Consolidation of AMA Policy on Tobacco and Smoking

Full Text

This report is based on a Council on Scientific Affairs initiative to consolidate existing American Medical Association (AMA) policies related to tobacco and smoking. Over time, this portion of the AMA Policy Database has accumulated numerous overlapping, and in some cases conflicting, policies. Given the AMA's longstanding role as an advocate for tobacco control policies, consolidation of the Policy Database will help articulate the AMA's policy and positions on various aspects of this important public health issue and assist in ongoing advocacy efforts.

As stated in AMA Policy H-600.111 (AMA Policy Database), the purpose of policy consolidation is to make information on House policy more accessible and readable. Policy consolidation also will improve the organization of the AMA PolicyFinder program database. The purpose of policy consolidation does not include the establishment of new policy positions. Changes in AMA policy can only be accomplished through other types of reports or by resolutions that are submitted to the AMA House of Delegates.

Recommendations

As recommended by the Council on Scientific Affairs, the AMA House of Delegates consolidated AMA policy on tobacco and smoking as follows:

Tobacco Coding and Death Certificates

The AMA:

1. promotes and encourages the use of ICD10CM codes among physicians as they complete medical claims, hospital discharge summaries, death certificates, and other documents;
2. supports cooperating with the National Center for Health Statistics (NCHS) in monitoring the four existing models for collecting tobacco-use data;
3. urges the NCHS to identify appropriate definitions, categories, and methods of collecting risk-factor data, including quantification of exposure, for inclusion on the U.S. Standard Certificates, and that subsequent data be appropriately disseminated; and
4. continues to encourage all physicians to report tobacco use, exposure to environmental tobacco smoke, and other risk factors using the current standard death certificate format.

Decreased Insurance Premiums for Nonsmokers

The AMA:

1. encourages insurance companies to review and make public their current actuarial experience with respect to smokers and nonsmokers and to consider ways of making available to nonsmokers, at reduced rates, policies for accident, auto, life, homeowners, fire, and health insurance; and
2. supports the concept of health insurance contracts with lower premiums for nonsmokers, reflecting their decreased need for medical services and serving as a financial incentive for smokers (tobacco users) to discontinue this destructive habit.

Physician Responsibilities for Tobacco Cessation

Cigarette smoking is a major health hazard and a preventable factor in physicians' actions to maintain the health of the public and reduce the high cost of health care. The AMA takes a strong stand against smoking and favors aggressively pursuing all avenues of educating the general public on the hazards of using tobacco products and the continuing high costs of this serious but preventable problem. Additionally, the AMA supports and advocates for appropriate surveillance approaches to measure changes in tobacco consumption, changes in tobacco-related morbidity and mortality, youth uptake of tobacco use, and use of alternative nicotine delivery systems. In view of the continuing and urgent need to assist individuals in smoking cessation, physicians, through their professional associations, should assume a leadership role in establishing national policy on this topic and assume the primary task of educating the public and their patients about the danger of tobacco use (especially cigarette smoking). Accordingly, the AMA:

