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~ COb~ONF_~NTS OF YOUTH SMOKING I~-B.E'vT.._NTION Testimony before the U.S. Senate Judiciary Committee Washington, DC March 12, 1998 William L. Roper, MD, MPH Dean, School of Public Health The. University of North Carolina at Chapel Hill • .and Chair, Partnership for Prevention Partner~ip for Prevention is a national non.profit organization committed to increasing vizibili~.. ntaional health polk'y a.~d practice.

Un~ ~Hm~ Carr~ ~ C~ Ca~rine M. Ba~e, MD The ~w C~e~ P~ssor, De~r~ent ~ Co~i~ Medicine and Di~c~r of ~ H~h Poli~ ~nd P~m~ry Ca~ R~ea~h Ce~er Universi~ of Connecticut School of M~icine K~n A. Bode~om, ~4, MPH ~ecutive Director Califomia Center for Health Implement Daniel E Bou~u~ Senior Vice PresMent VHA Peggy Cl~ke, MPH Co~ultant Glenna M. C~o~, P~ President Stmtegic Poli~ & Politics Inte~ational, Inc. Gordon H. DeFfiese, PhD Di~ctor, Cecil G. Sheps Center for Health Se~ice~ Resea~h Universi~ of North Carolina at Chapel Hill Jonathan E. Fielding, MD, MPH, ~A Co-Direaor UC~ Center for Healthier Children. Families & Communities Professor of Health Se~es & Pediatrics UC~ School of ~blic Health ~e Hono~ble Bill G~dison President Health Insurance A~sociation ~edca C~ne G~nt, JD, MBA Vice Prex~ent. Pub~c Policy Pasteur Mi~e~ Co,aught Robert H~mor~ MD, MPH H~o-~l Medical Direaor United HealthCar¢ Corporation Karen Ignagni, MBA President and CEO American Association of Health Plans Glendon E. Johnson Chairman and CEO John Alden Life Insurance Co. Stanley G. Karson, MA Consultant Corporate Community Involvement Jeffery P. Koplan, MD, MPH President The Prudential Center for Health Care Research Wayne Lednar, MD, PhD Corporate Medical Director Eastman Kodak Company Philip R. Lee, MD Senior Aa~isor to the Dean of the School of Medicine and Professor Emeritus of Social Medicine Institute for Health Policy Studies University of Callfornia at San Francisco J. Michael McGinnis, MD Scholar-in -Residence National Academy of Sciences Lois G. Michaels, MSHy President Emeritu~ Health Education Center Highmark Blue Crass Blue Shield Woodrow A. Myers, Jr., MD, MBA Direc~r Health Care Management Ford Motor Co. Micl~el 1a. O'l)~mdl, Pkl), MBA, MPH F_.~or-in-C~ief ond President American Journal of Health Promotion Gilbert S. Omeam, MD, PhD Executive Vice President for Medical Affairs University of Michigan Mary Pittman, DrPH President H~x~pital Research and Educational Trust Ronald J. Saldarini, PhD Wyeth-Lederle Vaccines and Pediatrics John R. Seffrin, PhD Chief Executive Officer American Cancer SocieD; Inc. P. John Seward, MD Executive Vice President American Medical Association Hugh H. Tilson, MD, DrPH Senior Medical Advisor fi~r Health Affairs Glaxo Wellcome Thomas M. Vernon, MD Executive Director Medical, Scientific & Public Health Affairs Metal; Vaccine Division " Merck & Co., Inc. Donald M. Vickery, MD Chairman and Chief Medical Officer Health Decisions International. LLC Martin P. Wasserman, MD, ID Secretary Maryland Department of Health and Mental Hygiene "l'ae Honorable ~ $.

