WASHINGTON--The most effective way to reduce tobacco use in both the short and medium term is a $2 per pack increase in the federal excise tax on cigarettes or some other equivalent means to raise the price of tobacco sharply, the National Cancer Policy Board of the Institute of Medicine (IOM) concluded in a recent report.
Rather than an immediate $2 per pack increase, President Clinton, in his State of the Union address, proposed a raise of up to $1.50 a pack over the next 10 years.
"The National Cancer Policy Board believes that a $2 price increment remains the single most effective way of reducing overall tobacco consumption. Such a price increase should also have the desired disproportionately greater impact on preventing the initiation of tobacco use among young people," the panel said.
But to ensure that young people do disavow tobacco, the panel argued that a tax increase alone is not sufficient. Noting that estimates vary widely about how much a 10% price increase could reduce consumption--from 4% to 13%--the board suggested that if tobacco consumption and initiation do not drop with a $2 tax, "taxes on tobacco products should be increased to further reduce demand."
Tobacco taxes should also be indexed to inflation so public health goals are not eroded over time, the board said. Additionally, it urged that financial penalties be targeted to specific brands of cigarettes and other tobacco products. Thus, if a particular brand did not meet targets for reduction in youth smoking, the firm making the brand would be required to pay more into antitobacco campaigns in order to induce further price increases.
The panel called upon Congress to strengthen and clarify the role of the FDA in regulating tobacco products. It also urged congressional enactment of a clear statute for the regulation of tobacco products, as recommended by the Institute of Medicine in its 1994 report, "Growing Up Tobacco Free."
"The need for congressional action regarding the FDAs efforts to restrict tobacco advertising, promotion, and marketing is particularly urgent," the panel said, pointing to a Federal District Court decision in April, 1997, that struck down the agencys regulation of advertising and marketing of tobacco products.
The National Cancer Policy Board was organized to address a number of policy issues, many outside of the scientific research arena. It held its first meeting last spring; after a public hearing in July, the panel chose the issue of tobacco control as the topic of its first policy statement.
In its report, the 22-member body, chaired by Peter Howley, MD, of Harvard Medical School, said that Congress could avoid a lengthy, costly court battle by going ahead now with legislation empowering the FDA to regulate tobacco.
The panel also recommended that the National Cancer Institutes ASSIST program to help state smoking intervention efforts be expanded from a demonstration program in one-third of the states to a nationwide program of aid to all state tobacco control programs.
Expanding this program would provide further data on which interventions work. "The goal for the next decade should be to achieve tobacco control rivaling that in California and Massachusetts, through the use of a combination of state, local, and federal funds and any payments resulting from a national [tobacco] settlement, and to improve the programs in all states through research, demonstrations, and program evaluation," the report stated.
Another priority for Congress, the policy board said, should be to repeal federal preemption of state and local regulation of tobacco advertising and promotion. Current law forbids states from regulating advertising and promotional activities based on smoking and health. "The opportunity for innovation at the state and local levels would be enhanced if this federal impediment were removed, as recommended in the 1994 IOM report."
The board said that all health insurance and managed care providers, as well as Medicaid, should cover programs for tobacco use cessation. The panel pointed out that "many who quit do so only after repeated attempts, so effective coverage cannot be a one-time benefit but must recognize the cyclical nature of quitting, and health programs must provide coverage for repeat attempts at cessation."
Ratings of the quality of health plans should include data on tobacco cessation programs, the panel added. Research priorities should also highlight aspects of treatment for adolescents, since "adolescent smokers have proven to be more resistant to treatment than adults."
Research is needed into "motivation, recruitment, retention, adherence and the long-term effectiveness of behavioral and pharmacological treatments" for youth smoking, the board said. There is need for a grants program that will investigate social, behavioral, and biological questions involved in tobacco control.
More research into tobacco-related diseases and the basic underlying factors of nicotine addiction is also needed. The board called for research that will improve future regulatory strategy, such as how to measure tar and nicotine and how to adjust measurements to take into account actual smoking behavior.
"The board recommends that the federal government create a mechanism to assess current scientific foundations for alternative regulatory strategies and to identify and support areas of research needed to lay the foundation for future regulation," the report said.
More research into "harm reduction" strategies is also necessary, the board added, citing the need for information on whether safer tobaccos should be developed for those who cannot quit, and on the effects of nicotine patches and sprays on nonsmoking teenagers.
The United States should also support international efforts to control tobacco and refrain from trade policies that would undermine such efforts, the board concluded.