Ending the Tobacco Problem: A Blueprint for the Nation

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The nation has made tremendous progress in reducing tobacco use during the past 40 years. Despite extensive knowledge about successful interventions, however, approximately one-quarter of American adults still smoke. Tobacco-related illnesses and death place a huge burden on our society.

Ending the Tobacco Problem generates a blueprint for the nation in the struggle to reduce tobacco use. The report reviews effective prevention and treatment interventions and considers a set of new tobacco control policies for adoption by federal and state governments. Carefully constructed with two distinct parts, the book first provides background information on the history and nature of tobacco use, developing the context for the policy blueprint proposed in the second half of the report. The report documents the extraordinary growth of tobacco use during the first half of the 20th century as well as its subsequent reversal in the mid-1960s (in the wake of findings from the Surgeon General). It also reviews the addictive properties of nicotine, delving into the factors that make it so difficult for people to quit and examines recent trends in tobacco use. In addition, an overview of the development of governmental and nongovernmental tobacco control efforts is provided.

After reviewing the ethical grounding of tobacco control, the second half of the book sets forth to present a blueprint for ending the tobacco problem. The book offers broad-reaching recommendations targeting federal, state, local, nonprofit and for-profit entities. This book also identifies the benefits to society when fully implementing effective tobacco control interventions and policies.

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Product Details

  • ISBN-13: 9780309103824
  • Publisher: National Academies Press
  • Publication date: 9/27/2007
  • Pages: 732
  • Product dimensions: 6.13 (w) x 9.28 (h) x 1.07 (d)

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Copyright © 2007 National Academy of Sciences
All right reserved.

ISBN: 978-0-309-10382-4

Chapter One


ABSTRACT The ultimate goal of the committee is to end the tobacco problem; in other words, to reduce smoking so substantially that it is no longer a significant public health problem for our nation. While that objective is not likely to be achieved soon, the report aims to set the nation irreversibly on a course for doing so. After reviewing the ethical grounding of tobacco control, the committee sets forth a blueprint as a two-pronged strategy. The first prong en visions strengthening and fully implementing traditional tobacco control measures known to be effective. The second prong envisions changing the regulatory landscape to permit policy innovations that take into account the unique history and characteristics of tobacco use, such as strong federal regulation of tobacco products and their marketing and distribution. Aggressive policy initiatives will be necessary to end the tobacco problem. Any slackening of the public health response may reverse decades of progress in reducing tobacco-related disease and death.

The substantial decline (58.2 percent) in the prevalence of smoking among adults since 1964 has been characterized as one of the10 greatest achievements in public health in the 20th century, but today about 21 percent of U.S. adults smoke, despite clear evidence of the numerous health, economic, and social consequences associated with tobacco use.

Tobacco use causes 440,000 deaths in the United States every year (CDC 2005), with secondhand smoke responsible for 50,000 of those deaths (DHHS 2006). All told, deaths associated with smoking account for more deaths than AIDS, alcohol use, cocaine use, heroin use, homicides, suicides, motor vehicle crashes, and fires combined.

The economic consequences of tobacco use are in the billions of dollars. Lost work productivity attributable to death from tobacco use amounts to more than $92 billion per year. Private and public health care expenditures for smoking-related health conditions are estimated to be $89 billion per year. In addition, the states and the federal government spend millions of dollars annually on tobacco use prevention and research efforts that could be directed to other needs.

Concerns about the waning momentum in tobacco control efforts and about declining public attention to what remains the nation's largest public health problem led the American Legacy Foundation to ask the Institute of Medicine (IOM) to conduct a major study of tobacco policy in the United States. The IOM appointed a 14-member committee and charged it to explore the benefits to society of fully implementing effective tobacco control interventions and policies, and to develop a blueprint for the nation in the struggle to reduce tobacco use. To carry out its charge, the committee conducted six meetings in which the committee members heard presentations from individuals representing academia, nonprofit organizations, and various state governments. The committee also reviewed an extensive literature from peer-reviewed journals, published reports, and news articles. The background information and supporting evidence for the committee's report are contained within 16 signed appendixes written by committee members and three commissioned papers written by outside researchers.