1. encourages physicians to refrain from engaging directly in the commercial production or sale of tobacco products;
2. supports (a) development of an anti-smoking package program for medical societies; (b) making patient educational and motivational materials and programs on smoking cessation available to physicians; and (c) development and promotion of a consumer health-awareness smoking cessation kit for all segments of society, but especially for youth;
3. encourages physicians to use practice guidelines for the treatment of patients with nicotine dependence and will cooperate with the Agency for Health Research and Quality (AHRQ) in disseminating and implementing evidence-based clinical practice guidelines on smoking cessation, and on other matters related to tobacco and health;
4. (a) encourages physicians to use smoking cessation activities in their practices including (i) quitting smoking and urging their colleagues to quit; (ii) inquiring of all patients at every visit about their smoking habits (and their use of smokeless tobacco as well); (iii) at every visit, counseling those who smoke to quit smoking and eliminate the use of tobacco in all forms; (iv) prohibiting all smoking in the office by patients, physicians, and office staff; and discouraging smoking in hospitals where they work (v) providing smoking cessation pamphlets in the waiting room; (vi) becoming aware of smoking cessation programs in the community and of their success rates and, where possible, referring patients to those programs; and (b) supports the concept of smoking cessation programs for hospital inpatients conducted by appropriately trained personnel under the supervision of a physician;
5. (a) supports efforts to identify gaps, if any, in existing materials and programs designed to train physicians and medical students in the behavior modification skills necessary to successfully counsel patients to stop smoking; (b) supports the production of materials and programs which would fill gaps, if any, in materials and programs to train physicians and medical students in the behavior modification skills necessary to successfully counsel patients to stop smoking; (c) supports national, state, and local efforts to help physicians and medical students develop skills necessary to counsel patients to quit smoking; (d) encourages state and county medical societies to sponsor, support, and promote efforts that will help physicians and medical students more effectively counsel patients to stop smoking; (e) encourages physicians to participate in education programs to enhance their ability to help patients quit smoking; (f) encourages physicians to speak to community groups about tobacco use and its consequences;; and (g) supports providing assistance in the promulgation of information on the effectiveness of smoking cessation programs; and
6. (a) supports the concept that physician offices, clinics, hospitals, health departments, health plans, and voluntary health associations should become primary sites for education of the public about the harmful effects of tobacco and encourages physicians and other health care workers to introduce and support healthy lifestyle practices as the core of preventive programs in these sites; and (b) encourages the development of smoking cessation programs implemented jointly by the local medical society, health department, and pharmacists.

Health Insurance and Reimbursement for Tobacco Cessation and Counseling

The AMA:

1. (a) continues to support development of an infrastructure for tobacco dependence treatment; (b) will work with the U.S. Public Health Service, particularly the Agency for Health Research and Quality, health insurers, and others to develop recommendations for third- party payment for the treatment of nicotine addiction; (c) urges third-party payors and governmental agencies involved in medical care to regard and treat nicotine addiction counseling and/or treatment by physicians as an important and legitimate medical service; and (d) supports the ready availability of health insurance coverage and reimbursement for pharmacologic and behavioral treatment of nicotine dependence and smoking cessation efforts.
2. (a) requests Congress to provide matching funds for Medicaid coverage for evidence-based programs and Food and Drug Administration (FDA)-approved products that lead to smoking cessation; and (b) seeks the requirement that state Medicaid programs, prepaid health plans, and insurance companies provide evidence-based approaches for smoking cessation and nicotine withdrawal, including FDA-approved pharmacotherapy, as part of their standard benefit packages.

Tobacco Use in Prison Populations

It is the policy of the AMA to (1) recognize and promote the policy that all anti-smoking policies that apply to the general population should apply equally to persons who are incarcerated in local jails, state prisons, and federal prisons; (2) work actively to stop the manufacture of cigarettes by any prison or jail system in the United States; (3) work actively to stop the subsidy of cigarette sales in all jail and prison systems; (4) ensure that the prohibition of smoking by minors be enforced in the correctional system; (5) be committed to smoking cessation programs in correctional facilities and encourage physicians working in correctional systems to include smoking cessation counseling and programs for their patients who smoke; (6) work through its representative to the National Commission on Correctional Health Care to ensure that smoking cessation counseling be made a national standard for correctional medicine; (7) develop model legislation providing for smoke-free prison areas for all inmates, and particularly that common areas including cell blocks and recreation areas not be smoking areas; and (8) support legislation banning smoking in prisons and jails.

