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THE NEED FOR A YOUTH-CENTERED TOBACCO CONTROL POLICY

Use of tobacco products is the nation's deadliest addiction. Smoking cigarettes is the leading cause of avoidable death in the United States. More than 400,000 people die prematurely each year from diseases attributable to tobacco use.1 The toll of deaths attributable to tobacco use is greater than the combined toll of deaths from AIDS, car accidents, alcohol, suicides, homicides, fires, and illegal drugs (figure 1-1). Smoking is the main cause of 87% of deaths from lung cancer, 30% of all cancer deaths, 82% of deaths from pulmonary disease, and 21% of deaths from chronic heart disease.2 Use of smokeless tobacco* is a cause of oral cancer.3 In a study of women who did not smoke but did use snuff chronically, the risk for oral cancers was 50 times greater than for nonusers.4

According to a recent estimate by the Office of Technology Assessment, each smoker who died in 1990 as a result of his or her smoking, on average, would have lived at least 15 additional years if a nonsmoker. (This assumes that individuals who die from smoking-related causes would have experienced the life expectancy of the total population—that is, smokers and nonsmokers combined—had they not died prematurely.) For the population at large, this premature mortality translates into 6 million years of potential life lost each year.5

It is difficult, of course, to calculate a dollar value for the human costs of

*The term ''smokeless tobacco" is used in this report to comprise all forms of nasal snuff, oral snuff, and chewing (spitting) tobacco.



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Page 3 THE NEED FOR A YOUTH-CENTERED TOBACCO CONTROL POLICY Use of tobacco products is the nation's deadliest addiction. Smoking cigarettes is the leading cause of avoidable death in the United States. More than 400,000 people die prematurely each year from diseases attributable to tobacco use.1 The toll of deaths attributable to tobacco use is greater than the combined toll of deaths from AIDS, car accidents, alcohol, suicides, homicides, fires, and illegal drugs (figure 1-1). Smoking is the main cause of 87% of deaths from lung cancer, 30% of all cancer deaths, 82% of deaths from pulmonary disease, and 21% of deaths from chronic heart disease.2 Use of smokeless tobacco* is a cause of oral cancer.3 In a study of women who did not smoke but did use snuff chronically, the risk for oral cancers was 50 times greater than for nonusers.4 According to a recent estimate by the Office of Technology Assessment, each smoker who died in 1990 as a result of his or her smoking, on average, would have lived at least 15 additional years if a nonsmoker. (This assumes that individuals who die from smoking-related causes would have experienced the life expectancy of the total population—that is, smokers and nonsmokers combined—had they not died prematurely.) For the population at large, this premature mortality translates into 6 million years of potential life lost each year.5 It is difficult, of course, to calculate a dollar value for the human costs of *The term ''smokeless tobacco" is used in this report to comprise all forms of nasal snuff, oral snuff, and chewing (spitting) tobacco.

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Page 4 FIGURE 1-1  Number of deaths per year, 1990. Source: Office on Smoking and Health. Centers for Disease Control and Prevention.

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Page 5 tobacco-related diseases. The suffering of patients and families resulting from tobacco-related morbidity and mortality is unquantifiable. Lost productivity and health care expenditures can be quantified, but the magnitude of the estimates depends on a variety of theoretical and technical questions, including whether the costs of health care should be offset by the "savings" in social security expenditures and health care costs not incurred because people died prematurely.6 The Office of Technology Assessment put the social cost of smoking in 1990 at $68 billion. This high-end estimate includes $20.8 billion in direct health costs, $6.9 billion in lost productivity attributable to smoking-related disability, and $40.3 billion in lost productivity attributable to smoking-related premature deaths.7 Whatever its total magnitude, the social cost of smoking is substantial. Even based on conservative assumptions, expected lifetime medical expenditures of the average smoker exceed those of the average nonsmoker by 28% for men and 21% for women. Each year, decisions by more than I million youths to become regular smokers commit the health care system to $8.2 billion in extra medical expenditures over their lifetimes.8 (These figures, which are in 1990 dollars discounted at 3%, reflect the average experience in the population of persons who become smokers and take into account variations in the number of years of smoking.) The nation has a compelling interest in reducing the social burden of tobacco use. This can be accomplished by preventing people from starting to use tobacco and by getting users to quit. The premise of this report is that, in the long run, tobacco use can be most efficiently reduced through a youth-centered policy aimed at preventing children and adolescents from initiating tobacco use. Moreover, because the prevalence of tobacco use among youths has remained stubbornly constant for 10 years, and may even be rising, a youth-centered prevention policy must be aggressively implemented if tobacco-related morbidity and mortality are to be significantly reduced. Tobacco Use: Addictive and Mostly Initiated During Childhood and Adolescence In 1988, the surgeon general issued a major report demonstrating that cigarettes and other forms of tobacco are addicting, that most tobacco users use tobacco regularly because they are addicted to nicotine, and that most tobacco users find it difficult to quit because they are addicted to nicotine. Tobacco use is not a choice like jogging or a habit like eating chocolate; it is an addiction that is fueled by nicotine. Most smokers begin smoking during childhood and adolescence, and nicotine addiction begins during the first few years of tobacco use. Moreover, decades of experience in tracking tobacco use show that if people do not begin to use tobacco as youngsters, they are highly unlikely to initiate use as adults. For any cross section of adults who smoke daily, 89% began using cigarettes and

