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ABSTRACT The ultimate goal of the committee is to end the tobacco problem; in other words, to reduce smoking so substantially that it is no longer a significant public health problem for our nation. While that objective is not likely to be achieved soon, the report aims to set the nation irreversibly on a course for doing so. After reviewing the ethical grounding of tobacco control, the committee sets forth a blueprint as a two-pronged strategy. The first prong envisions strengthening and fully implementing traditional tobacco control measures known to be effective. The second prong envisions changing the regulatory landscape to permit policy innovations that take into account the unique history and characteristics of tobacco use, such as strong federal regulation of tobacco products and their marketing and distribution. Aggressive policy initiatives will be necessary to end the tobacco problem. Any slackening of the public health response may reverse decades of progress in reducing tobacco-related disease and death.

The substantial decline (58.2 percent) in the prevalence of smoking among adults since 1964 has been characterized as one of the 10 greatest achievements in public health in the 20th century, but today about 21 percent of U.S. adults smoke, despite clear evidence of the numerous health, economic, and social consequences associated with tobacco use.

Tobacco use causes 440,000 deaths in the United States every year (CDC 2005), with secondhand smoke responsible for 50,000 of those



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Ending the Tobacco Problem: A Blueprint for the Nation Summary ABSTRACT The ultimate goal of the committee is to end the tobacco problem; in other words, to reduce smoking so substantially that it is no longer a significant public health problem for our nation. While that objective is not likely to be achieved soon, the report aims to set the nation irreversibly on a course for doing so. After reviewing the ethical grounding of tobacco control, the committee sets forth a blueprint as a two-pronged strategy. The first prong envisions strengthening and fully implementing traditional tobacco control measures known to be effective. The second prong envisions changing the regulatory landscape to permit policy innovations that take into account the unique history and characteristics of tobacco use, such as strong federal regulation of tobacco products and their marketing and distribution. Aggressive policy initiatives will be necessary to end the tobacco problem. Any slackening of the public health response may reverse decades of progress in reducing tobacco-related disease and death. The substantial decline (58.2 percent) in the prevalence of smoking among adults since 1964 has been characterized as one of the 10 greatest achievements in public health in the 20th century, but today about 21 percent of U.S. adults smoke, despite clear evidence of the numerous health, economic, and social consequences associated with tobacco use. Tobacco use causes 440,000 deaths in the United States every year (CDC 2005), with secondhand smoke responsible for 50,000 of those

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Ending the Tobacco Problem: A Blueprint for the Nation deaths (DHHS 2006). All told, deaths associated with smoking account for more deaths than AIDS, alcohol use, cocaine use, heroin use, homicides, suicides, motor vehicle crashes, and fires combined. The economic consequences of tobacco use are in the billions of dollars. Lost work productivity attributable to death from tobacco use amounts to more than $92 billion per year. Private and public health care expenditures for smoking-related health conditions are estimated to be $89 billion per year. In addition, the states and the federal government spend millions of dollars annually on tobacco use prevention and research efforts that could be directed to other needs. Concerns about the waning momentum in tobacco control efforts and about declining public attention to what remains the nation’s largest public health problem led the American Legacy Foundation to ask the Institute of Medicine (IOM) to conduct a major study of tobacco policy in the United States. The IOM appointed a 14-member committee and charged it to explore the benefits to society of fully implementing effective tobacco control interventions and policies, and to develop a blueprint for the nation in the struggle to reduce tobacco use. To carry out its charge, the committee conducted six meetings in which the committee members heard presentations from individuals representing academia, nonprofit organizations, and various state governments. The committee also reviewed an extensive literature from peer-reviewed journals, published reports, and news articles. The background information and supporting evidence for the committee’s report are contained within 16 signed appendixes written by committee members and three commissioned papers written by outside researchers. The committee found it useful to set some boundaries on its work concerning the goal (“reducing tobacco use”) and the time frame within which it should be achieved. To make its task manageable and well-focused, the committee decided to focus its literature review and evidence gathering on reducing cigarette smoking, without meaning to overlook or dismiss the health consequences of other forms of tobacco use. However, the committee believes that its recommendations, although derived from the evidence regarding interventions to reduce cigarette smoking, are fully applicable to smoking of other tobacco products and that most of the recommendations are also applicable to smokeless tobacco products. First of all, trends in smokeless use and cigarette use tend to move in tandem, suggesting that the population-level factors at work at any given time are affecting all forms of tobacco use. Although some smokers may switch to smokeless tobacco as a “risk-reducing” tactic, thereby offsetting some of the gains from smoking cessation, successful efforts to curtail smoking initiation do not appear to be compromised by increased initiation of smokeless use. Second, the committee believes that most of the interventions shown to be effective for