Tobacco Prevention and Youth

The AMA:

1. (a) urges the medical community, related groups, educational institutions, and government agencies to demonstrate more effectively the health hazards inherent in the use of tobacco products; (b) encourages state and local medical societies to actively advise municipalities and school districts against use of health education material sponsored or distributed by the tobacco industry; and (c) publicly rejects the tobacco industry as a credible source of health education material;
2. opposes the use of tobacco products of any kind in day care centers or other establishments where pre-school children attend for educational or child care purposes;
3. advises public and private schools about the very early smoking habits observed in children and encourages appropriate school authorities to prohibit the use of all tobacco products in elementary through senior high school by anyone during the school day and during other school-related activities;
4. (a) supports the concept that a comprehensive health education program stressing health maintenance be part of the required curriculum through 12th grade to: (i) help pre-teens, adolescents, and young adults avoid the use of tobacco products, including smokeless tobacco; and (ii) emphasize the benefits of remaining free of the use of tobacco products; (b) will work with other public and private parties to actively identify and promote tobacco prevention programs for minors and encourages the development, evaluation, and incorporation of appropriate intervention programs, including smoking cessation programs, that are tailored to the needs of children; and (c) recommends that student councils and student leaders be encouraged to join in an anti-smoking campaign.
5. urges state medical societies to promote the use of appropriate educational films and educational programs that reduce tobacco use by young people;
6. (a) favors providing financial support to promising behavioral research into why people, especially youth, begin smoking, why they continue, and why and how they quit; (b) encourages research into further reducing the risks of cigarette smoking; and (c) continues to support research and education programs, funded through general revenues and private sources, that are concerned with health problems associated with tobacco and alcohol use;
7. opposes the practice of tobacco companies using the names and distinctive hallmarks of well-known organizations and celebrities, such as fashion designers, in marketing their products, as youth are particularly susceptible;
8. supports working with appropriate organizations to develop a list of physicians and others recommended as speakers for local radio and television to discuss the harmful effects of tobacco usage and to advocate a tobacco-free society; and
9. commends the following entities for their exemplary efforts to inform the Congress, state legislatures, education officials and the public of the health hazards of tobacco use: American Cancer Society, American Lung Association, American Heart Association, Action on Smoking and Health, Inc., Groups Against Smoker's Pollution, National Congress of Parents and Teachers, National Cancer Institute, and National Clearinghouse on Smoking (HEW).

Smoke-free Environments and Workplaces

On the issue of the health effects of environmental tobacco smoke (ETS) and passive smoke exposure in the workplace and other public facilities, the AMA:

