Tobacco Documents Online

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

Tobacco Use in America Conference • January 27-28, 1989 for research on tobacco use in minority groups and women; increasing the budget for the Office of Minority Health for anti-smoking programs for rninorities; encouraging women and minority groups not to purchase magazines which adver- tise tobacco products; deveboping alternative sources of sup- port for youth and minority programs that now depend upon support from the tobacco industry. A number of other initiativos can complete a comprehen- sive anti-tobacco campaign. They include: increasing the budget for the Office on Smi ~king and Health; requiring feder- ally funded educational instititions to provide a smoke-free environment for children; ap;)ropriating additional federal funding for anti-smoking activities; including graphic pictures on cigarette package warnin(l labels; eliminating any pre- emption clauses in federal le;lislation that might prevent states from taking more strir gent action against the tobacco industry; tying anti-tobacco :ftorts with drug prevention ef- forts; and encouraging additional efforts by physicians to help prevent patients from siarting to smoke and to help them stop. Recommendations For children: 1. Federal policy should est, blish, or provide incentives for states to adopt, age 21 a°; the minimum age for purchase of tobacco products. Provisions for strong enforcement should be made, including meaningful penalties for viola- tions. 2. The federal government should ban the sale of tobacco products through vending machines. 3. The federal government should ban the distribution of free samples of tobacco i roducts through the mail, on public property and other places open to the public. 4. The federal government should require federally funded educational institutions to provide a smoke-free environ- ment for children. For women and minorities: 5. The federal government should increase federal funding for research on how to d:-crease tobacco use by minority groups and women. 6. Congress should fund a strong program of anti-smoking public service announcen ents, as well as a paid counter- advertisement campaign :;pecifically directed to women and minorities. 7. Federal grants should be provided to minority health pro- fessional and other organ zations to support programs to prevent tobacco use and :o help smokers stop. 6 For all Americans: 8. Congress should eliminate the tax deduction for tobacco advertising and promotional expenditures. 9. Congress should increase the budget of the Office on Smoking and Health. In addition, the budget of the Of- fice of Minority Health should be increased for anti- smoking programs targeting minorities. 10. Congress should provide additional federal funding for anti-smoking activities provided within existing federal public health programs serving women, children and minorities. Tobacco Use in Awrtica Conference TIMN 295319

T)bacco Use in America Conference • January 27-28, 1989 Nicotine Addiction Introduction The Surgeon General's 988 report, "Nicotine Addiction," concludes that cigarettes <<nd other forms of tobacco are ad- dicting, that nicotine is th_ addicting drug in tobacco and that the addictive process for nicotine is similar to that for drugs such as heroin and i;ocaine. People who are in troubl:_~ in our society are especially likely to use tobacco. They may be attracted to tobacco because it literally makes them feel good about themselves-euphoric, relaxed, less anxious. Scientists now know that nicotine regularly causes addiction in the users of tobacco products. And like other addicting drigs, nicotine more and more is victimizing vulnerable groups, especially the poor, women, children and minorities. Addiction to nicotine is tie most common serious drug problem in the United Stai:;s today. It is a complex disease with social, behavioral, physiologic and pharmacologic aspects. Like other addictions, it can be prevented and treated. However, at this time, adequate services are not available for the large numier of people who may benefit from such therapy. Therefore, treatment services need to be expanded in number and it scope to provide help for highly addicted persons as well a:, those who suffer from psychi- atric conditions or other dr.ig problems which are compli- cated by nicotine addiction Products such as cigareites and smokeless tobacco are nicotine delivery systems, and many other devices for ad- ministering nicotine are technically feasible. Nicotine itself can have harmful effects not only because it helps to main- tain smoking and tobacco iise. Therefore, our objective is to prevent and treat all forms of nicotine dependence. Understanding Nic•>tine and Addiction Classification Nicotine is the active dru) in tobacco. The 1988 Surgeon General's report reviews th; extensive literature on nicotine Prepared by: John Slade, MD St. Peter's Medical Center University of Medicine & Dentistry of New Jersey and concludes that nicotine regularly causes a true drug ad- diction in a high proportion of regular tobacco users. Many professional societies, including the American Medical Association, the American Psychological Association and the American Medical Society on Alcoholism and Other Drug Dependencies, agree that nicotine causes addiction, also known as dependence. The American Psychiatric Association has classified tobacco dependence with other addictive diseases since 1980, and in 1987, changed the technical name of the condition from tobacco dependence to nicotine dependence. In the 1950s, the World Health Organization classified tobacco use as an habituation. This classification was con- sistent with the belief at the time that drug addictions were manifestations of personality disorders and that in order to be considered addictive, a drug had to produce physical and psychological dependence. Under this paradigm, nicotine, cocaine, marijuana, and LSD were not thought to cause ad- diction, only habituation. This view is reflected in the 1964 Surgeon General's report. Today, addictive' diseases are no longer regarded as per- sonality disorders. And, although recent research has clearly shown that nicotine produces a true physiologic dependence, this characteristic is no longer essential for classifying a drug as addictive. Instead, scientists define addiction in terms of certain behavioral interactions of an individual with a drug. The primary criteria for a drug addiction used in the 1988 Surgeon General's report are: -There is a highly controlled or compulsive pattern of drug use, -Psychoactive or mood-altering effects are involved in the pattern of drug taking, and -The drug functions as a reinforcer to strengthen be- havior and lead to further drug ingestion. Additional criteria used in the report are tolerance, physical dependence, continued use despite harmful effects, pleasant 7 Tobacco Use in America Conference TIMN 295320

Tobacco Use in America Conference • January 27-28, 1989 (euphoric) effects, stereotypic patterns of drug use, relapse following drug abstinence an(I recurrent drug cravings. All of these criteria apply tc nicotine. People use tobacco for the nicotine: nicotine-free products do not succeed in the market)lace. A major policy issue for the federal government is wh;;ther and how the Food and Drug Administration. (FDA) or some other agency should regulate products which deliv;r nicotine. While the FDA has not asserted jurisdiction over traditional tobacco products (ex- cept in extraordinary circums:ances), the 1988 report recom- mended that the federal gove,nment review new, alternative nicotine delivery systems for toxicity and addictive potential before they are marketed. It i:, time to develop a system of regulatory oversight for tradit'onal tobacco products. Health Complications The 1989 Surgeon General's report estimates that in 1985, one in six deaths in this coun try was caused by cigarettes. These 390,000 deaths were distributed among the following terminal illnesses: Diagnostic Category Deaths (thousands) Coronary Heart Disease 115 Chronic Obstructive Pulmoi ary Disease 57 Cerebrovascular Disease 27.5 Other Vascular and Pulmon ary Diseases 45 Lung Cancer 106 Other Cancers 31.6 Infant and Neonatal Deaths 2.5 Lung Cancer in Nonsmoker:, 3.8 Deaths from Fires caused by Cigarettes 1.7 TOTAL 390.1 In addition to these diagnoctic categories, there is substan- tial evidence that among non-,mokers, tobacco smoke polllu- tion also causes deaths from coronary heart disease and cancers at sites other than th;; lung. In Environment Interna- tional, J.A. Wells estimates the additional number of deaths among nonsmokers from tobacco smoke pollution at 43,000. Determinants of nicotine addiction and recovery Nicotine addiction occurs m the result of complex interac- tions of the drug nicotine witi a specific individual living in a specific social and cultural coitext. For the most part, it is a pediatric disease: if an individual has not started to smoke by age 20, it is very unlikely he t_ir she will ever become ad- dicted to nicotine. On the ord;;r of three-fourths of children growing up in this country experiment with tobacco; about 70 percent of use has begun )y age 15, half by age 13. Be- tween one third and one half •)f those who experiment be- come chronic users; and most of these people are addicted to nicotine. Table 35 (page 11) from th:; 1989 Surgeon General's report summarizes the pharmacologic, cognitive, personal 8 and social factors involved in the onset of this disease, in its chronic stage, and in recovery from the addiction. Typically, nicotine addiction develops over a period of several years from late childhood to early to mid-adolescence. There is evidence that most teenagers who smoke want to quit, and most make at least one serious attempt to do so in these early years of the disease. For adults, too, thoughts about quitting and attempts to stop smoking are common, although repeated failure makes many relatively reluctant to try yet again. Still, more than two-thirds of adults and adolescents who smoke would like to quit. At the same time, people who smoke are highly condi- tioned to continue. This happens in part because the smoker perceives the pharmacologic effects of nicotine as positive. Thus, the person addicted to nicotine has lost control over his or her use of the drug, and truly free will is not operative. Thus, recovering from addiction involves a number of pro- cesses, including deconditioning, or unlearning all the associations with nicotine. Social and cultural influences are important in starting and continuing smoking as well as in recovering from addiction. Some of these influences are the smoking behavior of people around the individual (the smoking status of peers and rela- tives have been specifically studied), availability of tobacco products, advertising and promotion of tobacco, public health messages about tobacco, counter-marketing and policies about where smoking is permitted, if at all, in public places, schools and workplaces. If we understand these influences, we can begin to control the nicotine addiction epidemic by adopting policies that encourage young people not to start smoking and support and encourage smokers of all ages to quit. Most former smokers have quit smoking without formal treatment assistance. However, in many cases stopping smoking was associated with important personal or social changes in a person's life. (These are outlined in the section on nicotine and other addicting drugs.) But for many people addicted to nicotine treatment is not only helpful, it is essential for them to become abstinent. And treatment works. An extensive collection of scientific literature is devoted to the treatment of nicotine addiction and documents a number of valid intensities and approaches to treatment from single brief encounters with a therapist and self-instruction courses to inpatient treatment programs and Smokers' Anonymous groups. Adjunctive drug therapy, such as with nicotine resin complex (Nicorette) along with behavior modification treatment is also proved to be useful for selected patients. Other drugs such as clonidine and some anti-depressants, and other forms of nicotine have also shown promise as adjunctive therapies in preliminary studies. There are many settings in which treatment may be under- taken. Unfortunately, an important limiting factor is the lack 7bbacco Use in America Confererace TIMN 295321

Tobacco Use in America Conference • January 27-28, 1989 of health insurance reimbu,sement for stop-smoking ser- vices. The reimbursement ssue is complicated by the fact that there are no formal standards for what constitutes ac- ceptable therapy of this disease or for therapist training, and many proprietary clinics oi er unproved remedies. Comparisons with other addicting drugs Data in the 1988 Surgem General's report indicates that the use of nicotine shares inany characteristics with the use of cocaine, opiates and alcohol. People who use any of these drugs in a sufficient dose can detect the presence of the drug by their subjective feeling state. The drugs produce ef- fects regarded as pleasural_le, and they all have been shown to be positive reinforcers in both animal and human studies. Place conditioning-the association of a specific environment with drug use, drug effects and/or drug withdrawal-is com- mon to all four. Tolerance .ind withdrawal phenomena are regularly observed (physical dependence). Finally, each drug has been used in medicine as a therapeutic agent. It is well known that man y people have recovered from nicotine addiction without formal treatment. Tobacco in- dustry spokespersons are particularly intrigued by this phe- nomenon, as though it suggests that nicotine does not cause addiction. However, so-call:;d spontaneous remission is not unique to nicotine; it is also seen with other addictive di- seases, including those related to alcohol and heroin. The 1988 report reviews many factors which are important moti- vators for spontaneous remission in all three conditions. These include health proble:ns, social sanctions, significant others, financial problems, :>ignificant accidents, manage- ment of cravings, positive r;inforcement for quitting, internal psychic changes and chang;s in lifestyle. In fact, the resolu- tion of an addiction is seldom (if ever) a random event, stim- ulated merely by the freely oxercised choice of the individual involved. Nicotine addiction, alcoholism and psychiatric illness There is a significant overlap between alcoholism and nicotine addiction. While less than 30 percent of the adult population smokes, around 30 percent of those presenting for treatment of alcoholism are also addicted to nicotine. Similar patterns are well kntlwn for other drug dependencies among both adults and adol;scents. Patients in psychiatric hospitals and clinics also have high rates of nicotine addic- tion. Traditionally, there has been a profound reluctance on the part of clinicians to interfere with nicotine addiction in these settings: quitting has often been discouraged by those in authority. However, this approach lacks empirical support, and many experts question ihe special status nicotine addic- tion enjoys in these settings The growing popularity of smoke-free hospitals, the inc;reasing recognition that nicotine addiction shares much in common with other addictive dis- orders, and, especially, the :;normous risk of morbid compli- cations from smoking are bringing these issues into focus for both the mental health and the addiction treatment communi- ties. Federal policy initiatives might help foster changes which will lead to nicotine addiction being treated as a primary problem in these patient groups. Product liability Tobacco product liability suits have been brought in recent years by individuals who have developed major complica- tions from smoking such as lung cancer. Litigation has a number of benefits for the overall effort to control the nicotine addiction epidemic. Liability suits typically claim that the plaintiff was addicted to tobacco, usually becoming addicted before the age of consent and before the legal age of sale. Although the plaintiff accepts some responsibility for smoking, the claim is that this responsibility should be shared with the tobacco company because of nicotine addiction, the inherently dangerous char- acteristics of the product and the company's behavior. The grounds available for pursuing these suits have been limited in many jurisdictions by court opinions that the Federal Cigarette Labeling Law pre-empts tort actions against ciga- rette companies. While this issue may yet be resolved by the judiciary, a clarification of the law by Congress-as has been done for smokeless tobacco-would facilitate the pursuit of these actions. Need for Action Nicotine addiction is the cause of the greatest epidemic of disease in this century. Its complications resulted in 390,000 deaths in 1985 alone. The disease is both preventable and treatable, and the federal government has many opportuni- ties to control this deadly disease. Summary of Workgroup Discussion Nicotine causes an addictive disease in a high proportion of users. The disease typically beings in childhood or adoles- cence and continues through a large proportion of adult life. Personal, social and cultural factors act in conjunction with nicotine to produce the disease. Recovery is possible at any age or stage of the condition, and although a minority need specific clinical treatment, most can learn to not smoke with only general support from society. Because treatment ser- vices are not now available for the 40-million plus smokers who may want them, a major challenge facing public health is how to provide no-smoking support and how to minimize influences which encourage and sustain the addiction. There are many opportunities for prevention and treatment of nicotine addiction. The 1988 Surgeon General's report has brought the fact of nicotine addiction into clear focus for policy makers for the first time. It is now time to explore the policy implications of nicotine dependence being an addictive disease. Tobacco Use in America Conference 9 TIlVI~i 295322

Tobacco Use in America Conference • January 27-28, 1989 Recommendations 1. Nicotine leads to more deaths than any other addictive drug in our country. Adi itionally, it is implicated in the development of other drug dependencies, it contributes to the severity of other : ddictions and it is often a com- plicating factor in treatin 3 these conditions. Therefore, legislation should ensure that all programs for the pre- vention and treatment oi alcohol and other drug depen- dencies should address nicotine as well. 2. Preventing nicotine addit:tion is critical because the ad- diction which develops can be so strong. Prevention programs need to begin at the preschool age and should include educatior about the dangers of drug ad- dictions in general and :,fhat these conditions are. Op- portunities to begin the :;ducation exist in programs which target young children and pregnant women, such as the Special Supplemental Food Program for Women, Infants and Children (WI1j), AID to Families with Depen- dent Children and Head :3tart. 3. Because nicotine is such a highly addictive drug, aggres- sive efforts to counter-market tobacco products are needed to help shift the momenium which initiates and sus- tains this disease. 4. Tobacco use and nicotine addiction are not a matter of free choice. Therefore, warning labels on tobacco prod- ucts should not be cons :rued as protecting tobacco manufacturers from procluct liability. Legislation which establishes labeling requirements for tobacco products should specify this. 5. Tobacco product manuf.[cturers' stated intent for their products is to provide tobacco taste, pleasure and satisfaction. Pleasure and satisfaction are actually ac- complished by producinii changes in the structure and function of the body, intluding increasing nicotine receptors, modulating m:urochemicals and activating nicotinic receptors. Therefore, new legislation should affirm FDA's authority tc regulate existing tobacco products. 6. New nicotine delivery sy3tems should be evaluated by the FDA for toxicity and addictive potential. 7. Because the addiction to tobacco is the greatest public health problem facing orir nation, a portion of revenues from increased excise taxes on tobacco products should be devoted to co antermarketing, public health promotion and research efforts to prevent and treat tobacco use. The use of tax money for anti-tobacco efforts should be clearly stated on package labels. In addition, increases in ex,,ise taxes on tobacco products are themselves an important part of a comprehensive program to control tobarco use: such taxes are known to reduce use, especiall;, among the young. The same phenomenon is observed when the "cost" of heroin or cocaine is manipulated experimentally. 8. Current levels of funding to reduce tobacco use are in- adequate considering the magnitude of the problem. Therefore, funding should be substantially increased. 9. Studies of the public's level of awareness of the enor- mity of nicotine addiction and its consequences should be conducted serially at the Federal level. 10. Treatment for nicotine addiction should be widely available and reimbursed by insurance carriers, in- cluding Medicare and Medicaid. Standards and guidelines for managing nicotine addiction ought to be developed as have been done for other diseases in- cluding alcoholism and other drug addictions. 11. The training of health professionals such as physi- cians, nurses, psychologists and counselors should specifically include instruction and clinical experience with managing nicotine addiction. 12. Tobacco-free environments enhance efforts of those who have stopped using tobacco to remain abstinent, encourage currerit users to consider quitting and help discourage the young from beginning to experiment with nicotine. Further, tobacco-free schools, work- places, healthcare institutions and other facilities also help prevent health problems caused by tobacco smoke pollution. 13. The behavioral and physiological processes of addic- tion begin with the first dose of nicotine, and the easy availability of tobacco products encourages use and promotes relapse to nicotine addiction. Therefore, ac- cess to nicotine delivery systems should be limited to those age 21 or over, free sampling of tobacco prod- ucts should be banned and the locations where to- bacco is sold should be sharply limited. 10 7bbacco Use in America Conference TIMN 295323 ~

hbacco Use in America Conference • January 27-28, 1989 Determinants of smoking within each domain by stage Stage Domain Pharmacologic processes and conditioning Onset/development Regular use Cessation Initial psychopharmacologic effects encourage transition from experimental to regular use Cognition and decision- Poor awareness of long- and making short-term health conse- quences and addictive nature of smoking Positive characteristics are attributed to smokers and smoking Personal characteristics arid Inclination toward problem social context behaviors Extraversion Peer and family norms and values support smoking Youth-oriented advertising Numerous conditioned asso- ciations among smoking, environmental events, and pharmacologic effects of nicotine Health consequences are minimized or depersonalized Positive characteristics are attributed to smokers and smoking Stress/negative affect are reduced by nicotine Social acceptability and peer and family norms support continued smoking Cigarette marketing en- courages and legitimizes smoking Withdrawal symptoms and conditioned and reinforcing effects of nicotine en- courage relapse Increased awareness of smoking-related symptoms or illness Perceived benefits of cessation Belief in one's ability to stop Social norms and support for stopping and maintained abstinence Skills for coping with stimuli associated with smoking Economic, educational, and personal resources to minimize stress and main- tain cessation 7bbacco Use in Awerica Conference 11 TIMN 295324

'Ibbacco Use in America Conference • January 27-28, 1989 Federal Regulation of Tobacco Products Introduction In spite of the fact that tobacco products are responsible for more than 300,000 d:aths each year-more deaths than from alcohol or drug abus:;, accidents and suicides combined- tobacco products are the least regulated of all. The reasons for the lack of regulation :are historical, economical, and political-not logical. Tobacco regulations arp, a haphazard patchwork of incom- plete and diminishing control. To date, only the Congress has had any clear authori :y to regulate these products for health and safety purposcs. Attempts by the states in the late 19th century to regulate tobacco and cigarettes have all but disappeared as laws to ban cigarette sales have gradually been repealed. No federal laws have been enacted to take their place. Regulating Comp-ments of Tobacco Products Nicotine The recent Surgeon General's Report, "Nicotine Addic- tion," notes that cigarett:s and other tobacco products that contain nicotine are powerfully addictive. The National In- stitute of Drug Abuse call:, cigarettes the most widespread form of drug abuse in the United States. Yet despite these conclusions, tobacco products and the nicotine in them are out of the control of any ;ederal regulatory agency. The Food and Drug Administration (FDA) regulates nicotine when it is sold as a drug, such as in Nicorette brand gum. This is a prescription druii manufactured by Lakeside Phar- maceuticals and is a drug therapy to help people quit the nicotine habit. To sell thiF product, Lakeside must adhere to all the regulatory standards required for new drugs, including the manufacturing, labelhig, distribution, sale, and advertis- ing requirements established under the Food, Drug and Cosmetic Act (FDCA). Prepared by: Scott D. Ballin Vice President, Public Affairs American Heart Association Additives Today's tobacco products are not the tobacco products of the past. They contain hundreds, if not thousands, of chem- ical additives used as flavors and fillers. No federal agency has any authority to require that these additives be disclosed or even removed if found to be harmful. Many of the addi- tives used in tobacco products are suspected of being car- cinogens or cocarcinogens. The FDA requires that food prod- ucts list and ensure the safety of additives. In fact, the Delaney clause of the FDCA requires FDA to remove any ad- ditive from the market found to induce cancer. It seems ironic that for cigarettes, which cause an estimated 80,000 lung cancer deaths each year, the FDA is powerless to im- pose the same authority. The 1984 Surgeon General's report sums up the problem of additives as follows: A characterization of the chemical composition and adverse biologic potential of these additives is urgently required, but is currently impossible. . .. With this lack of basic information and the usually prolonged latent period before manifestation of adverse effect of smok- ing, it is likely that a long time period will elapse before we know the hazards of the new cigarettes. Testing and labeling of tobacco products for tar, nicotine, carbon monoxide and other constituents Until 1988, the Federal Trade Commission (FTC) tested cigarettes for amounts of tar, nicotine, and carbon monox- ide. But now the FTC laboratory is closed, and all testing is the responsibility of the tobacco industry. While the FTC tested the cigarettes, the tobacco industry used the results for its own economic advantage in selling cigarettes. Cigarette manufacturers embarked on the so- called "tar wars," with each company trying to outdo the other by producing the lowest tar, but best-tasting cigarette ibbacco Use in America Conference 13 TIMN 295325

Tobacco Use in America Conference • January 27-28, 1989 on the market. These marketing strategies (and the use of "federally" determined tar am_ nicotine levels) lull con- sumers of cigarettes into believing that low-tar and low- nicotine cigarettes are safer. But, in addition to the tar and nicotine, tobacco smoke contains an estimated 4,000 constituents. None of these constituents are disclosed to u e public, nor does the Public Health Service have any authority to ensure the safety or reduction of these constituents. The 1983 Surgeon General's report notes: A cigarette considered less harmful for cancer etiology might not reduce the risk of -oronary disease. It appears a formidable task to develop a product that satisfies the smoker and does not increase disease risk exposure to carbon monoxide, cyanide, nitrous oxide or still unknown agents. Interesting enough, as far ba,,k as 1959, Philip Morris was well aware of the problems of potential FDA regulation of its products. An internal Philip Morris document released in a tobacco litigation suit (Plaintiff's exhibit 323) notes "if the food and drug laws were ever ~ pplied to cigarettes certain constituents like arsenic and otier insecticides and certain minor smoke constituents migi t have to be controlled." Again, in 1963, in another iniernal memo (Plaintiff's exhibit 605) the Philip Morris research director notes, "We believe that the next medical attack on cigarettes will be based on the cocarcinogen idea. With hundreds of compounds in smoke this hypothesis will be hard to oontest." In more than 20 years of anti-smoking activity, ihis is an area that is unre- solved and unregulated. Regulating Cigarette _,'-~aies and Promotion Sale of Cigarettes to Minors Although many states have I: ws that restrict the sale of cigarettes to minors (varying from no restrictions to age 21) these statutes are rarely enforc;d. Cigarettes and other to- bacco products are readily obtained from vendors, as free samples, or uncontrolled vendirig machines. There are no federal restrictions on the sale and distribution of cigarettes sold in interstate commerce. B1 cause the use of tobacco products is a national problem, and because almost all cig- arettes and tobacco are market:;d in interstate commerce, federal action to limit the acces3ibility of cigarettes to minors may be warranted. Advertising The advertising and marketinq of cigarettes clearly requires federal regulation. Without appropriate federal r~ gulatory control, the tobacco industry will continue to adverti:,e and promote their prod- ucts with one goal-profits at i1he expense of health. 14 Regulating of Tobacco Products Under the Food, Drug and Costmetic Act Expanded Definition of "Drug" In 1906, Congress enacted the first federal food and drug law. The primary purpose of the Act was to ensure safety of products sold as foods and drugs. The Act defined "drug" very narrowly to include only those articles which were listed in the U.S. Homeopathic Pharmacopeia. Tobacco or ciga- rettes were not listed at that time. Since 1906 the authority of the FDA has been expanded to include cosmetics and medical devices as well as food and drugs. 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 only covers the composition of the products, but also their labeling, sale, distribution, advertising and promotion. In the 1930s Congress, concerned with an increasing number of ineffective, unsafe and dangerous products and devices appearing on the market, expanded the definition of "drug" under the Act. The Senate Committee Report accom- panying the 1935 Act noted: The definition of "drug" has been expanded to include, first substances and preparations recognized in the Homeo- pathic Pharmacopeia of the United States; second devices intended for use in the cure, mitigation, treatment or prevention of disease; third substances, preparations and devices intended for diagnostic purposes, and fourth such articles other than food and cosmetics intended to affect the structure or function of the body. Such expan- sion of the definition of the term "drug" is essential if the consumer is to be protected against a multiplicity of devices and such preparations as "slenderizers," many of which are worthless at best and some of which are distinctly dangerous to health. Court Tests The expanded definition of "drugs" was applied against cigarettes in three court cases in the 1950s. In two of the cases relevant to FDA jurisdiction, the courts found that con- ventional cigarettes could be "drugs." The question of whether or not the FDA could assert jurisdiction hinged on whether or not the products were being sold as articles in- tended to either mitigate or prevent disease or intended to affect the function or structure of the body. As the court in U.S. v. 46 Cartons Fairfax Cigarettes noted: If claimant's labeling was such that it created in the mind of the public the idea that these cigarettes could be used for the mitigation or prevention of the various named diseases, claimant cannot now be heard to say that it is selling only cigarettes and not drugs... The ultimate impression upon the mind of the reader arises from the sum total of not only what is said, but also all that is 7bbacco Use in America Conference TIMN 295326

