Tobacco Documents Online

NVork.ihops Environmental Tobacco Smoke Introduction The support for public policy ehanges on issues related to envi- ronmental tobacco smoke (E3'S) has changed drantatirallyduring the last decade. By 1986, the scientific and public health commu- nities had reached a consensus thatexposure to ETS was a sigrtifi- cant cause of lung,caneer in nonsmokers. This scientific consensus rapidly expanded to include the regulatory agencies, local governmental jurisdictions, the business community and thee general public. Wath~the release of the EPA risk assessment dassi- fying ETS'as a Group A Carcinogen earlythis year, it is only the representatives of the tobacco industiy who question the validity of the datalinking ET6 exposure to disease. Gutsently,even those groups opposing ehanges in local ordinances generally accept the health evidence: There is no longer significant disagreement that, ETS exposure causes dtsease at the levels of exposure ~that'~occur in everydayilfe in US society, and that separationof smokers an& nonsmokers in the same air space, or filtration of the air with commercially applicable technology, does not:reduce exposure sufficiently to lower the risk below the regulatory threshold!for other occupational~or environmental'caexinogens. The evidence indicating thauEPS is responsible for the deaths of 53,000 Ameri- can nonsmokers each gear from caneer4 beart disease, and other illnesses, a number of deadts substantially larger than that cat>5ed by automobile accidonts,,has fueled efforts to ~restrict smoking in workplaces and public pl9ces to protect nonsmokers. The consequences of Ef5 exposure for children ane partiaulariy severe: In children, EfS exposure causes an increased risk of bronchitis and pneumonia, reduced lung function growth, in- creased prevalence otmiddle ear disease and asthmatic excerbations, and is a risk factor for the develnpmenUof new, cases of asthma This increased vulnerability of children to ~injury from ETS exposure makes!them a high priority for efforts to protect nonsmokers. 7fie widespread acceptance of the health evidence allows afunda- mental shift in the strategy used to prrotect indiMduals firom ECS exposure: Instead of focusing energy on convincing,public poiicy, , makers that the data establish a health risk„efforts can now shih' to persuading them that they need to respond to the risks gener- ated,by ETSexposure using: the same logic and+standards that apply to other occupational!and environmental toxins and car- cinogens. A substantial body of experience and legal precedent already exists to protect individuals from toxic and carcinogenic Julia Carol David Bums, M.D, exposures in the ge.neral environment and especially in worksites. and this experience and precedent can now be applied to ETS exposure. The norms that establiish,roles and responsibilities of'emplorers; levels of acceptable risk, justification for'84vemmental interven- tion; compensation for worker,s injury, and legal liabilityused for other occupational and environmental agents can now be broughtt to bear to reduce exposure to ELS. Once the risks are acknowl- edged and other mitigation strategies are examined,,it,becomes dear thatlasmokefree environment is the only option that does not require a special exemption for ETS from the existing stan- dards for acceptable rislts dtte to environmentaljexposures: The pressures for change generated by the existing ftamework for environmental and occupational protection can be linked with the community based grassroots movement currently driving efforts to protect the ttonsmoker,,and the result would be a more com- prehensiweand effective approach to protection of nonsmokers. By combiningincentives from a variety of directions, inclttding economic benefits and risks, social pressure and the appropriate combination of ordinances and regulation„it is possible to both promote the cutting edge of change in nonsmoker protection and motivate those lagging behind'to catch up:. It is far cheaper and easier for employers to prohibit smoking in the workplace than it is to install several cpmplicated expensive ventilation systetns to segregate the smokers.lfie implementation of smokefree policies is easier when empioymean tell'their customers and employees,that ~thelaw, requires them to be smokefree;,and'worksite policies are more effective in~actuallv protecting nonsmokers from!exposure when diere is also a stronF, local ordinanee: Employees are winning workers' compensauion i cases based upon being forced'to work in a smoky environment For eramplo;,in Sat>5alito; California a nonsmoking, vegetaraan waiter with no (amily history of heart disease was awarded an $85,t)0!Q settlement after suffering a heart attack caused by %cork- ing for five years in a restaurant that permitted smoking., This case represents only the tip of a very large iceberg of potential work- ers' liability in this ar7ea, The current state of scientific data on k`lIS exposure is adequate to define ET6 exposure as a conttibuting factor or exacerbating factor (the operationall'anguage for compensable injury in the workers'' compensation~system) in cardiovascular disease, lung disease and nespirvory, cancers in smokers as wellla5 nonsmokers.lltis creates a potential workers''

Worksliops compensation claim for approximately two-tbitds of;the disease that occurs in the US:. As this body of'legal precedent develops it will create a powerfuf economic incentive to become smokefree in all areas of'employ- ment. In addition, as employers acknowledge the risks or can be shown to have been informed of the risks and'do noutake action to eliminate ETS exposure;,they mayalso.incur liabiliry based on claims of~ negligence. Public places such as restaurants are also workplaces for many people. In fact, according,to Smoking and Restattrants: A Guide for Policy-Niakets, published by the Universityof'California; restaurant workers are exposed to three to five times more E15 than other workers, and consequently have about four times the expected lung cancer mortality and two-and-a-half times the expected heart disease mortaiity rate. The perception of what is acceptable protet:tion for nonsmokers in a restaurant changes dramatically when the restaurant is considered as a worksite exposing employees as opposed to a public place exposing only the patrons. Actions Taken to Protect Nonsmokers- State and Local Although some states restrict smoking in public places, the vast majority of this protection occurs at the loeal level. To date, over 540ciUes and counties throughout the country have enacted! ordinances to:protect nonsmokers. In the 11980's, these ordinances provided for smoking and non- smoking areas in workplaces and restaurants, while eliminating smoking inmost other public places. It is interesting,to note that the tobacco industry, opposed the creation of separate sections and warned businesses of economic disaster if these sections wereput in, to effect. In 1986, then-SutgeonGeneral C.. Everett Koop acknowledged that these ordinances provided onlypartial protection when~he declared that "the simple sepanation,of smok; ers and nonsmokers within the same air space may reduce, but does not eliminate: the exposure of nonsmokers to environmental tobacco smoke." This declarstion led to a1sh&in the proposed protection of nonsmokers toward a smoke free work environment insteadlof separate sections. After the EPA's drafU risk assessment was released in,199U; a number of cities and counties began to adopt complete elimina- tion of srnoking in workplaces and restaurants, Four cities efimi- nated!smoking in restaurants in late 1996;,another seventeen did' so in 1991, with most of the new ones also eliminating smoking in all!workplaces: To date; 13 cities.eliminate smoking inirestau- rants, i l eliminate smoking in workplaces, and 24 aties or counties eliminate smoking in both-a total of 48 smokeftree ordinances. The tobacco industry is ~now supporting separate sections, and maintaining that instituting a smoke free environ- ment will lead'to economic disaster. The shift from ordinances restricting smoking to ordinances completely eliminating smoking represents the most dramatic and significant change over the Ihst fewvears: This shift is possible Tp1JaGcof *SE' .-lrt.~?mP+,C.In crsi'S because of the strong support from nonsmokers and smokers alike for these ordinances. Smokefiee ordinances have been upheld by voters in communities throughout ~ the country despite attempts by the tobacco industry to repeal them. In November of ' 1'992; voters upheld five different local smokefree restaurant ordinances bv an average margin of victory of 21 percent: The heated, public campaigns to enact these ordinanees aree important to their effectiveness because diey raise the entire communitys awareness of the dangers of secondhand smoke and of the changes being mandated by the ordinance. As a result, these communities know about the existence and importance ofl these ord'utances;,and''by forgittg,a consensus become invested in their success. This process helps ensure compliance with the new law in ~a manrter ttiat istate and federal regulations often cannot aecomplisli. In addition, it is easier to develop a consensus within local communities on the appropriate extent of restrictions nn smoking,to be applied, and this consensus is critical to sustaining the ordinance and promoting effective peer enforcement. The extent of'restriction that can be sustained on a local level in individual communities is generally greater than that sustainable byastatewide consensus which must include bothithose commu- nities who are supportive of restrictions and those which have not yet 1 reached thatievel of consensus, The result is that statewide laws are likely, to be less comprehensive in their protection of nonsmokers and less effective in their implementation. The devell opment of'a national consensus to supportilegislation protecting nonsmokers on the federal level would be even more dill'icult and would be likely to lead to even less comprehensive andleffective policy change. Although local laws have become stronger and more numerous at the local' level, the tobacco ihdustty has been able to prevent strong, effective laws from passing at the state level; and'the general population is often isolated from the debate surrounding passage of state laws. These laws often go into effectwithotu the communitys awareness of the need for the law; the details of its provisionsi,or the process for its enforrement The tobacco industry knows thatlocal!laws tendito be stronger, and more effective than state laws;,and their primary strategy is to strip cities and counties ofxheit power to : restrict smoking by passing weak ineffective state laws that preempt,local'control. Eight.states partially or completely preempt local smoking restric- tions, Even when state laws do not include preemption, they c:ui have a chilling eHect on local action. Fxperienee in the U.S. has shown that dte recipe for succecs is a combination of education and legislation; both are needed to ensure support for and1eompl'iattce with strong. comprehensivee smoking control legislation. The public debate over dte enactment of local tobacco control ordinances is one of dte best public education campaigns available:. Federaf! Legislative and Regulatory Actions In 1989, Congress enacted!an amendment offered by [Reprcsenta- uve Dick Durbin (Dlti:) and Senator Frank Lautenberg (D-v.1) eliminating,smoking onvictuall~°all domestic airline flis;ltts: Thr 202419ss5s

tiri'clrishops law strengthened and made permanenta 1987 amendment that eliminated smoking on domestic flights of two bottrs or less. The airtine smoking;ban remains the most significant federal action protecting nonsmokers. Mthough the airline smoking bandoes.not extend to international flights,,the United States representative to the Intemational.civili AviationOrgan'v.ation supported a resolution encouraging mem- bership nations to prohibit smoking on their international flights. Other federal measures to protect nonsmokers were defeated, however. andlpresident Bush failed to respond to a proposal from Louis Sulliwan, Secretary of Healdi & Human Serviees, for an executive order requiring federal agertcies to be smokefree. In late 1992, Senator Gautenberg successfully, amended an appro+ priations bill to require programs receiving federal funds that serve children under the age of five to be smokebree: A similar proposal introduced by Representative Durbin was not consid- ered in the House; and the Lautenberg amendment died in confer- ence committee. Over the objections of the Secretary of Veterans Affairs, Edward Derwinski: the House voted to overturn the veterans' hospitals smokefree policy, which had been established'to comply with new standards estabiished.by the JointiCommission oaAccreditation of Healthcare Organizations. Congress subsequently approved legis- lation that may jeopardize the VA policy. To date, the only significant federal law protecting nonsmokers remains the airiitte smoking ban. Policy Questions Federal, state, and local!governments have all provided important protection for nonsmokers, and each level of!government can make unique contributions to this protectim For example;,smok- ing restrictions on aircraft could not be enacted on a state-by, state basis. Airlines needed to be covered'by a federal law. Similarly, federal agencies are exempt ftom state and lbcal laws, andlederal action is needed toproteehemplores and4he publicc in these facilities. The goal of regulation at any level is to change the behavior of smokers in order to reduce or eliminate the exposure of non- smokers to E1'S;,and it is the effectivertess of agiven regulatory approach in actually changing smokers' behavior„ratherthan simply the comprehensiveness of,the regulations enacted, that determines the extent of~protection provided to nonsmokers. The effectiveness of an ordinance in changing the behavior of smokers is heavily influenced by the norms for expected behavior among smokers and nonsmokers; by the support and peer enforcement within the community;,and by the awareness o0smokers and nonsmokers that the rides have changed. For these reasons; the federal government may not always be the most appropriate jurisdiction for regulating smoking.lfie federal government may have the authority and responsibility to regulate worksites and other environments uniformly across the nation, but tharauthority does not automaticaily translate into a protection of.nonsmokets un le~s there is compliance with the ~riegulations by individuall smokers and enforcement ofthe regulation by individual nott- smo kers and i individual employers. Local jurisdictions have been able to respond more rapidly to the changing understanding ofthe risks ofETS exposure because it is easier to develbp a consensus to supportithese changes in a single locality as compared to nationally. Similarly, local workplace and public places laws are often stronger and more effective than federal'laws because they can be developed and enforced based on the locally derived consensus. The federal regulatory structure must recognize the limitations of~develbping,and!implementing regulations protecting nonsmokers; andj in the process of!fulfill- ing its mandate to provide a safo environment, it should nott restrict the freedom of the states and cities to enact strong, effec- tivemeasttres tailored to the needs of their own communities. Regulatory agencies like the Occupational Safety & Healih Admin- istration (IOSHA) must recognize the critical role played by local ordinances in ertsuring the control and enforcement.thatprovide effective protection for nonsmokers,. In determitting where to direct efforts to regulate smoking,,thee following issues must;be considered 1. Each jurisdiction should take action to eliminate e:xposure to environmental tobacco smoke: 2. Each jurisdiction should take care to provide the most effectivee enforcement ofthe elimination of exposure to environmental tobacco smoke. Recormnendaiions The following list of recommendations is in order of priority:. 1. All'jurisdictions should!take action to protect children from exposure to environmental tobacco smoke. For example, we endorse the legislation proposed bylfwngressman Dick Durbin and Senator Frank lautenberg which ~would require all feder- aily.funded'children'S programs to establish and make,a good faithi effort to enforce a nonsmokirtg'policy that protects chil- dren from exposure to environmental tobacco smoke. !n, addition: A. f.ocal and State governments should enact legislation requir- ing that agencies receivittg government funds for providing services to children be 100 percent smokefree. B. State legislatures and!local school boards should enact regulations requiring allipublic elementary and secondary schools to be 100 percent smokefree in all areasof the ctmpus. C. The Congress should enact legislation requiring allcollOcs andI universities thatireceive federal'funds to be 1011percent0 smokefree in all enclosed areas, 2. All jurisdictions should take action to protect workm and other people from exposure to environmental tobacco smoke. A. The local governments should establish ordinances requir- ing the elimination of environmental tobacco smoke in all restaurants and other worksites.

Wcrrksltops B, The State governments sbouldlestabli.sh atlean Indoor Aii law without preemption of local tnandates. C. The Presidentishoutd sign an executive order making en- dosed federal workplaces, including all branches ofthe mili, tary, and the veteransAdministration ,hospital.s; 100 percent smokefree to ensure that,affemployees are prrotected from exposure to envinonmental tobacco smoke. The Congress should'institutionalize this policy by enacting legislation to protect employees from the hazards of environmeatalitobacco smoke and should~ extend this policy to cover all buildings in the Legislktive andjudicialBranches. D. The Congress should enact legislation requitang all!internay tional airline flights by, American carriers originating from or landing in ahe United States or its territories to be 100 percent smokefree, and the Department of'Ttansportation shouidd support and aggressively pursue international standards to make all international airlines 1IDO peticent smokefrae. E: OSHA should develop regulations covering smoking in the workplace, and shoul&aonsider the irnportaace of'local norms in the effective enfoncement of policies to protect nonsmokers. 3. Economic incentives for businesses tu go smoke hee should be developed A. Tobacco conttol ieommittee.s should work with insurers to acquaint them with the liabidtty implications of environmental tobacco smoke exposure and encourage them to differentially rate worksites by their smoking policies for purposes of work- ers' compensatdon insurance. B. Members of the scientific and legal communities should support the development of legal precedent that indltdes, diseases secondary to ETS exposure under those conditions covered by the workers' compensation system for, both,smok< ers and nonsmokers. Tobacco t"se .-1n .3mericnn Crisis ` l

WWrlcshctlts Whio's Minding~ the Tobacco Store.? It's T'une to Level the Regulatory Playing Field "We accept an interest in people'sbea!!b as a basic responsibility, paramount to every ot,ber consideration in our business. " Tobacco Industry Advertisement to the American Public. The New YorkTimea, January, 1954 I. Introduction As the Food and Drug Administration continues to use its authori- ties to protect the health and welfare of'the Mterican~public from misbranded, adulterated, dangerous products, there still~remains one product that in spite of the fact that it kills over 430,000 Americans each year remains, as columnist Ellen Goodman noted, the "Missing Entree in the Regulatory Menu." Thatprodirct iss tobacco. Its absence from specific:regtilatory controls is not an accident but rather a tribute to the tobacco industr}rs long,time strangle hold over the Congness and the Executive branch. What other producrcan boast that it is a major cause of caneer4 heart disease, emphysema, stroke, premature births and other ai.finents and still be allowed on the tnarket? What other addictive drug (nicotine) can be sold on the markerwith virtually no federal advertising, promotion and distribution constraints except for so- called industry'woluntary efforts,', which have not protected the public, for nearfy 34 years. Aitd'whatlother product can make, unsubstantiated implied health claims about itself (Le. low tar, low nicotine and weight control), contain dozens of untested and undisclosed chemical additives, as well as undisclosed harmful constituents, and still remain on the market-2 It is now almost thirmy years since the first SarggoniGeneral'.s Report was released!implicxring cigarettes as aleause of'cancer- almost thirty years since Surgeon General Luther Terry,,MD:fiist indicated that any voluntary efforts by the tobacco industry didbot "obviate the desirabiliry of enacting specific regulatory authority to express those minimum standards that protection of the publicc interestirequires." in 1964, when the first Surgeon General's Report on cigat ette. smoking andlcancer was first released, numerous bills were introduced in Congress that would have resulted in specific au- thorities being vested in the Federal Trade Gommissioner and!the FoodI and Drug Administration designed to ensure the proper reyulationiof this dangerous consumer product Unfortunately; the tobacco ind'ustrs was quick to develop: leqislative and public John S1adb, hiD : Scott Ralfin, JD relations strategies that were designed to ensure that no such lawss were ettacted As a4ormer Y'ice President of the Tobacco Institute, Frederick R: Pattzer, was to later aclmowledge in a 1'972 confi- dential memorandum to then~Tobaoco institute president, Horace Kornegay;,the holding strategy was °brilliiantlyconceived and exeauted," and imofved: •"creating doubt about the health charge without actually deny- ing it" •"advocatittg the public's right to smoke without actually urgin& them to 1 take up the practice." •"encottragipg objective scientific research as the only way to resolve the questionof health harrrd." The strategy according to ~Panzer involved particular attention : to issues in the areas of'litigatlon, legislation, and public relkt9ons; In July 1992, a Goalition of national health organizations (includ- ing the American Cancer Society, the Ameri:can Heart Association, the American tutttg,Association, the American Public Health :1.s.so~ ciation; the American Academy of'Pediatncs, the American t:ol- lege ofGardiology„the American Association for Respicatory Gare, the Association of State and Territorial Health Offcials, and the American Society of Internal Medicine) senra letter to Congress- man John Dingell, Chairman of the House Energy and Commerce Committee, asking that he open a thorough imestigation into whether representatives of the tobacco industry and the Tobacco Institute sought on i nttmerotu occasions to defraud the House Energy and Commerce Gommittee and its subcommittees as well as the public by repeatedly stating that the tobacco industry was engaged in an objective, independent scientifie inquiryas to the link between tobacco and disease. In its closing,paragraphs the Coalition asked that Chairman Dingell "explore the need to once and for all bring this addictive drug in Line with the way other legalj dangerous products are regulated. It is time, after 25 years of patience, to do what Surgeon General Luther Terry; MD and FTC Chairman Paul Rand'Dixon and a number of other Congres- sional members believed crucial to the protection of the public health -thatis to regulate the manufacture, distribution, sale: labeling, advertising and promotion ~of this nation's leading cause of death." It'is a natlonal health travestythat an inherentl.y dangerous prtxl- uct; that is by far the number one cause of preventable death inn the nation, should'go virtually unregulated': The few fcdcrall;uid

Workshops st7te lmvs and'regulations that do exist ane a patchwork of incom+ plete and ineHective eontrols. To date only the Congress has had any specific authonity toregulate these products for health and safety, p,urposes: Unfortunately for the health of the Americart public, tobacco has been exempted!fcom every major federal' health and safety lawenacted by Congress including the Constuner. Product Safety Act,,the Fair Gabeling and Packaging Act, the Toxic Substances Act and the Federal Harardous Substances :Act: Be- cause the-Congress has failed to deal~with the tobacco issue, millions of people have needlessly died or been disabled!frlom~ cardiovascular disease, cancer, emphysema, stroke and a host of other diseases. With health care costs eontintting,to skqrooketj with,preventive health measures finally being viewed as critical to health care reform, many national health organizations as well as many members of Congress believe it is timelor a change: FDA Commissioner David Kessler has on many occxsions ex- pressed, hisstrong,belief about the role hesees#ordte FDAincarrying out its statutory, responsibilities, eapet•ially for high rosk . products which ltave the greatest impact on health. As he said in aa speech published in the iVovember 1991 edition of the Food.Drug Cosmetic Law, journal; "I have sev a range of goals to make the agencymore credible, more eEficient and better equipped to serve the country in the future: But ifiyvu ask whauia the essence of my program I'would answer quite simply thatit is to enforce the law:'- Settaag aside the historical, political, or economic circumstances surrounding the tobacco issue, it is obvious that this product should have and wouldhave beenIremoved from the marketplace a long time ago. Instead, today we find ourselves at the other exteeme-faced with the manufgeturing, distribution, sale, L1beh ing and advertising of a widely used, addictive product that is subject to minima!'and ineffective regulation. What follows is a three pronged proposal to correet this;national travesty. • The Executive Branch at both federal'and state levels should use every, available means to make the regulation of tobacco products a central feature of health policy and practice. • The FDA and the analogous existing authorities within states should'regttlate tobacco products which make health claims (implied or direct) or which seek to alter the structure or func- tion of'the body and therefore fallsquarebyunder the definitional requirements for "drugs". • The Food, Drug and Cosmetic Act (iFDC Act) should be amended through legislation to specifically and unequivocally bring tobacco in dine with the ways and means other products (parricularly ttiosepresenting;health rnsks to the public) are regulated. IL. What can the FDA and states do under existing authorities to regulate tobacco products Legislative and Legal Actions Defining "Drugs" In 1906, Congress enacted the firstI federal food and drug law: The primary purpose of the Acrwas to ensure safety of products sold as foods and drugs. The Act defined "drug" very narrowlyto include onlythose ar<icfoswhich were litted in the US !Phamna- copeia. Manufactured tobacco proI including cigarettes, were not listed at thatItime. Since 1906 the authority of the FDA has been expartdedito include, cosmetics and medical devices as well as food and dtugs. All!of the products covered by the Act are products that are either ingested by man, are applied to the skin,,or implanted into the body, FDA regulation of these products not onlycovers the com- position of the products, but in most cases their labeling, sale; dist„ibutinn; adirrristng and promotim In the 1930s, Congress, concerned with an increasing number ob ineffective, unsafe and dangerous products and devices appearing on the market, expanded the definition of"drug" ttnderthe Act. 1fie Senate.Cotttmittee Report accompanyjrtg dte 1935 Act noted: "Thedefinition of'dnug` has beert exp,nded'to inciude, first, substances and prep'drations recognized ia the Homeopathia Pharmacopeia ofthe United States;,second„devices lntended fpr use in tbe cure, mitigution, tteatment'olprectention of dis- ease; third, substances, preparationsand'devines intended for diagnostic purposes; and fourth, such articles other thxn foodIand cosmetics intended to affect the structure or function.of the body. Such expansion of the definitibn of the term 'diug!'i.s essen, tial'if the consumer is to be protected against a multiplicity of devices and such preparations as 'Mendedzers,' many of'which, are worthless acbesrand some of which are distinctly dangcrous; to health." (Emphasis added.) Congress was also very dear that product definitions am notI and should not be mutually exclusive. As the Senate Report furifier noted:' "The use to which the product is to be put will determine the category into-whiiih it will fall. If it is used only as;a food it will come under the definition of food ornotte other. lfiit contains nutritive ingredients but is sold for dtug use only, as shown by Meling and advertising; it will come under the de9nition of dnig but not that of'food. If it is sold to be tued both as a food and for the prevention or treaunent of disezse tl,would satisfy both de6ni+ tions-and be subject to the substantive requirementsof both.l7ie manufacturer of the article, through his representations in con+ nection vith its sale can determine the use to which the article is to be put." (Senate Report 74-361, 74th Congress: Session. l'935p. 4. See also„C/.S: u. Artdcle--,Sudden Change, 409 F.?el 734, 739., 1969)i It is, thus„legall~ arguable that low tar and low nicotine cigareues dearlyfit'within the parameters of what both the Congrctssand the courts and state laws intended when theydefined.drug.c. Tobacco companies manufacture, advertise, promote, and sell low tar and low nicotine with the obvious intention of playing,on the publie's perceptionthat use of these products will mitigate and prevent the onset of disease assoeiatediwith smoking. S3 Tnn,.cco l';e: .1i:r •?rnerican Cris:s . 202419sgGo

Wor. 6itttyps . Court Rulings Find Tobacco Products to be "Di:ugx" Under the FDC Act The expanded definition of~"drugs" was applied against cigarettes in two FDA related courticases in the 1950s. The courts found!tfuat conventional cigarettes could be "drugs" under certain circum- stances. In the court's view;,the question of whetheror not the FDA could assert jurisdiction over tobacco hinged on whetfier or not the prodttcts were being sold as articles intended toleither mitigate or prevent disease or intended to affectthe function or structure of, the body and thus were not sold just for "smoking, pleasure only." As the court noted in U.S: v. 46 Cartons Fairfax Cigorettesr. "lfIclaimanCs libeling was such that it created in the mind of the public the idea that these cigarettes could be used for the mitiga- tion or preventionof the various named diseases,,claimartt cannot now be heard to say that it is selling only cigarettes and not drugs... The ultimate impressionuponihe mind o[the reader arises from the sum total of not only what is said'; but also all that is reasonably implied if claimant wisbes to rmp the reuvrd of sucb claims let'it bear the responsibility as Congrez, bas seen fst to impose on it:"' This was the first time that cigarettes were found to ~besubject~to the FDA's jurisdiction because they; were nousold""tnerely for smoking pleasure" but had other intended purposes. Because those cigarettes could not meet the statutory and regulatury re- quirements of the FDC Act;,they were removed from the market- place. The idea of classifying cigarettes as drugs has been reaffirmed by the FDA in testimony before Congress on~ntunerous occasions and' again more recently bythe courts. In 1977, for esample;,ia at- tempting to further cfarify FDA's jurisdiction, A'ction~on Smoking and Health, (ASH) and others filed a petition with EDA seeking to classifiy all'ciganettes as drugs under Section 201 (g) (C) as ar- ticles "intended to affect the structure or any funcflon of the body of man ~or other animals." The premise onwhich the petition was filed was that because all cigarettes contain nicotine "they fall easily and squarel j+wvitttin the broad'langttage of the act" FDA denied the petition-a decision upheld in c.otut in 1980. Then FDA Commissioner ponald'Ketutedy and the Court held thai'the petitioners had failed to establish an "intenP' on the part of the manufacturer to sell a product which "affected tttesiructure or function of the body" Specifically,,the Commissioner wrote: "Statements by the petitioners and!citations in the petition that cigarettes are used by smokers to affect the structure or functions of their bodies are not evidence of such intentbythe manufactur- ers or vendors as requiied;under provisions of the FDC Act." However~ in denying the petition„the case gave further clarifica- tion as to the requirements needed to be satis6ed before FDA would assert jurisdiction under Sec. 201. The FDA said that inithe case of cigarettes in general, petitioners f9iled to provide suffi- cient eidence to establish that manufacturers sell cigarettes with an intention of affecting the structure or function of the body. The issue of whether tobacco was coatained in the products was and is not pertinent to a determimtioo asto whether or, not a tobacco product is a'.tirug„ifit meets the statutory and court requirements. Consumer intent alone (absent a showing ofI ven- dor interest), said the Court;,was evidence, but was notsuffieient by itself to bring the cigarettes under the definition of~"d ivg" under the Acti In 1988, with this decision dearly in mind, the Coalition on Smokirtg OR Health (American Cancer Soeiety, American Lung Association, and the American Heart Association) filed.a petition with FDA seeking:to classify all so-called "low.tar"'and "low- nicotine"'cigarettes as "drugs" under the FDC Act The Coalition's petition is based!on a thorough review of the advertising and marketing strategies of'these products by the inditstny as well as evidonce relea.sed as a result of the 1988 CipoQone v. Liggett Group Inc. liabitity case. In that case;,for example;,[7S District Court Judge Sarokin noted that the tobacco companies: "were well aware of the extreme difficulty smokers had and have in quitting smoking. Tfiey knew based upon sophisticated re- search that a smoker who found!it difficult to quit, particularly faced with claims of hazards of risks, would4ocus on any rational- ization to justifr his or her continued smoking;."and "plaintiff ~ offered expert testimony which demonstrated that evenafter the companies erased ma}dng,specific health claims, the vast adver- tising of the industry created a consistent message of purity, health, safety; reduced tars and nicotine, etc This campaign served to create doubt in the minds of the consumer as to smok- ingd9rtgers, and played on the wealmess of'those who were either addicted andror deaendent" The Coalition's petition concludes that there is a clear indication that the tobacco industry has marketed these products with the clear intention that by using low-tar and low-nicotine products a smoker can "mitigate" or "prevent" diseases associated with the smoking habit A series of advertisements run by, Vantage brand cigarettes;such as the one below in Time on January 8, 1973, biatantlyindicated this intended'purpose: "For years, a lotof people have been telling the smoking public not to smoke cigarettes, espeeialri cigarettes with high 'tar''and nicotine...Since the cigarette critics ane concerned about high 'tar' and nicotine, we would like to offer a constructive proposal. Perhaps, instead of telling us not to smoke cigarettes;,they can telli us what to smoke. Forinstance; perhaps they ougjtt to recom- mend that the Americatr public smoke Vantage cigarettes...Vantage gives the smoker flavor like a fuMavor cigarette. Butit's the onlyciganette that gives him so mudt flavor with so little 'tar' and nicotine:..": Tfie message contained in that Vantage advertiseJnent is one that is repeated'over and over again in today's marketing of low yield' cigarettes. In one recent edition,of Life magazine, three (3) such advertisetnents appeared. The Coalition's petition has remained pendinI FDAsince 1988. Since that petitionwa.s filed, over one and a halfimillioni Americans have died from ciganette smoking