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Ending the Tobacco Problem: A Blueprint for the Nation smoking (cessation, health-based interventions, school-based interventions, media efforts, sales restrictions, marketing restrictions) can be implemented in behavior-specific or product-specific manner, and that there is no apparent reason why their effectiveness would be weakened in relation to use of smokeless products if they were sensitively designed. Overall, therefore, the committee believes that it is reasonable to assume that implementation of its blueprint will, in the aggregate, lead to a reduction in all forms of tobacco use. Thus the committee refers throughout the report to the goal of “reducing tobacco use.” The overarching goal of reducing smoking subsumes three distinct goals: reducing the rate of initiation of smoking among youth (IOM 1994), reducing third-party environmental tobacco smoke exposure (NRC 1986), and helping people quit smoking. For the purposes of this report, the committee sets to one side additional strategies that might reduce the harm of smoking for smokers who cannot quit, a topic dealt with extensively in another recent IOM report (IOM 2001). Another important question regarding the scope of the committee’s work concerns the time frame. The committee wanted to design a blueprint for achieving substantial reductions in tobacco use, but to have a realistic opportunity for doing so, an ample period of time is needed. Yet, the target should not be so far in the distance as to lose its connection with current conditions or to outstrip the committee’s collective capacity to imagine the future. The committee decided to set a 20-year horizon for its projections and for the policies that it recommends. The common interest of all nations in reducing tobacco use has been declared and effectuated by the World-Health-Organization–sponsored Framework Convention for Tobacco Control, which went into effect in 2005 and has been ratified by 142 nations (unfortunately not including the United States). The United States has a direct stake in reducing smuggling of tobacco products into this country that could undermine domestic tobacco control efforts, and the committee also recognizes the compelling importance of international tobacco control efforts for world health. However, the committee’s charge was to develop a tobacco control blueprint for the nation, not for the world. We hope, though, that some of the measures recommended in this report will provide useful models for other countries, just as the domestic interventions undertaken by other countries in recent years served as useful models for us. In sum, the ultimate goal of the committee’s blueprint is to reduce smoking so substantially that it is no longer a significant public health problem for our nation; this is what is meant by the phrase “ending the tobacco problem” used in the title of this report. While that objective is not likely to be achieved in 20 years, the report aims to set the nation irreversibly on a course for doing so.

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Ending the Tobacco Problem: A Blueprint for the Nation REPORT OVERVIEW The committee’s report is divided into two parts. Part I, comprising Chapters 1 through 3, provides the context for the committee’s proposed policy blueprint. Chapter 1 discusses the extraordinary growth of tobacco use during the first half of the 20th century and its subsequent reversal in 1965 in the wake of the 1964 Surgeon General’s report. This chapter also closely examines recent trends in tobacco use. Chapter 2 summarizes the ways in which the addictive properties of nicotine make it so difficult for people to quit, thereby sustaining tobacco use at high levels, and the factors associated with smoking initiation, especially the failure of adolescents to appreciate the risks and consequences of addiction when they become smokers. Chapter 3 reviews the history of tobacco control and concludes by projecting the likely prevalence of smoking over the next 20 years if current trends remain unchanged or if tobacco control efforts are weakened. Part II of the committee’s report presents a blueprint for reducing tobacco use. After reviewing the ethical grounding of tobacco control in Chapter 4, the committee sets forth its blueprint as a two-pronged strategy. The first prong, presented in Chapter 5, envisions strengthening traditional tobacco control measures that are currently known to be effective. Chapter 5 closes with a projection of the likely effects over the next two decades of implementing the policies outlined in this part of the blueprint. The second prong, described in Chapter 6, envisions changing the regulatory landscape to permit new policy innovations that take into account the unique history and characteristics of tobacco use. Building on the foundation laid in Chapter 6, Chapter 7 briefly explores new frontiers of tobacco control, and urges the federal government to establish the necessary capacity for long-term tobacco policy development. The committee specifically reviews a proposal for gradually reducing the nicotine content of cigarettes. Although the committee acknowledges that this proposal requires further investigation and careful assessment before it is implemented, carrying it out offers a reasonable prospect of substantially curtailing and eliminating the public health burden of tobacco use. Tobacco Use Since 1965 Wide-angle comparisons of measures of smoking behavior between 1965 and 2005 clearly show that the rates of tobacco consumption and smoking prevalence have declined among adults, the rate of smoking initiation has declined among adolescents, and the rate of smoking cessation has increased. However, a closer look at the trends over the past two decades tells a somewhat more complex story of both modest progress and some backsliding. For instance, although smoking prevalence has continued to

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Ending the Tobacco Problem: A Blueprint for the Nation decline in the new millennium, it appears that progress in some areas may now be stalling. Between 1965 and 2005, the percentage of adults who once smoked and who had quit more than doubled from 24.3 to 50.8 percent. Furthermore, the percentage of adults who had never smoked more than 100 lifetime cigarettes increased by approximately 23 percent from 1965 (44 percent) to 2005 (54 percent). Smoking initiation among adolescents and young adults has also declined since the mid-1960s. Among adolescents aged 12 to 17 years, 125.5 of every 1,000 smoked a cigarette for the first time in 1965. In 2003, 102.1 per 1,000 youths in the same age range had smoked a cigarette for the first time. The reduction in smoking initiation saved more than half a million adolescents from having a first cigarette between 1965 and 2004. The steady decline in tobacco use since 1965 can be divided into two phases, the first running from 1965 to about 1980 and the second running from 1980 to the present. During the initial period, there was a sharp decline in smoking prevalence due to reduced initiation and increased cessation, accompanied by a modest increase in the average number of cigarettes smoked per day by smokers. However, since then, the continued decline in smoking prevalence has been accompanied by a substantial decline in cigarettes smoked per day among those who smoke. The committee believes that a substantial portion of the declines in smoking prevalence and smoking intensity over the past 25 years is attributable to tobacco control interventions, especially price increases and the emergence of a strong anti-smoking social norm. Current trends, however, suggest that the annual rate of cessation among smokers remains fairly low, that the decline in the initiation rate may have slowed, and that overall adult prevalence may be flattening out at around 20 percent. These trends suggest that substantial and sustained efforts will be required to further reduce the prevalence of tobacco use and thereby reduce tobacco-related morbidity and mortality. Factors Perpetuating the Tobacco Problem What factors are perpetuating the tobacco problem? First and foremost, tobacco products are highly addictive because they contain nicotine, one of the most addictive substances used by humans. Nicotine addiction stimulates and sustains long-term tobacco use, with all of its serious health hazards and social costs, and poses significant challenges to smoking cessation efforts at both the individual and the population levels. Although an overwhelming majority of smokers (90 percent) regret having begun to smoke, overcoming the grip of addiction and the associated withdrawal symptoms is difficult; most smokers must try quitting several times before

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Ending the Tobacco Problem: A Blueprint for the Nation they are successful. Progress in helping smokers who want to quit achieve successful and permanent cessation requires that a variety of cessation technologies—both clinical and population based—be readily available to the smoking population, and that they be used, and that they be effective. Second, factors such as distorted risk and harm perceptions, which are associated with the initiation and maintenance of tobacco use among young smokers, pose a continuing obstacle for prevention and control strategies. Unfortunately, many youth view themselves as invulnerable to addiction and its associated harm. They are also sensitive to the social factors and norms that promote smoking, such as the influences exerted by peers, family members, and the exposure to smoking in the media. These influences tend to override the information about the risks of smoking. Therefore, to substantially reduce the rate of smoking initiation, it will be necessary to do a better job of counteracting the perceived benefits of smoking and to develop new tools that make the personal risks of starting to smoke more salient. All new smokers are not young, however; some initiate smoking during their college years, which helps to explain why some new smokers have characteristics that differ from those of usual smokers. Specifically, they tend to have higher levels of education and income than other smokers. It is also noteworthy that some new smokers smoke at lower levels, and some never reach a level of dependence. It will be important for tobacco control experts to pay close attention to these emerging trends and to design appropriate interventions to respond to them. On the other side of the ledger are smokers who have a more difficult time quitting, such as “hardcore” smokers with a long career of smoking and individuals with psychiatric comorbidities or special circumstances, including incarceration and homelessness. These groups have not been the primary targets of traditional cessation treatments or research studies. Achieving success in substantially reducing tobacco use will require taking stock of the progress made with current tobacco prevention and control strategies and identifying where they fall short in responding to emerging smoking trends and the characteristics and behaviors of subpopulations of smokers with particular vulnerabilities. The Consequences of Unchanged or Weakened Tobacco Control The committee has tried to project the likely public health consequences of intensified or weakened investments in tobacco control compared with those of the status quo. The good news is that even if tobacco control activities remain at present levels, smoking prevalence is likely to decline from about 21 percent in 2005 to a little less than 16 percent in 2025. This continued decline will occur because of the system’s inertia: there are currently more middle-aged and older smokers than there would have been had their

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Ending the Tobacco Problem: A Blueprint for the Nation birth cohorts passed through the ages of tobacco initiation under higher tobacco prices and stronger tobacco controls. Over time, as those birth cohorts are replaced by aging younger cohorts who had lower rates of initiation, the prevalence of tobacco use will continue to decline. Shortly after 2025, however, the decline in prevalence appears likely to plateau at about 15 percent, well above the Healthy People 2010 target of 12 percent. This steady-state scenario should be compared with a worst-case scenario, based on a weakening of tobacco control policies and programs. If a significant retrenchment occurred, the projected smoking prevalence in 2025 would be about 17 percent, resulting in approximately 4 million more people smoking than would otherwise occur. Although the momentum generated by the last four decades of tobacco control is unlikely to be erased altogether—the model does not take into account new smoking fads, other changes in demand, or industry innovations—these projections do show that a weakened commitment to tobacco control will affect millions of lives. A BLUEPRINT FOR REDUCING TOBACCO USE The committee believes that substantial and enduring reductions in tobacco use cannot be achieved simply by expecting past successes to continue. Continued progress will require the persistence and nimbleness needed to counteract industry innovations in marketing and product design as well as the larger cultural and economic forces that tend to promote and sustain tobacco use. The challenge is heightened by the fact that the customary tools of tobacco control may not be effective in reducing use among some tobacco users. Any slackening of the public health response not only will reduce forward progress but also may lead to backsliding. Over the past 10 to 15 years, the operating assumptions of tobacco control policies in the United States and elsewhere in the world have fundamentally changed. The old paradigm that shaped public opinion and policymaking on tobacco control efforts tended to emphasize consumer freedom of choice and to decry all government intervention as paternalistic. In retrospect, however, the committee believes that these assumptions were rooted in the tobacco industry’s successful efforts to deny and obscure the addictiveness and health consequences of tobacco use and on an array of resulting market failures, including information asymmetry between producers and users, distorted consumer choice due to information deficits, and product pricing that did not reflect the full social costs of tobacco use (especially the effects on nonsmokers). As the scientific evidence about addiction and initiation has grown and the tobacco industry’s strategies have been exposed in the course of state lawsuits and other tobacco-related litigation, public understanding of tobacco addiction has quickly deepened and, as a result, the ethical and political context of tobacco policymaking has been

