New York Joins Other States with Growing E-Cigarette Restrictions

In a little under a month in New York state, electronic cigarettes (e-cigs) will be banned wherever standard tobacco cigarettes are prohibited. The move adds to a growing list of states restricting e-cig use because of concerns about their impact on health and safety.

Although e-cigs are often marketed as safer alternatives to standard cigarettes – with some analyses showing they could have some benefits in narrow scenarios – good evidence remains lacking on their risks, on their effectiveness as a smoking cessation aid, and on their impact on youth and adult smoking rates.

The lack of such important information warrants restrictions on their sale and use.

Standard cigarettes remain the top preventable cause of death in the United States, and the primary goal of any tobacco smoker should be to quit. E-cigs, however, are not an FDA-approved method for helping smokers quit. Approved cessation aids include nicotine gum, lozenges and patches, and certain medications. Seeing a doctor for help quitting can double a smoker’s chance of success.

Low-Income Smokers May Not Be Able to Afford Health Insurance Coverage in the Marketplace

A new study shows just how tough it can be for low-income smokers in the United States to get adequate, affordable health insurance coverage.

In an analysis looking at the plans offered in the Affordable Care Act marketplace, in a state that did not expand Medicaid coverage, Washington University School of Medicine researchers found that some smokers would need to pay more than they actually earned in a year for health insurance.

Smokers face significant challenges when it comes to purchasing health insurance. Insurers are allowed to charge smokers up to 50 percent higher premiums. This surcharge is not offset by premium subsidies that help make coverage affordable for those at low incomes, below 400 percent of the federal poverty level.

In addition, in states that did not expand Medicaid, low-income smokers (below 100 percent of the federal poverty level), eligible for Medicaid in other states, would have to pay full price for health insurance plans in the marketplace -- plus the additional smoking surcharge.

The high cost of plans can keep smokers from purchasing insurance. Yet smokers often have health needs from conditions such as chronic bronchitis, emphysema, and asthma. They use more health care and take more medications than non-smokers. So, while they often need more health care, insurance is often unaffordable.

Researchers Denise Monti and Marie Kuzemchak, led by Mary Politi, studied the intended ACA insurance marketplace choices of 327 people in a state without Medicaid expansion. About a third of people in the study were either smokers or lived with a smoker who would be covered under a plan. Fifty-eight percent of the smokers, and 46 percent of non-smokers had incomes below the federal poverty line - around $12,000 per year for an individual or $24,000 for a family of four.

What they found was that smokers overall in this group would have to spend an average of 14 percent of their annual income on their preferred insurance plans, whereas non-smokers would have to spend just half that - around 7 percent.

Rates, though, varied vastly depending on income. Smokers with incomes above the poverty line would have to spend around 5 - 9 percent of their annual income on premiums for their preferred plans. Those below the poverty line, however, would have to spend 165 percent of their annual income on premiums - more than they actually earn each year. Someone making $5,000 per year, for example, might need to pay $8,250 in premiums annually to be covered.

Rates for non-smokers were generally lower across the board. Non-smokers earning below the poverty line would have had to pay 60 percent of annual income on premiums for coverage for their preferred plans - a prohibitive amount but around two-thirds lower than that for smokers in the same category.

The premiums are even higher for very low-income smokers if they want plans that provide coverage that best meets their health care needs. Because smokers typically have more chronic health conditions than non-smokers, plans that have higher premiums might provide more affordable coverage than plans with lower premiums that often require more out-of-pocket costs for care throughout the year.

Annual premiums for smokers for plans that provide the lowest overall costs each year were an average of 167 percent of their annual income for those below the poverty line, and 3 - 7 percent for those above it.

What these numbers show is that a group already at risk because of income and health status is compromised even further by the inability to afford care. This care can not only help them manage and treat chronic conditions, but also provide resources to help them quit smoking.

One way to alleviate the health insurance burden on smokers - especially low-income smokers - is to do away with premium surcharges. Rather than providing an incentive for smokers to quit smoking (so they can get a lower rate), surcharges may simply make plans unaffordable. And this can take a toll on individuals and their families as well as impose a burden on society to cover the costs of their care.

