Tobacco Documents Online

   I@   U     U 0 a a a U 0 Recommendations of the Working Group On Tobacco Jesse Steinfeld, M.D. President, Medical College of Georgia Augusta, Georgia CHAIRPERSON Craig White, M.D. RAPPORTEUR -D3-

In 1964, a group of consultants, all considered impartial by the tobacco industry and many of whom were heavy smokers, submitted a report to the Surgeon General which indicated that cigarette smoking was a causative or social factor for many diseases including many cancers and cardiovascular and lung diseases. The tobacco industry laughed and said, "You have mad a terrible mistake! Cigarettes cannot cause cance...This is ridiculous." Since then, literally hundreds of thousands of reports, citing statistical, epidemiological and pathological evidence, have shown that the Surgeon General's report was right: cigarette smoking is the single greatest public health hazard in this country. And, it is not surprising when you consider that the human body is not equipped either immunologically or biochemically to handle the more than 6,000 chemicals - many of which are poisonous - in cigarette smoke. Approximately 53 million Americans smoke. Anyway you look at it, that is a devastating number, but it is encouraging to note that cigarette consumption is declining - in the developed nations. However, we express great concern over the rapid increase in the use of tobacco and tobacco - associated diseases in the deveLoping countries. Currently, it is accurate to say that tobacco is one of the most significant health problems in the world today. We must make nonsmoking the social norm. We must through every avenue available, make smoking socially unacceptable. 0 - D4 -

I I I I I I I I I I I I I r I I I Recent surveys reveall that although most people know tobacco is harmful, well over half to three-quarters do not associate smoking with heart disease. They may associate smoking with cancer, but many do not realize that the cancer it causes may be deadly and largely incurable. Everyday, approximately 1,000 people die prematurely from cigarette smoking. 'Chat is equivalent to four jumbo jets crashing each day with no survivors. Can you imagine the outcry in this country if New York, Atlanta, Chicago and Los Angeles had a 747 crash everyday? We would not tolerate it, yet, we have come to accept tobacco, with its monumental risks, as a pervasive element in our society. It is a social norm. We have developed many recommendations that could assist in making nonsmoking the social norm. These recommendations involve increasing the public's knowledge of tobacco, restricting the promotion of tobacco products, increasing litigation against tobacco manufacturers and instigating active economic and public policies. (Please consult the list of intervention strategies which accompany this summary.) We need to work with the media to increase the coverage of smoking, tobacco and health issues and request equal space/time to counteract the effect of advertisements. Maybe we should list all tobacco - related deaths in a separate section in the obituary pages and report tobacco on death certificates as we do the heavy use of alcohol. 19

Recently, the U.S. District Court in New Jersey, gave us a powerful tool in combatting tobacco use: litigation. The judge ruled that people injured from tobacco and who claim the warnings on cigarette packs are not adequate are entitled to the right to present their claims for adjudication. Although highly controversial, this tool could be highly successful. If a number of lawsuits are successful, the cigarette industry could follow the abestos industry and find they cannot afford to manufacture cigarettes because the price is too high. We should restrict the promotion of tobacco products, including smokeless tobacco, by either banning the promotion of all tobacco products or requiring the industry to conform to their own advertising standards which prohibit ads that suggest smoking is essential to social prominence or attraction or portray smokers participating in strenuous physical activity. We must solve the dilemma of the small tobacco farmer and work with insurance companies to establish and expand non-smoker differentials for insurance policies. We could increase the federal excise tax on cigarettes and eliminate the price support and allotment programs for tobacco. And, we should restrict the sale of cigarettes to retail outlets only, and prohibit their sale at all health - care institutions. We should better train our physicians on the hazards to tobacco and encourage them to refer patients to smoking cessation programs. Our efforts to curtail smoking during the last twoj decades have been somewhat successful: some 33 million Americans have quit. Without the programs and public education that have been implemented, we would be a population of 90 million smokers, smoking non-filtered, high-nicotine, high-tar cigarettes. -D6-

