Category Archives: cigarette smoking

Why Doesn’t The USA Have Graphic Warning Labels On Cigarette Packs Like The Netherlands?

While strolling the delightful (and typically debris-free) streets of Haarlem in The Netherlands the skeptical cardiologist espied an unusual cigarette pack on the ground.

In comparison to the typical American cigarette pack I noted a very prominent and disgusting picture of a leg which had been ravaged by peripheral artery disease.

The large print translates “smoking clogs your arteries.”

This is one of many potential warnings on Dutch cigarette packs. My favorite is

Roken kan leiden tot een langzame, pijnlijke dood

(Smoking can lead to a slow, painful death)

Perhaps, if such warning had been on American cigarette packs in the 1990s my mother would have been able to walk without severe pain in her legs (claudication) from the severe blockages caused by her decades of cigarette smoking.

When cigarette smoking patients tell me that “you have to die from something” I tell them that although they are greatly increasing their chance of dying from lung and cardiac disease, the smoking may not kill them but  leave them miserable and unable to walk or breath.

Experts on tobacco control note that these large, graphic and direct warnings are much more effective than the first small boxed warnings:

After the implementation of the first warning labels in 1966, the FTC’s 1981 report concluded that the original warning labels were not novel, overexposed and too abstract to remember and be personally relevant.46 Warning labels, like advertisements, wear out over time.47 Written warning labels wear out faster than graphic ones.48,49 In response, Congress passed a law mandating four rotating warnings. Studies on them began appearing in the late 1980s, demonstrating that several years after the implementation, those written labels on cigarette packs were also not noticed and not remembered by smokers and adolescents.5053 Since then, the diffusion and evolution of tobacco warning labels have been propelled by observational and experimental studies showing the effectiveness of large graphic warning labels in informing consumers about the health harms of smoking and reducing their smoking behavior.45,54

Here’s how Australia’s warnings have evolved

autralia-cigarette.jpg

 

 

 

 

 

 

 

In 2011 the US Congress passed legislation moving America towards such effective graphic warnings:

However, the law was challenged by Big Tobacco and has never been enacted. From the FDA site:

The Family Smoking Prevention and Tobacco Control Act requires the FDA to include new warning labels on cigarette packages and in cigarette advertisements. On June 22, 2011, the FDA published a final rule requiring color graphics depicting the negative health consequences of smoking to accompany the nine new textual warning statements. However, the final rule was challenged in court by several tobacco companies, and on Aug. 24, 2012, the United States Court of Appeals for the District of Columbia Circuit vacated the rule on First Amendment grounds and remanded the matter to the agency.[1] On Dec. 5, 2012, the Court denied the government’s petition for panel rehearing and rehearing en banc. In 2013, the government decided not to seek further review of the court’s ruling.

The FDA has been undertaking research related to graphic health warnings since that time.

[1] R.J. Reynolds Tobacco Co., et al., v. Food & Drug Administration, et al., 696 F.3d 1205 (D.C. Cir. 2012)

What Other Countries Are Doing

According to a Canadian Cancer Society report from late 2016,

More than 100 countries/jurisdictions worldwide have now required pictorial warnings, with fully 105 countries/jurisdictions having done so. This represents a landmark global public health achievement.

Increasingly, the United States stands alone, because of a constitutional doctrine privileging commercial speech above public health.

Here are the countries requiring pictorial warnings courtesy of that Canadian Cancer Society report.

And some of their warning pictures:

And this a picture that FDA would have required:

 

Skeptically Yours,

-AcP

Vote Yes on Missouri’s Amendment 3 To Cut Cigarette Smoking and Enhance Early Childhood Education

The skeptical cardiologist spent way too much time soliciting and analyzing the arguments against Amendment 3 on a gorgeous fall Sunday.

I found two sites to be very helpful in sorting through the “smokescreen” put up by opponents: Campaign for Tobacco-free Kids and the blog of Megan Green.  Both of these sites I have concluded are only interested in helping children and have unimpeachable credentials.

If you take the time to read these discussions I think you will conclude as I have that Amendment 3 should be supported as a measure that will both reduce cigarette smoking and enhance early childhood education in Missouri.

Megan Green points out that the complexity of the Amendment relates to :

Washington University in St. Louis put out studies in 2009 and 2012 about the reasons that the last two cigarette tax increases failed. It was largely because proponents of the tax were fighting big tobacco, wholesale tobacco, convenience stores, and pro-life, each of which are very powerful lobbies. It is nearly impossible to fight all of them and win.

