Tobacco use is still the leading underlying cause of death in the United States and worldwide. Smoking prevalence in the United States is declining, albeit slowly. Smoking-cessation counseling and treatment are effective clinical interventions, but public health interventions, including raising tobacco taxes, expanding smoke-free public places, running hard-hitting antitobacco advertising campaigns, reducing images of smoking in movies and television, and increasing the purchase age to 21 years, can reduce smoking rates much more. In its first 3 years, the “Tips from Former Smokers” advertising campaign from the Centers for Disease Control and Prevention helped at least 300,000 smokers quit and saved at least 50,000 lives, at a cost of less than $500 per smoker who quit, less than $400 per year of life saved, and less than $3,000 per life saved.29 Regulation of the toxicity and addictiveness of combustible tobacco holds promise for reducing the harms of tobacco but faces certain opposition from the tobacco industry.

Improved cardiovascular care, particularly better blood-pressure control, can save far more lives than any other clinical intervention but will require substantial improvement at the fourth level of the pyramid. Better implementation of the “ABCS” — daily aspirin use for people at high risk, blood-pressure control, cholesterol management, and smoking cessation — could save 100,000 lives yearly in the United States if rates of clinical service utilization increase to those achieved by high-performing systems.7 Every 10% increase in the number of people effectively treated for hypertension would lead to prevention of an additional 14,000 deaths — a greater impact than that of any other intervention studied.7 Nationally, just over half of adults with hypertension have it under control, up from slightly over 40% 15 years ago.30,31 But health systems such as Kaiser Permanente Northern California32 and communities such as Minneapolis–St. Paul33 have increased control rates to 70 to 80%.

Some of the highest-performing U.S. health systems — Geisinger,34 North Shore,35 and others — examined data from electronic health records and found that nearly a third of people with multiple elevated readings were never told that they had high blood pressure, much less had it treated. Investigators identified and treated patients with elevated blood-pressure readings and created automated reminders to find and treat patients who would not otherwise be included in the denominator for clinical quality measures.36

High sodium intake is a leading contributor to hypertension, and Americans consume an average of 3500 mg of sodium per day, far more than recommended. Reducing average sodium intake by a third could save up to half a million lives and nearly $100 billion in health care costs over the next 10 years.37,38 Because the sodium content of most processed and restaurant foods puts reducing intake beyond personal or clinical reach,39 action is needed at the societal level, such as working with food manufacturers and restaurants to steadily reduce sodium content.

In the United Kingdom, industry initially resisted government calls to voluntarily reduce sodium content but then reduced sodium levels in many food categories by 14 to 36% in 2 to 3 years — achieving a 20% reduction in bread between 2001 and 2011 and a 57% reduction in breakfast cereals between 2004 and 2011.40 Average British sodium intake fell by 15% between 2003 and 2011, and there was a substantial reduction in average blood pressure, a 40% drop in the number of deaths from heart attacks, and a 42% decrease in deaths from stroke, with reduced sodium intake estimated to account for a quarter to a third of the mortality reduction.41

Although the rapid increases seen in obesity since the 1970s appear to have leveled off, obesity and overweight continue to be serious problems in the United States.42 Increasing physical activity and improving nutrition are keys to obesity prevention and control, and policies that change the environment to make healthful eating and regular physical activity easier, safer, and more attractive are likely to be most effective.43