Wt,rkshops ~",.N~.~~ ... . Also in 1988, the Coalitionion Smoking tDR'Nlealth and the Ameri'- can Medir.allAssociation filed separate petitions seeking to classify a newly developed R. J. Remolds', cigarette-like device named Premier as a drug under the FDC Act The arguments asking FDA to asserrjurisdietion were based on ia premise similar to the low, tar and low-nicotine petii that R. J. Remolds called its new, product "deatter,"'one which "reduces the controversial com- pounds7and sold it as "safer," that is, designed to mitigate and prevent disease and to affect functions or structures of the body. Because R J. Reynolds withdrew the product from the market, place, no action from the FDA was forthcroming; Petitions on other similar products were filed in 11991 and 11991 Defining wfien FDA can-or cannot-assert jurisdiction over, cigarette or cigarette-like products was further clarified in Febru- arv 1,9&'. A manufacturer wanted to market a non-tobacco "ciga- rette-like device consisting of a plug impregnated with nicotine: solution inserted with a small tube--cornesponding in appear- ance to a conventional cigarette." FDA had no difficulty inclassify- ing the product as a"drug.' After reviewing promotional ~ material as well as registration material filediwith the Securities and Ex- change Commission (SEC), the FD'A'reached!the following conclu• sion: "It is our position that, Favor is a nicotine delivery system intended to satisfi a nicotine dependence and to affecnthe structure or one or more functions ofithe body." Masterpiece Tobacs is another case of 'FDA asserting jurisdiction over ai nicotine delivery system, in this instance one which con- tained tobacco. The product was being soldiin the form oflai chewing'gum. T1tte manufacturer argued that because the product contained shreds of tobacco„it was outside the FDA's jurisdiction. The FDA disagreed and ruled that the productiwas a"food'..' under the FDC Act because that definition included "chewing gum " Because tobacco is not an approved substance for use as an additive in foods, the FDA ruled that the product was aditlterated and could not be marketed for health and safety reasons. Finally, in 1'989 the FDA issued a regulAtoryletterto C.A. Blbckers, Inc. indicating that a cigarette additive, "N=Bloetin, "was a "drug" subject to regulation bythe FDA. "N-Bloctin," according to the FDA regulatory letter "is analcohol-containing cigarette additive, the intended uses of'iwhieh include, throughiactionat the tissue cells, to inhibit the accumulation in the lungs of nitro- samines present iniconventionai cigarette smoke and thereby to prevent lung cancer."'The regulatory letter goes on to state that "[;c] jgarettes marketed as containing the 'N-Bloctin' additive such as the '(;!ptima' and 'Spectra' brands, are also 'drugs' under Section 201(g)(11) (IB) and (C) of the Food, Drug and Cosmetic Act. When one or more of'these uses for cigarettes containing, 'N+Blocun' is recommended or suggested!in the labeling they would be 'new drugs"as defined in Section 201 (p) of the FDC Act and subject to Section 5o5(a) and 802 of the FDC Act:" At the state level, efforts are already underway to seek classifica- t;on of low tar and low nicotine product~ as drugs under; state laws Petitions have been Piled!in a number of states citing state drug laws which mirror alhnosrword for word the federal drug statutes. State attotne}rs general hape afSo been asked to use tfkir authorities to crack down on the adverti5ittg„promotion; and sale of these products u'drugs''thereby avoiding the issue of federal pr eemption. While the federal Gganette Izbelittg and Advertising Aetipreempts states from regulatingthe advertising and Iabeling of cigarettes, states retain their full authority to regulate any and all products which are deemed'to be drugs. If Congress had!intended to limit their authorities in this area they would have done so. The neer! for FLfA to use exfstdng,autborities is urgent. While the 1990 Surgeon General's re.port, Tbe FJealt h' Beneftts of Smoking Ceasation, touts the beallti benefits of quitting, the tobacco indtt.stry continues to promote low-tar andilow-nicotine brands of cigarettes at an ever increasirtg,rate. The cl.ear, implica- tions of this calculated stmtegq'ts that, instead of quitting, smok- ers will continue to smoke, believing tharthe products they switch toare somehow safer and!will mitigate their risks of disease. More and more so-called "safer" products are appearing on the mar- ket A consortittm iof over 60'national health otgitnizati.ons be- lieves the FDA has the authority to puta slop to this deception, and to prohibit unsubstantiated health claims. III0(l The need!to amend the Foodj Drug and Cosmetic Act to regulate the tnanufaeture, distribution, sale, advertisittg, and promotion of tobacco products Because tobacco products are dangerous and addietive: it is onlv rational that, atialminimum, tobaccarproducts be reguLtted in a marmer similkr, to how other dangerous but legal consumer products are regulated. Past attempts to bring tobacco under the jurisdiction of one ormore ofithe federal health and safety agutt- ci.es have falled in recentl}ears, however, new efforts to regulate tobacco have enjoyed incteasing support inside and!outside of Congress:. The Congress and dte public are beconting increasingly aware that, unlike other eonsumer prodttas, and because ofithe clout of the tobacco industry, no federal regulatory agency has exerted or been able to exert any health or safety jurisdiction over tobacco products except in the narrow exceptions outlined above: The tobacco industry would rather this fact be ignore(L otte of tEte tobacco industrn?s public relations ploys has been to try to con, vince legislators and the public t}iat they are already burdensomely over-regulated and that there is no need to apply standards similar to those that are applied1to foods, drugs andd cosmetics to tobaeco:lhe reality of the matter is that tobacco products are so dangerous ttiat subjectirtg them to present FDA lawsgqverning other products would!likely result in their total ban. Thus the industry has had to ensure that no health and Isafetv regulations are applied to their products. The discovery dbcu- ments released in the Cipollone case indicate that thev_ have done this with exceptional skill. Somewhere between the extremes of the presetttabsence of significant health and safety regulation and a complete ban of the prodltct is aimiddle ground thatwill both allow the product to remain on the market and at ahe same titne subject it to necc-,sarn• T,>fi;:cco l's,, .l;":1mc7icirn C.-ais, `5 . 20,114-04196962

t1 atrksltclits regulations governing its tmnutacntre, distribution, sale, labeling, advertising and promotioa Achieving this wifl require amending the Federal Food; Drug and Cosmetic Act to,specificany and unequivocally give the FDA authorityover tobacco products. Under such an approach„the tobacco indusuywould be required to adhere to requirements with which manufacturers of other products have had to eomply. For example, does it tnake settse for the FDA to live full regulatory control ot+er nicotine patcties and gum which are designed to help people quititheir addictive smoking habits and not be able to have comparable regulatony, ccontrol over the products causing addiction and'death?'Cleariy, the double standard'must end. The health of the public should'be put above the political clout of the tobacco indttstry: Tobacco products shottldrthus be subjected to.regulation~governing:; • toxicologic testing and disclosure oflchemical additives in tobacco products, • disclosureand warnings related to constituents in both main- stream and'sidestream smoke (there are some 4;000 distinct chemicals in tobacco smofce), • requirements for additional labeling such as warning ofaddic- tion, stroke, use of tobacco products with birth control pills;,and other eontraindications (imclhding information about the health effects of environmental tobacco smoke), and practical advice and assistance to consumers on stopping,'tobacco product use, • distribution and sale of tobacco prodltcts (for example, prohib- iting free sampling, prphibiting sales through vending machines and enforcing restrictions on sales to ~minors), . • prohibiting advertising and promotional practices commensu- rate with the risks inwolved from use of the product; (comparable with other legal drugproducts, Le. prescription drugs),. For tobacco products this might «tean a complete el3minationof positive tobacco advertising and promotional!practices, • prohibiting the use of unsubsta<ttiated health or other dtims (i.e. low tar4 low nicotine, etc.), • right of inspection of manufacdirittg plants, subpoena power, seizureof adulterated and misbranded products by the FDA: 1Jegislative recommendations were seriously proposed in 1964 wiuctt would!have accomplished many of the above objectives either by putting tobacco directly under the FDA"s jurisdiction or by, strengthening,the authorities of the Federal Trade Commission. In what is now regarded as standard heaThanded tactics by the tobacco industry, these legisLative proposals were significantly watered downto require only a weak, inconspicuoas; Congres- sionally-written health warning on cigarette packages. While that label has been updated'since 1964, nothing has been accom- plished that would subject the tobacco industry to federal stan- dards thatare applied to every other legal product in our society:. in 1988, and again in 1991„legislationwas intn®duced forthe first time since 1964', that would attemptto correct the gaping regulatory loophole. The legialation introduced originally by former Congressman Bob Whittaker and Senator Jeff Bingaman and later in the 1002nd!Congress by Congressman !Nike Synar wouid establish a new chapter under, the Food, Drug and!Gos- metib AaG For the last thirty years, the tobacco industry has assured the U:S:. Congress that, as a responsible indusuy, it would do everything it could to find the answers as to whether cigarette smoking causes disease. Ih 1954 the Tobacco Indtutryran an advertisement in The New York Times that stated: "We accept anlinterest'in people:s bealtb as a basic responsi- bilfty, paramount to et,ery otber conslderation in our6u.rdr ness: " (Emphasis added) "We believe the products we make are not injurious to health." 'We akuays bave and always mill'cooperrste dosely tuitvti those tubose task it'fs to safeguard tbe public beallh "(!Emphasis added): In 1964 Bopmtan Gtay, Chairman of the Board of'R. J. Reynolds told aMouse Committee;,"lf it is proven that cigarettes are hwm- ful we want to,do something regardless of what somebodv else tells us to do. Ahd1we would do our level besc This is ju.a being human." Thirty years later, after 50;0(D0 studies have proven that cigarette smoking is amajor cause of cancer, cardiovascular disease, emphysema and!stroke, the tobacco industry still denies that'any relationship,between use of their products and disease has been proven and,is still engaged in a "holding strategy"de- sigued to head off any serious or significant attempts at having itss products properly regubwd. Congress was presented wittt te oppottnttity, in 1964 to pass significant legislation that could have restilted in the sawing,:of millions of American lives, but,failed The recent decision bv the US Supreme Court iniCtpoQone; while rea6irming the right of' individuals to sue tobacco contpanies tmdermanycauses of action, also reminded'us of dte glaring loophole that exists, in our federal health and1 safety laws when it comes to tobacco. By at- tempting to reservefor itself the role of solo regulator of tobacco products and'then failing to carryout its responsibilities;,Con- gres,s has done a tremendous disservice to the health of all Amen~ cans. Unless Congress (as wdl as the FDA) has the courage to uttdo wliat1 it did!in 1964 uttder pressuresfran the industry, tobacco products wilL tragically, remain the leading cause of preventable death and disability in the UiS: IV. Opportunities for state regulation of'f tobacco products Under our federal system of'goveinunent; the protection of thc public health,is largely a, responsibility of state and„by extension, local goventment. Although there has been little regulation ot tobacco products at the state level, states have a varietyof powers to protect their citizens. Existing consumer protection laws u:ui be used for this purpose, and the Supreme Court's decision in CipoQone (June 1992) opens up additional opportunities for protecting the public at the state and local leveLs, lnte first part of this century, 24 states severely restricted or banned'the sale of cigarettes. These laws carne about aK part of i

1ti orl:shops the prohibitionist movement. in the wake of the commercial success ofxhe Ameritart blend cigarette following,the 1913 iintro- duction of'Camel, these laws were either tepealed or amended to onlylimit sales to minors by the 1'930s. More recently, two states banned the sale of dove cigarettes in the 1980s following reports of serious acute toxicitv fbom these producis, (Gove cigarettes, or kretek„are a producvof Indonesia which contain a mixture of tobacco and clove.) In the early 1980s, the marketing of moist snuff products by'US Tobacco rtesulted in alepidemic of oral tobacco use among ado- leseentand pre-adolescent boys, an epidemic which continues to this day. Within a few years, several states eitherpassed or consid- ered legislation to regttlate the advertising and labelingof chewing tobacco and moist snuff. Faced with the possibility of diverse regulationat the state level, this segment, of the tobacco industty, began serious negotiations in Washing(on for alfederal law. This was passed ~ in 1986 and resulted in watning labels on chewing tobacco and~moist snuff prodtictsand advertising and a ban on, broadcasradvertising for these products. Consumer Protection lrrws. FuCisting consumer protection laws are amajor potential ltool for tobacco product regulation at the state level. Don Garner, a law professor at the University of filinois School of'Iawin Ckbondale has outlined!this approachimost dearly. State consumer protectionilaws generally describe the following as being inviolation: • Unfair or deceptive trade practice, • omission ofmaterial fact, and! • Creating confusion in the marketplace. The state does not need to prove that consumers relied on unfair, deceptive; incomplete or confusing information, only that such practices occurred: Fraud, since it leads to many if notall of these practices, is, itself, actionable as well. There are manypotentiai bases for cases, including the systematic way the industry has misled the pubGc about hazards caused by its products, the health claims inherent in sa-called low °tar" products, and the bait and switch tactics involved in much of'low tar cigarette advertising., These Laws permit several remedies, including res6tution (di.k- gorging the ill-gotten g.ains) 1 and penalties. States pursuing actions under, these laws might:seek remediess u tiich have symmetry with the losses suffered because of tobacco, products. These might indude: • Funding a public information campaign,' • Payments to Medicaid for the costs of care for tobacco-caused' illness, and! • Undoingthe fraud by paying for quit}smoking,treatment Under many lkws, individuals can pursue private actions as well. lnsuch actions, the person(s) bringing the complaint must make a showing of injury or damage. As with state action, thougha the private party'need not show reliance on the deceptive practice. TfAiccn~!se,.4n.4n:E~rcnn Crisis Penalties are only avaifable for injury or damage caused by decep- tive practices. New Opportunities to Regulate Tobacco ProductS. The Supreme Court"s decision inCipollone severely limits the degree to which federal law preempts state regulation of tobacco products. While the tobacco indusuy had claimed an expansive protection, immu- niattg itself'fbom vitmtally all state action, the Court held that the onlything states could not do was regulate cigarette advertising in a couple of'narnow, specific ways. Section 5 of the Federal Cigarette Labeling and Advertising Act ( 15 . U~.S:Ca S 1334, as amended) includes the fo0owing preemptionn provision: (a) No statement relating to smoking and health, other than the statement required by section 4 of this Act, shall be required lon any cigarette package. (b) No t equirement or prohibition based on smoking and health shall be imposed under State law with respect to the advertising or promotionof any cigarettes the packages of which are labeled in conformitywith the provisions of this Acx. Edward 0: Correia, a professor of law atiNortheastern University School of law; has explored the opportunities available to states in the wake of the Cipollone decision in his paper "State [.egislk- tion After Cipollone." He outlined, several areas in which states maynow aet to protect their citizens$om~tobacco products. These ane: • The regulation of express warranties under state contract law. • Requiring tobacco companies to furnish information to the govemment (for instance, informationabout ingredients and information about the toxicity oPtheproducts), and •'Dhe regulation of the flow of information about tobacco prod- ucts and their use through channels of Wormationother than advertising. In additiona,he points out that states may define the remedies available in each ofIthese areas by statute. V. Recottunen+dations. Political maneuverings by the tobacco industry have closed off nearly all regulatory avenues for these most dangerous products. Cigarettes and other tobacco products are both the leasurel;ulaied' and the mosrdangerous consumer produets in the country: ihe only existing ~ potential authority to regulate tobacco products is that of the Foodland Drug Administration (FDA). indeed. FDA has been willing to regulate specifio products when the agency became convinced that the manufacturer had intended a dnig effect. The Coalition on Smoking OR Health has petitioned FDb to regu- late so-catled "lovv tar" cigarettes as drugs because of heaithh claims intheiradsertising and has petitionedIthat certainibr.uidstargeted at womenibe regplittedibecause of their promise of weight control. 202419G9G4

Wu ri;shops Discussion in the;worlshop~considbredopporwnities to regulate these pradiicrsatibbth the Federal and~State levefs. Aederal • The Executive Branch should make the regulation of tobacco products-regttlntion ~of their manufacture, distribution, sale; labeling, advendsfng;,and promotion=apriotnry in federal heaith, care reform and other tiealth policy initiatives. • FDA should use its existing authorities to regulkteall "bW,yield" tobacco products as drnigs under Sec. 201 of the Federal!Food, Drug and Cosmetic Act. • Congress sh ould enact specific statutory authorities whieh mith. out question give the Food and Drug Adntinistradon the authority, and tJie resouv+oes to, regulate the tnaaufmre, distribtttion; sate, hbeling, adl'erfisiag, and promotion of tobacco prodttcts. swe • 11he nation's govenorsshould make the regulation of tobacco- produas a priority in health policy initiatiroes.. • States should use their existing,drug authorities to regulate "low y'eld" tobacco products as!drugs. • States should consider enacting,speci8c statuwryprovisions which would,regulate the manttfactune, distributlon,,sale, label• ing, advertising, and promotion of~ tobxcco products as a c.lass of drug. These new requirements should include full disclosures of ingrnedients and of information known to the tnattufactutets about . the toarictity of'the products as well as requirements that the manu- facturers assist customers who wantAo quiG • States should ban billboards which advertise tobaeco produds. . • States shoufd use existing consumer protection authorities to regulate the tnattufacture, distribution, sale;,labelittg, advertising and promotion of tobacco products. ' Pub/kJfadtb Community • The public heaftti cotnmunity should develnp, support, an& maintain a-resource library which would serse as a repository, for informatiott about the tobacco problem needed by, policy makers and regulators. ' Atnesican Brattds; the maker of'NR,STY cigarettes calls its direct mailoperatiowa,"Smoicers fnforrmtion Certter."'Since each, tobaaoo eofnpany maintains extensive mailing lists of its custmm- ers and potentialcuswmers, information on harms fnom smoking and advice on how to quit could easily be sent to these indiNiduals directly as part of public information campaigns.

Wurkshops Tobacco Use: An American Crisu The Role of Federal and Sta.te Excise Taxes The Effect of Taxation It is a basic rule ofeconomics that, as the price of a commodity rises; demand for that commodity,falls. There is aisubs'tantiali body of evidence, frotn the United States and other, ccountries, that demonstrates that acigarette price increase leads to a fall-but a less than proportionate fall-in cigarette eonsttmptioni Much of' the evidence was summarized in the'1992 report'of the Surgeon General, Smok'ingand tdealtb in theAmaricas (pages 127-1'36). That evidence is based on econometric studies. Empirical experi- ence in countries whichihave seen substantial'priee ihcreases tells a sirnilar tale., The relationship between the real ('ie: inflation adjusted) price of tobacco and per capita consumption for Canada showsthisclearfy (figure 1). The'Canadian experience also suggests that price has been associ- ated with~a particularly rapid!fall in consumption among teenag- ers (figure'2), fiut Canada, i's not speciaL It is typical. Exacttv the same phenom- enon can be seen in the United States (figure 3). As shown, in figure 4, taxes in the U:S: have fallen in real ternrs since the time Figure 1 ARfIGL rEREAfdTA' COMSOMt1'IOROF (1GARflT6 UIDRULH00['or7D64C110 0e 7 veu.1 CANADA t5S1 - MIS'. l1A' u:N aN I sus/ uN I SI,N ~ S3s1 N IZ ~ SIN, IfM IIM 1155. 1964 a1f1 1571 17T71 IMt 1511IH1 -~ Asd i Ier ~ e.~lt1 ~ na~}W ~ - G.wnam...n ie, MIYe, nuw~e s,~I,q ~~ s r.,l«d Y a qd>d !ne 0 ToOu» ~.IMI l.Ibnl David'Sweanor, JD Kenneth' E. Warner, PhD of the landmark 1964' report of the United States Surggon Gen- eraL In nominal terms; tbtal taxes rose from 14 cents per pack that year to 44! 5' cents in 1991 ~ Adjusted for inIlktion, however, the tax would have needed to be 61.6 cents simply to maintain its real value. As such, , real taxes are 28% lower in 1991 than they were in 1964. Both state and federal taxes fell during this time. Adjusted for inflation, federal'''taxes fell bv'more than40%. Taxes on ~a pack of'cigarettes have fallen from 50% of ihe',selling price tb only 25%,,a.s shown in figure 5. One result of this is thatt the United States now has the lowest taxes on tobacco of anv' major industrial country, and is much lower than Canada and northern European countries, as shown in appendix A. lhrough most of the 198Ws total taxes have remained rather constant in real tetmts. While manygovernments balked'atithe idea of raising'taxes, the tobacco industry showed no such qualms: the industry raised wholosale prices frequently and substantially: The resulti cigarette prices rose by 60% more thann the general'rate oflinflation: As the economic analyse,s would predict, consumption felll (figure 3). Eig!ure 2 UAL C1GAR.ETSE.rRICTS'~.ANO L7GARETiE.SMOK]MG AMONG U'NADIAI6AGE ~,S TO If' 501 .ri 41S 41% ?Is 1pi M US 2l'S 111 IK tl s1 1 110 co 0 uf7' HN If9TI •"Nn,Smatngl -Reel ToDattp Pewe InOe. ('96'.100{: ~ ~ i - - ~ - ~ T,-,haccn l-se .a+:--lmw*ic::in Cr:sts `i

Yti'orhshup, Precise estimates of the relationship between price and demand vary. A reasonable estimate,is that a ll0% increase in price leads to. about a 4% fall in consumption. For children, the effect of'price increases on smoking is believed to be at least as substantial. In recent years, the tobacco industry has introduced discount, brands of cigarettes and offt'red significant percentage discounts through in-store promotions and the use of coupons. This means that price-sensitive people have been able to move to less expen- sive cigarettes as an alternative to leaving the market altogether, or not entering it'in the first place. Reseanch on price-sensitivity does not address the implications of the fact that~'average' price is no lbnger indicative of what price-sensitive people are paying for their cigarettes. Arguments for Increasing Tobacco Taxes Raising tobacco taxes to the levei Ieurrently exiating in places such as'Sdandlitavia„the British Isles, and Canadk could result in millionsfewer tobacco-caused deaths among Americans currently, alive. In termts of health impact, there has probably never been aa sing'fe intervention in American historytharhas accomplished what could be achieved through reform of federal and state to- bacco tax laws. Indeeda,flarris (1'987) estimated that the 8-cent- per-pack federal tax increase in 1983 would mean thaL54,000 additional then-teens would live to 65 years of age: Eataminingthe same tax increase; Warner ( 1986) noted that if the real value of the tax could be maintainedi some 450,000 premature deathss caused by smoking would ultimately be avoided. Note that this extraordinary'health achievement was estimated to nesult from a small tax increase.. Besvnd4he health impact, there are tnany otherpowerful argtt- ments thatsupport sustained increases in tobacco taxes: • Increased tobacco taxes can raise considerable revenue. US tobacco taxes in 1'99'1i amotmted to $13 billion: By companison,. Canada, with one tenth the population of the States, raised over E66 billion, and the UIC with less than a quarter of the US populatim raised 1E 10 billion.llhere is little doubt that the United States could be raising at least $30 billionimore annually, even taking into account the substantial drop in smoking tliatwould be ex- pected to foilowthe tax increases,. • lttoseadditional billions of'tax dolL4rs cottld itmd better health care provision, school programs, nutritlon1progruns--or simply be used to reduce the deficit or reduce other taxes (higher ttr bacco taxes do not ~ have to mean higher, overall taxes) .: • Smokers'do not derive the entire economic benefit from keepingg taxes down. The tobacco companies are given greater freedom to increase their owniprices, thus increasutg,their profits and their economic andipolitical power. As anexample, PhilipMorris reports that it, sold 191.2 billion cigarettes in the United States in 1980 and had operating,ineome of $786 million fnom1 those sales, By 1991 sales hadincreased by 15% but'operating ineome had increased by'over 500% to f 4.8 billion. This income level repre- sents, in:1991i alone, three and one half billionldollars more than would be required to have simply kept pace with infiation. In the absence of tax increases,,tobaceo companies show no pLans to. restrain their own price increases., If prices are, instead, raisedd through tax increases, the health impact is realized whik providg ing revenue for important national and local programs. • People are prepared to vote for higher cigarette taxes, as, the necent ~ experiences in California and Massachusetts make clear. In fact polling from around the country shows stnongsupportlor tobacco tax increases, particulardywhen introduced as part of a comprehensive program. If we use the intensity of'the industry's opposition to any given measure as the true indication ofits prohablo impact on consump• tion; the tobacco industry has clearly acknowledged the impact Figttre 46 ANNIIAy /E0. CAfRA CONfUMld7OM OIC7GAl[TTt7 ANOR[AL InUO[ O• TOLWCO . (rr M~yney UXtiYL rCANflD 11l1 .IM 3404 1 sus• ua¢ $1.20 :.Ir s lso 26" $1.40 12.0 $120 ® a tol hlu' f1L0 GP~ d LMn lY% mlLn 23N 5010 $1.50 IIILC SsM N SOb 1S 5030 70110 lsN . , , $1.0 054 1959 lsu 1964 leTl Nn 1903 1966 ' usl. - Ina i.p. upu caw..0/e. - Itca f"ce~.e( TeMC<a~IIMI EdMru~ TplACCO /RlCF! A ' TA7[l7 UNl7E4'. lTNTEi ~. 1YJ7'. . 1AI RGL T[tYf ~~. 0 szA7t'E smm1AL toaACCO Ty12t ®.InOrt I•/CL n(1

that taA increases can lhm We need only iook at tbe recent mulel+ million idollar (but unsttccesdull) effortimounted by the industry to oppose a 25 cent per pack tax increase in Massachusetts. Tobacco Industry Argttments against Tax Increases The industry uses numerous arguments to defend!its profits. To accept them means to accept a huge continuing death toll from smoking. These arguments are either bogus or can be met in a way that is less dangerous to public health than perpetuating the sale of'low, priced tobacco: • Inl tobacco-growing states, the industry,will atguerthat l increased taxation will devastate tobacco fanners: In fact in-state consump- tion, even in the largest tobacco growing!states, is insignificant compared to out of state consumption: Governments would ordi- narily have to forgo over $ 1100 in potential revenue for euery' dollar of ~ retained sales by its tobacco'growers. The key point is thatJarmers, as opposed to the tobacco tnanufacturets; make so Gtt1e out of the sale of each cigarette that they could easily be compensated for the adverse income effects of any fall in sales- and encouraged out of tobacco growing. • in states with 1 tobacco manufacturing facilities, the industry will argue'that jobs could'be lost Again, since little of what is pro- duced in-state is actually consumed there, the impact'is quite small. When these jobs are then measured in terms of taxes forgone per job saved, or lives lost per job saved, the industrl?s argumentiiecomes absurd. •'In states with no serious tobacco industry presence-the vast majority of US'statesl arguments will be made about the impact on local retailers. in such states a substantial proportion of expenditures on tobacco products are immediately'.exported" to tobacco companies and tobacco states: Increased taxes will increase'state revenues, and spending,neallocated to other good.k and services will produce more jobs, as allarger fraction~of such expenditure will remain in-state: • The industry will also attack tobacco tax' inct eases with the argument that all tases are bad and!must!be avoided. The fact is Figure 5 TpEACCO.TAXATIOM M THEUNrtEOSTATES AVEAAOE.tl6ARERE TAX AS A 1l OF~NETAIL PRICE 50% .oz 30% 2as 20% that golverrtments need money. While an income tax can discour- age work'ing; land investutent taxes can discourage savings and ittvestment, tobacco'taxes discourage the use of'otu leading cause of'preventable death. If any taxes are to be increased, it makes sense to increase the'ones which discourage behavior society seeks to discourage. • The'industry presents itself as the defenderl of the poor.lt will argue that higher tobacco taxes are a regressive form of taxation, that they hit the less weU-0ff far more than the better-ofL' That 1 is due in part to the fact ttiat the better-off and better-eduoated have responded to health information, while the poor have been tar= geted by an industry anxious to hang on to customers: The indus- tryne9er points out that • for all its concerns about the poor it hasbeeniraising tobacco prices over the pasi decade, at rates well1in excess of tax in- creases, to boost its own profits; • that'the money raised from higher taxes coukf be'used to fund projects, tax or welfare changes that would improve the lives of the poor. • that the real "regressivit}+, is the higher rates of~death andd dis'ease'among the poor resulting from their continued addiction to tobacco, fostered by targeted'industry ad campaigns. Developing a Strategy Drawing on these facts and arguments, the key is to start influcnc= ing leatlirtg,opinion,formers, legislators, healfli and medical organiparions and the public at large about the role tobacco taxescan play in both health and fiscal policy~ This means directing, information andllobbying efforts both at those interested in health and those responsible for finance, at the state and federal level. It means tailoring the argument to local circumstances. It means beginning to understand the budget ptoess and getting the riglu information to the right people at the right time. Recent experience at the state level suggests this can be done. This should 'be replicated in states that'have not raised taxes recettdy, and progress should be maintained'm states which have- since the effect of a one-time nominal tax increase is underminedd every year due to infiktion. lttdividual states can start following their neighbors"'lead That;,in tnm, reduces the risk that some of the impact of higher taxes could be diminished by 9nctea5ed i cross-border shopping for cigarettes. By far the most dramatic impact would come'from a substantial hike in the federal tax. In 1951 the federal tax was set at 8 cents a pack. It stayed'there foroxer 30 years. If'the federal tax was adjustedimerely to eover inflation since 19511 it would be about 43 cents in 1993'rather than 24 cents. Th at would do no more than return the tax level to thatiprewailing before the risks of smoking were known. But it would be a start. Far more significantt would be an increase that reflects the fact that taxes, to comple- ment health goals, should be significantly higher ihan they were before we knew the'magnitude of the health problem.lfiis has been achieved in our neighbor to the north. Canada, :utd inim:uiv other industriali¢ed'nations around the world. TohQcco L'se An american Crisis o?~~, ~~,' 9~'~{~Q, G1 I I tg5S 1901 1967 ' 1973 ,. 197~9 INea ,'Y.9n

..4VttrE;.shitps. Can it be Done? The simple answer is: yes: In fact some states have alreydj+atovad and many others are in the process. Other countries have tobacco industries, tobacco lobbies; tobacco farmers and large numbers oftobacco users, and have anainedJsubstantial increases in to- bacco taxes: Canada is a ptnme example: In the early 198n's, Canada's tobacco taxes were lower than rthe rates presently found in the United States: Despite vigorous opposition from a pow!ertul tobacco tobby, a eoncerted effort by Canadiatt health groups has led to taxes which now amount to about $3 1 (US) 1 perpaelt Cana- dian per capita consumption since 1983 has fallen by over 40%, half again as fast as that of the United'States. N(any other places, inciudittg Ireland; the United IGngdbm, France;,Sweden, New Zeaiand; Australia and Hong Kong have t ecentiy brought forward substantialltobacco tax increases. The challenge;to the American health commtmity is to learn from previous eEforts,,ereate the infrastructure within health organi;2- tions necessary todirectthis campaign, and to see if we can create a bigger and more decisive public health success,storl+than has ever been achieved in this country: The prize will be millions of premature deaths avoided! and a bankroll of'biilions of addi- tional dollars to assist financially strapped govetmments.to serve the nation's people. Recommendations The participants of the workshop examined various optiotu, including the position paper recently put together by the Coalition on Smoking or Health. That document calls for a federal tax increase of'at least $2.00 per pack. Such an iitcrease, if main- tained in,real value, is estimated.to reduce cigarette use by roughly 25%, eventually preventing,about two million tobacco- caused deadu while simultaneously raising $35 billion per year in additional revenue. The Coalition ~has also reeommendbd ;itr creases of about $ 1.00 per pack ia,state excise taxes. There was very strong support for these goals. As such the;workslwp has made the following two recommendatiotts: 1. The federal government should'intx+ease the clgarette exciserout by at loast $2:00 per pack with an equivalent amount assessed on alffother tobacco products. The reai'(in9ation-adjusted),vafue;of this tax should be at least maintained thereafter. 2. We encourage the individual states to inctease state excise taxes by approximately $1.00 per pack with an eqltivalent amount assessed on all other tobaccoproducts: The real ~(ihflntion-ad= justed): value of this tax should be maintained thereafter. Implrmentation Itm7s reoognized!thatirecommettdatioas of this magnitude will have little tfiance of stxcess, without a serious effort!on the pata off the heaNti cotnmunity. It was agt eed that a well-fiutdbd; profes- sionxl ieampaign will be aecessary and'that it will need to be given operational independence while being siinultaneousty'suppotted by a broad coalition of grassroots organizations. iztfrunucture will haNe to be buik to assist these effortsaad significant!sums of money will need to be misedlWhileour task is a big~one, there was gen- eraf agreement that the oppottuttityto save two million lives makes this not only an unprecedented opportunity but a potentiall y ex• tremely cost-effectiwe oae. There was a recognized need to tnove. qaiatdy aed decisively if we ane to achieve these gqals. Appendix A Average totalitazes and tax incidtxtce of a pack of ' 20 cigarettes in various countries as of+October 1'5„ 1992 Countrv Avg. Total'Tattes (American Dollars) Tax Incidence Denmark $4.18 85% Nortwiy, $3:93 68% Sweden $3•77' 73% Canada (British Columbia): $3.26 -69% Ireland $3.13 75% Finland $2.86 74% UK~ $2.86 76% Canada (Otttario) r2:85 69% NetherUnds $2:63 , 70% Germany $2.35' 72% Belgium $1.94' 73% NewZeaLhnd Frattce M92 , $1.56 6'8% 7't % Attstralia (Y~ctoria) $1.46 60% Italy $1I.32 72% Japan $1.09 60% US'(Hawaii)-Highest $0.75 37% US (Michigan)-AWerage $0.52, 29% US, (hirginia)-Lowest$o:3p~ I9%

