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FRAMEWORK FOR THE PUBLIC POLICY ACTIVITIES OF THE COALITION ON SMOKING OR HEALTH FOR 1993 TABLE OF CONTENTS Page Overview 1 Background 2 Public Policy Objectives for Freedom From Tobacco 10 Advertising and Promotion of Tobacco Products 10 Sale and Distribution of Tobacco Products 12 Tax and Pricing Policy 13 Clean Indoor Air and Environmental Tobacco Smoke 14 Regulation of Tobacco Products 16 Government Tobacco-Use Prevention and Cessation Activities 18 Governmental Support for Tobacco 20 Agriculture 20 Trade 21 Coalition uo Smnkiog OR Health Fnmewurk for Public Policy Activiliea 1993

9 The federal government has promoted the export of tobacco to Thailand, Japan, South Korea, and, most recently, Taiwan. It has been exercising its trade leverage with these nations to force them to open their doors to U.S. tobacco products and to require them to weaken health-based restrictions on tobacco marketing. Forcing U.S. tobacco products and U.S. marketing techniques for those products on foreign nations at a time the U.S. Govemment has declared war on drugs like cocaine is particularly ironic. Many more people die each year from tobacco than from heroin, cocaine, and all other illegal drugs combined. To continue the efforts begun in 1982, the Coalition on Smoking OR Health will be pursuing the following objectives at the federal and state level in the coming year:

FRAMEWORK for PUBLIC POLICY. ACTIVITIES of tlee COALITION ON SMOKING OR HEALTH 1993

11 State The Coalition on Smoking OR Health recommends: • Enactment of legislation to prohibit or limit the ways and places that tobacco advertising can be used, particularly that which appeals to children and teenagers, including: J banning brandname promotional practices, including sponsorship of sporting events, concerts, jazz festivals, and the like, that include the use of product names and logos; and / banning advertising in publicly owned or controlled space, such as public transportation, municipal stadiums and arenas, and billboards. • Enactment of legislation to limit or eliminate the taxpayer subsidy of tobacco industry advertising and promotion through the business tax deduction. Cudilion on Smo6ng OR HuIEa Fmmerork for Public Policy Activities 1993

~ American AMERICAN ~ LUNG ASSOCIATION' ~ AEAN ~ Heart = ea,.e~el y Association ' SOCIETY6 Coalition on Smoking OR Health FRAMEWORK FOR THE PUBLIC POLICY ACTIVITIES OF THE COALITION ON SMOKING OR HEALTH FOR 1993 Overview This nation's three largest voluntary health organizations, the American Cancer Society, the American Heart Association, and the American Lung Association, are united as the Coalition on Smoking OR Health. The Coalition was formed in 1982 and since then has been working to educate public policy makers about issues related to tobacco and disease prevention and health promotion. The Coalition has been successful in such projects as banning smoking on domestic airline flights; revising warning labels on cigarette packages and advertising, and obtaining warning labels on smokeless tobacco products. In addition, the Coalition is active on the state level, and has achieved several successes in clean indoor air and limiting youth access to tobacco. Tobacco use continues to be a major public health problem in the United States. The Coalition on Smoking OR Health believes that strong efforts should be made to discourage tobacco use in all segments of the population, including youth, women, and minority populations who increasingly are targeted by the tobacco industry. To accomplish this goal, and to continue working towards the Surgeon General's goal of a Tobacco Free Society by the Year 2000, the Coalition has identified seven major policy areas for action: • Advertising and Promotion of Tobacco Products • Sale and Distribution of Tobacco Products • Tax and Pricing Policy • Clean Indoor Air and Environmental Tobacco Smoke • Regulation of Tobacco Products • Government Tobacco-Use Prevention and Cessation Activities • Governmental Support of Tobacco