Thank you for the opportunity to contribute to such an important policy forum along with many other distinguished scientists, policy-maker~, and public: health practitio~. My name is Bill Roper, and I am dean of the School of Public Health at the University of North Carolina at Chapel Hill. I have the privilege of serving as Chair of Partnership for Prevention, a national coalition of private businesses, national health organizations, and other entities committed to incre~_sing the visibility and priority for prevention in national health policy and practice. Partnership is a founding member of the ENACT tobacco control coalition, and is aetivel-y involved in developing and promoting the principles of this effort. On behalf of these organizations, I -,,could like to congratulate the members of this committee on its efforts to advance the policy debate on tobacco control and to bring the issue of youth smoking to the forefront of this debate. We face a serious threat to the health of our nation's young people-one which has proven resilient against the many interventions which have been employed to date. As former director of the Centers for Disease Control and Prevention (CDC), I have a great appreciation for the scientific advances that have been made in understanding the disease risks and the behavioral mechanisms underlying tobacco use. I also have a profound sense of frustration in examining the persistently high rates of tobacco use among our nation's youth. If we continue the stalemate on youth smoking, our society will incur huge human and economic costs in the years to come. We now face a unique opportunity to rethink traditional approaches to youth smoking prevention, and to put into place a new set of policies and programs which are targeted to address the shortcomings of previous efforts. The need now for comprehensive legislation on youth smoking prevention is beyond debate. YOUTH SMOKING: TRENDS, DETERMINANTS, AND I~dSK FACTORS I would like to begin by describing some of the trends in tobacco use among children and youth which make this issue so very urgent. Each day, an estimated 3,000 additional children become regular smokers, amounting to more than one million new youth smokers annually.I The CDC estimates that at least a third of these children will eventually die from a tobacco-related disease.2 Among adolescents age 12 to 17 years, 4.1 million report being current smokers.3 Smoking prevalence among high school students now stands at 35 percent, up from 28 percent in 1991. Compounding these problems is the strong link between youth smoking mad adult smoking. Almost 90 percent of adult smokers report beginning their use at or before age 18, and more than halfbecarne daily smokers before that age.4 The health consequences of tobacco use are now well documented. Cigarette smoking causes heart disease, lung and esophageal cancer, and chronic lung disease.5.~-7 Smoldng also contribme.s to cancer of the bladder, pancreas, and of the gum, mouth, pharynx, lat3mx, and esophagus,s Each year over 400,000 adults die from these and other diseases as a consequence oftheir tobacco use? Direct health care expenditures Compo~at~ of Youth Snmkiag Prevention Page 2

being paid through government programs such as Medicaid and Medicare.te'tt Additionally, lost economic productivity asz-ociated with smoking is estimated to eo~ more than $47 billion annually.~2 A key step in ackh--essing this problem involves understanding the deterrnir~nts mad risk factors of tobacco use among youth. Epidemiological studies indicate that children and youth follow a staged process of tobacco use which includes: (1) susceptibility to toba,.~o ttse through attitudes, norms, and beliefs; (2) initiation of tobacco through a first-time exf.z.~'ie'nee; (3) continued experimentation with tobacco; (4) regular use of tobacco; and (5) @_,diction to tobacco use. ~ As I will discuss later, Lifts staged process is critical for identifying the key intervention points and for developing a eompre_hensive tobacco prevention strategy which tailors prevention activities to the relevant stages of adoption and use. Epidemiological studies have identified an array ofsocio-demographic, envirorhmental, and personal characteristics which place children and youth at increased risk of tobacco use. Children from f~milies with low socioeconomic status face much higher risks of tobacco use. While African American and Hispanic youth face somewhat lower risks for tobacco use than white youth, Native American youth face substantially higher risks. Environmental risk factors for tobacco use include: the accessibility and availability of tobacco products from parents, peers, and vendors; use and approval of tobacco use by parents, peers, and siblings; and lack of parental involvement in youth activities. Personal risk factors include: low self-image and low self- esteem; the betief that tobacco use is functional and normal; and the lack of self-efficacy in refusing offers of tobacco. GENERAL PREVENTION PRINCIPLES FOR TARGETING CHILDREN AND YOUTH These determinants and risk factors suggest a set of general prevention principles which should be used in targeting tobacco use among children and youth. First, policies and programs need to have the flexibility to adapt to changes in the attitudes, beliefs and norms among ot.~r children and youth. These characteristics are not static, nor is our scientific knowledge about how these risk factors affect behavior. We cap, not assume to have all the answers now, and therefore we need the flexibility to adjust our prevention strategies as new information becomes available. Second, we need to recognize the heterogeneity across our nation's children and youth an<l adopt tailored strategies for different groups based on socio-demographic, environmental, and personal risk factors. We cannot ignore the diversity of needs, resources, preferences, knowledge, and attitudes that exist within our society. T~nird, we must recognize [hat parents arc key forces which shape the attitudes, norms, and behaviors ofchiklren and youth with reslg~ to tobacco. Suscept~ility to tobacco--the critical Components of Youth Smoking INevealiou Page 3

