Tobacco Documents Online

HIGH PRIORITY FEDERAL GOVERNMENTAL INITIATIVES Work Group Leader: Philip R. Lee, M.D. The overall objective of the Work Group was to develop strategies for the elimination of smoking-related illness, disability and death. Five specific objectives related to this long-term goal were developed: 1. Reduce the number of smokers by five million within the next two years. 2. Provide adequate disclosure of the hazards of cigarette smoking on ci- garette labels and in all cigarette advertising. 3. Provide adequate information on the hazards of smoking for all school-age children, women of childbearing age, and groups at special risk of disease, disability and death related to cigarette smoking. 4. Provide adequate protection from cigarette, cigar and pipe smoke for all nonsmokers at work, in hospitals, other health care facilities, businesses serving the public, public buildings, and in all public transportation. 5. Eliminate cigarette-caused fires and fire-related deaths. Among the major issue areas considered by the group were the following: 1. An increased federal excise tax on cigarettes, cigars, and other tobacco products. 2. There is the need for a new warning label on cigarette packages and in ad- vertising with respect to the whole gamut of hazards of smoking. Among the issues considered were the need for rotation of the warnings, both on cigaret- te packs and in advertising; the frequency of the rotation; the content of the messages; the size of the warnings; and the possible use of a logo on cigaret- te packs and in advertising that would clearly identify the warning label. There was a consensus within the Group that labels should be rotated periodi- cally, a minimum of twice a year (preferably quarterly); and that the rota- tional laws should not necessarily be established by Congress. Rather, they should be at the discretion of the Secretary of Health and Human Services in order to facilitate administration and responsiveness to the emerging science base. The warning label should be associated with a logo, both on the pack and in advertising. The highest priority in this warning label should be given to pregnant women, and to those at risk of cardiovascular diseases, cancers, and chronic lung diseases. The warning should be sufficiently specific so that people reading it might apply it to themselves rather than just to other smo- kers in general. Within the Work Group there was a dissenting view: all cigarette advertising should be banned by the federal government; and anything less would fail to effectively deal with the problem. -152- L_ TIMN 185569

3. For the federal role in information and educarion related to cigarette smoking, there is the need to maintain financial support for the Office on Smoking and Health (part of H.H.S.) for adequate staffing, both in the short and long terms. Reductions in the budget already have reduced staff in the Office on Smoking and Health; and if not stopped or reversed in the future, the Office could be totally eliminated, thereby rendering impotent their fe- deral role in information and education related to cigarette smoking. It seems incomprehensible that the federal government should not play a major role in public education in this area, complementing the efforts of the major voluntary health agencies. To leave the education of the public primarily to the cigarette companies would be a backward step, unparalleled in the last 20 years that the federal government has been actively involved in providing in- formation on the hazards of smoking. t/ 4. Although actions with respect to nonsmokers' rights will come, primarily, at the state and local levels, the federal government could do a great deal more than it has done in this area. Federal executive departments and agen- cies should follow the policies initiated for HRE (now the D.H.H.S.) during the tenure of Joseph Califano as Secretary. These included setting aside public areas as nonsmoking areas, which included elevators, conference rooms, hallways, office waiting rooms, sections in government-operated cafeterias and restaurants, and other public facilities. These measures provide protection for nonsmokers, particularly those susceptible to the adverse effects of ci- garette smoke; and smokers in their efforts to stop smoking. Other branches of government, i.e., Congress and the Judicial Branch, could take similar actions as employers, in adopting reasonable standards for the protection of the rights of nonsmokers in the workplace, and the right of all citizens to smoke-free public places. An additional and related area is the role of the Defense Department in sub- sidizing the sale of cigarettes to members of the armed forces and their fa- milies. This practice should be discontinued. In addition,'if the authority of the Civil Aeronautics Board over smoking practices on airplanes is elimi- nated, some other federal agency should be assigned the responsibility for protecting nonsmokers' rights on airplanes. 5. The need to protect smokers and innocent victims from the risk of injury, disability and death due to fires and cigarettes that are not self-extinguish- ing was another important area considered by the Work Group. Note was taken of the legislation already introduced by Senator Alan Cranston of California that would require all cigarettes marketed in the U.S. and sold by U.S. cigar- ette manufacturers to be self-extinguishing in order to reduce the potential for burn, injury, disability, and death. It is not known the extent to which additives currently used in cigarettes compound the problem and make cigaret- tes continue to burn instead of being self-extinguishing when not being smo- ked. 6. Another area that attracted a good deal of attention is tobacco price sup- ports and acreage allotments. It•was the consensus of the Group that the eli- mination of price supports would be symbolically very important in terms of identifying the federal role with respect to the promotion of tobacco pro- ducts. At the present time,the public receives very confusing signals with continued federal price supports for tobacco. Equally important as a symbol of the federal support for tobacco is the inclusion of tobacco subsidized by -153- TIMN TIMN 185570