1. (a) supports classification of ETS as a known human carcinogen; (b) concludes that passive smoke exposure is associated with increased risk of sudden infant death syndrome and of cardiovascular disease; (c) encourages physicians and medical societies to take a leadership role in defending the health of the public from ETS risks and from political assaults by the tobacco industry; and (d) encourages the concept of establishing smoke-free campuses for business, labor, education, and government;
2. (a) honors companies and governmental workplaces that go smoke-free; (b) will petition the Occupational Safety and Health Administration (OSHA) to adopt regulations prohibiting smoking in the workplace, and will use active political means to encourage the Secretary of Labor to swiftly promulgate an OSHA standard to protect American workers from the toxic effects of ETS in the workplace, preferably by banning smoking in the workplace; (c) encourages state medical societies (in collaboration with other anti-tobacco organizations) to support the introduction of local and state legislation that prohibits smoking around the public entrances to buildings and in all indoor public places, restaurants, bars, and workplaces; and (d) will update draft model state legislation to prohibit smoking in public places and businesses, which would include language that would prohibit preemption of stronger local laws.
3. (a) encourages state medical societies to: (i) support legislation for states and counties mandating smoke-free schools and eliminating smoking in public places and businesses and on any public transportation; (ii) enlist the aid of county medical societies in local anti-smoking campaigns; and (iii) through an advisory to state, county, and local medical societies, urge county medical societies to join or to increase their commitment to local and state anti-smoking coalitions and to reach out to local chapters of national voluntary health agencies to participate in the promotion of anti-smoking control measures; (b) urges all restaurants, particularly fast food restaurants, and convenience stores to immediately create a smoke-free environment; (c) strongly encourages the owners of family-oriented theme parks to make their parks smoke-free for the greater enjoyment of all guests and to further promote their commitment to a happy, healthy life style for children; (d) encourages state or local legislation or regulations that prohibit smoking in stadia and encourages other ball clubs to follow the example of banning smoking in the interest of the health and comfort of baseball fans as implemented by the owner and management of the Oakland Athletics and others; (e) urges eliminating cigarette, pipe, and cigar smoking in any indoor area where children live or play, or where another person's health could be adversely affected through passive smoking; (f) urges state and county medical societies and local health professionals to be especially prepared to alert communities to the possible role of the tobacco industry whenever a petition to suspend a nonsmoking ordinance is introduced and to become directly involved in community tobacco control activities; and (g) will report annually to its membership about significant anti-smoking efforts in the prohibition of smoking in open and closed stadia;
4. calls on corporate headquarters of fast-food franchisers to require that one of the standards of operation of such franchises be a no smoking policy for such restaurants, and endorses the passage of laws, ordinances and regulations that prohibit smoking in fast-food restaurants and other entertainment and food outlets that target children in their marketing efforts;
5. advocates that all American hospitals ban tobacco and supports working toward legislation and policies to promote a ban on smoking and use of tobacco products in hospitals, health care institutions, and educational institutions, including medical schools;
6. supports the development and dissemination of model language to administrators of American hospitals and the membership of the AMA Hospital Medical Staff Section to emphasize and facilitate the importance of a smoke-free hospital environment, and as a matter of high priority, the incorporation of this requirement by the Joint Commission on Accreditation of Healthcare Organizations and the American Hospital Association.
7. In hospitals where smoking has not been banned, the AMA encourages hospitals and physicians to support the following guidelines with respect to smoking in hospitals: (a) Physicians should take a leadership role in promoting the development of nonsmoking policies and programs in hospitals; (b) Smoking should be prohibited in areas where oxygen or flammable materials are stored or in use; (c) Smoking should be prohibited in all corridors, elevators, and acute care areas; (d) Bedridden patients should not be permitted to smoke; (e) Smoking on patient floors by visitors, hospital staff, and ambulatory patients should be restricted to designated, well-ventilated areas equipped to meet fire standards; (f) If smoking is permitted in cafeterias, other dining areas, employee lounges, waiting areas, and library facilities, there should be separate sections for smokers and nonsmokers. Where segregation is not feasible, smoking should be prohibited; (g) Smoking should be prohibited in all hospital staff meetings, Board meetings, and conferences (e.g., Grand Rounds); (h) Hospitals should ask all patients prior to or upon admission about their preference for a smoke-free room and should guarantee that preference; (i) Hospitals should seriously consider designating one or more entire floors as completely nonsmoking; (j) No tobacco products should be sold in hospitals or on hospital grounds; (k) Signs should be posted at entrances to the hospital and in all nonsmoking areas to inform patients, staff and visitors where smoking is prohibited. When indicated, the signs should be multilingual or should make use of symbols; (l) Designated smoking areas should not be interpreted as approval of smoking by the institution and its physicians; (m) Hospitals should develop, implement, enforce, and maintain a formal written smoking policy, to be distributed to all staff, visitors, and patients; (n) Either directly or in conjunction with other community agencies, hospitals should make smoking education and cessation programs, literature and other materials available to patients, employees, and the community; (o) Hospitals that restrict or eliminate smoking within the institution should initiate discussions with their fire and casualty insurance carriers to consider reductions in insurance premiums; and (p) Hospital administrators should be aware of all of the hazards of smoking and should take the necessary steps to reduce these hazards. Administrators should utilize appropriate nonsmoking resource materials (e.g., those of the American Hospital Association) in developing policies on nonsmoking; and
8. will work with the Department of Defense to explore ways to encourage a smoke-free environment in the military through the use of mechanisms such as health education, smoking cessation programs, and the elimination of discounted prices for tobacco products in military resale facilities.

