New Frontiers of Tobacco Control
Ending the tobacco problem will require creative policymaking. Effective use of the traditional tools of tobacco control, reviewed in Chapter 5, can move the nation closer to that goal, but is unlikely to take us all the way. The next big step forward will require a new legal foundation and a substantial federal presence. The plan outlined in Chapter 6 is designed to lay that foundation and to authorize new approaches to tobacco control, such as adopting pictorial warnings, regulating claims about products that purport to reduce exposures to toxicants, and restructuring the retail environment for tobacco products. However, these innovations require thorough analysis before being implemented and careful monitoring afterward. Such an analysis will require a robust capacity to conduct tobacco policy analysis, including state-of-the-art modeling of the effects of new industry initiatives and potential regulatory interventions.
This chapter has two objectives: first, it fleshes out the case for investing in tobacco policy analysis and development and highlights several new frontiers of tobacco control that merit investigation by the new policy development office. Second, it discusses in some detail the most promising of these ideas—gradually reducing the nicotine content of cigarettes. If this idea proves feasible, its implementation could provide the nation’s best hope for ending the tobacco problem.
TOBACCO POLICY ANALYSIS AND DEVELOPMENT
An investment in tobacco policy analysis and development is an essential component of a comprehensive federal effort to reduce the heavy
public health burden of tobacco use, especially when history so clearly documents the capacity of the tobacco industry to mount effective countermeasures against and to neutralize potentially effective innovations in tobacco control.
Recommendation 41: Congress should direct the Centers for Disease Control and Prevention to undertake a major program of tobacco control policy analysis and development and should provide sufficient funding to support the program. This program should develop the next generation of macro-level simulation models to project the likely effects of various policy innovations, taking into account the possible initiatives and responses of the tobacco industry as well as the impacts of the innovations on consumers.
The proposed tobacco policy development office might sensibly be located in the Food and Drug Administration (FDA) after Congress confers on FDA the necessary authority to regulate tobacco products.
Improving Policy Simulation Models
One of the policy office’s first tasks should be to foster improvements in tobacco policy simulation models. The current generation of tobacco policy models has been valuable to the committee, and the committee is confident that the projections provided to the committee represent the best that can be produced with the currently available tools. However, the implications of tobacco policy decision making are of sufficient magnitude to warrant a greater investment to help policy analysts advance the state of the art. The current tobacco policy models could benefit from the following improvements.
Incorporate State-Dependent or Endogenous Transition Rates
Smoking initiation is influenced by peers, particularly peers’ rates of smoking. More generally, individuals’ decisions to start, stop, or restart smoking may be influenced by the smoking or nonsmoking of others. These feedbacks from current prevalence to various flow rates include personal interaction effects (e.g., when smoking teens encourage their friends to smoke), societal-level effects (e.g., if smoking is rare, it is more likely to be shunned, which might reduce relapse rates), and market-level effects (e.g., if there are fewer smokers, and hence less demand for tobacco, the market equilibrium price for cigarettes might be affected, which in turn can affect smoking rates).
Distinguish Between Different Intensities of Smoking
Policy simulation models of other forms of substance abuse differentiate between light and heavy users. The incorporation of such distinctions in tobacco-use models would be valuable, inasmuch as a nonnegligible proportion of current smokers are not daily smokers, various policy interventions (including tax increases) may affect the frequency of smoking as well as the overall smoking prevalence, and some health outcomes of interest may be state-dependent.
Recognize Behavioral Response on the Part of Industry
The tobacco industry may undertake new innovations in smoking or respond to changes in smoking prevalence, or it may respond to changes in smoking policies in various ways that are not reflected in current models. A simple example is the industry’s response to a tax increase. Current tobacco policy models typically assume that excise tax increases are passed along to consumers in the form of dollar-for-dollar increases in the retail prices, but tobacco manufacturing is an oligopolistic industry, so other outcomes are possible, as are other forms of strategic behavior or product innovation. For example, declining sales might trigger the aggressive promotion of new products, such as flavored cigarettes, which might affect smoking initiation rates.
Model Black and Gray Market Behavior
Excise tax increases are a particularly important and appealing policy lever. Yet, various forms of retail tax evasion and other forms of illicit marketing already exist, and one would expect them to become more common as taxes increase further. Modeling of that behavior is essential to determining the best tax policies.
