Back in 1964, 42% of American adults smoked tobacco. That same year, the U.S. Surgeon General’s office issued a landmark report about the link between smoking and lung cancer. Since then, there have been 31 additional reports from various Surgeons General, each adding more insight into the health hazards of smoking. In that time, the percentage of adult smokers has been cut by more than half to 18%, but the latest report says people aren’t quitting fast enough.

A massive new report [PDF] from Acting Surgeon General Boris Lushniak cautions that the percentage of adult smokers has begun to plateau in recent years, and that the “burden of smoking-attributable mortality is expected to remain at high and unacceptable levels for decades to come unless urgent action is taken.”

In spite of 50 years of anti-smoking campaigns and the dramatic drop in the number of adult smokers, smoking remains the leading preventable cause of disease and premature death in the U.S., with some 480,000 people dying each year from smoking-related illnesses. More than 20 million preventable deaths have been attributed to smoking since the first Surgeon General’s report in 1964.

Of particular concern are the number of younger Americans who use multiple tobacco products, including electronic cigarettes. Between 2011 and 2012, the number of middle and high school students using e-cigs more than doubled.

“Each day, more than 3,200 youth (younger than 18 years of age) smoke their first cigarette and another 2,100 youth and young adults who are occasional smokers progress to become daily smokers,” reads the report.

“Although the prevalence of smoking has declined significantly over the past one-half century, the risks for smoking-related disease and mortality have not,” writes Lushniak. “In fact, today’s cigarette smokers—both men and women—have a much higher risk for lung cancer and chronic obstructive pulmonary disease (COPD) than smokers in 1964, despite smoking fewer cigarettes.”

Each year, $130 billion is spent on direct medical care of adults who smoke, while over the economy waves goodbye to $150 billion in lost productivity due to premature death, concludes the report.

The Surgeon General writes that for every adult smoker who dies of smoking-related illnesses, there are two youth and young adult smokers who start. With the slowdown in the number of people quitting, Leshniak expresses doubt that the U.S. will meet the goal of only 12% of adults smoking by 2020.

He puts the blame for the slowdown on the tobacco industry.

“The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risk of smoking cigarettes,” reads the report.

Leshniak says that it’s time to get tough on tobacco regulation, meaning everything from raising the price on tobacco products to media campaigns about the dangers of smoking to making cessation programs accessible to more Americans.

“Enough is enough,” said the Acting Surgeon General at a press conference about the new report. “It’s astonishing that so many years later we’re still making these findings.”

“It is my sincere hope that 50 years from now we won’t need another Surgeon General’s report on smoking and health,” writes Lushniak, “because tobacco-related disease and death will be a thing of the past.”

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