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Ending the Tobacco Problem: A Blueprint for the Nation transformed. A widespread popular consensus in favor of aggressive policy initiatives is now emerging, and this shift in popular sentiment has also been accompanied by support across most of the political spectrum. From a policy standpoint, many analysts think of the tobacco problem as a product safety problem. In an economic and social system that values freedom of choice, consumers are generally permitted to select products and activities as they see fit. If they want to assume risks, they are permitted to do exactly that. Government does not guarantee absolute safety, nor should it. Of course, some dangers are too high to be acceptable. So long as consumers are properly informed, however, the presumption has traditionally been in favor of consumer sovereignty and freedom of choice. Yet, even most libertarians will admit that the tobacco market has been characterized by severe market failures, as noted above. They acknowledge the legitimacy of interventions aiming to prevent youth smoking, to disseminate accurate information and correct misinformation, and to assure that nonsmokers are protected from involuntary exposure to tobacco smoke if the market does not function properly. The residual issue concerns the legitimacy of interventions that burden the choices of the minority of smokers who do not want to quit. The notion of consumer sovereignty—of unambivalent respect for private choices—runs into serious difficulty when the underlying product creates serious long-term harms and has addictive properties, when its use is usually initiated by young people who lack a full and vivid appreciation of the associated risks, and when most users want to quit. Even in such circumstances, consumer sovereignty should not be abandoned but must be rethought to take account of the unique characteristics of tobacco products. Cigarettes and other tobacco products are not ordinary consumer products. For no other lawful consumer product can it be said that the acknowledged aim of national policy is to suppress consumption. The committee’s major goal here is to set forth a framework for reducing tobacco use, and its associated morbidity and mortality, while being duly respectful of the interests of consumers who choose to smoke and do not want to quit. The committee makes 42 recommendations in the report, 22 regarding ways to strengthen traditional tobacco control measures and 20 regarding the new regulatory landscape. This summary highlights 19 key recommendations that represent the major components of the committee’s blueprint for ending the tobacco problem. A listing of all 42 recommendations organized by chapter can be found at the end of this summary. Strengthening Traditional Tobacco Control Measures The first prong of the committee’s blueprint assumes that the existing legal structure of tobacco control remains unchanged. It envisions steps

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Ending the Tobacco Problem: A Blueprint for the Nation taken to strengthen traditional tobacco control measures that are known to be effective. Support Comprehensive State Tobacco Control Programs The committee finds compelling evidence that comprehensive state tobacco control programs can achieve substantial reductions in tobacco use. To effectively reduce tobacco use, states must maintain over time a comprehensive, integrated tobacco control strategy. However, large budget cutbacks in many states’ tobacco control programs have seriously jeopardized further success. In the committee’s view, states should adopt a funding strategy designed to provide stable support for the level of tobacco control funding recommended by the Centers for Disease Control and Prevention (CDC). The committee also finds that Master Settlement Agreement payments are not a reliable source of funds in most states. Tobacco excise tax revenues pose a potential funding stream for state tobacco control programs. Setting aside about one-third of the per-capita proceeds from tobacco excise taxes would help states fund programs at the level suggested by CDC. Recommendation 1: Each state should fund state tobacco control activities at the level recommended by the CDC. A reasonable target for each state is in the range of $15 to $20 per capita, depending on the state’s population, demography, and prevalence of tobacco use. If it is constitutionally permissible, states should use a statutorily prescribed portion of their tobacco excise tax revenues to fund tobacco control programs. Increase Excise Taxes It is well established that an increase in price decreases cigarette use and that raising tobacco excise taxes is one of the most effective policies for reducing use, especially among adolescents. Many states have increased their tobacco excise taxes, but these increases vary widely and there is some evidence of cross-state smuggling. The committee believes that equalizing tobacco excise tax rates across the states would help remedy this problem. Furthermore, an increase in the federal excise tax would have the dual purposes of reducing consumption and making more funds available for tobacco control programs. Recommendation 2: States with excise tax rates below the level imposed by the top quintile of states should substantially increase their own rates to reduce consumption and to reduce smuggling and tax evasion. State excise tax rates should be indexed to inflation.