Workshctips Tobacco Marketing and P7romotion. Introdiictioa In 1964 ; the Surgeon General's first report on smoking and health proved bevoand any reasonable doubt that cigarette smoking is the single most preventable cause of premature death andAisease in the United States. Vonetheless;,despite repeated reports by gov- erttmental and private sector orgattirations which focus on the nature and impact of'tobacco-advertising;andJmarketing;,such, promotion continues unregulated!and unrestricted, and tobacco, industry efforts to recruit new users, maintain current users, andi silence its opponents continue unabated. !n providing an analysis of public policy options, this paper will brieflv review the current d'ata and literature about the si cance of 'advertising and promotion of tobacco products in the United States. It will discuss the infiuence oftigarette and spitting tobacco advertising on yroung people, adults, and the media; how tobacco and'health issues are covered in the mass media, how societyv'iews tobacco and tobacco advertising;,and'how the gov- ernment responds totobacco and health issues. tiatntre and extent of tabacco advertising and promotion. How Much is Spent? While the tobacco industry contends thatobacco advertising andd marketing is not intended to and,does not help to attraa new. smokers, in 1990 the tobacco inditstty spent over E3:9 billion- or more than1]0.6 million a dity-promoting its products. These figures represent an increase ofover E!370 ihillion since 1989 and another increase of $342 million since 1988. Even when these expenditures are adjusted for inllation, the 11990 figures represent an increase of more than one hundred percent in advertising and promotion expenditures by, the tobacco industty during the 1980s. Today, annual!expenditures on cigarette advertising promotion total more than $4 billion-or $'14 for every man, woman and child in this country. The advertising promotional expenditure per carton is in excess of $1.35. In contrast, in 1980, after adjusting for inflation to constant 1'989 dollars, the tobacco industry only. spent $.58 per carton on advertising and promotion. Tobacco Advertising and Promotion Expenditures while tobacco industry advertising;spending in magazittes ($380 million in 1989), newspapers ($7? million in 1'989')S and bill- To~hacco U;ce an An:ecican Crisis Alan Bhun, MD Matt Myers, JLl boards ($39 million in 1989), continue to be large enough to have a major impact on each of these media„such traditional advertising has been suppiemented by other forms of promotion. For example, point-of-sale advertising;in ruetail establishmenvi, totaled'E24Tmillion in 1989; an increase of 99% from the previ- ous year. Simitariy, the amount spent on give-awaynon-cigarette utility items, such as calendars, Iighters, and T-shirts, increased by oNer $72 million~ftiom 1988uo reach a totallof $262 million in 1989. tf this figure were to~include retail value added~give-aways, such as key chains andllighters, which ane given as a bonus when a consumer purchases a pack of ciganettes, the expenditure would be far higher. (Incidentally, point-of-sale advertising and advertising on utilitarian ~ items are exempted from the health warning requirements.) Expenditures on the promotion of sports and sporting events also i's growing. In 1989, the tobacco inditstry spent $97:7 million on sports and sporting events, an increase of'more than 8% in one year from the S84 million spent in 1988. Such activities includo golfi tennis; and various froms of motor racing., Tobacco bill'+ boards also continued to be the dominate advertisements in manv . major professional stadiums in which non-tobacco sponsored events are pLayed,and televised. A number of promotional themes and campaigns that began in Europe have found their way to the United States. For example, in 1992,Pliilip Morris,announced a•new campaign en6tted.the: "Marlboro Adventure Team ...Tprt guys who wilUhike and bikc, a.s well as ride the rapids of the SouthwesL" According to Philip Morris, as ,of March , 1993, more than 300;000 people had applied, to participate in the events. Doubtless the most significant trend in tobacco advertising expen- ditures-and the least addressed by,tobaccm control advocates-- is that'of ptromotionallallowattces, such as the amount paid by cigarette companies to retailers for shelf space; cooperative advertising with retailers, trade promotions to wholesalers- Pro- motional allowances,,which constitute the single fkr" advenis- ing categPry„totalled $999:8 million in11989. Discounaeoupons and retail value added!promotions, such as multiple pack promo- ~ tions and offers of a free key chain or lighter (blister-packed to cigarette pack), comprise the secondUrgesuadvertising and, promotional expenditure by the tobacco industry. in 1'989, $959.9 million was spent~on this type of advertising and prorno, tion, N[ealth advocates liave devoted scant attention to atticxamina~ 2024~.,969'~p

1r ttrhSlutylts tion of the role stwli promotions have had litreotuuer'xcting;die intended cigarette consumption-mducing effect of'ezcise taxes. The amotmuof moneybeing,spentonAiscottntcouppns, give- aways, and cut-rate cigarettes illustrates the etnphasis plaeed by the tobacco industry on those consumers who have fewer dollus to spend on tobacco: While such emphasis may, inpart,,be a reaction to the .recent ~ recession, it also appears to represent a strategy designed to offset any reduction in cigarette consumption as result of increasediexcise tazes;,as well as knowledge by the, tobacco industry that the prevalence of smoking is inversely proportional to income. Targeted marlceting Tobar.co Marketing and Youth cigarette manufacturers say theydo not market to young people (to not want chifdten~to smoke.lndeed, Philip Morras and R.J. Reynolds have created national advertising campaigns built upon prevalence theme. However, the tobacco industry's claints are contradicted by its heavy use of image-based advertising in~eon- texts where the ads will be observedby yamg,people:. Fach yea.r, more than three million Americanwuttg'people under the age of 18 'consume 947 million packs of ctganettes. Almost 900 percent of all new smokers start by the age of'21. The age of initiation of'smoking has declincd over the last 40 years by 2.4 years overall and 5.4 years for white females: it is no coincidence that teena$ers smoke precisely those brands with advertising messages which appear to be targeted!at adoles- cents. A 1989 ~GDC study, confftming,an earlierstndy, conducted by D0G (Doctors Ought to C.ane) regarding agarette brand ptmf-, erences among adolescents, found that 71 pereent of white teen- agers who buy tlieir own cigarettes smoke Marlboro; while 61 percent, of black teenagers buy Newport, a menthol brand. Camel represents the second most popular brattd among white ywtdi, while for blacks; the ttext most ptreferred!brands are Kool and Salem, two other menthol brands. In two recent stu+veys, at least 84 percent ofthe adolescent aurreat'smokers saho usually bought their own cigarettes purchased one of three most highly a&w- tised targeted'brands-Martboro, Newport or Camef--each of which empliasizes image-based advertising. The same sttrveqs found that brand preference is muchimore aooeentrated among adolescents who smoke than among adults whostnoke. For years, Marlboro has beenthe predominantbrand used by adolescents, who appear to be attracted to the brand's image of'f strength and independence promotediin the long-nunt»ng . Marlboro Man"'adxertising campaign. The longstanding success of Marlboro has been partly explkiited by William J1 MoCartliy and Ellen Gritz, who examined the pa}cltological and social factors that influence teenagers to smoke. Aeeording,to testimony pro- vided by Dr. McCarthy before the Subcommittee on Health and the Envi ronment of the Committee on 1 Energy and Commerce, "To the degree thati adolescents consciously try to reduce the distance between their ideallse{f-'image and their owniself:images, and the scientific literature supports thatthey do; there is reason to conchxie thRt~tfie personality traits poptilarfy'imputed to ciga, rette smokers and cigarette advertisements are sufficiently allur, ing to induce adolescents to s:aoke.... For the typical teenagerr seeking to make his/her real!self'corrx:spond more closely to his/ her ideal selfa' the portrayal in cigarette ads of;valuedaspect.~c of identity such as independence, social and physical lattractiveness andleonfidence cannot fail to make cigarettes appear more attrac- tive to teeflagers thani they would be without such associated imagetN." The Joe Camellcartoon caricature introduced in the US in the mid-1980's contains none of~the subtlety of'the Marlboro cowtiov;, but few advertising campaigns have been more effective in such a short period of time with young people: In 1'986, Camel ranked seventh among the youngest age group of people who smoke. in 1'989, one year after the advertising'catnpaigtt began, the brand' ranked third among teenagers surveyed. Three studies pubfished in the December 11, 1991 issue of the JourrtaGof tbeAmers'can :Me.fical ASsociatdon OIAM) confiemed' what every expert (and anyone with commonsense) had alreadv concluded. Whatever the intent, the "Old Joe" cartoon camel advertising campaign had'its greatest influence on children andd adolescents: Two of these studies specifically examined the influ- ence of the "Old Joe" campaign on teenagers. Both studies of teenagers found: (11) thai teenagers are far more likely to have seen and remember these advertisements than adults; (2) that teenagers associated!these advertisements withithe product being advertised far more than adults; and (3) most impotnanttyn a stunning,and'dramatic rise in the use of Camel cigarefles directly paralleled the introduction and pursuit of this advertising,campaign. The same two studies documented an explosive growth in the sale of Camel cigarettes in pre-teens andiadolescents: While surveys conducted on seven different occasions between 1976 and 19M among seventh to twelfth graders revealed that only 0.5 percent of those surveyed used Camel lcigarettes, the study released in ithe . December 1991 issue of;4M of'the same age group in 1990 found that 32.8 percent reported using Camel cigarettes.lfie . second study fotmd that among teens and pre-teens surveyed the use of Camel cigarettes rose 230 percent between 1986 and t.. .990: As shocking as are the results of these two studies, a shird studv published in the same issue ofAW, which examined the infiu- ence of this campaign on three to sitt year old lchlldren; is,even more disturbing. Among six year olds surveyed, nearly as manyof the childrett could identify an illustration of the "Old J oe" camel cartoon logo as could'identify; a commonly used logo of Mickey Motise: fie "Oldloe" campaign has combined every m$rfceting,tool avaiiable to the tobacco industry to reach out, to children. Nbtonly do the print, advertisements using "Old Joe" stress themes that uniquely'appeal to young people, but the overall campaign has also included ifree T=shicts, baseball caps, posters, inflatabM air mattresses, and other items of clothing far more likely to be worn or used by adolescents than by adults. Furrther, the campaigtt hus 64

made heavy use of discount aoupons. At least one adverti.sement went so far as to explaia to individuals who do not like to redeem i coupons (that is, children too ytxmg to legalty do so), tiow to ask a ftnend'or a stranger to do so for thetn. While the "Old Joe" camfraign'.s appeal to youth is so blatant that Adir?rtdsdngAge has editoriati¢ed'thatttiis catnpaign,..erossed the divider between [a company's] legal right to advertise and its unique social responsibility to the general public", the advertising campaign has continued'unabated. Howevers those concerned about the influence of adierti5ing on ytxtt>g,people also should not lose sight of the fact that while "Old Joe"'has prompted a public outcry for reform, countless other image-based ubiquitous cigarette advertising campaigna,,exempli6ed!by the "Marlboro" cowboy and Vitgirtia Sllms models, pose every bit as serious a problemi Tobacco Marketing and Women Over the last 25' years, tobacco marketing targeted at women has become evertnotre pervasive. It was less than 30 years ago that'the first cigarette introdueed solely for women was brought~on thee market. It is no coincidence that advertising campaigns targeted at women preceded land then accompanied the rapid spread of smoking among teenage girls in the United States in the late 1960s and the early, 1970s. Taking advantage of major changes in social' attitudes about1 the role of women in our, societv, the tobacco industry'in the late 1960s began a massive campaign to associate smoking with independence and social progness -ttte type of values portrayed by Yirginia Slims advertising campaigns. Wttile the tobacco industry has long marketed tobacco products to women implying that smoking provides a mechanism for stay- ing thin, the 19805 witnessedlan explosion of~ advertising using false images that link smoking with tall, thin, elegant, attractive women using ad0ertising slogans which associate tobacco use with good health through thinness and weight reduction: Recent . advertisements for Sttper Slims from Virginia Slims feature photo- graphs of taUL ultra thin young women dressed in tight, revealutg, dottiing wftose images have been elongated andibodies made too appGar'even more slendr:r through trick photography. The ads make use of words with double meanings, all oPwhich have weight or thinness-related meanings, sttdt as "Ultra 11ght", and tag lines, such as "We can't make ypur calls shorter, just slim- mer." Ads for Qapri Super Slime carry the bold slogan„'"Itfe Slimmest Slim." The 1'989 Teenage Attitudes an0ractices (TAPS) Survey of ado• lescents fbund that while non-smoking adblescent girl.s strongly disagree with the statement that smoking helps keep weight down, the survey found tharamong current teenage girls who smoke, over 66 percent of those surveyed agreed with the statement that smoking helps keep one's weight down. The 1986 Adult Use of Tobacco Survey found that'52.7 percent of all women age 21 through 49 strongly or somewhat agreed with the statement'that smoking helps control weight These ads are successful. Inithe 1960s, far more teenage boys smoked thaniteenage girls. In the 197tis;,teenage girls were the only i.on cohort where smoking'actually'increased Today, mon teenage boys and!teenage girls smoke in almost equal numbers. Tobacco Marketing and'Ethnic MinoRities The tobacco industry has been especially adeptiatlezploiting raci:d identity in defining aprofitable market'among ethnic minorities. The result is an increase in smokfng-related disease andldeath among targeted ethnic groups in the US: Seeking new markets through advertising and promotional cam- paigns in certain minorfty,commtmities has been a,nece,caity for tobacco companies as the smoking white male population has decreasedlihthe US during the past two decades. While major daily newspapers have experienced a decrease in irevenue from cigarette advertising accounts, the African American-owned and Hispanic-owned newspapers continue to be a major context for cigarette advertisingtargeted to these specific ethnic communities. Tobacco companies and the minority press have become allies in the effort to pramote cigarettes iniethnic communities and inner, city neighborhoods. IniNovetnber 1985, Philip Morris hosted 93 publishers of the African American newspapers at its corporate headquarters in New York for a forum on preserving freedoms in American life. Early in 1986, these publishers voted to condemnn attempts to restriction on tobacco advertising. In 199d:,the wa- tional Association of'Hispanic Publications made a similar state- ment. The 350 Hispanic newspapers that belong to tlie association receive about 20% of their advertising revenue from alcohol and tobacco companies. Perhaps the greatest concentration of tobacco company advertis- ing is in Afriean American publications such asJet; Essence, and Ebony, which reach 47 percent of African American women and 38% of Afritan American men: Despite frequent health topics head-linedion the front covers of 6bon}^ andiEssence, 6bonv'h;L; never published'almajor article on the leading cause of death among African Americans: tobacco; in its 40-year history. Es- sence, which positions itself as a Black lifestyle magazine; h:cKs never published anartide on smoking;,much les.s on cigarette advertising. Billboard;and transit:advertising„whilemotA'fcican AmerRcan-orHi.spattic-owned, represent an importanrmedia within these communities. Studies conducted by Scenic America and other organizations have xhown disproportionate advertising of tobacco and alcohol products in,inner-city neighborhoods: In many Afri- canAmericart and Hispanic neighborhoods, virtually 80% to 90% of all billboard advertising is for btand+ of tobacco and acohol. Ini African American communities especially;,cigarette advertifiing is the single common theme in a variery of retail outlets from food stores and supermarkets to beauty paribrs and barber shops (;v; well as dry cleaners; laundromats, gas stations, and!bars and . grills). Ironically, money saving offers are perhaps the major appeal'th:u the tobacco industry makes to the people with the lbtvest dispos- able income.lfiere has been aldramatic increase in the number 55 Tobacco G'se; An Anterican Chsas 2?lJh+4,,ZV.771r.

Wctrkshops of rebate coupons in magazines and!newspaFers and in-store discounta good for up to ~5U'% oH~oncigarette parks, In a subur• ban, predon»nently white neighborhood, promotions indude a~ free t-shirt or other item for the purchase of three packages of cigarettes. The same promotional offer in an;-(rican American or Hispanic neighborhood is available for alone-pack purcha5e: The free distributionof sample packs is also common in inner-city communities. Tobacco companies have also linked cigarette promotions to African American and Hispanic music andcultural events. R.J, Reynolds and United States Tobacco (UST) sponsor Hispanic street fairs and festivals, such as Qutco de Maw eelebrations, and, Brown and Williamson foots the bill for numerous Spanish and jazz musicals in Hispanic communities. BroAVtrand Williamson also presents annual "Koof Achiever" awards (named for Kool cigarettes) to people who want to improve the °quality of life in inner-city communities." The tobacco compatn• has even enlisted the National Urban League, the National Newspaper Publishers Association, and the NAACP in the nominating pt•ocess: Johnso n Publications, publishers ofiELiony andJet, adds another insidious twist by permitting itself to be the apparent sponsor of a national' traveling fashionfairthat is in large pant paidfor by R.J. Reynolds to promote its More brand of cigarettes. Sitnilnrly, Philip Morris has sponsoredcultural events such as the Alvin ,liley American Dance Theatre: jazz and blues concerts, and a photographic display of the late Dr. Martiit Luther King, Jr In 1990, R.J. Reynolds announced plans to Launch anew menthol' cigarette brand called Uptown (more,than65% of blacks who smoke buy menthol brrartds);. Ptiiladelphia, Pennsylvania was selected as the test market for a promotional blitz aimed'at wung urbanafrican Americans. However, before the tobacco company could get its marketing off the ground, a local group callingitself the Uptown G,oalition was fotmed, by IDr: Robert Robinson, then with~Eox Chase Cancer Centen With the help from other health advocacy groups and' a blast at R.J. Reynolds by Secretary of ' Health and Human Services Louis Sullivan: the Uptown Coalition was successful in preventingthe test market of the brand. Despite .the Goalition's success, R.J. Reynolds began anaggt•essive national' campaign for Salem cigarettes (`"t'tte Box") i in inner-city African American neighborhoods for, which Uptown had. been intendedl Similarly, other cigarette brands popular among African Ameri- cans, such as Newport and!Bettsott and Hedges, continue to be: agressively marketed in much the same way. Tobacco advertising and promotion: Market expansion or brand switching The tobacco industry, claims that the $4 billion it spends each year on cigarette advertising is intended onlyto maitttain "brand lovaltv" and that it does not seek to attract new smokers, (or,, conversly; that cigarette advertising is only designed to persuade smokers to switch brands). The tobacco industry has further argued that unless those who are concerned about the impactof tobacco can~proHe that advertising and marketing actually causes people to startor not to stop, cigarette advertising and marketing should remain unrestricted. In support obits position, thetobacco industry often quotes ouvof context a single sentence in the 11989 Report of the Surgeon General that states P'There ,is no scientificallj+ rigorous study avail- able to ttie public that~provides a definiti.ve answer to the basic question of whether advertising and promotion increase the level of! tobacco consumption." However, thetobacico indltstry, conseiously and!deceitfully fails to put the sentence in context by omitting the followingsentences from the Surgeort General's Repoat which appear iinmediately after the quotedlsetttence: "Givenrthe complexity ofthe iasue, none is likely to be forthcom, inginthe foreseeable future. The most comprehensive review of both the direct and!indirect mechanisms (whereby advertising may affeeueonsumption) concluded thatithe collective empirical, experiential, and logical evidence makes it more.hkely than not that advertising and promotional activities do stimulate cigarette constanption." Aside from; its dishonesty;thetobacco indostt3's position lacks merirfor three distinet; independet-t reasons. Frst;,tlie point of; the Surgeon General, as statediin testimony before the Subcom- mittee onTranspotnationand Hazardous Substances of the Energy and Commerce Committee of the United States House of Repne- sentatives oniSeptember 13, 11989, is that a perfectly, ddesigned study to prove that cigarette advertising increases cigarette con- sumption will probably never be accomplished because proof of that type in a single study, is virtually never available "when study- ing human behavior."The overwhelming evidence demonstrates that tobacco advertising and marketing'practices do have an impacton the use of tobacco in a variety of complex, interrelated' ways that are not capable of beingproven or disproven in a sinrJe study, but are no less significant Second, the tobaeco industry tiaF attempted to manipulate the debate into a focus on the availability of a single scientific study precisely to avoid public policy action in much the same way that the tobacco industry established the Q,ounsel on Tobacco Re- search to avoid public policy action on the health effects of to- baceo long after more than enough evidence was available to act. Third, in*ht of the available dka, the tuKttruroverted'health eEfectsof tobacco use, andiihe st$ted1goal ofour government to discourage tobacco use, especially among children, the burden ~ shoul8 be on the tobacco industry to demonstrate that its $3.9 billion marketing effort does not play any role, direct or indirecti in the uptake of tobacco use rather than on those responsible officials concerned about the health ofour nation to prove to the contrary. The data demonstrating that marketingand advertising of tobacco products does play a role in tobacco use comes from many ili.ci- plines and from many sources: Combined, it can lead to only one conclusion. Briefly;these data fall iinto six categories. 1. The tobacco industry annually loses more of its customers than do the manufacturers of any other producL An average of 1.5 milllon Americans quitsmoking each ycar and an additional 434,()00 die from smoking-related causes: Since over 90 ~per-

cent of all'new smokers are under the age of 20, this means that thousandsof children have to begin srnoking ,each day in order for the tobaccw industry to maintain the status quo. The tobacco industry,knows that if one hasn't,startedismoking by their 18th birthday, they only have a one in ten chanee of ever doing,so: 2: only a small percentage of a!l smokers switch brands each year. Three manufacturers cutTently sell over 80,percent of'all' cigarettes sold in the Utrited'Stgtes. Thus, too few smokers switch to justify, a $3.9 billion expenditure each year. Also, many of tliose who do switch simpiyswitch to a different brand of the same manufacturer. if the sole purpose of advertising was brand switching, the three major tobacco manufacturers would make fir more money if they agreed to discontinue tobacco advertising and marketing because they spend far more each year on advertising and!marketing than they make by acquiring new smokers from their competitors. 3. Tobacco advertising has been shown rto work. Advertising campaigns targeted at women preceded and then accompaniedd the rapid,spread of smoking among women. Advertising cattt- paigns on behalf'of smokeless tobacco products precedediand then accompanied the rapid rise of the use,of~smokeless to- bacco products by teenagers. The recent "Old Joe" advertising campaign has documented the dramatic influence over a shoru period of time a single advertising campaign,can have onn tobacco use among adolescents. None of these changes in smoking rates can be pritttarily explained by any, factor other than the impact of advertising and marketing for specific, brands. 4. Advertising experts agree that market expansion is a signi6cant objective of advertising for virtually all products: There is no evidence that advertising operates differently for tobacco prod- ucts. Tobacco is not the type of matttre.market where nevv consumers do not need to be attracted. The matttre market argument applies in situations where a society becomes fully educated as to the need for and benefits of a product,andiwill' continue to purehase that product without further education or persuasion. Nfattyhouseliold prodttar, such as soap, tissue paper, or latmdrydetergent f911 into this category. However, tobacco-is differenu Given the educational efforts to discourage people from using tobaeco producxs and'given the known health hazards of.tobaccoproducts, each new generation of children must be convinced and persuaded of1 a1 reason to buy the product Thus, by depicting tobacco products as an integSal part of'a highly desirable lifestyle and personal,image„tobacco advertisersattraet~individuals who do notcurretttly use that, product, but who want to emulate that lifestyle and project a depicted image. Advertisements that effectively assoeiate,smok- ing w,ith the latest trends or ideas or with independence, so- phistication, sexual, social, or athletic success and happiness attract smokers and non-smokers alike who wantito be like the people in the ads. 5. If adventising does not increase consumption for tobacco products, why do state monopolies advertise in.countries where there is no competition? Auone time or another, several countries which,thenhad state monopolies, inclucing;Au.stri,, Japaa,,South Korea,lMiland; and thtrkey, have engaged in widespread cigarette advertising. 6. The tobacco indusuy, has generated considerable debate over what can~be teatned:about the role of advertising from the international experience of countries that banned advertising after preriously permitting it: While several countries with free market economies have enacted statutory bans on the advertis, ing attd/or promotion of tobacco, only, a few have instituted effectiue bans: Even fewer countries have combined those bans or restrictions with a comprehensivesmoking-educ:uion pro- gram or counteradvertising campaign. While the tobacco industry has funded a study which manipulates the data in an effort to tnake it appear as if restrictions or bans.on tobacco advertising have had no impact, an increasing number of impartial govetmmentaliyfunded studies provide substantial evidence to the contrary: A 1989'swd j' by the Government of vew 2,ealand~providedlpersuasive evidence that in,those countries which enacted!serious bans, there was a measurable overall decrease ia tobacco use from what would,have existed had there been no ~ban and/or restriction. In 1993 the Chief'Eeonomic Advisor of the Department oCHeaith of the Government of Great Britain issued a report whiclifound that advertising ten& to increase consumption of tobacco prod1 ucts and that bans on tobacco advertising,tend to result in a decrease of tobacco use from wtiat'would have occurred in the absence of such a ban. The reporteottsidered 19 keystudiesfnom the United tCutgdom, United States attd'elsewttere. Focusingon the four countries with the most sufficient data-Notway, Finland. Canada,and'~tiiew7.ealand--the report's author found'that in all four countries, bans or restrictions on advertising resulted in an overall decrease in consumption. The limitations of'these data must be understood. Multiple anti- tobacco actions accompanied the advertisi,ng ban. It is impossible to know the effect of the advertising ban alone. Nonetheless, the data ftom these couturies show a positive correlation between elirninsarttg advertising and promotion and a declining percentage of'yvung'people whosmoke: Despite any argument the tobaaao,industry decides to proulgate during the debate on cigarette advertiaing;,everyone can agree that an advertisement for cigarettes, regardless of brand, is an advertise.menrto smoke. Currentgove7rnrnenta[ restrictions on tobacco advert9si ng ; an d~ promotion At, the federal!level, there has been remarkably little done to restrict the influence of tobacco advertising,and promotion: In, 1965, 'Congress rejected a proposal by the Federal Trade Commission to requinedetaited health warnings on all cigarene advertisements and packages and, instead, required'only that all cigarette packages carrv the following message: "Caution: Ciga- rette SinokingiMay Be Hazardous To Your Health." No warning 6- To6acco C"se.•.-inAmerican Crisis 2024196974

11 a>rks(uyh, was required on dprette print advertisementsu that ~dme: In 1969, Congress amended the message on cigarette patatages to : read, "Warrtittg: The Surgeon~GeaeralHas DeterminedT= Cigarette Sawlang Is Dangerous To Your Heahh"'and banned cigarette advertisements from the broadcast media after January 1'. 1'971!. But at the same time, Congress preemptedithe Federal Trade Commissiitwo (FTC) from imposing;any, health warning requirements on cigaretteprintiadvertisements for a period of, two years. Whett the Cottgtressional preemption expired in 1971, the FTC and the siicmxjor, tobacco manufacturers entered into a consent decree by which the companies ag;eed to include the martdated package warning in their, print advertisements. For the next decade, neither the FTC, nor Congress took any further action to limit tobacco advertising or to require tobacco companies to do more to educate the Ainerirut public aboucthe health huards.of smoking. In 1'98'1; the Ftsderal'Trade Conuttis- sion issued a report which found that the then-existing health warning on cigarette ads and packs was inadequate and recom- mended!that Congress take additional action to nemedythe sittta- tion, In 1984; Congress eaaeted the Comprehensive Smoking Education Act, which replaced the single health warning on ciga- rette ads andipackages with the four, health warnings which now appear. A similar set of'warttings was required for smokeless tobacco products by Congress through the Comprehensive Smokeless Tobacco Health Educarion Act of 1'986. Congness has otherwise imposed no restrictions or other require- ments which directly affect tobacco advertising and promotion. The Food and Drug Administration takes the position that it has no authority over tobacco products:or their advertisements as long as the ads make noheafth+related claims: The authorityof the Federal Trade Commission overtobaceo.advertising promo- tion is limitedito enforcittg the warning,label legislation and!to carrying ;out its traditional mandate to prohibit false or deceptive advertising, an authoritywhinh the FTC has exercised only rarely, In 1992, for the fim time, Congress took a step to restrict the sale of tobacco products to individuals under the age of 18 as pan of the Alaohol/Drug Abuse and Mental! Health Administruion Reor- ganization Act. In that Act; Congress limitedlthe rigbt of the Secre- tary of the Deparmnent of:Health and'Humzn Services to make certain state funding grants unless the state invotbed has a law making;iris unlawful for any manufdcturer4 retaikr;,or, distributor of tobacco produets to sell or distribute such products to any individual under the age of 18, and unless the state has submitted a plan to indicate that it will lenforce suclt a l$w in a manner "that can reasonablybe expected'to reduce the extent to which tobacco products are available to individuals under, the age of 18." Piiblic poiicy optaions Given the nature, extentiand impact of tobacco advertising and promotion today, the two questions are: (1) Whatishould be done to most effectively reduce and counter the influence of advertising and marketing on tobacco use in the United States todsy; and (2). given the political realities, what; if any, actions should be taken to eliminate or counter the mosregegious tobacco advertising abuses while progress is'made tovvardk long-term goals? The followingpollcyoptions are not new, but neither have they been adopted nor implemented: Ptoposal! I: Ban Advertising and Promotion A ban on advertising and promotion would eliminate all advertis- ing of any Idnd'for tobacco products, including all billboartds, print! advertisements and utilitarian items, such as T-shirts and hats, It would also prohibit tobacco companies from sponsoring events such as rock concertsand tennis tournaments under the cigarette brand names. Organizations such as the American Lung ASsociation, ,the American Heart Association, the American Cancer Society andlthe AYnerican Medical Association have endorsed a ban on advertising and promotion. Legislatiott to baniall advertis- ing and promotion of tobacco products was first introduced in Congress in 1 1986 and has been introduced again in the I OOtlt i and 1p1st Congresses without being enacted. Pro A banwouldnot only eliminate the direct influence of! tobacco marketing efforts, such as the lure of seduetive advertisements and billboards„but the indirect effects as well„such as the inad- equate coverage of the health consequences of smoking by adLer- tising-doerident news media Reeent US Supreme Cour[decisions sttpport the position thaca legislativetymartdated ban on tobacco advertisin& and promotion would probably be upheld as constitutional„if4t were based on the government's desire to reduce the number of deaths caused' by tobacco usage by reducing the prevalence of smoking. Can l Opponents of an advertising ban raise three principal objections: l) an advertisirtg ban is unconstitutional; 2) a ban would be ineffective in reducing the prevalence of smoking; and 3) a ban would lead to bans on other consumer products. The,debate over an advertising ban is made more complicated because it engenders opposition bythe mass media, who have become dependent upon tobacco advertising dollars and who argue that they would be financially hurt by eliminating these revenues. Otganizations,,such as the American Civil llibentie,s Union (ACLU) have expressed!First Amendment concerns. Fur- ther, the proposed ban also engenders opposition by many attKs and minority organizations, which receive substantial financial support from tobacco companies. Proposal II: Develop aiMechanism to Fund and Produce an Effective Ongqing Counter-Advertising,Program Counter-advertising is often mentioned as an alternative or complement to restrictions on tobacco advertising., lYounter- advertisingmay indeed lend support for restrictions only cigarette xn

