This is the first in a six-part MyHealthNewsDaily series examining the problems and solutions related to six "winnable battles" in public health, as recently announced by the U.S. Centers for Disease Control and Prevention.
It's banned in restaurants, stores and airplanes, taxed through the roof and illegal to advertise on television. And it contributes to the deaths of an estimated 400,000 Americans every year due to lung cancer alone. Yet smoking's grip on Americans continues to alarm health experts, who had hoped the battle to "kick butts" was closer to victory.
The controversial issue has been given fresh prominence by its recent selection as one of six "winnable battles" by the director of the U.S. Centers for Disease Control and Prevention (CDC), Thomas Frieden.
Frieden has taken heat from some for his picks — which also include AIDS, teen pregnancy, obesity and poor nutrition, health care infections and auto injuries — from public health advocates whose own priorities didn't make the short list.
But anti-smoking experts say this fight is a smart choice, because tobacco use may be lower than ever, despite a few recent small increases in smoking rates in some groups.
Who still smokes
A 40-year-decline in smoking leveled off about five years ago, and now about 46 million Americans smoke, according to the Campaign for Tobacco-Free Kids. But 4,000 kids under age 18 try smoking for the first time every day. [Infographic: Who Still Smokes? Smokers in the U.S. Today]
"You get the early gains first, so the people who quit smoking based on initial anti-smoking strategies are not as 'tough' as those who keep going," said Dr. David L. Katz, director of the Prevention Research Center at Yale University School of Medicine. "To a certain extent, we're pushing against a more immovable object."
One of the factors impeding further progress is nicotine's irrepressible pull on smokers. Recent research published by Gillinder Bedi, assistant professor of clinical psychology at Columbia University in New York, indicated smokers who are trying to quit experience increasingly intense cigarette cravings over time, raising the odds of an eventual relapse.
"It's a very difficult thing, but I think a lot of things can happen from a public policy standpoint that can make this a winnable battle," said Bedi, whose study took place at the University of Chicago and appeared last month in the journal Biological Psychiatry. [Related: Why Its So Hard to Quit Smoking ]
What's working, what's not
Strong initiatives – including tough secondhand smoke laws and higher cigarette taxes – on both U.S. coasts have significantly cut tobacco use in those locales, said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids.
For example, New York City's smoking rate is about 8.5 percent, less than half the national rate, he said, and lung cancer rates in California are one-fourth those of the nation's most afflicted states.
"These are the result of consistent, significant and sustained efforts," Myers said, "but at a cost remarkably small compared to health care costs" of smokers, which total about $95 billion each year.
Both Katz and Myers pegged the tobacco industry, and those who protest its further regulation, as impediments to achieving the goal, which Katz defined as "the eradication of tobacco from our society."
"What propagates the tobacco market now is that it's actively promoted with large sums of money," Katz said, pointing to a cigarette-smoking character in the recent hit movie "Avatar" as an example of subtle, pro-smoking messages in the entertainment industry.
"It is a poison being sold at a profit, at the expense of our society," he said. "It couldn't be more blatant. It should be completely banished from our culture."
Hazy proposition: Is this battle really winnable?
Katz and Myers have differing ideas and levels of optimism about what it might take to snuff out smoking for good.
Winning the battle — completely abolishing smoking over the next decade — is possible, Katz said, but only if our politically polarized society bands together on legislation. And that's not something he anticipates happening.
"I'm not sure the political will is there to win this war right now," he said. "What if smoking were allowed only in our own homes? Maybe that would be a victory."
Although he doesn't think the battle is truly "winnable," pushing forward with widespread no-smoking policies similar to the strongest ones in place would produce acceptable results, Myers said.
"If we just do what we know to do, we can cut smoking rates in half in the next 10 years,” Myers said. "I would consider that the minimum we can do."
Katz said total victory won't be possible as long as the U.S. government worries more about tobacco companies — and their role in a robust economy — than about what they’re peddling.
"It's too bad. We don't worry very much about the cocaine industry or the opium industry, and we shouldn't worry about lost jobs in the tobacco industry," he said. "There are kinds of work nobody should be doing."