Health officials have begun to predict the end of cigarette smoking in America.
They have long wished for a cigarette-free America, but shied away from calling for smoking rates to fall to zero or near zero by any particular year. The power of tobacco companies and popularity of their products made such a goal seem like a pipe dream.
But a confluence of changes has recently prompted public health leaders to start throwing around phrases like "endgame" and "tobacco-free generation." Now, they talk about the slowly-declining adult smoking rate dropping to 10 percent in the next decade and to 5 percent or lower by 2050.
Acting U.S. Surgeon General Boris Lushniak last month released a 980-page report on smoking that pushed for stepped-up tobacco-control measures. His news conference was an unusually animated showing of anti-smoking bravado, with Lushniak nearly yelling, repeatedly, "Enough is enough!"
"I can't accept that we're just allowing these numbers to trickle down," he said, in a recent interview with the AP. "We believe we have the public health tools to get us to the zero level."
This is not the first time a federal health official has spoken so boldly. In 1984, Surgeon General C. Everett Koop called for a "smoke-free society" by the year 2000. However, Koop - a bold talker on many issues - didn't offer specifics on how to achieve such a goal.
"What's different today is that we have policies and programs that have been proven to drive down tobacco use," said Matthew Myers, president of the Campaign for Tobacco-Free Kids. "We couldn't say that in 1984."
Among the things that have changed:
-Cigarette taxes have increased around the country, making smokes more expensive. Though prices vary from state to state, on average a pack of cigarettes that would have sold for about $1.75 20 years ago would cost more than triple that now.
-Laws banning smoking in restaurants, bars and workplaces have popped up all over the country. Airline flights have long been off-limits for smoking.
-Polls show that cigarette smoking is no longer considered normal behavior, and is now less popular among teens than marijuana.
-Federal officials are increasingly aggressive about anti-smoking advertising. The Food and Drug Administration launched a new youth tobacco prevention campaign last week. At about the same time, the Centers for Disease Control and Prevention debuted a third, $60-million round of its successful anti-tobacco ad campaign - this one featuring poignant, deathbed images of a woman featured in earlier ads.
-Tobacco companies, once considered impervious to legal attack, have suffered some huge defeats in court. Perhaps the biggest was the 1998 settlement of a case brought by more than 40 states demanding compensation for the costs of treating smoking-related illnesses. Big Tobacco agreed to pay about $200 billion and curtail marketing of cigarettes to youths.
-Retailing of cigarettes is changing, too. CVS Caremark, the nation's second-largest pharmacy chain, announced last week it will stop selling tobacco products at its more than 7,600 drugstores. The company said it made the decision in a bid to focus more on providing health care, but medical and public health leaders predicted pressure will increase on companies like Walgreen Co. and Wal-Mart Stores Inc. to follow suit.
"I do think, in another few years, that pharmacies selling cigarettes will look as anachronistic" as old cigarette ads featuring physician endorsements look today, said CDC Director Dr. Tom Frieden.
These developments have made many in public health dream bigger. It's caused Myers' organization and others to recently tout the goal of bringing the adult smoking rate down to 10 percent by 2024, from the current 18 percent. That would mean dropping it at twice the speed it declined over the last 10 years.
The bigger goal is to reduce U.S. smoking-related deaths to fewer than 10,000, from the current level of 480,000. But even if smoking rates dropped to zero immediately, it would take decades to see that benefit, since smoking-triggered cancers can take decades to develop.
But while some experts and advocates are swinging for the fences, others are more pessimistic. They say the key to reaching such goals is not simply more taxes and more local smoking bans, but action by the U.S. Food and Drug Administration to regulate smoking.
A 2009 federal law gave the FDA the authority to regulate tobacco products. The law barred FDA from outright blocking the sale of cigarettes, but the agency was free to take such pivotal steps as prohibiting the use of appealing menthol flavoring in cigarettes and requiring cigarette makers to ratchet down the amount of addictive nicotine in each smoke.
But nearly five years after gaining power over cigarettes, FDA has yet to even propose such regulations. Agency officials say they're working on it.
Many believe FDA's delay is driven by defense preparations for an anticipated battery of legal and political challenges.
A spokesman for Altria Group Inc., the maker of Marlboro, said the company supports FDA exercising its regulatory authority over tobacco products. But as a whole, the industry has tended to fight regulation. Some of the nation's largest tobacco companies - though not Altria - sued to stop FDA-proposed graphic warning labels on cigarette packs. A federal court blocked the ads.
"The industry makes money as long as they can delay regulation," said Kenneth Warner, a University of Michigan public health professor who is a leading authority on smoking and health.
Warner and Michigan colleague David Mendez estimate that, barring any major new tobacco control victories, the adult smoking rate will drop from its current 18 percent only to about 12 percent by 2050. If health officials do make huge strides, the rate could drop as low as 6 percent, they think.
But Lushniak said zero. Will that ever happen?
Some experts doubt it. As long as cigarettes and other combustible tobacco products are legal, it's likely some people will smoke them. Efforts to prohibit them are likely to fail, they say. (Remember Prohibition?)
"It's hard to do a ban on cigarettes because you're taking something away from people they have and are using. Once you have something, you hold tight," said Richard Daynard, a Northeastern University law professor who focuses on tobacco issues.
Better, he said, to bar people from having a product in the first place. He is intrigued by legal efforts in Singapore and a handful of other countries to ban sales of tobacco to anyone born after a certain year - 2000, say. That would be constitutional, he said. The question is: Would our culture accept it?
Probably not, said Ruth Malone, editor-in-chief of the scientific journal Tobacco Control.
"In our culture, we tend to think we have a right to things even if they're terrible for us," she said.
A growing number of experts believe the most promising option is to get people to switch voluntarily to something else, like electronic cigarettes.
Electronic cigarettes are battery-powered devices that provide users with aerosol puffs that typically contain nicotine, and sometimes flavorings like fruit, mint or chocolate. They've often been described as a less dangerous alternative to regular cigarettes. But there are few studies exploring exactly what chemicals are in them, and in what concentrations, and whether those levels are harmful.
They're controversial: Some experts believe that at a time when cigarette smoking has finally become passe in popular culture, e-cigarettes may re-glamorize puffing away in public places. Cigarette sales could surge.
"It could go in either direction," said John Seffrin, the American Cancer Society's chief executive officer.
But if the FDA can ratchet down nicotine in conventional cigarettes to levels below what's in e-cigarettes, perhaps everyone who clings to smoking will switch to the higher-nicotine new products. That could achieve the end of smoking, at least of combustible, carcinogen-filled cigarettes - or so the thinking goes.
In the past, "the country really wasn't ready" to walk away from cigarettes," Daynard said. "I think the country's ready now."