With the imminent death of the proposed FDA tobacco legislation and the revelation that this bill resulted from a negotiation between the Campaign for Tobacco-Free Kids and Philip Morris in which the Campaign appointed itself as the sole representative of the tobacco control movement and sold out the public's health for the protection of tobacco industry profits, I believe it is time for the tobacco control movement to abandon the current legislation and go back to the drawing board.
This time, there needs to be an inclusive process in which the entire community is involved in the development of the legislation. It should not be developed by just one group at a negotiating table with a tobacco company.
The discussion should begin by dropping the mistaken notion that the best approach to dealing with the tobacco problem is to give the FDA limited regulatory authority over tobacco products. The idea that the FDA can come up with regulations that would make cigarettes substantially safer is not only absurd, but it is not science-based. There is absolutely no evidence to support such an approach to tobacco control. It is only if we drop our obsession with FDA regulation that I think we can actually develop an effective national strategy to combat the tobacco problem.
In the spirit of putting something on the table which could serve as a basis for further discussion, I present here what I think would be the most effective and meaningful legislation to address the problem of tobacco use.
The Rest of the Story
The basis for an effective tobacco control strategy should be a focus not on the supply side, but on the demand side. Cigarettes are an irredeemably unsafe product and there is no science to support the idea that cigarettes could ever be made safely. Moreover, there is no evidence that interventions that focus on cigarette supply have ever been successful.
In contrast, all of the proven, effective tobacco control interventions have focused on reducing cigarette demand. This is where we should be placing our energy and our resources.
The centerpiece of a national tobacco control strategy should be the single most effective intervention to reduce smoking: a state-of-the-art mass media campaign to educate the public, increase awareness of the important issues, discourage smoking initiation, and encourage smoking cessation.
The American Legacy Foundation has run such an effective campaign - the "truth" campaign. However, due to a dramatic decline in funding, this campaign can no longer have the same kind of impact. An effective national tobacco control strategy would provide a steady stream of funding for a sustained, aggressive, national anti-tobacco media campaign.
While a number of states - such as California and Massachusetts - have run their own highly successful anti-smoking media campaigns, sustaining funding for these programs has been a challenge and the overwhelming majority of states do not have such media campaigns. The second major component of an effective national tobacco control bill - in addition to a national anti-smoking media campaign - would be provision of sustained funding for aggressive anti-smoking media campaigns in all 50 states.
In fact, the coordination of campaigns at the national and state/local levels is an important part of an effective tobacco control strategy. An effective bill, therefore, would provide for sustained funding of tobacco control campaigns - including those using the mass media - at the national level and in every state.
The development and coordination of the national anti-tobacco campaign could either be placed in the hands of a newly created federal tobacco control agency, an existing agency (the Office on Smoking and Health at CDC), or a non-government foundation (such as the American Legacy Foundation). Similarly, the statewide anti-tobacco campaigns could be coordinated at the level of state health departments or by existing or newly-created independent state tobacco control foundations.
Where would the funding come from to support this unprecedented level of tobacco control intervention? The answer is simple: from penalties to tobacco companies that are based on the number of youth smokers who smoke their cigarette brands. It is very easy to determine the number of youths who are smoking and the brands that they are smoking. Based on this information, we could assess penalties to tobacco companies that are based on the market share of their brands among underage smokers.
This funding strategy makes sense for several reasons.
First, it would create a true financial incentive for the tobacco companies not to market their products to youths. In fact, the "target" levels of youth smoking prevalence that would be allowable before penalties are assessed could be gradually reduced over time in an attempt to produce a gradual reduction in youth smoking prevalence.
Second, there is little that the tobacco companies could say in opposition to such a proposal. This would test whether they are truly sincere about their goal of reducing youth smoking. If they are sincere, then they should have no problem developing their own effective campaigns to reduce youth smoking, or at least, to curtail their aggressive marketing practices aimed at underage smokers.
Third, there is no concern about making the anti-smoking funding dependent upon sustained youth smoking. As youth smoking declines, it is true that funding would also decline. However, less funding would be needed. As long as the youth smoking prevalence targets were being met, the goals of the program would be met. Less funding would be needed if fewer smokers needed to be reached. In fact, the ultimate goal of the program would be to reduce the need for the program itself. If smoking rates declined substantially and less revenue were available, that would not be a problem - that would be the goal.
There do exist several pieces of legislation that could serve as the basis for developing this idea. The idea of youth smoking targets was proposed in the McCain bill that ultimately failed in 1997. The idea of gradually reduced smoking prevalence targets with penalties to tobacco companies that would pay for national and state anti-smoking campaigns was proposed by Senator Enzi in legislation he filed this year as an alternative to the FDA tobacco legislation.
Senator Enzi's bill could well serve as the basis for the development of the legislation I propose. The major changes necessary from his proposal would be: (1) relying upon youth smoking prevalence, rather than overall smoking prevalence, to derive the tobacco company penalties; (2) ensuring that all 50 states be allotted funding for anti-smoking campaigns; and (3) placing a clear and unequivocal focus on mass media anti-smoking interventions, rather than youth access, school-based, or other ineffective programs.
The greatest strength of this proposal over the FDA legislation is that it is evidence-based. It is based on very solid science which documents that anti-smoking campaigns - especially those employing state-of-the-art mass media techniques - are the single most effective intervention available to reduce tobacco use.
Unlike the Campaign for Tobacco-Free Kids, which has no evidence to support its contention that the FDA legislation would save "countless" lives, I can provide solid evidence to support my assertion that this proposal would save lives (we could even use the results of published research to count them).
In essence, this is a self-regulating system for the reduction of youth smoking by targeted amounts. If the youth smoking rates do not decline as rapidly as outlined, then more money goes into aggressive anti-smoking programs, which will reduce youth smoking. If the youth smoking rates fall as outlined, then less money will go into anti-smoking programs, but the youth smoking reduction targets will have been met.
I believe that this is a strategy around which all tobacco control groups could rally. It would energize and mobilize the entire movement. It would bring an unprecedented amount of new and sustained funding for tobacco control activities at the national and state levels.
In addition, I believe this is a policy that would have a reasonable chance of Congressional support. Senator Enzi has already thrown his weight behind the proposal, and he is one of the opponents of the current FDA bill.
There is tremendous room for discussion among tobacco control advocates about how the details of such legislation would be worked out. Every organization and advocate could play a role in doing this. Everyone would have a place at the table. There could be inclusion of advocates representing minority groups and special attention to making sure that the interventions supported by the program would be culturally appropriate and targeted, in good part, to communities of color and other disadvantaged or under-served groups.
In contrast to the FDA legislation, which has divided and torn the tobacco control community apart, this proposal would bring the entire movement together and allow much-needed healing to occur.
And unlike the process that led to the FDA legislation, which was and remains secretive because of the Campaign for Tobacco-Free Kids' need to hide the truth, this process could be truly transparent and inclusive.
Finally, unlike the FDA legislation, which had to sell out the public's health for financial security for Big Tobacco because the Campaign needed to keep Philip Morris on board, this legislation would not depend upon tobacco industry support. It is simple and straightforward enough that it would serve as a test of whether a legislator truly stands up to Big Tobacco or not. The current FDA legislation is not such a test because those who support the legislation are actually standing with Philip Morris and those who oppose the legislation can do so on the grounds that they are standing against Philip Morris.
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