3 infections per year in children under 18 months of age, resulting in about 7,500 to 15,000 hospitalizations. Exposure to ETS also exacerbates and aggravates symptoms in children with asthma. There is some evidence that ETS exposure also causes asthma in children who have not had the disease previously. Chewing Tobacco and Snuff Tobacco-use includes chewing and sniffing, as well as smoking. Although less popular than smoking, use of other forms of tobacco is a growing public health concern. Chewing tobacco and snuff can cause oral cancer, lead to the development of oral leukoplakias (white patches or plaques) and other oral conditions, and cause addiction to nicotine. Use of these substances is also associated with coronary artery and peripheral vascular disease, hypertension, peptic ulcers, and fetal mortality and morbidity. Smoking-Related Deaths Tobacco-related diseases cause more than 434,000 deaths annually in the United States. This toll would be higher if deaths related to ETS were included. More people die each year in the U.S. from smoking than from AIDS, suicide, alcohol, cocaine, crack, heroin, homicide, car accidents, and fires combined. Based on current smoking rates, recent estimates predict that in the next 20 years more women than men will die from tobacco-related diseases. Among women, lung cancer has surpassed breast cancer as a cause of death. Already, U.S. women, who account for 5 percent of the females in the world, have half the world's female deaths from tobacco-related causes. True health care reform, focused on preventive health as a means of reducing death and disease and empowering people to manage their health, must deal with the issue of tobacco use. The ability to prevent hundreds of thousands of death caused by the use of tobacco products is within our grasp. Dramatic reduction in the use of tobacco can end the tragedy of death and disease that has been allowed to perpetuate for too long. Smoking Prevalence Since the Surgeon General's 1964 call to action, government and private organizations have moved to eliminate the health hazard of tobacco. Progress has been made. In 1965, 43 percent of adults in the U.S. were smokers. By 1990, the adult smoking rate in the U.S. had been reduced to 25.5 percent. About half of all people who ever smoked have quit. But close to 50 million Americans still smoke. Coelition on Snwking OR Health Fnmework for Public Policy Activitics 1993

4 While this news is generally encouraging, other evidence shows clearly that the epidemic of tobacco-related death and disease is far from over and is likely to continue for many years. While overall smoking rates have declined, smoking among young people under the age of 18 has remained relatively steady since 1981. Overall smoking rates for high school seniors have remained level at about 18 to 21 percent. Moreover, those who do not plan to go to college have a significantly higher smoking rate about 30 percent. Also the smoking prevalence among high school females is higher than for males. One recent survey found that among high school students (grades 9-12), over 25 percent smoked cigarettes monthly or more frequently. This rate was up from 23 percent the previous year. The rate for junior high students (grades 6-8) was over 13 percent for monthly or more frequent smoking, up from 11 percent. This trend does not bode well for the future. Today's smokers are tomorrow's casualties in the war against death and disease. Prevalence of Chewing Tobacco and Snuff Use Approximately 15 percent of the population over age 12 has used chewing tobacco or snuff at least once. Young boys, in particular, are attracted to chewing tobacco and snuff by watching sports stars use these products. Some teams are beginning to recognize this problem by banning their players from using these forms of tobacco. Use of snuff and chewing tobacco is reported by over 19 percent of male high school students. White male students report a significantly higher rate of almost 24 percent. Use of chewing tobacco and snuff varies by sex and race. Among the population age 18 and older, 4.2 percent of white men use chewing tobacco compared to 3.4 percent of black men. Almost no white women chew (0.1 percent), while a small percentage of black women (1.7 percent) do. Similar disparities are found in snuff use, with 3.3 percent of white men using it, compared with 1.1 percent for black men; only 0.3 percent of white women use snuff, compared to 2.2 percent of black women. Chewing tobacco consumption has declined from its peak in 1980, but appears to have stabilized. On the other hand, snuff consumption has increased each year for the last five years. Cost to Society Tobacco use costs the U.S. economy approximately $72 billion, based on 1990 data, in direct health care costs and lost productivity. The cost to Medicare and Medicaid alone in 1991 is estimated at $7.2 billion. Other federal health care programs such as the Indian Health Service, CHAMPUS (for military dependents and retirees), and veterans health care also incur high costs. These estimates do not include the emotional toll on families and friends as loved ones suffer Coalition on Smoking OR Health Fnmework for Public Policy Activities 1993

12 2. SALE AND DISTRlBUTION OF TOBACCO PRODUC75 Forty-eight states and the District of Columbia have some restrictions or prohibitions on the sale of cigarettes to minors. Nonetheless, tobacco products remain readily available to young people because of virtually nonexistent enforcement efforts, unrestricted free sampling, the availability of tobacco products from vending machines, and the paucity of rules and regulations designed to discourage tobacco sales to underage young people. National leadership is needed to provide a consistent and effective way to control access by youth to tobacco products. F eral The Coalition on Smoking OR Health recommends: • Enactment and enforcement of nationwide policies to restrict the distribution of tobacco products to minors, including / enforcement of an amendment to the Alcohol Drug Abuse and Mental Health Administration Reauthorization Act, introduced in the 102nd Congress by Rep. Mike Synar, to require states to enforce their age restriction on the sale of tobacco products or lose a portion of their federal block grant funds; r enactment of bans on free sampling, sale of tobacco products through vending machines, and licensing requirements for sellers of tobacco products; and • Enactment of a requirement that tobacco products sold on military installations be priced at levels comparable to prices charged in civilian stores. State The Coalition on Smoking OR Health recommends: • Enforcement of laws setting age restrictions for the sale of tobacco products, including requiring licenses for retail sellers of tobacco products, with revocation as a penalty for violation of minimum age laws; • Enactment and enforcement of bans on free sampling and the sale of tobacco products through vending machines. Coelition on Snqking OR Hubh Fnmework for Public Policy Activitiea 1993