Wot-kyttops advertising. To be effective, cotutter-advertisements need to be professionally produced and placed frequently in oftea-seea media. This requires adequate funding to purchase advertising, space and time on television and radio. The success of the pro- gram cannot depend on the media's good will in placing these ads for free (public service announcements). Small-scale pioneering paid cotmter-advertisingprograms were begun in the 1970's and. 1980's bydDOC'and by media consultanrTony Schwartz: Major cotmter-adverbsiitg,pnograms have been launched by several states in Australia. In the US, voters in California and Nfassachu- setts approved referendano increase cigarette excise taxes, a portion of!which are dedicated to paid counter-advertising to discourage smoking. A bill introduced by Senator Ted ltennedy to fund a federallagency to purchase counter-advertising did not pass in the 1100dt Congress. Pro Supportersof~thisapproach point to the fact thatanti'-to,bacco counter-ads run inthe late 1960s-prepared asasesult of appljing, the Fairness Doctrine to tobacco advertisements on television and radio-accompanied a significant decline in tobacco consumption. Studies demonstrate that the counter-ads played an important role in reducing tobaccoconsumptionduring this periodiof time. A major advantage of this optioniis that it involves no restrictions on speech. Thus; it obviates any argument of First Amendfnent eoncerns even by ttie most zealous supporters of~ the tobacco industtry and the ACLU: Con The largest obstacle to creating an effective counter-advertisingg campaign is financing. In the late 1960s, counter•advertisements were broadcast on television and radio without charge,,as re- quired by the Federal Communication Commission. Today, an effective health campaign would'reqnire substantiallfund'utg to compete successfully against the $4 billion spent annually by the tobacco industry. Givenihe high federal budget deficit, itwould be diificult to obtain an annual appropriation of this amount One funding option is to earmark a portion of the cigarette excise tax for this purpose. Each penny of the federal tax generates almost E300 million, so a relatively small increase dedicated to counter- advertising could'provide measurable returns. Putother, funding option,i5 to require that tobacco advertisers provide funds to purchase space for counter-ads on a propor- tional basis to their advertising,expenditunes: Or, this proposal might be combined with the proposallto eliminate the tax deduct, ibility of tobacco marketing expenditures, and earmark a portion ofithe additional taxes received for counteradvertising, Proposaf IiII: Elirninate Advertising Expense Deductions This proposal would deny tobacco eompanies a tax;deduction for cigarette advertising expenses. Currently,,tobacco comapnies can deduct 100% of their advertising expenses as a business expense:. Senator Harkin (D-IA) introduced legislation to this e6eet near the ez»i of the 107.nd Congreas, but it'was defeated, 5(r 3& . These proposal'; would not prohibititobacco manufacturers from advertising,, but would eliminate the manufactuners"privilege of deducting these expenditures from their taxes as tax-deductible business expenses. Pro The tobacco ~indttsuy saves over a billion dollars each year be- cause its huge advertising and promotion budgets are tax-deduct- ible. Removing this governmental privirege would substgntially, increase the cost of advertising and promotion and presumably„ reduce tobacco manufacturers' financial incentive to spend so heavify. This proposal also relieves American taxpayers of some ofi the burden of'subsidizing,the tobaceo manufactuners"marketing efforts. Furttier,,the Supreme Court has made it clear that a companyy does not have a constitutional right to such a tax deduction. Con~ opponents of this legislation have argued that this approach is an unconstitutional restriction onfvee speech. The coastitutional challenge to eliminating the advertising tax deduction has even less merit than the challengg to an outright advertising,ban, Con- gress has broad latitude in establishing elassifi+cations widtin the tax code which confer benefits on some groups tfiat are denied to others. Proposal! [V: Tombstone Advertising. "Tombstone advertising" is an alternative to proposals to ban tobacco advertising or eliminate the tgx deduction for tobacco advertising expenses. There are a variety of configurations of tombstone advertising, but the most common would prohibit the use of models, slogans, scenes or colors in tobacco advertise- ments or on tobacco packages. Only text wouldlbe permitted. Restricting,tobacao advertising or tombstone aditertising could also be tied to strietdimits on tobacco promotions and!brand- name sponsorship. Pro. Many tobacco advertisements rely on slogans and'unages. By and large, these ads sell the potential smoker an image which he/shee may wish to emulate. This form of'image advertising is most effective with young people, who are very image-conscious, seee tobacco use as one way of'being somebody, they are not and pay- little attention to advertisements that are pcimarily, text oriented. Restricting,tobaeco advertising to tombstone ads would be an action designed to reduce the effectiveness of tobacco advertising with young people by eliminating the form of advertising consid- eredimosrpersuasnue with this group: It wouldleliminate botlrthe Marlboro cowboy, "Old Joe" andithe image projected byYirginia Slims advertisements. 69 Toba,ccoC°se: An.4ime-ican Crisis o20~24196976

11'atrkslrops : . Thematic imaggry ads are not'just aiined at the young, btttaLSo att women and minorities. Strictly prohibiting the use of thematicc imagery would dramatically alter tobacco indttstrymarketing towards these groups as welL Tombstone advertising,does not restrictwhatiaitobaceo manufac- turer can~sayaboutits products in its ads:ttor does it, limit thee amount a manufacturer can spend to advertise. Thus, it is likely to rai'se fewer hee speech concerns. Con, This proposal does not, reflect an understanding of the impor- tance of the brand-name of a product as an essential component of advertising. The brand:name itself is as important as any asso. ciated imagery. Moreover„tmless a totnbstone advertising polit.q also restricted promotional;atxivities, its effectiveness would be limited. Cigarette marketing expendittues have steadily shihed from~newspaper and magaane advertisements to promotionall activities, such as sponsoring events,,coupons and other price oriented mechanisms. Indeed,,tobaceo company expenditures for promotions now exceed expenditures on advertising, Proposal Vi Enact a Version of the Tobacco Industay Advertising Code The federal government could enact legislation modeled after the tobacco industrys voluntary advertising code, but with its most glaring weakrtesses corrected. Among other things, the Code cutrently, states thavit prohibits advertisittg,in publications di- ret:ted at those under 2'1' years of age, the ,use of models under, or appearing to be under„ 25 years of age, and advertisements sug- gesting that smoking "is essential to social prominence, distinc- tion„success; or sexual attraction:..." To date„the tobacco industry has used its Code as a pubtic relations gimmick, but has never seriously abided!by its provisions. Pro The principalI advantage of this approach is that it simplycodifies and creates :an enfoncement mechaaism ~for pritmiples that the tobacco indttstty, itselfi purports to have adopted. Itwould be difficult for the tobacco industry to claim the new Code represents governmental restrictions on~comnter+cial speech, if'the Code were based oni the industry's own attempt to eliminate abusive adverrtising,practices. Con Codifying the industry's advettiaing,guidellites,,or any other code of conduct, would'require Congress to establish amorphouss standards that might be difficultito enforce: For instance, what is a publication "direeted primarily to those under 21 years of'age?"' How does one determine whether ani actor appears to be under 25 years of age?'Sttcli a code would aLso likely permit the contin- ued use of some of the marketing methods, such as the Marlboro Man, whichlare mosteffecti.ve wzth young'people. Enforcing a 'woluntaryr"code without restricting promotionallactivities would also fail to address one of the principal marketing techniques of theto,bacco industn'. Proposal VI: Eliminate the Federal Preempdoniof State Itegplation of~ Tobaccu Advetrtlsing The Public Health Cigarette Smoking .Act of 1969 prohibits statess from enacting,requirements or prohibitions based on smoking and health with regard to ~cigattette idvertising or promotion: Repealing this clause would enable states to impose additionall requirements and;resttnctions,inclutling bans in appropriate circumstances-oni tobacco advertising and marketing which takee place wtiollywithin their borders. Pro States should have the right to protect their own citizens; repeal- ing thls limitation would allow states to :enactialruietv o6their own ! measttres to discourage tobacco consumption within their jurisdictions. Con opponents contend that repealing this provision would given states license to violate manufacturers' First Amendment rights and would create the possibility of 50 different states enacting 50 different sets of i rules. Proposal' VIL• Ettact Improved Warning fabels The current warning labels required on tobacco products and advertisements were establishedby the 1984 amettdment,, to the Federal Cigarette [abefing and!Ativertising Act. They were enacted becattse of the ineffectiveness of~the then-existing warning label. Concerns have been raised about the effectinueness of the 1'984, warnings as well, including the adequacyof the text of the current label~, the visibility of the wamings and the lbCationof'the current warning$. Congress could amend the Act to require a different warning label fotmat, content or location to help improve the labels"effective- ness on tobacco prodttcts and in tobacco ads. Information not now, inchtded„such as "Smoldngis addictive," could be added. This Act could also be amended to require a "circle and arroiv'•' format similar to that ~ requiied on smokeless tobacco producta packages and advertisements: This graphic device would'make the current warning labels more visible. If'this were done. the size of the circle and arrow and warning label print might;both have to be increased. Congress should also consider placing,the warning label on the front of tobacco packages to improve the frequeney with which they are seen, Moreover, the health warning on billboar& shouldi be made more prominent to be effective, they mustibe legible from a distance, and at high speeds. Pro Improved health warnings can be enacted withoutappropriating substuttialladditional funds and without raising new inct.Amend- ment concerns. They also can be tallored!to fill in speci6c gaps in

Wtrr6cshatps :.. constunerlatowledge: Finally,,the concept of a health warning is one legislators accept Con Questions are raised about the effectiveness of warning label+ as a, major component of an anti-tobaeco effort. Whatever role warn- ing labeLk may play, in a comprehensive tobacco education pro- gram, the increased benefit of strengthening,the current warnings is difficult to predictwithieert.vrtty. Warning labels have provided tobacco companies with added immunity fromilitigation even as they disarow the truth of the warnings. Proposal VIII: Authorize FDA to Riegulate'IIobacco Advertising Federal laws and regulations of foods and!drugs set very strict standards on ihow these products may be advertised artd pro- moted. FDA has takenrthe position tbarit does not have authority over tobacco or tobacco advertising. Congress can remedy this by enacting;appropriate legislationj Pro FDA regulations already contain dozens of restrictions on phar- maceutical advertising and promotion. These restrictions have in effect prevented pharmaceutiral companies from certain types of advertisements aimed at consumers on television and radio, billboards and general eiictilationnewspapers and1magazines: Since tobacco and its components are more hazardous than many regulated!drugs, the regttlatory, exemption oPtobaceo products is at best inconsistent. By providing the FDA with authoritq to regu- late tobacco advertising, Congress could assure tfiat a strict code is applied and avoid many of the difficulties in formulating new standards for tobacco advettising and promotionj . Con Giving the FDA authoritV to regulate tobacco advertising and pro- motion will leave the degree of such regulation largely at the discretion of'the federal agettcy, Regulation migtitinctease or decrease based on idie views of agency'personnel at any given time: Recommendl3tions 1'. Effectivellj pressure the govetnment to,enforrcx the existing law:; a. Document the violation of the exiatinglaws: b. Document the failure to enforce the existing laws: 2. Counter the tobacco industry's misinformation by educating the public. Develop aimectiartism fon an ongoing campaign to: a. Counter the brand-name images promoted by the industry: b. Educate the public about the effects of tobacco use and the tactics of the tobacco industry. c. Educate the public about the needifor restrictions onn cigarette advertising and promotion. w-. d. Expose those who enter agreements with the industry to promote tobacco. 3:1tie group restates its long-term commitment to eliminate exploitation by the tobacco inditstry through advertising and marketing. a. Itis in America's best interest to take into account the dv- namic nature of the industry and for any ban to be broad enough to cover traditional forms of advertising and more recent trend5like sponsorship, product placement:,utilitarian items, etc. and learn from other countries where the industry, has circumvented a ban. b~ Any restrictions on advertising,should~ '~move forwain svnc with alcounteradvertising and edutxtional campaign. c. It must be recognii:ed,thatithere need to be a numberof' interim steps while any proposal for the elimination of'tobacco marketing is debated: These include 1.11he items mentioned in priorutiie li and 2. 2. Sustained educational campaigna onthe evils of tobacco marketing„and 3: Interim steps that attack tactics which have the greatest impact onictuldren; such as sports andimusic sponsorship, utilitarian items, state action, etc. 4. Eliminate the tax deduction on tobacco advertising. 5: Increase the emphasis on what'states can do: eliminate the federal preemption iof tobacco adcertising regulations by,%ttes: 6. Develop a mechanism or funding for current mechanisms to more effectively monitor and evaluate the tobaeco industry's activities. Develbp this research so we will have adequate data from which to develop strategies for the future. 7. Reject the tobacco indusuy's voluntary code in its current or any future form. Challenges to otusel.ves. 1. Challenge the loader5hip of ourmoventent to develop a strate- gic plairtfor potential futtfiiitg, and designate individual-c sutd organizations to implement recommendations of each of the workgroups. 2'. Identify and develop additionali resources devoted to accom- plishittg the above. 3. Broaden the diversity of our group to include those being exploited bythe tobaceo industry. 4. Broadenour base of support in tenns of numbers, meaning grassroots support. 5. Explore and assess the impact of warning labels in countries that require stronger labels. 6. Idorttifyand develop leadership to implement recommenda- tions and action steps: 2012419696-m- T-)ha<cn l'ce ar..?n:erc.rn ,'risis 1

Wtrrl:sltops International Health and Tobacco Use An estimated one billionipersons smoked5,2 trillion cigarette in 1988 resulting in 3' million deaths from smoking related diseases that year.' Of major concern is the fact that the burden of smoking nelated'diseases will be shifted ditring the next two decades from developed nations to newly developed ones.0 The World Hlealth organization (WHO) predicts the number of deaths will increase tttcee-fold to 8 million by the year 2025.' Aecording to WH@;, progress made in curbing deaths fnom, malnutrition and infectious diseases in lesser developed countries will be lost to deatl>5 caused by smoking.. Prevention of this future epidemic is one of the greatest'public health challenges we face today: Tobacco control policies have reduced smoking in the United Staies (US) and in many other developed nations. Smoking ryues are declining 1.5 percent per year in the US and Westernt Eunope, but rising 2 percent'peryeat'inlesserdevelopedcountriess'Tliis increase is due to internal social and economic factors such as increased disposable income and women entering the work fotne: f:xternai pressure from Trartsnational Tobacco Companies (TTCs) is also contributing,to the probiemwith the introductiomof sod phisticased cigarette marketing practices: Developing countries are also more dependent on tobacco tazes and jobs tttan devel- oped countries, therefore;,less liltely,tocurR.vl the ptPoduction and sale of cigarettes..'b The key to prtevention~of this futtre epidemic is passage of stnok- ing controllpoticies in newly developed counotues including higher taates;,prohibition on advertising and promotkrns And restrictions on t.tse: Many newly developed countries maintain closed cigarette mar- kets which limivthe manufacture andisale obcigarettes to national firnts or state owned tobacco monopolles.""Until recently, Asian nations such as, Japan, Thailand, Taiwan, and Ko>rea severely restricted or prohibited sale offoneign brands. Thecentralty planned economies of'Eastern Europe also excluded foreign competition with the exception of minor licensing anrangementss to produce and sell foreign brands locally," A cloyed cigarette market may have the unintended effect of' curtailing smoking, In the absence of competition„cigarettes are generally notadvertised. There is little price competitionud the '.quality' of cigarettes is far below thauof the highly tlavored,easy, to smoke international brands. Yet. as world trade is liberalized newly developed nations, rather than~adopting,smoking control policies, aredikelv to do the opposite over the next two decades.' Gregory, Connolly, DMD; MPH Ted (hena,PhD The pereerved short term economic benefit of tobacco production may result in many, nations expanding production and cigarette advertlslrtg.''Anexternallforee,,US tradt policy, also hasbeen~ used to transform noncompetitive markets into competitive ones with the forced,entry, of international TTf'6 Philip Morris and!RJ Reynolds into Asia.' In the case of Fastern~Europe, the move to free markets has led to thecomplete acquisition ofthe former EastiGermany tobact:o industry, b,v the TTCs in 1'989 and a pur- chase of majority interest in the Caeahoslotrakiani and Hungarian tobacco industry in 1992.10 Tobacco Trade and Export Policies Expanded world trade of tobacco and cigarettes is clearly not in the best interestlof world!health. Nor is the trartsfer of tobacco modern manufacturing and marketing,technologies fnom the developed world to.developing worldJ Yet, decliningconsumption in North American and'Westetm Europe has resulted in the cip- nette manufacturers from the US and Great Britain and the govern- ment of the US turning to these areas of the world for new smokers to replace those at home who have quit or died from ~ smoking. Entryof foreign manufacturers into ctosed lmarkets results in significant changes in the market which may push up consumption In 1984, tfie US amended the 1974 Trade Act allowing the Presi- dent to investigate alleged unfaic trade practices against US prod- uets by foreign cotuttries. Section 301 of the trade latv allowed'the President to levy, tariffs on exports to the US if a nation was found to unfairly restrain US imports, Given the high trade deficits with newly dpveloped!nations in Asia and the political power of the tobacco industry~ four tobacco 301 investigations were conducted from 1985 to 1990 on the restrictions on imporrof US cigarettes to Taiwan, lGorea and Japan: Trade threats were successfully usedd against these nations to repeal "restrictive"'measures including, bans and tariffs on US imports and advertising restrictions.' Other US policies and programs harve been used to further aid' expansion of llS cigarette companies into developing eountries. During the 1970s and early 1980s, the US Depairtment of Agriculture's Foodlfor Peace Program exported over El billion in tobacco leaf to developing nations to help the local industry, and increase demand for "lighter" US blendWeigarettes:' Tobacco was excluded in 1'982 from Food for Peace but included in a new program in 1984, the Expori Credit Gttarantee Programi This program was used to export L'S tobacco leaf and help US cigarette

Wo .rk,ltops companies penetrate Ntideastzaarkets of Iraq, Fgypt,l?tulcey and Algeria. Over f 188 million in credits were given under the pra gram from 1984 to ~ 1988!' lfie high profits US'cigarette companies make in the US provide needed capital to diversify at home into nontobacco areas and to acquire and build'eigarette plants in the developing world. Philip Morris reported in 1989 that it'willlinvest $2 billion in capital for its international tobacco operations over the next four ymrs." Many tobacco companies in developing companies seek foreign funds and technology to modernize their industries: Yet, once the TTGs gain i a foot in the door, market domination usually results.' Once a market is opened and the TTCS enter a number of changes occur. These include modernization of cigarette manufacture with the intraduction of lighter, easy to inhale, American blended cigarettes. Introduction of these cigarettes may result in current smokers smoking more per day and nonsmoking women and children takutg up the habit. The introduction of cigarette adver- tising and promotions on a massive scale are ofteni targeted to roung people who are easily entiaed Ito experiment with the for- eign brands: Two years after the TTCs entered Japan television advertising increased ten-fold and in Taiwan, entry into discos popular with teens cost five empty, packages of Winstons. In Japan there was a sharp increase inithe number of'retait outlets and price competi- tions between the Japanese monopoly and foreign companies. Wotnents cigarette brands;,suchias Yirginia Slims, were introt duced for the firsi time:in Asia (where less than 10 percent ~ of females smoke) i after entry of the TTCs:x' The effects of these market changes in Asia have been seen in the increase smoking rates among Japanese females and Taiwanese and Korean teeas; The Japanese market was openediin 1986 and from 1986 through 1991 smoking preralence among Japanese females rose from 8.6% to 18:2%, and,27 percent of the 20-29 year old women curretttlysmoke. Total'eigarette consumption has risen 5 percent in japan from 1 1989 to 1991. Ia Taiwan smokutg, rates rose 4 percenttwo years after, the market was Gberalized.° Neighboritig Hong Kong and Singapore have adopted very strin- gent tobacco control policies and smoking rates among women, have remained below 10 percent and overall consumption has fallen. Public Health Policies and' Restrictions on Tobacco Trade In 1989 the world's international'trsde body;,General!Agreements on Tainffand Trade (GATr), was petitioned by the US to deter- mine if 1ltailand?s ban and tariffs on cigarette imports violated GATf articles. GATT ruled that trade policies applied only to foreign brands were discriminatory and inconsistent with GATT' articles:15 Yet; GATT also ruled that a variety of tobacco policies were consistent if applied to both foreign and domestic cigarettes. Policies cited by, GAd'f included bans on adverrtising;and promo- tions, restrictions on ttse; limits on tar and nicotine, taxes and other measures. GATT determined Ithat nations have the right to limit'trade of harmful substances for health masons. . a. 4 These policies serve the short term economic self iuterestof a state tobacco monopoly by freezing markei share, and denying;the foreigners the 3ools they need'to enter. The same policies also promote the long;term interest of the public health community to curb smoking over time.?3„ The Thai decision was historic and is a major set back for the TTGs: The anger generated by the US trade tht eals generated considerable media attention in ilttaiLvtd and made tobacco control a national cause. The fledging tobaceo control movement gainedipolitical power and qtticklypassed!laws banning advertising, raisutgtaxes and~nestric.tiitg smoking ini public places: Taiwan is pursuing similar legislation. Other recent events inclltde a decision by, the World Bank to eliminate suppnn of tobacco agricultural,projects from their loan programs.. The GATT decision and passage of 7lhailand's smoking control law came about through dose cooperation between control public health activists in the US and Thailand. In summarq, passagc of smoking control policies in newly developed nations is essential i to the prevention offutttre epidemic of smokang related diseases in these areas. Not only do policies maintain, noncompetitive markets but based on the exputsion in North America can sharply reduce consumption. Wltether or not what Thailandihas done will spread'to other nations faced with similar threats is unknown. Success will be determined by what occurs in the foreign country as well as in the United States, the principal home of the TTCs. Adoption of a comprehensive smoking eontrol policy by the United States is perhaps the mosr important action that can be achieved in the U5: Stt•ong,US'policies would reduce the economic and political power the US transrtational tobacco companies by redUcing profitability and the population of smokers. in turn, die inditstrryts ability to dictate control over US'trade policy willlbe weakened. Both the United States as well'as the world would be healthier. Recommendations 1. Congress should pass legislation to prohibit the USTR, the Deparomettsof State and Commerce, or any other agencv of the Us government from actively encouraging, persuading or compelling;any foreign gopernment:to expand the marketing of tobacco products whether it;be byrepealing of'laws restricting, marketing practices or securing agreements to introduce ne,v measures or expand current ones. This applies to the promo+ tiw advertisement, distribution and taxation of tobacco prod- ucts. 2. Congress should use afiAed percentage of revenue collected through foreign tobacco sales to fund US federal agencies to provide technological assistanee onsmok6ttg controlI and prevention to countries that import US tobacco. Areas of tech- nological assistance to ibe considered could'iinclude, but uocbe limited to the following areas: smoking survey methodology; strategies to initiate cigarette excise tax and tobacco product hazard control legislation, and intervention strategies to control andiprevent tobacco usage. 3. Congress should eliminate alllfunding for USDA programs th:tr provide assistance or promote the export of tobacco :uid'to- bacco products and promote tobaccogriowang overseas. ~ r--,hacc,) V,~e,AnA,nerfcan Cnsrs~~ 2p~24~'196~980~ 73

Y~'or6iltops 4. Congress should amend federal laws governing the eVort of hazardous substances to include tobacco and tobacco products. 5. The Worid Health Otiganization (WHO) should significantly increase its funding of tobacco control projects, either by reallocation of existing funds, or by increased US fundittg of 'the organization. These projectshotlld include collaborative efforts by WHO and!the Deparnment of Health and Human Services (especially, the National Cancer lnstitute and the Centers for Disease Control) initobacco control technology exchange. lncluded in such efforts will be annual reports on tobacco control programs and their impact,,development and tnainte+ nance of international„national and local tobacco eontrol intrasuvctttrres, and training and exchange of information on effective tobacco control interrentions (including policy tnedia, educational: and other program interventions) and data collec- tion activities that supportithese interventions. 6. Congress and the Clinton administration should encourage: GATT'to eiiminate.subsidies for tobacco agriculture among member nations. 7. US andInternational health~ voluntary and professional orgarli'- zations: International and voluntary organizations should collaborate with WHO to provide a comprehensive annual update on tobacco-related data by country,; including epide+ miological dafa„policyinformation, local tobacco control infrastructure, and information on tobacco control programs in each country, induding the status of the researoh 1 regarding the emironmenu These same agencies should greatly expand their, support of;programsaimed atcurbing,tobaecouse andi track international tobacco control programs in developing countries, 8, I2N affiliated agendes should adopupolicies on programs that eliminate support for tobacco trade, manufacture, and market- ing of tobacco anditobacco products and adopt new policiess and programs to discourage tobacco ttse. These agencies include Worltl'Bank„IMF, fJNdC,EF;,aad others. 9: US and international public and ptit^ate agencies should en- courage and provide resources to insure represetttatfon that is ctilturally diverse within each participating nation and inclusive oFindigenous leadership in all efforts to drvelop and'promote tobacco prevention and'eontrol~initiative, conferences, and plarutingmeetings: - _ r.:q,,. Rreferenr.es 1) Cbandler WV: B1biu,G'rng tobacco: Worldraattbppaper6B.1 Washing- ton, IDC: Worldwatch Institute; ,1986, pp. 1.-42: 2) Taylor P: The Smoke Ring. New Yoric Mentor Press, 1985, pp. 1 386. 3) Stevens D: World tolr.eco consumption to inerea.se through 2dN10 A.D: Todasco Reporter. 44-42, JanvaY 1990. 4), World Health Organization: Report~of a WHO eonsultation on stmisti- cat aspects of Tobacco-related mortality. World Health organization: (Yenevx 1989:1-121 5) Stebbins KR: Tobacco or health in the,third aorld'. A political economy perspective with emphasis on Mexico. Jnl.'J. HeaUb. .Aerrrk 1987;,17'521-537. 6) Agro-Economic Services: The,Employment, Tax Revenue and Wealtb ThaCttie Tobacco Industry,Creates: London: Agno-Etonomic;Serviees. September 1987. 7) Shepherd PL: Transnational coarporations and!die international cigaretleindustry, In Profits, Progrrss anrl Pouerty: South Bend; IN: Univ: of Notre Dame Press;1985, pp. 63-111. 8) ERC Statistics InternationaL The WorldiCigatette Market, 1988. International Survey: Suffolk, UK ERC, 1988, pp. 1-1300 9) ConnoUyGN: Worldwide Eiepansion of Transnational Tobacco Com- panies, f. Na1: Cancer lns., ,1992, 12.24-35:. lo))ossens L: Test the EasrTobacco [ndustry, and Eastern Europe. Brus- sels: European Bureau for Action on Smolang,Prevention, November 1990. 11) Anonymous. The making of a big deal,in cigarettes. Ni Timec. June 21, 1992:F6. 12) Connolly GN: The International Marketing of Tobacco. Tobacco L'-s-e in America Conference. Ctiicago, 11.:Am. Med. Assoo... 1989 .

Walrl:sltctps Building Coalitions for State and Locall Tobacco Control Legislation Introdltctnon The pathogen that is the number one cause of death inithe United States, responsible for the deaths of almost a half'amillion Nneri- cans every yeart is not a microbe or an undiscovered viinis. lt is the tobacco industrv, The tobacco industry gets away with murder figurxtivelyand Gterally because society acquiesces in this devastation. To change this situation, broad social changes, in general, and political and! legisllitive actions, in particular; are necessary. Therefore, the tobacco control movement must become expert, in bullding coalitions and in passing,legislation: (For information on historv or current situations regarding spe- cific areas of tobacco control, for example women, taxes, protect- ing nonsmokersi etc. please see specific topic sections. This section~addresses the processes of coalition building and passing legislation.) Purpose The goal of tobacco control is to save lives, to create individual and community experiences which foster, self worth; cooperation, and participation in political'and social processes, and to have. fun. The award1for elegance goes to those who save the most lives with the smallest expenditures of money and time. The Players The tobacco conttrolhnovement is a dynamic andidiverse grouping of organizations and individuals: This diversity is a source of stnength~and can also be, and has been at times, a source of weakness and division-a state of affairs that can only assistithe tobacco industry. lfis imperative that the various elements of the movement understand!each others' roles andloperating struc- tures. Such understanding will lead to more and better coopera- tion at the federal, state and local level. Currently, the tobacco control movement is made up of: • individual activists-t?oncetmed'citizens; well+credentialed professionals, legislators, and!essentially single-person "non- smokers'groups" • state and/or local nonsmokers' groups Note: the nonsmokers' advocacy movement is a true grassroots movement, comprised of'citv, counM;,region; or statewide groups, Regina Carfsort Peter Fisher created and run by citizens. Organizations are independent (rthough many use the acronym GA.SP)„with small budgets :uid staff (only :Nlassachusetts, Vew Jersey, Kinrtesota, and Colorado have paid staff),,and cooperation among them is high. • national nonsmokers' groups (Americans for vbnsmokers' Rights, Action on Smoking and Heaitfi) • lbcalJ,state;,and national units of Doctors (>ught To Care (DbC)i health professionals and others concerned about health promo- tion and disease prevention; and Stop Teenage Addiction to To- bacco (STAT) • local, state, and national units oflCancer, Heart;,and Lung Associations; their Coalition for Smoking OR Health in Vl"a.shint;- ton, D:C.; medical societies, and public healtti orqanizations • local, state, and national interagency councils on smoking: coalitions for~ legislation, ad hoc committees on particular iSSues or questions • broad i8sue advocacv organizations. most notably the :vdvocacti Institute, and, lately; Public Citizen and Common Cause • governmenrorganiiations, particularly the new generation~of professional, publiclyfunded'tobacco control specialists created in California by Prop 99, the Offlce on Smoking and Health. state and local health~deparunents, governor's offices, etc. • legislative caucuses. Expanding the Tobact:o Control Mowement To achieve a tobaeco-free society all sectors of society must be involved, including childten, schools, families, businesses, mediitc governments; and alllkinds of'organizations, including,civic,g religious, professional, etc. Recent successes include tJie rapid! a.ssembling,of ll00organizations in the Coalition for a lleathv. VewJersey (advocating increased cigarette and alcohol taxes); and the stunning victory of,the Massachusetts tax increase initia- tive, accomplished by coalition of more than '_5(1 member org:u;, zations. N O These groups need to be included in tobacco control coaditii>ns N • businesses and business groups; including,professioir.tl organizations • government watchdog,grottps, taxpayer grotips Tohacco Use- .9n .9merican Crisis

Witr6ltops • governmenrorganizations; suchas mayprs' groups • fire departments, assoeiations : • unions, labmr networks • Democratic and Republican party organizations I • medical'specialty organiiations, hospitallassociations, visiting nurses, mental healthiorganizations, etc. • health promotion organizations • anti-alcohol and anti-drug,communities • law enforcement organizations • laryngectomy groups, tobacco victims and sutvivors groups • smokers for tobacco control • self-help orgXiizations, cancer survivors, environmentally, sensitive, disability, groups • educational organizations, professional~and lay, including,PTA, school boards associations; eoUege cottsortittms; AAUW • childhood welfare and protection organizations • media associations, newspaper publishers • AARP, other older people's groups • civic groups, Kiwanis, lions, Rotary, • charitable organiiations • environmentai organizations, consumer groups • fraternal organiza.tions, Elks, Moose • religious organizations, churches • minority groups, ethnic, women„sezual identity. • youth groups, student councils, 4-H, scouts, SADD, college service fraternities, university students' groups • sports groups;,athletic confenetaes,l:ittle League, Ys • arts and cultural.groups • celebrities. Working Together, Worlting Apart Broad-based coalitions are almost unbeatable in~tobaceo control. When individuals and organizations are really determined to eliminate tobacco s toU,,whenthey decide to devote appropriate time and resources to tobacco eontrol (and obtain professional media and lobbying advice and advertising time)„when eachh active individual and organization is allowed to make its own contribution, and when alllare valited for thein role, then the emphasis focuses on the goal and!mutual respect is high. Small,, underfunded coalitions; however, are limited in what they ran accomplish. (For informationionprocess, case studies, etc.,,see Resources for Action, below.). Worldng separately mayaL4o be effective. A broad-based concern in society about'smoking,will ultimately, Involve large and small organirations, and traditional andlxctivist organizations. (Activist groups are sometimes perceived as radicai. Radical, derrred from the Latin "raditC, means root. Activists recognize thauthe root causes of;tobacco's toll are the tobacco industry and social acqui- escence. Activists tend to speak bluntly about this and to~deal directly witli it ) Fstablished and grassroots segments of'sociery can play ut effec- t't++e game of I"good cop, bad cop". Activists can articulate farr sighted goals„whiie organizations with impeccable reputations, like the American Cancer Society; can give respeetabiUty and marshall large resources. Tireditional organizations speak with authority and grassroots groups have the authenticity of speaking for the people affected by tobacco. Each individual and organiza- tion has the right to set its own priorities which all should'honor. albeit after enlightening discussion. As more actors come into the movement, there will be more elbow room for individuals and organizations to find their niche: ltwill'aLso be appropriate for more specialization to develop. How to Lobby for Lives in Three Simple (But Not Necessarily Easy) Steps 1'. Know the processes for legislation, regulation, and!policy change:. 2: Know and work with the players within legislative bodies, government organizations,,businesses, commtutity~organird~ tions, etc., responsible for chattge: Know the media and how too use them effectively, Know the role of the tobacco industrv, the strategies it will try, and its allies. Exposing the role of tbe tobacco industry, especiaily itspoliticrr!'contrib'utions, artd making it unacceptable for legislators, corporations, and otber sectors of society to collude tuttb the tobacco industfys must b'ecome a majorfocus for tbe tobiacco aontroGmoue- ment: This has been done brilliandy in the past in Canada and inGalifornia Recently The Advocacy Institute, Colbrado GASP, V'irgini*G,aSP; Arizona GA,SP„Smokefree Pennsylvania, and some reporters have atttcoPened tobacco money's'bul!irtg, power. Know and use the suengths of the tobacco control, movement 3. Commit major resources.. Recommendations Internalprocess 1. Educate national, state, and lbcal units of prohealth org:u»za1 tions about the monumental health effects of tobacco use and the enormous influence of the tobacco industry. Recognize that media underreporting of this problem is a symptom of tixe problem and that even some health organization staff and volunteer board members and officers are often tmaware th:ut almost a half million Americans die annually from one panlio- gen-the tobacco industry. Education should include ca.e histories of successes.

