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In his first Guest Editorial for CA as newly elected President of the American Cancer Society, Dr. Dileep Bal moves beyond the encouraging trends reported in the annual cancer statistics article to target areas for future efforts and improvement. Noting that resources and the public health activities of local, regional, and national medical communities should focus on cancer prevention, screening and early detection/treatment, technology transfer, and research, Dr. Bal emphasizes the feasibility of the 2015 goals set by the ACS: A 25% reduction in cancer incidence and a 50% reduction in mortality from cancer.

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One of every three persons who starts smoking falls ill and dies prematurely because he or she smoked. Smoking has been causally linked to heart disease, cancer, and respiratory diseases and continues to be the number one preventable cause of death in this country. To prevent these deaths and the incidence of these diseases, California's Tobacco Control Program was established in 1989 specifically to reduce tobacco use in the state. The strategy of the program is to "denormalize" tobacco. This strategy emphasizes three areas of programmatic activity: to counter pro-tobacco influences, to reduce exposure to environmental tobacco smoke, and to reduce access to tobacco products, with a focus on both social and commercial sources. A fourth priority area, cessation, is considered more of an outcome. California's Tobacco Control Program has touched the life of every Californian. Adult smoking prevalence in the state has gone from approximately 11% lower than the rest of the nation in 1988 to 20% lower in 1996. There are now approximately one million fewer smokers in California than would have been expected. Overall, per capita cigarette consumption has fallen by more than 50%. Seventy percent of adult smokers reported that they tried to quit in the last year. Exposure to secondhand smoke has plummeted. California's lung and bronchus cancer incidence is already declining at a significantly higher rate than that seen elsewhere in the nation. Youth smoking rates have also declined significantly. However, contrary to the message of its massive public relations campaign, the tobacco industry has not changed its stripes after the national tobacco settlement. They are still aggressively marketing their products to teenagers, ethnic minority groups, and young adults. They need to be combatted with renewed vigor by a vigilant health community.

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BACKGROUND: Cancer incidence and mortality rates both began to decline in the U. S. in the early 1990s. Recognizing the unprecedented potential benefits of accelerating this decline, the American Cancer Society (ACS) has set ambitious challenge goals for the American public for a 25% reduction in cancer incidence rates and a 50% reduction in cancer mortality rates by the year 2015. This analysis examined the feasibility of reaching those goals by estimating future changes in cancer rates that can result from past and future reductions in cancer risk factors. METHODS: Estimates for future declines in cancer risk factors in the U. S. under alternative scenarios were applied to conservative population-attributable risk estimates for cancer incidence and mortality rates in 1990 to estimate cancer rate trends in the year 2015. RESULTS: If the current trends toward a decline in the prevalence of cancer risk factors continue over the next decade, by the year 2015 one can expect a 13% decline in cancer incidence rates and a 21% decline in cancer mortality rates below their 1990 levels. With redoubled efforts to reduce the prevalence of known cancer risk factors further, by the year 2015 cancer incidence rates could be reduced by 19% and cancer mortality rates reduced by 29%. Such redoubled efforts would equate to approximately 100,000 cancer cases and 60,000 cancer deaths prevented each year by the year 2015. CONCLUSIONS: Past reductions in cancer risk factors in the U.S. population have led to recent declines in the rates of cancer incidence and mortality in the U.S. Redoubled efforts to act on current knowledge regarding how to prevent, detect, and treat cancer can result in attaining approximately 80% of the ACS challenge goal for cancer incidence rates and 60% of the ACS challenge goal for cancer mortality rates by the year 2015. New findings from cancer research are needed and will have to be applied quickly if the ACS challenge goals are to be met fully.

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In this report, the author traces the history of the development of the first statewide tobacco control program, from its early obstacles and legislative-imposed deadline through the development of its three priority areas. Woven into this review is Dr. Bal's emphasis on the role of a cohesive leadership tied into the needs of the tobacco control constituency.

