Endgame thinking means transitioning from merely trying to ‘control’ the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as ‘endgame’ policies are so-called ‘tobacco-free generation’ or ‘smoke-free generation’ policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.

States, for example, the Center for Disease Control (CDC) provides primary funding for each state ’ s tobacco control program [10]. This includes funding to help make available state-sponsored provision of free quitline tobacco treatment counseling in all US states and territories, potentially including provision of mail-order pharmacotherapy and coordination with health plan cessation services [10]. While quitlines are under-funded and under-marketed, a portion of government tobacco control program funds (per-haps cost-shared by non-pro fi t and private sectors) could concurrently be used to expand low-cost state-wide dissemination of apps through state departments of health. This could be less costly per person served than live quitline counseling, and expand reach for people who prefer not to talk to a person over the telephone. Through the Washington State Department of Health, the CDC now funds dissemination of an ACT-based smoking cessation app free to all Washington State residents who smoke [11]. The CDC, National Cancer Institute, and NHS all support digital cessation programs [12 – 14]. An ongoing chal-lenge for this delivery model is ensuring a robust marketing/social media effort and integration within healthcare systems (e.g. direct link to apps within the electronic health record). to cacious apps need to be broadly and openly accessible to achieve their public health impact potential.

Over the past decades, demand-side tobacco control efforts in many countries have focused primarily on younger populations, including prevention of initiation in youth and young adults, and encouraging quitting among those in their 20s, 30s and 40s.1 This focus has been explained primarily based on limited resources and long-term efficiency: it is more cost-effective over many decades to prevent initiation or get someone to quit young than it is to get older people who have smoked a long time to quit.2 But there has been almost no examination of this paradigm and its effects from a health equity perspective. In the US private health insurance sector, smoking status is among few factors besides age that health insurers are legally allowed to use to charge a higher premium amount.3 Because premiums for older people are already as much as three times higher than those for younger individuals, the discriminatory effect of this policy is a greater burden for older smokers. Clinicians are also less likely to refer older individuals for cessation support or to prescribe cessation medications.4 Public health agencies likewise expend little effort specifically to motivate and help older tobacco users, compared with outreach and specially designed programmes for younger people who are members of priority populations suffering from health disparities. Yet older smokers as a group have grave intersectional disadvantages: they are poorer, less educated, have higher rates of mental illness, are more likely to be non-White, disabled and have multiple chronic conditions than younger smokers.5 6 The lack of attention has consequences: in the USA, smoking prevalence in those 65 and older did not decrease from 2000 to 2015.7 This lack of progress is likely due to an actual decrease in quit attempts and successes in older smokers, while among those under …

IntroductionThe Centers for Disease Control and Prevention's Tips From Former Smokers® campaign encourages smokers to get help with quitting smoking by promoting 1-800-QUIT-NOW. Campaign advertisements featuring an offer of help with obtaining free cessation medication aired nationally on radio for 2 weeks in 2016. Similar advertisements aired nationally on TV for 3 weeks in 2017. The comparison period of 2016 radio campaign and 2017 TV campaign was used to examine the characteristics of quitline registrants by a media referral source (TV or radio).MethodsData on the number and demographics of quitline registrants in 2016 and 2017 were obtained from the Centers for Disease Control and Prevention's National Quitline Data Warehouse. The investigators conducted t-tests to assess the demographic differences between registrants who heard about the quitline through the radio advertisements and those who heard about it through the TV advertisements during the comparison period. This analysis was conducted in 2019.ResultsThe registrants who heard about the quitline from radio advertisements were more likely to be male, younger, and have more years of education. However, the registrants who heard about the quitline from TV advertisements were more likely to be Black, non-Hispanic, and have fewer years of education.ConclusionsThe findings suggest that the demographic profiles of quitline registrants vary significantly based on how registrants hear about the quitline (via radio or TV). These differences in the characteristics of registrants can help inform the tobacco control mass media purchasing strategies and may enable media efforts to target the specific subgroups of smokers in a better way.

