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OCR for page 99
~ 0. Tobacco
By 1985, the midpoint in the 1^ Objectives process,
it appeared that 12 of the 13 smoking objectives for
which data were available would be met. Clearly,
during the 1980s, the United States made progress in
reducing smoking among all groups of Americans-
except teenage girls. Yet according to those
testifying on the Year 2000 Health Objectives, much
needs to be done: 19 individuals concentrated
primarily on the issue of smoking, and 31 others
included smoking as a major part of their testimony.
Many others mentioned it in their discussion of
chronic diseases and other issues.
Most witnesses agreed that cigarette smoking is the
single most important preventable cause of death in
our society and that efforts to reduce tobacco con-
sumption will result in improved health. Each year,
about 390,000 Americans die of tobacco-caused
cancer, coronary heart disease, chronic obstructive
lung-disease, and other diseases.2 Disease outcomes
associated with the use of cigarettes include lung,
laryngeal, esophageal, bladder, and pancreatic cancer;
chronic obstructive lung disease; atherosclerosis,
coronary heart disease, cerebrovascular disease, and
myocardial infarction. (#002) However, according to
Woodrow Myers, Commissioner of the Indiana State
Board of Health, smoking habits are difficult to
change because they involve not only personal habits
and addictions, but also political will. (~405J
Many testifiers concentrated their remarks on the
need to direct future objectives toward helping those
groups who still have relatively high smoking rates,
whose rates of smoking are increasing, or at whom
tobacco advertising is directed. In addition to teenage
girls, testifiers identified prime target populations as
adolescents in general (see also Chapter 4~; pregnant
women; ethnic minorities, including Blacks, Hispanics,
and Native Americans (see Chapter 6 for a more
thorough discussion of racial and ethnic minorities);
and the economically disadvantaged. Education, poli-
tical action, and both local and federal legislation
were identified most often as the avenues for reaching
these audiences.
The potential for reaching large numbers of
smokers through the workplace also received con-
siderable attention from testifiers, as did the increased
use of smokeless tobacco, which was not even
addressed in the 1990 Objectives.
ADOLESCENT SMOKING
Gabrielle Acampora of the Greater New York
Association of Occupational Health Nurses explains,
and others agree, that adolescents, especially Black
adolescents and those in lower socioeconomic groups,
are more likely than others to initiate smoking and
resist cessation. (#002) Kenneth Kaminsly of the
Wayne County Intermediate School District in
Michigan reports that nearly one-fifth of high school
seniors are daily smokers and more convert from
occasional to regular smokers in the years after high
school.3 He also notes that research and surveys
indicate that smoking has increased especially among
teenage girls. (~426) Surveys also tell us, according
to Kenneth Warner of the University of Michigan,
that teenagers believe illegal drugs to be the principal
cause of premature death in our society, whereas in
fact, cigarettes kill as many Americans in a single day
as cocaine does in a year. (#429) The American
Academy of Pediatrics says that more than 30 percent
of high school seniors do not believe that a great
health risk is associated with smoking.4 (~115)
The early- to mid-teen years are Important because
smoking behavior tends to be formed (or avoided)
during this period and retained over the life course.
(~419) According to Diane Allensworth, the Ameri-
can School Health Association (ASHA) suggests that
the 1990 objective about adolescent smoking be
retained, namely, that "the proportion of children and
youth aged 12 to 18 who smoke (or use tobacco
products) should be reduced to below 6 percent."
(~005) To help accomplish this by the year 2000, the
ASHA proposes process objectives for kindergarten
through twelfth grade for health education, teacher
training, and "interventions that combine and coor-
dinate multiple forces of the community with those of
the school. (~0053 It further suggests that schools
ban all smoking by students and teachers. Acampora
says that "by 2000, 85 percent of adolescents aged
15-18 should be able to state that they perceive great
risk associated with frequent, regular cigarette smok-
ing." (~002) Particularly important, because it is
very difficult to unlearn addictive behavior, is the
development of good smoking education programs
early in life that involve not only families but also
schools. As Harriette Zal of the Southern California
Tobacco 99
OCR for page 100
Association of Occupational Health Nurses mentions,
the challenge is in developing programs that address
"assertion skills, increasing self-control and self-
esteem, and learning to cope with stress without
drugs.n (#230J
Kaminsky further recommends that "by the year
2000, students who enter elementary school in 1988
be smoke-free" and that "advertising for tobacco be
banned." (#426) Furthermore, to help control the
availability of tobacco to minors, Acampora suggests
that By 2000, 50 states have legislation restricting sale
or distribution of tobacco products to minors."