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Ending the Tobacco Problem: A Blueprint for the Nation Recommendation 3: The federal government should substantially raise federal tobacco excise taxes, currently set at 39 cents a pack. Federal excise taxes should be indexed to inflation. Strengthen Smoking Restrictions The committee finds that smoking restrictions serve three purposes: (1) they protect nonsmokers from the health effects and the noxious odors of secondhand smoke; (2) they help smokers quit, cut down on their smoking, and avoid relapses; and (3) they reinforce a nonsmoking social norm. Clean air laws have done more to reduce tobacco consumption than any intervention other than cigarette price increases. The committee believes that smoking restrictions are a critical part of any tobacco control strategy. Smoking restrictions should be strengthened and should have broad coverage, including nonresidential indoor locations, health care facilities, correctional facilities, and residential complexes. The committee also believes that local government bans on indoor and outdoor smoking should not be preempted by state laws. Recommendation 4: States and localities should enact complete bans on smoking in all nonresidential indoor locations, including workplaces, malls, restaurants, and bars. States should not preempt local governments from enacting bans more restrictive than the state ban. Limit Youth Access to Tobacco Products A reasonably enforced youth-access restriction is an essential element of modern tobacco control. Age verification, as contained in the 1996 FDA (Food and Drug Administration) Rule, as well as placing product displays behind the counter and banning self-service modes of access to tobacco work effectively to reduce youth access. Although a considerable number of states and localities currently license tobacco sales outlets and impose youth-access restrictions, weak enforcement in many states suggests that the potential deterrent threat of license suspension or revocation is not being realized. Recommendation 11: All states should license retail sales outlets that sell tobacco products. The number of Internet tobacco retailers has increased dramatically in recent years, generating concerns about minors accessing tobacco products and consumers evading excise tax payments. Given the inadequacy of current point-of-sale age verification for Internet transactions and the difficulty

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Ending the Tobacco Problem: A Blueprint for the Nation of policing Internet tobacco transactions, as well as constitutional barriers to additional, state-imposed delivery requirements, the only practical way to effectively regulate online tobacco retailers is through legislation prohibiting both online tobacco sales and direct shipment of tobacco products to consumers. Recommendation 12: All states should ban the sale of tobacco products directly to consumers through mail order or the Internet or other electronic systems. Shipments of tobacco products should be permitted only to licensed wholesale or retail outlets. Intensify Prevention Interventions The most fully developed programs for preventing tobacco use by youth have been implemented in school settings. School-based programs will and should remain the mainstay of group-oriented or individually-oriented tobacco use prevention activities. However, because teenage smoking initiation rates remain high, the committee also believes that investing in programs for families and health care providers is warranted, even though the evidence base remains thin. Furthermore the committee supports the funding of mass media campaigns, which a recent state-of-the-science panel of the National Institutes of Health identified as one of three effective approaches for reaching the general population and preventing tobacco use among adolescents and young adults. Recommendation 13: School boards should require all middle schools and high schools to adopt evidence-based smoking prevention programs and implement them with fidelity. They should coordinate these in-school programs with public activities or mass media programming, or both. Such prevention programs should be conducted annually. State funding for these programs should be supplemented with funding from the U.S. Department of Education under the Safe and Drug-Free School Act or by an independent body administering funds collected from the tobacco industry through excise taxes, court orders, or litigation agreements. Recommendation 15: A national, youth-oriented media campaign should be funded on an ongoing basis as a permanent component of the nation’s strategy to reduce tobacco use. State and community tobacco control programs should supplement the national media campaign with coordinated youth prevention activities. The campaign should be implemented by an established public health organization with funds provided by the federal government, public-private partnerships, or

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Ending the Tobacco Problem: A Blueprint for the Nation federal coordination mechanism affecting the coverage and collection of state tobacco excise taxes applies to Indian tribes. Restrict Advertising and Promotion by Manufacturers The scientific evidence documenting the relationship between exposure to tobacco advertising and tobacco consumption has accumulated, and prevailing scientific opinion is that the relationship is a causal one. Recommendation 35: Congress and state legislatures should enact legislation limiting visually displayed tobacco advertising in all venues, including mass media and at the point-of-sale, to a text-only, black-and-white format. Recommendation 36: Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. If a tobacco company wishes to support youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing, and evaluating the program. CONCLUSION The committee recognizes that important advances in reducing tobacco use have been made over the past two decades. Accordingly, the recommendations offered in Chapter 5 of the report seek to emphasize and strengthen tobacco control interventions that have proven effective over time. If this part of the blueprint is successfully implemented and sustained, it could have a significant impact on tobacco use; but even an optimistic projection leaves prevalence at 10 percent in 2025, and a more realistic projection might be 15 percent. The main argument presented in Chapter 6 is that a more substantial long-term impact requires a change in the current legal framework of tobacco control and the adoption of regulatory innovations that take into account the unique history and characteristics of tobacco. It is too soon to project the effects of such new regulatory initiatives, but the committee believes that a concerted effort to transform the regulatory environment is a necessary condition for ending the tobacco problem in the United States.