Track Vectors of Health Outcomes in Addition to Smoking Prevalence
Policy is ultimately more concerned with health outcomes than with smoking per se, so it would be useful if tobacco policy models translated smoking rates into various types of health consequences. Some models can do this to some degree, but in many cases the current state of the art is rather limited.
Beyond these structural changes, a range of more pedestrian measures can be taken to improve the modeling infrastructure and to better inform tobacco policy. These include calibration of the models to longer and more age-specific age series, the use of more detailed demographic modeling
(e.g., immigration), allowance for more multidimensional parametric sensitivity analysis and associated confidence interval calculation (e.g., through Monte Carlo simulation), and investigation of more scenarios (e.g., advances in lung cancer treatment and the introduction of low-nicotine cigarettes).
Policy Innovations Worthy of Study
Among the interesting ideas that should be studied by a tobacco policy development office are the ideas explored in the previous chapters, including restructuring the retail market and reducing the number of retail outlets (Chapter 6) and implementing a nicotine-reduction strategy (see below). Other suggestions presented in the tobacco policy literature include establishing a wholesale purchasing monopsony (Borland 2003) and creating policy mechanisms for changing the incentives of tobacco companies to align their goals with public health goals.
Tobacco Wholesale Purchasing Monopsony
Borland has proposed an innovative model of tobacco distribution designed to eliminate marketing and to spur competition for reduced-exposure products (Borland 2003). Under the proposal, a new agency, the Tobacco Products Agency (TPA), would be chartered to be the exclusive buyer and distributor of tobacco products. It would purchase the products from domestic manufacturers and importers and distribute them to retailers. The agency’s goal would be to promote the public health by reducing tobacco consumption and otherwise reducing harm. It would negotiate with the manufacturers to purchase the least-harmful products, giving them an incentive to compete on the basis of safety and thereby serving a quasi-regulatory function. In turn, the TPA would distribute the products generically, thereby cutting the link between manufacturer and consumer and removing any marketing incentive. Similarly, the TPA would control the marketing at the retail level. The core idea is eliminating any entity with a vested interest in promoting smoking. Only a Borland model or something like it (a retail nonprofit monopoly) will be able to maintain high prices and eliminate the promotions that have been the most important marketing tools used by the companies (Chaloupka et al. 2002). Similarly, the TPA could be expected to use plain packaging, which would eliminate brand identity and the various devices that manufacturers use to signal reduced-harm messages without making explicit claims. The committee believes that the Borland proposal is worthy of serious study by the proposed policy development office.
Changing the Incentives of Tobacco Manufacturers
In the clear light of history, there can be no doubt that the promotion and marketing of cigarettes by tobacco companies have been the vectors of an enormous public health problem. The extent to which industry efforts to suppress the truth about tobacco’s health effects contributed to and sustained the tobacco problem, and whether this conduct persists are factual inquiries that have recently been addressed by federal district Judge Gladys Kessler in the U.S. Justice Department’s Racketeering Influenced and Corrupt Organization (RICO) suit, United States v. Philip Morris (2006). Judge Kessler noted in her opinion that she was doubtful that the industry’s aims have changed:
As Defendants’ senior executives took the witness stand at trial, one after another, it became exceedingly clear that these Defendants have not, as they claim, ceased their wrongdoing or, as they argued throughout the trial, undertaken fundamental or permanent institutional change (p. 1605)…. [D]espite Defendants’ claims that they have materially altered their management and are now “new” companies, the evidence demonstrates that they have not changed their policies or personnel in any meaningful way (p. 1609).
In the committee’s view, even if the industry’s misleading and deceptive conduct has ended, it is difficult to see how an industry whose aggressive marketing was the primary vector of a major public health problem and whose profits continue to be generated by selling cigarettes could possibly be an ally of public health efforts to discourage smoking and, eventually, to eliminate it. Indeed, evidence of industry efforts to defeat and curtail the tobacco control measures outlined in Chapter 6 is abundant, as are the industry’s current promotional expenditures.
What conduct should now be expected of tobacco companies? Recent efforts by Philip Morris to align the company “with society’s evolving expectations of a responsible tobacco company,” including support for enactment of federal legislation that empowers the FDA to regulate tobacco products and support for cessation and prevention programs, are intriguing. However, unless public policies fundamentally transform a tobacco company’s economic incentives, the committee knows of no model of corporate responsibility that can reconcile a tobacco company’s responsibility to its shareholders with a business plan of discouraging smoking and promoting cessation, that is, with measures designed to put itself out of the tobacco business.