T)bacco Use in America Conference • January 27-28, 1989 reasonably implied. If cl aimant wishes to reap the re- ward of such claims let it bear the responsibility as Con- gress has seen fit to impose on it. This was the first time Mat cigarettes were found to be subject to the FDA's jurisdiction because they were not sold "merely for smoking plea.-;ure" but had other intended pur- poses. Because those cigprettes could not meet the statutory and regulatory requirements of the FDCA, they were re- moved from the marketplace. The idea of classifying c'garettes as drugs has been reaf- firmed by the FDA in testiinony before Congress and more recently by the courts. In 1,977, for example, in attempting to further clarify FDA's jurisdiction, Action on Smoking and Health (ASH) and others filed a petition with FDA seeking to classify all cigarettes as drugs under Section 201 (g)(C) as articles "intended to affeci the structure or any function of the body of man or other <<nimals." The premise on which the petition was filed was ihat because all cigarettes contain nicotine "they fall easily and squarely within the broad lan- guage of the act." FDA deiied the petition-a decision up- held in court in 1980-and FDA Commissioner Donald Ken- nedy stated the petitioners had failed to establish an intent on the part of the manufacturer to sell a product which "af- fected the structure or function of the body." Specifically, the Commissioner wrote: Statements by the petitirners and citations in the peti- tion that cigarettes are u3ed by smokers to affect the structure or functions of their bodies are not evidence of such intent by the manu:acturers or vendors as required under provisions of the ; DCA. However, in denying the petition, FDA did not say that cigarettes could not be cla:;sified as drugs under Sec. 201. The FDA merely said that in the case of cigarettes in general, petitioners failed to provide sufficient evidence to establish that manufacturers sell cigarettes with an intention of affect- ing the structure or functio,7 of the body. In 1988 the Coalition on 3moking OR Health (American Cancer Society, American i.ung Association, and the Ameri- can Heart Association) filed a petition with FDA seeking to classify all low-tar and low-nicotine cigarettes as "drugs" under the Act. The Coalition's petition is based on a review of the advertising and marketing strategies of these products by the industry as well as evidence released as a result of the 1988 Cipollone v. Liggett Group Inc. liability case. It con- cludes there is a clear indication that the tobacco industry has marketed these products with the clear intention that by using low-tar and low-nicot ne products a smoker can "miti- gate" or "prevent" diseas~is associated with the smoking habit. A series of advertisements run by Vantage brand cig- arettes such as this one in rime on January 8, 1973, blatant- ly indicated this intended purpose: For years, a lot of people have been telling the smoking public not to smoke cigarettes, especially cigarettes with high 'tar' and nicotine. . .. Since the cigarette critics are concerned about high 'tar' and nicotine, we would like to offer a constructive proposal. Perhaps, instead of tell- ing us not to smoke cigarettes, they can tell us what to smoke. For instance, perhaps they ought to recommend that the American public smoke Vantage cigarettes ... Vantage gives the smoker flavor like a full-flavor ciga- rette. But it's the only cigarette that gives him so much flavor with so little 'tar' and nicotine. ... This petition is pending at the FDA. Also in 1988, the American Medical Association and the Coalition on Smoking OR Health filed separate petitions seek- ing to classify the newly developed R. J. Reynold's cigarette- like device Premier as as drug under the FDCA. The arguments asking FDA to assert jurisdiction are based on a premise similar to the low tar and nicotine petition: that R. J. Reynolds is calling its new product "cleaner," one which "reduces the controversial compounds" and selling it as "safer," that is, designed to mitigate and prevent disease and to affect func- tions or structures of the body. Defining when FDA can-or cannot-assert jurisdiction over cigarette-like products was further clarified in February, 1987. A manufacturer wanted to market a non-tobacco "cigarette-like device consisting of a plug impregnated with nicotine solution inserted with a small tube-corresponding in appearance to a conventional cigarette." FDA had no dif- ficulty in classifying the product as a "drug." After review- ing promotional material as well as registration material filed with the Securities and Exchange Commission (SEC), the FDA reached the following conclusion: It is our position that Favor is a nicotine delivering sys- tem intended to satisfy a nicotine dependence and to af- fect the structure or one or more functions of the body. While tobacco products can be deemed drugs under the FDCA where their marketing and sale meet the definitions under the Act, it remains unclear where FDA will draw the line in asserting its jurisdiction. Masterpiece Tobacs is another case of FDA asserting jurisdiction over a product containing tobacco. The product was being sold in the form of a chewing gum. The manufac- turer argued that because the product contained tobacco it was outside the FDA's jurisdiction. The FDA disagreed and ruled that the product was a "food" under the FDCA because that definition included "chewing gum." Because tobacco is a dangerous, unapproved substance for use in foods, the FDA ruled that the product was adulterated and could not be marketed for health and safety reasons. 7bbacco Use in Anzerica ['or;fereuce 15 T~`~ '95311

Tobacco Use in America Conference • January 27-28, 1989 Regulation of Tobaci--o Products Under Other Health and Saf ~ty Laws Attempts to regulate tobaccD and tobacco products under other federal health and safeby statutes have not fared well. Of laws enacted since 1964 to regulate a variety of consumer products, the tobacco industp/ has been successful in having tobacco and tobacco products specifically exempted under:  The Consumer Product Safety Act  The Fair Labeling and Pa;kaging Act  The Federal Hazardous S abstances Act  The Controlled Substanc:.s Act  The Toxic Substances Act The Consumer Product Safety Act governs the safety of a large array of consumer prodi:cts, but tobacco products are excluded. The Toxic Substanc:; Act was enacted to ensure that authority existed to "regulate chemical substances and mixtures which present unreasonable risk of impairing health," but tobacco products are excluded. Despite its harmful ef- fects on health and its addictir g qualities, tobacco is exclud- ed from the Controlled Substances Act. Despite Congress's desire to ensure that consumers are fully and adequately in- formed about the products they use, tobacco products are excluded from the Fair Labeling and Packaging Act. One could reasonably argue that tobacco products would undoubtedly have been strictly regulated or even banned under these Acts if Congress r ad not provided the statutory exemptions. New Regulatory and I.egislative Options Tobacco products are dangerous and addictive. It is only rational that at a minimum tob icco products be regulated in a manner similar to how other dangerous consumer products are regulated. Past attempts tc bring tobacco under the juris- diction of one or more of the fnderal health and safety agen- cies have failed. In recent year3, however, new efforts to regulate tobacco have enjoyed increasing support inside and outside of Congress. To develop strategies for regulating tobacco it is necessary to consider first, the use of existing law, and second, legisla- tive proposals that specify and designate an agency as re- sponsible for regulating tobacc ~ products. Existing Law Over the years, Congress ha:> effectively ruled out using major health and safety statutes to regulate tobacco prod- ucts. The one narrow exception is with the FDA which has the authority to regulate: articles intended for use in ii e diagnosis, cure, mitiga- tion, treatment, or preventiori of disease in man or other animals, and articles (other tian food) intended to affect the structure or any function of the body of man or other animals. 16 Applying these statutory provisions to tobacco products is only feasible when health claims are made, either directly or implied. Even then, if FDA fails to take any independent ac- tion, it is incumbent upon the private sector to initiate action through petitions. While it may have a positive outcome, the petitioning process-as is evident by FDA's failure to act on the RJR Premier cigarette and on low tar and nicotine ciga- rettes-can be long and tedious and may have to be resolved in the courts. But in the absence of clear-cut statutory au- thority to regulate tobacco for health and safety purposes, filing petitions asking FDA to apply its well-established regulatory muscle is one of the few available options. In spite of obstacles, petitioning and demanding that the agency continue to define when it will and when it won't take jurisdiction over tobacco products is important to do. Each time a petition is considered, the public and Congress are reminded that while tobacco products remain the major pre- ventable cause of death and disability, they also are the least regulated products. Legislative Action to Regulate Tobacco Products The Congress and the public are becoming increasingly aware that unlike other consumer products, no federal regu- latory agency has any health and safety jurisdiction over tobacco products except in narrow exceptions outlined above. During the 100th Congress numerous bills were introduced that would for the first time give a specific federal regulatory agency power over tobacco. H.R. 2376 was introduced by Rep. Jim Bates (D., Cal.) to remove the statutory exemptions for tobacco and tobacco products from the Consumer Product Safety Act. The total regulatory ramifications of this approach are not clear, but at the extreme, could result in the product being banned. While logical, this approach may not be feasible at this time. In September 1987, Rep. Bob Whittaker (R., Kan.) intro- duced legislation that would specifically give the FDA juris- diction over all tobacco products. Because incorporating tobacco products under the definition of "food" or "drugs" could result in a total ban, the bill establishes a separate chapter of "Tobacco Products" under the FDCA. Thus, the product remains legal, but regulated. The bill is comprehen- sive in its scope giving FDA specific authority to regulate the manufacture, distribution, sale, labeling, testing of chemical additives such as tar, nicotine and carbon monoxide and pro- motional activities. The debate over whether Premier should be declared a drug under the FDCA has drawn attention to the fact that tobacco products have escaped regulation, because of statu- tory and other legal loopholes. In discussing FDA's failure to act quickly against R. J. Reynold's Premier product, the Chairman of the House Subcommittee on Health and the En- vironment recently stated, "failure to act decisively will only 7bbacco Use in America Conference 'TIMN 295328

Tobacco Use in America Conference • January 27-28, 1989 encourage the tobacco i idustry to exploit and widen loopholes in the federal aw, thereby reversing the gains we have made." In mid-1988, Rep. Thon-as Luken (D., Ohio) introduced H.R. 5113. That legislatior would ban all tobacco advertis- ing; regulate the sale of cii iarettes, except as over-the-counter products and where a sign has been posted stating that sale to minors is strictly prohibited; require that the Federal Trade Commission undertake responsibility for studying consti- tuents of tobacco smoke and report to the Congress; allow for state actions to be brought against cigarette manufac- turers; and require that ci( arette packages carry warning labels stating that tobacco is addictive. Both the Whittaker and Luken bills attempt to accomplish similar objectives using diiferent federal regulatory agencies, the FDA and the FTC. It is important to note that these two members sit on committe:!s and subcommittees that will ultimately make the decision about how tobacco is regulated. Rep. Luken chairs the Subcommittee on Transportation, Tourism and Hazardous Materials. Rep. Whittaker is the ranking minority member on that Subcommittee, and also sits on the Subcommittee 3n Health and the Environment as well. Summary of Work-Iroup Discussion Each year more than 300,000 people die as a result of cigarette smoking-an addictive habit which the Surgeon General of the United Stats has called the single most pre- ventable cause of death ai d disability in the United States. If cigarettes and tobaccr products never existed and were developed today, they woi Id be prohibited from being mar- keted on the sole basis of health and safety. Instead, however, we have a product class which remains virtually unregulated, enjoys special statutory exemptions from the very laws designed to protect the public from unsafe con- sumer products, and is adrertised and promoted at a cost of over $2 billion a year. Tobacco products are e;;empt from regulation under such laws as the Consumer Product Safety Act, the Federal Hazar- dous Substance Act, the Toxic Substances Act, and by ad- ministrative and judicial determination from FDCA. FDA ac- knowledges and the court- concur that tobacco products can in fact be regulated by the FDA if a determination is made that cigarettes meet the d: finitional requirements of "drugs" under the FDCA. However, FDA has been reluctant to use its discretionary authorities. The Congress and the public are becoming increasingly aware that, unlike other ccnsumer products, no federal regulatory agency has cle: r-cut jurisdiction over tobacco pro- ducts. During the 100th Congress, numerous bills were in- troduced that would for th;.~ first time give a specific federal regulatory agency jurisdici on over tobacco. Tobacco Use in Arnerica Coi;ference In 1987, Rep. Bob Whittaker introduced legislation that specifically gives the FDA jurisdiction over all tobacco prod- ucts. Because incorporating tobacco products under the defi- nition of "foods" or "drugs" could result in a total ban, the bill established a separate Chapter, "Tobacco Products." Rep. Whittaker's bill adds a meaningful and useful provision to the FDCA to give the FDA specific authority to regulate the manufac- ture, distribution, sale, labeling, testing and disclosure of ad- ditives and other constituents, and promotion of all tobacco products. A number of events have occurred over the past few years that underscore why the regulatory loopholes for tobacco need to be closed. In the spring of 1988, the Surgeon Gen- eral released his report on nicotine addiction. In 1987, the FDA ruled that a non-tobacco, nicotine-containing cigarette called Favor was a drug under the Food Drug and Cosmetic Act. The FDA also ruled that a chewing gum containing to- bacco was an adulterated food product and was therefore prohibited from sale. In 1988, the Coalition On Smoking OR Health and the American Medical Association filed petitions with the FDA to classify R. J. Reynold's smokeless cigarette, Premier, as a drug. A similar petition was filed by the Coali- tion on low-tar, low-nicotine cigarettes. Recommendations 1. A separate chapter should be established under the FDCA to regulate the manufacture, sale, distribution, labeling, advertising, and promotion of tobacco products. 2. Under this chapter, a federal minimum age of sale of tobacco products should be set at 21, with the states given primary enforcement responsibility. However, if the FDA determines that such enforcement is not being carried out, then the Commissioner will have the au- thority to regulate the form, manner, and location of the sale of tobacco products. 3. Under this chapter, all tobacco sampling, distributing of discounted products and couponing would be prohibited. 4. Under this chapter, the FDA would require tha all addi- tives in tobacco products be disclosed to the public and tested for health and safety reasons and that any addit- ives found to be harmful be removed from the marketplace. 5. Under this chapter, the Commissioner will have the authority to require the disclosure of tar, nicotine, car- bon monoxide and other harmful constituents, and the manner and means by which such disclosure is made. 6. Under this chapter, the FDA will have the authority to require any additional labeling for tobacco products, in- cluding the strengthening of existing language on pres- ent warning labels. 7. Under this chapter, all tobacco products will carry an additional label warning consumers of the addictive nature of tobacco and clearly stating that federal law prohibits the sale of tobacco to minors. 17 TIMN 295329

Tobacco Use in America Conference • January 27-28, 1989 8. Under this chapter, the FDA will be given specific au- thority to regulate the advertising and promotion of tobacco products. 9. Under this chapter, ti e FDA will be given authority to regulate other nicotin:;-containing products as drugs. 10. Under this chapter, tf e Commissioner shall report to Congress and the Serretary on any other legislative recommendations that would further reduce the risk to health associated witii the use of tobacco products. 18 Tobacco Use iii Amer•icu Corrfcrencc TIMN 295330

Tobacco Use in America Conference-w-January 27-28, 1989 Cigarette Excise Tax Introduction The harmful effects of smoking are suffered by smokers and nonsmokers alike. I` ot only does smoking cause thou- sands of preventable deaths every year, it costs our economy billions of dollars in lost productivity and healthcare expenses. A cigarette excise tax is one technique to discourage smoking by raising the price of cigarettes. Historically the tax has been successful in ( eterring smoking, but it hasn't kept pace with the cost of living or the actual financial burden smoking imposes on society. Health Conseque nces of Smoking Like all other tobacco-related legislation, the need for a cigarette excise tax can )e traced to the harmful effect cigarette smoking has on the health of the American people. Overall, the total numbei of smoking-related deaths recorded annually is approximatel,i 390,000 persons. But 390,000 deaths is just part of the equation; hundreds of thousands more suffer debilitating diseases caused, or complicated, by smoking. And when we ~;onsider the full extent of diseases, it becomes apparent why we need to pursue legislative ef- forts to discourage smoi;ing. For example, consider cardiovascular disease. According to the American Heart A:;sociation, cardiovascular disease has the deadly distinction of being the number one killer in the United States. In 19€_;5, nearly one million Americans died from cardiovascular disease. Smokers have more fi an twice the risk of heart attack as nonsmokers. Cigarette s-noking is the most important risk factor for sudden cardiac; death, increasing the smoker's risk by two to four times over that of the nonsmoker. A smoker who has a heart attack i:; more likely to die from it and is more likely to die sudden y (within an hour) than a nonsmoker. Cigarette smoking is responsible for 21 percent of deaths Prepared by: David Kendall Legislative Assistant Congressman Michael A. Andrews Mary Crane Legislative Representative American Heart Association from coronary heart disease in the United States among men and is responsible for 40 percent of coronary heart disease deaths. Surgeon General C. Everett Koop states, "Cigarette smok- ing should be considered the most important of the known modifiable risk factors for coronary heart disease in the United States." Similar evidence exists regarding the relationship between cigarette smoking and cancer, the second most frequent cause of death in the United States. According to the Amer- ican Cancer Society, if present trends hold, about 75 million Americans now living will eventually have cancer, or about 30 percent of the population. Over the years, cancer will strike in approximately three of every four families. Cigarette smoking is responsible for 85 percent of lung cancer cases among men and 75 percent among women- about 83 percent overall. Smoking accounts for about 35 percent of all cancer deaths. The American Cancer Society has noted that the higher in- cidence of cancer in men reflects the fact that in the past, more men than women smoked, and smoked more heavily. In recent years, however, the gap between male and female smoking has been narrowing. The unfortunate result is that in 1986 lung cancer surpassed breast cancer as the leading cancer killer among women. Surgeon General Koop states, "There is no single action an individual can take to reduce the risk of cancer more ef- fectively than quitting smoking, particularly cigarettes." In addition, consider the statistics on the relationship be- tween smoking and chronic obstructive lung disease. Citing a National Health Interview Survey, the American Lung Asso- ciation estimates the prevalence of chronic bronchitis and emphysema to be 13.4 million. In 1986, 76,559 deaths were certified as due to Ghronic obstructive pulmonary disease (COPD) and allied conditions, making it the fifth leading Thacr•u L'se in .4mef•tv•a Conference 19

Tobacco Use in America Conference • January 27-28, 1989 cause of death in the United States. According to the 1984 report of the Surgeon Genera , "The Health Consequences of Smoking: Chronic Obstructivc Lung Disease," it is estimated that cigarette smoking accounts for 80 to 90 percent of COPD lung conditions. For this reason Surgeon General Koop states, "Cigarette smoking is the major cause of chronic obstructive lung disease in the United States for both men and women." Cigarette smoking is now iiaplicated in other serious health problems. As reported in the 1989 Surgeon General's report, "Cigarette smoking is now considered to be a probable cause of unsuccessful pregnancies, increased infant mortality and peptic ulcer disease; to be ai -ontributing factor for cancer of the bladder, pancreas and kid ney; and to be associated with cancer of the stomach." Financial Impact of Smoking The most complete analysis of the financial impact of cigarette smoking was compi,_ted by the Office of Technol- ogy Assessment (OTA) in 1983. The analysis, "Smoking- Related Deaths and Financial (,osts," reviewed a series of epidemiologic studies relating smoking to disease and nu- merous estimates of the costc of smoking-related disease. OTA is careful to point out that it was "conservative" in its choice of assumptions, stating, "The estimates presented. .. should. ..be considered minirium estimates." OTA estimates cigarette smoking costs our economy $65 billion annually in healthcare and lost productivity costs. This figure includes:  Smoking-related healthcare costs of $22 billion annu- ally, or approximately six percent of gross national product (GNP). Seventy-five percent of these costs are incurred by those under ihe age of 65.  Annual smoking-related healthcare expenditures by the federal government include $4.2 billion in Medicare and Medicaid payments, $210 million through the Depart- ment of Defense, and $400 million by the Department of Veterans Affairs.  Annual smoking-related lost productivity costs of $43 billion. Lost productivity includes smoking-related absenteeism and disabilit/. In sum, the OTA concluded :hat each pack of cigarettes sold in the United States costs our economy about $2.17. Health Implications o : Increasing the Federal Excise Tax An analysis by University of Michigan economist Kenneth E. Warner published in the Jor.rnal of the American Medical Association in February 1986 concludes that an increase in the federal cigarette excise tax would have the positive effect of discouraging tobacco use. More specifically, Warner ca culates that, "a 16-cent in- crease in the excise tax would encourage almost 3.5 million 20 Americans to forego smoking habits in which they would engage if the tax were to remain at 16 cents per pack. This figure includes more than 800,000 teenagers and almost 2 million young adults aged 20 to 35 years." A cigarette excise tax will also affect the incidence of cigarette smoking among the older adult population, though the impact will be far less dramatic. Because teenagers and young adults are more price sensitive than older persons, the greatest impact of an excise tax increase will be ex- perienced by the former group. A study of the impact of the 1983 increase in the federal cigarette excise tax published in 1987 by Jeffrey E. Harris, MD, PhD in Tax Policy and the Economy, noted, "During 1981-1986, ... the real price of cigarettes increased by 36 percent. Concomitantly, per capita consumption declined by 15 percent." As Harris observes, it is important to remember that the price increases of 1981-1986 were not solely due to an in- crease in the federal cigarette excise tax. Certainly, manufac- turers also increased prices during this time frame. Yet, Har- ris emphasizes, it is equally important to know that during this same time period, cigarette manufacturers' advertising and promotional expenditures rose in real terms by nearly 20 percent. And real disposable personal income rose by 10 percent, yet tobacco consumption still declined. Harris con- cludes, "most of the decline during 1981-1984 could be ex- plained on the basis of price increases alone." The tobacco industry recognizes the impact of increased excise taxes on smoking. An August 1988 article in The Washington Post, "Canada Tries to Clear the Air," reports that a 25-cigarette pack, which cost $1.00 in 1980, now costs $3.00 because of increases in federal and provincial taxes. The taxes range from 82 cents in Alberta to $1.30 in Newfoundland. And, while the price has gone up, Canadian tobacco sales have fallen 23 percent over the past five years. The article continues, and quotes Jacques Lariviere, spokes- man for the Montreal-based Canadian Tobacco Manufac- turers Council, who states, "The single most important fac- tor in all of that has been the very dramatic increase in the retail selling price as a reflection of the equally dramatic in- crease in taxation." History of Federal Cigarette Excise Taxes A federal cigarette excise tax was first imposed during the Civil War. The first tax, imposed in June 1864 at a rate of 8 cents per pack of 20 cigarettes, increased to 10 cents per pack by March 1868. The rate declined, however, and by the turn of the century rested at about one cent per pack. Since World War II, the federal cigarette excise tax has been increased twice. In 1951, the tax was increased from 7 to 8 cents per pack. In 1982, the Tax Equity & Fiscal Re- sponsibility Act (TEFRA) temporarily increased the tax from 8 to 16 cents. Under TEFRA, the tax was scheduled to revert 7bbacco Use in Ame?-ica Co1ference ~~y TIMN 295,

'[bbacco Use in America Conference • January 27-28, 1989 to 8 cents on October 1, 1985. However, the 16 cent ciga- rette excise tax was mad n, permanent by the Consolidated Budget Reconciliation Ac: of 1985 (P.L. 99-272) enacted on April 7, 1986. Interesting y, during the time period in which the cigarette excise tax duubled, the cost of living more than quadrupled. On July 23, 1986, the :ienate Finance Committee voted to increase the cigarette exuise tax by 8 cents (to 24 cents per pack) as part of a budget reconciliation package. However, the House Committee on Ways and Means did not enact a similar proposal and a cioarette excise tax increase was not included in the final version of the 1986 Budget Reconcilia- tion Act. In the 100th Congress, several bills to increase the federal cigarette excise tax were introduced, all of which would have increased the excise tax hy at least 16 cents-raising the tax from the current 16 cents to 32 cents per pack. A proposal to increase the tax by 25 cents per pack was introduced by Representative Michael A Andrews (D., Tex.) in the second session of the 100th Congress. The proposed increase in the federal cigarette excise tax has been opposed by the Coalition Against Regressive Taxa- tion, a group of business interests-including representatives of the tobacco industry-who argue that increasing excise taxes is regressive. Their position is supported by a 1987 Congressional Budget Office (CBO) staff working paper, "The Distributional Effects of an Increase in Selected Federal Ex- cise Taxes," which revie:^fs the distributional effects, among income classes, of a simulated increase in certain federal excise taxes. According to the analys s, "The average increase in taxes as a percentage of total int;ome would be about twice as large (more than three times as large in the case of the tax on beer or tobacco) for families with incomes between $10,000 and $20,000 compared to families with incomes of $50,000 or more." However, as the CBO noted, "Other excise taxes can be seen as compensation for the social costs that society in general ultimately bears bocause of certain activities. For example, the tax on tobac;o products may offset some of the higher medical costs Mat smokers incur. ..." Many persons contend that compared to other tax alterna- tives, an increase in the ci-jarette excise tax is less regres- sive than many other optiuns. For example, a cigarette ex- cise tax increase would adversely affect far fewer individuals than would be affected by an increase in the gasoline excise tax or telephone excise ta=, given the clear necessity of these latter two items in our current economy. Or, since the incidence of cigarette smo<ing is relatively low in the elderly population, an increase in the federal cigarette excise tax would adversely affect far fewer elderly than would a tax on Social Security income or additional catastrophic health in- surance taxes. 7ffbacco Use in America Co);ferexce What seems most important is that an increase in the fed- eral cigarette excise tax will be regressive only among those who smoke. No one socioeconomic, racial, or population group will bear the burden of a cigarette excise tax increase to the exclusion of ether groups. Only those individuals who choose to smoke will incur any additional cost. In addition to the federal tax, state and local governments have enacted cigarette excise taxes. One notable, recent in- crease was in California. In 1988, Californians supported a ballot initiative to increase the state's cigarette excise tax by 25 cents, raising the tax from 10 to 35 cents. The measure was enacted with the support of 58 percent of the voters, despite a multi-million-dollar campaign opposing it. Policy Options Society in general, and Congress and the Administration in particular, have three decisions to make about cigarette ex- cise taxes: 1. Should the federal cigarette excise tax be increased? 2. If so, by how much? 3. Should any of the revenues derived from a cigarette ex- cise tax increase be dedicated? Each of these questions will arise during the upcoming months, and the ramifications of each should be fully con- sidered. Should the federal cigarette excise tax be increased? An increase in the federal cigarette excise tax will cause fewer individuals, particularly teenagers and young people to start smoking. In a nation that is increasingly concerned not only with the health of its citizens but also with spiraling healthcare costs, any action that may deter the single most preventable cause of death, cigarette smoking, should be en- couraged. However there are additional justifications. We know that the federal government is currently expending billions of dol- lars to treat the smoking-related illnesses of its citizens. We further know that doubling of the current federal cigarette ex- cise tax-raising the tax from 16 to 32 cents-will generate an additional $2.9 billion in revenues annually to the federal government according to the Joint Committee on Taxation of the Congress. Considering our nation's staggering federal deficit and the smoking-related health care costs that the federal govemment is now bearing, a cigarette excise tax is justified. One additional justification should also be explored. Mem- bers of Congress and the President are elected to represent the people. When the American people are asked how to reduce the federal deficit, they consistently and overwhelmingly call for increases in federal excise taxes. Consider the following polling data:  In 1984 Americans were asked, "To reduce the size of the deficit, are you willing to see the Government raise 21 TIMN 295333

Zbbacco Use in America Conference •January 27-28, 1989 taxes on tobacco?" Ii creased taxes were supported by 77 percent of respondents according to Time, February 20, 1984.  In 1986 Americans w~ re asked, "Would you favor one of the following reven je hikes or would you rather con- sider some other way to raise money for the govern- ment instead?" Higher taxes on liquor and cigarettes were favored by 81 p,-ircent of respondents according to the Los Angeles Time.>, March 2, 1986.  In 1987 Americans w: re asked, "I am going to mention some things that havc been proposed to help balance the federal budget, and for each, please tell me whether you approve or disapprove of that proposal?" Raising taxes on liquor, beer <<nd cigarettes were approved by 75 percent of respondents according to a Washington Post-ABC News poll, . uly 2, 1987.  In 1988 the Gallup Ortianization polled Americans for their views on the federal budget deficit. Gallup reported, "Given a list of 20 deiicit reduction measures, majori- ties favor only three-all tax hikes... 61 percent sup- port a tax increase on tobacco products."  In a poll conducted immediately after the November 1988 general election, Media General-Associated Press found, "More than 7 in 10... approved of higher ciga- rette and alcoholic beverage taxes," according to the Wall Street Journal, N)vember 28, 1988.  In a report issued shoilly after the November 1988 elec- tion, "Reclaiming the American Dream: Fiscal Policies for a Competitive Nation," the Council on Competitive- ness, comprised of 157 chief executives from business, labor, and higher education, called for an increase in the federal cigarette e;ccise tax upon noting that "the effective tax rates on oigarettes and alcohol have deteriorated significan :ly as a result of inflation." Past political leaders hav.; recognized the efficacy of in- creasing the federal cigaretie excise tax. Former Presidents Gerald Ford and Jimmy Carter endorsed a cigarette excise tax increase in their 1988 report to the 41st president of the United States, "American ^genda." That report states, "In- creases in revenues would reduce the amount of spending cuts necessary to reach budget balance by 1993. If revenues are to be raised, a case can be made for taxing consump- tion, especially increasing eKcise taxes on alcohol and tobac- co to discourage their use. ..." Clearly the American people believe that a federal cigarette excise tax is justified. It is i p to their representatives to act in a manner consistent with the peoples' wishes. If a cigarette excise tax is j! ,stified, how much should it be increased? If the cigarette excise tax is solely a health concern, then the tax should be increased to such level as would make the cost of cigarette smoking p,*ohibitive. Perhaps a $5.00 or 22 $10.00 increase would help achieve this goal. Political reali- ties, however, suggest it is unlikely that such an increase can be enacted. In recent years, attention has focused on doubling the cur- rent federal cigarette excise tax-raising the tax from its cur- rent level of 16 cents to 32 cents. The rationale for this in- crease is that it essentially adjusts the tax for the inflation that has occurred since the 1950s. Beyond doubling the tax, there is also justification for an additional increase, given the smoking-related health care ex- penditures that the federal government must now make. Federal cigarette excise tax increases in excess of 16 cents per pack are currently being discussed. Health considera- tions as well as economic considerations would appear to justify substantially larger increases. Should any of the revenues derived from a cigarette excise tax be dedicated? To date, all revenues received by the government from federal cigarette excise taxes have been dedicated to general revenues of the Treasury. No amounts are reserved in trust funds or set aside for specific programs. Considering the current budget deficit, the need to find new sources of revenue to reduce the deficit, and the poten- tial absence of funds to finance new or continuing programs, dedicating revenues from a cigarette excise tax increase might be justified. Potential dedications of a federal cigarette excise tax include:  Dedicate all new revenues to a trust fund to help reduce the federal deficit. In an excise tax increase proposal, include a provision to roll back the increase once the deficit is eliminated.  Dedicate a portion of any increase to the Medicare and Medicaid trust funds to help reimburse those programs for costs incurred through the treatment of smoking- related illnesses.  Dedicate a portion of an increase to fund the programs of the National Heart, Lung, and Blood Institute, the Na- tional Cancer Society, and the Office of Smoking and Health, all of which are federal entities concerned in part with addressing smoking-related health issues.  Dedicate a portion of any increase to new federal edu- cation and health promotion efforts aimed at those sec- tors of society that have a higher incidence of smoking. In the past, Congress has been hesitant to dedicate any portion of the federal cigarette excise tax. New political realities may, however, make this option far more attractive. Additional Issues Some additional issues cannot be ignored when examining a potential increase in the federal cigarette excise tax, including: 7bbacco Use in America Conference TIMN 295334

