Tobacco Documents Online

Tobacco Use. An American Crisis Final Report of the Conference January 9-T2;,19'93 Washington„DC Conference Sponsors American Medicxl Assoeiatlon City of Hope National Medical Center The Centers for Disease Control and Prevention Coaii6onon Smo{dng OR Health American Cancer Society American HeartlAssociation! American Lung Associadoni Memorial~Sloan-Kettering Cancer Center University of TRxas M.D. An&rson Cancer Center Editor, Thomas P. Houston, MD American MedicallAssociation Tobacco Use: An rlmerican Crisis i

Tobacaco Use: An A:meri'canCrisis In only seven1 yeats, we,willlreach the date the US Department of. Health and Human Services has set for a series of national'health goals called".Healthy People 2000."'lhe US Surgeon Generalhas calledifor a"Smokefnee Society by, Year 2ID00:"'Looking ahead to thataltnost mystical dkte,,members of the tobaceo.control com- munity assembled in Washington, DC January 9-12,,1993 to discuss, plan, and issue a series of goals and objectives in twelve areas concerning tobacco and health. Co-sponsored by the American Medical Association, the Centers for Disease Control and Pievention; the City of'Hope National Medical Center, the Coalition on Smoking OR Health (the Atneri- can Cancer Society, the American Hearrt Association;, and the American Lung Association), the Memorial Sloan-Kettering Cancer Center,,and the Univetsity, of Texas KD: Anderson Cancer Center, this conference represented a unique gathering of organirations and individuals concerned abourtobacco use and its impact on health. Putting aside "turf' issues,and differences in policy and priorities;,over 200 participants were educated, stimulated, and challenged by plenary, speakers and workshop activities. This document includes several of the plenarv, addresses,as well I as reports frotn each of the work areas. Each workshop report contains background information relevant to the issue, and ends with a series of recommendations for the future for each area. The recommendations are also summatnted at the end'of this report. The conference sponsors,hope that the proceedings will be a useful blueprint for the groups and!individuals represented arthe conference; local; state; and federal agencies andL^twmak-, ers; andlothers interested in preventive medicine and public health. Since the early 1950's; medical research has brought our knowl- edge about tobacco and health from an observation made by a few physicians that related smoking with lung cancer to our current realization that tobacco use is the single most important preventable cause of illness and premature death in this country. More than 60,000 studies about tobacco use have made this the most thoroughly studied subject in medical science. A stnall sample of tobacco's impact on American society reminds us of the importance of tobacco control in public health. Foreword • The annualltotal of premature deaths inAmerica from tobaccoo use is about 434,000 persons. Smoking is the major cause of lung cancer, of deaths from emphysemaland chronic bronchitis, and is a principal cause ofheart'disease and stroke. ..~bout'one-third off smokers will die from a tobacco- related illness or condition- almost 25% of the total deaths in the US. • Exposure to environmental tobacco smoke when nonsmokers inhale thousands of chemicals during "passive' smoking may kill as tttanyas 53,000 Americans yearfy. One analysis estimates that about 35,000 of these deaths are from heart disease: other stud- ies, including new conclusions released by the L5 Environmental ProtectionAgency, projectabout 3000 lung;cancer deaths from environmental tobaceo smoke exposure each year. In addition. environmental lstnoke imposed upon children causes I50',Ot>D to 3t)0,000 cases of bronchitis and!pneumonia each year. and Iwors= ens asthma in up to I million children annually. • Smoking among adults has fallen to the lowestilevel in over 5U yrars;,about 25%, but teert,smoking has not changed significantly since 1980. Eighty-five to ninety percent of new smokers begin before age 20. About 3.t>D0 childrert begin smoking each day in the United States. The tobacco industry spends about $4 billion each year for advertising and promotion of its products: activities that recruit new smokers and!attempt to convince current smok- ers not to quiC • Inereased'health care costs, lost productivity and misaed work. higher insurattce costs, and higher maintenance costs in busi- nesses in which employees may smoke are at least $68 billion annually. Conclusions of the conference Across different work groups, conference participants came to several points of concurrence that transcended their issue-spe- cific areas: ~. ~ Increase the Federal excise tax on cigarettes by 0) . two dollars per pack to The present Federal tax on cigarettes;,24 cents per pack, put.s the 0 United'States near the bottom of'the list among the indu.ctri.dized Ul nations, which tax tobacco atamuch higher rate. Conference Tobacco Use: An Antericart Criais iii

participants suggest $2 per pack as more in keeping with the health costs due to tobacco use. EWen more important, it was estimated that a $2 tax increaxe will save 2 million lives over time. The tax would deter.youth fiom~starting to smoke, perhaps more effectively than any other single health promotion tactic. Adults would also have an increased incentive to quitsmoking. Indepen- dentpublic opinion polls show broadbased support for a ciga- rette excise tax by over '0% of~ respondents. While not tying use of tax revenues to specific projects, participants agreed that the t7uc shouldibe indexed1 to the consumer price index or another suit- able marker that would keep ~the tax from being absorbed by inflatiom State governments should also raise the excise tax on tobacco products appriopriately: The Galifornia and Massachtsssetts expe- rience shows that voters ulll pass a tax increase if it gets on the ballot Enable regulatory agencies to assume jurisdiction over tobacco products. Cigarettes and other tobacco products are both the,most danger- ous and the least regulated consumerproduct;in the country, It;is the opinion ofimattyin the health community that the Food and Drttg Administration ~(FDA) currendy has the authority to regulate tobacco products as dmtgs when direct or implied health claims are made. The FDA should be given specific statutory, power by Congress to expand its authority to regulate the tnantdacxure, sale, labeling, advertising, and promotion of tobacco products. The Federal Trade Commission should use its authority, to regulate "vnfair and!deceptive" advertising, and the Departrrtentof Justice should enforce the ban on televised cigarette advertising,currently being broken by tobacco industry sports promotions:. Protect the public, especially children; from environmental tobacco smoke (ETS)exposure. As health professionals, we must educate our patients about the risks and dangers of ETS, and advocate for clean indoor air ordinances that protect the public from its harmful effects. This could cut costs related to acute illness among smoke-exposed chi9dren; and in the workplace, smoking bans would have thee dual effect of'health protection from ETS and help increase the number of adults that stop smoking: Restrict the tobacco industry's advertising and promotional campaigns. The tobacco industry currently spends about $4 billion each year on advertising and promotions, Banning sports sponsorships and other promotions and the tobaeco;industrys use of'healthy;,sexy, athletic models and cartoon figures in advertising should resultin a decrease in tobacco use, especially amongyouth, At the local level, the health community should be vocal in opposing the tobacco industry's use of sports sponsorships and other prorrto- tionallenticements, distributionof samples, and targeting of' minoritygroups for high concentrations of advertising.. Foreword sdapted!ftom Mouston4 TP: Tobacco Control: Toward the Year 2tNN1:7befounnal'ofPamityPractice 1993; 3G:60t-6o2i Reptinted'with permission. Ack11owl*CIrierits As chair of'~the conference planning cotnmittee, I would'like to thank its members for their hard work;,and the support from their institutions to the conference: City of Hope Yational Medical Center Karen;Warren; Executive Vice President Tite Centers for Disease Control and Prevention Michael Eniksen, ScD, Director, Office on Smoking and Health Coalition on Smoking OR Health~ Alan Davis, American Cancer Society Scott Ballin; Atnerican Heart Association Fran DuMelle, American Lung Association Memorial iSloanlKetteting Memorial Cancer Center James Quirk, Senior, Vice President University of Texas M. D: Anderson Cancer Center Harry Holmes, Associate Vice Presidentfor GoverrtmentRelations The eommittee sends special thanks to Jackie Craig, Margaret Garikes, Leslie lutdwick, and Michiko Sidney, of the AMA; Joy Epstein of'the Coalition, Karen Deasy and Gailya Walter of OSHI and also gcatefull}+ acknowledges financial support from the Roswell Park Cancer (nstitute and~GIBA-GE1GY: Ralph Reed,,MD, of the AMA Washington stalE,'shotild also be remembered for his thoughtful assistance in planning the confer- ence. Doctor Reedlwas forced to interrupt his participation with the committee midway through its work because of his fight against lympharic cancer. His death reminds us of life's fragiGty;o andlof the importance of our task in preventing tobacco s contri- bution to:its premature end. Thomas P: Houston„MD Director, Department of Preventive Medicine and Public He:dth American Medical Association, This conference was supported in Part'by G'rant ,Vumber RP,Y CCR5D7945-41 from the l1S Department of fdealtb andldrnnan Services; Centers for Disease Contnol and Prievention (CDC)': !ts contents are solely the responsiliility of the aut,bors arrd do not neces',sarrfy represent the qffwial views of the CDC iv

Table! of Clantents Foreword Arknowledgements; 27 Workshops Women's Issues Plenary Presentations 32 Childten and Youth Issues 1 Charies LeMaistre, MD 43' Minority Issues. President 48 Ehvironmental Tobacco Smoke (ETS) University of Texas A1.D. .Anrlerson Cancer Center 52 Regulation of'Toba,cco Products 3 Michael Eriksen, ScD Director, office of, Smoking and :Wealth 59 Excise Tax Centers forlJiserrse Control and Prevention 63 Tobacco Marketing and!Promotion 7 Michael Pertschuk 72 International Health and Tobacco Use Co-Director Adrlocac7+ Institute 75' State and Local Tobacco Control Battles 11 Alexander B_ Grannis 80 Gegal Issues iniTobacco Control Xew York State Assemh'lyrrran : 84 Agricultural Policy 12 Dianne Waison 89' Nicotine Dependence California State Senator 93' Workshop Recommendations 14 Antonia Novello, MD 21 U.S: Surgeon General Anne Northup 109 Appendlit 11I0~ Conferenoe Participants. 23 Kentucky Stlite Repnesentuta7,!e Honorable Henry A, Waxman Congressional Speaker

Introd'u~cti~on I would like to welcome you all to this meeting. t'.m Joe Painters from Houston, Texas, President-Flect of the httterican Medical Associationi (AMA) andihave the privilege, on betialf.of the orgatti- tations sponsorirtg,this meeting, to welcome you alL Almost a year ago;,during my tenure as chairman of the Board of Trustees of the AhL1,,I asked our staff to explore the possibility otconvening a, conference that would be a sequel to the 1'989 meeting,held in Houston„"[obacco Use inAnerica" Many of:the same groups co-sponsored that meeting and'have come together again to organize this weekend's conference. t would like to recognize those groups who have worked together so well!the last few months andlbave put together wktat l believe will an outstanding meeting.Representing;ttie Centers for Disease Control. Dr. Michael Ericsen,,who heads ttie OfBce of Smoking Health. l've Rnown Micliael Ifor a number of years, when he was at vl.D Anderson, before going,to his present post. He was a mem- ber of'the conference planning committee. Representing the City of Hope NationallWedicafCenter, Karen Warren, its Executive Vice President and Chief Executive Officer. She also served on the conference planning committee. Representing the Coalition on Smoking OR Health are Dr. John Seffritt, EVP of the American. Cancer Society, Dr. Alfred Munson, Pi•esident=elect'of the Atteri- can Lung Association and fiiially, Mr. Dudley Hafner, EVP of the American Heart Association. Representing the Memorial Sloan Kettering Cancer Center, Jim Quirk the Executive Vice President for admi.nistration, who also served on the,eonference planning committee. Josepb T: Painter, MD President-elect of the American MedicalA.ssociation, The other members of the planning eonference committee should also receive thanks for their work. Dr. Tom Houston from.the Atnerican Medical Associati.on; the Coalition on Smoking OR Health~has been represented!by tdeir steering committee: Alan Davis of'the American Cancer Society, Scott Ballin of the American Heart Association, and Fran DuMelle of the American Lung iLcso- ciaationi The MD Anderson Cancer Cznter was also represented by Dr. Harry Holmes. He's the executive assistant to Dn LeMaisure; who will Ibe our first speaker. like the 1989'meeting, this gathering of the tobacco control community is designed to consider a variety of!elements inithe tobacco control poli.cy. The AMA is not only, proud to be one of the sponsors andipartners in this conference, but is committed to: helping to forge ainew dimension in unut, cooperationiand joint effort as we fight to protect the healtli of the Anerican public in the war against tobacco. Tobacco use is really an American crisis, This meeting can setithe stage for the work thaf!must!be done to continue our'progress since the previous meeting two years aGo:. Again, Iiwekome youito this task as we set about developing.a program that will continue the fight against tobacco and the conmollof its use.

T'obacw Use: An American Crisis Our conference title'7obacco Use: An American Cilsis'"is most fitting. The awareness of crisis crystallized 29 years ago on a coldd and bleak Saturday morning here inWashington. The setting was the State Department auditorium. The participants were carefully screened: The committee making the report had surprisingly passed muster with the voluntary health agencies-and the tobacco interests. As it is today, the topic then was tobacco. And the message was the same as today-that cigarettes constitute a grave medical,, economic and moral issue. The occasion, however, was very different-a news conference, called by Dr. Luther Terry. He had summoned the media to re, lease the findings of the first report of the Surgeon General's Advisory Committee on Smoking and!Health. The atmosphere that moming was tense; the security was tight- word had already leaked out-to the media and to the tobacco indttstry that the findings were "explosive:" Saturday was chosen to minimize the impact of'the report on the stock market, if you can believe that! The media were escorted into the room; issued a copy of the report and, as incredible as it may seem today;,the doors were locked behind them, just to make sure no copies disappeared prematureiy. )ust how explosive was this evidence?'Franldy, pretty tame. by today's standards, Listen to jusra few of'our finding;, as they appeared in that first volume: •"Cigarette smoking,is causally related to lung cancer in men... The data for women, though less extensive, point in the same direction." • Here's another. "The evidence on the tobacco-esophageal~ cancer relationship supports the belief that an association exists:" • And: "Women who smoke cigarettes during pregnancytend!to have babies of lower birth weight. lt is not known whether, this decrease in birth weightihas any influence on the biological; fitness of the newborn," • And another. "Smoking is associated with accidental!deaths from fires in ttie home." Opening Remarks Charles A LeMaistre, M.D. President University of TeaaS. M.D. Anderson Cancer Center And, in the spirit of assuaging those who might be offended, aa chapter was devoted to the "beneficiall"aspects of tobacco, and on the report cover were tobacco leaves. And so itgoes,,as Linda Ellerbee would'say, A document couched inthe most conservative of'scientificterms, yet a document that was to begin a revolution in American behaw'ior„culture and health policy,.. A ret,olution that began qttite slowly and tentatively-dtte that would languish until the 1980's when for the firsttime anti- tobaccodegislation passed Congress withoutcompromse-and yet one that ha5 been gathering increasing momentum in the yearss since. But a revolution that is far from over-far too farfbom over,, considering the weight;of the preliminary scientific evidence that was already available in 11964, and the overwhelming;evidence that has been amassed since. On that preamble of reminiscences, I welcome you~to this impor- tant conference on An American Crisis: AnAmerican Crisis that has been without a final solution for diree decades and likely will continue for decades more at the rate progress is being made in bringing it under control.. Whavis the setti:ng,in which we meet to map strategy? First, the problem is no donger a medical or scientific controversv. The problem is now societal-it is political--it is economic cmd& it is moral. Second, we must accept the embarrassment thavit trulv is an American Crisis--made in America--marketed!and promoted in America and imposed largQlybyAmerica upon the rest of the world through marketing---driven by, disregard for human life and high regard for profiting, even if it involves the suffering of others. Third„we consider this crisis at a time when America is prx?occu- pied witti another erisis--the unrelenting spiral in the costr of tteating disease. Surprisingly few who talk about the cost crisis seem to understand the role of tobacco in the production of disease. Tobacco is by far the most sigtuficant cause of cata• strophic illness, a prunary driver of the rise in health care cost.: Consider for a moment health care costs--less one-third of~ all cancer, less one-half of cardiovascular disease and less nearly all' chronic bronchitis and!emphysema: Tobacco Use: An Ameri'can Crisrs 1

Even so today we are better prepared to addi ess this American Crisis than ever before. Thtartk goodness, the conservative rhetoric of the ficstiSurgeon. General's Report has been replaced by plain-spea{dng that is both strident andlunderstandable. Thank goodness, we have moved beyond;the individual, indepe.n- dent interests of agencies;,associations and centets and now focus on the synergism~that comes from working together. Tltank goodness, that we have rallied many, many more to the cause and that the collective impact of theireffort is the reason why our countrys mores changed so radically in the 1980's. And thank goodness, we have learned a thing or two about ctNm- munication and behavior change, about advocacy and market- ingo so that we can meet the merchants of death on almost-equal footing. ,artd!even now; three decades after the cau3e of [he A[nerican Crisis was crystal clear, there are those who seek to soften the truthrthat is so patently obvious. Today tobacco remains the single most-preventable cause of illness, of catasttrophic disease and of death. Today, tobacco is a highly profitable, legally tttanufactttredd and deadly product that neither our state nor federaligovernments have seriously, attempted''to regulate or control in the protection of the publids health. Today, inlaNatant disregard 6orthe rest of the world's health, our, government has fostered participationof tobacco in favored trade status, When inthe light of humanhistory; our American society i5 judged for its 20th century performance on soeial; moral and httmanvalues, we can indeed be proud that manyachievements will resound to.our credit Regrettably, the disgrace that is the Artterican tobacco crisis will not be one that we can take pride in. It likelq; will be said that we have placed greed ahead of our regard for human life and con= cetm for suffering;. We are but seven shortwears from the close of the books on the 2'0th~eentury.lfiere can be little doubt that we know the ultimale solution~to this American Crisis. The only real unltnownis whethervou and I have the will to achieve the solution. Now the time has come to do more, and who better to set the stage for our discussions than two great lea+ders in American health promotion. What a nice privilege it is to share,tlie platform this morning with these two friends, whose contributions to the goals we share I admire so much - My long-time M.D. Anderson colleague, Michael Eriksen, who hass recently gone on to become the Director of.tbe Office of~ Smoldng and Health at the Centers for Disease ContnolJ who will'speak first_ He will be followed by Michael Pertschuk; whose taughtus all soo much about the power of persuasion„who eo-iiirects the Advo- cacy Institute. I'am delighted to call Michael Eriksen to the podium now, and!he will be followed!by Michael Pertschttk~. 2

"Healthy People Zooo" and its Tobacco Control Objectives Introduction Today, my presentation is entitled "Healthy~People 2000" and it is my goal to attempt to link the Year 2000 tobacco objectives to the recommendations thatcame out of the Houston Conference andi to similar recommendations that might~emattate from our current meeting. Year 2000 framework National objectives provide useful planning perspective for to- bacco control in the 1990s. There are 16 major tobacco objec- tives which provide specific measurable targets for us to aim for. These objectives also cover most oPthe major contemporary tobacco control strategies (clean indoor air, advertising and youth access). There are specific gaps relktedto excise taxes and product regulation and hopefully during this meeting we can discuss ways of integrating conference recommendations into the Healthy People framework wherever possible. Year 2!()00 progress ,4ttal~sis ofour movement toward these objectives reveals a mix of good and bad news, Some of our key indicators: First, theGood News.... 0bfpctive 3.4: Reduce cigarette smoking to a prevalence of no more than 15percent among people aged 20 and olde>i. Last year we reported that U.S: adulrsmoking prevalence in~ 1990, the most current year ofidata available: was at its lowesrpoint since the government fustbegan national surveys-25,5 percent for the population overall. 0bjectiue 3.11: Increase to at least'75 percent tbe proportion of worksites with a fwrmal smokingpoticy that probibits or severely restricts smoking at the workplace. Eighty-five percent of workplaces have some form of smoking policies, up from 36 pereentin 1986. .utd 59 percent of compa, nies with 50 or more employees have policies that ban or severely restrict, smoking-up from 27 percent in 1985:. :Yow,, Some Bad' News.... 04fectirae3.5.' Reduce the initiation of cigarette smoking by children andyoutb so that no more than 15 percent bave become regular cigarette smokers by age 20; Hichael P. Eriksen;ScD Director, Office on Smoking and Health Centers for Disease Control and Prevention Overall smoking'ratesamong young people have remained virtu- ally unchanged over the pasrdecade. In fact; smoking among mafe high school seniors actually has been inching up since 1'987: Smoking among black youths continues a dramatic decline that began more than a decade ago---daily smoking among black high school seniors now has fallen to 5 percent--one glimmer of'hope we must endeavor to understand. Obj'ectke 3.4b: Reduce cigarette smoking to a preualence of no more than 15percent among blue-collar workers aged 20 and older. The rate of smoking among blue-collar workers did not decrease between 1987 and 1990 and is still nearly double the target level for the year 2000-37 percent vs. 20 percent. Objectii!e3:12; Enact in 3C3 States comprehensive laws on clean indoocair tbat'pr~obibit or strictly limit smoking in the workplace and enclosed public places. Aithough allstates but Montana have some form of laws restnct- ing,minors! access to tobacco, enforcement is virtually nonexist- ent in many states. We reported this year (from TAPS) that if 12- to 17-year-oki5 want to buy cigarettes, they, have little or no trouble doing so. Objectiae 3.15: Elirninate or sewenely restrict all forms of to- bacco product advertising and pramotion to which youtb younger than age 18 are likely to be exposed Tobacco-advertising andlpromotions that appeal to young people remain virtually unrestricted. There is a direct connection be- tween the amount of advertising ofspecific cigarette brands :,nd' young people's preference for those brands-witness the sricce.cs oflNarlboro, Camel, andiYewportin gaining the loyalty of new smokers: The national response I am pleased to report thatime've made some real progress in accelerating tobacco control at the national and'state levels, For example, just 2 days ago here in Washington, EPA relea.sed its finaf risk as5es.sment on ETS and respiratory disease. The desiGna- tion of ETS as a Group A carcino8en (known to cause eancer, in humans) by EPA along with NIOSH's classification of f.'7'S as a ..potential occupational carcinogen," provides its with powerful Tobacco Use: An American Crisis 3

new ammunition to mork harder to protect the he•alth of non- smokers. OSH is working ciosely with EPA to publicize the results of this report and to motivate the public to take action: The American Stop Smoking Intervention Stu&• for Cancer Pre- vention, or ASSIST, has entered its second year of planning and will begin full-scale implementation in 17 states this fall. At the same time, California enters a new year of acavity inlits statewide tobacco control effort with a redueed! but still remarkable, level' of funding: Now the challenge is to provide necessary, help to thee other 32 stgtes and DC so that they can take advantage of the training and technology developed for the A'SSLST'and California, initiatives. We at OSH are hoping to ~do so, both by beginning to provide,direetinancialiassistartee to States' tobacco control efforts via a competitive cooperative agreement program„but also identifying;,collectingand redistributing the best available tobacco control programs and materials among States and organizations. In addition, the Preventive Services Block Giant legislation has beeni rewritten providing for greater opportunity for use of these funds for chronic disease prevention, including,tobacco controL The SGIRCNET efectronic tobaceo control network, spearheaded' by Mike Pertschuk and his staff at the Advocacy Institute, eontin- ues to be an invaluable source of'news and intelligence for advo- cates across the nation. SGItCNEf has made our jobs easier tracking such tireaking,issues as the Cipollone Supreme Court decision; efforts to divert funds from tobacco control in Califor- nia; and the tobacco industry's unsuccessful attempt to derail the. Massachusetts excise tax initiative. The tecentlypassedlAlcohol;,IDrug Abuse, and Mental Health Administration ReorganirationAct now requires States to have minimttm age laws for the purchase of tobaixo: products, and to enfor+ce these latvs--otherwise the states will lose a considerable portion of their federal block grartt monies for substance abuse programs. We owe our thanks for this provision to the efforts of : Oklatioma Congressman Mike Svnan. who as it turns out was one of the congressional co-sponsors of the 1989 Houston meeting. NCI, A.titA; ACS, and a number of other professional organizations have continued a national initiative to train health~care providers in smoking cessation. AICI hopes that, 1tDB,000'professionais will be fully trained by the end of this year. The Coalition on Smoking or Health continues its persistertt, focused advocacy to influence Federal tobacco control policy. Most recently, the day before the EPA "Group A'' announcement, the Coalition held its own press conference to call for greater Federal andState clean indoor air legislation, regulation of to- bacco:products by, the FDA, and a $2 incre3se in the : Federal excise tax on cigarettes. Our "activist" partners-DOC, ANR, STAT; GASP, and others-- continue theiraggressive;,creative efforts u both the national and community levels to upset the status quo in ~tobacco control!and bring,about faster change. I would give tttany more examples if;time permitted. I'll let Mike Pertschuk expand on mylist; which he will do from~his keen andd unique perspective, Butlit's my observation that there is more happening currently in tobaeco eontrol than at any time in our history. Our charge now, and l use the word'^our" in its most collective sense, is to orchestrate these efforts as strategically as possible: An unusual strength of the tobacco control movement! is that it is ertremely broad and'deeentralized-we never want to sap that strength with unnecessary bureaucracy or centralized!decision making. Butithere's a clear need for greater communication and coordination, both to enhance what is already happening and to unlock new opportunities. That also is a theme that Mike will underscore emphatically, Proposal!for a unifying f'ramework. Returrttittg to my initial comments;l propose that this conference consider sttucturing its conclusions and recommendations in 1993' around the Healthy People 2000 objectives. Except for the issue of'excise taxes, an imporrtant approach that I would supporr adding, the Healthy People objectives address all the critical components of a comprehensive tobacco control strategy. 7fiese objectives already have broad-based support from both within andioutside the public health community. They have beenn adopted'and adapted by,countless public and'iprivate organiza~ tions at the national, state, and local levels, and are actively being used to.plan programs and establish budgets. Though far, from perfecti the Healthy People 2000 objectives benefit from being,feasible, specific, and measurable-the three hallmarks of effective health promotion and disease prevention objectives. Lessons from Houston The Houston meeting 4'years ago made a valiant attempt to set aa common tobacco control agenda for the Mation;,but 1'think the impact of its recommendations has been tempered by, two basic shortcomings: oLwrambition.of purpose and underestimation of political reality:. First, the issue of 'overambi6on. The conference advanced 766 separate recommendations for controlling tobacco use, all of them.thoughtfulland insightful. But their sheer number and leveli of detail has, in my judgment„somewltat blurred the strategic vision of.the conference organizers---to develop a common national agenda to reduce the death andI disea.se caused'byto- bacco: I don't mean for a momentito discount the outcome of that meet- ing. A number of its recommendations have been realiied„and' with considerable impact • Smoking,was banned on all domestic flights, thanks largely to the efforts of Senator Frank Lautenberg and Representative fDick Durbin, who,was the other Congressional lco-sponsor of that conference: • As a requirement for continuing aeereditation, all hospitals soon wdll be smoke+fnee. 4

