"Enough is enough," acting Surgeon General Borish Lushniak declared at a White House ceremony unveiling the 980-page report that urges new resolve to make the next generation a smoke-free generation.
"The clock is ticking," Lushniak said. "We can't wait another 50 years."
On the 50th anniversary of the landmark 1964 surgeon general's report that launched the anti-smoking movement, far fewer Americans are smoking - about 18 percent of adults today, down from more than 42 percent in 1964.
But the government may not meet its goal of dropping that rate to 12 percent by 2020, the new report cautions.
Nearly half a million people will die from smoking-related diseases this year. Each day, more than 3,200 youths smoke their first cigarette. New products such as e-cigarettes, with effects that aren't yet understood, complicate public health messages.
And if current trends continue unabated, 5.6 million of today's children and teens will go on to die prematurely during adulthood because of smoking, the report says.
What's particularly remarkable is that 50 years into the war on smoking, "we're still finding out new ways that tobacco maims and kills people," added Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention. "Tobacco is even worse than we knew it was."
Lung cancer and heart disease have long been known to be the top causes of death for smokers. Friday's report adds more entries to the official list of smoking-caused diseases, many of them costly chronic illnesses that people struggle with for years. Included are Type 2 diabetes, rheumatoid arthritis, erectile dysfunction, the macular degeneration that can blind older adults, and the birth defects cleft palate and cleft lip. Also new to the list are two additional cancers - liver and colorectal.
Smoking is costing the nation nearly $300 billion in medical bills, lost productivity and other costs, officials said. Yet Frieden said states are spending less than $1.50 a person on tobacco control each year when they should be spending about $12 a person.
The report urges increased use of proven tobacco-control measures, including price hikes for cigarettes and expanding comprehensive indoor-smoking bans that currently cover about half the population.
The report also encourages research into newer ideas, such as whether lowering the amount of addictive nicotine in cigarettes would help people quit.
Here are some ways the smoking landscape has changed between the 1964 surgeon general's report and Friday's:
1964: The surgeon general declares that cigarette smoking increases deaths.
2014: About 20.8 million people in the U.S. have died from smoking-related diseases since then, a toll the report puts at 10 times the number of Americans who have died in all of the nation's wars combined. Most were smokers or former smokers, but nearly 2.5 million died from heart disease or lung cancer caused by secondhand smoke.
1964: Heavy smoking is declared the main cause of lung cancer, at least in men. "The data for women, though less extensive, point in the same direction."
2014: Today, lung cancer is the top cancer killer, and women who smoke have about the same risk of dying from it as men. As smoking has declined, rates of new lung cancer diagnoses are declining nearly 3 percent a year among men and about 1 percent a year among women.
1964: Male smokers were dying of heart disease more than nonsmokers, but the surgeon general stopped short of declaring cigarettes a cause of heart disease.
2014: Today, heart disease actually claims more lives of smokers 35 and older than lung cancer does. Likewise, secondhand smoke is riskier for your heart. Smoke-free laws have been linked to reductions in heart attacks. Friday's surgeon general report also finds that secondhand smoke increases the risk of a stroke.
1964: Smoking in pregnancy results in low-birth-weight babies.
2014: Friday's report says 100,000 of the smoking-caused deaths over the past 20 years were of babies who died of sudden infant death syndrome, or SIDS, or complications from prematurity, low birth weight or other conditions related to parents' smoking. And it adds cleft palate birth defects to that list of smoking risks to babies.
1964: The more you smoke, the bigger the risk of death.
2014: Smokers are estimated to shorten their lives by more than a decade. But stopping can lower that risk; sooner is better.
1964: That first report focused mostly on lung effects and couldn't prove whether certain other illnesses were caused by smoking.
2014: Doctors now know that smoking impacts nearly every organ of the body, and Friday's report says medical care for smoking-caused illnesses is costing the country more than $130 billion a year. Add to that lost productivity of more than $150 billion a year.
1964: Cigarettes were the major concern. "The habitual use of tobacco is related primarily to psychological and social drives, reinforced and perpetuated by pharmacological (drug) actions of nicotine."
2014: "The tobacco industry continues to introduce and market new products that establish and maintain nicotine addiction," Friday's report says. The percentage of middle and high school students who use electronic or e-cigarettes more than doubled between 2011 and 2012.
1964: That first report called for "remedial actions" to reduce smoking. Warning labels on cigarette packaging started appearing a year later.
2014: With warnings now everywhere, Friday's report says, "We know that increasing the cost of cigarettes is one of the most powerful interventions we can make." In 2012, the average price of a pack of cigarettes was $6, largely reflecting an increase in state and federal taxes. For every 10 percent increase in the price, there's a 4 percent drop in smoking.