`~bbacco Use in America Conference • January 27-28, 1989  Should the tax on tr_bacco products be recomputed as an ad valorem tax, rneaning a percent of the retail price, rather than as an excise tax?  How significantly wi I state revenues be affected by an increase in the fedeial cigarette excise tax?  As the incidence of dgarette smoking continues to de- cline, what impact can be anticipated in terms of a pro- jected loss of corporate revenues from tobacco companies? Summary of Workgroup Discussion The Tobacco Excise Ta_< Workgroup concludes that the overall benefits from an increase in the federal cigarette ex- cise tax outweigh the dis: vantages for the following reasons: 1. It is a policy of the t1.S. government to promote the health of the American people. 2. Cigarette smoking is the single most important prevent- able cause of death and disability in the United States today. Cigarette smiiking accounted for an estimated 390,000 deaths in 1985 alone. Other forms of tobacco use contribute to death and disability in our country. 3. There is a broad corsensus in our society that children should not smoke. This consensus cuts across all socio- economic groups. Aniong high school seniors that smoke, nearly 60 percent report having smoked their first cigarette in eighth gtade. 4. Cigarette price increases and enhanced educational ef- forts are important ways to reduce smoking by children. 5. Cigaretee smoking ir iposes enormous costs on society. The OTA estimates total healthcare costs and loss pro- ductivity to exceed $65 billion annually. This is a mini- mal accounting that (foes not reflect the pain and suffer- ing inflicted on the vctims of smoking-induced diseases and their families. 6. According to the Joint Committee on Taxation a 25 cent increase in Federal cigarette excise would raise $4.4 billion each year and $21.8 billion over five years. 7. The federal cigarette excise tax has been increased only once in 38 years. Cig arette taxes are a shrinking portion of the cost of a pack of cigarettes because cigarette companies have rais:.d and continue to raise the price of their products. 8. Independent public o)inion polls consistently show broad support for an increase in the cigarette excise tax. 9. The health consequences of cigarette smoking are far more regressive than the cigarette excise tax may be. Tobacco Use in America Coi~ference Recommendations 1. An increase in the cigarette excise tax should be en- acted in the 101st Congress. 2. Any increase in federal cigarette excise tax should be accompanied by a similar increase in excise taxes on non-cigarette tobacco products. 3. Increased revenues from a cigarette excise tax could be used to finance education and counter-advertising to discourage children and people at high risk from smoking. 23 TININ 295335

'Ibbacco Use in America Conference a-January 27-28, 1989 Protecting Nonsmokers Introduction According to the Surgem General, as many as 5,000 nonsmokers die each year of diseases caused by inhaling smoke released into the air by tobacco products. With the exception of asbestos, environmental tobacco smoke is responsible for more deaihs than all other known airborne pollutants combined. Stalistics also show that a woman who smokes during pregnancy places the health of her unborn child at risk of premature birth, low birthweight or perinatal death and the Surgeon G:,neral has reported that "involun- tary smoking" can and does cause disease, including lung cancer, serious acute effccts in otherwise healthy adults and severe respiratory problems in young children and infants. While much is known about the adverse health conse- quences of tobacco use by smokers, more recent studies have shown a clear healtf i danger to nonsmokers. As a result, the public policy dabate has also begun to focus on the health and safety risks associated with exposure of nonsmokers to tobacco smoke. The nonsmoker's right to breathe clean air in the workplace, restaurants, public con- veyances and other publit places has resulted in a growing number of legislative initi;tives on the federal, state and local levels. Three major scientific r:ports have examined the link be- tween involuntary smokinil and health problems. The National Academy of Sciences (NAS) 1986 report, "Environmental Tobacco Smoke, Measuring Exposures and Assessing Health Effects," concludes that <<n increased risk of lung cancer due to exposure to environme-ital tobacco smoke (ETS) is biolog- ically plausible. Moreover, children exposed to ETS from parental smoking, show an increased frequency of pul- monary symptoms and respiratory infections. A second NAS report is3ued in August 1986, "The Airliner Cabin Environment-Air Quality and Safety," examined the issue of cigarette smokin!i aboard airplanes. This report rec- ommends that smoking b~; banned on all domestic com- Prepared by: Susan A. Lightfoot Legislative Assistant Rep. Richard Durbin John M. Pinney, Exec. Director Institute for the Study of Smoking Behavior and Policy Harvard University mercial flights to lessen irritation and discomfort to passen- gers and crew, reduce potential health hazards to cabin crew, eliminate the possibility of fires caused by cigarettes and bring the cabin air quality in compliance with established standards for other closed environments. Finally, the 1986 Surgeon General's Report, "The Health Consequences of Involuntary Smoking," concludes that in- voluntary smoking is a cause of disease, including lung cancer, in healthy nonsmokers. This report also states that simply separating smokers and nonsmokers within the same air space may reduce, but will not eliminate the exposure of nonsmokers to environmental tobacco smoke. Actions Taken to Protect Nonsmokers- State and Local Significant actions to protect nonsmokers from environ- mental tobacco smoke have been taken on the state and local levels. These actions are a good indication of the grow- ing public sentiment toward protecting the health and safety of nonsmokers. According to the October 1988 Tobacco-Free America report, "State Legislated Actions on Tobacco Issues": Forty-two states and the District of Columbia restrict smoking in some manner in public places. These laws range from simple, limited prohibitions, such as no smoking on a school bus while the bus is in operation (South Carolina), to comprehensive clean indoor air laws that limit or ban smoking in virtually all public places, in- cluding elevators, public buildings, health facilities, pub- lic transit, gymnasiums and arenas, retail stores, and educational facilities (Massachusetts). The most exten- sive clean indoor air laws include restaurants and private workplaces (Washington). Of the states that limit or pro- hibit smoking in public places, 25 have comprehensive clean indoor air laws; 31 require restrictions on smoking 7bbacco Use in Amer•iec Conference 25 TINEN 295336

Tobacco Use in America Conference • January 27-28, 1989 in the public workplace, while 14 have extended those limitations to private sector',vorkplaces. Over the past two years, tiere has been a clear and dramatic increase in the nuiinber of cities and counties in the United States that have :;nacted local ordinances to limit smoking in public place-. According to the Tobacco- Free America report, there a,e now nearly 400 city and county smoking control laws. Public opinion polls are also showing an increase in sup- port for smoke-free environme its. For example, a 1986 survey conducted by the American Lung Association, American Cancer Society and American Heart Association found that Americans overwhe mingly favor "no smoking" sections in public places. While the actions taken on the state and local levels to protect nonsmokers have increased, they impose inconsis- tent restrictions and limits. Th._~re are substantial gaps in the protections provided to nonsm )kers in public places. In order to provide all nonsmokin 1 Americans with equal pro- tections, a more comprehensive smoking policy may be necessary. The federal government may play a role in developing such a uniform poli,,y. Federal Legislative ard Regulatory Action In 1987, Congress enacted an amendment offered by Reps. Richard J. Durbin (D., III.) and C. W. (Bill) Young (R., Fla.) and Senator Frank Lauten )erg (D., N.J.), which pro- hibits smoking on commercial aircraft flights of two hours or less (H.R. 2890). The law went into effect on April 23, 1988 and will expire in two years unless extended by Congress; Rep. Durbin has already introduced legislation in the 101st Congress to make the two-hour airline smoking ban perma- nent (H.R. 160). Since the ban went into effect, the Federal Aviation Administration has dor:umented only 18 enforce- ment actions against individuai:; violating the ban. The law also permanently prohibits tamoering with aircraft smoke detectors and authorizes fines of up to $2,000 for violations. Other bills introduced during the 100th Congress also dealt with smoking on airline flights. Reps. Oberstar (D., Minn.), Torricelli (D., N.J.) and Scheuer (D., N.Y.) introduced bills to ban smoking on all domestic commercial flights (H.R. 3377, H.R. 1078 and H.R. 432, respectively). The bills did not receive action but have been reintroduced in the 101st Con- gress as H.R. 598, H.R. 561 ard H.R. 817, respectively. Also in the 100th Congress, Rep. Durbin introduced a bill (H.R. 5394) to ban smoking in all Medicare/Medicaid par- ticipating hospitals, which did rot receive action before adjournment. There has also been regulato 'y action taken recently to protect nonsmokers. In 1986, tie Secretary of Defense in- itiated an "aggressive anti-smoking campaign" throughout the Department of Defense and the Armed Services. The 26 General Services Administration, which controls one-third of all federal office space, issued regulations to increase protec- tion for nonsmokers working in and visiting GSA-controlled buildings. The Secretary of Health and Human Services has taken a leadership role in establishing smoke-free HHS build- ings. Most recently, the Department of Veterans Affairs an- nounced plans to make the acute care sections of all VA hos- pitals and outpatient clinics smoke-free by mid-1989. Policy Questions From a public policy perspective, smoking and involuntary smoking are very different problems. To date, public policy has dealt primarily with smoking. Efforts to address the prob- lems caused by cigarette smoking have focused on providing smokers with information about the dangers of smoking and encouraging them to quit. Parallel efforts work to convince nonsmokers to avoid starting to smoke. But now the debate is broadened to include involuntary smoking. And the public policy response to involuntary smoking has to be very different from the response to smok- ing, because the risks of involuntary smoking result from the actions of others and are not necessarily self-imposed. What then, are the policy questions and policy responses to consider on the issue of involuntary smoking? A 1987 re- port, "The Policy Implications of Involuntary Smoking as a Public Health Risk", propose these questions for debate:  What role should the federal government play in protect- ing nonsmokers?  What level of risk to nonsmokers should be tolerated? Should the policy goal be to totally eliminate exposure to tobacco smoke for those who do not smoke? Or, is it suf- ficient to eliminate exposure for those who receive the greatest exposure or for those who are at special risk?  What can and should be done to protect children when they are in the care of institutions, such as daycare cen- ters, schools and health care facilities?  When should government intervene to protect the health of the nonsmokers and when should the private sector re- solve this issue?  Should smoking be banned in all public places? On all public conveyances? In schools? In hospitals?  What role should existing regulatory mechanisms such as OSHA play, and at what level of government? Are new ap- proaches and new laws needed?  Who should be legally responsible for injuries suffered by nonsmokers from involuntary smoking? It is obvious that the public policy debate must continue to address not only the dangers associated with smoking, but also the health and safety concerns of nonsmokers set forth in reports issued by the Surgeon General and the National 7bbacco Use in America Conference TIMN 295337

lbbacco Use in America Conference • January 27-28, 1989 Academy of Sciences. Sijrgeon General Koop's final state- ment in his report, "The Health Consequences of Involuntary Smoking," provides us with a clear and concise message: "The right of smokers to smoke ends where their behavior affects the health and w®II-being of others." Protection of Nonsmokers-Summary of Workgroup Discussion Involuntary smoking-ihe exposure of nonsmokers to en- vironmental tobacco smcke-is a serious public health and safety problem. The Surt eon General of the United States has determined that involuntary smoking is a cause of disease, including lung cancer in healthy nonsmokers. It is estimated that involuntary smoking causes 2,400 excess lung cancer deaths each year. Environmental tobacco smoke has also been shown to be a signi ficant health risk for infants and children. Finally, recent s;ientific evidence suggests that in- voluntary smoking contributes to substantial morbidity and mortality from heart and ung diseases among nonsmokers. Given the nature and ir agnitude of the risks posed by in- voluntary smoking, the federal government should play a sig- nificant role in protecting nonsmokers, especially in circum- stances and settings whe,e federal funds are expended. There has been signific ant progress at all levels to protect nonsmokers in public places, workplaces and other settings. However, uniform protective policies and regulations need to be adopted more rapidly io help eliminate exposure. There also is a need for increas:;d public education about the health risks of involuntary smoking. Finally, all regulatory, educa- tional and research activities would benefit from more exten- sive and effective coordination at the federal level. Congress can take the lead, for exa Tiple, by imposing restrictions and creating incentives that w II ultimately eliminate smoking in all federally supported or 3ponsored facilities, activities and programs. Recommendation, addition, health and labor organizations should explore joint union-management approaches to protecting nonsmoking workers. 4. Congress should adopt the goal of eliminating smok- ing in all healthcare settings. To hasten achievement of this goal: -The American Hospital Association (AHA) should study the experience of hospitals that have become smoke-free. -The AHA, American Medical Association (AMA), the American Nurses Association, Coalition on Smoking OR Health and other health professional groups should intensify efforts to eliminate smoking in all healthcare facilities. -Congress should enact legislation providing incen- tives through Medicare, Medicaid and other federal grant and payment programs to encourage health- care facilities to eliminate smoking. -Healthcare facilities should be encouraged to pro- vide information and referral to stop-smoking ser- vices for all employees and patients. -The Health Care Financing Administration should be directed to study the cost effectiveness of in-hospi- tal stop-smoking services. 5. Congress should enact legislation to encourage 1. The Congress shoult I adopt the goal of eliminating smoking in all public transportation and transportation terminals. At a minimum, the 101st Congress should make permanent the ban cn smoking on all flights scheduled for two hours or les- and assure that newly constructed airline terminals prw.ide separately ventilated nonsmok- ing areas, if smokinr is allowed. 2. Congress should adcpt the goal of eliminating smoking in all federal facilitiec. At a minimum smoking should , be permitted only to the extent that it does not en- 6. danger life or proper :y or risk impairment of non- smokers' health. 7. 3. Congress should dircct that a study be conducted to identify and assess iiie legislative and regulatory op- tions for protecting nonsmokers in all workplaces. In Tobacco Use in Affzerica Conference elementary and secondary schools to adopt policies that: -Prohibit smoking by students and the sale of tobac- co products on school property or at school-spon- sored functions. -Encourage teachers and staff to be role models by refraining from smoking on school property or at school sponsored functions. -Make stop-smoking information and services avail- able for students. -Require information on tobacco use to be included in all health curricula. -Support joint efforts by organizations of teachers and staff and the AMA, PTA and health profes- sionals and volunteers to encourage smoke-free schools. Congress should enact legislation to require that all Head Start programs be smoke-free. Congress should direct that the Special Supplemental Food Program fo Women, Infants, and Children (WIC) incorporate information on the risks of smoking, invol- untary smoking and how to get stop-smoking help. 27 TINiltil 295338

Zbb.~cco Use in America Conference • January 27-28, 1989 8. Congress should includ; in any day care legislation provisions to encourag:~ such programs to be smoke-free. 9. Health professional and voluntary organizations should make increased efforts to inform and protect groups at high risk of exposure to environmental tobacco smoke. 10. Congress should explor;; ways to require that recipi- ents of federal funds establish policies to protect non- smoking workers and provide assistance to those who wish to quit. 11. Federal legislation on sr ioking should contain appro- priate mechanisms to erisure that existing state or local laws that may be more 3trict and/or more broad are not preempted. 12. Congess should appropr ate funds to support increased research on health and indoor environmental effects of tobacco smoke. 13. Congress should includ~ in the Drug-Free Schools Act a requirement for education on the health and safety risks of smoking and involuntary smoking. Voluntary and professional groups should work with local non- smoking groups to incrcase public education on invol- untary smoking. 14. Congress should encourage development of model state and local laws to protect the nonsmoker in pub- lic and work places. 15. The Secretary of Health and Human Services should direct the existing Interagency Coordinating Committee on Smoking and Health to explore ways to improve coordination of federal r:,~gulatory, research and edu- cational efforts on the p-otection of nonsmokers. I M_ N 29."55 3 3 28 9bbacco Use in America Corkference

'lbbacco Use in America Conference • January 27-28, 1989 Tobacco Marketing and Promotion Introduction What is the significanc: of advertising and promotion of tobacco products in the Lnited States? What impact does advertising and promotior of tobacco products have on who smokes, who quits, how ihe media covers tobacco and health issues, how societv views the use of tobacco prod- ucts, and how the government responds to tobacco and health issues? To fully unlerstand the role of tobacco adver- tising and promotion in tl'e United States, these issues must be examined together, be ;ause the impact is cumulative. Recently, much has be:;n written about tobacco advertis- ing and promotion. The Interagency Committee on Smoking and Health, for example, held three separate full-day sessions to explore the subjects. Kenneth E. Warner, Ph.D., published Selling Smoke: Cigarette Advertising and Public Health, with a superb summary of the background facts and questions raised by tobacco adverti~;ing and promotion. In addition, two days of hearings conducted by the Committee on Energy and Commerce of the United States House of Representa- tives in the summer of 1C86 added close to a thousand pages to the literature. What follows is a brief synopsis of the current data and literl-ture to help stimulate discussion and public policy analysis. Nature, Extent and Effect of Tobacco Advertising and P ,omotion How Much is Spent In 1981 the Federal Trale Commission (FTC) found that cigarettes are the most h~.avily advertised and promoted product in the United Staies. In 1986 the six major cigarette companies spent close to $2.4 billion-or more than $6.5 million a day-on adverticking and promotion. As Professor Warner notes in Selling S,noke: Cigarette Advertising and Public Health, annual exp;;nditures on cigarette advertising and promotion equal almo~st $9.00 for every man, woman and child in this country. Prepared by: Matthew L. Myers Staff Director Coalition on Smoking OR Health John Hollar Legislative Director Congressman Mike Synar Cigarette advertising and promotion expenditures have in- creased substantially over the last decade and continue to grow. In 1970-the year before cigarette ads were banned from television and radio-the tobacco industry spent $361 million on advertising and promotion. By 1979 tobacco in- dustry spending on advertising and promotion exceeded $1 billion for the first time. Only five years later, in 1984, the tobacco industry's annual advertising and promotion budget exceeded $2 billion and only one year later, it jumped again to approximately $2.4 billion. In constant dollars, expendi- tures on the advertising and promotion of cigarettes have in- creased more than fivefold since 1971, when radio and television advertising was banned. For perspective, contrast the tobacco industry's spending on promoting its products, with the $3.5 million annual budget of the entire operation of the Office on Smoking and Health in the Department of Health and Human Services. How Tobacco Advertising and Promotional Expenditures are Spent In 1987 Philip Morris and R.J. Reynolds (RJR) ranked first and fourth, respectively, among American magazine adver- tisers. Among newspaper supplement advertisers, RJR and Philip Morris ranked third and fifth, respectively. The top five outdoor billboard advertisers were all tobacco companies. And, as Philip Morris and other tobacco companies have diversified, their advertising clout has grown considerably. In 1987 the Philip Morris Companies became the leading na- tional advertiser in the United States, ending Procter & Gamble's 24-year reign as the number-one advertiser. Two other trends are noteworthy. First, as Professor Ed- ward Popper testified in his June 4, 1986 presentation to the Interagency Committee on Smoking and Health, the tobacco industry has shifted an ever-increasing proportion of its ad- vertising and promotional dollars into direct promotional ac- tivities. Today, domestic tobaceo companies spend more on promotional activities than on advertising. In 1963, promotional 7bbaceo Use in America Conference 29 TIMN 295340

Tobacco Use in America Conference • January 27-28, 1989 expenditures were less than 10 percent of the total cigarette advertising promotional budget; in 1963 they were more than 52 percent of the budget. This ~,hift in emphasis to promo- tional expenditures has enabled the tobacco companies to target specific populations mor_ precisely. Moreover, the promotions are usually designed to motivate consumer pur- chases by placing tobacco prod icts directly in the hands of the consumer at minimal or no `inancial risk through free sampling and/or "couponing." Tobacco promotion techniques also include sponsoring sporting, cultural and other speoial events. According to Dr. Popper, rock concerts, rodeos, skiing competitions and golf and tennis tournaments deliver he youth market to sponsor- ing tobacco companies, who reinforce their presence by put- ting their brand names on numerous promotional products such as T-shirts and hats. The second recent trend is th:, increased attention paid by tobacco manufacturers to advertising and promotions directed toward blue-collar workers, worrien, minorities and children. Since 1981 Philip Morris has <<nnually published A Guide to Black Organizations filled with ci;iarette advertising featuring black models and distributed it t) black politicians and other black leaders. As columnist Carl T. Rowan noted in 1986, "Wherever blacks are putting oi a convention or other affair of consequence, R.J. Reynolds, Philip Morris, Brown & Wil- liamson and the other companie3 are there, or trying to be, pushing cigarettes. ..." The companies also advertise heav- ily in black magazines and newspapers. Cigarette ads account for mor.; than 12 percent of total ad- vertising in Essence magazine, which calls itself, "the maga- zine for today's black women." 'n January 1987, The New York Times noted that you can Fick up any black publication and the same message is there, "beautiful black models, always enjoying themselves, smoking cigarettes and urging blacks to follow suit." The Time:, further noted that, "On street corners and in many inner cities, attractive young women tempt passers-by with free samples of popular brands or discount coupons." A large share of contemporary cigarette advertising also is directed to women. An article in Advertising Age in 1981 bore the title "Women Top Cig I arget." Another article in the same magazine two years laier was entitled "Marketers Clamor to Offer Lady a Cigarette." In 1985 cigarette adver- tising contributed more than 10 percent of total advertising revenues for the Ladies' Home Jqurnal, McCalls, Redbook, Women's Day, Working Mother, and more than nine percent of the total advertising revenue of BetterHomes and Gardens. Cigarette promotions targeted Co women are not limited to suggestive print advertising. Is u ere a women alive who does not associate Virginia Slims with women's tennis? Con- sidering that the first cigarette ta,geted solely at women was introduced in 1968, and that adv:rtising targeted towards women skyrocketed over the next decade, it is no coincidence 30 that the percentage of teenage girls who smoke nearly doubled from 8.4 percent in 1968 to 15.3 percent in 1979. Tobacco Advertising and Promotion: Market Expansion or Brand Switching? The tobacco industry claims that the $2.4 billion it spends each year is intended only to maintain brand share and that it does not help to attract new smokers, provide encourage- ment to current smokers not to quit, encourage quitters to relapse, or increase smokers' daily consumption. However, the evidence does not support the tobacco industry's claim. Information on whether or not advertising and promotion affect consumption comes from a variety of different sources. First, the tobacco industry annually loses more of its cus- tomers than do the manufacturers of any other product. Since 1964 an average of 1.5 million Americans have quit smoking each year. In addition, cigarettes kill 390,000 smokers each year. Add to these figures the number of smokers who die of other causes, and it can be safely said that the tobacco in- dustry has to attract more than two million new smokers a year just to maintain its market. Since over 90 percent of all new smokers are under the age of 20, this means that some 6,000 children and teenagers have to begin smoking each day in order for the tobacco industry to maintain the status quo. Second, fewer than 10 percent of all smokers switch brands each year. Since there are only six major manufacturers of cigarettes in the United States and two of the manufacturers currently have about 75 percent of the total cigarette market, many, if not most, of those who switch brands change to another brand of the same company. At these rates, the tobacco industry is spending more each year for each person who switches than it makes. Third, advertising campaigns targeted at women preceded and then accompanied the rapid spread of smoking among women. Similarly, recent advertising campaigns on behalf of smokeless tobacco products preceded and then accompanied the rapid increase in the use of smokeless tobacco products by teenagers. Certainly, there was more than one factor that influenced the growth in smoking by women; but the data suggest that the advertising campaign intended to, and suc- ceeded, in exploiting this growth market. Likewise, the num- ber of users of smokeless tobacco had long stagnated prior to a massive marketing effort by the United States Tobacco Company beginning in the early 1980s. Almost immediately, and for no other apparent reason, the use of smokeless tobacco products among teenagers in virtually every region of the country began to increase at an unprecedented pace. Fourth, advertising experts agree that market expansion is a significant objective of advertising for virtually all products, even in mature markets. Emerson Foote, the founderof Foote, Cone & Belding and the former Chairman of the Board of McCann-Erickson, one of the world's largest advertising agencies, once observed, 7bbacco Use in America Cor fereraee . p ky V TilyiN 295341

' bbacco Use in America Conference • January 27-28, 1989 "The cigarette industry has been artfully maintaining that cigarette advertising ha3 nothing to do with total sales. .. This is complete and u:ter nonsense. The industry knows it is nonsense... I am always amused by the sug- gestion that advertisini, a function that has been shown to increase consumpticn of virtually every other product, somehow miraculously fails to work fortobacco products." This view is echoed by Ihe testimony in 1986 of advertising executive Charles Sharp, a former vice president of Ogilvy & Mather, Inc., before the iubcommittee on Health and the En- vironment of the Committee on Energy and Commerce of the U.S. House of Represent.itives. Mr. Sharp stated: "A review of cigarette advertisements reveals that the industry communicate:' their message about smoking in a variety of attention-g;tting, frequently changing for- mats. The ads are rich in thematic imagery and portray the desirability of smo,;ing by associating it with the latest trends in life-styl~,, fashion and entertainment as well as associating smoking with youthful vigor, social, sexual and professional success, intelligence, beauty, sophistication, independence, masculinity and feminin- ity. The ads are filled with exceptionally attractive, healthy-looking, vigorois young people who are both worthy of emulation, free of any concerns relating to health and who are livi ig energetic lives filled with sexual, social and financial success and achievement. "Why is this advertising approach significant? By depict- ing a product as an int,,gral part of a highly desirable life-style and personal image, in addition to current users, an advertiser can attraut individuals who do not currently use that product but who want to emulate that life-style and project a depicted image. Thus, ads which effective- ly associate smoking with the latest trends or ideas or with independence, sophistication, sexual, social or athletic success and happiness will attract smokers and nonsmokers alike who want to be like people in the ads." Fifth, if advertising do: s not increase consumption, why would state tobacco mor opolies advertise in countries where there is no competition? Nonetheless, at one time or an- other, a number of coun ries with state monopolies, such as Austria, Japan, South Kcrea, Thailand and Turkey, have engaged in widespread cigarette advertising. Sixth, there has been a great deal of debate over what can be learned about the rolo of advertising from the internation- al experience of countrie 3 that banned advertising and pro- motion after previously permitting it. While a number of free- market economies have ;;nacted statutory bans on the adver- tising and/or promotion of tobacco, very few have effectively instituted total bans. Even fewer countries have combined those bans and/or restrii tions with a comprehensive smok- ing-related program. NorNay, Finland and, to a lesser degree, 7bbacco Use in Ay7aei•ica Coi~fererzce Sweden, provide the best examples of comprehensive anti- tobacco actions. In each of these countries, restrictions or an all-inclusive ban were accompanied by a variety of other actions, such as an increase in the excise tax on cigarettes, strengthened health warnings and/or increased educational activity. The limitations of these data must be understood. Because multiple anti-tobacco actions accompanied the advertising ban, it is impossible to know the effect of the advertising ban alone; or even of the overall role of advertising and promo- tion in those countries. Nonetheless, the data from these countries show a positive correlation between eliminating advertising and promotion and a declining percentage of young people who smoke. For example, in 1975 Norway banned all advertising of to- bacco products, prohibited the sale of tobacco products to anyone under age 16, required that all packages be labeled with a symbol and health warning and began a vigorous na- tionwide educational campaign. Prior to these actions, per capita consumption of cigarettes in Norway was increasing steadily. The percentage of 13, 14 and 15 year-olds in Nor- way who smoked also rose steadily from 1963 to 1975. In contrast, in the decade after the advertising ban, per capita cigarette consumption dropped every year except one in Nor- way. Smoking among 14 year-olds, which had been on the increase prior to 1975, dropped from 17 percent to close to 10 percent after the ban took effect. Similarly dramatic de- clines in smoking occurred among 15 year-olds and among both males and females between the ages of 16 and 20 after the ban took effect. The data from Finland and Sweden are consistent with the Norwegian experience. Finally, a number of formal analytical studies have sought to measure the effect of tobacco advertising and promotion. These include regression analysis studies of the statistical relationship between advertising expenditures and cigarette consumption and survey studies of respondents' reaction to cigarette ads and their current and future smoking status. In Selling Smoke, Professor Warner notes that enough studies exist on both sides of the question to permit either side of the argument to appeal to scientific studies to bolster their case. Professor Warner concludes, however, that the more recent studies do tend to support the proposition that adver- tising encourages smoking. Tobacco Marketing and Youth The tobacco industry claims that its advertising has no im- pact on young people and denies any purposeful attempt to recruit young users. However, the industry's claims are con- tradicted by its own actions, including its targeted advertis- ing and promotion and heavy use of image advertising in lo- cations where the ads will be frequently observed by young people. Eight-five to 90 percent of all new smokers start before or during their teenage years. The age at which smoking 31 "UlVIN 295342

