OBJECTIVE C - Promote policies and programs aimed at reducing tobacco use.

Tobacco's Link to Cancer
Tobacco use is the leading preventable cause of premature disease and death in the United States 57 as well as in Texas. Nationally, tobacco use is related to more than 400,000 deaths each year.58 While it has been widely known for several decades that smoking causes lung cancer, in 1996 M.D. Anderson Cancer Center researchers established the causation link between a carcinogen found in cigarette smoke and a genetic mutation that can lead to cancer.59 Tobacco use also has a strong association with many cancers, including cancers of the larynx, esophagus, bladder, kidney, pancreas, and cervix.60 Spit tobacco, such as chewing tobacco and snuff, causes various forms of oral cancer.61

The effect that tobacco use has on the cancer mortality rate is staggering. Smoking is responsible for about 87 percent of lung cancer deaths each year.62 In 1997, approximately 9,400 people in Texas and approximately 140,000 people nationwide died from lung cancer as a result of smoking 63 About one-third of all cancer deaths can be attributed to tobacco use,64 equating to nearly 12,000 deaths in Texas annually. Tobacco use also takes its toll on the United States economy by causing more than $100 billion in health care costs and lost productivity.65 Tobacco use, therefore, imposes a great burden upon society in terms of lives lost, health care costs, lost economic productivity, and human suffering.

Tobacco and Other Illnesses
Tobacco use, which includes cigarette, cigar, and pipe smoking, along with spit tobacco use, is a risk factor for many other diseases besides cancer. It is responsible for nearly one out of five deaths that occur in the United States.66 Smoking can cause atherosclerosis, coronary artery disease, and chronic obstructive pulmonary disease, and can exacerbate the symptoms of respiratory illnesses such as asthma and bronchitis.67 There is evidence of reduced lung capacity in youth as a result of being exposed to tobacco smoke.68 Studies also indicate that cigarette smoking increases the risk of age-related macular degeneration, the leading cause of severe visual impairment among the elderly in the United States.69 Spit tobacco use causes halitosis, periodontal degeneration, and soft tissue lesions.70

Youth and Tobacco
Many scientific studies document that the health problems associated with tobacco use are correlated with the number of years and amount of use. The younger people begin to smoke, the more likely they are to continue smoking as an adult.71 An early onset of tobacco use also is associated with heavier use in adulthood.72 The average age at which people begin smoking is 13 years. Only 10 percent of tobacco users begin to do so after age 20.73 The average age at which people begin smoking is dropping, thereby increasing the potential duration of use and the risk of more serious health problems.74 Preventing tobacco use among young people will have a dramatic effect on long-term health consequences of tobacco use and the cancer mortality rate.75

According to the U.S. Surgeon General, tobacco use is associated with a range of behavioral problems during adolescence.76 Tobacco is considered to be a "gateway" drug, meaning that it is often the first drug used by youth who experiment with alcohol, marijuana, or narcotics. Adolescent tobacco users are more likely to use alcohol and illegal drugs than their peers who do not use tobacco. Youth who smoke cigarettes are also more likely to get into fights, carry weapons, attempt suicide, and engage in high-risk sexual behaviors. Preventing the use of tobacco among youth may delay or prevent cancer as well as these other high-risk behaviors.

Approximately one-third of high school students in the United States smoke cigarettes or cigars or use spit tobacco.77 Nationally, about 20 percent of high school males and 1 percent of females report using spit tobacco currently.78

Despite the existence of state laws that prohibit the sale of tobacco products to minors, tobacco use among Texas children has not fallen as it has for the adult population. The 1996 Texas School Survey of Substance Abuse among Students, conducted by the Texas Commission on Alcohol and Drug Abuse (TCADA), found an increase of 25 percent in reported experimentation with tobacco among elementary and secondary school children. Fifty-five percent of all school children in 1996 reported having used some type of tobacco product in their lifetime, and of the remaining 45 percent, 30 percent reported they had been offered cigarettes or spit tobacco. Hispanic children in elementary schools reported a higher rate of cigarette smoking (13 percent) than their White or African-American peers (9 percent each). White students, however, reported a slightly higher rate of spit tobacco use (4 percent) than Hispanic or African-American students (3 percent each).

The TCADA study also analyzed rates of tobacco use by school children's grades and academic performance. Elementary students who usually earned C's or below reported lifetime and past-year use of tobacco at rates twice that of students who usually earned A's or B's. Among sixth graders, 31 percent of those making C's or below reported tobacco use, while only 15 percent of those making A's or B's reported using tobacco.

