Meeting Summary
Public and Private Sector Roles in Tobacco Use Reduction
Interagency Committee on Smoking and Health (ICSH)
Hyatt Regency Bethesda
November 06, 2003
9:00 a.m. – 1:00 p.m.
Welcome, Overview and Charge to the Group
Richard H. Carmona, M.D., M.P.H., FACS, Surgeon General
Michael Schooley, Executive
Secretary for the Interagency Committee on Smoking and Health, welcomed
participants to the meeting and introduced the Chair of the Committee,
Surgeon General Richard Carmona.
Dr. Carmona began by talking
about his personal interest in addressing tobacco. Both of his parents died
from smoking related illnesses and as a child, Dr. Carmona suffered from
various health conditions related to his exposure to secondhand smoke. A
trauma surgeon for much of his professional career, he became increasingly
aware that he was, in his words, a surgeon of “societies’ indiscretions.” This led to his current firm belief in the importance of prevention and his
commitment to this issue as Surgeon General.
Dr. Carmona continued by
describing the background and history of the Interagency Committee on
Smoking and Health (ICSH). This committee was established by Congress
under the authority of the Comprehensive Smoking Education Act of 1984. It
reports to the Secretary of Health and Human Services (HHS) through the
Surgeon General and is staffed by the Centers for Disease Control and
Prevention (CDC) Office on Smoking and Health (OSH). The ICSH is charged
with helping to coordinate HHS and other federal research, educational
programs, and other activities related to smoking and health, and provides a
liaison function to appropriate private organizations and federal, state and
local public health agencies regarding smoking and health activities.
New public members of the
committee were introduced.
Michael Fiore, MD, MPH
University of Wisconsin Medical School/Center for Tobacco Research and
Intervention
Madison, Wisconsin
R. Nicolas Trane, MD
Blank Children’s and Methodist Hospital/Department of Radiology
Des Moines, Iowa
Dennis Richling, MD
Union Pacific Railroad
Omaha, Nebraska
Dr. Carmona concluded his
introductory remarks by reviewing the agenda and telling meeting
participants that he would brief Secretary Thompson on the day’s
discussions. He then introduced the first speaker.
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The Federal Government’s
Role to Reach Tobacco Use Reduction Goals.
Dr. Larry Fields, M.D.,
M.B.A., F.A.C.C., Senior Executive Advisor to the Assistant Secretary for
Health, U.S. Department of Health and Human Services
In the last 40 years, the
United States has made great strides in its efforts to control the epidemic
of tobacco use. The prevalence rates of tobacco use among adult men and
women have continued to decline and data tell us that 70 percent of current
adult smokers in the United States want to quit. Youth tobacco use has also been on
the decline and if it continues to decline at the current rate, we may meet
our Healthy People 2010 objective of reducing current smoking rates among
high school students to 16 percent. Some of the most impressive declines
have occurred in the area of exposure to secondhand smoke. During the last
decade, there has been more than a 75 percent decrease in median cotinine (a
metabolite of nicotine) levels for nonsmokers in the United States. All of
these successes have been due to strong public and private partnerships.
It is fortunate that those
who work in tobacco control have a strong body of evidence on which to rely
which supports effective tobacco prevention and control interventions. The
Task Force on Community Preventive Services has released recommendations on
such effective interventions including: smoking bans and restrictions;
increasing the price of tobacco products; mass media campaigns; telephone
counseling and support to help tobacco users quit; and reducing patient
out-of-pocket costs for effective cessation treatment. Therefore, we know a
lot about “what” to do, but continue to be challenged by the “how-to” —
getting these evidence-based approaches into practice.
Dr. Fields continued his
remarks by describing some of the activities in which the federal government
is currently involved to address tobacco use. He followed the four goal
areas that many states as well as CDC have identified which are: preventing
initiation of tobacco use among young people; promoting quitting among young
people and adults; eliminating nonsmokers’ exposure to environmental tobacco
smoke (or secondhand smoke); and identifying and eliminating disparities
related to tobacco use and its effects among different population groups. Dr. Fields also reviewed the nine elements of statewide comprehensive
tobacco control programs as described in the CDC publication, Best
Practices for Comprehensive Tobacco Control Programs. These elements
include: community programs to reduce tobacco use; chronic disease programs
to reduce the burden of tobacco-related diseases; school programs;
enforcement; statewide programs; counter-marketing; cessation programs;
surveillance and evaluation; and administration and management.
