Tobacco 1
- 1. Tobacco and HealthImplications for Families and Individuals
- 2. Today, what do we know?Studies show that smoking causes…Bladder cancerEsophageal cancerLaryngeal cancerLung cancerOral cancerCerebrovascular disease (stroke)Coronary heart diseaseChronic obstructive pulmonary disease
- 3. Research also shows that smoking is associated with the risk of…Cervical cancerKidney cancerAbdominal aortic aneurysmsReduced lung function among infantsAccelerated decline in lung function with agePerinatal mortalitySudden infant death syndromeConception delayLow birth weight babiesPregnancy complicationsLower bone densityPeptic ulcer disease
- 4. Second Hand SmokeIs associated with increased risks of…Pregnancy complicationsTuberculosisSudden infant death syndromeHeart diseaseLung cancer
- 5. What else do we know?Research shows that smoking cessation reduces the risk of…Pancreatic cancerRespiratory symptoms such as cough, sputum production, etc. Research shows that nicotine is a powerfully addictive drug
- 6. Rates of Smoking in America: 2008Source: CDC, 2009.
- 7. More on smoking ratesAge18-24, 26.9% current, 7.8% former25-44, 25.9% current, 14.5% former45-64, 23.8% current, 29.4% former>64, 10.2% current, 39.3% formerEducation<12 yrs, 27.5% current12 yrs, 27.8% current13-15 yrs, 23.3% current>15 yrs, 11.3% currentIncomeBelow poverty, 19.3% currentAt or above poverty, 23.0% current
- 8. So, how did we get here?The Scientific Research: 1950’sEarly 1950’s, three epidemiological studies link smoking to the risk of developing lung cancer (JAMA, BMJ).1954, BMJ publishes “The Mortality of Doctors and Their Smoking Habits.” Leads many doctors to give up smoking.1957, First Surgeon General declares link between smoking and lung cancer. SG Leroy E. Burney issues “Joint Report of Study Group on Smoking and Health,” stating, “It is clear that there is an increasing and consistent body of evidence that excessive cigarette smoking is one of the causative factors in lung cancer.”Leroy E. Burney
- 9. Scientific Research: 1960’s1962, Advisory Committee on Smoking and Health established and asked to report to the Surgeon General1964, first Surgeon General’s report linking smoking and lung cancer released1964, The AMERICAN MEDICAL ASSN accepts a $10 million grant for tobacco research from six cigarette companies. The AMA shelves its previous plans to issue a report on smoking’s relationship to cancer; the official AMA word on smoking and health won’t be issued for another 10 years1967, second Surgeon General’s report links smoking to heart disease1969, Surgeon General’s reports links maternal smoking to low birth weight babies
- 10. Scientific Research: 1970’s1972, 6th Surgeon General’s report addresses public exposure to air pollution from tobacco smoke and danger of smoking to the unborn child1979, Surgeon General’s report is first to address the risks of smokeless tobacco products
- 11. Scientific Research: 1980’s1988, 20th Surgeon General’s Report: The Health Consequences of Smoking: Nicotine Addiction, A Report of the Surgeon General (C. Everett Koop) calls nicotine “a powerfully addicting drug.” In a 618-page summary of over 2,000 studies of nicotine and its effects on the body, Koop declares, “It is now clear that…cigarettes and other forms of tobacco are addicting and that the actions of nicotine provide the pharmacological basic of tobacco addiction,”.C. Everett Koop
- 12. Federal Government’s Response: 1960’s1960, FTC tells cigarette manufacturers to stop “tar derby” advertising and cease referring to improved health effects of filters1962, Sen. Moss (D-UT) introduces a measure to give the FDA the power to police content advertising and labeling of cigarettes1963, FDA expressed its interpretation that tobacco did not fit the “hazardous” criteria stated in the Federal Hazardous Substances Labeling Act (FHSA) of 1960, and withheld recommendations pending the release of the report of the Surgeon General’s Advisory Committee on Smoking and Health
- 13. 1965, Florida enacts the first statewide preemptive legislation, after a dozen communities adopt clean indoor air ordinances1965, Congress passes the Federal Cigarette Labeling and Advertising Act requiring the following Surgeon Genera’s Warning on the side of cigarette packs: “Caution: Cigarette Smoking May Be Hazardous to Your Health.”…
- 14. Federal Government’s Response: 1970’s1970, President Nixon signs a measure banning cigarette advertising on radio and television, to take effect after January 1, 1971. 1972, Tobacco advertisements, direct mail and point-of-sale material are all required to carry health warnings1979, A residential fire started by a cigarette kills five children and their parents in Westwood, Massachusetts, in the congressional district of Rep. Joseph Moakley. Moakley began a 20-year quest to mandate a fire-safe cigarette. He introduces legislation that would require the U.S. Consumer Product Safety Commission (CPSC) to regulate cigarettes as a fire hazard. His efforts culminate after his death, in the federal Joseph Moakley Memorial Fire Safe Cigarette Act of 2002