Although not statistically significant, there was a slight decrease in the lifetime tobacco prevalence among Texas elementary students, decreasing from 21 percent in 1990 to 19 percent in both 1992 and 1994. Past-year prevalence rates also decreased, dropping from 13 percent in 1990 to 12 percent in 1992 and 1994. Among Texas school children, current and lifetime prevalence rates for tobacco use are higher than any other substances except alcohol. Lifetime tobacco use remained fairly stable between 1992 and 1994; however, current use increased by 16 percent, with eighth and tenth graders having the highest rates of increase.

As with the elementary school children, differences among various ethnic groups were found. In 1996, Hispanic secondary students had the highest lifetime prevalence rates for cigarette smoking (57 percent), as compared to their White and African-American peers (56 percent and 42 percent, respectively). White students reported the highest lifetime use of spit tobacco (24 percent), as compared to Hispanic and African-American students (12 percent and 8 percent, respectively). Lifetime prevalence rates among secondary school children decreased by 3 percent between 1990 and 1994; however, current use increased by 6 percent. The Commission's study found that the current use increases occurred most frequently among tenth graders, African-Americans, and students who did not live with both parents.79

The alarming number of Texas children who use tobacco necessitates that more extensive efforts to influence their knowledge and attitudes about tobacco use and to reduce their addiction to nicotine. Many adolescent smokers are addicted to nicotine and experience the addiction in a manner and severity that is similar to adult smokers.80 To prevent nicotine addiction and the other adverse health effects of tobacco use, it is imperative that youth prevention programs are strengthened and that youth access to tobacco products is curtailed. Further, parents and adult role models must set good examples for youth by not using tobacco products.

Despite the wealth of research on smoking, relatively little attention has been given to cessation methods for youth. To date, little is known about youth preferences for trying to quit, or actual experiences of attempting to quit.81 Additionally, recruitment of adolescents into formal cessation programs has had minimal attention and the success rates in adolescent cessation programs have been low.82 Educational approaches should consider the needs and preferences of young smokers in order to remedy these problems.83 Coalitions should be built within local communities to offer conveniently located, low-cost smoking cessation programs and to continually evaluate the effectiveness and accessibility of local youth cessation programs.

In 1996, the Texas Cancer Council initiated the School/Community-Based Adolescent Tobacco Use Cessation Program (ATCP) through the University of Houston and Texas A & M University. By utilizing focus groups of youth educators and adolescents while designing the curriculum and evaluating of pilot program outcomes, the project seeks to define the combinations of interventions that appear to be the most effective in helping youth stop smoking. ATCP incorporates a stage-matched, peer-led, developmentally and culturally-appropriate, social-learning oriented design to address the issues confronting youth who try to quit smoking. Additionally, the American Medical Association is pilot-testing a clinically-based model of adolescent tobacco use cessation. These two pilot initiatives will enhance understanding about interventions for youth and lead to more effective cessation programming.

Reducing Youth Access to Tobacco
During the mid-1990s, sweeping federal and state laws were enacted to prevent youth access to tobacco products. Many studies indicated that youth had little trouble obtaining tobacco products despite laws prohibiting the sale of tobacco to minors.84 Nationally, minors who try to buy tobacco are generally successful in purchasing it over-the-counter 50 to 75 percent of the time, and 80 to 100 percent of the time from vending machines.85 Despite state laws prohibiting the sale of tobacco products to minors, Texas children can successfully access these products through vending machines, self-service displays, free samples, and mail-order sales. Although statewide vendor compliance surveys conducted by the Texas Department of Health show a decrease in sales to minors, the rates at which minors can purchase tobacco products remain high.


tobaccopurchase


Several state agencies have been involved in efforts to reduce minors' access to tobacco products. The Office of Tobacco Prevention and Control (OTPC) of the Texas Department of Health, TCADA, and Drug Abuse Resistance Education (DARE) jointly focus on retailer and youth education, compliance inspections, and law enforcement training. Beginning in 1997, the Texas Comptroller's office has statutory authority to enforce state laws pertaining to tobacco sales to minors.

Active enforcement of age verification policies is needed. Tobacco products are widely available at a variety of retail stores, making them easily accessible to youth. The placement of tobacco products in prominent displays and at checkout counters falsely reinforce the idea that tobacco is safe, in great demand, and a part of everyday life.86 Tobacco products placed near candy and snacks or near self-service displays are more appealing to young children.