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Page 6 FIGURE 1-2  Source: Data from the National Household Surveys on Drug Abuse, United States, 1991. Office on Smoking and Health. Centers for Disease Control and Prevention. 71% began smoking daily by or at age 18 (figure 1-2).9 In short, decisions by youths about whether to use tobacco have lifelong consequences. On the one hand, if a person reaches the age of 18 without being a user of tobacco products, he or she is highly unlikely to become a tobacco user during adulthood. On the other hand, most children and youths who initiate regular tobacco use become addicted and their addiction persists for many years thereafter, perhaps throughout their lives. This is why a youth-centered prevention policy is an essential part of any coherent strategy for countering tobacco-related disease and death.

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Page 7 Tobacco Use by Children and Youths: No Longer Declining Since 1964, when the surgeon general called the nation's attention to the health hazards of cigarettes, the prevalence of smoking has declined substantially—from 40.4% of the adult population in 1965 to 25.7% in 1991. This trend accelerated between 1987 and 1990, when the rate of smoking among adults dropped by 1.1% per year, more than double the rate of decrease in the preceding 20 years. Among adults, the number of former smokers (43 million) is now nearly that of current smokers (46 million). In fact, among men alive today, more are former smokers than current smokers.10 Despite these impressive successes, the nation's progress toward eliminating tobacco-related disease is in jeopardy. The estimated prevalence of smoking among adults appears to have leveled off in 1990 at around 26% (figure 1-3). FIGURE 1-3  Source: Data from Monitoring the Future Project, 1976-1993, University of Michigan, 1994.

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Page 8 The use of smokeless tobacco, especially snuff, continues to increase, having tripled between 1972 and 1991. The estimated prevalence of use of smokeless tobacco by adults was 2.9% in 1991—5.6% among men and 0.6% among women. Among 18- to 24-year-old men, the rate was 8.2%.11 Unless these current trends are reversed, the nation will fall far short of two key Year 2000 Health Objectives—a 15% prevalence of regular smoking among adults and a reduction of smokeless tobacco use by males ages 12-24 to a prevalence of no more than 4%.12 Why has the momentum toward reducing tobacco use been stalled? The answer lies in the replenishment of the tobacco-using population with new recruits. Despite the marked decline in adult smoking prevalence and the intensifying social disapproval of smoking, it has been estimated that 3,000 young people become regular smokers every day.13 According to 1993 data from the University of Michigan's Monitoring the Future Study, 29.9% of the nation's high school seniors were current smokers (that is, they smoked within the past 30 days) and 19% smoked daily. Among eighth grade students in 1993, 16.7% were current smokers and 8.3% smoked daily.14 Estimates of the number of cigarettes consumed annually by about 3 million children and youths in the United States has been estimated conservatively at 516 million packs.15 According to the Monitoring the Future Study, in 1993, 10.7% of high school seniors were using smokeless tobacco and 3.3% were doing so daily.16 It has been estimated that children and youths consume 26 million containers of smokeless tobacco annually.17 The prevalence of smoking by youths has remained basically unchanged since 1980. Among high school seniors, the prevalence of regular smokers (i.e., those who have smoked in the past 30 days) was 30.5% in 1980 and 29.9% in 1993; the prevalence of daily smokers was 21.3% in 1980 and 19.0% in 1993 (figures  1-4 and 1-5). Small increases and decreases occurred in the rates over the years, but a statistically significant increase of 1.8% in daily smoking from 1992-1993 has concerned public health officials.18 Although little use of smokeless tobacco was seen among adolescents before 1970, the prevalence of its use among older teens (16-19 years old) increased nearly 10-fold between 1970 and 1985,19 and overall appears to have remained constant since then.20 As these trends clearly show, the forces that have been reducing tobacco use by adults—especially getting adults to quit—have not been as effective in reducing the onset of tobacco use among children and youths. Beneath these aggregate prevalence figures lies an intriguing reminder of the ethnic diversity of American society. Since 1980, while daily smoking prevalence has remained stubbornly high among non-Hispanic white youths who are high school seniors (22% in 1980, 20% in 1992, and 23% in 1993), there has been a dramatic decline in daily smoking among African-American youths (16% in 1980, to 3.7% in 1992, and 4.4% in 1993).21 Public health officials are uncertain about the reasons for these divergent trends among ethnic subgroups of American youths, and the research needed to clarify those reasons has not yet

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Page 9 FIGURE 1-4  Source: Data from Monitoring the Future Project, 1976-1993, University of Michigan. Courtesy of Office on Smoking and Health, Centers for Disease Control and Prevention. been done. However, the Committee is hopeful that a tobacco-free norm may have taken root among African-American youths. The key questions are whether this trend will be sustained in the African-American population and whether well-crafted public policies can extend it to the U.S. population as a whole. In any case, the decline in smoking among African-American youths is a bright spot in an otherwise dim picture. The Emerging Public Health Consensus There seems to be general agreement among public health officials that

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Page 10 FIGURE 1-5  Source: Data from Monitoring the Future Project, 1976-1993, University of Michigan. Courtesy of Office on Smoking and Health, Centers for Disease Control and Prevention.

