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Originally published as JCO Early Release 10.1200/JCO.2003.04.154 on May 31 2003 © 2003 American Society for Clinical Oncology
American Society of Clinical Oncology Policy Statement Update: Tobacco Control—Reducing Cancer Incidence and Saving LivesAdopted on May 23, 2003, by The American Society Of Clinical Oncology From the American Society of Clinical Oncology, Alexandria, VA. Address reprint requests to Suanna S. Bruinooge, American Society of Clinical Oncology, Cancer Policy and Clinical Affairs, 1900 Duke St, Suite 200, Alexandria, VA 22314; email: bruinoos{at}asco.org.
Executive Summary: As an international medical society dedicated to cancer prevention, the American Society of Clinical Oncology (ASCO) advocates a fundamental reform of United States and international policy toward addictive tobacco products. ASCO’s goal is the immediate reduction of tobacco use and ultimate achievement of a tobacco-free world. The centerpiece of ASCO’s policy is the recommendation for an independent commission to study the tobacco problem in all of its dimensions: social, medical, legal, and economic (both domestically and globally). The commission membership should include broad-based representation and expertise on tobacco issues. In ASCO’s view, tobacco control efforts to date have been less than successful because they are too fragmented and incremental, leaving many important issues unaddressed. A more comprehensive solution could flow from this study, including input from a variety of government agencies involved with public health, agriculture, First Amendment and other legal considerations, and international trade. The study, within defined time limits, should culminate in a report that outlines a strategy for achieving immediate reduction of tobacco use and ultimate achievement of a tobacco-free world, including explicit plans and a timetable for implementation. Although this comprehensive approach to tobacco control will take many years to implement even under the best of circumstances, there are certain measures that could be undertaken immediately with meaningful impact on tobacco usage. These include:
THE AMERICAN Society of Clinical Oncology (ASCO) is dedicated to the prevention of cancer and urges a comprehensive assault on addictive tobacco products, which constitute the largest preventable cause of death and disability in developed countries and a rapidly growing health problem in developing nations.1 As physicians and other healthcare professionals, we are entrusted with preventing disease, preserving health, and saving human lives. In addition, as cancer specialists, our commitment is to decrease death and suffering from cancer. Given these charges, we conclude that radical steps are necessary in the near term to reduce significantly the availability and use of tobacco products, which are responsible for 30% of cancer deaths.2 The long-term goal must be the achievement of a tobacco-free world. A strategy to immediately reduce tobacco use and achieve a tobacco-free world is well grounded in science and medicine and is a crucial public health priority. ASCO advocates a thorough re-evaluation of our nation’s policies toward tobacco products, both domestically and internationally. On the domestic front, we should acknowledge that our regulatory efforts to date have been piecemeal and inadequate, and that they should be replaced by a comprehensive science-based initiative addressing all elements of the tobacco problem, with a strategic imperative to increasingly marginalize and eventually achieve a tobacco-free world. Internationally, the United States government must take responsibility not only for its failures to control tobacco use in this country, but also for pursuit of agricultural and trade policies that contribute significantly to disease and deaths from tobacco globally. Finally, as healthcare professionals, we must assume personal responsibility for our actions in combating this worldwide public health scourge.