Tobacco Product Labeling

The AMA:

1. supports working toward more explicit and effective health warnings regarding the use of tobacco (and alcohol) products, including the extension of labeling requirements of ingredients to tobacco products sold in the United States;
2. supports legislation or regulations that require (a) tobacco companies to accurately label their products indicating nicotine content in easily understandable and meaningful terms that have plausible biological significance; (b) picture-based warning labels on tobacco products produced in, sold in, or exported from the United States; (c) an increase in the size of warning labels to include the statement that smoking is ADDICTIVE and may result in DEATH; and (d) all advertisements for cigarettes and each pack of cigarettes to carry a legible, boxed warning such as: "Warning: Cigarette Smoking causes CANCER OF THE MOUTH, LARYNX, AND LUNG, is a major cause of HEART DISEASE AND EMPHYSEMA, is ADDICTIVE, and may result in DEATH. Infants and children living with smokers have an increased risk of respiratory infections and cancer."
3. urges the Congress to require that: (a) warning labels on cigarette packs should appear on the front and the back and occupy twenty-five percent of the total surface area on each side and be set out in black-and-white block; (b) in the case of cigarette advertisements, warning labels of cigarette packs should be moved to the top of the ad and should be enlarged to twenty-five percent of total ad space; and (c) warning labels following these specifications should be included on cigarette packs of U.S. companies being distributed for sale in foreign markets.

FDA Regulation of Tobacco Products

The AMA:

1. reaffirms its position that all tobacco products are harmful to health, and that there is no such thing as a safe cigarette;
2. asserts that tobacco is a raw form of the drug nicotine and that tobacco products are delivery devices for an addictive substance;
3. reaffirms its position that the Food and Drug Administration (FDA) does have, and should continue to have, authority to regulate tobacco products, including their manufacture, sale, distribution, and marketing;
4. strongly supports the substance of the August 1996 FDA regulations intended to reduce use of tobacco by children and adolescents as sound public health policy and opposes any federal legislative proposal that would weaken the proposed FDA regulations;
5. urges Congress to pass legislation to phase in the production of less hazardous and less toxic tobacco, and to authorize the FDA have broad-based powers to regulate tobacco products;
6. encourages the FDA and other appropriate agencies to conduct or fund research on how tobacco products might be modified to facilitate cessation of use, including elimination of nicotine and elimination of additives (e.g., ammonia) that enhance addictiveness; and
7. encourages the FDA to assert its authority over the manufacture of tobacco products to reduce their addictive potential at the earliest practical time, with a goal for implementation within 5-10 years.

Tobacco Taxes

1. The AMA will work for and encourages all levels of the Federation and other interested groups to support efforts, including legislation, to pass increased excise taxes on tobacco in order to discourage smoking;
2. An increase in federal excise taxes for tobacco should include provisions to make funds available that would be allocated to health care needs and health education, and for the treatment of those who have already been afflicted by tobacco-caused illness, including nicotine dependence, and to support counter-advertising efforts;
3. The AMA continues to support legislation to reduce or eliminate the tax deduction presently allowed for the advertisement and promotion of tobacco products; and advocates that the added tax revenues obtained as a result of reducing or eliminating the tobacco advertising/promotion tax deduction be utilized by the federal government for expansion of health care services, health promotion and health education.

Tobacco Product Sales and Distribution

The AMA:

1. encourages the passage of laws, ordinances and regulations that would set the minimum age for purchasing tobacco products at 21 years, and urges strict enforcement of laws prohibiting the sale of tobacco products to minors;
2. supports the development of model legislation regarding enforcement of laws restricting children's access to tobacco, including but not limited to attention to the following issues: (a) provision for licensure to sell tobacco and for the revocation thereof; (b) appropriate civil or criminal penalties (e.g., fines, prison terms, license revocation) to deter violation of laws restricting children's access to and possession of tobacco; (c) requirements for merchants to post notices warning minors against attempting to purchase tobacco and to obtain proof of age for would-be purchasers; (d) measures to facilitate enforcement; (e) banning out-of-package cigarette sales ("loosies"); and (f) requiring tobacco purchasers and vendors to be of legal smoking age;
3. requests that states adequately fund the enforcement of the laws related to tobacco sales to minors;
4. opposes the use of vending machines to distribute tobacco products and supports ordinances and legislation to ban the use of vending machines for distribution of tobacco products;
5. seeks a ban on the production, distribution, and sale of candy products that depict or resemble tobacco products;
6. opposes the distribution of free tobacco products by any means and supports the enactment of legislation prohibiting the disbursement of samples of tobacco and tobacco products by mail; and
7. (a) publicly commends (and so urges local medical societies) pharmacies and pharmacy owners who have chosen not to sell tobacco products, and asks its members to encourage patients to seek out and patronize pharmacies that do not sell tobacco products; (b) encourages other pharmacists and pharmacy owners individually and through their professional associations to remove such products from their stores; (c) urges the American Pharmacists Association, the National Association of Retail Druggists, and other pharmaceutical associations to adopt a position calling for their members to remove tobacco products from their stores; and (d) encourages state medical associations to develop lists of pharmacies that have voluntarily banned the sale of tobacco for distribution to their members.

Smokeless Tobacco

Given that the use of smokeless tobacco (snuff and chewing tobacco) is associated with health risks, the AMA:

1. supports publicizing the increasing evidence that the use of snuff or chewing tobacco is associated with adverse health effects and encourages ongoing research to further define the health risks associated with snuff and chewing tobacco, including the risk of developing cardiovascular disease, and the effectiveness of cessation and prevention programs;
2. objects strongly to the introduction of "smokeless" cigarettes;
3. opposes the use of smokeless tobacco products by persons of all ages;
4. urges that the same requirements and taxes placed on cigarette sales and advertising be applied to smokeless tobacco products;
5. supports legislation to prohibit the sale of smokeless tobacco products to minors and encourages states to enforce strictly the prohibition on purchasing and distributing all tobacco products to individuals under the age of 21 years;
6. supports public and school educational programs on the health effects of smokeless tobacco products;
7. urges the commissioners of professional athletic organizations to discourage the open use of smokeless tobacco by professional athletes and recommends that professional athletes participate in media programs that would discourage the youth of America from engaging in this harmful habit; and
8. is committed to exerting its influence to limit exposure of young children and teenagers to advertising for smokeless tobacco and look-alike products, and urges that manufacturers take steps to diminish the appeal of snuff and chewing tobacco to young persons.

Tobacco Advertising and Media

The AMA:

1. in keeping with its long-standing objective of protecting the health of the public, strongly supports a statutory ban on all advertising and promotion of tobacco products;

2. as an interim step toward a complete ban on tobacco advertising, supports the restriction of tobacco advertising to a "generic" style, which allows only black-and-white advertisements in a standard typeface without cartoons, logos, illustrations, photographs, graphics or other colors;
3. (a) recognizes and condemns the targeting of advertisements for cigarettes and other tobacco products toward children, minorities, and women as representing a serious health hazard; (b) calls for the curtailment of such marketing tactics; and (c) advocates comprehensive legislation to prevent tobacco companies or other companies promoting look-alike products designed to appeal to children from targeting the youth of America with their strategic marketing programs;
4. supports the concept of free advertising space for anti-tobacco public service advertisements and the use of counter-advertising approved by the health community on government-owned property where tobacco ads are posted;
5. (a) supports petitioning appropriate government agencies to exercise their regulatory authority to prohibit advertising that falsely promotes the alleged benefits and pleasures of smoking as well worth the risks to health and life; and (b) supports restrictions on the format and content of tobacco advertising substantially comparable to those that apply by law to prescription drug advertising;
6. publicly commends those publications that have refused to accept cigarette advertisements and supports publishing annually, via JAMA and other appropriate publications, a list of those magazines that have voluntarily chosen to decline tobacco ads, and circulation of a list of those publications to every AMA member;
7. urges physicians to mark the covers of magazines in the waiting area that contain tobacco advertising with a disclaimer saying that the physician does not support the use of any tobacco products and encourages physicians to substitute magazines without tobacco ads for those with tobacco ads in their office reception areas;
8. urges state, county, and specialty societies to discontinue selling or providing mailing lists of their members to magazine subscription companies that offer magazines containing tobacco advertising;
9. encourages state and county medical societies to recognize and express appreciation to any broadcasting company in their area that voluntarily declines to accept tobacco advertising of any kind;
10. urges the 100 most widely circulating newspapers and the 100 most widely circulating magazines in the country that have not already done so to refuse to accept tobacco product advertisements, and continues to support efforts by physicians and the public, including the use of written correspondence, to persuade those media that accept tobacco product advertising to refuse such advertising;