As the researchers conclude:

"Smokers may forgo health insurance due to the exorbitant costs that are not subject to subsidies for those of low-income. This places an untenable burden on smokers to cover the cost of potentially frequent health care needs. It also leaves other taxpayers and the health care system to bear the health care costs (e.g., procedures, medications, emergency room visits) of smokers who are uninsured. If insured by a marketplace plan, smokers would pay for at least a portion of this care themselves; if uninsured, they would be unlikely to do so. It is more beneficial, both for the health and wellness of the smoker and for the health care system, for smokers to be supported in the process of quitting smoking through coverage of tobacco cessation programs and products…Health insurance costs should not be structured in a way that makes insurance unattainable for smokers."

Smoking remains the single biggest burden on health to individuals and society. To make meaningful strides against smoking, it's important that we make it possible for all smokers to get both the health coverage that meets their needs and the support they need to quit smoking for good.

As this new study shows, we are still falling short.

Photo: Cigarette by AJTiner (CC License, CC BY 2.0)

Tailoring Smoking Cessation Outreach: Specialty Tools of Smokefree.gov and an Innovative Study in American Indian/Alaska Native Communities

by Katy Henke

A new study sheds some light on strategies that may help smokers in under-researched communities take steps to quit. Recently, researchers from Washington University in St. Louis led a study that looked at the potential impact that graphic cigarette labels might have in sparking social interaction around smoking cessation in American Indian/Alaska Natives communities. Published in BMJ Open, the study focused on how individuals perceived graphic warning labels on cigarettes and found that participants who saw graphic images were more likely to approach a friend or family member and discuss the idea of quitting smoking. Images that portrayed children or the physical harms of smoking drew the most reaction from participants.

Sample graphic warning labels (Used with author permission) 

This was the first study of its kind to focus on cigarette labels and their potential impact within the American Indian/Alaska Natives communities, where rates of smoking are around double that of the general population. Future research will be able to build on these findings and further explore ways to bolster cessation efforts and help lower rates of smoking in these communities.

Quitting smoking is still the number one way to improve overall health, and, increasingly, efforts that promote prevention and cessation can now be effectively tailored to meet the needs and concerns of specific populations.

A number of tailored cessation programs are offered through the federal government's site, Smokefree.gov. In addition to the site's free telephone counseling at 1-800-QUIT-NOW and text message program, smokefreetxt, it offers a number of specialty websites, including:

smokefreeVET: Focuses on why many veterans begin smoking, how and why to quit smoking, and how to transition back into the civilian lifestyle while quitting. 

smokefreeWomen: Addresses the unique concerns of women who are considering or trying to quit smoking. The smokefreeMOM text messaging specifically helps pregnant women with quitting. 

smokefreeTeen: Provides information to teenagers about the importance of choosing to quit and/or staying smoke free. The site focuses on both the immediate and long term impact of smoking on the health and lifestyle of teens.  

smokefreeEspañol: Provides culturally appropriate tips and advice in Spanish on how to prepare for and begin quitting smoking.

Smokefree.gov also has a strong presence on social media that continually offers advice and education information about the benefits of quitting.

Other health resources with information on smoking and its impact on health and wellness: 

8 Ways to Prevent Cancer and Stay Healthy: This website highlights ways to lower your risk of certain cancers, including advice for quitting smoking.

Your Disease Risk: An interactive online tool designed to estimate your risk of important chronic diseases, which also offers personalized information about reducing your risk.

Still Important To Be a Quitter - Looking at Cessation and Lung Cancer Screening

In 2008, scandal struck the world of cancer screening.  A rare occurrence, to be sure. About two years after the release of a groundbreaking study showing that low-dose CT scans could catch lung cancer early and save lives in smokers, it was revealed that the study's principal investigator had close ties to the tobacco industry.

That revelation threw into deep suspicion the study results. It seemed to many that findings showing that lung cancer could be successfully caught in early stages and treated would greatly benefit the tobacco industry because many smokers would not feel a pressing need to quit.  "Why can't I just keep smoking and rely on screening to catch any issues and fix them," the logic might go.  

As we've written about previously, the study results were eventually replicated by other researchers and the principal investigator largely exonerated. And low-dose CT is quickly becoming a standard screening test for many with a history of heavy smoking.

But one key concern voiced during that tumultuous period may now be coming true.  As highlighted in a New York Times story this week, a small study of smokers found that lung cancer screening may actually be providing many of them a disincentive to quit smoking.