• And there have been other successes. But now let me move to my second point, the issue of political realism. The six major recommendations of the conference dealt squarely with topics under the primary, purview of the Federall Government 1) regulation of all tobacco products by the FDA, 2)) elimination of the Tobacco Price Support Program; 3) reversal of the government's international tobacco trade poliicies, 4) elimi+ nating the influence of tobacco advertising, 5) increased excise taxes,,and 6) action to protect nonsmokers. These all are politically charged issues, owing to a single prevail- ing,force: the economic enormity of the tobacco industry: We'ree getting smarter each day;,but I still think we underestimate our foe and fail to learn allme can from its high-powered marketing and publia relations machine. But I'd like to end today by reflecting on what I believe is even more fundamental to the success of our mission than the issue of organizational process and goodwilL It's the issue of citizen involvement I've spoken in recent months to a number of'state and community groups, from North Carolina to Arizona. I hear one consistent lament despite the commitment, gqod ideas, andlboundless energy, of individuals working in tobacco controi; they often find that the doors to substantive change are closed because of pur- chased influence by the tobacco industry at all levels. The pervasive influence of tobacco interests on the entire politicall process has been demonstrated, in startling color, through recent reports leaked by industry lobbyists ... through secret corporate memos obtained by our advocate-sleuths...through reports of tobacco company campaign contributions:..through other indus- try documents subpoenaed'for court ca5es...and through the bitter anecdotal experiences of our allies working in the field. We now know, for eaatnple; that the industtywillfully launched a massive misinformation campaign to undermine the credibility of the 1964 Surgeon General's report:ltte industry poured the same energy into its unsuccessful attempts to scuttle the EPA risk as sessment and vilify the reputation of the agency itselE And ask our friends from California and Massachusetts about the behavior of the industry in those states. What does this influence mean? It means, quite simply, that decisionmakers both in government and in oqanizations, at the local, State and Federal levels; are being paid for their silence on the tobacco issue. Ibmean,s that these decisionmakers will choose not to bring a tobacco control issue out of committee ... choose to vote against a community smoke-fbee ordinance ... choose not to protect the health of children by continuing to allow teachers too smoke in school buildings ... choose not to include tobacco control in health promotion offerings to their memberships. It means that the best-pl.vuted tobacco control efforts maywither, and the from failing to see the light of'dA}+. Let me quote directly from Secretary Sullivan?s remarks at Ttiursday's EPA press conference: "Now it is time for our public officeholders of both parties to withstand'the pressure of the tobacco industry to water down,or defeat anti-smoking legislation--pressure fueled by millions of dollars in political contributions and additional fundS to support so-called 'smokers rights' campaigns." He continuedi "Quitesimply; if the concern expressediby our officeholders for the health and well-being of their constituents is to be considered genuine, then they cannot allow the tobacco industry to influence their decisions on issues of such vital impor- tance as the health and survival of our citizens-particularly our childten." None of us at this meeting, even with our collective budgets, can . fightitobacco influence with money, After all, how can we compete with an industry that reported afler-tax profits of $7.2 billion in, 1989-an industry that spends $4 billion just on advertising and promotion each year? The only weapon we have as Americans is ourselves. Yes, we have the truth and the statistics on our side. And yes, we have public opinion on our side. But we really donlt have the public on our side--not actftaely on our side. To do that-to get people to embrace tobacco as apersonalt concern-we have to move far beypnd the medical facts that smoking is harmful and addictive. We must instead educate people about the greed and influence of tobacco interests. We must stir'people so that they view tobacco with social andmoral outrage. We must publicly shame the tobacco industry for their actions. We must raise the issue of tobacco control on people's personal agendas so that they will talk to-their neigtibors abourit-tettify publicly about it-andieonsider it in their actions, including,thein voting decisions about political candidates. I believe decisionmakers will turn down tobacco money only when they perceive such contributions to be a political liability: For that to happen everyday Americans must voice their eon- cerns-loudly and consistently-abouthow the tobacco industrys self-interests are perverting our very system of democ- racy, and how they will translate that concern at thetiallot box. only then willitobacco money become worthless;,and!the tobacco industrv lose its influence. We must strive to create a national in,dignaldon. But how can we mobilize the citizenry? This same concern wa-,;expres3ad at this same meeting four years ago: "Qollectively„ the participating,orgartir,ttions can mobilize millions of citizens at the grassroots level!to create a strong coherent body able to more effectively influence and educate poliw-makers throughout goven:tment." But I say that it will take more, much more, than getting our health constituencies involved. Wemust get involved the very people who are not partlof the .'movement'.'We musrget aU of America involved! Tobacco Use: An AmeriCan Crises

I am heartened at the presence at today's meeting of the °lnterre- ligious Coalition on Smoking or EHealth" who can begin to bring our message to the homes of ald 'Artericans through the churches--the United Hethodistfhurch, the Church of Qtirist and others. We must work not only through the churches„but through all other, possible venues to get the word out--the word, not that smoking is bad for you, but the truth abouut;the industrv, its tactics and;the aftetmath. Cnfortunately;,the tobacco industry has not only influenced gov, emment officials, but has also financially contributed to other natural allies and avenues to the AmericanipubGc-yOW; NAACP, unions, progressive g;oups... the list goes on. Clearly, we're not going to solve,ttiis problem today, but in my opinion, there was neveraibetter day to start. We have recently enjoyed many successes,,public opinion„as evidenced by Drponesbury„ Ellen Goodnsan, Anna Quindlen and George Will has never been strongen There is a certain electt+icity in the air antici- pating the potential of a new administration, but also fearing,that the industry will be one step ahead: Our challenr is to make tobacco control not our issue, butAmerica's issue:. At this time, in this city, I feel it's appropriate to repeat one of the most famous quotes of our generation: "A'lllttiis will not be fiitished in the first 100 days, nor will it be finished in the fitst 1000 days, nor in the life of this administra- don, not even perhaps in our lifetime on this planet. Burletus begin." Thank you. 6

Opportunity Knocks; ~~ill' We Open the Door? As we look back over the four years sinee many of us met in Houston, how have we done?' Are we winning? Are we losing? Have weset our horizons high enough to challenge us to the utmost, but realistic enough to be achievable? Andhave we marshalled our will and our resources to achieve the achievable?' In some ways, it's hard to tell: If we look atCanada or Australia, or Thailand and Taiwan-even that lnst bastion of aggressive. Gauloise-blowing, France -we must look with admiration and not a little envy. But if we look at Germarty or Japan, and' most of the Third World-and if we acknowledge that we face the most concen- trated and politically potent tobacco industry opposition.-we're not doing so badly. As we take stock, it's hard not to be assailed by competing,im- ages; some of which herald great progress; others. just as com - pelling, auger stagnation. • Ttte :Wassachttsetts Division of ~the American Cancer Society and the coalition it led with great skill and!persistenee, with heart and soul, withstands an $8,000,000 onslaught by the tobacco industry to iemergg triumphant in its vanguard cigarette excise tax initiative. • In a small meeting,room in Springfield, at the annual STAT Conference, a group of tobacco control advocates bitterlyvent' their frustrations at, their felt exclusion from the I' state ASSIST coalitions, reflecting deep resentments thatthe activists who are the most dedicated tobacco control freedom fighters remain ,. unappreciated, uninvited to the table; unsupported while, as they see it, bureaucrats wallow in misdirected tobacco control dollars. • Yet in Raleigh, North Carolina, where tobacco control requires a quality of fortitude and courage which ~few of us are required to match, an ASSLST launched!conference, packed to standing;.,deaLk openly and'courageously with the challenges of 6ghting,tobacco in the very states for which tobacco is the perceived economic life blood. Keynote Address Michael Pertschuk Co-Director, Advocacy Institute • One thousand tobacco control workers gather in Los wtgeles too celebrate three boisterous years of Prop 99-an ethnic rainbow of newly minted, enthusiastic, resourceful tobacco control advo- cates who have radically altered the community environment for tobacco use in California--under the risk-talkrtg, politically unintimidated guidance of the California state heaith~department stafE.' Yet, look arottndIthis room. vationally;,we are no rainbow coali+ tion-and the very communities which are the prime marketing, and propaganda and organizing targets of the tobacco industry are largely missing from, the councils and inner coalition coreof' mosttobaeco control efforts,. We have come together here today with a shared~vision for the future: First, to achieve an authoritative, comprehensive, articulated National Tobacco CAntrol'PolicyAgenda, setting concrete national, state;and local objectives and'strategies for tobacco controL Simultaneously, to forge an organized core of unnversallv accepted, leaders and leadership groups, as in Canada, capable of tltwelop- ing and directing coordinated'national campaigns to achieve priority policy objectives. But before we can do that, we need to deal'openly and honestl4 with both our strengths and'our current limitations. Let me begin by; offering foryour consideration~over the next few days what strategic planners call a SWOT anahsis of our m rnve- mentas it'now stands: our internal strengths. our internal weak- nesses, the new external opportunities that beckon to us. and the ttireats that shadow our best efforts. Whst are our strengths? fI come up with no less than l 1-tltey are formidable -:uid we need!to take just pride in them: l. Among mainstream tobacco control advocates, there docs exist broad consensus on the four horsemen of tobacco control policy:lD excise tax increases; 2) extending smoke-free public places; 3) curbinq,advertising,and promotion; and 4) rt.strir- tions on youthaccess: 2. The movement has broughtforth a talented and diverse lraulur- ship pool: federal and state legislators, such as the itt-mvmlx-r Tobacco Use: An American Crisis 7

-and grrowing--Congressional (i.e., House of Representa- tives) ~ Task Force on Tobacco and Health; public health advo- cates both in and outside of government; deep6y coaunitted, energetic, and effective grass roots activists, including activists Rithin the healthrvolttntaries,,researcher/activists; lobbyists and' advocacy specialists. knd we are fortunate in being able to dtaw upon ttie successes and the battle-tested expertise of our skilled Canadian col- leagues, .Vnong;these leaders, there exists a potential~eore group ca- pable of providing coherent, respected„collective direction, a goodly number of whom are convened here today. 3. In, Wastiing4ott, the tri-ageny Coalition has developed the frame- work for a national legislative program. And it has just Ikunrhed a timely and ambitious federalexcise taAinitiativearound which all of us can now mobilize. tt coordinates its state affiliates, has built good'working rela- tions with key legislators and staff;,and is nowdeveloping a capaeity for influencing the new Administration's policies. It draws suppotrt,from as many as 150 national organir.ttions. Individual.membets of the Coalition have played'lead roles in tobacco controt'campaigns, most recently the campaign to achieve smoke-free international "skies, and the eHort to force the FDA to take responsibility for regulating tobacco products. And, in convening this meeting, the members of the Coalition and the AMA have signaled thein recognition of-die need and their commitment to strengthen the cohesion and capacity of our national tobacco control movement. 4. A(S, with new leadership at ttie,top, strong mid-level leadership on tobacco control, the sweet taste of success in the Massacltu- setts ezcise tax initiativve; and a long-term commitment;to the ASSIST coalitions;,is poised to cotnmit substantiaUnew funding and new national direction and energy to tobacco controL i. The !4MA House of'®eiegates:has been in the vanguard calling for strong action ~against tobacco advertising and promotion. Key AMA leaders and staff like Ron Davis and Tom Houston and the editors of JNMA have provided strongieadershi.p, andithe AMA has begun to mobilize actively, as with its sponsorship of: the Chicago protest march against the "Joe Camel" advertising campaign. 6. From ANR to IDOC to GASP to STAT to Sinoke-Free Pennsylva- ni.a, activists, the shock troops of'tobacco control, with daunt- less detemnination; almost no money and institutional support,, but awesome energy, have been the sparkplugs of change in city after city,; state after state, throughout America. ASH, and others have forged good and mostly successful state legisUdw battles to stop or disatm miscttievous and'divetsionaty Stnok- ers" Rights,lkws. 7: The 17'state ASSIST site coalitions are gaining rapidly,in capac- ity and cohesion. Through NCI, ASSISi is providing a planning, technical support and'staffing structure for sustained policy advocacy initiatives for the five }aeus beginning in September, 1993: And,,despite the perception,of some activists, NCI and ACS'are committed to bringing,the grass roots activists into the fold. 8: The Office on Smoking and Health (OSH), with strong CDCC support, has signaled!its;readiness-to commit its resources, its convening role, and its leadership voice to achieving a national infrastructure and strategic planLplkntting process. It has new, tresources, is li.kely,to gain more. and1as a[ready beenbuilding a support system for state health department tobacco control officers. 0SH is perceived as both committed and neutral, among the players, and has shown its readiness to reach out to, previously outlying constituencies. 9. Califotnia's massive resources, learning, and!techttical support infrastructure can be draavnuponto support; national~efforts: ll0: The emergence of such organimnons as the National As.cocia- tion of AfricatrAmericans for Positive Imagery (N14WPI) and the National Coalition of Hispanic Health, and Human Services Organizations (COSSMHO) hold great promise for new, con- centrated efforts to draw critical ethnic groups into full and equal partnership in~tobacco control. 11, (With all due modesty) , the Advocacy Institute provides a generally trntsted, respected, independent core of policry profes- sional5 committed to strategic planning and coordination of' tobacco control policy advocacy, andiSCAItGNet is close to achieving optimum reach as a universal communications and technical support pillar for media and!polit.yy advocacy initia- tives. These are our strengths--that's ahe easy part.lVow the internal weaknesses. Forgive me if'I tread on toes. But this week marks my 60th biithday, and d feel both obligated and entitled ito engage in unaccustomed,truth telling: And, in truth, while we have many ablo.and talented and commit, ted leaders, that ieadership is fragmettted. The limited finaneial resources committed by both,gavemmeat and non-gpvemment, funders are, too often, mis-iinected. We still lack the structures and!capaciryforoverafl priority setting; strategieplanning„tactieal coordination, and effective communications: sperfficallr. 1. Other than the modest..HeaWty People 2000" objectives, there exists no comprehensive, authoritative national tobacco eontrol policy: 2. Amo,ng,the~federal agencies,!VQI, which earliershamed'CsDC by the boldness of its ASSIST initiative has lately weasled and waffled on its commitment to full'funding af;ASSIST. EPR drops ETS!research. The FTC has been guilty of L3Lse andimisleading protnises by failing to match with action its rhetorical commit- ment;to challonging such,bligbts,as the Joe the Camel txm, paign. FDA reacts to calls that it assume jupsdiction over tobacco products as if it had!beentossed a red hot coal! HHN gingerly omits excise taxes ftrom the Healthy People 20t10:

objectives. And OSH has yet to purits new money where its mouth is. We are still awaiting,theWhite House executive order decreeing a government-wide non-smoking policy. The Office of Trade Representative has not quite finished pushing V'irginia~ Slims advertising campaigns dovm the throats of'countries who would spare their not yErsmoking women tharblight Perhaps the good riddance of~the Quayle-Sununnu White House will remove the hidden, encumbrances to actionby these agen- cies. Perhaps. 3. In DC, the Coalition on Smoking OR Health is essentially limited to the Cancer, Lung, and Heart voluntaries. While enlisting support from other organizations, the Coalition has had limited success in forging close alliances with the rest ofthe tobacco control movement. The leaderstiip of the three major voluntar- ies have provided'the coalitionmithithe barest of staff're- sources: It'operates with onlyasmalllstaff and1 no fullltime tobacco control lobbyists, and, while the Coalition has access to other staff and volunteers, tobacco control advocacy is onlyy one of manyissues engaging the voltmtarbes and their Washing- ton offires,. At the same time, it has been the three voluntaries alone who have committed staff time and resources to federal tobacco control lobbying-which is more than can be said of'other national groups nominally committed'to tobacco control, some of whom are quick to carp atthe Coalitioni 4;14te AM'rA' has never applied its formidable lobbying resources to tobacco conmol!with anything resembling its legendaryy mobilization on health care issues. 5. While ASH's voice is loud, it!shuns alliances and its legendary fund raising capacity dwarfs its tangible contribution to tobacco control mobilization. 6. The African-Amerioan,,Iatitto-Amenicatt, women's; and labor communities are wooed!by thetobacco industry; and neglected by the tobacco control entities (exceptithe California Health Department). The ASSIST coalitions are nominally committed to such outreach, but little true diversity has yet been achieved in the working eores of these coalitions.. VAAAPf„for example, lacks any futancial or staff underpinning. 7. The Carter Center has the potentiatlto help with both strategic planning and broadened outreach;,but it lacks both human andl financial'resources; 8. Too many activists are alienated, envious, obsessed with col- umninchesenvy;,intolerant of moderate or divergent views. Tfiey are offensively self-righteous. They are chronically underfunded in proportion to their undoubted'eontribution to tangible policy achievements and are chronically resentftil. 9. As a resource center, responsive to tobacco control advocacy groups (andlits futtdets),,rather than a"Crontline" advocacyy grooup; the Advocacy Institute is only able to make indirect contributions to the movementis strategic cohesfonj A number of activists have not'too gently suggested that the funds spent to support the communications and tectytical support activities of the Institute would be far, more effetxively investedldithey were divided among the activistswho actttallywork the front lines of tobacco controL And they; may be right. (Though we hope not). (If~I're thouOtlesslyoverlooked any of you, please let me know Dm confident I can find something at least equally offensive to say about everyone here. After all, none of us are perfect orclose:) These weaknesses are the more painful as we move into a new era of opportunity-opportunity which we tnay's'imply not be ready to seize: Among these external opportunities are the following:, 1. The new Administration offers hope and promise for the emer- gence of a broader, bolder national tobacco control policy. Though hardly single-mittdedicrntsaders, the Pt,esident-elect and' Hillary Clinton have tgken both personal and policy; standss against smoking.-a sharp contrast;,fbr example, with all I earlier presidential candidates. Donna Stialah was a strong. advocate of non-smoking policies both within the IDniversityof Wisconsin and the city of'Mladisott;,Bob Reich worked on tobacco control initiatives at the Ft1C. I would be surprised if the Clinton FTC transition team has not called for aggressive action by the FTC challenging youth-oriented cigarette advertis- ing sucha5 the ' Joe Camel" campaigns. Though it should be noted that; while issues ranging,fiom AIDS to health caree reform are receiving considerable attention, no dear A'dminis- tration leader on tobacco control has yet emerged. 2. The new Congress offers hope. Changes in the tnake-up of the House Energy and Commerce Cbmmittee, the House Appro- priations Committee, and the Senate Labor and Human Re- sources Committee, among others, may advance tobacco control initiatives --especialty, if these are supported rather than resisted by the Administration. The Congressional'tobacco task force is growing,l4te Women's Caucus appears ready to embrace tobacco control on its healthpromotion agenda. And tobacco control'leaders in the House and Senate are poised to pursue a broad and ambitious tobacco control agenda. And. Jesse Helms quit smoking. 3. As the Administration's health care reform proposals take shape, two opportunities emerge; I) sentiment approaching' consensus that cigarette and'alcohol excise taxes are a pre- ferred!sounce of revenues to fund an improved system. and 2), growing interest in developing a prevention component of tlte reform package, including tobacco and alcohol control poli- cies. 4. 4lomentum grows at federal, state and'local lecel.s for cigarette excise taxes, clean indoor air policies; and effective restraints on youth access. There is less momentum, butbroad!public suppoM for restraints onadvettising and promotion. 51 Analysis of'media content and tone reveals eoactartt progress (forwhicli we do claim some modest credit) in delegitimi7ing, the tobacco enterprise;,thereby undermining its politicaf power to resist and deflect appropriate tobacco control policies. For Tobacco G/se.• An American Crisis 9

example, the furor and focus on Yernon Jondan's RJR connec- tions highlighted the negative ethical implications of all such connections. Michael Eriksen is dead right Pursuing the public shaming of all those whoare prepared to profit, even remotely,, fnom the death and'~debilitation caused by smokirtg is a primary building; block for ourefforts. We know the'main source of our external threats, the transnational tobacco companies. We may nod, but the tobacco industrn never sleeps. While their moral resources erode, their finaneial!resources are inexhaustible. And they continue to be able to buy a vast army oflobbyists, propagandists, andlawyers- among them~,aLas„otherwise worthw'community leaders and vanguard community organizations. lfianks again to the uncanny'intelligence gathering efforts of Dt}C, we now have newi;r liberated' Philip Morris internal lobbying memos to remind ius that the industry's oampaign contributions and the tobacco ties of key transition figures and nominees will be a constant threat to uninhibited tobacco control policies. But the industtyis not the onlythreat, to tobacco control progress. Ignotance-sometiines willful-among both the public andd policy makers as to the enormity of tobacco's toll petsists.lttus, competing claims on the public agenda--suclt as AfDS, illicit substance abuse, and pollutioni--are still perceived as more seriotu and more pt7essing. A third threat is complacencv-complaceney in'the face of real gains in tobacco control. What does this snapshot--these strengths, weakrtesses,,opportu- nities; threats tell us about our tasks over, the next tiiree days? Let me suggest tbat, as we addeess the range'of specific and criti- cal issues which we have assigned ourselves, that we pay heed in each meeting-and in the invaluable informal networking which links us-to our meta-needs; • With a new Administration which gives promise of'more'open: ness ao tobacco control initiatives;,we need'to revisit both "ittside'' and ..outside"'s'ttategies: what'can we realisticallyexpect fi•om an enlightened Administration, and how'ean we help make sure that what might happen does happen? When, and how should we expect to join forces with and coalesce to support OSH, NCI, the state health departments?. • When and how best can we maintain outside pt essure on gov- errtment to make sure it remains upright? • Speci6rrally; how can we combine to develop a strategic plan to achieve a+lational!Policyon Tobacco Contnol'issued and em- braced by the Ptesident? • And how can we best maintain constant vigilance over the insinttating influence of tobacco industry money, and agentF on the nascent policies of'the new Adtninistration? • How can we broadeni and strengthen existing coalitions, both at federaland stateaevels, including:, finding the'will and'the ways to open up our coalitions to true partnership and cooperation with all significant tobacco con- trol entities, allowing ample rmom for independent,,but coordi- nated initiatives led by those with the energy'and skill to move'e beyond!eoalition consensus priorities: building'bridges of'financial support and'understartding to the gcass noots activists. meeting;the needsand'eoncerns of ethnic communities and leaders in shaping the tobacco control agenda and leadership structures. • How can we help provide financial and!technical support for emerging ethnic tobacco control leadership ~networ[cs? • How can we strengthen the technical support ittfrastructure, especially strategic communications and coordination including timely intelligence on tobacco industry'strategy and tactics, coun- seling pn counter•stategies, policy guidance based upon sound research andianalysis and readv.access to key data bases? • And finally, how do we find within ourselves the internal. spiritual resources to reach outto~eaehother as,friends.and~alliesd in a great cause, transcending the self-righteousness and means ness of spirit, the pettiness and vanity, the personal and institu- tional self-interesrthat too often corrode our efforts? Coming together is our start Leaving united!is our ehallenge: iin

Tobacco Control Battles: State Legislatures The tobacco control movement has no lack of information about the issues and4bout what needs to be done to help reduce to- bacco use in this countay. Advocates need to focus on how to accomplish their goals. Because this conference is being held in Washington, D:C., the focus appears to be on the federal govem- ment, but I1would urge you to focus on the other, end of the politi- cal system„local government. New York (city and state) has achieved many recent policy victo- ries; Cigarette advertising will be banned on mass trartsili Smok- ing is banned in New York City schools. The state has banned! vending machines that are available to kids. Free distribution of cigarettes is banned. Proposals have been made to stnengthente state clean indoor air act. Enforcement procedttres have been changed fromictimiital to civil in,the youth access legislation. Parents now have the right to initiate action against retailers who sell cigarettes to their children, along with licensing,requirements for cigarette vendors, requirements for lDs for cigarette purehas- ers: An increase in the state excise tax is in the works. Tobacco control legislation is no easier to pass in New York ttian any other state, but we have had success by starting first with local government.l4tis strategy divides and dilutes the ciganette cotttpa+ nies.' ability to use their resources. It is harder for the companies to work at the local level than at the state level. A number of counties had dean indoor air legislation before the state. Local governments have been enacting their own restrictions on smok- ing in public places: When state legislators saw those actions going ahead with popular support and no damage to.the local politicians who promoted them, they became interested We worked ion the state clean indoor air law for 13 years. As localI governments moved ahead, we were able to pass our billlalmost unanimously in both houses of'the legislature: And then came other successes, especially the adolescent tobacco youth prevention act. Among the groups that helped us to get this legislation passed were local public and private agencies„loeal'components of the American Cancer Society; American Heart Association, andlAttteri{ can Lung Association, and citizen advocates. They were very effective. People in the field were wrdtingletters, visiting legisla- tors, talldttg;to the media, and questioning legislators whose votes allied them with cigarette companies. Excerpts from the Remarks of New York State Assemblvman Alexander (Pete) Grannis In particular, we organized 13'0'groups throughout the state thatt brought school children to,Atbany: Teachers had class projects that uaed the adolescent tobacco youth prevention bill js a civicss lesson. Legislators who would not notrtttalljy have been supporters of tobacco control legisiationwere a ittle intimidated when facedd with ateacher and 30 third grade students. The students asked their legislators to pledge to support the bill! When one legislator who had pledged his support to the children voted against the bill. a press release was sent to his district pointing out that he went against his pledge: Thatonly had to happen once. The next time around, that legislator supported!the bill right away. In addition to the effective tactics of'the coalition, we were helped by the pressures of an election year and the uncertainties gener- ated among legislators by reapporrtionmenu We were in a good position to persuade legislators to do what was right in 1992. Looking ahead in New York, we expect the governor to propose a cigarette tax increase. His focus will be on the revenue that the taxx will provide, but it will also advance the health agenda: The em- phasis on revenue will help force an issue that otherwLse miGht not find support in the state legislature. Again, I urge you in to consider recommendations ttiatare aimed not just at Gongress: You should have recommendations that ~ are targeted with as muchdirectness as possible on loeal lgovern- ments: ThatiS where we will win the fighu We can make a real difference by getting the tail big enough so that the dog,cannot ignore that itis being wagged. In closing, I would like to add ttiatyou should try using a little humor in fighting the tobacco companies. One year. t'decided to have an AprillFool's IDaypress release describing a state wide effort by school children to have cigarettes declared the official New York state poison. The release was dated April 11 and said it was not for immediate release. National Public Radio. AP. and some local newspapers used'the story anyway, Wtteni the press discovered;the storywas a joke, they, were not pleased. So :dter all the fuss, lUdid turn the proposal into albill. This issue got tlre public's attention when we used'a frivolous approach to a serimus isaue: Humor ean-e a useful tool in trying to get :t mes:eagee across. While the issues are serious, humor can provide a way to focus attention on the tobacco industry. Tobacco Use: An Americaa Crisis I t