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Page 11 aggressive measures will be needed to make a substantial and enduring reduction in the prevalence of tobacco use by America's children and youths. Indeed, public health officials are worried that the incidence of youthful consumption will rise unless decisive steps are taken to prevent it. These concerns are rooted in the economics of the tobacco market. Because of the overall decline in adult consumption, and a significant increase in tobacco taxes over the last few years, the tobacco companies have been competing for shares of a shrinking market. Declining demand has led to the introduction of generic brands, discount pricing, and other forms of price competition. It has also led to a remarkable increase in expenditures for advertising and promotion. Collectively, the tobacco industry spent more than $4.6 billion in 1991 to advertise and promote tobacco products, a 13% increase over 1990 expenditures.22 The population of the United States is exposed to this massive array of pro-tobacco messages every day. Inevitably, these messages "promote" tobacco use to children and youths as well as adults, and to impressionable nonusers of tobacco products as well as users. The surgeon general has observed that "clearly, young people are being indoctrinated with tobacco promotion at a susceptible time in their lives."23 Many public health officials and observers are convinced that the tobacco industry has purposely targeted its promotional activities on youth. The Committee is not in a position to assess the intentions of tobacco advertisers and producers, but the ubiquitous display of messages promoting tobacco use clearly fosters an environment in which experimentation by youths is expected, if not implicitly encouraged. This social environment is inimical to the health and well-being of the nation's children and, ultimately, to the health of American society. It should be changed. The justification for such a change does not depend on proving that makers and sellers of tobacco products intend to induce nicotine addiction among the nation's young people: it is enough that their promotional activities make tobacco use seem attractive and have a natural tendency to trigger a chain of events that has disastrous public health consequences in the long run. In sum, two trends have raised widespread concern among public health officials regarding the present status of tobacco control efforts. First, the prevalence of smoking and smokeless tobacco use by youths has remained stubbornly high while the prevalence of tobacco use by adults has declined. Second, aggressive marketing by the tobacco companies has increased the volume of pro-tobacco messages at the same time that public health advances seem to have slowed, or even come to a halt. These combined concerns have led to a consensus among public health experts that tobacco control efforts must focus more heavily on preventing children and youths from using tobacco products and becoming dependent on them. A vigorous effort to prevent initiation of tobacco use by children and youths must be the centerpiece of the nation's tobacco control policy and should be among its highest public health priorities.

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Page 12 Public Support for a Youth-Centered Tobacco Control Policy A youth-centered tobacco control strategy has broad public support. In a national survey of adults, a majority (73%) favored an increase in the tax on cigarettes as a measure to help finance health care reform. Those who were opposed to the tax on cigarettes were asked how their support would change if the money were used for various other purposes. A majority of that group (73%) said that they would be more likely to support a tax if the money were used to discourage smoking among young people. Of the entire population surveyed, 62% believe that increasing the cigarette tax would discourage young people from starting to smoke, and 76% favor restrictions of cigarette advertising that appeals to children.24 Another poll, of U.S. voters, found that the most popular restriction on the sales of tobacco products would be a ban on cigarette vending machines: 73% (including 66% of all smokers) said they favor banning cigarette machines "in order to make it more difficult for kids to obtain cigarettes."25 Two-thirds of voters favor banning smoking in all public places, such as restaurants, stores, and government buildings—policies that would promote a tobacco-free social norm for youths. About two-thirds of the voters surveyed agree with the assertion that tobacco companies "do everything they can to get teenagers and young people to take up smoking."26 In a third poll of smokers, 70% were concerned that their children would eventually start smoking because they see them smoking, 93% agreed that more should be done to educate kids about the dangers of cigarettes, and only 17% believed that tobacco manufacturers should be allowed to advertise their products to high school students or to children (7%).27 Growing public support for youth-centered tobacco control measures is also reflected in the activity of local advocacy coalitions and in grassroots political action. Hundreds of localities have enacted local ordinances banning vending machines, establishing smoke-free environments in public places, and otherwise promoting a tobacco-free norm.28 Unfortunately, strong grassroots support for tobacco control policies at the local level has too often been neutralized through powerful lobbying by the tobacco industry at the state level, resulting in weak state legislation that preempts more restrictive local measures. Legislative initiatives at local and state levels relating to advertising and promotion have also been stymied by a preemptive provision of federal law that precludes "any requirement or prohibition based on smoking and health." As discussed below, this preemption must be repealed in order to enable state and local governments to implement youth-centered tobacco control initiatives and thereby carry out the public will. Ethical Foundation of a Youth-Centered Tobacco Control Policy A youth-centered tobacco control policy has a firm ethical foundation. American society ordinarily values and respects the prerogative of adults to de-