If such attitudes translate nationwide, even partially, it could be a major public health concern.  While effective lung screening can lower the number of deaths from lung cancer, that is all it does.  But smoking causes many different cancers and raises the risk of heart disease, stroke, and diabetes.  Stopping smoking lowers the risk of all of these, and the benefits only increase over time.

The figure below shows that screening lowers the risk of dying of lung cancer by around 20 percent after six years.  Stopping smoking does the same after about five years. As the years off cigarettes stack up, though, deaths from lung cancer drop dramatically, by over 80 percent after 15 - 20 years of cessation.  Even more notable, perhaps, deaths from all causes also drops shortly after stopping smoking, with the benefits increasing year after year of cessation.

It is a clear picture of the benefits of smoking cessation.

While there is no doubt that CT screening for lung cancer is an important tool, it should not be used in place of effective efforts at cessation.  They should go hand-in-hand.  The power of cessation to lower the risk of cancer, heart disease, stroke, and other chronic diseases is unmatched.  Stopping smoking is the single best thing any one person can do for his or her health.

Smokers need to know that and to be encouraged and supported to quit.   Equally, if not more, important is the dedication of governments, communities, and health systems to cessation.  It's easy to feel that we've won the war against tobacco.  But the reality is that a large proportion of the population still smokes. To continue to make strides and reduce the burden of tobacco-related diseases, we need to devote time, training, and resources at a level in line with cessation's potential impact.

John Oliver Skewers Big Tobacco's Heavy-Handed Global Efforts (Video)

We're not prone to posting video clips from satirical news programs, but this weekend's piece from Last Week Tonight with John Oliver really captured why it is so important to keep up the fight against Big Tobacco.  While we still have a great deal of work to do to get tobacco under control in the United States, the situation is even more pressing across the globe, where tobacco companies use heavy-handed tactics to squelch anti-tobacco efforts.  Mr. Oliver deconstructs these tactics in great - and humorous - detail, finishing with his own campaign idea to subvert their efforts.

Warning: video contain [EXPLICIT] language.

Study Finds Tobacco is Even Deadlier Than Typically Estimated. Fighting It Should Remain "Our Highest Priority"

Photo (Creattive Commons): Flickr/jeffjose

It can be easy to think that we've won the fight against tobacco.  Rates of smoking have plummeted since the 1960s.  Most restaurants, bars, and workplaces across the country are now largely smoke-free.  And many of us may have trouble coming up with a single family member or close friend who smokes.

Yet, the reality is that tobacco remains a persistent and insidious problem.   Over 40 million adult Americans still smoke.  That's 18 percent of the population, and rates can vary wildly, with some groups of people in the single digits and others closer to 50 percent.  Smoking rates in adults with  advanced college degrees hovers around 6 percent, while rates in those with GEDs is over 40 percent.  Smoking rates break across income as well, with those making more money smoking at significantly lower rates than those making less.

Now, a new paper published today in the New England Journal of Medicine finds that the ill-effects of tobacco likely reach well beyond what we've typically understood.  It's estimated that in the United States there are approximately 480,000 deaths per year from the 21 broad diseases said to be caused by smoking.  This new study by Carter et al pulls together data from five large cohort studies and reveals that a number of additional categories of diseases should likely be included in the smoking mortality estimates - things like breast cancer, prostate cancer, infections, and kidney failure.  When these diseases are taken into account, the number of deaths each year in the United States from smoking balloon by an additional 60,000 to 120,000 deaths.

Cancer News in Context's Graham Colditz, MD, DrPh writes in an accompanying editorial that:

A total of 60,000 excess deaths is a number that by itself would have an important public health impact, since it is in line with annual deaths in the United States from excessive alcohol intake or low fruit and vegetable intake.

When combined with the existing estimates of smoking-related deaths it becomes abundantly clear that while there have been great successes in tobacco control there is still a great deal of work to accomplish.  Colditz continues in the editorial to highlight the complexities of tobacco use in society and that successful efforts to curb use and aid smoking cessation will take wide-ranging efforts that cut across issues of policy and healthcare, among others.

He concludes by reaffirming the need to keep up the vigorous fight against tobacco - not only for society and for the United States, but for individuals and for other countries as well:

Tobacco control must be our highest priority here and globally to advance population health, to reduce economic burden, and to extend years of health and productive life for all citizens.

More CNiC posts on tobacco, included the latest evidence on smoking and breast cancer.