Tobacco's Targets: . . . Msnorxtles and Women Good Morning Iadies and Gentlemen. I appreciate the opportunity to speak to you!today, particulanly,; beeause I feel so passionately on the subject before us. I have: been asked to speak to:the special'eoncems of women and mi- norities as.targets of tobacco marketing and the effects oPthis exploitation. The market targeting,of minorities and women is syfnptomatic of the cortuptii^e int7uence of the tobacco industry: This influence penetrates and demeans our nation's journalism„science, politics and economics. The corruption is pervasixe, and symbolizes that ~ which is worst in our sociaVeconomic system: The pernicious influence of the tobacco:industry; based onobsceae and perfectly legal profits, tells us somethirtg;important atwutthe moral char- acter of this country. In this country we condone an industry that addicts children and murders the elderly: We knowing(y accept, in the name ofcommerce, a business that afflicts the most vulner- able and defenseless members of our society. The continued sale of this addictiti~e, destructiue drug i5 made possible only by an extended and complex perversion of our public institutions. I would like to explore wjth~youbriefiy; how we continue to accept a product that appeals exclusively to chiidrenl that ravages minorities and women, and'yet enjoys the sanction of lawand protection of government. This conditionis nowhere betoer dem, onstrated than in its impact on minorities andwomea. There is no doubt{ despite claims to the contrary by the industry; that tobacco companies target women and minorities. fiis is done through massive media buys in targeted market areas and throughrthe creation of special brands like "Dakota," °Slims;' or .,L'ptown." In f.alifornia's central ci6es and r1frican-Amerncart communities, itlis not uncommon to find four of every five bill- boards a&ertising alrohol or cigarettes. Tobacco advertising,is the pnncipal support of a great many minority publications; Tobacco is the primary sponsor of women's sports and maga- zines, Hundreds of'millions of~dollars are spent onmarketing for tninorities andiwomen, and it is obvious to anyone who cares to look I think we can all stipulate thartargeted'marketing is centrall to maintaining cigarette sales: Why, do tobacco companies target minordties and women? Simply because these populations are the most vulnerable. They will, for a vamery, of complex: reasons, buy; a product that most adults rejecrout of hand. Remarks of California State Senator Diane E. Watson It!is important to keep in mind that while this product i's sold'tn adults, iC is iititiaued exdusively among childten. Marketing or advertising aimed at minorities and'womenis in fact aimediav minority, children and adolescent women. Smoking is a symbolic acufor the young.. It is most often associated with blue-collkr, urban, disaffected lifestyles. Itlis a symbol ofdefiance, indepert- dence, rebellion,,sophistication and a rejectionof traditional values, It is all these things becanse a $4 billion ~annttal media effort creates this image. Can~you imagine anyone who would be more responsive to such a message than disaffected, adolescent, urban minorities longing for an, independenridentity-oryputtg women caught up in the emotional turbulence of puberty and initiation into the adulr woridP Who eM lacks the education; discipline and experience neces- sary too ignore the ealCulated appeal'of smolang? In~trutli only one other population is as vulnerable to smoking's appeal as minority and female children. This is third world minonty popula- tions: Economically vulnerable, medically unsophisticated, and consciously longing for symbols of westenn sophistication, these foreignpopulations: provide the consumer stock for future com- merce in tobacco. The tobacco industry is fully conscious of who it has to sell to. and obviously,; targets both domestic minority and!female children as well'as unsoptiistieatedipopulations in South America andl.asia. There is no great secret here. This is common knowledge. It is familiar to all of us and i most of the woriti. itte ac+erage age of ' smoking initiation in the United States today is ~ 12 and a half ye•ars, This state of affairs is accepted onlybecause ofsmokittg s long history and'the pervasive corruption of'public institutions. 7fie results of this targeted marketing are predictable. Smoking rates are higher among,Afrocan-Americans than whites, quitting rates are lower, and age adjusted!smoking death rates are 12' percent higher for African-Americans. The average lung,cancer death rate for Afincan-Americans during the 1980's was moree than double that of whites. unong those of my heritage, there is a well established and disproportionate predisposition to heart disease, hypertension, and cancers of the lungs, cervix, thrroat;, blkdder andilddney. These ane the primary afsictioru resulting ftomitobacco use, and Afncatt-Amedcatts suffer disproportion- ately from every single one of these diseases.

.#mong the most vulnerable and susceptible of our citizens, to- . bacco ~is the single largest preventable cause of death in this nation. In this simple fact'i5 demonstrated the cruelest, mostt mercenary exploitation of 'childt en in the world today. Tlus ezploitation is sustaitted1by a far more extended corruption than the legallsale ofan addictive drug to innoeent, ehildren. This corruption, fueled by obscene profits, seeps into itbe very core of'~ our society: This corruption afflicts our government, institutions„ our community leadership, our commerce, our science and our journalism. Tobacco profits finance the co•option, of leadership within minor- ity commtutities. Millions of dollars annually are spent, to support legitimate and committed minority setvice organizations. This money buys tobacco the silent approval of many in the minority community. My office has seen tobacco memos, for example, which compared minority recipients of tobacco dollars, and the relative valite these organizations provided in the fight against California's tobacco tax. The influence of toba,cco eontributions to public officialk is well- known and widely documented. In California„where we have seriously threatened tobacco interests, we enjoythe dubious disstitttctioniof ltavittg thesingle largest individttal recipient off tobacco political contributions. One hundred and'nine of 120 California legislators receive tobacco contributions. For 15'years, this pernicious influence prevented!any significant restriction on tobacco use: For 20 years, this influence prevented anysignibcanr federal interference in tobacco consumption. This influence perverts a critical purpose of democratic gpvernment Govern- ment, is intended to protect those unable to defend themselves--- yet our, government tia* twisted this responsibility to protect the weak into tax breaks and subsidies and legal shelter for this lethall industry. The pattern of perverting the purpose of public institutions is repeated in journalism, eotnmeree and science. Several long-term studies have found a direct, negative, correla- tion between a publication's tobacco advertising revenues and coverage of.tobacca stories. During Califorttia's aggressive and: tobaccamedia advertising campaign, numerous outdoor and television advertisers refused to sell us space or time. They feared! retaliation of tobacco eompany subsidiary, advertisers. Tobacco: advertising revenue is able, on occasion, to control journalLsticc editorial!policy. Tde indttstry makes a speciafeffort to silence minority publications. Tn'btisittess, the profits of selling death to children overcomes any hesitation an investor mayfeel in helping to killthousattds. Selling cancer to third world populations is °jusrbusiness." The single most widely held'stock among institutional investors in this coun+ try is Phillip Morris. Iast'year, TYmia magazine named R:J. -- -- Reynold.s the best managed company in the ttation, Busittess claims not to make moral judgments-only business decisions. But the investors, retailers, growers, shippers and advertisers who profit~from tobaceo give moral sanction~to the avoidable death ofi thousands. The corruptive inIluence of tobacco and tobacco profits on sci- ence has gone on for a long time:llThe tobacco industry subsidizes dozens of "scientists" to grind out sympathetic studies, confusing, intetpretations;,and misleading conclusions. WhDe such studies enjoy no credibility, the industry has been icapable of disputing or preventing legitimate research on the effects of tobacco usage. k single state, California, now produces more tobacco related' research than the National Institute of Health and all majorfoun- dations combined. This means that until California.s public acted, diseases which kill 400,000 people every year received hardly any attention. These circumstances represent a profound moral failure. The influence of the tobacco industry and its corruption of our public and community institutions is tragic. We condone the addiction of chlldren and death of the elderly. Government and community leaders surrender their: integrity out of avarice and our national character turns.a:tidy profit selling legal dope to the poorest andmostdefettseless people on earth. It is easy to condemn an industry which cripples our population. Itis convenientto don a holier-than-thou attitude and!as:sume a superior attitude. Butithe blame for this circumstance falls on all of'us. It falls on the minorirycommunity for not demanding change. It falls on mycolleagues in public office who turn a deaf ear to demands for change. It falls on a business community which makes tobacco available and on our media and scientific communities who allow themselves to be used!for the monetary gaini of others:. I realize this is a sweeping condemnation. But some shock is necessary. Tobacco is such a familiar, accepted a®iction~thac we tend to forget its fearsome toll. We cannorundo the insidious and sophisticated'frattdlof generations without bold strokes: Despite this depresssing assessment, I belleve tobaeco~ase will continue to diminish in this eountry and!worldivide. The EPA's reeenneonfirmation ofthe harmful effects of second-hand smoke should unleash ~a haii lof liability claims in workplaces and public places aeross this country. F'-trtally; tobacco users tnay have to take responsibility for at least the injury they do others. In California, we have tripled the quit rate of the general public t}irough counter advertisirtg: In this Nation's cities, tobacco ase among minoriry,children has been cut in lialf; due principally to new social attitudes. We need to recognize the culpability of our social and economic institutions. We need'to hinder the practice of smoking at every turn, and we must never stop. Tobacco 1Jse: An Ainerican CriSis 113, 1

Ch alenges in Tobacco' Control Good afternoon ladies and gentlemen„colleagues,,and distin- guished guests. It is an honor to jpiit you-our eountry's top leaders in the to- bacco control movement-at this important and compelling conference. So much has happened since we last carne together at,our 1989: meeting. Because of our hard'work, we are enjoying'tnany'suc- cesses-thanks in large part, to your leadership, your vision of a healthier society; and your success in fostering,an atmosphere of collaboration and cooperaflon. Tfiis conference couldn't bave eome at a better, more opptarttute time. Whatzw}tirlwind week we have jtt.st had-a week, I assure you, that the tobacco indusrrywill not easily~forget! All of us have ~gained''a,ttremendbus;, renewed sense of confidence and!vigor by EPA's long-a+waited'endotsement: an endorsement that showed that exposure to secondhand tobac co smoke does, indeedi causes lung cancer inimmn-smoking,adults and greatly inctease of risk of respiratory, illnesses in ctlildren. It's about;time the public knew the facts and risks,,and under- stood the severe conseqttences, But most impottantly;,it aPU also about time that our government shared its concern with its citizens. The CDC's public information campaign launchediThucsd7yto: inform Americans ofthe dangers of secottdliand tobacco smoke is also a majprstep in getvng the public to think, precisely, along, these !}nes. Ttieir campaign action guide;,,'It's time to Stop Being a~Passive Y,*Lctim;"'puts prevenGon in the hands of the indi~~- vidual--where it truly belongs. Your presence here, under one roof,' during this exciting time ofi opportunities just waiting to be tapped--is very, significant, in- deed. It sends apowerful message to the industryp loud and clear, that we have had enough of the smoke and mirrors, enough of the mombo jumbo, enough of the relentless distortion of facxs into Gction. We are here, we are prepared, we mean business, and we are noqoing to take.ivanymore. As Surgeon General, the issues that lie at the heart of tobacco control'are of great concern to me-those thatpertaia to tobacco ur,e by our yputh;,the increaseinusre by womenr-pardcularby Keynote Speech Antonia C. Yovello, MD, MPH Surgeon General (;S Public Health Service young women-and the targeting of women,,childrM and mi- noritygroups by ttie industry. I have ahvays devoted a latge portion of myagRnda to.opening,the eyes of those who tnay not yet see the real hazards and risks of tobacco use. Andii assure you, as long as I am Surgeon General,l urill not Jet up: not when so much more remains to be done. Because i~feelso strong(y about ~thia subject,itii5 especia!!yre- warding to see the soiidarityshown by the presence of so many cosponsors at this conference. What'a tremendotu line ot hardhitters we have here: • '11he:AmericanfMedicalAssociation; • The Centers for Disease Control (pSH);. • The City of Hope National Medical Genter, • The Qoalition on Smoking;OR'f9ealth--madee up of the American Cancer Society, American Heart Association, and ,Anerican f.ung,Association; • The Memorial Sloan-KetteringCancerCenter;;and • The University of Texas M.D. Anderson Cancer Center:. I know that in these few critical days, we will all have a chance to renew old ties; build new relationships, and develop an even stronger proactive stance to achieve a great deal more in~the coming years. Most importantly; I hope that we cut through our respective disciplines and experiences with a sharply boned; common goal: to come away from this conference with a struegic plan of action that is iilspiPed,~ yet I£3llstic.' We are in need of a plan of action that;can,diamatically save the lives of millions of Americans--especially our youtto--by helpmg them make informed'deeisions to avoid the risks and hazards of tobacco use. We ane in need of a plan of action tbat ean speak for our younger childrett-who have rrosay and no choice regarding'exposure to, secondhand smoke -wtiose resulting health problems, ranging fmm watery eyes and rttnny rtoses to asthma and pneumonia, are not for them to inhemt-~e of an aduk's pleasure:

Let me tell you what stands out most in mymind as we cut throu gh talk and' get down to aetioo-as we really spell out what we all can do to make our goals a reality. The Chalienges Ahead I call them the.Surgeon~General's ten challenges for tobacco control„because eolleagues, the time to act is nour,,there is a generation at risk. Challenge 1 The first challenge is to use ourvoice clearly, collectively, and assertively. Let's speak in one voice to broadcast our messages loud atid clear. Messages thavsav • Smoking is the single most ~ preventable cause of death in our society -and it is costing this Nation pienty-52 billion do lars ; per year, a billion dollars per week. •'fiat tobaeeo is the only prodtict tliatwhen used'as directed- results in death ~and disability. • That it is never too late to qtd • And that prevention does, indeed,,work! But we must all get involved and1work together to prevent this needless loss of'httman life. LeCs remind the public tharwe're talking about something quite devastating: tbe prema,ttrre deat,Bs of f nearly one iralf million people euery year in this country alone. 'Dltat! s tantamount to wiping out the population of! Boston in one year, Seattle the next; vashvilleADavidson the nexq and El Paso the year after that - Or,,put another way~ the annual number of premature deaths due to smoking is equal to three fttlly-loadedijEtmbo jets crashing andi killing everyoneon boaad every single day of the year! Think about itl Half a million needless deaths -and all of them preventable. Challenge 2 The second challenge is to expose the saeductionof our children by the tobacco industry-and to work proactively to counter their effective message and techniqpes. After all; the tobacco industrti must replenish the halfmillion smokers who.die each year from smoking-reiated disease and the one million wfio quit. What beuer replacement than those;with young, impressionable minds? The sobering facts eonceming tobacco and youth speak for them- selves:: • In the US every year, over one million children start to smoke: • What this means is that ttationally, each day, 3,UC10'young'people become regular smokets-roughly equivalent to the entire student bodies of about 4 average-size middle schools all stuntirtg to smoke, each and every day. We know thazi • Ten percent of these smokers begin smoking by the fourth grade, and by the 10th grade, nearly two-thibd+ have initiatedd smoking. •:1ttd. 90 percent of smokers begin smoking before the age of 21-7.5 percentdo so before 18; the legal age to purcha.se to- bacco in mostStates. And by the time they realize it, 90 percent are hooked on nicotine: • We estimate that if 20 million of the 70 million children now living in the U.S: wiIl smoke cigarettes as adults-at least 5 ~ mil- lion of them will die of smoking-related diseases. We know from years of research that the majority oflehildren who smoke are from homes where one or both parents smoke: And that the earlier they starrsmoking, the greater theit risk of lung cancer, heart disease; chronic lUttg disease, and a wide range of other smoking-related!health conditions. • We also know thatthree in four teenagers who smoke make at least one attempt to quit-but are unsuceessfu!-underscorittg, the powerful addiction of 'nicotine. • Nevertheless, the tobacco inditstry spends a staggering E4. billion each year onicigarette advertising and promotion. And each,year, the tobacco indtrstrygarners,b22'P million in profits from illegal sales of'tobacco to children. And each year, the inditstry tells us that they advertise only to promote brand lovaltv! We know better. We know that cigarette marketing takes on a wide variety of activities and distribution of goods that appeal to our kids. Youth-0riented events, displays ausporting eventt: and the distribution of~promotional items such as T-shirrts, posters, and caps--these are typicallof such marketing schemes alll around the country. I am deeply concerned that many young people are lured to these actrviues and start smoking and using tobacco as a result of the.tiee aggressive marketing ploys:. As a Nation; I believe we are not doing our part in tobacco control' by failing to insist that the tobacco indttstry become more soctallv responsible. I recognize the power of a free market and the importance (if advertising to make suchaimarket operate successfully. IloweverI when advertisements portray a dangerous habit like smoking :rs an exciting, youttiftti, and'healthy activiry, suchadverti_sementa do not honestly represent the real.life consequences of tobacco. ~ ~. ~ h d d l b l d uate t istri e, an a vertisement, We must then reeva e ution„sa of such products ifwe are indeed to protect the public, especially ~ the health of our children. CD The "seduction of'childrert" by advertising,will always remain a0) ~,~ hotly contt oversial issue-but we cannot let that intimidatc us or W halt our'pr~ogress in developing,effective preventionprogcunsn or~ l'V in speaking our minds. kfter all, the First Amendment w;is cre:uedAi ' for all Americarts.. Tobacco Use: AhAmerican Crisis 15

Gast year„as rott know; I joined!mycolleagues at the American HedicalAssaciation in calling forRJl Reynolds Tobacco Company to voluntarily with&zwits Joe Camel advertising campaign-a campaign that shamelesstyappeals to children through the use of one of the most widetv recognizedI earrnoon characters among, y,oungchiidren today. [f the tobacco industry really wanted to be responsible in its adxertising,practices, it would voluntarily have taken steps to limit such advertisements among yottng people. It woutd'tiave played a truly supportive role in helping to educate our youth about the dangers of tobacco. But itiese are only pipe dreams. Because the bottomdtne is,,that, forthe tobacco indttstry; profit speaks louder than ethics. Colleagues, our bottom line is this: we have had enough irre- sponsibility and hypocrisy. Enough of tiiding;thetruth behind a lot of smoke and mirrors. • We absolutely canm letthe tobacco industry continue to target our ehildren with false messages aegarding smoking. • We absolutelycannot let the industry dictate who the next . smoker will be. • We absoluteiy cannot let the tobacco industry continue to put their profit agenda ahead of'our Healthy People 2000 agenda. We know betier ... and we must act, NOW: Challenge 3 The third challenge is to speak out against the seduction of women by the tobaceo,industry and-develop effective prevention messages to counter tbe,industry's misleading enticements. To the average Mterican, the slogan '~you've come a long way baby"is just an advertising ploy, but to those concerned aboutthe dangers of:tobacco, the meaning is more serious and goes much deeper than that: The women of tliis country are continuously being exposed to numerous advertising messages that subtly encourage them to begin a lifelong, often deadly addiction to smoking-an addiction that was not present in US women prior to 1900. Today, in this cottntrythere are 22 million~women smokers, I would say thaYs.a pretty big special interest marketi Women's magazines are flooded with ads for tobacco products, while very littlp coverage is given to the dangers and negatir!e consequences of smoking. Unfortunately, the so-called enticing "benefits"'of tobacco products-evetything from,a glamorous soeial' life to weight loss-have very little to do with the reahGfe consequences: cancer of the lung, cancer of'the cervix, and cancer of the bladder -notto mention wrinkles, premature aging, and ulcer aggravation. As a result of this widespread, seductive courting by the tobacco, industry, lung cancer deaths in women have surpassed deaths caused by breast cancer. • About 46,000 women die from breast cancer every year, while. 53:oW women areestimated'to have died from lung eancer in 199,7--equivalent to the entire student body of Ohio State, or the combined number of employees in the Depanmentof Health utd the Department of Justice in the Washington.VfetrQpolitan area. Wotnenwho smoke are also at a higher risk for cancer of the uterine cervix than women who do not smoke, not to mention the short- and long-term consequences of'low birth weight in tlleir children. (Maternai smoking accounts for 3,500 infartt deaths each Pear.); In addition, women who smoke cigarettes and!use oral contra- ceptives are 10 times more likely to suffer heart attacks; com- pared with those who do not use either~ produa Something else that worries me tremendbusly is that more and more young tuomen are beginning to smoke-in Fact,,cigdrette smoking prevalence among adolescents is about equal for both males and females---between 18 and 19 pertent And the smoking prevalence rates among adult women are pre- dicted to-eventually reach,those of adulumen. It may be a harsh sentence, but women who smoke like men are predestined todle like men. We owe it to all the women in our lives to see to it that Virginia Slims women do not follow in the tragic steps oflthe Marlboro man-butdowna path that will'lead to greater health and fulfill- ment Challenge 4 The fourth ehallrjnge,is to spur federal, State and local legislative action for tobaeco eontrol that will have meaningful, long-lasting impacts, We cannot remind the public oiten~enougli that the sale of'tobacco to~those underthe ageof 18 is iDegalitt 47 States- and t„for one, would love to see that number go to :50:-but most importantly, enforced! Let;me remittd!you of the facts about minors' access: • Each year,,more than three million ,tmerican children under the age of ll8 eonsume 947 million packs of cigarettes. So, when I say tivhere there's smoke -dtene's chiidrem"I'm dead serious! • A reeentstudy by CDC found that there are currently 2.6 million youths 12-17 years of'a$e who smoke-t.5 million of1whom usually buytbceir own cigarettes. ~ • Eighty-five percent of youth.s 12-i7'years of age buy cigarettes at ~ ~ ~ convenience stores and gas stations, 50 percent buy cigarettes from large stores, and 15 percent buy cigarettes from vendinG machines. ~ ~ In short,,our children can purchase tobacco praetically wherever, andiwheneverthey want-many local jurisdiaions realize this and want to do something about iL A new reporp,YoutbAccesrto To~co, prepared by the ofTice of the Inspector General, found that all'but three States ban thc sale of tobacco to minors under the age of 18, but in many State~ there ,/

is a serious problem of enforcing the laws. In fact only two States;-Florida and Veronont'---are actively enforcing thei minors' access to tobacco laws statewide! A new Federal law, the ADA,tit1Ly Reorganization,#ct, will assist inn curbing tobacco sales to minors if properly enforced by the States. The new lawwill reqpise States to ban the sale and distn- butioniof tobacco to anyone under the age of 18 bydDctober 1,. 1994:. In response to this problem. The Department of Health and'Wu- man Services developed a model bill'two years ago to encourage the active enforcement of strong laws against, selling,and promot< ing tobacco products to youth-and urged the Governor of every State to adopt it. Colleagues, my true concern is that that we siinpiy cannot have a double standard for alcohol anditobacco-two of the most addic- tive drugs available in our society. The public and the policy- makers alike must come to view the sale of tobacco to minors as critically as the sale of alcohol!or other haaardous substances. States must take a more active lead in requi nng identification wheniselling tobacco to minors. And responsible businesses: all'stores and all other ret$il'outlets that sell tobacco should'vbluntaruly aet'and prohibitisales of' tobacco to tninors--whether or not there is a law, whether or nott the laws are being enforced We simplycannorafford to lose ground in these areas.lPe must become partners with legislators, policymakers; and'other State and local officials to ensure that the "long arm of the law" does, indeed, reach out, swifily;,and consistently; to prevent ouryoung, people from beginning a lifetime of addiction. Challenge 5 The Fifth challenge concerns dte dkttgers of environmental toa bacco smoke (ETS);,more commonly {atown~as a secondhand or passive smoke: As the press events of the last week have conveyed, we must continue to bring the facts about the dangers of second- hand smoke to the attention~of the public. Seventy-five percent of our citizens don't smoke-they should not have to endure the consequences of the smoke of others. We must help make that a reality: EPA's designation of E1'S as a GtoupA human carcinogen will be the catalyst for strengthening regulations to protect the public's health bycontrolling smoking in public places. Above all, let us not forgevthe healthha7ards of'ETS'on our chi1- dben--our most valuable, yeuour most vulnerable. last week's dramatic developments must galvanize all of us in the health community to spread the word far and wide-to our patients, our families, our sctiools„businesses-and!throughout our community: the consequences of secondband smoke affect usall. Now, more than ever; let us not remain second-band victims• but become the sure victors--tbrougb foist band Pnetaention. Challenge 6 The sLxttt challenge has to do with addressing another serious problemthat threatens the health and well'' being of,our yrnuth- the widespread'use of smokeless or "spiC"tobacco. In recentyears we have witnesses an upward trend in young, people who begin to use tobacco in a different way. But tobacco is tobacco is tobaccn-rto matter if you chew it, smoke it; or spit it. I am deeply concerned by the attempts of the spit tobacco indtts- try to downplay the health hazards posed by this type of tobacco. iastmonth I released twospecialirepor2s, one prepared for me bvy the EHHS Office of the Inspector General and the other from the National Cancer Institute. The reports contain some alarming; conclusions about the use of smokeless;tobacco by American youth. We found that: • In recent years;,the use of'spit tobacco by our young people has rapidly climbed!to very high levels, with youngsters' use of "moist snuff"tripling in five years. The spit tobacco indu.stry spends nearly half of its 100 million~advertising budget onpromotiorts and sponsorship of this ptoduct. • In some areas, the use of spit tobacco is well establishedihv kindergarten! • Conttury to what manywould have us believe,,spittob:tcco use by our young,people.is norconfined to only one region or popula- tion group. It, is not a Southernproblem, or a white male prob- lem-it is an American problem! • In 199 1, about 7 mi.llion persons 12'years of age and over used spit tobacco in~the U.S.-the tnajorityof ihem; young males- who most Wtely do not understand that spit tobacco is NDT'a safe alternative to cigarettes-despite our warnings. Spit tobacco is as addictive as cigarettes-after, all, nicotine is nicotine. In the short terrn, spit tobacco : eauses serious health effects. Leukoplakia, gum recession, tooth loss,,coronary arteiy disease, and total touicity for pregnant women,,are all short term consequences. In the long term, spit tobacco can be deadly. There is a definite relationship between prolonged spit tobacco use and oral cancer. About75'percent oforal;and phatyngeal cancers are attributed to smoked and spit tobacco. Sadly, the relative surviVaf ratesfor these cancers are among the lowest of the majpr eancerc; 1fie majority of our experts predict an oral cancer epidemic beginning two to three decades from now if the current trends in spit tobaceo use contintNe. Leume remind you that this is an epidemic in which our children will be the victima:. Tobacco Use: An American Crsrsis 17