Evidence suggests exposure of nicotine-containing e-cigarette aerosol to nonusers leads to systemic absorption of nicotine. However, no studies have examined acute secondhand exposures that occur in public settings. Here, we measured the serum, saliva and urine of nonusers pre- and post-exposure to nicotine via e-cigarette aerosol. Secondarily, we recorded factors affecting the exposure. Six nonusers of nicotine-containing products were exposed to secondhand aerosol from ad libitum e-cigarette use by three e-cigarette users for 2h during two separate sessions (disposables, tank-style). Pre-exposure (baseline) and post-exposure peak levels (Cmax) of cotinine were measured in nonusers' serum, saliva, and urine over a 6-hour follow-up, plus a saliva sample the following morning. We also measured solution consumption, nicotine concentration, and pH, along with use behavior. Baseline cotinine levels were higher than typical for the US population (median serum session one = 0.089 ng/ml; session two = 0.052 ng/ml). Systemic absorption of nicotine occurred in nonusers with baselines indicative of no/low tobacco exposure, but not in nonusers with elevated baselines. Median changes in cotinine for disposable exposure were 0.007 ng/ml serum, 0.033 ng/ml saliva, and 0.316 ng/mg creatinine in urine. For tank-style exposure they were 0.041 ng/ml serum, 0.060 ng/ml saliva, and 0.948 ng/mg creatinine in urine. Finally, we measured substantial differences in solution nicotine concentrations, pH, use behavior and consumption. Our data show that although exposures may vary considerably, nonusers can systemically absorb nicotine following acute exposure to secondhand e-cigarette aerosol. This can particularly affect sensitive subpopulations, such as children and women of reproductive age.

Background While antismoking media campaigns have demonstrated effectiveness, less is known about the country-level effects of increased media dosing. The 2012 US Tips From Former Smokers (Tips) campaign generated approximately 1.6 million quit attempts overall; however, the specific dose-response from the campaign was only assessed by self-report.Objective Assess the impact of higher ad exposure during the 2013 Tips campaign on quit-related behaviours and intentions, campaign awareness, communication about campaign, and disease knowledge.Methods A 3-month national media buy was supplemented within 67 (of 190) randomly selected local media markets. Higher-dose markets received media buys 3 times that of standard-dose markets. We compared outcomes of interest using data collected via web-based surveys from nationally representative, address-based probability samples of 5733 cigarette smokers and 2843 non-smokers.Results In higher-dose markets, 87.2% of smokers and 83.9% of non-smokers recalled television campaign exposure versus 75.0% of smokers and 73.9% of nonsmokers in standard-dose markets. Among smokers overall, the relative quit attempt rate was 11% higher in higher-dose markets (38.8% vs 34.9%; p< 0.04). The higher-dose increase was larger in African-Americans (50.9% vs 31.8%; p< 0.01). Smokers in higher-dose markets without a mental health condition, with a chronic health condition, or with only some college education made quit attempts at a higher rate than those in standard-dose markets. Non-smokers in higher-dose markets were more likely to talk with family or friends about smoking dangers (43.1% vs 35.7%; p< 0.01) and had greater knowledge of smoking-related diseases.Conclusions The US 2013 Tips antismoking media campaign compared standard and higher doses by randomisation of local media markets. Results demonstrate the effectiveness of a higher dose for engaging non-smokers and further increasing quit attempts among smokers, especially African-Americans.

ObjectivesIn 2012, theCenters for Disease Control and Prevention initiated a national anti-smoking campaign,Tips from Former Smokers(Tips). As a result of the campaign, quit attempts among smokers increased in the general population by 3.7 percentage points. In the current study, we assessed the effects ofTipson smoking cessation in pregnant women.MethodsWe used 2009–2013 certificates of live births in three US states: Indiana, Kentucky and Ohio. Smoking cessation by the third trimester of pregnancy was examined among women who smoked in the 3 months prepregnancy. Campaign exposure was defined as overlap between the airing ofTips2012 (March 19–June 10) and the prepregnancy and pregnancy periods. Women who delivered beforeTips2012 were not exposed. Adjusted logistic regression was used to determine whether exposure toTipswas independently associated with smoking cessation.ResultsCessation rates were stable during 2009–2011 but increased at the timeTips2012 aired and remained elevated. Overall, 32.9% of unexposed and 34.7% of exposed smokers quit by the third trimester (p<0.001). Exposure toTips2012 was associated with increased cessation (adjusted OR: 1.07, 95% CI 1.05 to 1.10).ConclusionsExposure to a national anti-smoking campaign for a general audience was associated with smoking cessation in pregnant women.

