Huang Idaho Presentation on tobacco and Comp Cance

Tobacco Control IS Cancer Control: 

Tobacco Control IS Cancer Control Idaho Comprehensive Cancer Control Summit May 30, 2007 Philip Huang, MD, MPH

Session Goals: 

Session Goals Review the burden of cancer and the relationship to tobacco use. Discuss Five CCC Issues related to tobacco control that CCC can address: 1 Comprehensive Tobacco Control Programs 2 Smoke-free environments 3 Countering tobacco industry tactics 4 Cessation 5 Raising excise taxes on tobacco products and Use Funds for Tobacco Control and CCC Identify tobacco control outcomes for CCC.

Tobacco ControlISCancer Control: 

Tobacco Control IS Cancer Control

Tobacco Use in the USA: 

Tobacco Use in the USA

Tobacco’s Toll in U.S.: 

Tobacco is the leading preventable cause of death, killing more than 400,000 each year (over 1500 in Idaho) Tobacco kills more people than from AIDS, alcohol, illegal drugs, car accidents, murders, suicides, and fires - COMBINED Tobacco results in $89 billion in annual health care costs Tobacco’s Toll in U.S.

US Mortality, 2004: 

US Mortality, 2004 Source: US Mortality Public Use Data Tape 2004, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006. 1. Heart Diseases 652,486 27.2 2. Cancer 553,888 23.1 3. Cerebrovascular diseases 150,074 6.3 4. Chronic lower respiratory diseases 121,987 5.1 5. Accidents (Unintentional injuries) 112,012 4.7 6. Diabetes mellitus 73,138 3.1 7. Alzheimer disease 65,965 2.8 8. Influenza & pneumonia 59,664 2.5 9. Nephritis 42,480 1.8 10. Septicemia 33,373 1.4 Rank Cause of Death No. of deaths % of all deaths

2007 Estimated US Cancer Deaths*: 

2007 Estimated US Cancer Deaths* ONS=Other nervous system. Source: American Cancer Society, 2007. Men 289,550 Women 270,100 26% Lung & bronchus 15% Breast 10% Colon & rectum 6% Pancreas 6% Ovary 4% Leukemia 3% Non-Hodgkin lymphoma 3% Uterine corpus 2% Brain/ONS 2% Liver & intrahepatic bile duct 23% All other sites Lung & bronchus 31% Prostate 9% Colon & rectum 9% Pancreas 6% Leukemia 4% Liver & intrahepatic 4% bile duct Esophagus 4% Urinary bladder 3% Non-Hodgkin 3% lymphoma Kidney 3% All other sites 24%

Tobacco and Cancer: 

Tobacco and Cancer Tobacco use is associated with at least 15 types of cancer including cancer of the lung, larynx, oral cavity, nasopharynx, nasal cavity, paranasal sinuses, esophagus, stomach, cervix, kidney, bladder, pancreas, and acute myeloid leukemia Lung cancer is the leading cause of cancer death and cigarette smoking causes nearly 87% of all cases Compared to nonsmokers, men who smoke are about 23 times more likely to develop lung cancer and women who smoke are about 13 times as likely From the 2004 Surgeon General’s Report

Tobacco Use in the US, 1900-2000: 

Tobacco Use in the US, 1900-2000 *Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Public Use Tapes, 1960-2000, US Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002. Cigarette consumption: US Department of Agriculture, 1900-2000. Per capita cigarette consumption Male lung cancer death rate Female lung cancer death rate

Adult Smoking Trends1992 - 2004*: 

Adult Smoking Trends 1992 - 2004* Year Adult Smoking Rate * Data are from the National Health Interview Survey N/A

Youth Smoking Trends 1991 - 2005*: 

Youth Smoking Trends 1991 - 2005* Year Youth Smoking Rate * Data are from the Youth Risk Behavior Surveillance Survey (1991-2005) 28.5% 34.8% 36.4% 34.8% 30.5% 27.5% 21.9% 37% decline 34% decline 19% decline 23.0%

State Facts 2004: 

State Facts 2004 Prevalence Adult Range: 12.7% (UT) – 32.6% (KY) Youth Range: 8.3% (UT) – 36.5% (AK) Total Number of smokers Adults: 48,069,688 Youth: 3,109,506 Youth Projected to Start: 20,126,608 Tried to Quit Adult Range: 42.4% (HI) – 66.2% (UT)