I. Reducing Youth
Initiation
Although more than one of
four U.S. high school students still smoke cigarettes, rates among this
group have been declining since 1997. This positive trend is a result of a
combination of factors including: a 70% increase in the retails price of
cigarettes from 1997-2001; exposure to effective counter-marketing campaigns
such as the American Legacy Foundation’s truth campaign; and
an increase in the percentage of schools required to teach tobacco use
prevention and having strict tobacco free policies.
Raising Price
To maintain this positive
downward trend in youth tobacco use, and to counter tobacco industry
marketing to teens, we must remain vigilant in our efforts to alter social
norms around smoking. One of the most effective strategies for doing this
is to raise the price of tobacco products and the Department of Health and
Human Services is supportive of states’ efforts in this area. Raising the
price is also an effective strategy for getting current smokers — youth and
adults alike — to quit. Dr. Fields cited as an example the Department of
Defense’s successful effort to decrease discounts of tobacco products in
commissaries to within 5–10 percent of prevailing local rates.
Reducing Access
The Department also supports
efforts to reduce youth tobacco use by curtailing access and availability of
tobacco products through the Synar regulation, which is implemented and
monitored by SAMHSA’s Center for Substance Abuse Prevention.
II. Promoting Cessation
Dr. Fields began by
acknowledging the creation of the first ever subcommittee of the ICSH
focused on cessation and chaired by Dr. Michael Fiore. He recognized Dr.
Fiore, and asked that a brief update on the cessation subcommittee be
provided later in the meeting.
In the area of smoking
cessation, there is a strong body of evidence indicating the most effective
strategies to help people quit smoking. The Public Health Service’s
Treating Tobacco Use and Dependence: A Clinical Practice Guideline and
the CDC’s Guide to Community Preventive Services: Tobacco Prevention and
Control provide clinical, health system and population-based
recommendations on the most effective interventions. “A National Blueprint
for Disseminating and Implementing Evidence-Based Clinical and Community
Strategies to Promote Tobacco-Use Cessation” (still in draft form) is a
consensus document developed through a public-private partnership that aims
to ensure that effective interventions are implemented nationwide.
Cost is a barrier
One of the barriers to
reaching smokers who want to quit is the cost associated with treatment, and
current coverage varies widely. Medicare does not currently provide
coverage for tobacco use treatment, but a demonstration program through the
Centers for Medicaid and Medicare Services is currently underway to
determine the most feasible and effective cessation intervention for older
Americans. HHS has also worked to expand coverage of tobacco dependence
treatment for federal employees and dependents whose benefits come under the
Federal Office of Personnel Management. Participating health plans are now
“encouraged” to cover tobacco use treatment consistent with the PHS Clinical
Practice Guideline.
Brief interventions are
effective
Unfortunately, many health
care systems do not have systems in place to screen patients for tobacco use
and providers often do not feel equipped to assist patients who want to
quit. Evidence demonstrates that even with a relatively simple and brief
intervention such as advising a patient to quit, cessation rates can be
increased to 5–10 percent annually. More intensive interventions such as
those that combine behavioral and pharmacologic treatment can produce 20–25
percent quit rates in a year.
Federal support is
available
Through the National Cancer
Institute’s Cancer Information Service, its manual called “Clearing the
Air,” and a state-of-the-art website currently in development in partnership
with the CDC, there are ways that people who are ready to quit smoking can
get support. Additional research underway through the NCI, National
Institute for Drug Abuse, and private foundations, will help us better
understand the most effective tobacco cessation interventions.
III. Eliminating
Nonsmokers’ Exposure to Secondhand Smoke
Secondhand smoke is a leading
cause of disease and death in adult nonsmokers and serious health problems
in children. Clean indoor air policies in schools, health care facilities
and workplaces have been shown to promote health by contributing to changes
in community norms regarding smoking and by reinforcing the smoking
prevention message to youth. Such restrictions lead many to reduce their
consumption or quit entirely and similar results are found from self-imposed
restrictions in the home. Efforts such as the Smoke-Free Home Pledge and the
“Go Out for Your Kids” campaign produced by the Environmental Protection
Agency, the American Medical Association and the Consumer Federation of
America Foundation are a great step forward.
