Taking Action to Reduce Tobacco Use

The nation needs a strategy to reduce the death and disability caused by use of tobacco products. That strategy may develop out of a renascent public debate about tobacco control policies that has intensified over the past three years. When the Institute of Medicine (IOM) released its 1994 report, Growing Up Tobacco Free,1 prospects for federal action were highly uncertain. That same year, the surgeon general's report was also focused on youth tobacco use.2 Prospects for tobacco control grew brighter when the Food and Drug Administration (FDA) asserted jurisdiction over tobacco products, with strong presidential support, state attorneys general brought suit against tobacco firms on a new legal basis, and class-action lawsuits became more palpable threats to the financial future of private tobacco firms. Media coverage of these events and revelations of hitherto secret files and depositions from former tobacco firm employees has been intense. These and other developments have resulted in a vigorous national debate about tobacco control among the various groups with a stake in tobacco policy—tobacco firms, state attorneys general and health officials, public health groups, tobacco growers, tobacco control advocates, and others. Attention now focuses on the U.S. Congress and the executive branch, which are seriously considering federal legislation.

Although public debate has intensified, tobacco use among youths has escalated. Smoking rates among youths have increased for four years in succession (1993-1996), as measured by the largest national survey, the University of Michigan's "Monitoring the Future" project. 3 Today's tobacco use will become tomorrow's health statistics. As a four-decade longitudinal study of smoking in British physicians concludes, "about half of all regular cigarette smokers will eventually be killed by their habit."4 New users will become addicted to nicotine, followed years later by a sharply increased incidence of tobacco-related diseases. Cancer, cardiovascular disease, and lung disorders cause most tobacco-related deaths, although tobacco use is associated with many other medical conditions. Among the 419,000 Americans who died from smoking in 1990, for example,



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Taking Action to Reduce Tobacco Use The nation needs a strategy to reduce the death and disability caused by use of tobacco products. That strategy may develop out of a renascent public debate about tobacco control policies that has intensified over the past three years. When the Institute of Medicine (IOM) released its 1994 report, Growing Up Tobacco Free,1 prospects for federal action were highly uncertain. That same year, the surgeon general's report was also focused on youth tobacco use.2 Prospects for tobacco control grew brighter when the Food and Drug Administration (FDA) asserted jurisdiction over tobacco products, with strong presidential support, state attorneys general brought suit against tobacco firms on a new legal basis, and class-action lawsuits became more palpable threats to the financial future of private tobacco firms. Media coverage of these events and revelations of hitherto secret files and depositions from former tobacco firm employees has been intense. These and other developments have resulted in a vigorous national debate about tobacco control among the various groups with a stake in tobacco policy—tobacco firms, state attorneys general and health officials, public health groups, tobacco growers, tobacco control advocates, and others. Attention now focuses on the U.S. Congress and the executive branch, which are seriously considering federal legislation. Although public debate has intensified, tobacco use among youths has escalated. Smoking rates among youths have increased for four years in succession (1993-1996), as measured by the largest national survey, the University of Michigan's "Monitoring the Future" project. 3 Today's tobacco use will become tomorrow's health statistics. As a four-decade longitudinal study of smoking in British physicians concludes, "about half of all regular cigarette smokers will eventually be killed by their habit."4 New users will become addicted to nicotine, followed years later by a sharply increased incidence of tobacco-related diseases. Cancer, cardiovascular disease, and lung disorders cause most tobacco-related deaths, although tobacco use is associated with many other medical conditions. Among the 419,000 Americans who died from smoking in 1990, for example,