11 ock,luops 2. Organizations should examine their mission statements and the role of'tobacco in blocking these objectives andI should devote commensurate resources to tobacco control advocacy. They should employ methods which are most cost-effective. Training in advocaeyskillsy especially in~lobbying techniques, media1 relations, and coalition building should be a priority for staff and volunteers. There should be nationalland state conferences annually on tobacco control legislation and there should be annual lobbying days at federal and state levels. National, state, and local medical societies, along with medical l speciaity societies, should actively participate with coalitions in " tobacco control. The AMA should reqpest yearly progress reports from its component organizations regarding each year's progress in state and local tobacco control, and the next year's priorities for activism. The tobacco control movement should acknowledge the impor- tance of, not only making recommendations but implementing them. The gpal is not just to make recommendations, but to save lives. 3. There should be the widest possible recruitment into the to- bacco control movementftom all aspects of'society, recogniz- ing that this is a society-wide problem. Some organizations will'not be involved inievery issue, even though rthey share a common ultimate goal. Therefore, working groups may be formed around specific issues. The movement should become more sophisticated in under- standing;which segment of the tobacco contnol!movement can best carry, fotWard each issue. The tobacco control movement should acknowledge the importantand unique role whichreach organization has to pli;y: "Citizen spark-phigs"---etfective grass roots activists -should be encouraged, supported, and rewarded as valued publicc citizens and the heart of the smoking control movement The larger nationallvoiuntary organizations should continue to send, in writing, information to their state and local organira: tions encouraging them to work with local grass roots activist groups and to support them'with resources (staffitime, office space, supplies, materials, printing, etc.). In returm; grass roots activistgnoups, which often have new and creative ideas and a deeper knowledge of the tobacco issue, should share their information and skills with national organi+ zations, to educate and to activate. Tactics t. Legislators have a statutory, and moral responsibiliry, to protect the welfare of their constituents and to preserve the integrity of democratic government Nothing else impacts as negatively on public well'being as tobacco products and nothing else cor- rupts the representational'legislative process as much as the tobacco industry. LegisLators should refuse donations from the tobacco industry andlits subsidiaries. State, county, and local organizations should seek non-tobacco dollars for sponsorshipp of events. In the words of Surgeon General Novello, "71tev should be a parrt of the solutlon, not a part of'the problem:" 2. In order to destroy the tobacco industry's attempts to gain public credibility and in order to furrther isolate the tobacco industry, tobacco control ladvocates should actively expose tobacco industry political contribudons; lobbyists, "front" organizations, inditstry-fomented "grassroots" smokers' groups, and instances where tobacco industry lobbyists repre- sent any other group in i society. Tobacco control activists should recognize segments of socicty which, have already been coopted by the tobacco industtv, especially tobacco farmers; should anticipate that the tobacco industry will continue these activities,,and should seek to bring these segments into the tobacco control movement or at least neutralize their opposition to tobacco conttol.. 3. Actively'oppose any, legislation that.preempts stnonger, locai laws;,thsu criminalizes minors , fortobaceopurchase, useore possession; that shields tobacco companies from product, liability; or elevates smoking to protected i"rights" category These strategies protect the tobacco industry. Tobacco control advocates should be aware of bills which are repteserttedlas tobacco control measures but which contain these features and of'Iast-minute legislative attempts to amend pending legislation with these provisions: 4; Actively involve childten, women, minotity groups; and tobacco victims and survivors in tobacco education and'advoeacv activi- ties. These groups are special targets of the tobacco industry and these groups are effectire advocates: 5. Utili,ze other public sector avenues such as regulations, erecu- tive orders, bureaucratic rules,,and petitions to gpvernment to control the tobacco industry. Regulatory bodies may be more free of tobacco industry influ- ence and may be made up of 'experts. However these bodies should be carefiillymonitored:l as the tobacco industry hat a history of misusing them. 6. Local ordinances ane highly recommended for a variety of reasons. They are locally'appropriate and most enforcement is local. opposition can usually be identified as coming from outside the community and from the tobacco ~industry. Local laws influencean&supportstate legi5laaon. Campaigns for local ordinances have greativalue in public education and inn building the tobacco control movement 7. Positive vocabulary should be used„describing the movement members as prohealth activists, and defining the tobacco control issue as healthrversus greed Recognize and'newardls2ate and local leaders who oppose thee tobacco industry and.vho support the tobacco control movement Tobacco Cse: Ar. AmeriCan Crisis 02024"' "98`f

Workshops Resources for Action and Information B. Tobacco e=dse taxes Lqislatit!e gpproaches to a Smoke Frree Society, by Hanauer; Cigarettes - Barr, and Glant¢„published by the American Nonsmokers' Rights Every state and'the District of Columbia impose an excise tax on (ASR) Foundktion in 1986, remains a wonderfuf sourcebooie It cigarettes. These taxes range from a high of 564 per pack in,*w is stilllavailable for $ 1i0;,the Appendix (a telephone directory-size York to a lom of!2: S(per pack in Virginia compilation of documents) can be photocopied for $30. ANR may be contacted at (5110) 84'1'-3032. Smokeless tobacco ,.Lobbying for Lives: Lessons from the Front" is a 30 minute video about the passage of the Canadian tobacco advertising ban by a coalition headed by the Non-Smokers' Rights Association and1the Canadian Cancer Society: It, is available from MediC'inetnaLtd., 131 AlbanyAvenue, Toronto, Ontario M5R3C5, Cattadk„phone (416) 977-0569. It costs less than $100 U.S. "The Politics of Local Tobacco Control" by Samuel§ and Glantz ( J AMA.1991 I; 266: 2110-2117 ), Strategjes to Control Tobacco Use in the United States: a ~blue- pnint for pubfic health action in tbe 1990% was publishedlby the U:S: DepL of Health and Human Services. The 300:page monographi is NIId Publication No. 92.33'L6 The PofiticrrlBuoiution ofAnti-Smokingl.egt'slation, a 1i00- page book based on siz case studies,,i5 document # R-4152- I:COP, available from RAND, 1700 Maini Street, POB 2!138, Santa Monica, CG1 90407-2138, phone (310) 393-0411, for $10 plus $2 ' postage. Americans for Nonsmokers' Rights is experienced in fedetxl, state; and local!legislation and regularlj+ discttsses the issues involved in their newsletter, ANR Update, and in position papem . They are an up-to-the minute, source for current informaeon and strategy planning, Other sources are Action on Smoking and Health,(ASH); the Advocacy Institute;,the Coalition on Smoking OR Health, DOC, local nonsmokers groups, and individual activists, especiallyJohn Slade, Stan~Glantz, Joe Cherner,,Greg Cotutolly; Joe DiFranza;,and Bill Godshall. State legislated actions on tobacco issues Overviexc A. Restrictions on smoking in pubHc places Forty-five states and the District of'Coiumbia restrict smoking in public places in some manner. These laws range from simple, limited prohibitions such as restrictions on public transportation and in schools (West Virgipia),,to laws thatlitnit or ban smoking in virtually all public places,,including;elevators, public buildings, health facilities, public converances,,gymnasiums and,arettas; retail stores and educational facilities (Minnesota). The most extensive clean indoor air laws include restaurants and private workplaces (New York). Of the states that limit or prohibit smok- ing in public places, 41 restrict smoking in~the publ3cworkplace and 19 hawe extended those limitations to private sectorwork- places: Thirty-six states have excise taxes on smokeless tobacco products, inchtding;chewing tobacco and'snuff' In most states, tbe excise tax is calculated as a percentage of the wholesale salhs price to retailers, tttanufacturer's invoice price, or price at which the tobacco entered the state. Alabama and Arizona base their smoke- less tobacco excise taxes on the weight of~the tobacco package. C. Age restrictions on sales of'tobacco products Forty nine states and the Disu'ict of Cbltttnbia restrict ttte sale of tobacco products to minors. One state--Montana-has not vet acted to prohibit the sale of tobacco products to yaung persons. New Mexico prohibits onlythe sale of smokeless tobaeco.to minors. D, Restrictions on distributi'on of tobaoco. product samples U:S, localities have taken the leadlin restricting the dLktribution~of tobacco product samples. Atioast twenty-eight eit3es now prohibit the distribution of tobacco product samples. States have been slower in addressing this issue. While many'limit access of to- bacco products to minors by'prohibiting,sales or furnishing, only 21 states have taken action to restrict the distribution of free samptes. Minnesotaand'Utah~totallyban thedistrdbutionof dga- rettes, smokeless tobaeco: products, cigars, pipe tobacco or other tobacco products suitable for smoking. California prohibits the free di5trdbution of tobaeco: products in public places. Iowa: prohibits the ftee distribution ;of tobacco to persons under 18 andd within 500 feet of a school„ playground or other location normally populated by people under 18. Kansas prohibits the distribution of satnple cigarettes. Nebraska prohibit5 the distribution of sample smokeless tobacco products. Arkatrsas, Georgia, Illinoi:s, Indiana, Kentucky, Louisiana, Maine, Missourij New Hampshire. NewYork.,,Oregon, Pennsylvania,RhodeLsLand, Wisconsin and Wyoming ban the free distritwtion of tobacco product samples to minors only: & Restricdons on sales of tobacco products in vending machines Nineteen states and the Distriict of Columbia restmct ttte sale of ' tobaeco produats in vending machines. Only one, Color:ufo i,:uu: the sale of smokeless tobacco products in vending machines: Six states, Alaska, Michigan, Nebraska, NewYodc; Utah~and Ilaw:ui. ban sales from vending,maehines except for bars, private dubs with a liquor license and, in a few cases, workplaces that locate machines in adult-only areas, Nine states-Arkansas; Colorado. Indiana, Maine, Minnesota, Oregon, Ohio. Yermont; Wyoming, and the District of Columbia-restrictplacement of'vending machines simplij to areas unacce.csed by'minors. Nineteen-

Worhshtips Arkansas, Colorado: Gonnecticu4 Georgia; IndLuta,~ Louisiana„ Matyiand, Massachusetts, Minnesota, Missouri, New Hampshire;, Rhode Island; South Dakota, Texas, Utah„Vermont, Virginia, Wisconsin and Wvoming-require owners, operators, andYor supervisors of tobacco vending machines to post signs stating,thatj minors are prohibited from maJcinga purchase from tHat ma- chine. yew Jersey requires signs posted every place cigarettes aree sold or displayed: the signs must say it is against the law to sell cigarettes to minors, punishable by a $250 6ne: one state, Wi, nois, requires onmers or operators of cigarette vending machines to post signs warnirtg of the dang~rs of, cigarette use during preg- nancy, New Meaico restricts the placement of vending machines thavsell smokeless tobacco products andirequires the posting of signs on vending machi.nes that dispense smokeless tobacco. Tob'accobse: AnAintericavr iy'risis F. Ilsensing requirements Forty-six states and the District of Golumbia require the licensing of parties thatsell tobacco products. Iowa,,Rentucky; Soudh Daa kota and West Virginia do not requice licensing of such partie.c;. Ucensing regulations vary among,states;,and range from requiring only di5tributors to have licenses (Wornia) to requiring whole, salets,,distributors, manufacturers and retailers to obtain lioenses ([3elaware). The licensing laws in Alaska, florida~ Nebraska and Vevada indude a provision that penalizes a licensee wto fur- nishes tobacco products to minors, with an additional penalty of revocation of tNe license for subseqpentoffenses. G. Smoking protection laws Regrettably, 27 states and the District of Columbia passed some form of smoldng;protection legislation between 1989 and 1991

Wiirfcsitops Legal Issues in Tobacco Control Backgnound! This paper will!discttss the nature,,exten~ and public bealth potential of'various types of tobacco litigatiott, the tfit+eat pre- sented by industry-sponsored litigation against courageous indi- vidualfi and communities, as well as possible legislaflve actlonto maximite the public health benefits of tobacco ditigation and to exploit regulatory opportunities opened up by the Supreme Court's decision~in Crpollone v. lzg'get7 Group,,lnc. The mostwidely known~form of tobacco litigation, and the one with the most obvious potential for in~itating the industry, is product, liability. Tobacco products liability suits, like asbestos suits before them, have the potential to force cigarette manufac- theii turers to increase prices diamatically, in order to cover, liabilities and attorneys' fees. i.ike an excise t$x, these increases would result in substantial dedines in smoking, especially atnongg not-yet-addicted teenagers. Futthermore,,ttie publicity, surround- ing individual cases,has driven home the point to nevvspaperr readers and talk-show listeners that cigarettes kill real people (like the plaintiffs), rather than just.statisncs: Even the tobacco indtistry's public relations "spin," that the plairttiffs~should not!be blaming the tobacco companies whenthey chose to.smoke and assumed the risks, underlines the foolhandiness of smoking- hardly the point the indttstry, would choose to be mafdng., Finally, iheproeess of"discovering',.. andHntroducing at trial damagtng doctunents from the files of the opposing party has already produced evidencettiat;the cigarette matmfacturers..entered into a sophisticated coaspiracy''' which "was organized to refute, undermine, and'neutcilize information eoming from the scientific and medical cotnmunity." This has hurt the industrys credibility, in the poliflealiprocess, and excited the intenestof criminal investigators. While punitive damages have not yet been as.sessed„this conduct would certainly jusdfy awards large enough to threaten the viability of,the industry. The tobacco products liability approach has faeedithree principal hurdlr?s. The first was the ironic legal claim by the tobacco indus- try, that the Federal Cigarette labeling and Advertising Act of 1965 actually protected them against lawsuits, by "preempting" most or all'possible claims;,including those based on deliberate deception as well as on failure to warn. The United States Supreme Court resolved this issue in its June;,1992 Ci~+ollon,edecision, making clear that no claims arising before 1969 were preemptedj,that deliberate deceptionicliiims-whenever arising-are not;pre- Richard A. Daymrd , J[D empted, and that even post-1969 failttre-to-warn claims are preempted only to the extent that they claim the warnings should have been included in advertising, rather thuw in other eommtuu- cations to governments or consumets. The second hurdle has been the expense and di.fiicttlty of bringing these cases, caused by ttie industrys pollcaes of never settling, regardless of the merits of individttal cases, and of doing every- thing possible to run up the plaintlff s bill- As one industry lawsaer explained in an internal memorandtnn, "to paraphrase General Patton, the waywe won these cases was notiby spending all of Reynolds' money, but by malting that other son of a bitch spend i all his." In fact;,while the cases are not easy or cheap; they need norbe more difficult or expensive than other complex tort caFec:, Wtiile the plaintiffs' attorneys dismissedIthe landmark Cipollone case in Fzl1, 1992at'least partly for financial reasons, most of the financial btrdenaas probabty betiind them. Their, long,bdule on preemption had resulted in the lkngefy-favorable Supreme Court decision, while the fruits of their burdensome',discoverW' of industry documents are now available in a 51I25 package from the Tobacco Products liability Project! The third burdle.is the common-sense notion tharsmokers have: only thetnselves to blazne when their smoking causes disease. This perception ignores the facts that almostall smokers began as minors;,almost ad who continue smoking,ue demonstrably addicted, and almost all have been~exposed to the tobacco industry's health disinformation rampaign: The Supreme Court's Cspollone decision has evened the playing field for tobacco litigation. Formerly, the industry could harp on the fact dtatthe plaintiff continued!to smoke long after the pack- age warnings appeared, while the plaintiff was not able to refer too the industrys communicative misconduct after 1965, Many jurors accepted the industry's definition of the cases, as ttnals of the plainti(fs' condtxt "Should Rose Cipollone have sent her husband Tbny out at night to buy her cigarettes?" "Should she have hcx.da?d' Tony's admonitions to quiLl'' 'Vow, plaintiffs' lawyers canpoint to the industny's ongoing fraudulentiand reckless behavior and argue that 'lliese guys are killers. Somebody, has to stop them!" Ttiat is the strategy that willlprobably achieve abrrakthrough.. Asecondlform of tobaccodiGgation involves claims by nonsmtrk- ers, afflicted µith diseases or conditions caused or e.racerbated bv EPS, against!employers who permitted workplace smoking.lhu claims have taken various forms, including lawsuits seeking

Wurkslt-tp, injunctive relief itnder state or lbcal laws restricting smoking, or under the common law; unemplbymentieompensation claims where the employee left workto avoidlETS, workers cotnpensa- tion and disabilityclaims; where the employee has sttfferedlseri- ous EI'S-related healduproblems;retaliation and wrongful discharge cases, where the nonsmoking employee has been punished! for his or her complaints: and handicap discruninnation under the Rehabilitation Act of 1'973 (now, the Americans with Disabilities Act) i Wftile the efforts to achieve injunctive relief have had spotty results; the other cases have in recettt years generally been successflill Since employers, ttnlilte cigarette manufacturers or even retailers, have no financial stake in permitting smoking, even the modest legal risk which employers who permit smoking have faced has been an important factor ini persuading them to: ban smoking. The recent EPA report: dorumenting a variety of ihealth risks fnom, ETS ; including not only long-tetm lung cancer risks but also acute risks of severe exacerbation iof symptoms among large numbers of, current asthmatics, will strengthen the whole range of ET'S litigation. In particular, since a substantial proportion of the population are.asthmaties who cannot, or atleast as a medical matter should not, be exposed to environmental tobacco smoke, the reeently-implemented Americans with Disabilities Act (ADA) will presentimost employers with the situation in which one or more of their employees has a right to demand that the workplace be made accessible by being made smokefree. Since the ADA also applies to places of public accommodation, it may well be the vehicle for changing tlte national norm in restaurants, malls;etc: from "smoking permitted•" to "smokefree" : Another type of tobacco lawsuit involves claims broughtion behalf of minors againstistones which illegallysell them tobacco prod- ucts. The pioneering case, Kyte vStore 24, Inc., included claims that the two minor plaintiffs were addicted to nicotine as a result of the illegal sales, and that ttte store had committed a variety of torts as well as violating the Massachusetts Consumer Protection Act (which allows plaintiffs to recover attorneys' fees) in making these sales. The case was settled, with the store chain agreeing to require positine idettti6cation from youttg would-be tobacco customers: The settlement received nationalpubliciry,; encourag- ing other stores to adopt restrictive sales policies. The Tobacco Products lGability Project has a grant from the Thrasher Research Fund to assist activists to bring similar actions in iother states. A fourth type of civil claim„which is currently being tested, seeks recovery for the economic losses which smokers incur„at least in ~ part as a resultof tobacco industry disinformation~campaigns, The claim can be brought through either the simplest or the most complex of'legallptrocesses: in small claims court„by individuals seeking the costs ofistop-smokingprograms and devices;or as a class action on behalf of, eg,all smokers who have used nicotine replacement therapy in an effort to quit. The strengths of this claim„ati least when restricted to financial assistance forquitting, are that there can be noidoubt theplatintiff(s) is really addicted, no plaintiff ~ ean be accused of seeking a windfall, and it makes common sense that the manufactuner of an addictive substance is obliged to help its customers go unhookedl tDttterclaims have been brought for lung cancer caused by ronmental tobacco smoke, for mesotheioma caused by inhaling asbestos fibers from the original Kent Micronite fihers;,for ciip- rette-caused fireinjuriesandldeaths; and forharmcausedib+rusing tobaeco products which hati+e no warttinglkbels, such as spitting tobacco (untll 11986); duty-free cigarfnes: roiF wur-own tobacco, cigars, and pipe,tobacco. Federal criminal proceedings against:tobacco exeeutivec are also under consideration. based on the evidence of ftaudulent.beliav- ior educed in discovery in tobacco liability cases: Aiail fraud. wi re fraud, and RICO counts are possible: The United States fittornev General could also bring criminal ctaims based on the indaaty>s deliberate use of tobacco-sponsored sports events to circumvent the ban ion cigarette advertising on television: In many states. local district attorneys ean use reckless endangerment statutes to pursue tobacco executives for the same type of battdtilent behav- ior; given that a fully foreseeable consequence of this behavior is the death of many of their, ccustomers. Recent nmspaper reports and television documentaries, which have further documented fraudulenti industry behavior through intervieaswith industrv scientists, provide new leads and increa.se public pressure for criminal I p rosecutions. Unfortunately, litigation canialso be used'by the tobacco indctrv forits own purposes. Vendingmachines operators have sued communities which ban cigarette vending machines or limir where theymaybe placed- Courts in Massachusetts, Jlaniand and Utah have rejected these challenges, but aSupetior Court judge in, New Jersey hasbought the.industry's argument that such recuic- flons implicitlv violate state law by reditcing the state's overall tax revenue! This and some of the positive decisionsane under ap- peal,,andlmost or all of the restrictions are likely to be upliddl The indttstty also threatens communities that atoempt to lima abusive tobacco marketing techniques, as by banningsampling or, refusing to rent city-owned advertising space for cigarette adver- tisements. Most of these threats are blu$5, since ttie indtLstty has never challertgedlsuchiairestridion inicourtl perlups forfetr of establishing a pro-health1egal preeeden[wtiicb would encourage more such restrictions. In each instance the indiistYs;principal threat, is actually to force the community to spend substantial amounts of'theic scarce resources defending their public he.ilth policies in court. A 1981 tobacco industry metnorecommends attacking adwrse research and, where possible, "attacking researchers them- selves." In 1992 R:). Reynolds saw an opportunitv a#tert ttie complaint in a California test case seeking to require G»und I paraphernalia to bear the Surgeon General's warnings mentiontxl the tluee jt4NA articles which hadbrought public attention to Joe Camel's popularity among youngchildren, RJR subpoenacd the records of the authors of the articles, and subjected one of diem to a two-daydeposition, They then leaked some ofttie subpioe- naed materiallto the Winston-SalemJournal. w#iich,pubiisheal ai sl Tobncco Cse:.9n American Crisis 2o241sss%

Workshctps defamatory article using RJR"s spin. This type of harassment may discourage less intrepid investigators from doing research likely to upset the tobacco industry: (infortunately, just as litigation is a two-waystreet,,tobacco com- panies also use the legislative andlregulatorN processes to obtain immunitv f'rom seraous~regulation1 arlower levels inourgovern- mental hietnrchy: Thus, Congress preempted!state and loeal. lawmakers from requiting appropriate health warnings on ciga- rette packages, advertising, andipromotions. This has not only inhibited produculiability suits, but;prevented states from carrying out their basic obligationto protect the health~of their citizens. In the Fall of 1992; 27'state attormeys general petitioned Congress to remove this preemption. Similarly, action by OSHA to limit smok- ing,in workplaces may have.the legalleffeecot of wiping outxtate and local lworkplace smoking,restrictions throughout the countty. A similar relationship holds betweenstate and loeat governments. Thus, local regulations are regularly attacked as explicitly or implicitly preempted by weaker state regulation.lfie tobacco industrv has made preemption a centerpiece oflits strategy for fighting local regulations, not only asserting the alleged preemp- tive effects of existing,state laws in legal attacks (actual or threat- ened) against local actions, butipromoti.ng weak state laws for the very purpose of obtaining express preemptions of aggressive locall regulations, In addition, the tobacco industrw has obtained legisla- tive grants of immunity for product liability suits in California and Texu, and lesser "relief"in other jurisdictions, under the cover of "tort reform." A legislative agenda for tobacco control advocates therefore needs to include efforts to:repeal or limit eKistingfederaf andstate preemptions: as well'as preventing the tobacco industry from obtaining,new or expanded protections: We can, however„go much ifarther. The Cipollone case estab- li,shed, among other things, (1) thatsec. 1334(b) of the Federal Cigarene Labeling and'Advertising Act;,whichpreempts any, "re- quirement orprohibition based on smoking and health... with, respect to the advertising or promotion" of cigarettes, has no greater'pt+eemptive force with respect to the.traditionallforms of state or local regulations than it does with respect to claims in products liabilityrases;,and (2) that this pteemptionisquite narrow, only affecting reqtilretnents that sellers provide additionall health information 1 in their advertising or promotion. Thus, state and local!goverrunents can require manufacturers„as a condition for permission to sell cigarettes in their jurisdictions, to furnish the governments with information over and above what appears oni the package label, eg, about any studies they have done, com- missioned, or know about regarding the health effectsof smok- ing, or the effects ofitheir marketing tactics on public attitudes and buying,behavior: Furthermore. they can also condition this permission on the manufacturers' providing package inserts and/ or an "800" number witlvdetailed and accurate health informa- tion. F'inally; tobacco litigation can easilN be pressed'into the service of hcralth care cost containment. A state legislature, or Congress,, could ena,ct a law declaring cigarette manufacturers liable regard- less of'fault,for medical expenses and lost income of smokers who contraot lung cancer and other dgarette-c dlseaccs: Then, the ordinary contractual provisions which pertnit health : insurers to recover their expenditures from responsible third parties will permit them to sue the cigarette companies for their smokinglrelated expenses. Additional legal modifications couldi smooth this recovery process, as by, permitting individual insurers to use statisticafinethods to combine all their smoking;related expense:s in a single diaiim. and to recover from the six cigarettee companies according to their market shares. Recommendations Il Enforce Federal Law A: Americans withdDisabilities Act (ADA): the Civil Rights IDivi- sion of the Jttstice Depattmenrshottld issue guidelines recog- nizing that the ADA's requinement, that all places of public aecommodationbe accessible to asthmatics and to people with other pulmonary diseases or, with cardiovascular diseases, requires in practice that these places be smokefree (or ltavee separated and'separately ventiLated smoking sections). Simi- larly, the Equal ©pportunity Employment Commission should commit itself to enforcing the ban on discrimination by em- plovers against people with compromised pulmonary or car= diovascular functions who requine asmokefiee environment. Private suits by affected individuals to obtain access to places of public accommodation; and to obtain nondiscriminatory em- ployment opportunities, should also be encouraged. B. The Occupational Safety, and Health Administration (OSHA) should!proeeed immediately to carry out its statutory mandate to prevent any employiees from developing litng cancer or other~ diseases as a result of exposure to ETS. Ttiis will require a ban on smoking in all workpla+ces;,except for eompletelyseparated and separately ventilated smoking areas which nonsmoking employees are never required to enter. Since OSHA regulations preempt most state and all!local regulations, it is essential that OSHA not be permitted to take half*measures, which wouldiin any event, be inconsistent with its statutory duty C.14te Depatvttent of Jttstice should promptly rarry out' its duty under the Public HealthiSmoking Act of'1'9b9 and bring action against broadcasters andVor agarrette manufacturers which violate the prohibition against cigarette advertising on elec- tronic media by using cigarette brand names or logps, in con- nection with sporting events. D. The Federal Trade Commission should promptly initiate proceedings under Sec. 5 ("unfair or deceptive acts or prac- tices... affecting commerce") against tobacco product manu- facturer6 who direcu marketing at minors or who misreprescnt. explicitly or implicitly, the safety of theirproducts: 2. Repeal!I,egislation Providing Special Immunities forTobacco Industry; andlResist New Immunities A: CongSess should promptly repeali 15' U.S.C. see. 13:;-+. tho preemption provision of die Cigarette Advertising,and lrbeling, R2

Worl:shops Act. It has served no inhibit major public health initiatives stxfi as billboard bans, restrictions upon youth-oriented marketing, and product liability suits. Cigarette manufacturers should not enjoy this extraordinary exemption from state regulatory and judicial power. B~ State legislatures should repeal the custom-tulored exemp- tions and advantages incorporated in manytecent "tort re- foran" acts, andlshould refuse to enactnew ones regardless of' the financial incentives offered. 3. State legislatures should adopt statutes holding tobacco compa- nies liiilile on an no-fault basis for health care expenditures and lost earnings attributable to the use of'tobacco products. The statutes should provide that proof of tobacco use beyond a specified threshold (eg 20 pacW)rars) andiof a tobacco- related!disease (eg lung,cancer, oral~pharangeal cancer6 orr emphysema) 1 establishes liability regardless of'faulUby either manufacturer, or user. The statutes should also provide that third-party payers (eg Medicaidj,Medicare; or Blue CrossLBlue Shield) shall have the rigktt'to recover their tobacco-related health care expenditures directly fbom the tobacco manufactur- ers;,and that they mayvse statistical methods to estimate their, total'tobacco-relaled healthcane expenditures, as well as to estimate the market share of the various tobacco manufactur- ers. Such statutes will provide hard-pressed states and!employ- ers with a substantial measure of financial,relief, as well as allocating these costs where they properly belong. 4: State legislanues should adopt.statutes requiring tobacco manufacturers wishing to sell their products within tbe state to disclose to state heaith authorities; and through ithem to the . public;,all information in their possession relating to (a) ingre- dients in their product and the chemioal'analysis of the smnke. (b) adverse health effects of their produet's use, (c) all re- search undertaken directly or indirectly by the manufacturers involving possible adverse health effects, and (d) the likely or intended effects of their marketing. These statutes should alsoo require these manufacturers to disclose dinecilyto consumer (a) throug(t package inserts and through ,.800" numbers, all adverse healthieffpcts of using their product, as establi.dted by scientific consensus; and (b) through package labels, that the product may not be soid!to minors. (The Supreme Qourtis decision in Cipollone v. LrgeH Group Inc. makes clear that, these types of state regplations are indeed perntissible.) S; Tobacco C'se: .9n American Crisis

