[C-U Smokefree] More re smoking

[Alan.Cohen at med.va.gov]

See especially highlighted area toward the end:

New England Journal of Medicine
Volume 350:293-301  <<...OLE_Obj...>>  January 15, 2004  <<...OLE_Obj...>>
Number 3    <<...OLE_Obj...>>   	
Tobacco Control in the Wake of the 1998 Master Settlement Agreement
Steven A. Schroeder, M.D. 

Tobacco takes an enormous toll on the health of the public as the cause of
440,000 deaths annually in the United States and 4.8 million deaths
worldwide.<http://content.nejm.org/cgi/content/full/350/3/>,<http://content.
nejm.org/cgi/content/full/350/3/> An estimated 8.6 million persons in the
United States have serious smoking-related
illness.<http://content.nejm.org/cgi/content/full/350/3/> The World Health
Organization projects that by the year 2030 the use of tobacco will kill 10
million persons annually - including 7 million in developing countries -
which will make tobacco use the world's leading cause of preventable
death.<http://content.nejm.org/cgi/content/full/350/3/> 
In 2001, the prevalence of smoking in the United States stood at 25.5
percent among men and 21.5 percent among women, down from the peaks of 57
percent among men in 1955 and 34 percent among women in
1965.<http://content.nejm.org/cgi/content/full/350/3/> Rates of smoking have
plateaued, however, since
1990.<http://content.nejm.org/cgi/content/full/350/3/> The prevalence varies
by state, ranging from 31 percent in Kentucky to 13 percent in Utah, and it
is increasingly concentrated in populations that have relatively little
education and low incomes.<http://content.nejm.org/cgi/content/full/350/3/>
Smoking rates are declining in all age groups, except among persons 18 to 24
years of age, among whom the prevalence rose from 23 percent in 1991 to 27
percent in 2000.<http://content.nejm.org/cgi/content/full/350/3/> 
Mental illness and smoking have been closely linked. For example, smoking
rates have been reported to be over 80 percent among persons who have
schizophrenia,<http://content.nejm.org/cgi/content/full/350/3/>,<http://cont
ent.nejm.org/cgi/content/full/350/3/> 50 to 60 percent among persons with
depression,10 55 to 80 percent among those who have alcoholism,11
<http://content.nejm.org/cgi/content/full/350/3/>,12
<http://content.nejm.org/cgi/content/full/350/3/> and 50 to 66 percent among
those who have substance-abuse problems.12
<http://content.nejm.org/cgi/content/full/350/3/>,13
<http://content.nejm.org/cgi/content/full/350/3/> One study estimated that
smokers with coexisting psychiatric or substance-abuse disorders account for
44 percent of all cigarettes smoked in the United States, a percentage that
reflects both the high prevalence of smoking in connection with these
conditions and the fact that patients with these disorders are very heavy
smokers.12 <http://content.nejm.org/cgi/content/full/350/3/> 
Worldwide, it is estimated that 47 percent of men but only 12 percent of
women smoke.14 <http://content.nejm.org/cgi/content/full/350/3/> As compared
with smoking rates among men in other countries, in the United States the
rate ranks in the lowest fifth, but it is higher than in Australia, Sweden,
and many of the developing countries. By contrast, smoking rates among women
in the United States are in the highest third for women worldwide. Globally,
smoking rates among men are highest in Asia (e.g., 67 percent in China, 65
percent in Korea, and 53 percent in Japan), but the rates are also high in
Russia (63 percent), Yugoslavia (52 percent), and Mexico (51 percent). In
almost all nations, women are much less likely to smoke than men; among
women, the smoking rate is a mere 4 percent in China and in Korea (and the
rate is even lower in most Arab countries) but is about 33 percent in
Argentina and Norway.<http://content.nejm.org/cgi/content/full/350/3/> 
In the relatively few countries that have antitobacco policies, government
has provided the essential leadership; the exception is the United States,
where grassroots action and litigation by citizens have generated most of
the changes, including changes that were mediated by laws and regulations.15
<http://content.nejm.org/cgi/content/full/350/3/> In the face of an
aggressive tobacco industry that in 2001 spent $11.2 billion on advertising
and promotion in the United States alone,16
<http://content.nejm.org/cgi/content/full/350/3/> effective control of the
use of tobacco requires multiple policy strategies. Most of the promising
approaches have not been fully implemented.17
<http://content.nejm.org/cgi/content/full/350/3/>,18
<http://content.nejm.org/cgi/content/full/350/3/>,19,20
<http://content.nejm.org/cgi/content/full/350/3/> 
In this Special Report I review the landmark $209 billion Master Settlement
Agreement (MSA) of 1998 between 46 states and the U.S. tobacco industry and,
after a brief history of the MSA, assess its strengths and limitations as an
instrument of tobacco control. Current U.S. tobacco-control policies at the
federal, state, and local levels are summarized, with an emphasis on recent
developments in the area of policy. 
