GROWING UP
TOBACCO FREE

PREVENTING NICOTINE ADDICTION
IN CHILDREN AND YOUTHS

Barbara S. Lynch and Richard J. Bonnie, Editors

Committee on Preventing Nicotine Addiction
in Children and Youths
Division of Biobehavioral Sciences and Mental Disorders
Institute of Medicine

NATIONAL ACADEMY PRESS
Washington, D.C. 1994



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GROWING UP TOBACCO FREE PREVENTING NICOTINE ADDICTION IN CHILDREN AND YOUTHS Barbara S. Lynch and Richard J. Bonnie, Editors Committee on Preventing Nicotine Addiction in Children and Youths Division of Biobehavioral Sciences and Mental Disorders Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1994

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Page ii NATIONAL ACADEMY PRESS ··2101 Constitution Avenue, NW ··Washington, DC 20418 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 this report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This project was funded by the Robert Wood Johnson Foundation (Grant No. 20520-R); Metropolitan Life; the American Heart Association; by funds provided by the Cigarette and Tobacco Surtax Fund of the State of California through the Tobacco-Related Disease Research Program (Grant No. 3SP-0416); the Centers for Disease Control and Prevention and the National Institute on Drug Abuse (Grant No. M93-OSH-DASH); the Indian Health Service; the Center for Substance Abuse Prevention; and the National Cancer Institute, the Maternal and Child Health Bureau of the Health Resources and Services Administration, and the Agency for Health Care Policy and Research (Grant No. I-R13-CA62355-01). Library of Congress Cataloging-in-Publication Data Growing up tobacco free : preventing nicotine addiction in children and youths / Barbara S. Lynch and Richard J. Bonnie, editors; Committee on Preventing Nicotine Addiction in Children and Youths, Institute of Medicine. First Printing, September 1994 p. cm. Second Printing, January 1996 Includes bibliographical references and index. Third Printing, May 1997 ISBN 0-309-05129-0 Fourth Printing, October 1998 1. Children—Tobacco use—United States—Prevention. 2. Youth-Tobacco use—United States—Prevention. I. Lynch, Barbara S. II. Bonnie, Richard J. III. Institute of Medicine (U.S.). Committee on Preventing Nicotine Addiction in Children and Youths. HV5745.G75  1994 362.29'67'083—dc20                    94-31455                               CIP Copyright 1994 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 image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin. Credit: Cover artist, Juan Morrell, P.S. 54, Brooklyn. Cover poster and additional posters throughout book taken from Kids Say Don't Smoke by Andrew Tobias. Copyright 1991 by Andrew Tobias and Smokefree Educational Services, Inc. Reprinted by permission of Workman Publishing, New York.

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Page iii COMMITTEE ON PREVENTING NICOTINE ADDICTION IN CHILDREN AND YOUTHS Paul R. Torrens, M.D., M.P.H. (Chair) Professor of Health Services Administration Department of Health Services School of Public Health University of California, Los Angeles Albert Bandura, Ph.D. David Starr Jordan Professor of Social Science in Psychology Department of Psychology Stanford University Neal L. Benowitz, M.D. Professor and Chief Division of Clinical Pharmacology Departments of Medicine, Pharmacy, and Psychiatry School of Medicine University of California, San Francisco Richard J. Bonnie, LL.B. John S. Battle Professor of Law Director, Institute of Law, Psychiatry, and Public Policy University of Virginia School of Law K. Michael Cummings, Ph.D., M.P.H. Director, Smoking Control Program Department of Cancer Control and Epidemiology Roswell Park Cancer Institute Buffalo, New York Donald R. Dexter, Jr., D.M.D. Executive Director Klamath Tribal Health and Family Services Klamath, Oregon Ellen R. Gritz, Ph.D. Professor and Chair Department of Behavioral Science M.D. Anderson Cancer Center University of Texas, Houston Gerardo Marín, Ph.D. Professor of Psychology and Associate Dean College of Arts and Sciences University of San Francisco Mark Nichter, Ph.D., M.P.H. Professor Department of Anthropology University of Arizona, Tucson Peggy O'Hara, Ph.D. Associate Professor and Director of Graduate Programs in Public Health Department of Epidemiology and Public Health University of Miami School of Medicine Cheryl L. Perry, Ph.D. Professor Division of Epidemiology School of Public Health University of Minnesota

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Page iv Thomas C. Schelling, Ph.D. Distinguished Professor of Economics and Public Affairs School of Public Affairs University of Maryland at College Park Herbert Severson, Ph.D. Research Scientist Oregon Research Institute and Associate Professor School of Psychology University of Oregon Sarah Moody Thomas, Ph.D. Associate Director for Community Education and Applications Stanley S. Scott Cancer Center Louisiana State University Medical Center Institute of Medicine Staff Barbara S. Lynch, Ph.D., Study Director Robert Cook-Deegan, M.D., Director, Division of Biomedical Sciences and Mental Disorders Sharon Russell, Project Assistant