BackgroundFew studies have examined the extent of inhalation or dermal contact among bystanders following short-term, secondhand e-cigarette exposure.ObjectiveMeasure PM2.5 (particles < 2.5 microns), UF (ultrafine particles < 100 nm), and nicotine in air and deposited on surfaces and clothing pre-/during/post- a short-term (2-hour) e-cigarette exposure.MethodsE-cigarettes were used ad libitum by three experienced users for 2 hours during two separate sessions (disposable e-cigarettes, then tank-style e-cigarettes, or "tanks") in a 1858 ft3 room. We recorded: uncorrected PM2.5 (using SidePak); UF (using P-Trak); air nicotine concentrations (using air samplers; SKC XAD-4 canisters); ambient air exchange rate (using an air capture hood). Wipe samples were taken by wiping 100 cm2 room surfaces pre- and post- both sessions, and clean cloth wipes were worn during the exposure and collected at the end.ResultsUncorrected PM2.5 and UF were higher (p < .0001) during sessions than before or after. Median PM2.5 during exposure was higher using tanks (0.515 mg/m3) than disposables (0.035 mg/m3) (p < .0001). Median UF during exposure was higher using disposables (31 200 particles/cm3) than tanks (25 200 particles/cm3)(p < .0001). Median air nicotine levels were higher (p < .05) during both sessions (disposables = 0.697 ng/L, tanks = 1.833 ng/L) than before (disposables = 0.004 ng/L, tanks = 0.010 ng/L) or after (disposables = 0.115 ng/L, tanks = 0.147 ng/L). Median accumulation rates of nicotine on surface samples were 2.1 ng/100 cm2/h using disposables and 4.0 ng/100 cm2/h using tanks; for cloth samples, it was 44.4 ng/100 cm2/h using disposables and 69.6 ng/100 cm2/h using tanks (p < .01). Mean room ventilation rate was ~5 air changes per hour during both sessions.ConclusionsShort-term e-cigarette use can produce: elevated PM2.5; elevated UF; nicotine in the air; and accumulation of nicotine on surfaces and clothing.ImplicationsShort-term indoor e-cigarette use produced accumulation of nicotine on surfaces and clothing, which could lead to dermal exposure to nicotine. Short-term e-cigarette use produced elevated PM2.5 and ultrafine particles, which could lead to secondhand inhalation of these particles and any chemicals associated with them by bystanders. We measured significant differences in PM2.5 and ultrafine particles between disposable e-cigarettes and tank-style e-cigarettes, suggesting a difference in the exposure profiles of e-cigarette products.