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Page 13 cide how to live their own lives as long as they do not endanger anyone else. If adequately informed, adults are assumed to be capable of making rational and voluntary choices that involve weighing the risks and benefits of a particular behavior in light of their own preferences and values. The applicability of the informed choice model to tobacco use has been a subject of ongoing controversy in the literature of applied moral philosophy.29 Although some writers30 have accepted the possibility of a rational and voluntary choice to use tobacco by adequately informed (and unaddicted) adults, others have pointed out that the onset of addiction compromises the voluntariness of subsequent choices, even by adults.31 As a practical matter, however, arguments about the rationality of choices by adults to initiate tobacco use are beside the point because at least 70% of adult daily smokers already became daily smokers, and presumably were addicted, by the time they were 18 years old. Thus, the critical issue is whether children and adolescents are in a position to make informed and rational choices about whether to become tobacco users. No one argues that preteens have the necessary abilities to make rational choices about tobacco use. Yet, as shown in chapter 2, a significant proportion of adult smokers begin using tobacco before becoming teenagers. Data from the 1990 Youth Risk Behavior Survey indicate that 56% of youths have tried smoking and 9% have become regular smokers by age 13.32 Some researchers have suggested that adequately informed adolescents (over age 13) exhibit cognitive decision-making skills similar to those used by young adults (through age 25).33 Others have claimed that adolescents are well informed about the health risks of tobacco use.34 Even if these controversial assertions were accepted, they do not show that adolescents are in a position to make sound choices about tobacco use. One must also take into account other faulty beliefs held by adolescents regarding the consequences of tobacco use as well as adolescent tendencies to evaluate and weigh risks and benefits within a shortened time frame. Adolescent decisions to engage in risky behaviors, including tobacco use, reflect a distinctive focus on short-term benefits and an accompanying tendency to discount long-term risks or dangers, and to believe that those risks can be controlled by personal choice. Decision-making deficiencies exhibited by children and youths who choose to use tobacco are most evident when their perceptions and reasoning are compared with the perceptions and reasoning of their peers who choose not to use tobacco. Clearly, youths who choose to use tobacco perceive greater benefits relative to risks than youths who choose not to do so.35 What is most striking, however, is the nature of the trade-off. When children and youths begin to use tobacco, they tend to do so for reasons that are transient in nature and closely linked to specific developmental tasks—for example, to assert independence and achieve perceived adult status, or to identify with and establish social bonds with peers who use tobacco (see chapters 2 and 3). Youths who smoke or intend to smoke

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Page 16 However, model tobacco prevention programs have not been widely disseminated or adopted and, as a result, most school-based instruction appears to have only a modest impact. It is generally agreed by experts in the field that these programs cannot be expected to have an impact commensurate with the scope of the problem. More aggressive measures will be needed to counteract the social forces that continue to induce a quarter of the nation's young people to use tobacco products. A successful strategy of preventing nicotine dependence in children and youths must encompass measures for reducing the accessibility of tobacco products to young people, and for increasing their cost; for strengthening the social factors tending to discourage consumption; and for erasing or mitigating social factors tending to encourage consumption. These devices typically require legislative or regulatory action. The body of this report summarizes what is known about the potential utility of various preventive measures and offers recommendations for action grounded in existing knowledge. During the course of its study, the Committee reviewed a wide range of activities—federal efforts, state government programs, the actions of advocacy and health professional organizations, and policies of several foreign nations where tobacco control has been successfully pursued. Subsequent chapters deal with research and policy questions surrounding the addictive process, setting social norms, preventive and cessation interventions, advertising and promotion, pricing and taxation, diminishing youth access, and regulating tobacco products. Table 1-1 on pages 18-20 synthesizes the Committee's conclusions and recommendations. During its deliberations, the committee assessed a variety of possible recommendations in terms of extent of potential impact, practicality of implementation, and likelihood of adoption. Model programs in Canada, Australia, New Zealand, California, and Massachusetts have implemented multiple program and policy components at the same time, rendering analysis of the impact of specific measures methodologically difficult. However, the composite effects have been substantial and there is strong reason to believe that a multi-pronged attack is far more likely to produce results than any single measure taken alone. Based on a review of results to date, the Committee concludes that several measures should be the subject of immediate attention at the state, federal, and local levels of government, and in the private sector. In addition, several other major initiatives will be required to sustain long-term progress. Actions That Should Be Taken Immediately Among the recommendations made throughout the report, several deserve emphasis as the most promising to achieve a pronounced impact on tobacco use by children and youths. The Committee believes that three recommendations should have top priority for immediate action:

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Page 17 Congress should enact a substantial increase in the federal excise tax on tobacco products to increase their price and to raise revenues for tobacco control, health care, and other uses. Data indicate that children and youths are more price-sensitive than adults, and that pricing has a strong and immediate impact on reducing sales of tobacco products overall. Increasing the price puts a higher barrier between youths and easy access (affordability) to the products, and therefore between youths and sustained tobacco use. This barrier will delay the initiation and reduce the number of new tobacco users. The Committee recommends that the federal excise tax be raised to a level comparable with that in other major industrialized countries. A reasonable target would be to increase the tax by $2.00 per pack of cigarettes, with proportional increases for smokeless tobacco products. This recommendation is discussed in chapter 6. Congress should repeal the federal law that precludes state and local governments from regulating tobacco promotion and advertising occurring entirely within the state's borders. Many states and local governments have signaled a willingness to experiment with stronger measures to control the messages projected about tobacco use, particularly those to which children and youths are exposed. California, Massachusetts, and Maryland, for example, have strong anti-tobacco media programs in place. Yet, currently, state and local governments are impeded by federal law from regulating promotion and advertising of tobacco products in various visual media, including billboards, and at the point of sale. Federal preemption of this nature limits the ability of local communities to enact the public will and to restrict the pro-tobacco messages to which youths are regularly exposed. As a result, the effectiveness of public education and public health efforts in reducing tobacco use is also limited. This recommendation is discussed in chapter 4. Congress should increase the capacity of state and local governments and coalitions of interested organizations to pursue youth-centered tobacco control policies. In recent years, major initiatives on tobacco control have taken place in states and in local communities. California, Massachusetts, and Michigan, for example, have implemented targeted programs that provide promising models for other states. Many local governments have established innovative programs to enforce youth access laws that have become models for other states and localities. The National Cancer Institute (NCI) has cultivated state initiatives in the 17 states participating in its pioneering American Stop Smoking Intervention Study

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Page 18 TABLE  1-1   Synthesis of key findings and recommendations Chapter Key findings Selected policy recommendation Research needs. 2. The Nature of Nicotine addiction * Nicotine Addiction is the cause of long-term tobacco use * Once a person is addicted, cessation of tobacco use can be difficult. * Most smokers begin smoking during childhood or adolescence, and nicotine addiction becomes established in youthful smokers. * See chapter 8 * Determine factors that influence individual susceptibility to nicotine addiction * Examine factors that predict nicotine addiction in its early stages. * Examine the relationship between characteristics of tobacco products and addiction. 3. Social Norms and the Acceptability of Tobacco Use * A variety of social factors influence youths to experiment with tobacco. * Youths tend to overestimate the prevalence of tobacco use by adults and peers. * Communicating a tobacco-free norm is critical to discouraging youths from using tobacco. * Parents should clearly and unequivocally express disapproval of tobacco use by their children. * Paid anti-tobacco advertising campaigns should be conducted to reverse the image appeal of pro-tobacco messages. * Tobacco-free policies should be adopted in all public locations. * Elucidate the reasons for racial/ethnic group differences in tobacco use by teens. * Include youths in designing and evaluating health message campaigns. 4. Tobacco Advertising and Promotion * The weight of evidence indicates that tobacco advertising and promotions encourage children and youths to use tobacco. * Some types of advertising and promotions especially appeal to children and youths. Bans or restrictions on advertising and promotion appear to reduce tobacco consumption. * Congress should repeal the law pre-empting states and localities from regulating cigarette advertising and promotion entirely within the states' borders. * States should ban tobacco ads or restrict them to a tombstone format. * Congress should adopt comprehensive restrictions on the advertising and promotion of tobacco products. * Assess youths' responses by children and youths to tobacco advertising and promotional messages. * Determine differences in the responses to tobacco image advertising of various ethnic, gender, and social classes. (continued on next page)

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Page 19 5. Prevention and Cessation of Tobacco Use: Research-Based Programs * Refusal skills training and a comprehensive tobacco-free policy are essential elements of school-based tobacco prevention programs. * Most schools currently do not devote sufficient time or resources to teaching children about tobacco and its dangers. * School-based programs without a community-wide tobacco control effort will not have much impact on discouraging youth tobacco use. * All schools should adopt the CDC guidelines to prevent tobacco use and addiction. * The federal government should develop a national child health policy that gives high priority to prevention of tobacco use. * Tobacco prevention should be integrated into existing drug prevention programs aimed at youths (e.g., DARE). * Determine what schools currently are teaching about tobacco and what factors impede the adoption of the CDC guidelines. * Develop programs to help youths who are regular tobacco users to quit. 6. Tobacco Taxation in the United States * Tobacco consumption is related to price. * Youths are more sensitive to price changes than are adults. * The United States has one of the lowest taxes on cigarettes of any industrialized country. * Higher taxes will reduce smoking. * Congress should increase the federal tax on cigarettes by $2 per pack. * States should also consider increasing tobacco taxes as a way to reduce tobacco use. * Tobacco taxes should be increased periodically to account for inflation. * A portion of the excise tax revenue should be set aside for tobacco control programs. * Assess the impact of tobacco price changes on consumption by youths. * Assess the effect of tax hikes on the use of alternative goods and smuggling. 7. Youth Access to Tobacco Products * Nearly all youths report that it is easy to get tobacco products. * Among adolescent tobacco users, most buy their own tobacco despite laws prohibiting sales to minors. * Regular enforcement of youth access laws reduces illegal sales to minors and promotes a tobacco-free norm * States should eliminate tobacco vending machines. * States should license retailers, using fees to pay for enforcement. * Avenues of easy access to tobacco products should be eliminated, e.g., self- service displays, mail order, and free samples. * Evaluate the effect of programs to enforce access laws on minors' use of tobacco. * Assess and compare the cost of different policies (e.g., local vs. state). *Determine the effects that access restrictions would have on tobacco use. * Monitor methods of youth access as the market changes. (continued on next page)

