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F I N A L and Recommendations From the Health Community to The 101 st Congress and the Bush Administration R E P 0 R-_I On the Occasion of the 25th Anniversary of the Surgeon General's First Report on Smoking U.T.M.D. Anderson Cancer Center, Houston, Texas January 27-28, 1989 TIMN 295309

Ellen McConnell Blakeman, Editor Alan L. Engleberg, M.D., M.P.H., Scientific Editor T1-)4N 295310

The final report of th a Tobacco Use in America Conference was published by The American Medical Association. For adc itional single copies contact: The American Medical Association, Public Affairs Group, 1101 Vermont Avenue, N.W., Washington, D.C. 20005. TIMN 295311

Tcbacco Use in America Conference • January 27-28, 1989 Acknowledgments The Tobacco Use in America Conference was initiated by Congressman Michael A. Andrews of Texas and funded by the American Medical Association in cooperation with the University of Texas M.D. Anderson Cancer Center, Houston. The conference was co-sponsored by the American Medical Association, the Ameri- can Cancer Society, the American Heart Association and the American Lung Association. Congressmen Richard J. Durbin, Illinois and Mike Synar, Oklahoma served as con- gressional co sponsors and made invaluable contributions to the conference plans. The sponsors extend their thanks to everyone who helped make the Tobacco Use in America Conference a success. Special recognition is given to the workgroup leaders and Members of Congress who participated in the conference. The sponsors express their gratitude to the Conference Planning Committee: Scott Ballin, American Heart Association; Alan Davis, American Cancer Society; Fran DuMelle, American Lung Association; Harry Holmes, Ph.D., University of Texas M.D. Anderson Cancer Center; John Hollar and Kim Koontz, staff to Rep. Mike Synar; David Kendall, staff to Rep. Michael A. Andrews; Susan Lightfoot, staff to Rep. Richard J. Durbin; John Madigan, American Cancer Society; Matt Myers, Coalition on Smoking OR Health; and John H. Scott, American Medical Association. Special thanks goes to Bill Romjue, Administrative Assistant to Congressman Michael A. Andrews, for his leadership in planning the conference. The sponsors also recognize several people for`their extraordinary contributions to the workgroup papers: Mary Crane, American Heart Association; Cliff Douglas, Coalition on Smoking OR Health; Shirley E. Kellie, MD, American Medical Association; Angela Mickel, Tobacco-Free America; and Jonathan Slade, University of Medicine and Dentistry of New Jersey. Thanks are extended to Jeff Rasco, Director of Conference Services at the M.D. Anderson Cancer Center and his fine staff, and Sharon Kremkau of the American Med- ical Association's Division of Meeting Services, for outstanding conference arrangements. And special thanks to Pam Bauemfeind, staff of the American Medical Association's Department of Congressional Relations, whose hard work helped ensure the confer- ence's success and to Mike Zarski with the American Medical Association's Department of Federal Legislation who made invaluable contributions to the planning of the con- ference and to the final report. TIMN 295312

Tobacco Use in America Conference • January 27-28, 1989 7able of Contents I. Introduction ............................................. 1 II. Tobacco Use: Women, Children and Minorities ................. 3 Ill. Nicotine Addiction ........................................ 7 IV. Federal Regulation of Tobacco Products ...................... 13 V. Cigarette Excise Taxes .................................... 19 VI. Protecting Nonsmokers .................................... 25 VII. Tobacco Marketing and Promotion ........................... 29 VIII. U.S. Agricultural Policy on Tobacco .......................... 43 IX. International Marketing and Promotion of Tobacco .............. 49 X. Grassroots Lobbying ......................................55 XI. References ..............................................65 XII. Conference Participants ................................... 67 ThvZN 295313