Challenge 7 The seventh challenge is to develop our strategies andiaction plans in close coordinarion with the;Department of Health and Human Services' Year 2000 Objectives. These objectives give us a blueprint, or roadmap,,if you will, of what direction-as ajYation, State;,or community-we must take to improve the health and wellbeing of our soeiety:. To the degree we use these objectives as a tallyittg point in our tobacco control efforts, we will be more focused and!eohesive. For example, one of the key, objectives of~the Year 2000 Report is to remove the appeal that tobacco advertising has upon young, people. .A.s you know, for years now, ads for cigarettes and smokeless tobacco have been banned on television and radio. In addition, a number ofsports facilities nationwide regulate tobacco advertise- ments. However, as I have mentioned, thepublic--particufarly childten;,are still exposed to tobacco images and advertisementss everywhere. Let's take the Objectives to;hearrt---by continuing to build,coali- tions and partnerships at the local, State and federal level+ that are dedicated to restricting or eliminatingiobacco promotions to underage youth. .And let me reiterate that to protect children fcom beeom9ng regular smokers, we must strive, not only to enact minors~ accesss laws in all 50 States prohibiting the sale of tobacco products to- minots;,but to see to it that the laws must be enforced to be of any value: In addition, we musrcontinue to speak out to ensure that our children receive tobacco and health education and prevention as pa.rt of their routine health,and classroom curriculutn: They must understand both the serious health risks and the addictive nature of smoking and.tobaeco use. And they must become more savvy to advertising ploys. Similarlj+; we must ensure that our children have positive and visible role models, and that school!boards in every Statemust adopt nonsmoking policies for students and school staff alike:. Af'ter all, what, message does a, student receive when she sees her health teacher smoking openly outside in the schoolyard? We have a long way to go here. In 1990, less than half of the Nation's students attended smokefree schools; and less than half of our s condary schools were offering activities in tobacco-use prevention, In order to achieve a smokefree society, a11,States must have plans to reduce tobacco use;,especially among youth. In 1990, onfy 22 states had specific plans for preventing and controlling tobacco use. We absolutelv need more. Challenge 8' The next challenge has a lot to do with the waywe health profes= sionals do our work and how we contribute by virtue of our respective distaplines. Challenge 8 is the challenge of'helping to assess, document, and change socieWs attitudes and practices with regard to tobacco tcse-especially where our childrett our concerned.. Forwhether we like itor not, our chifdrenare susceptible to the allure of smoking. Uilee it or not: • Ten years from now, we will have an addicted generation. • Twenty years from now; we willlfaee an epidemic of lUng can- cer, bladder cancer, chronic lung disease, ischemic heart distrase: complications of pregnaney, low biirth weig6t; and as,a conse- quence -an increase in lurfant mortality:. • Thirty years ftiom~now-and thereafter-if'we do not startt prevention today, we will confront a social and economie healtti care burden whose upward trajectory will be impossible to after: In light of;these predictions, we need more accurate data more ways to disseminate that, information, and more ways to reach those at greatest, risk. Above all, we must improve our ability tocollecuinformaGon on morbidity andimortality. Information that is comprehensive:. gender-speci6c, culturally-specific, responsible, and responsive. Equally important, we must examine and evaluate information on the economics of,tfie tobacco indu.stm :~ as to understand'the pervasive role that tobacco plays in our Nation's economy, We must aLso gain,a better understanding of the tools that ane available to use to counteract smoking; legislation, taxation, and individual andlpublic health education aimediat, altering social norms and attitudes. Knowledge is indeed power. If we trulijwisti to help others take control of their lives, we must continue to empower ourselvcs with new knowledge. Challenge 9 The ninth challenge has to do with strengthening the resources,we have and!finding additional resources we need,-to,succeed in our mission to control tobacco. We mighrnot have resources equal to the industry; but what we do have on our side. is the tbutH-backed by scientific integrity. Conferences such as.this are essential to tapping the knowledge and expertise of professionals from many disciplines. They give us a chance to gain new insights and perspectives, share lessons learned, galvanize leadership, and plunge ahead with greater momentum: During these next few days;l urge you to listen carefully to one another. And do, by, all means, bring, noronlyyour intellect to these discussions, but your passion, imagination, atd creativity: Wlthout these essential.t, our best Lvd'plans with have no empa- thy, and our solutions will have no depth. In finding,trsources, let's remember, too, thatlong.-lasting part+ nerships come about,in the least expeeted!ways: from the le:cst

expected soutxes< We have learnedmuch, in prevention, about the value of public/private partnerh.cips. And those lessions can certainly be applied to alliances and col- laborations among our many varied disciplines and callings. Let's make jra point to findicommon ground with other profes- sionaLk who have expertise in their, areas of competence; at least equal to our own: teachers, nurses, technicians, engineers, phar- macists; adtninistrators„police, lawyers; ludges, legislators, public official5--andiyes, even Congress. In addition, let's now forget the value andthe clout of public opinion. 7kteir, sincere sentiments and loud, vocal stances can bolster our cause and move mountains --mountains of tobacco, alcohol, or anythingelse for that matt8r! Challenge 10 And now, for my tenth and final challenge. Let's make personal involvement our watchwords-both in preventionand control. There is an infinite amount of room on the pulpit for those who- are enough to make a difference. We know the devastating consequences that~tobacco causes in our society. We know the shocking tolls of disease and death that tobacco causes. And we know the practices of the tobacco indus- try to promote this doadl~producx. I think the time has come for us to insist that-the tobacco industry be operatedlas responsibly as-any other manufacturer of con- sumer products in this country. ObviouslV; takirig onte matter of tobacco advertising and pro- motion has noubeen a traditional role of physicians and other, health professionals: t8owever,,it is so closely related to tobacco consumption that it ia iittppssible to separate the two issues. Physicians and other health professionals must become the chain- pions of prevention, increasing public awareness of the issttes,; and promoting public action to counuer the industry's daily on- slaughts. Our next generation depends on what we do now, and how well we play, this game. Conclusion Imdosing; I believe thatwe have indeed come alongway! •Who wouldihave believed-44 }earsaga-that the 1492Olym- pics in Barcelona would be smoke free? • TtiatAustralia would jpin other countries and approve aban on advertisement and promotion of tobacco products? • That the WorldBanic decided that no further loans would be made for the production of tobacco? • That smoking, chewing, and snuffing would be banned 'ua Colb- nialWilliamsburg; Yirginia-a society portrayed as being builron tobacco trade? •'[7iaGpassiMe tobacco smoke would be designated as a human rarcinogen? Yes, we have come along way. Victories are oecunring in this country, and!in countries at every level oftobacco control sophis- flcarion. Concerning how far we have come;itwould norbe presumptuous for me to say, that when tliere's srnoke--tGere's pnevention: Colleagues; as we continue to work together in, the explosive new millennium ahead, we must learn from our mistakes and cel- ebrate our successes, no matter how small. I gugrantee ttiat success will build if we persist Burin the face of success, let's not become complacent. We must remain forever vigilant in the future,,women and childt+en will be the l9rgest targets for the tobacco companies-the trouble is, the futureis already here! We must work even harder to let the tobacco industry kno>v that as long as we are around, the industry will not decide who the nezt smokera will be. Thank you- Tobacco Use: An Amenican Crisis 119

Report on the Tobacco Industry's Impact on Agriculture and Heal& Care Policies Yothing has united Kentucky politicians in the past as solidly as their uneqpivocalsupporrfortobacco: Republicans and Detno= crats, conservatives and liberals, tural Kentuckians and,ttieir urban counterparts--these men and women, have been united in their 8ght for the rights of smokers: They argue against laws limiting cliildren's easy,aceess to cigarettes; they decry tobacco excise taxes (which are the second lowest in the country). In Kentucky; politicians who can agree on nothing else agree to support tobacco. Tobacco has profoundly ~ impacted Kentucky;,especialiy, inthe areas of public health and agriculture policy. Few states have a higher percentage of smokers; It has the highest per, capits~eon- sumption of cigarettes and, notsurprisingly; the highest death rate associated with tobacco. tt has the highest percentage of smokers in the 18-34 year-old age group, dite in pan to the implicit mes- sage of political and business leaders that smoking is "politicalty, correcd' in Kentucky. These new, young smokers begin smoking despite health education; frightening medical evidence-and' probably, the tobacco-related death of a close friend or relative. The effect of tobacco is also felt by Kentucky's farmers. As the number one cash crop, burley tobacco will be worth more than $890 million to approadmately 6Q;000 burley growers. Tobacco manufacturing and~processing are major employers throughout the state. Kentuckians were exposed recently to two stark reminders of: their state's pro-tobacco message. First, the Council for Burfey. Tobacco paid for numerous billboards delivering the messagee that tobacco pays fon college tuition, nice homes,,and a higher standard of'living,for the people of our communities. There was nothing,subde about the implication that;,without tobacco, Ken+ tuckians would lose "the gqod'life." The second remin&r came from (I. S. Senator Wendell Ford, the. Senate's Democratic Whip, who-campaigned across Kentucky last year with the boast that he has smoked for 50 years without harm. In most states, politicians no longer smoke in public. They have either kicked the habit or smoke only in private. In Kentucky, however, many politicall leaders smoke publiciy„ believutg il will impro!+e their image=and their margin of victory at the polls. The economic dependence on tobacco makes it difficult to pass any tobacco-health care legislation. The tobacco companies and the firn organizations with which they, work promote the idea Kentucky State Representative Anne Meagher Northup that any youth access bill, any increase in taxes, or any clean air measure will cause the price and~demand for raw tobacco to: decrease. Berwse the survival of so; many Kentucky farmers- depends on tobacco, the political strategy of establishing an inverse relationship between health legislation ~and tobacco mar~ kets is very effective. While estabi;shing the perception that health legislation wilt hurt the tobacco darmer may make good political sett,se, for the indus- try, it is counterproductive to understanding what has really effected the dhtnand for tobacco. Continuedlsmoking by Kentuck- ians cannot offset the national decline in the use of'tobacco prod- ucts. In,fact if'every Kentuckian were taugbt to smoke in the sixth grade and beeame a lifelong smoker, it is unlikely that the pros- perity,of the tobacco farmer would improve. On the othertiand, if every Kentuckian quit smoki:ng;tomarrrow;,thene would hartlly be a measurable decline in demand or price for raw tobacco be+ cause Kentueky smokers!do not create the demand for tobacco. and the tobacco industry knows that Even if Kentacky smokers could sustain the demand for tobacco, it is importantrto state emphatically that economic prosperitv does not jttstify,the promotion of tobacco products;,regardless of thee effect on farmers. In this country, tue do not necogniie death as a fair excbangoe for prosperity or a higher starrdard ,of liuing. At the expense of the Tobacco Institute, Price Waterhouse eon- ducYed a study which concluded that the tobacco industry pro- vides 8oo.Opo jobs (including producti.w advertising, distribution. andlegal services). The Center for Disease Control states that approximate~ 400,000 smokers die each year as a result of their habit. This means one person musrdie each year to sustain~tuo jobs. Put anotlter way, 22 people must die to support the 44:year career of a Philip Monris employee. Surely, no one would argue that this is an acceptable trade-off. It is absurd for the tobacco industry to use lost jobs as a rationale for not saving Gves. Wliiie health legislation has to be our primary otijective; the poiiti- eal leaders in Kentuckv should be much more concerned about the future of'tlie tobaceo.farmer. In the last Presidential aunlr.tign. much was said about "family values." However "familyvalue+" is defined,,ourfarm families epitomize the besti They are hard- working, they are self motivated; and they are self=suflicicnt. Tiuy, are not looking for governmenuhandouts. Seeing them ~surNin•e and 20

prosper should be a concern to us all, and an aggressive state and federal agriculture policv should reflect that concern. Unfortunately;,most politicians from Kentucky, have used their dout to blindl~ back the tobacco industry`s agenda instead of trul?r helping the tobacco farmer. Their gamble is that if the for- tunes of the industry are goodi then the farmers will also prosper. This is a rather errant assumption considering the difference in the current fortunes, The tobacco industry is experiencing rapid growth in sales and profits, while the tobacco farmers have to pray for a couple of pennies' annual increase in the price for a pound of tobacco. It:is worth noting that while Kentuckys burley tobacco farmers are struggling to survive;,the retiring Chairman of the Board of Philip'Vlorris took:home a whopping E26million bonus. As the demand for tobacco products changes, the tobacco compa- nies have the besttninds moneycan,btty to strategically prepare them for the future. From all indications, that ~ future does not inctude the majority of our tobacco farmers, What minds do the farmers have strategir,ing for their futtue? Most farmers are beginning,to realize thatthe strength of tbdays tobacco market is a result of the overseas market As the national demand for cigarettes declined„the domestic tobacco industry began diversifying. The national companies purchased food processing and distributing companies to replace lost tobacco business. While these ventures were-and!are--compatible wi6 tobacco, they ane far less profitable. Iniorder todevelopnew tobacco markets, the industry expanded overseas. The international emphasis on free trade eliminated many obstaele.s to these markets, especially in communist block and the Pacific-rim countries whose populations are fascinated' with emulating American culture. While smoking was common- piace in, these countties, it previously had not been glamorized through advertising. Ini these countries, adult men dominated the purchasing,market; even though they consumed much less than American smokers, The U.S. trade negotiators have been committed to opening,these overseas markets. it has been correctlyassumed by many Ameri, cans that this has been accomplished by lower tarafs, but the success is largely due to negotiations that have eliminated the ban on advertising: Overseas audiences are now seeing for the first time advertisements thatlink smoking to young;,active lives. While the moralimplications oPthis trade policy and industryinitiatives are staggering, the foeus of this article is:; What does this trade policy mean for our farmers? tn order to open the overseas tobacco opportunities, our trade negotiators had to overcome stiff opposition,to the elimination of the advertising bans. In fact„in some instances the UnitedStates threatened the most extreme measures possible (301i sanctions) in order to force countries to acquiesce to these demands. In some countries, concessions to our tobacco industry tequired tradeoffs by the United States in other agriculture commodities. Thus; we kicked in the door for tobacco butebsed iton other opportunities such as meat products and corn. It can be reasonablt assumed that this tradp-off'is a direct rcsult~ of the political pressore that exists in Washington. Recent reponss show that the tobacco industry is one:of the highest contributors to both Congressiotrai and Presidential campaigns. Furnhermore, by conveying to tobr.ao farmers that their futures are intrinsically linked to the C,ongressional delegations''commitment to tolrucco, the indtutry insures. that these politicians from tobacco states do their bidding,in order to be re-elected. It'is easier for senators and representatives to go along with the tobacco industry than ~to independently eomince the farmer that some of the industry's priorities are contrar,v to his best interest- Unforrtunatety, these new overseas markets do not mean~that Americanfarrrtetsnr production workers have new; long-ringe markets for tobacco. The industry has been very consistent in its reaction to these new trade opportunities: With great speed, the industry built new plants, purchased existing;plants„or fonned joint venture vvlth overseas companies. They have outfitted these faalities with state,of-'tlie-artequipmenrand are prepared to ~ manufacture °Mmericart', cigarettes in the overseas backyards of' their new eustomers. The industry has insested millions to find new sources for high qualityj lower crost tobacco. Since tobacco farming is heavily labor intensive, American tobacco farmers cannot possiblymatah the price of high qttaiity tobacco from Brazil, Argentina, or b4exico, ln U991, the average price paid for Kentucky~grown burley wa+:. $1.75' per pound, while Argentinean burley of similar quality was purchased for $0.46 per pound The pattern of the tobacco com- panies' investmems leads us to believe that they intend to supplv their ever-expand'mg cigarette markets and new customers with tobacco grown ot>cside the United States. It is ironic that the United States ignored'moraliinhibitions and used its trade clout to open foreign markets for companies whose strategies will not benefiUAmerican tobacco farmers or production workers. In the short run, these new foreign markets have provided Ken- tucky tobacco farmers with awirtdow of opportunity. Untit'over- seas production cotdd meet demand, our farmers enjoyed new and higher quotas that exceeded their ability to grow. The price rose steadily, giving,our farmers a false sense of security. Now th:m window is about to close. The quota that each farmer can l;row will'be reduced bv 10 percent--the maximum drop allowed- next year. After 1993, there is no limin on how much it can be reduced eachyeat: Many predict that;itwill fall 50% in three to I'rve years: Furthermore;,as more foreign tobacco is importctil, ~ there will be less pressure on the inditsuy to raise the bid price ~ each,y~ear. J'J! , Tobacco farmers have been told by the industry for years that Nz~l foreiga leafs could'inot match Kentucky quality. For that rr.uon: }.1 the recent expansion in the market has encouraged farmers to (~ invest in new barns, equipment, and a larger tobacco b.a.ce: t6y Q1 failing to warn these farmers of the precarious future of tobacco,w the indttstty and supporrtive politieallr'aders have allowed such, ~ investments to further jeopardize our farmers. Tobacco Use: An.9meri+can Crisis 21.

Kentucky, is full of'leaders that excuse their failure to develop any ~iable alternatives by claiining that there is no other crop rthatcan replace totiacco.incomey--which is currentlytrue. It will continue to be true if'no new initiatives are begun. Our very, inaction in- sures that there will continue to be an absence ofviable alterna, tiNes. Make no mistake: The rocky, hilly terrain andlthe small siz!e of many tobacco farms make it especiallydif6cult to develop alternatives, It is frustrating tha[it is the verypepple who repre- sent farmers--the same ones who aeras though the situation iss hopeless-who are failing to address the issue with any foresigf tt Since the fortunes of the tobacco industry and the fortunes of the tobacco farmers are no longer the same;,it is time to ask the leaders in Kentucky whose interests they represen4 the tobacco industry, or the tobacco farmert'State agriculture programs must be adapted to deal with the obstacles to new crops. Rather than . looldng for "alternative" crops to replace tobacco, we;should be: thinking of "supplemental"'erops while tobacco can istill support the farm.lThe purpose i's to make non~tobacco acreage more profitable: Distribution systems to help compensate for small farms, carefiiltrop selection to overcome terrain and!land prob- lems, and food processing plants to raise,die value of local prodl ucts are worthy approaches.lhte cigarette tax couldbe raised and& dedicated to provide grants and low-interest loans to individual farmers for new, farm equipment, irrigation systems, and indus- trial bondS to food processingand other non-tobacco companies. This has the double benefit of raising the price of cigarettes to : discourage use and could eliminate the usual source of political opposition in southern states to an excise tax on tobacco prod- ucts. The tobaceo industry could help. Since they have d'rversified. ttiep own a wide vaniety of food processing companies. It is not unrea, sonablo for the tobacco industry to locate its food processing plants in our rural communities, nearer to ~the tobacco farmers that provided the companies with their profits all these years. These processing plants help ensure that!crops grown to supplv the plants would brotg higher prices. 'Phe tobacco companies should at leasrbe asked publicly the questions about investment so that it will be dear as to where their loyalty and appreciation lie and1to determine if thev feel'any responsibility, to help in a transition if they no longer need such large quantities of~tobacco from Kentuclty fartners. Since I fusi became involvediwitli the question of health and tobacco, I have discussedithe concerns of the tobaeco.farmer. While maybe reluctant at first, the health organizations today in Kentucky, are a welld informed force advocating for these farmers. These otganizabons watch for new quota levels andiovetseas purchase totals almost as much as health statistics. It is ironic that those who are seen as the opponent~of the tobacco farmer are today his best, and most public advocate:

Tobacco Use: An American Crisis Today,you will norhear a traditional Washington speech. l didn'r want to come here to tell you what you already know; oronly what you want to hear, liwant to tell you what you'..te up against when you challenge the tobacco industry in Washington and how you can become more effective. The timing for your, conference coincides with the EPA's recently released report on the adverse health effects of envirortmental tobacco smoke or "EI'S'" The report declares tobacco smoke a Class A human carcinogen. Notisince release of Surgeon General Luther T2rry's landmark report on lung cancer almost 30 years ago has the public health community had a scientific weapon of such profoundland long- term importance. The government has now made official'what, we've suspected for years: Smoking exposes ruonsnwkers to an increased and significant risk of disease. The report provides a solid scientific basis for Federal„State;,and local governments to move beyondicurrent ETS'restrictions to eliminate the risk of'secondhand smoke in the workplace and public facilities. The report is a clarion call to ban smoking, for example, from all Federally funded facilities that provide childeare servtces or which provide care to pregnant women. The evidence of increased risk of sudden infant death should help persuade the smoking parents of newborns to qtilt -if not for their own health, theni for the health of their children. The election of Bill Clinton has assttred that the health care needs of chiidrenwill''be altop priority in Congress. The EPA's documen- tation of increased risk to children from tobacco smoke should be used to integrate tobacco control into a national child health agenda. The EPA report underscores the inherent danger that tobacco poses to smokers and nonsmokers but also calls attention to the inherent evil of the industry that promotes the addiction of chil- dren and costs the health care system $50billion annually: in fact, until we better control tobacco use, it will be difficult to control'medical costs. Tobacco use represents the single most preventable factor in the rising cost ofhealtti care. Raising,the excise tax on tobacco will be vital to raising the revenue necessary to finance the health reform proposals under discussion in Con- gress. Higher taxes are also the mosteffective means we know of' to reduce tobacco consumption by children: Remarks of the Honoreble Heruy,k. Waxman None of you shouldibe surprised to learnrthat as the number ofi tobacco deaths and'disabilities rise, tobacco industry exPendi- tures for advertising, promotion and lobbyists increase. You :dsoo knowthat it is becoming increasingly di[licult to promote public health policies in the face of such enormtous economic power. The tobacco companies are little more than nicotine pushers in expensive suits. Philip Morris, RJ!Reynolds and US'Tobacco spend $4 billion a year selling their addictive product for the same reason Columbiamdrnig,lords traffic in cocaine: It pays. If inot for, the money, they wouldn it hire top legal talent in Wash- ington and in every State capital to block increases in excise taxes, to defeat restrictions on advertising and evade tobacco control i laws. If not for the money, they wouldn't beguile our children with cartoon characters like "Cancer Joe:" !f not for the monev; thev, wouldn't put so much creative effort into targeting our minority communities for sales ofan addictive and life-threatening,poison. If not for the money. lung,cancer wouldn't be the leading cause of cancer death among women During President=Elect Clinton's campaign; a much talked'ahout sign in the lieadquarters reminded workers and the candidate '"Dhe Economy, Stttpid" The sign spoke about the need to focus. Keeping on your message was obviously good advice for a~eam- paigt challenging an incumbent PresidenL It is also good advice for going up against the tobacco industry, which seeks incum- bency status in every, administration. I want us to have a sign, too. It would read "The Children. Situ+ pid:"'It may already hang in the tobacco industry offices. Children shouldibecome our focus. oursuccess will be dhtermined; pnliti+ cally and medically, by how rigorously, we hone legislatlve efFoias to that message. The Surgeon Generallwarned you on Sunday ttiarwherever there is smoke, there are children. Childi•en should be our priority, because they are the tobacco industrws priority. Children are the indttstry's replacement smokers. Adults don't stamsmoking- childten do. If we can protect our young people from nicotine addiction, they are unliltely to die of smoking-related diseases as adUlts:. And, let us not forget, the use of tobacco products by childrun is dangerous and it is illegal. Tobacco Glse: An AmeriCan Crisis 23

i:~st year Congress passed the "Sytar Amendment" which broke new ground by linldng tobacco control with te "War on Drugs." For the first time, all divg;abttse prevention programs mustiir- clitde anti-tobacco strategies. More importantly, each of our 50 States must enact anrd e„ jjectiue~ enforce tobacco control laws as a condition ofreceivirtg $1 billioniin Federalisubstattce abuse treatment and prevention funding. It is a powerful incentive. Failure to adequately enforee tobaceo control laws can now cost States hundreds of milllons in Federal' funding. Full implementation of the Sy~nar Atnendment is the single most important tobacco control initiative we can address this year: The extent to which you and y+our, oorganization can use this new~Llw to persuade or compel State and local enforcement activities will be ameasure of'both our effectiveness and'eommit- mentto curtailing youth~acce,ss: The tobacco industry is busy weaving aiweb of apathy, and fear within the agencies to weaken this law. They must not succeed. The inaugurat4on,of a new Arlministnation ls heartening, Despite the rhetoric that we heard from Dr. Sullivan during the Bush yeans, no legislative proposalsrelatirtg,to tobacco controi were submitted or endorsed. We are optimistic that: President Qlinton ~ andlhis health officials will approach tobacco control as a serious and life-threatening public health problem that requines more than talk As we look toward the new Congress, several initiatives are under consideration: Warning,lnbel reform The EPA report and a growing body of scientific evidence about' the addictiv!e nature of nicotine underscore the urgency to revise the mandated healthwarnings. It's time the warnings spoke to the addictive nature of nicotine: It's time the Uels cv-artted that envi- ronmental tobacco smoke can kill nonsmokers. It's time U.S. warnings were equal in size and prominence to those on tobacco products sold in Canada. We need larger warn- ings, unambiguous wamiitgs, warnings of effect and'sttbstanced lt's also time to take on the billboard industry. We must put an end to the special tt+eatment tobacco billboards enjoy: Federal health warnings on billboards are virtually invisible and ineffective. Billboard reform would require that the health warat- ingbe no smaller than the company's brand name. Frattkly, with your support we should simplify the warning and require a skull and crossbones on every tobaceo billboard. Advertising and Promotiow The tobacco industry first;told us tobacco didn't cause death and disability: Then they told us advertising didn't cause smoking. In past years we have attempted to enact legislation to lLnit the industry to tombstone advertising.llhey have successfully resisted these proposals. A total ban,is ideal. Tombstone,adLertising is justifiied. Cltattging the tax deductible status of advertising would be helpful. But it"s time to: eonsider proposals for other, perhaps more narrow forms of'advertising txstrictions. We are considering proposals to pro- hibit specific forms of advertising which have a demonstratedl appeal'to youth. Regulation Ironically, tobacco products are among,the most under-regulated consumer products. But the Executive branch has far more ;ut- thority to regulate tobacco than it is now using:, The authority to regulate deceptive or unfair advertising lies with the Federal Trade Commission, and they could do more: The authority to get cigarette sponsorship of sport off television broad- casts rests with the Department of Justice, and'they could do) more. The responsibility to regulate implied health claims-such as those for low tar cigarettes--rests with the Food and Drug Administration, and they too could do more. We must work together to hold enforcement and regulatory agencies accountable for their actions or lack of aetion. The inauguration of a new Administration provides a good opportunity to put tobacco contnol back on the regulatory agenda. I would like to make this effort before we attempt to enact legislation to expand the jurisdiction of regulatory agencies over tobaeeo,prod- ucts. Tobacc o , fizports One of~the mostishameftu!'legades of Bush Administbation health policy was the failure of their health officials to contest trade, practices that promoted the addicction of'Third World consumers to tobaeco: The sale of U.S: tobacco to the Third Worldis a trade issue, but that is not the questioa fie sale and promotion of :vt inherently lethal product is unethical. The immorality of such practices cannot be dismissed simply because its victims arc not U.S. citizens. It would be ironic if the humanitarian in.stinetthat sent U.S: troops taSomalia resulted in expanding the promotion of tobacco prod, ucts to its suffering;people. We can do better.lt is our responsibility as Americans. The pro- motion of public health has no borders: Caring is not limited by nationality: Z l,et`s change howwe do business. We all want the tobacco industry to change how they do business. If we are to aehieve this goal, the public health community must also change the way it does business. Unless anti-tobacco organi- zations can channel the good will and public credibility of thiss movement into political acflon; the industrywilllparry our attacks. and emerge unscathed and profitable ftom, each encounter. If'you are to be effective, it!requires serious efforts to persuade and!cajole Senators and.Members of'Gongress to your cause. It requires yott to idbrttify kcy political iand financial ~supporters in their districts who share your convictions. This is hard work: lt's quiet work: But the tobacco indttstcy repeatedly demonstrates that when done correctly, it can be very effective.

