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aim, prevention of smoking initiation is essential if the nation is to achieve a long-term permanent reduction in prevalence.) Understanding of nicotine addiction as a “pediatric disease” (Kessler 1995) also strengthened the ethical case for aggressive efforts to reduce smoking initiation by teenagers, even if the measures also had spillover effects on adult smokers. Reports by the Surgeon General and the Institute of Medicine in 1994 established the scientific foundation for a youth-oriented policy initiative (eventually spearheaded by Food and Drug Administration [FDA] Commissioner David Kessler in 1995) and also galvanized public opinion against the tobacco industry for targeting young people (DHHS 1994; IOM 1994).

Third, the state Medicaid lawsuits and other tobacco litigation led to revelations of industry deception and duplicity and confirmed the industry’s role in fostering and perpetuating tobacco use. These disclosures weakened the force of the antipaternalism principle as a constraint on tobacco policy and eroded the supposition that smokers have freely assumed the risks of smoking and are responsible for the often fatal consequences. Instead of being a champion of individual freedom and consumer sovereignty, the tobacco industry is now more often seen as a vector of disease and death, bringing public understanding into alignment with the premises of the public health community.

In sum, over the past 15 years, the operating assumptions of tobacco policy in the United States and elsewhere in the world have changed dramatically in part because of the fundamental realization that tobacco use is grounded in addiction to nicotine and that nicotine addiction typically begins before smokers become adults. Most smokers actually start smoking and become addicted while they are adolescents; and most addicted adult smokers want to quit, try to quit, and would rather be nonsmokers. The deeper public understanding of tobacco addiction has, over a short time, transformed the ethical and political context of tobacco policy-making. 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 (see material in Chapter 5 on the proliferation of state laws and local ordinances prohibiting indoor smoking and on increases in state tobacco excise taxes).

THE ETHICAL CONTEXT

The committee believes that this shift in popular sentiment rests on a solid ethical footing, and that the blueprint is securely grounded in either of two ethical frameworks.

From a traditional public health perspective, the legitimacy and importance of reducing tobacco use is grounded in the enormous social costs attributable to tobacco-related disease: reducing tobacco use increases over-



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