Public Health Consequences of Tobacco Use The scientific and medical evidence is indisputable that tobacco products cause great harm not only to users, but also to nonusers, creating devastating health consequences and incalculable economic damages in both the United States and abroad. The overwhelming majority of mouth, throat, esophageal, and lung cancers are associated with tobacco use. The mortality of lung cancer is particularly sobering, with nine of 10 people diagnosed with the disease ultimately succumbing to it.1 Perhaps less well appreciated by the public is tobacco’s significant role in the development of a spectrum of other cancers, including, but not limited to, tumors of the bladder, pancreas, uterine cervix, colon, and kidney. In addition, tobacco use is associated with a host of other diseases (among them emphysema, coronary heart disease, stroke, osteoporosis, and reproductive health complications [including erectile dysfunction and infertility]), and thus adversely affects health in the broadest of terms. In the United States, 46.5 million adults,3 approximately 30% of United States high school students, and 10% of United States middle school students4 continue to smoke. Although smokers in the United States are consuming fewer cigarettes per person, the percentage of adults who smoke has remained constant at roughly 25% during the last decade.5 Tobacco use causes an average of more than 440,000 deaths annually at a cost of more than $75 billion in direct medical expenses.6 The National Cancer Institute (NCI) estimates that tobacco is responsible for one in five deaths in the United States, making tobacco use among the most costly, yet preventable, causes of death.2 The problem of tobacco use is not simply a domestic one. Tobacco use rates are increasing worldwide, especially in developing countries. Most of the world’s smokers (82% or 950 million) live in the developing world. Close to half of all men in low-income countries smoke daily, and this number is increasing. In Africa, Asia, South America, and certain areas of Southern Europe, the tobacco epidemic is at an earlier stage than in the United States, so the majority of smokers remain men and boys.7 Nevertheless, women’s tobacco use rates in developing countries are also on the increase. This increase caused the United States Surgeon General to conclude the following in a 2001 report: "Thwarting an increase in tobacco use among women, especially in countries where prevalence is still relatively low, represents one of the greatest disease prevention opportunities in the world today."8 The high rates of tobacco use in the developing world translate to significant mortality from tobacco. According to the World Health Organization and the World Bank, tobacco use kills eight people every minute or more than 4 million people each year. If current trends continue, the global tobacco death toll will grow to 10 million annually by the year 2030, with about half of these deaths in people aged 35 to 69 years.9 By 2030, people from developing countries will account for 70% of all tobacco deaths.9 The young are particularly at risk from tobacco because addiction at an early age results in long-term exposure to deadly carcinogens and other toxins. Preventing children from using tobacco is therefore critical to reducing tobacco’s deadly consequences. Several studies indicate that if tobacco use is not commenced in childhood or adolescence, it is unlikely to be initiated in adulthood.10
Limited Progress There have been additional actions by federal, state, and local governments in the United States and in other nations, as well as voluntary private sector initiatives, to discourage the use of tobacco and educate the public regarding its dangers. These efforts include:
These efforts have achieved positive results and should be commended. However, after smoking rates among men decreased after the Surgeon General’s first report,14 progress seems to have stalled. ASCO is concerned that the number of adults in the United States who use tobacco has remained virtually unchanged over the last decade, rates of tobacco use among racial and ethnic minorities have increased steadily over the last decade, and global use is increasing.3,15,16
A Domestic Strategy for Tobacco Control Regulatory approaches in the United States to date have been unsuccessful in reducing usage below the current, unacceptably high levels of approximately 25% of adults. These efforts, largely conducted through the Federal Trade Commission, the Office of the Surgeon General, and for a short time the United States Food and Drug Administration (FDA), have focused on advertising and information. Little has been done to address the addictive qualities of tobacco products that make cessation so difficult. Moreover, although some agencies of the government have been involved in steps to restrain commerce in these products, others have actively promoted them, not only in this country but also abroad, perhaps especially in developing countries that are least able to deal with the consequences of tobacco use. Fragmented solutions have proven inadequate. A new, more comprehensive strategy is required. Tobacco use permeates many aspects of our culture, domestically and internationally, and has wide-ranging economic and other implications. Every agency of the United States government must embrace a mission to eliminate the public health consequences of tobacco use. To that end, ASCO recommends the immediate formation of an independent commission charged with development of a comprehensive plan for immediate reduction in tobacco use and achievement of a tobacco-free world. The commission membership should include broad-based representation and expertise on tobacco issues. Among the topics for consideration by this study group should be the following:
The last issue is critical, as the mission of the designated tobacco control agency (or agencies) will be complex, multifaceted, and of uncertain duration. At present, tobacco control advocates are united in their belief that the FDA is the agency that is best qualified to provide the scientific expertise necessary to commence a strategy of immediate reduction of tobacco use. However, as the tobacco control effort proceeds, the goal of achieving a tobacco-free world may require a more expansive approach, taking into account the many dimensions of the tobacco problem, including not only scientific questions, but also issues related to agriculture support, tax and revenue collection, trade and international relations, and marketing and advertising restraints in light of First Amendment protections. The independent commission should be charged with the responsibility of assessing the role of the FDA in achieving the goal of a tobacco-free world, considering the extent to which regulatory authority beyond that of the FDA may be required to reach that goal. The full range of options should be considered, among them, expanded authority of the FDA to address matters beyond its current expertise, assignment of responsibilities to agencies other than the FDA, and creation of an entirely new agency with the broad powers and ample resources necessary to comprehensively address the goal of a tobacco-free world.