fi~t sty© in the modd of i~w.o ~e---h~ i~ the Im~. C~, w~ ~ed Io inlom~ and support the effo~ ofparents to ~ strong and compelling messages to their childr~m regarding tol~cco use. Additionally, tl~ nation's public health pro~ a~d policies need to reinforce the parental message, so that children are not f~:xt with conflicting messages on tobacco use outside the home. This is the essence ofa coml~"ehensive tobacco prevention strategy. Similarly, hhc iss~ of adult tobacco use is inextricably linked to the problem of susceptibility among children a,'~:l youth. Our nation's youth reflect adult culture far more than even they are willing to acknowledge. Therefore, a comlxrehcnsivc prevention strategy cannot treat adult and youth behaviors as wholly separate issucs~ We must actively combat adult tobacco use as an essential strategy for preventing use among children and youth. Another key principle of prevention is the need for continual surveillance and evaluation. To effectively address the issue of tobacco use, both researchers and policy-makers must have accurate and timely information about knowledge and behaviors among our nation's youth and adults. This information allows policies and interventions to be adjusted over time to reflect shifts in tobacco use and susceptibility. This information also allows us to evaluate the effects of our tobacco policies and programs, and to continually improve upon these strategies over time. A comprehensive tobacco prevention strategy for youth should incorporate all of these core prevention principles and be flexible, targeted, parent-focused, linked with adult strategies, and supported by strong surveillance and evaluation. VITAL PREVENTION AND CONTROL STRATEGIES For us to be successful in preventing youth smoking, we need to implement a broad, coherent set of public policy and regulatory strategies. An array of effective strategies exist which are designed to discourage continued experimentation and eventual addiction, although few of them have been implemented on a scale sufficient to counteract the tobacco industry's powerful marketing efforts. First, youth demand for tobacco products should be addressed through significant, across-the- board price increases. It is now welt established that price is a primary determinant of demand, and that youth are much more sensitive to price increases because of their lower discretionary incomes..Analysts believe, for example, that a $1.50 increase in price will be needed to have a significant effect on youth demand. Second, strong youth access restrictions ~e proving to be an effective means of controlling the supply of tobacco products to our nation's youth. The key to restricting youth access is strong and consislent enforcement of regulations on the sale and use of tobacco products. To be ~tivein ~ youth ~'t'e~, ~ need to aeltleve at least 90"Z, compline with these regulations. T~ne O.S. Foo~ ~I Dm~ ~ (FDA) maint~im a demonstrated capacity Components of Youth Smoking l~evemion Page 4