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Page 20 8. Regulation of the Labeling, Packaging, and Contents of Tobacco Products * Current warnings on tobacco products are inadequate. * Tobacco products are currently unregulated despite their harmfulness. * Congress should enact legislation that delegates to an appropriate agency the necessary authority to regulate the labeling, packaging, and content of tobacco products. * Congress should strengthen the federally mandated warning labels for tobacco products. *Congress should authorize the agency to impose ceilings of tar and nicotine yields and to reduce those ceilings over time. * Research is needed to help guide regulation of tobacco products. * Develop sound methodology for ascertaining actual yields of tar and nicotine based on human consumption. 9. Coordination of Policies and Research * Too much focus is on programs with little impact, rather than on policies to influence large populations. * Tobacco control efforts tend to be independent and duplicated, rather than coordinated strategically. * Major policy initiatives have been made at the state and local levels. * The federal government should provide unequivocal leadership in the effort to prevent nicotine addiction and tobacco- related disease and death. * OSH should be given the responsibility for coordinating federal tobacco control initiatives. * Funding to the non-Assist states should be increased to a level commensurate with ASSIST states. * Federal agencies should fund policy research. * The base of groups concerned with tobacco control should be broadened * Fund research to determine the efficacy of policy interventions for preventing youths from initiating tobacco use. * Assess the cultural and regional differences and factors influencing norms of tobacco use. * Elucidate the factors important in the initiation and prevention of tobacco use by children and youths.

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Page 21 (ASSIST). The Centers for Disease Control and Prevention has initiated programs in the non-ASSIST states, although funding for individual states under this program (IMPACT) is very low. In addition, the Robert Wood Johnson Foundation is collaborating with the American Medical Association to mount the SmokeLess States program. The Committee urges the federal government to broaden these initiatives with technical assistance, grants, and cooperative agreements to enable all interested states, local governments, and community coalitions to undertake youth-centered tobacco control policies. Actions Required To Sustain Progress in the Long Term The recommendations for immediate action will have a stronger impact if they are viewed as first steps in a long-term strategy for preventing nicotine dependence in children and youths and thereby reducing the adverse health consequences of tobacco use. Such a long-term strategy should include the key components that follow. Congress should establish a regulatory program for tobacco products with a long-term public health objective of dramatically reducing the prevalence of nicotine addiction. Tobacco products have been consistently exempted from coverage under consumer safety, food, and drug legislation, and as a result have been largely unregulated. This lack of regulation stands in stark contrast to other products that have far less disastrous long-term health implications than the use of tobacco products. The Committee recommends that Congress enact legislation that delegates to an appropriate agency in the Public Health Service the necessary authority to regulate tobacco products for the dual purposes of discouraging consumption and reducing the morbidity and mortality associated with their use. Such authority should encompass the packaging and constituents of all tobacco products, including the possibility of prescribing ceilings on yields of tar and nicotine. The regulation of tobacco products is discussed in chapter 8. Congress and state legislatures should eliminate allfeatures of advertising and promotion of tobacco products that tend to encourage initiation of tobacco use among children and youths. Children and youths believe that adults and even their peers smoke and use tobacco products far more than they actually do. Ubiquitous messages that associate tobacco use with images of youthfulness, athletic prowess, and sexuality reinforce a social norm that encourages tobacco use. Once initiated on a regular basis, tobacco use becomes further reinforced by the physiological and psychological processes of nicotine addiction. The pro-tobacco messages in

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Page 22 advertising and promotion are particularly difficult to combat among children and youths. The Committee therefore concludes that advertising and promotion of tobacco products should be severely curtailed. A more detailed discussion of this issue, and a series of relevant recommendations, can be found in chapter 4. Governments and voluntary organizations at all levels should sustain and reinforce the continued evolution of a tobacco-free norm in American society. Within a relatively short period of time, tobacco use has declined in prevalence and has become widely disapproved. Only a few decades ago, smoking was the social norm; now it is approaching a status of social deviance. The continued evolution of a tobacco-free norm is a potentially powerful component of a long-term strategy for reducing the prevalence of tobacco use among children and youths. This tobacco-free norm also protects children's health by reducing their exposure to environmental tobacco smoke. It is therefore important for governments and private organizations to promote and reinforce the evolving tobacco-free norm by implementing smoke-free policies in schools, workplaces, fast-food restaurants, and all other places where children and youths spend their time. A detailed discussion of the many opportunities for promoting a tobacco-free norm appear in chapter 3. Agencies and foundations that sponsor tobacco-related research should implement a youth-centered research agenda including studies of the efficacy of policy interventions. These efforts must recognize cultural differences among members of the major ethnic groups and attempt to develop culturally appropriate strategies. The above recommendations, and many others in this report, focus on setting social parameters to reduce the likelihood that children and youths will begin to use tobacco or that they will "graduate" into a lifetime of addiction. These recommendations are based on the knowledge at hand. Research to improve prevention and cessation interventions can help improve those efforts over time. Understanding the reasons for the remarkable decline in smoking prevalence among African-American youths is a major research priority. A better understanding of the molecular and cellular correlates of nicotine addiction, and the factors that mediate the adverse health effects of tobacco use can also provide helpful clues to guide future efforts. Moreover, improving smoking cessation treatments to help the 49 million Americans who smoke will benefit the smokers and foster knowledge about nicotine addiction as well. Finally, some of the data most useful to the Committee came from studies of tobacco control policy, such as epidemiologic studies and risk-factor analyses that monitor the effects of policy change. For example, decisions about which policies are most

