STIGMATIZED BEHAVIOR

TOP INTRODUCTION THE FACTS THE SHAPE OF OUR... SMOKING AS A STIGMATIZED... SILENCE IN THE GOVERNMENT PUBLIC HEALTH References

 
To change the social norms around tobacco use and to build a tobacco-free world, we must recognize that tobacco use in the United States is increasingly stigmatized. As local and statewide policies are enacted that restrict the use of tobacco products in public places, smokers can be seen enclosed in small glass smoking rooms in airports or huddled outside restaurants, bars, and office buildings. They are becoming a visible and stigmatized minority. To be successful, we must add the voice of smokers to our movement and support all Americans with evidence-based cessation services.

The debate about tobacco use is often clouded by discourse about smoking as a personal choice or a question of civil liberties. Public debate on smoking restrictions can devolve into a discussion of paternalism and prohibition. The debate often lacks a rigorous discussion of the power of nicotine addiction and the role of the tobacco industry in supporting the concept of smoking as an "adult choice." Insufficient attention is paid to the insidious work of the tobacco industry in marketing tobacco in minority communities and to the industry’s philanthropic support of leadership organizations, unions, and community-based organizations.¹²

	SILENCE IN THE GOVERNMENT

TOP INTRODUCTION THE FACTS THE SHAPE OF OUR... SMOKING AS A STIGMATIZED... SILENCE IN THE GOVERNMENT PUBLIC HEALTH References

 
Although the facts speak for themselves, the governmental response to this epidemic of death and suffering is not on a par with the impact of tobacco use on American health, either on the prevention or the treatment side. Where is the concerted effort of government commensurate with the death, disability, and suffering that tobacco causes?

Every US surgeon general since 1964 has known about the death and suffering linked to tobacco use, and today the government is still documenting the mortality and morbidity linked to tobacco use but not supporting comprehensive plans for its eradication. On average, 1200 people are dying each day in America as a result of tobacco use.¹ The US Public Health Service knows how to prevent these deaths,^13,14 yet the political will to act remains absent. The government has supported the development of comprehensive plans for tobacco use prevention and control and it has supported the development of a scientific basis for action, yet collective action and a collective voice calling for sweeping change are missing.

	PUBLIC HEALTH

TOP INTRODUCTION THE FACTS THE SHAPE OF OUR... SMOKING AS A STIGMATIZED... SILENCE IN THE GOVERNMENT PUBLIC HEALTH References

 
Public health must take a leadership role and demand that the health care system and public policy protect Americans from the consequences of tobacco use. We know what to do to prevent tobacco-related deaths, but we have failed to demand systemic change from our government and from our colleagues in the health care field. We have let our voices be silenced. We must speak out to prevent needless suffering. Studies have demonstrated that health care providers fail to assess patients’ smoking status and advise them to quit, yet a brief intervention by a doctor is one of the most effective methods of increasing use of cessation services.¹⁵

We, the public health community, must find our voice on this issue. We must confront the social inequities of tobacco use and its burden of death and disease. We must communicate a sense of urgency and engage all Americans in the battle against tobacco use. We must demand action and we must demand scientifically sound programs and policies that will help us build a world where young people reject tobacco and where anyone who does use tobacco can quit. Our future depends on it.

	Acknowledgments

 
The author thanks (in alphabetical order) Jane Appleyard Allen, Sharon Carothers, Cheryl G. Healton, Mary Northridge, and Steve Schroeder for their ongoing support and dialogue about the challenges of building a national movement to reduce the burden of death and disease caused by tobacco use in America.

Accepted for publication November 7, 2003.

	References

TOP INTRODUCTION THE FACTS THE SHAPE OF OUR... SMOKING AS A STIGMATIZED... SILENCE IN THE GOVERNMENT PUBLIC HEALTH References

 
1. Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995–1999. MMWR Morb Mortal Wkly Rep. 2002;51:300–303.[Medline]

2. Arias E, Anderson RN, Kung HC, Murphy SL, Kochanek KD. Deaths: final data for 2001. Natl Vital Stat Rep. 2003;52:1–115.[Medline]

3. Centers for Disease Control and Prevention. Projected smoking-related deaths among youth. MMWR Morb Mortal Wkly Rep. 1996;45:971–974.[Medline]

4. Glantz SA, Parmley WW. Passive smoking and heart disease: mechanisms and risk. JAMA.1995;273:1047–1053.[Abstract]

5. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington, DC: World Bank; 1999.

6. American Cancer Society. What are the key statistics for lung cancer? Available at: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?rnav=cridg&dt=26. Accessed December 17, 2003.

7. Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General. Atlanta, Ga: Centers for Disease Control and Prevention; 1989.

8. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2000. MMWR Morb Mortal Wkly Rep. 2002;51:642–645.[Medline]

9. Northridge ME, Morabia A, Ganz ML, et al. Contribution of smoking to excess mortality in Harlem. Am J Epidemiol. 1998;147:250–258.[Abstract/Free Full Text]

10. Ryan H, Wortley PM, Easton A, Pederson L, Greenwood G. Smoking among lesbians, gays, and bisexuals: a review of the literature. Am J Prev Med. 2001;21:142–149.[ISI][Medline]

11. Bach PB, Cramer LD, Warren JL, Begg CB. Racial differences in the treatment of early-stage lung cancer. N Engl J Med. 1999;341:1198–1205.[Abstract/Free Full Text]

12. Siegel M. Tobacco industry sponsorship in the United States, 1995–1999. Available at: http://dcc2.bumc.bu.edu/tobacco. Accessed December 17, 2003.

13. Best Practices for Comprehensive Tobacco Control Programs. Atlanta, Ga: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; August 1999. Available at: http://www.cdc.gov/tobacco/bestprac.htm. Accessed December 17, 2003.

14. Task Force on Community Preventive Services. Recommendations regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke. Am J Prev Med. 2001;20(suppl 2):10–15.[Medline]

15. The Tobacco Use and Dependence Clinical Practice Guideline Panel, Staff, and Consortium Representatives. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report. JAMA. 2000;283:3244–3254.[Abstract/Free Full Text]

This Article Extract Full Text (PDF) Submit a response Purchase Article View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via ISI Web of Science (1) Citing Articles via Google Scholar Google Scholar Articles by Haviland, L. Search for Related Content PubMed PubMed Citation Articles by Haviland, L. Related Collections Tobacco Control Health Promotion Public Health Practice Socioeconomic Factors Other Tobacco