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SPECIFIC RECOMMENDATIONS, BY CHAPTER

Chapter 2: The Nature of Nicotine Addiction

1. Research should be conducted to determine individual susceptibility to nicotine addiction.

2. For all forms of tobacco products, research should be conducted on the characteristics of nicotine addiction in the early stages, that is, in the first few years during which the transition between experimental and addictive nicotine use occurs.

3. Research should be conducted on the relationship between the characteristics of tobacco products and addiction.

Chapter 3: Social Norms and the Acceptability of Tobacco

1. Public education programs and messages should be increased and implemented on a continuous basis to (a) inform the public about the hazards of tobacco use and of environmental tobacco smoke and (b) promote a tobacco-free environment. In particular, mass media campaigns, including paid counter-tobacco advertisements, should be intensified to reverse the image appeal of pro-tobacco messages, especially those that appeal to children and youths.

2. Tobacco-free policies should be adopted and enforced in all public locations, especially in those that cater to or are frequented by children and youths, including all educational institutions, sports arenas, cultural facilities, shopping malls, fast-food restaurants, and transit systems.

3. All levels of government should adopt tobacco-free policies in public



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Page 281 A SPECIFIC RECOMMENDATIONS, BY CHAPTER Chapter 2: The Nature of Nicotine Addiction 1. Research should be conducted to determine individual susceptibility to nicotine addiction. 2. For all forms of tobacco products, research should be conducted on the characteristics of nicotine addiction in the early stages, that is, in the first few years during which the transition between experimental and addictive nicotine use occurs. 3. Research should be conducted on the relationship between the characteristics of tobacco products and addiction. Chapter 3: Social Norms and the Acceptability of Tobacco 1. Public education programs and messages should be increased and implemented on a continuous basis to (a) inform the public about the hazards of tobacco use and of environmental tobacco smoke and (b) promote a tobacco-free environment. In particular, mass media campaigns, including paid counter-tobacco advertisements, should be intensified to reverse the image appeal of pro-tobacco messages, especially those that appeal to children and youths. 2. Tobacco-free policies should be adopted and enforced in all public locations, especially in those that cater to or are frequented by children and youths, including all educational institutions, sports arenas, cultural facilities, shopping malls, fast-food restaurants, and transit systems. 3. All levels of government should adopt tobacco-free policies in public

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Page 282 buildings. The Department of Defense should continue its aggressive efforts to adopt tobacco-free policies in all military services. 4. All workplaces should adopt tobacco-free policies. 5. All organizations involved with youths should adopt tobacco-free policies that apply to all persons attending or participating in all events sponsored by the organizations, and should actively promote a tobacco-free norm. 6. Parents should clearly and unequivocally express disapproval of tobacco use to their children, and, if smokers themselves, should quit smoking. 7. Research should be conducted to determine the factors influencing the substantial decline in tobacco use by African-American youths, with particular attention to the role of social norms. 8. Youths should be involved in the development of research questions and approaches and in designing and evaluating health messages and programs. Chapter 4: Tobacco Advertising and Promotion 1. Congress should repeal the federal law preempting state regulation of tobacco promotion and advertising that occurs entirely within the states' borders. 2. After state regulatory authority has been clarified and restored, states and localities should severely restrict the advertising and promotion of tobacco products on billboards and other outdoor media, on vehicles, in facilities of public transportation, in public arenas and sports facilities, and at the point of sale. 3. Congress should enact comprehensive legislation establishing a timetable for gradual implementation of a plan for restricting tobacco advertising and promotion in interstate commerce. Essential components of this plan, which should become fully effective by the year 2000, include: (a)restricting to a tombstone format the advertising of tobacco products in print media, including magazines and newspapers, or in other visual media, including videotape, videodisc, video arcade game, or film; (b)banning the commercial use of the registered brand name of a tobacco product, trademark, or logo, or other recognizable symbol for such a product in any movie, music video, television show, play, video arcade game, or other form of entertainment, or on any other product; and (c)banning the use of the registered brand name of a tobacco product, a trademark or logo, or other recognizable symbol for such a product, in any public place, or in any medium of mass communication for the purpose of publicizing, revealing, or documenting sponsorship of, or contribution to, any athletic, artistic, or other public event. 4. Research should be conducted that attends to ethnic, gender, and social class differences; that is sensitive to youths' responses to advertising and promotional messages; and that assesses the success as well as the failure of advertising campaigns.