Admittedly, the cause of tobacco control is better off today than it was when the tobacco companies were uniformly denying that smoking was addictive or harmful and when smoking was aggressively promoted in every
mass medium and on much of the visual space on highways and in urban centers. However, the emergence of the truth about smoking and about the tobacco industry’s efforts to suppress it has not ended the companies’ interest in generating profits. Nor has it erased the interests of convenience stores and other retailers in selling as many cigarettes as possible. For this reason, the committee has repeatedly emphasized the need to remove or offset the influences that tend to promote tobacco use or that otherwise impede successful efforts to reduce it.
The only socially useful role for the tobacco industry is to satisfy the residual demand among current smokers for tobacco products while financing compulsory remedial measures to undo the damage caused by the companies’ past conduct. To the extent that the tobacco companies want to shift into the “harm reduction” market, these initiatives need to be carefully policed to ensure that consumers are not misled and that the marketing of reduced-exposure products is not actually a disguised effort to deter smoking cessation and to preserve the demand by addicted smokers—and that it does not, in fact, have that effect.
The challenge for policy makers is to develop creative measures for aligning the companies’ incentives as closely as possible with public health interests. Specifically, how might incentives be created to deter companies from stimulating new demand for smoking, especially among youth (defined as those younger than 21 years of age); to encourage them to reduce the harmfulness of tobacco products; and, ideally, to help addicted smokers quit?
In its RICO suit against the major domestic manufacturers, the U.S. Department of Justice unsuccessfully urged the district court to set goals for youth smoking and penalize the companies $3,000 for every underage smoker exceeding the annual target (as had been proposed by the state attorneys general in 1997 during negotiations for a so-called global settlement of the state Medicaid reimbursement suits). Targets could also be set for reducing the prevalence of adult smokers based on a finding that smoking prevalence is substantially higher than it would have been in the absence of the manufacturers’ illegal behavior.
The committee is not in a position to assess the economic plausibility of different incentive plans. However, responsible agencies of the federal government, including the policy development office, should evaluate the possible effects of different approaches to aligning the incentives of tobacco manufacturers more closely with public health objectives.
REDUCING THE NICOTINE CONTENT OF CIGARETTES
As discussed in Chapter 4, the ethical case for the forceful regulation of cigarettes and other tobacco products is squarely grounded in the ad-
dictive property of nicotine. Young people begin using tobacco products without genuinely appreciating the risk and meaning of addiction, and most addicted users experience deep regret and frustration about their inability to quit. One possible long-term strategy for reducing tobacco use and its associated harms is to reduce the addictiveness of tobacco products. For this reason, the committee believes that the responsible federal agencies, including the proposed tobacco policy development office, should give a high priority to exploring the feasibility of a long-term policy of gradually reducing the nicotine content of cigarettes. The goal of such a policy would be to reduce the addictiveness of cigarettes, thereby reducing the likelihood of progression from occasional to regular smoking by adolescents and young adults and making it easier for addicted smokers to quit by reducing their level of nicotine addiction (Benowitz and Henningfield 1994).
The committee acknowledges that the FDA’s 1996 Tobacco Rule rejected a nicotine-reduction strategy in the short run. Similarly, recent reports on nicotine and on tobacco ingredients by the World Health Organization’s Scientific Advisory Committee on Tobacco Product Regulation (SACTob) conclude that major scientific uncertainties and practical concerns preclude such a strategy, at least in the short term (SACTob 2003a, 2003b).
However, neither the FDA nor the WHO Scientific Advisory Committee has ruled out nicotine reduction as a long-term strategy—implemented over decades, perhaps—as its supporters have envisioned it (Benowitz and Henningfield 1994). In addition, to be implemented successfully, nicotine reduction would have to build on, and be integrated with, other components of the blueprint identified in Chapters 5 and 6, especially innovations in product regulation. Developing knowledge and experience with tobacco product regulation is a necessary precondition for implementing a nicotine-reduction strategy; however, regulation of tobacco product characteristics to make them less addictive could be a first step in the direction of the nicotine-reduction strategy (Henningfield et al. 2004).
With these caveats in mind, the committee elaborates below on the rationale for giving serious consideration to nicotine reduction as a long-term strategy.