IV. Reducing Disparities
Both the CDC’s Office on
Smoking and Health and the NCI have committed significant resources to
helping eliminate disparities in tobacco use. These two groups, together
with other key partners such as the Robert Wood Johnson Foundation, American
Legacy Foundation and the American Cancer Society are sponsoring the
National Conference on Tobacco and Health Disparities in Tampa Florida on
December 11-13, 2002. The purpose of the conference is to review the
current science regarding disparities and define a research agenda necessary
for a richer understanding of how to define and eliminate population
disparities. Although progress as been made in this area, there is more
that needs to be done to effectively decrease tobacco related diseases.
Federal Government’s Role
Dr. Fields concluded his
remarks by outlining three roles that he believes the federal government
should play in tobacco use prevention and control.
First, the federal government
must continue to support strong research in tobacco use prevention and
control to better understand and develop effective interventions.
Second, the federal
government must continue to provide leadership in the translation of science
into effective interventions and the dissemination of these interventions at
the national, state and community levels.
Third, the federal government
should continue to monitor and evaluate the impact of our efforts on
reducing tobacco use and improving the health of our nation.
In conclusion, Dr. Fields
stressed the critical importance of developing, facilitating and supporting
partnerships with all of the various individuals and groups — public and
private — involved in tobacco prevention and control.
Following Dr. Fields’
remarks, Surgeon General Carmona asked ICSH members to introduce themselves.
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Update on Cessation
Subcommittee of the Interagency Committee on Smoking and Health
Dr. Carmona asked Dr. Michael
Fiore to provide an update on activities of the Cessation Subcommittee of
the ICSH.
Dr. Michael
Fiore, director of the Center for Tobacco Research and Intervention at the
University of Wisconsin Medical School in Madison Wisconsin and Chair of the
Subcommittee began by providing background to committee members. In August
2002, the Department of Health and Human Services requested the
establishment of a separate working subcommittee of the ICSH to focus
national attention on cessation. This subcommittee is an advisory group to
the ICSH and is charged with developing a set of proposed action steps that
will be presented to HHS Secretary Tommy Thompson in the winter of 2003.
These recommendations will serve as the basis for a Secretary’s initiative
on cessation, beginning in 2003, that will involve a series of federal
initiatives and public-private partnerships designed to reduce tobacco
prevalence in the U.S. by promoting evidence-based cessation.
The action plan will be
informed by four evidence-based documents: the Public Health Service’s
Clinical Practice Guideline: Treating Tobacco Use and Dependence; the
U.S. Task Force on Community Preventive Services’ Guide to Community
Preventive Services: Tobacco Use Prevention and Control; the Action
Plan on Tobacco Use Cessation: Recommendations from the Interagency
Committee on Smoking and Health (after the August 14, 2001, meeting
entitled “Smoking Cessation: Facing the Challenges of Tobacco Addiction.”);
and the National Blueprint for Disseminating and Implementing
Evidence-Based Clinical and Community Strategies to Promote Tobacco Use
Cessation (still in draft form).
The action plan will also be
informed by the oral and written public testimony presented to the
subcommittee during three regional meetings in Washington, DC; Denver,
Colorado; and Chicago, Illinois. Testimony can also be submitted to the
Office on Smoking and Health through December 20, 2002.
During the first regional
hearing held in Washington, DC on October 24, 2002, the subcommittee heard
from 21 individuals testifying. Some of the key themes and recommendations
presented focused on the need for a comprehensive approach to addressing
cessation; the important role that clinicians can play and the need for
additional training on tobacco use intervention; barriers created by the
absence of health insurance coverage for tobacco dependence treatment; the
importance of reaching underserved populations; the importance of
population-based strategies such as quitlines, media campaigns and
increasing the unit price of tobacco; and the difficulties posed by an
absence of secure funding at the state level for tobacco cessation efforts.
Dr. Fiore closed his remarks
by informing the committee that HHS Secretary Tommy Thompson has challenged
the cessation subcommittee to present him with a bold and innovative plan
that will substantially decrease tobacco use rates – thereby reducing
illness and mortality in the United States — by promoting smoking cessation.
Dr. Carmona introduced the
next speaker.
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State and Local
Government’s Role to Reach Tobacco Use Reduction Goals
Howard Koh, M.D., M.P.H.,
F.A.C.P., Commissioner of Public Health, Commonwealth of Massachusetts,
Boston, Massachusetts
Dr. Koh began by showing
slides of tobacco industry advertisements as well as some examples of
counter-advertisements that have been produced in an attempt to denormalize
the use of tobacco products. Dr. Koh described the 20th century
as the “tobacco and cancer century.”