Tobacco Use in America Conference • Januar,y 27-28, 1989 starts has declined over the past 25 years so that, now, chil- dren start smoking earlier than ever before, many before they leave the ninth grade. William Meyers reports in hi:, book, The Image Makers, how Philip Morris made Marlbciro the number-one selling cigarette in this country. After interviewing top Philip Morris executives, Meyers found: "When [George] Weisman [a top executive at Philip Morris] assumed responsibility for Marlboro in the late 1950s, the always analytical executive, who wanted to learn more about the tobacco market, felt that a re- search study of American smoking habits was in order. The results of this investigation were fascinating. The one group of consumers tha: cigarette manufacturers had neglected was the impressionable young Emulators. In search of an identity, thes3 post-adolescent kids were just beginning to smoke as a way of declaring their in- dependence from their parents. But until now, marketers hadn't addressed their special needs. Weisman thought that if Marlboro could somehow appeal to them, then maybe the brand could be turned around and made prof- itable." "Jack Landry, a brilliant arlvertising mind at Philip Morris, was given the job of Norking with Leo Burnett to produce commercials that would turn rookie smokers on to Marlboro... At last, it latc'ied onto the concept of a weathered-looking cowboy riding off into the sunset-a perfect symbol of independence and individualistic re- bellion." "The Marlboro Man, as he was called, was an im- mediate hit. Insecure young Aults flocked to the brand because they wanted to be a:; cool and confident as the cowboy-they, too wanted to be tough and free. Flushed with success, Landry expand;d the scope of the ads with the unforgettable line, "'Jome to Marlboro Coun- try." This wasn't an invitation to visit Wyoming or Col- orado; it was a call to Emulaiors to get it together by smoking Marlboros. Landry's cowboy campaigns dem- onstrated the real power of p3ychological advertising. By 1976, the once floundering bi-and had become the best selling cigarette in America, md today it provides Philip Morris with close to four billion dollars a year in revenue." Who smokes Marlboro today':' More than 50 percent of teenage smokers smoke Marlboro. The efforts to attract in- secure developing youngsters obviously worked. Philip Morris knew what it was doing. Research conducted by William J. McCarthy and Ellen Gritz has examined the psychological and social factors which influence some teenagers to smoke. According to Dr. McCarthy, in testi- mony before the Subcommittee on Health and the Environ- ment of the Committee on Energy and Commerce, "The child 32 psychology literature provides strong reason to believe that the unique characteristics of adolescent development magni- fies the effectiveness of some forms of cigarette advertising on these teens." Dr. McCarthy concluded: "To the degree that adolescents consciously tried to reduce the distance between their ideal self image and their own self images, and the scientific literature sup- ports that they do, there is reason to conclude that the personality traits popularly imputed to cigarette smokers in cigarette advertisements are sufficiently alluring to induce adolescents to smoke. "In general, the personality and social variables which distinguish adolescent smokers from nonsmokers-risk taking, inpulsivity-are congruent with the images of in- dependence, strength, maturity, and adventurous behavior portrayed in many cigarette advertisements. "For the typical teenager seeking to make his/her real self correspond more closely to his/her ideal self, the portrayal in cigarette ads of valued aspects of identity such as independence, social and physical attractiveness and confidence cannot fail to make cigarettes appear more attractive to teenagers than they would be without such associated imagery. "The data support the conclusion that smoking is a behavior for which there is 'a period of enhanced vulner- ability' and that smoking onset occurs most often be- tween the ages of twelve and sixteen." In subsequent research, Drs. McCarthy and Gritz found that image-based cigarette ads do, in fact, have this effect. They also found that these image-based ads have the greatest im- pact on those children whose poor performance in school in- creases the distance between their ideal self-image and their current self-image. Dr. McCarthy further found that, "The evidence that advertisers use more image advertising with pictures of actors who appeal to a younger audience is so obvious that we hardly need statistics to describe the difference." Indirect Role of Cigarette Advertising and Promotion Tobacco advertising also appears to have substantial in- direct effects. Studies have shown a relationship between media dependence on tobacco advertising revenue and cov- erage of smoking and health topics. Tobacco sponsorship of organizations and events appears to discourage those organi- zations from speaking out and educating their constituents about smoking and health. Cigarette advertising and promo- tion also seems to affect and/or promote an atmosphere in which tobacco use is legitimate, even wholesome, and cer- tainly acceptable. Cigarette advertising revenue and media coverage ofsrrioking Substantial evidence points to a link between ae magazine or newspaper's dependence on cigarette advertising revenue 7hbacco Use in America Conference TIMN 295343

'Ibbacco Use in America Conference • Januar,y 27-28, 1989 and the extent of its coverage of smoking and health issues. A decade ago, R.C. Smit'ri wrote in the Columbia Journalism Review that "The record cf national magazines that accept cigarette advertising. . . (i:;) dismal." More recently, a numb::r of studies have been done of the coverage of these issues 'n magazines for women. These studies found a significant inverse relationship between a magazine's dependence cn cigarette advertising revenue to coverage of tobacco and iealth related articles. In one study of ten prominent women' 3 magazines, four of the 10 maga- zines carried no anti-smoking articles in the entire 12-year period studied. By contra:;t, two prominent magazines which did not accept cigarette ajvertising ran 11 and five such ar- ticles, respectively, durintl the same period. Other impartial studies iave found a similar relationship. A 1986 survey by the Amercan Council on Science and Health examined a group of 20 riagazines. Of the magazines sur- veyed, four of the five ratsd best in terms of overall cover- age of hazards of smokirna and health did not accept cig- arette advertisements. Aiiiong those who scored the worst in terms of covering the smoking and health issues were Cos- mopolitan, Redbook, Ladles' Home Journal, and Ms., all of which depend heavily on Dbacco advertising. Further, an increasing rumber of examples of censorship by magazines and newsp;ipers have been reported by health writers who have prepared anti-tobacco articles. The censor- ship has been both partia! and complete. In Selling Smoke, Professor Warner reports that Susan Otrie, a physician who writes a health column fo, Cosmopolitan, has stated that smoking is one subject for which the editors often "soften" their drafts. An investigailve reporter for the television show "20/20" reported that a number of years ago, Family Circle asked him to write an article, but told him: "Don't write about cigarettes, it might offend advertisers." Other ex- amples abound. Thus, several noted observers have concluded that tobacco advertising directly and adversely affects the coverage of the tobacco and health issue. The irony is that tobacco advertis- ing and promotion probaLly result in a more substantial in- fringement of free speech than would a ban or limitation on these activities. Individual and Organizatio7al Self-Censorship The impact of tobacco :idvertising and promotional rev- enue sometimes takes amther form. For years the profes- sional women's tennis tour has been sponsored by Virginia Slims. While the health eifects of smoking on women have been the subject of much study and concern during this period, no female tennis star has been willing to speak out. Self-censorship as the recult of a dependence on tobacco sponsorship extends to o her areas. For years the Kool Jazz Festival has been sponsored by the Brown & Williamson Tobacco Corporation. Th: tobacco manufacturers give sub- Tobacco Use in Ameylcc Conference stantial amounts of money to the Congressional Black Caucus, and the United Negro College Fund also receives thousands of dollars in contributions from R.J. Reynolds. The implications are troubling: Are these activities intended to-and are they successful-in causing organizations to take a less active role than they otherwise would in promoting health prevention and reduced smoking among their constit- uents? Cigarette Advertising and the Smoking Environment Professor Warner reports that tobacco advertising and pro- motion may have another effect in influencing our attitudes and behavior regarding its use. Tobacco advertising and pro- motion is ubiquitous. It portrays tobabbo use as an impor- tant part of the American way of life and as an integral part of social, athletic, financial and sexual success. The per- vasiveness-and persuasiveness-of positive tobacco mes- sages create an image that tobacco is, in fact, a legitimate, wholesome and healthy part of everyday life. After all, if tobacco use were so hazardous, would the federal govern- ment really permit it to be portrayed in such a positive light? Current Restrictions and the Need for Further Governmental Action Is additional governmental action necessary to limit the in- fluence of tobacco advertising and promotion, or is a strat- egy that relies upon the status quo and voluntary self- regulation sufficient? Current Legislation and Regulation Which Affects Tobacco Advertising and Promotion What has the federal government done thus far to offset the impact of tobacco advertising and promotion? Are these actions adequate to cope with the issues noted above? In 1964 there were no restrictions on tobacco advertising and promotion and few, if any, governmental efforts to edu- cate the American public about the health hazards of smok- ing. In 1965 Congress rejected a proposal by the FTC to re- quire detailed health warnings on all cigarette advertisements and packages and, instead, required only that all cigarette packages carry the following message: "Caution: Cigarette Smoking May Be Hazardous To Your Health." No warning was required on cigarette print ads. At the same time Con- gress pre-empted the FTC from taking further action for a period of five years. In 1969 the FTC again proposed dramatically strengthening the health warning and expanding its coverage to include ad- vertisements. Congress intervened to weaken and pre-empt the FTC proposal. In 1970 Congress amended the message on cigarette packages to read, "Warning: The Surgeon General Has Determined That Cigarette Smoking Is Danger- ous To Your Health." In 1970 Congress banned cigarette advertisements from' 33 TI1V1N 295344

Tobacco Use in America Conference • January 27-28, 1989 the broadcast media after January 1, 1971, but pre-empted the FTC from imposing any requirements on cigarette print ads for two years. In 1971 the f•-:'C announced its intention to file complaints against the cigarette companies for failing to include a health warning voluntarily in their advertise- ments. Subsequent negotiations aetween the FTC and the six major tobacco manufacturers led to the execution of a con- sent decree by which the companies agreed to include the congressionally mandated packaiie warning in their adver- tisements. The ban on cigarette advertisements in the broadcast media was in part the result of tre tobacco industry's own response to a 1967 decision of tiie Federal Communications Commission (FCC). At that time, the FCC determined that cigarette advertisements on the Lroadcast media involved public issues of a sufficiently controversial nature that they were subject to the Fairness Docirine, and therefore the broadcast media had to provide opponents of tobacco prod- ucts with a free opportunity for c)unter-advertising. By removing cigarette ads from the broadcast media, the re- quirement that the broadcast media provide free time for anti-smoking ads was also removed. Not surprisingly, in the aftermath of the broadcast ban ii e number of anti-smoking ads aired during prime time dropped dramatically. Neither the FTC nor Congress t)ok any further action to limit tobacco advertising or to require tobacco companies to do more to educate the Americar public about the health hazards of smoking. In 1981 the =TC issued a report which found that the then-existing health warning on cigarette ads and packs was inadequate and recommended that Congress take additional action to remedy the situation. In 1984 Con- gress enacted the Comprehensiv, Smoking Education Act, which replaced the single health warning on cigarette ads and packages with the four healu- warnings which now ap- pear. A similar set of warnings was required for smokeless tobacco products by the Comprehensive Smokeless Tobacco Health Education Act of 1986. Congress has otherwise impos.~d no restrictions on or other requirements which directly affect tobacco advertising and promotion. The Food and Dn g Administration (FDA) takes the position that it has no authority over tobacco prod- ucts or their ads as long as the ads make no health claims. The authority of the FTC over tobacco advertising and pro- motion is limited to enforcing the warning label legislation and to carrying out its traditional mandate to prohibit false and/or deceptive advertising. The current power of state and local governments to restrict tobacco advertising and promo- tion has been severely restricted loy a provision included in a 1970 congressional act, which liniits the power of state and local governments to impose additional restrictions on cigarette advertisements. Self-Regulation Voluntary self-regulation has not been successful in limit- ing the abuses of tobacco advertising and promotion. Neither the media nor the tobacco industry have demonstrated by their past acts that they are prepared to eliminate the nega- tive consequences of tobacco advertising and promotion on their own. Voluntary Self-Regulation By The tobacco Industry The tobacco industry has neither developed nor given any indication that it will develop an effective self-regulatory mechanism to limit the harms posed by tobacco advertising and promotion. The few instances of voluntary self-regula- tion on the part of the tobacco industry have been a farce. In 1964 the tobacco industry established its own "Cigarette Advertisers Code." In 1969 and again in 1981, the FTC eval- uated the Code's effectiveness. On both occasions FTC found that the data amply demonstrated the "futility" of relying upon voluntary regulation to achieve any significant changes in the content and meaning of cigarette advertising. Even a cursory comparison of the Cigarette Advertisers Code with current cigarette advertising practices demon- strates that the code serves no useful purpose. Consider the following passages from the so-called code adopted by the industry: 3. Cigarette advertising shall not suggest that smoking is essential to social prominence, distinction, success or sexual attraction, nor shall it picture a person smoking in an exaggerated manner. 5. Cigarette advertising shall not... show any smoker par- ticipating in, or obviously just having participated in, a physical activity requiring stamina or athletic condition- ing beyond that of normal recreation. 7. Persons who engage in sampling shall refuse to give a sample to any person whom they know to be under 21 years of age or who, without reasonable identification to the contrary, appears to be less than 21 years of age. Contrast these standards with the reality of the beautiful models in the Virginia Slims or Capri ads, and the sensuous women, the prosperous and handsome men, the mountain climbers, tennis players, football players and others, who ap- pear in the ads for numerous brands today. It is apparent that the voluntary code serves only one purpose: to relieve the tobacco industry of any real responsibility toward con- sumers. Self Regulation By the Media Few American newspapers on their own have decided not to carry tobacco advertisements because of the health con- sequences of smoking. An investigative report by Morton Mintz of the Washington Post found that in Canada, 34 1bbacco Use in America Conference TIMN 295345

`lbbacco Use in America Conference • January 27-28, 1989 newspapers that account;;d for 20 percent of total weekday circulation had voluntarily stopped taking tobacco advertise- ments. In contrast, Mintz 'ound that newspapers in the United States with a combined U,eekday circulation of only 0.6 per- cent had done so. When questioned on their views about tobacco advertising, some representatives of the American print media state that as long as a product is legal to sell, it is not up to the news media to restrict advertising for that product. However, these same representatives fail to note that newspapers and maga- zines frequently decline alvertising for other legal products for a wide variety of reasons, including the media's own perception of what is in good taste and what is consistent with a particular community's moral and social standards. Thus, many newspapers will not accept advertising for X- rated movies and, until r:-cently, few members of the print media accepted advertisements for items such as condoms. Unfortunately, this same subjective discretion has not re- sulted in any significant lii iits being placed on ads for tobacco products. Public Policy Pro; iosals Given the nature, extent and effect of tobacco advertising and promotion today, and the legislative, regulatory and edu- cational efforts of the government and the private sector to date, the question is: Wha: more, if anything, needs to be done? A number of public polic;~ options have been raised and debated over the last several years, but none enacted into law. These proposals offer :arious solutions. Some call for di- rect restrictions on tobac.,,o advertising and promotion, rang- ing from a ban on all advertising and promotion, to restricting advertisements to tombsione ads, to enacting and enforcing some version of the industry's own advertising and sampling code, to simply expandin 3 and/or strengthening the warnings which appear on tobacco ;idvertisements and packages. Other advertising-related propo:;als, which would not necessarily involve any direct restricilon on tobacco advertising and pro- motion, include expandin ] government-funded educational efforts and counter-advertising. In addition, three other proposals have been seriously de- bated. They include eliminating the tax deduction for tobacco industry expenditures on tobacco advertising and promotion, eliminating the pre-emption of the authority of state govern- ments to restrict advertis ng and promotion, and, finally, en- acting legislation giving the FDA clear authority to regulate tobacco advertising and promotion. Each of these proposal 3 and their pros and cons are briefly discussed below. Proposal Number One: Ban Advertising and Promotion A ban on advertising and promotion would eliminate all advertising of any kind for tobacco products, including all 7bbacco Use in Americr. Confcrence billboards, print ads and utilitarian items, such as T-shirts and hats. It would also prohibit tobacco companies from spon- soring events such as rock concerts under their cigarette brand names. Organizations such as the American Lung Association, the American Heart Association, the American Cancer Society and the American Medical Association have endorsed a ban on advertising and promotion. Legislation to ban all advertising and promotion of tobacco products was first introduced in Congress in 1986 by Rep. Mike Synar (D., Okla.) following the adoption of this proposal by the American Medical Association at its annual meeting in January 1986. Two days of hearings were held before the Subcommittee on Health and the Environment of the Com- mittee on Energy and Commerce on July 18 and August 1, 1986, where testimony was heard from 47 witnesses repre- senting health groups and the tobacco and advertising indus- tries. No further action was taken on the legislation during the 99th Congress. Rep. Synar again introduced an advertising and promotion ban, H.R. 1272, at the beginning of the 100th Congress. Shortly thereafter, Rep. Bob Whittaker (R., Kan.) introduced a similar advertising ban, H.R. 1532, which differed primarily on enforcement provisions. The Subcommittee on Transpor- tation, Tourism, and Hazardous Materials held a hearing on both bills on April 3, 1987. Two additional days of hearings were held on both measures before the Subcommittee on Health and the Environment on July 27 and 28, 1987, at which 32 witnesses testified. No further action was taken on either bill before the 100th Congress adjourned. Pro A tobacco advertising ban could have an impact on long- term consumption by reducing the number of smokers, par- ticularly children and members of other groups which are the subject of the tobacco industry's targeted marketing efforts. A ban would not only eliminate the direct effects of tobacco marketing efforts, such as the lure of seductive advertisements and billboards, but the indirect effects as well, such as the inadequate coverage of the health consequences of smoking by advertising-dependent news media. Recent U.S. Supreme Court decisions support the position that a legislatively mandated ban on tobacco advertising and promotion would probably be upheld as constitutional, if it was based on the government's desire to reduce the number of deaths caused by tobacco usage by reducing the number of smokers. Con Opponents of an advertising ban raise three principal objec- tions: 1) an advertising ban is unconstitutional; 2) a ban would be ineffective in reducing the number of people who smoke; and 3) a ban would lead to bans on other consumer prod- ucts. Each of these arguments is discussed below. 35 TIMN 295346

Tobacco Use in America Conference • January 27-28, 1989 The debate over an advertisinrl ban is made more com- plicated by several interested pa lies. The proposed ban engenders opposition by the media, which have become dependent upon tobacco adverti:,ing dollars and argue that they would be financially hurt by eliminating these revenues. Respected civil liberties organizations, such as the American Civil Liberties Union (ACLU), have expressed First Amend- ment concerns. Further, the proposed ban also engenders opposition by organizations, such as arts organizations, which receive substantial tobacco sponsorship dollars for their activities. Tobacco Industry Argument 1: Constitutionality of an Ad Ban Opponents of an ad ban argue that an advertising ban would violate the First Amendmeit. Many assert-without constitutional authority-the prol_osition that if a product is legal to sell, then it is unconstitu :ional to restrict advertising for that product. Indeed, the Supreme Court expressly re- jected this point of view in Posaaas de Puerto Rico Associates v. Tourism Co. of PuLrto Rico, 106 S. Ct. 1968. In fact, for nearly 200 years the c;ourt held that commercial speech was not entitled to any protection under the United States Constitution. It was not until 1975 that the Court for the first time held that the First Amendment did provide pro- tection to some forms of comme -cial speech. The Court in Central Hudson _G.,!s & Electric Corp. v. Public Service Commission, 447 U.S. 5'`7 (1980), established a four-part test for determining if commercial speech restric- tions are constitutional. This test has subsequently been ap- plied to every case involving commercial speech restrictions. The Court set forth the test, as follows: "[1] At the outset, we must de:ermine whether the expres- sion is protected by the First Amendment. For commercial speech to come within that provision, it at least must con- cern lawful activity and not be rnisleading. [2] Next, we ask whether the asserted gover imental interest is substan- tial. If both inquiries yield positi/e answers, we must deter- mine [3] whether the regulation directly advances the governmental interest asserted, and [4] whether it is not more extensive than is necessai-y to serve that interest." Six years later, in Posadas de Puerto Rico Associates v. Tourism Co. of Puerto Rico, supr, the Court provided clear guidance as to how it would apply the Central Hudson test to a tobacco advertising ban. In Posadas, the Court upheld a Puerto Rico statute which outlawed gambling advertisements aimed at Puerto Ricans. While the gambling advertisements concerned lawful activity and wen! not misleading, the Court found the Central Hudson test to I e satisfied. The Court had "no difficulty in concluding that the Puerto Rican Legislature's interest in the health, safety, and welfare of its citizens con- stituted a 'substantial' governmeii `al interest." 36 The Court found the third part of the test to be met simply because the advertiser chose to litigate the restrictions all the way to the Supreme Court. It noted that the advertiser would not have challenged the restrictions if they were not effective in discouraging gambling by Puerto Rican residents. Finally, the Court found that the restrictions were no more extensive than necessary to advance the governmental in- terest, and thus met the fourth part of the Central Hudson test. The Court held that it was up to the legislature to deter- mine whether the challenged restrictions were more effective than a less restrictive measure, such as a counter-speech requirement. The Court's application of the Central Hudson test to gambling, an activity deemed harmful by the Puerto Rican legislature, provides a clear view as to how a tobacco adver- tising ban would be analyzed. The court specifically consid- ered and rejected the argument that the legislature could not ban advertising for gambling because it involved a legal activity: "It is precisely because the government could have enacted a wholesale prohibition of the underlying con- duct that it is permissible for the government to take the less intrusive step of allowing the conduct, but reducing the demand through restrictions on advertising." There is no doubt that Congress could, if it wishes, consti- tutionally ban the sale of tobacco products. Thus, after Posadas there is little doubt that Congress could also consti- tutionally take the lesser step of banning the advertising that promotes the use of tobacco. Significantly, in its opinion the Court gives a clear signal as to how a tobacco advertising ban would be viewed: Legislative regulation of products or activities deemed harmful, such as cigarettes, alcoholic beverages, and prostitution, has varied from outright prohibition on the one hand to legalization of the product or activity with restriction on stimulation of its demands on the other hand. To rule out the latter, intermediate kind of re- sponse would require more than we find in the First Amendment." (Emphasis added.) Tobacco Industry Argument 2: Effectiveness of a Ban To analyze the constitutionality of commercial speech restrictions, it is also necessary to determine whether the proposed restrictions would be effective, that is to reduce the number of persons engaging in an activity. In Posadas, however, the Court required little or no empirical evidence to establish the effectiveness of the advertising restrictions and instead gave great deference to the judgments of the legisla- ture on the likely effects of its action. In both Central Hudson and Posadas, the Court accepted the logical assumption that advertising promotes consumption, and that restrictions on advertising have the reverse affect. lbbacco Use in America Conference TIMN 295347

Ibbacco Use in America Conference -OJanuary 27-28, 1989 In the case of tobacco, iiowever, proponents of an advertis- ing ban will need to com.vince members of Congress of the likely impact of a ban in order to motivate Congress to act. There are two principal ways to demonstrate the link be- tween tobacco advertisirg and tobacco consumption: first, by examining advertising expenditures and the demographics of smokers; and, second, by analyzing the experiences of foreign countries which have b_a med or limited tobacco advertising. The tobacco industry <<sserts that the purpose of advertis- ing is simply to maintain or increase market shares for in- dividual brands. This noiion is dispelled by a few simple facts about smokers. Apiroximately 390,000 Americans die each year as a result of smoking-related diseases. An average of 2.5 million Americans quit smoking each year. An additional 650,00 smokers die frorri other causes, so the industry must recruit two to 2.5 million new smokers each year simply to maintain its current mar„et. To agree with the industry's market-share argument, one would have to believe that the tobacco industry would blithely accept a rapidly dwindling market of smokers. While the total number of smokers is declining slightly, the decline is less than it would be if no new smokers took up the habit. Since 90 percent uf all new smokers are under the age of 20, the vast majority of new recruits are children and teenagers. Another way to gauge the effectiveness of tobacco adver- tising restrictions is to analyze patterns of smoking in foreign countries which have banned or restricted tobacco advertis- ing. It is important, how:;ver, to recognize the limitations of any comparative analysi:; of foreign advertising and smoking trends. First, data is limi:ed because few countries have established comprehensive advertising bans. Second, in those countries where advertising bans have been enacted, the bans often are not enforced. And, third, simply compar- ing U.S. smoking rates and initiation rates with those in foreign countries does not take into account the many social and cultural variables th: t influence smoking behavior. Nonetheless, it is possible to conclude from the experi- ences of several countrics, particularly in Scandinavia, that advertising bans as part r_f comprehensive tobacco and health programs have helped to reduce smoking rates. In the mid- 1970s, Norway, Sweden and Finland each enacted compre- hensive smoking reduction programs. In Finland and Norway, tobacco advertising and )romotion is completely banned and in Sweden severe restric:ions are placed on tobacco advertis- ing and promotion practims. A decade of experienc:: in these countries reveals that as part of a comprehensive anti-smoking effort, tobacco adver- tising and promotion bans are effective in reducing smoking rates, especially among %roung people. The data include:  In Sweden, smokin(i rates among 16-year-old boys fell from 45 percent in 1974 to 33 percent in 1980. Among 16-year-old girls, si ioking rates fell from 31 percent in 1974 to 21 percent in 1980.  In Norway, two years after enactment of a comprehen- sive advertising and promotion ban, the smoking rate among 14-year-old boys was more than halved, from 19 percent to 8 percent. Critics of the effectiveness of advertising bans cite several other western European countries such as France and Italy whose advertising restrictions are said to have been less ef- fective. However, in both countries the bans go virtually unenforced and tobacco advertising is widespread. Critics also cite several Eastern Bloc nations, such as Poland, Czechoslovakia and Rumania, where cigarette adver- tising has never been permitted, but smoking rates have in- creased. However, as Professor Kenneth Warner points out: "The fact of increasing smoking in countries lacking advertising says nothing about whether advertising in- fluences consumption. It simply indicates that advertis- ing is not the only cause of smoking, a premise that no one would challenge. . .. The appropriate question is how, if at all, the observed growth patterns would have been different if advertising had existed." Tobacco Industry Argument 3: The Slippery Slope Perhaps the favorite argument by opponents of a ban on tobacco advertising is that it will inexorably lead to bans on other consumer products-the "slippery slope." The premise is that if one action is taken, it will set off a chain of events that will inevitably lead to similar actions in situations which are not comparable or in which the action would be undesir- able. The fallacy of this argument is that it presumes no in- tervening events between the favored and disfavored actions and no ability on the part of reasonable decisionmakers to draw rational lines. In reality, one would expect Congress to apply the same scrutiny to any other proposed advertising restrictions as it has to tobacco advertising ban legislation. The proposed ban on tobacco advertising is clearly different from hypothetical bans on advertising sugar, salt, alcohol and fatty foods, which tobacco supporters claim to fear. Tobacco is the only product which is harmful to health when used as intended, and the death toll from tobacco use is qualitatively and quan- titatively different from any other product. Proposal Number Two: Eliminate Advertising Expense Deductions Rep. Pete Stark (D., Cal.) and Sen. Bill Bradley (D., N.J.) in the 100th Congress introduced legislation, H.R. 1563 and S. 466, to deny tobacco companies a tax deduction for ciga- rette advertising expenses. H.R. 1563 was introduced on March 11, 1987 and had 24 cosponsors at the adjournment of the 100th Congress. S. 446 was introduced on February 3, 1987 and had five cosponsors. No hearings or markups were held during the 100th Congress on either bill. Tobacco Use in Anzericx Cor;f'erence 37 'yi, 4N 2TY3.48