References

Smoking and Mortality — Beyond Established Causes
Brian D. Carter, M.P.H., Christian C. Abnet, Ph.D., Diane Feskanich, Sc.D., Neal D. Freedman, Ph.D., Patricia Hartge, Sc.D., Cora E. Lewis, M.D., Judith K. Ockene, Ph.D., Ross L. Prentice, Ph.D., Frank E. Speizer, M.D., Michael J. Thun, M.D., and Eric J. Jacobs, Ph.D.
N Engl J Med 2015; 372:631-640

Smoke Alarm — Tobacco Control Remains Paramount
Graham A. Colditz, M.D.
N Engl J Med 2015; 372:665-666

Current Evidence on Smoking and Breast Cancer

Photo: flickr/saneboy (Creative Commons lic; cropped)

Though the most recent Surgeon General’s report on the health effects of tobacco stops just short of classifying smoking as a cause of breast cancer, current evidence seems compelling enough to finally push tobacco smoke from simple risk factor to full-fledged “cause.”

While research into the tobacco/breast cancer link can be confounded by certain differences in the habits of smokers and non-smokers - such as cancer screening frequency and alcohol consumption - studies that take such factors into account have found a fairly consistent impact of smoking on breast cancer risk.

Meta-analyses from the Surgeon General’s report, which combined the results from numerous case-control and cohort studies, are remarkably similar in their findings, showing around a 10 – 15 percent increase in risk in women who actively smoke (or smoked) compared to non smokers (1).

Looking at more recent analyses, the large Cancer Prevention Study II, which followed over 73,000 women for up to 14 years, found that current smokers had a 25 percent higher risk of breast cancer compared to never smokers, while past smokers had a 10 percent higher risk (2). A related meta-analysis, which included data from 14 others studies, found that both current and former smokers had a 10 percent higher breast cancer risk compared to never smokers.

These broad numbers, though, likely don’t paint the full picture of the tobacco/breast cancer link. As with other risk factors, such as alcohol consumption, studies are showing that smoking early in life – between the first period (menarche) and first full-term pregnancy – may have the greatest impact on cancer risk. A recently released long-term Norwegian study of over 300,000 women found that those women who smoked for at least 10 years before their first pregnancy had a 60 percent increased risk of breast cancer compared to those who never smoked (3). Results from the Cancer Prevention Study II found similar risk with smoking starting early in life.

While smoking doesn’t increase breast cancer risk on the order that it increases the risk of lung cancer, it nevertheless has a real and measurable impact. Healthy behaviors can prevent 50 percent or more of all breast cancers. On top of its many other health benefits, avoiding smoking - or stopping smoking -  should be included as a key way for women to take control and help lower their breast cancer risk.

--  --  --  --  

Evidence Summaries from 2014’s 

Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General (1)

Smoking and Breast Cancer Incidence (New Cases)

“Based on 22 cohort reports published prior to 2012 and 27 case-control reports published from 2000– 2011, evidence suggests that a history of ever smoking is associated with an increase in the RR for breast cancer by an average of 10%; long duration of smoking (20 or more years), greater number of cigarettes smoked per day (20 or more), and more pack-years of smoking (20 or more) significantly increase risk for breast cancer by 13–16%, depending on study design and the exclusion of studies with design or analysis issues.”

Smoking and Breast Cancer Mortality

“To date, the evidence is insufficient to conclude that either active or passive smoking influences breast cancer mortality. Studies have been complicated by prob­lems with misclassifying exposure and a lack of specific­ity because smoking increases risk for several noncancer, comorbid conditions that contribute to mortality in survi­vors of breast cancer.”

Potential Causal Mechanisms

"The available evidence supports biologically plausible mechanisms, particularly for DNA adduct formation and unrepaired DNA mutations, by which exposure to tobacco smoke could cause breast cancer. However, data are limited and a detailed mechanistic model of how exposure to tobacco smoke may affect risk for breast cancer cannot yet be assembled. "

References

1. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. In: U.S. Department of Health and Human Services CfDCaP, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, ed. Atlanta, GA2014.
2. Gaudet MM, Gapstur SM, Sun J, Diver WR, Hannan LM, Thun MJ. Active smoking and breast cancer risk: original cohort data and meta-analysis. J Natl Cancer Inst 2013;105:515-25.
3. Bjerkaas E, Parajuli R, Weiderpass E, et al. Smoking duration before first childbirth: an emerging risk factor for breast cancer? Results from 302,865 Norwegian women. Cancer Causes Control 2013;24:1347-56.