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Page 23 likey to succeed were aided by assessments of the large-scale programs undertaken in Canada and California, measurements of the effects in local jurisdictions where youth access laws have been rigorously enforced, and studies describing the political influences that shape tobacco policy. The State of California and the Robert Wood Johnson Foundation have been leaders in promoting such policy research, joined recently by the National Cancer Institute. Recommendations and a discussion about research on the addictive process are presented in chapter 2, on prevention and cessation interventions in chapter 5, and on policy intervention throughout the report. During the course of its deliberations, the Committee was mindful that many youth-centered policy recommendations will also tend to reduce tobacco use by adults.  However, the Committee does not think that justified youth-centered interventions should be weakened simply because they will make tobacco use more costly or inconvenient for adults. After all, the ultimate goal of a youth-centered prevention strategy is to reduce the health toll associated with tobacco use. Indeed, the Committee came to understand that the relationship between a youth-centered prevention strategy and a broader tobacco control policy is a reciprocal one. On the one hand, reducing the onset of tobacco use by youths is an essential element of a successful strategy of long-term tobacco control. On the other hand, successful tobacco control initiatives in the society as a whole—such as the widespread adoption of tobacco-free policies establishing a normative climate unfavorable to smoking—play an important role in preventing nicotine addiction among youths. In both respects, a successful youth-centered prevention policy is the most expeditious way to reduce tobacco-related disease. REFERENCES 1. Centers for Disease Control and Prevention. "Cigarette Smoking—Attributable Mortality and Years of Potential Life Lost—United States, 1990." Morbidity and Mortality Weekly Report 42:33 (27 Aug. 1993): 645-649. 2. Centers for Disease Control. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Pub. No. (CDC) 89-8411. Washington, DC: U.S. Department of Health and Human Services, 1989. 3. National Cancer Institute. Smokeless Tobacco or Health. Monograph 2. NIH Pub. No. 933461. Washington, DC: U.S. Department of Health and Human Services, Sept. 1992. 4. Winn, D. M., W. J. Blot, C. M. Shy, L. W. Pickle, et al. "Snuff Dipping and Oral Cancer Among Women in the Southern U.S." New England Journal of Medicine 304:13 (1981): 745-749. 5. Herdman, Roger, Maria Hewitt, and Mary Laschober. Smoking-Related Deaths and Financial Costs: Office of Technology Assessment Estimates for 1990. Testimony before the Senate Special Committee on Aging. Hearing on Preventive Health: An Ounce of Prevention Saves a Pound of Cure. 6 May 1993. 2-4. 6. Manning, Willard, Emmett B. Keeler, Joseph P. Newhouse, Elizabeth M. Sloss, and Jeffrey Wasserman. "The Taxes of Sin: Do Smokers and Drinkers Pay Their Way?" Journal of the American Medical Association 261:11 (17 Mar. 1989): 1604-1609. Compare with: Hodgson. Thomas A. "Cigarette Smoking and Lifetime Medical Expenditures." The Milbank Quarterly 70:1 (1992): 110-113.