I'm here to tell Nou that campaign contributions seldom outweigh effective grassroots organinng:lDnfortunately, grassroot lobbyirtg is hard work Startnow. Recruit'constituents of like mind. Recruit students avlocal high schools. Recruit local reporters. Try to follow the example of anU-tobacco organizations in England tha establLsh ~PAT groups, .`Parents Agaiit.st Tobacco", in the districts of Members of'ParliamenG Give Members a reason to worry about the political nsk of supporting the tobacco indtcstr!v, Currently members worry, about the risk of not supporting the industry. This is advice the tobacco industry wouldprefer you didn itheed. In fact, the}'re banking oniit In the 103rd Congress, the unprecedented number of new mem; bers creates great opportunities. Lassure you that the tobacco industry knows a greatideal about the new membets:of the Sub- committee on Health, and you should too: If we are going too succeed in passing new legislation we need allies. Take the initia- tive to meet members in their districts and enlist them in the anti- tobacco icause. I also want to suggest that increased efforts be placed on promot- ing pro-health, paidadverrtising and promotion campaigns suchh as those pioneered in Australia and adopted in the UiS: by the health departments of'California, Michigan and YewYork City,, We must seize the initiative and promote a smokefree society using the same advertising and promotional tacties thertobacco industry has usediso effectively, So 1 leave you andl}aur organizations with a challenge to become more effective. This conference is abeginning. You are talking together andlforming alliances.with organizations who have previously not been involved in the tobacco wars. Let: us resolve to succeed by becoming creative advocates. Be- come involved in the political process and remember what former Speaker T'ip O'Neil always said: "Politics is local." And remember: always rememberwhy we are here: '°[he Childre.n; Stupid." Focu., your efforts upon the mission ofiprotecting the young from a lifelong and lifethreatening addicdon. Finally, work at the grassroots to creatively use the promotional tactics of the industrv to sell'a positive message of health and independence from nioo- tine. I stand ready to help you and accept nothing short of success. Tobacco, llse: An American ~ Cnisi5~ 25'

Women, Girls and Tobac+co Introduction Tobacco use by women and girls constitutes one of the most important~and urgent~ehallenges to our nation's public health. Half of the world's female deaths from tobacco induced disea5es occur in ihe United St.ves. If is projected that by 1995', 2,40,000 American women will'die prematurely because of tobacco, each year• Women's and girls' use of tobacco may be explained by a variety of factors. Fotemost among these is the tobaccoindustrys efforts topromote smoking among women and girls. Individual motiva- tors, including psychosocial factors and nicotine addiction, also influence girls to start and to keep smoki:ng; Additionally, the absence of'~ a nationally coordinated strategy makes prevention and cessation of tobacco use for women and girls more dif6cuit These factors neffectwomen's lower social, economic and politi- cal status in American society. To successfully diminish tobacco's toll on American women and'girls, these issues must be recog- nized and rectified The Heah,h~Hazards of 8rnoking; for Women and ai'rls Smoking has been declining slowly among both men and women (F'ig. 1). However, smok nig among,men has been declining'since the 1950s, 'whereas the prevalence among women began to de- cline only, after 1977. The Centers for Disease Control and Preven- tion reports that in 1990 22.8% of women and 28;4% of men were smokers. White women smoked at a higher rate than blackk women (23:5% vs., 21.2%)~, and women of Non-Hispanic women at a higher rate than those of Hispanic orngirt, (23.4% vs. 1i6:3%), urtong both men and women, tobacco use is sharply circum; scnbed by level!of education, In 1990, 112.3% ofiwomen with college diplomas smoked„as comparediwitli 27.1% of women~ who had not completed high school. lt is projected that tobaeeoo use will continue to decline. If current trends continue, however, the deeline wiD occur fir, faster among educated'Americans:. In lighrof the well-documented health hazards, the fact that young people continue to start smoking is extremely distressingSmok- ing initiation occurs almost entirely during the teenage years, and the age of initiation has been dropping, especially among girls. It is estimated that 3000 children begin smoking each day,; and!for each year between 1'977 and 1989; girLs irtitiatedismoking at a greater rate thatt boys (Fig. 2). Recently, girls' initiationnate has Michele Bloch, MD, PhD Deborah McWlana MH5 dropped to that of ~boys, although both remain unacceptably high. In 1990, 119% of male andlfemalehigh school seniors were daily smokers. For both men and women, the health consequences of tobacco use are common and devastating. They include a dramatically increased!risk of'lung and other cancers, cardiovascular disease. pulmonary diseases, and a host of other serious, often lethal, conditions. l.ung,cancer deaths in women have risen diarnaticalh: in 1987 lung cancer surpassed breast cancer as the leading cancer killer of women (Fig 3) t In ~addition, female smokers incur other risks, including an increased incidence of cardiovas- cular disease among smokers who use oralleontracepti.ves: an increased'tnsk of cetvical cancer, and an increase risk of osteoporosis. Smoking ditrang,pregnancycan endanger the lffe and health of the fetus. Studies have shown a25 to 501percent higher rate of fetal and infanrdeaths among women who smoke; often the result1of preterm delivery and!or low birthweight attributed to smoking. Smoking has also beeni linked to Sudden infant Death Syndrome. Despite these risks, it is estimated that one out of five pregnant women smokes throughout her pregnancy. Once again, educa- tional attainment is the critical predictor of smoking during pregttanc,v. in 11989, the prevalence of smoking among college edueated pregnant women was 5%, while that among pregnant women without a high school diploma was 4296: EnvironmentallTobacco Smoke (ETS), also termed!second hand or passive smoking, was recently, ddeclared a "Group A" carcino- gen by the U.S. Fltvironmental Protection Agency: ETS is one of the most widespread and hazardous indoorair pollutants: and many women are exposed to ETS in~the home and/or the work- place. Women disproportionately occupy lower status jobs. ;uad are thus less able to control their work environmenG Researchers in California found that waitresses, who often face serious [:'T6 exposure, have the highest mortality, rate of any predominantlyy female occupation: They also demonstrated'a four-fold increase in lung cancer mortality among waitresses;,as compared with other women. . Because of ~the hazard of ~ ETS, people who smoke jeopardize the health of the adults and children around them, However, women are often the primary care-takers of'young children, whether in, the home or in other settings, and are also disproportionately involved in the care of'elderly relatives, Therefore smokinQ,lw Tobacco ~~ Use: An A)nerican : Cnisia~ 27

women can have a serious impact on the health of:those in their cam, parrticulaniy, young children. Why Do Women andlGirls Smoke? ' lnitiation Girls start smoki.ng because of a mixture of individual and social motiNations. Some of the personal factors which are predictors of' a: girl's decision to smoke are having low self-esteem, mateing attempts atweight control and appetite suppression, andlhaving less knowledge and positive;attitudes about smoking. Socio- cultural factors also influence whether or not a girt''wii'smoke, for example. the degree of social acceptability of smoking, and whether sibliitgs;,peers and/or parents smoke: Teenagers, both boss and girls;,are much more likelyto smoke if either older siblings or close friends smoke. Parental smoking also increases the likelihood of teensmoking. Additionally,,environmental factors have a tremendous influence on girls' smoking, Attractive and!manipulative advertising and' promotions create positive images and reminders of smoking. Ready access to and affordability of cigarettes also encourage teen ~ smoking. Clean indoor air policies, on the other hand, decrease smoking. Such environmental factors also influence how tobacco use is viewedby society, and thus inlluence individual behavior. Maintenance As with initiation, women continue to smoke because of a com= plex interplay ofiiadividualiand psychosocial factors. Continued smoking is often the result of a women's physiological addiction to nicotine and her dependence on smoking as method of weightt control. Adiiitionally; there are intricate and subtle reasons why women continue to smoke which are psychological and soeial in nature. Research shows that women often smoke in rresponse to negative life experiences. Often, these experiences are indicative of the lower status and roles women hold in~society; Although both men and women may, smoke to reduce stress, they experience different stt+essors in~their lives. For example;,in recentyears, women have entered the workforce in large numbers, but these women still shoulder the majority of child, elder, and household responsibili- t1es, These multiple workloads may contribute to women's smokin& Women in ~the workforce often hold lower-level service or manu. facturing jpbs; which provide little settse of autonomy or control. Both of these factors have been shown to increase stress: Indeed,, women who hold jobs filled with routine or repetitive tasks often %iew a"smoking-break" as a weltome rest from routine. Similarly women caring,for children may view cigarettes as a means to gain some "space" or personal time. Women~also smoke to control'their emotions, particularly to suppress anger. In general, it is not acceptable for women to i tlisplayezeessive amounts ofi anger and hostility,,or'ptiysical violence. Women use smoking to temper these emotions,,to betterr fitthe societal norrtn j Traditionally, our culture praises and rewards women for their beautM;,currenti* defined for mostwomen, as youthful and thin, Unfotrtunately;, many women strive for the cultural ideal. regard- less of the cost to their health. Women more often the men; use smoking as a mechanism to attain and maintain ideallbody weight. Childbearing, biologically unique to women, and childreanng,attd caregiving, traditionally performed by women, are nothighlyt esteemed by Western society. Nonetheless, most women will devote a portion of their lives ao these activities. Many believe that time spent in these activities conttibutes to women's lower self- esteem. Low self-esteem takes a significant toll on women's lives;, it undermines their self confidence, causes them to aspire to le.cs than they are capable of and renders them more susceptible to societt;l pressures; such ~as pressure to smoke. Some have arguediharmale-domittated'societies benefit from and may contribute to women's smoking; because smoking serves to placate women. Lorrairte Greaves; at the First International Con- ference on Women and Smoking, in Newcastle, Northern Ireland{ said, "(ilj f smoking can increa5e women's passivity and compll'- ance, and reduce women's...emotional expressiveness, then women's smoking is of great use to society." The factors which contribute to women's maintenance of smoking are indicative of women's lower status in society and the inequali- ties women often face. For despite significant gains, it is men who hold!the Gon's share of economic, social, and'politicailpower: Ttte often unequal treatment of women in societv must be consid- ered when planning interventions to impact upon wmmen~s smok- ing. As the Canadian background paper on Women and Tobacco states: ":..women must be seen:..distinctfrom men with1 respect to~their social status. Unless this principle is understood, an understand- ing of whywomen continue to smoke and resist quitting,smoking will t:emain incomplete:" How the Tobacco Industry Targets Women and Girls Advertising Advertising and'promotion are critically important mechanisms bvy which the tobacco industry, targets women and girls to smoke. Each year, the tobacco industry spends nearly4 ' billion dollars to advertise and!promote tobacco products. Tobacco advertisements are widespread in magszines, newspapers; billboards, and point of purchase displays; increasingly they are sent by direct mail.. Tobacco advertisements are prohibited by law from being broad'- cast on television and radio. However„the spirit if not the le+ter of the law is frequently, violated!when tobacco advertisements are televised via tobacco company sponsorship of sporting events. The tobacco industry has introduced many'tivomen's brands". although the vast tnajority of women smoke mainstream bt'attdn, such as Marlboro. However, the role oL'tivomen's brands"'to promote smoking,amaxtg women is far more important than these brand3 market share statistics wouldlsugggst. Mainstream brands 28

ran not carry me,csages'appealing specifically to women and giris. without endangering the loyalty of their male customers. Women's brands function to carry messages to appeal to women and girls, and thus create a milieu favoring smoking of'both mainstream and "women's brands." Of the many themes used to target women and girls, two are particularly, important appeals to independence and weight control. V'irginia Slims, the oldest andibest selling women's brand has long appealed to women1with the tagline,,"You've come a long way baby." In doing so;,it has attempted to fink smoking with womenls social progress:and emancipation. In reality, however, the Virginia Slims campaign is condescending to women; for example, few women enjoy being referred to as '.baby'. Similarly, manywomen's brands use code words for weight control, such,as thin,,slim„superslim, and'long. These "diet terms" are extremely effective in luring women to smoke because of the strong societal pressure to be thin experienced by tnanyy women and girls. lndeed, tttanygirls'report initiating,smoking to help ".managg" their weight; and fear of weight gain deters many women from quitting smoking. Advertising has several directieffects, includingithe ability to lure new smokers, virtually all of whom are youth: Advertising is also believed to make quitting more diffieult and to encourage relapse among,former smokers, by constantly presenting the public with images of cigarettes or of people smoking. Advertising aLso.exertsapowerful hold over the media's represen- tation of smoking and health. Research has documented that publications which accept tobacco advertisements do not ad- equatelv report on: the health hazards oEtobacco, toavoid'offend- ing tobacco.advertisers. This phenomena-termed!media self-cerLsorship--is particularly evident inwomen's magazines. As an example; not a single mnjor women's magazine covered the release of the landmark 1980 U.S. Surgeon General's Report, devoted entireJy to : the health hazards of tobacco for women. Self-' censorship on the partof the media is inpart, responsible for the public's ignorance of the depth and magnitude of both the health hazards of tobacco, and the political and economic ciout: of the tobacco industry. Promotion and Sponsorship In recent years, the tobacco industry has devoted an increasing part of'its marketing budget to promotion, including sponsorshipp o€community events and organizationa: Some promotions are extremely visible to the public;,for example, Philip MorriS's long- standing sponsorship~of'women's tennis through V'irginiaSlimss cigarettes. Other promotions are less visible, but no less important. For decades, the tobacco industry has cultivated relationships with women's polilieal and leadetship organizations, through generous donations to general funds,,programs, research projects, awards;, and individuaf events. Sponsorship serves to portray the tobaceo industry as a~friend andibenefactorof women,,and a good "cor- porate citiren." The success of this strategy is due in no small measure to the modest funding base of most women's organiza} tions, the lack of alternative corporate and philanthropic support, and the loyalty toan industry which has long supponed the women's movement This lo}altywas expressedl recently by the executive director oNimajarr women's organiza:tion: "Philip Morrus is probably the first corporate contributor that, (our organi2ationJ ever had..Politics is about taking care of the people who have been with you since the beginning, and thev have." 1fie,currentsystem oficampaign financing leaves politicians vulnerable to a wide variety of:corporate and other interest.s.lfie tobacco industry, like many other groups, has sought to influence political leaders, both men and womena anthe state and federal level. Many believe thatthe tobacco industry has successfullyy silenced!many politicians;, including many women's political leaders. However,,there are several female state legislators who have taken bold action on tobacco issues, for example Anne Northup (Dem:-KY), Anne Siebert (Dem.-VT), and'Diane Watson (Dem.-C11), These women deserve high praise for thei'r progres- sive leadership. International I Sales Thetobaeco industry has increased its attention to expanding; ovetseas,,and there is grave concern that the industry has targeted women and girls as:a "growth market" for cigarettes. In particu- lar„the industry has targeted women in countries where dispos- able income is rising. In the past, the industry's effort has been strongly supported by the U:S: government„in order to promote aa positive trade balance. Along with its smoother, tasting cigarette.s, the industry has broughtslick advertising and promotions to developing counuies, and the emerging nations of Central and. Eastern Europe, unaccustomed to such high-pressure sales pitches. In most developing countries, smoking by women and girLs is limited bytraditionalsocial custom and mores, and lack of eco- nomic resources. As women in developing countries advance politicalt,v and economically, the tobacco industry hopes to link smoking to women's emancipation and independence, as was done in the United States. In :A.sia,, the entry of an 4nerican com- pany into.a previously closed market increased'smoking among womenland girls. Ominou.cly, in some urban area5 of tatin America, highly educated ypung women smoke at a higher, r.tte than their male counterparts. Decreasing Women's and Girls' Tobacco, Use Working with Women's Organiyations Women's and girlS' organizations are likely allies in the effort to decreasetobaeco refated illttess among their constituents. There are an enornnous number of women's organizations, including civic, business and professional, religious, sportiand leisuree organizuions; sororitim and others. There are also organizations which serve girls specifically, and others which serve yvuth of both genders. The organizations are of varying scope-interna- tionalJ national, regional, state, or local-and of varying size:llie i . i Tobacco User An American Crisis 29 1

collective membership ~includes large numbets of~ women and ~rls, moreover; they are often very influential in their community. With few exceptions, these organizations have not been leaders in tobacco control'1ssues. principally because the health community, has never sought their involvement, in a concerted way. However, their potential for educatirtg,their members and their community is enormous. Women's Politicalland 4eadership Organizations Women's political and leadership organizations are a small„but importantsubgroupof women's and'girls organizations: These organization's participation in tobacco controllhas beendimited because of funding constraints and competing priorities: Many, womeWs organizations feel that tobacco issues are the purview of the voluntary andigovernmenrhealth agencies, and that their main role is to providb information and services wktich are notavailable elsewhere. Many organizations have long been enmeshed in the struggle to secure and maintain reproductive freedom. As Bobbie Jacobson has said in Beating the Lady Kfllerr Women and Smoking, , "In, the face of repeated threats to reproductive rights from the 'moral majoritW it is easy to:understand whythe American women's movement sees smoking as a peripheral issue." In parrt; however, the reticence of women's leadership and politi- cal organizations to participate in tobacco control activities stems from dependence onrtobacco indtistrymonies, lfietobacco industry has targeted these organizations for fmattcial'support, precisely because their involvement in tobacco.control activities would be dr'vastating tothe industry: Eor examplh,,aPhilip Morrus internal document delineatedithe names of women's organiza- tions, the amount of money given, and the kutdiof pay.back Philip Morris received; for example, public opposition to increased excise taxes. Generally, neither the tobacco industry nor womenis organiza- tions which receive funding are eager to have these arrangements known to the public. A rare exception to this rule came in 1989; when a prominent women's political organization gave an award to (6eorge Knox, Vice President of Phi.llp Morris Companies tnc. Klthough it maybe difficult to assess the indUstrys influence, it is thought to be substantial. Increasingly, however, tobacco industry support of'.women's organizations is recogniied as ethically unacceptable,'and as an embarrassing,liabilityg fJddassab magazine stopped accepting tobacco advertising at the requesrof the organization's member- ship in 1987. Similatdy, the National 0rganivation for Women (NOW), stopped!aceepting tobacco industry contributions severall years ago. Other women's organizations are considering adopting these positions. This is an important tirettd;,which should be lauded and encoura$ed by the health community. Women's Health Organizations Several women's health organizations have had a long and active involvement in tobacco control! The American MedicalWomen's Association, the National Women's Health ;iletwork, the Boston Women's Health Book Collective, Girls Inc., andlothers. have worked to edbcate women on the health risks of tobacco, encour- aged cessation, and, mosnimportartt, opposed the tobacco industry's targeted!marketing to women and girls. The efforts of these groups have been hampered by insufficient resources. eompeting priorities, andloften, by poor ties to the mainstream of tobacco controC Health Organiiations The major federal health agencies and the voluntary health orga- nizations were asked to provide information about their agencv's tobacco prevention and'eessation programs specifically, targeting, women and'girls (Appendix I). With few exceptions, programs have targeted!pregnanuwomenand mothers of young children. Although these programs are very important to improve and' protect maternal and child health, they do not targerthe majorityv of women and'girls. Critically lacking are prevention and cessa- tion programs which targetwomen and girls throughout their lives, and which address the social and economic causes of fe- male tobacco use. Additionally;,ttiese agencies have rarely sought to involve women's and girls' organizations in theiroutreach efforts. Recommendations Tobacco controlipoiicies must be socially responsible and gen- der-sensitive; to reflect women's inequality andifewer resources in society: Ideally, these policies will be develbped in conjunction with social, economic, environmental, and welfare policies. Research Recommendations • The federal and voluntary healthiagencies should support researeh on how tobacco affects women across the life cycle. To facilitate this, data should be collected and'analyted; and prrD- grants developed, by race, class;,gendpr, and sexual orientation. The information obtained should be disseminated in both pnofes- sional and lay publications. Specific research issues should in- clude: • smoking prevention, initiation. maintenance, cessation: and relapse specific to women. • the use of nicotine replacement therapy during pregnancy:. • qualitative research which explores the impact of advertising, and promotion of!tobacco products on women. • the extent to which,women's groups accept tobacco money :mdd how this effeets their activities. • how tobacco control laws, regulations, and policies dilthren- tially affect women. • economic issues, such as the market share women represent. amount of money womenspend on tobacco. and;the effect of increased excise taxes on a family's nutritional status:

Action Recotnmendations Women will benefit greatlyftromgenerral measures aimed;at preti•enting,and decreasing tobacco consumption, incfuding adver- tising restrictions, dean indoor air measures, increased excise, taxes, and restrictions on youth access. However, specific steps are nece<saryto preYent and decrease tobacco consumption among women and girls. 1. The Office on Smoking and Health of the Centers for Disease Control and Prevention should work in collaboration with other appropriate agencies to coordinate an on+going, national', women-centered prevention and cessation program for women across the life'cycle: The program should include research, policy, and public informationcomponents: 2. Tobacco control'orgattizations should continue to strive to reflect the populations they serve, by inr.luding more women, and racial and ethnic minorities in positions of policy andd program development and implementation. 3. Popula6ons with a high prevalence of smoking are alreadjr disproportionately burdened by tobacco. Therefore, excise tax increases should'be offset in,part by the earmarking of'funds for progt'ams that specifically benefit these populations. 4. The Women's Health Initiative of the National Institutes of Health should~include the prevention and reduction of'tobaceo use among~women and1ginfs. 5. Legislators at the federal, state, and local levels should receive brie@ngs;on women, gitik, and!tobacco issues. 6. Proposals for health care reform should include tobacco use prevention and reduction in women and g'trls. 7. The Congressional Caucus on Women's Issues should • request the Federal Trade Commission to assess both the impacrof'advertising and promotion targeting women, and the amount;of tobacco industry expenditures devoted to promoting tobacco use among women and girls; and • request the Women, InfanU and Chlldt<ett (WIC) program m prohibit smoking in its clinics andsequest the clinics provide cessation and educattonal~materials that aneculturally and gender appropriate to program participants. Suggestied Reading Chollat-Traquet, Claire. Women and Tobacco; World Health Organization, 1992. FErnster, Virginia Mixed Messages for Women. A' Social History of Cigarette Smoking and Advertising. New York StateJournal of Medicine, 1985; 85: 335-340. )acobson„Bobbie. Bdating,tbie Ladykilkrs: Women and Smok- in& f.ondon: Pluto Press, 1986. Gteaves, Lorraine: Background Paper on Women and Tobacco (1'987) and'Update (1990). Health and!Welfare Cana& Greaves,,Lorraine: The Psychosocial Detertninffits of Women's. Tobacco Use. Presentation to the Fihst Intetmafiatral Conferenre on Women and Smoking. Newcastle, Northern lslknd! October 6,. 1'992. Warner,l4enneth E. Selling Smoke: CigaretteAiivertising,and Public Healtb. American Public Health Assodition. 1986. Appendix I American Cancer Society (ACS) The ACS has two programs targeting pregnanrw,onten"Special! Delivery'', a smoking cessation program to aeast low.income pregnant women to stop smoking, and!"Don't Start tife Under a Clbud", a self:help,guide tarting prnegnant women. American Heart Association (AHA) None specifically targeted~to women and giifs American Lung Association.(AI:A), "Freedom From Smoking forYou and Your Bcatby"'is .UA's iUay quit smoking program for pregnant women.-'I QuitSmoking Because I Love My Baby', available in English and Spanish, is an introd{tetory, packet describing why1women shouldquit when they are pregnant and remain abstinent after deli": "Smoking and Pregnancy" is a pamphlet describing about,smoking during pregnancy. The AL1 collaborated with the.%merican Academy of Pediatrics to develbp "Healtliy Beginnings: The Smoke Free Famili+ Guide for New Parents"'to help healthprokssionalS educate new parents on environmental,tobacco smoke. Stop Smoking Stay Trim, ", which addresses concerns about gainittg weight after quitting smoking, targets both pregnant and non-pregnant women.. Division of'Cancer Prevention and Coatrol (DCPC); 1Yational' Cancer ihstitute There have been numerous research ~stttd'ies on women andd smoking fttntiedby DCPC. However;,the American Stop Smoking Intervention Study for Cancer Prevention, GlSSIST.); project, in which 17 states.are funded'to develop tobacco control programs. has no programs specifically targetingwo®ett or girls. Individual ASSIST states may be developing womeKmtered'programs. DCPC has also produced, aself-help guide IiDrpregnant women and newmothers. "Don't Smoke There's a Baby inthe House:'' Office on Smoking and Health (OSH), Centers for Disease Controliand Prevention °Is Your Baby Smoking?", highlights the dmgers of.passive smok- ing,to infants and children. "Pregnant? mt's Two Good Reasons to QuitSittoking;" discusses the dangers of;smoking to the fetus. Both are available in English and Spanisiti OSH also produces the Surgeon,Getteral'S reports on the health consequences of ~smok- ing. The;1980 Report'was entitle&'"Ihe Health Consequences of Smoking for Women ". Tobacco Use. An American Chisia 31.

