The National Action Plan for Tobacco Cessation – A 2007 Status Report

1. The National Action Plan for Tobacco Cessation – A 2007 Status Report May 4, 2007 Michael C. Fiore, MD, MPH Professor of Medicine Director, Center for Tobacco Research and Intervention University of Wisconsin School of Medicine and Public Health

2. Support • National Institutes of Health (NIH) Transdisciplinary Tobacco Use Research Centers (TTURC) Program • Robert Wood Johnson Foundation (RWJF) Innovators Combating Substance Abuse Program

3. Click to edit Master title style Prevalence in Cigarette Smoking* Among Adults – United States, 1965-2004 HP2010 goal Source: National Health Interview Surveys; selected years, United States—1965-2004 Behavioral Risk Factor Surveillance System , California—1984-2004 *Estimates since 1992 include some-day smoking

4. Cigarette Smoking Among Adults in U.S., 2004 Source: MMWR 11/11/05

5. Key Milestones in Treating Tobacco Dependence

6. 1964 First Surgeon General’s Report directly linking smoking to lung cancerin men.

7. Key Milestones in Treating Tobacco Dependence 1950-1970s • 1950s – First scientific reports linking tobacco use with cancer • 1964 – First Surgeon General’s Report directly linking smoking to lung cancer in men • 1970s – Counseling strategies, including group and individual, for smoking cessation • 1970s – Aversive smoking studies completed

8. Key Milestones in Treating Tobacco Dependence 1980-1990s • Early 1980s – Nicotine Gum approved for tobacco cessation • 1988 – Surgeon General’s Report documents nicotine as addictive • 1990s – Nicotine patch and other nicotine replacement medications approved by FDA • 1991 – Smoking status recommended as the fifth vital sign • 1996 – AHCPR Clinical Practice Guideline #18 – Smoking Cessation release • 1996 – Bupropion approved by FDA

9. Key Milestones in Treating Tobacco Dependence 2000-Today • 2000 – S.G. Report on Cessation • 2000 – PHS Clinical Practice Guideline – Treating Tobacco Use and Dependence • 2004 – National Action Plan for Tobacco Cessation • 2005 – National Quitline Network 1-800-QUIT NOW • 2006 – Varenicline approved by FDA • 2006 – Tobacco Industry found guilty of racketeering • 2008 – Proposed PHS Clinical Practice Guideline – Treating Tobacco Use and Dependence Update

10. 2004 National Action Plan for Tobacco Cessation

11. National Action Plan to Tobacco Cessation – Key Features • Designed to result in meaningful reduction in tobacco use and its effects • Science-based • Addresses disparities • National in scope, regional in application • Public Private Partnerships

12. National Action Plan to Tobacco Cessation – Key Features (continued) • Impact must be both immediate and sustained • Comprehensive & integrated • Evaluated • Securely funded

13. Recommendation #1 • Establish a federally-funded National Tobacco Quitline network by FY 2005 that will provide universal access to evidence-based counseling and medications for tobacco cessation. This quitline would provide a national portal to available state or regionally managed quitlines. Estimated Cost: $3.2 billion/year

14. National Network of Tobacco Cessation Quitlines • Launched by DHHS in 2004 • Built on existing state quitline infrastructure • $25 million in Federal funds • Joint CDC and NCI initiative • By the end of 2005, all states had quitlines • Challenges: funding; reach 1-800-QUIT NOW (1-800-784-8669)

15. Recommendation #2 • Launch an ongoing, extensive paid media campaign by FY 2005 to help Americans quit using tobacco. Estimated cost: $1 billion/year

16. National Paid Media Campaign • “Be a Quitter Campaign” (NCI) • Target audiences: young adults age 18-29, active and returning military, and low SES • Television and radio PSAs in English and Spanish • ABC & USA networks agreed to broadcast the PSA in March • URL: www.1800quitnow.org

17. National Paid Media Campaign (continued) • “Become an EX” campaign (American Legacy Foundation) • Target audience: “weary smokers” • Campaign being pilot tested in Buffalo, NY; San Antonio, TX; Grand Rapids, MI; Baltimore, MD • Hope to disseminate nationally through partnerships and collaboration • URL: www.becomeanex.org

18. National Paid Media Campaign (continued) • Challenges • Resources • State quitline funds for promotion decreased from an average of $325,000 in 2004 to $193,750 in 2005 • States with newer quitlines or less well funded quitlines reported few or no funds for promotion • Reach • What media are smokers using and how can this be harnessed to foster a quit attempt?