The 1998 Master Settlement Agreement 
The background and terms of the MSA between four major tobacco companies
(Brown & Williamson, Lorillard, Philip Morris, and R.J. Reynolds) and the
states' attorneys general illustrate the tension between the tobacco
interests and those working to protect the public's health, as well as the
conflicting pressures faced by those making tobacco-control policy in a time
of budget deficits. 
Background 
In 1994, which was the year in which David Kessler, then the commissioner of
the Food and Drug Administration (FDA), asserted the agency's authority to
regulate tobacco products, Michael Moore, the attorney general of
Mississippi, and Hubert Humphrey III, the attorney general of Minnesota,
sued the large tobacco companies to recover the costs to their states'
Medicaid programs of treating tobacco-related illnesses. Every state in the
country soon followed their lead. In 1996, a group of attorneys general,
private attorneys, public health advocates, and tobacco-industry
representatives began closed-door meetings to discuss a global settlement,
as it was called, of all public and private litigation. At about the same
time, Florida, Mississippi, Texas, and Minnesota settled with the tobacco
companies on their own. In June 1997, details of the global settlement were
announced. It required Congress to grant the tobacco industry limited
immunity from new lawsuits for past actions and to enact certain public
health provisions. Many advocates of tobacco control, most notably former
surgeon general C. Everett Koop, Kessler, and Stanton Glantz of the
University of California at San Francisco, criticized the global settlement
as not going far enough.21 <http://content.nejm.org/cgi/content/full/350/3/>

In April 1998, legislation to implement the global settlement - which was
sponsored by Senator John McCain (R-Ariz.) and strengthened in response to
criticisms by advocates of tobacco control - was voted out of the Senate
Commerce Committee by a vote of 19 to 1 (with the one negative vote cast by
then senator and now attorney general John Ashcroft).22
<http://content.nejm.org/cgi/content/full/350/3/> However, the legislation
never came to a vote in the full Senate, because its supporters failed by
three votes to overcome a filibuster. The general settlement faltered owing
to lukewarm support by the Clinton administration, ambivalence on the part
of the public health community, and vigorous opposition from the tobacco
industry, which spent $50 million on a two-month campaign that was waged
against the proposed legislation.21
<http://content.nejm.org/cgi/content/full/350/3/> 
Six months later, in November 1998, the attorneys general of the 46 states
that had remained party to the suit did reach an agreement, called the MSA,
with the four large tobacco companies to recover their Medicaid expenses and
to penalize the companies for their deceptive practices.23
<http://content.nejm.org/cgi/content/full/350/3/> Because the MSA did not
address federal regulation or federal programs, it did not require
congressional approval. 