Smoking cessation: The rapid road to preventing cancer mortality

One third of the 571,000 cancer deaths in 2011 are due to smoking. That is 188,744 men and women will die unnecessarily because of their smoking habits. These are avoidable deaths. Strong evidence supports the benefits of smoking cessation, not just lowering cancer deaths but also reducing deaths form heart disease and total mortality. The time for prevention to achieve a reduction in cancer incidence or mortality is quite rapid. Despite this strong scientific evidence a substantial gap in implementation of prevention strategies remains. Smoking cessation reduces lung cancer and total mortality with benefits increasing over time. See Figure. Compared to continuing smokers, those who successfully quit have a 20% reduction in lung cancer mortality within 1 to 4 years of quitting and more than a 40% reduction within 5 to 9 years [1]. Smoking cessation also reduces total mortality by 13% in less than 5 years and by 33% in less than 10 years, due to the additional benefits of reduced risk of cardiovascular death and other smoking related cancer deaths [1].

New excitement has been present in the cancer control community since the results of the randomized trial of CT screening for lung cancer was published. This trial screened current smokers between age 55 and 74 who had a history of smoking 30 pack-years or more, or those who had quit within the past 15 years. This randomized controlled trial showed a 20% reduction in lung cancer mortality after an average of 6 years of follow-up, and a reduction in total mortality of 6.7% [2]. These results are not as strong as those observed for smoking cessation and apply only to the lung cancer – screening for lung cancer does not reduce mortality from heart disease, for example. Thus, the benefits for smoking cessation are unarguable.

Within the USA, states such as Utah that have a low prevalence of current cigarette smoking, 9.8% overall by 2009. This is a huge difference from the smoking prevalence of more than 25% in Kentucky and Oklahoma [3].  Based on the National Program of Cancer Registries, the CDC estimates that the corresponding lung cancer mortality varied from 26.4 per 100,000 in Utah to 97.7 deaths per 100,000 in Kentucky, a rate 73% lower when almost 10% of the population continues to smoke cigarettes [4].

Based on state level differences like these, we conservatively estimate that 75% or more of lung cancer could be prevented through elimination of cigarette smoking in the USA. We have the potential to achieve enormous improvements in our population health – the time to act is now.

 Literature cited

1.            Kenfield, S.A., et al., Smoking and smoking cessation in relation to mortality in women. Jama, 2008. 299(17): p. 2037-47.

2.            Aberle, D.R., et al., Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med, 2011. 365(5): p. 395-409.

3.            State-specific prevalence of cigarette smoking and smokeless tobacco use among adults --- United States, 2009. MMWR. Morbidity and mortality weekly report, 2010. 59(43): p. 1400-6.

4.            National Program of Cancer Registries. United States Cancer Statistics. 2011  May 15, 2011]; Available from: http://apps.nccd.cdc.gov/uscs/statevsnational.aspx.

Don't Quit on Quitting: Smoking Cessation Still an Important Focus

John Seffrin, CEO of the American Cancer Society, made the point at last week's meeting of the Clinton Global Initiative that tobacco control should remain the highest priority in combatting chronic disease.  It's a point we've certainly echoed on this blog - that efforts to curb tobacco use shouldn't be relegated to the second tier just because they've been around a while and have made some great strides.

There's still a long way to go.

In the United States alone, although smoking prevalence has dropped from around 43 percent in 1965 to 20 percent in 2009, tobacco remains the leading cause of cancer and a major contributor to other serious chronic diseases.

A great deal of tobacco control efforts focus rightly on keeping youth and young adults from starting smoking, yet 47 million Americans are currently smokers who stand to benefit a great deal from stopping.  Risk of stroke and heart attack drop significantly within a year after stopping, as does the risk of lung cancer within 10 years.

This week's New England Journal of Medicine helps put some of the focus back on cessation with a very nice guide for doctors on helping the smokers they see in their practices successfully quit (link).  The take away, not surprisingly, is that quitting it tough, but with a little effort from both doctor and smoker - and the right interventions - chances for successful quitting can increase dramatically.