Feasibility of a Reduced-Nicotine–Cigarette Strategy
The nicotine content of cigarettes could be lowered independently of changes to other constituents of cigarette tobacco, although the agency authorized to regulate tobacco products could also require manufacturers to reduce or eliminate specific toxic constituents of tobacco smoke, according to the perceived health risks and technical feasibility (see Chapter 6). However, it is unlikely that making cigarettes “safer” will ever be a satisfactory long-term strategy as long as tobacco use is addictive. Furthermore, on the
basis of the experience with other addictive drugs, a gradual reduction of the nicotine content of cigarettes is more sensible than an effort to eliminate cigarettes altogether, given the costs of enforcing prohibition. The exact decrements of nicotine content and the rate at which these decrements are mandated would depend both on scientific considerations and on the practicality of changing tobacco manufacturing procedures. For a nicotine reduction strategy to work, it must apply to all manufactured cigarettes, and the extent of nicotine reduction across cigarette brands must be uniform. If not, smokers will simply select higher-nicotine–content cigarettes to sustain their addiction. Most likely, a nicotine-reduction strategy would need to take place in decrements over 10 to 15 years, with decrements of 10 to 15 percent of nicotine content per step. Currently available research suggests that smokers will find a gradual reduction of nicotine content acceptable when the other characteristics of tobacco smoke remain the same (Benowitz et al. 2004).
The ultimate level of nicotine reduction would need to be determined by ongoing scientific research and by the results of surveillance of the smokers of reduced nicotine products over time. Currently, marketed cigarettes contain 10 to 15 milligrams of nicotine per cigarette. The smoker systemically absorbs only about 10 percent of the nicotine in the rod of tobacco (cigarette), so the machine-determined nicotine yields of current cigarettes are approximately 1 milligram. Benowitz and Henningfield estimated that a reduction of the total nicotine content of cigarettes to 0.5 milligrams per rod would be a good initial estimate of what would be necessary to minimize the addictiveness of cigarettes (Benowitz and Henningfield 1994). The estimate was based on a daily intake level of 5 milligrams per day (compared with the 20 milligrams per day currently taken in by the typical addicted smoker) and the possibility that a person smokes up to 30 cigarettes per day very intensively. The nicotine content of tobacco can be reduced either by extracting nicotine from the tobacco or by using tobacco that is genetically engineered to have a lower nicotine content. Both of these methods have been used in the manufacturing of low-nicotine-content cigarettes in the past (for the Next™ brand of cigarettes by extracting nicotine and for the Quest™ brand of cigarettes by using genetically engineered tobacco). The nicotine content of cigarette tobacco can be determined by straightforward and unambiguous chemical analytical methods. It would also be essential that cigarette manufacturers be prohibited from changing the design of cigarettes to make nicotine more bioavailable than it is at present. (Bioavailability could be assessed by smoking machine testing or human bioavailability studies by using biomarkers of nicotine exposure. The details of testing and enforcement would have to be worked out by the regulatory authority.)
One of the consequences of reducing the nicotine available from cigarettes might be that smokers would smoke cigarettes more intensively or smoke more cigarettes per day, thereby increasing their exposure to other toxic smoke constituents. This could produce short-term adverse health consequences. It is well known that when smokers switch from higher- to lower-yield commercial cigarettes, they adjust their smoking behavior to maintain the desired levels of nicotine intake (NCI 2001). Smokers take deeper and more frequent puffs, block ventilation holes, or smoke more cigarettes to sustain adequate levels of nicotine. It should be recognized, however, that currently available commercial low-yield cigarettes contain as much nicotine as high-yield cigarettes (NCI 2001). Therefore, it is quite easy for a person to adjust his or her smoking behavior to compensate for low yields. However, these are not the same types of low-nicotine cigarettes that would be part of a nicotine reduction regulatory strategy.
Recent research with low-nicotine–content cigarettes in which the nicotine content was gradually tapered down (by extracting the nicotine from the tobacco) suggests that smokers do not increase their toxic exposures, despite substantial reductions in their nicotine intakes. Benowitz and colleagues conducted a 6-week longitudinal study of 20 smokers who smoked their usual brand and who then smoked five different types of research cigarettes with progressively lower nicotine contents (ranging from 10 to 0.6 milligrams), each for 1 week (Benowitz et al. 2004). The intake of nicotine, as measured by determination of the smokers’ plasma cotinine concentrations, declined progressively as the nicotine content of the cigarettes was reduced, with little evidence of compensation. The level of cigarette consumption and biomarkers of exposure to carbon monoxide and polycyclic aromatic hydrocarbons remained stable, whereas the level of urinary NNAL (tobacco-specific nitrosamine) excretion decreased. These data suggest that the availability of nicotine in tobacco can be lowered without increasing the level of exposure to the toxins of tobacco smoke.
