Ending the Tobacco Problem - Resources for Local Action
Institute of Medicine

Call To Action


Recommendations from Ending the Tobacco Problem: A Blueprint for the Nation


Recommendation 1: Each state should fund state tobacco control activities at the level recommended by the CDC. A reasonable target for each state is in the range of $15 to $20 per capita, depending on the state’s population, demography, and prevalence of tobacco use. If it is constitutionally permissible, states should use a statutorily prescribed portion of their tobacco excise tax revenues to fund tobacco control programs.


Recommendation 2: States with excise tax rates below the level imposed by the top quintile of states should substantially increase their own rates to reduce consumption and to reduce smuggling and tax evasion. State excise tax rates should be indexed to inflation.


Recommendation 3: The federal government should substantially raise federal tobacco excise taxes, currently set at 39 cents a pack. Federal excise taxes should be indexed to inflation.


Recommendation 4: States and localities should enact complete bans on smoking in all nonresidential indoor locations, including workplaces, malls, restaurants, and bars. States should not preempt local governments from enacting bans more restrictive than the state ban.


Recommendation 5: All health care facilities, including nursing homes, psychiatric hospitals, and medical units in correctional facilities, should meet or exceed JCAHO standards in banning smoking in all indoor areas.


Recommendation 6: The American Correctional Association should require through its accreditation standards that all correctional facilities (prisons, jails, and juvenile detention facilities) implement bans on indoor smoking.


Recommendation 7: States should enact legislation requiring leases for multiunit apartment buildings and condominium sales agreements to include the terms governing smoking in common areas and residential units. States and localities should also encourage the owners of multiunit apartment buildings and condominium developers to include nonsmoking clauses in these leases and sales agreements and to enforce them.


Recommendation 8: Colleges and universities should ban smoking in indoor locations, including dormitories, and should consider setting a smoke-free campus as a goal. Further, colleges and universities should ban the promotion of tobacco products on campus and at all campus-sponsored events. Such policies should be monitored and evaluated by oversight committees, such as those associated with the American College Health Association.


Recommendation 9: State health agencies, health care professionals, and other interested organizations should undertake strong efforts to encourage parents to make their homes and vehicles smoke free.

Recommendation 10: States should not preempt local governments from restricting smoking in outdoor public spaces, such as parks and beaches.


Recommendation 11: All states should license retail sales outlets that sell tobacco products.


Recommendation 12: All states should ban the sale of tobacco products directly to consumers through mail order or the Internet or other electronic systems. Shipments of tobacco products should be permitted only to licensed wholesale or retail outlets.


Recommendation 13: School boards should require all middle schools and high schools to adopt evidence-based smoking prevention programs and implement them with fidelity. They should coordinate these in-school programs with public activities or mass media programming, or both. Such prevention programs should be conducted annually. State funding for these programs should be supplemented with funding from the U.S. Department of Education under the Safe and Drug-Free School Act or by an independent body administering funds collected from the tobacco industry through excise taxes, court orders, or litigation agreements.


Recommendation 14: All physicians, dentists, and other health care providers should screen and educate youth about tobacco use during their annual health care visits and any other visit in which a health screening occurs. Physicians should refer youth who smoke to counseling services or smoking cessation programs available in the community. Physicians should also urge parents to keep a smoke-free home and vehicles, to discuss tobacco use with their children, to convey that they expect their children to not use tobacco, and to monitor their children’s tobacco use. Professional societies, including the American Medical Association, the American Nursing Association, the American Academy of Family Physicians, the American College of Physicians, and the American Academy of Pediatrics, should encourage physicians to adopt these practices.


Recommendation 15: A national, youth-oriented media campaign should be funded on an ongoing basis as a permanent component of the nation’s strategy to reduce tobacco use. State and community tobacco control programs should supplement the national media campaign with coordinated youth prevention activities. The campaign should be implemented by an established public health organization with funds provided by the federal government, public-private partnerships, or the tobacco industry (voluntarily or under litigation settlement agreements or court orders) for media development, testing, and purchases of advertising time and space.


Recommendation 16: State tobacco control agencies should work with health care partners to increase the demand for effective cessation programs and activities through mass media and other general and targeted public education programs.


Recommendation 17: Congress should ensure that stable funding is continuously provided to the national quitline network.


Recommendation 18: The Secretary of the U.S. Department of Health and Human Services, through the National Cancer Institute, the Centers for Disease Control and Prevention, and other relevant federal health agencies, should fund a program of developmental research and demonstration projects combining media techniques, other social marketing methods, and innovative approaches to disseminating smoking cessation technologies.


