Anti-tobacco advocates applauded the surgeon general's 2004 report but are worried about cuts in prevention and cessation programs.

Public health officials are hoping that the publication of the latest surgeon general's report on tobacco, the 24th since the landmark 1964 document that diagnosed smoking as unhealthy, will encourage even more smokers to attempt to quit. The new report found that the health impact of tobacco use goes far beyond the lungs and the other organs traditionally considered at risk. The habit can also be linked to cataracts and reductions in fertility as well as cancers of the stomach, cervix and pancreas. "Everyone knows how bad smoking is, but it's actually worse," said U.S. Surgeon General Richard H. Carmona, MD, MPH. The report also found that smoking diminished overall health and that cigarettes with reduced tar or nicotine provided no benefit. Longtime anti-tobacco crusaders applauded the report for gathering together disparate research into one authoritative document. "It is a step forward in terms of raising awareness about how important tobacco is as a health hazard," said Mel Kohn, MD, MPH, state epidemiologist at the Oregon Dept. of Human Services. Meanwhile, physicians hoped the expanded list of related health concerns would involve more specialists, such as ophthalmologists in the case of cataracts, in promoting smoking cessation. The longer list could also appeal to patients' varying priorities. For instance, the possibility of cancer many years down the line may be less scary to some than the chance of reduced fertility right now. "There are a lot of women trying to get pregnant and who are smoking," said AMA Trustee Ronald Davis, MD, MPH. "Maybe they don't respond very well to messages about lung cancer or heart disease in 20 or 30 years. This might be the message that has the strongest impact on them." Experts note, however, that most smokers need more than motivation, and additional government action has been promised. According to a statement by Health and Human Services Secretary Tommy Thompson accompanying the report, HHS plans to establish a single national toll-free number to access local quitlines and is developing additional strategies to help pregnant smokers quit. The Centers for Medicare & Medicaid Services is funding a demonstration project to determine the best way to help Medicare beneficiaries give up the habit. Thompson also announced that he is exploring ways to make his department the first federal agency to become completely smoke-free. "The scientific evidence contained in this new report provides an even stronger reason for action at all levels of society," he said. But there is some worry that there might not be enough political will to follow this report with the action needed to make a dent in the number of smoking-related deaths. Policies in both the public and private sector continue to raise concern. As an example, funding for the American Legacy Foundation's Truth campaign, which is targeted at preventing youth smoking, is in jeopardy. Also, Oregon recently had the budget for its anti-smoking programs cut from $20 million to $7 million. "We think this program is an excellent investment for the state, but there are other folks out there who don't believe that's the case," said Dr. Kohn. Many physicians also warn that their role is crucial, but that reimbursement for smoking cessation, counseling and nicotine replacement is still patchy. "The real disgrace is that health plans won't cover smoking cessation by a physician, which is by far the most effective intervention," said Stephen L. Hansen, MD, coordinator of the AMA's Tobacco Control Coalition. There is particular concern over smoking at the present time because, although rates of smoking have declined significantly since 1964, that decline has slowed. In 1964, 44% of the country smoked, including then Surgeon General Luther Terry, MD. Dr. Terry quit, and, according to the Centers for Disease Control and Prevention's latest report on smoking prevalence published in the Morbidity and Mortality Weekly Report last month, only 22.5% of adults smoked in 2002. That amount, however, is only a slight decline from the 2001 rate of 22.8% and a long way from the Healthy People 2010 goal of less than 12%. "The good news is that the prevalence is going down, but it's not going down fast enough," said Corinne Husten, MD, MPH, a medical officer in the CDC's Office of Smoking and Health.

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