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Page 24 7. Herdman. 8. Hodgson. 9. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Washington, DC: U.S. Department of Health and Human Services, 1994. 65. 10. Centers for Disease Control and Prevention. ''Cigarette Smoking Among Adults— United States, 1991." Morbidity and Mortality Weekly Report 42:12 (2 Apr. 1993): 230-233. 11. Centers for Disease Control and Prevention. "Use of Smokeless Tobacco Among Adults—United States, 1991." Morbidity and Mortality Weekly Report 42:14 (16 Apr. 1993): 263-266. 12. U.S. Department of Health and Human Services. Public Health Service. Healthy People 2000. National Health Promotion and Disease Prevention Objectives. USDHHS Pub. No. (PHS) 9150212, 1990. 140, 147. 13. Pierce, John P., Michael C. Fiore, Thomas E. Novotny, Evridiki J. Hatziandreu, and Ronald M. Davis. "Trends in Cigarette Smoking in the United States." Journal of the American Medical Association 261:1 (6 Jan. 1989): 61-65. 14. Johnston, Lloyd, P. O'Malley, and J. Bachman. "Monitoring the Future Study." Press release. The University of Michigan, Ann Arbor. January 31, 1994. 15. Cummings, K. Michael, Terry Pechacek, and Donald Shopland. "The Illegal Sale of Cigarettes to U.S. Minors: Estimates by State." American Journal of Public Health 84:2 (1994): 300-302. 16. Johnston et al., 1994. 17. DiFranza, Joseph R., and Joe B. Tye. "Who Profits from Tobacco Sales to Children?" Journal of the American Medical Association 263:20 (1990): 2784-2787. 18. Johnston et al., 1994. 19. Marcus, Alfred C., Lori A. Crane, Donald R. Shopland, and William R. Lynn. "Use of Smokeless Tobacco in the United States: Recent Estimates from the Current Population Survey." In Smokeless Tobacco Use in the United States: National Cancer Institute Monographs 8 (1989): 17-23. 20. Johnston et al., 1994. 21. Johnston, Lloyd D., Patrick M. O'Malley, and Jerald G. Bachman. Data supplied by the Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta. 22. Federal Trade Commission. Report to Congress for 1991 Pursuant to the Federal Cigarette Labeling and Advertising Act. Washington, DC: Federal Trade Commission, 1994: 5. The percentage has been adjusted for inflation. 23. M. Joycelyn Elders, "Preface," Centers for Disease Control and Prevention, Preventing Tobacco Use, iii. 24. Gallup Organization, Inc. The Public's Attitudes Toward Cigarette Advertising and Cigarette Tax Increase. Conducted for Coalition on Smoking or Health. Princeton, NJ: Gallup Organization, Inc., Apr. 1993. 3, 10, 17. 25. Marttila & Kiley, Inc. Highlights From an American Cancer Society Survey of U.S. Voter Attitudes Toward Cigarette Smoking. Boston: Marttila and Kiley, Inc., Sept. 1993. 26. 26. Ibid. 28. 27. SmithKline Beecham. Gallup Report: A National Survey of Americans Who Smoke. New York, 1993. 28. National Cancer Institute. Major Local Tobacco Control Ordinances in the United States. Monograph 3. NIH Pub. No. 93-3532. Washington DC: U.S. Department of Health and Human Services, May 1993. 29. Rabin, Robert, and Stephen D. Sugarman. Smoking Policy: Law, Politics, and Culture. New York: Oxford University Press, 1993; and Goodin, Robert E. No Smoking: The Ethical Issues. Chicago: University of Chicago Press. 1989. 30. Feinberg, Joel. Harm to Self. Volume 3. New York: Oxford University Press, 1986. 128-134; and Viscusi, W. Kip. Smoking: Making the Risky Decision. New York: Oxford University Press, 1992.

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Page 25 31. See for example: Schelling, Thomas C. "Addictive Drugs: The Cigarette Experience." Science 255 (Jan. 1992): 430-433; and Robert Goodin, ibid. 32. Escobedo, L. G. "Sports Participation, Age at Smoking Initiation, and the Risk of Smoking Among U.S. High School Students." Journal of the American Medical Association 269:11 (1993): 1391-95. 33. Office of Technology Assessment. "Consent and Confidentiality in Adolescent Health Care Decisionmaking." Adolescent Health: Vol. 3. Crosscutting Issues in the Delivery of Health and Related Services. Chapter 17. Pub. No. OTA-H-467. Washington. DC: U.S. Congress. 1991. 111.141111.150; and Quadrel, Marilyn J., Baruch Fischhoff, and Wendy Davis. "Adolescent (In)vulnerability." American Psychologist 48:2 (1993): 102-116. 34. Viscusi. 35. Benthin, Alida, Paul Slovic, and Herbert Severson. "A Psychometric Study of Adolescent Risk Perception." Journal of Adolescence 16 (1993): 153-168: and Eiser, J. Richard. "Smoking, Seat-Belt Use and Perception of Health Risks." Addictive Behaviors 8:1 (1983): 75-78. 36. Levanthal, Howard, Kathleen Glynn, and Raymond Fleming. "Is the Smoking Decision an 'Informed Choice'? Effect of Smoking Risk Factors on Smoking Beliefs." Journal of the American Medical Association 257:24 (26 June 1987): 3373-3376. 37. Centers for Disease Control and Prevention. Preventing Tobacco Use, 80. 38. 32. Slovic. Paul. What Does It Mean to Know a Risk? Adolescents' Perceptions of Short-Term and Long-Term Consequences of Smoking. Report No. 94-4. Eugene, OR: Decision Research. June 1994. 39. Allen, Karen, A. Moss, G. A. Giovino, D. R. Shopland, and J. P. Pierce. "Teenage Tobacco Use Data. Estimates from the Teenage Attitudes and Practices Survey, United States, 1989." Advance Data No. 224 (1993): 9. 40. Centers for Disease Control and Prevention. Preventing Tobacco Use. 84. 41. Johnston et al., 1994. 42. Centers for Disease Control and Prevention. Preventing Tobacco Use. 76. 43. Allen et al., 9. 44. Centers for Disease Control and Prevention. Preventing Tobacco Use. 78. 45. Centers for Disease Control and Prevention. Division of Adolescent and School Health. Youth Risk Behavior Survey, unpublished data, 1994. 46. Centers for Disease Control, MMWR 42:33. 47. USDHHS, 143.

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