19. Recommendation #3 • Include evidence-based counseling and medications for tobacco cessation in benefits provided to all Federal beneficiaries and in all federally-funded healthcare programs by FY 2005. Estimated cost: $0.47 to 0.73 PMPM

20. Coverage of Tobacco Dependence Treatment for all Federally-Covered Lives • Medicare: coverage provided for cessation counseling (2005) and prescription medications (2006) • Medicaid: 42 state programs provided at least some coverage (2005)1 • VA: co-payments eliminated for counseling (2006) 1CDC, 2006

21. Recommendation #4 • Invest in a new, broad, and balanced research agenda (basic, clinical, public health, translational, dissemination) by FY 2005 to achieve future improvements in the reach, effectiveness and adoption of tobacco dependence interventions across both individuals and populations. Estimated cost: $500 million/year

22. New Tobacco Research Infrastructure • Opportunities: program announcements from NIH, CDC, and AHRQ; NIH Roadmap initiative, the TTURC initiative • Challenge: reductions in federal funding for research overall

23. Recommendation #5 • Invest in training and education by FY 2005 to ensure that all clinicians in the United States have the knowledge, skills and support systems necessary to help their patients quit tobacco use. Estimated cost: $500 million/year

24. New Tobacco Training Infrastructure • Opportunities: state-level programs and initiatives for tobacco dependence treatment training • Challenges: no coordinated, federally supported infrastructure

25. Recommendation #6 • Establish a Smokers’ Health Fund by FY 2005 by increasing the Federal Excise Tax on cigarettes by $2.00 per pack (from the current rate of $0.39 to $2.39) with a similar increase in the excise tax on other tobacco products. At least 50% of the new revenue generated by this tax increase (at least $14 billion of the estimated $28 billion generated) should be earmarked to pay for the components of this action plan. Est. revenue generated: $28 billion/year

26. Increased Federal Excise Taxon Cigarettes • No excise tax increase at the Federal level • 43 states and the District of Columbia have increased cigarette taxes since January 1, 2002 • The current average state cigarette excise tax is $1.02 per pack – more than double the rate at the beginning of 2002 (43.4 cents).

27. State Level Cigarette Excise Tax Rates, February, 2003 Source: RTI Data

28. State Level Cigarette Excise Tax Rates, March 2007

29. Department of Justice Lawsuit

30. Dept of Justice Lawsuit • September 22, 1999: U.S. Department of Justice filed a civil RICO lawsuit to hold the tobacco companies legally accountable for decades of illegal and harmful practices • September 21, 2004: Trial begins • June 9, 2005: Trial ends • August 17, 2006: Judge Kessler issues ruling • Finds tobacco companies liable • Is constrained in remedies due to earlier appellate court ruling requiring that all penalties be “forward-looking”

31. Key Aspects of Ruling • Prohibits the tobacco companies from committing acts of racketeering in the future or making false, misleading or deceptive statements concerning cigarettes and their health risks • Bans terms including "low tar," "light," "ultra light," "mild," and "natural" that have been used to mislead consumers about the health risks of smoking and prohibit the tobacco companies from conveying any explicit or implicit health message for any cigarette brand • Requires the tobacco companies to make corrective statements concerning the health risks of smoking and secondhand smoke and their deceptive practices through newspaper and television advertising, their web sites and as part of cigarette packaging • Extends and expands current requirements that the tobacco companies make public their internal documents produced in litigation • Requires the tobacco companies to report marketing data annually to the government • Financial remedies requested by DOJ not implemented due to the appellate court ruling requiring that penalties be “forward-looking”

32. Judge Kessler’s Ruling: 1. Defendants have falsely denied, distorted and minimized the significant adverse health consequences of smoking for decades.

33. Judge Kessler’s Ruling: 2. “Every aspect of a cigarette is precisely tailored to ensure that a cigarette smoker can pick up virtually any cigarette on the market and obtain an addictive dose of nicotine.”

34. Judge Kessler’s Ruling: 3. “Defendants extensively – and successfully – marketed and promoted their low tar/light cigarettes as less harmful alternatives to full-flavor cigarettes, although they knew for decades that there is no clear health benefit from smoking low tar/low nicotine cigarettes.”

35. Judge Kessler’s Ruling: 4. The defendants “suppressed, concealed, and terminated scientific research; they destroyed documents including specific reports and studies;…”

37. by G.B. Trudeau(Page 1 of 2)

38. by G.B. Trudeau(Page 2 of 2)

39. U.S. Smoking Prevalence U.S. Adults Smoking Prevalence

40. A Hundred Years War? U.S. Adults Smoking Prevalence ?2055?

42. www.ctri.wisc.edu 42