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151,000 died of cancer. The increased numbers of deaths among women are particularly alarming. Since 1987, more women have died each year of lung cancer than breast cancer. An American Cancer Society graph illustrates the dramatic rise in the rate of lung cancer among women, which follows the rise in women's smoking that began several decades earlier.5 There are only three basic ways to reduce the death toll: to prevent the initiation of tobacco use, to get current users to quit, and to reduce exposure to tobacco toxins. The vast majority of those who use tobacco start doing so in childhood or youth, so prevention efforts must focus there. Individuals of all ages can quit using tobacco, and the cessation of tobacco use is associated with immediate economic and health benefits from reduced cardiovascular disease6 and long-term reductions in the likelihood of developing cancer.7 Reduced exposure to tobacco toxins has followed from bans in public places. Preventing the initiation of tobacco use among children and youths remains the preeminent long-term goal, but cessation of tobacco use by individuals in all age groups is also essential. The projection that 10 million people will die of tobacco-related illness in the year 2030 is mainly based on the number of current users.8 This enormous health toll will thus drop only if current users quit and are not replaced by other users, and if tobacco exposure is reduced. The worldwide health consequences also clearly indicate that national tobacco control policies must look beyond national borders. At its first two meetings in the spring of 1997, the National Cancer Policy Board identified tobacco control as a priority, and tobacco control was the subject of its initial policy statements. The board organized a workshop on July 15, 1997, in Washington, D.C., and summarized its views in a July 18, 1997, letter to Secretary of Health and Human Services Donna Shalala, the president's Domestic Policy Advisor Bruce Reed, and members of the U.S. Congress. This white paper builds on those efforts, addressing (a) price increases, (b) federal regulation, (c) state and local tobacco control programs, (d) performance monitoring, (e) cessation programs, (f) research, and (g) international health impacts. BACKGROUND Even as the IOM Committee on Preventing Nicotine Addiction in Children and Youths was completing its work in 1994, FDA was beginning an investigation that culminated in the precedent-setting regulation of tobacco products. This effort began with a petition to FDA Commissioner David Kessler in February 1994 from the Coalition on Smoking OR Health and culminated in an assertion of FDA's jurisdiction over tobacco products under the Food, Drug, and Cosmetics Act. Following an extensive FDA investigation, in August 1995 President Bill Clinton announced his intention to assert FDA jurisdiction over tobacco products as nicotine-delivery devices. (A more complete chronology of events leading to the FDA action is available on-line at: http://www.os.dhhs.gov/news/press/1996pres/960823f.html.) Most states have also brought suit against tobacco firms to recoup state funds expended on health care for those suffering from tobacco-related diseases. In May 1994,

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Michael Moore, the attorney general of Mississippi, filed the first such lawsuit. In August 1994, Minnesota Attorney General Hubert H. Humphrey III filed a similar suit. Since then 38 more states and many city and county governments have joined Mississippi and Minnesota in filing suits against tobacco manufacturers. In March 1997, the Liggett Group, Inc., reached a settlement with the attorneys general of five states and, a few days later, with the plaintiffs in one of the class-action suits. This agreement acknowledged that nicotine is addictive and that marketing has been directed at youths. Liggett also agreed to make public previously secret industry documents. On June 20, 1997, the attorneys general of 40 states announced an agreement (hereafter "the settlement") with five additional tobacco firms, which among them account for more than 95 percent of tobacco sales in the United States. The settlement would entail payments of up to $368.5 billion over 25 years. The settlement proposed FDA regulation, marketing and promotion restrictions, some antitrust exemptions for tobacco firms, and liability limits with escrow funds for class-action, individual, and state suits. On July 3, 1997, Mississippi reached its own settlement of more than $3 billion, but this will be superseded by the congressionally ratified settlement if it comes to fruition. On August 25, 1997, Florida reached an $11.3 billion settlement that would likewise be superseded by federal legislation, except that a $150 million pilot tobacco control pilot program will continue with or without federal settlement. A three-phase Texas Medicaid suit was scheduled to begin in October 1997, but this was delayed until January 1998 due to the judge's illness. The suit brought by Minnesota is scheduled to go to trial in January 1998. In addition to the actions of the state attorneys general and FDA, dozens of individual and class-action lawsuits have been filed against tobacco firms. Suits have also been filed in several countries in Europe, Latin America, Asia, and Africa. On October 9, 1997, a class-action suit brought by flight attendants was settled out of court, creating a $300 million fund. Those funds "shall be used solely to establish a Foundation [the Norma Broin Foundation, named for the flight attendant who initiated the suit] whose purpose will be to sponsor scientific research with respect to the early detection and cure of diseases associated with cigarette smoking." The various lawsuits have forced to the surface documents related to the tobacco industry. In December 1997, the House Committee on Commerce issued subpoenas for over 800 documents identified in connection with the Minnesota state suit, and made them publicly available. In addition to the courtroom drama, industry whistle blowers have publicly disclosed previously secret documents and practices, and the 1996 U.S. presidential campaign featured a lively debate about tobacco control. Despite a mounting debate, consensus about the details of national tobacco control policy is not complete. Public health advocates differ sharply about whether a national settlement is desirable at all, let alone about the terms of such a settlement. With expressions of support for legislation from both the president and the leaders in the U.S. Congress, however, the debate has shifted from theory into the political arena. The findings and recommendations of this report are directly pertinent to the policy decisions now under active consideration, including but by no means restricted to legislation related to the settlement. Several bills have been introduced in late 1997, and several other bills are being actively drafted with the expectation they will be introduced early in 1998.9 Federal