- 15. Federal Government’s Response: 1980’s1985: “The Washington Clean Indoor Air Act” prohibits smoking in government facilities, museums, and office buildings, but allows it in restaurants, bars, bowling alleys, and casinos1985: Minnesota enacts the first state legislation to earmark a portion of the state cigarette tax to support smoking prevention programs
- 16. Federal Government’s Response: 1990’s1994, FDA commissioner David Kessler announces plans to consider regulation of tobacco as a drug1995, FDA declares nicotine a drug1995, the 5 largest tobacco companies file suit in a North Carolina court challenging the FDA’s authority to regulate tobacco and advertising1996, FDA releases statements of 3 tobacco industry insiders who claim Philip Morris carefully contains nicotine levels in cigarettes1996, President Clinton approves proposed FDA regulations, giving FDA authority to regulate cigarettes as a drug delivery device1997, NC federal judge William Osteen rules FDA may regulate tobacco as a drug because nicotine is addictive; strikes down provisions to regulate advertising. Ruling is reversed on appeal1999, Supreme Court hears FDA arguments2000, U.S. Supreme Court Rules 5-4 against FDA Regulation of Tobacco, FDA does not have congressional authority to regulate tobacco
- 17. Family Smoking Prevention and Tobacco Control Act of 2009Creates tobacco control center within FDAGives FDA authority to regulate the content, marketing, and sale of tobacco productsRequires manufacturers to reveal all product ingredientsRequires manufacturers to seek FDA approval for new tobacco productsAllows FDA to require changes in products’ contentsCalls for new rules on sales of tobacco products (can’t be purchased over internet)Requires cigarette warning labels to cover 50% of the packageLimits advertising that focuses on attracting young smokers
- 18. State Government’s Response: Sales TaxSource: Campaign for Tobacco Free Kids, 2010.
- 19. State Government’s Response: The AG’s1994, MISSISSIPPI becomes the first state to sue tobacco companies to recoup health care costs associated with smoking through their Medicaid program1997, Attorneys General confirm that they are talking with PM and RJR about a settlement1998, Attorneys General of 46 states and 5 territories sign agreement with tobacco companies to settle lawsuits. ImposesMarketing restrictionsYouth access restrictionsSmoking cessation and prevention programsPayments to states ($206 billion paid out over 25 years)
- 20. Examples of Local Government Responses1977, Berkeley, CA became first community in CA to limit smoking in restaurants and other public places1979, Minneapolis and St. Paul become first U.S. cities to ban the distribution of free cigarette samples1987, Aspen, CO becomes first city in U.S. to ban smoking in restaurants1990, San Luis Obispo, CA becomes first city in the world to ban smoking in all public buildings – including bars and restaurants1992, NYC passes Vending Machine Law: bans distribution of tobacco products through vending machines except those placed at least 25 feet from the door of a tavern1993, Davis CA bans smoking in restaurants1993, LA, CA bans smoking in restaurants
- 21. Why should the government get involved?Asymmetry of information regarding the health consequences of smoking between consumers and tobacco companiesAddictiveness of nicotineNegative health externalities associated with using tobacco productsPowerful profit motives, and lobbying efforts of tobacco companies
- 22. Reviewing…Scientific evidence of the detrimental effects of smoking began to emerge in the 1950’sWe know today that use of tobacco products cause certain types of cancer and heart diseaseUse of tobacco products is also associated with higher risks of acquiring other diseases for smokers and those exposed to second-hand smokeThe federal government has been slow to respond but in 2009 did give the FDA the authority to regulate tobaccoStates and communities have also been involved in this regulatory environment
- 23. So, what’s next?Look at tobacco’s response to the scientific findings and government regulationsImplications for family and consumer healthFocus in on youth and tobaccoMost important point to intervene for changing overall health of families and consumers, with respect to tobacco related illnesses
Editor's Notes
- #2: This week we are going to be focusing on how tobacco affects health and the families within which we live.
