Policy Coherence in US Tobacco Control: Beyond FDA Regulation

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. A bill to grant the US Food and Drug Administration (FDA) regulatory authority over tobacco products [4] was the central element of federal tobacco control efforts during the Bush administration. The bill, recently passed by the US House of Representatives, was drafted to obtain approval from a Republican Congress and the Bush White House. With a new administration in place and broad political and public support for health care reform, however, a comprehensive reassessment of the federal agenda on tobacco control is needed. Efforts to pass strong legislation to grant FDA regulatory authority over tobacco products must continue, but can no longer be the central focus of tobacco control efforts at the federal level. This paper explores the potential of the US government (USG), with its extraordinary reach and extensive infrastructure, to develop and implement a policy-coherent agenda—defined as a series of consistent and mutually supportive institutional approaches to an important public health problem—to reduce tobacco-related morbidity and mortality. Tobacco use prevention and cessation measures have public support from both nonsmokers and smokers; in fact, 70% of smokers desperately want to quit [5]. These measures also mitigate health care costs [6]. To fully realize these cost savings and to answer the public’s support for tobacco control measures, however, a functional approach requires policy integration across agencies, especially those under the Chief Executive, and support from the legislative branch of government.