Children and Youth Children and youth hold ithe key to preventing tobacco use-the single most important preventable cause of deatha,disease, and disability in the United States. Although smoking and chewing tobacco adversely affects people of all ages, the addiction that les& to life-threatening illness largely begins during childhood and adolescence. Over 90 percent of adults who smoke agarettes. start smoking before age 20, and two-thirds of~adult males who use smokeless tobacco (c.ltewing,tobacco and snuff) ~ initiate use before they are 21 years old. Preventing tobacco tue among the roung therefore mustibe the highest priority in tobacco conttrol' policy: Tobacco Use by Children and Youth Over 4 million American teenagers regularly smoke, and balf a million males betweett 12 and 17 years of age use smokeless tobacco at leastweekly: Ewery day of the year, more than 3;U00 additional young people.in the U:S. try their first cigarette and an unknown number try snuff'.dipping" and tobacco chewing. The younger individuals are when they start to use tobacco, the more likely they are to become heavy, users in later years and to have difficulty in quitting. Unfortunately, by all methods otcalculktion, the average age of smoking,initiation is dropping: Comparable data are not available for smokeless tobacco use, but tobacco chewing and snuff dipping has been observed iamong pre-school children: The onset of sTnoking,is viewed as aprocess evolvingfrom prepa- ration and anticipation to initiation, esperimentationa,and then maintenanee of regular smoking.. Less is known about the etiology of smokeless tobaeco use, but the process of onset appears simi- lar. Different detetmutants seem to be influential at each stage of onset, and individital childben, as well as coHorts of'yotttlt, progress through these stages at a variable pace: These concepts imply that the challenges of prevention change with children's development, personal'characteristirs,,and socisl emironment Early Cbililbwd Through early lean,ing from their environment, ctiildren develop attitudes about tobacco use and intentions to try it themselves. Ptevention may be most effective.at ttiis stage; however, tobacco use by fkmily members and tobacco industry practices undermine preventive efforts. Parents and older siblingss who smoke or chew teach ~ehildren that tobacco use is socially acceptable, model the specific behaviors involved!in use, and increase youngsters' access to tobacco products: Some children report trying their first puff of a cigarette or taste of chewing Carol N. D'Onofrio, Dr PH David G. Altman, PhD tobacco at agg five or six. In such cases, tobacco frequently, is supplied by a family member. Late Cbildhood mtd 6arfyAdoaeenCe. The proportion of chil- dren who have tried tobacco gradually increases through thee upper elementary grades, and'then jumps sharplywith the transi- don to middle or junior high sehool. Substantial ~increases occur each year thereaften Two recent surveys both found that among high school students who had ever smoked, about one-quarter had smoked their$rst cigarette by grade 6, one-half'by grade 8, three-fourths by grade 9, and 94 percent by grade 11. Whites start smoking at a younger age than blacks; and miles tend to.begin smoking earlier than females, but girlS catch up with higher rates of initiation in grades 7-9. Trial of smokeless tobacco varies markedly by $ender, age, and geographic region. For example, the proportion of sizth grade boys who have tried smokeless products ranges from 7 percent in New York City to 68 pereentlin ruralMonianz Youth who try smokeless tobacco also tend to experiment with cigarettes. Children try, tobacco for many, different reasons; however, initia• tion is strongly associated with tobacco use by, family members and fziends: The great majority of youngsters first use tobacco soeiall'y with peers. Social influences aLw lead to repeated tobacco ttse; however, youngsters who tiave an initial'avetsiNe reaction: those who experience few, symptoms or feel dirziness may be especially'likely to try tobacco again. Withcontinuing experimen- tation, soaal land physiological reinforcement is experienced andi conditioned. By the eighth grade;,8'percent of both boys and gir15 report smoidng;a pack or more of cigarettes in the past month„ and this proportion more than dbubles by grade IIO. Many ligltt smokers make the transition to daily smoking by age 14; Adolescenta of Higb ScboolAp: Smoking'prevalence among , adolescents has beert i estimated in several surveys with differing results. DiHerettces in sampling,and'other aspects of survey meth- - odoiogy may account for dilierences in findings, but sueh varia- tions make it difficult to estimate ttue smoking prevalence among, youth of.tiigh school age. For example, the proportion of tenth graders who smoked in the paat month was reponed!to be 21 percent and 30'percent, respecarely, by the 11991, Monitoring the Future surveyand the 1990 Youth Risk Behavior Survey (YRBS): The YRBS surrey also found that 36 percent of all students in grades 9-12 had smoked in the past month; while the Teenage Attitudes and,Practices Survey (TAPS) conductedione year earlier

foundlsmoking;prevalenc.e among,youth~ages 12-18 to be 16 percent Monitoring the Future provides useful trend data through an annual!survey of high school seniors. In 1991, this survey found that about two-thirds (66%) of graduating high school seniors reported ever smoking, 28'percentsmoked in the pasr30 days, 1'9 percent were daily smokers, and! 11 percent smoked a half-pack or more per day. Reflecting the inverse relationship between smoking,and educational levellin the adult, populktion, the preva• lence of daily smoking among seniors who plan to attendleollege is ataout half that of seniors who are not college bound! (14% v 30%)i However, since this survey excludes school drop-outs;,it underestimates smoking prevalence in the 17-19 year-old age group. Drop-outs smoke at a rate as high as 75 or 80 peraenL Smoking among,high school seniors declined by approximatelyy one-third from the mid-1970s to the early 1980s;,but very little change has occurred subsequentiy. In, 1991,,smoking in the past month was down only 1 percent from 10 yeats earfier,,white daily smokfng was:down less than 2 percent. From 1'977 until!recendy, the rate of daily, smoking among,senior girLs consistently ex- ceeded that of senior boys by about 4 percentage points; however current data show seniors boys and girls smoking at about the same rate: Due to increased use of smokeless tobacco;,whieh has been heavily marketed to young men~in recenr}ears;,more teenage male than female teenagers use tobacco producta: Between 1970 and 11986, males aged 17-19 years of ageincreased their ttse of snuff fifteenfold and that o(ichewirtg tobacco more than fburfold to become the age group with the highest rate of smokeless to- bacco use in the UiS. In 1985, over 8 percent of males aged 17-19 reported current use of smokeless tobacco, In the 1990 YRBS survey, use of smokeless.tobacco within the past 30 days was reported by 19 percent of male respondenes: Regular use of smokeless tobacco by girls is rare, excepuamong American Indians. In 1990, for the first time, smoking prevalence among black and white adults was similar (about 26%). However, many fewer black than ~white high school!seniors report daffy smoking (8% v 20%). The 1990 YRBS survey of youth, in grades 9-12 also found smoking prevalence lower among,blaeks: 36 pereertt1 of whites and 31 percent of Hispanics, buuonly 16 percent of'blaeks re- ported smoking within the past 30Aays.lfie TAPS survey of youth ages l 2-18 yielded lower smoking rates, but the same rank order of smoking prevalence among ethnic groups: 18'percettt of whites,,12 percent of Hispanics, buronly 6 percent of'blacks reported smoking;inthe past 30'days. Black and Asian adolescent males are less likely to use smokeless tobacco tfiart are white and' Hispanic males, while American Indian males and females report higher rates of use than youth in other ethnfegroups. Nonethe- less, ethnia pattetns of smokeless tobacco use may vary by region. llttle is known about adolescent cessation of'tobacco use, but several studies indicate that from 1'8 to 25 percent of yK)uth who smoke stop within one year, Data from Germany suggest that teenagers may go through several cycles of experumentaUon, regular smoking, and cessation before becoming either con- firmed smokers or quitters. In 11991, only 17 percent of graduat- ing high school seniors who had ever smoked regttlarly reported that they did not smoke at all in ttie past;30 day5. OlderAdol¢scents and YoungAdults. The transition to addlthoodd is symbolically marked by the 18th birthday at which age young people in most States can legally purchase tobacco for the first time. Other changes in work, school, and'living arrangements alter social status and roles, initiating processes of self-redefini- tion. Tobacco use may be initiated or intensifled!during this vulnerable period: Data collected from ever smokers aged!20-24 indicate that°ebout 33 percentof these males and137 percent of these females start smoking between ages 18,20. Sharp increases in the initiation of cigarette smokdttg,through the late teenage years also have been observed in a longitudinal study; Follow ups to the annual'survey of"high school seniors have fotmd more modesrincreases in smoking initiation after high school; but respondents who were active smokers while in high school reported smoking more intensively after graduation. Smoking;rates among college students vary witfi the type of iiuti- tutionattendedn ln a 1989 surveyof full.time coflegefreshmen. "frequent smoking" within the past year was reported by 12 percent of men in two-year colleges, 7 percent of those enrolled in four year institutions, and slightly under 6 percent of those attending universities: Comparable figpres for freshmen women were 17 percent, 9 percent, and 8 percent, respectively. .,a cer a 22 year decline in the proportion of college freshmen who reported' frequent smoking, rates rose in 1988. In: this same year, a~record higb,percentage of freshmen said they frequently felt deprmaedj. while a deciining;proportionrated'their emotional health above average. These data are consistettt with research associating tobacco use with stress. In 1990, smoking,prnwalence among young adults ages 20-24 was 29 percent for males and124' percent for females. However, smoking prevalence was 55 percent for males and 47 percent for females who had less than 12 years of education, compared to 16 percent of males and 14 percent of females who had attended co0ege: whites smoked at a higher rate than blacks (39% v 24% for males, 28%v 17% for females) ~ Hispanic males smoked'atiaboutthe same rate as white males, but smoking was reported by only 15%6,of young, Hispanic women. There are no reliable estunatesofsmoldng,prcva- lence among young adults in other ethnic groups. Several studies show that a large proportiofil ofyoung adults who smoke have made one or more attempts to:quit, but smoking cessation in this age group is limited. In 1987, regular smokeless tobacco use was reported by 9 percent of'males aged 18'-25._ . Adolwscent Smokiag during Pnegnwuy: Smofdng prevalence among preg;nant women in the United States is estimated'au 25' percent or greater; however, smuking prevakflce amottg,prLTit;utt teenagers is unknown. A companisort of data collected from married women in 1967'and 1980 revealed a decline in smoking Tobacco (i<se: AhAmPrican Crsis 33

rates during pregnancy, for some groups, but rates among mar- ried'teenagers remained fairly constant at 39 percent for whites and 27 percent for blacks. No data were available on smoking, prevalence among unmarried pregnant adblescents, but rates were projected to be higher. Health Consequences of'Tobacco Use dddiction! Tobacco use is the most widespreadlorm ofdrug dependence in the United States. The processes that determine addiction to tobacco.are similar to:those that determine addiction to other psychoactive substances such as heroin and cocaine. Nicotine addiction can qµickly become established in children, as evidenced by the difficulty that }routh who smoke and chew to- bacco often have in quitting.. Cigarette Smoking. Tobacco smoke eontains over 4.000 known compounds, including many thatare pharmacologically active, toxic, mutagenic, or carcinogenic.llhe fact that the constituents.of cigarette smoke have diverse biological effects helps to explain why stnoking has multiple adverse health consequenaes. Although the tobacco industry has developed filtered, low-tar, and otherr cigarette forms purported to reduce the health hazards of smok- ing;,no cigarette or level'of smokingean be considered safe. The start of even modest cigarette smoking during Iheschoof-age years reduces lung,ftutction; increases respiratory symptoms, and results in pathologic changes. Conversely;,smoking cessation has major and immediate health benefits for persons of all ages and for those with and withoutsmoking-related dlsezse:. one-fourth or more of all regµlhr smokers die of smoking-relatedd diseases: Thus of the 3',000 young people who start smoking every day;,approximatelp 23 will be murdered, 30 will die initraffic accidents, and 750 will die from smoking-related disease. Ifiadult smoking rates remain at the cutment level of about2fi pereatt, 18 million of the 70 millionichildren now living inithe United States will smoke cigarettes as adults and nearly, 5 million of them wilf die as a consequence. As former Surgeon ~General' Koop observed, "This figure should alarm anypne who is concerned with the future health of todays children". More than one of every six US deaths, or an estimated 434,000 deaths annttallj+ are directly attnbutable to cigarette smoking. Smoking causes more premature deaths than caused by AIDS, cocaine, heroin, alcohol, fire, automobile accidents, homicide, and suicide combined. The cigarette toll includes anestimated'87 percent of lung,caneer deaths, 30 percent of all cancer d~t, 21 percentof deaths from~coronaryheartdisease, lU8'percentof' deaths from stroke, and 82 percent of deaths fnom chronic ob- structive pulmonary disease: Smoking also causes over 145 mi1- lion days of~excess bed disability and over 80 million excess days of~ work lost!each yean The annual cost oHsmoking-relited health care and lost productivity in the United States has been estima,ted' atabiout'E65 billion, or $2.17 for every pack of cigarettes sold. The more tlian 1 million young persons who statt to smoke each year will add an estimated E 10 billion to the cost of healtti care in the US during their lifetimes. ,ttaternal smoking duringPregmsncy. Maternal smokirtg during, pregnancy retards fetal growth and is associated with an in+ creased incidence of spontaneous abortion, stillbirth, premature delivery;,low birth weight, sudden infant death s}mdrome; and infant mortaiity. In the United States, cigarette smoking during pregnancy accounts for 20 to 30 percent of low, birth weight babies, up to 14 percent of'preterm deliveries, and about 10 percent of all infant deaths. The risk of these outcomes increases with the,ntunberof cigarettes.smoked by pregnanrwomen. Smok- ing cessation prior to or early in pregnancy can partly reverse the reduction in infant birth weight associated with maternal smoking. Smokelesa Tobacco. Snuff "dipping" and tobacco chewing in- crtase riskfor cancers of the oral cavity. Short tetm effects in- clude gingival recession and oral! leukoplaldas (precancerous white patches); as well as sores, blisters, and ulcers on the gums, lips, and!tongue- Other effects on both softand hard tissues of the mouth are suspected, but have not been~confinned Swallowing the excess saliva produced by smokeless tobacco use cart pro- duce nausea, and other symptoms. Because smokeless tobacco use canlead to nicotine dependence, scientists also are con- cerned'that its use may result ini increased cigarette smoking Tobacco;Use andiOther High Risk f3phavsor. Tobaceo use by youth is widely recognized as the "gatewav'' too other high risk behaviors. Both cigarette smoking and smokeless tobacco use'are highly correlated with use of alcohol.,marijtuna- and other drugs. Although young people often expernmentwith alcohol before they try tobacco, tobacco use is more likely to lead to dependence. Moreover;,ineneasing levels of'tobacco use are associated4ith increased use of other psychoactive substances: and development of tobacco dependence appears to precede development of dependence on alcoholiand illicit drugs. Adolescentfemales who smoke and drink are more likely to become sexually active at an earlier age and to be less effective users of contraception than girls who abstain from tobacco and alcohol use. Tobacco use by youth is also linked with low school achievement, rule-breaking, and ggneral!delinquem.y: Smoking, and!ehewing;in combination with other behaviors often multipliess the risk of'health, as well as socialiproblems. For example, use of tobacco with alcohol substantially increases the risk of developing oral'and pharyngeal cancers. Girls who smoke and use oralleon- traeeptives greatly increase their risk of'cardiovascuiar disease. Children's Exposure to Environmental Tobacco Smoke Exposure to environmental tobacco smoke (E1'S) is a ca.u.u of disease, including lung cancer and various respiiatory illne.c*~, in healthy non-smokers. Cttrrently 534000 UiS:' deaths annually are attributed to ETS; 3,000'of theseare due to lung cancer. GStitttates indicate that more nonsmokers will ldie as a result of exposure to EfS'than from exposure to any odterair pollutant. Those most affected by ETS are children.

Infants who are nursed by smoking mothers and who are exposed to ETS in their home absorb tobacco constituents, even when smoke is blown awayfbom the baby, room ventilation~is in, crea,sed! or smoking occurs in another toom: A reeentstudy found that infants are three times more likel}+, to die ftom sudden, infant death syn&ame (SI)S) if 'their mothers smoke during and after pregnancy, and are twice as likely to die if their mothers stop smoking during pregnancy but then resume following bimh, (hildren of parents who smoke are more likely than the chiklren of non-smokers to develop bronchitis, pneumonia, and!other lower, respiratory tract infections. Each year second hand smoke causes lower respiratory tractiinfections in as manyas 300;000 children under 18 months of'agQ: up to 1'5',000 of these cases require hospitaliration: Parental smoking is also rausally, associ- ated with children's symptoms of respiratory irritation,,including, chronic coughutg, wheezing;,and phlegm production; with in- creased' middle ear effusion, a sign of middle ear disease and the most common reason for hospitalizing }burtg;childrert for an operation; and with a reduction in children's lung,funetion ass tested by objective measures of lung capacity. In addition, expo» sure to ETS increases the number of asthma attacks and the severity of asthmatic symptoms in about 20 percent of'the nation's two million to five million asthmatic children: Mothers who i smoke 110 or more cigarettes a day can acntally cause as many as 26,000 new cases ofa astiima among their chil8nert each year. Since many childrenwhose parents smoke become smokers themselves, the long-term effects of exposure to ETS during child' hood have beeni difficult to study. However, a reee nt investigation foundithat approximmately, 17 percent of lung cancers among adult nonsmokers can be attributed to high levels of exposure to ETS during childhood and adolescence. Parental smoking also may contribute to the rise of chronic airflow obstruction ut later life. A 1986 survey found!a cigarette,smoker living in 39'percent of households with one or more children aggd sitc or younger. Current estimates are that 9 to 12 million American children under five years of age,,or one-half to two-thirds of all children in this age group, may be exposed to ETS in the home: Tobacco Industry Activities For the tobacco industry, youth who smoke and chew replace the 1,200 older Americans who die daily from tobacco-related dis- ease and the 500 Americans per day who quit smoking and'chew- ingtobacco. The industry's highlysophisticated marketing, strategies provide pervasive encouraganent of tobacco tue.. Concurrently, other industry activities impede efforts to limit the exposure of youth to marketing influence. Produ ct Dievelopm,ent: The development of new products and packaging is an important component of marketing for the to- bacco industry. The marketing of moist snuff'provides a dramatic illustration. Prior to 1975, smokelesa tobacco use rates were highest among persons over age 50: However, in the early 1970's, the industry extended its line of moist snuff products and began aggressively marketing them to males between ages 18 and 30, with a°substantial emphasis on the 18 to 2d grawp": Many young boys also were influenced. In 1973', US Tobacco introduced moist snuff'in new packaging and carrying this round,tin can in the back leans pocket quickly became a status symbol'among boyF and young men. US Tobacco more than doublediits sales in the ensuing decade, and in 1983 the introduction of moist snuff in small premeasured pouches boosted sales still higher. These pouches containa miid formlof snuff and come witb, step-bu-step: instructions for use. Other proditcts,,varyittg'intobacco strengthh and flavor, provide a graduated continuum to addiction. Advectfsing and Rromotirm. Youth are bombarded with appeals by the tobacco industry. In 1990; the tobacco industry spent $3,99 billion to advertise and promote its products;,a, 10% in- crease from the previous year and over twice the amount spent ten years earlier. The current figures translate into about E 10:9 million each day or over $7,650 each minute spent on tobacco advertising and promotion. Promotional expenditures are grow- ing while advertising expenditures are shrinking: Whereas adver, tising represented 87% of total spending in 1970, it now represents less than 30%. Promotion includes such activities as offering fiee trials (e:g:,,samples) or discounted purchase of a product (e.g., coupons), the appearance of'a tobacco product name on television (e.g„ sports sponsorship), and sponsorship of cultural and community events.Althiough the tobacco industry vor;iferousl y denies that its advertis- ing is directed to young people, awareness of cigarette brands has been demonstrated in children. For example, a recent!study found that preschool children recogctite "Old Joe Camel" as well as. Mickey Mouse. Other research shows that brand preference is much more tightly concentrated!among adolescent smokers than among adult smokers, and that teenagers who purchase their ownn cigarettes prefer those brands mostheavily advertised. In 1981 the Federal Trade Commisaion forced cigarette manufAc- turers to release a study revealing a five point strategy for reach- ing youth. This information was excluded from the public version of the FTC reporti but leaked to the public. The recommended techniques are still apparent in tobacco advertising: tobacco use is associated with maturity, good times, good looks, popularitv, independence, afffitence, adventure and risk-taking.. These themes relate to basic developmental needs of children and adolescents. In essence, they promote tobacco use as a sign of adulthood and a short-cut to the difficult processes of'growing up: The tobacco industry maintains that advertising and promotion is directed!to influencing brand 'preferences among current tobacco users. This brand switching argument flies in the face of logic because only about 10 percent oftobacco users switch brands each year and'much brand switching occurs among brands ownediby the same company:. Aside from recruiting replacement smokers and decreasing the resolve of'current users to quit, the high saturation of tobacco advertiaing and promotion helps to create an emironment in which tobacco use is considered socially acceptable, if not~desir, able: Inaddition, stndiesbave found an inverse relationship between cigarette adverrtising revenue and!coverage ofitobacco Tobacco Use., An American CrdsrS 3'5

and heahh issues in national womenis magazines, illustrating that tobacco advertising serNes to silence editorials and coverage of tobaccocontrol issues in magazines thatiaceept tobacco adver- tisements- ReeentfN several major print advertis!ers whose products have nothing,to do with tobacco have featured cigarette smoking mod- els. Guess jeans ran an advertisement in the October 1992 issuee of P.squire showing their newest model, Anna Smith„in a sexy pose holding a cigarette with a dangling,ash. Cigars are focal . points in new print ads for Bijan Fragrances and Donna lfarart fashions. Cigarette smoking is atso:showing up imphotographs thatappear,withmaga¢inestories. Arecentissue ofVanttyFair ran several pbotos featuring Luke Perry of the "Beverly Hills 90210" television series smokiutgwith gusto. In one pictore;a pack of Nfarlboro cigarettes was sticking out of1is fiortt pocket. Adventisirtg psrchologists say that the sexy and rebellious images of these smoking models, similar to.those promoting tobacco products, could strongly influence teenagers. Product Plaeemeat. Tobacco is widely awailable in superntarkets, dlugstores;,eonvenience stores, gas stations, and vending ma chittes. This pervasive availability not only encourages impulse buying and makes tobacco easily accessible to y,outh: itconveys messages that tobacco products are safe; in great demand, and an integral part of everyday life. Product placemenCwithin stores ofteni reinforces these impressions. For example, one survey, of' stores surrounding C,alifornia high schools found smokeless tobacco next to candy and snacks in 42% of these establLshments:. Conversely, placing tobacco products next to alcohol or out of consumer reach behind the counter associates use with the attain- ment of adult status, or for youthl with risk-taking:. Sales Force. The tobacco industry has an extr•aondinary saless system with over 1.4 million outlets,lncentives are offered to salespeople at every level from clerks who are encouraged too wear clothing with tobacco product logos to wholesalers who cart strive to be named Masters in Distribution Excellence. Fieid representatives assure that products are freshand optimally placed to encotuage sales. They serve as emissaries.for their produets by providing retailers and customers with friendly, personalized attention. At the same time, they obtain ideas for further market development This sales system also has the poten, tial for political action. tn Fall 1992, field representatives in Vew Jersey brought copies of articles about proposed!tobaeco tax hikes to each of their: retail stores. Retailers can earn Masters points bywriting letters to newspapers and politicians. PGilantb%py.~ The enormous profits derived from tobacco sales - allow companies to generously fund a variety of community ser• vice, cultural; sports, and artistic groups, some of whom are connected to youth. The tobacco companies have prominentlyy supported the events of these organi>;atiorts, making their contri- butions weflknovtm in the commttnity and often eartttarking funds for high profile items such as directories, annual meetings, in, ternships, and cultural events. Not surprasittgly, these organiza- tions rarely, support tobacco control measures and often defend the "rights" of tobacco companies. Public Relations. The tobacco indttstty, ettgagcs public relktions firms and works through the Tobacco lnstittme to help create a positive image for tobacco companies and a less negative image for their products. For example, Philip Morris sponsored a high~ tech multi-million dollar national tour of the Bill of Rights on its two-hundredth anniversary as a means of championing the companys commitment to freedom and'free speech. The tour offeredithe company entre to school;cliildren, for whom theyv developed a Bill''of Rights curricufum; as well as occasion subtly to frame tobacco ttse as a civil right. The industtys public relations efforts inclttde a long history of disinformation. A't every, opportunity, inditstty spokespersons refute the dangers of active tobacco use and pa,ssive smoking; reframe the discatssion from health to smokers' rights, and em+ phasize how they oppose minors using tobacco. Smoker's Rigbts. ln efforts to promote the idea of tobacco use as a right, the tobacco companies have supported "grassroots" stnokets"rights organizations, ptmviding them~with materials and promotional support:. Theirpublications encourage smokers to contact their elected representatives about tobacco issues, often i providing ready; ursend postcards. Political Campaigns and'Lobbying: The tobacco companies are consistently, among the top non+partisan campaign contributors at national and state levels and,provide numerous perquisites for elected officiais (e.g„ "conferences" held at resorts)i Well-paid lobbyists for the industry are ubiquitous, working to prevent thee introduction of tobacco control'legislation, to pass weak legisla- tion that atndermines tobacco control goals (e.g., weak state davs that preempt stronger 16cal ordinances), and to challenge e.cisting laws thcrough ballot measures: To create the perception of broad support, the industry covertlp funds front organizations to serve as its representatives, Tobacco inditstry insiders are often active at the highestievels of government As a recent example, Presidenr tlinton is transition team ~was led by Vernon Jordbn, Head'of the Urban League and a Boand'Member of RJ6t Nabiseo. Mickey Kantor, al.os Angeles attortteyvlto often represents Philip Morris, was also on the team, andlis no+w the lIS Trade Representative. Illustratio>rs of Tobacco Induatry Staategies The tobacco indti.s- try has developed various campaigns to create positive public perceptions and to influence poliry, decisions: ln December 1990 the Tobacco Institute launched "lt's the law',,a highly publicized campaign to "discourage" sales of tobarco to minors. The Tb- bacco Institute stated'that it would spend $10 million over five years on ttus campaign. In ~eomparison, current estimates are that illegal sales to minors will generate over $1 billion in profits for _ the tobacco companies over this same period. Point-of-purchase signs are the primary componentof the c.vn- paign. These read "It's the haw / 1'ou must be 18 to btry tobacco products", butione study has.shown ~ttiese signs to be ineffective. ]nterestin*, the sign,s messagc is inacatrate in thtyse states where it is illegal for retailers to sell tobacco to ~mutors and!not forthem to buy it The subtle shift in responsibility away from the retailers to minors and,their parettts is a eommon strategy used ,14