Immediate Strategies to Reduce Tobacco Use
Restrict access by children and teenagers. The powerful, early addiction to smoking may be partly caused by the fact that teenagers seem to become addicted to nicotine at a faster rate than adults. NCI-supported research demonstrates that children do not need to be daily smokers to become dependent on nicotine and experience withdrawal symptoms. In a group of children aged 12 to 13 years who smoked one or more cigarettes a month, 63% reported experiencing at least one symptom of nicotine dependence.2 Some data also indicate that approximately 20% of high school students exhibit substantial levels of nicotine dependence comparable with those experienced by adult smokers.20,21 Because early tobacco use may lead to a life of tobacco addiction and serious health consequences, restricting children’s access to tobacco must be a fundamental element of any tobacco control program. Despite state laws prohibiting the sale of tobacco products to minors, children are able to buy such products easily. Roughly half of all young smokers buy their own cigarettes directly from retailers, from vending machines, or by giving money to others to buy for them. Another third usually receive cigarettes from others for free, and shoplifting or stealing is the source for a smaller but significant percentage of children who smoke.22 ASCO recommends the following actions to reduce adolescent access to tobacco products:
Increase tobacco excise taxes. As of March 1, 2003, the federal tobacco tax is 39 cents per pack. Taking into account the state tax increases scheduled to take effect in 2003, the average state tobacco tax is 67.3 cents per pack, ranging from $1.51 in Massachusetts to 2.5 cents in Virginia. The average tax in major tobacco-producing states (KY, VA, NC, SC, GA, TN) is 8.25 cents, and 76.2 cents in all other states. As a result of state budget shortfalls, several states are considering tobacco tax increases to raise revenue. In addition, there are numerous local taxes, such as the $1.50 tax per pack in New York City.27 Several studies demonstrate that increases in the price of cigarettes significantly affect children’s likelihood to smoke. Among teenagers especially, increasing taxes on cigarettes will lead to significant reductions smoking frequency and prevalence.28–30 In 1989, when California increased its tax on tobacco products by 25 cents, there was a 17% decrease in smoking. In 1992, Massachusetts increased its tobacco tax by 25 cents and an 18% decrease in cigarette sales was observed in the first 18 months. In Canada, total cigarette consumption declined by more than 20% from 1980 to 1989, as the real price of tobacco products increased by 101%. Conversely, reductions in tobacco taxes may result in increases in smoking rates. For example, Canadian youth smoking increased for the first time in nearly 15 years when Canada reduced tobacco taxes to combat smuggling.31 A subcommittee of the United States Department of Health and Human Services Interagency Committee on Smoking and Health issued a report in February 2003 recommending a $2 increase in the federal excise tax. The subcommittee argued that the increase could prevent 3 million premature deaths and help 5 million people in the United States quit smoking within a year.32 ASCO commends the subcommittee for its recommendation and endorses a substantial increase (a minimum of $2) in the federal excise tax on cigarettes and other tobacco products. ASCO also supports increases in state tobacco taxes (a minimum of $1 per pack) and urges prompt action to boost the rate in those states where taxes are well below this level. We suggest that the Department of Health and Human Services Committee consider proposing a system of incentives to persuade the states to boost their excise taxes. In addition, evidence indicates that, in the face of price increases, tobacco users may substitute use of one tobacco product for another.26 ASCO is concerned that a dramatic increase in the tax of cigarettes may lead cigarette smokers to the use of less expensive—but nonetheless harmful—alternative tobacco products. Allowing this shift to occur would undermine the health benefits of a tax increase. Therefore, ASCO recommends that local, state, and federal tax policies apply proportionately to all types of tobacco products.
