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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



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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 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.

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Ending the Tobacco Problem: A Blueprint for the Nation “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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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-

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Ending the Tobacco Problem: A Blueprint for the Nation 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.

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Ending the Tobacco Problem: A Blueprint for the Nation 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

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Ending the Tobacco Problem: A Blueprint for the Nation Contents SUMMARY   1 INTRODUCTION   29 PART I:  BACKGROUND     1   EPIDEMIOLOGY OF TOBACCO USE: HISTORY AND CURRENT TRENDS   41      Growth of the Tobacco Problem,   41      Decline in Tobacco Use: 1965–2005,   45      Recent Trends: A Closer Look,   51      Emerging Challenges,   68      Summary,   70      References,   71 2   FACTORS PERPETUATING THE TOBACCO PROBLEM   77      Nature of Nicotine Addiction,   77      Smoking Cessation,   82      Smoking Initiation,   88      Atypical Patterns of Tobacco Use,   93      Populations at Greater Risk of Continuing Smoking,   95      Conclusion,   97      References,   99 3   CONTAINING THE TOBACCO PROBLEM   107      Public Health Takes on the Tobacco Industry: 1964–1988,   109      Advances in Tobacco Control: 1988–2005,   116

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Ending the Tobacco Problem: A Blueprint for the Nation      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

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Ending the Tobacco Problem: A Blueprint for the Nation      Tobacco Advertising Should Be Further Restricted,   319      Youth Exposure to Smoking in Movies and Other Media Should Be Reduced,   330      Surveillance and Evaluation Should Be Enhanced,   333      Summary,   335      References,   336 7   NEW FRONTIERS OF TOBACCO CONTROL   341      Tobacco Policy Analysis and Development,   341      Reducing the Nicotine Content of Cigarettes,   346      Conclusion,   353      References,   353 INDEX   355 APPENDIXES1     A  ABRAMS: COMPREHENSIVE SMOKING CESSATION FOR ALL SMOKERS     B  BONTÃ: CLEAN AIR LAWS     C  FERRENCE: WARNING LABELS AND PACKAGING     D  FLAY: THE LONG-TERM PROMISE OF EFFECTIVE SCHOOL-BASED SMOKING PREVENTION PROGRAMS     E  HALPERN–FELSHER: ADOLESCENTS’ AND YOUNG ADULTS’ PERCEPTIONS OF TOBACCO USE     F  HALPERN–FELSHER: INTERVENTIONS FOR CHILDREN AND YOUTH IN THE HEALTH CARE SETTING     G  HALPERN–FELSHER: REDUCING AND PREVENTING TOBACCO USE AMONG PREGNANT WOMEN, PARENTS, AND FAMILIES     H  HALPERN–FELSHER: SMOKING IN THE MOVIES     1 All appendixes are available on a CD in the back of the report and at http://www.nap.edu/catalog.php?record_ id=11795.

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Ending the Tobacco Problem: A Blueprint for the Nation     I  KINNEY: STATE STATUTES GOVERNING DIRECT SHIPMENT OF ALCHOLIC BEVERAGES TO CONSUMERS     J  LEVY: THE ROLE OF PUBLIC POLICIES IN REDUCING SMOKING PREVALENCE     K  MENDEZ: COMMISSIONED SIMULATION MODELING OF SMOKING PREVALENCE AS AN OUTCOME OF SELECTED TOBACCO CONTROL MEASURES     L  RABIN: CONTROLLING THE RETAIL SALES ENVIRONMENT     M  RIBISL: SALES AND MAREKTING OF CIGARETTES ON THE INTERNET     N  SLATER: MEDIA CAMPAIGNS AND TOBACCO CONTROL     O  SPARKS: ADVOCACY AS A TOBACCO CONTROL STRATEGY     P  WALLACE: SPECIAL POPULATIONS WITH HIGHER RATES OF CIGARETTE SMOKING