(~002)
The problem of smoking among working youth also
was perceived as requiring attention. Acampora
proposes that By 2000 at least 40 percent of workers
aged 15-18 years should be offered smoking educa-
tion and smoking cessation programs." Those who
drop out of school and then work in small enterprises
without health programs might be reached by peer
group teens trained as health educators, by occupa-
tional health nurses in outreach vans traveling to
worksites, or by community agencies. (~002)
SMOKING AND PREGNANCY
Cigarette smoking is the most common drug addiction
during pregnancy. It is associated with fetal growth
retardation, premature delivery, and low birth weight.
Those who testified on this issue were concerned with
the limited amount of available data on the number
of women who smoke during pregnancy. Data that
do exist apparently show an increase in the last
decade in the number of women smokers In the
unmarried, under-24 age group. Data exist for
married women, but collecting data on unmarried,
especially young, women is also important because
this subset may have more difficulty in quitting.
Moreover, say Robert Welch and Robert Sokol of the
Hutzel Hospital in Detroit and Wayne State
University, While public education appears to be
reaching the married, cover 24-year-old age group, we
do not seem to be communicating the No Smoking
message as well to the under 25-year olds.n (~421)
Richard Windsor of the University of Alabama at
Birmingham adds that Universal use of available
smoking cessation methods by nurses, physicians, and
patient educators in obstetrical settings, all of which
need little adaptation or revision for different practice
settings, has the potential to produce an additional
100,000 pregnant women quitting in the United States
each year. This represents 10 percent of the total of
100 Healthy People 2000: Citizens Chart the Course
approximately 1,000,000 pregnant smokers.nS (~267J
Welch and Sokol, who also spoke on behalf of the
American College of Obstetricians and Gynecologists,
propose as an objective that 'by the year 2000, the
prevalence of cigarette smoking in pregnant women be
one half that of the U. S. population or appro~-
mately 12 percent, 50 percent below the projected
1990 level, with needed focus on educating the under
24-year-old age group about the hazards of smoking
in pregnancy." (#421) Terry duPont of the Ameri-
can Association for Respiratory Care suggests that
"the proportion of women who smoke during pregnan-
cy should be no greater than 25 percent of women
who smoke overall." (#054) Windsor suggests a
revision to the 1990 objective on teaching smoking
cessation to pregnant women, namely, that "by 1995,
at least 80 percent of all pregnant women will be
taught smoking cessation skills to suit or s~onificantiv
reduce their intake." (~267)
WORKSITE SMOKING
~ _ ~
Worksite smoking and the effect of passive smoking
on workers who do not smoke were of particular
interest to many testifiers. Alice Murtaugh of New
York City emphasizes the concern of many others
that nonsmokers, by common law, have the right to a
safe and healthy workplace. (#159J Some testifiers
felt that the 1990 Objectives paid too little attention
to worksite health promotion. Murtaugh sees the
problem as one that goes well beyond a simple
question of whether or not workers should be allowed
to smoke.
In allowing people to smoke in the workplace,
we are encouraging a basically healthy segment
of the population to destroy their health. As we
have recently observed, they are not only ruining
their own health, but also the health of their
families and coworkers. Since most adults spend
a fourth of their time at work, smoke in the
workplace is a serious problem for many
individuals. A worker with a smoking habit will
not only affect the health of his coworker, but
may be responsible for the habit continuing into
a new generation. (#159)
Loring Wood of the NYNEX Corporation says
that Ha strong workplace smoking policy delivers a
clear message, and when this is combined with
smoking hazard awareness publicity to employees, and
the offering of smoking cessation programs on or off
OCR for page 101
premises, this achieves reduction in numbers and
intensity of smokers. (#736J Robert Rosner of the
Smoking Polipy Institute in Washington state says that
Pacific Northwest Bell's stringent no smoking policy
improved employee morale, improved the work
environment, and most important, led to increased
smoking cessation. He reports that "smoking policies
have a positive impact on both the participation and
success levels of company-sponsored smoking cessation
programs. This has a great potential for impact on
the smoking and health objectives for the nation."
(~349)
Many specific worksite outcome objectives were
suggested. Some call for a basic but far-reaching
objective such as "a smoke-free workplace for every
individual," a goal thought by some testifiers to be
possible in view of recent reports on smokers'
opinions, health Endings, local legislation, and the
growing pattern of smoke-free policies in a wide range
of companies. (#159) Others suggest very specific
objectives, for example, that worksite health promo-
tion programs which include smoking cessation be
present in 75 percent of the Fortune 5()0 companies
and for 75 percent of government workers by the year
2000. (#712J Wood further recommends that the
1990 objective pertaining to employer/employee
sponsored or supported smoking cessation programs
at the worksite be changed to include that "3S percent
of all businesses with more than 500 employees have
smoking policies in place that ban smoking at all
work stations, including private offices, whether or not
they provide alternative smoking areas on site. In
addition, 70 percent of employees of such businesses
should have been offered smoking cessation programs
by their employers by the year 2000." Wood adds
that a national survey of worksite health promotion,
which includes smoking in the workplace and data on
access to smoking cessation programs, is necessary.