Who Smokes – By Education and IncomeCurrent Population Survey - Tobacco Use Supplement: 

Who Smokes – By Education and Income Current Population Survey - Tobacco Use Supplement

Tobacco Control Issues That Comprehensive Cancer Coalitions Can Address: 

Tobacco Control Issues That Comprehensive Cancer Coalitions Can Address

Issue 1Support for Implementation and Funding for Comprehensive Tobacco Control Programs: 

Issue 1 Support for Implementation and Funding for Comprehensive Tobacco Control Programs

The Most Successful Programs Combine Individual Assistance with Evidence Based Population Level Solutions: 

The Most Successful Programs Combine Individual Assistance with Evidence Based Population Level Solutions Approaches that “are likely to have the greatest long term population impact” are “economic, regulatory and comprehensive”. 2000 Report of the Surgeon General

Comprehensive Approach to Tobacco Control: CDC Best Practices: 

Comprehensive Approach to Tobacco Control: CDC Best Practices Community programs to reduce tobacco use Chronic disease programs to reduce the burden of tobacco-related diseases School programs Enforcement Statewide programs Counter-marketing Cessation Surveillance and evaluation Administration and management

Comprehensive Programs Help Adult Smokers Quit: 

Comprehensive Programs Help Adult Smokers Quit Massachusetts: Cut adult smoking by 21% between 1993 and 2000 Arizona: Cut adult smoking by 21% between ‘96 and ‘99 California: Cut adult smoking by 32.5% between 1988 and 2004 Maine: Cut adult smoking by 12.5% b/t 2001 and 2004 WA: Cut adult smoking by 13% between 1999 and 2004 New York: cut adult smoking by 14% between 2001 and 2004 Southeast Texas: cut adult smoking by 27% between 2000 and 2004

Comprehensive ProgramsReduce Youth Smoking: 

Comprehensive Programs Reduce Youth Smoking Maine: Cut high school smoking by 59% b/w 1997 and 2005 Oregon: Cut smoking by 51% among eighth graders between ‘96 and 2002 Mississippi: Cut smoking among public middle school students by 48% in 5 years Florida: Cut middle school smoking by 47% & high school smoking by 30% b/w 1998 and 2001 Ohio: Cut high school smoking by 45% b/w 1999 and 2003 WA: Cut youth smoking by 50% b/w 2000 and 2004 SE Texas: Cut 6-12 grade tobacco use by 37% between 2000 and 2004

Comprehensive Programs Work: 

Comprehensive Programs Work Saves Lives

Comprehensive Programs Work: 

Comprehensive Programs Work Saves Money for Taxpayers

ROI Results from SE Texas Tobacco Pilot Initiative : 

ROI Results from SE Texas Tobacco Pilot Initiative In 2003, single year program costs of $11.3 million ($2.71 per capita) implementing comprehensive tobacco programming in Houston and Beaumont/Port Arthur resulted in: over 29,800 fewer adult smokers in 2003 savings of over $252 million in medical care and productivity costs over 5 years.

Issue 2Smoke Free Environments: 

Issue 2 Smoke Free Environments

Slide25: 

A toxic soup of more than 4,000 chemical compounds Secondhand smoke contains at least 69 carcinogens With Every Breath of Secondhand Smoke...

More Than an Annoyance;Secondhand Smoke Causes: 

More Than an Annoyance; Secondhand Smoke Causes Cancer Heart Disease and Stroke Chronic Lung Disease Asthma Respiratory Infections Low Birth Weight SIDS Eye and Nasal Irritation At least 38,000 U.S. deaths each year

100% Smokefree Ordinances: 

100% Smokefree Ordinances 17 States - California, New York, Delaware, Connecticut, Maine, Massachusetts, Rhode Island, Montana, Vermont, Washington, New Jersey, Utah, Colorado, Hawaii, Ohio, Arizona and New Mexico have passed 100% smokefree legislation. Many major centers for tourism now totally smoke-free including: Los Angeles, San Francisco, Washington D.C., San Diego, New York City, Boston Idaho is one of only 12 states that contains NO smokefree jurisdictions

Slide29: 

Percent of Population Covered By Smoke-Free Restaurant Laws 2006: 42% 1995: 12.6% CA & UT Laws in effect