Terms of the Agreement 
In exchange for the states' abandonment of their suits, the tobacco
companies awarded the states $206 billion, to be paid over a period of 25
years and to be used by each state at its own discretion. After that time,
payments will continue to be based on the volume of domestic cigarette sales
by the four companies. Because state attorneys general do not have authority
over state spending, the MSA was silent with regard to the ways in which the
states would spend their funds. Indeed, with the exception of the creation
by the MSA of the American Legacy Foundation for public education and other
tobacco-control activities, which was to be supported for at least five
years at a cost of approximately $1.7 billion, no funds were earmarked by
the settlement. Nevertheless, at the time of the settlement many states
declared their intent to use the funds to help defray the costs to Medicaid
of smoking-induced illnesses.24
<http://content.nejm.org/cgi/content/full/350/3/> In addition, the MSA
required the dissolution of the Tobacco Institute and other
industry-promoting organizations, prohibited advertising targeted to young
people (e.g., the use of cartoon characters such as "Joe Camel" and
billboard advertising), and permitted wide dissemination of industry
documents that had previously been kept secret.21
<http://content.nejm.org/cgi/content/full/350/3/>,25
<http://content.nejm.org/cgi/content/full/350/3/>,26
<http://content.nejm.org/cgi/content/full/350/3/>,27
<http://content.nejm.org/cgi/content/full/350/3/>,28
<http://content.nejm.org/cgi/content/full/350/3/> 
Limitations 
Many tobacco-control elements that had been part of the general settlement
were dropped from the MSA; these included the assignment of jurisdiction
over tobacco to the FDA, strengthened warnings on packages of tobacco,
tighter enforcement of rules banning the sale of tobacco to minors, and
strong regulations in support of clean indoor air.26
<http://content.nejm.org/cgi/content/full/350/3/> The MSA also included
language that later hampered efforts aimed at tobacco control. For example,
the bulk of the funding for the American Legacy Foundation expired after
five years, because the funds depended on the four settling tobacco
companies' maintaining a share of the domestic cigarette market of at least
99.05 percent.28 <http://content.nejm.org/cgi/content/full/350/3/> In
retrospect, that percentage was probably based on erroneous projections. 
In the current climate of fiscal crises, the MSA funds have become an
irresistible target from the perspective of state policymakers to help
address budget deficits and avert new taxes.26
<http://content.nejm.org/cgi/content/full/350/3/>,29
<http://content.nejm.org/cgi/content/full/350/3/> In many states, important
tobacco-control activities - such as the landmark antismoking programs in
Minnesota, Massachusetts, and Florida - are being dismantled. For example,
in 2003 state antitobacco budgets were slashed by 99 percent in Florida and
by 92 percent in Massachusetts. Even before the current fiscal crisis, less
than 5 percent of state funds from the MSA was spent on tobacco control, and
some states spent essentially nothing.25
<http://content.nejm.org/cgi/content/full/350/3/>,29
<http://content.nejm.org/cgi/content/full/350/3/> In fiscal year 2003, 47
percent of the MSA payments went into state budgets, which represents a
sharp increase from 29 percent in the previous fiscal year and from 16
percent in the three preceding fiscal years.24
<http://content.nejm.org/cgi/content/full/350/3/> Some might argue that
because smoking-related Medicaid spending contributes to the states' budget
deficits, the use of payments from the MSA fund to reduce the deficits is
appropriate. Senator McCain, however, thinks otherwise and on November 12,
2003, held hearings on the use of the settlement funds. He opened the
hearings by criticizing the National Governors Association and the National
Council of State Legislators for failing to fulfill their promises.30
<http://content.nejm.org/cgi/content/full/350/3/> According to McCain, at
the time of the settlement there was general agreement that the money would
be used "for tobacco education and treatment of smoking-related
illnesses."24 <http://content.nejm.org/cgi/content/full/350/3/> 
The states are increasingly mortgaging future payments from the MSA through
bond issues and are thereby forfeiting future income for the sake of a
smaller bird in the hand. To date, 20 states and the District of Columbia
have either securitized their future MSA payments or announced their
intention to do so31 <http://content.nejm.org/cgi/content/full/350/3/>
(Gallogly M, Campaign for Tobacco-Free Kids: personal communication). These
transactions are known as "naked bonds," because they transfer risk to the
investors, with no state guarantee of payment. Recently, however, New York
and California have sold tobacco bonds that were backed by state tax
revenues. These states now have a financial incentive to keep the tobacco
industry healthy, because if the companies forfeit their MSA payments, the
financial obligations will revert to the states.32
<http://content.nejm.org/cgi/content/full/350/3/> In an example of the
states' protectiveness toward the tobacco industry, this year 37 state
attorneys general supported the successful effort by Philip Morris to reduce
a $12 billion bond that had been ordered by an Illinois judge as part of a
private suit that is currently under appeal. The states' concern was that if
the tobacco companies were to be bankrupted as a result of high,
court-mandated judgments, then the payments to the states under the MSA
would cease. Thus, the MSA has created perverse incentives for the states to
keep the tobacco industry financially healthy. 
