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Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

ENDING THE TOBACCO PROBLEM

A BLUEPRINT FOR THE NATION

Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences

Board on Population Health and Public Health Practice

Richard J. Bonnie, Kathleen Stratton, and Robert B. Wallace, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

THE NATIONAL ACADEMIES PRESS

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Grant ID Number 6210 between the National Academy of Sciences and the American Legacy Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

Library of Congress Cataloging-in-Publication Data

Institute of Medicine (U.S.). Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences.

Ending the tobacco problem : a blueprint for the nation / Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences, Board on Population Health and Public Health Practice ; Richard J. Bonnie, Kathleen Stratton, and Robert B. Wallace, editors.

p. ; cm.

Includes bibliographical references and index.

ISBN-13: 978-0-309-10382-4 (hardback : alk. paper)

ISBN-10: 0-309-10382-7 (hardback : alk. paper) 1. Tobacco use—United States—Prevention. 2. Smoking—United States—Prevention. 3. Public health—United States. I. Bonnie, Richard J. II. Stratton, Kathleen R. III. Wallace, Robert B., 1942- IV. Title.

[DNLM: 1. Tobacco Use Disorder—prevention & control—United States. 2. Health Policy—United States. 3. Smoking—legislation & jurisprudence—United States. 4. Smoking—prevention & control—United States. 5. Smoking Cessation—legislation & jurisprudence—United States. WM 290 I585e 2007]

HV5763.I67 2007

362.29'660973—dc22

2007027676

Additional copies of this report are available from the

National Academies Press,

500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2007 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museum in Berlin.

Suggested citation: IOM (Institute of Medicine). 2007. Ending the tobacco problem: A blueprint for the nation. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES


Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

COMMITTEE ON REDUCING TOBACCO USE: STRATEGIES, BARRIERS, AND CONSEQUENCES

RICHARD J. BONNIE, L.L.B. (Chair), John S. Battle Professor of Law and Director,

Institute of Law, Psychiatry, and Public Policy, University of Virginia School of Law, Charlottesville

ROBERT B. WALLACE, M.D., M.Sc. (Vice Chair), Irene Ensminger Stecher Professor of Epidemiology and Internal Medicine,

Department of Epidemiology, College of Public Health, University of Iowa, Iowa City

DAVID ABRAMS, Ph.D., Director,

Office of Behavioral and Social Sciences Research, and

Associate Director,

NIH Office of the Director, National Institutes of Health, Bethesda, MD

NEAL BENOWITZ, M.D., Professor of Medicine, Psychiatry, and Biopharmaceutical Sciences,

University of California, San Francisco

DIANA BONTÃ, Dr.P.H., Vice President,

Public Affairs, Southern California Region, Kaiser Permanente, Pasadena, CA

JONATHAN CAULKINS, Ph.D., Professor of Operations Research and Public Policy,

Qatar Campus and H. John Heinz III School of Public Policy and Management, Carnegie Mellon University, Pittsburgh, PA

ROBERTA FERRENCE, Ph.D., Director,

Ontario Tobacco Research Unit, Toronto, Ontario

BRIAN FLAY, D.Phil., Professor of Public Health,

College of Health and Human Sciences, Oregon State University, Corvallis

BONNIE HALPERN-FELSHER, Ph.D., Associate Professor,

University of California, San Francisco

JEFFREY HARRIS, M.D., Ph.D., Professor of Health Economics,

Massachusetts Institute of Technology, Cambridge, MA

ROBERT RABIN, J.D., Ph.D., A. Calder Mackay Professor of Law,

Stanford Law School, Stanford, CA

MICHAEL SLATER, Ph.D., Social and Behavioral Sciences Distinguished Professor,

School of Communication, Ohio State University, Columbus

CAROLINE SPARKS, M.A., Ph.D., Associate Professor of Prevention and Community Health and Deputy Director of the Prevention Research Center,

School of Public Health and Health Services, George Washington University, Washington, DC

CASS SUNSTEIN, J.D., Karl N. Llewellyn Distinguished Service Professor of Jurisprudence,

University of Chicago Law School, IL

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

STUDY STAFF

KATHLEEN STRATTON, Ph.D., Study Director

AMBER CLOSE, M.F.S., Senior Program Associate

MELISSA FRENCH, M.A., Senior Program Associate (through August 2005)

AMY GELLER, M.P.H., Research Associate (through August 2004)

DAVID GILES, Research Assistant (through January 2007)

REBECCA KLIMAN HUDSON, M.P.H., Research Associate (through August 2004)

SHEYI LAWOYIN, M.P.H., Senior Program Assistant (through October 2005)

RENIE SCHAPIRO, Consultant

KRISTINA VAN DOREN-SHULKIN, Senior Program Assistant

MONIQUE B. WILLIAMS, Ph.D., Program Officer

ROSE MARIE MARTINEZ, Sc.D., Director,

Board on Population Health and Public Health Practice

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:

Lois Biener, Ph.D., University of Massachusetts, Boston

Richard Clayton, Ph.D., University of Kentucky

Phillip Cook, Ph.D., Duke University

Gordon DeFriese, Ph.D., University of North Carolina

Paul Fischer, M.D., Center for Primary Care

Gary Giovino, Ph.D., State University of New York, Buffalo

Jack Henningfield, Ph.D., Johns Hopkins University

Howard Koh, M.D., M.P.H., Harvard School of Public Health

Harold Pollack, Ph.D., University of Chicago

Eric A. Posner, J.D., University of Chicago Law School

Steven Schroeder, M.D., University of California, San Francisco

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Nancy E. Adler, Ph.D., University of California, San Francisco, and Robert S. Lawrence, M.D., Johns Hopkins University. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

Preface

“Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action.” So stated the Advisory Committee to the Surgeon General of the Public Health Service in its seminal Report in 1964 (p. 33). Since then, the Surgeon General has issued 28 more reports on tobacco and health, most recently in 2005. The health effects of cigarette smoking and use of other tobacco products, including smokeless tobacco, are by now well-known.

Cigarette-smoking has decreased considerably in the United States since 1964 when about 52 million adults (representing 42 percent of the adult population) smoked, and public health leaders and tobacco control specialists deserve praise for what they have been able to accomplish over the past four decades. However, there are still approximately 44 million smokers in this country, and cigarette smoking is the “underlying cause” of more than 440,000 deaths a year in the United States.

Why has there not been greater progress in ending the tobacco problem? Although many social, economic, and political factors have played a role, perhaps the most important one is that the tobacco industry obscured the addictive properties and health risks of smoking, impeded and delayed many tobacco control interventions, and has so far successfully thwarted meaningful federal regulatory measures. As a result, more than forty years after the first Surgeon General’s report, the necessary “remedial action” has not yet been taken. This report presents a two-prong strategic plan for intensifying and accelerating public health efforts, thereby taking long strides toward ending the tobacco problem in the United States. The first prong of the plan calls for making better use of tobacco control interven-

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

tions known to be effective. These steps can be implemented immediately. The second prong of the committee’s plan calls for federal legislative action to transform the current legal structure of tobacco control and for deploying innovative new regulatory approaches. Taken together, the blueprint outlines the strong measures that will be needed to reduce substantially the prevalence of cigarette-smoking and to assure that other forms of tobacco use are simultaneously contained or reduced. How quickly this can be done depends on how quickly the plan is implemented.

This is not the first time the Institute of Medicine (IOM) has addressed the need for strong remedial measures to control tobacco use. In 1994, the IOM issued Growing Up Tobacco Free, a report outlining a blueprint for reducing tobacco use among children and adolescents. The recommendations in that report figured prominently in the drafting of the FDA’s Tobacco Rule—promulgated in 1996 but invalidated by the United States Supreme Court in 2000. In 2001, the IOM issued Clearing the Smoke, a report assessing the science base for reduced-risk tobacco products and specifying principles to guide federal legislative and administrative action. Although the IOM principles have provided a foundation for legislative proposals in both houses of Congress over the past 5 years, federal law remains unchanged.

The blueprint for action presented in this report is both comprehensive and specific. Although the recommendations are more detailed than those offered in most IOM reports, the committee followed the path plowed by the two previous IOM reports on tobacco policy, recognizing that the key elements of the blueprint require strong and unambiguous legislative and administrative action at all levels of government.

The committee commissioned 16 papers reviewing the literature in many of the areas of tobacco control covered in the report, and these papers are published in an appendix accompanying the committee’s report (prepared as a CD). We asked the authors (most of whom also served as members of the committee) to draw conclusions from their work and, if indicated, to make policy recommendations. To avoid any confusion, it bears emphasis that the recommendations appearing in the committee’s report represent the consensus judgment of the committee as a whole and are endorsed by all members of the committee except where otherwise indicated. In contrast, the recommendations appearing in the individually authored chapters in the Appendix should not be attributed to the committee itself.

The title of the committee’s report warrants some explanation. What does the committee mean by “ending the tobacco problem”? We do not mean eliminating smoking and other forms of tobacco use altogether. That is both unrealistic and unnecessary. Instead, we have in mind reducing tobacco use so substantially that it no longer has a significant impact on public health.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
×

The magnitude of tobacco’s impact on the public health is inextricably linked to the highly addictive property of cigarettes and other tobacco products as they are currently designed and used. Four out of five current adult cigarette smokers are addicted to them, and the average length of a smoking career is several years. One strategy that should be explored, as the committee explains in Chapter 7, is gradually reducing the nicotine content of tobacco products so that they are no longer addictive. If that were accomplished, the residual use of tobacco decades from now might not amount to a significant public health problem.