Slide30: 

Percent of Population Covered By Smoke-Free Laws (Including Bars) 2006: 34% 1998: 12% CA Law in effect

Slide31: 

Smoke-free workplace policy coverage by major occupational group (2001-2002) Current Population Survey of U.S. workers, 2001-2002

Slide32: 

Current Population Survey of U.S. workers, 2001-2002 Restaurant and Bar Workers are the Least Protected

Measuring Air Quality: 

Measuring Air Quality Cigarettes, cigars and pipes are major emitters of respirable suspended particles less than 2.5 microns (PM2.5) in diameter that are easily inhaled deep into the lungs TSI SidePak AM510 Personal Aerosol Monitor (weight: 1 lb) This instrument measures and records in memory the PM2.5 concentration every minute during sampling PM2.5 very sensitive marker of SHS

Slide37: 

2005 Zagat Survey: America's Top Restaurants New York Do you think smoking should be banned in restaurants? Philadelphia Atlanta Chicago

Survey conducted soon after Montana passed a smoke-free law. The first phase of the law went into effect 10/1/05. The state’s bars and casinos will become smoke-free in 2009.: 

Support: 71% Oppose: 25% Montana Voters Overwhelmingly Support The State’s Smoke-Free Workplace Law Statewide survey of registered Montana voters – May 2005 Mason-Dixon Polling & Research Inc. for Lee Newspapers Survey conducted soon after Montana passed a smoke-free law. The first phase of the law went into effect 10/1/05. The state’s bars and casinos will become smoke-free in 2009.

Slide39: 

Map Legend:   Yes   No   No Data Washington Secretary of State – November 8, 2005 http://vote.wa.gov/election/2005/general/measures.aspx?a=901 Washington Initiative 901 - Clean Indoor Air Act Statewide Vote: 62.5% Yes; 37.5% No (Majority support in every county)

Second-Hand SmokeEconomic Issues: 

Second-Hand Smoke Economic Issues Employer Issues Absenteeism Health insurance and life insurance costs and claims Workers comp payments and health awards Accidents and fires (plus related insurance costs) Property damage (plus related insurance costs) Smoke pollution (increased cleaning and maintenance costs) Illness and discomfort among non-smokers to SHS Liability

Figure 1. Gross Restaurant, Bar and Mixed Beverage Revenues By Fiscal Quarter*—El Paso, Texas, 1990-2002: 

Figure 1. Gross Restaurant, Bar and Mixed Beverage Revenues By Fiscal Quarter*—El Paso, Texas, 1990-2002 Smoking Ban in effect January 2, 2002 * First fiscal quarter of each year is January 1 –March 31

Slide42: 

A 2003 study offered a comprehensive view of all available studies on the economic impact of smoke-free workplace laws The study concluded that: “All of the best designed studies report no impact or a positive impact of smoke-free restaurant and bar laws on sales or employment. Policymakers can act to protect workers and patrons from the toxins in secondhand smoke confident in rejecting industry claims that there will be an adverse economic impact.” Scollo M, et al, Review of the quality of studies on the economic effects of smoke-free policies on the hospitality industry, Tobacco Control (2003); 12:13-20.

Slide43: 

“Back in 2002, when the City Council was weighing Mayor Michael R. Bloomberg’s proposal to eliminate smoking from all indoor public places, few opponents were more fiercely outspoken than James McBratney, president of the Staten Island Restaurant and Tavern Association. He frequently ripped Mr. Bloomberg as a billionaire dictator with a prohibitionist streak that would undo small businesses like his bar and his restaurant. Visions of customers streaming to the legally smoke-filled pubs of New Jersey kept him awake at night. Asked last week what he though of the now two-year-old ban, Mr. McBratney sounded changed. “I have to admit,” he said sheepishly, “I”ve seen no falloff in business in either establishment.” He went on to describe what he once considered unimaginable: Customers actually seem to like it and so does he. New York Times Feb 6, 2005

Issue 3Raising Awareness of and Countering Current Tobacco Industry Tactics: 

Issue 3 Raising Awareness of and Countering Current Tobacco Industry Tactics

Big Tobacco Has Not Changed?: 

