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Recent data show that progress has stalled toward achieving the Healthy People 2000 goal of reducing, by half, smoking initiation among youths. Preventing smoking initiation by youths is the most efficient means of reducing long-term morbidity and mortality from heart disease, cancer, chronic lung disease, and other tobacco-related disorders.

In recent years, the emphasis of tobacco control has been shifting from interventions aimed at individual smokers to those intended to change the social environment in which tobacco use takes root. The most effective preventive measures are likely to be universal interventions that reduce youth access to tobacco products and that promote and reinforce a tobacco-free social norm. These measures generally fall in the realm of social policy—taxation of tobacco products, enforcement of youth access laws, constraints on advertising and promotion, regulation of tobacco products, and tobacco control advocacy for tobacco-free environments.

Previous chapters have dealt with the addictive process, promotion of a tobacco-free social norm, preventive and cessation interventions, advertising and promotion of tobacco, pricing and taxation, youth access, and regulation of tobacco products. The potential policies are numerous and diverse, but the Committee has made specific recommendations in those chapters for policy measures it believes will achieve the greatest reduction in tobacco use in the shortest time. Those recommendations will not be repeated or summarized here. This chapter focuses on the coordination of policy and research on the implementation of comprehensive approaches to tobacco control.



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Page 257 Recent data show that progress has stalled toward achieving the Healthy People 2000 goal of reducing, by half, smoking initiation among youths. Preventing smoking initiation by youths is the most efficient means of reducing long-term morbidity and mortality from heart disease, cancer, chronic lung disease, and other tobacco-related disorders. In recent years, the emphasis of tobacco control has been shifting from interventions aimed at individual smokers to those intended to change the social environment in which tobacco use takes root. The most effective preventive measures are likely to be universal interventions that reduce youth access to tobacco products and that promote and reinforce a tobacco-free social norm. These measures generally fall in the realm of social policy—taxation of tobacco products, enforcement of youth access laws, constraints on advertising and promotion, regulation of tobacco products, and tobacco control advocacy for tobacco-free environments. Previous chapters have dealt with the addictive process, promotion of a tobacco-free social norm, preventive and cessation interventions, advertising and promotion of tobacco, pricing and taxation, youth access, and regulation of tobacco products. The potential policies are numerous and diverse, but the Committee has made specific recommendations in those chapters for policy measures it believes will achieve the greatest reduction in tobacco use in the shortest time. Those recommendations will not be repeated or summarized here. This chapter focuses on the coordination of policy and research on the implementation of comprehensive approaches to tobacco control.

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Page 258 THE ROLE OF THE FEDERAL GOVERNMENT Leadership The most important role of the federal government is to provide leadership for the nation in a comprehensive multi-pronged effort to achieve a society free of tobacco-related disease and death. This responsibility requires the setting of goals, together with a visible and emphatic commitment to achieve those goals. As discussed below, this does not mean that the federal government should try to manage or direct state and local initiatives or those of the private sector. The nation does not need a "czar" of tobacco control. However, the federal government must commit itself to the effort and, by its own actions, lead the way. Until now, this has not been the case. There are important signs of change. The General Services Administration has established a smoke-free policy for federal buildings. The Occupational Safety and Health Administration (OSHA) has initiated a rule-making process that could require smoke-free policies for all workplaces covered by OSHA. The Department of Defense has implemented a smoke-free workplace policy. The Food and Drug Administration has initiated an important discussion regarding the need for regulation of tobacco products. The surgeon general's 1994 report on smoking and health was devoted to children and youths and, upon its release, Surgeon General Elders called for restriction on advertising and promotion of tobacco products. Since 1964, the surgeon general has provided the most consistent and most authoritative federal voice on tobacco control. The annual reports on smoking and health have documented the health consequences of tobacco use and disseminated new research findings to broad public and scientific audiences, and substantial progress in reducing smoking prevalence has been achieved over the past three decades, since Surgeon General Luther Terry issued the federal government's first comprehensive report on the devastating health toll caused by smoking. However, the surgeon general has no direct-line authority to regulate tobacco products, provide technical assistance to states, monitor public health, conduct research, or provide service. Nor does the surgeon general have the authority to manage or coordinate these activities, which are spread throughout the Public Health Service. In the Committee's view, however, the problem of coordination, which will be addressed below, is separate from the issue of leadership. Federal leadership requires an unequivocal commitment to tobacco control, and specifically to a youth-centered tobacco control policy, that is acknowledged and vigorously pursued by all agencies of the federal government. This means that the goal of preventing nicotine addiction must be enunciated clearly and that the specific objectives of Healthy People 2000 (and successor documents) should

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Page 259 set the template for all federal activities. The commitment must be unequivocal and visible throughout the Executive Branch and in Congress. Regulation of the Tobacco Industry The most evident failure of federal leadership has been in Congress. In some instances, legislative action has actually retarded progress toward tobacco control. Many of the major recommendations in this report are directed to Congress, including those that have the highest priority in the Committee's view. Specifically, Congress should enact a major increase in tobacco excise taxes to discourage consumption as well as raise revenues. Congress should repeal the law that preempts state and local regulation of advertising and promotion occurring exclusively within the state's boundaries, and should also enact comprehensive restrictions on advertising and promotion of tobacco products. Congress should also rectify its massive regulatory default by enacting a comprehensive scheme for regulating the labeling, packaging, and constituents of tobacco products, and by conferring regulatory authority on FDA or a separate tobacco control agency. Some federal regulatory initiatives can be undertaken without congressional action. The Food and Drug Administration could use its existing authority to regulate tobacco products and labeling. The Federal Trade Commission could take a more active role in assuring that advertising and promotion of tobacco complies with existing statutory requirements. The Environmental Protection Agency has stepped forward in recent years to review the effects of environmental tobacco smoke, and OSHA is considering regulations restricting smoking in the workplace. The Department of Transportation has promulgated regulations that ban smoking on domestic airline flights. An active, multi-pronged regulatory effort at the federal level can set the tone for analogous actions at the state and local levels. Monitoring Public Health and Providing Technical Assistance to States One of the most promising federal initiatives in recent years has been community mobilization efforts for state-level tobacco control. This effort evolved from research and is developing into a technical assistance function that the federal government provides to the states. The movement was pioneered by the National Cancer Institute (NCI) through its American Stop Smoking Intervention Study (ASSIST), which concentrates on building a statewide infrastructure through a state's department of health and through local coalitions. The coalitions mobilize the community to conduct policy and media advocacy activities. The idea for the ASSIST program grew out of decades of work at NCI, particularly strategic planning by the Smoking and Tobacco Control Program.1 In 1991, NCI funded 17 states to participate in the ASSIST program, which

