Correspondence
Controlling Tobacco Use
N Engl J Med 2001; 344:1797-1799June 7, 2001
- Article
To the Editor:
The lessons from the California Tobacco Control Program, as reported by Fichtenberg and Glantz (Dec. 14 issue),1 are critical to public health. Unlike most other states, California, using 5 cents of every 25-cent tax collected on a package of cigarettes, undertook the largest tobacco-control program ever implemented, with subsequent declines in cigarette consumption and mortality from heart disease.
States newly flush with the resources from the Master Settlement Agreement between the states' attorneys general and the tobacco industry should allocate at least the per capita amount recommended by the Centers for Disease Control and Prevention,2 so that the whole nation can benefit, to the degree experienced in California, from the effect of comprehensive tobacco control. State and national programs of tobacco control should employ a multipronged approach. It should include efforts to reduce exposure to secondhand smoke, which is currently responsible for 50,000 deaths per year, including the deaths of many children and newborns.3 Other efforts should include the design and execution of programs that reduce the number of new smokers while helping current smokers to quit.
Only by practicing what we have learned from these hard lessons will the nation reap the same benefits that states such as California and Massachusetts have enjoyed as a result of their comprehensive tobacco-control programs. By our rough calculation, the 33,300 premature deaths from cardiovascular causes averted in California from 1989 to 1997 would have amounted to over 300,000 deaths nationally. Can we afford to wait any longer?
3 ReferencesCheryl Healton, Dr.P.H.
American Legacy Foundation, Washington, DC 20001Steven A. Schroeder, M.D.
Robert Wood Johnson Foundation, Princeton, NJ 08543Sidney C. Smith, Jr., M.D.
American Heart Association, Dallas, TX 752311
Fichtenberg CM ,Glantz SA . Association of the California Tobacco Control Program with declines in cigarette consumption and mortality from heart disease. N Engl J Med 2000;343:1772-1777
Full Text | Web of Science | Medline2
Best practices for comprehensive tobacco control programs, August 1999. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999.
3
Glantz SA ,Parmley WW . Passive smoking and heart disease: epidemiology, physiology, and biochemistry. Circulation 1991;83:1-12
Web of Science | Medline
To the Editor:
The Sounding Board articles by Glantz and Annas1 and by Myers2 (Dec. 14 issue) debate the regulation of tobacco products from legal, ethical, and public health points of view. Tobacco-industry support of legislators through campaign funding, lobbying, and monetary contributions is the reason we do not have successful regulation. The tobacco industry controls the regulatory agenda in Congress and state legislatures by financial largess, offering a glaring example of the need for campaign-finance reform. The current system is a public health disaster.
A manifestation of the control of state-legislature agendas by the tobacco industry involves the billions of dollars from the Master Settlement Agreement for illness caused by smoking. Only a few states spend this money on tobacco control: the attention paid to the priorities of the tobacco industry is reflected by the use of the money for unrelated programs.
Fichtenberg and Glantz document improvements in health from the control of tobacco. The California and Massachusetts comprehensive programs integrating the media, control of environmental tobacco smoke, taxation, enforcement of age-restricted sales, legal actions, and community activities have accelerated the downward trend of tobacco consumption; even among the young, consumption of tobacco products has declined, demonstrating the effectiveness of all-encompassing tobacco control. These programs have, to a greater or lesser extent, overcome legislative obstruction. Restriction of industry-sponsored financial support of election campaigns, political parties, and politicians would help enormously.
2 ReferencesBlake Cady, M.D.
Women and Infants Hospital, Providence, RI 029051
Glantz LH ,Annas GJ . Tobacco, the Food and Drug Administration, and Congress. N Engl J Med 2000;343:1802-1806
Full Text | Web of Science | Medline2
Myers ML . Protecting the public health by strengthening the Food and Drug Administration's authority over tobacco products. N Engl J Med 2000;343:1806-1809
Full Text | Web of Science | Medline
To the Editor:
Fichtenberg and Glantz conclude that the California Tobacco Control Program, which was implemented in 1989, has been associated with a reduction in deaths from heart disease in the short run. However, their report suggests two other important influences on these relations. First, the accelerated decline in the smoking rate appears to have begun in 1987 and 1988 in California, and perhaps throughout the United States — a full year before the implementation of the program. This finding strongly suggests that other influences were related to the accelerated decline in smoking. Second, although smoking rates declined from 1980 to 1997 by a much greater extent in California than in the rest of the United States (55 percent vs. 31 percent), the decline in the rate of deaths from cardiovascular causes was quite similar (36 percent and 35 percent, respectively). By 1997, the rate of death from cardiovascular causes per pack of cigarettes smoked, which was almost identical in the two populations in 1980, remained essentially constant in the United States but had risen by almost 50 percent in California. This finding suggests that the risk of tobacco smoking is accentuated in California, that there are significant competing risks with respect to deaths from cardiovascular causes, or that both are true.
Kenneth M. Kessler, M.D.
University of Miami School of Medicine, Miami, FL 33101Author/Editor Response
The authors reply:
To the Editor: California's tobacco-control program was associated with a significant acceleration in the rates of decline of both cigarette consumption and deaths from heart disease relative to the rest of the United States, and when the program was scaled back, the magnitude of both effects was moderated. Kessler's simple comparison of percent changes in the rates of consumption and death in California and the United States between 1980 and 1997 ignores the different temporal patterns in these two variables that existed before the California program was initiated (as shown in Figure 1 of our article). These differences must be considered in order to obtain an accurate assessment of the effects of the program. Kessler notes that the increase in the rate of decline in consumption began the year before the program started. This was due to the antismoking publicity associated with the 1988 election campaign that established the program.1 Such publicity itself reduces smoking.2 Our analysis allowed for a lag in the effect.
In fact, our estimate of the effect of the California program on deaths was most likely too low. We obtained our estimate by multiplying age-adjusted mortality rates by the population. Because age-adjusted rates are based on a standard age profile that is much younger than the actual age distribution in California, we probably underestimated the effects of the program. Adjusting for the actual age distribution with the ratio of crude and adjusted death rates shows that 58,900 deaths may have been prevented between 1989 and 1997 and 15,000 additional deaths may have been caused by cutbacks in the program between 1993 and 1997 (as compared with the estimates of 33,300 and 8300 in our article). These larger numbers should be used.
We agree with Healton et al. and Cady that a strong tobacco-control program can quickly achieve important reductions in deaths caused by tobacco. We also agree that the tobacco industry uses campaign contributions and the legislative process to try and kill these programs3,4 because they cost the industry sales ($2.9 billion in California between 1989 and 1997). Realizing the lifesaving potential of tobacco-control programs requires strong and concerted action by public health advocates in the face of this reality.
4 ReferencesCaroline Fichtenberg, M.S.
Stanton A. Glantz, Ph.D.
University of California, San Francisco, CA 94143-01301
Glantz SA, Balbach E. Tobacco war: inside the California battles. Berkeley: University of California Press, 2000.
2
Laugesen M ,Meads C . Advertising, price, income and publicity effects on weekly cigarette sales in New Zealand supermarkets. Br J Addict 1991;86:83-89
CrossRef | Medline3
Glantz SA ,Begay ME . Tobacco industry campaign contributions are affecting tobacco control policymaking in California. JAMA 1994;272:1176-1182
CrossRef | Web of Science | Medline4
Monardi F ,Glantz SA . Are tobacco industry campaign contributions influencing state legislative behavior? Am J Public Health 1998;88:918-923
CrossRef | Web of Science | Medline
