Tobacco policy: addressing Public enemy number one.

Tobacco use remains this nation's leading cause of preventable morbidity and mortality. Each year smoking kills over 440,000 people at an economic cost of over $157 billion.

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This includes at least $75 billion in direct medical costs and $82 billion in non-health care costs. In addition, smoking reduces the average life expectancy by as much as 14 years.

Forty years ago the United States Surgeon General issued his landmark report formally documenting the role tobacco plays in causing cancer of the larynx and lung in men and chronic bronchitis in men and women.

Additional reports over the years--27, so far--emphasized the role tobacco plays in certain populations such as youth and women, demonstrated the role tobacco plays in diseases such as cardiovascular disease, low birth weight babies and a range of cancers and in 1986 the dangers of second-hand smoke.

In 1964 when the first report was released, many of the members of the advisory committee, including the Surgeon General were smokers. Today, tobacco use has become generally unacceptable but much more needs to be done to eliminate tobacco use.

Each year over 4,000 children under the age of 18 try smoking for the first time and over one half become regular daily smokers. About 45 million adults remain addicted to tobacco; most desire to quit smoking.

Several important policy initiatives are underway to address the public health concerns of tobacco addiction and will be acted on over the next year.

Surgeon General's report

Forty years after the initial report was released, the Surgeon General again reports to the nation on the effects of smoking.

The report, entitled "The Health Consequences of Smoking: A Report of the Surgeon General," emphasizes the central role tobacco use plays in a broad array of diseases and reports that tobacco negatively affects almost every organ in the body.

The report also attempts to categorize the known information about the role tobacco plays in disease by grouping conclusions concerning the causality of association into one of four categories with regard to strength of the evidence:

* Sufficient to infer a causal relationship

* Suggestive, but not sufficient to infer a causal relationship

* Inadequate to infer the presence or absence of a causal relationship

* Suggestive of no causal relationship.

Legislative initiatives

In March 2000, the U.S. Supreme Court decided that the federal Food and Drug Administration (FDA) did not have the authority to regulate tobacco products. Since then, efforts have been made to pass legislation to expressly give the FDA this authority.

On May 20 this year, U.S. Sens. Mike DeWine (R-Ohio) and Ted Kennedy (D-Mass.) and Reps. Tom Davis (R-Va.) and Henry Waxman (D-Calif.) introduced identical bills in the House and Senate to grant the U.S. Food and Drug Administration (FDA) authority to regulate tobacco products.

The bill known as the "Family Smoking Prevention and Tobacco Control Act" would give the FDA broad authority over tobacco marketing based on considerations of public health and would reinstate the FDA's marketing and youth access restrictions to ensure that tobacco products are not advertised or sold to children.

Also, the bill would require that tobacco products marketed as safer than other tobacco products are in fact demonstrated to be safer, by prohibiting the use of such terms as "light," "low tar" and "mild" unless given specific authority by the FDA.

Tobacco companies would be required to disclose the ingredients and smoke constituents of each tobacco brand. To date, this legislation does not have the support of the congressional leadership or the White House.

Another recent Senate bill (S. 2062, the Class Action Fairness Act of 2004) is designed to halt class action suits against tobacco companies. Currently, residents of all states can participate in a class-action lawsuit brought before their respective state courts. This bill would limit the class of individuals eligible to sue in state court to those within the state where the company is headquartered. All others would have to file in federal court.

The concern of many advocates of tobacco control is the fact that the federal court system is viewed as historically more friendly to corporations. Efforts are under way to amend this legislation to ensure this form of class action litigation remains in the state court system.

Legal action

On May 24, this year, U.S. District Judge Gladys Kessler ruled that the government could seek $280 billion in tobacco industry profits as part of its racketeering lawsuit against cigarette manufacturers. The Department of Justice is pursuing the case under the "Racketeer Influenced and Corrupt Organizations Act," which was created to prosecute those involved in organized crime.

The premise of the racketeering lawsuit is that tobacco companies deceived the public about the dangers of tobacco and the addictive nature of nicotine. Also, the federal government maintains that the companies have deceptively targeted children through advertising.

In addition to seeking the $280 billion that the Justice Department asserts was earned through fraud, the government aims to impose new restrictions on the industry as well, including banning vending machines. The trial, United States of America v. Philip Morris USA. Inc. et al, is scheduled to begin September 13 in the U.S. District Court for the District of Columbia. This case will be followed closely and supported by tobacco control advocates to reduce the incentive to target children for tobacco addiction.

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In the end

Effective efforts to reduce tobacco use would result in significant improvements in health status and free up dollars for other health programs. Physician executives should work within their communities and organizations to support aggressive efforts at tobacco control. It is a leadership issue that requires our support.

Resources

1. www.cde.gov

2. www.tohaccofreekids.org

By Georges C. Benjamin, MD, FACP 

Georges C. Benjamin, MD, FACP, is executive director of the American Public Health Association in Washington, D.C. He can be reached by phone at 202-777-2430 or by e-mail to georges [e-mail]