N1 orl.sj'tofts U.S. Agricultural Policy on Tobacco' [ntroductiiun The healthcare cotnmunity, believes stnongly that all Ifederal gov- ernment policies related to tobacco mti,st neflect the objectives set: by former Surgeon(neneral C. Everett Koop for a Smoke-Free Society, bv the Year 2000! and contained in the US Government"s Healthy People 2000 Objectives relating to tobacco ~use. 'ffiee federal government cannot; therefore, continue policies and prog;ams tttat encourage and:promote the growth ofltobacco. Unfortunately, the federal government's policies on tobacco remain inconsistent. On the one hand; the US government ac- knowledges that tobacco use:is the single most preventablecause of death, in the United States and through the US Public Health Service allocates funds for scientifia research and public health~ educatioa On the other hand, policies of the US Department of Agriculture (USDA) assure that federal assistance and tax dollars support the growth and use of tobacco products. Furthermore, the US trade representative has demanded that, foreign markets be opened to the tobacco industry imopposition to the aishes of the foreign governments concerns about the health of'the3r dtiEerts. Tolraaco Ptoduc tion Tobacco was an especially important crop in the eariy historyof' the:UnitedStates. Even though itino longer holds its once signifi- cant economic position, it is still a vitallagricuftutal commodity in the major producing regions. Today, tobacco is produced in 21 states and Puerto ftico: Six states--Notrth Garolitta, Tennessee, Kentucky, Yicginia„South Carolina and Georgia-account for over 90 percent of the $2.34 billion in 1990 f2rm cash receipts fromm tobacco,. Approximately 137,000 farms produce tobacco: (down~ftrom 179,000 in 1987), hatv!esting an estimated 763,000 acres in 1'990 (up from 602;000 in 1987). Appnoximately %percent of,US grown tobaeco is used1for domestic manufacture and about 35 percent is exported; According to recent data from, Phiiip Morris, over the past deeade; lower trade barriers, weaker governmentt monopolies and emenging markereconon»es in the former Soviet block more than doubled the theoretical export market for U.S.- made eigarettes from about 40 percent to nearly 9Q'percent of:the 5 1r2 trillion cigarettes consumed annual}V outside the US. Ex- ports in~ 1991-92 totalled 173 billion cigarettes. Ann Meagher Notthup ovetall, however, due to the lower demand for cigarettes in the. US and the increase in the import of foreign tobacco, tobacco production is ezpeeted'to fall in 1993: Tobacco fuonsuntption US cigarette eonsumption in 1992 will decline for the eighth consecutive year. Americans smoked an estimated 506 billion cigarettes in 1'991/92 (Jttly-June)', dowtt,ftom 60Q billion in i1984. US'tobacco output remains high. Estimated 1992 figures show an output oE685' billioa.cigarettes, a rise of 23 billion ifnom ,1984. Per capita consumption also fell from 3,446 in 1984; to approxi- mately 2;60(D in 1992. The reasons for the decline include industry price hiice,s; excise taxes and a continuing societal norm against the use of tobacco ati a result of rthe continuing mounting evidence of the dangers of smoldttg,and!the effects of enNironmental tobacco smoke (E1'C). tfily the use of snuff continues to rise, likely increasing for the fifth straight year in 1992. The Tobacco Support Program Tobacco is one of 1'5 agricultural commodities now neceiving direct federal support. 1fie USDA provides support and ststbility to tobacco makers through operation of a tobacco support program. Prices are supported and stabilized by means of nonrecourse loans in combination with marketing quotas. Significant federnl regulation of agriculture began in the t 9 g0's. The current tobacco program has its origin in the Agricultural Adjustment Act of, 1938, which provided for an average support: price for each type of tobacco. The law made non-recourse gov, etntment loans available through local cooperative associations to producers whose crops failed to bring a price from a pmvate buyer above the support levei. The government then charged interest on the loans while holding the.tobacco untii'it could be sold profitably. Different classes of tobacco each had their~ own separately administered, but operationally similar, price support pregram• In addition to price supports tobacco supply was also controlled through a national acreage allotment system. The Secretary of Agriculture would fix the total national acreage of tobacco ~every year. In the 1960s several changes were made in the supply control provision for the intra-county lease and transfer, of allot- ments fortlue-cureditobacco and'.the institution of poundage 84

Wurkshops quotas as a qttantity reshiction mechanism. These were the last major changes in tobacco programs until passage of the "No Net CostAct of 1982." Costs of the pre-1982 tobacco programs were significant For, example, if'allocal cooperative was unable to sell the tobacco it held as collateral for unpaid loans, the foderal government bore all losses. By April, 1982, past losses totaled $57 million in urr paid'loan pruncipal! By the end of 1981, loan policies had cost'the federal government $591 million in interest losses, Moreover, the adminictration ofthe pre-1'982 program bore an additional cost of $13.1 million in 1981 alone. Under the threatlof legislative dissolution of the tobacco program in 1982, Congress passed tlie "'Vo Net Cost Tobacco Program Act" The legislation imposed an assessment on growers for every pound of tobacco marketed'with the borrowed!funds. The.tnottey raised by assessments rebmburses the government for any future flitancial losses ftom tobacco loans; In theory, exeepr4or adminis- trative costs, the tobacco program was to be run at "no net cost" to the taxpayer.lfie adtninisttative costs, however4 are approzi- tnateiy $16.6 million annually. In practice, "no net eost" hasn't stopped the red ink The cumuli- tive loss from price supports from FY 1933 to.FY 1992 includes $644 million for tobacco, including,S423' million for loan and inventory opt;rations and $220 million f'oreacPort payments. The cumuL'un+e total of'realized losses of loan principal from 1'933 through 1993 amounts to an estimated E398'million, Interestt losses on tobacco loans show an estunated cumulative total lof $3~19 millioni ftom~FY3'3 to FY92. The cost of other tobacco-refated activities for the USDA for FY92 include $7.3 million for salaries; expenses, and support for seasonal!tobaccp inspectors employed by the USDA'S Agricultural Marketing Service (i1MS); 0:96 million for market news reports on attcriott, sales activity, 0.24 million for the development and, maintenance of'grading standards applledibythe ittspectors; E5:2 million for economic analysis related to tobacco production and marketing•, 55:4'mlllion for health related research and1$5.9 million (est.) in EY'1993 to subsidi¢e producer premiums for 211, risk crop insurance. The grower assessment under ttie "no-net;eost'' legislation was not expected to ever exceed one to two cents per pound since past losses were low: ($owever, loan prices were ll:gislated higher than market prices in the late 1970s and'early 1980s, resulting in a large increase in itnported,tobaeeo: In fact.,imports have risen from 13'%of manufacturedI tobacco (t967=69) to 32% (1'989- 92 )'• Further, the statutory limits on marketing quotas couldionly, be reduced so much each year. This allowed production which continuouslyexceeded'utilization and'the surplus went under government loans. As stocks increased, so did the as5essments until they, reachedi25 cents pen pound for flue-cured and! 30 cents per pound on burley in 1985. The highiassessments, declining market quotas, and accumulating surplus tobacco stocks creatediaicrasis for tobacco growers and the fedoral tobacco program: In early 1986 Congress enacted legisluion~as part of the Consolidated Budget Reconciliation Act, to lower tobacco loan prices byapproximately, 26 cents per potmd. Wbo Rea113^ Benefits, the Tobacco [ndttstty or the Barmer? Ironically, as it operates today, the tobacco support program bene8ts.least the people it was designed to assist small family fartners. Instead, the greatest benefits of this program are'shared' by, tobacco allotment holders, 74 percent;of whom do not grow tobacco. Allotment holders eharge the small family farmer who wants to grow tobacco large sums of money for permission~to lease their allotments. About 84 peraenrof all family farmers rent allotments, a cost:that can inct ease production expenses by :30 percent to 650 percerlt The federal price support program also impacts the abilt'tyof the American farmer to compete with foreign tobacco. As a result of' high Americatt prices created by the price support symern, for- eign-grown tobacco now comprises 35' percent of all tobacco used by American manufacturers overall'and 33 percent of all tobacco used byAmerican manufaeturersin their~ cigarettes. In 1969;,only nine million pounds of'foreign tobacco was imported. By 1!983; 240;000 metric tons were imported, an increase oh 1,900 percent, This does not ~ mean that our leaders should be unconcerned about the future of the tobacco farmen In the last Presidential campaign, much~was said about °fgmilyvwalues." However "family values" is detuted,,our famn families epitomize the best They are hard-working, self-motivased, andself-sufficient Seentg;them survive and prosper should be a concern to us all and an aggres- sive state and federal agriculturai policy should reflect that con+ eern. Furthermore, current agriculture policy is significant to those who ane interested in the health is5ues neganding'toaacco; By mafting,farmers aware of the fitcts and supporting new agricul- tural policies, it is fairly easy, to drive a wedge between the farmer and ithe tobacco industry and to ditninish opposition to health initiatives and the political support of the framesoork for dse tobacco industry: Unfortunatefy,, most'politicians from the southern tobacco states have used theic clout to blindly back the toba ao industrys agenda instead of truly helping the tobacco farnner: Their gamble is that iEthe fortunes of the industry are good,,the farmers will al}wo prosper: This is a rather errantassumption considering the difference in the current fortunes: the tobacco industry is experi- encing rapid growth in sales and profits while the tobacco farm- ers have to prayfor acouple of pentties annual increase in the price for a pound of tobacco. As the demand for tobacco products changes, the tobacco compa- nies iiave the best minds that money can buy to prepare their future strategies. From all indications, that future does not inelude the majornty, of'Americantobacco farmers. Who speaks for the future of'the American tobacco farmer?' 85 T-,haccoC';ce-.An American C'risis 2024196092

Wotrkshttips . Most farmers are beginning to realize that the strength of today'•s 9trategic Recommendations tobacco industry is a result of cut'rent export levels. As the na- tional demand for cigarettes declinedj,the domestic tobacco industry began diversifying. The national companies purchased food procesaing;and distributing companies to replace lost to- bacco business. While these ventures were-and!ane--compat+ ible with tobaccoa,they are far less profitable. The tobacco industry;,by eonveying to tobacco farmers that their futures are intrinsically linked to the Congressional delegationsl commitment to ~tobacco; insures that these politicians do their bidding in order to be re-elected. It is easier for senators and representatives to go along with the tobacco industay than to convince the faratter that the indiistry's priorities are contrary, to his best interest: There are leaders in every tobacco state who excuse their failure to develbp any viable alternatives by claiming that there is no other crop that can replace tobacco income. It will continue to be true if no new initiatives are begun. Our very inaction insures that there wil11continue to be an absence ofviable,altetnatives. Make no mistake: the rocky, hilly terrain and the small size of many tobacco farms make it especially diffictilt to develop alternatives. The very'people who represent farmers in many areas --die same . ones who act as though the situation is hopeless-- are failing to addtess the issue with any foresight It is time to turn tJienm around.Since the two may not have similar interests, do ~they represent the tobacco industry or the tobacco farmer? Healtfi vexsus Econorny The economic dependence on tobacco makes it difficult to pass health care legislation. The tobacco companies and the farm organizations with which they work promote the idea that any youth access bill, any inccease in taxes, or any clean air measune will cause the price and demand for raw tobacco.to decrease. Because the survival of so manyfanrtters depends on~tobacco, the political strategy of establishing an inverse relationship between 1 health legislationand tobacco markets is very effec6m Before discussing the notion that policies which decrtea5e ap rette consumption hurt the tobacco farmer, it is important to state emphatically that economic prosperity'does not Justify the promo- tion of tobacco products, regardless of the effection farmers. In this country;,we do nrrt'recognize deatb as a fair excbange for prosperJty or a bigbes standardof living. At the expettse of the Tobacco Institutt,,Price Waterhouse con- ducted a study which concluded that the tobacco industry pro- vides 8t)r7,t700 jobs (including;proditction, advertising, distribution, and!legal sern+ices). The Center for Disease Control states that more than 400,000 people die each year as a result~of tobacco use. Tftis means one person must die each year to sustain two jobs. Put anotherway,,at least twenty; two people must die to support the forty-four year, career, of a Phillip Morris employee. Surelv: 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,liires. As the summary of'enactted'legislation demonstr'aies, the tobacco pragram iit the United States is composed of a few major provi. sions concerning the production andimarketing of a variety of types of tobacco. Deregulaflng the tobacco support program requires that all!these provisions be repealed or significantlx reviewed The poGcy issue before the public health communitv should not be whether federal'financial assistance for the tobaccoo support'pnogfiam shotild!be ended, but'when.-attd how best to accomplish this task quickly and faitty: There are several options to reduce or eliminate the federal government's role-and its tobacco program: MOME tures--for regulating the 1. Eliminate the supporrand ttse the annttal budget and appro- priations ptrocess to phase out by the year 2000 these USDAA expenditures for the tobacco support program, ittclttdlitg: a developing;and, maintaining;inspection and grading stan- dards for tobacco auction 1 markets b: publishing market news reports on auction sales subsidizing producer premittms for all-risk crop insurance. 2: Use the annual budget and appropriations process to redirect, USDA tobacco research and development activity towards crop options to replace tobacco. 3. Phase out budget support for adminisocation of'the "No Net Cost" program 4. Phase out the price support and supply control/quouc provi- sions for tobacco. 5: Require tobacco companies to divulge the content on each pack of cigarettes in terms of percentage of domestic and foreiguitobacco used. 6. Raise the state and federatexcise tax on tobacco and use the money to help tobacco farmers diversify or to purchase (for die purpose of retiring from use) a farmer`s tobacco base. Further, the cigareue tax could be raised and dedicated to provide grants and low-interest loans to individual farmers for new farm equipment, irrigation systetna, and industrial bonds to food processing and other non+tobacco companies. This has the double benefit of raising the price of 'cigarettes to discour- age use, and could eliminate the usual source of politieal! opposition in southern states to,anexeise tax on tobacco prnd- ucts. ?: Encoucagg state agriculture depanhttents to adapt to deal with the obstacles to new crops. Rather than looking for'alterna- tive" crops to replace tobacco, we should be ttiinking of, "supplemental" crops while tobacco can still support the farm. The purpose is to make non-tobacco acreage more profitable. Distribution systems to help compensate for small farms;, careful crop selectionto overcome terrain and!Land prohleins. andlfood processing plattts to raise the value of local prcxtucLs ane worthy'approacttes.

U -orlshops ....._ ,_~t.. .. 8. It is impontant to add that since tobacco companies diversified, they own a wide variety of food ptocessing companies. It is not unreasonable for the tobacco industry to locate its food pro- cessing plants inirttral communities nearer to the tobacco1 farmers that provided the companies with their profits all these ~ears. limpact of! Recommendations Long term actions to,phase out or,elitninate the federal tobacco program will have several impacts: The direct, consequences include the loss of income for quota owners from the lease off allotments. However, elitninating costl4 allotment payments will benefit the original intended recipients of'tobacco- support pro- grams: small famll4farmers and their heirs. Many observers speculate that the price of tobacco products will fall if federal support is phased out. They predict that lower prices will cause increases in the use of lowen quality imports, in,the usee of'all'tobacco products,,and in overall ~exports of tobacco prod- ucts. Since the primary objectiiie oEeUminating the federal sup- port program is health relatedl-to reduee consumption of tobacco products-attention should be given to the issue of' tobacco use. Reduced costs will not necessarily increase use;,beoause thee actual cost of'tobacco only contributes about six cents to the price of apack of'cigarettes: However, phasing out the tobacco support. program should be accompanied byalcomprehensive package of proposals to reditce the use of tobacco pnoducts (as contained in, the legislative program of the Coalition on Smoking OR Health), .kccording to Kenneth E: Warner,,writing in the Jor<rna( of tbe Xational Cancer Institute, "the program ihas an indirect political consequence,that sustains tobacco consumption: The program, remains a highly wjsible symbol of government ambivalence about, tobacco, an ambivalence that diminishes the force of the health message. In fact, the demise of the program would dramatically alter the nature of tobacco agriculture in the US, would'give way to smaller numbers of farmers and as a consequence, the number oUvoters directly involved'in tobacco farming wouldiplummet;, and the artificially constructed constituency of allotment holdets would evaporate." The system tarnishes the image of a government committed to bettering the public's health. (t impedes legislative progress towards asociety free of tobacco-produced lung cancer, heart disease, and emphysema. Reading of'the health-oriented literature on the tobacco subsidy suggests that; in latge part, the health community is oblivious to this phenomenon Southern block cenators and~ representatives are not. Developing phase-out options should include carefuf consider- ation of the;impact on~the small family farmer. The number, size and organization of tobacco farmers is likely to change as a, result of a program phase out: This change, however, is not likelyto be more dramatic thanithat which has occurred,over the past 20 years as mechanized harvesting, bulk curing, and other techno- logical innovations have made it possible to grow more and more tobacco on a single farm. Any phase-out program should include funding mechanisms to facilitate the farmer's transition away from direct support Assistance should be given to tobacco farmers who for business or other purposes electito stop growing tobacco and to begiw growing other crops. A user fee mechanism canellminate the health commtmity's concern about using federalrevenue to support the growth of 'tobacco, Perhaps funds can also be ear- marked from substantial federal, state and local cigarette excisee tax increase towards this end. Goals To insure that the agricultural policies of the US are consistent with the tobacco related recommendations of the Healthy People 2C)OO objecGves: 1. Diminish opposition to health initiatives by reducing the politi+ callppwer the tobacco industry exercises through its influence over tobacco farmers. This can be accomplished bv: a. Reducing or eliminating tobacco acreage byd'tversification into other crops or land usage:. b. Federal legislation ~ and/or regitlations to access funds in tlte "No Net Cost" progrartt to be used for the purchase of to- bacco bases or toprovide grants and low-interest loans to tobacco farmers who are changing to new crops. c. Provide industrial bonds to food processing and otiter non- tobacco companies locatirtg in tobacco-producing areas: 3. Eliminate t>.se oFfederal tax revenues to administer the No Net Cost Tobacco Program and for USDA tobacco research and development. 4. Dedicate a portion oflthe higher state and'federal excise uxx on tobacco to provide grants and low-interest loans to indiridual farmters#or new farnt equipment, irrigation systems, etc:. 5: Include in the contenton each pack of'cigarettes tlte percent- age of'domestic andI foreign.tobacco used. Strategies, 1. Educate the business writers of,a1major media on the fallacv of linking economic prosperity of; rural southern states' to• bacco farmers andhealthi legislation in those states. StrL-,s better coverage of'the dilference between the wealth of thc tobacco industry and the struggle of the tobacco farmer. 2. Support a meeting between the Secretarn of Agriculture :utd':v representative of health to address these recommendations. 3: To identify, tobacco state public officials and create aieoalition who recognize the need for more consistency in gpvernmau regarding tobacco and health policies. Tobacco C"se An.-lbnerrcan Crisis 2424196994

w urk!,fiofis Bibliogr.tphy Womaafi; Jasper, Tobacco Programs of the USIDA: 'fieir'(Dperation and Cost Gongre.sstonalReseancb Service Reporrto Congress; June 8,1992. Tobacco: Situation and Outlook Report. USDA Economic Re- search Service, September 1992. Giise; Vemer Ni "Outiocakior Tobacco," Agriculture 0utiook. Q,onference, USDA,,IDecenber 2,,1992. Warner, benneth E:1he Tobacco Subsidy. Does it:Mntter? Journrri of tbe National Cancer lnstMcte, 1'988;' 8n: (2)~. E ! i ii !I

\1 ur. h;,http:; Nicotine Addiction WichadiFtore, Mn, MPH Ellen Gritz, PhD Introduction Despite an overwhelming bodyof scientific evidenee implicating tobacco use as the chief avoid9ble cause of morbidity and mortal- ity in~our society, cigarette smoking continues to hold 25% of adult Americans within its grasp. This paradox can be explained, in large part by the underlying determinant of continued smoking: nicotine addiction. 'Ihtis detRrminant~also explains why 46 million Amertcans continue to.smoke, when more than 70 pencent of them report that they want to iqutt, and have made at least one unsuccessful attempt at overcoming their addictioru The Impact of Public Policy on Nicotine Addiction Public policy changes during the 1990s can markedly enhance our capacity to:prevent and!trx'at nicotine addic6on. Central to achieving,thisgoallis to tecognize and classify nicotine addictionn as a disease that responds to health professional'treatment and watnattts reimbursetnent: Specificall'y„ reimbursement must be mandkted'for efft:ettve smoking eessation treatments including, counseling by health :care providers and payment for nicotine replacement (phatmacologic) treatment. At'the federal level, Medicare and Medicaid should mandate coverage nationally for tobacco prevention and cessation interventions. Most importantly, these treaoments should be a aentcaf component of anynational health care reform program. Finaay, clinical practice guidelines for the treatment of nicotine addiction must be established and promulgate& Tobaeco advertising and promotional activities have dispropor- tionate inflttences on ctiildren ~and adolescents and eontribute to the addictive nature of these products: Because of the uniquely totac and highlj+ addictive characteristics of tobacco, a total'ban on all advertising and promotional activities shoutdbe imple- mented. Taxation is another effective way to limit, nicotine addic+ tion, particularly among etiildren~and adolescents: The Nicotine Addiction VRorkshop strongly endorses the conference recom- mendation ofartwo dollarperpack increase in the federal excise tax on cigarettes as one of the most effective means of preventing and treating nicotine addicaon. Policies that permit smoking in public places exacerbate 1he nicotine addiction problem in two ways-ihey eondone the use of tobacco products, and theyeontribute to environmental tobacco smoke exposure among healthy non-smokers: Legislation man- dating smoke-free envieonments will enhance efforts to eontrol nicotine addiction and shouldbe implemented!locally, statewide, and nationally with effective enforcement provisions: The Role of'Research and Education in Combating Nicotine.Addictioni Research to understand, prevettt,,and treat nicotine addiction is underfunded and limited in the United States: To correetxhis inequity, the NIH should mandate a larger proportion of'national research dollars to combating nicotine addiction, commensurate with the health impact of tobacco use. A standing NIH review group'stttdy, section on tobacco use and nicotine addiction should be created. The education of'health eare providers in the U.S. including physicians, dentists, nurses,,psychologists, and others should include insttuction, training, and clinical experience in effective methods to prevent'and treat nicotine addiction: Currently; such activities are extretnely limited, resulting in disappointingly low rates of health care provider intervention with patients who smoke. Approxittately, half of'all smokers report not receiving' advice to stop smokutg from their physicians. Establishing smok- ing status as the new vital sign is one no-cost institutional change to promote the identification of smokers for clinical intervention. Preventing Nicotine Addiction While 1.3 million Americans sucoessfully overcome their addic- tion to eigarettes each year; tftey'are replaced by I million ~adoles - cents who start to smoke, that ~ is, 3,00o children who become addicted to tobacco each day: Public policies that prevent youth from using tobacco proditcts such as excise tax increa.ses, a total ban on tobacco advertising and promotion, and smokefree envi- rotunents are among the most effective ways to prevent the epi- demic of nicotine addiction ini our country. Pairing Public Policy Changes with Treatznent for Nicotine Addiction .as public policies increasinglyplace geographic. financial, and societal limitations on tobacco use, it is incumbent upon us to pair these appropriate actions with effective treatment options fnrr individuals dependent upon nicutine Many smokers today report asense of helpless isolktion, addicted to.aiproduct they would like to abandon but are unable to overcome withoutihelp. Recog- nition of nicotine.addiction as a disease mandates a comp:cssion- ate approach to treating this problem. This recognition also Tobacco Use: An .9mencan Crisis K.0o%419699V 1 19

WtNrl:tihops allows for acarrot and stick approach tocreabrtg a stnokefree society bA the }ear 2000;:the stitk might inctllde placing increas- ingly onerous limitations on smoking while the carrot provides effective treatment options for the majoritv of smokers who want to quit using tobacco. Policies which curb tobacco use should be paired with efforts to educate the public about the harms of' tobacco use including counter-advertising, and to increase access to staue-of-tlte-art treatments for the 46 million Americans who are current smokers and the 12 million who use spit (smokeless) tobacco products. The pairing of policy initiatives and treatment access will help ~to guard'against the promotion of rabid intoler, ance, blaming those who use tobacco for the problem without providing them with effective means to overcoming their addiction to nicotine and'ultitnately make the gteatest contribution to the nation's health. Workshop recommendations 1. Guidelines fon the effective treatment of nicotine addiction are long overdue: The AHCPR'process needs to move ahead quickly with the following considerations: a) Clinical practice guidelines will need to,recognize nicotine addiction as a highly heterogenous disorder, requiring a'range of diffetent treatments options: The treatment gpidelines should consider adopting alstepped care model with treatment based on the severity of dependence, previous quitting experience, and needs for special attention to factors complicating tobacco cessation (eg, depression, chemical dependency, other health lifestyle risks).. b) Special attention is needed regarding;the tneasmenrof nico- tine addiction within selected populations induding: those in ~ which tobacco use rates are highest (Arnericans with the least education and income, Americans with the greatest levels of stressJdi'stresudlsadvantage)'4 populations in which the risks are greatest (especially pregnant smokers), and populationss which have long been underserved (minorities, adolescents):. c) Training and certification standard.s for nicotine addiction trextment counselors should be adopted, recognizing the heterogeneity of treamtentfor, thia disorder, both in terms of intensity and type of health care providers. In, 19'93, elii»cians treating nicotine addiction range from the primary care physi- cian who utiliies the three minute NationaliGancer Institute's modelj how to flelP Your Pati ents Stop Smoking„to the dediaated!nicotine addiction counselor, working exclusively; on a tobaeco:dependence inpatient service. Continuing profes- sional!education ineffeetive treatments of nicotine addiction should be encouraged or mandated by accreditation soeieties and boards for health care professions and institutions. d) Adopt institutional changes in the practice of medicine that highlight and promote intervention with patients who smoke or use other, tobaceo products: Speeifically;,adopt as a new stan= dard of rare the dttermination andidocumentation of tobaceoo use status as the new vital!sign: This step will!mandate tharall patients who use tobacco are identiFied!for clinical inten-ention. e) Promote the recognition of nicotine addiction:as a chronic disease. As with other chronic diseases such as diabetes, hyperlipidemia, and congestive heart failure, nicotine addiction is charactetized''by periods of exacerbation and remission and requires long term intervention by clinicians with the potential utilization of a number of treatment modalities over time. Only with the recognition of nicotine addiction as a chronic di.~_ se can we move bevond!the current, standard of care which fo• cuses on.one-stop, isolated!interventions and unrealistic expec- tations of'cure rates. 2. Appropriate reimbursement and I insurance coverage foo nica tine addiction treatment'is essential to ensuring that this treat- ment is available to all indiindtials who use tobacco. Specifically: a) Nicotine addiction treatment'waiAants reimbursement for both counseling and nicotine replacement therapies, Medicaid Medicare, government and prdvate insurance companies musr. assure their: subscribers that appropriate nicotine addiction treatment ia reimbursable. Nicotine addiction treatment options should be a cornerstone of the proposed national health care: reform program that will'highiight preventive health interventions, b) Simil'arrly, treatment for nicotine addiction for adUlts and adolescents should be,a mandated component oCevery basic benefit package including the proposed national'health care reform proposals. While primary prevention is the most effec- tive means of obviating the need, for nicotine addictiontreat- ment„ 1000 wuth in America still begin to smoke every dky. Innovative nicotine addictioni treatments appropriate foryouth and adolescents siiouldlbe provided to young people who.are experimenting with or addicted to tobaeco: c) Economic incentives and disineentives can promote both tobacco prevention and cessation. for example, a health insur- ance discount for nonsmokers andla surcharge for smokers would provide economic motivators to overcome nicotine addiction. These incentives and disincentives should be applied at the iitsurer, health care provider; andiheaith care recipient level. As part of these incentives, the IRS should allow tax dedttctions for nicotine addiction treatment'for individuals and corporations„a deductionithat is currently denied, and'simulta- neouslv deny corporate tax deductions for expenditures on tobacco advertising and promotion. d) End the double standard that demands thatprevention interventions achieve the gold'standard ofisdfety, efticacy; :uidl cost}savings while ever,v other medical and surgical'trcatment in the Onited States is only required'to be safe and, sometimc5. effective. Additionallv; it is important to recognize that nicotiiie addiction treatment is a cost-effective means of expending limited health care resources and is an intervention that war- rants reimbursement 3. Tie all tobacco control mandates to mandated nicotine addic- tim treatments. Some examples follow:

Workshops a)'PairJGA}i0 standirds with mandated!nicotine addiction treaunent for hospitalized patients who smoke and!desire such treatment- As hospitals become smokefree, this is a uniquee opportunitv to offer both inpatients and employees ongoing, treatment options for their nicotine addiction. These smokefree policies should not exclude chemical dependency, psychiatric, or other selected units. ' b) Proposed policies by OSHL4 regarding workplace standards for exposure to environmental tobacco smoke should be paired with nicotine addiction treatment options and recom- mendations for emplo~-ees. c) LegicL'ttion to make schools smoke-free should be paired withipro,rams that insure students, faculry, and all school personnelincreased!aecessto state-of-the-arttreatments, d) Earlnark some portion ofi tobacco excise tax revenues for, the treauttent of tobacco addiction, with special!efforts to assure access to these treatments among low-income underserved populations. 4. Public understanding ofinicotine addiction is limited!and must be promoted through educational activities. These educational activities are essential in order to inerease information regard- ing tobacco dependence and to provide motivation for smokers to quit. Public education is particularly important in the follow- ing,area_s: a) Recognition of nicotine addiction as a treatable disease; that manv users of tobacco may require or benefit from clinical assistance to successfully quit smoking: b) Tobacco product information is limited and misleading. Speci6cally; awarning label on all tobacco products that spe- cifically highlights tobacco as an addictive drug is needed- Infotmation on the constituents of tobacco smoke, inciuding toxins and'detailed dhta on nicotine content, is needed Specifi- callv: we recommend!a warning on tobacco products address- ing the danggts of environmental tobacco smoke exposure. c) Public recognition of nicotine as an addictive drug would be enhanced iflthe Food'and Drug Administration appropriately regulated this substance, rather than exempt tobacco from such regulation as under current legislation. 5. The science of nicodn+e addiction needs to be advuiced uW deficiencies in our kn base must'de mddrec5ed: Specifl- cally a) There ane areas of nicotine addiction whichihave notibeen adequately studied. These areas include understanding factors thatipromote the uptake of tobacco. effective matching of' treatment interventions based on a priori patient characteris- tics, post-marketing assessments of nicotine replacement treatments, the role and safety of iong+term, nicotine replace- ment, the efficac,v of innovative behavio,raftreatments and! pharmaceutical adjuvants. the development ofmore effective interventions for pregnant women who smoke and ihe safet}- of nicotine replacement, in this population, the safety of nicotine replacement therapy atnong,patients with cardiovascular dis- eases;,neurobiologic effects of eariy nicotine exposure, the tailoring of treatments for smokers with medical and1'or psychi- atric co,morbidity„ treatments for spit (smokeless), tobacco addiction„and treatment cost-effectiveness. b) Current NIH',and other federal research agencies currently provide inadequate funding for thedevelopmentof innovative and effective treatments for nicotine addiction. Specificallv, there needs to be an increased focus on the behavioral sci' ences in relationto biomedical research when studying nico- tine addiction. As specific suggestions, it is recommended that OSAP include a nicotine addiction component in its research efforts and that a standing NIH review group/study section on tobacco use andladdictionibe created. Tobiuco~~l ;ce: :in~:lmeric'un Cris~is~