Unless and until a nicotine reduction strategy is successfully implemented, however, the central aim for tobacco policy must continue to be reducing the number of tobacco users through a two-pronged strategy of reducing initiation and facilitating cessation. Harm reduction (reducing the risks of consumption) is, at best, an ancillary component of a comprehensive strategy for protecting the public health.

What levels of cigarette smoking, smokeless tobacco use, and cigar smoking would be “acceptable” from a public health perspective? Reducing the current adult prevalence of cigarette smoking in half (from about 21 percent to about 10 percent) would still leave more than 20 million adult smokers. That is not good enough. Is 5 percent good enough? 3 percent?

Ultimately, the committee concluded that answering this question has little practical significance at the present time. We see no reason to go through the hypothetical exercise of identifying particular initiation and prevalence rates that would signal “ultimate” success. Setting such targets requires delicate judgments based on data not now available and circumstances that cannot now be foreseen. There will be time enough for another committee to set these targets in the coming years. For the next decade or two, the aim must be to reduce initiation and increase cessation as much as possible without stimulating a substantial black market and its associated costs.

Speaking for the Committee on Reducing Tobacco Use, I hope that the recommendations outlined in this report are implemented with vigor, speed, and perseverance. Many components of the committee’s plan can be implemented immediately without any federal action. However, if Congress moves quickly to empower FDA and the states to launch new regulatory initiatives recommended in this report, the nation will be on a promising course toward ending the tobacco problem by 2030.


Richard J. Bonnie, Chair

Committee on Reducing Tobacco Use

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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 Tobacco Control in the Years Ahead: Will Progress Continue?,

 

128

   

 Summary,

 

136

   

 References,

 

137

PART II:  A BLUEPRINT FOR REDUCING TOBACCO USE

 

 

4

 

REDUCING TOBACCO USE: A POLICY FRAMEWORK

 

145

   

 Product Safety and Consumer Sovereignty,

 

145

   

 The Policy Context,

 

146

   

 The Ethical Context,

 

148

   

 An Aside on the Paternalism Problem,

 

150

   

 Tobacco Products Are Inherently Dangerous,

 

152

   

 Blueprint Outline,

 

154

   

 References,

 

154

5

 

STRENGTHENING TRADITIONAL TOBACCO CONTROL MEASURES

 

157

   

 Comprehensive State Programs,

 

158

   

 Funding for Comprehensive State Programs,

 

172

   

 Excise Tax,

 

182

   

 Smoking Restrictions,

 

189

   

 Youth Access,

 

203

   

 Retail Shipments,

 

207

   

 Prevention Interventions,

 

210

   

 Media Campaigns to Prevent Smoking,

 

223

   

 Cessation Interventions,

 

231

   

 Community Mobilization,

 

241

   

 Special Populations with Higher Rates of Cigarette Smoking,

 

247

   

 Projected Impact of Strengthening Existing Tobacco Control Measures,

 

249

   

 References,

 

253

6

 

CHANGING THE REGULATORY LANDSCAPE

 

271

   

 Federal Regulatory Authority Is Needed,

 

272

   

 Empowering FDA to Regulate Tobacco,

 

275

   

 A Regulatory Philosophy,

 

277

   

 Tobacco Product Characteristics Should Be Regulated,

 

279

   

 Messages on Tobacco Packages Should Promote Health,

 

289

   

 The Retail Environment for Tobacco Sales Should Be Transformed to Promote the Public Health,

 

299

   

 The Federal Government Should Mandate Industry Payments for Tobacco Control and Should Support and Coordinate State Funding,

 

308

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press. doi: 10.17226/11795.
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The nation has made tremendous progress in reducing tobacco use during the past 40 years. Despite extensive knowledge about successful interventions, however, approximately one-quarter of American adults still smoke. Tobacco-related illnesses and death place a huge burden on our society.

Ending the Tobacco Problem generates a blueprint for the nation in the struggle to reduce tobacco use. The report reviews effective prevention and treatment interventions and considers a set of new tobacco control policies for adoption by federal and state governments. Carefully constructed with two distinct parts, the book first provides background information on the history and nature of tobacco use, developing the context for the policy blueprint proposed in the second half of the report. The report documents the extraordinary growth of tobacco use during the first half of the 20th century as well as its subsequent reversal in the mid-1960s (in the wake of findings from the Surgeon General). It also reviews the addictive properties of nicotine, delving into the factors that make it so difficult for people to quit and examines recent trends in tobacco use. In addition, an overview of the development of governmental and nongovernmental tobacco control efforts is provided.

After reviewing the ethical grounding of tobacco control, the second half of the book sets forth to present a blueprint for ending the tobacco problem. The book offers broad-reaching recommendations targeting federal, state, local, nonprofit and for-profit entities. This book also identifies the benefits to society when fully implementing effective tobacco control interventions and policies.

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