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Page 260 encompasses 2 years of assessment, analysis, and planning, and 5 years of program implementation. During that time, states will attempt to build permanent capabilities for continuing tobacco control activities when federal funding ceases. In 1993, in its IMPACT Project, CDC initiated cooperative agreements with the non-ASSIST states to help them develop tobacco control efforts. Similarly, through the SmokeLess States program, the Robert Wood Johnson Foundation has funded 10 states to enhance their efforts. The Committee commends the National Cancer Institute, the Centers for Disease Control and Prevention, and the Robert Wood Johnson Foundation for these important programs, but has several concerns about their future. As initially planned, the ASSIST program is time-limited. ASSIST is a demonstration program, a culmination of a research approach; in time, the emphasis should shift from demonstration to permanent program operation and support. To expedite the progress of state-based policy efforts, the CDC IMPACT states, which currently receive an average of $211,000 per year (for core states) and $74,000 per year (for states in the planning phase), should be funded to an amount commensurate with their task. The ASSIST states receive an average of $900,000 per year. Funding to the non-ASSIST states should be increased to a level commensurate with ASSIST states. This could be accomplished by expanding the current ASSIST project to non-ASSIST states with an expectation of long-term support, or by increasing CDC's IMPACT program to increase the funding per state to ASSIST levels and expanding the program to include ASSIST states as NCI funding terminates. The NIH Revitalization Act of 1993 opted to increase the set-aside of annual NCI cancer control activities and exhorted NCI ''to assume increasing leadership in the demonstration, implementation, and operation of programs to reduce or control the incidence of cancer" and specifically to use the increased funds "to fully fund each of the existing 17 ASSIST states and support related programs of the 33 states without ASSIST programs" (Report of the Conference Committee on S.I, Congressional Record 139:72 [May 20, 1993]: H2648). The Committee believes that state-based efforts along the line of the ASSIST and IMPACT programs are among the most promising policy initiatives. For effective continuation, these programs will require either a commitment to practical operation of a non-research effort at NCI until states develop the requisite infrastructure, a significantly increased funding and staffing of the IMPACT program at CDC, or a combination of the two options. The level of federal funding should depend on whether the states have successfully established the infrastructure required to sustain the tobacco control effort over the long term. The federal funding role is not envisioned to be a permanent one. How long it will be necessary remains to be seen. The program of technical assistance to states is but one of the promising avenues pursued by the Office on Smoking and Health (OSH), whose budget

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Page 261 rose from $3.5 million in 1984 to $20 million in 1994.2 CDC is also the nation's preeminent public health monitoring agency, with a series of health-reporting structures and periodic national data-gathering surveys. Tracking statistics on smoking, use of smokeless tobacco, and health outcomes such as the morbidity and mortality caused by tobacco-related diseases will be an essential feature of national tobacco control policy. Gathering those data is one of CDC's main functions. In addition to CDC, the Office of the Assistant Secretary for Health and the Inspector General's Office of the Department of Health and Human Services have important public health monitoring functions. The inspector general monitors the functioning of the agencies with the department, and has issued reports on various aspects of tobacco control. The Office of the Assistant Secretary for Health administrator, the Public Health Service, and its Office on Health Promotion and Disease Prevention coordinate prevention activities throughout the Public Health Service, including progress toward achieving the goals set forth in Healthy People 2000. Support of Research The federal government has traditionally carried the major responsibility for funding tobacco-related research. In recent years, other sponsors, such as the California Tobacco-Related Disease Research Program, funded under Proposition 99, and the Robert Wood Johnson Foundation, have underwritten important investigations. Even with diversification of support, however, the federal government will continue to play a central role. In so doing, federal agencies should coordinate their efforts in order to ensure that research support is available for all aspects of tobacco-related research. The research strategy should be rooted in a comprehensive public health model of nicotine addiction, one that encompasses environment, agent, host, and vector. ("Vector" refers, in this paradigm, to the industry.) Specifically, further research is needed to elucidate the basic biology of addiction and how tobacco use results in adverse health outcomes. Such research is needed to provide valuable clues about how better to prevent nicotine addiction and to avoid specific diseases associated with tobacco use. Simultaneously with a basic and clinical research agenda, a complementary agenda should be supported to conduct epidemiologic studies to identify the characteristics of children and youths most at risk for initiating tobacco use, behavioral research to test prevention programs, sociocultural research to elucidate differences in risk and responsiveness to prevention interventions among various ethnic and racial groups, and surveillance to monitor the trends in tobacco use. Epidemiologic research should include nationally representative samples, preadolescents at the beginning of longitudinal investigations, and multiple levels

