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We have an opioid overdose crisis, but cigarettes still kill 15 times more people

Here's what we need to do to save more lives.

The smoking rate in America has declined dramatically — from around 32 percent in the 1980s to 15 percent today. But over the last couple of years, this smoking prevalence hasn’t budged while rates have continued to decline in other rich countries.
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Cigarettes still kill nearly half a million people in the US each year — 15 times the death toll from the opioid crisis. That’s also more than alcohol, car accidents, AIDS, illegal drugs, murders, and suicides combined.

Thanks to tobacco taxes and cigarette bans, the smoking rate in America has declined dramatically — from around 32 percent in the 1980s to 15 percent today. But over the past couple of years, the smoking prevalence here hasn’t budged while rates have continued to drop in other rich countries like the UK and Canada. Australia has even managed to reduce its smoking rate to an all-time low of 13 percent.

The picture in the US may be about to change.

On Thursday, the US Food and Drug Administration announced plans to move ahead with an initiative that could drive down the US smoking rate much, much further. Scott Gottlieb, the commissioner of the FDA, said the agency will soon issue a new regulation for much lower limits on the amount of nicotine in tobacco, essentially forcing companies to reengineer cigarettes so they’ll be less addictive.

Since tobacco use is driven by nicotine addiction, researchers who study tobacco control, like the University of Waterloo’s David Hammond, told me, “[This] would be one of the most significant tobacco control measures ever undertaken.” (It’s also an approach clinical trial data suggests helps wean people off smoking.)

The move is unprecedented — no other country has attempted to limit the nicotine content in cigarettes — and it would likely affect every brand of conventional cigarette on the market, Hammond said. But the FDA announcement hasn’t catalyzed change overnight, however; it only commenced a rule-making process that involves gathering input from the public and other stakeholders and is expected to take several years.

In the meantime, though, there are many other policies the US could pursue to bring down the smoking rate. Adding graphic picture health warnings to cigarette packs or ratifying the UN's Framework Convention on Tobacco Control are among a couple of measures America hasn’t put in place even though dozens of other countries have. So while the new nicotine announcement is a real public health power move, we’re still missing some tobacco control basics.

Other countries have proven that making cigarette packaging plain deters smoking

Cigarette packs have long served as portable advertising for tobacco companies, with smokers conveniently disseminating branding and imagery wherever they go.

Tobacco marketing is considered a massive driver of cigarette use — which is why the industry shells out tens of billions every year pushing its products to consumers. Cigarette companies also mislead consumers about the relative harms of certain types of cigarettes through the use of colors (light colors appear to imply a product is safer) and language (think "light," "organic," or "low tar").

To counteract those marketing efforts, more than 100 countries around the world have added gruesome pictures of the health effects of cigarettes on packs. (The most recent review of the research suggests the graphical warnings are more effective than text-only warnings at curbing the appeal of smoking.)

Plain packaging came next, with Australia introducing the world's first regulations in 2012. Tobacco companies there are now restricted in their use of logos, colors, and brand images, and instead have to use a standard (unsavory green) color and plain font. The boxes also prominently feature warnings about the harms of smoking, including nasty images that show what cigarettes can do to the body. (There's good evidence from a number of systematic reviews that plain packaging works, too.)

Others countries — including France, the United Kingdom, Norway, Ireland, Hungary, Slovenia — have followed Australia's lead, putting in place plain packaging regulations of their own. Meanwhile, dozens of countries in Latin America and Asia have already gone through several generations of pictorial health warnings on packaging over the past decade.

The US hasn't updated the health warnings on packs in 33 years

Cigarette packaging in the US, on the other hand, hasn't changed much since 1985. A text-only surgeon's general warning was introduced in 1966, but it hasn't been updated in 33 years.

Why? Typically the First Amendment argument is invoked: Protections on free speech here are so strong that public health officials don't stand a chance, the thinking goes. Tobacco companies could sue the government and perhaps win.

But according to Hammond, "Protection of free speech in the US is not unique." The UK has it, too, but also managed to implement plain packaging measures after tobacco companies (including British American Tobacco, Philip Morris International, Japan Tobacco International, and Imperial Brands) challenged the law, taking the case up to the UK High Court. (The court rejected the challenge.)

Kenneth Michael Cummings, co-leader of the Medical University of South Carolina's tobacco research program, said the US sluggishness is “all about the lobbying."

The powerful tobacco lobby in the US has managed to delay federal regulation of the industry for decades. The Food and Drug Administration only gained authority over the tobacco industry in 2009 with the Family Smoking Prevention and Tobacco Control Act. Cummings added, "We have the best Congress money can buy."

We lag some third-world countries in terms of tobacco control policies on labeling

What's more, there are 180 countries that have ratified the UN's Framework Convention on Tobacco Control, which commits countries to requiring graphic warnings on packs and other anti-smoking regulations.

The US isn't one of them, which "means the US isn’t obligated to do what other countries have done," Cummings said.

"The lack of movement on packaging in the US is consistent with a lot of other areas [in tobacco control]," Hammond said. "The US probably falls below third-world countries in terms of some of the tobacco control policies related to labeling."

The FDA has added some packaging restrictions on tobacco products in recent years, including prohibiting the use of descriptors such as "light," "low," or "mild." In 2016, FDA also began asking companies to warn smokers that "nicotine is an addictive chemical" — but that statement won't appear on all packaging until 2018.

Attempts to go any further have so far flopped, however. In 2011, the FDA published a rule that required companies to use new text and graphic images on packs — but that was challenged in court by several tobacco companies. For now, FDA spokesperson Michael Felberbaum said the agency is seeking Office of Management and Budget approval to simply collect data on the impact of graphic health warnings.

So while the new nicotine limiting policy is truly significant — if it’s not also blocked by tobacco companies — the US still lags behind most other countries on these basic measures. “More than anything,” Hammond said, “[this] raises questions about the industry's commitment to harm reduction. If they actively oppose pictures that help to communicate the harms of smoking to children, how will they react to measures to substantially reduce the addictiveness of their products?”