11. (a) supports efforts to ensure that sports promoters stop accepting tobacco companies as sponsors; (b) opposes the practice of using athletes to endorse tobacco products and encourages voluntary cessation of this practice; and (c) opposes the practice of tobacco companies using the names and distinctive hallmarks of well-known organizations and celebrities, such as fashion designers, in marketing their products;
12. will communicate to the organizations that represent professional and amateur sports figures that the use of all tobacco products while performing or coaching in a public athletic event is unacceptable. Tobacco use by role models sabotages the work of physicians, educators, and public health experts who have striven to control the epidemic of tobacco-related disease; and
13. (a) encourages the entertainment industry, including movies, videos, and professional sporting events, to stop portraying the use of tobacco products as glamorous and sophisticated and to continue to de-emphasize the role of smoking on television and in the movies; (b) will aggressively lobby appropriate entertainment, sports, and fashion industry executives, the media and related trade associations to cease the use of tobacco products, trademarks and logos in their activities, productions, advertisements, and media accessible to minors; and (c) advocates comprehensive legislation to prevent tobacco companies from targeting the youth of America with their strategic marketing programs.

Tobacco Litigation Settlements

The AMA:

1. strongly supports the position that all monies paid to the states in the Master Settlement Agreement and other agreements be utilized for research, education, prevention and treatment of nicotine addiction, especially in children and adolescents, and for treatment of diseases related to nicotine addiction and tobacco use;
2. supports efforts to ensure that a substantial portion of any local, state or national tobacco litigation settlement proceeds be directed towards preventing children from using tobacco in any form, helping current tobacco users quit, and protecting nonsmokers from environmental tobacco smoke, and that any tobacco settlement funds not supplant but augment health program funding;
3. strongly supports efforts to direct tobacco settlement monies that are not directed to other specific tobacco control activities to enhance patient access to medical services;
4. strongly supports legislation codifying the position that all monies paid to the states through the various tobacco settlements remain with the states; and that none be reimbursed to the Federal government on the basis of each individual state’s Federal Medicaid match; and
5. opposes any provision of tort reform legislation that would grant exclusion from liability or special protection to tobacco companies or tobacco products.