Marketing techniques, advertisements, product names, and packaging also influence youth attitudes about tobacco products. Children are highly susceptible to repetitive advertising of retail products, including tobacco. Promotions by tobacco companies such as packs of less than 20 cigarettes ("kiddie packs"), individual samples ("loosies"), coupons, and the sponsorship of sports events are appealing to youth. Products and packages, such as the Marlboro logo merchandise, are especially attractive to children, as are cartoon-like icons such as Joe Camel. Tobacco use prevention education must do more than teach children about the health hazards. Children must also be made aware of the ways in which tobacco companies influence them with promotion and advertising of tobacco products.

Two primary ways to prevent and reduce tobacco use among children is through effective educational programs and enforcement of laws restricting sales of tobacco products. Comprehensive school health education is an excellent vehicle for reinforcing the dangers of tobacco use in a systematic way from kindergarten through high school. As with the other components of comprehensive school health education, tobacco use prevention must be age and culturally relevant and meet the developmental needs of students. Proven and effective teaching methodologies should be used, such as peer instruction. Peer influence seems to be especially important in the early stages of tobacco use.87 Schools and school districts can underscore tobacco use prevention messages to youth by enforcing policies that ban tobacco use on school grounds and at school functions.

The effectiveness of school-based programs appears to be enhanced by involving parents, youth-oriented media, and community organizations.88 Influential adults, such as coaches, the clergy, neighbors, scout leaders, and other role models for youth should set a good example for youth and enforce the anti-tobacco message that is taught in schools. Adults also should support programs which seek to reduce tobacco use among youth, such as the Drug Abuse Resistance Education (DARE) Program, and educate retailers about the importance of enforcing tobacco laws. Sports professionals can be especially powerful educators and should take it upon themselves to set a good example for youth by not using tobacco products.

Active enforcement of local, state, and federal laws is an essential component of tobacco prevention and control efforts. Enforcement of laws that limit youth possession and use of tobacco is especially important in areas where youth gather, such as in malls, arcades, restaurants, and recreation centers. In Texas, several laws limit youth access to tobacco products. In 1997, the Legislature enacted Senate Bill 55 which strengthened state laws prohibiting minors' access to tobacco products. Further, the Texas Education Code 89 prohibits tobacco use and possession by students at school-related or school-sanctioned activities, on or off of school property. It also gives school personnel the responsibility of enforcing these prohibitions on school property.

As of 1998, the Texas excise tax rates were $.41 per pack of cigarettes and 35.1 percent of the retail price of spit tobacco. Studies indicate that higher costs of tobacco products discourage youth from purchasing them.

During the 1990s, the federal government focused increased attention on youth access to tobacco, most notably the 1992 "Synar Amendment" and the Food and Drug Administration rules enacted in 1996. The Synar Amendment requires states to enact and enforce laws that prohibit the sale of tobacco products to people under the age of 18. It also requires states to conduct random, unannounced inspections to assess compliance with the law and to develop a strategy for achieving an inspection failure rate of less than 20 percent. Further, states are required to annually report on their enforcement activities and success rates in reducing tobacco availability to minors. The Synar Amendment authorizes the U.S. Secretary of Health and Human Services to withhold federal Substance Abuse Prevention and Treatment Block Grant funds if states do not comply with the enforcement and reporting requirements.90

The FDA Regulations
The final FDA tobacco regulations, which were released in August 1996, regulate the access and appeal of tobacco products to children and adolescents, while leaving tobacco products accessible to adults.91 These recent federal laws, coupled with the state laws, city ordinances, and organizational policies, form a strong regulatory basis on which to help prevent tobacco use among youth.

The Food and Drug Administration regulations to reduce children's use of tobacco:
Require age verification and face-to-face sales for anyone less than 27 years of age, except for mail orders
Ban free samples, sales of single cigarettes, and packages with fewer than 20 cigarettes
Ban vending machines and self-service displays except in facilities that are totally inaccessible to persons under the age of 18
Ban outdoor advertising within 1,000 feet of schools and public playgrounds
Restrict advertising to black-and-white text for outdoor and point of sale advertising
Permit advertising with color and imagery within "adult only" facilities
Require black-and-white, text-only advertising in publications with a readership of more than 15% youth or more than two million
Prohibit the sale or giveaway of products with cigarette or spit tobacco brand names or logos
Prohibit brand-name sponsorship of sporting or entertainment events


Litigation
In June 1997, an historic pact was reached between the tobacco industry and a group of 40 states and Puerto Rico. The states brought suit against the tobacco industry to recover Medicaid funds spent on treating people who develop illnesses from smoking. If enacted, the settlement would require the tobacco industry to pay billions of dollars to federal and state governments for health care costs resulting from tobacco use, anti-smoking education, advertising, and enforcement of the settlement. The tentative pact also addresses further class-action suits, consolidation of multiple suits, punitive damages for past conduct, and individual claims for medical bills or lost wages. The tentative agreement also includes regulations on warning labels, advertising of tobacco, access to minors, and smoking in public places. In early 1998, a settlement agreement, which requires federal legislation, was being considered by the United States Congress. Its outcome is uncertain at the time this Plan is being printed.