Here’s what I concluded:

Misguided Argument 1 :There are restrictions on the money being used on stem cell research. This appears to be why Washington University sent an email to all their faculty urging them to vote no.

Megan Green, (self-described as Progressive | 15th Ward Alderwoman | PhD Student in Ed Policy | Change Agent | Social Justice Activist | STL City Advocate) who helped craft  A3 answers this clearly in a blog post:

Utilizing lessons learned from the 2006 campaign detailed in the study, an attempt was made to neutralize the opposition by adding specific language stating that the money would not be used to support abortions or stem cell research in the 2012 initiative, which also failed. As detailed in a 2012 study also from Washington University in St. Louis, the pro-life groups were still not satisfied, but were not as active as in prior campaigns due to the ballot language excluding funding of stem cell research.

Fast forward to 2016, and once again proponents of a cigarette tax took the recommendations of the Washington University in St. Louis study, (ironically, the same group that is now opposing us) and added the protective language to the policy. The Washington University report recognized the 2012 anti-abortion, anti-stem cell language helped, but it was not strong enough to stop all pro-life opposition. In order to neutralize opposition, we made adjustments and used the following language:

2016 language: “None of the funds collected, distributed, or allocated from the Early Childhood Health and Education Trust Fund shall be used for human cloning or research, clinical trials, or therapies or cures using human embryonic stem cells, as defined in Articles IX, section 38(d).”

The effect of this language is ensuring the revenue from this screen-shot-2016-11-07-at-6-45-19-amspecific 60-cent tobacco increase can only go towards early childhood and smoking cessation/prevention programs. The language does nothing to change Missouri’s existing laws as they relate to abortion or stem cell research or funding. A legal opinion was even issued by retired Missouri Court of Appeals Judge James R. Dowd where he stated that “It is evident that there is no risk that a Missouri court could read the proposed amendment as a repeal of Amendment 2 (the Amendment authorizing stem-cell research), either expressly or by implication.”

Misguided Argument #2. The measure will fund religious and private schools with public money.

Raise Your Hands for Kids (an excellent site devoted to supporting the amendment which addresses in detail all of these concerns)  has a succint document that addressess all the opponents issues which answers this concern by saying:

The Establishment Clause of the U.S. Constitution prohibits public dollars going towards religious instruction. Missouri education leaders suggest that to adequately serve our birth through 5 population and deliver quality pre-K, Missouri must have a blended funding model.

For a really detailed analysis of the early childhood education screen-shot-2016-11-07-at-6-45-03-amsituation in Missouri (which is shockingly lagging other states) take the time to read Megan Green’s answer to this argument:

As the daughter of a retired NEA Local President there are few things that matter more to me than the protection of public education. I also think that it is important to understand a few things about the landscape of early childhood education in Missouri. First, the Establishment Clause of the U.S. Constitution prohibits public dollars from going toward religious instruction. Funds cannot be used on religious education, period. With that said, religious organizations, such as the YMCA already receive public money to provide early childhood programing so long as that funding does not go toward religious education.

Second, it’s important to understand how the current system of early childhood education is funded. In Missouri we already have a blended funding model between public and private institutions. Private schools already receive early childhood programs and, in fact, most programs in this state are private. Parents receive child care subsidies, or for lack of a better term, vouchers. Programs also receive food and other health related government funding. In return, these programs must adhere to state licensing standards.

Although I would love for Missouri to have a completely public early education system, it is irrational to think we could move to a completely public system. Most of the supply in Missouri is in the private sector, and we also use public money at private institutions in the form of child care subsidies and child and adult food care program reimbursement. A prime example of this are Head Start programs, which are often private organizations, such as Grace Hill, the YWCA, and the Urban League, who receive government contracts to run the program.

Facilities have to be licensed or accredited in Missouri to receive those funds. Missouri recently passed a quality rating system this past year that ensures quality. Although I support when St. Louis Public Schools added pre-k programming to its elementary schools, the decision was done without the consultation of those in the private sector, and as a result, some really high quality programs serving low-income kids went out of business because they couldn’t compete with free.

The best delivery model for early childhood education services for children ages birth through 5 is a public/private model. Public schools are not in the business of taking care of infants and toddlers. The only way we can reach all children is through a blended model, and we already do that in Missouri — Head Start and Missouri Preschool Project public money’s go to private providers.