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Page 283 Chapter 5: Prevention and Cessation of Tobacco Use: Research-Based Programs 1. Under federal leadership, the United States should develop a national child health policy that gives high priority to the prevention of tobacco use by youths. 2. All schools should adopt and implement the CDC guidelines to prevent tobacco use and addiction. 3. Already proven models of school-based prevention programs should be systematically integrated into a comprehensive approach to reducing tobacco use by children and youths. 4. Tobacco prevention should be integrated into any drug prevention program aimed at youth. 5. Systematic research should be conducted on the optimal way to disseminate and implement tobacco use prevention programs on a large scale. 6. Research should be conducted on the development and evaluation of programs to help children and youths who are regular tobacco users to quit their habitual use of cigarettes, snuff, or chew. 7. Research should be conducted to identify the need for, and to develop and evaluate, prevention programs aimed at reducing tobacco use among specific ethnic groups. Chapter 6: Tobacco Taxation in the United States 1. Tobacco tax policies at the federal and state levels should be linked to the national objectives for reducing tobacco use. In other words, government policymakers should use tobacco taxes as an intervention to accomplish these health goals. 2. The excise tax on cigarettes should be increased to a level comparable with that in other major industrialized countries. A reasonable target would be to increase the federal cigarette tax by $2 by 1995. Accomplishing this objective would also have the added benefit of reducing illegal smuggling of tobacco products between Canada and the United States. 3. All tobacco products should be taxed on an equivalent basis. For example, when cigarette taxes are increased, taxes on non-cigarette tobacco products should also be increased on an equivalent basis to discourage substitution of one harmful form of tobacco for another (such as smokeless tobacco). 4. The real value of tobacco taxes should be maintained to account for inflation over time. Optimally, tobacco tax policy should take into consideration the affordability of tobacco products to prevent tobacco from becoming more affordable. 5. Tobacco products in U.S. military stores should be priced at the same rate that exists in the surrounding community. This policy change would have

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Page 284 an effect on the smoking behavior of military personnel, many of whom are young adults. Also by eliminating the price differential between military and nonmilitary retail outlets, the incentive for illegal smuggling of tobacco products out of military bases would be eliminated. Chapter 7: Youth Access to Tobacco 1. The federal government should set national goals for reducing youth access to tobacco and should provide resources and leadership to facilitate state and local efforts to effectuate those goals. 2. The federal government should use its spending power to induce states to adopt and implement state plans for tobacco control, including specific plans for enforcing access restrictions. The states' obligation to enforce youth access restrictions should be tied to eligibility for CDC grants for tobacco control activities, and these grants should include sufficient funds to cover the costs of enforcement during the developmental phase of the new program. In addition, the states should be required to establish a mechanism for independent assessment of retailer compliance with youth access restrictions. 3. A federal agency should serve as a clearinghouse and resource center for information, models, and technical assistance for implementing access restriction programs. 4. So that local communities may act as needed regarding local needs for tobacco control, states should adopt a youth access plan that does not preempt local governments from adopting stronger local initiatives. 5. States should establish a licensing system requiring merchants to obtain a license to sell tobacco products, which may be suspended or revoked if the merchant sells tobacco to minors or violates other state and local laws designed to reduce youth access. 6. Licensing fees should be earmarked for the enforcement of youth access legislation and should be set high enough to cover those costs. If possible, responsibility for operating the licensing system should be assigned to a public health agency. However, each state should assess existing regulatory structures to determine which agency is best able to administer effectively the licensing program. The agency selected should retain the authority both to administer the licensing program and to receive licensing fees. 7. States should ban tobacco vending machines; less restrictive alternatives to a complete ban should be adopted only if shown to be effective. 8. States should prohibit the sale of tobacco products by self-service displays. During compliance checks, authorities should verify that tobacco is being sold only from behind the counter or from locked cases. 9. Sale of single cigarettes, which violates federal tobacco labeling law, should also be banned by state youth access laws. During compliance checks,