(~736) Murtaugh confirms that many companies
have recently implemented policies without studying
their effects on smoking habits. (#159)
Some testifiers feel that health care facilities have
a special responsibility to set examples as nonsmoking
worksites. According to the National Hospitals
Tobacco Policy Survey, conducted by the American
Lung Association of Lancaster County and the
Pennsylvania Academy of Family Physicians, 93.6
percent of responding hospitals agreed that they have
a responsibility to discourage tobacco smoking within
their physical confines. Yet only 5.3 percent were
considered "smoke free," according to Terry duPont.
She recommends that by the year 2000, 75 percent of
all health care facilities be smoke free and 100
percent have smoking policies in place. (~054J
More emphasis also should be placed on training
physicians to counsel patients against smoking,
according to Robert Van Citters of the University of
Washington. (#779J
SMOKELESS TOBACCO
Smokeless tobacco was not addressed in the 1990
Objectives. Moon Chen of Ohio State University says
that this omission is not surprising because the
resurgence in the use of smokeless tobacco is a recent
phenomenon.6 (#039J Conan Davis of the Alabama
Department of Public Health explains, and others
agree, that Scientific evidence is strong that the use
of smokeless tobacco can cause cancer in humans.
The association between smokeless tobacco use and
cancer is strongest for cancers of the oral cavity.n7
(#249J Myers says that smokeless tobacco use also
is associated with stained teeth, bad breath, tooth
abrasion, leukoplakia, gingival recession, and bone
loss. (~405J Data show that smokeless tobacco has
made serious inroads among young people primarily
among males and particularly in the South. (#419)
Myers mentions that among certain groups, children
as young as kindergarten age are trying and using
smokeless tobacco and that most youth who use it
become regular users by the time they are 12 years
old. (#405) Bernard Turnock of the Illinois Depart-
ment of Public Health mentions a 1987 survey in
Illinois schools which revealed that of the eleventh
grade males in rural areas, 28 percent used smokeless
tobacco and 28 percent smoked cigarettes. (#215J
Education in this area is important, according to
Myers. (#405) Davis explains that attempts to re-
verse this increase must counter peer pressure, the
influence of the media and advertising, endorsements
by athletes and celebrities, the ease of obtaining and
using smokeless tobacco, and the widespread m~scon-
ception that it is safer than cigarette and other
smoking. (#249)
Several outcome objectives were proposed. Linda
Randolph of the New York State Department of
Health suggests reducing the proportion of males who
use smokeless tobacco In rural areas from 24 to 10
percent. (~177J Turnock adds that "by 2000, the
proportion of youth aged 21 and under who use
smokeless tobacco will be reduced to no more than 4
percent.' (#215) Chen further mentions several
objectives relating to reducing the prevalence of those
who have ever smoked from lSeS percents to 8
Tobacco 101
OCR for page 102
percent. (#039)
Chen proposes that "by 2000, all U.S. legal jurisdic-
tions should establish 18 as the minimum age to
purchase tobacco products, including snuff and
chewing tobacco, and ban distribution of free tobacco
products in public places." He also suggests objec-
t~ves dealing with the teaching of hazards due to
smokeless tobacco in elementary schools, making
health professionals and the public more aware of the
hazards, and devoting more funds to education and
research activities in this area. (#039)
IMPLEMENTATION ISSUES
To foster the success of the smoking outcome objec-
tives for the year 2000, many suggestions for
implementation, some in the form of process objec-
tives, were offered by testifiers. Many testifiers
recommended that new and more effective methods of
educating the general public and specific target groups
(including adolescents, especially girls; pregnant
women; ethnic minonties; and the poor) be devel-
oped, sometimes in combination with political action
or legislation.
Warner suggests that a professionally designed, paid
broadcast media advertising campaign be developed
against the use of tobacco and alcohol products, with
increased excise taxes on cigarettes being used to pay
for it. (~429) Ruth Roemer of the University of
California, Los Angeles also sees the need to limit
advertising and increase taxes.
Government has an obligation to protect the
health of the people, and a ban on advertising
would promote the social norm of a nonsmoking
society. Moreover, commercial speech enjoys
less protection than other speech, and the First
Amendment does not protect the right to
promote death. Since tobacco is addictive, every
influence promoting it should be eliminated.
Taxes and prices of tobacco products need to be
raised substantially and at regular internals, and
tobacco products should be excluded from the
cost of living index, if a significant decline in
smoking is to be achieved. (#184)
REFERENCES
Business executive Jack West of Puro Corporation
of America calls for rescinding farm subsidies for
tobacco. "Do not use my tax dollars against me,
against my employees' health. When my employees
are sick, I do not make any money." (~734) Young
says that "every state should have a coalition of
organizations to combat proliferation of tobacco
promotions." (#712) Action by health insurers to
offer differential rates for nonsmokers also has the
potential of decreasing smoking rates according to
John Banzhaf of Action on Smoking and Health.