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Ending the Tobacco Problem: A Blueprint for the Nation COMPLETE LIST OF RECOMMENDATIONS Strengthening Traditional Tobacco Control Measures Recommendation 1: Each state should fund state tobacco control activities at the level recommended by the CDC. A reasonable target for each state is in the range of $15 to $20 per capita, depending on the state’s population, demography, and prevalence of tobacco use. If it is constitutionally permissible, states should use a statutorily prescribed portion of their tobacco excise tax revenues to fund tobacco control programs. Recommendation 2: States with excise tax rates below the level imposed by the top quintile of states should also substantially increase their own rates to reduce smuggling and tax evasion. State excise tax rates should be indexed to inflation. Recommendation 3: The federal government should substantially raise federal tobacco excise taxes, currently set at 39 cents a pack. Federal excise tax rates should be indexed to inflation. Recommendation 4: States and localities should enact complete bans on smoking in all nonresidential indoor locations, including workplaces, malls, restaurants, and bars. States should not preempt local governments from enacting bans more restrictive than the state ban. Recommendation 5: All health care facilities, including nursing homes, psychiatric hospitals, and medical units in correctional facilities, should meet or exceed JCAHO standards in banning smoking in all indoor areas. Recommendation 6: The American Correctional Association should require through its accreditation standards that all correctional facilities (prisons, jails, and juvenile detention facilities) implement bans on indoor smoking. Recommendation 7: States should enact legislation requiring leases for multiunit apartment buildings and condominium sales agreements to include the terms governing smoking in common areas and residential units. States and localities should also encourage the owners of multiunit apartment buildings and condominium developers to include nonsmoking clauses in these leases and sales agreements and to enforce them.

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Ending the Tobacco Problem: A Blueprint for the Nation Recommendation 8: Colleges and universities should ban smoking in indoor locations, including dormitories, and should consider setting a smoke-free campus as a goal. Further, colleges and universities should ban the promotion of tobacco products on campus and at all campus-sponsored events. Such policies should be monitored and evaluated by oversight committees, such as those associated with the American College Health Association. Recommendation 9: State health agencies, health care professionals, and other interested organizations should undertake strong efforts to encourage parents to make their homes and vehicles smoke free. Recommendation 10: States should not preempt local governments from restricting smoking in outdoor public spaces, such as parks and beaches. Recommendation 11: All states should license retail sales outlets that sell tobacco products. Licensees should be required to (1) verify the date of birth, by means of photographic identification, of any purchaser appearing to be 25 years of age or younger; (2) place cigarettes exclusively behind the counter and sell cigarettes only in a direct face-to-face exchange; and (3) ban the use of self-service displays and vending machines. Repeat violations of laws restricting youth access should be subject to license suspension or revocation. States should not preempt local governments from licensing retail outlets that sell tobacco products. Recommendation 12: All states should ban the sale and shipment of tobacco products directly to consumers through mail order or the Internet or other electronic systems. Shipments of tobacco products should be permitted only to licensed wholesale or retail outlets. Recommendation 13: School boards should require all middle schools and high schools to adopt evidence-based smoking prevention programs and implement them with fidelity. They should coordinate these in-school programs with public activities or mass media programming, or both. Such prevention programs should be conducted annually. State funding for these programs should be supplemented with funding from the U.S. Department of Education under the Safe and Drug-Free School Act or by an independent body administering funds collected from the tobacco industry through excise taxes, court orders, or litigation agreements. Recommendation 14: All physicians, dentists, and other health care providers should screen and educate youth about tobacco use during

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Ending the Tobacco Problem: A Blueprint for the Nation their annual health care visits and any other visit in which a health screening occurs. Physicians should refer youth who smoke to counseling services or smoking cessation programs available in the community. Physicians should also urge parents to keep a smoke-free home and vehicles, to discuss tobacco use with their children, to convey that they expect their children to not use tobacco, and to monitor their children’s tobacco use. Professional societies, including the American Medical Association, the American Nursing Association, the American Academy of Family Physicians, the American College of Physicians, and the American Academy of Pediatrics, should encourage physicians to adopt these practices. Recommendation 15: A national, youth-oriented media campaign should be funded on an ongoing basis as a permanent component of the nation’s strategy to reduce tobacco use. State and community tobacco control programs should supplement the national media campaign with coordinated youth prevention activities. The campaign should be implemented by an established public health organization with funds provided by the federal government, public-private partnerships, or the tobacco industry (voluntarily or under litigation settlement agreements or court orders) for media development, testing, and purchases of advertising time and space. Recommendation 16: State tobacco control agencies should work with health care partners to increase the demand for effective cessation programs and activities through mass media and other general and targeted public education programs. Recommendation 17: Congress should ensure that stable funding is continuously provided to the national quitline network. Recommendation 18: The Secretary of the U.S. Department of Health and Human Services, through the National Cancer Institute, the Centers for Disease Control and Prevention, and other relevant federal health agencies, should fund a program of developmental research and demonstration projects combining media techniques, other social marketing methods, and innovative approaches to disseminating smoking cessation technologies. Recommendation 19: Public and private health care systems should organize and provide access to comprehensive smoking cessation programs by using a variety of successful cessation methods and a staged disease management model (i.e. stepped care), and should specify the