Recommeuctaxions of Work Group om, Women's Issues l. Request an appropriate agency to coordinate anongoing na- tional women's,centered smoking prevention and cessation ~ program across the life cycle including research;,policy and public information. 2. While recogni,zing the strides made in increasing gender and cultural representation, we recommend that Tobacco Control organizations reflect the populAtlons they, representby incHtd- ing more women, racial'and ethnic minorities in positions of' policy and program development and implementatioa. 3. Call for funding agencies to requesti research on how tobacco affects women across the life cycie. 4. Request National Institutes of Health~to includetobaeeo on the Women's Health Initiative. 5. Request diat the tobacco eontroi movematchold a briefing forr legislatures and poGcy, makers avall levelfi on~women and tobacco issues. 6. Request that recommendations regarding tobacco excise taxess make certain that populations alteady, heavity burdened!by tobacco do nottake on more increased burdens of tobacco cost 7. Support and promote Health Care Reform packages with pre. vention components which focus on tobacco use prevention, and reduction in women and girls. 8: Ask the Congressional ICaucus on Women's Issues and other groups: a To request the Federal Trade Commiss;on,to assess the impact of advertising and promotion targeted toward women and the amount of tobacco industry expenditures devoted to promoting tobacco use among women and girls. b. To: request Women Ittfant Care (WIC) to prohibit smoking in WIC Clinics andiprowide cessation and educational materiaLsthat are culturally andigender appropriate. TnAucoC'se.'.3n.-1me-ican Oisis9

~Vorhshop Recommendatiotts Recommendations of Work Group, on Chiidren and Youth Issues Excise Tax 'Federal tax of a minimumof $2.00 per pack 'Military tax: itttroduce a $2.00 per pack tax onithe sale:of to- bacco products in tnilitary commissaries and exchanges stores with proceeds being delivered'to support military morale, welfare, and recreation programs. State tax: States should'increase excise tax by at least E.25 per pack: tied to inflation, Possibly tie to increases in purchase of cigarettes. Campangn iReform i Support efforts to reform congressional campaign financing, limiting PAC contributions and encouraging public 6nancin& f.ocal! or State LicerLsing, 'Uocal governments shouldllicense and regulate tobacco vendors as thev do alcoholJ Smokefree Environment' for Children. •Federallvfunded prrograms for infants, children„and adolescents should be required to provide a smokefiee environment since ETS is a Group A human carciitog~rt. Public environments accessible to children ~should provide a smokefree environment. 'All schools, public and private, should be smokefree. Drug Free School Zones shouldlindude tobacco. Advertising and Protnotioa Develop a nationalI respositoryoflinformation on tobacco adver- tising targeting,yRUth and'the development of related counterstrategies, '!r'ationalI groups,,including nontraditional partners;,should petition the Ju-atice Department and Federal Trade Commission (FTC) to enforce e!cisting laws regarding tobacco advertising and promotion. Petition owners of'sports and!cultural organi7ations to haMe smokefree sports and cultural facilities without tobacco advertis- ing. State and local organizations should provide tobacco free slwn- sorship of sports and cultural events. Vo tobacco sponsored events should!occur on government prop- erty or government funded facilities. Commttnity groups shouldiwork toward the elimination of'public signage advertising tobacco. The federal'governmentshould fund an aggressive paid counter- advertising campaign to discourage all youth tobacco use. Access. Federal policy should establish, or provide incentives fbr states to adopt, age 21 as the minimum age for purchase of tobacco prod- ucts. Provisions also should be made for stnong,enforcement ofl this age limit with meaningful penalties for violations, through licensing of tobacco.retailet& State and loeallgovernments should ban the sale of tobacco prod- ttcts through vending machines, without pteerttptinglocal juris- dictions from enacting more stringent regulations. 'Federal regulations for the implementation of the new provisions related to tobacco of the Substance Abuse and Mental Ite•alth Block Grant (Synar Amendment) should be enforceable, effective. and not preempt local and state auttiorities or jurisdiction.c f mm adopting more stringent laws to reduce yottlt access to tobacco. implementation of provi5ions should allow stateslturisdictions to use block grartt funds for enforcerrnent activitie5: Federal„state, and'local governments should effectively ban the distributiomof free samples ofitobacco products. Research. Congress should significantly increase funding for rese•arch and diffusion (disserrtirtation, adopsiort, implementation, :ut&m:unte- nance) of programs aimed at preventing and reducing tobacco use ;ttnong children and youth. Problems of'special interest include smoking initiation:md cessa- tion among,girls and young,women; tobacco use among,minori- tie.c, and use of smokeless tobacco by youth: School Health ''tfie nation's schookshould implement tobacco prevention progr.uns within a comprehensive school health program di:u

~ocRsrlnp Kecommendations indudes egecdve curriculum, teacher training, smokefree ficilt ties, and!access to cessation progSams for students and school employees. Anti-Drug Prognams 'Tobacco should be targeted by, all Federal anti-drntg,prAgrams involving children and youth. Health Professiions Education, Accrediting boards for health professional'schools should require instrucflon in the prevention and control of tobacco use among children and youth: Tobacco G'se: AhMmerican ' Crisis Teacher Training The National Council for: the Accreditation of Teacher Education should require schools of education to provide instruction in comprehensive health education that includes tobacco use. Tobacco Use Cessatiow Ul fodE'rally funded programs andiservices for pregnsmt', tcenagersshould'provido an effective program of'tobacco use cessation. Congress should provide additional funding for all federally funded public health programs servicing children to use for effective programs of tobacco:use cessation. * PnoritV recommendations N C N ~ N ta ~ O N ' 95

Worl:shop R;ea:crnuttcndatiutrs Reconmendutions of Work Group on Minority Issues L Obtain appropriate data~on tobacco consumption, and tobacco related morbidity and mortality for all minoroty groups. This should be pursued at both the federal and the state level. The geographical!and cultural areas of extreme excess morbidity and mortalitv related to tobacco ttse should be delineated. These chronic rlisaster areas shouldlbe targeted with ispecial federal, state, and local resources for tobacco conttoll 2. Aggressive counter-advertising strategies, both offensive and defensive, should be developed in those communities most heawily tangeted by the tobacco industry for sales. i. Hinoritv communities should become empowered bv develop- ing leader!ship among children in the tobacco control effort, and bv fostering Jbcal adult leadetship,as well, particularly in those communities writhiexcess morbidity and mortality related to tobacco, use. 4. Vtinorities should be inclitded and actively participate in enact- ing all other tobacco related recommendations set forth bs• other tobacco control workshops. • Support of the b2Ypack excise tax on tobaecoproduct.F; which is most likely the single awst influential~faetor in the reduction of tobacco use among minorities. • Suppont of'eomprehensive school-based education as a primary mode of prevention. • Enactment of worksite smokefree policies in those settings that would1particularly impact minornties, such as those that are federally funded, which would serve as a major menue; of cessation and elimination of a primary source of em•ironment:d tobacco smoke among the minority community. 96

Worf;sttttp Rccorntncndations . I~ecorr~men ~ ~ti~o sof. Work Groap on Environmental Tobacco Sinoke (ETS) In determining where to direct efforts to: regulate smoking, the following issues must be considered: 1. Each jurisdiction should take action to.eliminate exposure to environmental tobacco smoke. 2. Each juri5diction should take cam to provide the most e$ective enforcement of the elimination of'exposure to environmental tobacco smoke. Recommendations The following list of recommendations is in order of priority. 1. qllljurisdictions should take action~to protect children fromm exposure to ~environmental'tobacco smoke. For example, we endorse the legislation proposed by Gongressman Dick Dubin and Senator Frank Lautenberg which would require all feder- ally-funded children's programs to establish and make a: good faith.e(fort to enforce a nonsmoking policy that protects cliif- dren from exposure to environmentalitobacco smoke. A: The Uocal and State governments should enact legislation ~ requiring that agencies receiNing,government funds for provid• ing services to childtett be 100 percettismokefree: B: The State legislatures andkrcal school boards should enact regulations requiring all public elementary and!secondkry schools to be 100 percent smokefree in all areas of the campus. C. The Congress shtauld enact legislation~requiring'allieolleges and~universities that receive federal'funds to be 100 percenr smokefree in, all enclosed areas. 2„All jurisdictions shoulditake action to protect workers and', other people from exposune to environmental tobacco smoke. A_ The Local governments should establishlordinances requir- ing the elimination of environmental tobacco smoke in alll restaurants and otherworksites: B. The State governments should'establlsh a Clean lndoor ar lawwithout, preemption of local mandates. G The President should sign an executive order making cm- dosed federal!workplaees, inelitding all branches of the mili- tary and the Veterans Administtaon hospitals 100 percent smokefree to ensure that all employees are protectedlfiom exposure to environmental tobacco smoke:ltleCongress should institutionalize this policy, by enacting legislation to protecremployees from the hazards of envirottmentgl'tofiacco smoke and should extend this;policy to cover all buildings in the Legislative and Judicial Branches. D.11he Q,ongress should enact legislation requiiing,all intetna- tional airline flights by American carriers originating from ior landing in~the United States or its territories to be 100 percent smokefree„and the Department of!Transportationshouldl support and aggSess'tvely pursue international standards to make.all!international airlines 100 percent smokefree: E. OSHA should develop regulations covering smoking in the workplkce; and should consider the importance of local norm, in the effective enforcement of policies to protect nonsmokers. 3: Economic incentives for businesses to go sntokefree should be developed, A: Tobacco control committees should work with inatrers to acquaint them with the liability itnplications of environmental tobacco smoke exposure an&encourage them to dillerentially rate worksites by their smoking,policies for purposes of work-: ers' compensation lnsuronce- 4. Comprehensive school-based health education that incorpo- rates tobacco :issues should include the effects of environmen- tal tobacco smoke and one's rights to a smokefree environment:. Tobacco b'se.-.An.4mcTican Crisis 9'

Workshop Etccctt.nmcndatiott, Recom mendations of Work Group on Regulation of Tobacco Products tntroduction, Political maneuverings -by the tobacco industry have dosed off ; neardy all regulatory arenues for these most dangerous products. Cigarettes and other tobacco products are;both the least regulated and most dangerous consumer produet'in the country. The oniy exiszingpotendaliauthority,to regulate tobacco products is thatof the Food'and Drug Administration (FDA). Indeed, FDA has been willing to regulate specific products when it became convinced that the manufacturer had intettdbd a,dnzg effeat:. The coalition on Smoking OR Health has petitioned FDA' to regu- late;so called "low tar" cigarettes as drugs because of~health elaifis in their advertisutg andihas petitioned that certain brands targete&at women be regulated because of their promise of weight contnol. Discussion in the worlcshop considored opportunities at both the Federal and!State levels mxegulate theseproducts. Recommendations The 6tecuttve Brnnch should make the regulation of tobacco products---reguladon of their manActure, distribution, sale labeling, tadycrti.sing and promodon-a prtortty in ,federal health ~ care oeform andiother health polity ln}datixes, FIDA.should use ita exi+;tinglauthoritlos,to regplate all1"Ibwyield" tobacco products as dtugs under Sec. 201 of the Fedbtal Food, Drug ttnd Costnetlc Act: Congressshould enactspeci8c stauutorl+,authoriti+es,which~without question give the Foodiand Drug Admini,ctntdon the.authorltyand The resoiuces to regulate the tnanufactttnt:, distribution, sale, labeling; advettising and,promotkut of'tobacco products. State T1he;nat2on's governors should make the regulation ofltobacco products a priority in health policy initi>ztivcs. States should use;their drug authorides to regulate "low yield" tobacco products as drugs. States should consider enacting specific statutory, provisionss which regulate the manuhacxttre, distribudon, sate, labeling, adveNsing and promotion of tobacco products as a claiss of drug. llhese new requirements should include full disclosures of ingre- dients and of lnformadon known to the manufacturers about the toxiCity of the products as well as requir ements that the;manufac- turers assist custom ers who want;to quit. Statesshould ban billboudswliichadvertise tobacco products. States should use existing consumer protection authorities to regulate the manufacture, distributlon; sale, labelittg, advertising and promotion of tobacco products. Public Health Community The public health cotntnunity should ddwelop~,supporrt and mainn tatit a t asource library whidt mould serve as a repository for Information about the tobaeco problem needed by poiicy makers and regulators: N ~ ~ ~ ~ ~ ~ 98 ~

Recommendations of Work Group on Excise Tax. Federal and Sta w 1. [ncrease the federal cigarette excise tax by at least $2 per pack with an equivalent; amount assessed on all other tobacco prod- ucts. 2: Encourage states to increase state excise taxes by approm- matelv $l per pack with an equivalent amount assessed'on all other tobacco products. 3. Once these nominal tax increases are attained, the real,' infla- tion-adjusted, value should be at least maintained thereafter. n,-!nWriC:t?7 r"'r*~Ix~

Worlshop Reconunt:nlCations Recommendations of Work Group on Tobaeco Marketing and Promotion Proposals 1. Effectively pressure the government to enforce the existing law: A. fDocument the violation of the existing laws. B. Document the failure to enforce the existing laws. 2. Counter the tobacco industry's misinformation by educating the pubiic. Develop a mechanism for an ongoing campaign to include: A. Counter the brand-name images promotedibyte industry. B! Educate the public about the effects of tobacco use and'the tactics of the tobacco industry, C. Educate the public about the need for restrictions on ciga- rette adi^ertising and promotion. D. Expose those who enter agreements with the industry to promote tobacco. 3. The group restates its long-term commitment to eliminate exploitation by the tobacco industry through advertisingand marketing. It is in America's best interest to: A. Take into account the dimamic nature of the industry and'be broad enough to cover traditional forms of.advertising and more recent trends like sponsorship, product placement, utilitarian items, etc, and leamt ~ftom other countries where the industry has circumvented a ban: B! Recognize that there need'to be a number of interim steps while any proposal for the elimination of tobacco marketing,is debated. These include: l. The items mentioned in pmorities 1 and 2. 2: Interim steps that attack tactics which have the greatest impact on cliildren, such asspoRs and music sponsorship, utilitarian items, state action,,etc:. 4: Eliminate the tax deduction onitobacco advertising. 5. State and local governments should be granted regulatorv authority concerning tobacco advertisingland promotion: ending the current Federal preemption. 6. Develop a mechanism or funding for currertt mechaniams to more e9'ectixely monitor and evaluate the tobacco industrvs activities. Develop this research so we will have adequate data ~ from which tadevelop strategies for the future. 7. Rejectthe tobacco industry's voluntarycode in its current or any future form. Challenges to Ourselves 1. Challenge leadership of our movement to develop a strates;ic plan for potential funding, and designate individuals and onxt+ nizations to implement recommendations.of each of the workgroups. 2; Identif)r and dtwelop additional resources devoted to accom- plishing the above. 3. Broaden the diversity of our gnoup to include those being exploited!by the tobacco industry. 4. Broaden our base of support in terms of numbers, me.utmg gramwts suppoR 5. Explore and assess the impact of warning labels in countries that require stnonger, labels. 6. Identify and develop leadership ~to implement recommenda- tions and action steps.

WatrltrtiNtoP I(ccomnicndatittns Reconnaendations, of Work Group m International Health and Tobacco Use Discussion The fotlowing,recommendations were made by the group and are conditionedlon the belief that aaveffort to curb tobacco trade and use internationally must begin with the US'putting its own house in order and adopting comprehensive national tobacco control policies including high taxes,,bans on advertising and promotion, effective health warning labels. }puth access laws;,cJassification of tobacco and tobacco products as hazardous substances, and cleanair legislation. Recommendations 1. Congress should pass legislatiottito prohibit the USTP, the Departments of'State and Commerce, or any other agency of the US government from actively encouraging, persuading or compelling any foreign government to expand the marketing of tobacco products whether it be by repealittg of laws restricting , marketing practices or securing',agpeetnents to introduce new measures or expand currentones; This applies to the promo- tion„advertisement; distributioni and taxation of tobacco prod- ucts. 2. Congress should use a fixed percentage oPrewenue oollected through foreign tobacco sales to fund US'federaf agencies to provide technological assistance on smoking controLLand prevention to countries that import US tobacco. Areas of tech- no logical assistance to be considered could!Ltclttde, but'not be limited to the following aneas: smoking surYey methodology, strategies to initiate cigat ette excise tax and tobacco product hazard control legislation, and intervention strategies to control and prevent tobacco ttszge. 3. Congness should eliminate allUunding,for USDA progSams that provide assistance or promote the export of tobacco and to- bacco products and promote tobacco gnowing overseas. 4. Congress shouldlamend federal laws governing the export of' hazardous substances to include tobacco and!tobacco prod- ucts: 5. The World Health Organization (WHO) should significantly increase its funding of tobacco control projects, either, byy reallocation of existing funds, or by increasediC'S funding of the orgartization, These projects should indudo collaborative efforts by; WHO and the Departtnent of'Health and,Human , Services (especialiy the National Cancer Institute and the Cen- Tobaaco ~ L ~se~ ~:1 rt~_3 merirrr~n ~G~risrs~. ters for Disease Control) in tobacco control technology er- ctiange: Included in such efforts willlbe annual reports on tobacco control programs and their impact, development and maintenance of international, national and local tobacco con- trol ittfrastntctunes, and training and exchange ofInfotmation on effective tobacco control interventions (inclitding policy media, educational and other program interventions) and data collection activities that support these interventions. 6. US and international health, voluntary and professional organi- r.ations: International'and voluntary organizations should collaborate with WHO to provide a comprehensive annual update on tobacco-relatedI data by country;,including,epide- miologieal data, policy information„localltobacco control infr,cstructure„and inforrnationon tobacco control programs in each country;,including the status of the research regarding the environment These same agencies should greatly expand their support of programs aimed at curbing tobacco use and track international tobacco control programs in developing countrues. 7. Congress and'the Clinton administration should encourage GATT'to eliminatesubsidies for tobacco agriculture among' member nations. 8. UN'affiliated agencies should adopt policies on programs that eliminate support for tobacco trade, manufacture, and market- ing of tobacco and tobacco products and!adopt new policies and programs todi.scourage tobacco use: These agencies include World'Bank, IMF, UVICEF, and others. 9. US and international public and private agencies should en- courage and provide resources to insure representation that is culturally diverse within each participating nation and inclutive of indigenous leadership in all efforts to develop and1pcromote tobacco prevention and control initiatives, conferences, and l planning meetings. N O N rP 1+ ~ ~

Workshop Itct:omLttendatioris Recomnendations of Work Group oni State and Local Tobaccol Control Battle$, Internal Process A. Editcate state and loeal chapters of pro-health organizations about the monumental health eHects of tobacco use and the enormous influence of the tobacco industry: Almost 500,000 deaths per ,vear are caused by this industry. Editcation should include case histories of successes. B. Organizations shotild :exantine their mission statements and the role that tobacco plays in blocking these objectives and should devote commensurate resources to tobacco~eontrol advocacy. They shouldlemploy methods which are most cost-effective. National, state and!local medical societies along with medicall specialty societies should,activelN participate with coalitions in effective tobacco control pollt.y, The AMA should request yeatpro$zess reports from ~its com- ponent organizations regarding each year's progress in state and, local tobacco control, and the ne.+n year's priorities for activism. The tobacco control movement should acknowledge the impor tance of not only making recommendations but implementing them. Our goal should not be only to make recommendations,, but to save lives. C. Recommend the widest possible recrniitment into the tobacco control movement from allaspects of society; recognizing that' this is a society-wide problenL Some organizations will not be invotved in every issue, even though we share a common ultimate goaL Therefore, working, groups may, be formed arpund specific issues. Recommend'that the movementbecome more sophisticated in understanding which segment of'the tobacco control movement can best earrv forward each4ssue: We should dr4dlcate our- selves to acknowledging the important and unique role which each organization has to play. Effective grass roots activists should be encouraged and re- warded as valued' members of the smoking control movement:. The larger national volunteer organizations should continue to send, in writing, information to their state and local organipa-.g tions esplaining how it would be in their best interest to work withlocalgrassroots activists groupswhen,possiblo: or tooffor resources (staff time, office space, copying, etc.) whenpocsible. Grass roots activist groups very often have new and creative ideas and often ateeper knoAVlodge.of the tobacco issue and they should'be willing, in return to pass this on to the national organizations and their local affiliates both to edilcate and to activate. Tactics A. l,egisLators have statutory and moral!responsibillty for thc health and welfare of their constituents. No si.nglp issue so impacts negatively on healthiand weifare as tobacco-related disease. We therefore urge legislators to refuse donations from the tobaeco industry artd its subsidiaries: State, county and local organuations should seek non-tobacco dollars for sponsorship of events. B. in order to do.stroy the tobacco industrl?s anempts to gain public cnedibility and further i5olate tlie tobacco indtUstrn,: tobaeco eontrol advocates should,aetively, expose tobacco industry poli6calicontributions, lobbyists, "front" organiz>ixrns and cases where these tobacco industry lobbyists represent anv other group in society. Tobaaco eontrol activists should recognize that segments of society have already been coopted by the tobacco industr... especially tobacco farmers. We sfiould anticipate that the tobacco indttstry will leontinue these activities. We should seek to bnng,the segments into the tobacco control'movement or at least neutralize these groups. C: We should actively oppose any legislation that preempts stron- ger local laws, that criminalizes cltddren for tobacco purchase, use or possecaon; that shields tobacco companies from prnd, uct liability or elevatessmoking to protected "tbQJtts" cattQory: These issues serve to protect the tobacco indicstrv:. We recommend that tobacco control advocates be aware of' "bogus" bills which contain these features or of last+minute legislative attempts to tagithese on to other pending IcgisLiuun: D. Aetively involve children;,women, tobacco victims :uxl'stirvi, vors, and minority groups in tobacco education and'adi.x:arv

'1VorksRtop Ret'ommcirtlatityits Y activities.lhese groups are'special targets of the'lobaacw ind¢utY, and!these gnoups are very effective advocates. E. We recommend'in addition to legislation, tobacco contnol advocates utilize other public sector avenues such as reguhl dons, executive orders, bureaucratic rules and petitioningg government to control the tobacco industry. Regulatory bodies may be freer of tobacco industry influence utd may be made up of experts, However these bodies should be canefutly monitored as the tobacco indiistry, has a history of misusing them. F. Goeallordinances influence state legislarion and have great value in public education and building the tobacco control movement Tobacco Lse.tAn American Crisis G: We recommend positive vocaixilAry used describing;oumelves as pnoheaith tictivist5 and'defining the tobacco control issue as health vs. greed. We recommend recognizing and rewarding;state and locall leaders who oppose the tobacco industry and support the tobacco eontrol movement.

Wtrrkslhclp RecottttncrtcLtlitftt9 Recommendations of Work Grou on. Legal Issues in Tobacco Control Enforce Federal Law A: Americans With Disabilities.Act-Gtivil IRights Division of the Justice Department should sue to enforce the requirement that alllplaces of public accommodation be accessible to asthmatics and people with other pulmonary diaease and with cardiovas- cular disease, i.e., that they, be smokefree; and that the Equal Opportunity Binployment'Commission sue to enforce the ban ondiscrintinationiby employers against people with compro- mised pulmonary or cardiovascular functions who require.a smokefree emironment Pritrate suits by affected individuals to obti+n access to place of public accommodation, and to obtain nondiscriminatory employment opportunities, should 'also be encouraged. Note that both types of suits are unambiguously supported!by the language of the.Aerand of the accompanyittg; t egttlations. B. Occupational Safety and Health Adtninistration (OSHA) should proceed rapidly to carry out its statutory mandate to prevenr any employees from developing lung cancer or other diseases as a result of exposure to ETS. This will require a ban on smok- ing in all workplaces, except perhaps for completeiy'separated and separately ventilated smoking areas: Since OSHA' regulal tions preempt most state and all local regulations, it is essential that OSHA nor be permitted to take half-measures, which wouki . in ury event be inconsisteut'with its statutory duty. C. The Department of Justice should prompdy rarty outs its dutyy under the Public Health Smoking Act of 1969 and bring action against broadcasters and/or cigarette mant:laCturers which violate the prohibition against cigarette advertising on elec- tronic media by using ciguette.brand'names or dgarette logos in connection with sporting events. D. The Federal Trade Commission, should promptly initiate pro- ceeding5 under Sec. 5("unfair or deceptive acts or practices:..affecting commerce") 1 against tobacco manufactur- ers who direct marketing at minors or who misrepresent, explicitly or implicitly;,the safety of 'their, products. 2: Congress Should promptly repeal 1'5 U.S.C. Sec. 1i334(b)„the preemption provision of the Cigarette Advertising,and Labeling Act It has served to inhibit majorpublic health initiatives such as billboard bans, restrictions upon!youth-oriented marketing, and producr.liabiliry suits. Cigarette manttfacturen should not enloy this extraordinary exemption from state regulatory and judiaal power: 3. State legistaasres shouldiadopt statutes holding tobacco compa- nies liable on a no-fault basis for heahh care expenditures and losrearnings attributable to the use of tobacco products. The statutes should provide that proof'of tobacco use beyond a specified threshold (e.g. 20 pack)ears) and of a tobacco- caused disease ('eg, lung,cancer, oral-phary^ttggai cancer, or emphysema) establishes liabilityregardless of fault by either manufacturer or user.ltte statutes shouidalso provide that third-partypayers (e.g., Medicaid, Niedicare;,or Blue Cross/ Blue Shield): shall'have the right~to recover their: tobacco : re- lated healthcare expenditures directly from the tobacco manu- facturers (under a"subrogatiod' theory), and!that theymax use statistical methods to estimate their total tabzacco-related health care expenditures, as well as to estimate the market share oftlie various tobacco manufacturers. Such statutes will provide hard'-pressed states and employers with alsubfitanual measure of financial relief, as well asallocating these costs where they properlybelong., 4: State logislatures should adopt statutes requiring ,tobacco manufacturers wishing to sell their products within the stato to disclose to state health authorities and; through them, to the public all information in their possession reladng to (a) ingre- dients in the product and!the chemical analysis of the smoke, (b) adverse health effects of the product's use; (c) all neseardt undertaken directly or indirectly by the manufacturers Urvolv- ing possible adverse health effects; andi (d) : all research known to the manufacturer invoiving the likely or intended effects of their marlCeting., These statutes shouid:aLSo require these manufacturers to disclose directly to consumers (a) through package inserts and through "800" numbers„all adverse health effects of using their product, as established by scientific con- sensus; and' (b) through package labels, that the product may not be sold to minors. The Supreme Court's recent decision in QipoUone v. Liggen Groap, Inc. makes dear that these tvpec of state regulation are indeed permissible: 5: (a) Federal prosecutors should vigorously pursue indictments against those tobacco executives and attorney5 who have par- ticipated in conspiracies to fraudulently misrepresent the state of knowledge reganiing tobacco use and health, as well as misrepr~_enting the scope and purpose oE the research thrv

War1:>hop IZccottunctttlatiuits are aonducting.. Mall hnd, wire hancl, and RadAeer.l*n- enced Craniaal Otgnirrtion,statutes provide legal bases for such indictments. (b) State and local prosecutors s6ouldirigoroUsly pursue indictments of tobacco companies; organizations, and execu- tives for recklessly endangering the health and lives ~of citizens by, misrepr+ese.ming the stite o[imowledge asto the dangers of ~ their products. Manslaughter indictments are also possible, but the crime of reckless eadangerment, which exists in many states, does not require the prosecutor to connect the defen- dants' actions with any specific victim'S disease or death. 6. Congress should undertake an invesflgattoainto misrepresenta- tions which were made by the tobacco industny, to Congress and the general public with respect to the industtys ltnovell;dge and' activities regarding smoking and health. 7. Legal protection of minors: (a) Encourage state l6gislatures to pass statutes enabling,pu- ents to sue retailers who sell cigareues to their, minor children. (b); Encourage legal xctlons seeking injunctive relief against day,-care centers, fast-food restaurants, schools, and'other, indoor establishments frequented bq, minors, to require them, to forbid smoking. ' (c) Eaaourgge ddld advocat' grotrps and family court judM to construe child prawctton istamn to facljde children who suffer ftom serious ptilmonary, disorders (e.g. asttima) and continue to be exposed to Ei'S!at!home. 8. Provide finartcLzl!as well as moral support'to researchers whose work is attacked by the tobacco industry. 9. Support ongoing research into a wide range of legal'actions against, tobacco companies, including cigarette fire czes. 1sbe.stos'/toba+qco synergy cases, cm imolving,environmental tobacco smoke esposure, and medical costs associated with smoking cessatiom 10, Support a clearing6otue and a legal backup center for local governmental bodies which have passed or are contemplating tobacco control measurers and'which face 113ga1 attacks by ihe tobacco industry. N 0 N ~ F+ ~ N Tobacco L'se; 9n Americun Crisas 105

lWrkshttp Lta:cotHrncndatiotts Recommendations of Work Group on Agricultural Policy Strategic Recommendations As the summary ofienacted legislation demonstrates,,the tobacco program in the United States is composed of a few major provi- sions cortcerning the production and marketing oftivariety of'~ types of tobacco. Deregulating the tobacco support'pnogram requires thatiall these provisions be repealed or significantly reviewed. The policy issue before the public healtheommunity should not be whether federal financiai assistance for the tobacco support programishould be ended, but1whett+-and how best to accomplish this task qtilckly, and fairiy, There are several options to.reduce or eliminate the federal government's role-and its expenditures-for regulating the tobacco progtram: Impaet of Recommendations Long term actions to phase out or eliminate the federal tobaeco ! program will have several impacts. The direct consequences include the loss of'income for quotalowners from the lease ot allotments. However, eliminating costly allotment payments will benefit the original intended recipients of'~tobacco supportipro- grams: small family farmers and their heirs. Many observers speculate that the price of tobaeco products will fall,if federalI support is phased out They predict thatlower, prices will cause increases in the use of kower qttality, imports, in the use of all tobacco products, and in overall exports of tobacco prod- ucts. Since the primary objective of eliminating the federalsup- pont program is healthi related---to: reduce consumption of tobacco producxs-atterttionshould be given to the issue of tobacco use. Reduced costs will not necessarily increase use, because the actual cost of tobacco only contributes about six cents to the pt?ice of a pack of cigarettes: However,,phasing out the tobacco supportt program should be accompanied byaleomprehensive package of proposals to reduce the use of tobacco products (as contained in the legislative program of the Coalition on Smoking OR Healih); .Acc ording to. Kenneth 1 E. Warner, writing,in the Journal of the NaAional :C,ancer bsstitute, "the program has an indirect political consequence that sustains tobacco consttmption: The program remains a highly visible symbol of government; ambivalence about tobacco, an ambivalence that diminishes the force of thetiealth message. In fact, the demise of the program would dramatically alter the nature ofnobacco agraculture in the US; would give way to smaller numbers offar<tters and as a consequence, the num her of voters directly irrvolved!in tobacco farming wottld plummett and the artificially constructed constituency, of allotment holders would evaporate." . The sysiem tarnishes the imageof a goverrtment 1 committedito bettering,the public's health. It impedes legislative progress towards a society free of tobacco- produced lung caneer, heart disease, and!emphysetrta, Reading of the health-0riented literature on the tobaeco,subsidlj suggests that,, in large part; the health community i5 oblivious to this phe- nomenon. Southern block senators and representatives are not. Developing pha.se-out options should include careful consider- ation of the impact on the small family farmer. The nutnber; sizee and organization of tobacco farmers is lilcely, to change as a result of a program phase-out. This change, however,,is not liketyto be more dtamatic.than that which has occurred over the past 20 years as mechanized harvesting, bulk curing, and other techno- logical innovations have made it possible to:g.row more and more tobacco on a single fanm; Any phase-out program should include funding mechanisms to facilitate the faraner's transition away from direct support: Assistance should be givett to tobacco farmers who for bu.ane.cc or other purposes elect to stop gnowing tobacco and to begin growing other crops. A user fee mechanism can eliminate the health eommunit}'s concern about using federal revenue to supporrt the growth of tobacco. Perhaps funds can also be ear- marked!from substantial federal; state andllocal cigarette excise tax increase towards this end. Goal§ To insure that the agricultural!policies of the US ane consistent with the tobacco related recommendations of the Healthv Ptfople 2.0U0 objectives: 1. Diminish opposition to health initiatives by reducing the politi- calI power the tobacco industiy exercises through its influence over tobacco farmers. This can be accomplished by: a. Reducing or eliminating tobacco acreage by diversification into other crops or land usage. V, .