Dr. Koh reviewed the ten year history of the Massachusetts tobacco
control program. The initial goal of the program was to change the social
norm around tobacco use, and the slogan that was used to successfully
increase the tobacco tax in 1992 was “Tax Tobacco. Protect Kids.”
Components of the comprehensive program include: youth-focused efforts (mass
media, school-based education, restricting sales to minors, and litigation
to restrict advertising near school grounds); adult-focused efforts (media,
tobacco dependence treatment and education including a Web site —
www.trytostop.org* — and a toll-free telephone number – 800-TRYTOSTOP —,
and partnerships with health plans); and secondhand smoke efforts (media,
promoting local regulations to restrict smoking, and a website —
www.getoutraged.com*). Dr. Koh then showed seven advertisements that had
been produced for the tobacco control program.
Next, Dr. Koh shared data demonstrating the effectiveness of the
Massachusetts tobacco control program. Adult prevalence is currently
at 19.4 percent, which places the state at the fourth lowest in the country
and cigarette sales have dropped by approximately 40 percent during the past
10 years. The prevalence rate among women, which is currently 10.8 percent,
has seen the steepest decline in the country (with California not reporting
data). In terms of evidence that mass media has an effect on youth
prevalence, a longitudinal study was conducted indicating that 12 and 13
year olds who had been exposed to the Massachusetts youth advertising were
50 percent less likely to progress to smoking as those who had not been
exposed.
Dr. Koh went on to mention
some of the litigation that has occurred in the state related to the tobacco
control program. In 1996, a State Senator helped pass a tobacco product
disclosure law which required tobacco companies to report their cigarette
nicotine yields and all additives in all their brands by descending order of
weight. The tobacco industry filed suit and it continues to be held up in
court. Another lawsuit, led by Attorney General Tom Riley was filed to
prohibit tobacco ads from within 1,000 feet of school grounds and
playgrounds. The suit went all the way to the Supreme Court but
unfortunately the court ruled against Massachusetts.
Dr. Koh concluded his remarks
by describing the dire budget crisis that the state is currently facing and
how as a result, the tobacco control program has lost all but $6 million of its funding (at the time of this meeting). He stated his
commitment to rebuild the program and work with others around the table to
continue to sustain funding for programs that we know are effective.
To close, Dr. Koh showed a
brief video clip.
Dr. Carmona thanked Dr. Koh
and introduced the next speaker.
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Non-Governmental
Organizations’ Role in Tobacco Use Reduction
John Seffrin, Ph.D., Chief
Executive Officer, American Cancer Society, Atlanta, Georgia
Dr. Seffrin began his talk
with a definition of the term non-governmental organization (NGO): any
non-profit or voluntary organization which is independent from government
and typically depends, in whole or in part, on charitable donations and
voluntary service.
The American Cancer Society
(ACS) is one of the oldest non-governmental organizations and is the largest
voluntary health organization in the world. In the 90 years since ACS was
founded, the organization has helped to make cancer one of the most curable
and most preventable diseases that humans face. ACS sees its role in
fighting cancer as a “co-equal partner” with the private for-profit and
public sectors and has set measurable goals for cancer incidence and
mortality rates for the year 2015 to hold itself accountable. Dr. Seffrin
summarized the major goals: a 50 percent reduction in cancer mortality
rates, a 25 percent reduction in cancer incidence rates, and an improved
quality of life for every person with cancer by the year 2015.
Dr. Seffrin identified five
roles that he believes NGOs can play to reduce tobacco use: citizen
engagement, advocacy, filling voids, targeted research and collaboration to
effect change. He then commented briefly on each role.
1.
Citizen Engagement — Getting “ordinary”
citizens involved in an issue and mobilized to make change happen. Dr.
Seffrin described how the ACS has successfully done this by bringing
volunteers – many of them cancer survivors – to Washington and having
them visit Capitol Hill to talk about the need for more commitment to
eradicating cancer.
2.
Advocacy — A crucial element in the
control of cancer and eradication of tobacco use, and only the NGO sector is
able to do it as part of their overall mission. Dr. Seffrin illustrated the
concept of advocacy by talking about “Partners for Effective Tobacco Policy”
which was formally knows as ENACT. This was the largest public health
coalition ever assembled and represented 60 organizations and public health
groups and five million volunteers. ACS has also been involved in efforts
in 20 states to increase tobacco excise taxes.