5 through their addiction, illness, and death due to smoking. Tobacco Taxes Tobacco taxes have a significant impact on tobacco consumption, and are especially effective in discouraging children from smoking. In 1989, the General Accounting Office reviewed research on teenage response to cigarette price increases and concluded that a 21 cent increase in the price of a pack of cigarettes at that time would result in about a 12 percent decrease in the number of teenaged smokers and a concomitant decrease in the number of premature deaths due to smoking. Adult smokers are also sensitive to price increases. Since the California excise tax was increased by 25 cents in 1989, smoking in the state has decreased by 17 percent. As of January 1, 1993, the federal excise tax on a package of cigarettes is 24 cents, a four cent increase from the tax that had been in effect for the previous two years. In 1991, the federal government collected $4.8 billion in taxes on tobacco products, state governments collected $6.1 billion, and local governments $198 million. The average retail price per pack is $1.735. State taxes range from 2.5 cents per pack in Virginia to 51 cents in Massachusetts. In contrast, Canadian provincial taxes range from $2.89 to $3.90 (US$) per pack. When state and federal excise taxes on tobacco products are combined, they are much lower today in constant dollars than they were before the release of the 1964 Surgeon General's report. At its peak in 1965, the tax share of the price of a pack of cigarettes in the U.S. was just over 50 percent. By 1990, that share had dropped to just under one-fourth. Among the world's industrialized nations, only Spain has a lower cigarette excise tax rate, and most - such as the U.K., Australia, New Zealand, Canada, Germany, Denmark and Ireland - have much higher rates. Marketing, Promotion, Sales and Distribution The tobacco industry spends almost $4 billion a year to advertise and promote its deadly products. In contrast, the federal office responsible for coordinating federal tobacco-use education, prevention and research efforts had a budget of $7.3 million in fiscal year 1992 and will receive $10 million in 1993. To look at this another way, every da_y the tobacco industry spends the equivalent of the entire year's budget for the federal Office on Smoking and Health. As cigarette sales decline in this country, expenditures on advertising and promotion increase at a rate far exceeding the rate of inflation. In 1981, sales peaked at 636.5 billion cigarettes, or nearly 32 billion packs. Advertising and promotion expenditures that year were $1.5 billion. By 1990, domestic sales were down to 523.7 billion cigarettes, but advertising and promotion Coalition on Smoking OR He.hh Fnmcwork ror Public Policy Activities 1993 ~ ~ ~ Cn N N N N

6 expenditures were $3.99 billion. Tobacco companies spend a great deal of money to keep people smoking and to entice new smokers. Forty-eight states and the District of Columbia have some restrictions or prohibitions on the sale of cigarettes to minors. Nonetheless, tobacco products remain readily available to young people because of virtually nonexistent enforcement efforts, unrestricted free sampling, the availability of tobacco products from vending machines, and the paucity of rules and regulations designed to discourage tobacco sales to underage young people. National leadership is needed to provide a consistent and effective way to control access by youth to tobacco products. Current military tobacco pricing policies encourage tobacco use by military personnel by subsidizing the cost. In military stores, tobacco products sell for 10% to 60% less than in civilian stores. Effects of Tobacco Advertising The 1990 report of the National Commission on Drug-Free Schools found that tobacco advertising and promotion clearly influences young people to take up smoking. It glamorizes and legitimizes tobacco usage, increasing social and peer pressure among young people to use tobacco products in order to be accepted, and creating the false impression that tobacco products pose no significant health risk. Tobacco advertising and promotion overwhelm the efforts of the public and private sector to educate this nation's youth about the health effects of tobacco; create a climate that increases peer pressure on young people to use tobacco; and, trivialize and diminish the significant health hazards of tobacco use. The tobacco industry also tailors its advertising to play on the public's concerns about health and addiction, including the concerns of women about weight gain if they stop smoking. Advertisements that emphasize the low tar and low nicotine properties of certain brands imply that these products reduce the health risks associated with smoking. Other brand advertising, aimed at women, implies that use of the product will suppress appetite and help control weight. In 1964, the tobacco industry assured the Congress it would not only develop, but also rigidly adhere to voluntary advertising and sampling codes. The industry created the codes but has never adhered to nor enforced them. Enforcement provisions in the original code were eliminated in 1970. The voluntary advertising code includes standards stating that cigarette advertising will not indicate that smoking is essential to success or sexual attraction or use models for smokers who are younger than twenty-five. Athletes are not to be depicted, nor are smokers who have just participated in rigorous physical activity. Coelition on Smuking OR Hulth Fnmework for Public Policy Activitics 1993