Allocate state tobacco settlement funds for tobacco prevention and cessation. There is some evidence that comprehensive state initiatives to reduce tobacco use are effective. In 1988, California became the first state to increase tobacco taxes and dedicate a portion of the revenues to a comprehensive tobacco-use prevention program. As a result of the initiative, California’s smoking prevalence decreased by nearly 5% and per-capita cigarette consumption was nearly halved from 1988 to 1999. In addition, California residents observed greater declines in lung and bronchus cancer incidence rates compared with those in the rest of the country.35 Massachusetts and Oregon also reduced cigarette consumption by combining tax increases and tobacco prevention and education programs.36,37 ASCO believes that it is imperative for all settlement funds to be dedicated to health-related projects, including medical treatment, biomedical research, and tobacco prevention efforts. It is not appropriate to expend these settlement funds on matters utterly unrelated to health care and research. States should also be discouraged from embarking on long-term funding schemes that are based on settlement funds, such as the plans under consideration by some states to issue tobacco settlement bonds. This reliance on tobacco-related financing may undermine efforts to restrict future tobacco use.
Restrict advertising and promotion. ASCO proposes measures to restrict tobacco advertising, promotion, and misleading claims, especially those directed at children. At a minimum, such national efforts should:
Significant attention should also be paid to the portrayal of smoking and the use of tobacco products in movies and television. Too often, smoking is presented on screen as a fashionable, desirable, and trendy activity. We should not underestimate the impact that these images have on audiences in the United States and internationally, particularly the young. Data indicate that exposure to smoking by characters in movies strongly and independently promotes smoking among adolescents who view those movies.41 ASCO challenges the entertainment industry to end these popularized tobacco-use depictions in movies and television programs.
Immediately require disclosure of ingredients.
Enhance public education. Education funds should be specifically targeted at preventing young people from smoking and using other tobacco products. The Surgeon General concluded in a 1994 report that nearly all first-time tobacco use occurs before high school graduation, indicating that successful prevention efforts within these ages will significantly decrease the number of people who smoke in adulthood.10 In addition, a 2000 Surgeon General report found that educational strategies, combined with community- and media-based activities, can postpone or prevent smoking onset in 20% to 40% of adolescents.23 Because parents are the first and, in many cases, most significant influence on younger children, educational programs might be more effective if parents are included, particularly if the parents are smokers.42–44 Another area that requires particularly enhanced attention is tobacco use among women and girls, which has led to a 600% increase in women’s deaths from cancer; this has been referred to by the Surgeon General as a "full-blown epidemic."8 The rate of tobacco use by girls and young women increased from 27% to 34.9% between 1991 and 1999.45 Fortunately, rates are beginning to decline, but they remain unacceptably high. A contributing factor to the increase in female smoking is marketing efforts with themes targeted at women. Women are particularly susceptible to advertising campaigns that describe cigarettes as "slims" or "thins," such as the successful Virginia Slims campaign launched by Philip Morris.46,47 Fears about gaining weight while trying to quit may make women and girls more reluctant to try cessation. Once they become smokers, women have a more difficult time quitting than do men.48 Girls and women aged 12 to 24 years are more likely to report being unable to cut down on smoking than are men and boys of the same age.10 In the 1980s, increased use of tobacco among women caused lung cancer to overtake breast cancer as the leading cause of cancer death of women, a fact not fully appreciated by women when they consider their various health risks. The American Cancer Society estimates that 68,800 women will die of lung cancer and 39,800 women will die of breast cancer in 2003.49 The dramatic increase in lung cancer deaths occurred in the last 50 years. Only 3% of all cancer deaths among women were associated with lung cancer in the 1950s, but lung cancer rapidly increased to cause 25% of all women’s cancer deaths in 2000.8 Women who smoke are also particularly susceptible to cervical dysplasia and cancer, especially if they also use oral contraceptives. Treatment for cervical or uterine cancer (or both) can result in permanent infertility, which is another fact that is not fully appreciated by women. Evidence also strongly links female smoking to increased risks for other cancers as well. Female smoking also increases risk for accelerated osteoporosis.50 Health professional societies and public health organizations should work together with organizations focused on women’s issues to incorporate tobacco-use prevention and cessation more prominently into the broader women’s health agenda.