the U.S. government in the Food for Peace program. The Group thought that both the tobacco price supports and the support for tobacco in the Food for Peace program should be eliminated by the U.S. Congress. On the matter of acreage allotments,it was not thought necessary for the government to take specific action in this area. r 7. The question of incentives for industry, particularly tax incentives for business and industry to develop smoke-free work areas and to develop smoking prevention and smoking cessation programs,was considered. Members of the Work Group thought that this would be particularly important in industries where occupational exposure increases the risk from smoking, such as in the asbestos industry, mining, and probably in the chemical and textile industries. Some industries have already undertaken such programs voluntarily, restricting or prohibiting smoking in the workplace. Congress should evaluate this problem and should consider the most effective incentives to encourage business and industry to move forward rapidly in this area. 8. The role of physician and hospital reimbursement with respect to health promotion and smoking cessation programs was considered. The Health Care Financing Administration (through the Medicare program), states (through the Medicaid program), and private health insurance (including Blue Cross/Blue Shield and commercial insurance companies) should undertake reimbursement experiments to determine the most effective means of achieving these objec- tives. It seemed clear to the members of the Group that the broader applica- tion of effective prevention programs and smoking cessation programs would reduce the costs of medical care of cigarette smoking-related illnesses. Al- though this area was not explored in depth, it was considered an important area for exploration by the health insurance industry, health care providers (particularly physicians and hospitals), and by 'the major voluntary organiza- tions that are already carrying out effective smoking cessation programs. 9. Although federal support for research was the responsibility of another Work Group, this area was considered briefly. The research to support a "less hazardous" cigarette represented product development for the tobacco industry and was not really an appropriate goal for the federal government. Much more support is needed for research related to the social, behavioral, and environ- mental factors that initiate cigarette smoking, particularly among teenagers; and more support is needed for research on effective means of preventing ci- garette smoking. In addition, more research should be carried out on addi- tives; on the effects of cigarette smoking and other occupational or environ- mental exposures; and on other diseases as well as lung cancer. In a time of growing budget stringency, the Group emphasized the need for con- tinuing support for the National Center for Health Statistics, and for*the National Cancer Institute's efforts to monitor cancer incidence. It is parti- cularly important that studies on health status, on smoking behavior and on attitudes and knowledge about cigarette smoking be continued. It is only through such studies that more effective programs of prevention and smoking cessation can be initiated. 10. The Work Group discussed health professions education, and a possible federal initiative related to providing incentives for medical schools, nur- sing schools, and other professional schools with respect to tobacco and =154- -154- ; TIMN 185571

