Thirty-eight percent fewer Americans smoke today than 20 years ago, but 129% more are obese, which threatens to cost the U.S. health system hundreds of billions of dollars in the upcoming decade, according to a new public health report. "There is a tsunami of chronic preventable disease about to be unleashed into the American health care delivery system," said Reed V. Tuckson, MD, executive vice president at the insurer UnitedHealth Group. Public education, taxes and restrictions on smoking appear to be working. More than 3 million Americans quit since 2008, reducing the nation's smoking rate to 18.3%, a decrease of 1.5 percentage points. The 1990 rate was 29.5%, according to the 20th anniversary edition of "America's Health Rankings," released Nov. 17 by the UnitedHealth Foundation, the American Public Health Assn. and the Partnership for Prevention. However, 26.6% of Americans are obese, up from 26.3% in 2008. If trends continue, the nation will spend an estimated $344 billion in obesity-related health care costs in 2018, up from $80 billion in 2009, according to a supplemental analysis by Kenneth Thorpe, PhD. He's chair of the Dept. of Health Policy and Management at the Rollins School of Public Health at Emory University. In the early 1960s, "when the surgeon general, Dr. Luther Terry, first talked about the danger of tobacco, he left a smoke-filled room," said Georges C. Benjamin, MD, director of the American Public Health Assn. Americans changed the acceptability of smoking over the years, but now they urgently need to prioritize preventive care and find nonclinical ways to improve people's health, he said. "We cannot manage our way out of the health care crisis until we manage our way by reducing the demand," Dr. Benjamin said. Of the $2.4 trillion in national health spending, $1.8 trillion is associated with treating chronic diseases such as diabetes, heart disease and cancer, according to America's Health Rankings. U.S. trends affecting health have been mixed in the last two decades, the report found. Rates have improved for infectious diseases, violent crime, childhood poverty, infant mortality and air pollution. Rates of people lacking health insurance, graduating from high school and accessing prenatal care have stagnated or worsened. Vermont is the nation's healthiest state, up from 4th in 2008. Mississippi remained at the bottom of the rankings for the eighth straight year. America's Health Rankings began in 1990 as a measure of the relative health of state populations based on 16 criteria. The report, now with 22 measures, is available online ( The full and original article can be found here: