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Introduction

In 1964, almost half of the adults in the United States smoked cigarettes. Today, the prevalence of cigarette smoking among adults is 20.9 percent (CDC 2006). This substantial decline led the Centers for Disease Control and Prevention to characterize the reduction of smoking as one of the 10 greatest achievements in public health in the 20th century (CDC 1999). It was a great achievement, but the mission remains unfinished. Tobacco use still causes 440,000 deaths in the United States every year (CDC 2005), with secondhand smoke responsible for 50,000 of those deaths (DHHS 2006). All told, approximately one in every five deaths is smoking-related, accounting for more deaths than those from AIDS, alcohol use, cocaine use, heroin use, homicides, suicides, motor vehicle crashes, and fires combined (Healthy People 2010 2005).

The health consequences of tobacco use are numerous (CDC 2005). Each year between 1997 and 2001, smoking caused 160,000 deaths from cancer that affect the lips, mouth, throat, stomach, pancreas, lungs, cervix, kidney, and bladder. Smoking caused 140,000 deaths annually from hypertension, stroke, heart disease, and other cardiovascular problems. The third largest specific cause of smoking-related death is respiratory diseases, comprising 100,000 deaths annually. Smoking is a major cause of morbidity and mortality from infectious diseases, including influenza, pneumococcal pneumonia, tuberculosis, and others (Arcavi and Benowitz 2004). Smoking during pregnancy and infant exposure to tobacco smoke also causes poor birth outcomes such as prematurity, low birth weight, respiratory problems in the newborn, and sudden infant death syndrome (CDC 2004; DHHS 2006).



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Ending the Tobacco Problem: A Blueprint for the Nation Introduction In 1964, almost half of the adults in the United States smoked cigarettes. Today, the prevalence of cigarette smoking among adults is 20.9 percent (CDC 2006). This substantial decline led the Centers for Disease Control and Prevention to characterize the reduction of smoking as one of the 10 greatest achievements in public health in the 20th century (CDC 1999). It was a great achievement, but the mission remains unfinished. Tobacco use still causes 440,000 deaths in the United States every year (CDC 2005), with secondhand smoke responsible for 50,000 of those deaths (DHHS 2006). All told, approximately one in every five deaths is smoking-related, accounting for more deaths than those from AIDS, alcohol use, cocaine use, heroin use, homicides, suicides, motor vehicle crashes, and fires combined (Healthy People 2010 2005). The health consequences of tobacco use are numerous (CDC 2005). Each year between 1997 and 2001, smoking caused 160,000 deaths from cancer that affect the lips, mouth, throat, stomach, pancreas, lungs, cervix, kidney, and bladder. Smoking caused 140,000 deaths annually from hypertension, stroke, heart disease, and other cardiovascular problems. The third largest specific cause of smoking-related death is respiratory diseases, comprising 100,000 deaths annually. Smoking is a major cause of morbidity and mortality from infectious diseases, including influenza, pneumococcal pneumonia, tuberculosis, and others (Arcavi and Benowitz 2004). Smoking during pregnancy and infant exposure to tobacco smoke also causes poor birth outcomes such as prematurity, low birth weight, respiratory problems in the newborn, and sudden infant death syndrome (CDC 2004; DHHS 2006).

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Ending the Tobacco Problem: A Blueprint for the Nation Although cigarette smoking is often referred to as the single leading preventable cause of death in the United States, other forms of tobacco are also dangerous. For example, men who report moderate inhalation and smoke at least five cigars a day experience lung cancer deaths at about two-thirds the rate of men who smoke one pack of cigarettes a day. Cigar smokers experience higher rates of lung cancer, heart disease, and chronic obstructive lung disease than nonsmokers. Cigar smokers who inhale are 6 times more likely to die from oral cancer and 39 times more likely to die from laryngeal cancers than nonsmokers (NCI 1998). Bidis and Kreteks are associated with increased risks of cancers in the gastrointestinal and respiratory systems as well as other respiratory problems. Smokeless tobacco contains 28 carcinogens and is associated with the risk of oral cancer. It is also associated with gum recession and a condition called leukoplakia, a precancerous change in buccal and gingival mucosa (CDC 2004). The health consequences of tobacco use have substantial economic effects. Because of smoking-related mortality, more than 3.3 million years of potential life among men and 2.2 million years of potential life among women are lost annually (compared with the life expectancies among nonsmokers). The lost productivity attributable to these years of life lost amounts to more than $92 billion annually (CDC 2005).1 Other economic costs of tobacco use amount to more than $155 billion every year. Private and public health care expenditures for smoking related health conditions are an estimated $89 billion, including $28.4 billion in federal and state payments to Medicaid. Health care expenditures for secondhand smoke alone are approximately $5 billion per year (Lindblom and McMahon 2005). Other social costs associated with tobacco use include the costs associated with smoking-related fires and casualties and degradation of the environment. Smoking is the fifth most frequent cause of residential fires—the leading cause of fire deaths. In addition, states and the federal government spend millions of dollars annually on prevention and research efforts relating to tobacco use. In FY 2002, for instance, state and federal funding for tobacco control programs totaled $861.9 million, or $3.16 per capita (CDC 2002). In FY 2005, state spending alone totaled $538.4 million, or $2.76 per capita (data for state and national funding combined since FY 2002 are not available). Tobacco use will not disappear in the United States simply because of the momentum of past achievements. The decline in tobacco use achieved over the last several decades is likely to flatten out in the coming decade, and strong measures are likely to be needed to maintain continued progress 1 This estimate of years of potential life lost and its associated productivity losses does not include deaths from burns or deaths from secondhand smoke.

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Ending the Tobacco Problem: A Blueprint for the Nation thereafter. One problem is that the annual rate of cessation, never very high, has been flat since 2002. In addition, a major impediment to achieving a permanent long-term reduction in the prevalence of tobacco use is the high smoking initiation rate among teenagers. Notwithstanding substantial investment in tobacco control efforts in recent years, prevalence of current smoking among high school seniors remains at about 20 percent, and most of these individuals will remain smokers as adults. Approximately 90 percent of adult smokers began smoking as teenagers (SAMHSA 2006). THE COMMITTEE’S CHARGE Concerns about the waning momentum of 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 assess past progress and future prospects in tobacco control and to develop a blueprint for reducing tobacco use in the United States. The study’s statement of task is presented in Box I-1. To carry out its charge, the committee conducted six meetings between May 2004 and June 2005 at which the 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 in 12 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

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Ending the Tobacco Problem: A Blueprint for the Nation BOX I-1 Statement of Task The nation has made tremendous progress in reducing tobacco use over the past 40 years. Despite extensive knowledge about successful interventions to reduce tobacco use, approximately one-quarter of American adults still smokes. Tobacco-related illnesses and death place a huge burden on our society. A committee at the Institute of Medicine will examine which prevention and treatment interventions are most promising to reduce tobacco use further, the barriers to action, and which policies need to be changed or adopted. The committee will also explore the benefits to society of fully implementing effective tobacco control interventions and policies. The committee’s recommendations will be broad reaching, targeting federal, state, local, non-profit, and for-profit entities. The purpose of this committee is to generate a blueprint for the nation in the struggle to reduce tobacco use. committee believes that most of the interventions shown to be effective for 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 (ETS) 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 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. In sum, the ultimate goal of the committee’s blueprint is to reduce tobacco use so substantially that it is no longer a significant public health

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Ending the Tobacco Problem: A Blueprint for the Nation problem; 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. The committee also needed to decide what it means to formulate a “blueprint.” One possible approach was for the committee to regard its task as a purely scientific one—simply to offer technical advice to policymakers. Under this approach, the committee would confine itself to the task of evaluating the effectiveness (and perhaps the costs) of various policy tools for reducing smoking, leaving it to policymakers to take individual liberty, justice, and other values into account in deciding which policies to implement. However, such a restrained approach struck the committee as incompatible with the specific, direct, and emphatic nature of the instruction we had been given “to generate a blueprint for the nation in the struggle to reduce tobacco use.” Accordingly, the committee’s recommendations are direct and specific. The Policy Context For many years, a policy paradigm emphasizing consumer freedom of choice and decrying unwarranted “paternalism” dominated public opinion and policymaking on tobacco. In retrospect, however, the committee believes that predominant emphasis on consumer choice in public opinion during this period was largely shaped by 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 (especially the effects on nonsmokers). As the scientific evidence about addiction and the health effects of tobacco use has grown, and the industry’s deceptive strategies have been exposed in the course of state lawsuits and other tobacco-related litigation, public understanding of tobacco addiction has quickly deepened and the ethical and political context of tobacco policymaking has been transformed. Consequently, over the past 10–15 years, the operating assumptions of tobacco policy in the United States and elsewhere in the world have fundamentally changed. As shown in Chapters 3 and 5, a widespread popular consensus is now emerging in favor of aggressive policy initiatives, and this shift in popular sentiment has also been accompanied by support across most of the political spectrum. In this context, it is worth pausing to take note of the ethical foundation for taking strong steps to reduce tobacco use. From a traditional public health perspective, the legitimacy and importance of reducing tobacco use

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Ending the Tobacco Problem: A Blueprint for the Nation lies in the enormous social costs attributable to tobacco-related disease; reducing tobacco use increases overall population health. Further, even within a libertarian paradigm, each of the subsidiary goals of tobacco policy is clearly justified: reducing exposure to ETS prevents harm to nonsmokers; preventing initiation by youth is justified by the recognized shortcomings of adolescent judgment; and promoting cessation helps to restore the liberty of smokers who are able to quit. Ethically speaking, the most controversial interventions are those aimed exclusively at reducing use by the minority of adult smokers who do not want to quit. This is the nub of the so-called paternalism problem. However, since every intervention aimed at current smokers serves the interests and express wishes of the subset who want to quit, interventions designed to protect the health of adult smokers do not necessarily rest on a paternalistic foundation. Instead, they entail both liberty-enhancing effects (achieved by assisting addicted smokers to quit) and liberty-restricting effects (insofar as they also “burden” the choices of smokers who do not want to quit or object to the restrictions and costs imposed on them). Thus ethical analysis of tobacco control interventions within the libertarian paradigm requires a weighing of liberty-reducing effects of particular intervention against the liberty-enhancing effects of these interventions for nonsmokers whose freedom to avoid ETS exposure is protected, youths whose long-run autonomy is preserved, and adult smokers whose ability to quit is enhanced (and therefore regard the intervention as a benefit rather than a cost). This problem is addressed further in Chapter 4. Limits of the Charge Reducing tobacco use is, of course, a global challenge. According to a recent World Health Organization (WHO) study, tobacco-related diseases will kill 6.4 million people a year by 2015, accounting for 10 percent of all deaths worldwide. There are now many millions of smokers in the world, served by increasingly aggressive transnational tobacco companies. The common interest of all nations in reducing tobacco use has been declared and effectuated by the WHO-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

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Ending the Tobacco Problem: A Blueprint for the Nation interventions undertaken by other countries in recent years served as useful models for us. This is not a report about a research agenda. Many gaps in current knowledge were noted in our deliberations, and the committee is concerned that current National Institutes of Health expenditures on tobacco use (including both initiation and cessation) are not commensurate with the disease burden of smoking and other forms of tobacco use. However, our charge was to propose a blueprint for tobacco control, not for research. OUTLINE OF REPORT 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 on the harmful health effects of smoking. Chapter 1 also examines closely 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. Chapter 2 also reviews the salient factors associated with smoking initiation, especially the failure of adolescents to appreciate the risk and consequences of addiction when they become smokers. The chapter concludes by discussing several recent trends in smoking epidemiology that may pose problems for tobacco control in the future. Chapter 3 reviews the history of tobacco control. After the 1964 Surgeon General’s report, the public’s opinion toward smoking changed dramatically. However, until the mid 1980s, antismoking efforts had little success in combating the financial and political power of the tobacco industry. Tobacco control efforts began to make progress when grassroots initiatives galvanized public concern about the health effects of environmental tobacco smoke and began to erode pro-smoking social norms. The tobacco policy debate became transformed in the late 1980s and 1990s, when the public recognized the addictive nature of nicotine, the continued importance of teenage initiation in sustaining the public health burden of tobacco use, and the tobacco industry’s extensive efforts to manipulate and deceive the public. Chapter 3 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 and offers a vast array of recommendations. The first prong, presented in Chapter 5, envisions strengthening traditional tobacco control measures.

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Ending the Tobacco Problem: A Blueprint for the Nation The committee summarizes the evidence regarding the effectiveness of the tobacco control methods now being deployed and makes recommendations for broadening and strengthening them. For the most part, the chapter emphasizes state and local initiatives supported by public health partnerships and community advocacy programs. The two pillars of the blueprint are substantial increases in excise taxes on tobacco and smoke-free-air laws with broad coverage. In addition, the blueprint includes other elements of comprehensive state programs, such as youth access restrictions, school-based prevention programs, programs aimed at families and health care systems, media campaigns, smoking cessation programs, and grassroots community advocacy. Chapter 5 closes with a projection of the likely effects over the next two decades of implementing the policies outlined. The premise of Chapter 6 is that a more substantial long-term impact on reducing tobacco use requires a change in the current legal framework of tobacco control. The second prong of the blueprint envisions changing the regulatory landscape to permit new policy innovations that take into account the unique history and characteristics of tobacco. Under the proposed approach, federal power would enhance and support state efforts in the traditional domains of tobacco control while taking aggressive steps in the currently under-regulated areas of tobacco marketing, distribution, and product design. A key feature of the federal program would be the exercise of regulatory jurisdiction by the Food and Drug Administration. In addition, the federal government would also play a more substantial role in funding and coordinating state tobacco control activities. One of the most important aims of the plan outlined in Chapter 6 is to establish a platform for major innovations in tobacco control. However, any major innovations will have to be formulated with great care, based on thorough analysis of the possible consequences. It will be essential, therefore, for the federal government to create a capacity for tobacco policy research and development. In Chapter 7 the committee recommends that a new policy development office undertake a major program of policy analysis, based on improved statistical models, and that it explore new frontiers of tobacco control, including proposals to gradually reduce the nicotine content of cigarettes. REFERENCES Arcavi L, Benowitz NL. 2004. Cigarette Smoking and Infection. Archives of Internal Medicine 165:2206-2216. CDC (Centers for Disease Control and Prevention). 1999. Ten great public health achievements—United States, 1900–1999. MMWR (Morbidity and Mortality Weekly Report) 48(12):241-243. CDC. 2002. Tobacco Control State Highlights 2002: Impact and Opportunity. Albuquerque M, Kelly A, Schooley M, Fellows JL, Pechacek TF. Atlanta, GA.

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Ending the Tobacco Problem: A Blueprint for the Nation CDC. 2004. The Health Consequences of Smoking: A Report of the Surgeon General. Web Page. Available at: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm; accessed May 25, 2007. CDC. 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. CDC. 2006. Tobacco use among adults—United States, 2005. (MMWR Morbidity and Mortality Weekly Report) 55(42):1145-1148. 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. Healthy People 2010. 2005. Leading Health Indicators. Web Page. Available at: http://www.healthypeople.gov/document/html/uih/uih_4.htm; accessed May 7, 2007. IOM (Institute of Medicine). 1994. Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youth. Editors Lynch BJ, Bonnie RJ. Washington, DC: National Academy Press. IOM. 2001. Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction. Washington, DC: National Academy Press. Lindblom E, McMahon K. 2005. Toll of Tobacco in the United States of America. Web Page. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0072.pdf; accessed August 11, 2006. NCI (National Cancer Institute). Cigars: Health Effects and Trends. Smoking and Tobacco Control Monograph No. 9 ed. 1998. NRC (National Research Council). 1986. Environmental Tobacco Smoke: Measuring Exposures and Assessing Health Effects. Washington, DC: National Academy Press. SAMHSA (Substance Abuse and Mental Health Services Administration). 2006. Results from the 2005 National Survey on Drug Use and Health: National Findings. Web Page. Available at: http://oas.samhsa.gov/nsduh/2k5nsduh/2k5results.pdf; accessed November 28, 2006.

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