Tobacco Use in America Conference • January 27-28, 1989 Introduction Twenty-five years ago the first Report of the Advisory Com- mittee to the U.S. Surgeon General was issued on the impact of tobacco use on health. I his 1964 report presented stark conclusions: that cigarette ~moking causes lung cancer and is the most important causo of chronic bronchitis. The Re- port also linked smoking with emphysema and other forms of cancer. The tobacco industry contested the report, arguing that there was no conclusive lin,( between smoking and poor health. Yet while the "debate" raged, the evidence support- ing that landmark report co itinued to mount. Just three years later, in 1967, the late Dr. Luther Terry, then the Surgeon General, declared the "debate" closed: There is no longer any d)ubt that cigarette smoking is a direct threat to a user':> health. There was a time when we spoke of the sr noking and health contro- versy. In my mind, the days of argument are over. With each passing year since 1964, the link between cigarette smoking and deati and disease has become even more incontestible. Subsequent reports of the Surgeon General on the health consequences of smoking have shown unequivocally that, among r nany other things, cigarette' smoking is the most important of the known modifiable risk factors for coronary heart disease; is a major cause of stroke; is a cause of diseas:, including lung cancer, in healthy non-smokers; and is a cause of fetal injury, pre- mature birth and low birthw:;ight in the case of smoking by pregnant women. Much progress in curbing tobacco use has been made since 1964, but even more remains to be done. What crucial problems confront this nation about tobacco use today? What obstacles must be overcome to reduce the death and disease caused by tobacco i se? And what strategies must be undertaken to eliminate the number-one preventable cause of premature death ard disease in this country? Prepared by: Rep. Michael A. Andrews U.S. House of Representatives Charles LeMaistre, MD President, M.D. Anderson Cancer Center, Houston Joseph Painter, MD, Vice- Chairman, Board of Trustees American Medical Association * To answer these questions, the American Medical Associa- tion, the American Lung Association, the American Cancer Society, the American Heart Association, key members of Congress, and many other concerned citizens and organiza- tional representatives came together in a remarkable two-day gathering early this year, The Tobacco Use in America Con- ference. Never before had such a broad-based coalition assembled to develop a common agenda to reduce the death and disease caused by tobacco. The Conference achieved exceptional consensus on the scope, objectives and tactics for future tobacco-control ef- forts. The conferees agreed that in order to maintain current progress, decisive public policy action at the federal level must be combined with similar actions at the state and local levels, and that public policy must be developed in tandem with traditional public health initiatives. Only a comprehen- sive approach that recognizes the fundamental importance of public policy action will succeed. The dominant issue of the conference was how to dra- matically reduce smoking among our nation's children, young women, minorities and those Americans with fewer years of formal education. The recommendations of the con- ference call for developing more effective ways to work with these populations which have been so effectively targeted by the tobacco industry. Another key concern reflected in the conference recom- mendations is the need for public policy-makers to recognize the powerfully addictive nature of nicotine. The conferees agreed nicotine addiction is a grave problem because it causes most tobacco users to become "hooked" before they are old enough to appreciate the health consequences of their actions. More than 90 percent of all tobacco users begin while teenagers or younger; 50 percent of high school seniors who smoke begin by the seventh and eighth grade; and 25 percent of all high school seniors who smoke begin before or during the sixth gradb. 7bbacco Use in America Conference 1 '1'I1VI74 295314

'Macco Use in America Conference • January 27-28, 1989 The major recommendations of the conference are:  The U.S. Food and.Drag Administration should be given authority over all toba;co products;  Tobacco advertising aid marketing must be severely restricted to eliminate its influence on our nation's children;  Excise taxes and user fees on tobacco products should be increased to raise ievenues and discourage use by children;  The financial umbilical cord tying the federal govern- ment to the tobacco ir dustry-Tobacco Price Support Program-should be severed to reduce tobacco's un- due political influence on the federal decision-making process;  Action is needed to pr.)tect non-smokers from invol- untary smoking in public places, on trains, buses and planes, and in the workplace; and  The federal government must eliminate the cynical in- consistency between i:s domestic health policy and the way in which it exerci-es its international trade leverage to open up tobacco markets in other nations thereby enabling American tob3cco manufacturers to increase overall tobacco use in those countries. The conference participar ts agreed that in order to imple- ment their recommendation3, the major health-related orga- nizations must continue to work together in support of a united agenda. Collectively, the participating organizations can mobilize millions of citi~ens at the grassroots level to create a strong, coherent body able to more effectively in- fluence and educate policy-inakers throughout government. In 1981 the first National 'lonference on Smoking or Health served as a catalyst for mar y of the public policy gains of the last decade. If the coop:;ration, unity, good sense and energy displayed at this year's Tobacco Use in America Con- ference translate into action, this conference, too, may serve as an important steppingstone towards achieving the Surgeon General's goal of a smoke-fiee society by the year 2000. *Dr. Painter presided on beiralf of all the conference spon- sors: The American Medical Association, The American Cancer Society, The American Heart Association, and The American Lung Association. TIMN 295315 2 Zbbacco Use in America. Co7tference