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The future holds great promise for translating advances in cancer control research to populations at risk-much is known about how to prevent cancer. Within the Institute of Medicines overall framework of assessment, policy development, and assurance, this article summarizes 10 cancer control priorities. Important themes include evaluation, cost-effectiveness analysis, shrinking the "latency period" between elucidation of preventive technologies and widespread application, coalition building, and development of adequate cancer control resources. Despite increased cancer control efforts among public health agencies over the past decade, little measurable progress has been made in reducing overall cancer mortality. A renewed commitment to controlling cancer is needed from health policy makers and even the public health community.

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The annual toll of diet-related diseases in the United States is similar to that taken by tobacco, but less progress has been achieved in reaching the Public Health Service's Healthy People 2000 objectives for improving food consumption than for reducing tobacco use. In 1988, the California Department of Health Services embarked upon an innovative multi-year social marketing program to increase fruit and vegetable consumption. The 5 a Day--for Better Health! Campaign had several distinctive features, including its simple, positive, behavior-specific message to eat 5 servings of fruits and vegetables every day as part of a low-fat, high fiber diet; its use of mass media; its partnership between the state health department and the produce and supermarket industries; and its extensive use of point-of-purchase messages. Over its nearly three years of operation in California, the 5 a Day Campaign appears to have raised public awareness that fruits and vegetables help reduce cancer risk, increased fruit and vegetable consumption in major population segments, and created an ongoing partnership between public health and agribusiness that has allowed extension of the campaign to other population segments, namely children and Latino adults. In 1991 the campaign was adopted as a national initiative by the National Cancer Institute and the Produce for Better Health Foundation. By 1994, over 700 industry organizations and 48 states, territories, and the District of Columbia were licensed to participate. Preventive medicine practitioners and others involved in health promotion may build upon the 5 a Day Campaign experience in developing and implementing efforts to reach the nation's dietary goals.

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OBJECTIVES: In the face of rising costs of surveillance systems, it is time to reexamine the feasibility of including proxy respondents in surveys designed to provide population estimates of smoking prevalence. METHODS: Data are from the California. Tobacco Surveys, which are random-digit dialed telephone surveys. One adult provided demographic information and smoking status for all household residents. Additionally, some adults were selected for in-depth interviews that also included smoking status questions. We matched information from proxy respondents and self-respondents and evaluated smoking status discrepancies between them relative to demographic and other factors (n = 2930 matched pairs) in 1992. We address the potential bias these discrepancies might introduce into the population estimate of smoking prevalence. RESULTS: Overall, the discrepancy between proxy report and self-report was 4.3%, and it increased particularly when the self-respondent reported nondaily smoking or recent quitting. Discrepancies acted in both directions, and the net bias was that the screener survey overestimated smoking prevalence by 0.1% in 1992 (0.3% in 1990). CONCLUSIONS: Smoking status questions can be added to ongoing surveys such as the census or labor force surveys; one adult could provide smoking status for all household members.

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Government action and the advocacy activities that influence it are as important a concern for cancer control as they are for any other public issue. Policy advocacy strategies have proven themselves effective in cancer prevention efforts involving tobacco use and nutrition. Much of what has been learned from this experience can be applied with great effect in advocacy efforts for other cancer control measures. The implementation of Proposition 99, the 1988 tobacco tax initiative in California, illustrates the effectiveness of aggressive policy advocacy strategies such as provocative paid advertising, mobilization through coalitions, and community-level public relations, to bring about government action at all levels of government and in the private sector. Today, largely as a result of these activities, more than 70 of California's 471 cities have a 100% smokefree workplace and/or a 100% smokefree restaurant ordinance, and nearly 300 cities currently have ordinances that restrict smoking pollution and/or restrict youth access to cigarette vending machines. About 150 cities have ordinances that were either adopted or greatly strengthened since 1990 when the program hit the streets. Ironically, although the primary aim of these strategies has been to reduce uptake of tobacco use by adolescents, the program's gains so far--including the reduction in adult smoking prevalence from 26% in 1988 to 20% in 1993, for an estimated savings in 1993 alone of $386 million in direct medical costs in the state--have been the result of adult smokers quitting, especially those older than 50.