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Page 262 of risk factors, including larger social-environmental factors (such as price, exposure to advertising, and promotional activities). Such studies would necessitate large sample sizes and careful selection of proximal to distal factors but might provide a more complete explanation of etiology than that which is currently available. Particular attention should be paid to further understanding some of the well-known risk factors and correlates of tobacco use, such as low socioeconomic status, and psychosocial characteristics, such as sensation-seeking. Knowledge about health interventions and the system of care is needed in addition to understanding the biology of addiction and the mechanisms of tobacco-related disease. The Agency for Health Care Policy and Research (AHCPR) is the part of the federal Public Health Service responsible for carrying out health services research. This includes the study of health outcome measures, clinical practice guidelines, quality assurance, and system performance indicators. AHCPR has, for example, focused on clinical use of nicotine patches in the treatment of nicotine addiction. AHCPR could, in addition, become the home for policy-relevant research focused on the health care system. A Multicultural Research Agenda The marked divergence in smoking prevalence between African-American teens and white teens over the past decade, for example, is clear in multiple data sets, but its underlying cause is unknown. Some attribute the disparities to reporting bias, that is, they believe that African-American youths report lower than actual use. To explain the differences in the data, this reporting bias would have to be selective for African-American youths compared with other groups, and would also have to differ consistently between younger and older African Americans. If there is consistent bias, it may be that the survey instruments used to gather the data are culturally biased and need to be improved. If, on the other hand, the results reflect a real trend, the implications are intriguing and important. It could be that progress in tobacco control among African-American youths is a success story revealing a stronger tobacco-free norm, or a failure of tobacco advertising to reach this market segment. If the norm was created by a specific intervention of, for example, churches, or by cultural consensus against youth tobacco use, then efforts to pursue similar measures for other populations might be productive; if the reductions stem from lack of attention from advertisers, or inadvertent alienation of African-American youths from advertising messages, then it could be highly instructive to learn how these processes worked, in hopes of devising effective measures for other groups. The United States comprises an immense diversity of subcultures, both rural and urban, within this multiethnic, multiracial population. The Committee has also repeatedly observed in reports from national data and small pilot studies, and in focus groups conducted by Committee members, that tobacco use varies

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Page 263 regionally and among ethnic and social groups and even within these groups. Hence, underlying the aggregate statistics that describe large-scale trends over time is a multitude of differences in norms and behaviors regarding tobacco use. Elucidating those differences requires social science research. Much more work is needed to elucidate the etiologic factors that affect prevalence of tobacco use among different cultural groups and to understand how environmental and cultural influences interact with biological factors. The public health goal of reducing tobacco use is clear, but the appropriate approach to achieving that goal is certain to depend critically on social organization and cultural norms. Social science research should be conducted to enhance understanding of how norms are formed and transmitted, and of the regional and cultural differences in the acceptability of tobacco use. A Youth-Centered Research Agenda The Committee requested descriptive abstracts of research studies and funding amounts from all federal agencies known to have research programs related to youth tobacco use and control, and from private foundations and large state efforts. Our analysis of data obtained from the CRISP system (Computer Retrieval of Information on Scientific Projects) shows that total funding for research grants from 1990 to 1993 on issues related to tobacco use by children and youths was approximately $119 million. Of this amount, about $47.5 million (less than half) supported primary research efforts, that is, studies that identified youth tobacco issues as the principal subject of investigation. The remainder of related research funding went to studies that included youth tobacco issues as incidental (secondary) to the investigation. It is important to note that not all primary studies directly or specifically targeted issues related to youth tobacco use. Primary studies included research that looked at all related issues, such as the effects of environmental tobacco smoke exposure on respiratory control in infants, the effects of in utero exposure to the components of tobacco on fetal growth and development, the effects of cigarette smoke constituents on the immune system, smoking cessation programs for pregnant women, and so on. Funding for primary research that directly and specifically targets tobacco use in children and youths represents approximately 25% ($30 million) of the total for those years. Breaking the research into categories by type, in addition to principal focus (primary versus secondary), reveals a clearer picture of public health funding for research on tobacco use in children and youths. For the purposes of this report, research was placed in one of five categories for analysis: basic science, epidemiology, prevention, cessation, and psychosocial factors. Basic Science (biophysiologic, pharmacologic, technologic, and/or training studies): Primary studies were funded for around $3.5 million; however, no

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Page 264 research dollars were reported on basic research specifically relating nicotine addiction or the biological consequences of tobacco use to children and youths. Epidemiology (prevalence, relation to disease, and/or risk factor studies): Primary epidemiologic research directly targeted to tobacco use in children and youths (2 studies) accounted for a little over $500,000, or around 10% of all dollars spent on primary epidemiologic research. Prevention (school-based, community-based, and skills training projects, policy studies, and/or education through the media): Twenty primary research studies on prevention of initiation were targeted directly to children and youths, representing just over half ($22.5 million) of total grant monies allocated for prevention studies. While proportionately more funding went to prevention research, this amount is still less than one-fifth of all research dollars allocated for youth tobacco-related research for the period. Cessation (school-based, community-based, and skills training projects, policy studies, and/or education through the media): Studies directly targeted to cessation of tobacco use in children and youths (5 studies) accounted for almost $6 million of about 13.5 million primary cessation dollars allocated. Psychosocial (theoretical models of behavior change, social factors or predictors of tobacco use, and/or development of assessment tools):  Primary psychosocial research received just under $3 million in funding, of which about half ($1.4 million) was specifically directed to tobacco use by youths (5 studies). In all five categories of primary research, 32 of the 62 funded studies directly targeted tobacco use in children and youths. Of these 32 studies, 8 addressed culturally specific populations (1 study looked at Hispanic, African American, and non-Hispanic white teens, one at Hispanic teens only, 4 at American Indian teens only, and 2 at African American teens only). Of these 8 studies, 6 were prevention studies and 2 were epidemiologic studies. One primary study directly targeted to children and youths addressed policy. This was one prevention study that looked at local policy change to reduce tobacco availability. Four studies looked specifically at preventing the use of smokeless tobacco by youths, while an additional 8 studies included smokeless tobacco use in conjunction with smoking prevention. After reviewing these data, the Committee concluded that the focus of the research effort relative to youths and tobacco use has been preventive interventions, especially school-based interventions. These interventions have achieved some success, and such efforts should continue to be an element in a youth-centered tobacco control policy. Unfortunately, few if any of these studies explored in a culturally appropriate way the group-specific characteristics of tobacco use among members of the major ethnic groups in the United States. Apart from the preventive intervention research, however, the research base is weak. For example, despite intriguing and potentially important insights about ethnic differences in youth smoking that have been widening for two decades,