Zbbacc) Use in America Conference • January 27-28, 1989 Neither proposal would prohibit tobacco manufacturers from advertising, but both propo 3als would eliminate the manufacturers' privilege of deducting these expenditures from their taxes as tax-deductiblo business expenses. Pro The tobacco industry saves clrse to a billion dollars each year because its huge advertisinil and promotion budgets are tax-deductible. Removing this governmental privilege would substantially increase the cost of advertising and promotion and presumably, reduce tobacco manufacturers' financial in- centive to spend so heavily. This proposal also relieves Amer- ican taxpayers of some of the bi rden of subsidizing the tobacco manufacturers' marketir g efforts. Further, the Supreme Court has made it clear that a com- pany does not have a constitutional right to such a tax de- duction. Con Opponents of this legislation have argued that this approach is an unconstitutional restriction on free speech. The consti- tutional challenge to eliminating :he advertising tax deduction has even less merit than the challenge to an outright adver- tising ban. Congress has broad latitude in establishing classi- fications within the tax code whi.,h confer benefits on some groups that are denied to others As the Court stated in Regan v. Taxation with Represertation of Washington. "This Court has never held that the Court must grant a benefit such as TWR claims here to a p„rson who wishes to exer- cise a constitutional right. . .. Wa again reject the notion that First Amendment rights are som3,how not fully realized un- less they are subsidized by the state." Opponents also argue that certain constitutional problems would be created because this Lgislation distinguishes be- tween tobacco and other product advertisements. But under Central Hudson and Posadas, th; Supreme Court has held that Congress may distinguish batween various forms of commercial speech if its action i'urthers a substantial govern- mental interest. The purpose of these bills is to eliminate the taxpayer subsidy of tobacco marl;eting. While these proposals increase the practical cost of tobacco marketing, they im- pose no additional restrictions c i what may be said in adver- tisements or where they may be placed. These proposals are intended to reduce the total amtunt of advertising, and thus reduce tobacco consumption. In short, a tobacco manufacturer is not constitutionally en- titled to deduct its expenditures on advertising and promotion. Proposal Number Three: Tombstone Advertisin-i "Tombstone advertising" is an alternative to proposals to ban tobacco advertising or eliminate the tax deduction for tobacco advertising expenses. There are a variety of con- figurations of tombstone advertising, but the most common 38 would prohibit the use of models, slogans, scenes or colors in tobacco advertisements or on tobacco packages. Only text would be permitted. Restricting tobacco advertising to tomb- stone advertising could also be tied to strict limits on tobac- co promotions and brand-name sponsorship. Pro Many tobacco advertisements rely on slogans and images. By and large, these ads sell the potential smoker an image which he/she may wish to emulate. Studies demonstrate and advertising experts agree that this form of image advertising is most effective with young people, who are very image- conscious, see tobacco use as one way of being somebody they are not and pay little attention to advertisements that are primarily text oriented. Restricting tobacco advertising to tombstone ads would be an action designed to reduce the ef- fectiveness of tobacco advertising with young people, by eliminating the form of advertising considered most per- suasive with this group. Thematic imagery ads are not just aimed at the young, but also at women and minorities. Strictly prohibiting the use of thematic imagery would dramatically alter tobacco industry marketing towards these groups as well. Restricting tobacco advertising to tombstone advertising rather than enacting an outright ban may be perceived more favorably by those concerned about the First Amendment im- pact of an advertising ban. Tombstone advertising does not restrict what a tobacco manufacturer can say about its prod- ucts in its ads nor does it limit the amount a manufacturer can spend to advertise. Thus, it is less likely to raise free speech concerns. Because limiting tobacco advertising to tombstone adver- tising is a less extensive restriction than an outright ban, this proposal is less likely to be declared unconstitutional than an outright ban. Under Central Hudson, one criterion the Court sets in evaluating the constitutionality of a restriction on commercial speech is whether the restriction is no more ex- tensive than necessary to serve the government's interest. In light of this and the Supreme Court's analysis in Posadas, there is good reason to believe the Court would uphold the constitutionality of either an outright ban or a restriction of tobacco advertising to tombstone advertisements. Con Unless a tombstone advertising policy also restricted pro- motional activities, its effectiveness could be limited. Ciga- rette marketing expenditures have steadily shifted from news- paper and magazine advertisements to promotional activities, such as sponsoring events and providing free samples. In- deed, tobacco company expenditures for promotions now exceed expenditures on advertising. Some experts contend that promotional activities are more important than advertis- ing in influencing smoking behavior. ibbacco Use in America Conference TIMN 295349

Tobacco Use in America Conference • January 27-28, 1989 Proposal Numbe r Four: Enact a Version of Industry Advertising Code The federal governm,,nt could enact legislation modeled after the tobacco industry's voluntary advertising code, but with its most glaring w~ aknesses corrected. Among other things, the Code currently states that it prohibits advertising in publications directed at those under 21 years of age, the use of models under, o.- appearing to be under, 25 years of age, and advertisement3 suggesting that smoking "is_essen- tial to social prominenc;;, distinction, success, or sexual at- traction...." To date, :he tobacco industry has used its Code as a public relatio is gimmick, but has never seriously enforced or abided by iis provisions. Pro The principal advantage of this approach is that it simply codifies and creates an enforcement mechanism for prin- ciples that the tobacco industry itself purports to have adopted. It would be tli ficult for the tobacco industry to claim the new Code represents governmental restrictions on commercial speech, if the Code is based on the industry's own attempt to elimina;e abusive advertising practices. Con Codifying the industry's advertising guidelines, or any other code of conduct, would require Congress to establish relatively amorphous standards that might be difficult to en- force. For instance, wh at is a publication "directed primarily to those under 21 year:; of age"? How does one determine whether an actor appears to be under 25 years of age? Such a code would also likely permit the continued use of some of the marketing methods, such as the Marlboro man, which are most effective with young people. And, as with tombst(ine advertising, enforcing a "volun- tary" code without alsu restricting promotional activities would fail to address one of the principal marketing tech- niques of the tobacco i-idustry. Banning promotional activ- ity would have to be ccupled with code restrictions. Proposal Numb=r Five: Develop a Mechanism to Find and Produce an Effective Ongoi, ig Counter-Advertising Program Counter-advertising i:; often mentioned as an alternative or complement to restrictions on tobacco advertising. But to be effective means discouraging tobacco use. To be effective, counter-advertisement- need to be professionally produced and placed frequently i1 often-seen media. This requires ade- quate funding to purchase advertising space and time on television and radio. The success of the program cannot de- pend on the media's good will in placing these ads for free. Tobacco Use in America Conference Pro Supporters of this approach point to the fact that anti- tobacco counter-ads run in the late 1960s-prepared as a result of applying the Fairness Doctrine to tobacco advertis- ing on television and radio-accompanied a significant decline in tobacco consumption. Studies demonstrate that the counter- ads probably played an important role in reducing tobacco consumption during this period of time. A major advantage of this option is that it involves no restrictions on speech. Thus, it obviates any argument of First Amendment concerns even by the most zealous sup- porters of the tobacco industry and the ACLU. Con The largest obstacle to creating an effective counter- advertising campaign is financing. In the late 1960s, counter- ads were broadcast on television and radio without charge, as required by the FCC. Today, an effective health campaign would require substantial funding to compete s-uccessfully against the $2.4 billion spent annually by the tobacco in- dustry. Given the high federal budget deficit, it would be dif- ficult 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 $300 million, so a relatively small increase dedicated to counter-advertising could provide measurable returns. H.R. 4740, introduced by Rep. Michael Andrews (D., Tex.) in the 100th Congress, would designate 10 percent of a proposed 25-cent excise tax increase to a "smoking cost recovery and education trust fund." This would raise about $400 million for counter-advertising and education. Another funding option is to require that tobacco advertisers provide funds to purchase space for counter-ads on a pro- portional basis to their advertising expenditures. Or, this pro- posal might be combined with the proposal to eliminate the tax deductibility of tobacco marketing expenditures, and earmark a portion of the additional taxes received for counter-advertising. Proposal Number Six: Eliminate the Federal Preemption of State Regulation of Tobacco Advertising The Public Health Cigarette Smoking Act of 1969 prohibits states from enacting requirements or prohibitions based on smoking and health with regard to cigarette advertising or promotion. Repealing this clause would enable states to im- pose additional requirements and restrictions-including bans in appropriate circumstances-on tobacco advertising and marketing which take place wholly within their borders. 39 'I'Iimi 295350

Tobacco Use in America Conference • January 27-28, 1989 Pro States should have the right to protect their own citizens; repealing this limitation would allow states to enact a variety of their own measures to discourage tobacco consumption within their jurisdictions. Con Opponents contend that repealing this provision would give states license to violate manufacturers' First Amendment rights and would create the possi 3ility of 50 different states enacting 50 different sets of rules. Proposal Number Seveii: Enact Improved Warning Lab_Is The current warning labels reqi _ ired on tobacco products and advertisements were established by the 1984 amend- ments to the Federal Cigarette L?Oeling and Advertising Act. They were enacted because of th:; ineffectiveness of the then-existing warning label. Concorns have been raised about the effectiveness of the 1984 wariings as well, including the adequacy of the text of the currer t labels, the visibility of the warnings and the location of the current warnings. Congress could amend the Act to require a different warn- ing label format, content or locatim to help improve the labels' effectiveness on tobacco products and in tobacco ads. Information not now included could be added. For ex- ample, Rep. Jim Slattery (D., Kan.) and Sen. Bill Bradley (D., N.J.) introduced legislation in the 100th Congress to require, respectively, that tobacco producis and advertisements carry a label warning that "Nicotine in cigarettes is an addictive drug" and "Smoking is addictive. Once you start, you may not be able to stop." The Act could also be amended to require a "circle and ar- row" format similar to that requir;d on smokeless tobacco products 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 inprove the frequency with which they are seen. Moreover,th:; health warning on bill- boards should be made more prominent: to be effective, they must be legible from a distance, and at high speeds. Pro Improved health warnings can be enacted without ap- propriating substantial additional f inds and without raising new First Amendment concerns. I hey also can be tailored to fill in specific gaps in consumer knowledge. Finally, the con- cept of a health warning is one leiiislators accept and, there- fore, additional legislation might ba easier to enact than other proposals. 40 Con Questions are raised about the effectiveness of warning labels as a major component of an anti-tobacco effort. What- ever role warning labels may play in a comprehensive tobac- co education program, the increased benefit of strengthening the current warnings is difficult to predict with certainty. Warning labels have not served as an effective counter- force to the massive marketing efforts of the tobacco indus- try. Strengthening warning labels, if done in isolation, is unlikely to alter that situation. In addition, the current warn- ing labels have become an impediment in resolving product liability lawsuits filed as a result of smoking related deaths and injuries of consumers. Simply improving the current warning system would also not alter that situation. Proposal Number Eight: Authorize FDA to Regulate Tobacco Advertising Federal laws and regulations of foods and drugs set very strict standards on how these products may be advertised and promoted. FDA has taken the position that it does not have authority over tobacco or tobacco advertising. Con- gress can remedy this by enacting appropriate legislation. Pro FDA regulations already contain dozens of restrictions on pharmaceutical advertising and promotion. These restrictions have in effect prevented pharmaceutical companies from ad- vertising to consumers on television and radio, billboards and general circulation newspapers and magazines. Since tobacco and its components are more hazardous that many regulated drugs, the regulatory exemption of tobacco prod- ucts is at best inconsistent. By providing the FDA with authority to regulate tobacco advertising, Congress could assure that a strict code is applied and avoid many of the difficulties in formulating new standards for tobacco advertis- ing and promotion. Con Giving the FDA authority to regulate tobacco advertising and promotion will leave the degree of such regulation large- ly at the discretion of the federal agency. Regulation might increase or decrease based on the views of agency person- nel at any given time. Summary of Workgroup Discussion The work group dealt with three key issues. First, to deter- mine whether additional actions to control tobacco advertis- ing and promotion are needed and, if so, what priority this public policy issue should be given in the near future. Sec- ond, to evaluate the available options for controlling tobacco marketing and to determine which are likely to be most ef- fective, which are feasible to enact and what combinations of 7bbacco Use in America Conference TIMN 295351

'lbbacco Use in America Conference • January 27-28, 1989 actions, if any, should be ecommended. Third, to develop strategies to see that policy recommendations are adopted. Findings 1. There is sufficient evidence to conclude that tobacco advertising and promotion- a) Play a role in the decisions by young people to start smoking and make it attractive and socially acceptable to srroke; b) Encourage current smokers to keep smoking and ex-smokers to relapse; c) Adversely affect 'nedia coverage of tobacco-related health issues, as well as coverage of tobacco in- dustry practices which inaccurately distort the rela- tionship between tobacco and disease; and d) Adversely affect :he willingness of individuals and organizations to :;peak out forcefully on tobacco- related issues. 2. More than 90 percent of new smokers are teenagers or younger. Fifty peicent of high school seniors who smoke began by the 8th grade and 25 percent by the sixth grade. 3. Children are the mo-t affected by tobacco advertising and promotion whicii, through models and imagery, associate tobacco u-e with adult behavior, sophistica- tion, masculinity, feinininity, and sexual, social, finan- cial and athletic success, and those which associate tobacco use with sports and other youth-related ac- tivities through direc: adverfising and a wide variety of promotional practice:3. 4. Tobacco use is addictive and the younger one starts, the harder it is to quit. 5. Efforts to discourage tobacco use among children are inhibited by the combined effect of current advertising and promotional prat tices. 6. The recent report of the Surgeon General demonstrates that reductions in thc smoking rate have been smallest among children, young women, minorities and those with fewer years of elucation-the very populations which have been the major targets of tobacco industry marketing efforts in nacent years. 7. More needs to be done to educate children, young women, minorities ard those with fewer years of education about tobai;co, and discourage its use. The techniques used by tiie tobacco industry to entice these populations must be eliminated if we are to succeed. 8. The report of the Surgeon General demonstrates that action is needed now if we are to dramatically reduce smoking among young women, children, minorities and those Americans with fewer years of education. Tobacco Use in America Goi;ference 9. Efforts to attack unacceptably high smoking rates must include increasing educational efforts and eliminating the advertising and promotional practices of the tobacco industry which affect these popula- tions. 10. It is morally repugnant for American tobacco manufac- turers to engage in advertising and promotion prac- tices abroad that are prohibited in the United States. 11. The current warning labels on tobacco products and advertisements fail adequately to convey the dangers of smoking to potential and current smokers. Recommendations 1. Tobacco Health Education, Promotion and Advertising Campaign. Legislation is needed to create a major, federally funded, long-term program of tobacco health promo- tion and advertising. The public service announce- ments of the late 1960s contributed significantly to the large decline in tobacco use in the late 1960s. Virtual- ly all experts agree that a major anti-tobacco promo- tion and advertising campaign is one of the most ef- fective ways to counter the billions of dollars spent by the tobacco industry to promote its products and to enable the public to have a more complete under- standing of the hazards of tobacco use. 2. Tombstone Advertising/Promotion Reform The most effective methods used by the tobacco in- dustry to reach targeted consumers are visual imagery in advertising and positive associations with sports and entertainment. A comprehensive approach to restrict the most effective means of attracting new smokers must include these steps: a) A limit on all remaining tobacco advertising to tombstone advertising, defined as, "No human figure or facsimile thereof, no brand name logo or symbol, and no picture other than the picture of a single package of the tobacco product being adver- tised displayed against a neutral background, shall be used in any tobacco product advertisement, provided that the product package displayed shall be no larger than the actual size of the product package and shall contain no human figure or fac- simile thereof, no brand name logo or symbol and no pictures." The ads should be restricted to black print on white background, with type size and typeface in the ad identical to the size and typeface of the warning label. The tombstone restrictions also apply to all tobacco packages. The text on tobacco packages shall contain and be limited to brand 41 TIMN 295352

Tobac Jo Use in America Conference • January 27-28, 1989 name, ingredients, tar, nicotine and carbon monox- ide levels, corporate name and any other govern- mentally mandated inf)rmation. The FTC has the authority or, if appropriate, the FDA, to restrict ads which are likely to be attractive to children, even if they include only texts. b) A ban on all tobacco-r;lated advertising in locations where sports are perfrrmed. c) The elimination of brand name promotions includ- ing brand name sponst rships, free sampling, "cou- poning," the display oi a brand name in connection with events open to the general public, the place- ment of brand names )r logos on any consumer products, including but not limited to hats and t- shirts, as well as sporis cars and other sporting equipment, and the payment of any money to any other person to engag:; in any practice prohibited by this provision. 3. Improved Warning Labels ,m Tobacco Ads and Packages Current warning labels 'ail to convey in a meaningful way all of the dangers of tobacco use. The following changes should be considered: a) Require warning labels to state that tobacco con- tains nicotine, and to i onvey the addictiveness of tobacco; b) Require the FTC to corduct a study of the size, content, presentation d nd effectiveness of the cur- rent health warnings ol tobacco products. As a result of this study, th:; FTC should recommend changes to increase the effectiveness of warning labels to communicate health information, dis- courage new users and encourage current tobacco users to stop. The FTC's recommendations shall become law unless vetoed by Congress and the President. 4. The right of state and loc<<I governments to regulate purely local advertising ard promotional activities should be clarified through legislation. TIMN 295353 42 7bbacco Use in America,Cokt'erence

' bbacco Use in America Conference • January 27-28, 1989 U.S, Agricultural Polic,y on Tobacco Introduction The federal government's policies on tobacco are inconsis- tent. On one hand, the government acknowledges that tobac- co use is the single most preventable cause of death in the United States, and through the U.S. Public Health Service allocates funds for scientiiic research and public health education. On the other h.-.nd, policies of the U.S. Depart- ment of Agriculture (USDP) assure that federal assistance and tax dollars support th:i growth and use of tobacco products. Legislation should be designed to eliminate the direct or indirect expenditure of any federal funds to support the growth of tobacco. Further, clear policies should be adopted within the USDA to eliminate management activities that en- courage the growth or marketing of tobacco products. As proposals are developed tc revise USDA's current tobacco policies, the economic wel 'are and well-being of the small family tobacco farmer shmild be carefully considered. Tobacco Production Tobacco was an especially important crop in the early history of the United State-. Even though it no longer holds its once significant econorric position, it is still a vital agricultural commodity in tie major producing regions. To- day, tobacco is produced hi 21 states and Puerto Rico. Six states-North Carolina, Ternessee, Kentucky, Virginia, South Carolina and Georgia-acccunt for 91 percent of the $1.9 billion in 1987 farm cash receipts from tobacco. Approx- imately 179,000 farms protluce tobacco, harvesting an estimated 602,000 acres in 1987. 1988/89 U.S. tobacco production is approximately 10 per- cent more than that of 198; , due to additional acreage and higher yields. Although proiluction is up, the 1988/89 tobac- co supply is forecast to decline about eight percent, with decreases in all types of tohacco. Stocks entering the new marketing year are likely to equal 2.85 billion pounds, or 7bbacco Use in Anierica -."onference Prepared by: Fran Du Melle, Director Office of Government Relations American Lung Association about 14 percent less than last year. Approximately 65 per- cent of U.S.-grown tobacco is used for domestic manufac- ture and about 35 percent is exported. The 1988 flue-cured crop is estimated at 780 million pounds, an increase of 13 percent over 1987. Beginning stocks were down 14 percent with the total supply at 2.27 billion pounds, or seven percent less than the previous year. Flue-cured sales began July 26, 1988. By mid-September three-fifths of the anticipated marketings had been sold. Prices remained near last year's higher prices. The 1988 burley crop is expected to be seven percent larger than the small 1987 crop. Because the 1987 crop was small, ending burley stocks are projected to be about 14 per- cent smaller than last year. Tobacco 1965-1988 Year Acreage Harvested Yield/Acre Production Average (1,000s) (Pounds) (Million Ibs) 1965-69 942 1,958 1,845 1970-74 886 2,053 1,819 1975 1,086 2,008 2,182 1976 1,047 2,041 2,137 1977 966 1,982 1,914 1978 964 2,101 2,025 1979 827 1,845 1,527 1980 921 1,940 1,786 1981 977 2,113 2,064 1982 913 2,185 1,994 1983 789 1,811 1,429 1984 792 2,183 1,728 1985 688 2,197 1,512 1986 582 2,001 1,164 1987 587 2,028 1,191 1988* 621 2,101 1,304 *as of September 1, 1988 TIMN 295354 43

Tobacco Use in America Conference • January 27-28, 1989 Tobacco Consumptitin U.S. cigarette output is expected to increase from the 1987 level of 689 billion pieces because of increased ex- ports. During the first seven rionths of 1988 cigarette ex- ports increased 25 percent. However, while output is up, there is a downward trend in J.S. consumption. In fact, because of increased prices aid the changing public attitude towards smoking, U.S. cigare ae consumption may decrease by one and one-half percent, lowering per capita smoking from the 1987 rate of 3,196 c garettes per year. See Table: Cigarettes: U.S. Output, Remtivals, and Consumption, 1979-88 on page 00. The Tobacco Suppor"-Program Significant federal regulatioii of agriculture began in the 1930s. The current tobacco program has its origin in the agricultural Adjustment Act of 1938, which provided for an average support price for eaci type of tobacco. The law made non-recourse government loans available through local cooperative associations to producers whose crops failed to bring a price from a private buyer above the support level. The government then charged interest on the loans while holding the tobacco until it could be sold profitably. Different classes of tobacco each had their own separately adminis- tered, but operationally similar, price support program. In addition to price supports, tobacco supply was also controlled through a national acreage allctment 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 provisions for the intra-county lease and transfer of allotments for flue-r,ured tobacco and the institu- tion of poundage quotas as a t _ uantity restriction mecha- nism. These were the last major changes in tobacco pro- grams until passage of the "No Net Cost" Act of 1982. Costs of the pre-1982 tobaa,o programs were significant. For example, if a local cooperative was unable to sell the tobacco it held as collateral for unpaid loans, the federal government bore all losses. By April 1982, past losses to- taled $57 million in unpaid loar principal. The government's method of charging and computing interest on loans also led to additional losses. Cooperatives were allowed to make loan payments on the principal first rather than on principal and interest. They also were charg,=d below-market rates and the interest was not compounded. By the end of 1981, these loan policies had cost the federal government $591 million in interest losses. Moreover, the administration of the pre-1982 program was an additional cosi: $13.1 million in 1981. Under the threat of legislativ~_~ dissolution of the tobacco program in 1982, Congress pa-~sed the "No Net Cost Tobac- co Program Act." The legislation imposed an assessment on growers for every pound of tobacco marketed with the bor- rowed funds. The money raiser by assessments would reim- burse the government for any fiture financial losses from 44 tobacco loans. In theory, except for administrative costs, the tobacco program was to be run at "no net cost" to the tax- payer. The administrative costs, however, are approximately $15 million annually. In practice, "no net cost" hasn't stopped the red ink. For FY88, cumulative losses of loan principal will reach an esti- mated $505 million. Further, the estimated cumulative loss of loan interest will reach $319 million. The administrative cost of managing the entire price support program will be about $12.4 million in FY88. The cost of other tobacco- related activities of the USDA for FY88 include $0.2 million for development, maintenance, inspection, and grading stan- dards for tobacco at auction markets; $0.8 million for market news reports on auction sales activity; $8.8 million for research and extension on tobacco production and market- ing, and $4.9 million to subsidize producer premiums for all- risk crop insurance. ' The grower assessment under the "no-net cost" legisla- tion was not expected to ever exceed one to two cents per pound since past losses were low. However, loan prices were legislated higher than market prices in the late 1970s and early 1980s, resulting in a large increase in imported tobacco. Further, the statutory limits on marketing quotas could only be reduced so much each year. This allowed pro- duction which continuously exceeded utilization-and the surplus went under government loan. As stocks increased, so did the assessments until they reached 25 cents per pound for flue-cured and 30 cents per pound on burley in 1985. The high assessments, declining market quota, and ac- cumulating surplus tobacco stocks created a crisis for tobac- co growers and the federal tobacco program. In early 1986 Congress enacted legislation as part of the Consolidated Budget Reconciliation Act to lower tobacco loan prices by approximately 26 cents per pound. At the same time, ciga- rette manufacturers agreed to buy over the next five years the surplus tobacco stocks at discount prices of up to 90 percent. The deep discounts on old surplus are expected to generate loan losses of $1 billion for U.S. taxpayers. Ironically, as it operates today, the tobacco support pro- gram benefits least the people it was designed to assist: small family farmers. Instead, the greatest benefits of this program are shared by tobacco allotment holders, 74 percent of whom do not grow tobacco. Allotment holders charge the small family farmer who wants to grow tobacco large sums of money for permission to lease their allotment. About 84 percent of all family farmers rent allotments, a cost that can increase production expenses by 30 percent to 60 percent. The federal price support program also impacts the ability of the American farmer to compete with foreign tobacco. As a result of high American prices created by the price support system, foreign-grown tobacco now comprises 35 percent of all tobacco used by American manufacturers overall and 33 .7bbacco Use in AYner•ica Conference TIMN 295355

' bbacco Use in America Conference i7January 27-28, 1989 percent of all tobacco us;;d by American manufacturers in their cigarettes. In 1969, only nine million pounds of foreign tobacco were imported. :3y 1983, 240,000 metric tons were imported, an increase of 1,900 percent. See table: Estimated U.S. Imports of flue-curel and burley tobacco, and domestic use, 1967-87, on page 01). Congress and the federal government show no movement towards changing their inconsistent policies toward the sup- port of tobacco producticn and marketing. In August 1988, the Drought Assistance Actwas enacted, providing an estimated $3.9 billion in disaster payments for a wide variety of U.S. agricultural commodities, including tobacco, affected by ad- verse weather conditions. Under this act, payments are avail- able to tobacco producer:; if production is reduced more than 35 percent because of drought, hail, excessive moisture, or related conditions. And, t rowers are eligible to receive a pay- ment based on how mucii production falls below 65 percent of the expected level. For flue-cured and burley tobacco, the shortfall is based on the tlifference between production and effective quotas. Deregulation of the Tohacco Support Program As the summary of enu;ted legislation demonstrates, the tobacco program in the U iited States is composed of a few major provisions concerning the production and marketing of a variety of types of tobaco. There are also multiple minor provisions not reviewed. Oeregulating the tobacco support program requires that all ihese provisions be repealed or significantly revised. The policy issue before the public health community should not be whether federal financial assis- tance for the tobacco support program should be ended, but when-and how best to acromplish this task quickly and fairly. There are several optiors to reduce or eliminate the federal government's role-and it .3 expenditures-for regulating the tobacco program. -Immediate Action A. Use the annual budget and appropriations process to phase out these U:3DA expenditures for the tobacco support program: 1. developing and maintaining inspection and grading standaids for tobacco auction markets; 2. publishing mar„et news reports on auction sales; 3. subsidizing producer premiums for all-risk crop insurance. B. Use the annual budget and appropriations process to redirect the USDA tobacco research and development activity towards crop options to replace tobacco. -Long-Term Action A. Phase out budget ;;upport for administration of the "no net cost" prociram. 7bbacco Use in Arner7;ca Conference B. Phase out the price support and supply control/quota provisions for tobacco. Long-term action to phase out or eliminate the federal tobacco program will have several impacts. The direct con- sequences include the loss of income for quota owners from the lease of allotments. However, eliminating costly allot- ment payments will benefit original, intended recipients of tobacco support programs and their heirs, the small family farmers. Many observers speculate that the price of tobacco prod- ucts will fall if federal support is phased out. They predict that lower prices will cause increases in the use of lower quality imports, in the use of all tobacco products, and in overall exports of tobacco products. Since the primary objective of eliminating the federal sup- port program is health related-to reduce consumption of tobacco products-attention should be given to the issue of tobacco use. Reduced costs will not necessarily increase use, because only three cents of the price of a package of cigarettes is the actual cost of tobacco. However, phasing out the tobacco support program should be accompanied by a comprehensive package of proposals to reduce the use of tobacco products. Developing phase-out options should include careful con- sideration of the impact on the small family farmer. The number, size, and organization of tobacco farms is likely to change as a result of the program phase-out. This change, however, is not likely to be more dramatic than that which has occurred over the past 20 years as mechanized harvest- ing, bulk curing, and other technological innovations have made it possible to grow more and more tobacco on a single farm. Any phase-out program should include funding mecha- nisms to facilitate the farmer's transition away from federal support. Summary of Workgroup Discussion Tobacco agricultural interests continue to provide a polit- ical base for opposing strong public health policy responses to the use of tobacco products. It is, perhaps, the expendi- ture of U.S. tax dollars to support the growth of a crop which the Surgeon General has found responsible for 390,000 deaths each year, that has made the tobacco price support program so politically controversial and so vulnerable; The health community believes strongly that all federal government policies related to tobacco must reflect the ob- jective set by Surgeon General C. Everett Koop for a smoke- free society by the year 2000. The federal government can- not, therefore, continue policies and programs that encour- age and promote the growth of tobacco. While it is inappropriate to fund the tobacco price support program through general revenues, the health community finds nothing objectionable about requiring those who manufacture 45 T I M N 2 9 - 53" 5 6