PROBLEM/CONDITIONIn the United States, marijuana is the most commonly used illicit drug. In 2013, 7.5% (19.8 million) of the U.S. population aged ≥12 years reported using marijuana during the preceding month. Because of certain state-level policies that have legalized marijuana for medical or recreational use, population-based data on marijuana use and other related indicators are needed to help monitor behavioral health changes in the United States.PERIOD COVERED2002-2014.DESCRIPTION OF SYSTEMThe National Survey on Drug Use and Health (NSDUH) is a national- and state-level survey of a representative sample of the civilian, noninstitutionalized U.S. population aged ≥12 years. NSDUH collects information about the use of illicit drugs, alcohol, and tobacco; initiation of substance use; frequency of substance use; substance dependence and abuse; perception of substance harm risk or no risk; and other related behavioral health indicators. This report describes national trends for selected marijuana use and related indicators, including prevalence of marijuana use; initiation; perception of harm risk, approval, and attitudes; perception of availability and mode of acquisition; dependence and abuse; and perception of legal penalty for marijuana possession.RESULTSIn 2014, a total of 2.5 million persons aged ≥12 years had used marijuana for the first time during the preceding 12 months, an average of approximately 7,000 new users each day. During 2002-2014, the prevalence of marijuana use during the past month, past year, and daily or almost daily increased among persons aged ≥18 years, but not among those aged 12-17 years. Among persons aged ≥12 years, the prevalence of perceived great risk from smoking marijuana once or twice a week and once a month decreased and the prevalence of perceived no risk increased. The prevalence of past year marijuana dependence and abuse decreased, except among persons aged ≥26 years. Among persons aged ≥12 years, the percentage reporting that marijuana was fairly easy or very easy to obtain increased. The percentage of persons aged ≥12 reporting the mode of acquisition of marijuana was buying it and growing it increased versus getting it for free and sharing it. The percentage of persons aged ≥12 years reporting that the perceived maximum legal penalty for the possession of an ounce or less of marijuana in their state is a fine and no penalty increased versus probation, community service, possible prison sentence, and mandatory prison sentence.INTERPRETATIONSince 2002, marijuana use in the United States has increased among persons aged ≥18 years, but not among those aged 12-17 years. A decrease in the perception of great risk from smoking marijuana combined with increases in the perception of availability (i.e., fairly easy or very easy to obtain marijuana) and fewer punitive legal penalties (e.g., no penalty) for the possession of marijuana for personal use might play a role in increased use among adults.PUBLIC HEALTH ACTIONNational- and state-level data can help federal, state, and local public health officials develop targeted prevention activities to reduce youth initiation of marijuana use, prevent marijuana dependence and abuse, and prevent adverse health effects. As state-level laws on medical and recreational marijuana use change, modifications might be needed to national- and state-level surveys and more timely and comprehensive surveillance systems might be necessary to provide these data. Marijuana use in younger age groups is a particular public health concern, and changing the perception of harm risk from smoking marijuana is needed.

What is already known on this topic? Since 2010, the proportion of U.S. 12th grade students who reported using marijuana during the preceding 30 days (21.4%) has surpassed the proportion reporting use of cigarettes during the preceding 30 days (19.2%).What is added by this report? During 1997–2013, the proportion of white, black, and Hispanic high school students overall who were exclusive cigarette or cigar users decreased 64%, from 20.5% to 7.4%. The proportion of white, black, and Hispanic students who were exclusive marijuana users more than doubled from 4.2% to 10.2%, and among cigarette or cigar users, marijuana use increased, with considerable increases identified among black and Hispanic students toward the end of the study period.What are the implications for public health practice? Despite significant declines since 1997, approximately 30% of white, black, and Hispanic U.S. high school students were current users of cigarettes, cigars, or marijuana in 2013. Policy and programmatic efforts might benefit from integrated approaches that focus on reducing the use of tobacco and marijuana among youths.

INTRODUCTION:Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smokings (e.g., those with lower education and incomes).METHODS:Education and income are the 2 main social determinants of health that negatively impact health. However, there are other social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This article will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control.RESULTS:Tobacco control policy interventions can be effective in addressing the social determinants of health in tobacco prevention and control to achieve equity and eliminate tobacco-related disparities when they are implemented consistently and equitably across all population groups.CONCLUSIONS:Taking a social determinants of health approach in tobacco prevention and control will be necessary to achieve equity and eliminate tobacco-related disparities.

Several provisions of the ACA address the long-standing gap in insurance coverage for smoking cessation and thereby increase cessation rates. These provisions could help improve quality of care and achieve better health outcomes while reducing costs.

In a recent study by Ayers et al., 1 Ayers J.W. Althouse B.M. Emery S. Changes in internet searches associated with the "Tips From Former Smokers" campaign. Am J Prev Med. 2015; 48: e27-e29https://doi.org/10.1016/j.amepre.2015.03.015 Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar the authors analyzed Google search patterns associated with health conditions depicted in CDC’s national tobacco education campaign, Tips From Former Smokers (Tips). Although examining search trends to inform the effectiveness of health campaigns holds promise, the authors make a number of statements that we, as the principal scientists and campaign managers, disagree with. “Tips From Former Smokers” Can Benefit From Considering All Available Data: Reply to McAfee et al.American Journal of Preventive MedicineVol. 49Issue 6PreviewWe agree1 that “Tips from Former Smokers” (Tips) has been incredibly important and has likely helped many smokers kick the habit. We also agree that campaign evaluations should be based on all available data. Full-Text PDF