In March 1996, Texas Attorney General Dan Morales sued the tobacco industry on behalf of the State of Texas. The lawsuit addressed financial restitution for Medicaid expenditures for smokers and specific activities by the tobacco industry that were perceived to be illegal. In January 1998, the tobacco industry agreed to settle the lawsuit for $15.3 billion and to eliminate most billboard advertising in Texas. As this edition of the Texas Cancer Plan was being written, Texas legislators were beginning discussions about future allocation of the tobacco lawsuit settlement funds, pending final disbursement of funds.

Adults and Tobacco
While the Texas Cancer Plan places priority focus on the prevention of tobacco use among youth, attention also must be given to reducing tobacco use among adults. Approximately 23 percent of adults in Texas and the United States were smokers in 1997. About 2 percent of adults in the United States and 3 percent of adults in Texas use spit tobacco.92 The percentage of smokers has declined in Texas since 1987, and smoking prevalence has shifted from older age groups to the 18 to 24-year-old age groups.93 The advent of cigar bars, "virtual" cigar shops, books devoted to cigar smoking, the glamorization of cigar smoking by Hollywood, and cigar smoking viewed as a status symbol seem to explain the national increase in cigar smoking.

One way to reduce tobacco use among adults is to develop, implement, and enforce policies restricting tobacco use in workplaces and communities. Despite the concern of business owners, especially restaurant owners, that prohibiting smoking in their establishments will cause sales to decline, several studies found the opposite to be true.94 Employer incentives for workers who quit smoking and work site tobacco use cessation programs also help reduce adult use of tobacco. Additionally, insurance companies can promote tobacco use cessation through lower premiums for nonsmokers, those in cessation programs, and those who quit successfully.

Minorities and Tobacco
A 1998 report of the U.S. Surgeon General entitled Tobacco Use Among U.S. Racial/Ethnic Minority Groups provides key information about tobacco use among African Americans, Native Americans, Asian Americans, and Hispanics. The report also describes national and regional efforts to reduce consumption of tobacco products among these four groups. The report concluded that cigarette smoking is a major cause of disease and death in each of the four groups studied. In particular, African Americans bear the greatest health burden. Lung cancer is the leading cause of cancer death for each of the racial/ethnic groups. Among adults, Native Americans are among the highest users of tobacco, as are African-American men. Asian-American and Hispanic women have the lowest prevalence. Among adolescents, cigarette smoking prevalence increased in the 1990s among African Americans and Hispanics after several years of substantial decline. Prevalence of cigarette smoking is higher in men than in women, except among Native Americans. In addition, men are far more likely than women to use spit tobacco in all groups, except African Americans.

Tobacco Use Cessation Programs
Routine tobacco prevention and cessation counseling interventions by clinicians have the potential to reduce tobacco use prevalence and ultimately decrease the incidence of cancer.95 Counseling sessions as brief as three minutes are effective, but longer and more intensive efforts improve cessation outcomes.96 Cessation materials given to patients in conjunction with counseling should include age and culturally relevant advice on how to quit effectively. In a 1998 Texas Medical Association survey of physicians, almost all physicians report that they routinely determine the smoking status of new patients and record that information in the patient's chart. Respondents indicated that the most important factors in the decision to counsel a patient about smoking are the associated health risk and the physician's personal belief that this counseling is important. When asked to rate their preparedness, participating physicians reported themselves to be moderately well-prepared to counsel adolescent patients on risks related to smoking and smoking cessation.97

In 1996, the U.S. Agency for Health Care Policy and Research (AHCRP) released clinical practice guidelines on how to counsel patients on smoking cessation. The guidelines advise clinicians on what questions to ask patients and how to counsel patients according to their individual needs and attitudes toward cessation.98 Health care professionals need to be encouraged to incorporate these guidelines into their practices. The guidelines recommend that insurers, purchasers, and hospital and managed care administrators work together to incorporate smoking cessation services into health plans, implement them systematically and reimburse providers accordingly.