lbbacco Use in America Conference • January 27-28, 1989 Tobacco Use: Women, Children arid Minorities Introduction Tobacco use by women, children ad members of minority groups is unacceptably hii h in the United States. Potentially preventable morbidity and mortality from diseases associated with tobacco use in women and minorities populations are not declining at rates comparable to those in other groups. To better understand the problem of tobacco use by women, children and minorities, this background paper summarizes trends in tobacco use; the health consequences of smoking; and effective anti-tobacco interventions in women, children and minorities. Tobacco Use The incidence of smoking among men peaked at 54 per- cent in the mid-1950s, and declined to 32 percent in 1987. The highest rate of smokin j in women-34 percent- occurred in 1966, and decl ned to 27 percent in 1987. Although fewer women thai men smoke, the fastest growing segment of smokers is wornen under age 23. More than 80 percent of smokers start smoking before age 21. Based on data collected in 1986 by the Office on Smoking and Health, more black me i (32 percent) than white men (29 percent) smoke. A similar trend is noted in higher prevalence of smoking by black women (25 percent), compared with white women (24 percent). Data from the Hispanic Health and Nutrition Examination :;urvey conducted between 1982 to 1984, reveals that about 40 percent of Hispanic men smoke (Mexican-Americans, 43 percent; Cuban-Americans, 42 percent, Puerto Ricans, 40 percent). Smoking prevalence in Hispanic women is lower than that in white and black women, and ranges from 21 percent among Mexican- Americans and Cuban-Ameeicans to 30 percent among Puer- to Ricans. There also appear to be specific cigarette brand purchasing patterns within minority populations. The available evidence indicates that the tobacco industry clearly recognizes the need to recruit additional snokers to insure its very survival Prepared by: Shirley E. Kellie, MD, MSc Dept. of Preventive Medicine American Medical Association and this had led to targeting of certain identified groups: women, children and minorities. These purchasing choices may reflect tobacco company marketing practices. For in- stance, 47 percent of Mexican-American men smoke Marl- boro (Philip Morris) and 20 percent Winston (R. J. Reynolds); 30 percent of Mexican-American women smoke Marlboro, 20 percent Winston and 16 percent Salem. Use of menthol cigarettes is very common among blacks, with 76 percent reporting that they smoke that type of cigarette. Based on data collected by the National Institute on Drug Abuse, smoking prevalence among high school seniors declined from approximately 28 percent in 1977 to 19 per- cent in 1987. The decline was rapid among both adolescent males and females between 1977 and 1981, and then leveled off between 1982 and 1987. Now, more adolescent females than males smoke, however the use of smokeless tobacco is highest in young boys. Reliable national estimates of the prevalence of smoking among American Indians and Asian Americans are not avail- able, and additional data regarding tobacco use are urgently needed for these groups. However, data from local surveys among these groups are available. Among American Indians, the highest smoking rates are seen in Northern Plains In- dians (42 percent to 70 percent), with lower rates among In- dians in the Southwest (13 percent to 28 percent). Smoke- less tobacco products are reportedly used at high rates by adolescents of both sexes in Alaska and among Northern Plains Indians. Smoking rates among Asian Americans, based on data from local surveys in Hawaii, were 27 percent for both Hawaiians and Filipinos, and 23 percent for Japanese. Health Consequences of Smoking Women who smoke are at increased risk for the same tobacco-associated morbidity and mortality as men: cancer of the lung and other sites, cardiovascular disease, stroke and chronic obstructive lung disease. However, in addition, women who smoke cigarettes are at increased risk for adverse 3 7bbacco Use in America .' onference TIMN 29531.6