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Page 265 there are only two epidemiologic studies for a total of $500,000 focused on youth. The Committee did not find quantitative or qualitative sociological or anthropological studies that might test the validity of the reported ethnic differences, or elucidate the mechanisms if they are indeed valid. Only 5 studies address the wealth of social and interpersonal influences that the Committee believes are central to youth initiation. And the federal support for policy studies is extremely weak with only a single study, except to the extent that youth smoking is made part of NCI's ASSIST, CDC's states initiative, and the general service programs of the Center for Substance Abuse Prevention (CSAP). The budgets for research on the diseases caused by tobacco use—such as cancer, heart disease, and lung disease—are considerably larger than the amounts devoted to direct study of the cause—tobacco use. The NCI budget for tobacco research and control was $47 million in 1991 and $60 million in 1993.3.4 Smoking accounts for an estimated 30%  of deaths from cancer, for example, but tobacco control accounts for only about 3% of the National Cancer Institute's $2 billion budget. Tobacco use is linked to 20% of deaths from heart disease and is the main cause of chronic lung disease,5 but tobacco-related research accounts for only $24 million of the National Heart, Lung, and Blood Institute budget, and only $122 million of the total NIH budget.6 Nicotine is the most prevalent addiction, and the health toll from tobacco is vastly greater than that for illicit substances, and yet relatively little nicotine research is supported by the National Institute on Drug Abuse. While the disability caused by tobacco use should not necessarily bear a linear relationship to the research effort at the federal research institutes, the Committee nonetheless believes that nicotine addiction and the health effects of other tobacco constituents merit greater emphasis. The Committee concludes that initiation of tobacco use by youths is a critical event in the causation of a large number of severely disabling and deadly conditions. Federal agencies that sponsor tobacco-related research should increase the resources devoted to understanding and preventing initiation of tobacco use by children and youths. In particular, attention should be given to the factors that predict tobacco use initiation among members of the major ethnic groups in the United States. The critical problem of youth initiation has received inadequate research support, and studies that explicitly attend to youth should be given high program priority. As background for this effort, Congress might request that the relevant federal agencies (1) prepare a baseline report on their specific research activities aimed at preventing initiation of youth tobacco use during the past 5 years, and (2) use that foundation as a starting point for developing long- and short-term research plans, with funding needs and allocations specified. Congress should require a tracking of progress, possibly by requesting the federal agencies to prepare annual reports summarizing program announcements, requests for applications, targeted training grants, relevant program project and center grants, and other relevant activities.

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Page 266 A Policy-Oriented Research Agenda In its review, the Committee was constrained by the dearth of policy research on tobacco control. Policy research, both empirical and theoretical, is conducted to generate information useful in making and implementing policy choices by local, state, and federal governments and by the private sector. Policy research is usually interdisciplinary, involving the social sciences and other fields. It includes, for example, studies of how excise taxes decrease consumption, how community organization affects the effectiveness of tobacco control measures, how enforcement of youth access laws can reduce illicit sales, the impact of "tombstone" advertising on sales and use rates, and similar studies. In particular, policy research that distinguishes what is effective for youths is lacking. If tobacco control policies come to focus on prevention of youth initiation, determining what works for youths, regardless of its effectiveness for adults, will be important. For example, policy studies support the concept of an increase in the excise tax (and hence price) as a means of reducing purchases (and presumably use) among youths. As discussed in chapter 6, data indicated that youths are sensitive to price; smoking prevalence declines among youths when the price of cigarettes increases. Evidence from California also support this price-sensitivity hypothesis for the general population.7 Determining the effect of price on the purchasing behavior of youths is a central question in tobacco control. This is but one example of important unanswered questions amenable to research which, if answered, could lead to effective policy and program choices for preventing nicotine addiction in children and youths. Recently, general policy initiatives have been introduced. The Robert Wood Johnson Foundation (RWJF) initiated a tobacco policy research program in 1991, and renewed that effort in 1993; the National Cancer Institute began a $1 million policy research effort in 1993. The California and Massachusetts programs have also included a component of policy research. Federal agencies should give special attention to research on the efficacy of policies aiming to prevent initiation of tobacco use by youths. Services Several agencies of the federal government provide or fund services relevant to youth tobacco use. The Health Resources and Services Administration funds grants and demonstrations for health programs, primarily through block grants. The Center for Substance Abuse Prevention also funds block grants, but its mission is focused as its name implies. CSAP's mandate was expanded in 1993 to include nicotine addiction, and recent grants have reflected this change. Services for treatment are federally funded through the Center for Substance Abuse Treatment, a sister agency to CSAP. In addition to their block grant authority, the Health Resources and Services Administration, the Center for Sub-