The reasons for a lack of compensatory smoking are likely to include the difficulty in obtaining more nicotine (because less nicotine is available in the tobacco) and the satiating effects of the tar, the levels of which remained unchanged in these reduced-nicotine cigarettes. Smokers could smoke more cigarettes per day in the first phases of a gradual reduction strategy, but for most smokers, compensation for low-yield cigarettes is done primarily by puffing more intensively. Although there is strong evidence of titration of nicotine intake from cigarettes, sensory aspects such as the taste and harshness of cigarette smoke do provide some reinforcement and may lessen withdrawal symptoms compared with those experienced when both nicotine and tar deliveries are reduced in combination. Similar findings of little compensation from the smoking of reduced-nicotine, higher-tar ciga-
rettes have been reported by Rose and Behm (2004), using tobacco that was genetically engineered to be low in nicotine content, and by Benowitz and colleagues using manufactured cigarettes from which nicotine had been extracted (Benowitz, Peyton, and Herrera 2006).
A key element in any regulatory proposal must be careful surveillance of smokers over time. Surveillance would need to include measurement of cigarette consumption, measurement of the smokers’ level of exposure to nicotine and tobacco toxins by determining the levels of various biomarkers, and assessment of smoking initiation rates and subsequent cigarette consumption by adolescents and young adults. Surveillance of biomarkers could entail cross-sectional or longitudinal studies of cohorts of smokers. The numbers and characteristics of smokers who would be selected and which biomarkers would be monitored would need to be determined by the regulatory authorities.
Some smokers may not get enough nicotine from reduced-nicotine cigarettes to sustain their addiction and may experience withdrawal symptoms. To deal with such smokers, nicotine-containing medications should be made readily and inexpensively available. Making nicotine-containing medication available could also be done as part of a tobacco regulatory strategy (NCI 2001). Although nicotine in itself is likely to have some intrinsic toxicity, such toxicity is minimal compared with the toxicity of cigarette smoking. Smokers who move from cigarettes to pure nicotine either could continue to take nicotine in pure form over time to sustain their addiction, or could gradually reduce their level of nicotine over time. In any case, the health risks associated with nicotine use is far less than those of continued smoking.
A nicotine-reduction strategy would require considerable education of the public about the goals of the program and the nature of the new cigarettes that will be introduced every year or two. The potential utility of nicotine replacement therapy to deal with insufficient nicotine intake would need to be explained, and resources would need to be available to help those smokers who do decide to quit as their level of addiction is reduced. Vehicles for public education might include media campaigns and information supplied in cigarette package “onserts.” The details of the public information program would most logically be coordinated by a central regulatory authority working with local communities to ensure that various populations of smokers are reached.
One concern with a mandatory reduction in the nicotine content of cigarettes is the creation of a demand for contraband or other tobacco products that do not meet the requirements set by the agency of regulatory authority. Such products might include manufactured cigarettes with high levels of nicotine that are illegally imported or manufactured, or loose tobacco which could be rolled into cigarettes by the user. The regulatory
agency would need to monitor such activities and products and determine whether intervention is needed to protect the public health. If contraband use is relatively low and if contraband products are used by only a small percentage of smokers who are highly addicted and want to continue to be addicted, then the public health problem would not be great and enforcement may not become a major issue. However, if a substantial market for contraband products arises, the regulatory agency would have to consider alternative approaches, such as raising the authorized level of nicotine for all cigarettes or allowing a higher-level nicotine cigarette to be obtained with a prescription.
If the nicotine reduction approach were successfully implemented, it is anticipated that cigarettes containing very low levels of nicotine would eventually appeal to a very small number of consumers and would be smoked primarily in social situations. The decision to smoke or not to smoke would not be driven by drug addiction and could be exercised more rationally by the smoker. A marked reduction of cigarette consumption and the promotion of quitting by currently addicted smokers would have an enormous impact on the adverse health effects of tobacco use.