Strengths 
Matt Myers, director of the Campaign for Tobacco-Free Kids and a major
figure in the global-settlement discussions,21
<http://content.nejm.org/cgi/content/full/350/3/> said in an interview that
he credits the MSA with "the most significant increase in spending on
tobacco prevention and cessation in history. These funds have forever
changed the debate about the appropriate level of funding for tobacco
control." Certainly, even the paltry state expenditures broadened national
tobacco-control efforts far beyond the earlier isolated examples of state
spending for this purpose. The MSA funded the first important national
countermarketing effort in 30 years (the American Legacy Foundation's
"truth" campaign), which, along with increased tobacco taxes and other
factors, has reduced the smoking rate among young people to a 27-year low.33
<http://content.nejm.org/cgi/content/full/350/3/> 
To pay for the antitobacco programs required under the MSA, tobacco
companies have increased the price of cigarettes by 45 cents a pack. Given
that the price elasticity of demand for tobacco in the United States is
about -0.4 - that is, for every 10 percent increase in price, there is a 4
percent decrease in demand - the increase may turn out to be the most
important antitobacco benefit of the MSA, leading to both the prevention of
smoking and smoking cessation.34
<http://content.nejm.org/cgi/content/full/350/3/> High prices, however, may
merely raise the age at which people start to smoke.35
<http://content.nejm.org/cgi/content/full/350/3/> 
The MSA has also made more tobacco-industry documents available. Researchers
across the country are poring through these documents and publishing new
revelations based on them about industry practices and tactics.36,37
<http://content.nejm.org/cgi/content/full/350/3/>,38
<http://content.nejm.org/cgi/content/full/350/3/> 
Winners and Losers 
Of course, it would be easier to assess the effects of the MSA if it were
possible to know what would have happened had the 46 settling states instead
pursued separate litigation. How many suits would have come to trial, and
with what results? How many states would have settled separately, and what
settlements would have been reached? Although the answers to these questions
will never be known, the consensus that has emerged is that the public lost
a golden opportunity to improve its health. For example, the two state
attorneys general most involved in both the global settlement and the MSA -
Christine Gregoire of Washington and Michael Moore of Mississippi - as well
as tobacco-control experts such as economist Ken Warner of the University of
Michigan, wish that the states had been more committed to tobacco control.
In Moore's words, "I call it moral treason. The losers are the people in the
states where the legislators have chosen to spend the money on budget
deficits instead of long-term investment in health."24
<http://content.nejm.org/cgi/content/full/350/3/> 
Some saw the tobacco industry as the clear victor. For instance, Myers said
in an interview that the settlement of "the most serious litigation threat
the industry had ever faced, under terms that had little impact on how it
conducts its business and at a cost it was able to pass on to its
consumers," was a boon to the industry. Glantz, in an interview, took an
even darker view: "Probably the tobacco industry will win in the long run,
largely because of the securitization of the money putting pressure on
states to keep tobacco consumption up to get their bonds paid off." 
Glantz and Joseph Califano, Jr., the former secretary of Health, Education,
and Welfare and now the president of the National Center for Addiction and
Substance Abuse at Columbia University, are skeptical that Congress will
ever pass global settlement-type legislation. "The MSA results from the
failure of the U.S. Congress and most state legislatures to do their jobs,"
Califano said in an interview. "The result: the money is being spent to
close budget deficits rather than to stop kids from smoking and help adults
who are hooked. On balance, however, I believe we are far better off with
the MSA than without it, because the alternative was nothing from a Congress
that continues to pander to the tobacco interests." 
Federal, State, and Local Tobacco-Control Policies 
For policymakers, there are three ways to reduce the harm caused by the use
of tobacco: prevent initiation, encourage smoking cessation, and limit
exposure to secondhand smoke. The universe of tobacco-control policies
encompasses a wide variety of interventions that have had varying and often
untested efficacy39 <http://content.nejm.org/cgi/content/full/350/3/> (Table
1 <http://content.nejm.org/cgi/content/full/350/3/>). As summarized in 2000
in the surgeon general's report on reducing tobacco use, "A hierarchy of
effectiveness is difficult to construct."19
<http://content.nejm.org/cgi/content/full/350/3/> That said, the evidence
seems strongest for the effect of tobacco taxes34
<http://content.nejm.org/cgi/content/full/350/3/> and legislation to promote
clean indoor air.58 <http://content.nejm.org/cgi/content/full/350/3/> In
part, this reflects the ease of measuring these effects - taxes are either
levied or not, smoking is either banned in offices, restaurants, and bars or
not - as compared with interventions such as countermarketing. And granted,
there may be mitigating factors, such as the extent to which cigarette
smuggling lowers selling prices or the extent to which laws to promote clean
indoor air are enforced. But such factors pale beside the variable
implementation of, for example, countermarketing efforts (the quality of the
advertisements, the frequency with which they are aired, and the audiences
to which they are targeted). And, in part, the evidence reflects the
likelihood that raising taxes and imposing clean-indoor-air regulations may
simply be more robust ways to reduce tobacco use than implementing programs
to prevent people from starting to smoke or to promote smoking cessation. 