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Page 267 stance Abuse Prevention, and the Center for Substance Abuse Treatment also have technical assistance mandates. CSAP, for example, has established a clearinghouse for substance abuse prevention programs, which will be a national clearinghouse and technical assistance center. It will include tobacco products under its purview, although it will also address alcohol and illicit drugs. In addition to the agencies that fund primarily through block grants, several federal agencies provide direct services. The Department of Defense provides health services for those in the military and their dependents. It also manages commissaries, post exchanges, and other tobacco outlets, and controls policies over tobacco use on its bases and in its facilities. The Indian Health Service (IHS), part of the Public Health Service, provides services to American-Indian populations throughout the nation. Because of its expertise and access to American-Indian populations, IHS is ideally suited to address the distinctive tobacco use issues among the various tribes, for example, the high rates of use of smokeless tobacco by boys and girls in some tribes. The Department of Education prepares curriculum aids for health education to assist teachers throughout the nation; these can incorporate a focus on the use and harmful effects of tobacco products. This mechanism has been used to produce programs on drug abuse, and could be similarly used in the education of youths about tobacco use. Some ASSIST states have included educational materials that could be used as models. THE ROLE OF STATE AND LOCAL GOVERNMENTS Much of the leadership on tobacco control has come from states and local governments. In 1988, California passed Proposition 99, which increased the state excise tax by $0.25 per pack and devoted a fraction of those revenues to support education (20% was stipulated by law, but the actual figure has never matched this) and research (5%). In 1992, Massachusetts also passed a comprehensive tobacco control package. In 1993, 23 states passed 37 less comprehensive tobacco control laws, including excise tax increases, youth access restrictions, vending machine restrictions, indoor air controls, public smoking bans, and other measures—many of which will have an impact on youth tobacco use. This state initiative is similar to NCI's ASSIST program, CDC's initiative to bolster state public health departments, and the RWJF SmokeLess States initiative. Local governments have passed a multitude of ordinances against smoking in public places and workplaces, restricting vending machines, and establishing licensing procedures. By May 1993, NCI found that there were more than 700 such ordinances nationwide.8 In tobacco control, the federal government has lagged well behind the more venturesome states and local governments. One feature of Proposition 99 that most appealed to voters was the direct linkage between the new excise tax and expenditures on tobacco control (education and research). A similar measure would have been unlikely to emerge from

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Page 268 the legislative process, because it crosses the jurisdictional boundaries of committees. (One committee controls tax collection and finances, and other committees control expenditures.) By linking taxes collected to tobacco control measures, Proposition 99 created a tax that, if successful in reducing tobacco use, also reduces public expenditures toward that end. This has already begun to happen in California. In addition to this self-regulating feature, however, the linkage between levying a tax and using it to promote a directly related public health goal helps focus political accountability. Unfortunately, that same linkage has made the program a continuing source of political wrangling, as the tobacco industry confronts the tobacco control features. The educational and research elements funded by Proposition 99 have, therefore, gone through many fits and starts in their short and tempestuous history. In addition to the dedicated tobacco control programs that have emerged in a few states, all states also maintain a capacity to monitor public health, provide services, and regulate products—functions parallel to those discussed above for the federal government. The exact configuration of these functions varies widely, but all states have some public health capacity that can incorporate tobacco control policies. Most states do not sustain a large research capacity, unlike the federal government, although California has been an exception in this regard: the Tobacco-Related Diseases Research Program is larger than its counterparts in federal agencies, remarkable given its origin in a single state. Much work of national importance is thus being supported by this one state's research program. The nation would benefit if other states were also to contribute to research as they become more engaged in tobacco control. Discussions on the tobacco excise tax at the federal level have to date focused on generating revenue for health care reform and other programs, not on the public health goal of reducing use of tobacco products. There has been little discussion of replicating this feature of the California tobacco control program. The Committee acknowledges that an exactly parallel program at the federal level is politically and practically infeasible. Making a tax policy serve the purposes of public health cuts across jurisdictions among congressional committees, making it difficult to develop a coherent policy. Furthermore, many executive branch agencies already have a role in tobacco control, a situation more complex than in many states where tobacco control is being developed. And there is no federal counterpart to citizen-initiated ballot initiatives such as Proposition 99. For these reasons, the states are likely to provide the policy leadership and models for the federal government rather than the reverse. THE ROLE OF PRIVATE SECTOR ORGANIZATIONS Tobacco control policy has largely grown from the bottom up; private organizations have been crucial to the policy successes that have been achieved. Many corporations, labor unions, religious organizations, and other

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Page 269 groups have taken steps on their own, without government pressure, to discourage tobacco use. Their actions have served as models for other organizations. Private voluntary health organizations such as the American Cancer Society (ACS), the American Heart Association (AHA), and the American Lung Association (ALA) have also played crucial roles. Those three groups took a further significant step in 1981 by forming the Coalition for Smoking OR Health. The coalition invites participation from other groups, but the three private voluntaries have been its stalwart supporters. The Advocacy Institute in Washington, D.C., has become a clearinghouse for tobacco control information, offering the Smoking Control Advocacy Resource Center Network (SCARCNet), an on-line source of information contributed by members throughout the country. Dozens of advocacy organizations have emerged throughout the nation to promote tobacco control policies. Prominent among these grassroots organizations are Americans for Nonsmokers' Rights (ANR) (which started as Californians for Nonsmokers' Rights), Doctors Ought to Care (DOC), Stop Teenage Addiction to Tobacco (STAT), Action on Smoking and Health (ASH), and the Tobacco Products Liability Project. Among these, STAT is the major national advocacy group primarily concerned with youth tobacco use. There are also several regional groups that have effected local policy change, such as Smokefree Educational Services in New York City and Stop Tobacco Access for Minors (STAMP) in Northern California. Joseph DiFranza edits Tobacco Access Law News, a bimonthly newsletter disseminated to tobacco control advocates. The Robert Wood Johnson Foundation has emerged as the leading source of foundation support for tobacco control, as a prominent part of its work against substance abuse. Many other foundations have supported projects from time to time, particularly foundations that support local activities throughout the nation, but RWJF alone has channeled a part of its substantial funding resources into tobacco control. Its attention to policy research, beginning in 1991, has been a major factor, as well as its support for most of the nationally and regionally prominent advocacy organizations, including all those mentioned above. (See table 9-1 for a list of organizational roles in tobacco control.) LINKAGE BETWEEN EXCISE TAX REVENUES AND TOBACCO CONTROL PROGRAM FUNDING Some of the policy proposals made in this report can be effected with little expenditure of public funds or loss of revenues. Bans on advertising and vending machines, for example, or restrictions on promotional activities require only modest resources for enforcement. Some items are moderate in cost, such as increased budgets for research and coordination. Some options are costly: for example, creation of a regulatory regime for tobacco products will require a moderate increase in public funding for tobacco control. Expansion of