Tobacco Use in America Conference • January 27-28, 1989 or use tobacco products to fund the tobacco price support program through a system of user fees. Such a system also should fund all associated admii istrative expenses. Any effort to reform the tobac,,o price support program must balance the concerns of the health community and the interests of the family tobacco f:irmer. Assistance should be made available to tobacco farmers who, for business or other purposes, elect to stop grriwing tobacco and to begin growing other crops. Such assistance should include direct grants or interest-free loans to c)ver income losses incurred during the transition period from tobacco to another crop and for capital expenditures nec:;ssary throughout the transi- tion period. The user fee mechanism can diminate the health com- munity's concern about using federal revenues to support the growth of tobacco, yet still provide tobacco farmers with a system for funding the tobacco price support program. This approach addresses both the current needs and pro- vides an orderly transition to the growth of other crops. Recommendations 1. ELIMINATE FEDERAL FINAiJCIAL SUPPORT FOR THE GROWTH OF TOBACCO. No federal expenditures should be permitted to pay for, ad ninister or otherwise sup- port the tobacco price support program. Further, no federal funds should be plc iged to guarantee tobacco loans or the sale of tobacco for export. To the extent the program continues to edst, a system of user fees on tobacco manufacturers :>hould be developed to replace federal financial support. 2. FEDERAL FINANCIAL ASSI: ;TANCE SHOULD BE AVAIL- ABLE FOR FARMERS WHO WISH TO STOP GROWING TOBACCO. A federally fund:;d program should be created to provide financial assistance to tobacco farmers who are willing voluntarily to stop growing tobacco. Such an assistance program might be funded from a portion of revenues generated by the federal ex- cise tax on cigarettes. Tobacco allotments owned by farmers who participate in Ihe program would be re- tired, thereby decreasing the overall number of tobacco allotments and the total acreage devoted to the growth of tobacco. TIMN 295357 46 7bbacco. Use in America Conference

'[bbacco Use in America Conference *--January 27-28, 1989 ;,igarettes: U.S. Output, Removals, and Consumption, 1979-1988 Removals Tax-exempt Estimated Total Overseas Inventory U.S. Year Output Taxable Total Exports Shipments' Forces2 Increase Consumption3 Billions 1979 1980 1981 1982 1983 1984 1985 1986 19874 19885 704.4 714.1 736.5 694.2 667.0 668.8 665.3 658.0 -689.4 -705.0 614.0 620.5 638.1 614.1 597.5 597.8 595.0 583.1 577.2 563.0 93.8 94.2 92.0 82.1 69.7 67.1 66.5 74.3 111.3 125.0 79.7 82.0 82.6 73.6 60.7 56.5 58.9 64.3 -100.2 -115.0 1.1 1.1 1.0 1.0 .9 .8 .7 .8 .8 .8 13.0 11.1 8.4 7.5 8.1 9.8 6.9 9.2 10.3 7.2 5.7 2.3 8.0 -10.8 7.2 8.8 9.5 10.9 14.6 9.1 621.5 631.5 640.0 634.0 600.0 600.4 594.0 583.8 -575.0 -567.0 Year Ending June 30 1979 707.0 615.2 92.2 78.8 1.2 12.2 12.1 616.0 1980 697.0 605.8 93.2 82.9 1.0 9.3 -7.2 622.0 1981 727.8 631.4 92.0 83.0 .9 10.1 5.9 637.0 1982 721.5 632.2 86.8 78.8 .8 7.2 5.1 635.7 1983 678.4 603.3 75.3 65.5 .8 9.0 6.2 620.0 1984 661.5 596.6 65.0 56.4 .8 7.8 5.8 600.0 1985 665.4 595.4 66.3 55.8 .8 9.7 8.8 598.0 1986 662.0 589.2 70.3 62.2 .8 6.9 8.8 589.0 19874 667.1 579.4 90.2 78.9 .8 10.5 11.9 580.0 19885 702.8 571.3 122.3 112.1 .8 9.4 10.9 572.0 'To Puerto Rico and other U.S. possessions 2lncludes ship stores and small tax-exempt categories 3Taxable removals, overs.-as forces, inventory change and imports 4Subject to revision 5Estimated Compiled from reports of the Bureau of Alcohol, Tobacco, and Firearms and the Bureau of the Census. Tobacco Use in America Coi;fererace 47 TIMN 295358

Tobacco Use in America Conference • January 27-28, 1989 Estimated U.S. mports of Flue-Cured and Burley Tobacco, and Domestic Use, 1969-1987 (Farm-sales weight) Flue-cured Burley Year Imports' Imports Beginning Domestic Total Share of Domestic Total Share of July 1 Imports' Disappearance Use Total Imports' Disappearance2 Use Total Million pounds Percent Million Pounds Percent 1969 5.7 645.9 651.6 0.9 3.3 507.1 510.4 0.6 1970 10.6 640.1 650.7 1.6 3.2 503.0 506.2 0.6 1971 11.2 662.5 673.7 1.7 4.6 515.2 519.8 0.9 1972 12.7 664.2 676.9 1.9 8.9 543.5 543.5 1.6 1973 20.4 703.4 723.8 2.8 30.7 533.1 563.8 5.4 1974 23.1 652.3 675.4 3.4 47.7 518.8 566.5 8.4 1975 24.4 670.6 695.0 3.5 46.7 510.1 556.8 8.4 1976 30.8 634.0 664.8 4.6 37.9 489.6 527.5 7.2 1977 55.0 608.2 663.2 8.3 85.4 494.8 580.2 14.7 1978 60.1 584.1 644.2 9.3 89.1 502.8 591.9 15.1 1979 84.8 563.1 647.9 13.1 113.6 498.5 612.1 18.6 1980 72.7 529.4 602.1 11.7 136.9 477.6 614.5 22.3 1981 63.3 488.8 552.1 11.5 109.7 463.9 463.9 19.1 1982 103.1 478.5 581.6 17.7 141.3 444.1 585.4 24.1 1983 94.43 441.6 536.0 17.6 135.03 388.7 523.7 25.8 1984 120.13 454.2 574.3 20.9 163.83 402.6 566.4 28.9 1985 151.04 476.5 627.5 24.1 137.84 425.0 562.8 24.5 1986 176.64 479.6 656.2 26.9 120.44 401.7 522.1 23.1 1987 209.74 541.0 750.7 27.9 162.4° 460.05 622.4 26.1 'Imports for consumption (du.y paid) of leaf, scrap, and manufactured or unmanufactured (beginning 1980), prorated according to reported stocks of imported flue-cured and burley. 2Marketing year beginning Ociober 3General imports adjusted for stock change 4Volume inspected by Agriculiural Marketing Service adjusted for stock change 5Estimated 48 7bbaeco Use in Amerr',~a__(7orrference TIMN 295359

Tobacco Use in America Conference • January 27-28, 1989 . The International Marketing of Tobacco Introduction The United States is the world leader in promoting interna- tional health. As a nation we have worked aggressively to eliminate infectious dise.ses, malnutrition and use of addic- tive drugs. We have also made significant progress in im- plementing measures to ,ontrol tobacco use within our own borders, and are in an id„al position to assist other countries in adoption of similar measures. In practice, however, the United States' tobacco trade pol- icy actually encourages tiie proliferation of tobacco use in other countries. Using tha threat of trade sanctions, the U.S. Trade Office helps open i_ip new marketing opportunities overseas for our tobacco companies that are losing business at home. Thanks to our cwn trade policy, U.S. cigarette ex- ports have doubled since 1983, with 100 billion sent to foreign countries last year. In fact, the United States is the world's leading cigarette tixporter. The United States cannDt be Number 1 in world health and Number 1 in cigarette exports. Our own tobacco policy may reverse all the gains we have made in promoting world health. Our own tobacco policy noakes an hypocrisy of our efforts to curb international trade in addictive drugs. As the leader of the fre:; world, the U.S. must adopt a new tobacco policy to prevent the expansion of tobacco market- ing; assure that people, r:;gardless of their country of origin, are adequately warned of the dangers of tobacco use; and encourage the worldwide adoption of measures that will curb tobacco consumption. A iiew tobacco policy will require that new legislation be passed by Congress and new international health programs be imple nented by the Administration. Background Inforination An estimated one billior persons woridwide smoked five trillion cigarettes in 1986, resulting in 2.5 million deaths at- tributed to smoking. By the year 2000, the number of deaths are expected to rise to foi _ r million annually. While smoking Prepared by: Gregory N. Connolly DMD, MPH American Cancer Society Dir., Div. of Dental Health Dir., Office of Non-Smoking and Health Massachusetts Department of Public Health rates are declining in developed nations at a rate of 1.5 per- cent per year, they are rising 2 percent a year in developing countries. According to the World Health Organization (WHO), progress made in curbing deaths from malnutrition and in- fectious diseases in developing nations will be lost to deaths caused by smoking unless tobacco consumption is curbed. There are a number of reasons why smoking is increasing in developing countries. Tobacco production creates agricul- tural and manufacturing jobs and generates substantial tax revenue. As nations progress economically consumers have more disposable income to purchase luxury items such as cigarettes; stresses brought on by urbanization and in- dustrialization may also increase consumer demand for nicotine. And considering the long expoure time needed for smoking-induced diseases to occur, countries have little in- centive to address future health problems caused by tobacco use. The international marketing efforts of the world's six transnational tobacco companies (TTCs) also help create de- mand. These companies produce approximately 40 percent of the world's cigarettes-and up to 85 percent of cigarettes if production by nations with state-owned tobacco monopo- lies and centrally planned economies are excluded. The indus- try is highly concentrated with little real competition occurring between the six. The TTCs effectively control 85 percent of the tobacco leaf sold on the world market and in doing so, indirectly determine the price of the cigarettes. The six act as an oligopoly dividing the world's cigarette markets with the European firms dominating Africa and the United States companies, Latin America. All six are currently expanding their market operations in the newly developed countries and less developed countries of Asia. If the companies are able to gain free access to Asia, they will likely capture large shares of that market. The companies have developed highly effective promotional and advertising programs which very persuasively promote tobacco use in countries where the health risks of smoking are not well Tobacco Use in Arnericr._ Conference 49 TIMN 295360

Tobacco Use in America Conference • January 27-28, 1989 known. The companies have also amassed large amounts of capital from sales at home to u-e in developing new markets overseas. In 1985, in the book, Transnarional Corporations and the International Cigarette Industry: Profile, Progress and Pover- ty, P.L. Shepherd analyzed how the TTCs penetrated the closed cigarette markets of Latiri America in the 1960s and how they eventually acquired tho former state companies. The push into Latin America in the 1960s came in direct response to the decline in United States smoking rates that followed publication of the first :iurgeon General's report on smoking and health. Liberalization, making the cigarette market more competitive, also allowed the TTCs to dominate South America. Smoking rates r)se in response to the in- creased marketing of tobacco ar d the public health suffered. By the early 1980s diseases caused by smoking in Brazil rivaled the magnitude of diseases caused by infectious disease and malnutrition. History is repeating itself toda-1: Smoking rates are falling again in the United States and companies are looking abroad for new smokers to replace those who quit at home. The new targets are the closed cigarette markets of Japan, Korea, Taiwan, Thailand, and China. M~ny of the same strategies used to open the markets •of Sorth America are being used again. But this time, there is a new twist: the United States is using governmental trade threats to force resistant coun- tries to remove tobacco trade re 3trictions. It is interesting to compare the experience of open-ng up Latin America in the 1960s to what is occurring in tho Far East today. Opening a Closed Mar!k:et, Then and Now Marketing and Manufacturing Agreements Countries have uniformly resisted entry into their markets by multinational tobacco companies. Many less developed and newly developed countries chose to operate closed ciga- rette markets dominated by a st<<te-owned tobacco monopo- ly. This decision is based on the belief that scarce consumer capital should not leave the naticn for purchase of a foreign cigarette-a nonessential, luxury item. State-owned monopo- lies dominated Latin America uniil the 1960s and still do to- day in many Far East nations. St -me countries protect their monopolies from foreign compeiitiori by banning sale of for- eign cigarettes, which is the caso in South Korea, Columbia, Thailand, and Nigeria. However, it is more common-and equally effective-for countries to place high tariffs on im- ported cigarettes and their distriilution and advertising. In the absence of competition, the vast majority of state tobacco monopolies advertise and promote smoking at a minimum level. They also generdly produce a harsh, less "flavorful" cigarette which uses locally grown tobacco. Both factors tend to minimize smokinti. The incidence of smoking in many of these countries is si« ilar to that found in the 50 United States 30 years ago. High smoking rates are found among adult males and low rates among females and adoles- cents. For example, in Japan and China smoking rates among men are 60 percent and 80 percent, respectively, and among women, 12 percent and 6 percent. Per capita consumption is also lower than in more competitive markets with 900 ciga- rettes consumed per person per year in China, 1,500 in Taiwan and 1,700 in Korea. The United States rate is 2,600 cigarettes consumed per person per year. The TTCs have two objectives when entering a closed market. The first is to remove laws that prohibit sale of foreign cigarettes and other protectionist measures such as tariffs or restrictions on marketing. The second is to expand marketing opportunities by repealing laws that limit Western- style advertising or securing guarantees that such advertising can be used. In his analysis, Shepherd found that the multinationals can gradually penetrate a closed market by entering into a series of manufacturing arrangements with the national company. Through this process, the multinationals progressively gain more control over the market until they dominate it. The first step is to secure a licensing arrangement with the state firm to sell international brand name cigarettes. This "foot in the door" approach is tolerable to local policymakers since local leaf is used in cigarettes which are produced by the national company. Such an arrangement does not threaten local farm- ers or other tobacco workers. Joint manufacturing ventures between the state company and multinationals usually fol- low. These arrangements give the multinational a firm foot- hold and in exchange for the agreements, the TTCs give ad- vanced agricultural and manufacturing technology to the local company. At the same time the TTCs push the local govern- ments to denationalize the state tobacco monopoly and form a private firm. This action removes any residual sentiment that the government may have had for protecting the na- tional company and sets the stage for future acquisition of it. The decision to lift trade barriers or denationalize a state company rests with the local governmental or legislative offi- cials who face strong internal economic and political pres- sure not to do so. In negotiations with foreign officials, the TTCs argue that opening the market is in the nation's economic and health in- terest. The TTCs say that competition will make the state company more competitive. They also promise to introduce modern tobacco growing and agricultural techniques, thus improving the tobacco industry. This concept is being widely pushed by multinationals throughout the Far East today, par- ticularly in China and Korea. However, Shepherd found these arguments to prove false in Latin America. Rather than the state mono.poly becoming more competitive in an opers market, the vast majority of Latin firms were seriously weakened by the multinationals. 7bbacco Use in America Conference TIlVIN 295361

Tobacco Use in America Conference • January 27-28, 1989 Based on the economics of scale, the locals were unable to compete with the inten:>ive advertising and short-term preda- tory pricing practices or the TTCs. By 1976, the TTCs had formed 12 subsidiaries in 17 Latin American countries. These subsidiaries conirolled 90 percent or more of the market share in their respective countries and the vast majority of them were acquisitions of former national companies. The multinational cornpanies also tell foreign officials that an open market will shift consumer preference to "safer" Western-style low tar/Ii_w nicotine brands. Two recent Sur- geon General's reports found that smokers receive only marginal benefits from smoking these brands. In fact, many smokers just smoke more often or inhale more deeply to compensate for the lower yield. A 1988 analysis of Marlboro and Winston light cigar.3ttes sold in the Philippines found their tar and nicotine ci intent to be 50 percent higher than that of the same brand:; sold in the United States. Shepherd observes that the multinationals use their inter- national brands as a lure to gain a foothold in the market. According to him, the ITCs promote the sale of contraband international cigarettes to help stimulate local demand. The loss of tax revenue froin bootlegging serves as an added in- centive for local governments to legalize the sale of foreign brands. This tactic is siill being used today. Sales of contra- band cigarettes are a a ajor problem throughout all of the markets of Asia, particularly in the closed market of China, Korea and Thailand. Brands such as Marlboro and Camel convey powerful image:; of Western life style and success. Smoking these brands uonveys status to many citizens of a less-developed or newly developed country. In the long run, however, Shepherd fouid that these brands don't capture a major portion of the m;,rket. After the multinational acquires the local firm, national )rands continue to be popular and remain a large portion of the market. Government Contracts The companies also iise other strategies to remove bar- riers to entry. According to a 1976 Security and Exchange Commission Report, Pi ilip Morris and R.J. Reynolds made $2.8 million in "questicnable payments" in their Latin American Operations in the 1970s. In at least seven coun- tries payments were made to government officials to secure favorable agreements r.;lative to their market operations. Civil servants in newl y developed countries of the Far East are not as susceptible tu this type of influence peddling, so the TTCs have changed their tactics. In 1986 and 1987, United States companics asked key members of the United States Congress to pre:,sure trade officials of Korea, Taiwan, Japan and Thailand to open their cigarette markets. The Con- gressmen threatened these countries with passing protec- tionist United States trade legislation unless tobacco trade barriers were removed. Similar threats by four United States Tobacco Use in Arraer..'ca Conference Senators were made against Hong Kong in 1986 when that government proposed a ban on smokeless tobacco. The only manufacturer of that product was the United States Tobacco Company. Administration officials have also been involved. In 1985, Michael Deaver, former chief of staff to President Reagan, was paid $250,000 by Philip Morris to secure trade conces- sions from Korea on cigarettes. Michelle Laxalt, daughter of then-Senator Paul Laxalt was also hired by Philip Morris. Richard Allen, former United States national security direc- tor, was hired to do the same by R.J. Reynolds. At a meet- ing with the President of Korea, Mr. Deaver said he would take care of pending United States protectionist legislation that would hurt Korea's textile industry if Korea opened its market to United States cigarettes. A few months later the President vetoed the protectionist Jenkins Thurmond Textile bill and Korea unilaterally opened its market. Another strategy to force opening of the market is to use retaliatory trade threats by the United States government. In 1984, the United States Congress amended Section 301 of the 1974 Trade Act to allow the president to conduct investi- gations of alleged unfair trade practices against the United States' products by foreign countries. Under pressure from the United States Cigarette Export Association, which represents Philip Morris, R.J. Reynolds and Brown and Williams, the United States government conducted three investigations on unfair tobacco trading practices of Japan, Taiwan and Korea. In 1984, Korea had a law prohibiting sales of foreign ciga- rettes and both Taiwan and Japan had high tariffs on imported brands and restrictions on their distribution and advertising. Between 1985 and 1988, the United States' Trade Represen- tative (USTR) threatened these nations with sanctions on goods they exported to the United States unless United States cigarette companies were given free access to their markets. No other United States agricultural product received the same attention and all three nations capitulated to the United States' demands. Japan and Korea were also pressured to denationalize their tobacco companies. Japan did so and Korea is committed to following suit. Trade threats by the United States were also used to expand adver- tising and promotional opportunities. Both Taiwan and Korea were pressured by USTR to repeal their restrictions on cigarette advertising and even to allow television advertising. The countries refused to permit television advertising but bowed to the pressure and did allow print advertisements. Advertising United States companies contend that their intention in the Far East is to encourage Oriental smokers to switch to their brands and not to target nonsmokers. Shepherd found that following entry into Latin America, the TTCs greatly ex- panded promotion and advertising. In Argentina, per capita advertising expenditures rose 30 percent from 1968 through 51 TIlYIN'295362.

Tobacco Use in America Conference • January 27-28, 1989 1975. As a consequence, per capita cigarette consumption rose an average of 6.4 percent ;ach year from 1966 to 1975-almost three times more than the 2.4 percent annual rate increase reported for the p-ars prior to TTC entry. The same is occurring in Asia today. Two years after TTC entry into Japan, there is a tenfold increase in the number of television advertisements for cit arettes. Cigarette ads now rank number two on Japanese t-;levision in terms of total minutes of air time. Japanese r: tail sites selling cigarettes have also been greatly expanded, particularly vending machines. In Taiwan hundreds t _if small shops are contracted by United States companies to iioth sell their brands and serve as sidewalk advrtisements for cigarettes. Beginning in 1986, product prDmotions, something rarely done by Oriental monopolies, were introduced on a wide scale. Now, it is common to see younii women giving away free samples on the streets of Tokyo, In Taiwan young people received free disco tickets in exchange for empty American cigarette packages. Multinationa tobacco companies also sponsor motorcycle racing event:; and dance troupes in China. Commercials for Virginia Slim~; cigarettes began airing on Tokyo television in 1987. Similar targeting of nonsmoking women is being done in Taiwan and Hong Kong. Considering the relatively low smoking rates among Oriental women, ads targeted to women give a clear -ignal that the multinationals' actual intent is to convert nons«okers. Recent data shows sharp increases in smoking among urban Oriental women. The effect of the marketing is already being seen. One 1987 study found Japanese female college students to be four times as likely to smoke than th_ir mothers. In Taiwan, cigarette consumption was declining until the entry of the Western companies. Taiwan consumption rose 4 percent in 1987. Korea's consuiiiption also rose 2 percent. In Japan, a decline in consumption that preceded the entry of the United States firms has been halted. Foreign com- panies which before had virtually no cigarette market share now hold 11 percent of Japan's inarket and 22 percent of Taiwan's. Within a few years for::ign companies are ex- pected to control 20 percent to 30 percent of the markets of these countries as well as Kor:;a. These statistics demonstrate ti at the health and economic claims made by the multinationals to justify opening a closed market are fallacious. Opening th; closed cigarette markets in the Far East will likely result in increased consumption among current smokers and in many nonsmoking women and adolescents starting to smoks. Controlling Worldwide =Expansion What can be done to curb multinational tobacco companies from further expanding their influ;nce worldwide? Shepherd argues that a decaying state-own ;d monopoly is just "what the doctor ordered" and keeping the market closed is good medicine for any national tobaccc control program. 52 But unfortunately, as long as smoking rates continue to decline in the developed countries and the United States con- tinues to incur high trade imbalances with the newly devel- oped countries in the Far East, considerable pressure will be placed on countries with closed markets to open them. It is likely that national monopolies will be dismantled worldwide. Thailand is under pressure by the United States to open its market. Joint ventures in China may only be the beginning of multinational dominance of that country. And if the Korean and Japanese companies are able to become competitive and learn how to make and market cigarettes the way they learned to make cars, the health of the world will suffer immeasurably. The Sixth World Conference on Smoking and Health held in Japan in 1987 took note of this problem and recommend- ed that tobacco not be used as trade leverage. The General Agreement on Tariffs and Trade (GATT)-an international agreement which nations use to resolve trade disagreements- currently includes tobacco. United States and international health and religious organizations should petition member nations of GATT to remove tobacco from the list of trade items. This is justified based on the heavy toll that tobacco takes on human life worldwide. Other international economic developmental agencies such as the World Bank, Interna- tional Monetary Fund and FAO should also be called upon to exclude tobacco or tobacco products from their program ac- tivities and should fund activities to curb tobacco use. It is evident that the United States tobacco trade policies promote world smoking. Public opinion can and should be tapped to change U.S. policies. For example, tobacco is still eligible for support in the "Food for Peace Program" but, in response to public concern in the United States, the Depart- ment of Agriculture has decided not to allow tobacco in the program. Similar pressure could be used to influence United States trade officials not to use 301 trade sanctions to force unwanted American cigarettes onto friendly nations. Governments in the Far East are to be blamed for their fail- ure to aggressively address the smoking problem. Certainly, their neglect is due in large part to concern about the eco- nomic implications of controlling tobacco. But foreign coun- tries can still institute policy actions that protect the public health. The first option is to prohibit all forms of tobacco marketing and advertising. This action would prevent the multinationals from capturing a large segment of the existing market, but more importantly prevent the TTCs from market- ing to nonusers of tobacco such as women and adolescents. Foreign governments can also take a second action, to in- crease cigarette excise taxes. The tax would have the public health benefit of curbing smoking and replace revenue lost to the multinational company. Citizen-based antismoking groups in the United States and other industrialized countries have been highly effective. These groups are not influenced by governmental officia:s Tobacco Use in Anaet•ica Coqfercuce TIMN 295363

Tcrbacco Use in America Conference • January 27-28, 1989 and have successfully userl the issue of nonsmokers' rights and lawsuits against tobac.o manufacturers to change public attitudes. Over time, United States government policy has been influenced by these groups. As American tobacco com- panies export Western cig;rettes, activists in the United States should export the A,merican antismoking movement. There are fledgling consumer-based antismoking groups in Japan, Taiwan and Korea. Until recently, these groups were perceived as fringe elements in the conformist societies of the Far East. However, United States trade pressure has sparked charges of cigaret:e dumping and neocolonialism. The antismoking groups h:,ve been able to link their mes- sages with the public anger about the U.S. actions. The antismoking movement h_a.:; become a national cause in Taiwan and Korea. In mamr respects, the United States governmental pressure ha~ backfired and given legitimacy to the fledgling antismokin ] groups. The groups have been successful. Smoking is banned on many Japanese railroads and the Taiwanese Ministry of Health is proposing to ban smoking in public places. Laws are pending in Taiwan and the Philippines to ban all forms of tobacco advertising. A clacs action suit on behalf of ten Filipino children was filed iii a Manila court in 1987 against two United States multinat onal companies. The plaintiffs claim that Philip Morris and R.J. Reynolds fail to provide the same level of protection to Filipino children as to American children, specifically, warn ng labels on print ads and pack- ages and no television advartising. The failure of the TTCs to place health warning labelc on cigarettes sold in many poor countries makes them vulr erable to future product liability. In combination, these actions provide hope for curbing world smoking-hope for iie billions of children in the world who are at risk of becoming 21st-century customers of the six multinational tobacco companies. Summary of Work. Iroup Discussion United States tobacco trade policies have enabled it to become the world's leading cigarette exporter. And, in addi- tion to export dominance, U.S. trade policies allow United States tobacco companies to virtually control domestic tobacco farming and prodi ction in many developing coun- tries. As a result, United State3 tobacco companies are more than replacing smokers who are quitting in developed coun- tries with new smokers in developing countries. In large part, these new smokers are women and children. While this may be good for the tobacco crimpanies, it is bad public policy for the United States. The United States tobac(;o trade policy is bad because it has the potential to revers:., all the gains we have made in promoting world health. It makes a mockery of our claim to be the world's leader in health. It is grotesquely inconcsis- tent with our efforts to cur3 international trade in addictive drugs. And, the gains made from tobacco have hurt export opportunities of other United States goods and have caused serious harm to the image of the United States overseas. As a leader of the free world, the United States must adopt a new policy that prevents the world smoking epidemic from expanding. The United States government's roles is to pro- mote the health of the American people and to serve as a positive example to the rest of the world in the active sup- port of world health. To that end, a new tobacco policy should be based on the following general principles:  The United States government and U.S. health organi- zations, along with international health organizations, should encouarge worldwide adoption of effective smok- ing prevention and control measures. Together, these groups should collect data on mortality and disease related to worldwide tobacco use.  Tobacco should not be used as trade leverage.  All people regardless of country of residence should be warned of the dangers of tobacco.  Efforts should be made to discourage international development agencies from introducing and supporting tobacco growth, production, marketing, and sales as an economic strategy. All nations in the world should be encouraged to adopt policies that curb the reckless and irresponsible promotion and advertising of tobacco products. Such a policy requires that we pass new legislation, imple- ment new international health programs, develop international collaborative health projects between U.S. health agencies and their international counterparts and launch advocacy and public education programs to regain our leadership in world health. Recommendations I. Legislative Recommendations 1) Congress should pass legislation to prohibit the USTR, the Departments of State and Commerce, or any other agency of the United States government from actively encouraging, persuading or compelling any foreign government to expand the marketing of tobacco prod- ucts whether it be by repealing of laws restricting marketing practices or securing agreements to intro- duce new measures or expand current ones. This ap- plies to the promotion, advertisement, distribution and taxation of tobacco products. 2) Congress should pass legislation requiring any manu- facturer who sells tobacco products in the United States to place the same health warning labels that are required in the United States on advertisements and packages sold abroad untess more stringent health disclosures are required. Manufacturers shoufd„also be required to disclose the tar and nicotine content of brands if the level is different from the same brand ToUaccn Lae in America Confercncc 53 ~~~LN 2-9, 53 64