View this table: [in this window]
<http://content.nejm.org/cgi/content/full/350/3/293/T1> [in a new window]
<http://content.nejm.org/cgi/content-nw/full/350/3/293/T1>    Table 1.
Tobacco-Control Policies.   	
 
A full discussion of all the tobacco-control policies listed in Table 1
<http://content.nejm.org/cgi/content/full/350/3/> is not possible here.
Accordingly, I shall focus on four policies - tobacco taxes,
clean-indoor-air requirements, smoking-cessation programs and services, and
a convention on tobacco control sponsored by the World Health Organization. 
Taxation 
The price elasticity of the demand for cigarettes is estimated to range from
-0.3 to -0.5, indicating a decrease in demand of 3 to 5 percent for every
increase of 10 percent in price.19
<http://content.nejm.org/cgi/content/full/350/3/>,34
<http://content.nejm.org/cgi/content/full/350/3/> Thus, it would appear that
one of the best ways to reduce smoking is to raise the cost of tobacco
products through taxation, thereby both encouraging smoking cessation and
discouraging the initiation of smoking. Between 1993 and 2002, the federal
tax on cigarettes rose from 24 cents to 39 cents per pack. In 2002, the
federal Interagency Subcommittee on Cessation, created by the secretary of
Health and Human Services, Tommy G. Thompson, proposed raising the tax to
$2.39 per pack and using the resultant revenues to fund comprehensive
smoking-cessation programs and services, a recommendation that was rejected
by the administration of President George W. Bush.59
<http://content.nejm.org/cgi/content/full/350/3/> 
The rates of cigarette taxes vary greatly from state to state, ranging from
a low of 2.5 cents per pack in Kentucky to a high of $2.05 per pack in New
Jersey, for an average of 66 cents per pack. Not surprisingly, tobacco taxes
are generally lower in states that grow tobacco and in those that have more
smokers.25 <http://content.nejm.org/cgi/content/full/350/3/> Increases in
state taxes either can be legislated or can result from ballot initiatives,
such as the passage of Proposition 99 in California in 1988.60
<http://content.nejm.org/cgi/content/full/350/3/> Recent budget crises have
goaded many states to raise tobacco taxes: 21 states raised this tax in
2002, and another 17 in 200361
<http://content.nejm.org/cgi/content/full/350/3/> (Gallogly M, National
Center for Tobacco-Free Kids: personal communication). Municipal taxes
provide a less powerful deterrent, because residents can easily purchase
cigarettes nearby, where a lower tax is levied. Still, some cities impose a
substantial tax; in New York City, the tax of $1.50 raised the cost of a
pack of cigarettes to more than $7. The effect of tobacco taxes can be
blunted by smuggling, which has become an international issue; countries
vary greatly in the vigor with which they combat smuggling.62
<http://content.nejm.org/cgi/content/full/350/3/>,63
<http://content.nejm.org/cgi/content/full/350/3/> 
Clean-Indoor-Air Initiatives 
The creation of smoke-free public areas has been a major success of the
antitobacco movement in the United States. A poll conducted in 1978 for the
now-defunct Tobacco Institute showed that the nonsmokers'-rights movement
"is the single greatest threat to the viability of the tobacco industry."64
<http://content.nejm.org/cgi/content/full/350/3/> Mounting evidence of the
dangers of secondhand smoke catalyzed action to create smoke-free areas and
gave added support to the nonsmokers'-rights movement, which included the
rights of workers in such industries as transportation and entertainment.
Especially important was the decision of the Environmental Protection Agency
in 1993 to classify secondhand smoke as a carcinogen.65
<http://content.nejm.org/cgi/content/full/350/3/> The establishment of
smoke-free areas has undermined the social acceptability of smoking, and
concern about secondhand smoke has served to counter the tobacco industry's
claim that smoking is a matter of individual choice. 