by the tobacco indiistty: The campaignatso tia.s a legislative strategy to pass weak statewide laws that preempt anystronger action at the local llevel where communities have been successful in passingstrortg„pro-health legislation, Finally, the campaign includes distribution, and advertisement of a booklet entitled "Tobacco: Helping Youth Say Vo:" The booklet, distributed to governors, school boards, community groups, and parents who request;it, framessmoking as an adult;decisionand makes no reference to the health and addictive effects of tobacco use. "Support the laxw-itWorks"'is a similar campaign started in. 1992 by RJ f2 Nabiseo. Like "lt"..s the Lacd", the program centers around the posting;of signs and!educatittg merchants through a videotape about sales to minors. National Health 0'hjectiives. National health objectives for the year 2000 set challenging targets for tobacco use prevention and!control. These include reducing, smoking initiation among youth and smoking prevalence among adults to no more than 15 percent, reducing smokeless tobacco use to a prevalence of'no more than 4 percent among men ages 12 through 24, reditcing to no more than 20 percent;the propor- tion of children age 6 and youngerwlio are exposed'to cigarette smoke at home, increasing to 50 percent the proportion of smok- ers age 18 and'older who make serious quit attempts each year, and increasing smoking cessation among',pregttant women to 6,0 percent Retated service and protection objectives particularly reievanrto children and youth call for establishing tobacco-free school' environments; including tobacco use prevention in the curriculaa of all elementary, middlb, and secondary schools, preferably as part of quality school health education; enactittg in 50 States comprehensive Laws on clean indoor air that prohibit or strictly limit smoking in enclosed public places; enacting and enforcing, in 50 States laws prohibiting the sale and distribution of tobacco products to youth younger'ttian age 19; increasing to 50 the number of States withpL3ns to reduce tobacco use, especially among youth; and'eliininatirtg,or severely restricting all forms of tobacco product advertisirtg;and promotion to which youth younger than age 18 are likely to be exposed. Establishing Tobaceo-free Environments A'tobacco•ft•ee school environment is importanrnot only to protect children andyottth during the time they spend at school, but also to reinforce anti-tobaceo messages in the classroom andlthed community. The 199t.-92 National School Boards Association Stu vey sponsored by the Atoerican Cancer Society, the American Heart Association, and the American Lung Association found that 94 percent of school districts have a written policy with some restrictions on smoldttg; but only 40 percent of'school districts have written policies that provide for a total Iban of smoking on school grounds. Only 4' percent of districts allow smoking by students in designatod areas in buildings, but'43 percent petmit smoking by fatmlty, staff, and administrators in such places. Gen- eral compliance with non-smoking policies and regulations varies, but most districts report that it, ranges from good to ezcellent Compliance is better in those districts with a total smoking ban. Federal„state, and local legislation that prohibits smoking inn other public places can do muchito protect youth from passive smoke exposure. However, because these policies only protectt youth in public settings, passive smoke exposure can be signifi• cant if parents or other family members smoke in endosediplaces (e.g., at home or in,the car). Educational interventions encouraging voluntary action are the only feasible way to prevent passive smoking exposun: in non- public settings. Research is needed to develop and'te.ct educa- tional approaches that!effectiYely lead parents and other adults to reduce the exposure of children and!yottth to passive smoking. Educational research is also needed to develop ways ofhelping children themsell+es develop skills in avoiding exposure to smoke from other people's cigarettes. Edueating,Chlldren and Youth about Tobacco Scbood-6ased Ptewntfon Programs. In a 1988 survey of school distticts, 78'petr.eltt reported providing,antismoking education at the high school level,,81 percent at the middle school level, and 75 percent at the elementary school leveL However, the nature and e@'ectiveness of the antismoking education provided is un- knowni By the mid 1970s, research~clearlyestablishedlthat merely provid- ing information about the health hazardsof tobacco use will neither prevent smoking onset, nor motivate cessation among youth of any age. During the next decade, new theoretically-based, reseanch4driven prevention curricula therefore weredeveloped'to help children understand!and resist social!influentres promoting, tobacco use. Since smoking onset increases at the time that children i make the transition from elementary; school to a middle or junior high school„most of these programs are targeted to students in gr de.c 6»9. ln addition to teaching about ways in which parents, peers, and the medialint3uence youthfid smoking behavior, these pro- gnams emphasize the short-term ph}sioal iand social conse< quences of tobacco use, social norms discouraging use, and the development of skills to resist pressures promoting use. They rely on experientiallearning more than didactic teaching,, and there- fore require adequate teachertrainin& l4tany prograttts involve peers as teaching assistants_ Controlled field trials conducted by ~ the National Cancer Institute (NCI)'and other agencies have ~) shown that these programs havea positive effect in delayin&the ~' onserof tobacco use for up to three years. ~ Efforts are being made to disseminate these tested antd tobacco ~ curricula to schools and to encourage their utilizatiottr A mini. ~ (~ mum of two 5-session blocks of dim on tobacco prevention, delivered in separate school years between 6th land 9th grade, is ~, recommended. Tobacco use prevention can be inelitded in the ~ curricutum as a stand-alone program, as part of a substance use progratn, or as part of a school health eurrictdum. Nevertheless, tested tobacco prevention programs are not widely used in the . Tobacco Use: A»Avn,erican Crrsia 37

nation's schools. Where such a program has been adopted, teaclt- erx often ,modify the curriculum or teach onlvparts of it. More- over, teaching about tobacco frequently changes from year to year. ovecall;,then, school-based education about tobacco tends to be sporariic and inconsistent. While there is growing agreement in all sectors that tobacco preventiomidealtyshould be part of a compreftensive K- 12 school health curriculum, tested anti-tobacco programs are not readily ar•ailablefor elementary and high school students. Moreover, relatively few schools have a comprehensive health education program as almandated part of the curriculum. As of 1989, school health education programsweremandated!in 25 States and recommended by another 9 States, but the number of school districts actually implhmenting,planned, sequential multi+topic school health programs has not been accurately estitnaiedReflecting the influence of Federal initiatives to prevent drug and alcoholI use, many schools provide some instruction about these substattces; but tobacco often receives minimal attention. For aatnple, some schools have adopted a generric model of preven- tion which attempts to reduce risk factors and increase protective factors related to all!forms of substance, as well!as other health and safety problems of youth. Widely varied activities aimed at improving,schoolaehievement and self-esteem are classified'as prevention, but these activities may not address tobacco use directly or even involve classroom instruction. There is no evi- dence that this generic modellprevents and reduces tobacco use by youth. Community-based Prevention Acttvttiei The NCI-funded field trials of programs to prevencand control tobacco use included! several projects that coordinated school-based!approaches with interventions through the medialand/orcommunity-ba5ed'activl-, ties: ln addition, two programs were developed for and tested in community.based youth organizations, 4-Hiand l.ittle League, respectively. These programs can enhance and complement schooi-based prevetttion programs, especially when they are well coordinated. The challenges of coordination; however, shouldlnot be underestimated. Local I communities with strong anti-tobacco coalitions have devel- oped a variety of activities for children and youth: These range from traveling puppet shows and clowns encouraging tobacco- free environments to special youth forums on tobacco. While such activities help to communicate strong community norms against tobacco use, their effects on youthful behavior have not been evaluated Some observers note that matty, of these activities are only one-time events that involve limited numbers of youth, most of whom are not at highxnsk for tobacco use. Youtb Smoking Cess,ztirrn Pnmgrams. Few tobacco use cessationn programs have been designed especially for youth, and'of these, very few have proven effective. These latter programs tend to combine several individual or group counseling sessions with media, take-home materials,,and telephone folbw-ttps. Resource requirements have inhibited widespread disseminatlon. Few schools or other organizations serving yuuth offer on-site cessa- tion programs, and frequerttly staf! members do not~ know how to refer youngsters who use tobacco to cessation programs in the community. The effectiveness of adult cessation programs forr youth has not beeni evaluated. Parent Education. Some tobacco use prevention programs have anemptedlto involve parents by informing them about the pro- gram, encouraging family television viewing of anti-tobacco inter- ventions, and4ssigning homework that requires parent participation. Materials also have been developed to help parentss and othercare-givers instill stnonganti-tobxco attitudes in chil- dren while they are very young., Although some parents are recepi tive, participation, at best, is uneven. Parents who use tobacco have been most difficult to reach. Limiting Youth Access to Tobacco Sales of tobacco generate huge;profits for the tobacco industty, some of which are from illegal sales to minors. Suehillegal l sales-about 947 million packs of cigarettes and 26million containers of chewing tobacco in 1988T-total $1.45 billion in sales and'generate more thatt $221 million of industry profits (3 percent of total profits): Retailers also profit ani undetermined amount from these sales: Study after study has illustrated that minors have little trouble obtaining tobacco from generally anyy location where they attempt to buy it. Access is not concentrated in certain "orstores; or in certain parts of the country, or at particular times of 'the d'ay: Overall, minors trying to buy tobacco are typically successful'in purchasing it over-the-eounter 50-75 percent of the time andifrnfm vending machines 80- 100 percent of the time. If parents, government officials, and health professionak are to succeed in convincing childten and teenagers notto use tobacco, it catutot be sold as if it were milk or candy. Although most states (n=46) and the IDistrict of Columbia have laws regulating tobacco sales to minorsa,ttiey are rarely enforced. A review of those stateswith laws foundhhat five hadlnominal restrictions (e.g., laws banning salesbelvw alminimum age)„38 had basic restrictions (e.g., laws banning sales to teenagers under age 18, fines for the sales or distribution of tobacco to minors), four had'moderate restrictions (e:g:, the basic restrictions plus warning signs at point of purchase, state issued retaiiitobacco license, and!alprovision for license suspension or revocation when sales to minors are made)', and ttostate had comprehensive regulations (e:g:, moderate regulations plus a ban on free distri- bution of'tobacco and coupons, use oflicense fees for enfonce- meat; vending machine restriction or ban;,absence of a preemptive clause, and allowance for compliance checksJstings at' the local level). A U989 random digit'dial population survey of'3,654 persons aged 25'-64' in the 10 Communiry, Intervention Trial'for Smoking, Cessation (COMMIT) dties i.llusttates tbrpublic strongly supports regubAng minors' acce% to tobaeeo. Actass the ten COMMIT cities, the percent;of respondents agreeing to various policy states was as follows: tobacco ptoducts should be as strictty controlled a5 alcohol products (70 percent); merchants who sell tobacco to. 38

Wotrl:stltlps minors shotildI be fined (88 percent); and cigarette vending machines should be eliminated in places where teens gather (84 percent), Most people now agree thatmerchant education is a necessary but not sufficient intervention to reduce over-the-counter tobacco sales to minors. Accessibilitv to cigarette vending machines is best, prevented through eliminating these machines entirely. A less desirable butaeceptable solution is to limit ~ machines tobars:. Interventions that include active enforcement of access luws (eg, ..stings" that tresult in citations of violators) and restrictions limiting access and availability, (eg; bans on vending machines, restrictions on how over,ttie-counter sales are made) are needed for sustained reductions in minors' access to tobaeco: These types of interventions require that public health professionals work in the political arena, an area in which many lack experience or expertise. Administration ofaitobacco vendor's license is anothereffective method for monitoting tobaeco sales activity, and for funding increased enforcement of laws. Cbnsensus is thatcitations for illegal sales are most appropriately handled through civil rather than criminalleourts. There has been considerable debate about the efficacy and desirability of laws that~prohibit possession of tobacco by minots; Prime concerns are that making the posses- sion of'tobacco illegal may increase underground sales activity, enhance the attractiveness of tobacco use to youth who rebel against authority; and!defect attention away from the retailers who illcgallV sell tobaeco: to minors and from the industrythatproy motes tobacco use to youth. Interventions to~Reduce the Advertising and Promotion of Tobacco Warnit3g Labels: The ficst of a series of Congrmional statutes requiring warning labelson tobacco products and!advertisettteltts became effective in 1966, Qongressional legislation passed!in 1'984 and i 1986 now requires rotating health warning labels on all cigarette and smokeless tobacco packages and advertisements in the US. The effectiveness of these warnings has been difficult to establishj but research indicates that they their design neither draws attention nor encourages reading. One study of 61 adbles, cents found that 20 percent lboked at warnings in magazine ad5 but did not read them, while 40'.percent did not look at the warn- ings at ali.. Efforts have been unsuccessful over a period of two decades to require disclosure of tobacco product and tobacco smoke eon- stituents on packages and in advertising: Some cigarette manufac- turers voluntatilydisclose levels of'selectediconstituents, such as tar and nicotine. Limited evidence suggests that information about the haaardous substances inaobacco may influence some adults to change brands, but the effects of such knowlodge on children and youth are unknownj Because there is no known safe level of tobacco product consumption,,dieclosure of the constituents in tobacco is valuable only to the extent that this contributes to the prevention and cessation of product use. Restrictions on Adtarrtdsing; In response to anti-smoking public service announcements aired tmder the Fairness Doctrine be- tween 1968 and 1970; the tobacco industry supported fegislation banning eigarette advertising on television and radio, effective in 1971. In 1973 and 1986,,this banwu extended to the broadcast advertising,of little cigars and smokeless tobacco prodttct+s: re- spectivetv: Nevertheless, tobacco billboards.prominently displayed near scoreboards in sports arenas and indttstry sponsotship of sporting events assure that tobacco logos are fnequently aired on television. These images assooiate tobacco with athletic prowess, health, and!excitement. Thlevised sporting events draw lkrge youth audiences. The Federal Trade Commission tias attempted to regulate false and misloading advertisements about tobacco, butde;cpite some limited success, the regttlatory process has been slow: Effects of these efforts on tobacco ttse behavior have been d3lbctilt to dcter- mine. Many proposals havebeett alvattced to increase testric- tions on the advertising and promotion~of tobacco. Some would place tlghter controls on the imagery and content of advertising either by developing and enforcing a stricter code or by pertnit - ting only "tombstone" advertising with no models, slogans, scenes, or colors. Other policy ptroposals would eliminate to- bacco advertising and promotion as a tax deducti.on~,prohibit advertising in certain media, prohibit certainpromotional!tech- ttiques, ban advertising,and!promotion accessible to childrett, or ban advertising and'promotion of'tobaceo products completely: In 1'9g8, Canada enacted!a total ban which is now becoming effective in stages. The Public Health Cigarette Smoking Act of'1969 (PL 91-222): preempts regulation of'cigarette advertising by States and "any . political division thereoP', but the Comprehensive Smokeless Tobacco HcalUi Education~Act of 1986 (PL 99-252) does not preempt.State and local regulation of smokeless tobacco advertis- ing. Several states and!local jurisdictions have banned tobacco advertising on public transirsystems and the distribution of free cigarette samples. These local policies have not been challenged in court, but again their effeCSs on tobacco tLse are unknown: At the very least, they may eommunicate the important message that tobaccouse is not socially acceptable: Counter-adterti5ing. Because the anti-tobacco public service announcements broadcast in 1967-1970 apparently helped to neutralize tobacco advertising, the establishment of a continuous Government anfl+tobacco campaign has been proposed. Taxing some pottioniof cigarette companies' advertising and promotion budget or earntarking a portion of the Fedcral cigarette excise ta.xx have been identified as possible sources of funding to support such a campaign: Although these proposals have not progressed in Congress, several States have implemented'aggre.ssive tobacco counter-advertising media campaigns supported by incre.ued State taxation on~tobacco. Certain activist'organiaations have been highly creative in counter- advertising,againsttobacco: Fbrexample, members of Doctors Ought to Care (QDOG); dressed in white coats, make "house c:dls.t at local Ievents sponsored bythe tobacco industry. Stop Tcenagc. )C'se .4n:an;erir.rn Czisis 2GZ41.7G946 39 Tnh'acc(

Yt'ttrk-shttps Addiction to Tobacco ~('STAT) emphasi¢es communityorganizationn to protest the spoasorship.of local events and the free distribution of samples by tobacco companies. DOC, STAT; and other groups also produce humorous and'hard! hitting posters and promotional items spoofing,tobacco advertising themes. Tncreasingly;,schoolk and commtmity,''groups are imolirrttgyvuth in the creation, pro- dttctiotta and dissemination of local counter-advertising materials, Economic Interventions Options for exerting economic pressure on the tobacco industry include taxes, divestment, shareholder resolutions, boycotts, and litigation. Each of these strategies is bne4 neviewed below. Taxes. Because children and!adolesasnts typically have less disposable income than adults, their decision to purchase to> baeeo products is affected by its cost There are several compo- nents to the cost of tobaeeco--manufacutrers' price, wholesale and retail markups, tobacco taxes, and sales taxes. Wftile the tobacco industry routinely increases its prices, increasing state and federal eaciye taxes fs a potent andavailable means for in, creasing cost The price eLasticityof demand'for cigarettes ranges from -0:2 to -114. A-0.2 slisticity means that a 1096' increase inn the price of cigarettes results in a 2'percent decrease in consump- tion. A-1.4 elasticity means that a 110 percent price increase results in decreases consumption by 14 percent The few studies of tobacco price elasticity among,youth~have found it to beat the higher end of this range. Teen smoking in Cattada has been cutiby about two-thirds since 1980 when taxes on tobacco began rising.. (Inwanted Pnofsts. Reptesetttatives of!the tobacco industry havee stated that they do not want to sell their products to children and that profits on sales to minors are unwanted Accordingly, it has been proposed that tobacco eompanies should donate these unwanted profits to state health deQar'anents:for prevention. In 1'989, this donation would have amounted to an estimated $270 million. Diut„rtment In recent years, divestment of 'tobaccostoclts has become a~ new strategy in the tobaeeo eontrol effort Universities such as CUNY, Haivard, Johns Hopkins, and Tufts have all'di- vested. Other organizations, including the Robert Wood Johnson Foundation, the Hetuy J. Kaiser Family Foundation;,and the American Medical Association also have divested. Sbarebolder Resolutirnu: Filing of shareholder resolutions is a relatively new strategy employed by tobaaco control activists. Resolutions have been filed both with tobacco companies and companies associated in some way with tobacco (eg, media, companies that make elements of'tobaeeo products, pharmacies, insurance companies, etc) : For example, at the 1992 annual meetingof Philip Morris, a resolution was presented aslangthe Board toevalttate its efforts to dissuade youth from using tobacco, The Board rejected this resolution„but it was supported by about 7 percentof'the shareholders. Boycotts. Boycotts of consumer products have proven to be an effective practice in influencing corporate behavior. Stop Teenage. Addiction to Tobacco (STAT) has an ongoing caarnpaignito boNcott Nabisco food products. Althoug,h, the effects obttiis boyeott on RJR Nabisco ane not'readily apparettt, it does serve to raise public awareness of corporate behavior and gives indMdttals a relativetv simple, concrete way to express their feelings about RJR:. Litigation. Utigations targeting unfnir artd!illegal consumer practices directed at youth has begun to appear in recent ye.trs. A landMark case in Maseachusett5 (Kyte v Stose 24 Lnc) was broughtiby two smoking teenagers who were illegally sold ciga- rettes by Store 24. This case was settled when i the Store 24 conve- nience store chain agreed to require proof of~age from ypunggr loo(dng customers attempting to buy tobacco. Federal' Leadershlp to Prevent and Reduce Tobacco Use Despite strong,public support for tobaeco eontrollmeasures, Congress has taken relatively few votes on tobacco control legisla- tion in the past 30 years and has yetto take anysignificantlaction to combat thispublic heafthiproblem. The United States lags far behindlother industrialized countries in federal tobacco control policies. The 1989 Surgeon General's Report,,Reducing the filealtb Conse= quences of'SYnoking,• 25 Years of Progress, states ahat"Governi- ment smoking control efforts have been characterized by some observers as modest;"'In that year, the Otfice on Smoking and Health ((DSH); the only; Federal agency devoted exclusively to the smoking issue, had a budgetthat, in real do6lars;,was roughly one+half of the budget in 1966 when its predecessor, the National Clearinghouse, was established. Recently relocated to AtLanta, the OSH continues to provide important leadership in the prevention and control of tobacco use. The budget of! the Offiae has been tripled and staff expertise has been enhanced The Office is now positioned to.have a substantial~inBttence on tobacco prevention and controi. With continued financial support comprehensive prevention programs can be'widely suppotted. Ftom 1983'through 1990, the Sinoking, Tobacco;,and Cancer Program in the Division of'CancerPi~evention and Control within the National Cancer Institute (NCI) provided alstrong federal local point, for research on effective tbtttmunity-based strategies to prevent and'reduce tobacco use in high risk populations; includ- ingyoudi: However, leadership for this programihas been weak- ened!in recent years by, decentralizing program components and moving them out of the office of the Divisionls Director to various Brartches.l2fe NCL s 1994 ByPass bndget narratiHe acknowledges that the prevention and control of tobacco»related cancers repre- sents one of the areas most ready for wide-spread disseminationn of'reseanch results and also describes plans for new research on the development and testtng ofismoking cessation programs for adolescents, as well as for older Americans. However, research on tobacco control no longer stands out as one of the NGI's topp priorities. The Bush administ'ration proposed cuts for cancer prevention and control in the NGI's 1993 FY'budget Although funding was restored by Congress, reports of appropriations committees neither mentioned stnoldng nor identified1lung can- cer as a priority for prevention.