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Page v PREFACE In March 1991, the Institute of Medicine's Board on Biobehavioral Sciences and Mental Disorders identified the need for a study on preventing nicotine addiction in children and youths as one of its highest priorities, and directed the IOM staff to seek the resources required to conduct such a study. The Robert Wood Johnson Foundation generously took the lead in funding the project, joined by Metropolitan Life, the American Heart Association, the Tobacco-Related Disease Research Program (State of California), the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, the National Cancer Institute, the Maternal and Child Health Bureau of the Health Resources and Services Administration, the Indian Health Service, the Center for Substance Abuse Prevention, and the Agency for Health Care Policy and Research. In April 1993, a committee of 14 individuals was appointed to conduct an 18-month study on the prevention of nicotine dependence among children and youths, addressing the following tasks: ·  to review and evaluate the scientific literature on the epidemiology of nicotine dependence among children and youths; · to review and evaluate the scientific literature on primary and secondary prevention of nicotine dependence among children and youths; · to review and evaluate the scientific base of knowledge about the causes of nicotine addiction, including physiological, social, psychological, educational, and environmental factors; product advertising and promotion tactics; and public policy; · to review important "grass roots" programs on tobacco use and youths; and · to outline a research agenda that makes practical, science-based policy

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Page vi recommendations that will contribute to accomplishing the Healthy People 2000 Goals of reducing nicotine dependence among children and youths. The Committee met five times over the course of the study. It invited presentations and written submissions from experts in the field of tobacco control. The Committee also held six focus groups with adolescents in different geographical regions. In a cooperative effort with the Coalition for America's Children, the Committee conducted a survey of 250 organizations that have youth memberships or that serve youths. To assess the level of tobacco-related research relevant to youths, the Committee contacted federal research agencies and private foundations to solicit information about their activities related to youth tobacco use. In addition, the Committee carefully reviewed the extensive research literature on nicotine addiction and youths as well as the comprehensive summary and analysis of this literature compiled by the surgeon general in the 1994 report on smoking and health. 1 The relation between scientific knowledge and social policy is often complex and controversial. In this study, however, the Committee's task was immensely simplified by the clarity of the nation's public health objectives in relation to tobacco use. The premises of this report, as discussed in chapter 1, are that the nation has a compelling interest in reducing the morbidity and mortality caused by nicotine addiction, and that nicotine addiction can be most efficiently reduced in the long run by preventing children and youths from using tobacco products and from becoming addicted to them. The question is not whether society should try to prevent tobacco consumption by children and youths, but rather how this objective should be accomplished. The disputed issues, in short, relate to means, not ends. Within this framework, the Committee has sought to conduct a rigorous and open-minded inquiry. The Committee has identified the menu of social interventions that might be undertaken to prevent nicotine addiction among children and youths and reached a common view regarding the policies and programs that are likely to be most effective in achieving this goal. These issues are largely, though not exclusively, scientific ones. The main questions are whether and to what extent a given policy or program can be expected to reduce the onset of tobacco use and addiction among children and youths. Informed judgments on these questions provide an essential foundation for prudent policymaking and priority-setting. The Committee could have confined itself to scientific judgments about the efficacy of various policies and programs, leaving to policymakers the evaluative task of weighing the costs of these interventions against anticipated public health gains. However, the Committee was charged with the additional responsibility of making "practical science-based policy recommendations that will contribute to accomplishing the Year 2000 goals of reducing nicotine dependence among children and youths." The Committee has tried to respond to this challenge.

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Page vii The material in this report is organized as a blueprint for policymaking. In the context of each type of intervention, the Committee has summarized the pertinent empirical evidence and sought to demonstrate why, in our opinion, the recommended policies or programs are justified. The Committee did not think it necessary to duplicate in this report all the information on the etiology of smoking by children and youths appearing in the surgeon general's recent report. Instead, the Committee presents the information bearing most directly on the potential effects of policies and programs designed to reduce nicotine addiction among children and youths. In conducting its study and writing this report, the Committee has benefitted immensely from the path-breaking efforts of researchers and policymakers in other countries, especially Canada, Australia, New Zealand, and Finland, and from information provided by the World Health Organization and the International Union Against Cancer. This debt can be partially repaid if the proposals made in the report provide a useful model for reformers in other parts of the globe. Tobacco use is a worldwide epidemic, and every nation is confronted by a challenge similar to the one faced in the United States. During the 1990s in developed countries, tobacco will cause approximately 30% of all deaths among persons 35-69 years of age, making it the largest single cause of premature death in the developed world. 2 The global health burden of tobacco use is likely to increase geometrically in the coming decades. It also seems likely that aggressive marketing by the international tobacco companies will require an aggressive response by public health officials in the developing world and in the countries of Central and Eastern Europe and the former Soviet Union. The Committee was not charged to address international tobacco control. In the course of its deliberations, however, the Committee unanimously reached the conclusion that decisive actions taken here at home to promote a youth-centered strategy to prevent tobacco-related disease and death should be accompanied by an unequivocal commitment to help other nations achieve similar aspirations. REFERENCES 1. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services, 1994. 2. Peto, Richard, Alan D. Lopez, Jillian Boreham, Michael Thun. and Clark Heath. Jr. "Mortality from Tobacco in Developed Countries: Indirect Estimation from National Vital Statistics." The Lancet 339 (1992): 1268, 1274-1275.

