Public Policy Update
In 1997 and 1998, APA's Public Policy Office staff were privileged to be part of one of the largest public health advocacy efforts Washington has ever seen. The agreement between several leading tobacco manufacturers and the State Attorneys General suggested that the United States was finally going to gain some ground in the fight against tobacco dependence. The agreement would have provided much sought after regulatory authority by the Food and Drug Administration (FDA). It also promised a wellspring of funding for tobacco use research, tighter youth access restrictions, strictly prohibited marketing aimed at minors, and more treatment options for those addicted to tobacco.
Congress spent the first half of 1998 trying to codify that agreement, pressured by the tobacco industry on one side and a newly formed coalition of public health groups on the other.
APA became a charter member of that coalition, called ENACT (Effective National Action to Control Tobacco), and spent many a long summer day bunkered at the base of operations--the dining hall of a Holiday Inn on Capitol Hill dubbed the "War Room"--plotting legislative strategy. Sadly, by the fall of 1998, the entire federal legislative package unraveled and a weaker substitute in the form of the Multistate Settlement Agreement took its place. While tobacco control advocates hoped that these state funds would address many of the issues raised by the federal legislation, analyses by the Center for Tobacco Free Kids and others have shown that most of the funds are being spent on programs unrelated to tobacco. The public health community took a further hit when the Fourth Circuit Court ruled against the FDA's regulatory authority, and then again when that ruling was upheld by the Supreme Court on appeal last year.
So, why this disquieting trip down memory lane? Because we are making some progress and psychologists continue to be involved in moving tobacco control forward across research and practice.
Two recent reports have increased the sense of urgency for the FDA's regulation of tobacco and for expanded treatment of tobacco dependence. The first was the Institute of Medicine's Clearing the Smoke, which the FDA commissioned to look at the science base for tobacco harm reduction. As alternative tobacco products are entering the market, the FDA recognized that it would need advice on how to deal with health claims of "reduced-risk" products.
For example, past experience showed that individuals who smoked low-nicotine or low-tar cigarettes actually smoked more of them or smoked them more deeply, essentially negating any intended health benefit. Further, even if new "reduced-risk" products provide a benefit to individuals, increasing rates of initiation or decreasing rates of cessation might injure the overall public health. In addition, the long-term use of standard pharmacological cessation aids in Europe has begged the question as to whether the FDA should approve their long-term use in the United States as a means to help individuals cut down rather than quit tobacco use altogether. Questions raised by the report suggest the need for a new level of surveillance, research and regulation to ensure that new products don't do more harm than good.
A second report, Women and Smoking, continues the Surgeon General's series and expands upon the 1980 report The Health Consequences of Smoking for Women. Because smoking became commonplace for women about 25 years after it did so for men, there was a commensurate delay in the cumulative morbidity and mortality related to tobacco use by women. As a result, serious and gender-specific health consequences have only recently come to light and heighten the importance of developing successful cessation treatments for women. And although smoking prevalence has decreased for men and women since the 1960s, the broad gender gap in smoking behavior declined in the mid-80s and has remained relatively constant ever since.
In addition, the report identifies troubling differences in smoking related to educational attainment: women with nine to 11 years of education are three times more likely to smoke than those with 16 years or more. Further, although the number of women who smoke during pregnancy has steadily declined over the years, only about one-third of those who quit during their pregnancy are still abstinent a year after the birth. So perhaps now more than ever, women need help quitting.
Good news ahead?
Fortunately, this Congress appears poised to take action on tobacco but with many false starts on the legislative calendar we can only be cautiously optimistic. This year APA was invited to join the ENACT Management Team and, along with the American Heart Association, American Cancer Society and the Campaign for Tobacco Free Kids, will play a central role in setting ENACT's agenda for tobacco control. Included in the current portfolio of activities are a number of legislative initiatives including:
FDA regulatory authority over tobacco.
Increased funding for the Office of Smoking and Health at the Centers for Disease Control and Prevention.
Reimbursement for tobacco cessation treatment.
Support for the U.S. Department of Justice lawsuit against the tobacco industry in its attempt to recover federally funded health-care costs related to tobacco use.
We hope PPO's advocacy efforts in Washington, D.C., will help augment the efforts of APA scientists in the field who have assumed leadership roles in tobacco dependence research, including Ken Perkins, PhD, president of the Society for Research on Nicotine and Tobacco, and Gary Swan, PhD, editor-in-chief of the journal Nicotine and Tobacco Research.
Others charting new ground are David Abrams, PhD, Dorothy Hatsukami, PhD, Caryn Lerman, investigator at one of the seven Transdisciplinary Tobacco Use Research Centers jointly funded by the National Institute on Drug Abuse, the National Cancer Institute and the Robert Wood Johnson Foundation. Further, Drs. Hatsukami and O'Malley will likely raise the primacy of nicotine addiction in other forms of drug dependence as they begin their new roles as presidents of the College on Problems of Drug Dependence and the Research Society on Alcoholism, respectively.
We salute these APA scientists and the many others past and present who have taken ownership of this research area. Psychologists have clearly demonstrated the pivotal role behavioral science must play as policy-makers consider the options for combatting the nation's leading cause of preventable death and disease.