It has been overshadowed a bit by concerns about obesity, but the fact remains that one in every five American adults is a smoker, and almost all of them began to smoke as teenagers, making tobacco the number-one threat to public health and a special danger to young people, the Institute of Medicine (IOM) said in a report issued last month.

It's tempting to believe that the downward trend in tobacco use since 1964 will continue, but don't count on it, the IOM cautions. Current trends suggest that the rate at which adult smokers give up smoking remains fairly low, that declines in the rate at which teens initiate smoking may have slowed, and that overall adult use of tobacco may be flattening out at around 20 percent of the population. "These trends suggest that substantial and sustained efforts will be required to further reduce the prevalence of tobacco use and thereby reduce tobacco-related morbidity and mortality," the report concludes.

One of the largest obstacles to achieving permanent long-term reduction in tobacco use is the alarmingly high rate at which teenagers take up smoking—and then continue to smoke because of the addictiveness of nicotine. "Currently, one out of every five high school seniors smokes, and most of them will become adult smokers."

Asked by the anti-tobacco American Legacy Foundation to look at the present situation and suggest future actions, the IOM in a major report titled "Ending the Tobacco Problem: A Blueprint for the Nation" lays out a two-pronged strategy for building on past gains.

What we know from experience, the report points out, is that comprehensive state tobacco control programs can achieve substantial reductions in tobacco use, especially if those programs include higher excise taxes. Teen smoking, in particular, seems especially sensitive to increases in the price of a pack of cigarettes. Currently, states differ widely in how steeply they tax tobacco, and there is evidence of cross-state-lines smuggling, which could be eliminated by equalizing excise taxes. There's also room for an increase in the federal tax on tobacco, which currently stands at 39 cents a pack.

Then there are bans on smoking in specific locations, intended to protect non-smokers from the health effects of second-hand smoke—not a small factor, since it is estimated that for every eight smokers who die from smoking, one non-smoker dies from second-hand exposure. In a broad recommendation, the IOM report urges states and localities to "enact complete bans on smoking in all non-residential indoor locations, including workplaces, malls, restaurants, and bars." As of July 2006, 305 municipalities had banned smoking in restaurants and 222 required smoke-free bars.

But the biggest way to reduce the number of people who use and become addicted to tobacco products is to keep young people from starting to smoke in the first place, the report emphasizes. That would include limiting youth access to tobacco in retail outlets and prohibiting the sale of tobacco products directly to consumers through mail order or other electronic systems. And the report recommends that school boards "require all middle schools and high school to adopt evidence-based smoking prevention programs and implement them with fidelity, coordinating those programs with public activities and/or annual mass media programming."

Having made all of those recommendations, the report says the nation should be prepared to do much more over the long run. "Ultimately, for long-lasting changes in tobacco use, Congress and other policy-makers will have to change the legal structure of tobacco policy. Congress should confer upon the FDA [the Food and Drug Administration] or another regulatory agency broad regulatory authority over the manufacture, distribution, marketing, and use of tobacco products."

As part of such broad regulation, the report suggests, tobacco manufacturers would be required to disclose all chemical compounds found in both their product and the product's smoke, whether added or occurring naturally, by quantity; be required to disclose to the public the content and delivery of nicotine; and be required to disclose to the public research on their products, including "behavioral aspects of their use."

New Frontiers

Going where few previous reports have gone, the Institute of Medicine suggests another long-term possibility for "substantially curtailing and eliminating the public health burden of tobacco use."

"Weakening the addictiveness of tobacco products over time is another strategy for reducing tobacco use. It would likely take over 10 to 15 years, with decrements of 10 percent to 15 percent of nicotine content per step. This would reduce the level of nicotine intake and hopefully reduce dependence. It would result in a different type of product than currently available commercial low-yield cigarettes, which contain as much nicotine as high-yield cigarettes. The goal of reducing nicotine addiction would be to reduce the likelihood of progression from occasional to regular smoking by adolescents and young adults and should make it easier for addicted smokers to quit."

Calling for "a whole new set of tools in the fight against smoking," the report concludes that "Aggressive policy initiatives are necessary to sustain decades of progress in reducing tobacco use in the United States."

The full text of the report, "Ending the Tobacco Problem: A Blueprint for the Nation," is available at the Institute of Medicine website, www.nap.edu.