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32 CHAPTER 2 ■ Reducing Tobacco Use in the United States

also possesses several territories in the Caribbean and Pacific. At 3.8 million square
miles (9.83 million square kilometers) and with more than 300 million people
(BBC News, 2008), the United States is the third largest country in the world, by
land area and by population. The major religion is Christianity, and it is one of the
world’s most ethnically diverse nations, the product of large-scale immigration
from many countries. In terms of gross national product (GNP), it is the largest
national economy in the world (BBC News, 2008).
The United States is fundamentally structured as a representative democracy,
and the federal government is composed of three branches: legislative, executive,
and judiciary. Politics in the United States have operated under a two-party system
(currently, the Democratic and Republican parties) for virtually all of the country’s
history. The greatest challenges facing the country (judging by the 2008 presiden-
tial debates) include the war in Iraq, the economy, illegal immigration, health care,
education, and the environment.
Life expectancy in the United States is 76 years for men and 81 years for
women (BBC News, 2008). The following 10 current leading health indicators re-
flect the major public health concerns in the United States, chosen based on their
ability to motivate action, the availability of data to measure their progress, and
their relevance as broad public health issues: physical activity; overweight and obe-
sity; tobacco use; substance abuse; responsible sexual behavior; mental health; injury
and violence; environmental quality; immunization; and access to health care. Goals
for each of these indicators have been established for 2010 and are used to help
measure the health of the nation (Healthy People 2010, 2005).

The Tobacco Problem in the United States

Tobacco use is the single most preventable cause of death and disease in the United
States. An estimated 21% of adults (45.3 million; CDC, 2007), 20% of high school
students, and 6% of middle school students smoke cigarettes (CDC, 2009). Annually,
cigarette smoking causes approximately 440,000 deaths, and for every person who dies
from tobacco use, another 20 suffer with at least one serious tobacco-related illness
(CDC, 2008). Astoundingly, approximately one in every five deaths in the United
States is smoking related, accounting for more deaths than those from AIDS, alcohol
use, cocaine use, heroin use, homicides, suicides, motor vehicle crashes, and fires com-
bined (IOM, 2007).
And then there are economic costs. Estimates are that this addiction costs the
nation more than $96 billion per year in direct medical expenses as well as more
than $97 billion annually in lost productivity. Furthermore, there are the effects of
exposure to secondhand smoke, costing the United States an additional $10 billion
per year (CDC, 2008).