If a new disease emerged and killed this many people, everyone would be talking about it. This death rate has been constant over the last decade, despite the declining prevalence of cigarette smoking. The decline in prevalence is, for the most part, due to reduced adoption of smoking by teenagers, and younger smokers have been shifting to vaping. The prevalence of smoking among older, poor, less well-educated, and rural populations remains high, especially people with mental illness, or people who identify as LGBTQ.

How can we explain the neglect of 25 million people who currently smoke? We know that on average, they will die ten years sooner than non-smokers. Perhaps these smokers belong to a group other than ours.

These premature deaths can be prevented by effective treatment, which is well established and fully covered by health insurance. Physicians, accountable care organizations, and hospitals all perform poorly in the treatment of tobacco and miss many opportunities to provide evidence-based treatment.

The impact of this medical failure goes beyond the many early deaths and family tragedies associated with tobacco use. Tobacco-related disease contributes 8.3 percent of our total annual medical expense which now exceeds $4 trillion. We, the taxpayers, are paying this bill.

In order to improve awareness of tobacco-related illness and improve performance in tobacco treatment, it may help to unwind some of the reasons.

The manufacture of doubt

The tobacco industry has long manipulated public opinion for calls for more research when the causes of our epidemics of heart disease, cancer, and emphysema are well known. Many scholars to this day reiterate self-serving calls for more research where there are over 3 million papers published on the topic. That extraordinary volume of work is summarized in 35 Surgeon General’s Reports. We know what can be done to control tobacco, but the many recommendations have only been partially implemented.

The most recent version of this doubt is the national paralysis regarding the role of vaping in smoking cessation. Notwithstanding a Cochrane review that shows that vaping is more effective than nicotine patches, no U.S. professional or public health organization has supported the use of vaping to help smokers stop. In England, vaping is standard therapy.

Self-censorship

There are few health problems where the causal relationship is more apparent and the solutions more readily attainable, yet the absence of public conversation necessarily reflects a decision to avoid the topic. Local politicians avoid the topic because they know that they will be primaried. Health insurers, who have a strong economic interest in reducing tobacco use, do not promote political advocacy because they seek to avoid public controversy, and do not promote cessation strategies to their members because of the short-term cost of medications. Editors of newspapers and magazines think that the subject is not of interest to their readers. Doctors avoid the subject because it would take up too much time and they do not believe that they can be effective. Physicians have told me that they were concerned that their patients would leave their practice. My response to this is to discuss tacit acquiescence. Patients know that tobacco is harmful, when their doctor fails to address it, what do they hear? That it must be OK. A physician’s silence is taken as acceptance. We can only overcome our cultural tacit acquiescence by speaking out.

Tobacco use is not as visible as it used to be

Work environments and public places are now smoke-free. Smoking is increasingly concentrated among marginalized populations: low SES, rural, mental illness, and LGBTQ. While these communities each have their advocates, tobacco has not been a priority. Concern has shifted from people who smoke cigarettes to kids who vape.

Smoking is an old problem

People have come to accept the death rate and medical expense as normal background. There are many new problems that have a rising trend.

The public health crisis appears to be resolving as the prevalence is trending down

Public health leaders have been discussing an endgame strategy as if the game is almost over. With 49 million current tobacco users, half of whom smoke cigarettes, this is premature. Tobacco companies are finding new ways to entice young people to explore nicotine as a recreational drug, a situational mood modifier, an athletic performance enhancer, and as a tool for self-medication.

The focus on nicotine use by kids has reduced attention on current smokers

The prevalence of tobacco use among people over 65 has remained unchanged for the last 12 years. All of the changes in the overall prevalence of cigarette smoking have occurred in younger adults who are taking up or switching to vaping.

Tobacco use in general, and adult smoking in particular are not covered in the news and social media feeds. The main sources of information in the public domain are manufacturers of tobacco products and Zynfluencers. The CDC’s highly successful “Tips from former smokers” has ended with the closing of the CDC’s Office on Smoking and Health.

Doctors, and medical school deans, do not think tobacco cessation is interesting. There is very little funding for research in tobacco treatment and curriculum guidance for medical and osteopathic schools does not identify treatment of tobacco as a core competency.

Conflict of interest

The total annual tobacco tax revenue (federal plus state) in the U.S. is around $22.7 billion in recent years, with federal taxes contributing about $12.4 billion and state taxes contributing around $10.3 billion. The potential loss of this revenue from state and federal budgets may explain the behavior of some government officials.

“Do not enter” sign on tobacco topics

While many agencies at the CDC were cut, the entire Office of Smoking and Health has been eliminated. Tobacco companies are major donors to the Trump administration. Susie Wiles, White House Chief of Staff, and Pam Bondi, the U.S. Attorney General, have served as tobacco company lobbyists. Journalists and health care advocates are learning that it is best to dwell on other topics. The tobacco industry continues to lobby governments to ensure that effective interventions such as increased tobacco taxes and smoke-free environments are not advanced.

Excuses I have heard from health insurance executives: All not true

1. There is insufficient data from randomized clinical trials.
2. The time to return on investment is too long because of member turnover.
3. Medical groups in value-based contracts don’t have the bandwidth for new quality initiatives.

Taken together, these reasons and many more amount to tacit acquiescence on a grand scale.

We have gold standard science on health interventions for the treatment of tobacco that save lives and save money. Even worse than not using this information is that we are not talking about it.

Edward Anselm is a board-certified internist with a long-standing focus on public health, tobacco control, and preventive care. He earned his medical degree from the Chicago Medical School at Rosalind Franklin University and completed his internal medicine residency at Montefiore Medical Center in New York. Over the past three decades, Dr. Anselm has served in senior leadership roles across clinical, corporate, and managed-care settings, including chief medical officer positions at HIP Health Plan of New York, FidelisCare, and Health Republic Insurance of New York.

Recently retired from his role as medical director at Aetna, Dr. Anselm continues to teach at the Icahn School of Medicine at Mount Sinai as a clinical assistant professor. His current work focuses on strengthening reimbursement pathways for tobacco cessation and preventive services, helping clinicians integrate evidence-based care that improves patient outcomes while supporting practice sustainability. His research has been published in the American Journal of Accountable Care, the American Journal of Preventive Medicine, AJPM Focus, and Health Affairs Forefront, including articles on tobacco control in accountable care, underbilling of cessation services, and the financial and quality benefits of treating tobacco use as a clinical priority.

Dr. Anselm’s educational and policy work is shared through EdwardAnselmMD.com and The Anselm Nicotine Prescription, with professional updates available on LinkedIn.