Since 1973, federal legislation has required passenger airlines to establish
separate sections in the airplanes for smoking and nonsmoking passengers on
domestic flights, and it now bans smoking on all domestic flights, on all
flights to and from the United States, and in most U.S. airports.15 Five
states - California, New York, Delaware, Connecticut, and Maine - have
banned smoking in essentially all public places, including work sites,
restaurants, and bars. (The Massachusetts legislature has passed similar
legislation, and Governor Mitt Romney has announced his intention to sign
the bill when it reaches his desk, in early 2004.) Another 32 states have
imposed partial restrictions against smoking. More than 1600 counties and
municipalities have passed laws to promote clean indoor air (Hallett C,
Americans for Nonsmokers' Rights: personal communication). Increasingly, the
states have become battlefields for legislation to promote clean indoor air;
20 states have passed such legislation in order to preempt efforts by local
communities to enact stricter clean air laws than those required by (usually
relatively weak) state statutes (Hallett C, Americans for Nonsmokers'
Rights: personal communication). Attempts by the Occupational Safety and
Health Administration to control tobacco smoke in the workplace nationwide
were defeated in 2001, after a lengthy campaign by the tobacco industry.66
<http://content.nejm.org/cgi/content/full/350/3/> 
Support of Smoking-Cessation Programs 
Of the 46 million smokers in the United States, 70 percent would like to
quit, but each year less than 5 percent of these smokers are able to quit
without assistance.67 <http://content.nejm.org/cgi/content/full/350/3/> The
odds of successfully quitting smoking can be doubled or even tripled if
counseling, nicotine-replacement therapy, and treatment with drugs such as
bupropion are used.68 <http://content.nejm.org/cgi/content/full/350/3/>
Because government pays half of all health expenditures in the United
States, its payment policies greatly influence smoking-cessation practices.
Medicaid covers some services and drug therapy in support of cessation in 34
states, but a 2001 study of 2 of these states showed that only a small
percentage of patients and providers were aware of the coverage.69
<http://content.nejm.org/cgi/content/full/350/3/> Medicare does not yet
cover prescription drugs, nor does it provide a separate payment for
outpatient smoking-cessation counseling. Coverage for smoking-cessation
programs for federal employees is also spotty. Neither the military, despite
its history of giving free cigarettes to the troops, nor the Indian Health
Service, which provides health care to a population that smokes heavily, has
developed a comprehensive program to identify and treat smokers. 
The Veterans Health Administration (VHA) is poised to serve as a model
health care system for smoking cessation. Among veterans, the smoking rate
is higher than that in the general population, 33 percent as compared with
23 percent, and veterans are heavier smokers as well. Among veterans of the
Vietnam war, the prevalence of smoking is 47 percent.70
<http://content.nejm.org/cgi/content/full/350/3/> In 1997, the VHA mandated
that veterans cared for in its system be asked about smoking and that
smokers be counseled. Subsequently, the reported percentage of veterans
asked about smoking rose from 49 percent in 1996 to 95 percent by 1999, and
the reported percentage of smokers counseled increased from 33 percent in
1996 to 93 percent by 1999.70
<http://content.nejm.org/cgi/content/full/350/3/> These rates are
substantially higher than the rate among members of the private health plan
that was reported to have the best performance (68 percent of smokers
received advice to quit), according to the National Committee for Quality
Assurance.71 <http://content.nejm.org/cgi/content/full/350/3/> Only 38
percent of all smokers covered by Medicare who were hospitalized as the
result of an acute myocardial infarction in 2000 and 2001 received
smoking-cessation counseling, as compared with 62 percent of similar
patients in VHA facilities in 2000.72
<http://content.nejm.org/cgi/content/full/350/3/> Fewer than half of the
smokers receiving care from the VHA, however, received drug therapy to aid
smoking cessation, reflecting variable local coverage policies.70
<http://content.nejm.org/cgi/content/full/350/3/> 
Telephone "quit lines," which are available in 32 states and are available
nationally through the American Cancer Society and the National Cancer
Institute, greatly enhance the probability that smokers will quit,
especially when the quit lines can provide a personal interaction with
callers. So far, however, quit lines have been used by only a tiny minority
of smokers.29,73 <http://content.nejm.org/cgi/content/full/350/3/> Funding
for quit lines depends on an unstable amalgam of state and voluntary
sources, and as a result not all callers can be served.74
<http://content.nejm.org/cgi/content/full/350/3/> Two states (Oregon and
Michigan) closed their quit lines in 2003 because of budget constraints, and
other states are poised to follow suit. A federally funded national quit
line that would have a toll-free number and that would be linked with a
media campaign to encourage smokers to call the number would be a major
help, as would support for Web-based smoking-cessation services. 