The committee found it useful to set some boundaries on its work concerning the goal ("reducing tobacco use") and the time frame within which it should be achieved. To make its task manageable and well-focused, the committee decided to focus its literature review and evidence gathering on reducing cigarette smoking, without meaning to overlook or dismiss the health consequences of other forms of tobacco use. However, the committee believes that its recommendations, although derived from the evidence regarding interventions to reduce cigarette smoking, are fully applicable to smoking of other tobacco products and that most of the recommendations are also applicable to smokeless tobacco products. First of all, trends in smokeless use and cigarette use tend to move in tandem, suggesting that the population-level factors at work at any given time are affecting all forms of tobacco use. Although some smokers may switch to smokeless tobacco as a "risk-reducing" tactic, thereby offsetting some of the gains from smoking cessation, successful efforts to curtail smoking initiation do not appear to be compromised by increased initiation of smokeless use. Second, the committee believes that most of the interventions shown to be effective for smoking (cessation, health-based interventions, school-based interventions, media efforts, sales restrictions, marketing restrictions) can be implemented in behavior-specific or product-specific manner, and that there is no apparent reason why their effectiveness would be weakened in relation to use of smokeless products if they were sensitively designed. Overall, therefore, the committee believes that it is reasonable to assume that implementation of its blueprint will, in the aggregate, lead to a reduction in all forms of tobacco use. Thus the committee refers throughout the report to the goal of "reducing tobacco use."

The overarching goal of reducing smoking subsumes three distinct goals: reducing the rate of initiation of smoking among youth (IOM 1994), reducing third-party environmental tobacco smoke exposure (NRC 1986), and helping people quit smoking. For the purposes of this report, the committee sets to one side additional strategies that might reduce the harm of smoking for smokers who cannot quit, a topic dealt with extensively in another recent IOM report (IOM 2001).

Another important question regarding the scope of the committee's work concerns the time frame. The committee wanted to design a blueprint for achieving substantial reductions in tobacco use, but to have a realistic opportunity for doing so, an ample period of time is needed. Yet, the target should not be so far in the distance as to lose its connection with current conditions or to outstrip the committee's collective capacity to imagine the future. The committee decided to set a 20-year horizon for its projections and for the policies that it recommends.

The common interest of all nations in reducing tobacco use has been declared and effectuated by the World-Health-Organization-sponsored Framework Convention for Tobacco Control, which went into effect in 2005 and has been ratified by 142 nations (unfortunately not including the United States). The United States has a direct stake in reducing smuggling of tobacco products into this country that could undermine domestic tobacco control efforts, and the committee also recognizes the compelling importance of international tobacco control efforts for world health. However, the committee's charge was to develop a tobacco control blueprint for the nation, not for the world. We hope, though, that some of the measures recommended in this report will provide useful models for other countries, just as the domestic interventions undertaken by other countries in recent years served as useful models for us.

In sum, the ultimate goal of the committee's blueprint is to reduce smoking so substantially that it is no longer a significant public health problem for our nation; this is what is meant by the phrase "ending the tobacco problem" used in the title of this report. While that objective is not likely to be achieved in 20 years, the report aims to set the nation irreversibly on a course for doing so.


The committee's report is divided into two parts. Part I, comprising Chapters 1 through 3, provides the context for the committee's proposed policy blueprint. Chapter 1 discusses the extraordinary growth of tobacco use during the first half of the 20th century and its subsequent reversal in 1965 in the wake of the 1964 Surgeon General's report. This chapter also closely examines recent trends in tobacco use. Chapter 2 summarizes the ways in which the addictive properties of nicotine make it so difficult for people to quit, thereby sustaining tobacco use at high levels, and the factors associated with smoking initiation, especially the failure of adolescents to appreciate the risks and consequences of addiction when they become smokers. Chapter 3 reviews the history of tobacco control and concludes by projecting the likely prevalence of smoking over the next 20 years if current trends remain unchanged or if tobacco control efforts are weakened.

Part II of the committee's report presents a blueprint for reducing tobacco use. After reviewing the ethical grounding of tobacco control in Chapter 4, the committee sets forth its blueprint as a two-pronged strategy. The first prong, presented in Chapter 5, envisions strengthening traditional tobacco control measures that are currently known to be effective. Chapter 5 closes with a projection of the likely effects over the next two decades of implementing the policies outlined in this part of the blueprint. The second prong, described in Chapter 6, envisions changing the regulatory landscape to permit new policy innovations that take into account the unique history and characteristics of tobacco use.