If we already had the bulk of our early childhood programs in the public sector, then I would be all for it going just to the public sector, but that is not the system we have. Only having the funds in the public sector would disenfranchise many children in rural areas where schools would have to build additions to accommodate rather than being able to use existing programs. Couple that with the travel times induced by closing programs in small towns and having to bus or drive kids that young to school districts is not in the best interest of kids. There has to be a public/private partnership where school districts can contract with quality programs to replicate their programs in a public setting rather than starting from scratch. I’m rarely on the opposite side as the teachers unions, but I am in this case because we have real financial, logistical, and educational reasons to not switch to a completely public system.

In sum, if we only want early childhood education in the public sector are we saying that we should defund programs like Head Start and the Missouri Pre-school Program? Then are we further saying that no non-profit organization should receive government funding because they do not operate in the public sector? I think not.

Unless we are ready to draw those hard lines in the sand, that no non-profit or Head Start Program should be receiving government money since they are not public entities, I encourage you to vote YES on Amendment 3.

Misguided Argument #3. Studies have shown that the increase in cigarette tax proposed is not enough to impact cigarette smoking. This seems to be the argument of the major health organizations that have come out against the tax.

I really searched hard to find any study that supports this claim and couldn’t find one. For a discussion of how effective cigarette taxes are in reducing smoking read this pdf from The Campaign for Tobacco-Free Kids

Misguided Argument #4. This is a regressive tax which will hurt the poor more than the affluent.

From a review in Tobacco Control:

The regressivity of existing taxes, however, does not necessarily imply that tax increases are regressive as well. In many countries, tobacco use among the lowest income/SES populations is most responsive to price, while use among the highest income/SES populations is least responsive. Thus, a tax increase that raises tobacco product prices will lead to the largest declines in smoking among the lowest income persons, and the burden of tax increase will fall more heavily on higher income consumers whose smoking behaviour changes little in response to the tax increase.

I urge all Missouri readers to educate yourself on Amendment 3 by reading the source documents and fully understanding the document.

I now strongly advocate voting yes for Amendment 3

Antinicotinely Yours

-ACP

And here’s some more stuff to ponder

The St. Louis Post Dispatch supports Amendment 3 after a judge ruled that verbiage in the Amendment would not limit funding for stem cell research in the state

Quotes from Transnational and U.S. Tobacco Companies (from tobaccofreecenter.org)

  • Tobacco companies have opposed tobacco tax increases by arguing that raising product prices would not reduce adult or youth smoking. But the companies’ internal documents, disclosed in the U.S. tobacco lawsuits, show that they know very well that raising cigarette prices is one of the most effective ways to prevent and reduce smoking, especially among kids.

    • Philip Morris: Of all the concerns, there is one – taxation – that alarms us the most. While marketing restrictions and public and passive smoking [restrictions] do depress volume, in our experience taxation depresses it much more severely. Our concern for taxation is, therefore, central to our thinking . . .
    • Philip Morris: When the tax goes up, industry loses volume and profits as many smokers cut back

    Higher Tobacco Taxes Reduce Tobacco Use / 4

    • Philip Morris: It is clear that price has a pronounced effect on the smoking prevalence of teenagers, and that the goals of reducing teenage smoking and balancing the budget would both be served by increasing the Federal excise tax on cigarettes.22
    • Philip Morris: Jeffrey Harris of MIT calculated…that the 1982-83 round of price increases caused two million adults to quit smoking and prevented 600,000 teenagers from starting to smoke…We don’t need to have that happen again.23
    • Philip Morris: A high cigarette price, more than any other cigarette attribute, has the most dramatic impact on the share of the quitting population…price, not tar level, is the main driving force for quitting.24[For more on cigarette company documents and price/tax increases see the 2002 study in the Tobacco Control journal, “Tax, Price and Cigarette Smoking: Evidence from the Tobacco Documents.”25]

Cigarette Smoking Kills: Should Missourians Vote Yes To Raise Cigarette Taxes?

Recent statistics show that cigarette smoking is  responsible for 167, 133 cancer deaths annually in the US or 29% of all cancer deaths.

Cigarette smoking also kills annually in the US  160,000 people by promoting cardiovascular disease.

Thus, from a health standpoint we should be doing everything possible to stigmatize and make more difficult cigarette smoking.

One approach to this is to tax cigarettes, raising the financial burden of smoking. Across the US, therefore, states have added cigarettes taxes which average 1.65$ per pack.

My state of Missouri has the lowest state tax on cigarettes of 17 cents per pack. Multiple ballot attempts to raise this amount have failed in the past.

However, on this Tuesday’s ballot there are two competing options that we can  vote on that will raise cigarette taxes: Amendment 3 (raises cig taxes  60 cents and earmarks funds for a newly created Early Childhood Education and Research Fund) and Proposition A (raises taxes 23 cents and earmarks funds for infrastructure.) (Links are to Ballotpedia, a reputable source of information nationwide.)