Big Tobacco Has Not Changed? Evidence shows the industry is ... Still marketing to kids BUT even more aggressively Still deceiving the public about their products Still making unsubstantiated health claims for new products and no change in low tar product marketing Still failing to reduce the toxicity of existing products or provide critical information about tobacco products Still refusing fully to acknowledgement of the health effects of their products

Marketing of Products: 

Marketing of Products

Domestic Cigarette Advertising and Promotional Expenditures 1998 - 2003(Billions of dollars): 

Domestic Cigarette Advertising and Promotional Expenditures 1998 - 2003 (Billions of dollars) Source: Federal Trade Commission Cigarette Report for 2003 $6.73 Billion $8.24 Billion $9.59 Billion $11.22 Billion $12.47 Billion $15.15 Billion

Keep In Mind: 

Keep In Mind Kids are three times more sensitive to tobacco advertising than adults. Kids are more likely to respond to tobacco advertising than peer pressure. 1/3 of underage experimentation is attributed to tobacco advertising

Slide52: 

International Communications Research (ICR) Nationwide survey of teens aged 12-17; Nationwide survey of adults March 2006

Slide53: 

International Communications Research (ICR) Nationwide survey of teens aged 12-17 March 2006

2005 - 50 Years of Marlboro: 

2005 - 50 Years of Marlboro Since 1955 – when Marlboro was transformed from a cigarette for women into the Marlboro Cowboy – more than 2.3 million Americans have died from using Marlboro If current trends continue, in the next 10 years an additional 1.6 million Americans will die from Smoking Marlboro ------------------------------------------------------------------ AND how did Philip Morris Respond? On November 5, 2005 Altria/Philip Morris CELEBRATED its 50th Birthday You decide – has Philip Morris Changed? Hyland, A. et al, Happy Birthday Marlboro, Tobacco Control 2006

THEY’RE STILL NOT TELLING THE TRUTH ABOUT THEIR PRODUCTS AND INTRODUCING NEW ONES: 

THEY’RE STILL NOT TELLING THE TRUTH ABOUT THEIR PRODUCTS AND INTRODUCING NEW ONES

Is History Repeating Itself?: 

Is History Repeating Itself?

Slide59: 

An important development today in the federal government's case against the industry. Tobacco exec challenged about key stance in trial. By Peter Kaplan, 24 January 2005 (c) 2005 Reuters Limited WASHINGTON, Jan 24 (Reuters) - The departing executive chairman of ReynoldsAmerican Inc. refused to concede that cigarette smoking causes diseaseduring testimony on Monday in the government's $280 billion tobacco industry racketeering trial. Long-time Reynolds executive Andrew Schindler defended Reynolds' view that cigarettes "may contribute" to disease in "some individuals" as a government attorney raised the company's position as an example of how cigarette makers have deceived the public about the dangers of smoking. U.S. public health officials concluded decades ago that smoking leads to lung cancer and a range of other serious diseases. Some other tobacco companies, such as Altria Group Inc.'s (MO.N) Philip Morris USA, a co-defendent, now concede the point unequivocally. Schindler was asked to explain why Reynolds still does not acknowledge -without conditions - that smoking causes lung cancer and other diseases. He said he had decided against changing the company's stance several years ago after consulting with scientists at company. "They all concluded that they were comfortable with the Web site the way it is," said Schindler, who stepped down as chief executive of R.J. Reynolds Tobacco Holdings last summer when it bought Brown & Williamson in 2004 and emerged from the deal with a new name. He was met with skepticism when he told the presiding judge that the company's current position is "a pretty straightforward expression of my own feelings" on the issue. "If it's so straightforward, why not use simple language to convey it?” asked U.S. District Judge Gladys Kessler. Schindler is due to leave Reynolds American next week. The government's suit, filed in 1999, targets Altria and its Philip Morris unit; Loews' Lorillard Tobacco unit, which has a tracking stock, Carolina Group (CG.N); Vector Group Ltd.'s (VGR.N) Liggett Group; Reynolds American Inc.'s R.J. Reynolds Tobacco and British American Tobacco Plc (BATS.L) unit British American Tobacco Investments Ltd. The departing executive chairman of Reynolds American Inc. refused to concede that cigarette smoking causes disease during testimony on Monday in the government's $280 billion tobacco industry racketeering trial. Long-time Reynolds executive Andrew Schindler defended Reynolds' view that cigarettes "may contribute" to disease in "some individuals" Reynolds' stance on the hazards of smoking, as posted on the company Web site, reads: "We produce a product that has significant and inherent health risks for a number of serious diseases, and may contribute to causing these diseases in some individuals."

