Tobacco. In Texas, tobacco stands out as the agent most responsible for avoidable illness and death. Its use brings premature death to one-half of all tobacco users and contributes to profound disability and pain in millions of Texans. In addition, secondhand smoke is one of the most dangerous and unregulated occupational chemical exposures in America's workplaces.
The vast majority of adult tobacco users report a strong desire to quit, and current treatments for tobacco dependence offer physicians their greatest single opportunity to staunch the loss of life, health, and happiness caused by this chronic condition.
While physicians are uniquely qualified to advocate for smoke-free policies because of the dangerous health effects of tobacco use, physicians also must be aware of the economic costs of tobacco use in Texas - totaling $20 billion each year for health care and from lost work productivity and premature death. Physicians must advocate for measures that will reduce the impact of tobacco use in health and the state's economy.
The Texas Medical Association supports the following policies to help physicians reduce, and eventually eliminate, tobacco use and its impact on Texans.
Tobacco Use. TMA strongly encourages all people who currently do not use tobacco products to remain tobacco-free and all people who currently use tobacco products to quit. TMA further encourages people who are ready to quit to actively participate in a proven tobacco cessation program, consulting their physician or other health care professional as appropriate. TMA urges public and private agencies, institutions, and businesses to establish tobacco prevention and cessation programs to help their employees, faculty, staff, and students quit their tobacco use. TMA condemns the use of tobacco as a behavior modification reward under all circumstances.
Tobacco Products. TMA opposes the sale of all tobacco products (cigarettes, cigars, smokeless tobacco), tobacco substitutes for use other than tobacco cessation pharmacotherapy (nicotine mints, nicotine gum, nicotine water, clove cigarettes, snus, shisha, nicotine strips and other dissolvable tobacco products), and tobacco look-alike candy, gum, and jerky that are made to resemble real tobacco products and potentially encourage tobacco use.
Tobacco Regulation. TMA opposes any state or federal law exempting tobacco products from product liability or litigation and supports the classification of tobacco smoke as a Class A carcinogen and supports its stringent regulation with other Class A carcinogens regulated by the Occupational Safety and Health Administration and the Environmental Protection Agency. TMA supports the inclusion of all tobacco products under the regulations and jurisdiction of the Federal Drug Administration (FDA) and encourages strong FDA regulatory action such as a requirement for color picture warning labels and plain packs as done in other countries. If tobacco products are sold in Texas, TMA suggests the packaging of all tobacco products in a plain white container with only the name of the brand and all of the following: a colored warning label covering at least 50 percent of the surface area of the front and back of the package, a label listing all ingredients, and an insert that presents in detail all health and safety risks associated with tobacco use.
Smoke-Free Environments. TMA prohibits smoking at all of its official functions and calls for all future TMA contracts for hotel and event venues to include a prohibition on smoking. TMA supports regulations and legislative action establishing all public places and workplaces, including any place where people seek medical care, day care facilities, residential daycare facilities, public and private schools, prisons, and airplanes, and bars and restaurants as smoke-free environments. Surrounding grounds also should be made smoke-free for a distance sufficient not to expose others to secondhand smoke. TMA urges its members, county and state medical societies, and the American Medical Association to facilitate and support the establishment and enforcement of smoke-free policies and ordinances in the above locations and to promote, honor, and help publicize companies and governmental agencies that become smoke-free. No exemptions should be made for concerts for theatrical performances
Tobacco-Free Environments. TMA endorses any proposal to make the following entities completely tobacco-free: hospitals or any place people seek medical care, psychiatric hospitals, and prisons. Additionally, physicians should assist in eliminating the sale of tobacco products on these premises.
Physician Education. TMA strongly encourages all physicians to become formally trained in tobacco prevention and cessation methods and to utilize these proven techniques in their daily practices. TMA encourages physicians to be aware of effective tobacco cessation programs that support integration of tobacco cessation in health care settings.
