US smoking rate falls below 10 percent for first time

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how old am i Old enough to fly on planes that had ashtrays in the armrests. Old enough to remember restaurants with smoking sections separated from the non-smoking section by essentially nothing. Old enough to remember when “to smoke or not” was a question the restaurant host actually asked you. Old enough that in the year I graduated high school — 1997 — more than a third of high school students smoked.

I’m 47 — not old, though I sometimes feel that way — and yet the America I grew up in in the 1980s was still so saturated with cigarette smoke that these memories feel like send-ups from another civilization. In 1980, about a third of American adults still smoked. The smoking mascot Joe Camel, which critics would later accuse of being designed to appeal to children, debuted the year i turned 10.

Now here is a figure from 2024: 9.9 percent. That’s the share of American adults who smoke cigarettes, according to data from the National Health Interview Survey analyzed in a paper published this month in NEJM Testimony. This is the first time the rate has fallen below 10 percent in the history of the survey. In the language of public health, smoking in America is now official”scarce.”

This decline—from 42.4 percent in 1965 to 9.9 percent, over about 60 years—is one of the great public health achievements of the modern era. It didn’t happen because of a single breakthrough or a panacea. It happened because science, politics, litigation and sheer collective will chipped away at the problem for six decades against the fierce resistance of one of the most powerful industries on earth. If you’re looking for evidence that large-scale, long-term progress is possible—even when the odds seem impossible—there are few better examples than the story of smoking.

The smoke got in your eye

The extent of the change is difficult to appreciate now. At its peak, Americans overconsumed 4,000 cigarettes per person per yearor more than half a packet a day. Approximately half of all doctors smoked. Cigarette companies have spent billions on marketing and vehemently opposed any regulation while actively suppressing evidence of harm.

The toll was staggering. Since 1964, more than 20 million Americans died of smoking-related causes. Still smoking kills about 480,000 Americans a yearcontribute to about one in five deaths. Globally, tobacco killed approx 100 million people in the 20th century – more than the total number of people killed in World War II. It is, by a wide margin, the leading cause of preventable death in the modern world.

The turning point came on January 11, 1964 when Surgeon General Luther Terry agreed at press conference at the State Department to announce what its advisory committee found after reviewing more than 7,000 scientific articles: Cigarette smoke causes lung cancer and probably causes heart disease. He deliberately chose to release the findings on a Saturday – both to minimize stock market fallout and to maximize Sunday newspaper coverage. It worked. The report, as Terry later recalled, “hit the country like a bomb.”

But the tobacco industry did not go quietly. Internal documents showed that cigarette companies already knew smoking caused cancer in the late 1950s and worked tirelessly to hide it. A famous internal memo from RJ Reynolds distilled the strategy: “Doubt is our product.”

For decades, the industry funded bogus research organizations, lobbied Congress with enormous budgets, and targeted children with advertisements. In 1994, the CEOs of the seven largest tobacco companies testify before Congress that they did not believe nicotine was addictive. Internal documents proved they knew otherwise.

At that point, the industry had never lost a lawsuit – in more than 800 cases. But that would change. In 1998, 46 state attorneys general the Master Settlement Agreement with the tobacco companies – a $246 billion settlement, the largest redistribution of corporate malpractice costs in American legal history. In 2006, a federal judge went so far as to rule that the tobacco companies violated the RICO Act — the racketeering statute typically reserved for organized crime.

How cigarettes were beaten

No single policy killed the cigarette. It was a combination of interventions deployed over decades: warning labels on parcels (1965), a ban on broadcast advertisements (1970), Smoke-free workplace laws (distribution of Minnesota in 1975 against most of the country), growing awareness of the risks of secondhand smoke (1986), progressive tax increases (a 10 percent price increase reduces consumption by about 4 percent), FDA regulatory authority (2009), and nicotine patch cessation programs to the CDCs Tips From Former Smokers campaign. Perhaps most importantly, smoking went from something that almost everyone did to something that was banned in most public spaces—changing social norms as much as any law.

The result: an estimated 8 million lives saved between 1964 and 2014 alone, representing 157 million life years – an average of about 20 extra years for each person who did not die prematurely from smoking. A 40-year-old American man in 2014 can expect to live almost eight years longer than its 1964 counterpart, and about a third of that improvement comes from tobacco control alone.

But we still have a way to go in the effort to end tobacco permanently.

For one thing, 9.9 percent is an average, and averages lie. Smoking rates among people with a GED — meaning they haven’t graduated high school — are still 42.8 percentbarely less than the national rate in 1964. Rates remain high among low-income Americans (24.4 percent), rural residents (27 percent), people with disabilities (21.5 percent), and workers in construction and mining jobs (about 29 percent). As overall consumption rates have declined, smoking has increasingly become a disease of poverty and disadvantage. The people who still smoke are disproportionately the people with the fewest resources to help them quit.

Second, even if cigarette smoke goes away, nicotine does not. E-cigarette use is holding steady at 7 percent among adults, and while cigarettes are almost extinct among 18- to 24-year-olds, almost 15 percent vape nicotine.

But vaping is still better for you than smoking. E-cigarettes have helped people quit tobacco and are generally less harmful than setting fire to dried leaves and inhaling the smoke, even if their full long-term effects will not be known for years.

Third, notably, this milestone of government action was not actually announced by the US government, even though that is where the data comes from. Federal cuts have deleted the CDC’s Office on Smoking and Healththe very office that has tracked and driven this progress for decades. Instead, the analysis was published by a independent researcher through NEJM Evidence’s “Public Health Alerts” initiative – a new collaboration created specifically to fill gaps left by the depleted CDC. There is every reason to worry that the federal health infrastructure as it stands now will struggle to keep the anti-tobacco momentum going.

And in the rest of the world we have much more work to do. Over 80 percent of the world’s 1.3 billion tobacco users live in low and middle income countries. Tobacco kills more than 7 million people a year worldwide, a number expected to rise to 10 million by 2030 based on current trends. While the 20th century saw around 100 million tobacco deaths, mostly in rich countries, some project estimates to 1 billion in the 21st centurymostly in developing countries. Cigarette consumption in the Eastern Mediterranean and African WHO regions actually increased by 65 and 52 percent respectivelybetween 1980 and 2016.

But if we look at what has happened in the US, we know that these trends can change. From 42.6 percent to 9.9 percent, in 60 years. Eight million lives saved. It’s the kind of progress that’s so gradual you barely notice it’s happening. And then you look at the numbers, and they’re incredible.

The ashtrays are now gone from the armrests. The smoking sections are away from the restaurants. The yellowish ceilings have been painted over. Most Americans under 30 have probably never seen someone light a cigarette indoors. And the world they live in is measurably, dramatically safer because of decisions made — over decades, against long odds — before most of them were born. That’s what progress looks like.

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