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Page 285 authorities should verify that retailers do not offer single cigarettes for sale, whether openly displayed or from behind the counter. 10. Distribution of free tobacco products in public places or through the mail should be prohibited. 11. Education programs to increase merchants' awareness of and support for youth access laws should be fostered as a valuable complement to legal enforcement measures. 12. CDC, through the Office on Smoking and Health, should provide technical assistance and resources to support states and localities wishing to implement youth access community education programs. 13. Youth access laws should be effectively enforced. An enforcement plan should implement a graduated penalty system proportionate to the extent of the violation, beginning with fines for minor infractions and followed by stronger penalties (suspension, then revocation) for serious and repeated violations. 14. Legal penalties should not be imposed on youths who are able to obtain tobacco products; existing legal penalties on minors should be repealed. 15. Criminal penalties should not be imposed on licensees who sell tobacco to minors. Rather, appropriate civil penalties, including fines and tobacco license suspension or revocation, should be prescribed and enforced. 16. Youth access plans should not set excessively high age limits; states should set the minimum age of purchase at age 18. 17. States and localities should adopt long-term strategies for reducing the number of outlets licensed to sell tobacco products. Initial steps should include creation of tobacco-free zones around schools and bans of tobacco sales in pharmacies. 18. As part of a long-term access strategy, Congress should enact a suitably limited federal ban on the distribution of tobacco products through the mail. At a minimum, the law should bar free distribution, as well as redemption of tobacco coupons, a promotional activity likely to be particularly attractive to children and youths. 19. Sponsors of research should support (a) studies of retailers regarding their motivation for compliance for noncompliance; (b) studies of the cost-effectiveness of various enforcement approaches being developed in response to the Synar Amendment; and (c) most important, a surveillance system for monitoring the tobacco market in order to ascertain the sources (and cost) of tobacco products to youths, in both legal and illicit commerce. Chapter 8: Regulation of the Labeling, Packaging, and Contents of Tobacco Products 1. Congress should enact legislation that delegates to an appropriate agency the necessary authority to regulate tobacco products for the dual purposes of

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Page 286 discouraging consumption and reducing the morbidity and mortality associated with use of tobacco products. 2. Congress should take steps to strengthen the federally mandated warning labels for tobacco products. 3. Congress should take steps to increase the salience and effectiveness of health warnings on both advertising and packaging. 4. Based on current knowledge, Congress should enact specific warning and format requirements now, and should delegate regulatory responsibility for future modifications to the secretary of health and human services. The secretary should ensure that ongoing research is conducted on the effectiveness of prescribed warnings. 5. To the extent that promotional use of logos and trademarks of tobacco products is legally permitted, Congress should make accompanying health warnings mandatory. 6. Congress should confer upon an administrative agency the authority to regulate the design and constituents of tobacco products whenever it determines that such regulation would reduce the prevalence of dependence or disease associated with use of the product or would otherwise promote the public health. The agency should be specifically authorized to prescribe ceilings on the yields of tar, nicotine, or any other harmful constituent of a tobacco product. 7. The regulatory agency, as its first step, should develop a sound methodology for ascertaining the actual yields of nicotine, tar, or any other constituents of tobacco products, based on human consumption. 8. At a minimum, the regulatory agency should take steps to inform consumers about the meaning of statements regarding tar and nicotine yields, and particularly about the behavioral influences on intake, and the relative importance of the characteristics of the cigarette and the way it is smoked. 9. If the regulatory agency finds that reduction of tar and/or nicotine yields would reduce morbidity or mortality associated with use of tobacco products, it should be authorized to prescribe ceilings of tar and/or nicotine yields and to develop a regulatory program of phased reductions in those ceilings over time. Chapter 9: Coordination of Policies and Research 1. Funding to the non-ASSIST states should be increased to a level commensurate with ASSIST states. 2. 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. 3. Federal agencies that sponsor tobacco-related research should increase the resources devoted to understanding and preventing initiation of tobacco use by children and youths.

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Page 287 4. Federal agencies should give special attention to research on the efficacy of policies aiming to prevent initiation of tobacco use by youths. 5. 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. 6. 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. 7. 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.

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