Recommendation 19: Public and private health care systems should organize and provide access to comprehensive smoking cessation programs by using a variety of successful cessation methods and a staged disease management model (i.e. stepped care), and should specify the successful delivery of these programs as one criterion for quality assurance within those systems.


Recommendation 20: All insurance, managed care, and employee benefit plans, including Medicaid and Medicare, should cover reimbursement for effective smoking cessation programs as a lifetime benefit.


Recommendation 21: While sustaining their own valuable tobacco control activities, state tobacco control programs, CDC, philanthropic foundations, and voluntary organizations should continue to support the efforts of community coalitions promoting, disseminating, and advocating for tobacco use prevention and cessation, smoke-free environments, and other policies and programs for reducing tobacco use.


Recommendation 22: Tobacco control programs should consider populations disproportionately affected by tobacco addiction and tobacco-related morbidity and mortality when designing and implementing prevention and treatment programs. Particular attention should be paid to ensuring that health communications and other materials are culturally-appropriate and that special outreach efforts target all high-risk populations. Standard prevention or treatment programs that are modified to reach high-risk populations should be evaluated for effectiveness.


Recommendation 23: Congress should repeal the existing statute preempting state tobacco regulation of advertising and promotion “based on smoking and health” and should enact a new provision that precludes direct state regulation only in relation to tobacco product characteristics and packaging while allowing complementary state regulation in all other domains of tobacco regulation, including marketing and distribution. Under this approach, federal regulation sets a floor while allowing states to be more restrictive.


Recommendation 24: Congress should confer upon the FDA broad regulatory authority over the manufacture, distribution, marketing, and use of tobacco products.


Recommendation 25: Congress should empower the FDA to regulate the design and characteristics of tobacco products to promote the public health. Specific authority should be conferred

  • to require tobacco manufacturers to disclose to the agency all chemical compounds found in both product and the product’s smoke, whether added or occurring naturally, by quantity; to disclose to the public the amount of nicotine in the product and the amount delivered to the consumer based on standards established by the agency; to disclose to the pubic research on their product, as well as behavioral aspects of its use; and to notify the agency whenever there is a change in a product;
  • to prescribe cigarette testing methods, including how the cigarettes are tested and which smoke constituents must be measured;
  • to promulgate tobacco product standards, including reduction of nicotine yields and reduction or elimination of other constituents, wherever such a standard is found to be appropriate for protection of the public health, taking into consideration the risks and benefits to the population as a whole, including users and non-users of tobacco products; and
  • to develop specific standards for evaluating novel products that companies intend to promote as reduced-exposure or reduced-risk products, and to regulate reduced-exposure and reduced-risk health claims, assuring that there is a scientific basis for claims that are permitted.

Recommendation 26: Congress should strengthen the federally mandated warning labels for tobacco products immediately and should delegate authority to the FDA to update and revise these warnings on a regular basis upon finding that doing so would promote greater public understanding of the risks of using tobacco products or reduce tobacco consumption. Congress should require or authorize the FDA to require rotating color graphic warnings covering 50 percent of the package equivalent to those required in Canada.


Recommendation 27: Congress should empower the FDA to require manufacturers to include in or on tobacco packages information about the health effects of tobacco use and about products that can be used to help people quit.


Recommendation 28: Congress should ban, or empower the FDA to ban, terms such as “mild,” “lights,” “ultra-lights,” and other misleading terms mistakenly interpreted by consumers to imply reduced risk, as well as other techniques, such as color codes, that have the purpose or effect of conveying false or misleading impressions about the relative harmfulness of the product.


Recommendation 29: Whenever a court or administrative agency has found that a tobacco company has made false or misleading communications regarding the effects of tobacco products, or has engaged in conduct promoting tobacco use among youth or discouraging cessation by tobacco users of any age, the court or agency should consider using its remedial authority to require manufacturers to include corrective communications on or with the tobacco package as well as at the point of sale.


Recommendation 30: Congress and state legislatures should enact legislation regulating the retail point of sale of tobacco products for the purpose of discouraging consumption of these products and encouraging cessation. Specifically:

  • All retail outlets choosing to carry tobacco products should be licensed and monitored. (See also youth access section in Chapter 5.
  • Commercial displays or other activity promoting tobacco use by or in retail outlets should be banned, although text-only informational displays (e.g., price or health-related product characteristics) may be permitted within prescribed regulatory constraints.
  • Retail outlets choosing to carry tobacco products should be required to display and distribute prescribed warnings about the health consequences of tobacco use, information regarding products and services for cessation, and corrective messages designed to offset misstatements or implied claims regarding the health effects of tobacco use (e.g., that “light” cigarettes are less harmful than other cigarettes).