- #3: So the story that we are going to tell about tobacco today is one where we need to go back in time, but lets begin by stating what we know about what we know about tobacco today as it relates to health. There are literally thousands of studies that show that tobacco has adverse effects for the individual using it, and for the family and friends of the individual who are also exposed to the tobacco product. Studies show that smoking and also chewing tobacco are associated with a whole range of cancers and cardiovascular diseases, many which are listed here.
- #4: So, while we know that it causes certain types of cancer and cardiovascular disease, causal relationship hasn’t been proven for this diseases, but there are clearly strong associations.
- #5: Again, this is for individuals who are not smokers, but who are living in families where there is a smoker.
- #6: Finally, there is research showing if individuals stop smoking, that they can, in fact, reduce their risks for certain types of cancer. And so there are benefits to having an individual stop smoking. There is also increasing research that shows that nicotine is a powerfully addictive drug, so the story that we have here is a story of a product that is a cause of many serious health problems for Americans, that is linked in an associational way with other serious illnesses, that has spillover or externalities effects for the families in which tobacco users live, in that they can also effect the health of their loved ones and friends, and that if we can get people to stop smoking that we actually improve their health in many ways.
- #7: Nevertheless, as of 2008, according to the CDC,there were approximately 20% of individuals or 1 in 5 who were current smokers, another 20% who were former smokers, and roughly 60% who had never smoked. So, while the majority of the adult population has never smoked, there is a sizeable minority who are either current smokers or were previous smokers. These are individuals who are putting their own health at risk, and putting the health of their families at risk.
- #8: More information about who the smokers are, well, it turns out that young people are the most likely to be current smokers, almost 27% of those age 18-24 were current smokers in 2008, with another almost 8% being former smokers. We see as we go into the older ages of the population, that that balance shifts, with many people actually quitting, so that when you get to older than 64, only 10% were current smokers and 39% were former smokers. People are most likely to smoke if they have less education, those with a college education or more are the least likely to smoke, and interestingly enough, income appears to be positively associated with smoking rates, with those living below poverty being less likely to smoke than those who live above the poverty line.
- #9: So, the question is, how did we get here? If we have this product that is clearly associated with some serious negative health outcomes, how did we manage to get ourselves into this, where we have roughly one in five adults exposing themselves to a hazardous product that has very serious health consequences. Let’s focus first on the scientific research which began in the early 1950’s with 3 studies that were published in the Journal of American Medical Association and the British Medical Journal. Those early studies were the first to identify any possible negative consequences of using tobacco products, So, this was the first time that a public official had come out and identified a scientific link between smoking and cancer risk.
- #10: So, it appeared in the mid 1960’s that the scientific community essentially go hush money from the tobacco industry to keep quiet on the relationship between cigarette smoking and health risks. So, now it had been linked to two very serious health problems, lung cancer and heart disease.
- #11: So, this is basically where we begin to see the issue raised of the health consequences of second hand smoke.
- #12: Really we were talking about a drug here and consumers using a drug.
- #13: This is the first time that the federal government has said that maybe cigarettes should be regulated by the FDA, but unfortunately, the measure did not pass. Essentially they bowed out of the regulatory arena when it came to tobacco. They said it wasn’t their purview, they werent’ going to get involved, because they didn’t have the mandate from congress to do so.
- #14: You could not smoke in certain buildings
- #15: The federal government became more aggressive about their regulation of cigarettes. Where before it was common to see cigarettes prominently placed in television advertising, and that actually supported a lot of television, with that ban, this could no longer be the case, and the networks actually lost a lot of advertising revenue because of this, so it was not a very popular ban. So, his quest was not to regulate cigarettes because they were a drug or hazardous to health, but rather because there was fire safety concerns. Unfortunately he was not successful in getting that legislation passed, that put restrictions on cigarette manufactures to take precautions to reduce the likelihood that unattended cigarettes would cause fires in homes.
- #16: This was the start of restricting indoor smoking activities in public areas.
- #17: In the 1990’s the federal government got very aggressive with their actions to try and regulate tobacco with the goal of improving American’s Health. Suggesting again, that what is really going on here is that tobacco products contain powerful drugs and that the FDA should be allowed to regulate them. So, the FDA is essentially shot down in this 5-4 ruling by the supreme court, and told that they have to back off, they can’t regulate tobacco, even though there is a mountain of evidence that tobacco has serious consequences for American’s health.