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Ending the Tobacco Problem: A Blueprint for the Nation successful delivery of these programs as one criterion for quality assurance within those systems. Recommendation 20: All insurance, managed care, and employee benefit plans, including Medicaid and Medicare, should cover reimbursement for effective smoking cessation programs as a lifetime benefit. Recommendation 21: While sustaining their own valuable tobacco control activities, state tobacco control programs, CDC, philanthropic foundations, and voluntary organizations should continue to support the efforts of community coalitions promoting, disseminating, and advocating for tobacco use prevention and cessation, smoke-free environments, and other policies and programs for reducing tobacco use. Recommendation 22: Tobacco control programs should consider populations disproportionately affected by tobacco addiction and tobacco-related morbidity and mortality when designing and implementing prevention and treatment programs. Particular attention should be paid to ensuring that health communications and other materials are culturally-appropriate and that special outreach efforts target all high-risk populations. Standard prevention or treatment programs that are modified to reach high-risk populations should be evaluated for effectiveness. Changing the Regulatory Landscape Recommendation 23: Congress should repeal the existing statute preempting state tobacco regulation of advertising and promotion “based on smoking and health” and should enact a new provision that precludes all direct state regulation only in relation to tobacco product characteristics and packaging while allowing complementary state regulation in all other domains of tobacco regulation, including marketing and distribution. Under this approach, federal regulation sets a floor while allowing states to be more restrictive. Recommendation 24: Congress should confer upon the FDA broad regulatory authority over the manufacture, distribution, marketing, and use of tobacco products. Recommendation 25: Congress should empower the FDA to regulate the design and characteristics of tobacco products to promote the public health. Specific authority should be conferred

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Ending the Tobacco Problem: A Blueprint for the Nation to require tobacco manufacturers to disclose to the agency all chemical compounds found in both product and the product’s smoke, whether added or occurring naturally, by quantity; to disclose to the public the amount of nicotine in the product and the amount delivered to the consumer based on standards established by the agency; to disclose to the pubic research on their product, as well as behavioral aspects of its use; and to notify the agency whenever there is a change in a product; to prescribe cigarette testing methods, including how the cigarettes are tested and which smoke constituents must be measured; to promulgate tobacco product standards, including reduction of nicotine yields and reduction or elimination of other constituents, wherever such a standard is found to be appropriate for protection of the public health, taking into consideration the risks and benefits to the population as a whole, including users and non-users of tobacco products; and to develop specific standards for evaluating novel products that companies intend to promote as reduced-exposure or reduced-risk products, and to regulate reduced-exposure and reduced-risk health claims, assuring that there is a scientific basis for claims that are permitted. Recommendation 26: Congress should strengthen the federally mandated warning labels for tobacco products immediately and should delegate authority to the FDA to update and revise these warnings on a regular basis upon finding that doing so would promote greater public understanding of the risks of using tobacco products or reduce tobacco consumption. Congress should require or authorize the FDA to require rotating color graphic warnings covering 50 percent of the package equivalent to those required in Canada. Recommendation 27: Congress should empower the FDA to require manufacturers to include in or on tobacco packages information about the health effects of tobacco use and about products that can be used to help people quit. Recommendation 28: Congress should ban, or empower the FDA to ban, terms such as “mild,” “lights,” “ultra-lights,” and other misleading terms mistakenly interpreted by consumers to imply reduced risk, as well as other techniques, such as color codes, that have the purpose or effect of conveying false or misleading impressions about the relative harmfulness of the product.

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Ending the Tobacco Problem: A Blueprint for the Nation Recommendation 29: Whenever a court or administrative agency has found that a tobacco company has made false or misleading communications regarding the effects of tobacco products, or has engaged in conduct promoting tobacco use among youth or discouraging cessation by tobacco users of any age, the court or agency should consider using its remedial authority to require manufacturers to include corrective communications on or with the tobacco package as well as at the point of sale. Recommendation 30: Congress and state legislatures should enact legislation regulating the retail point of sale of tobacco products for the purpose of discouraging consumption of these products and encouraging cessation. Specifically: All retail outlets choosing to carry tobacco products should be licensed and monitored. (See also youth access section in Chapter 5.) Commercial displays or other activity promoting tobacco use by or in retail outlets should be banned, although text-only informational displays (e.g., price or health-related product characteristics) may be permitted within prescribed regulatory constraints. Retail outlets choosing to carry tobacco products should be required to display and distribute prescribed warnings about the health consequences of tobacco use, information regarding products and services for cessation, and corrective messages designed to offset misstatements or implied claims regarding the health effects of tobacco use (e.g., that “light” cigarettes are less harmful than other cigarettes). Retail outlets choosing to carry tobacco products should be required to allocate a proportionate amount of space to cessation aids and nicotine replacement products and, after regulatory clearance by the FDA or a designated state agency, to “qualifying” exposure-reduction products. (The FDA or a suitable state health agency should promulgate a list of “qualifying” exposure-reducing products.) Recommendation 31: Congress should explicitly and unmistakably include production, marketing, and distribution of tobacco products on Indian reservations by Indian tribes within the regulatory jurisdiction of FDA. Authority to investigate and enforce the Jenkins Act should be transferred to the Bureau of Alcohol, Tobacco, Firearms and Explosives. State restrictions on retail outlets should apply to all outlets on Indian reservations. Recommendation 32: State governments should develop and, if feasible, implement and evaluate legal mechanisms for restructuring retail tobacco sales and restricting the number of tobacco outlets.