Toba(;co Use in America Conference • January 27-28, 1989 sold in the United States. Nothing in this recommen- dation should be constri _ ed as preempting any local law or regulation includiiig product liability of the tobacco manufacturer arid seller. 3) Congress should restrict the use of United States funds by international tr;ide and monetary agencies such as the World Bank and International Monetary Fund from being used to provide financial or technical support for tobacco agrit;ulture of manufacture. 4) Congress should significantly increase United States funding for smoking con Irol activities for WHO and work with it to establish an international data base and clearinghouse on toiiacco control. II. Regulatory Recommendatioiis: 1) The Surgeon General in his capacity as the Govern- ment's chief international health officer should devote an upcoming Surgeon G:;neral's report to the world health consequences of :;moking. 2) The General Accounting )ffice should undertake a study on the economic costs and benefits to the United States of the expurt of tobacco. The study should include analyses of the past activities under- taken by the USTR to de:ermine if tobacco products have been accorded pref3rential treatment. Other areas to be studied inclG Je an environmental impact study on the use of pesticides, deforestation and other environmentally destructive practices for the growth of tobacco. In adlition, the study should in- clude the financial implications of reducing tobacco exports on American farmers. 3) The National Institutes of Health should establish a collaborative project with other nations to gather health data on the consequences of worldwide tobacco use. III. Public Education: 1) A world conference should be held on the world health consequences of tobaccr use. The conference should encourage foreign health experts and government representatives to participate. 2) A clearinghouse should.be established as a corporate entity and in collaboration with voluntary health agen- cies, professional groups, the United States Public Health Service, Pan Ame ican Health Organization and the World Health Organization to provide relevant data on health, economic, enJronmental and social im- pacts related to worldwide use of tobacco. ~ 4Ir ~y536;~ 54 7'obacco Use in America CWerence

Tobacco Use in America Conference • January 27-28, 1989 Grassroots Lobbying Introduction Building a consensus be:ween members of Congress and the health community on f;deral tobacco-control issues is merely the first step towar•i the ultimate goal of a "tobacco- free" society in the United States. Consensus must then be articulated as legislation; _a.nd passing legislation designed to deter tobacco use requires a massive, well-coordinated and well-run lobbying campaign with a broad base of support. While the economic dominance held by the tobacco industry has proved to be a significant barrier in this battle, it is in no way impenetrable. Once a federal blueprint for action on tobacco control is- sues is developed, it may be rendered useless without an ac- companying implementation plan. Fortunately, the tobacco- control movement has strength in its numbers. Today, there already exists a major graassroots network in the United States that is responsible f)r hundreds of state and local laws restricting tobacco use and consumption. Tapping into this vast resource and making it a part of federal initiatives will be a key element in a~,uccessful tobacco-control cam- paign. Our mandate is to devise a strategy for energizing the existing grassroots networlc and building it into a national tobacco-control alliance. Grassroots TobaccD Control at Work The overall effectiveness of the grassroots tobacco-control movement is best demonsirated through a review of the ex- isting state and local restri(;tions on tobacco. This section summarizes information compiled by the Tobacco-Free American Legislative Cleari ighouse on state laws for limits on smoking in public place:,; tobacco excise taxes, including cigarettes and smokeless tobacco; age restrictions on sales of tobacco products; restriotions on distribution of tobacco product samples; restrictions on sales of tobacco products in vending machines; and licensing requirements. Prepared by: Angela T. Mickel, Coordinator Tobacco-Free America Legislative Clearinghouse American Cancer Society American Heart Association American Lung Association Limits on Smoking in Public Places Forty-two states and the District of Columbia restrict smok- ing in some manner in public places. These laws range from simple, limited prohibitions, such as no smoking on a school bus while the bus is in operation (South Carolina), to com- prehensive clean indoor air laws that limit or ban smoking in virtually all public places, including elevators, public build- ings, health facilities, public transit, gymnasiums and arenas, retail stores and educational facilities (Massachusetts). The most extensive clean indoor air laws include restaurants and private workplaces (Washington). Of the states that limit or prohibit smoking in public places, 25 have comprehensive clean indoor air laws; 31 impose restrictions on smoking in public workplaces, and 14 have extended those limits to pri- vate sector workplaces. (See Attachments A and B.) Over the past two years, there has been a dramatic in- crease in the number of cities and counties in the United States that have enacted local ordinances to limit smoking in public places. There are now nearly 400 city and county smoking control laws. Tobacco Excise Taxes  Cigarettes-Every state and the District of Columbia impose an excise tax on cigarettes. These taxes range from a high of 38 cents per pack in Minnesota to a low of 2 cents per pack in North Carolina. In 1988, three states-Iowa, Michigan, and Texas-increased their cigarette excise taxes; and one state, Michigan, began earmarking part of the revenue collected from these taxes to tobacco and health programs. (See Attach- ment C.)  Smokeless Tobacco-Thirty states have excise taxes on smokeless tobacco products, including chewing tobacco and snuff. (See Attachment D.) In most states, the excise tax is calculated as a percentage of the' Tobacco Use in Ainer*a Confer•ence 55 TIMN 295366

Toba,,.co Use in America Conference • January 27-28, 1989 wholesale sales price to retailers, manufacturer's in- voice price, or price at which the tobacco entered the state. Alabama and Arizona base their smokeless tobac- co excise taxes on the w::ight of the tobacco package, which may vary. Two staies, Alaska and Iowa, increased their smokeless tobacco xcise tax rates in 1988.  Age Restrictions on Sate= of Tobacco Products-Forty- three states and the Distr ct of Columbia restrict the sale of tobacco products to minors. South Dakota im- poses this restriction only on smokeless tobacco prod- ucts. This year only the state of Wisconsin approved legislation to prohibit the sale of tobacco products to children by setting the age of a minor at 18. On July 1, 1989, it will no longer be legal in Wisconsin to sell tobacco products to persons under age 18, nor will it be legal for one under ag; 18 to purchase such prod- ucts. Six states-Kentucky, Louisiana, Missouri, Mon- tana, New Mexico, and Wyoming-have not yet acted to prohibit the sales of to )acco products to young per- sons. (See Attachment E). Restrictions on Distribution of Tobacco Product Samples U.S. cities have taken the lead in restricting the distribu- tion of tobacco product samples. Since 1979, 12 cities banned the distribution of tobacco product samples. One city, New Orleans, prohibits the distribution to minors only. States have been slower thai cities in addressing the issue of tobacco samples. While maiy limit access of tobacco products to minors by prohibiT ng sales or furnishing, only 10 states have taken action to restrict the distribution of free samples. Minnesota is the only state that totally bans the distribution of cigarettes, smol:eless tobacco products, cigars, pipe tobacco or other t)bacco products suitable for smoking. Kansas prohibits the distribution of sample ciga- rettes. Georgia, Indiana, Louisiana, Maine, New Hampshire, Rhode Island, Utah and Wiscoosin ban the free distribution of tobacco product samples to minors only. Restrictions on Selling Tobacco Products in Vending Machines Thirteen states regulate the :-,ale of tobacco products in vending machines. Only one, c;olorado, bans the sale of smokeless tobacco products ir vending machines. Nine states-Colorado, Georgia, Hawaii, Indiana, Massachusetts, Minnesota, Rhode Island, Virginia and Wisconsin-require owners, operators and/or supervisors of tobacco vending machines to post signs stating that minors are prohibited from making a purchase from that machine. Five states- Alaska, Idaho, Maine, New Hampshire, and Utah-require that placement of vending mauhines be placed in supervised areas to deter use by minors. Wisconsin prohibits vending machines from being placed within 500 feet of a school. Licensing Requirements Forty-six states and the District of Columbia require parties that sell tobacco products to be licensed. Iowa, Kentucky, South Dakota and West Virginia do not require any such licensing. Licensing regulations vary among states, and range from requiring only distributors to have licenses (California) to requiring wholesalers, distributors, manufac- turers, and retailers to obtain licenses (Delaware). The licens- ing law in Nebraska includes a penalty for any such licensee who furnishes tobacco products to minors, and may revoke the license for subsequent offenses. Recent Actions: November 1988 Ballot Initiatives  Catifornia-Proposition 99 California voters accepted a 25 cents increase in the cigarette excise tax by approving Proposition 99 by a 58 percent majority. In addition to increasing the ciga- rette excise tax, the initiative set an excise tax on smokeless tobacco products. Beginning January 1, 1989, cigarettes will be taxed at 35 cents per pack, and an excise tax of 41.67 percent of the wholesale price will be imposed on smokeless tobacco products. The expected $660 million additional revenue will help fund tobacco education, health care for the indigent, tobacco- related medical research and wildlife protection. The tobacco industry spent nearly $15 million on an intense radio and television advertising.campaign in an attempt to defeat the measure. In contrast, proponents of the measure, the "Coalition for a Healthy California," spent $1.5 million.  Oregon-Measure 6 Measure 6 would have banned smoking in virtually all indoor work areas, including private homes used as of- fices and enclosed places frequented by the public. If passed, it would have been the toughest smoking- control law in the country-but it was defeated by a 61 percent to 39 percent margin. The tobacco industry spent more than $3 million in casting the campaign against Measure 6 as a question of "personal liberties," instead of a public health issue. Proponents of the initiative spent only $55,000 and despite the loss, viewed it as a valuable opportunity to educate the public about the hazards of environmental tobacco smoke. Coordinated Grassroots Efforts to Influence Federal Legislation During the 1980s, several significant,federal tobacco- control laws were enacted, including the Comprehensive Smoking Education Act of 1984, which required rotating warning 56 7bbacco Use in America Cori}`erence

lbbacco Use in America Conference • January 27-28, 1989 labels on cigarette packar es and advertisements; the Con- solidated Budget Reconciliation Act of 1985, which estab- lished a permanent 16 cents per pack federal cigarette excise tax; and the Comprehensive Smokeless Tobacco Health Edu- cation Act of 1986, which banned smokeless tobacco adver- tising on radio and television. It was not until 1987 that an organized grassroots lobbying effort emerged as a factor influencing federal tobacco control legislation. At that time, a proposal by Rep. Richard Durbin (D., III.) to ban smoking cn domestic airline flights of two hours or less was attacheJ to the FY88 Transportation Ap- propriations bill. Under th,- aegis of the Coalition on Smoking OR Health-American Carcer Society (ACS), American Heart Association (AHA), and American Lung Association (ALA)- for the first time multiple health, consumer and union orga- nizations united to form the Ad Hoc Clean Indoor Air Lobby Group to see this measur.; through the Congress and ensure its enactment. The Ad Hoc Clean Indoor Air Lobby Group consists of more than 25 organizatioiis, including the American Associa- tion of Flight Attendants, :he American Medical Association (AMA), and members of the sponsoring group, the Coalition on Smoking OR Health. To help secure passage of the Dur- bin proposal, the group coordinated lobbying strategy, con- ducted attitude surveys, sponsored a lobby day in Washing- ton, D.C. and energized it; state and local volunteers and staff. Plans are already uriderway to seek a permanent exten- sion of the law. Need for Action Clearly a majority of th~- efforts in the tobacco-control movement have been concentrated in the state and local arenas. This is due to several factors:  The tobacco industry has less influence with local lawmakers than with national lawmakers. The political consequences of supporting tobacco-control measures are less for local lawmakers who are not as dependent on the financial cont'ibutions of special-interest groups or political action committees to win reelection.  There is a strong naflonal, cultural tie with tobacco in the United States, d<<ting back to the first settlers of this country. For instanco, tobacco financed the American Revolution and was his country's first cash crop. Moreover, tobacco use has been socially acceptable, and legal, for centuries.  Federal government aolicies, such as tobacco price supports, and powerful Congressional opponents of tobacco-control laws deter efforts to pass such laws. Our goal should be to unify our state and local members into a national grassroots lobbying network. By creating such a structure, we can profit from the vast experience of the local coalitions and gain tile ability to mobilize instantly. A Tobacco Use in Americt, Cof;ference coordinated advocacy campaign, one that becomes self-suffi- cient over time, will enhance our effectiveness and influence change. Existing Options for Building a Network Numerous groups on the national, state and local level are in place and working on tobacco-control issues. They might be organized into a united lobbying entity with a national and local presence. Major National Health and Health Advocacy Organizations Aside from the Coalition on Smoking OR Health, no real cooperative effort exists to affect tobacco-control legislation. Although there are numerous organizations committed to health promotion and disease prevention that have actively lobbied on tobacco issues, they have done so separately and at their own pace. Examples of the national agencies and ad- vocacy groups that could join with ACS, AHA, and ALA to form a national tobacco-control alliance are listed below: ACTION ON SMOKING AND HEALTH ADVENTIST HEALTH NETWORK AMERICAN ACADEMY OF FAMILY PHYSICIANS AMERICAN ACADEMY OF OTOLARYNGOLOGY AMERICAN ACADEMY OF PEDIATRICS AMERICAN ASSOCIATION FOR RESPIRATORY CARE AMERICAN ASSOCIATION OF RETIRED PERSONS AMERICAN CHIROPRACTIC ASSOCIATION AMERICAN COLLEGE OF CARDIOLOGY AMERICAN COLLEGE OF CHEST PHYSICIANS AMERICAN COLLEGE OF PREVENTIVE MEDICINE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS AMERICAN COUNCIL OF LIFE INSURANCE AND HEALTH INSURANCE ASSOCIATION OF AMERICA AMERICAN DIABETES ASSOCIATION AMERICAN MEDICAL ASSOCIATION AMERICANS FOR NONSMOKERS' RIGHTS AMERICAN PUBLIC HEALTH ASSOCIATION AMERICAN SOCIETY OF INTERNAL MEDICINE ASTHMA AND ALLERGY FOUNDATION CONSUMER FEDERATION OF AMERICA State Networks  Tobacco-Free America (TFA) Legislative Clearinghouse The TFA Legislative Clearinghouse is the primary infor- mation bank and advisory resource to the state and local coalitions of ACS, AHA, and ALA, as well as to government agencies, private corporations and individuals and the media. This clearinghouse monitors state and local tobacco- related legislation and regulations and analyzes trends and effects of the information collected. Information compiled by TFA is used to advise and assist coalitions, agencies and individuals in formulating and. implementing strategies 57 TIMN 295368

Tobacco Use in America Conference • January 27-28, 1989 for getting involved in tobai;co-related legislative initia- tives.  Smoking Control Advocac; Resource Center (SCARC), The Advocacy Institute SCARC serves as a national support system and com- munications network for th;; tobacco-control movement. Primarily, SCARC assists in the strategic use of the mass media as a resource lo advance the anti-tobacco cause.  Nonsmoker's Rights Grou,is Americans for Nonsmok_rs' Rights (ANR), state non- smokers' rights groups (N:iRs), and local Groups Against Smoking Pollution ;GASP). ANR is the only national antisrnoking group solely devoted to restricting smoking in public places. However, there are numerous independent state anO local organizations devoted to the rights of and protections for nonsmokers, such as New Jersey GASP and the New York-based Anti-Smoking Educa- tional Service. Summary of Workgroup Discussion In the 1980s, the leadership of the major voluntary health associations and the AMA joineO with nonsmokers' rights groups and tobacco-control activists to build a national move- ment to support the enactment o appropriate tobacco-control policies at the federal, state and local levels. This movement recognized not only the threat o' smoking as the nation's number one preventable public health problem, but the orga- nized, resourceful, unflagging political resistance of the tobacco lobby. If the tobacco-control movem ,nt is to achieve its public policy goals in the last decade cf the 20th century, its efforts must be strengthened. The mat:;rial and human resources dedicated to the cause must be greatly increased, and the commitment of both professional staff and volunteers must be further encouraged, support.id and rewarded. The move- ment needs both professional advocacy resources and dedicated, trained, empowered volunteers. It needs coordinated strategic planning; interactive com- munications networks; mutual support at the local, state, national, and international levelt; and advocacy training and skills building. A national tobacco-control grissroots lobbying network should include:  Coordinated communications system within and among national, state, and local networks  Coordinated communications system for legislative action  Complete, A to Z, lobbyini strategy that can effectively compete with the economic power of the tobacco industry 58  Media strategy that uses all forms of broadcast and print media  Media relations training to assure that comprehensive, compelling messages are delivered.  Coalition-building techniques Recommendations 1. The leadership of each sponsoring organization should act internally to raise the level of commitment to tobacco-control advocacy. They should consider allocating greater financial resources and hiring pro- fessional lobbyists and organizations at local, state and national levels. 2. Turf battles, institutional rivalries, bureaucratic resis- tance and institutional inertia must be transcended in the common pursuit of the overriding public goal. 3. The staff and resources of the national organizations should be dedicated to the political education, recruit- ment, confidence-building and institutional recognition of their volunteer members who can advocate tobacco control policies at each level of government. 4. National and state coalitions should be strengthened with added financial resources, aggressive outreach to new and potential alliances, professional lobbying staffs, and greater strategic planning and communications capability. (See Attachment F.) 5. Training in advocacy skills, especially in lobbying techniques, media relations and coalition building should be made a priority for professional staff and volunteers of each sponsoring organization. 6. Systematic and coordinated efforts should be made to track and anticipate tobacco industry lobbying strate- gies, and to pre-empt or counteract them. 7. A national campaign to "de-legitimatize" and expose the tobacco lobby should be launched as a major un- derpinning for tobacco-control policy initiatives. Cor- porations, trade associations, legislators and govern- ment officials who collude with the tobacco lobby must be held publicly accountable. 8. All tobacco-control advocates should have ready ac- cess to essential information sources. To this end, a national interactive communications program should be developed. Furthermore, national and state legisla- tive clearinghouses and data banks should be strength- ened and made readily available to advocates at all levels of government. 9. "Citizen spark-plu gs "-effective advocates-should be encouraged, supported and rewarded as valued "public citizens" and the heart of the smoking-control movement. 10. A task force should be cbnvened immediately by the conference sponsors to develop both short-Xerrn arld long- term plans for implementirig the above recommendatons. 7bbacco Use in America Uoriference TIMN 295369

'Ribacco Use in America Conference • January 27-28, 1989 A TTACHMENT A STATES WITH LAWS THAT LIMIT SMOKING IN PUBLIC PLACES (43) ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE - DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO INDIANA IOWA KANSAS KENTUCKY MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TEXAS UTAH VERMONT WASHINGTON WEST VIRGINIA WISCONSIN STATES WITH COMPREHENSIVE CLEAN INDOOR AIR LAWS (25) ALASKA CALIFORNIA COLORADO CONNECTICUT FLORIDA HAWAII IDAHO IOWA KANSAS MAINE MASSACHUSETTS MICHIGAN MINNESOTA MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NORTH DAKOTA OKLAHOMA OREGON RHODE ISLAND UTAH WASHINGTON WISCONSIN .;TATES WITH LAWS RESTRICTING SMOKING IN PUBLIC WORKPLACES (31) ALASKA ARIZONA CALIFORNIA COLORADO CONNECTICUT FLORIDA HAWAI I IDAHO INDIANA IOWA KANSAS MAINE MARYLAND* MASSACHUSETTS MICHIGAN MINNESOTA MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NORTH DAKOTA OHIO OKLAHOMA OREGON RHODEISLAND UTAH VERMONT WASHINGTON WISCONSIN STATES WITH LAWS RESTRICTING SMOKING IN PRIVATE WORKPLACES (14) ALASKA CONNECTICUT FLORIDA IOWA MAINE *By Executive Order Tobacco Use in Americc! Conference MINNESOTA MONTANA NEBRASKA NEW HAMPSHIRE NEW JERSEY RHODEISLAND UTAH VERMONT WASHINGTON 9 TIMN 29"r

STATE LAWS RESTRICTING SMOKING IN PUBLIC PLACES [ [ Extensive Moderate Basic Nominal No Restrictions 1 I y 03

STATE CIGARETTE EXCISE TAXES (cents per pack) a l-q ~ z N .~ ~ .*4 *40% of Wholesale Price

Zbbac;co Use in America Conference • January 27-28, 1989 ATTACHMENT D STATE SMOKELESS TOBACCO EXCISE TAXES CHEWING TOBACCO AND SNUFF STATE TAX STATE TAX AL Tax based on weigh' MT 12.5% of wholesale price AK 25% of wholesale price NE 15% of purchase price AZ $.02/ounce NV 30% of wholesale price AR 16% of manuf. inv. price NH None CA 41.76% of wholesal:; price2 NJ None CO 20% of manuf. prici_, NM 25% of wholesale price CT None NY None DE 15% of wholesale price NC None DC None ND 20% of wholesale price FL 25% of wholesale price OH None GA None OK 30% of wholesale price HI 40% of wholesale price OR 35% of wholesale price ID 35% of wholesale price PA None IL None RI None IN 15% of wholesale price SC 5% of manuf. price IA 19% of wholesale sdes price SD None KS 10% of wholesale price TN 6% of wholesale price KY None TX 28.125% of manuf. price LA None UT 35% of manuf. sales price ME 45% of wholesale price VT 20% of distributor price MD None VA None MA 25% of wholesale price WA 64.9% of wholesale price MI None WV None MN 35% of wholesale price WI 20% of wholesale price MS 15% of manuf. list i rice WY None MO None 'Chewing Tobacco: 3/4 cents/ou ice or fraction thereof. Snuff: (a) 5/8 ounces or less, /2 cent; (b) Over 5/8 ounce not exceeding 1-5/8 ounces, 1 cent; (c) Over 1-5/8 ounces, ;iot exceeding 21/2 ounces, 2 cents; (d) Over 21/2 ounces, nct exceeding 3 ounces; 21/2 cents; (e) Over 3 ounces, not :;xceeding 5 ounces (cans, packages, gullets), 3 cents; (f) Over 3 ounces, not :;xceeding 5 ounces (glasses, tumblers, bottles), 31/2 cents; (g) Over 5 ounces, not :;xceeding 6 ounces, 4 cents; (h) One cent additional :ax for each ounce or fraction part thereof over 6 ounces. 2Effective January 1, 1989. Sources: State Departments of Revenue, Bureaus of Tobacco and Miscellaneous Taxes, 1988. The Tax Burden on Tobacco: Historical Compilation, Vol. 22, The Tobacco Institute, 1987. 2 9ZA73?3 62 Tbbacco Use in Ame*a Cprfjexence

y STATE AGE RESTRICTIONS FOR SALES OF TOBACCO PRODUCTS ~ N. ~ ~ ^'• ~ ll ~ 0 * Cigarette/Smokeless *' 7/1 /89 NEW JERSEY 1 8 DELAWARE-1 7 'MARYLAND-1 6/1 8 * D.C -16 ~ M co

Zbb: ,cco Use in America Conference • January 27-28, 1989 ATTACHMENT F SUGGESTED TARGET GROUPS FOR OUTREACH 1. Older Americans 2. Educational groups 3. Youth groups 4. Non-tobacco related businesses 5. Unions 6. Health professionals' groups 7. Minority groups 8. Smokers for tobacco control 9. Religious organizations 10. State and local governments 11. Unlikely allies 12. Other professional associations 13. Political parties 14. Sports organizations 15. Womens' gropus 16. Celebrities 17. Arts and cultural communities 18. Farmers 19. Civic and community organizations 20. Fire fighters 21. Consumers groups 22. Environmental groups 23. Insurers 24. Victims TEVIN 2.95375- ; 64 7bbacco Use in Aanerica Conference

T)bacco Use in America Conference • January 27-28, 1989 References Altman DG, Foster V, Rasenick-Douss L, Tye JB. Reducing illegal sales of ciga- rettes to minors. JAMA. 1989; 261:80-83. Anonymous. $4M Worth of Smokes Seized. Hong Kong Standard; November 24, 1988. Anonymous. Asian Markets Open to U.S. Cigarettes. Tobacco Observer. 1987; 12:1. Bruneman K, American Health Foundation. Personal communication to G. Connolly. May, 1988. Centers for Disease Control. Cigarette smoking among blacks and other minority populations. Morbid Mortal Week Rep. 1987; 36:404-407. Centers for Disease Control. Cigarette smoking in the United States. Morbid Mortal Week Rep. 1987; 36:581-585. Chandler WU. Banishing Tobacco. Worldwatch Paper 68. Washington, DC: Worldwatch Institute; 1986. Cipollone v. Liggett Group Inc., et. al, CA 83-22864 (SA) (U.S. District Court DNJ, 1988). Plaintiff's Exhibit 605. Connolly GN. The American Liberation of the Japanese Cigarette Market. World Smoking and Health. 1988; 13:20-25. Connolly GN, Walker BW. Restrictions on Importation of Tobacco by Japan, Taiwan, South Korea. New England Journal of Medicine. May 28, 1987; 316:1416-1417. Davis RM. Current trends in cigarette advertising and marketing. New England Journal of Medicine. 1987; 316:725-732. Davis RM, Jason LA. The distribution of free cigarette samples to minors. A J Prev Med. 1988; 4:21-26. DiFranza JR, Norwood BD, Garner DW, Tye JB. Legislative efforts to protect children from tobacco. JAMA. 1987; 24:3387-3389. Federal Trade Commission. Report to Congress Pursuant to the Federal Cigarette Labeling and Advertising Act, 1986. Washington, DC: Federal Trade Commission; May 1988. Harris, Jeffrey E., The 1983 Increase in the Federal Cigarette Excise Tax, Tax Policy and the Economy, Vol. 1, M.I.T. Press, 1987. Interagency Committee on Smoking and Health: The impact of cigarette smoking on minority populations. National Advisory Committee Proceedings; March 31, 1987. Jameson S. Cigarette Issue Riles South Koreans. Los Angeles Times; October 22, 1986. Office of the U.S. Trade Representative. The President's Trade Policy Statement: An Update. Washington, DC: Office of the U.S. Trade Representative, Executive Office of the President; 1986. Schmeisser P. Pushing Cigarettes Overseas. New York Times Magazine; July 19, 1988. Shepherd PL. Transnational Corporation and the lnternatiarial Cigarette IndusPry: Profits, Progress and Poverty. South Bend, Indiana: University of Notre Dame Press; 1985. 7bbacco Use in America Cor{}erence 65 TIMN 295370

