The Most Dangerous Drug (Hint; It’s Legal)

Occasionally we are asked what we would recommend if we could do only one thing to address America’s drug problem.  We also ask a similar question in public presentations, “What is the most addictive drug in America and the one that causes more harm than all of the other drugs combined?” The answer to the latter question is nicotine, specifically tobacco, and the answer to the former question is eliminate tobacco from the American culture and diet.

The case against tobacco has a long history. Sir Francis Bacon discovered the addictive nature of tobacco in the 17th century.  In modern times, anti-smoking campaigns began anew in the 1950s with the rediscovery of a causal link with lung cancer.  The report of the Advisory Committee to the Surgeon General in 1964 called for remedial action across society and empowered Surgeon General Luther Terry to champion a multi-pronged approach. Resulting actions included legislating the content of tobacco products, enforcing legal age restrictions, extraordinary State and federal taxes, smoke free zones including second hand smoke, and extensive media promotion of the scientifically proven, deleterious effects of tobacco that included warning labels.  A near national resolve to reduce the use and ill effects has reduced the percentage of smokers in the U.S. from 42% in 1965 to near 11% today with a commensurate reduction in deaths from smoking related illness. 

The Centers for Disease Control recently reviewed the evidence-based literature about the long list of ill health effects from tobacco (“Cigarette Smoking”, Centers for Disease Control, September 2024) .  Included:

·        Cigarette smoke contains more than 7,000 chemicals, at least 69 of which can cause cancer and interfere with the body's ability to fight cancer 

·        Smoking weakens the body's immune system making it harder to kill cancer cells

·        Smoking damages or changes a cell's DNA resulting in a cell growing out of control creating a tumor

·        Cigarette smoking causes one out of every three cancer deaths in the United States

·        Smoking increases the risk for coronary heart disease by 2 to 4 times and stroke by 2 to 4 times

·        Secondhand smoke increases the risk of developing heart disease by 25%–30% and the risk for stroke by 20%−30%

·        Smoking causes as many as 8 out of 10 COPD-related deaths

·        Children exposed to secondhand smoke are at increased risk for respiratory infections, ear infections, asthma attacks, and sudden infant death syndrome

·        Smoking during pregnancy doubles the risk of abnormal bleeding, premature rupture of membranes, placenta previa, placental abruption, and ectopic pregnancy, stillbirth, low birth weight, premature or preterm delivery, underdeveloped lungs and brain, and Sudden Infant Death Syndrome (SIDS).

This may seem like old information and causing significant reduction in smoking behavior yet in October of 2024, the Centers for Disease control reported that 13% of adult males and 10% of adult females in the United States smoke.  Cigarette smoking remains the leading cause of preventable disease and death in U.S. killing more than 480,000 Americans each year at a cost of more than $600 billion two-thirds of that in lost productivity.

Some believed that the introduction of vaping would be a source of relief from smoking tobacco.  According to the Centers for Disease Control (“Health Effects of Vaping”, Centers for Disease Control, January 2025) most vaping products contain nicotine and result in the same though sometimes lesser incidences of the physical and mental health issues that result from smoking tobacco.

Given the extraordinary efforts that occurred in the second half of the 20th century many believe that there is little left to do or that further efforts may yield little results.  Yet, recent reports have identified a resurgence of smoking among teens.  Again from the Centers for Disease Control (“Public Health Strategies for Tobacco Prevention and Control”, Centers for Disease Control, March 2024) there are several, recent efforts that have yielded additional benefits:

·       California enacted multiple tobacco control laws, closed loopholes in the state's smoke-free law, made hotel lobbies, small businesses, and break rooms smoke-free, defined e-cigarettes as a tobacco product, prohibited vaping wherever smoking is not allowed, required all K–12 public schools to be tobacco-free, raised tobacco retail licensure fees, and increased the legal age of sale of tobacco from 18 to 21

·       Massachusetts adopted two area pharmacy free retail sales bans and at least 146 authorities in the state followed suit

·       25 colleges and universities in Michigan adopted tobacco-free campus policies voluntarily, and 77 of 124 public housing authorities adopted smoke free policies

·       Oklahoma integrated cessation treatments into routine care for Medicaid patients including eliminating copays and use of the benefit increased by about 50%.

·       Philadelphia capped the total number of tobacco retailer permits and restricted new retailers from being located within 500 feet of schools.

These and other efforts have continued to chip away at tobacco use and resulting in improved health outcomes in these jurisdictions. Yet there is more that can be done.  From that CDC review:

• Continue to provide information and education to community leaders, other decision makers, and community members about the harms of smoking and secondhand smoke exposure and the benefits of smokefree policies

• Increase the number and reach of tobacco-free policies in K–12 schools, colleges, and universities. workplaces, restaurants, bars, and casinos, multi-unit housing and  behavioral health facilities

• Increase evidence-based health communication to reach groups affected by tobacco-related disparities tailored and/or culturally appropriate, evidence-based, featuring people who experience tobacco-related disparities using culturally and linguistically appropriate protocols, channels, and cessation messages

• Ensure smokefree policies are linked to increased access to, and promotion of, cessation services

• Increase the number and reach of private and public insurers and employers that offer barrier-free coverage of cessation medicines and behavioral counseling

• Expand clinical screening and treatment for all patients who use tobacco products in all health care settings, including rural health clinics, Federally Qualified Health Centers, Urban Indian Health Centers, integrated health systems, and behavioral health centers

• Educate community leaders and decision-makers about the link between location, number, and density of tobacco retail outlets and tobacco-related health disparities

• Increase local policies that reduce access to tobacco products, including those that relate to retailer licensure, availability, pricing and promotion, minimum legal sales age, and bans on menthol and other tobacco flavors.

As a nation we have shown that prohibition has little if any impact on the use of most toxic, recreational drugs.  Further, our experience with tobacco use reduction has us resting on this topic.  Yet, 11% of American adults smoke causing 480,000 deaths annually.  This compares with an estimated 178,000 deaths from alcohol use  (“Facts About U.S. Deaths from Excessive Alcohol Use”, Centers for Disease Control, August 2024) and 105,000 drug overdoes deaths (“Drug Overdose Deaths in the United States 2003–2023” Centers for Disease Control, December 2024) both annually.  The question we introduced was “what would we choose to pursue if we could do only one thing to impact drug abuse in America and its negative effects?”.  The answer; double down on tobacco cessation.