Earlier this fall, my oldest son invited me to watch him run his first half marathon in Durham, North Carolina. While standing at the starting line, facing hundreds of runners of different ages, I could not help but be amazed by the irony of the situation: In the midst of a region in the United States known as “tobacco road,” there was tangible evidence of a significant, healthier turn in people’s norms and behaviors.
Why the irony, you may ask? After the U.S. Civil War in the 19th century, the tobacco industry became the backbone of North Carolina’s economy, and the city of Durham developed rapidly as a tobacco manufacturing center. Although cigarettes are no longer manufactured there, its historic district, where the race took place, still preserves the physical legacy of tobacco factories, which have now been converted into upscale apartment buildings and retail spaces.
While North Carolina is still the top tobacco-producing area in the United States, over the past two decades, tobacco employment, and the number of tobacco farming, processing and manufacturing establishments have declined steadily across all segments of the tobacco value chain in the U.S. In 1992, the U.S. tobacco industry employed over 80,762 people in 2,144 establishments. By 2012, this number had dropped to 42,531 workers in 1,955 establishments, a decline of 47.3% and 8.8%, respectively.
The continuous decline in the relative economic importance of the U.S. tobacco industry is due in large measure to the translation of medical and public health evidence, and knowledge about the negative health effects of tobacco use, into effective public policy measures, such as smoke-free laws and tobacco tax increases, which make these products unaffordable. Education campaigns and cessation programs have also helped to reduce the social acceptability of smoking and have changed consumption patterns. And funding from the 1998 Master Settlement Agreement--an accord between the state Attorneys General of 46 states, five U.S. territories, the District of Columbia, and the five largest U.S. tobacco companies, which requires the tobacco industry to pay the states approximately US$10 billion annually for the cost of health care for tobacco-related illnesses -- is being used to support crop diversification away from tobacco.
Beginning with the first U.S. Surgeon General’s report on tobacco released in 1964, a broad consensus now exists that tobacco use is the single-most preventable cause of death and disease in the United States. As documented in the Healthy People 2020 report, for every person who dies from tobacco use in the United States, 20 more people suffer with at least one serious tobacco-related illness. Overall, smoking in the United States kills about 480,000 Americans a year and costs nearly $280 billion a year in health care costs and lost productivity.
Thanks to widespread application of anti-tobacco policy measures, smoking rates have declined significantly. Survey data from the U.S. Centers for Disease Control and Prevention (CDC) show a significant downward trend in current cigarette smoking among adults in the U.S.: from 42% in 1965 to 19% in 2011.
In spite of the significant progress achieved over the past 50 years, the 2014 Surgeon General’s report warns against complacency. The list of illnesses caused by smoking has grown, and smokers today have a greater risk of developing lung cancer than they did in 1964, even though they smoke fewer cigarettes, due to changes in the design and composition of cigarettes that raise health risks. It is notable that, for the first time, women are as likely as men to die from many of the diseases caused by smoking.
As the tobacco industry and tobacco use in the United States gradually but inexorably continue to fade away, there are other deep-seated and far-reaching changes taking place in social and cultural norms, attitudes and behaviors that have had an impact on the population’s health.
Scientific evidence and knowledge about the health benefits of regular physical activity, for example, are influencing youth and adults alike to participate in moderate and vigorous physical activities, such as running. Events such as the Durham Half Marathon reflect the “running/jogging/walking boom” that has grown over the past decade. Since 2004, Americans’ estimated total running/jogging participation (6+days/year) has increased 70% to a record of nearly 42 million people, across both genders.
Public health warnings and advice on effective ways to deal with the growing U.S. obesity and diabetes epidemic are also making more people cognizant about the food they eat. CDC data show that improvement in eating habits, including reductions in the average number of daily calories children and adults consume; a decline in the amount of soda Americans drink by about one-quarter since the late 1990s; and a rise in physical activity, have all contributed to the fall in the rate of new diabetes cases by about one-fifth, from 2008 to 2014.
On the trip back home from Durham, I concluded that all of us who are involved in supporting the realization of universal health coverage across the world now have a tremendous opportunity to contribute to the attainment of longer lives, free of preventable disease, disability, injury, and premature death. But to do so effectively in today’s era of competitive priorities and vested commercial interests, we need to advocate and support sound policymaking by disseminating and adapting to specific country contexts, good practices such as the ones observed in the United States. We also must bring evidence to bear on the broad social and economic benefits of public health action, as well as the costs of inaction.
We have a ways to go, but “running away from tobacco road” is a step in the right direction.
Follow the World Bank Health team on Twitter: @WBG_Health
2014 Surgeon General's Report: The Health Consequences of Smoking—50 Years of Progress
Global Effects of Smoking, of Quitting, and of Taxing Tobacco
US CDC. Incidence of Diabetes in the Population Aged 18–79 Years
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