Tobacco Use in America Conference • January 27-28, 1989 Stebbins KR. Tobacco or Health in the Third World: A Political Economy Per- spective with Emphasis on Mexico. International Journal of Health Services. 1987: 17:521-537. Taylor P. The Smoke Ring. New York: Mentor Press; 1988. Tobacco Products Litigation Reporter. 3.357, 1988. Published in Boston. Plain- tiff's Exhibit 323. United States Cigarette Export Association. 301 Submission Tobacco Products Japan, Memorandum to Office of the United States Trade Representative. Washington, DC; November 11, 1985. United States Department of Agriculture. World Tobacco Situation. USDA/FAS. FT6-88, June, 1988. United States Public Health Service. Smoking and Health. Report of the Advisory Committee to the Surgeon General of the Public Health Service, Center for Disease Control. (PHS) 1103, 1964. United States Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: United States Depart- ment of Health and Human Services, Public Health Service, Office of Minority Health. 1985-1986. United States Department of Health and Human Services. The Health Conse- quences of Smoking: Cardiovascular Disease. A Report of the Surgeon General. The United States Department of Health and Human Services, Public Health Ser- vice, Office on Smoking and Health. DHHS Publication (PHS) 84-50204, 1983. United States Department of Health and Human Services. The Health Conse- quences of Smoking: Chronic Obstructive Lung Disease: A Report of the Surgeon General. The United States Department of Health and Human Services, Public Health Service, Office on Smoking and Health. DHHS Publication (PHS) 84-50205, 1984. United States Department of Health and Human Services: The Health Conse- quences of Involuntary Smoking: A Report of the Surgeon General. United States Department of Health and Human Services, Public Health Service, Centers for Disease Control, Office on Smoking and Health, DHHS Publication No. (CDC) 87-8398, 1986. United States Department of Health and Human Services. The Health Conse- quences of Smoking: Nicotine Addiction. A Report of the Surgeon General. United States Department of Health and Human Services, Public Health Service, Centers for Disease Control, Office on Smoking and Health. DHHS Publication No. (CDC) 88-8406, 1988. United States Department of Health and Human Services. Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. United States Department of Health and Human Services, Public Health Service, Centers for Disease Control, Office on Smoking and Health. DHHS Publication No. (CDC) 89-8411, Prepublication Version, January 11, 1989. United States v. Michael K. Deaver, CR 87-0096, (U.S. District Court CDC, 1987). Warner KE. Smoking and health implications of a change in the federal cigarette excise tax. JAMA. 1986; 225:1028-1032. Warner, KE. Selling Smoke: Cigarette Advertising and Public Health. Washington, DC: American Public Health Association, 1986. 66 7bbacco Use in Arrr,erica Conference TIMN 295377

'lbbacco Use in America Conference • January 27-28, 1989 ~ on erence Workgroup Leaders ~.,,,~ ~ Tobacco Use: Women, Children and PGLl UI~~IpG~nl,s Minorities Congressman James H. Scheuer U.S. House of Representatives Washington, DC 20515 Lonnie Bristow, MD Member, Board of Trustees American Medical Association 535 North Dearborn Street Chicago, IL 60610 Ronald Davis, MD, Dir. Office on Smoking and Health Department of Health & Human Services 5600 Fishers Lane Rockville, MD 20857 Nicotine Addiction Edwin Fisher, Jr., PhD Dept. of Psychology, 215 Eads Hall Washington University One Brookings Drive St. Louis, MO 63130 American Lung Association Jack Henningfield, PhD Addiction Research Center National Institute on Drug Abuse 4940 Eastern Avenue Baltimore, MD 21224 Federal Regulation of Tobacco John Oates, MD, Prof. & Chairman Dept. of Medicine-Vanderbilt University Medical Center North B 3218 School of Medicine Nashville, TN 37232 American Heart Association Senator Jeff Bingaman The United States Senate Washington, DC 20510 William T. McGivney, PhD, Dir. Div. of Health Care Technology American Medical Association 535 North Dearborn Street Chicago, IL 60610 Tobacco Excise Tax Congressman Michael A. Andrews U.S. House of Representatives Washington, DC 20515 Jeffrey E. Harris, MD, PhD Dept. of Economics, Bldg. E52-171 Massachusetts Institute of Technology Cambridge, MA 02139 Protecting Non-Smokers Congressman Richard J. Durbin U.S. House of Representatives Washington, DC 20515 John M. Pinney, Exec. Dir. Institute for the Study of Smoking Behavior and Policy Harvard University, JFK School of Govern. 79 John F. Kennedy Street Cambridge, MA 02138 Tobacco Marketing and Promotion Congressman Mike Synar U.S. House of Representatives Washington, DC 20515 Kenneth Warner, PhD Dept. of Public Health Policy & Admin. School of Public Health University of Michigan 1420 Washington Heights Ann Arbor, MI 48109-2029 American Heart Association Tobacco Agricultural Policy James A. Swomley Managing Director American Lung Association 1740 Broadway New York, NY 10019 International Trade Congressman Chester G. Atkins U.S. House of Representatives Washington, DC 20515 William M. Tipping, Exec. V.P. American Cancer Society 1599 Clifton Road, N.E. Atlanta, GA 30329 William R. Hendee, PhD, V.P. Science & Technology Group American Medical Association 535 North Dearborn Street Chicago, IL 60610 67 7bbacco Use in Anze~•ica Coi;ference TIMN 2953-1-8 .

Tobacco Use in America Conference • January 27-28, 1989 Gregory N. Connolly, DMD, MPH Mona Sarfaty, MD Participant Roster- Massachusetts Dept. of Public -lealth Senate Labor and Human Resources Tobacco Use in America 150 Tremont Street Committee Conference Boston, MA 02111 Washington, DC 20510 Joseph Ainsworth, MD American Cancer Society U.S. House of Representatives U.T.M.D. Anderson Cancer Center in Grassroots Lobb Box 43 1515 Holcombe g y Dave Kendall Houston TX 77030 Esq. Michael Pertschuk Office of Representative Michael , , Advocacy Institute Andrews C.R. Allen, MD 1730 Rhode Island Ave., NW, Suite 600 DC 20515 Washington AAPHP Washington, DC 20036 , Project Director Giamfortone Joe P.O. Box 171438 , y Texas 76003 Arlington Bill Albers Office of Representative Michael , Albers and Company Andrews David Altman 1731 Connecticut Avenue NW Washington, DC 20515 Stat/Stanford University , ton DC 20036 Washin S 201 Congo Street , g ecretary Deborah Matthews, Press San Francisco CA 94131 Office of Representative Michael , Additional Congressi=nal Andrews Lynn Artz Participant Washington, DC 20515 Office of Disease Prevention Congressman Thomas A. Luken Bill Romjue 2132 Switzer Boulevard U.S. House of Representatives Office of Representative Michael 330 C Street, S.W. Washington, DC 20515 Andrews Washington, D.C. 20201 Washington, DC 20515 Virginia Bales Speaker Center for Disease Control Jim Kessler 3 RM 117 1600 Clifton Boulevard Alan Blum MD Office of Representative Chester C. , , Atlanta GA 30333 Doctors Ought to Care Atkins , Baylor College of Medicine Washington, DC 20515 Dan Ballard 5115 Loch Lomand Susan Lightfoot Clark Thomas Winters Houston, TX 77096 Office of Representative Richard J Newton . Suite 1300 70 Lavaca Durbin , Congressional Staff TX 78701 Austin DC 20515 Washington , Participants , Scott Ballin Jean Perih The United States Senate Office of Representative Don Ritter American Heart Association N.W. 1250 Connecticut Avenue Carrie Billy DC 20515 Washington , , Suite 360 Office of Senator Jeff Bingamai Greg Hodur DC 20036 Washington Washington, DC 20510 Office of Representative James Scheuer , Ross Bannister Joy Silver DC 20515 Washington , American Lung Association Office of Senator Frank Lauten')erg Anne Zeppenfeld 777 Post Oak Boulevard #222 Washington, DC 20510 Office of Representative Pete Stark Houston, TX 77056 Sharon Waxman DC 20515 Washington , Flavia Bare Office of Senator Frank Lauten 3erg John Hollar American Cancer Society Washington, DC 20510 Office of Representative Mike Synar 3000 United Founders Boulevard Wyn Froelich, MD, JD Washington, DC 20515 Oklahoma City, OK 73112 Senate Labor and Human Resi iurces Kaye Drahozal Patrick Baum Committee Office of Representative Bob Whittaker Houston GASP Advisory Board Washington, DC 20510 Washington, DC 20515 , 1945 West Lamar Louise Little Ben Cohen Houston, TX 77019 Senate Labor and Human Resources Energy and Commerce Committee Bauthan, Prof Karl E Committee U.S. House of Representatives . . University of North Carolina at Chapel Washington, DC 20510 Washington, DC 20515 Hill, 08 7400 Chapel Hill, NC 27516 68 Tbbacco Use in America Co?jf'erence TIMN 295379

Tobacco Use in America Conference • January 27-28, 1989 Mary Berger, PhD, MD American Heart Associatio i 10 Suburban Drive West Orange, NJ 07052 Robert Bernstein, MD Commissioner Health State of Texas 1100 W 49th Street Austin, TX 78756 Erwin P. Bettinghaus, Dean Michigan State University 286 CommArts Building East Lansing, Michigan 48324 Holis Bivens M.D. Anderson Cancer Center 1515 Holcombe Blvd. Houston, TX 77030 Kay Bonham Delta Airlines 855 Augusta, #57D Houston, TX 77057 Cheryl Brown American Association of R ispiratory Care 11030 Ables Lane Dallas, TX 75229 Toni Brown American Lung Associatioii 9735 Main Street Fairfax, VA 22031 Kathy Bryant American College of Obstetricians/Gynecolou 1 409 12th Street, S.W. Washington, DC 20024 David Burns MD UCSD Medical Center 225 W. Dickinson Street San Diego, CA 92103-199f- Marilyn B. Byrd 7411 Park Place Boulevard Houston, TX 77087 Lynda Calcote 3499 Santa Monica Abilene, TX 79605 E. L. Calhoon, MD Box 70 Beaver, OK 73932 Craig Campbell P.O. Box 27227 Houston, TX 77227-7227 Susan Campbell American Academy of Pediatrics 1331 Pennsylvania Avenue, N.W. #721 N Washington, DC 20004-1703 Robert Caraway, Jr., MD 2100 Regional Med Drive Wharton, TX 77488 Reginal Carlson New Jersey Gasp 105 Mountain Avenue Summit, NJ 07901 Julia Carol Americans for Nonsmoking Rights 2054 University Avenue, Ste. 500 Berkeley, CA 94704 David Carr M.D. Anderson Cancer Center 1515 Holcombe Houston, TX 77030 Robert M. Chamberlain, PhD U.T. M.D. Anderson Cancer Ctr. 1515 Holcombe Blvd. Houston, TX 77030 Portia S. Choi, MD, MPH Los Angeles County Health Services 612 West Shorb Street Alhambra, CA 91803 Paul Cinciripini, PhD University of Texas Medical Branch Behavioral Medical Laboratory RT D-29 Galveston, TX 77550 Anna Clapper American Lung Association 12104 Camelot Place Oklahoma City, OK 73120 Tom Clapper American Lung Association 12104 Camelot Place Oklahoma City, OK 73120 Betty Cody University of Texas M.D. Anderson Cancer Center 1515 Holcombe Houston, TX 77030 Joel Cohen University of Florida College of Business Gainesville, FL 32611 Neil Collishaw Department of National Health and Welfare Ottawa, Canada KLA OL2 Marianne Corr 1450 G Street, N.W. Washington, DC 20005 Jay Cox American Lung Association 1740 Broadway New York, NY 10019 Mary Crane American Heart Association 1250 Connecticut Avenue, N.W. #360 Washington, DC 20036 K. Michael Cummings, MD Roswell Park Memorial Institute 666 Elm Street Buffalo, NY 14263 William Darity, PhD School of Health Sciences University of Massachusetts Amherst, MA 01003 Alan Davis American Cancer Society 316 Pennsylvania Avenue, SE, #200 Washington, DC 20003 Richard Daynard TPLR, Inc. Box 1162 Back Bay Annex Boston, MA 02117 Karen Deasy Parklawn Building 5600 Fishers Lane Rockville, MD 20857 William de Groot Professor University of Texas Medical Branch Galveston, TX 77051 Chris Deputy American Lung Association P.O. Box 7065 Richmond, VA 23221 7bbacco Use in America Cor;ference 69 TIIVIN 2953861

Tobacco Use in America Conference • January 27-28, 1989 Jo Deutsch Association of Flight Attendarits 1625 Massachusetts Avenue, N.W. Washington, D.C. 20036 Clifford E. Douglas, Esq. Assistant Director Coalition on Smoking OR Health 1607 New Hampshire Avenuc, N.W. Washington, D.C. 20009 Fran Du Melle American Lung Association 1029 Vermont Avenue, N.W. Washington, D.C. 20005 Jim Dunne Houston GASP 11835 Cedar Pass Houston, TX 77077 Catherine Edwards, PhD Texas Medical Association 1801 N Lamar Austin, TX 78701 Michael Ericksen, ScD M.D. Anderson Cancer Cente- 1515 Holcombe Boulevard Houston, TX 77030 Virginia Ernster, PhD University of California Dept. of Epidemiology Box 0560 San Francisco, CA 94143 Richard Evans, PhD University of Houston Houston, TX 77204-5341 Harmon Eyre, MD American Cancer Society University of Utah 50 N Medical Drive Salt Lake City, UT 84132 Leland Fairbanks, MD Arizonans Concerned About `lmoking 1866 E. Vinedo Lane Tempe, AZ 85284 Betty Jean Farb P.O. Box 4509 McAllen, TX 78502 Steve Fenoglio Clark Thomas Winters Newton 700 Lavaca, Suite 1300 Austin, TX 78701 Donald Fernbach, MD Baylor College of Medicine 6021 Fannin Houston, TX 77030 David B. Ferris Friends of Austin Nonsmoker 5603 Chadwyck Drive Austin, TX 78723 June Ferris Texas Department of Health Office of Smoking and Health 1100 W 49th Austin, TX 78756 David Fine Southwestern Bell 1667 K Street, N.W., Ste. 1000 Washington, DC 20006 Paul Fischer, MD Medical College of Georgia Family Medicine Augusta, GA 30912 James Forde California Black Health Network 6069 Rancho Mission Road San Diego, CA 92108 Harold Freeman, MD American Cancer Society Harlem Hospital 135th and Lenox New York, NY 10583 Margaret Garland American Lung Association 93 Cumberland Road Burlington, VT 05401 J. Greg Getz Adj Associate Professor University of Houston Department of Psychology Houston, TX 77004 Charles Gibson Texas Association of Nonsmokers 5201 S. 7th Abilene, TX 79605 Jan Gibson Texas Association of Nonsmokers 5201 S. 7th Abilene, TX 79605 K.H. Ginzel, MD University of Arkansas Dept. of Pharmacology 4301 W Markham Little Rock, AR 72205 George Gitlitz, MD 5 Riverside Drive Binghamton, NY 13905 Stanton Glantz, Ph.D. Medical Center Hospital of Vermont Burlington, VT 05401 Alexander Glassman, MD New York State Psychiatric Institution 722 W. 168th Street New York, NY 10032 Jerome Goldstein, MD American Academy of Otolaryngology 1101 Vermont Avenue, N.W., Suite 302 Washington, D.C. 20005 Jose Gonzalez Laredo Webb County Health Dept. P.O. Box 2337 Laredo, TX 78041 Margarita Gonzalez Texas Medical Association 1801 N. Lamar Boulevard Austin, TX 78701 Nell Gottlieb American Heart Association 104 West 32 Street Austin, TX 78705 Reginald M. Greff Houston Health Department 7411 Park Place, #200 Houston, TX 77087 John Guyton, MD Methodist Hospital Department of Medicine 6565 Fannin Houston, TX 77030 Nancy Hailpern American Cancer Society 316 Pennsylvania Avenue, SE, #200 Washington, DC 20003 Edwin B. Hutchins, PhD Program Director Carter Center 1989 North WiNiamsburg Drive Decatur, GA 80035 70 7bba.eco Use in Ameriea Ca4ference TIMN 295381

Tobacco Use in America Conference • January 27-28, 1989 Lovell A. Jones, MD David Hill Lynn Jones U.T.M.D. Anderson Cancer (;enter Canadian Cancer Society American Hospital Association 1515 Holcombe 99 Bank Street 840 N. Lake Shore Drive Houston, TX 77030 Ottawa, Ontario K1 P 6C1 Chicago, IL 60611 Walter F Leavell MD CANADA . , William Kane PhD President Chesley Hines, Jr., MD , American College of Preventive Charles Drew American Coll. Gastro. Medicine University Med & Science 1514 Jefferson Highway 1015 15th Street, NW, Suite 043 1621 E 120th Street New Orleans, LA 70121 Washington, DC 20005 Los Angeles, CA Russell Hinz Shirley Kellie, MD M. Arnita Hannon American Lung Association Senior Scientist American Lung Association 8 Mountain View Avenue American Medical Association 1029 Vermont Avenue, NW Albany, NY 12205 535 North Dearborn Street Washington, DC 20005 Con Hitchcock Chicago, IL 60610 Robert Harmon, MD Public Citizen Litigation Group Karen Kitchens, MA Missouri Department of Health 2000 P Street, NW, Suite 700 University of Texas, Medical Branch P.O. Box 570 Washington, DC 20036 Behavioral Med. Lab. RT D-29 Jefferson City, MO 65102 Harry Holmes, PhD Galveston, TX 77550 Joyce Hartman, Director Assistant to the President Rear Adm. Harold Koenig Houston Behavioral Center UT M.D. Anderson Cancer Center Dep. Cmdr. Health Care Operations 1200 Post Oak Blvd., #342 1515 Holcombe Blvd. (MEDCOM-03) Houston, TX 77056 Houston, TX 77030 Naval Medical Command Lawanda Hartman Tom Houston, MD Washington, DC 20372 American Cancer Society DOC Lynn Kozlowski, MD P.O. Box 140435 3243 E. Murdock Addict Research Foundation Austin, TX 78714-0435 Wichita, KS 67208 33 Russell Street Kerry Harwood, MSN, RN Lois Hoyt Toronto, Ontario M5S 281 Johns Hopkins Oncology Ceriter American Academy of Family CANADA 2221 Chesterfield Avenue Physicians Ken Kyle Baltimore, MD 21213 600 Maryland Avenue, SW Canadian Cancer Society Rick Hay, MD Washington, DC 20024 77 Metcalfe Street American Heart Association John Hughes, MD Ottawa, Ontario K1 P 5L6 20 N. Wacker, Suite 1240 University of Vermont CANADA Chicago, IL 60606 Dept. of Psychology Diana Lamberson Rebecca Herron 1 South Prospect Street Texas Medical Association American Lung Association Burlington, VT 05401 1801 N. Lamar Blvd. 3520 Executive Center Drive John Hughes, MD Austin, TX 78701 Austin, TX 78731 Vercellino GI Cancer Inst. John Langdon Robert C. Hickey, MD 7000 Fannin, Suite 1240 University of Central Florida Association of American Cancer Houston, TX 77030 Student Health Service Institutes Susan Islam Orlando, FL 32816 1515 Holcombe Blvd., Box 59 American Cancer Society Lynn Lapitsky, MA Houston, TX 77030 1180 Avenue of Americas University of Texas, Medical Branch Glenn Hildebrand New York, NY 10036 Behavioral Med. Lab RT D-29 American Cancer Society Sharon Jaycox Galveston, TX 77550 P.O. Box 2061 American Lung Association Charles LeMaistre, MD, President Oakland, CA 94604 1740 Broadway UT M.D. Anderson Cancer Center New York, NY 1515 Holcombe Blvd. Houston, TX 77030 7bbacco Use in America Conference 71 TIMN 295382.

Tobacco Use in America Conference • January 27-28, 1989 Edward Lichtenstein, PhD Oregon Research Institute 1899 Williamette Eugene, OR 97401 Scott Lippman, MD UT M.D. Anderson Cancer Cent_r 1515 Holcombe Blvd., Box 80 Houston, TX 77030 John Lore, MD St. David Community Hospital 919 E 32nd Street Austin, TX 78705 John Lukeman, MD 1515 Holcombe Blvd. Houston, TX 77030 Henry Macintosh, MD American College of Cardiology P.O. Box 95000 Lakeland, FL 33804-5000 Kenneth MacKenzie IT Corp 10910 Braesforest Houston, TX 77071 Mary MacKenzie Hotelier, Inc. 10910 Braesforest Houston, TX 77071 John Madigan American Cancer Society 316 Pennsylvania Avenue, SE, #200 Washington, DC 20003 Diane Maple American Lung Association 1029 Vermont Avenue, NW Washington, DC 20005 Susan H. Mather, MD Veterans Administration 12144 Long Ridge Lane Bowie, MD 20715 Owen McCrory UT M.D. Anderson Cancer Cent: r 1515 Holcombe Blvd. Houston, TX 77030 Deborah McLellan American Public Health Associadon 10115 15th Street, NW Washington, DC 20005 Ed McMahon 216 7th Street, SE Washington, DC 20003 Donald Meade UT M.D. Anderson Cancer Center 1515 Holcombe Blvd., Box 153 Houston, TX 77030 R. E. Mecklenberg National Cancer Institute 12304 Rivers Edge Drive Potomac, MD 20854 Martin Meltz, PhD 7703 Floyd Curl Drive San Antonio, TX 78284 Angela Mickel Tobacco-Free America 1029 Vermont Avenue, NW, #710 Washington, DC 20005 Henry Miller, Esq. Clark, Gagliardi & Miller 99 Court Street White Plains, NY 10601 Sherry Milligan American Association Respiratory Care 11030 Ables Lane Dallas, TX 75229 Betty Moore Caring for Nonsmokers 7022 S. Janmar Dallas, TX 75230 D. L. Moore Executive Director, TCC 105 Riverside Austin, TX 78759 Cindy Morgan American Cancer Society P.O. Box 9863 Austin, TX 78766 Alfred Munzer, MD Washington Adventist Hospital 7600 Carroll Avenue Takoma Park, MD 20912 Leigh Anne Musser Community Education Specialist U.T. Health Science Ctr.-Educ. Svcs. P.O. Box 20036 Houston, TX 77225 Matthew Myers, Esq. Coalition on Smoking OR Health 1607 New Hampshire Ave., NW Washington, DC 20009 Claudia Nadig State Senator Cyndi Taylor Krier P.O. Box 12068 Capitol Station Austin, TX 78711 Mohan Nadkarni Public Citizen Health Research Group 2000 P Street, NW Washington, DC 20036 W. James Nethery Coalition Healthy Californians 999 N. Tustin Santa Ana, CA 92705 Guy Newell, MD UT M.D. Anderson Cancer Center 1515 Holcombe Blvd. Houston, TX 77030 Linda Nichols American Lung Association 3520 Executive Center Drive Austin, TX 78731 Sam Nixon, MD University of Texas Health Science Center P.O. Box 20367 Houston, TX 77225 Anne Marie O'Keefe Advocacy Institute 1730 Rhode Island Avenue, NW Suite 600 Washington, DC 20003 Joseph T. Painter, MD Board of Trustees American Medical Association 535 North Dearborn Street Chicago, IL 60610 Guadalupe Palos, RN 1511 Christa Lane South Houston, TX 77587 Joe Patterson American Cancer Society 3340 Peachtree Rbad, NE Atlanta, GA 30326 s K~ 1l IMN 72 7bbacco Use in Afnerica Conference

TUbacco Use in America Conference • January 27-28 1 89 Terry Pechacek Clarence Robison, MD Charles Sharp National Cancer Institute American Cancer Society 12400 Wilshire 9000 Rockville Pike 3000 United Founders Blvd. Los Angeles, CA Bethesda, MD 20892-4200 Oklahoma City, OK 73112 Donald Shopland Mark Pertschuk G.A. Robison National Cancer Institute Americans for Nonsmokers Rights University of Texas 9000 Rockville Pike 2054 University Ave., Suite 500 P.O. Box 20708 Bethesda, MD 20892 Berkeley, CA 94704 Houston, TX 77225 Barbara Silvestri-Dore Mike Pertschuk Amy Roome Chicago Lung Association Advocacy Institute American Heart Association 1440 W. Washington 1730 Rhode Island Avenue, NW 1700 Rutherford Lane Chicago, IL 60607 Suite 600 Austin, TX 78759 Carol Sipfle Washington, DC 20003 Jed Rose, PhD Smoking Intervention Billy Philips, PhD V.A. Medical Center 1025 Ashworth Road, #410 Univeristy of Texas Medical Branch Bldg. 29, Room 206 West Des Moines, IA 50265 1100 Mechanic Street Los Angeles, CA 90073 John Slade, MD Galveston, TX 77550 Jack Roth, MD N.J. Comm. on Smoking & Health Ed Pitt, Dir. Health UT M.D. Anderson Cancer Center 166 Montgomery Road National Urban League 1515 Holcombe Blvd. Skillman, NJ 08558-9642 500 East 62nd Street Houston, TX 77030 Susan Yale Smith New York, NY 10021 David Sachs, MD California Medical Association Edward Popper, DBA Smoking Cessation Research Institute P.O. Box 7690 67 Eldredge Avenue 750 Welch Road San Francisco, CA 94120 East Greenwich, RI 02818 Palo Alto, CA 94304-1509 Madeliene Solomon Nita Pyle Susan Schoenmarklin American Heart Association American Lung Association American Cancer Society 20 N. Wacker Drive, Suite 1240 777 Post Oak Blvd., Suite 222 5555 Frantz Road Chicago, IL 60606 Houston, TX 77056 Dublin, OH 43017 Roy Spezia Amelie Ramirez Dr. Charlotte R. Scott Clark, Thomas, Winters & Newton U.T. Health Science Center Jowers Center 700 Lavaca, Suite 1300 7703 Floyd Curl Drive S.W. Texas State University Austin, TX 78701 San Antonio, TX 78284 San Marcos, TX 78666-4616 James Stacey, Director James Reich John H. Scott Media and Information Service American Lung Association Assistant Director American Medical Association 7616 LBJ Freeway Dept. of Congressional Affairs 1101 Vermont Avenue, NW Dallas, TX 75251 American Medical Association Washington, DC 20005 James Repace 1101 Vermont Avenue, NW Dr. R. Craig Stotts U.S. Environmental Protect on Agency Washington, DC 20005 GASP Washington, DC 20460 John Seffrin, PhD 4827 Travis John W. Richards Jr. MD Indiana University, HPER 116 Galveston, TX 77551 , , Medical College of Georgia Bloomington, IN 47405 Barbara Sunderland Augusta, GA Iris R. Shannon 21 Briar Hollow Lane Robert Robinson, DR PH President Houston, TX 77027 Fox Chase Cancer Center American Public Health Association Ed Sweda, Esq. 430B Rhawn Street 1015-15th Street, N.W. GASP Philadelphia, PA 19111 Washington, DC 20005 25 Deaconess Road Boston, MA 02115 7bbacco Use in America Co4ference 73 TIIVIN 295384

Tobac Jo Use in America Conference • January 27-28, 1989 Gayle Thomas Texas Medical Association 1801 N. Lamar Blvd. Austin, TX 78701 Ron Todd Texas Department of Health 1100 W. 49th Austin, TX 78756 Robert S. Toth, MD American College of Legal Medi.,ine 7070 Edgewater Drive Willis, TX 77378-9185 W. E. Townsley STAT-Attorney 3550 Fannin Street Beaumont, TX 77701 Joe Tye STAT 78 Colton Place Longmeadow, MA 01106 Louise Villejo UT M.D. Anderson Cancer Cens_::r 1515 Holcombe Box 21 Houston, TX 77030 DeDe Vinson Potter-Randall County Medical 'bciety P.O. Box 50008 Amarillo, TX 79159 Edgar Vovsi American Heart Association 1181 N. Dirksen Parkway Springfield, IL 62708 M. Jeanne Weigum ANSR 1647 Laurel St. Paul, MN 55104 Raymond Weisberg, MD American Cancer Society 1734 Gough Street San Francisco, CA 94109 Joseph Weller American Lung Association Portland, Oregon 97205 Patrick Wells, PhD Texas South Univresity College of Pharmacology 3100 Cleburne Street Houston, TX 77004 Leonard Wheat American Dental Association 1111 14th Street, NW Washington, DC 20005 Judith Wilkenfield FOTOCO 601 Pennsylvania Avenue, NW Washington, DC 20580 John S. Zapp, DDS Director Division of Government Affairs American Medical Association 1101 Vermont Avenue, NW Washington, DC 20005 Mike Zarski Department of Federal Legislation American Medical Association 434 North Dearborn Street Chicago, IL 60610 Philip Zbylot, MD Utah Health Science Center Austin, TX 78712 Karen Zielaski Nonsmokers, Inc. P.O. Box 12666 Tucson, AZ 85732 Leslie Zoref, PhD Oregon Research Institute 1899 Williamette Eugene, OR 97401 TI-MIN 295385 74 7bbacco Use in Amerzca Gor{ference

A ' American Medical Association 535 N. Dearborn Street Chicago, IL 60610 T1.IVLN 295386