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Acting Surgeon General Boris Lushniak is the latest in a long line of surgeons general who have tried to pound the final nails into the coffin of America's smoking habit.
Smoking's persistence isn't for lack of evidence about the harms it causes. The latest report, which tops 900 pages, contains an impressive list of disorders newly deemed to be caused by smoking. They include diabetes, facial deformities in babies born to smoking mothers, liver and colorectal cancer, age-related macular degeneration, ectopic pregnancy, rheumatoid arthritis and erectile dysfunction, to name a few.
The newly recognized harms aren't limited to smokers. Secondhand smoke raises the risk of stroke by up to 30 percent.
"Smoking really is even worse than we knew," Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, tells Shots. Half of all long-term smokers will die from a smoking-related disease, with the annual toll now about 480,000 people.
Frieden says smoking is more lethal than it used to be. "Even though the Americans who smoke are smoking fewer cigarettes, the risk of dying among smokers is increasing," he notes, quoting the new report.
The trend is striking. Between 1959 and 2010, the risk of lung cancer among women jumped from about three times that of those who never smoked to 26 times. Among men who smoke, the lung cancer rate more than doubled, from 12 times to 25 times the risk of never-smokers.
The CDC says changes in cigarette design and composition since the 1950s have shifted the pattern of lung cancers from a type called squamous cell carcinomas to adenocarcinomas. That's one reason why smoking has become more deadly.
"However, the pattern of changes in risk and death rates in other diseases caused by smoking make it difficult to sort out what specific aspects of smoking are most responsible for increased risk of dying prematurely due to smoking," CDC spokesman Joel London writes in an email.
Whatever the reason, the report conveys a new sense of urgency.
"If we don't act now," Frieden says, "5.6 million of our children will be killed by tobacco," based on current rates of smoking among adolescents and young adults. And 3 1/2 million children in middle and high school now smoke, according to the new report; 3,200 youths start smoking every day.
About 43 million U.S. adults are smokers, or 18 percent. That's progress compared with 42 percent at the time of the first surgeon general's report in 1964, but it's not going down fast enough to meet a 2020 goal of 12 percent.
Many of the anti-smoking actions proposed in the report are familiar: raise cigarette taxes, fund more public education, increase the legal age for buying cigarettes from 18 to 21.
But there's one new wrinkle. Behavioral psychologist David Abrams says this report makes a significant distinction between the harmfulness of burning tobacco and less harmful ways of delivering the nicotine that keeps people addicted.
The report concludes that "cigarettes and other combusted tobacco products" should be eliminated.
"That is new because it implies that less harmful forms of getting one's nicotine — especially if one cannot quit smoking cigarettes — may be acceptable," Abrams tells Shots.
E-cigarettes are electronic cigarettelike devices that don't burn tobacco. They release nicotine in a vapor that doesn't contain the toxic chemicals that cause most of smoking's harm.
Abrams helped write the report's last chapter on "the changing landscape of tobacco control." He works for Legacy for Health, an anti-tobacco group set up as part of a 1998 legal settlement with the tobacco industry.
Abrams thinks e-cigarettes could help wean millions away from cigarettes. "For the first time in a century," he says, "we have an appealing alternative way to give addicted current smokers a satisfying way to give up their combusted products."
He calls this a harm-reduction strategy that would be a big change from the total-abstinence approach of current tobacco control efforts. It's sort of like condoms or clean-needle exchanges to prevent HIV infection.
And it promises to be equally controversial.
The CDC's Frieden, for one, is a skeptic. "It might be possible that things like e-cigarettes in the future will have a positive role," he says. "As they're being rolled out now, I have grave concerns that they're doing more harm than good."