fo~ effec6ve ~ mfivit~ md ~tmld ~ the focal po~ of tobacco control en~or~ment. A third promising strategy involws tl'~ us~ of look-back penalties t-or the tobacco industry. Th~se strategies s~hould be designed to giv~ tobacco companies thems~h, es a powerful incentive to reduce youth tobacco us~. To do so, thes~ l~'nalties should be company-specific, based on explicit targets for youth market siena-e, and graduated to reflect the degree and duration of missed targets. Furthermore, the economic disincentives created by these penalties should not be mitigated by caps or by provisions for tax deductibility. Fourth, strong community-bas.ed education and outreach efforts are needed to counter the effects of advertising and media messages regarding tobacco use. As discussed previously, early intereention strategies are needed to support parents and families ~s the main line of defense against these messages. Additionally, mass media educational efforts, prevention and cessation advertising, school-based information programs, community programs, and clinical involvement can help establish community norms that make smoking unacceptable. Furthermore, we need to insure that these efforts are targeted to address special populations through culture-specific language and social cues. At the same time, we need to insure coordination in the information that is disseminated through national, state, and local campaigns. Fifth, enhanced strategies are needed to address the persistent problem of environmental exposure to tobacco smoke. The primary source of children's exposure to environmental tobacco smoke is in the home, with more than one-fifth of children and youth under the age of 18 experiencing such exposure. Children are extremely sensitive to such exposure, which increases the risk of sudden infant death syndrome (SIDS), acute lower respiratory tract infections, asthma, and middle ear effusions. Strategies are needed to encourage adult smoking cessation, to reduce adult smoking in the home, and to prohibit smoking in public places. Comprehensive tobacco control legislation and public education campaigns must therefore include environmental tobacco smoke issues. Sixth, for the large numbers of youth who have already progressed to the stage of addiction, we need targeted tobacco cessation programs that begin early in the addiction cycle. For young people, the power of physical addiction is reinforced by the unique social norms, expectations, and stresses of adolescence. Youth cessation programs must be targeted to address these unique barriers to quitting smoking. Seventh, we face a responsibility for helping to address international issues in tobacco consumption, and for examining the effects of domestic policies on tobacco industry activities abroad. A comprehensive tobacco prevention strategy should not allow domestic tobacco-related health problems to simply be expr.hrted to other populations. We need to think of tobacco use as a globgfl pandemic, and ~ s_~ ~eng~a'~a~ ~col~abg~. ~ti.¢e~ ~tiotnd ~ topte~emiza. ~ a nation stand to learn much abont the seient:e and practice of tob~oco prevention through international collaboration. Compoaeats of Youth Smoking l~©ventien Page

control is essential for a ~ve ~ strategy. As mentioned earlier, tim U.S. Food and Drag Administration (F-DA) is unique in maintaining the resources and empertis~ ne~ssary to ,ffectively carry o~t this authority. To en~mre the ¢ff~ctiv~n~ of a national tobacco prevention strategy, the FDA must have full jtwisdiction over all tobacco products m~d nicotine delivery devices. Ftt,'lhermore, the FDA's authority to treat nicotine as a drug and tobacco products as drug delivery de-rices must ~ maintained and reaffirmed. The same standards of FDA re-dew and oversight that apply to other drags and devices must appl7 to nicotine and other tobacco products. These provisions will imare that the FDA can be as effective in addrassing the public health issues of tobacco as it can in addressing t_hose of other drugs and devices. ANOTHER K.EY PREVENTION STRATEGY: EARLY INTERVENTION The scientific evidence is clear that children learn to smoke long before they ever take their first puff on a cigarette. Studies of 3'a and 5th grade children have shown that among those who have never puffed on a cigarette, susceptibility to smoking is a major predictor of smoking initiation later in Iife.L4 Again, susceptibility is indicated by children's expectations and intentions regarding tobacco use. The evidence is also clear that initiation of smoking is prevalent among elementary school children. Recent studies indicate smoking has been initiated by about 10% of 8 year old children, up to 25% of 10 year olds, and up to 40% of 12 year olds.t4,1s Intervention studies demonstrate that once in the initiation stage, children's responsiveness to prevention programs is low. Early initiators are much more likely to progress through the subsequent stages of experimentation, regular use, and addiction. These findings suggest that our current efforts at tobacco prevention are not occurring early enough in the progression to tobacco use. Most school-based smoking prevention programs occur at the junior high school and high school grade levels--long after many children have passed through the stages of susceptibility and initiation. If we are truly interested in preventing tobacco use among our nation's children and youth, we must invest more attention and resources in early intervention strategies which aim to (1) prevent children from becoming susceptible to tobacco use, and (2) prevent susceptible children from initiating smoking. These strategies must focus on enabling parents---who have Lhe greatest impact on t_he socialization of children~to prevent smoking susceptibility and initiation among their children. Parents are critical to children's abilities to develop atedtudes mad eompetencies that have a protective effect with regard to tobacco and other substance abuse. A number of studies confitma the powerful effect of parental monitoring, rule setting, and expectations on child tobacco use. t~.tr.~7 Parent-based interventions are needed which encourage early initiation of prevention strategies, and which focus on strengthening i~arent-child commmfication, pa~enting parental monitoring and enforcement ~hes. Compoaeats of Youth Smoking Page 6