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Page 270 TABLE 9-1  Functions and organizations concerned with preventing tobacco use among children and youths Function Organization Specific roles Regulation Food and Drug Administration Possible role regarding tobacco products as drug delivery devices         Federal Trade Commission Enforce truth in advertising, possible role in regulating promotions         Environmental Protection Agency Environmental tobacco smoke standard         Consumer Product Safety Commission Tobacco currently exempted         State and local governments Enforcement of youth access laws; vending machine standards; licensing of sales outlets; advertising restrictions       Public health monitoring Centers for Disease Control and Prevention (esp. Office on Smoking and Health and National Center for Health Statistics) Office on Smoking and Health; prepare surgeon general's reports; staff Interagency Committee on Smoking and Health; coordinate federal public health efforts; monitor smoking rates; gather national health statistics; liaison with state health and substance abuse offices         Office of the Inspector General, Department of Health and Human Services Reports on youth access, spit tobacco, public health agencies' tobacco control measures         Office of the Assistant Secretary for Health Healthy People 2000 objectives; coordination of Public Health Service agencies         State offices for substance abuse and health Gather state health statistics, liaison with CDC, coordinate with local governments         Association of State and Territorial Health Officials Annual report on state tobacco control efforts

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Page 271 Table 9-1 Continued     Function Organization Specific roles Research National Institute on Drug Abuse Basic, clinical, and preventive intervention research on addiction   National Cancer Institute Basic, clinical, and preventive intervention research on cancer; ASSIST program; COMMIT program; new program on policy research         National Heart, Lung, and Blood Institute Basic, clinical, and preventive intervention research on pulmonary and cardiovascular disorders         National Institute on Child Health and Human Development Basic, clinical, and preventive intervention research on childhood disorders         Agency for Health Care Policy and Research Health outcomes, quality assurance, clinical practice guidelines, system performance measures, and health policy research         Tobacco-Related Diseases Research Program California state-funded research program: basic, clinical, prevention, and policy research       Services Health Resources and Services Administration Federal funding to state block grants for health; limited direct grants for health services; health professional training; program evaluation         Substance Abuse and Mental Health Services Administration (esp. Center for Substance Abuse Prevention) Federal funding to state block grants for substance abuse; technical assistance for state and local government; program evaluation       continued on next page    

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Page 272 TABLE 9-1 Continued     Function Organization Specific roles Services—continued State offices for substance abuse and health; county and local governments Direct funding of special programs; some states have dedicated tobacco control efforts; education through university system         Indian Health Service American-Indian health services         Department of Defense Tobacco use in military facilities; health services for military personnel and their dependents         Department of Education Materials and technical assistance for schools       Private research and professional organizations American Heart Association Cardiovascular research; Coalition on Smoking OR Health         American Lung Association Lung research; Coalition on Smoking OR Health         American Cancer Society Cancer research; Coalition on Smoking OR Health         American Medical Association SmokeLess States       Advocacy Advocacy Institute National advocacy   Coalition on Smoking OR Health National advocacy organization, funded by ACS, ALA, AHA and joined by many professional and private voluntary health organizations         Stop Teenage Addiction to Tobacco (STAT) National volunteer organization         Doctors Ought to Care (DOC) National physician and health professional advocacy organization         Americans for Nonsmokers' Rights National advocacy organization         Join Together Advocacy resource center

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Page 273 TABLE 9-1 Continued     Function Organization Specific roles Private foundation Robert Wood Johnson Foundation Support for research, demonstrations, policy, and advocacy on substance abuse programs for anti-tobacco media campaigns and assistance to state public health offices for tobacco control would entail substantial budget commitments. It is essential that agencies to which Congress and state governments delegate responsibility for tobacco control measures be given sufficient resources to accomplish their tasks. This was a theme that recurred often in interviews with government officials, advocates, and academic experts. The most sensible models have been established in California, Michigan, and Massachusetts, and should be adopted in other states. At the federal level, if an increase in excise tax on tobacco products is contemplated by Congress in the near future, as part of health care reform or other legislation, Congress should ensure that some fraction of revenues raised by the federal excise tax on tobacco products be devoted to a credible tobacco control effort. This may be difficult, as the revenues and expenditures may derive from separate pieces of legislation, but to the extent possible, the Committee encourages a linkage between new taxes and an energetic federal tobacco control program. OPTIONS AND RECOMMENDATIONS FOR COORDINATION The reduced rates in adult smoking have been achieved without a centralized and strongly coordinated national tobacco control policy. The Committee debated at some length the desirability and feasibility of a more centralized and planned effort. It considered the virtues of a federal tobacco control administration that could be held accountable for progress in dealing with the nation's most prominent public health problem. The functions of such an agency, however, would span a very wide range—from monitoring advertising and ensuring its accuracy, to measuring nicotine and tar levels in cigarettes, to public education efforts and public health monitoring. An effective tobacco control administration would require consolidation of functions currently performed in different departments, and in different parts of the Public Health Service. Such an institutional arrangement would face immense political obstacles, not only by forcing a new structure on existing functions, but also by perturbing long-standing congressional committee jurisdictions. Thus, despite the temptation to craft a clear organizational chart linking multiple government functions, the Commit-