THE TRUTH ABOUT “REDUCED RISK” PRODUCTS: 

Tobacco Industry Unleashes New Generation of Deceit “[It] will not kill them as quick or as much as other brands,” Bennett LeBow, CEO, Vector, Manufacturer of new Omni cigarettes. January 11, 2002 THE TRUTH ABOUT “REDUCED RISK” PRODUCTS

Other Tactics: 

Other Tactics Political Contributions Opposition to tax increases, clean indoor air, effective programs Support for community organizations, events and causes Pre-emption Giveaways

Issue 4Promote and Coordinate Tobacco Cessation Efforts: 

Issue 4 Promote and Coordinate Tobacco Cessation Efforts

Promoting and Providing Tobacco Use Cessation: 

Access to Services & Products That We Know Work Counseling (Phone & In-person) NRTs, Buproprion, Chantix Promotion of those products and services – through earned and paid media, community programs, etc. Promote Telephone Quitline through partners Target populations most at risk – low income, less educated, history of mental illness/substance abuse Engage health care professionals - Healthcare Provider Systems Changes and Toolkits Promote coverage in health plans (BC/BS: Coverage, Counseling, Capital, Collaboration, Count) Engage corporate community – worksite issues; health promotion; coverage issues; education on health care costs Promoting and Providing Tobacco Use Cessation

Slide64: 

Utah Example of Promoting Cessation Utah partners with the WIC program, local health departments, professional societies and managed care organizations to provide providers with screening and treatment guidelines for smokers - % of UT smokers who received advice to quit from physician increased by 13% between 2001 and 2002 Utah partnered with Association for Community Health to provide Zyban to uninsured Community Health Center clients Medicaid clients receiving Zyban prescriptions increased by 33% between 2001 and 2002

Issue 5Increase the Price of Tobacco Products and Use the Funds for Tobacco Control and Comprehensive Cancer: 

Issue 5 Increase the Price of Tobacco Products and Use the Funds for Tobacco Control and Comprehensive Cancer

 “The single most direct and reliable method for reducing consumption is to increase the price of tobacco products, thus encouraging the cessation and reducing the level of initiation of tobacco use” National Academy of Sciences Institute of Medicine, 1998: 

“The single most direct and reliable method for reducing consumption is to increase the price of tobacco products, thus encouraging the cessation and reducing the level of initiation of tobacco use” National Academy of Sciences Institute of Medicine, 1998 Tobacco Taxes and Public Health

Tobacco Tax Trends: 

Tobacco Tax Trends In 2000, 2 states raised their cigarette tax (average increase of 29.5 cents) In 2001, 4 states raised their cigarette tax (average increase of 18.9 cents) In 2002, 21 states raised their cigarette tax (average increase of 43.0 cents) In 2003, 16 states and DC raised their cigarette tax (average increase of 35.1 cents) In 2004, 7 states raised their cigarette tax (average increase of 39.1 cents) In 2005 (through 9/7), 12 states raised their cigarette tax (average increase of 58.3 cents) In 2006, 4 states raised their cigarette tax (average increase of 16 cents)

Tobacco Excise Taxes: 

Tobacco Excise Taxes A win for public health A win for state budgets A win among voters

Reasons to Raise Tobacco Taxes: 

Reasons to Raise Tobacco Taxes Reduce prevalence of tobacco use Increase quit attempts Reduce consumption Support comprehensive tobacco control at least at CDC minimum levels Support CCC plan implementation Budgeting CCC plans Thinking bigger than projects or CDC’s ‘ceilings’

10% Increase in the Price of Tobacco : 

10% Increase in the Price of Tobacco Nearly 7% decline in youth prevalence A 7% decline in prevalence among pregnant women A 2% decline in adult prevalence A 4% decline in overall consumption Means:

Tobacco Taxes & State Revenues: 

Tobacco Taxes & State Revenues Despite inevitable declines in consumption of cigarettes … Increasing tobacco taxes ALWAYS increase state revenues

Slide73: 

The NV Tax Experience From .35 to .80 on 7/22/03 Revenue -32.3% Packs Sold +96.9%