I’ve been researching both of these proposals over the last few days since receiving an email from a physician colleague urging  me to vote no on Amendment 3. Remarkably, a coalition of health organizations (The American Cancer Society Cancer Action NetworkAmerican Heart AssociationAmerican Lung Association in MissouriCampaign for Tobacco-Free KidsHealth Care Foundation of Greater Kansas City and Tobacco-Free Missouri) has come out against the propositions to raise cigarette taxes with the following statement :

Small increases to the tobacco tax – like the proposals being considered – will generate new revenue, but will not keep kids from becoming addicted to cigarettes or help adults quit.Tobacco taxes work when the price increase is substantial enough to motivate current smokers to quit and prevent kids from starting. A dime here or there is not sufficient. Tobacco companies are adept at finding ways to absorb small tax increases through adjusted pricing. What’s worse, these marginal increases could hamper future efforts; promising profitable returns for the tobacco industry at the continued expense of Missourians’ health…

Tobacco products in Missouri are too cheap and the health costs are too high. Our state is long overdue for a tobacco tax increase, but it needs to be one that will make a difference and save lives. A meaningful tobacco tax increase – of $1.00 per pack or more – has proven time and again to be an effective way to reduce tobacco use, cut healthcare costs and generate state revenue.[7]

Our local public radio station had a good discussion recently which is summarized here.

I found the PRO comments of Jane Dueker particularly persuasive as summarized below:

PRO: Jane Dueker wants people to vote “Yes” on Constitutional Amendment 3. Here are her main points:

Jane Dueker is a proponent of Constitutional Amendment 3.
CREDIT KELLY MOFFITT | ST. LOUIS PUBLIC RADIO
  • This tax would provide $300 million in funding for early childhood education, healthcare and smoking cessation programs. Right now, Missouri can’t even fund the K-12 Foundation Formula, so any extra funding is needed for early childhood education.

  • By filing this as an amendment, we were able to make a constitutional “lock box” that would keep the legislature and special interests from taking money that is specifically dedicated to this fund, like what happened with lottery funds.

  • Right now, only 3 percent of 4-year-olds in Missouri are in a publicly-funded preschool. Missouri is behind states like Oklahoma with 76 percent, Illinois with 27 percent and Arkansas with 38 percent.

  • Higher tobacco taxes have failed in 2002, 2006 and 2012. This is more reasonable and we don’t have a clause that says another tobacco tax could not be added on top of this one to give that “sticker shock” to consumers.

  • This closes a loophole that kept cheap cigarette companies from paying their fair share into a 1998 court settlement to recover some of state governments’ tobacco-related health-care costs. Now, smaller tobacco companies would pay a 67-cents-a-pack hike on low-cost cigarettes in addition to the 60 cent tax on all cigarettes. This would give Missouri $1 billion annually we currently don’t get. Missouri is the only state that hasn’t closed this loophole and the state is a “dumping ground” for the cheapest cigarettes in the country.

  • Groups that oppose this either think the tax is not high enough (health groups) or that they don’t get money from this fund (pro-choice and research institutions).

  • Missouri’s Foundation Formula public school funding starts at kindergarten and cannot fund early childhood education. This money could go to public or private early childhood education entities in a way it would not be distributed through the foundation formula.

  • $15-30 million dollars would be raised through this tax that would go to smoking cessation programs.

  • The fund will be administered by a board of unelected people because they have special experience in early childhood education. A “person of faith” is required on the board because of their position as a community anchor.

At this point, I’m leaning toward voting yes on Amendment 3 but confused as to why RJ Reynolds is supporting it to the tune of 12 million dollars and the “good guy” health organizations oppose it. I’d appreciate any input/comments on this from readers. I strongly urge everyone to read and learn as much as you can about the issue before walking into the voting booth.

By the way, I recently observed this Canadian cigarette package img_7957which I think excellently conveys the horror of cigarette smoking.

Truthily Yours

-ACP

Some more  stats to ponder from the CDC

Cigarette smoking causes premature death:

  • Life expectancy for smokers is at least 10 years shorter than for nonsmokers.
  • Quitting smoking before the age of 40 reduces the risk of dying from smoking-related disease by about 90%.

Exposure to secondhand smoke causes an estimated 41,000 deaths each year among adults in the United States:

  • Secondhand smoke causes 7,333 annual deaths from lung cancer.
  • Secondhand smoke causes 33,951 annual deaths from heart disease.