Tobacco Use in America Conference • January 27-28, 1989 reproductive outcomes and osteoporosis and its associated fractures, which lead to signi icant loss of function among older women. Approximately one in ten women in the U.S. will develop breast cancer. In 1986, lung cancer mortality reached that of breast cancer mortality. 1988 data from the American Cancer Society shows that lung canc:;r deaths have surpassed breast cancer deaths, making lung cancer the leading cause of cancer deaths in women. Worren who smoke have twelve times the rate of lung cancer as do nonsmoking women. Further, smoking accounts for approximately 41 percent of all coro- nary heart disease in women under age 65; women who smoke only one to four cigarettes pe, day have double or triple the risk for heart attackes than women who do not smoke. The harmful effects of cigaiette smoke to nonsmokers are well documented; exposure tf environmental tobacco smoke is particularly detrimental to spouses and children of smokers as well. Spouses of smokers are at increased risk for lung caricer. Children of smokers have retarded development of lung function, and increased r pisodes of bronchitis and pneumonia during the first two years of life. Women who smoke during 3regnancy expose the develop- ing fetus to serious health corsequences, and have increased risk for delivering low-birthweight infants. Low-birthweight in- fants are five times more likel,t to die during the first year of life than are infants of normal birthweight. Women who smoke during pregnancy are also more likely to spontaneously abort, deliver prematurely, deliver a still birth or suffer premature rupture of the mea branes. Compared with whites, blac<s experience significantly higher mortality from tobacco associated diseases and disorders, including cancer, c<<rdiovascular disease and in- fant death. Black men have a?0 percent higher mortality rate from heart disease, and 58 percent higher incidence of lung cancer than white men. ;1ack women experience 50 percent more heart disease mortality, and higher rates of fetal death and low-birthweigh t babies than do white women. Rates of smoking-related cancers are particularly high among blacks. Estimates indicate that the incidence of lung cancer will increase by 31.8 percent i,i black men compared with 20.7 percent in white men frorn 1980 to 1990. During the same decade, estimates predict that the incidence of lung cancer will increase by 98.6 p:;rcent in black women and by 86 percent in white women. American Indians have highcr rates of cervical and stomach cancers (both of which are ascociated with smoking) than do whites, and the incidences of lung and oral cancers are in- creasing to levels observed in nrhites. There are considerable differences in tobacco-associaied incidence and mortality rates among Asian Americans, including Japanese, Chinese, Filipinos, and Native Hawaiians. The incidence of lung cancer among Chinese and Native Hawaiian women is higher than in white women. 4 Intervention to Prevent Tobacco Use Effectively intervening to prevent women, children and minorities from starting or continuing to use tobacco is ex- tremely important. Anti-tobacco efforts may be either primar- ily legislative or educational. Current and proposed interven- tions in women, children and minorities include: bans on advertising and promotion; restrictions on children's access to tobacco products; increases in price of tobacco products; and educational efforts. Advertising and Promotion The tobacco industry claims that the intent of its advertis- ing is to promote brand loyalty and brand switching. How- ever, as Davis reports in an article in New England Journal of Medicine, " ...Others believe that cigarette advertising may perpetuate or increase cigarette consumption by recruiting new smokers, inducing former smokers to relapse, making it more difficult for smokers to quit, and increasing the level of smokers' consumption by acting as an external cue to smoke." The total expenditure for cigarette advertising and promo- tion in 1986 was $2.4 billion dollars. Recently, there has been an increase in outdoor advertising, and in 1985, expen- ditures for cigarette advertising accounted for 22.3 percent of total advertising expenditures ($945 million) in outdoor media. Advertising of tobacco products, particularly cigarettes, glamorizes the product. In fact, these advertising techniques make tobacco products appealing to various groups including women and youth who may be struggling with problems of poor self-image. A number of cigarette brands have been in- troduced and have been reported to be marketed specifically to women. Cigarette advertising in women's magazines is growing. In 1985, eight women's magazines were among the 20 magazines receiving the most cigarette advertising revenue (Better Homes and Gardens, Family Circle, Woman's Day, McCalls, Ladies' Home Journal, Redbook, Cosmopolitan and Glamour). Some cigarette brands are reported to be specifically pro- moted to blacks: Kool, Winston, More, Salem, Newport, and Virginia Slims. Advertising of cigarettes is heavy in black- targeted publications, such as Ebony, Jet and Essence. Cigarette advertising on small billboards, located close to streets, is increasingly common in low-income neighbor- hoods. In addition, cigarette cmpanies are major sponsors of athletic events, musical concerts and cultural events in black neighborhoods. A number of cigarette brands-Rio, Dorado, and L&M Superior-have been reported to be targeted to members of the Hispanic community. Cigarette companies increasingly sponsor entertainment events and advertise on small billboards in Hispanic communities. While the tobacco industry denies that its advertising is targeted to children and adolescents, there is good evidence Tbbacco Use in America Conference TIMN 295317

