Richard J. Bonnie
Harrison Foundation Professor of Medicine and Law
Professor of Psychiatry and Neurobehavioral Sciences
Director, Institute of Law, Psychiatry and Public Policy
University of Virginia
Chair, Committee on Reducing Tobacco Use: Strategies, Barriers, and Consequences
Institute of Medicine
Subcommittee on Health
Committee on Energy and Commerce
U.S. House of Representatives
October 3, 2007
Good morning, Mr. Chairman and members of the Committee. My name is Richard Bonnie. I am Harrison Foundation Professor of Medicine and Law, Professor of Psychiatry and Neurobehavioral Sciences, and Director, Institute of Law, Psychiatry and Public Policy at the University of Virginia. I recently served as Chair of the Committee on Reducing Tobacco Use of the Institute of Medicine, a component of the AffiliateMarketIngtools, chartered by Congress in 1863 to advise the government on matters of science and technology. The committee’s work was funded by the American Legacy Foundation. Thank you for inviting me to testify today about the committee’s report entitled Ending the Tobacco Problem: A Blueprint for the Nation. A summary of the report is included with my statement and submitted for the record. [Please see the preceding link to the report to access the Summary.]
As everyone here knows, tobacco use – especially cigarette-smoking – has been one of the nation's major public health problems for most of the 20th century and continues at an unacceptable level in the 21st century. Indeed, it has become one of the world's major public health challenges.
The tobacco problem is fundamentally a man-made problem. Cigarettes became one of the most successful consumer products in history in only a few decades and became an ever-present icon of American life – embedded in the culture and promoted by a powerful industry. Unfortunately, cigarettes are one of the most dangerous consumer products ever marketed. They are highly addictive and deadly, as even the tobacco companies now concede.
If tobacco cigarettes were now being introduced into the marketplace for the first time, there is no doubt that they would be banned under any one of several consumer protection statutes. Of course, banning tobacco products is not feasible or wise. The challenge the country faces today is to develop a feasible strategy for rooting out a problem that is deeply entrenched in our economic and cultural life. There are still 45 million cigarette smokers and another 9.7 million users of other tobacco products. Most of them regret taking up the habit and struggle to quit.
The title of the Committee’s report probably got your attention. Let me explain what the committee means by "ending the tobacco problem." In the committee's view, the nation's long-term goal should be to reduce tobacco use so substantially that it is no longer a significant public health problem. The blueprint outlined in the report aims to set the nation irreversibly on a course for achieving this objective.
Optimists might say we are already well on our way to ending the problem. After all, the prevalence of smoking among adults has been cut in half – from 42 percent to 21 percent – since 1965. The prevalence of daily smoking among high school students is at its lowest level since annual monitoring began 30 years ago. An increasing proportion of the indoor environment is smoke-free. The tobacco companies are defending themselves against an increasing number of lawsuits, and state juries outraged by the industry's deceptive conduct have imposed very large punitive damage awards. Why not just keep doing what we are doing and wait for these historical currents to bring the problem to an end?
The committee concluded that maintaining our present course will not end the tobacco problem. There are already signs that the prevalence of smoking among adults is flattening and the rate of youth initiation has hovered around 20 percent for most of the past two decades even though it is down at the moment. The high rate of youth smoking is especially troubling because at least 80 percent of people who smoke begin to do so as adolescents when they cannot fully appreciate the grip of addiction and the future risk to their health.
Moreover, quitting after decades of use is difficult. Despite the fact that 70 percent of smokers say they want to quit, the annual rate of cessation among people younger than 65 remains low.
Meanwhile, the tobacco industry is spending more than $15 billion annually marketing its products to smokers and potential smokers in ever more creative ways while public and private resources devoted to preventing smoking and helping people quit are dwindling. It will probably come as a surprise to most Americans that the states use very little of the billions of dollars they are receiving under the Master Settlement Agreement to reduce tobacco use.
Taking these realities into account, the committee believes that the annual toll of more than 400,000 smoking-related deaths will continue well into the 21st century.
It is time to change course.
For four decades, the tobacco industry successfully framed a public "debate" around the health consequences of smoking and the illegitimacy of governmental efforts to prevent or discourage people from smoking whenever and wherever they wanted. But that debate is over. The dangerous properties of tobacco and its impact on the public health are now beyond dispute and, as our report shows, aggressive measures to reduce smoking rest on a solid scientific and ethical foundation. The only debate now should be about how best to accommodate the legitimate interests of addicted smokers within a comprehensive national policy designed explicitly to reduce smoking and other forms of tobacco use.