Nicotine Replacement Therapy and Other Pharmacological Treatment of Nicotine Dependence
Nicotine replacement therapy, along with other pharmacological agents, are important tools for smoking cessation that should be included under insurance coverage for smokers who are trying to quit. Nicotine replacement therapy includes nicotine patches, gum, or nasal sprays that gradually help reduce a smoker's craving for nicotine. Health care professionals need training to effectively counsel patients about nicotine replacement therapy options, which are becoming increasingly available. Since the mid-1990s, smokers have been able to purchase certain nicotine gum and patches without a physician's prescription. Recently an inhalable nicotine replacement therapy became available by prescription. This inhalant helps to control nicotine cravings and also furnishes the behavioral patterns that go along with inhaling cigarette smoke. More recently, a prescription medication called bupropion HCl sustained release has been shown to be effective, when used in conjunction with an overall program, to help some people overcome nicotine dependence. The recent attention placed on nicotine replacement therapy and prescription medication aimed at smoking cessation suggests that all forms of nicotine replacement therapy and use of pharmacological agents must be evaluated to determine the most effective method for people who want to quit smoking. Such evaluation of these two areas also must address the different needs of smokers and the training needs of health care professionals in Texas. Additionally, attention needs to be given to financial barriers low-income Texans may face in obtaining nicotine replacement therapy, prescription medication, and access to cessation programs.

Strategy 1: Increase awareness of the risks of tobacco use by youth.

Action Steps:
a. Conduct media campaigns to educate youth about the risks of tobacco use and cancer and to encourage youth to be tobacco free.
b. Encourage local health officials, peace officers, and community leaders to conduct tobacco vendor and community education campaigns.
c. Educate parents, teachers, coaches, clergy, and other influential adults on the importance of being positive role models for youth by not using tobacco.


Strategy 2: Reduce access to and use of tobacco products by youth.

Action Steps:
a. Encourage local health and law enforcement agencies to take an active role in enforcing laws related to tobacco sales and distribution.
b. Include effective educational curricula and peer-driven programs on tobacco use prevention as part of comprehensive school health education in grades K-12.
c. Distribute age-appropriate prevention messages through existing youth-oriented community-based channels, such as organized athletics, youth councils, and scouts.
d. Enforce smoking prohibitions in facilities that provide services to children, as required by federal legislation.
e. Encourage tobacco free environments where youth congregate, such as arcades, recreation facilities, restaurants, and malls.
f. Enforce state laws:
prohibiting tobacco advertising on billboards close to schools or churches;
prohibiting the use of tobacco on school property and at school-sanctioned activities;
eliminating tobacco vending machines and self-service displays in areas frequented by youth, such as arcades, recreation facilities, restaurants, and malls;
requiring tobacco sales to be over-the-counter and vendor-assisted;
prohibiting the distribution of tobacco samples and coupons;
prohibiting the sale of single cigarettes and packages containing fewer than 20 cigarettes; and
requiring age verification for anyone under the age of 27 purchasing tobacco products.
g. Discourage the promotion of tobacco products at sporting or entertainment events that are attended by youth under the age of 18.
h. Develop and promote tobacco use cessation programs that are specially designed for youth under the age of 18 and address the educational needs of specific subpopulations of youth.
i. Evaluate the effectiveness of tobacco use prevention programs in schools, worksites, and the community.
j. Increase state tobacco excise tax as a disincentive for children to purchase tobacco products.


Strategy 3: Reduce the use of tobacco products by adults.

Action Steps:
a. Encourage businesses to prohibit the use of tobacco products on their premises.
b. Encourage employers to offer no-cost tobacco use cessation programs to their employees.
c. Encourage employers to offer financial incentives to employees who do not use tobacco products.
d. Encourage health and life insurance companies to reduce the cost of premiums for Texans who do not use tobacco products.
e. Advocate for health insurance coverage of nicotine replacement therapy, other pharmacologic treatment, and tobacco use cessation programs.
f. Reduce financial barriers to nicotine replacement therapy and tobacco use cessation programs.
g. Increase the availability and promotion of free or low-cost tobacco cessation programs within local communities.
h. Develop coalitions within local communities to carry out effective community-based tobacco use cessation programs.
i. Provide training to health care professionals on effective tobacco use cessation and control methods and materials.
j. Encourage health care professionals to use tobacco cessation counseling guidelines developed by the U.S. Agency for Health Care Policy and Research.
k. Increase the number of trained and certified cessation therapists and facilitate referrals from health care professionals.





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