v cigarette smoking. In view of the major cutbacks in the federal support for health professions education, this did not appear to be a likely area in the near-term for any significant federal initiative. 11. In addition to statistical studies and monitoring of health status,the federal government has a major role to play in policy monitoring, specifically monitoring the effects of block grants on education, information and smoking cessation programs at the state and local levels. Should there be significant reductions in these programs, the Congress should consider a specific categor- ical program in these areas. . An important consideration for policymakers is capacity-building with respect to smoking or health programs at the state and local levels. Although this will be increasingly difficult because of the shift towards block grants, there is no more important area in terms of health promotion and disease pre- vention than to strengthen the capacity of these units of government in order to carry out effective programs, both as employers and as agencies responsible for the public's health within their jurisdiction. V 12. Finally, the Group considered, but did not support, the concept of shift- ing the costs of illness or smoking-related illnesses to smokers. This could be accomplished through changes in health insurance premiums, including the Part B premiums from Medicare. It could also be applied in the Medicaid pro- gram where copayments or other financial burdens might be placed on smokers. The majority of the group, however, thought this was not an appropriate area for federal policy action. The following recommendations were made: 1. Enactment by the U.S. Congress of an increased federal excise tax on ci- garettes of three to four times the present level (e.g., stabilized at only 8¢ per pack since 1951) in order to adjust this rate for the inflation of the past 30 years. 2. Enactment by the U.S. Congress of the "Comprehensive Smoking Prevention Act• of 1981" proposed by Representative Waxman (H.R. 4957), and/or similar legislation soon to be introduced by Senators Hatch and Packwood to require: (a) maintaining all the activities of the Office on Smoking and Health; (b) rotating warning on cigarette packages and in advertising which describes the recognized hazards of smoking; and (c) disclosing the quantity and identity of all chemical additives by their common names. In addition, the cigarette industry should be made responsible for demonstra- ting the safety of cigarette additives through appropriate biological testing. 3. Expand and strengthen federal programs of prevention, education and infor- mation, including: -155- TIMN 185572

a) adequate funding for the Office on Smoking and Health: -scientific information, including the Surgeon General's annual report; -counter-advertising and media initiatives which focus its limited.re- sources on high risk groups, such as children, women, minorities, and other groups for whom smoking represents a greatly increased risk of illness and death; -special emphasis on the maintenance of adequate data bases and ad hoc surveys to monitor public awareness, behavior and health status in re- lation to smoking, including NCHS activities and other essential data sources such as the NCI; b) support for school health education programs related to smoking and health c) other educational initiatives, possibly including: 1 I ` -an appropriate postage stamp on the hazards of smoking; -information provided with payroll checks; -hand-outs in unemployment and other governmental offices with access to the public; -motto for government forms and stationery: "Smoking is Dangerous to your Health" A substantial portion of the enhanced federal revenues from the increased ci- garette excise tax should be used to support a major anti-smoking information and education initiative. The following actions were proposed: Actions for political coalition: Action 1: Major voluntary health agencies should make a major commitment to political action on a national smoking or health agenda if success is to be achieved. The American Cancer Society, American Heart Association, and Ameri- can Lung Association should provide the necessary leadership. This commitment will require a substantial increase in current levels of financial support and staffing for political action by these organizations, and health, consumer, labor, church, public interest and other voluntary organizations for the na- tional and grassroots political action required. Action 2: Establish an effective coalition of voluntary associations (health, church, elderly, youth, labor, public interest, business) to spearhead and coordinate the national and grassroots political action. This should include lobbying, petitioning or testifying before regulatory agencies and federal courts related to the smoking issue. This might be accomplished through an expansion of existing organizations (e.g., National Interagency Council on Smoking and Health), or it may require a special interagency task force poli- tical action. -156- TIMN 185573