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Ending the Tobacco Problem: A Blueprint for the Nation Recommendation 33: Congress should empower the FDA to restrict outlets in order to limit access and facilitate regulation of the retail environment, and thereby protect the public health. Recommendation 34: If most states fail to increase tobacco control funding and reduce variations in tobacco excise tax rates as proposed in Recommendations 1 and 2, Congress should enact a National Tobacco Control Funding Plan raising funds through a per-pack remedial assessment on cigarettes sold in the United States. Part of the proceeds should be used to support national tobacco control programs and the remainder of the funds should be distributed to the states to subsidize state tobacco control programs according to a formula based on the level of state tobacco control expenditures and state tobacco excise rates. The plan should be designed to give states an incentive, not only to increase state spending on tobacco control, but also to raise cigarette taxes, especially in low-tax states. Congress should assure that any federal coordination mechanism affecting the coverage and collection of state tobacco excise taxes applies to Indian tribes. Recommendation 35: Congress and state legislatures should enact legislation limiting visually displayed tobacco advertising in all venues, including mass media and at the point-of-sale, to a text-only, black-and-white format. Recommendation 36: Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. If a tobacco company wishes to support youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing, and evaluating the program. Recommendation 37: The Motion Picture Association of America (MPAA) should encourage and facilitate the showing of anti-smoking advertisements before any film in which smoking is depicted in more than an incidental manner. The film rating board of the MPAA should consider the use of tobacco in the movies as a factor in assigning mature film ratings (e.g., an R-rating indicating Restricted: no one under age 17 admitted without parent or guardian) to films that depict tobacco use.

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Ending the Tobacco Problem: A Blueprint for the Nation Recommendation 38: Congress should appropriate the necessary funds to enable the U.S. Department of Health and Human Services to conduct a periodic review of a representative sample of movies, television programs, and videos that are offered at times or in venues in which there is likely to be a significant youth audience (e.g., 15 percent) in order to ascertain the nature and frequency of images portraying tobacco use. The results of these reviews should be reported to Congress and to the public. Recommendation 39: State tobacco control agencies should conduct surveillance of tobacco sales and use and the effects of tobacco control interventions in order to assess local trends in usage patterns; identify special groups at high risk for tobacco use; determine compliance with state and local tobacco-related laws, policies, and ordinances; and evaluate overall programmatic success. Recommendation 40: The Secretary of HHS, through FDA or other agencies, should establish a national comprehensive tobacco surveillance system to collect information on a broad range of elements needed to understand and track the population impact of all tobacco products and the effects of national interventions (such as attitudes, beliefs, product characteristics, product distribution and usage patterns, and marketing messages and exposures to them). New Frontiers in Tobacco Control Recommendation 41: Congress should direct the Centers for Disease Control and Prevention to undertake a major program of tobacco control policy analysis and development and should provide sufficient funding to support the program. This program should develop the next generation of macro-level simulation models to project the likely effects of various policy innovations, taking into account the possible initiatives and responses of the tobacco industry as well as the impacts of the innovations on consumers. Recommendation 42: Upon being empowered to regulate tobacco products, the FDA should give priority to exploring the potential effectiveness of a long-term strategy for reducing the amount of nicotine in cigarettes and should commission the studies needed to assess the feasibility of implementing such an approach. If such a strategy appears to be feasible, the agency should develop a long-term plan for implementing the strategy as part of a comprehensive plan for reducing tobacco use.

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Ending the Tobacco Problem: A Blueprint for the Nation REFERENCES CDC (Centers for Disease Control and Prevention). 2005. Annual smoking-attributable mortality, years of potential life lost, and productivity losses—United States, 1997–2001. MMWR (Morbidity and Mortality Weekly Report) 54(25):625-628. DHHS (U.S. Department of Health and Human Services). 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. IOM (Institute of Medicine). 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youth. Washington, DC: National Academy Press. IOM. 2001. Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction. Washington, DC: National Academy Press. NRC (National Research Council). 1986. Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects. Washington, DC: National Academy Press.

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