Building on the foundation laid in Chapter 6, Chapter 7 briefly explores new frontiers of tobacco control, and urges the federal government to establish the necessary capacity for long-term tobacco policy development. The committee specifically reviews a proposal for gradually reducing the nicotine content of cigarettes. Although the committee acknowledges that this proposal requires further investigation and careful assessment before it is implemented, carrying it out offers a reasonable prospect of substantially curtailing and eliminating the public health burden of tobacco use.

Tobacco Use Since 1965

Wide-angle comparisons of measures of smoking behavior between 1965 and 2005 clearly show that the rates of tobacco consumption and smoking prevalence have declined among adults, the rate of smoking initiation has declined among adolescents, and the rate of smoking cessation has increased. However, a closer look at the trends over the past two decades tells a somewhat more complex story of both modest progress and some backsliding. For instance, although smoking prevalence has continued to decline in the new millennium, it appears that progress in some areas may now be stalling.

Between 1965 and 2005, the percentage of adults who once smoked and who had quit more than doubled from 24.3 to 50.8 percent. Furthermore, the percentage of adults who had never smoked more than 100 lifetime cigarettes increased by approximately 23 percent from 1965 (44 percent) to 2005 (54 percent). Smoking initiation among adolescents and young adults has also declined since the mid-1960s. Among adolescents aged 12 to 17 years, 125.5 of every 1,000 smoked a cigarette for the first time in 1965. In 2003, 102.1 per 1,000 youths in the same age range had smoked a cigarette for the first time. The reduction in smoking initiation saved more than half a million adolescents from having a first cigarette between 1965 and 2004.

The steady decline in tobacco use since 1965 can be divided into two phases, the first running from 1965 to about 1980 and the second running from 1980 to the present. During the initial period, there was a sharp decline in smoking prevalence due to reduced initiation and increased cessation, accompanied by a modest increase in the average number of cigarettes smoked per day by smokers. However, since then, the continued decline in smoking prevalence has been accompanied by a substantial decline in cigarettes smoked per day among those who smoke. The committee believes that a substantial portion of the declines in smoking prevalence and smoking intensity over the past 25 years is attributable to tobacco control interventions, especially price increases and the emergence of a strong antismoking social norm.

Current trends, however, suggest that the annual rate of cessation among smokers remains fairly low, that the decline in the initiation rate may have slowed, and that overall adult prevalence may be flattening out at around 20 percent. These trends suggest that substantial and sustained efforts will be required to further reduce the prevalence of tobacco use and thereby reduce tobacco-related morbidity and mortality.

Factors Perpetuating the Tobacco Problem

What factors are perpetuating the tobacco problem? First and foremost, tobacco products are highly addictive because they contain nicotine, one of the most addictive substances used by humans. Nicotine addiction stimulates and sustains long-term tobacco use, with all of its serious health hazards and social costs, and poses significant challenges to smoking cessation efforts at both the individual and the population levels. Although an overwhelming majority of smokers (90 percent) regret having begun to smoke, overcoming the grip of addiction and the associated withdrawal symptoms is difficult; most smokers must try quitting several times before they are successful. Progress in helping smokers who want to quit achieve successful and permanent cessation requires that a variety of cessation technologies-both clinical and population based-be readily available to the smoking population, and that they be used, and that they be effective.

Second, factors such as distorted risk and harm perceptions, which are associated with the initiation and maintenance of tobacco use among young smokers, pose a continuing obstacle for prevention and control strategies. Unfortunately, many youth view themselves as invulnerable to addiction and its associated harm. They are also sensitive to the social factors and norms that promote smoking, such as the influences exerted by peers, family members, and the exposure to smoking in the media. These influences tend to override the information about the risks of smoking. Therefore, to substantially reduce the rate of smoking initiation, it will be necessary to do a better job of counteracting the perceived benefits of smoking and to develop new tools that make the personal risks of starting to smoke more salient.

All new smokers are not young, however; some initiate smoking during their college years, which helps to explain why some new smokers have characteristics that differ from those of usual smokers. Specifically, they tend to have higher levels of education and income than other smokers. It is also noteworthy that some new smokers smoke at lower levels, and some never reach a level of dependence. It will be important for tobacco control experts to pay close attention to these emerging trends and to design appropriate interventions to respond to them.