- #18: This is a fairly comprehensive set of tasks that have now been given to the FDA with respect to regulating tobacco and one question that could be asked, is the FDA really up to the task? As you can recall from earlier readings and lectures, the FDA really has a limited budget, it is spread very thin in terms of regulating the processed food environment and the drug environment, and so there some detractors that have worried that the FDA without a large infusion of new funds, will find it quite challenging to take on these new regulatory activities.
- #19: While the federal government was slow to move forward, but have now moved forward with tobacco regulation, states have also moved forward. We have talked briefly about this by talking about the actions taken in Florida and Minnesota, in the 1980’s and 1990’s, but state government’s approach to trying to tackle the health problems caused by tobacco has been twofold. First, many states have placed very high sales taxes on tobacco products in order to discourage purchasing them. This shows that state with the very highest sales tax, the lowest sales tax, South Carolina, perhaps not surprisingly because it is a state that grows a lot of tobacco, Intersteingy, Utah is on the low side, We have very low smoking rates in the state, so maybe legislators have not seen the need to raise the sales tax in order to discourage smoking, I know that there has been some discussion, of rasing the sales tax in order to generate more revenue for the state during these tough economic times, and also to continue to reinforce the idea that cigarette smoking is harmful to health. The overall sales tax average is about $1.34 per pack, but if you look at those states that are major tobacco producing states, their average sales tax is only about .40 per package. So really, you have sharp differences in the states’ responses depending on what their economic engine is. Those states where tobacco farmers are political and powerful, those states have a much more low key response to smoking
- #20: The other way that states have responded to the health issues raised by tobacco use, is through the Attorney Generals’ office and this began in 1994 when Mississippi. In association with the federal government, who were paying a lot of money to help low income people with serious health conditions that had come from tobacco use. They had lung cancer, they had heart disease, and it was the state that was picking up that very expensive health care bill. Mississippi said, it shouldn’t be us paying this bill, it should be the tobacco companies that pay for this because it is their product that caused this. Phillip Morris and RJ Reynolds . States could use this money for tobacco prevention programs, smoking cessation programs, general health programs, and in some cases to simply balance their budget,
- #21: Finally, I do want to point out that local governments have gotten involved in this, primarily there are a number of communities that have banned smoking in public places, that may have banned the distribution of free cigarettes samples. So this is really a public health effort that has really had players at many different levels working to discourage the initiation of tobacco use, to encourage people to quit smoking, and to make the environment safe for those who don’t smoke but might otherwise be exposed to second hand smoke.
- #22: We have a lot of government entities involved in the regulating of the tobacco market now, and one might ask, what is it about this market that makes it so important for the government to get involved? In the case of other health care related issues, we let families and consumers make the decisions for themselves, but why should the government be restricting our choice when it comes to tobacco products? Tobacco companies have known for a very long time that nicotine is exceedingly addictive and that many of the additives in tobacco have a causal link to certain types of cancer and heart disease, yet consumers have not been as aware of this linkage between smoking and adverse health conditions. So you see in the 1950’s and 1960’s differences in the information held by the tobacco companies vs the information that consumers had. The government thought it was important to step in and try to level the playing field. In addition, I think that the federal government felt a need to get involved because you can argue this is a question of individual choice and I as a consumer, if I knowingly go into smoking knowing that it could have adverse consequences on my health, what's the bid deal as long as I’m willing to bear those consequences, but we need to recognize, and also the risks to families and friends who might be exposed to second hand smoke. There are also negative health externalities to the states, that many of these health costs are born by Medicaid and Medicare, which means that we all end up paying for the health consequences of smoking, and so the government felt the need to get involved to deal with these market externalities. The last reason that the government has likely become involved is because of the powerful profit and lobbying motives of the tobacco companies. They have been able to marshal their forces to push back whenever there have been calls for more education or more regulation of the tobacco market, and in some instances, they have been quite successful. The 5-4 decision by the Supreme Court was certainly hailed by the tobacco companies. I don’t think that they actually influenced the Supreme Court’s decision, but they certainly tried to get their perspective heard and argue a good case for the court, The court reached an objective decision independently, but certainly hear the tobacco companies’ opinions. SO, the tobacco companies here are a very powerful entity, they have a lot of money, they see that their profits are going to shrink if they aren’t allowed to market their product in the way that they have been able to historically, and so they are very prone to push back against any calls for more consumer information, or for more regulation.
- #23: Continued to grow really through the late 1980’s.
- #24: Talk about the implications of their responses to family and individual health. The most important