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Page 274 tee concluded that progress would be realized more quickly, and forward movement was far more likely, if its recommendations built on existing structures that could accommodate new tobacco control efforts by incremental expansion. The programs that promise to have a strong impact on tobacco use—such as those in Canada, California, and Massachusetts—have arisen from grassroots anti-smoking movements that produced new programs, rather than evolving out of a large federal bureaucracy with numerous agencies. Several parts of the federal government already have missions related to tobacco control, although none has it as a central objective. The Center for Substance Abuse Prevention has initiated a major effort to gather information about, and provide technical assistance for, preventive services. The Committee commends CSAP for this action, for taking steps to fill a critical gap, and notes the usefulness of including tobacco in drug abuse prevention programs. The tobacco control effort extends well beyond preventive interventions, however, and the Committee believes that similar efforts are needed at the federal level on tax policy, youth access, licensing, advertising and promotion, regulation, and other public policy domains. Monitoring of state and local tobacco control efforts can build on the excellent annual surveys of the Association of State and Territorial Health Officials. The incremental, multi-agency approach endorsed by the Committee does not solve an underlying problem—tobacco control is a small part of many agencies, but central to none. Experience in California, Massachusetts, and Canada reveals strong public support for tobacco control measures when voters are presented with direct choices. That type of public mandate—and the possibility of accountability that it entails—are sorely lacking at the federal level. Tobacco control at the federal level has consistently been marginal to the missions of multiple agencies, and this is also true of most private sector organizations. Michael Pertschuk, executive director of the Advocacy Institute and a longtime tobacco control advocate, recently observed, ''while we have many able and talented and committed leaders, that leadership is fragmented. The limited financial resources committed by both government and non-government funders are, too often, mis-directed. We still lack the structures and capacity for overall priority setting, strategic planning, tactical coordination, and effective coordination."9 The ACS, AHA, and ALA founded the Coalition on Smoking OR Health as a means of coordinating efforts and supplementing their public education approaches. The coalition has played a major role in several prominent successes, but the supporting agencies have numerous other priorities as well. The Advocacy Institute is well positioned, but can make only "indirect contributions to the movement's strategic cohesion."10 The many grassroots organizations—such as ANR, DOC, STAT, and others—have enormous energy, but they also have specific focuses. In the Committee's judgment, this lack of coherent organization and strategic planning may well have hampered tobacco control efforts to date. The Com-

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Page 275 mittee invited numerous policymakers and tobacco control advocates to discuss their concepts for a leadership structure. An option that the Committee finds appealing is a "Tobacco Control Institute in the private sector to function as an authoritative policy development and analysis center."11 It is difficult to determine, however, to whom this recommendation should be directed or how such a center would function in the absence of government authority and substantial resources. Nevertheless, it would seem appropriate for voluntary health agencies, professional associations, advocacy groups, and foundations to consider the concept. The major groups funding tobacco control efforts at the national level have in the past included the federal government, the Robert Wood Johnson Foundation, and the private voluntary health organizations noted above. A Tobacco Policy Coordinating Committee functioned for several years, bringing these groups together, and despite repeated and ample discussion about the advantages of a coherent policy leader, that committee did not evolve into an institute. The base of support for tobacco control must surely be broadened, but new players are unlikely to have resources equal to or larger than those already involved. The major potential funding organizations have historically decided not to establish a central policy institute, despite ample opportunities to do so. The Committee consulted with several individuals in government and private health organizations, and sees little prospect of their coming together to support a national tobacco control institute. Over time, one of the major academic centers might evolve into a national policy analysis center. The more likely scenario seems to be a policy analysis capacity distributed among many academic centers, government agencies, and private sector organizations. As a long-term goal, the Committee believes that prospects for a more coherent and accountable national tobacco control policy would be brighter if the various government and private organizations concerned with tobacco use pooled their resources to create such a national resource in the private sector. Regardless of whether a central policy analysis institute is possible or desirable, it will be important to broaden the base of support for tobacco control efforts at all levels, and to exhort federal, state, and local governments, private voluntary health organizations, and advocacy groups to collaborate. In recent years, responsibility for coordinating federal activities has been delegated mainly to the Office on Smoking and Health of the Centers for Disease Control and Prevention. OSH staffs an Interagency Committee on Smoking and Health that brings together most, but not all, of the federal agencies concerned with tobacco control. (The Bureau on Alcohol, Tobacco, and Firearms, for example, is not included.) The Interagency Committee on Smoking and Health has the potential to enhance coordination at the federal level. It held meetings on youth tobacco use in December 1992 and April 1994, for example, that highlighted innovative programs from throughout the country and the findings of the 1994 surgeon general's report. In general, however, the Interagency Committee

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Page 276 has not been a major policy force in tobacco control. This conclusion was corroborated in interviews with officials of Public Health Service agencies, advocates, academic researchers, and private sector organizations. The IOM Committee believes that the unique complexity of tobacco-related politics makes true leadership within the federal government difficult, and this complicates interagency coordination. However, the task of coordination can be simplified if the participating agencies coalesce around a single priority. The need to focus on youths seems to be a recognized priority in all the relevant agencies. Therefore, the Committee recommends that the Interagency Committee on Smoking and Health should set as its highest priority the achievement of the Healthy People 2000 goal for youth smoking and use of smokeless tobacco. The Office on Smoking and Health also generally takes the lead in preparing the surgeon general's report. In 1978 the National Clearinghouse for Smoking and Health was renamed the Office on Smoking and Health, was transferred from Atlanta to Washington, D.C., and was given expanded responsibilities to coordinate federal smoking and health activities. It was then moved structurally to the CDC, but remained in Washington. In 1991, the OSH moved to Atlanta, to CDC headquarters. This location has the advantage of bringing OSH closer to the core public health activities of CDC, including many programs that involve working with state health departments, but it has the disadvantage of being remote from the nation's political center; thus, CDC has retained a small liaison office in Washington for OSH. The Committee believes that OSH is an appropriate choice to coordinate efforts to reduce tobacco use among youth. This should not be construed as calling for consolidation of functions, along the lines of a tobacco control administration as outlined above, but rather for better linkage of activities in various federal agencies, in states, and in private sector organizations. It will probably fall short of the mission of even a tobacco control institute, as discussed above, which would be a national resource for policy analysis and planning (but without implementing authority for research, public health monitoring, regulation, and services). Where the office is located is less important than that it command sufficient resources to monitor policy initiatives at all levels and disseminate that information. This clearinghouse and technical assistance function would be a laudable, if incremental, advance in tobacco control at the federal level. CDC's Office on Smoking and Health should be given the responsibility for coordinating federal tobacco control initiatives, with a focus on reducing initiation of smoking and use of smokeless tobacco by children and youths, and should be given additional resources for this purpose. Funding needs cannot be predicted with any certainty, as they will depend on the degree to which states pursue tobacco control policy. So much activity is taking place at the state and local levels that funding needs may well increase dramatically in the near future. At a minimum, however, the Committee believes that the infrastructure for tobacco control in each state should resemble

