Tobacco Control in the Obama Era - Substantial Progress, Remaining Challenges.

T steady decline in smoking rates among U.S. adults that began in the early 1960s has accelerated substantially during the 7 years of the Barack Obama presidency. Since 2009, the prevalence of cigarette smoking in the United States has fallen at a rate of about 0.78 percentage points per year1 — more than double the rates observed during the administrations of Bill Clinton and George W. Bush (mean decreases of 0.28 and 0.36 percentage points per year, respectively; see graphs). If the current rate of decline were to continue, the prevalence of smoking among U.S. adults would fall from its current level of 15.3% to zero by around 2035. In contrast, at the slower rates of decline observed during the Clinton and Bush years, smoking would not reach zero until approximately 2070 and 2057, respectively (see graphs). (Although cigarettes account for most of the combustible tobacco products sold in the United States,2 sales of noncigarette tobacco products such as cigars have not decreased at the same rates.) The recent accelerated decrease in cigarette smoking has not occurred in a vacuum. The striking decline since 2009 is most likely due to the implementation of an array of tobacco-control interventions at the federal, state, nonprofit, and private-sector levels. These interventions, particularly those at the federal level, were highly intentional, well planned, and well organized. During the first 2 years of the Obama era, several legislative acts provided both the foundation and the essential tools for concerted action on tobacco control. Three of these new laws were particularly influential: the Children’s Health Insurance Program Reauthorization Act of 2009, which increased the federal cigarette excise tax rate from $0.39 to $1.01 per pack; the Family Smoking Prevention and Tobacco Control Act passed in June 2009, which gave the Food and Drug Administration (FDA) the authority to comprehensively regulate thousands of tobacco products for the first time; and the Affordable Care Act (ACA) passed in March 2010, which mandated insurance coverage of evidence-based smoking-cessation counseling and medications without barriers or copayments3 and expanded Medicare and Medicaid coverage for smoking-cessation treatments. The ACA also established the National Prevention Council and the Prevention and Public Health Fund. Other legislation that contributed included the American Recovery and Reinvestment Act (ARRA), the Prevent All Cigarette Trafficking Act, and the Health Information Technology for Economic and Clinical Health Act; these provided research funding, levied taxes on Internet sales of tobacco products, helped to reduce such sales to children, and incorporated assessment of tobacco use into “meaningful use” requirements for health information technology. The Obama administration also advanced tobacco control through its leadership choices for the Department of Health and Human Services (HHS), including many senior appointees with extensive tobacco-control experience, such as Deputy Secretary of Health William Corr, Centers for Disease Control and Prevention (CDC) Director Tom Frieden, FDA Center for Tobacco Products (CTP) Director Mitch Zeller, and Assistant Secretary for Health Howard Koh. All these appointees focused attention and energy on tobacco control. Koh, for instance, led the effort to develop the first HHS comprehensive strategic plan to confront tobacco use in America4 and created the HHS Tobacco Control Steering Committee, which brought together key HHS agencies each month to coordinate departmental actions designed to reduce tobacco use. The HHS agencies involved (including the National Cancer Institute, the National Institute on Drug Abuse, the Centers for Medicare and Medicaid Services, and the Substance Abuse and Mental Health Services Administration) capitalized on the tools and opportunities made possible by the new legislation to greatly increase tobacco-control interventions. HHS directed $200 million from ARRA to launch Communities Putting Prevention to Work, a program that encouraged 22 cities and counties to implement evidencebased strategies to reduce tobacco use. In September 2011, the CDC