The elimination of cigarettes and other combusted tobacco products in the U.S. would prevent tens of millions of tobacco-related deaths. It has been suggested that the introduction of less harmful nicotine delivery devices, such as electronic cigarettes or other electronic nicotine delivery systems, will accelerate progress toward ending combustible cigarette use. However, careful consideration of the potential adverse health effects from nicotine itself is often absent from public health debates. Human and animal data support that nicotine exposure during periods of developmental vulnerability (fetal through adolescent stages) has multiple adverse health consequences, including impaired fetal brain and lung development, and altered development of cerebral cortex and hippocampus in adolescents. Measures to protect the health of pregnant women and children are needed and could include (1) strong prohibitions on marketing that increase youth uptake; (2) youth access laws similar to those in effect for other tobacco products; (3) appropriate health warnings for vulnerable populations; (4) packaging to prevent accidental poisonings; (5) protection of non-users from exposure to secondhand electronic cigarette aerosol; (6) pricing that helps minimize youth initiation and use; (7) regulations to reduce product addiction potential and appeal for youth; and (8) the age of legal sale.

Tobacco use and addiction most often begin during youth and young adulthood. Youth use of tobacco in any form is unsafe. To determine the prevalence and trends of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis) among U.S. middle (grades 6-8) and high school (grades 9-12) students, CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2014 National Youth Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs (p<0.05), while decreases were observed for current use of more traditional products, such as cigarettes and cigars, resulting in no change in overall tobacco use. Consequently, 4.6 million middle and high school students continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical window for brain development, might have lasting adverse consequences for brain development, causes addiction, and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States.

Background Knowledge about the harms of tobacco use deters initiation and is associated with cessation. Most studies on this knowledge in the general population have been in high-income countries, but the tobacco use burden is increasing in low-income and middle-income countries. We sought to estimate levels of knowledge about tobacco-related diseases in 22 countries and determine the factors associated with differences in knowledge. Methods We used data from the Global Adult Tobacco Survey (GATS), a nationally representative survey of persons aged ≥15 years. GATSs were conducted from 2008 to 2013 in 22 low-income and middle-income countries. Information was gathered on tobacco-related knowledge and noticing of antismoking mass media messages and health warning labels on cigarette packages. We constructed a four-point knowledge scale and performed multivariate regression analyses. Results Median country values for the proportion of adults who believed smoking causes a specific illness were 95.9% for lung cancer, 82.5% for heart attack and 74.0% for stroke. Knowledge scores ranged from 2.1 to 3.8. In multivariate regressions, adults scored significantly higher on the knowledge scale if they noticed antismoking media messages (22 countries) or health warning labels (17 countries). Significantly higher knowledge scores occurred in all 9 countries with pictorial health warning labels compared with only 8 out of 13 countries with text-only warning labels. Conclusions Antismoking media messages appear effective for warning the public about the harms from tobacco use in all 22 countries, while warning labels are effective in the majority of these countries. Our findings suggest opportunities to motivate smoking cessation globally.

Background: In 2012, CDC launched the first federally funded national mass media antismoking campaign. The Tips From Former Smokers (Tips) campaign resulted in a 12% relative increase in population-level quit attempts.Purpose: Cost-effectiveness analysis was conducted in 2013 to evaluate Tips from a funding agency's perspective.Methods: Estimates of sustained cessations; premature deaths averted; undiscounted life years (LYs) saved; and quality-adjusted life years (QALYs) gained by Tips were estimated.Results: Tips saved about 179,099 QALYs and prevented 17,109 premature deaths in the U.S. With the campaign cost of roughly $48 million, Tips spent approximately $480 per quitter, $2,819 per premature death averted, $393 per LY saved, and $268 per QALY gained.Conclusions: Tips was not only successful at reducing smoking-attributable morbidity and mortality but also was a highly cost-effective mass media intervention. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine

Tobacco use and addiction most often begin during youth and young adulthood.1,2 Youth use of tobacco in any form is unsafe.1 To determine the prevalence and trends of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis) among U.S. middle (grades 6-8) and high school (grades 9-12) students, CDC and the Food and Drug Administration analyzed data from the 2011-2014 National Youth Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs, while decreases were observed for current use of more traditional products, such as cigarettes and cigars, resulting in no change in overall tobacco use. Consequently, 4.6 million middle and high school students continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical window for brain development, might have lasting adverse consequences for brain development,1 causes addiction,3 and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States. NYTS is a cross-sectional, schoolbased, self-administered, pencil-andpaper questionnaire administered to U.S. middle and high school students. Information is collected on tobacco control outcome indicators to monitor the impact of comprehensive tobacco control policies and strategies4 and inform FDA’s regulatory actions.5 A three-stage cluster sampling procedure was used to generate a nationally representative sample of U.S. students who attend public and private schools in grades 6 to 12. This report includes data from four years of NYTS (2011-2014), using an updated definition of current tobacco

FigureLung cancer is the leading cause of cancer death and the second most commonly diagnosed cancer (excluding skin cancer) among men and women in the United States.1,2 Although lung cancer can be caused by environmental exposures, most efforts to prevent lung cancer emphasize tobacco control because 80 to 90 percent of lung cancers are attributed to cigarette smoking and secondhand smoke.1 One sentinel health consequence of tobacco use is lung cancer, and one way to measure the impact of tobacco control is by examining trends in lung cancer incidence rates, particularly among younger adults.3 Changes in lung cancer rates among younger adults likely reflect recent changes in risk exposure. To assess lung cancer incidence and trends among men and women by age group, CDC used data from the National Program of Cancer Registries (NPCR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program for the period 2005–2009, the most recent data available. During the study period, lung cancer incidence decreased among men in all age groups except those younger than age 35 and decreased among women age 35 to 44 and 54 to 64. Lung cancer incidence decreased more rapidly among men than among women and more rapidly among adults age 35 to 44 than among other age groups. To further reduce lung cancer incidence in the United States, proven population-based tobacco prevention and control strategies should receive sustained attention and support.4Figure: Rate of Invasive Lung Cancer Cases Among Men and Women, by Age Group—U.S., 2005–2009Data on new cases of invasive lung cancer (International Classification of Diseases for Oncology, Third Edition: C34.0-C34.9) diagnosed during the most recent five-year period with available data (2005–2009) were obtained from population-based cancer registries affiliated with the NPCR and SEER programs, which when combined cover the entire U.S. population. Data from all cancer registries that met the United States Cancer Statistics (USCS) data-quality criteria for each year during 2005 to 2009 were used in this report (Additional information available at www.cdc.gov/uscs). Population denominators for incidence rates were race/ethnicity-specific and sex-specific county population estimates from the 2000 U.S. Census, as modified by SEER and aggregated to state and national levels. Annual incidence rates per 100,000 population were age-adjusted (using 19 age groups) by the direct method to the 2000 U.S. standard population. Annual percentage change (APC) was used to quantify the change in incidence rates over time and was calculated using least-squares regression. Rates were considered to increase or decrease if p<0.05; otherwise rates were considered stable. The rate ratio (RR) of incidence among women to men was calculated. Lung cancer incidence rates and trends were analyzed for men and women separately by age group for the United States and by U.S. Census region and state. During 2005–2009, a total of 569,366 invasive lung cancer cases among men and 485,027 among women were reported in the United States. Lung cancer incidence was highest among people age 75 and over and decreased with decreasing age (Figure). In all age groups except persons younger than 35 and 35 to 44 years, lung cancer incidence rates were higher among men than among women; this difference was greatest among those 75 and older and narrowed with decreasing age. From 2005 to 2009, lung cancer incidence decreased among men in all age groups except those younger than 35, with an APC of -2.6 percent overall; among women, lung cancer incidence decreased among those 35 to 44 and 55 to 64 and was stable in all other age groups, yielding an APC of -1.1 percent overall. Lung cancer incidence rates decreased most rapidly among adults age 35 to 44 years, decreasing 6.5 percent per year among men and 5.8 percent per year among women. Lung cancer incidence decreased to a statistically significant extent from 2005 to 2009 among men in all U.S. Census