In its blueprint, the committee offers a two-pronged strategy for putting the nation on an irreversible course for ending the tobacco problem. This strategy involves strengthening current tobacco control measures while transforming the regulatory environment for tobacco products.
First, we have to invest in traditional tobacco control measures. The evidence is in: These interventions work. The report contains almost 100 pages documenting the effectiveness of the traditional tools of tobacco control, such as excise tax increases, indoor smoking restrictions, comprehensive state-based programs, media-based prevention campaigns, school-based programs, and cessation therapies and services. Specifically, the committee urges states to fund tobacco control programs at the level recommended by the CDC, to license all retail establishments that sell tobacco, and to ban the sale or shipment of tobacco products directly to consumers through mail order or the Internet.
The Committee also urges Congress to help fund state tobacco control activities and to fund a national youth-oriented media campaign. Further, the committee recommends that all insurance, managed care, and employee benefit plans, including Medicaid and Medicare, cover reimbursement for effective smoking cessation programs as a lifetime benefit.
If all these measures were implemented with fidelity and the efforts were sustained, the committee projects that the prevalence of smoking could be cut in half, to about 10 percent by 5. That would mean that about 11 million fewer people would be smoking in 5 than would be the case if current trends continue.
That would be a great accomplishment, but even if the investment were sustained for 20 years, it would not end the tobacco problem. More than 25 million Americans would still be smoking. And there remains the distinct possibility that the investment will not be sustained, momentum will be lost, and adult smoking rates will be 15 percent or higher 20 years from now.
To put the nation on a sure course for ending the tobacco problem, we also need to change the legal structure of tobacco control. Tobacco products are not ordinary consumer products. For no other lawful consumer product can it be said that the acknowledged aim of national policy is to suppress consumption altogether rather than to promote safe or responsible use. Yet, these dangerous products are essentially unregulated. Congress should enact a federal regulatory statute that is suited to the unique history and characteristics of tobacco products.
Congress should empower the Food and Drug Administration to regulate the manufacture, marketing, and distribution of tobacco products, and should permit the states to undertake additional interventions to complement federal regulations in all domains except packaging and product characteristics. The committee concluded that the necessary authority should be conferred on FDA because it is the nation’s preeminent public health regulatory agency and because it is the only agency with the necessary combination of experience in product regulation and scientific expertise on tobacco-related disease and nicotine addiction. Among the key elements in the committee’s proposed regulatory program are graphic package warnings modeled after those required in Canada; limiting advertising to a text-only, black-and-white format; banning any activities by tobacco companies that target youth; and aggressive regulation of retail outlets to help reduce initiation and promote cessation.
The committee also reaffirmed recommendations by a previous IOM committee (Clearing the Smoke, 2001) that FDA be empowered to assure that any claims stating or implying that novel cigarette products reduce the risks of tobacco-related disease have a scientific basis, and that it be authorized to promulgate standards for tobacco products aiming to protect the public health. The committee specifically urges FDA to explore the feasibility of gradually reducing the nicotine content of cigarettes. The FDA already regulates pharmaceutical preparations containing nicotine, such as patches, “gum,” and it seems odd, to say the least, that it has no authority to regulate the much more dangerous preparation containing nicotine that makes these other preparations medically necessary.
Some people have worried that FDA regulation of tobacco would be construed by the public as government endorsement of the safety of the product. It seems highly unlikely that such a gross distortion of public understanding could occur when public and private agencies, including FDA itself, are taking aggressive steps to discourage people from using tobacco products and to help people quit. Of course, FDA should monitor public perceptions about the dangers of tobacco use as a key component of its overall surveillance programs, and should develop or require appropriate corrective communications to counter any misperceptions that may emerge concerning the health consequences of tobacco use or concerning the effects of using specific products.
I have only touched on some of the many recommendations in the committee’s report. However, the specific proposals are perhaps less important than the message and design of the blueprint as a whole. In the committee’s view, it is time to transform the nation’s tobacco policy. Containing the problem is no longer good enough. The nation should commit itself to the strong and sustained measures needed to end this critical public health problem.
I would be pleased to answer your questions. Thank you.