no 14 0 U U  U   N N r N N N N N Intervention Strategies to Reduce the Prevalence of Smoking and Tobacco Use Since the first Surgeon General's report on the hazards of smoking was released in 1964, many methods to reduce the prevalence of smoking have been studied and advocated. While slow but steady progress has been made by smoking cessation efforts, more than 350,000 individuals still die every year from smoking-related diseases. Further, although the overall prevalence of smoking has declined, with the nation's increasing total population and higher smoking rates among youth, the actual number of smokers in the U.S. has essentially remained the same. Of those still smoking, the proportion smoking 25 or more cigarettes per day has increased markedly. Tragically, this unnecessary morbidity and mortality is more immediately preventable than current rates indicate. Current attempts to reduce smoking prevalence focus on the individual almost exclusively, rather than on society as a whole, or on groups of individuals at particular risk for smoking uptake or smoking-related morbidity. In an effort to consider both societal as well as individual approaches, strategies to reduce smoking prevalence have been grouped on the following pages into 4 basic categories: Education and Information, Economic Incentives, Restrictive Policies, and System Interventions. The categories themselves are not particularly important; they simply provide a general framework within which intervention strategies can readily be grouped for the purpose of discussion. Specific interventions and efforts appropriate to each category may utilize existing knowledge and resources, and link efforts of health professionals, educators, legislators, and professional organizations. -D7- r

Intervention Strategies to Reduce the Prevalence of Smoking and Tobacco Use OUTLINE I. Education and Information A. Mass Media Efforts 1. Increase knowledge of smoking and tobacco hazards. 2. Encourage and promote smoking cessation. 3. Provide incentives for non-smokers (esp. youth) not to start. 4. Coordinate efforts between multiple agencies and organizations involved in anti-smoking activities. 5. Stimulate public participation in programs to reduce smoking. B. National Health Education Efforts 1. Promote educational activities in primary and secondary schools. 2. Promote educational activities in the community. C. Labeling 1. Develop'index of mutagenicity and include index on all cigarette package labels. II. Economic Incentives/Disincentives A. Subsidies 1. Eliminate the federal price support programs for tobacco. 2. Provide subsidies/low interest loans for farmers (small and large?) growing crops other than tobacco. B. Insurance 1. Expand discounts/rebates/benefits on health and life insurance to non-smokers. 2. Consider reductions in home/property and auto insurance for non-smokers. C. Federal Excise Tax on Cigarettes 1. Continue current tax authorization (expires in 1985), and make tax "ad valorem" so that it will reflect inflation. 2. Increase tax amounts to be commensurate with the direct health care costs attributable to tobacco (on the order of $1.00/pack). Target these revenues for Medicare/Medicaid to offset smokers' higher medical care expenses. III. Restrictive policies on the marketing, promotion, and use of tobacco A. Restrict marketing of tobacco products. 1. Approve sale only at licensed retail outlets. 2. Prohibit sale of cigarettes from vending machines (to make cigarettes less easily available to minors). 3. Prohibit sale of cigarettes in hospitals, nursing homes, other health care facilities, and pharmacies. - D8 -

I I I I I I I I I I I I I r r r I I B. Restrict promotion of tobacco products. 1. Ban all advertising of tobacco products if possible. 2. At the least, prohibit the use of models in advertising. This recommendation was made by the National Commission of Smoking and Public Policy in 1978. This is in keeping with the tobacco companies' voluntary advertising codes which prohibit advertising suggesting that cigarette smoking is essential to social prominence or social attraction, or portraying smokers participating in physical activity requiring stamina or athletic conditioning beyond normal recreation.. 3. If advertising is to continue, require compensatory time and space for health education messages regarding smoking. 4. Require that advertising of tobacco products strictly complies with "truth in advertising" ethics/codes. C. Prohibit smoking in health care institutions and all elementary, junior, and senior high schools. D. Appropriately restrict smoking in alil public areas and the workplace. IV. Integrate intervention activities into existing social systems. A. Health Care System 1. Prohibit smoking in all health care institutions. 2. Take responsibility for providing either direct aid for smoking cessation or appropriate referral to persons/programs which offer such aid. 3. Stress the health hazards of smoking in the education of health professionals and provide complete information regarding the health consequences of smoking and methods for smoking cessation. 4. Stress the importance of professionals serving as appropriate role models by refraining from using tobacco. B. Workplace 1. Provide appropriate guidelines which discourage smoking in the workplace and support non-smokers' rights. 2. Make smoking cessation and education programs available to all employees. 3. Provide incentives for non-smoking in the workplace (bonuses, vacations, dinners, etc.). 4. Generate support for anti-smoking policies and efforts. C. Educational System 1. Prohibit tobacco use in schools. 2. Stress the importance of teachers serving as role models by refraining from using tobacco. 3. Make cessation aid available for faculty, staff, and students. D. Voluntary Agencies 1. Coordinate education efforts on the health hazards of smoking and tobacco use. 2. Coordinate a professional media campaign to discourage smoking. 3. Coordinate cessation activities in appropriate sites. 4. Act as a referral network for professionals and the public regarding cessation programs, and establish guidelines and standards for programs. -D9-

