As devastating as the opioid epidemic is, however, its toll is modest compared to that of another substance: tobacco. Even though tobacco use has rarely made headlines in recent years, cigarette smoking is associated with an estimated 480 000 deaths in the United States annually, totaling approximately 5 million years of potential life lost each year.3,4 Of these deaths, approximately 41 000 are attributed to secondhand smoke exposure, a number that alone exceeds the number of US residents who die of an opioid overdose.3 Public outcry over the opioid crisis is by no means misplaced, but the contrast between the relative attention garnered by the opioid epidemic compared with tobacco use highlights the extent to which concern over tobacco has receded, despite the enormous adverse effects of tobacco on the health of society.
Why has the opioid crisis generated intense public concern and interest while tobacco has not? One reason might be that the trajectories of the 2 epidemics are quite different. The opioid epidemic is a relatively recent phenomenon that appears to be accelerating at a concerning pace. Tobacco use, by contrast, has been steadily decreasing in the United States, with smoking rates declining by more than half during the past 60 years.
The decline in smoking rates, while encouraging, can obscure the ways in which tobacco is still a real and pressing problem. First, the burden of disease attributable to tobacco remains substantial. For every person who dies from using tobacco, 30 live with serious tobacco-related illness.3 Second, and perhaps more insidiously, tobacco use has become more concentrated in vulnerable populations: among the poor, those with mental illness, and those with low educational attainment. Smoking prevalence has declined to less than 10% among those with a college education or more, whereas among those without a high school diploma, approximately 24% of the population smokes.5 Tobacco is becoming a key driver of health disparities in the United States.
The perceived importance of tobacco use has critical consequences for tobacco control and prevention efforts. Over the past decade, public funding for tobacco control has remained stagnant. State spending on tobacco control has been well below revenue generated by tobacco sales and represents a fraction of what tobacco companies spend on marketing. In some cases, states have elected to defund tobacco control programs entirely. For example, the state of New Jersey devoted zero state dollars to tobacco control and prevention between 2013 and 2017, suggesting that tobacco use was declining and that funding for tobacco control measures was not needed.
Despite declining or stagnant efforts on the state and local levels, tobacco control has received renewed attention from a key agency: the US Food and Drug Administration (FDA).6 In August 2017, the FDA announced a proposal to regulate and reduce the amount of nicotine in combustible cigarettes. High-quality (albeit short-term) data suggest that lowering nicotine levels in tobacco reduces nicotine dependence without promoting compensatory smoking.7 While the actual effects of such a policy remain to be seen, the policy represents a novel and aggressive approach to reducing cigarette consumption. The FDA has also proposed regulating noncombustible nicotine products, including electronic nicotine-delivery systems, and has suggested that these products may have a role in a broader harm-reduction strategy.
Implementing these policies will not be straightforward. The FDA’s authority to regulate nicotine in cigarettes was established by statute in 2009. Eight years have elapsed since this authority was granted, highlighting the difficulties of regulating nicotine. Vested interests, including tobacco companies, will surely oppose the policy. Policy makers concerned about local economic effects may also oppose and challenge the FDA’s authority. Even public health advocates and public health agencies wary of unintended consequences may challenge this approach.8
In many ways, the challenges faced by tobacco control are similar to those of the opioid epidemic: a profoundly addictive substance, use concentrated among marginalized and vulnerable populations, powerful interests that profit from consumption, and harm-reduction strategies that require a shift in approach. Perhaps a key difference is that the opioid epidemic has generated intense public concern as well as broad bipartisan political support. While the opioid epidemic has not yet abated, this public and political support has been critical at key policy junctures, including in shaping debate around the future of the Affordable Care Act and the structure of the Medicaid program, which are important in funding treatment for substance use disorders. Such support could likewise be critical in carrying the FDA proposal forward.
Perhaps public concern over the opioid epidemic can provide an opportunity to renew a sense of urgency around tobacco control. Indeed, the epidemics are not completely distinct. The communities most deeply affected by the opioid crisis also have some of the highest smoking rates, and individuals who use tobacco are also more likely to develop prescription opioid misuse. These overlapping epidemics suggest that common conditions may contribute to both and that common solutions may be useful. This moment, with attention focused intently on the opioid epidemic, may also provide the chance to address addiction to nicotine and thereby substantially reduce the harms caused by these 2 threats to health.
