Ending the Tobacco Problem: A Blueprint for the Nation
Institute of Medicine
May 24, 2007
Richard J. Bonnie
John S. Battle Professor of Law and Director, Institute of Law, Psychiatry, and Public Policy, University of Virginia School of Law, Charlottesville
Chair, Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences
Good morning. Thank you for joining us for the release of our report, Ending the Tobacco Problem: A Blueprint for the Nation. I am pleased to be joined by my fellow committee members Dr. Robert Wallace and Dr. Bonnie Halpern-Felsher to discuss this report with you. We were assisted in this effort by many distinguished colleagues, whose names you have in front of you.
As everyone here knows, tobacco use – especially cigarette-smoking – has been one of the nation's major public health problems for most of the 20th century and continues at an unacceptable level in the 21st century. Indeed, it has become one of the world's major public health challenges.
The tobacco problem is fundamentally a man-made problem. Cigarettes became one of the most successful consumer products in history in only a few decades and became an ever-present icon of American life – embedded in the culture and promoted by a powerful industry. Unfortunately, cigarettes are one of the most dangerous consumer products ever marketed. They are highly addictive and deadly, as even the tobacco companies now concede.
If tobacco cigarettes were now being introduced into the marketplace for the first time, there is no doubt that they would be banned under any one of several consumer protection statutes. Of course, banning tobacco products is not feasible or wise. The challenge the country faces today is to develop a feasible strategy for rooting out a problem that is deeply entrenched in our economic and cultural life. There are still 45 million cigarette smokers and another 9.7 million users of other tobacco products. Most of them regret taking up the habit and struggle to quit.
Let me explain what the committee means by "ending the tobacco problem." The nation's goal in the committee's view should be to reduce tobacco use so substantially that it is no longer a significant public health problem. The blueprint outlined in the report aims to set the nation irreversibly on a course for achieving this objective.
Optimists might say we are already well on our way to ending the problem. After all, the prevalence of smoking among adults has been cut in half – from 42 percent to 21 percent – since 1965. The prevalence of daily smoking among high school students is at its lowest level since annual monitoring began 30 years ago. An increasing proportion of the indoor environment is smoke-free. The tobacco companies are defending themselves against an increasing number of lawsuits, and have been hit by very large punitive damage awards by state juries outraged by the industry's deceptive conduct. Why not just keep doing what we are doing and wait for the historical currents to bring the problem to an end?
The committee believes that maintaining our present course will not end the tobacco problem. There are already signs that the prevalence of smoking among adults is flattening, the initiation rate appears to be up among young adults, and the rate of youth initiation has hovered around 20 percent for most of the past two decades even though it is down at the moment. The high rate of youth smoking is especially troubling because at least 80 percent of people who smoke begin to do so as adolescents when they cannot fully appreciate the grip of addiction and the future risk to their health.
Moreover, quitting after decades of use is difficult. Despite the fact that 70 percent of smokers say they want to quit, the annual rate of cessation among people younger than 65 remains low.
Meanwhile, the tobacco industry is spending more than $15 billion annually marketing its products to smokers and potential smokers in ever more creative ways while public and private resources devoted to preventing smoking and helping people quit are dwindling. It will probably come as a surprise to most Americans that the states use very little of the billions of dollars they are receiving under the Master Settlement Agreement to reduce tobacco use.
Taking these realities into account, the committee believes that the annual toll of more than 400,000 smoking-related deaths will continue well into the 21st century.
It is time to change course.
For four decades, the tobacco industry successfully framed a public "debate" around the health consequences of smoking and the value of individual freedom. But that debate is over. The dangerous properties of tobacco and its impact on the public health are now beyond dispute and, as our report shows, aggressive measures to reduce smoking rest on a solid scientific and ethical foundation. The only debate now should be about how best to accommodate the legitimate interests of addicted smokers in a policy designed explicitly to reduce smoking and other forms of tobacco use.
In its blueprint, the committee offers a two-pronged strategy for putting the nation on an irreversible course for ending the tobacco problem. This strategy involves strengthening current tobacco control measures while fundamentally transforming the regulatory environment for tobacco products.
First, we have to invest in traditional tobacco control measures. The evidence is in: These interventions work. The report contains almost 100 pages documenting the effectiveness of the traditional tools of tobacco control, such as excise tax increases, indoor smoking restrictions, comprehensive state-based programs, media-based prevention campaigns, school-based programs, and cessation therapies and services. Specifically, the committee urges states to fund tobacco control programs at the level recommended by the CDC; urges Congress to fund a national youth-oriented media campaign; urges states to license all retail establishments that sell tobacco and to ban the sale or shipment of tobacco products directly to consumers through mail order or the Internet; and the committee recommends that all insurance, managed care, and employee benefit plans, including Medicaid and Medicare, cover reimbursement for effective smoking cessation programs as a lifetime benefit. The committee urges government at all levels and the private sector to intensify and support these activities on a continuing basis. If all this were done, the committee projects that the prevalence of smoking could be brought down to 10 percent by 2025, and about 11 million fewer people would be smoking.
That would be a great accomplishment, but even if the investment were sustained for 20 years, it would not end the tobacco problem. And there remains the distinct possibility that the investment will not be sustained, momentum will be lost, and adult smoking rates will still be at 15 percent 20 years from now.
To put the nation on a sure course for ending the tobacco problem, we also need to change the legal structure of tobacco control. Tobacco products are not ordinary consumer products. For no other lawful consumer product can it be said that the acknowledged aim of national policy is to suppress consumption altogether rather than to promote safe or responsible use. Yet, these dangerous products are essentially unregulated. Congress should enact a federal regulatory statute that is suited to the unique history and characteristics of tobacco products.
Congress should empower the Food and Drug Administration to regulate the manufacture, marketing, and distribution of tobacco products, and should permit the states to undertake additional interventions to complement federal regulations. Our report specifies many features of the proposed regulatory program, some of which reiterate recommendations offered by previous IOM committees in 1994 and 2001. Among the key elements are graphic package warnings modeled after those required in Canada; limiting advertising to a text-only, black-and-white format; banning any activities by tobacco companies that target youth; and aggressive regulation of retail outlets, including state experiments to reduce the number of retail outlets. The committee also urges FDA to explore the feasibility of gradually reducing the nicotine content of cigarettes.
I have only touched on some of the many recommendations in the report. However, the specific proposals are perhaps less important than the message and design of the blueprint as a whole. It is time to transform the nation’s tobacco policy. Containing the problem is no longer good enough. The nation should commit itself to the strong and sustained measures needed to end this critical public health problem.
My colleagues and I would be pleased to answer your questions now; if you are here in the room, please come to one of the floor microphones. And I would remind everyone that we would appreciate it if you would identify yourself by name and affiliation before asking your questions. Thank you.