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thereafter. One problem is that the annual rate of cessation, never very high, has been flat since 2002. In addition, a major impediment to achieving a permanent long-term reduction in the prevalence of tobacco use is the high smoking initiation rate among teenagers. Notwithstanding substantial investment in tobacco control efforts in recent years, prevalence of current smoking among high school seniors remains at about 20 percent, and most of these individuals will remain smokers as adults. Approximately 90 percent of adult smokers began smoking as teenagers (SAMHSA 2006).


Concerns about the waning momentum of tobacco control efforts and about declining public attention to what remains the nation’s largest public health problem led the American Legacy Foundation to ask the Institute of Medicine (IOM) to conduct a major study of tobacco policy in the United States. The IOM appointed a 14-member committee and charged it to assess past progress and future prospects in tobacco control and to develop a blueprint for reducing tobacco use in the United States. The study’s statement of task is presented in Box I-1.

To carry out its charge, the committee conducted six meetings between May 2004 and June 2005 at which the members heard presentations from individuals representing academia, nonprofit organizations, and various state governments. The committee also reviewed an extensive literature from peer-reviewed journals, published reports, and news articles. The background information and supporting evidence for the committee’s report are contained in 12 signed appendixes written by committee members and three commissioned papers written by outside researchers.

The committee found it useful to set some boundaries on its work concerning the goal (“reducing tobacco use”) and the time frame within which it should be achieved. To make its task manageable and well-focused, the committee decided to focus its literature review and evidence gathering on reducing cigarette smoking, without meaning to overlook or dismiss the health consequences of other forms of tobacco use. However, the committee believes that its recommendations, although derived from the evidence regarding interventions to reduce cigarette smoking, are fully applicable to smoking of other tobacco products and that most of the recommendations are also applicable to smokeless tobacco products. First of all, trends in smokeless use and cigarette use tend to move in tandem, suggesting that the population-level factors at work at any given time are affecting all forms of tobacco use. Although some smokers may switch to smokeless tobacco as a “risk-reducing” tactic, thereby offsetting some of the gains from smoking cessation, successful efforts to curtail smoking initiation do not appear to be compromised by increased initiation of smokeless use. Second, the

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