3.
Filling Voids — ACS conducts research
that contributes to a better understanding of cancer and tobacco related
morbidity, operates a call center to respond to the public’s questions about
cancer, and supports smoking cessation quit lines in many states.
4.
Targeted Research — Given the overwhelming
proportion of research funding that goes to biomedical research, ACS and
other NGOs have made a greater commitment to prevention research,
intervention research, psychosocial and behavioral research, translational
research and reaching the underserved.
5.
Collaboration — ACS is currently
collaborating with organizations such as the American Legacy Foundation on
the Great Start program to provide a national quit line for pregnant
smokers, and with the Robert Wood Johnson Foundation, it founded the
National Center for Tobacco-Free Kids. Also, together with RWJF, the ACS
helped establish the Center for Tobacco Cessation which will provide
technical assistance based on evidence-based science to promote cessation. Dr. Seffrin described a final collaboration with the National Cancer
Institute on a spiral CT screening clinical trial which may provide a viable
early detection method for lung cancer to help improve survivability.
Dr. Seffrin closed his
remarks by reminding the committee and observers that because NGOs have more
freedom to change and adapt their missions than other sectors of society
they can play a crucial role in efforts to reduce tobacco use.
Dr. Carmona thanked Dr. Seffrin and introduced the next speaker.
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Academia’s Role in Tobacco Use Reduction
Jonathan M. Samet, M.D., Professor and Chairman, Department of
Epidemiology, Bloomberg School of Public Health, The Johns Hopkins
University, Baltimore, Maryland
Dr. Samet introduced his talk
by explaining a bit about his background as a pulmonary physician in New
Mexico and an epidemiologist interested in studying the environment. As he
explained, cigarette smoking “got in the way of everything else I really
wanted to study.” As a result, Dr. Samet began to conduct research in
tobacco use and health and has contributed to Surgeon Generals’ reports for
the past several decades.
Dr. Samet presented a graphic
description of how he envisions science should work. First, one starts with
a hypothesis, next a study is designed, funding is sought, the study is
conducted, the results are published, and then the work either disappears,
or it is incorporated into the policy utilization process. Although this
process can be long and arduous, much of the progress that has been made in
tobacco control has been based on this kind of process. As an example, Dr.
Samet talked about secondhand smoke and the progress that has been made in
the 21 years since the first major studies on the subject were published. The evidence on passive smoking has resulted in the clean indoor air
movement which began in the 1970s and has continued to develop momentum to
this day.
Moving from the important
role that science has played in tobacco control, Dr. Samet described his
view of the role of academia in these efforts. The first role is that of
generating research evidence ranging from basic science to policy studies. Translating evidence to policy is a crucial role of academics, who are, for
example, key in the creation of Surgeon General reports and other
documents. Academics are also advocates, and work with organizations such
as the American Cancer Society and other non-governmental organizations. Finally, academics play an important role in capacity building.
Research Evidence
To illustrate the continuing
commitment to expanding scientific evidence, Dr. Samet showed a slide
depicting the number of articles on smoking, epidemiology and smoking and
lung cancer that can be found through searching the Pub Med database. Dr.
Samet also briefly mentioned the commitment to research by various funding
agencies including the National Cancer Institute, and the states of
California and Maryland, to name only two.
Research continues to expand
and deepen. We continue to better understand causation and how smoking
causes disease as well as the genetic determinants of response. In the area
of prevention, we better understand the factors that influence initiation
and are exploring the genetic determinants of susceptibility to addiction. We also continue to understand more about cessation and have translated this
science into more effective programs and policies to help people stop using
tobacco.
Even with these advances,
however, there is still a great need for additional research. Lung cancer
is an example of an area with lots of unanswered research questions,
including the risks of “low-tar” cigarettes, changing lung cancer types,
molecular genetics, CT screening, secondhand smoke risks and national and
global variations in occurrence.
Translating Evidence to
Policy
Dr. Samet continued by
describing the key role that academics play in translational activities. Surgeon General reports and NCI monographs are just two examples of
documents that are produced with a great deal of academic input and have
been integral in using the science to identify policy implications. The
academic community has also been involved in litigation by discussing risks
associated with tobacco use.