Create more effective tobacco cessation services. Both cancer experts and public health officials recognize the important role played by healthcare providers in helping people to quit smoking. The NCI recommends follow-up "intensive treatment (pharmacologic and counseling by a smoking specialist) for those having difficulty quitting or remaining abstinent."51 Increasing the number of people who attempt to cease using tobacco depends in large part on the involvement of a caring healthcare professional. The United States Public Health Service (PHS) issued a treatment guideline to aid healthcare providers in treating tobacco dependence.52 The PHS Guideline asserts that significantly more smokers would quit each year with advice from their physician regarding smoking cessation. Some data indicate that approximately 70% of tobacco users visit a physician each year.53 Unfortunately, studies indicate that a minority of those smokers who visited a physician were offered assistance or follow-up in ending their addiction.52 In keeping with its goals to improve patients’ health, prevent cancer, and enhance the knowledge and training of healthcare providers, ASCO makes a number of policy recommendations to help more individuals successfully end their deadly addiction to tobacco:
Target use of noncigarette tobacco products.
The regulation and taxation of tobacco products should be consistent across all types of tobacco products. In particular, researchers have concluded that "control of cigar and pipe smoking is as important as cigarette smoking control for the prevention of lung cancer."67 In addition, public education campaigns should focus on the specific healthcare dangers inherent in noncigarette tobacco products, especially in cultures where use of these products is more accepted.
Eliminate public exposure to secondhand smoke. Eliminating exposure to secondhand smoke will have the immediate benefit of reducing public health risks and the indirect benefits of reducing tobacco consumption, encouraging people to quit, and presenting more positive role modeling for children. According to the tobacco industry’s own research, a total ban on tobacco use in the workplace would not only decrease consumption by 10% to 15%, but also increase cessation rates by 70% to 80%.71 ASCO firmly supports state and local efforts to ban tobacco use in all public spaces, including all bars, restaurants, workplaces, and healthcare facilities.
Assist tobacco farmers.
Enhance research efforts. The following topical areas merit specific research attention:
The federal government should enhance its leadership role in conducting and supporting research in these and other areas, and partnering, when possible, with private organizations. ASCO also acknowledges the important contributions already made by many private and nonprofit groups that have an established interest and track record in tobacco addiction, cessation, and control research.
Enhance global tobacco control. This complicity of United States policy in global tobacco use must cease. Specifically, United States trade officials should refrain from expenditure of government funds and influence to promote tobacco products in other countries. Moreover, the United States should give health and safety concerns related to tobacco-use primacy over other trade issues or agreements, especially within the context of international trade conventions. Other countries should impose their own rigorous regulatory regimes, with special emphasis on discouraging children from tobacco use. At a minimum, ASCO supports effective international polices and treaties containing the following elements:
ASCO understands that cultural variety requires a multiplicity of approaches suitable to local conditions and values. Accordingly, ASCO supports national autonomy in devising specific regulatory regimes but urges that each country embrace ASCO’s mission of immediately reducing tobacco use and ultimately attaining a tobacco-free world. A special concern is raised by countries that derive a significant portion of their overall revenue from operation of tobacco enterprises, and thus may have a fundamental aversion to tobacco cessation. To address these and other situations in which national authorities may be disinclined to adopt antitobacco postures, ASCO recommends that United States financial assistance to such countries be made dependent on progress against tobacco use. In addition, in extreme circumstances in which national authorities fail to address the problem of tobacco usage by children, such national policy should be considered a violation of international human rights.
Take responsibility as healthcare professionals. In addition, healthcare professionals must advocate for public and private insurance coverage of medically necessary—and often ongoing and time-sensitive—interventions, including cessation services and treatment of tobacco-related diseases. Cancer specialists and primary care providers must work in concert to address the significant problems posed by their patients’ tobacco use. In light of our responsibility as healthcare professionals and cancer specialists, ASCO previously adopted a policy prohibiting the Society’s investment in tobacco companies.