PRIORITIES FOR THE NATION (summary) DRAFT RECOMMENDATIONS provided by the working group on Tobacco Use. Intervention Strategies to Reduce the Prevalence of Smoking and Tobacco Use I. Education and Information A. Mass media efforts B. Health education efforts nationwide II. Economic Incentives/Disincentives A. Subsidies B. Federal excise tax and allotment programs C. Insurance III. Restrictive policies on the marketing, promotion, and use of tobacco A. Restrict marketing practices B. Restrict the promotion of tobacco products C. Restrict smoking to designated areas in schools, health care institutions, the workplace and public places. IV. Integrate Intervention Activities into Existing Social Systems A. Health care systems B. Workplace C. Educational system V. Specifically Target Intervention Activities at High Risk Groups Including Minorities, Pregnant Women, and the Poor

4 4 I 4 I 4 4 4 I I    a  I  PRIORITIES FOR THE CARTER CENTER DRAFT RECOMMFNDATIONS provided by the working group on Tobacco Use. Intervention Strateqies to Reduce the Prevalence of Smoking and Tobacco Use - MAKE NON-SMOKING THE SOCIAL NORM I. MEDIA AND THE TOBACCO/HEALTH MESSAGE A. Work with the media to accurately and appropriately increase the public's knowledge of the hazards of tobacco. 1. Improve communication between: science/health professionals and the media, media and the public, and health professionals and the public. 2. Work with the media to increase coverage of smoking/tobacco and health issues, recognizing that any attempt must deal with the issue of advertising revenues and their influence on publishing practices. B. Restrict the promotion of tobacco products. OR 1. Develop feasible and appropriate methods to accomplish this including either: • The implementation of a total ban on the promotion of all tobacco products (media advertising, sponsorship of sporting and cultural events, complimentary cigarettes). • The requirement that advertising conform to the industry's own standards (e.g., the tobacco companies' voluntary advertising codes which prohibit advertising suggesting that cigarette smoking is essential to social prominence or social attraction, or portraying smokers participating in physical activity requiring stamina or athletic conditioning beyond normal recreation.) Further, require that compensatory space for counter advertising be made available. 2. Immediately require that the promotion of smokeless tobacco products conform to the standards for advertising and promotion of cigarettes. II. TORT LAW: COMPENSATING THE VICTIMS OF SMOKING • Develop a repository of resource material and legal data for use in litigation by victims of tobacco-related disease and death. III. THE MORAL DILEMMA • There is a clear dilemma in several of the southeastern states between the cultivation of tobacco and the health toll exacted by tobacco products. 9

• In North Carolina a group of church leaders raised this issue as a central dilemma facing their state. As this applies to numerous states in the southeast region, the Carter Center should convene a group of church leaders of all denominations to examine these issues and to make recommendations. IV. ECONOMIC AND PUBLIC POLICIES A. Work with the small tobacco farmer to develop means to assist in the transition from tobacco to non-tobacco crops. B. Work with insurance companies to establish and expand non-smoker differentials for insurance policies (e.g., health, life, home, property, auto) C. Lend the moral support of the Carter Center to efforts to maintain or increase the federal excise tax on cigarettes, and to eliminate the price support and allotment programs for tobacco. D. Restrict the sale of cigarettes to licensed retail outlets, and prohibit any sale from vending machines. E. Lend the moral support of the Carter Center to efforts to promote non-smokers' rights. V. ASSIST IN THE PROMOTION OF THE NON-SMOKING NORM BY WORKING WITH LEADERS IN THE FOLLOWING FIELDS TO ACHIEVE THE ENUMERATED OBJECTIVES. A. Health Professionals and Institutions 1. Restrict smoking in all health care institutions to designated areas. 2. Prohibit the sale of cigarettes in hospitals, nursing homes, other health care facilities, and pharmacies. 3. Encourage health professionals to provide either direct aid to patients for smoking cessation or to refer patients to persons/programs which offer such aid. 4. Stress the health hazards of smoking in the education of health professionals and provide complete information regarding the health consequences of smoking and methods for smoking cessation. 5. Stress the importance of professionals serving as appropriate role models by refraining from using tobacco. B. Educators and Schools ~ C 1. Prohibit tobacco use in schools. ~ L.r'I ~ 2. Stress the importance of teachers serving as role models by ~ refraining from using tobacco. ~ ~ 3. Make cessation aid available for faculty staff and students iJl 4. , , . Promote educational activities in primary and secondary schools. M . - D12 -