Physician Advocacy. TMA encourages its members to support anti-tobacco education within their local communities and strive to gain cooperation from other health care professionals in these efforts. TMA rejects the tobacco industry and its affiliates as credible sources of health information or materials and discourages municipalities and schools from using tobacco industry-sponsored information or materials.
Physician Screening and Interventions. TMA recommends that all physicians and other health care professionals screen each patient for tobacco use and encourage and facilitate tobacco cessation for tobacco users. This intervention should include prompts to Ask the patient regarding their tobacco use and Assess their willingness to make a quite attempt. If ready, refer the patient to the state Quitline or provide cessation support and pharmacotherapy. If the patient is not ready to quit, the use of Motivational Interviewing (MI), a directive, patient-centered counseling intervention is effective in increasing future quit attempts. Physicians are strongly advised to routinely use a vital sign template that includes tobacco use in clinic charts and document all interventions and follow-up, including referral to a tobacco cessation specialist. Furthermore, TMA urges physicians to advise patients and patient caregivers to maintain a smoke-free home to promote recovery and prevent additional illness.
Reimbursement for Tobacco Cessation. TMA believes tobacco cessation therapy is one of the most cost-beneficial prevention activities available to physicians and encourages reimbursement by all third parties for tobacco cessation counseling and treatment services, including pharmacotherapy.
The Affordable Care Act requires all new private health insurance plans to cover services recommended by the U.S. Preventive Services Task Force (USPSTF) with no cost-sharing. Cost-sharing includes co-payments, co-insurance and deductibles. Beginning September 23, 2010, non-grandfathered group coverage and non-grandfathered individual health insurance policies must cover evidence-based items or services that have in effect a rate of A or B in the current recommendations of the USPSTF.
TMA recommends that the Texas Department of Insurance Essential Health Benefits standard for Texas include coverage for at least two quit attempts per year with up to four tobacco cessation counseling sessions of at least 30 minutes each, including proactive telephone counseling, group counseling, and individual counseling. Coverage should include all prescription and over-the counter drugs approved by the FDA to treat tobacco dependence for smoking cessation.
Tobacco Advertising. TMA supports a ban on tobacco advertising in all forms, both explicit and subliminal. This ban includes but is not limited to television, radio, newspapers, magazines, billboards and other outdoor signage, and the internet. This also includes all grocery stores, convenience stores, and other retail outlets. All tobacco products should be behind enclosed cabinets with no advertising on the outside. TMA also urges all athletes and sports figures to disassociate themselves from all forms of tobacco advocacy and use. Until all tobacco ads are banned, TMA supports ending tax deductions for advertising tobacco products. Further, TMA encourages its members not to subscribe to waiting room publications containing tobacco advertisements, or to mark the covers of such publications with a disclaimer stating that they do not support the use of tobacco products.
Tobacco Sales. TMA recognizes the danger that tobacco use and nicotine addiction poses to the public health and opposes the sale and use of all tobacco products. TMA recommends that the following entities prohibit the sale of tobacco products at their locations of business and provide tobacco cessation information for their customers: hospitals or any place people seek medical care, psychiatric hospitals, pharmacies, and prisons. TMA further supports the complete ban on tobacco sales from vending machines, the free distribution of tobacco samples, the free distribution or sale of tobacco at discounted rates through any organization or the military, the sale of tobacco products over the Internet or through the mail, and the licensing of tobacco vendors with appropriate penalties, as well as the revocation of license for selling tobacco to minors. TMA believes that where tobacco continues to be sold, all tobacco products should be kept secure behind the counter.
Tobacco Taxes. TMA supports sudden and significant increases in taxes on tobacco products as a proven method for decreasing rates of tobacco use and to increase revenue for tobacco prevention and cessation efforts. TMA supports bringing rolling tobacco and pipe tobacco up to an equivalent price with cigarettes. A portion of tobacco excise tax revenues should be used to completely fund a statewide tobacco cessation Quitline with counseling and FDA-approved over the counter pharmacotherapy.