Impact of a Reduced-Nicotine–Cigarette Strategy
The committee is in no position to assess the feasibility of a nicotine reduction strategy or to predict the consequences of implementing it. However, the committee believes that this approach has great promise and should be seriously explored by the regulatory agency recommended in Chapter 6 or the tobacco policy research office recommended in this chapter. The potential impact of federally mandated nicotine-reduction strategy was recently examined by an exploratory computer simulation conducted by Tengs and colleagues (2005). They developed a mathematical model based on the U.S. population in 2003, which was divided into cohorts according to age, gender, and smoking status. The smoking behaviors that were modeled included smoking initiation, cessation, and relapse. The model outcome was quality-adjusted life years. In examining the effects of a reduced-nicotine–cigarette strategy, Tengs and colleagues assumed that the nicotine content of cigarettes would be reduced over 6 years and that the reduced addictiveness of the reduced-nicotine–content cigarette after completion of the mandated tapering would result in an 80 percent increase in cessation rates and an 80 percent decrease in relapse and initiation rates over the 6 years. The model also included a 10 percent increase in the annual probability of death among continued smokers because of compensation and the probability that 10 percent of smokers would seek high-nicotine cigarettes from the black market, with both probabilities increasing linearly over 10 years. The simulation projects that the prevalence of smoking among the adult population could decline
from 23 to 5 percent over 50 years, with a cumulative gain of 157,000,000 quality-adjusted life years. The investigators also performed a number of sensitivity analyses. All showed a similar gain in quality-adjusted life years. The investigators concluded that “policy makers would be hard-pressed to identify another domestic public health intervention, short of historical sanitation efforts, that has offered this magnitude of benefit to the population.” Although the computer simulation by Tengs and colleagues includes too many ungrounded assumptions to serve as a basis for estimating the consequences of a phased-in nicotine reduction strategy, the study does reinforce the committee’s view that this approach merits serious consideration by policy makers.
Other Regulatory Approaches to a Reduced-Nicotine–Cigarette Strategy
Although a regulatory strategy that would mandate changes in product characteristics by a central authority is likely to be the most effective in reducing the addictiveness of cigarettes, two other regulatory approaches that could be implemented should be mentioned. One approach would be to mandate warnings on packages describing the nicotine content of the cigarettes and the relative addictiveness of the products. Individuals could choose to smoke less addictive cigarettes if they desired. Reduced-nicotine–content cigarettes are being marketed as the brand Quest™, but their sales are quite low. On the basis of prior experience with cigarette labeling and the compulsion of addicted individuals to continue the use of their addictive drug, if it is available, as well as the lack of public uptake of Quest™ cigarettes, it is unlikely that such an approach would be successful.
Another approach would be the progressive taxation of cigarettes on the basis of their nicotine content. Although highly addicted smokers are likely to accept moderate increases in price, so that they may obtain their desired dose of nicotine, if the tax increases were very high, the high taxes might force some smokers to accept lower-nicotine–content cigarettes. Progressive tax escalation based on the higher nicotine contents of cigarette tobacco over a number of years might result in many smokers switching to less addictive cigarettes. However, a mandated approach for nicotine reduction that is uniform across all cigarette brands might have the biggest payoff at the population level. The advantages and disadvantages of these alternative regulatory approaches should be explored by the regulatory agency.
Recommendation 42: Upon being empowered to regulate tobacco products, the FDA should give priority to exploring the potential effectiveness of a long-term strategy for reducing the amount of nicotine in cigarettes and should commission the studies needed to assess the feasibility of implementing such an approach. If such a strategy ap-
pears to be feasible, the agency should develop a long-term plan for implementing the strategy as part of a comprehensive plan for reducing tobacco use.
The new tobacco policy development office should be charged with conducting the necessary research and analysis to advise policy makers on the likely effects of existing policies and of proposed new ones and of measures that can be taken to increase the prospects of the successful implementation of these policies. For example, the aggressive tobacco control measures recommended in Chapter 6 rest on emerging public understanding of the characteristics of tobacco products that warrant such measures, and successful implementation over the long term will entail ongoing educational efforts to reinforce and sustain public understanding. In addition, tobacco use is a worldwide problem, and many other countries have embraced aggressive measures of tobacco control. The policy development office should also study the effects of policies adopted in other countries as well as the effects of free trade policies on tobacco control efforts in the United States and abroad.
In short, even if the aggressive measures recommended in this report were speedily adopted and implemented, ending the tobacco problem will require decades of sustained and careful policymaking, accompanied by vigilant monitoring and flexible response. A robust capacity for policy analysis and development is an essential component of a strategic initiative to end the tobacco problem. The policy development office as well as the FDA should take a long-term view and should initiate serious study of approaches on the frontier of tobacco control.
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