Tobacco Use in America Conference • January 27-28, 1989 that such advertisements t _lo in fact reach youth. Some recurring themes in tobacco advertising, such as indepen- dence and sexual attractivoness, have particular appeal to children and adolescents. Gigarette advertising is very heavy in several magazines with large readerships among adolescents, such as Glamour (about oi-e-quarter of readers are girls under age 18), Sports Illustrated (about one-third of readers are boys under age 18), ard TV Guide (reaches approxi- mately 8.8 million readers age 12 to 17). Because of these conceris, many anti-tobacco advocates have supported federal legislation to ban all tobacco product advertising. This legislation has been opposed by some on the grounds that it would infringe upon First Amendment rights. However, others have argued that First Amendment rights may not apply to the advertising and promotion of products known to be harmful to health. Instead of a total ban on tobacco advertising, some have also proposed a "stepwise" elimination of advertising, i)eginning, for instance, with advertisements of tobacco which glamorize the products. Access to Tobacco Products A major contributor to tobacco use among children and adolescents is their relatively free access to purchase tobac- co products. While 43 stat..s have legislation establishing a minimum age of purchase 'or cigarettes, lack of enforcement is a very serious problem. In addition, a number of states re- quire licenses to sell tobacco products, but this is generally for tax purposes and does not address the issue of enforcing the minimum age for purchasing tobacco products. Youth have access to cigarettes in vending machines, and at times through distribution of free samples by tobacco companies. One anti-tobacco initiativo recommended to restrict access of youth to tobacco product°; is to permit only over-the-counter sales of cigarettes. This measure could allow for the age of the purchaser to be verified by a responsible person, and if enforced could limit childre:i's and adolescents' access to cigarettes. Price of Cigarettes Because adolescents gen;rally have limited disposable in- come, their purchase of cigarettes is sensitive to increases in the price of cigarettes. Incr:;asing cigarette prices by increas- ing excise taxes can reduce tobacco consumption in children and adolescents. Such taxes should be structured to increase and not decline with time. Educational Interventions Educational programs are appropriate for young people to prevent them from starting Io smoke, or later to help smokers stop smoking. In either situation it is important that the educational services be indi ridualized and relevant to meet the needs of the groups for whom they are provided. For ex- ample, a disproportionate n amber of smokers are now from 7bbacco Use in Arnerica t"onference lower educational, socioeconomic and minority groups, yet current anti-smoking educational materials are most used by those who are white and socioeconomically advantaged. Very few materials have been developed specifically for use with blacks or Hispanics. Many women may not be aware of the consequences of smoking related to specific interactions between smoking and female physiology, such as increased risk for osteoporo- sis and the association between smoking and early onset of menopause. In addition, many young adolescent women ig- nore or do not recognize the harmful effects of smoking dur- ing pregnancy. Educational campaigns could include more information regarding the gender-specific harmful effects of smoking. Summary of Workgroup Discussion The available evidence indicates that the tobacco industry clearly recognizes the need to recruit additional smokers to insure its very survival and this has led to targeting of certain identified groups: women, children and minorities. The tobacco industry's efforts may be blunted-even pre- empted-by specific actions to control access to tobacco and advertising of tobacco to women, children and minorities. Further, outreach programs aimed at these target groups may make them less vulnerable to pro-tobacco messages. Access to tobacco products may be controlled in various ways. Options include: setting a federal minimum age for tobacco purchase with strong penalties for violation; institut- ing a federal ban on vending machine sales of tobacco; edu- cating merchants about sales to minors; requiring a federal license for merchants to sell tobacco products, subject to revocation for sale to minors; banning distribution of free tobacco samples through the mail; prohibiting the sale of candy cigarettes; and an increase of excise taxes on tobacco products. The frequency and content of tobacco advertising should be regulated. Options include: a total ban on advertising; a more limited ban on advertising and promotions to which a significant number of children are exposed; taxing cigarette advertising and promotion, and using the revenue for anti- tobacco activities; eliminating tax deductions for tobacco advertising; banning the use of the United States mail to distribute publications with current advertisements; making federal funds for mass transit contingent on no tobacco advertisements on vehicles; creating paid or public service announcements against tobacco directed to women, children and minorities; and having the federal government conduct a national survey to determine cigarette brand preferences of youth. Outreach programs for women and minorities include: pro- viding federal grants to minority health professionals and other organizations to support programs to prevent smoking and aid smokers to stop; providing federal government funding 5 TIMN. 295318