Setting the policy, education, and research agenda to reduce tobacco use. Workshop I. AHA Prevention Conference III. Behavior change and compliance: keys to improving cardiovascular health.

C ardiovascular disease is the leading cause of death in the United States, and cigarette smoking is a major preventable cause of cardiovascular mortality.1 More than 434 000 deaths are attributed to cigarette smoking annually. Environmental tobacco smoke is responsible for a 30% excess risk of coronary heart disease in those exposed to it and accounts for approximately 37 000 heart disease deaths annually.2 Consistent with epidemiological evidence, recent studies in animal models have shown a marked dose-response relation between environmental tobacco smoke and atherosclerosis, independent of other risk factors.3 In 1965 the prevalence of cigarette smoking in the United States was 43%. In 1990 it was 25.5%, with approximately 46 million smokers in the United States.4 Smoking prevalence remains high among many ethnic minorities, and the rate of decline among women has been relatively modest, compared with that among men. The prevalence of cigarette smoking among high school seniors has changed little in nearly a decade.5 It has been predicted that women in the United States will have a higher smoking prevalence than men by the year 2000 if current trends continue.6 If worldwide trends in tobacco use continue, annual smoking-attributable mortality will increase from an estimated 3 million in 1990 to 10 million in 2020.7 Because of the magnitude of the problem and the relatively modest impact of individual and small-group prevention and intervention strategies, this working group has developed policy, program, education, and research recommendations to reduce tobacco use. The recommendations emphasize a broad-based, public health, strong advocacy approach complemented by treatment interventions at the community level and throughout the health care system. All approaches require both organizational and individual behavior change and compliance. On a societal level, smokers must adapt to an environment that no longer sanctions smoking. Nonsmokers must assert, with increased vigor, the right to a smoke-free environment. On an individual level, highly addicted smokers will continue to require treatments that incorporate behavior change strategies and pharmacotherapy for nicotine dependence. A national combined policy and treatment paradigm like that designed to control hypertension and hypercholesterolemia must be created to accomplish behavior change.