Witrktihups Recommendations The tobacco industry historibally has responded to tobacco pre- ventioa and control'efforts with creative, highly sophistitaed;, sensitivelytargt'ted, and!rwell-financed counter-measures. lntensi- fied efforts, multiple strategies;,and a coordinated plan of action therefore will'be required to prevent and reduce tobaceo use amongryvuth and to achieve relksed!NationalI Health objectives. (Priority, stnategies are marked • );. Smoke Free Environments for Children • Since E1S'i5 a Group A' human carcinogen, Federally and State funded programs for infants, children, and adolescents should be required to provide a smoke-free environment for populations served by these programs. • All schools, public and private;,should be smoke-fiee: Drug Free School Zones should include tobacco. Public environments accessible to children should!prrovide a smoke-free envirottment- Heaftdt iEducation • Tobacco shouldibe targeted by all Federal anti+dntg programs involving cltildreni and youth. • The nation's schools should implement tobacco prevention programs within a comprehensive school health program that includes effecrtve curriculum, teacher training, smoke-free facili- ties, and access to cessation programs for students and school employees. Congress should provide additional funding for youth-oriented tobacco control programs within existing federal public health programs, including programs for mothers and chiidrett, mi- grants,,and Native Americans. A'lll federally and State funded programs and services for'pregtartt teenagers should provide an effectiveprogratn of tobacco use cessation. Youth Acoess to Tobacco • Federal regulations for; the implementation of the new provi - sions related to the enactment and enforcement of minimum age laws prohibiting youth access to tobacco (Synar Amendment) of ' the June 1992 Alcohol, Drug Abuse, and Mental Health Adminis- tration Roorgani2ation Act should be enforceafile,,effective, and not preempt local and state authorities or jurisdictions from adopting more stringent laws to reduce youth access to tobacco. Implementation of provisions should allow statesllurisdictions to use Substance Abuse and' Mental Health block gtattt'funds for enforcement actnvities. • Local governments should!license and regulate tobacco retail- ers in the same manner that they now license an&regulate retails ers of alcoholic beverages. Federal policy should establisha or provide incentives for states to adopt„agg 21 as the minirrtum age for purchase of tobacco prod- Tob'acco C'se.• An American Crlsis ucts. Provisions also should be made for stnong enforcentent of tbis age limit~ with meaningful'penalties for viofations, through Ilaertsing,4tobacco retailers. State and'lot;al governments should ban the sale of tobacco prod- ucts through vending machines, without preempting'local'jurii;. dictions from enacting more stringent regulations. Federal„state, and!local governments should'e$ecxively ban the distribution of freesamples oftobacco products. Advertising and Promotion • National groups, inciuding nontraditional partners,,should petition the Just" Department and FTC to enforce existing laws regarding,tobaeco advertising and promotion. The Federal government should develop a national repository of information on tobacco advertising targeting youth and related counterstrategies. Federal, State, andilocal governmentishottld but the distribution of free samples of, tobacco products. Congt•ess should ban tobacco adi+erti.sing in publications. Congress should prohibit ~ tobacco logos on promotional items, such as hats and T shirts. Anti-tobacco coalitions should petition owners of sports and cultural organizations to have smoke-free sports and cultural facilities without;tobacco advertising. State and!local orgatuiations should provide tobaeco-free spon} sorship of sports and cultural events. No tobacco sponsored events or promotions should occur on governmentpropetm+, or in government funded facilities:. Community groups should work toward the elimination of bill- boards and other public sig~tage advertising tobacco: The Federal government should fund an aggressive paid' counteradvertising campaign to discourage all tobacco use by Youth- Excise Tax •'ltte Federal excise tax on tobacco should be increased by a minimum of $2 per pack of cigarettes or container of smokeless tobacco. • An excise tax of atilea.sti2 per pack of cigarettes or container of'smokeless tobacco should be imposed on the sale of tobacco produets in military commissaries and'exchanges stores with proceeds being;delrvered to support military morale, welfare, and recreation programs, • States shouldlincrease the excise tax on tobacco over current levels by at least E.25 per pack of cigarettes or container of smokeless tobacco. The amount ofthis tax should increase with inflatton, The possibility of tying the tax to a percentage of tobacco product purchase price should be explored. At least a proportion FsVut~s4196948 4,1

'l6'arkshops , of 'resulting revenues shoufd be affoared to tobacco prevention and control in the States. Campaign Reform Anti-tobacco coalitions should support efforts to reform congres- sional campaign financing,, including limitations oncontributions that can be made by individuals, groups, or PACS to politic7l candidates. Divestment~ Ptowate and public organiratlons that directly or indirectly serve rvuth should evaluate theiu retirement imestment.holdings and consider divesting stock in companies that manufaeture;,distmb: ute, and!promote tobacco. Professional Edbcatlon Accrediting boards for health professiona! schools shouldIreQ4ure instrnlction in the prevention and control of tobacco use among children and youth. The National Council for the Accneditation of Teacher Education (NCATE) should require schools of'eduaation to provide instruc- tion in comprehensive health education that includes tlie preven- tion of tobacco use. Researx:h Congness shoufd significantly, increase funding for research ~on the prevention and reduction of cigarette smoking and smokeless tobacco useamong children and adoleseents and for the diffmion (dissemination, adoption, implementation, and maintenance) of' evaluated,tobaceo~prevention prpgrams~shown to be effective.Priority aneas for research include the development and evalua- tion of preventive programs for elementary school!children, and of both prevention andcessation programs foryouthof high, schooVage and!}aung adults. Different models and more targeted programs are needbd to reach high risk youth, including espe- cially school'absentees and dropouts, those with one or more parents who use tobacco, low-achiever groups;,gi'ris and young women, and youth from ethnic minority groups. Research is al.w needbd'to stnengthenand further test hypotheses about the role of tobacco advertising and promotion in smolung1 initiation by chil- dren and youth. Another research priority is the dovdopmentand~ testing of edurational'approaches that effectively lead parents and other, adults to reduce the exposure of children and youth to Et'S:

WtrrksYtctps M lnOl'1ty issues I Introditction Afcican-A.tnericans: Tobacco use bv Afriean-kmericans I5 tt'sponsiblefor nearly 48,000 deaths each year in the United States: Aggressive targeting of the African4merican community by the tobacco industry; particuLuiy in the urban, inner~city, environment, exacerbates the difficulty faced'by tobacco control advocates in~seekittg,to reduce the burden of tobacco-related disease experienced within the A'fmcan-American communrtv: Flispanacs:. Tobacco use among Hispanics is less well-documented than tobacco use among African-Autericans; It is known that the rates of tobacco use among Hispanic groups are somewhat, higher than those obsetvedfor non-Hispanicwtvtes. It also is apparent that aggressive targeted tnarketirtg by the tobaceo industry is not reserved for African-Americans, but also is being aimed at the growing'E9ispat>K population in the UnitedStates. For, example, tobacco manufacturer Philip Morris is the top advertiser in His- panic markets. To help inform eHorts to combat the problemlof tobacco use by Aftican-Atnericans and Hispanics, which constitute the two largest "minority' populations in the United States, tliis background paper summarizes the nature of the prroblkm, the factors eontrili- uting to the problem, the issues affectittg preverttion and inter ven= tion, strategies, and the tbMaeo-reiated public policy issues involving the Afriean-Atnerican and Hispanic communities:. Tobacco Use Africau-Amerncaas: As of 1990, 26.2 percent of African-American adults (aged 18 and older) smoked''ciganettes, including 32:6 percent of men ~and 21.2 percent of women, according to the National Heaith Inter- view Sutvey: Prevalence was highest among men who had not completed 12 years of education: In the same }ear, 25.6 percent of whites in the United States smoked cigarettes, including 27:9 percent of men and 23.5 percent of women. Smoking prevalence in the 20-24 age group, which can be used as an indirect measure of smoldng initiation,,wzs 17.3 percent for African-Americans and 28.3 percent for whites.lfie prevalence among African-Americans aged 20-24 declinediby one-third between 1983 and 1987;,from 38.7 percentito 25.6percent;,wtule the smoking rate among Harold Freeman, MD Jgne L Delgado, PhD Clifford E.llougLas, JD (With gtatehil'acknowledgement to tlte work of Robert G. Robinson~,llrPH, on which~this paper relies heavily) whites in this age gnoup declined by 17, percent, from 36:8 per- cent to 30:5' percent.lYhen considering these figures, it must be kept in mind ttiat4he age of'initlation forAftican-Americarts is somewhat older than for whites. It is possible that the decrease in cigarette use among youth is negated!by the increase in use of spitting tobacrao and snuff. Indeed, betweett 1970 and 1989, snuff use increased 1500 per- cent and spitting tobacco use increased 400percent among males . between 17 and 19 years-old Comparing African-American artdd witite males 17 and!older, whites ane 2.4 times more likely to ttse smokeless tobacco. A conttary statistic is the fact that older Afri- can-Americanwomen in southern states are much more likelv to ttse snttff than are women in the general population. Other pre- dictors of'.spitting tobacco and!snttff are t•esidence in the Sottth~ east„less education„povet tp, unemployment and lower income. Hispanics: As of 1990, 223.0 percent of Hispanic adults (aged! 18 and older) smoked cigarettes, including 30.9percent of inen and 16.3 per- cent of women, according;to the National'Health Interview Survey. Prevalence was highest among men who had not completed 12 years of education. Smoking,preralenae in the 20-24 age group was 20.7 percent for Hispanics, which was less than the 28'. i percent for whites but more than~the 17.3 percent for Africatt- Americans. Comparisons among Hispanic sub-groups show that smoking rates for women are mtd lower than those for meni irtespective of sub-group. According to a study publishedlin theAmerican Journal of Public tPealtb in December 1990, Mexican-.uneric:m men have the highest smoking rate among Hispanic sub-groups (42.5 percent), while Puerto Rican women hawe the highest smoking rate among,Hispanicwomen (i30;3 percent). The rates for other Hispanic sub-groups were: Cuban,American men (41.6 percent) i Puerto Rican men (39.8'percent), Cuban-Acnericart women (24.4 percent) and Mexicatt-American women (23',8 percent). Although the prevalence of smoking has been on the decline; rates among younger biRh cohorts of Hispanic women have increased over time, wbile smoking rates for all Hispanic women have remained essentially stable, according to a study published in ttteJournal of thegmerican NtedicalAssociation in Januarv 1989: By comparison, according to the same study; whites have 43 Tobacco Use-.9n Abnp-ican Crisis 2 ~6`41969~501

made more progress than Edispanics since the 1960s inreducing; their smoking initiation i rates. Smoking rates among Hispanic youth also are of gneat concern, as 19.4 percentlof Hispanics agedi12-17smoked cigarettes inithe preceding year;according to the 11990 Nationai Institute on Drug Abuse NationaliHousehold Survey on Drug Abuse. Tliiswas less than the 25:9 percent of whites in the same age group, but con- sidetablv more than the rate of 9.8 percent#orAfriean-American adolescents: Health Consequences ofTobncco Use A'frican-4mericans: African-Americans suffer from tobacco-related diseases at a higher rate than whites. African-American men and women have a higher incidence of respiratory system, esophagus and oral cavity cancers than do white men and womenj They also experience excessive mortality for many tobacco-related cancers. In 1988, nearlv 48,000 African-Americans died from preventable, smok- ing-attributable causes. Smoking-attributable deaths among African-American men (702.9 per 100,000) are more than double those among African•American womeni (23L5 per 100i000) . Afnican-Amerit:ans have not only a higher death rate from ciga- rette smoking than whites, but have algreater loss of productive years of life. This is because Afrucan-Americans tend to become ill from smoking at younger ages than whites. The age-adjusted years of potential life lost (YPI1L) attributed to smoking in 1984 was 8,14 for A'frican-Americans and 3.81 for whites; In 11988; the 16PIJL before age 65 for African-Americans was twice that forwfiites, and before age 85 the YPI1L was 52 percent higher than that for whites: The percentage ofilung cancer mortality attrib,uted to smoking is 86:11 percent. The average lung cancer death rate from 1980~ through 1'987 for African-Americans was 2.3 times higher than for whites. Estimates are that from 1980 through 1990, lung cancer increased 98.6 percentfor African-American females, 86 percent for white females,, 31.8 percent for African-American males and 20.7 percent for white males. Lung cancer tncidence and tnortal- itv are norexpected to plateau1 for African-Americans and whites until after the year 2013: However, because of thein higher smok- ing cessatlon rate, white male lung cancer mottality is expected to decline in the 1990s, with lung caneer mortality occurring later among African-Americans; While hfi+ican+Americans quit more freqpently than whites; Afri- can-Americans are less likely than whites to remain smoke-free for one year or more. In 1987„the propontion of persons who have ever smoked cigarettes and who have quit smoking was 31 percent for African-Americans and 46.4 percent for whites. Hispanics: Several studies have documented a rising lung,cancer rate among Hispanic males. For example, as reported in theArnericanJour~ nal'of Pu blic Idhaltli' in ~ Eebrntarv l 985, ,the Colorado Thmor Reglstryneported a 132-percent increase in lung cancer rates among Hispanic men between 1970 and 1980, comparedito a 12- percent increase among white men. One of!the suudy's co-authors, Al Marcus, a cancer specialist at VlA"s Jonsson Comprehensive Cancer Center, said, "There's an epidemic out there. Atd it hasn't received a lot ofanention. There aren't a lot of people studving cancer among Hispanics;" As noted in,ifirrketdng Disease to Hispanics, published by the Center#or Science in the Public Interest (11989), "Dr: JohnSamet of the University of'Vew Mexico School of Medicine, one of the researchers who documented'the increasing lung cancer rates in Hispanic males in New, Mexico, said the higher rates are occur- ring because Hispanic men have started smoking more cigarettes in the lastitento 15 years. In the past, Hispanic smokers smoked far fewer cigarettes per day thanaheir White or Black counter- parts. One study, for example, found tharMex9can-American males and females smoked about one-half a pack fewer cigarettes per day, tthan Whites ... However, that now seems to be changing:" Interventiion to Prevent Tobacco Use Effectiveli+ intervening to prevent African-Americans, Hispanics and other minoriry, population~groups from starting or continuing, to smoke is key to reducingthe burden of tobacco- related death and illness: Pro-health, anti-tobacco efforts can be of either an, advocacy or educational nature. Current andlproposed interven- tions include • Increases in the tax, and thus price, of tobacco piaducts: • Bans or restrictions on tobacco advertising and promotion; • Elimination of access by children and youth to tobacco pro& ucts;and • Educational efforts. Price of Tobacco Products Adolescents ofall races generally have limited disposable income: and their ability to purchase cigarettes is sensitive to inereases in the price of cigarettes. Indeed, research, and'the experience of other countries, have : shown that substantially increasing tobacco prices is the single mosreffectrve tool inmedueing tobaeeo use. particularly among children, and youth. For example, in Canada, where cigarette taxes were quadrupled between 1984 and 1991 so that theyare now about seven times the cumulative (combined federal and state) level in the United States, teenagesmoking,has been ~eut by well over half. The US General Aeeounting Office estimates that if the excise taxomcigarettes were increased by jicFt 21' cents per pack, the number of teenage smokers,wttite and African-American, in the United States would likely decline bv Q over 500,000, resulting in 125.000 fewer preventable deatlis. N Advertising and Promotion, Philanthropy, Influence- Peddling,and Related!Tactics Tobxco companies aggnes.sively target cigarette advertccing:md' promotion at the African.Americart, Hispanic and other minority CD communities. The itdluence of advertising and promotionlon

V atrksYlaips tobatxo use and premlence are importanrcriterin in assessing how, much control should!be exercised on tobacco industty marketing,catnpaigns: The impact of advertising and promotion on the behavior of media is also important The decision of mem- bers of the media, sometimes under the influence oftheir tobacco advertisers, not to include articles related to tobacco and health directly inhibits the flow of information which might be used by' readers to make ttuly, informed choices about tobacco ttse.In addition,, lack of exposure to tobacco-related articles about the health consequences or such issues as tobacco i6dustry, market- ing campaigns can influence cultural norms thatishape'percep- tions of tobacco use. Tobacco and alcohol ladvettising;have been the economic main- stays of the African-American press, for example, for decades. For, exampie, in 1950, Philip Morris was attacked by the segtegation+ ist publication Wfiite Sentt<nel for being "the first'cigarette com- pany to advertise in the Negro press." .Afracan-American magazines receive ptoportionarely greater revenues from cigarette advertising than do general market magazines. In 1987, tobacco advertisements accounted for 6.1 percent of~ the advertising in 166 consumer magazines, while the percentage was measurably higher in leading African-American magatines such asJet (10.2 percettt)„F.sSenre (9.2 percent) and!EGony (7:5 percent). In 1985, cigarette eompanies spent E3:3 million on advertisements inEbony alone. Moreover, the tobacco industry heavily markets mentholated cigarettes•-minduding Newport, Kool'and Sa1em-4o African-Americans. A comparison of tobacco advertisittg in maga- iines preferred by Afritatr Americans and whites, for example, showed that the percentage of menthol cigarettes advertised!in Essence, Ebony and jet was 65,9 percent compared to 15:4 percent in general market'publicationsAiudemoiselle,,Tlme, ,veovsweek and'Reopte: Similarly, Philip Morris is now the leading adOerti5er, in Hispanic markets, while RJR Nabisco is in rthe top 10. Tobacco companies also support minority-targeted media by undorwriting,key portions of their annual conferences and con+ ventions, induding the dedication in 1'987 of'the Black Journal~ ism Hall of Fame, the 1991 Mid-Winter Meeting of the Black Press and, meetings of the National Newspaper Publishers Association. Tobacco companies also have supported jounialism scholarships and internships and!provided entry-level opportunities for Afri- can-Americansin communications. Billboards advertising tobacco products are placed in predomi- nantly Africart-Americancommunities four to five times more often than in white communities. In 1987, for example, tobacco companies spent 55.8'million on adverrtisements on small bill- boards, often located close to sidewalks and storefronts, in pte- dominantlyAfrican-Americanneighborhoods,,accounting for 37 percenrof total advertising in this medium. By comparison, Afti, can-Americans comprise approximately 12 percent of the overall population. Special targeted advertising has been developed by tobacco com- panies for minority media: Paradbxically,,mosrof this advertising, has not been developed by minority-owned agencies. For ex- ample, in the past 20 years, only two African-Americaa-owned i advertising agencies have been assigned substantial cigarette billings: Burrell Advertising in Chicago, for Marlboro cigarettes in the early 1970s, and Mingo-Jones;,for Omni cigarettes in the early 1980s. Burrelllhassince stated that it'wouid not accept future cigarette accounts. Data from the six major h'S'eigarette manufacturers reveals that in 1990, United States cigarette advertising and promotional expen- ditures reached yet another all-time high of $3'.9 billion, equiva- lent to nearly E'li1 million per day. There are numerous linkages between social service and civil rights organizations within the Aft•ican-American community andi the tobacco industry. The reasons for this indude; among others, the following: • African-American organizations need money to run their opera- tions; and the tobacco indttstry is a ready source of such funds; particularly given the decrease in federal and otber govetnmental. funds that are available to African-American institutions and organizations. For organizations involved'in civil rights lobbying, and/or controversial issues, the options for fundraising are even more limitedJ • Long-standing personal friendships and business relationships between the traditionaf 4eadership of the African-American com- munity and their counterparts in the major cigarette companies migdCbe destabilized by organized,African-American opposition to tobacco interests. Foneuat»ple! VeroonJordan, formerpresi- dertt, of the National Urban League (M!L'), is a member of the board!of directors of, RJR Nabisco. Margaret Young, the widow of fbrmer .^M,' president Whitney Young, is a member of the board of directors of Philip Morris. Raymond Pritchard,' chairman and CEO of Birown & Williamson, serves on the board of directors of the NUL and is an advisor to Opportunities Industrialization Cen- ters of America. In a similar veina,the tobacco industtysuecessfully, targets the Attncan-Americatt and other minority communities by sponsoringg entertainment, sporting and cultural events and political and Ilteracycampaigns: For example, according to an internal Philip Morris company document shared by an anonymous source with Yorkshire Televasion oPCreat'Britain and!later with health advo- cates, in 1991 Philip Morris handedlout E17;339,1'54 in "philan- thropic" contributions. Among these contributions were a number of gihs to leading Afiucan-American organizations across the United States, a sampling,ofwhich follows: NAACP (national office and various chapters) $131,500 National iUrban League (and chapters) $329,070 African Americ.anCultural Center $ 1U.OCX) Associated Black Charities E to,t)(10 Thurgood Marshall Scholarship E 5p.n(10 Indiana Black Expo, Inc. $ 675(Nl National Minoritx APDS Councili $ Uo Oni 45 Toh'acco ('s? An.lme,^ican Crisis 2024196952

WOtrksiltypa Black American Political AssoQation $ 8,000 Alvin Ailey Dance Theater Fouttdation $200,920 AfricanMterican Arts Festival E 20,000. Similarly, the Philip Morris document listed, among others, the following contrdbutions made to Hispanic organizations: Vational Counciliof La Raza ET75',000. Hispanic PolicyDeuelopment $50,000 Ballet Hispanico of New York; $3,920 liberrtad, Inc. $3t10,000 NationaliHispanic Uninversity, f 30i000 The visibility of'African-Americqn elected officials and'their power at the locall state and federal levels has led the tobacco lobby to. provide strong financial support to these officials and their orga- nizations. Substantial contributions have beenimade bytobacco, interests on an annual basis to the Congressional Black Gaucus and the National Black Caucus of State Legislators, as well as individual legislators. For example, according to the internal Philip Morris documenticited above;,Philip Morris alone gave the Congressional Blkek C.aucus $86,1108 in 1991. Similar support has been given to the Congressional Hispanic Caucus. The tobacco industrWs ability to mobilize key segments of African- American. Hispanic and other minority leadership, combined with the contributions to individual politicians and their organizations, makes it difficult for, tobacco control!advocates to gain support, among minority legislative catxuses. However, there are indi- viduallelected officials whahave been pt oactive on the issue of tobacco controL Rep. John Lewis (D-GA), one of the leaders in the successful' legislktive battle to ban smoking on viirtually all domestic passenger airline flights, will not accept tobacco and alcohol i related contributions. Rep: John Conyers (D-MI) favors developing alternative funding,for organizations such as the Black Congressional Caucus Foundation, According to C(xtyers, the extent of African•Aaterican mortality directtiy related to the use of tobacco and!alcohol requires that leaders aad!organizations begin to reject tobacco contributions and support Access to Totiaaco Products A major contributor to tobacco use among children and adoles- cents of all Iethnic and racial groups is their easy access to to- bacco products. While vimually all states have laws prohibiting the sale of cigarettes to individuals younger than 18, not one state adequatelyenforces its minimtun~age law. This failure to take. seriously the minimum-age laws contributes directly to the fact that more than 3,000 children start to smoke every,dayin the: United States. Pro-health federal legislators responded by per- suading Congress to enact a compromise measure (dubbed the "Synar Attendinent") in 1992, which becomes effective in Octo- ber 1993, requiring,all states to: • Have in force a minimum-age law prohibiting the sale or distri+ bution of any, tobaceo produa to those under age 18; and • Enforce the inihimttm-age law "in a tttanner thaucan reasonably be expected to reditee tlie extertt~to which tobacco prodttcu are availiblb to individuals tmder the age of 18." The new lawprescttibes that„itastate fails to satisfry the Depalt- ment of Healthiand''Human Services in annual reports that it has met this standard, the state willilbse 10 percenrof specified blockk grant funds in the first yeaq increasing to,40 percent in the fourth and all subsequent years. The Symr Amendment i5 seen by health advocates as a step i n the righudinectionj At press time, however, regulations implementing the measure have not been finalized, and!ttncertaintyexists as to; how the new law will affect states"enforcement efforts. Educational and Related Inrterventions The major tobacco control activities that have dominated the field have been~those sponsored by the federal Igovenntnent through the National Institutes of'Health and voluntary organizations such as the American Cancer 5ociety (AOS)„ American Heart Association (AHA) and the American Lung Association (AW), andihave emphasized smoking cessation andI mass media educational and school-based programs:lltese efforts modelrtraditionallhealth promotion gqaLs that seek to.alter health status by encouragi,ng,indiHiduals to make lifestyle changes.111te seven-year demonstration ASSIST initiativo: a jointivettture bythe National Cancer, Institute,(NC!) and the,AQS includes as a partof its mission the training of'personnel in health, education, woticsite and cotttmtutityorganizations in traditional cessation and health education programs. AS5I5I"s emphasis. however, is on policy and media advocacy targeted at educating broad populations of, people, including Aftican-Americans, Hispan- ics and other minority groups, women, blue-collu workers, rural communities and others. If!new initiativesare to reinforce cessation efforts, itwill,be im- portant to understand the minimal work done in developing tobacco use cessation programs and matetials directed toward African-Americatts. Unfortunately, organized professional pro- grams are virtually unavailable to segments of the African+Ameri'- can populatiott, a problem which is,exacerbated by the paucity of materials and programs developed for persons at a low socioeco- nomic level orwithiminimalliteracy: Development of new pro- grams and materiaLsfor minority population groups would be beneficial if these programs and materials: • Are tailbred to minoritygroups' tobacco use patterns; • Are sensitive to the special obstacles encountered in the minor, ity communities; • Raise awareness of tobaceo's health risks and quitting benefits and bolster primary group norms for cessation: and • tntegrate problem definitions that reflect on the role of the tobacco industnyin the community. New minority-targeted initiatives to reinforce anti-tobaceo policy and community-based efforts will need to consider numerous impediments. First, the issue which motivates many urban com- munities concerns drugs and violence, unemployment, housinr;,

Workshups poverty and under-funded educational land health delirery sys- terns. Drugs are almajor concerrt because of the visible;relation- ship to violenee; often random and causing the deaths of innocent children, and the high priority gixen it'by the federal government. Thus, the no more than 10,000 annual deaths attributed to illibit, drugs; while not comparable to the 434;000 annual tobacco related deaths,,eonstitute the most immediate and!visceral experi- ence felt by the average community resident. Second, prevention and healthipromotion receive little support and are not:given priority in alhealth care delivery system oriented to the medical model. Third, the penetration of minority, commu- nities by the tobacco industry is pervasive through marketing efforts and!financial support of minority organizations and institu• tions: Fourth, there has been an absence, until recently (viz thee successful coming together andladvocacy effort of the (Dptown Coalition for Tobacco Control in Philadelphia), of'significant, A'fr6can-American, Hispanic and other minority anti-tobacco advo- cates and community organization support for policy, and DC2 initiatives. Fifth, there is no viable.inftastructure to enable minority, anti-tobacco advocates to communicate, network, plan and estah- lish an agenda based on principles of empowerment and self- determination. Sixth, there has been an absence of culturaflyy sensitive and racially relevant anti,tobaceo advocacy and commu- nity organiiing materials for use in loeal communities. Finally, viabfe interactions between minority anti-tobacco advocates and mainstream advocates and organizations have been lacking. Recommendations Black, Elispanic„Asian and Native-Atnerican commtutities:are tinder, attack by the tobacco companies; they are the targeted communities. As a result; these communities may be designated as a "chronic disaster area,' for the purpose of,focusing tobacco control activities. Given limited!ftutdirtg, we must also better target resources to communities:whioh suffer, eexcess mortality, and morbidity due to tobacco. To mount effective strategies, this committee decided to focus on children as the front line oftobacco use prevention efforts. Cessa- tion efforts were considered as critical for adults. The committee encourages the other comntittees to ensure that their recommen- dations include targeted communities. The committee makes the following recommendaiions; [. Data • There needs to be improved data on iall aspects of tobucco. controt'in African-American,, Hispanic, Asian and ]Vative- Americarccorrmmunities; The federal government must take the lead by encouraging the states to collect data, unifornily and include race and ethnic data in their data collection activities. The committee welcomes efforts by states to include information regarding tobacco-related deaths on deathi eertificates. ?'_n,hacco Vscr.-ln_thnEn-ican Crisis II: Education • Counter-adOertising is a,crdtleal componentto education. Messages must be detieloped,wttich lare culturadly competent; ,this means that the targeted1community should be irnolved! in the development ofcounter-advertisetnents. Additiottafty; it is essen- tial,to implement both offensive and defensive strategies. For example, the Department of F[ealthland Human Services should be allowed to purchase air time for the ads irdevelops, materials on counter-heroes within targeted!eommunities should'be dis- seminated, tobacco companies should be made more responsible for their, actions, etc. • Comprehensive school education is criticat fo>• K-17. as wefl as programs targeted to out-of-scboot youtb: IfI. Leadership and employment • We need more leaders. We need 'to develop a cadre of leaders of targeted communities to be active at all levels of tobacco con- trol.' We need to establish and reinforce communication channels among members of targeted'commtmities: There exist.s an oppor- ttmity to create ttew political leadership, with children being,the dinvurg force and tobacco being the motivator. • 1Re need to work witb community-based organizations, especialty credible ones wbic6 bave not taken tobacco money: Long-term funding for programs must be identified from the inception, and incloded ias part of the program strategy. • Tbegoals in "Healtby People 2000" sboulrt be made more cballenging, and t6egoals for the overaQ popuLation sbould be applied equally to all targeted communities IV: Excise tax • The committee reoommends enactment ofasignoficant and substantral federal excise tax ($Z)n wbt c6 is not earmarJred.' It is important to note that the prunary'purpose'obthis taaci5 to decrease consumption and not necessarily to raise funds for heaWi-related i acflvities . • State and loeali taies should be increased substarttialht; and can be earmardted for beafth. V: Worksite • Given the additdonat support provid6d by the recent findings of the Enuironmentat P,otectibnAgency rdatect to tbe barnn caused'to nonsmokers by environmental tobacco smoke, all e,(J''ortssbould'be mnde to make wonksitessmokefree. • Ali federTafly<funded facilities should be required!to be smokefree.

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