On the other side of the ledger are smokers who have a more difficult time quitting, such as "hardcore" smokers with a long career of smoking and individuals with psychiatric comorbidities or special circumstances, including incarceration and homelessness. These groups have not been the primary targets of traditional cessation treatments or research studies. Achieving success in substantially reducing tobacco use will require taking stock of the progress made with current tobacco prevention and control strategies and identifying where they fall short in responding to emerging smoking trends and the characteristics and behaviors of subpopulations of smokers with particular vulnerabilities.


Excerpted from ENDING THE TOBACCO PROBLEM Copyright © 2007 by National Academy of Sciences. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Summary     1
Introduction     29
Epidemiology of Tobacco Use: History and Current Trends     41
Growth of the Tobacco Problem     41
Decline in Tobacco Use: 1965-2005     45
Recent Trends: A Closer Look     51
Emerging Challenges     68
Summary     70
References     71
Factors Perpetuating the Tobacco Problem     77
Nature of Nicotine Addiction     77
Smoking Cessation     82
Smoking Initiation     88
Atypical Patterns of Tobacco Use     93
Populations at Greater Risk of Continuing Smoking     95
Conclusion     97
References     99
Containing the Tobacco Problem     107
Public Health Takes on the Tobacco Industry: 1964-1988     109
Advances in Tobacco Control: 1988-2005     116
Tobacco Control in the Years Ahead: Will Progress Continue?,     128
Summary     136
References     137
A Blueprint for Reducing Tobacco Use
Reducing Tobacco Use: A Policy Framework     145
Product Safety and Consumer Sovereignty     145
The Policy Context     146
The EthicalContext     148
An Aside on the Paternalism Problem     150
Tobacco Products Are Inherently Dangerous     152
Blueprint Outline     154
References     154
Strengthening Traditional Tobacco Control Measures     157
Comprehensive State Programs     158
Funding for Comprehensive State Programs     172
Excise Tax     182
Smoking Restrictions     189
Youth Access     203
Retail Shipments     207
Prevention Interventions     210
Media Campaigns to Prevent Smoking     223
Cessation Interventions     231
Community Mobilization     241
Special Populations with Higher Rates of Cigarette Smoking     247
Projected Impact of Strengthening Existing Tobacco Control Measures     249
References     253
Changing the Regulatory Landscape     271
Federal Regulatory Authority Is Needed     272
Empowering FDA to Regulate Tobacco     275
A Regulatory Philosophy     277
Tobacco Product Characteristics Should Be Regulated     279
Messages on Tobacco Packages Should Promote Health     289
The Retail Environment for Tobacco Sales Should Be Transformed to Promote the Public Health     299
The Federal Government Should Mandate Industry Payments for Tobacco Control and Should Support and Coordinate State Funding     308
Tobacco Advertising Should Be Further Restricted     319
Youth Exposure to Smoking in Movies and Other Media Should Reduced     330
Surveillance and Evaluation Should Be Enhanced     333
Summary     335
References     336
New Frontiers of Tobacco Control     341
Tobacco Policy Analysis and Development     341
Reducing the Nicotine Content of Cigarettes     346
Conclusion     353
References     353
Index     355
Abrams: Comprehensive Smoking Cessation for All Smokers
Bonta: Clean Air Laws
Ferrence: Warning Labels and Packaging
Flay: The Long-Term Promise of Effective School-Based Smoking Prevention Programs
Halpern-Felsher: Adolescents' and Young Adults' Perceptions of Tobacco Use
Halpern-Felsher: Interventions for Children and Youth in the Health Care Setting
Halpern-Felsher: Reducing and Preventing Tobacco Use Among Pregnant Women, Parents, and Families
Halpern-Felsher: Smoking in the Movies
Kinney: State Statutes Governing Direct Shipment of Alcholic Beverages to Consumers
Levy: The Role of Public Policies in Reducing Smoking Prevalence
Mendez: Commissioned Simulation Modeling of Smoking Prevalence as an Outcome of Selected Tobacco Control Measures
Rabin: Controlling the Retail Sales Environment
Ribisl: Sales and Marekting of Cigarettes on the Internet
Slater: Media Campaigns and Tobacco Control
Sparks: Advocacy as a Tobacco Control Strategy
Wallace: Special Populations with Higher Rates of Cigarette Smoking
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