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Page 277 that which has been established in the current 17 ASSIST states, implying a need for additional resources for the vast majority of non-ASSIST state programs. The nature of OSH's function will also vary according to state. California, Massachusetts, and Michigan are likely to be sources of expertise and information useful to other states, and their function in this regard will be to transfer knowledge, using the federal government as a clearinghouse. In other states where tobacco control is rudimentary, federal support can be a major impetus for reducing initiation of youth smoking. These incremental funds will be needed even more if federal activity is increased (for example in the Food and Drug Administration, if Congress gives it regulatory authority, or in the Federal Trade Commission, in connection with advertising and promotion constraints). EPILOGUE This Committee's work began in May 1993 and was completed in 10 months. During this brief period, the weight of public opinion seems to have shifted decidedly in the direction of reducing tobacco use in the United States. Actions and initiatives on Capitol Hill and in a variety of federal agencies, ranging from the Department of Defense to the Food and Drug Administration, have given an historic burst of political energy to the cause of tobacco control. The public health appears ascendant in what has been a 30-year struggle to modify social norms favorable to tobacco use. The stage is now set for aggressive action to reduce tobacco use by children and youths as a central feature of the nation's tobacco control efforts. The initiatives recommended in this report, which seemed so remote only a few years ago, are strongly justified and have broad public support. They should be undertaken with dispatch. Nascent optimism  among advocates for tobacco control must be coupled with resolve. If the necessary initiatives are not taken, the political momentum could be lost and the tobacco epidemic could take a new turn for the worse. The recent reversal of the nation's success in tuberculosis (TB) control provides a sobering lesson in the need for forceful efforts even when the prospects for success seem most bright. At the turn of the twentieth century, TB was the chief single cause of death in the United States and millions of Americans suffered from chronic illness and disability related to TB. In an extraordinary public health achievement, the rate of TB declined markedly throughout the century until, in the early 1980s, it seemed that the disease could be eradicated early in the twenty-first century. Unfortunately, however, the downward trend was suddenly halted in 1985, and the incidence of TB has risen every year since 1986. Even more alarming has been the appearance of a new drug-resistant strain of the disease. Complacency is always dangerous in public health. Notwithstanding significant changes in predominant social attitudes toward tobacco, smoking continues

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Page 278 to be associated with a variety of positive images, especially for children and youths. Notwithstanding recent political setbacks, the tobacco industry remains economically powerful and continues to spend more than $4 billion every year to promote and advertise its products. The prices of tobacco products continue to drop in real terms as the industry responds to a shrinking market, making tobacco products more affordable to children and youths. The prevalence of tobacco use now appears to be increasing among children and youths. The nation must commit itself to a vigorous public health initiative in tobacco control. The CDC recently responded to the upsurge in TB by formulating a new strategic plan for the elimination of tuberculosis in the United States by the year 2010.12 The nation cannot reasonably expect to eliminate tobacco-related disease and death by 2010. However, by putting a youth-centered prevention strategy at the center of tobacco control efforts, and by implementing the initiatives proposed in this report, the nation can take a firm and resolute step on that path. REFERENCES 1. National Cancer Institute. Strategies to Control Tobacco Use in the United States: A Blueprint for Public Health Action in the 1990's. Smoking and Tobacco Control Monograph No. 1. NIH Pub. No. 92-3316. Washington, DC: U.S. Department of Health and Human Services, 1991: ix-xii. 2. Walter, Gailya P., Program Officer, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Personal communication. April 22, 1994. 3. Shopland, D. R. "Smoking Control in the 1990s: A National Cancer Institute Model for Change." American Journal of Public Health 83:9 (1993): 1208-1210. 4. National Cancer Institute. 5. Herdman, Roger, Maria Hewitt, and Mary Laschober. Preventive Health: An Ounce of Prevention Saves a Pound of Cure. Testimony before the Senate Special Committee on Aging. Hearing on Smoking-Related Deaths and Financial Costs: Office of Technology Assessments Estimates for 1990. 6 May 1993. 2, 4. 6. National Heart, Lung, and Blood Institute. Data supplied by the Information Center of the NHLBI, 1994. 7. Hu, Teh-wei. "The Economic Effects of California Cigarette Taxation." Abstract in Annual Report from the University of California to the State of California Legislature Tobacco-Related Disease Research Program (1993): 74. 8. National Cancer Institute. Major Local Tobacco Control Ordinances in the United States. Smoking and Tobacco Control Monograph No. 3. NIH Pub. No. 93-3532. Washington, DC: U.S. Department of Health and Human Services, March 1993: ix-xii. 9. Pertschuk, Michael. Advocacy Institute. "Opportunity Knocks; Will We Open the Door?" In Tobacco Use: An American Crisis. Final Report of the Conference. January 9-12, 1993: 8. 10. Ibid., 9. 11. Slade, John. Letter to Paul Torrens, Chair, Committee on Preventing Nicotine Addiction in Children and Youths. 12 Sept. 1993. 12. Rieder, Hans L., George M. Cauthen, Gloria D. Kelly, Alan B. Bloch, and Dixie E. Snider. "Tuberculosis in the United States." Journal of the American Medical Association 262:3 (21 July 1989): 385.