A combination of increased excise taxes, nationwide indoor smoking bans, and other measures would significantly lower the U.S. smoking rate, which now hovers at around 21 percent of the adult population, says a new report from the Institute of Medicine. But to achieve faster, more certain reductions, the U.S. Food and Drug Administration (FDA) should be given broad regulatory authority over tobacco marketing, packaging, and distribution, and other revisions to current tobacco policy should be enacted, said the committee that wrote the report.
Although smoking in the United States has declined by more than 50 percent since 1964, tobacco use still claims about 440,000 lives every year, and secondhand smoke causes another 50,000 deaths annually. Smoking-related health costs are estimated to be $89 billion a year.
The report proposes a two-pronged approach to further reduce tobacco use in the United States. The first element focuses on strengthening existing tobacco control measures to preserve and enhance the gains already made. The committee's recommendations include:
These measures focus on reducing demand for cigarettes, but do not address the addictive aspects of tobacco or constrain manufacturers' incentives to attract more smokers. The committee expressed concern that overall smoking rates may not drop significantly below 15 percent and that youth smoking rates may not fall permanently below 20 percent unless the basic legal framework of the tobacco market is changed. Therefore, it proposed a second set of further-reaching recommendations. Specifically, the committee called for:
Cigarettes are a unique consumer product in that they contain carcinogens and other dangerous toxins and would be banned under federal public health statutes if these statutes did not expressly exempt tobacco, the report states. Tobacco is the only legal product for which the government's stated goal is to suppress use altogether rather than to promote safe or responsible use. Moreover, recent revelations of the industry's efforts to manipulate nicotine levels to encourage addiction have eroded the supposition that all smokers have freely assumed the risks of smoking and are solely responsible for the consequences, the committee noted.
"Smoking is a habit with potentially deadly consequences that is often taken up by adolescents before they can truly appreciate the risk of addiction," said committee chair Richard J. Bonnie, John S. Battle Professor of Law and director, Institute of Law, Psychiatry, and Public Policy, University of Virginia, Charlottesville. "We propose aggressive steps to end the tobacco problem -- that is, to reduce tobacco use so substantially that it is no longer a significant public health problem. This report offers a blueprint for putting the nation on a course for achieving that goal over the next two decades."
The desire to educate youth and limit their access to tobacco underlies many of the committee's recommendations because of the high rate at which teens start smoking. Most smokers start before they turn 18, and the rate of daily smoking among high school seniors has hovered around 20 percent for most of the past two decades. Adolescents generally recognize the harmful effects of smoking, but typically overestimate their ability to escape addiction and fail to appreciate fully the personal impact of the long-term health consequences, the report says.
The committee believes that federal regulation is an essential element of a comprehensive approach to tobacco control. Therefore, it urges Congress and the president to give FDA the authority to enforce standards for nicotine reduction and to regulate companies' claims that their products reduce exposure or risk. And the agency should have the authority to restrict the kind or number of outlets that can sell tobacco products and limit how the industry promotes its products.
The committee acknowledged that its recommendations to impose greater restrictions on tobacco advertising may not survive a challenge on First Amendment grounds. However, the report argues that restricting companies' ability to encourage smoking while still enabling them to relay information about the characteristics of their products to consumers satisfies the constitutional rights of the industry and consumers.
As a long-term strategy, the report also recommends that FDA look into developing a plan to gradually reduce the nicotine content of cigarettes and thereby decrease their addictive power. The committee noted that this proposal requires further investigation and careful assessment before it is implemented, but said it offers a reasonable prospect of making it easier for smokers to quit and to decrease the likelihood that youthful or casual smokers would progress to regular smoking.
The study was sponsored by the American Legacy Foundation. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies.
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