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~ 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

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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

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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

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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

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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