Social forces and tobacco in society.

The continued widespread use of tobacco is one of the greatest paradoxes of the 20th century. The cigarette was introduced to society early in this century, received a broad public acceptance in response to massive marketing and distribution efforts, and survives--or, more accurately, thrives--in a complex and controversial social, medical, and legal environment. Today, over 50 million Americans continue to use tobacco regularly, despite the fact that it is almost universally known that use of the product as intended is likely to result in ultimate death and disability for one out of two regular users. The latest statistics tell us that over 400,000 Americans die each year, accounting for over 5 million years of lost life, $50 billion in medical expenditures, and another $50 billion in indirect costs. We estimate that 10 million Americans have died from smoking since the first Surgeon General's Report in 1964, and another 25 million Americans alive today will ultimately die, including 5 million children, as a result of a fundamentally adolescent decision. Clearly, a unique mix of social and political forces have combined to result in a deadly and addicting product being sold and marketed like candy, resulting in 90% of users acknowledging the addictive nature of the product, 70% of whom would like to quit and wish they had never started. But despite near-universal knowledge of the harm and addictive nature of the product and widespread public support for changes in the status quo, the status quo has not changed. Despite a consistent belief that tobacco should be treated commensurate with the harm that it causes, changes in public policy have been surprisingly recalcitrant. This introduction briefly examines the social, cultural, economic, and public policy forces that have contributed to maintaining the status quo for nearly 100 years, the barriers to meaningful change, and the research needs that could result in profound improvements in public health.