International Trade Policies 
Until recently, the United States opposed the Framework Convention on
Tobacco Control (FCTC), which was sponsored by the World Health Organization
in 2003 and which bans tobacco advertising to the extent permitted by each
country's constitution, mandates aggressive warning labels (see, for
example, Figure 1 <http://content.nejm.org/cgi/content/full/350/3/>),
requires a list of tobacco ingredients on the packages, and imposes other
controls that would end the use of the terms "light" and "mild" on cigarette
packages and would crack down on tobacco smuggling.75
<http://content.nejm.org/cgi/content/full/350/3/> On May 21, 2003, shortly
after the United States dropped its opposition, the FCTC was adopted by a
voice vote of the 192 members of the World Health Assembly.76
<http://content.nejm.org/cgi/content/full/350/3/> For the FCTC to become a
binding international treaty, it must be ratified by the legislative bodies
of at least 40 nations. For ratification, a country's administration must
sign the treaty and then refer the treaty to its legislature for approval.
To date, 77 countries have signed the FCTC, but only Norway, Sri Lanka,
Seychelles, Malta, and Fiji have ratified it. Whether the Bush
administration will support the FCTC remains to be seen. The U.S. tobacco
industry, which had worked to weaken the treaty, is expected to oppose
ratification. Even if the FCTC is ratified, the vigor with which its
provisions will be enforced will depend on the zeal of each country and will
be greatly influenced by the attitudes and practice of the United States and
its major tobacco-exporting companies. 
 <<...OLE_Obj...>>  View larger version (57K): [in this window]
<http://content.nejm.org/cgi/content/full/350/3/293/F1> [in a new window]
<http://content.nejm.org/cgi/content-nw/full/350/3/293/F1>    Figure 1.
Warnings on Cigarette Packages Produced in Australia (Panel A) and Canada
(Panel B).   	
 
Conclusions 
There are four key ingredients of successful public health efforts - highly
credible scientific evidence, passionate advocates, media campaigns, and law
and regulation, usually at the federal level.77
<http://content.nejm.org/cgi/content/full/350/3/> In the battle against the
harmful effects of tobacco use, the scientific evidence came first, almost
50 years ago, and since then advocates of tobacco control have engaged in a
four-decade battle against the U.S. tobacco industry.15
<http://content.nejm.org/cgi/content/full/350/3/> Except for a two-year
national media campaign against tobacco use in the late 1960s, there was
little counteradvertising about tobacco until the mid-1990s, and initially
it was run in only a few states until the recent MSA-funded American Legacy
Foundation's campaign. At the same time, government initiatives,
particularly federal antitobacco efforts, have been relatively weak. In
addition to the 440,000 Americans who die each year from smoking, another
8.6 million suffer from serious tobacco-induced
illness.<http://content.nejm.org/cgi/content/full/350/3/> Although U.S.
smoking rates are slowly declining, progress toward that end would be faster
if federal policymaking matched both the rigor of the scientific evidence
against tobacco use and the resolve of antitobacco advocates. 
Supported by the Robert Wood Johnson Foundation and the Scholar in Residence
program of the Rockefeller Foundation at the Bellagio Study and Conference
Center, Bellagio, Italy. 
Dr. Schroeder is the unpaid chair of the American Legacy Foundation, which
is funded by the Master Settlement Agreement. 
I am indebted to Brian Eule, Elissa Keszler, Victoria Weisfeld, Stephen
Isaacs, and Garfield Mahood for their able assistance. 

Source Information 
>From the Department of Medicine, University of California, San Francisco. 
Address reprint requests to Dr. Schroeder at the Department of Medicine,
University of California at San Francisco, 3333 California St., Suite 430,
San Francisco, CA 94143-1211, or at schroeder at medicine.ucsf.edu
<mailto:schroeder at medicine.ucsf.edu>. 
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