mes~ag~ about tobacco use. These suppotl~ve interve~tion~ need to begin at least a~ early as the third grade--)~ear,z em'lier than many of the cth~reat interventions. CONCLUSION In conclusion, I would like to again stress that a truly comprehensive tobacco prevention strategy for youth must be flexible, targeted at l-tigah risk and vulnerable populations, parent- focused, linked with adult cessation strategies, and sugported by strong stnveillance, evaluation, and research. The current evidence on tobacco use among children and youth strongly suggests the need for early intervention sla'ategies that aim at preventing ehil&ren from becoming susceptible to smoking, and at preventing susceptible children from initiating smoking. The most effective early intervention strategies are those that target parents as the principal agents of prevention. At the same time, we must strengthen significantly the array of additional policies, programs, and regulations that we utilize to control the supply of and demand for tobacco products among our youth. These provisions include price increases, access restrictions, look-back penalties, educational campaigns, and cessation programs. Finally, continued research efforts are essential to the goal of a comprehensive prevention strategy. Existing policies, programs, and regulations must be improved over time through enhanced knowledge about the behavioral and biological mechanisms which underlie tobacco use. Again, I applaud the careful work of this committee in shaping our nation's tobacco policies, and I thank you for the opportunity to contribute to this effort. Compo~ of Youth Smokiag l~-veefim P~e7

!. Pierre IP et ai. 1989. Trends in cigarette smoking in the United States: pm~ to the "~e~ 2000. JAMA 261(1):61-65. 2. U.S. Centers for Disease Control and Prevention. 1996. Projected smoking-related deaths among youth--United States. MMff'R 45: 971-4. U.S. Substance Abuse mad Mental Health Services Administration. 1996. National Household Survey on Drug Abuse: Population Estimates 1996. Washington, DC: U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. 1994. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Ser'cices. o U.S. Department of Health and Human Services. 1983. The Health Consequences of Smoking: Cardiovascular Disease. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. 1982. The Health Consequences of Smoking: Cancer. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. U.S. Department of Health and Human Services. 1984. The Health Consequences of Smoking: Chronic Obstructive Lung Disease. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. o U.S. Department of Health and Human Services. 1986. The Health Consequences of Using Smokeless Tobacco. A Report of the Advisory Committee to the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services. 9. U.S. Centers for Disease Control and Prevention. 1990. Cigarette smoking-attributable mortality and years of potential life lost--United States, 1990. MMTP'R 42:645-9. 10. U.S. Centers for Disease Control and Prevention. 1994. Medical care expenditures attributable to cigarette smoking--United States, 1993. JAMA 272(6):42g-9: 11. U.S. Office of Technology Assessment. 1993. Statement on smoking-related deaths and financial costs. Senate Special Committee on Aging: Hearing on l>reventive Health. ~ ~: U.S. Senate, May 6, e993. Components of Youth Smokiag P~eventioe Page 8

13. lmstitute of Medicine. 1994. Growing Up Tobac, co Free. Waslfm~on, DC: Na "troP;al Academy of Sciences. 14. Greenltmd Ird, Johnson CC, Webt~r LS, Berenson GS. 1997. Cigarette smoking attittrtes and first use among third- tl'ffough sixth-grade students: the Bogalusa Heart Study. American Journal of Public Health 87(8): 1345-8. 15. Jackson C, Henriksen L. 1997. Do as I say: parent smoking, a~atismoking socialization, and smoking onset among children. Addictive Behaviors 22(1): 107-14. 16. Jackson C, Henriksen L, Dickinson D, Levine DW. 1997. The early use of alcohol and tobacco: its relation to children's competence and parents' behavior. American Journal of Public Health 87(3):359-64. 17. Jackson C, Bee-Gates DJ, Hen_riksen L. 1994. Authoritative parenting, child competencies, and initiation of cigarette smoking. Health Education Quarterly 21(1): 103-16. Componen~ of Youth Snmking Prcv'emi~a Page 9