Advocacy
The most critical element of
advocacy, according to Dr. Samet, is that it must be based in science.
Accordingly, the academic community is a critical resource for advocacy
organizations and many academics contribute their expertise by becoming
members of coalitions or providing training in how to use and translate the
evidence-base.
Capacity Building
Dr. Samet described capacity
building needs at many different levels including local, state, national and
international. He described a specific product that was developed for U.S
and international audiences by the Institute for Global Tobacco Control and
the Pan American Health Organization which focused on global tobacco control
resources and is available in several languages. This tool illustrates the
ability of academia to package these types of materials and make them widely
available.
Concluding his remarks, Dr.
Samet offered some of his thoughts about emerging issues in tobacco control
thereby reinforcing the need for additional research. These issues include
the genetic basis of addiction and disease susceptibility; the concept of
“harm reduction;” continuing surveillance of the epidemic, particularly in
special populations; disparities in the epidemic — local and global — and
finally; protecting the developing world from tobacco industry marketing.
Following the formal
presentations, Surgeon General Carmona asked for committee member comments.
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Committee Member Comments
Christine Williams, Agency
for Healthcare Research and Quality, stressed the importance of thinking
broadly in identifying research needs and considering not only basic
research, but also translational research, (e.g., how to get physicians to
ask the right questions in the clinical setting).
Jared Jobe, Ph.D., National
Heart, Lung and Blood Institute, emphasized the importance of working with
marketing and communications professionals to “un-sell” tobacco use. He
mentioned that NCI is currently doing some of this work through its
communications health research program.
Aron Primack, M.D., M.A.,
Fogerty International Center, talked about the unfortunate situation in
Massachusetts with its decreased tobacco control funding and how it provides
a natural “experiment” in determining the effects of funding loss over time.
Scott Leischow, Ph.D.,
National Cancer Institute, mentioned a public-private meeting underway
focusing on surveillance and evaluation of tobacco programs. He also
mentioned the challenge of thinking systematically about research and how to
most effectively and strategically use the results to move us forward. Dr.
Carmona responded by discussing a working group that he is part of
consisting of all the country’s Surgeons General. This group has identified
smoking and obesity as two areas of common interest, and has had discussions
about the importance of prevention initiatives that cut across several
health risk areas. Dr. Carmona also mentioned that he had had some
discussions with CDC and communications experts about Surgeon General
reports and whether they are communicating important messages in the most
effective manner.
Lynn Haverkos, M.D., National
Institute of Child Health and Human Development, mentioned several new
tobacco focused initiatives that this Institute was working on. One area is
to better understand how behavior change occurs in children and a second
area is in physician education about the effects of secondhand smoke.
Michael Fiore, M.D., M.P.H.,
Center for Tobacco Research and Intervention, University of Wisconsin
Medical School, directed a question to Howard Koh regarding the
Massachusetts initiative “Tax Tobacco. Save Kids.” He asked whether voters
believed that they were voting in favor of a tax increase to be dedicated to
smoking prevention when in fact, this is not where the tax revenues have
been placed. Dr. Koh responded by saying that the initiative included
wording that stated that this money would be “subject to appropriation by
the legislature.” He added that he was interested in other peoples’
thoughts about how to make initiative petitions more “iron clad” so that
they are not being raided in difficult economic times. Dr. Koh also
responded to Dr. Primack’s earlier comment regarding the “natural
experiment” in Massachusetts and mentioned Stan Glanz’s findings in
California that when the funding and media stopped, consumption went up, and
when the program and media came back, consumption went back down.
Dr. Carmona thanked Dr. Koh
for his comments, and agreed that this issue of “competing interests” is a
very difficult one. People working in prevention need to unite and not
position one group against the needs of another.
Thomas Hertz, Office of the
Secretary, HHS, followed the discussion of prevention by talking about how
the public health community could do a better job of linking prevention and
treatment messages together. He offered the example of the high price of
prescription drugs, and how many of the conditions people have that require
these drugs are preventable.
Nicolas Trane, M.D., Blank
Children’s and Methodist Hospital, suggested that the Surgeon General should
make statements and policy recommendations specifically targeted and
directed toward children and youth. Dr. Carmona responded by saying that he
thought it was a good idea, and would be happy to work with a group to
determine the correct messages and the appropriate way to reach and motivate
children.
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Public Comments
Following the member
comments, Dr. Carmona asked for public comments.