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We examined the association between ethnicity and cigarette smoking beliefs and behavior in a 1990 random-digit dialing telephone survey of 3,164 Hispanic and 17,975 non-Hispanic white adults in California. Ethnic self-identification and native language were associated with the prevalence of current smoking in women but not in men. However, both male and female Hispanics smoked fewer cigarettes per day than their non-Hispanic counterparts. Hispanics who reported smoking in the past 12 months were more likely than non-Hispanics to have reached the action stage of cessation and to report an attempt to quit smoking. Spanish-speaking Hispanics were most likely to believe in the harmful effects of smoking, but also most likely to believe that smoking was not addictive, that they were not addicted to cigarettes, and that smoking is something everyone should try once. Cessation and prevention programs that target Hispanic populations must be especially sensitive to values and gender-specific acculturation processes that create a discrepancy between the desire to adopt the lifestyles of the dominant society and the recognition of the concomitant health-related risks.

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BACKGROUND: Two-thirds of cancer cases are associated with two lifestyle practices: 35% with the typical American diet, and 30% with tobacco use. In contrast to the field of tobacco control, research and resources dedicated to the field of nutrition have been limited, in part because dietary change has been considered controversial and requires a more complex set of interventions. METHODS: This series of papers reviews the science base underlying diet as a cancer control strategy, including research about diet-cancer relationships, current nutrition policy recommendations, American dietary trends, models of dietary behavior change, and diet in health care delivery. The history of technology transfer of new knowledge into widespread application will be compared and contrasted with other cancer control measures. RESULTS: There is scientific and policy agreement about three priority dietary goals for the year 2000: increase fruit and vegetable consumption to 5 or more servings every day, increase breads, cereals, and legumes to 6 or more servings daily, and decrease fat to no more than 30% of total calories. Current data do not indicate that these goals will be reached. As yet there is no organized effort, with clearly identified steps, to translate research into practice. The parallel with delays in implementing other cancer control measures, including Papanicolaou testing, mammography, and tobacco intervention, is striking. CONCLUSION: Without resources dedicated to dietary modification in the general population, it is not likely that the potential savings of more than 300,000 new cases, 160,000 deaths, and the $25 billion in associated costs will be realized in the foreseeable future.

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As part of an evaluation of the 1990-91 anti-tobacco media campaign carried out by the California Department of Health Services, a study was conducted among 417 regular smokers who had quit during the period of the media campaign. In brief telephone interviews, all respondents identified up to three events or experiences that had influenced them to quit. In response to uncued questions, 6.7 percent of those interviewed indicated that they had been influenced to quit by an advertisement they had seen or heard on radio, television, or billboards. In response to direct questions about the media campaign, 34.3 percent of the respondents indicated that the media campaign's advertisement had played a part in their decision to quit. Applying the 6.7 percentage to the number of Californians who quit smoking in 1990-91, it can be estimated that for 33,000 former smokers, the anti-tobacco media advertisements were an important stimulus in their quit decision. Multiplying the 34.3 percent by the number of former California smokers who quit in 1990-91, the estimate of former smokers for whom the media campaign's advertisements played at least some part in their decision to quit rises to 173,000 persons. While causal attributions from such investigations should be made with caution, the evidence suggests that the 1990-91 campaign did influence substantial number of smokers in California to quit.

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We employed a time series design to evaluate the impact of the 1989 California cigarette tax increase on cigarette consumption in California. Adult per capita consumption data from 1980 to 1990 were analyzed for California and the United States. Trend data indicated a sharp drop in California cigarette consumption coincident with the tax increase. Time-series regression analyses support this observation, and suggest that a 5% to 7% decline in consumption is attributable to the tax increase.

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