Ac*_ion 3: the following specific actions will be required of the coalition: -fundraising -creation of a national Smoking OR Health network of grassroots support; and identifying so-called "golden bullets": people within this network of concerned citizens who are in positions to have special influence with key members of Congress on smoking-related legislation and funding issues; -develop specific ation plans of essential steps to influence legisla- tion, appropriations, judicial cases, and regulatory action related to smoking; -utilize the appropriate legal and legislative expertise required to carry out an effective political action program on smoking or health; -have direct communications (by mail, telephone, or visits) with indivi- duals in the network for purposes of fundraising, relaying information or for specific actions; -publish newsletters for distribution to the individuals in the network; -provide policy analysis on legislative proposals with specific ation recommendations for individuals and organizational members of the net- work; -lobbying ,/ -support legal activities to make cigarette manufacturers liable in com- pensation suits where cigarettes contribute to ill health. Ac:ions proposed for Congress: ?,ction 1: Eliminate federal price supports for tobacco; and eliminate tobacco from the Food for Peace Program by the U.S. Congress. Action 2: The U.S. Congress should enact legislation (similar to that intro- duced by Senator Cranston) to require that all cigarettes marketed in the U.S. or sold by U.S. cigarette manufacturers be self-extinguishing to reduce burn injury, death and disability. Action 3: Enact a "Sense of the Congress" resolution related to smoking and health. Action 4: Tax reform in the form of tax incentives should be aimed at encour- aging industry to develop smoke-free work areas, smoking prevention, and smo- king cessation programs, particularly in industries where occupational expos- ure increases the risk from smoking. Actions proposed for the Executive Branch: Action 1: The Department of Health and Human Services should monitor the block grant program in relation to preventive services, including smoking and health, and school health programs. If, in two years, it is determined that there is a diminution of preventive services, then selected categorical pre- ventive programs, including smoking and health, should be restored. The Department of Health and Human Services should monitor the magnitude and quality of preventive services provided by the states under the block grant program, in order to determine whether categorical preventive services and programs should be restored. -157- TIMN 185574

y Action 2: Support the requirement by the U.S. Department of Health and Human Services and the Department of Education that all grantee and contact insti- tutions adopt, in principle, the D.H.H.S. standards for the protection of nonsmokers (e.g., prohibit smoking in elevators, conference rooms and other public places and areas) and assure availability of nonsmoking areas in cafe- terias. The Department of Health and Human Services and the Department of Education should promulgate the required regulations. Action 3: Each branch of the federal government--Executive, Legislative, and Judicial--should set an example as an employer in adopting reasonable stand- ards for the protection of the rights of nonsmokers in the work place, and the rights of all citizens to smoke-free public places such as elevators and con- ference rooms, and no-smoking sections in cafeterias and restaurants, as well as providing smoking education and smoking cessation programs. In addition, the Department of Defense should no longer subsidize the sale of cigarettes. All departments and agencies of the Executive Branch, the Judicial Branch, and the Congress should promulgate regulation similar to that adopted by the Department of Health and Human Services for the protection of nonsmokers. The Department of Defense should promulgate a new rule requiring that cigaret- tes be sold at prices not lower than the average prevailing price of the sur- rounding state or jurisdiction. The American Cancer Society, American Lung Association, and the American Heart Association should take actions to immediately strengthen the capacity to mo- nitor federal legislation and take appropriate political action on high prior- ity legislative issues. For example, the American Cancer Society is in the process of strengthening its Washington presence and capacity. The American Cancer Society, American Lung Association and American Heart ~ Association should assess the capacity of the National Interagency Council on Smoking and Health to serve as an effective coalition of voluntary associa- tions to spearhead and coordinate the national and grassroots political ac- tion, including lobbying, petitions, or testifying before regulatory agencies and federal courts related to smoking issues. If the Council is not able as an organization to carry out this combination of educational and political action, the major voluntary health associations concerned with smoking or health should immediately take steps to organize a joint task force for poli- tical action. Support for the expanded program of political action included in the recommendation should be initiated immediately by the voluntary health associations and expanded rapidly within the next three to six months. 'During that period of time,it could be determined what the appropriate level of Wash- ington representation in grassroots political action would be and what the required level of funding would be to support an effective effort. A sus- tained long-term effort for at least a decade should be supported by these r organizations. Attempts must be made to include labor, consumer, community and (especially) minority group organizations. =158- TIMN 185575

il Summarv and Conclusions: Although the best opportunity in more than a decade for major federal initia- tives related to smoking or health now exists, nothing will happen in Congress or the Executive Branch unless a major commitment to political action in Wash- ington, D.C. and the grassroots is made by the major voluntary health organi- zations concerned with smoking or health. The American Cancer Society, Ameri- can Heart Association, and American Lung Association should be joined in this effort by such professional groups as the American Dental Association, Ameri- can Medical Association, American Nurses' Association, American College of Chest Physicians, and American Public Health Association. -159- TIMN 185576