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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