In the face of a 24 hour news cycle always looking to report on the newest, the most exciting health innovations - tobacco control can often be left behind - a victim of its own success.  It's important, though, that tobacco control - including efforts to boost cessation - remain a top priority in public health.  No other efforts have quite as much potential benefit, even if some people wrongly view them as yesterday's news.

That's a Wrap: Images of Smoking Way Down in Youth Movies

In what can only be viewed as a positive in the fight against tobacco, a new federal report finds that images of smoking in youth-oriented movies have plummeted since 2005.  In movies rated G and PG, the rate of tobacco "incidents" (as the report calls them) fell by over 90 percent (see figure).  Even in PG-13 and R rated movies, rates fell by over 60 percent and 40 percent, respectively.

Smoking in teens and young adults often leads to long-term, and frequently, lifetime smoking habits.  Quitting is possible but difficult for many.  So the best approach for cutting down on smoking rates is to stop smoking before it starts, which means fostering environments and communities that, at a minimum, don't promote and glamorize tobacco use.

Moves by studios and film makers to limit such images in youth-oriented movies are a great addition to efforts to prevent tobacco use.  If maintained over time, they could help provide real and lasting benefits for the nation's health.

The figure above shows the number of tobacco incidents in top-grossing movies, by rating, in the United States during 1991-2010. From 2005 to 2010, the total number of tobacco incidents in top-grossing movies decreased 56.0%, from 4,152 to 1,825. The total number of incidents in G or PG movies decreased 93.6%, from 472 to 30, whereas the number in PG-13 movies decreased 65.1%, from 1,621 to 565, and the number in R-rated movies decreased 40.5%, from 2,059 to 1,226 (Source: CDC).

Lance Armstrong has it right: Why tobacco taxes matter

News came out this week that Lance Armstrong will team up with a new partner - the California Cancer Research Act. The Act proposes increasing the state's tobacco tax by $1 and funneling that money toward cancer research. California is facing a budget crisis and may be cutting huge (billions) sums of money from health care funds. California was one of the states at the front edge of reducing tobacco use through community-wide campaigns and tax measures. We don't know how it will play out, but the proposal has the potential to improve health in the state in two different ways. First, tobacco taxes reduce consumption. Second, by putting the revenue gained toward cancer research, the monies go toward prevention and treatment of smoking's leading health outcomes.

Research has shown time and again that increasing taxes reduces consumption of tobacco, particularly among those in younger age groups. In fact, the World Health Organization has called taxation the single most effective method for reducing the demand for tobacco products. After previously increasing taxes and funneling money toward cessation programs, California saw a 16 percent per capita decline in cigarette consumption. In part, this is because youth are highly sensitive to price changes and the higher cost deters many from taking up smoking. Basically, they have trouble coming with the extra cash.

Proponents of the legislation have offered another benefit of the tax - jobs creation. With state universities facing major budget shortfalls, the revenue being directed toward research could create jobs.

Exactly where the money would wind up is always a little unclear, however.  Despite the best of intentions, politicians have ways of directing tobacco money away from intended programs, as we learned when the tobacco companies settled with the states in 1998.  From a health standpoint, though, the money raised from the tax would almost be secondary; the real payoff would be the drop in smoking rates.  And if the lure of extra state revenue gets the new tax on the books, so much the better for everyone. 

Tobacco Control Works – Now Implement It

As noted in the NCI Cancer Bulletin this week (see related story), Assistant Secretary of Health and Human Services, Dr. Howard Koh, describes the new tobacco control strategy released this month as four pillars of strategic action. These high impact approaches are known to work.

• Change social norms around tobacco use
• Improve the public’s health through implementing evidence-based tobacco control interventions and polices at the state and community level
• Lead by example and leverage all possible resources
• Advance knowledge, accelerate research, and expand the scientific knowledge base.

Tobacco smoking remains the leading cause of premature mortality in the US. Adults who quit lower their risk of chronic disease including a number of cancers, heart disease, stroke, and chronic obstructive lung disease, to name a few. Quality of life improves after quitting smoking. Lifetime costs of health care are reduced.

For more details on the strategic plan go to the posting by HHS, which includes the related press release and a Webcast of the press announcement (link).

Is your community doing all it can to help prevent youth from taking up smoking and to help adults who smoke to quit?

Do you prefer smoke free restaurants?

How does cigarette smoking impact your community?