There is a proposal to increase the state tobacco tax on cigarettes by a one dollar per pack — as part of an effort to reduce tobacco use, particularly among kids — with some of the new revenue to be used for tobacco prevention and programs to help smokers quit. . . : 

Total Favor: 65% Total Oppose: 32% There is a proposal to increase the state tobacco tax on cigarettes by a one dollar per pack — as part of an effort to reduce tobacco use, particularly among kids — with some of the new revenue to be used for tobacco prevention and programs to help smokers quit. . . North Dakota Voters Overwhelmingly Favor A $1 Increase In The Tobacco Tax With Part of The Revenue Dedicated To Tobacco Prevention Darker shading equals stronger intensity Total numbers are rounded North Dakota Statewide survey of registered voters – February 2003

Montana Voters Approve Tobacco Tax Increase (2004): 

Montana Voters Approve Tobacco Tax Increase (2004) The tobacco industry lost their legal challenge to throw Montana’s $1 tobacco tax increase off the 2004 ballot. The plaintiffs in the lawsuit included U.S. Smokeless Tobacco Co., R.J. Reynolds Tobacco Co. and the state association of convenience store owners. (Billings Gazette, 9/1/2004). While not a plaintiff, Philip Morris USA helped fund the lawsuit. (The Standard, 7/27/2004). By 63 percent to 37 percent, voters approved the initiative and increased the cigarette tax by $1 to $1.70 per pack, dedicating some of the revenue to health care programs.

Economic Support for Tobacco Control: 

Economic Support for Tobacco Control The amount spent by states for tobacco control declined 28% from 2002 to 2004 and then rose modestly in 2005 State expenditures for tobacco control are less than 3% of the monies derived from tobacco taxes and the Master Settlement Agreement (MSA). The average expenditure for tobacco control is $1.22 per person compared with the CDC recommended $5.98

Slide77: 

States that have funded tobacco prevention programs at a level that meets the CDC’s minimum recommendation. States that have committed substantial funding for tobacco prevention programs (more than 50% of CDC minimum). States that have committed modest amounts for tobacco prevention programs (25% - 50% of CDC minimum). November 30, 2005 States that have committed minimal amounts for tobacco prevention programs (less than 25% of CDC minimum). States that have committed no tobacco settlement or tobacco tax money for tobacco prevention programs. Funding for Tobacco Prevention

FY 2006 Tobacco Money for Tobacco Prevention: 

$1.6 Billion $551 Million $ 21.3 Billion $14.1 Billion Tobacco Tax Revenues $7.2 Billion Tobacco Settlement Revenues FY 2006 Tobacco Money for Tobacco Prevention

The Colorado Example: 

The Colorado Example 2004-2004 drastic reductions by legislature in MSA allocations Citizens initiative Raise cigarette tax by 64 cents and other tobacco products from 20% to 40% of manufacturer’s list price Earmark revenues: Expansion of health care for low income Coloradans Tobacco prevention and control (to minimum CDC level) Prevention, early detection, and treatment of cancer and heart and lung disease Better than 2:1 support Part of the state constitution; only voters can change it.

Mulligan Project: 

Mulligan Project In 2008 states will receive certain ‘bonus’ payments as a part of the MSA. This may be as much as $900M across the country. Questions: Were you aware of this before now? If so, what is happening relative to assuring some of this money goes to tobacco control? If not, what can your CCC and tobacco control communities begin to do now to take advantage of this potential opportunity.

Integrating Tobacco Control Activities with CCC Outcomes: 

Integrating Tobacco Control Activities with CCC Outcomes

Summary of Examples of CCC Outcomes Related to Tobacco Control: 

Summary of Examples of CCC Outcomes Related to Tobacco Control Implementation of comprehensive tobacco control programs Increased protection from exposure to secondhand smoke Exposure of tobacco industry tactics Increased tobacco use cessation Increased price of tobacco products with funding for statewide, comprehensive tobacco control funding at the minimum CDC recommended level and funding for Comprehensive Cancer Control

OUR CHALLENGE: 

OUR CHALLENGE What Has Been Achieved is Extraordinary For the First Time – the Concept of Fundamental Societal Change Is on the Horizon

THE BOTTOM LINE: 

THE BOTTOM LINE We Have a Vaccine Against Tobacco-Related Cancer Our challenge is to make sure that every person receives the benefit