Retail outlets choosing to carry tobacco products should be required to allocate a proportionate amount of space to cessation aids and nicotine replacement products and, after regulatory clearance by the FDA or a designated state agency, to “qualifying” exposure-reduction products. (The FDA or a suitable state health agency should promulgate a list of “qualifying” exposure-reducing products.)


Recommendation 31: Congress should explicitly and unmistakably include production, marketing, and distribution of tobacco products on Indian reservations by Indian tribes within the regulatory jurisdiction of FDA. Authority to investigate and enforce the Jenkins Act should be transferred to the Bureau of Alcohol, Tobacco, Firearms and Explosives. State restrictions on retail outlets should apply to all outlets on Indian reservations.


Recommendation 32: State governments should develop and, if feasible, implement and evaluate legal mechanisms for restructuring retail tobacco sales and restricting the number of tobacco outlets.


Recommendation 33: Congress should empower the FDA to restrict outlets in order to limit access and facilitate regulation of the retail environment, and thereby protect the public health.


Recommendation 34: If most states fail to increase tobacco control funding and reduce variations in tobacco excise tax rates as proposed in Recommendations 1 and 2, Congress should enact a National Tobacco Control Funding Plan raising funds through a per-pack remedial assessment on cigarettes sold in the United States. Part of the proceeds should be used to support national tobacco control programs and the remainder of the funds should be distributed to the states to subsidize state tobacco control programs according to a formula based on the level of state tobacco control expenditures and state tobacco excise rates. The plan should be designed to give states an incentive, not only to increase state spending on tobacco control, but also to raise cigarette taxes, especially in low-tax states. Congress should assure that any federal coordination mechanism affecting the coverage and collection of state tobacco excise taxes applies to Indian tribes.


Recommendation 35: Congress and state legislatures should enact legislation limiting visually displayed tobacco advertising in all venues, including mass media and at the point-of-sale, to a text-only, black-and-white format.


Recommendation 36: Congress and state legislatures should prohibit tobacco companies from targeting youth under 18 for any purpose, including dissemination of messages about smoking (whether ostensibly to promote or discourage it) or to survey youth opinions, attitudes and behaviors of any kind. If a tobacco company wishes to support youth prevention programs, the company should contribute funds to an independent non-profit organization with expertise in the prevention field. The independent organization should have exclusive responsibility for designing, executing, and evaluating the program.


Recommendation 37: The Motion Picture Association of America (MPAA) should encourage and facilitate the showing of anti-smoking advertisements before any film in which smoking is depicted in more than an incidental manner. The film rating board of the MPAA should consider the use of tobacco in the movies as a factor in assigning mature film ratings (e.g., an R-rating indicating Restricted: no one under age 17 admitted without parent or guardian) to films that depict tobacco use.


Recommendation 38: Congress should appropriate the necessary funds to enable the U.S. Department of Health and Human Services to conduct a periodic review of a representative sample of movies, television programs, and videos that are offered at times or in venues in which there is likely to be a significant youth audience (e.g., 15 percent) in order to ascertain the nature and frequency of images portraying tobacco use. The results of these reviews should be reported to Congress and to the public.


Recommendation 39: State tobacco control agencies should conduct surveillance of tobacco sales and use and the effects of tobacco control interventions in order to assess local trends in usage patterns; identify special groups at high risk for tobacco use; determine compliance with state and local tobacco-related laws, policies, and ordinances; and evaluate overall programmatic success.


Recommendation 40: The Secretary of HHS, through FDA or other agencies, should establish a national comprehensive tobacco surveillance system to collect information on a broad range of elements needed to understand and track the population impact of all tobacco products and the effects of national interventions (such as attitudes, beliefs, product characteristics, product distribution and usage patterns, and marketing messages and exposures to them).


Recommendation 41: Congress should direct the Centers for Disease Control and Prevention to undertake a major program of tobacco control policy analysis and development and should provide sufficient funding to support the program. This program should develop the next generation of macro-level simulation models to project the likely effects of various policy innovations, taking into account the possible initiatives and responses of the tobacco industry as well as the impacts of the innovations on consumers.


Recommendation 42: Upon being empowered to regulate tobacco products, the FDA should give priority to exploring the potential effectiveness of a long-term strategy for reducing the amount of nicotine in cigarettes and should commission the studies needed to assess the feasibility of implementing such an approach. If such a strategy appears to be feasible, the agency should develop a long-term plan for implementing the strategy as part of a comprehensive plan for reducing tobacco use.