Worh.sttttp Ftccutntrtettd.rtions xy -A: b. Federal legislation andior reg4ilatim to access funds in the 4„Dedieate a portion of the higher stue and fedetnl excise tax on "No Net Cost" program to be used'fbrttiepurchaseof tobacco tobaccoto~provide grants aodlow-interest toanstm individual bases for the purpose of'permutent retirement or to provide farmers for new fanm eqpipment, irrigation systems; etc: grants and low-interest loans to tobacco Earmers who are changing to new cnops. 5. Include in the content-on exh pack of cigarettes the percent- age of domestic and foreign tobacco used.' c. Prrnide industrial bonds to food processing and other nod- tobacco companies tocating in tobacco-producing areas. 3. Elintinate use of ifederal tax revenues to a dininister the No Ndt Cost Tobacco Pnogrxim andifor [ISDA tobacco research,uid'' developmenu Tobncco C!se~ AnArraerican Crisis 10-

3VetrksItop Ef,ccitnutiicndat.ictns '10vecommenddtions of Work Group on Nicotine Dependence 1. Treatment' of Nicotine A.dldiction-AHCPR Needs to Move Ahead With: 1. Standards of Care (Guidelines) for Nicotine Dependence A. Nicotine dependdnee,is a bighly beterogpnous disorder requiring alrange of'differenvtreatments: B. Stepped Care/based on severity, of Dependence C. Special~attention to treatment of special groups including: low socioeconomic statu.s (SES),,disadwantaged, undetsenved, understudied, nd adolescent'g;oups (youttu)i ID: Standards for treatment counselors. 2. Make tobaeco use a vital sign (physicians and ott>er healtb care providers). 11. Reimbursement andi ittsurance Poticy for Nicotine Dependence Treatment 1. Nicotine dependence treatment requires rrombursement for counseling andltreatmentlinterNerttions (Medicaid, Medicare, Government in.surance and'private insurance companies). 2. Treatment for Nicotine Dependence should be a part~of every basic benefit package. 3. Create economic incentives and dis'vtcentivea for patfeat/ providerfwsurer,payor mechanisms to promote tobacco ipre- veation and cessation. As part of'these inaentlVes the lRS sbotild, allow, = deducatloas for nicotine dependence treat, ment for individuals andicorporations. 4. Endorse a range of quall6ed providers; and continue profes- sional education. 5: End doublb standird mandating prevention aa ot~ty treaunent that is cost-saving. III: Tiie Tobacco Control Mandates to Mandated N.A. Tkeat<nent 1. Pair JCAHO standards and Nicotine Dependence Treatment. As hospitals become smokefree.more chemical dependency, units should ahso become smokefree, u well'as offering;both inpa- tients and empioyees treatment options. 2: Aiction ti<ken by OSHA regacdiug woticpluee standltrrdss for exposure to B115 shoufd'be paired with nicotine addiction treatment reeommendasions. 3. Pair curbing,ybuthladolesceat quittlag services with access (mandated N.A: treattnent):

.Yrhcnd.iz.Y s.. ri97Z'3~'~~3~1 State Cigarette Excise Taa State Tax per pack (cents) State Tax per pack (cents) AL 16.5 N10 13 A9f 29 MT 18! AZ 18 ;VE 27 AR' 34.5 NV 35 CA 35 NH 25 Co 20 NJ 40 Cf 4'Z N1U1 i 21 DE 24 NY 56 DC 65 NC 5 FL 33•9 ND, 4t GA 12 OH 24! HI 60 OK 23' iD 18 OR 28 IL 30 PA 511 LN 1'5.5 RI 37 [A 36 SC 7 KS' 24, SD 23 KY 3 TN 13 IA 20 TX 41. MY 37 UT' 26.5 MI) 36 VT 18 MA 51 VA 2.5 NiI 25 WA 54 IiIIy 48! WY 17 MS 18 WY; 12 Tobacco Lse; An American Crisis

appendir B Tobacco ~Contcoli Ordhaa+ces Local Vending Mxhinae Ordinances in the USCumulative by Year of Enactmerst NumDer or or0inarnces 180 20 0 198+t 1 9$'a 1988 1987 19891 19891 1990 19911 1982' Source:Americans faNbromokars'. Ffghts. usedwiNiperrnw,on:. ' nxOt,Qn Sepember:.19g2. 1100% Smokefree Ordinances Curnulative by Year of Enactrnmt' Number or ordinances 60', 5o 30 40 20 Cumulative Total Restaurants & Workplaces ---•-• RestaurantsOnly - - - Workplaces Ornly 10 p i i i i i i i 1 1985 1998' 1987 1988 19@9 199p', 1991 1992 Soure.: Am.e- 4or Neromokaa'. Riplti. Uh.d rtift 7»rmrtbti , 100% Smokefi+ee Ordinances By Year of Enactment Number or or ' 30 10 5' -_~ 0 '985 1986 1987 1988 1989 1990 SCUr.e Amerca.^s:'ori\ss+POkeGsf2~gMts! Uset) with perTtssK)t1. 1991 1992

(:unturattcc 1'articijlants Moderator Workshop Leaders Richard Daynard I Debomh M+rirelbtt N. Eastem Univ. of Scbool Law, APHA' John Pinney Dzvid G A trman . 400 HuntingtoaAvenue. 1015 115tB Street ' NW 7201 WLscoasin Avettue Stanford UniVeraty Bosuxt, MA' 02115 : , , Wsshington, DC 20005 Suite 620' 1000 Welch Road Bethesda, MD 20857 Stanfordl GA 94304' Jine Delgado, Ptesident Anne MnrieO'1(eefe COSSMHO President Scoa Bttllim 1501 16tti St t NW O'K f &A i Plenary Speakers Vice President and Legislative ree , Washington, DC 20036. ssoc ates ee e Govetrunent and Media Michael Eriltsen counsel. Relatioas Center for Diseue Conttrol Public Affairs Michael C: Fiore, Director. 7201 Wisconsin'Avenue, 1600 Clifton Road, NE Ameripn Heart Association Center for Tobacco Research Suite 620 MS'H.~50 1150 Connectian Avenue, NW, and Interrention Bethesda MD 20814 Atlanm Ga 30333 Suite 810 University of Wuconsin. , Washington, DC 20036 1300 Universiry Avenue John Slide Hon: Alexander B. Gi•annis Madison Wl' 53706 Gniversitcof'Medicine & Rep., State of New York. Michelle Bloeh Dentistry of New Jersey Room 522 14405 Briarwood Terrace Peter, Fisher St Peter's Medical!Center Uegislative Office Bldg., Rackville; MD 20853 Coalition on Scnoking or Healtd, 254 Faston Avenue Albany, NY 12248 11'50 Conneocicut Ave., NW New Brunswick, NJ 08903 Alan Blitm Suite 920 Charles LeMaistre Baylor University Washington, DC 20036 David Sweanor President 5510 Greenbriar 124 0'Connor Street Universityof Texas Houston, TX 77005 Harold Freeman Suite 300 M.D. Anderson Cancer Center Director, Department of Surgery Ottawa, Ontario 1515 Holcombe Boulevard i David Barns Harlem Hospital Center. Canada K1P 5M9 Houston, TX 77020 UCSD Medical Center 136th StreerandILenox Ave: 225 West Dickinson New York; NY 10037 Kenneth Warner Anne Northup San Diego, CA 92103: Deparmrenrof Public Health Kentucky State Representative El1en R: Gdt¢ Policy and Admini'stration 3340 Lexington Road ReginaCarlsott. Director Divuion of'Cancer. School of Public Health Louisville; KY 40206 New JxrseyGASP , Controli Univetsityof Michigan. 105 Mountain Avenue Jonssat lComprehensive. Ann Atfioq Ml 48109 Michael Pertschuk. Summit, NJ 0790'1 Cancer Center Co-Director UCL1 Arfvocuy lastitute Julia Carol 1100 Glendon Avenue, Suite 711 Distinguished Speakm 1730 Rhode LslandAveaue, Americans for Nonsmokers Los Angeles, CA 90024 MD Antonia Novello NW Right , US Surgeon ~Gienernl Suite 600 : 2530 San Pablo Avenue Ted Klein Deput¢tent of Healt>i & Human Washington, DC 20m36-3118 Berkeley, CA 94702 President Services. Ted Klein & Company SW 2001ndependence Avenue Greg,Rashford Ted Chen 740 Bi•oadlwly, Sltite 903'. , Wishington DC 20201 Legal Times Tulane University Medical Center New York, NK, 10003 , 1730 MiStreet; NW 1430 Ttilane Avenue Hon. Henry A. Waxmin Suite 802 New Orleans, lA 70112 Andrea Levin Rep., State of California Washington, DC 200'36 New York Attorney General'S Subconunittee on Chairman Gregory Connolly Office , Health and Environment Dianne Watson MA Dept of Public Health Bureau of Con.sumer Fraud US House of Representatives CiliforniaiSt2te Senator 150 Tremont Street 120 Broadway, 3rd F1oor DC 205155 Washington 4401 Grens6aw Blvd. Boston, MA 02'1111- New York, NY1IQ271 , Suite 300, Los Angeles, CA 90043' Carol!D'Ohofrio l PattyMallin tV 3 ~Reqµa P ace Piedmonti CA 94611 1730 Road Island Avenue. O , Suite 600 N Washington, DC 20036 ~ p F+ fD F+ Tobacco Use: An American Crisis

Q;on#crcncc Parlia:ip;.utts ..:} . Workshop Stcretarics VaUee M. Adatas-iNfBer 480 Taylor Street, NE +rI-23'. Washington, DC 20017' Carol BszeB 6226 Satan Wood Dtive. Coliunbia, MD 2'i1044. Theodore Carner Johns Hopkins University 624' North Broadway Baltimore, MD 21205 Mari1}m Ctumptoa Johns Hopkins Unive:sity, 624 North Broadway Baltimore, MD 21205 Christiny Farttp : University of'Maryland 655 WesrBaltitnore Street Baltimore, MD 2'1201 Vincent Fottseea. D'msion of Preventive Medicine Walter Reed Atmy'Institute .of Researrh Washington,, DC 20307 Daniei Jl Glatt 10301 Grosvenor Place #1605 Rockville, MD 20852 Clarice Green University of Muyiartd 655 West Baltimore Street Baltimore, MD ; 21201 StephemMoore Jphns Hopkins University 624 Northi Broadway Baltimore, MD 21'205 Eric SofbeqDoctors Ought To Care 5'510 ,Greenbriar Houston; TX 77005 David'Stein 701 West Monroe Street;,M301 Baltimore, MD 21209 Suzanne Steinberg University of Maryland 655 West Baltimone Street Baltimore„MD 21201 Conference Participants Ross Abtams . Johns Hopldns Sthool af Medicine 600 ~N. Wolfe Bhltiinore, MD 21205 Joseph Aisner Univ: of MD ~Rancer Center 22 S. Greene Street Baltimore, MD 21201 James R. Ailen American Medical Association 51'5 N. Stste Street Chicago, IL 60610 George Anstadt American College of Occupational & Envir. 1667 Lake Avenue Racchesters NY 14652 Puginia:S. Bales Prev. & Heaith Promotion, CDG 4770 Buford Highway, NE Atlanta, GA 30341 Jeff Baum Warner Lambert & Company 1667 K Street, NW Suite 1270 Washington,,DC 20006 Michael Bearhler Robert Wood Jphnson!Fdh. Route 1 & College Road, E.' Princeton, NJ 108540 Robert1W: Beandail U.S. Navy 23rd &:E:Sireet,,NW Wishington, IDC' 20372 Stacey Beckhardt American Society of Clinical Oncology 750 17th Street, NW Suite 1100 Washington„IDC 20006 JamesBerganan STAT 121 Lyman Street Suite 210 ! Springfield, MA' 0 1ll03 Ilisa Bernsteio Food & Drug Adinuustration 5600 Fishers L7ne, HF-22 Room.14:105. Rockville. MD : 20857 Puil Billings Ameritxn i Lung Association 1726 M Street, NW Suite 902 Washington, DC 20036 John Btoom Advoeaty Institute. 173'0 Rhode Island Avenue Suite 600 Washington, DC 20036 David Botrne Ark Dept o f Health 4815 W. Markham, M5-3 little Rock,,AR 72205 JuGe Brackett American Hew Association 333 Gutarie Street Suite 207 Louisville, KY 40202 Roy Brutsoa Inter-Rellgious Coalition 77 10 farrol Avenue Takoma Pirk; MD 20912 Cheryl Brovvn Amer. Assm for Respiritory Care 1655 North Fort Mver Dr. Suite 700 Arlington, VA 22209 Barbarn B[ooktnyer American Medical Student Association 1890 Preston White fkave Reston, VA 22091 Bob Bry 1'31'8!22ttd Street, NW Washington, DC 20037 Kevin Budich - - - @lfice of Compliance. FDA' 7520 Standish Place Room 260 Rockville, MD1 20855:

Willitin Al. Butler Alin Davis Ttrm PdeA i (3udex!(kntder US Navy Atnerican Cancer Society Offiae of Cong. Richard Durbih Tobaooo»rd Disease Research 2510 Walmer Avenue 316 Penn. Avenue, SE' US. House of'Represenqtdres U(LA 121ser Btdg., 30011ke Norfollt, VA 23'513 Suite 200 Washington, DC 20515 S'ide Washington, DC' 20003 12th Pdoor Blake Cady Paul IFiscHer C+ildtu>a CA 94612 110 Francis Street Karen Dessy, The Journal of'Pamily Prac6ce Suite 2-H Office on Smoking & Health 519 Pleasant Home Road Dudley Hafner Boston, MA 02215 330 C Street, SW Switzer Bldg: Suite A3 Executive Vice President Room 1229 ~ Augttsta, GA 30907 Americtin HeartA.s.soeiation Barb-m J1 Callans ~ Washington„DC 20201 7272 Gteeaville Avenue American Psyrbological!Assa. Ripley Forbes DiflL'ts, TX 752311 750 First Stneet, NE' Robert Denniston Office ofCong. Henry Wannan Wasttingdon,,DC 20002 CSAP; SAMHSA US. Hottse of Represetttadres Nancy HtilQern i TheodoreCarner 5600 Fishers Lane Rockwall fI Washington, DC 20515 ; Atneritan Cancer Soclety316 Penn Avenue, SE 103 E. MG RoyallAvenue Room 9C03 John Ftid Suite 200: Baltimore, MD 21202 Rockvitle;b71D 20857 FDA-Office of ESttetnallAfiairs Wiishington, DC,20003 5600 iF9sbers Lane Michelle (hang C,liff'Dot-glns Rockville, MD 20857 Steven Hansen Office on Smoking and Health Advocacy, Institute 1235 Osos Street 4770 Buford Highway, NE 1720 Rhode Island Ave., NW Margaret Gankes Sin LaiaObislw, CA 93401 MSK-50 Suite 600 American Medical Association Atlanta, GA 30471 Washington, DC 21D036 1101 Vermont Avenue,,NW Bryan P. Hirdin Wsshington,DC 20005 NIO5H CDC Sheldon B. Cohen Joel Dunnington 200 Independence Ave., SW Atlanta Coalition Against Dept: of Diagnostic Radiology Ricb Giibert HHHB Tobacco 1'515 Hotcotnbe Blvd. Ameripn, Public HeaUh 714B 490 Peachttee Stte+et, NE' Box 57 Assoaiarion i Washington, DC 20201 Suite 251B Houston; TX 77030 101515th Street; NE Atlnnta, GA 30308 Washington, DC 20005 John Hard= Frxn DuMbile Zhe Csrte<Center Robert Cook-Deegan American Lung Assorintion Mark Glassner 1 Copet>6i0 Institute of'Medicine 1726 M Street, NW Delawue DOC A'thnta, GA 30307 21,01 Constitution Avenue,,NW Suite 9U2 24 IAennison Smeet Washongton, DC 20418 Washington, DC 20036 Neaark„D8 19711 Robert Humon Admfnsft-aor, HR.Rl1 Edward Correia Jill Escher Bill GodSbaU 5600 Ft*,hers Lane Northeastern U. L1w School American Association for Resp. ExecutivrDin Smokefree Penn ParddaArn iBldg; 400 Huntington Avenue Care P.O. Box 81570, Room 14,05 Bostoa,,MA 021115 1655 NJ FL Myer Drive P9ttsburgh, ft 15217 Rockvide„6D 20857 Suite 700 David R Cundiff Arlington, VA 22209 Adam Goldstein )(>rhleefl Hsrty . Jr$erson County Health Dept NC ASSIST 114ttnesota Department of'Nealth Louisville, KY 40201 Briw Ellison 4'1I1 i LongleafDrive 717 S;E. Delaware Street Univ. of Mir.higan ~ Oiapel HiLNC 27599~ P.O.: Box 9441 Sandra Cuneo 1320 Wisteria Drive Minneapolis, MN 55440 CuneoLaw OfBces B.4624 Donna Grande 1301 K Street, NW Ann Arbor, M1 48104 Public Health Adviser, NCI' Susan Hildebnutt Suite ,650E 9000 Roclavine Pike American Academy of'F~rnily Washington, DC 20003 Roselyn Epps Exec. Pl=,N Physidans Steve Cunni on, MC, USN i National Cancer Institute 1775 N. Por!tal Driv+e;,NW Rootn 241 Bethesda„MD 20853 2021 Massitcltuseas~ Avenue, NWWasftington, DC 20036 US. Navy, Was6ington„Dc 20012 23rd & E Street, NW A1bcander B. Grannis Jaccit E. Henningfield Code 24 Joy Epstein lqislative Office Bidg: NIDIVARC Washin84on4DC 20372' Coalition on Smoking or Health Room 522 P.O. Box 5180 1150 Connecticut Avenue, NW' Albxny;,NY 12248 B7ltimore, MD 21224 Suite 820: Washington, DC 20036 2024~97019 Tobncco C"se: .anAhnericAn Crisis i 3

Ccrlxfar.dncc Rarticipants, . Susan Holden Stop Smoking Institute P.O. Box 474 Abington, MD 211009 Harrv Holmes M.D. Anderson Cancer Center 1515 Holcombe Houston; TR 77030 Robert Hughes Robert Wood Johnson Foundation College Road, East Stzciley G: Rarsort Center for Corp. Public Involvement l00'1I Pennsylvania Avenue, N.W: Washington, DC 20004 Martha Katz CDC10D OPPE' Mail Stop D,23. 1600 CliRon Rd., NE Atlanta, GA 30333 Sarah Kayson American HeartAssoriation Lou Manfredi American Cypamid Company One Cvoamid Ptazs~ Wayne, NJ 07470 Marc Manley Wational'Cancer Institute 9000 RockMiBe Pilie EPN Rm, 241 Bethesda, MD 20892 Bob Mzrshall National Cancer Institute EPN+241 Charles Morwick Journal AMA 110 1 Vetmon t Avenue, NW ' Washington, DC 20005 Deborah Mvers Ciba Geigy, 1747 Pennavbvania Avenue, NW' Suite 700 / Washington, DC 20006 Jeanne Nametz American Lung.k%sociation 1740 Broadwtp Box 2316 1 t50!Conneaicut Avenue, NW Bethesda,,MD 20892 . New York„HY c 00I18 Princeton,.NjI 08543 Pauline M:Jpckson State Medical Societq of Wisconsin 330 E. Lakeside Street P:0 j Box 1109 Suite 810 Washington, DC 20036, Martha Keintz Fox Chase Cancer Center 510 Township Line Road Cheltenham, PA 19102 Phillip Vlarty USF'COllege of Public Healthi 13201 Bruce B' : Down Blvd. Tampa, FL 33612 Chardene L. May Marcia Nenno ~ American Cancer Society Florida Division 3709W: LettonAvenueP:O. Box 320347 Tampa, FL 33679 Madison, WI 53701 Jennifer Johnson AHA 1150 Connect'rcut Avenue, NW' Jon Kerner Memorial Sloan-Kettering 1275 York Avenue NewYork;,Y1Y 10021 American College of'Cardiology 91:111;01dIGeorgetown Road Bethesda, MD 20814 Brigid McHugh Gary, Noble CIDC~ 200 Independence Ave., SW 7114B Suite 810 Washington, DC 20036 Lynn Jenkins American MedicaliStudbnt Association i 1890 Preston White Drive Restonj VA 22091 Luk Joossens Bureau of Action on Smoking Prevention 117, rue des Atrebates 1ID440 8nuxelles; ,Belgium Jerelyn Jordan Special Publications; ACS 1599 Clifton Road;,NE AWta„GA 30329 Gail Joyce ~; Robert [athan 1938 Peachtree Road Atlanta, GA 30309, Bruce Leistikow Nicotine Dependence Center 1215' 1/2 Se+renth Avenue, SE Mayo Clinic Rochester, MN 5 5904 Karen Lewis AdvoeatyInstitute 1720 Rhode Lsfand Avenue, NW Suite 600 Washingtott~ DIC 20036 Scott lutch American Assrti of Dental 1625' Massachusetts Ave:, NW 5th Floor American Heart Association 7272 Greenville Avenue Dallas, TX 75231 Robert Mecklenburg 12304 River's Ed'gt: Drive Pototnac, MD 20854 Alan MilLk Amertrut Caneer Society 3'16 Pennsylvania Ave., SE Suite Z00. Washington, DC 200031 Sherrp :Milk National Cancer Institute 9000 Rockville Pike Ezec Plaza N. Room 320 Bethesda, MD 20892 Wa,shinglon„DIC 20036 Stacy Nichols 1433 Brockton Avenue, #5 Las Angeles;,CA 90025: Carey 0!Connor Coalition on Smoking or Health 1150 Connectiau ANe:, NW Suite 820, Washington, DC 20036 Tracy Ckieans Fox Chze Canar Center 5:10 Township line Road Cheltonham, PA 190112 Barbara Z. Park American Dental Assn. 211 E.,ChicagoAvenue Chicago, Qi 6061111 1 Smoke-Free Class of 2000 208 S. LaSalle Suite 900 Washington, DC 20036 Douglas S. Uoyd Jane Moore ASTHO 4152nd Street, NE Michael Parkinson DAD &,PHP, HRSA to . Chicago; Q. 60604 Health Resources & Service Admin. Suite 200 Washington„DC 20002 Pankdaavn Building Room 8-101 Q N. tarry Joyce AMA 5600 Fishers Lane Room 14-15 John !A: Moorhead Rockville„MID 20857 }"1 515 :N. State Street Rockville, MD 120857' Navy Environmental I Health Michael Pertshuk ~. t2ticago,IL 60610 Leslie lutdwick Center 25 10 Wallner Avenue: Advocacy, fnsdtute 1730 Rhode Wand Avenue: "tW ~ AMA Washington Office Suite A Suite 600 ~, I l01 Vermont Avenue; "aW Washington, DC 20005'. Nortolk, VA 23513 Washington, DC 20036, O

Q:onCarcncc Pttrticipant. Joan A. Pietnme Ortcologq Nursing.Sodety, Route 3,,Box799.F PHS-Hea1d1 Res. & Svc. Admin. 5600 Fisher hne. RM 14-4'5' Barbara E. Silverstri I ChiC2go Lung Associatioa 1440 W. Wzshington Bldg. Etl ISwed! GASP of l141ass2chusetts P:0. Box 1'54'63 Harpers Ferry; WV 25425 Susan Polan Senate labor & Human Resources 527 HarnBuilding Washington, DC 20510, James S. Quirk Memorial Sloan-Kettering Cancer Center 1275 York Avenue New York;,NY 10021 Rockville, MD 20857 Rosemary Rosso FTC 6th &,Penn. Avenue, NW Washington, DC 20580 Catherine A'. Rudick Physicians for a Smoke-Free Camda l PA. Box 4649, Station E Ottawa, Ontario, Canada K1S51 cWcaga; a 60607 Sitsan Yael Smith TobaccoFree CA/'G' Medical P.O. Box 7690 Eric Solberg DOC 5510 Greenbriar Houston, TX 77005 Madellne Solomoni AHA•Metropolitan Chicago Kenmore Station . Boston;,MA 02215 Gregg C. Sytvester Senator Harkin's Office lII'3 Hart Building Washington, DC Pat Talmon Center for Substance Abuse 5600 Fishers in: Rockwall 11;,9di, Room 9D 10 Rockville, MD 20857 Nancy Rawdittg' Nat Assn. of County Health 440 1fiust,Street;11W Suite 500, Carol M. Russell California Depo: of~ Health Service P.O. Box 942732 208 South la.Sille Street Suite 900 Chicago,lL 601G04 Stephanie Sparks Julie Taylor AmerictinSoaetyofClinical. Oncologq 750 17th Street, NW' Washington, DC 20001 Sacramento;,CA 94234 American ~Hearrt kssociation. I 150 Conn. Avenue, NW Suite 100 Washington„DC 2 D006 Susan Hi Reid Texas Cancer, Council P :0 j Box 12097 Kuhleen!Ei Scheg Action on Smoking & Health 2013 H Street, NW Suite 8110, Washington, DC 20036 Mark Taylor Physicians for a Smoke Free Austin, TX 78711 Peter Reinecke Subcommittee on Disabilitv Policv U1S: Senate SH 113 Washington, DC' 20006 Bill Schultz House Subcomm. on Health 5'12 HotLse Annex 1 US Cong. Washington, DC 20515 Paul D. Stein American College of Chest. Physicians 3300 N. Dundee Road. Northbrook; IL 60062 Frances Stilltnan, Canada P.O. Box 4849i Stn. E Ottawa„Ontarno; Canada K'1S 5JF Pamela Thornton American College,of Physicians Washington, DC 20510' Gail Regan Jotin Seffritr Exe+cutiine Director The'Jphns Hopkins University 1839 E Monument Street ;«8024 700 13ttt Street, SAt" Suite 250 Wlshittgton; DC 20005 23rd & E'Street„NW Washington, DC' 20372 Rick Ricbards Doctors Ought to Care 1423 Harper Street American Cancer Society, 15991Clifton Road, NE Atlanta, GA 30329 Hiin. Ann ~Seibert, Rep, State of'Vertnont. Baltfmore„MD 21205 Jefferv M. Stokols American Medical Asstt. 51'5 North State Street Room 13530 Melodie Tilson Heart & Stroke Foundation 160 George Street, Suite 200 0ttawt;,0ntario, Canada K4N 9M2 Augusta, GA 309 12 Robert Robinson Office On Smoking and Health 4770 BufordHighway, NE' MS K-50. RR2; Box 428 Norflvick„VT 05055 Raymond Seltser AHCPR/PHS 210t E: Jefferson Street Chicago, IL 60610 RobertF: St. Peter U.S. Public Health Service 330 C Street, SW Room 2132' Dennis D. Tolsma Centers for Disease Control 1600 iClifton Road, NE Mztlstop D37 Atlanta, GA 30333 N Atlanta, GA 3034'1 Suite 502 Rockville, MD 20852 Washi'rtgton,,DC 20201 Rich Trachtman O ~ Thomas Robinson Carole Sullivan American Society, of ~ Deptt of Pediatrics & Medicine, 1000 Welch Road Pa1o Alto, CA 94304 Omega hogan Silra Amerimn Medical Women's Association 345 N Street, SW American iAcademy of Pediatrics 1331 Pennsylvania Avenue;, NW Suite 721N Washington, DC 20004 . International Medicine 2011 Pennsylvania Ave., N'W Suite 800 Washington, DC, 20005 . Mark Roebuck Washington, DC 20024' ~ IA 1:S Tobacco Cse: .-1 n _4bnerican Crisis

Cunl:crencc P:Irticip.uil, Bob Vollinger eSAeNSPps'. 5600Fishers Lane Rockwall 11 9th Floor Rockvillb;,MD1 20857 Gailya Walter Office on,Smoldng & Healthi 330 C StrM SW Switzer Bldg, Room 1229 Washington, DC 20201 Karen, M. Wa rren, EVPi'CEO Citv of Hope NationalMed.. Center, 1500 East i 1Duarte Road Duarte, CA 91,010 Sherri' Watson American Lung Association 1726 MiSoreet, NW Suite 902 . Washington, DC 2006 Roben'A: Waugh American Heart Associatlon. Duke Universiry Medical Center Box 3032' Durham,,NC 277110, Sharon L Webber Inst for Public Repcesetttatton 600 New Jzrsey Avenue, NW Suite :312 WashingRon„DC 20001 Judy Wllkcnhid Div: of Advertrsing Pric., F11C 60 d Pennsyh~ Avenue, NW Annex 4007 Washington, DC 20580 June A. Willenz American Veterans!Commitfee ! 6309 Bannockburn Drive Bethesda,,MS 20817 Suszn,F: Woodl Cong;essional'Caucus for Women 2471 Rayburn House Office Bldg: Washington, DC 20515 Mildred K Wurf' Girls Incorporated 3 101 New Mexibo Avenue, NW Suite 241 Washington, DC 20016, Eileen Z,eller Asthma & Allergy Foundation 1125 15th Street, NW' Suite 502 Wastrington„DC 20005 Bryan Zervos W2shington 1n.slitute 7710!Carrol Avenue Takoma P7rk; MD 2091'2 Jeanne Weigum Assn. for Nonsmokers-MN 2395 Unive:sity Avenue, West Suite 31!0 St_ Paui,,MN 55114. Mirhae11F: White Med. Marketing & Health Comm. 100 1 30th Street, NW Washington, DC 20007. Scott Wilbur AMA Washington, of6ce 1101 Vermont Avenue, NW Washington,,IDC 20005 € ,