(#516)
However, Rosner believes that "before the govern-
ment can advise any other organization on the issue
of smoking policy and cessation programs, it must get
its own house in order." A report by his Smoking
Policy Institute examining the response of various
federal agencies to regulations on smoking in govern-
ment facilities documented that "the government has
made progress, but still lacks consistent and com-
prehensive policies." (~349)
In terms of research, testifiers said that more data
are needed and should continue to be gathered on the
health hazards of passive smoking to nonsmoking
individuals, the evaluation of worksite smoking, the
reduction of smoking among minorities (#615), and
cost containment. Because Blacks have been a special
target for cigarette advertising, several testifiers point
to the need for focused research into ways to attract
Blacks into programs aimed at reducing smoking
rates. (#537; ~t615) Wood believes that the impetus
for collecting better information on the existence and
effectiveness of worksite policies and cessation pro-
grams will come from three sources:
First, the proliferation of municipal or state laws
requiring increasingly stringent worksite smoking
policies. Second, the pressure of media expo-
sure and a word of mouth from top
management about other businesses through
trade associations, coalitions, etc. And third,
the increasing voice of the nonsmokers within
the company. (#736)
1. U.S. Department of Health and Human Services: The 1990 Health Objectives for the Nation: A Midcourse
Review. Washington, D.C.: U.S. Government Printing Office, 1986
102 Healthy People 2000: Citizens Chart the Course
OCR for page 103
2. U.S. Department of Health and Human Selvices: Reducing the Health Consequences of Smoking: 25 Years
of Progress, A Report of the Surgeon General (DHHS Publication No. [CDC] 89-8411), 1989
3. Bachman JO, Johnston LD, O'Malley PM: Monitoring the Future: Questionnaire Responses from the
Nation's High School Seniors, 1986. Ann Arbor: Institute for Social Research, University of Michigan, 1988
4. Ibid.
5. Windsor R: An estimate of the behavioral, obstetric and economic impact of smoking cessation methods for
the annual U.S. cohort of pregnant women. Presented at the 75th Anniversary Meeting of the School of Hygiene
and Public Health, Society of Alumni. The Johns Hopkins University, Baltimore, June 7, 1989
6. Connolly ON, Winn DM. Hecht SS. et al.: The re-emer~ence of smokel~.~ tern N Fno1 ~ M^A
314(16):1020-1027, 1986
~.. ~. . ~.. ... .
~-Din I- ~ ~--At ~4~--~s
7. U.S. Department of Health and Human Services: The Health Consequences of Using Smokeless Tobacco: A
Report of the Advisory Committee to the Surgeon General (DHHS Publication No. [NIH] 86-2874), 1986
8. Centers for Disease Control: Smokeless tobacco use in the United States: Behavioral Risk Factor Surveil-
lance System, 1986e Morbid Mortal Wkly Rep 36~22~:337-340, 1987
TESTIFIERS CITED IN CHAPTER 10
002 Acampora, Gabrielle; Greater New York Association of Occupational Health Nurses
005 Allensworth, Diane; American School Health Association
039 Chen, Jr., Moon; Ohio State University
054 duPont, Terry; American Association for Respiratory Care
115 King, Caroler American Academy of Pediatrics
159 Murtaugh, Alice; New York
177 Randolph, Linda; New York State Department of Health
184 Roemer, Ruth; University of California, Los Angeles
215 Turnock, Bernard; Illinois Department of Public Health
230 Zal, Harriette; Southern California Association of Occupational Health Nurses
249 Davis, ~ Conan; Alabama Department of Public Health
267 Windsor, Richard; University of Alabama at Birmingham
349 Rosner, Robert; Smoking Polipy Institute (Seattle)
405 Myers, Jr., Woodrow; Indiana State Board of Health
419 O'Malley, Patrick and Johnston, Lloyd; University of Michigan
421 Welch, Robert and Sokol, Robert; Wayne State Universi~/Hutzel Hospital (Detroit)
426 Kaminsly, Kenneth; Wayne County Intermediate School District (Michigan)
429 Warner, Kenneth; University of Michigan
516 Banzhaf, III, John; Action on Smoking and Health (Washington, D.C.)
537 Greenberg, Michael; Rutgers University
615 Hargreaves, Margaret, et al.; Mehany Medical College
712 Young, Snip Walter; Colorado Department of Health
734 West, Jack; Puro Corporation of America (Maspeth, New York)
736 Wood, Loring; NYNEX Corporation
779 Van Citters, Robert; University of Washington
Tobacco 103
Representative terms from entire chapter:
smoking cessation
