Research Article: Policy Coherence in US Tobacco Control: Beyond FDA Regulation

Date Published: May 19, 2009

Publisher: Public Library of Science

Author(s): Joshua S. Yang, Thomas E. Novotny

Abstract: Joshua Yang and Thomas Novotny explore whether the US government can develop and implement a coherent policy agenda to reduce tobacco-related morbidity and mortality.

Partial Text: As the Obama administration moves to enact meaningful and comprehensive health care reform in the United States, tobacco control must be elevated as a public health priority [1]. Though tobacco control efforts have been recognized as a top public health achievement of the 20th century [2], tobacco use continues to be the leading preventable cause of death in the US [3]. As Box 1 shows, the US bears a heavy burden from the health and fiscal effects of smoking. Thus, continued progress in preventing tobacco use and promoting smoking cessation must be a leading priority for health care reform under the new administration. This policy paper gives the current status of tobacco control policies, initiatives, and legislative action at the time of going to press.

Over the past half-century, health has occupied a prominent role on the policy agenda for many US presidents, with some administrations having made attempts to achieve policy coherence on specific health issues. For example, President Johnson identified reducing heart disease, cancer, and stroke as a national health priority [7], and President Nixon initiated a “War on Cancer” [8]. President Clinton coordinated federal action on HIV/AIDS, an action built on by President George W. Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR) program [9].

USG agencies cover a range of populations, environments, products, and functions that may effectively support tobacco control. However, they are uncoordinated across agencies and not sufficiently on-message to be considered a coherent national strategy. To understand possible future federal action, we first describe briefly the roles of the current most important USG agencies in tobacco control. A more detailed discussion of existing policies and programs can be found in Text S1.

Three future tobacco control issues should be prioritized within the federal government: ratification of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC), authorizing the FDA to regulate tobacco products, and settling the DOJ’s Racketeer Influenced and Corrupt Organizations Act (RICO) case against the tobacco industry. Each of these issues should be part of a larger policy-coherent plan for the federal government on tobacco control, but are highlighted here for their significance and potential impact.

The current financial and political environment makes it difficult for the USG to contemplate any new programs aside from those that revive the economy and seek a resolution to the conflicts in Iraq and Afghanistan. Tobacco control, however, is nonetheless a critical element of the domestic health care reform agenda for two reasons. First, it can be initiated at little to no cost to the government. Creating smoke-free environments and engaging in public education are simple first steps that require little more than asserting tobacco control as a public health priority. Programs and policies that require government expenditure, including increased provision of smoking cessation services, can be introduced as the country’s economic condition stabilizes. Second, the economic return on investment in tobacco control could be remarkable [27],[28]. Thus, renewed commitment and mobilization within the programs and agencies described above, as well as others in the federal government, may be critical components of any health reform strategy for the new administration. The following agencies have a potentially important role to play in a revitalized national approach.

The wide public support and increasing political momentum for health care reform is an opportunity to advance the progress of tobacco control efforts, reducing the health toll on Americans and the economic burden on the American health care system. National plans to substantially reduce the burden of tobacco use have been put forth [10],[11]. Yet those plans are unlikely to be fully realized without the strong and committed leadership of the Office of the President and support of Congress. Existing policies and programs and opportunities for expansion of tobacco control within the federal government lead to the following recommendations for action.



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