To date, comprehensive efforts at tobacco control, both in the United States and globally, have been unsuccessful, except in limited circumstances. A dramatic new approach is needed. ASCO supports a total re-examination of our tobacco control strategy, with a goal of immediate reduction of tobacco use and the ultimate achievement of a tobacco-free world. Both the United States and its international partners should explicitly adopt the mission of immediate significant reduction of tobacco use and the goal of a tobacco-free world. In furtherance of those ends, United States trade policy must subjugate the economic interests of tobacco to the larger needs of global public health.
This policy statement was reviewed and transmitted to the ASCO Board of Directors by ASCO’s Public Issues Committee: John E. Niederhuber, MD, Chair (University of Wisconsin Comprehensive Cancer Center, Madison, WI); Arlene A. Forastiere, MD, Past Chair (Johns Hopkins Oncology Center, Baltimore, MD); Maria Quintos Baggstrom, MD (University of North Carolina at Chapel Hill, Chapel Hill, NC); Lodovico Balducci, MD (H. Lee Moffitt Cancer Center, Tampa, FL); Linda D. Bosserman, MD, FACP (Wilshire Oncology Medical Group, Inc., Pomona, CA); Jay L. Bosworth, MD (Long Island Radiation Therapy, Manhasset, NY); Marcia Brose, MD, PhD (Hospital of the University of Pennsylvania, Philadelphia, PA); Michael Goldstein, MD (Brookline, MA); Larry D. Cripe, MD (Indiana University Cancer Center, Indianapolis, IN); Michael Fisch, MD, MPH, Gabriel N. Hortobagyi, MD, and Leonard Zwelling, MD, MBA (M.D. Anderson Cancer Center, Houston, TX); Dean Gesme, MD (Oncology Associates of Cedar Rapids, Cedar Rapids, IA); Bruce G. Gordon, MD (University of Nebraska Medical Center, Omaha, NE); Julie Gralow, MD (University of Washington–Seattle Cancer Care, Seattle, WA); Steven M. Grunberg, MD (University of Vermont Medical Center, Burlington, VT); V. Suzanne Klimberg, MD (University of Arkansas for Medical Sciences, Little Rock, AR); Timothy Kuzel, MD (Northwestern University Medical School, Chicago, IL); Lawrence S. Lessin, MD, MACP (Washington Cancer Institute, Washington Hospital Center, Washington, DC); Richard Pazdur, MD (Food and Drug Administration, Rockville, MD); David G. Pfister, MD (Memorial Sloan-Kettering Cancer Center, New York, NY); Carolyn D. Runowicz, MD (St. Luke’s-Roosevelt Hospital Center, New York, NY); Steven E. Come, MD, and Lowell E. Schnipper, MD (Beth Israel Deaconess Medical Center, Boston, MA); Lynn M. Schuchter, MD (University of Pennsylvania Cancer Center, Philadelphia, PA); Ellen V. Sigal, PhD (Friends of Cancer Research, Washington, DC); Ellen Stovall (National Coalition for Cancer Survivorship, Silver Spring, MD); and John H. Ward, MD (University of Utah School of Medicine, Salt Lake City, UT). Others involved in development and review of the policy statement include: Heine H. Hansen, MD, PhD (Finsen Center, Copenhagen, Denmark); Jamie Ostroff, PhD (Memorial Sloan-Kettering Cancer Center, New York, NY); Bernard Levin, MD, and Alexandre Prokhorov, MD (M.D. Anderson Cancer Center, Houston, TX).
ASCO sincerely appreciates the contributions of the Public Issues Committee (PIC), which devoted significant time and effort to this project. The efforts were led by Paul Bunn, MD, ASCO President (University of Colorado Cancer Center, Denver, CO) and David G. Pfister, MD, Chair of the PIC Working Group (Memorial Sloan-Kettering Cancer Center, New York, NY). A list of Committee members and other project participants appears in the Appendix.
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