Lyndon Haviland, American
Legacy Foundation, directed a question to Dr. Carmona asking what he will do
as Surgeon General to insure that youth prevalence rates will continue to
decline, especially in the face of state budget crises. Dr. Carmona
responded by reiterating his personal commitment to the issue because of his
own secondhand smoke-related illnesses as a child. He also believes that as
Surgeon General his job is to translate good science in a culturally
appropriate manner to the American public. He believes that prevention
should always come first.
With no additional public
comments, Dr. Carmona turned back to any additional comments from committee
members.
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Discussion — Committee
and/or Public Comments
Christine Williams, M.Ed.,
Agency for Healthcare Research and Quality, referring to the situation in
Massachusetts where tobacco control funding is being cut due to the state
budget crisis, talked about the importance of building a strong business
case in support of tobacco use prevention and cessation programs. Not only
do these programs pay off in the long run, but there are also short–term
savings from investment in tobacco cessation programs.
Dennis Richling, M.D., Union
Pacific Railroad, mentioned the need to get the private payer community to
view tobacco cessation as treatment for an addictive disorder rather than a
preventive service. Dr. Carmona agreed with Dr. Richling’s point, and
talked about the “perverse incentives” in the healthcare system which favors
treatment over prevention.
Aron Primack, M.D., M.A.,
Fogerty International Center, talked about the need to approach tobacco use
not only from a medical perspective, but also from an educational
perspective. (He recognized the Department of Education representative
present at the meeting.) Liza Veto, Department of Education, introduced
herself and talked about her role as one that was doing exactly as Dr.
Primack suggested — translating what we think of as traditional public
health messages into education messages.
Scott Leischow, Ph.D.,
National Cancer Institute, mentioned a collaborative project between NCI,
the National Institute for Drug Abuse, and the National Institute on
Alcoholism and Alcohol Abuse to develop more effective medications to treat
tobacco dependence.
Dr. Carmona asked the
committee to consider an issue that he has been involved with as Surgeon
General which focuses on how to create incentives for prevention efforts and
eliminate what he considers “perverse incentives” in our current health care
system. Furthermore, he asked the committee to consider whether the
responsibility for this shift should come from the private or public sector.
Timothy Condon, Ph.D.,
National Institute on Drug Abuse, acknowledged that he did not have an
answer for Dr. Carmona, but talked about the stigma of addiction and how
important it is to educate people about the differences in how addictive and
other medical disorders should be treated.
Robert Mecklenberg,
consultant with the National Cancer Institute, offered a comment about the
need to consider the tobacco industry’s influence, and how this had not been
directly addressed by the committee.
Dennis Richling, M.D., Union
Pacific Railroad, went back to Dr. Carmona’s question regarding the need to
reorient the healthcare system to provide incentives for preventive
efforts. Dr. Richling believes that the business community accepts the
importance of prevention, but is also faced with growing healthcare costs
and the need to make difficult choices. He believes that national
leadership through a public-private partnership could begin this process of
change. Dr. Carmona responded by saying he is considering a future Surgeon
General report focused on prevention.
Jonathan Samet, M.D.,
commented that there are models available for estimating health costs, but
perhaps there is a need for tools that are easier to use to make these
estimates.
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Closing Comments
With no additional comments,
Dr. Carmona offered some closing remarks. He referenced Dr. Larry Field’s
discussion about the federal government’s commitment to evidence-based
decision making, but acknowledged that there is often a problem in
translating this evidence-base into practical programs and policies. Dr.
Carmona also acknowledged the importance of monitoring and evaluating the
impact of our efforts. Referring to Dr. Howard Koh’s presentation, he
talked about the impressive media campaign that had been created in
Massachusetts, and also the importance of the state’s ability to demonstrate
the success of its program through outcome measurements. Dr. Carmona
reminded the committee of Dr. John Seffrin’s presentation about the role of
nongovernmental organizations and their emphasis on citizen engagement and
participation. And finally, Dr. Jonathan Samet’s presentation focused on
the academic perspective and the importance of evidence-based decision
making.
The common element
demonstrated in all of the presentations, Dr. Carmona summarized, was the
value of partnerships in moving these issues forward. He stressed his own
commitment, as well as that of President Bush and Secretary Thompson, to
eradicating tobacco related morbidity and mortality in the U.S. and abroad. He thanked the committee members for their commitment.
The meeting adjourned at
12:33 p.m.
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