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Page ix ACKNOWLEDGMENTS The Committee on Preventing Nicotine Addiction in Children and Youths expresses its appreciation to the co-funders of this 18-month study: the Robert Wood Johnson Foundation, Metropolitan Life, the American Heart Association, the Tobacco-Related Disease Research Program of California, the Centers for Disease Control and Prevention, the National Institute on Drug Abuse, the National Cancer Institute, the Maternal and Child Health Bureau of the Health Resources and Services Administration, the Indian Health Service, the Center for Substance Abuse Prevention, and the Agency for Health Care Policy and Research. The Institute of Medicine thanks each of the institutions with which the Committee members are affiliated for the time and support services involved in the work of the Committee members and in the preparation of the report. The IOM extends special appreciation to Cornell University School of Law for its assistance to Richard Bonnie, who was a visiting professor at Cornell during the year of the Committee's work. Many persons outside of the Committee contributed to this study in various ways. The Committee gratefully acknowledges the assistance of the reviewers of the report, as well as the coordinator and monitor of the review process, all of whom made valuable suggestions for improving the report. Numerous other individuals provided technical information by sending materials, by engaging in telephone discussions, by making presentations to the Committee, and by writing background papers. The following consultants made presentations at Committee meetings: Ron Davis, M.D., Chief Medical Officer, Michigan Department of Health;

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Page x Cliff Douglas, Manager, Government Relations, American Cancer Society, Washington, D.C.; Gary Giovino, Ph.D., Chief, Epidemiology Branch, Office of Smoking and Health, Centers for Disease Control and Prevention; Larry Gruder, Ph.D., Director, Tobacco-Related Disease Research Program, University of California, Berkeley; Don Shopland, Coordinator, Smoking and Tobacco Control Program, National Cancer Institute, Bethesda, Maryland; John Slade, M.D., Associate Professor of Medicine, St. Peter's Medical Center, New Brunswick, New Jersey; Larry Wallack, Dr. P.H., Professor, School of Public Health, University of California, Berkeley. The following consultants presented commissioned background papers to the Committee: Judy Butler, Research Associate, Stanford Center for Research in Disease Prevention, Stanford University; Anthony Comerford, New Hope Foundation, Inc., and John Slade, M.D., St. Peter's Medical Center, New Brunswick, New Jersey; John Pierce, Ph.D., Associate Professor and Head, Cancer Prevention and Control, University of California, San Diego. The following research assistants were especially helpful in providing information and assistance to the Committee: Laura Akers, Oregon Research Institute, Eugene, Oregon; Peter Christianns, University of Miami, Department of Public Health; Elizabeth Davidson, University of Virginia, School of Law. Finally, numerous individuals helped expedite preparation of the report by providing assistance on a temporary or as-needed basis. The Committee thanks Karen Autrey, Jay Ball, Claudia Carl, Holly Dawkins, Mike Edington, Linda Humphrey, Brian Huse, Lynn Leet, Constance Pechura, Zoe Schneider, Gail Spears, Nina Spruill, Sally Stanfield, and Mike Stoto. During the course of the study, the Committee, in conjunction with the Coalition for America's Children, conducted a survey of the coalition's 250 member organizations to determine whether they have policies and programs for tobacco control. The survey provided information about the potential role of organizations that serve young people. As a means of providing input to the Committee from experts in the field of substance abuse prevention, the Institute for Health Promotion and Disease Prevention Research of the University of Southern California planned a prevention conference to dovetail with a meeting of the Committee. The presentations and recommendations that were generated at that meeting were considered by the Committee in its deliberations. As a

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Page xi means of assessing the level and type of research funding that is invested in nicotine addiction and tobacco control, the IOM staff conducted a search of all relevant government agencies and foundations for abstracts describing funded research on nicotine prevention in youths since 1990. A summary of those projects and funds is included in chapter 9. The Committee appreciates the efforts of all persons who made the above surveys and conference possible.

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Page xiii CONTENTS 1  TOWARD A YOUTH-CENTERED PREVENTION POLICY 3 2  THE NATURE OF NICOTINE ADDICTION 29 3  SOCIAL NORMS AND THE ACCEPTABILITY OF TOBACCO USE 71 4  TOBACCO ADVERTISING AND PROMOTION 105 5  PREVENTION AND CESSATION OF TOBACCO USE: RESEARCH-BASED PROGRAM 143 6  TOBACCO TAXATION IN THE UNITED STATES 177 7  YOUTH ACCESS TO TOBACCO PRODUCTS 199 8  REGULATION OF THE LABELING, PACKAGING, AND CONTENTS OF TOBACCO PRODUCTS 233 9  COORDINATION OF POLICIES AND RESEARCH 257 APPENDIXES   A  Specific Recommendations, by Chapter 281 B  Committee Biographies 289 INDEX 299

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