regions and 23 states, and among women in the South and West U.S. Census regions and seven states. By state and age group, lung cancer incidence rates decreased or were stable in most states. ‘Winnable Battle’ CDC has declared reducing tobacco use a “winnable battle” and supports comprehensive efforts to prevent the initiation of tobacco use, promote quitting, and ensure smoke-free environments. This report documents recent decreases in lung cancer incidence during 2005–2009 in the United States, with lung cancer incidence declining more rapidly among men compared with women in all age groups except those younger than 35. Since 1964 when the first Surgeon General's report on the health consequences of smoking was published, cigarette smoking cessation rates increased and cigarette smoking initiation rates decreased more rapidly among men than women.5 As a result, cigarette smoking behaviors have become more similar among men and women, especially among those in recent birth cohorts.5 Subsequently, the gap in lung cancer between men and women has been reported to be diminishing.6 This report shows that differences in lung cancer incidence between men and women narrowed with decreasing age, and that among adults younger than 45, men had slightly lower rates of lung cancer than women did. Another finding is that lung cancer incidence decreased most rapidly from 2005 to 2009 among men and women aged 35 to 44 compared with other age groups. Although many factors might have contributed to this decline, a study of 44 states showed that strong tobacco-control indicators were correlated with lower lung cancer incidence rates among adults 20 to 44.7 Whereas a coordinated, multicomponent approach to tobacco prevention and control is needed to reduce tobacco use, younger adults might be more sensitive than older adults to certain interventions like increased tobacco prices. A systematic review of tobacco control interventions found that for every 10 percent increase in cigarette prices, cigarette smoking prevalence decreased one to 14 percent among youth compared with one to 4.5 percent among adults.8 In 2010, a higher proportion of adults age 18 to 24 attempted to quit smoking cigarette and succeeded in quitting than adults age 45 to 64.9 Other population-based strategies proven to reduce tobacco use among youths and adults include comprehensive smoke-free laws, restriction of tobacco advertising and promotion, and mass media campaigns.4,8 These strategies are effective in changing the cigarette smoking behavior of both men and women, and can be combined with individual-based strategies such as providing access to telephone quitlines and health care coverage for tobacco-cessation treatments.4,8 Additionally, strategies for tobacco control have expanded now that the Food and Drug Administration has been granted the authority to regulate the manufacture, distribution, and marketing of tobacco products. In 2007, CDC updated recommendations regarding the estimated minimum level of funding needed to implement and sustain statewide comprehensive tobacco-control programs; the combined recommended amount across programs was $3.7 billion. In contrast, in 2010, states appropriated only $0.64 billion, amounting to 2.4 percent of their state tobacco revenues, for tobacco control.10 A previous report showed that states varied substantially in their success at reducing cigarette smoking prevalence and lung cancer incidence.2 This report shows that lung cancer incidence decreased during 2005 to 2009 among men in all U.S. Census regions and 23 states, and decreased among women in the South and West and seven states; lung cancer incidence rates were stable in all other states. Another finding is that lung cancer incidence rates during 2005 to 2009 stabilized among women 45 to 54. This age group includes women born during 1950 to 1960 who were young adults during an era in which cigarettes were aggressively marketed toward women.1 This generation experienced a high prevalence of cigarette smoking as young women and high rates of lung cancer mortality as older women.1 Limitations The findings in this report are subject to at least four limitations: First, populations were estimated from the 2000 Census by the U.S. Census Bureau; errors in these estimates might increase as time passes after the census, leading to underestimates or overestimates of incidence rates. Second, analyses based on race and ethnicity might be biased if race and ethnicity were misclassified; efforts were made to ensure that this information was as accurate as possible. Third, delays in cancer reporting might result in an underestimate of the incidence rate. Fourth, analyses of trends should be carefully interpreted; some rates might be actually increasing or decreasing although the trend is not statistically significant. From 2005 to 2009 lung cancer incidence rates decreased among men and women in the United States overall, more rapidly among men than among women, and more rapidly among adults age 35 to 44 than among other age groups. As a result, differences in lung cancer incidence between men and women narrowed with decreasing age. However, continued attention and support to proven population-based tobacco prevention and control strategies will be needed to reduce tobacco use among both men and women and further reduce lung cancer in the United States.4 Reprinted (slightly adapted) from Morbidity and Mortality Weekly Report 2014;63(1);1–5