Tobacco Investment Divestiture. TMA supports divestiture of tobacco investments, especially among physicians and health-related institutions.
Tobacco Funding for Research. TMA strongly discourages all colleges, universities, medical schools, and all associated faculty from accepting research funding, both directly and indirectly, from the tobacco industry, its subsidiaries, and its affiliates.
Tobacco Subsidies. TMA supports ending all agricultural price supports for tobacco, including crop support and crop buy-out with storage subsidies.
Reporting of Tobacco Research and Data. TMA urges the medical community and related groups, educational institutions, and government agencies to effectively and consistently report scientific data demonstrating the health hazards inherent in tobacco use, including but not limited to cigarettes, cigars, dissolvable tobacco products, e-cigarettes, and smokeless tobacco. In addition, TMA supports the inclusion of tobacco use history on death certificates and encourages physicians to complete this section of the certificate. Texas uses the expanded, revised birth certificate that allows for collection of either the average number of cigarettes or the average number of packs of cigarettes smoked in each of four time periods (three months before pregnancy and each of three trimesters). Providers should assess and record in the prenatal care record and delivery record of these four values so that they can be recorded on the birth certificate. TMA urges the Texas Department of State Health Services to release regular reports on deaths attributable to tobacco use.
Preemption of Local Laws. TMA supports cities and municipalities that have passed strong local laws and ordinances regulating tobacco sale and use and county restrictions on tobacco use on county-owned properties. TMA does not support the adoption of relaxed state legislation regarding tobacco regulation that may preempt these stronger local laws already in effect.
Tobacco Use in Entertainment. Recognizing the influence the entertainment industry has on culture in the United States, TMA requests that the entertainment industry stop portraying the use of tobacco as glamorous, sophisticated, or rebellious in movies, television, music, and music videos, video games, and professional sporting events, and strive to show the true devastation and disease that tobacco use causes.
Lawsuits Against the Tobacco Industry. TMA supports the prosecution of tobacco companies and their executives, board members, and affiliates for all violations of applicable state and federal laws.
Tobacco Settlement Monies. TMA affirms that the state's lawsuit against the tobacco industry was conceived and filed with the intent of compensating Texans for health care costs associated with tobacco-related diseases, and, as a matter of unwavering principle, will work diligently to convince the Texas Legislatures that all tobacco settlement monies be dedicated to improving the health of Texans, not for general purposes (i.e., roads and bridges). Furthermore, TMA supports the following prioritization of initiatives to be funded by tobacco settlement and tax monies:
Establish a comprehensive tobacco prevention advertising campaign with funding equal to the amount spent in Texas on promoting tobacco products.
Establish a statewide tobacco cessation campaign, including advertising, cessation counseling, and coverage for cessation pharmacotherapy.
Fund educational campaigns in support of tobacco-free workplaces.
Establish a comprehensive program to limit minors' access to tobacco products, including random unannounced vendor compliance surveys and enforcement activities.
Establish a school-based tobacco education curriculum that includes nicotine addiction, tobacco-related diseases, and tobacco industry activities and advertising.
Establish programs to train physicians and other health care professionals to identify and treat people at risk for tobacco-related diseases.
Fund the screening and treatment of patients with tobacco-related diseases.
Fund increased research on tobacco-related diseases and tobacco addiction.
Fund other public health-related activities.
Tobacco Prevention. TMA supports other community-based efforts such as increasing the unit price of tobacco products, health communication, mobile phone-based interventions, and reducing the out of pocket costs for cessation treatments and other evidence-based interventions recommended in the U.S. Guide for Community Preventive Services.
(22) Tobacco Treaty. The TMA supports the ratification of the Framework Convention on Tobacco Control Treaty by the U.S. Congress and the passage of the necessary laws to comply with the treaty (CM-C Rep. 2-A-03; amended CSPH Rep. 2-A-14).