AMA Corporate Policies on Tobacco

1. The AMA: (a) continues to urge the federal government to reduce and control the use of tobacco and tobacco products; (b) supports developing an appropriate body for coordinating and centralizing the Association's efforts toward a tobacco-free society; and (c) will defend vigorously all attacks by the tobacco industry on the scientific integrity of AMA publications.
2. It is the policy of the AMA to continue to use appropriate lobbying resources to support programs of anti-tobacco health promotion and advertising;
3. The AMA's House of Delegates endorses the April 24, 1996, statement by the AMA Secretary-Treasurer that all physicians, health professionals, medical schools, hospitals, public health advocates, and citizens interested in the health and welfare of the children should review their personal and institutional investments and divest of any tobacco holdings (including mutual funds that include tobacco holdings); and specifically calls on all life and health insurance companies and HMOs to divest of any tobacco holdings;
4. The AMA defines the Tobacco Industry as companies or corporate divisions that directly produce or purchase tobacco for production or market tobacco products, along with their research and lobbying groups, including the Council for Tobacco Research and the Smokeless Tobacco Research Council. A company or corporate division that does not produce or market tobacco products but that has a tobacco producing company as or among its owners will not be considered a prohibited part of the tobacco industry as long as it does not promote or contribute to the promotion, sale and/or use of tobacco products. If such promotional practices begin, the company will be placed on an "unacceptable for support" list;
5. Accordingly, it is the policy of the AMA (a) not to invest in tobacco stocks or accept financial support from the tobacco industry; (b) to urge medical schools and their parent universities to eliminate their investments in corporations that produce or promote the use of tobacco and discourage them from accepting research funding from the tobacco industry; (c) to likewise urge all scientific publications to decline such funded research for publication; and (d) to encourage state and county medical societies and members to divest of any and all tobacco stocks; and
6. The AMA (a) encourages state and local medical societies to determine whether candidates for federal, state and local offices accept gifts or contributions of any kind from the tobacco industry, and publicize their findings to both their members and the public; and (b) urges state and county medical societies and local health professionals along with their allies to support efforts to strengthen state and local laws that require public disclosure of direct and indirect expenditures to influence legislation or ordinances, given recent allegations about tobacco industry strategies.

Federal Tobacco Price Supports

The AMA:

1. supports federal legislation to cease all price supports from the federal government to farmers for growing tobacco and urges the federal government, for the three years after termination of price supports, to provide assistance to needy tobacco farmers to begin production of other agricultural products;
2. believes that it is glaringly inconsistent to mandate the reduction of death and disease through peer review organization activity, while continuing to subsidize tobacco--a substance known to be a major cause of cardiovascular disease and cancer;
3. encourages its members to gather signatures from their patients on petitions to be presented to their congressional delegations demanding that the U.S. government discontinue spending any tax dollars in support of the tobacco industry, and encourages state and county medical associations to urge all physicians throughout the U.S. to do the same in an effort to achieve the AMA's and the Surgeon General's goal of creating a smoke-free society; and
4. will inform all appropriate national medical-oriented organizations of the importance of AMA policy that expresses opposition to federal support to the tobacco industry and, further, urges and challenges other organizations to take similar action.

International Tobacco Control Efforts

The AMA:

1. supports the international tobacco control efforts of the World Health Organization and urges the appropriate bodies and persons within the U.S. government (including Congress, the State Department, the Department of Commerce, and the Department of Health and Human Services) to participate fully in international tobacco control efforts, including supporting efforts to bring to fruition a Framework Convention on Tobacco Control;
2. will work for the enactment of federal legislation or regulations that would prohibit the exportation of tobacco products to other countries. Pending the enactment of such legislation or regulation, the AMA (a) urges the U.S. government to alter trade policies and practices that currently serve to promote the world smoking epidemic; (b) continues to support the following activities: (i) federal legislation requiring health warning labels in the appropriate native language or symbolic form to be on packages of cigarettes exported and require foreign advertising by U.S. tobacco producers to be at least as restrictive as types of advertising permitted in the U.S.; (ii) labeling on tobacco products manufactured abroad to be at least as restrictive as those produced in the U.S.; (iii) opposition to efforts by the U.S. government to persuade countries to relax regulations concerning tobacco promotion and consumption; and (iv) encouragement of the World Health Organization to increase its worldwide anti-smoking efforts; (c) supports working with the World Medical Association as well as directly with national medical societies to expand activities by the medical profession to reduce tobacco use worldwide; (d) supports establishing close working relations with the World Health Organization to promote more physician involvement in anti-tobacco activities, particularly in developing and recently developed countries; (e) supports working with the Centers for Disease Control and Prevention's Office on Smoking and Health to promote worldwide anti-tobacco activities; (f) supports periodically monitoring the success of worldwide anti-tobacco efforts to control the growing worldwide smoking epidemic; and (g) supports the right of local jurisdictions to enact tobacco regulations that are stricter than those that exist in state statutes and encourages state and local medical societies to evaluate and support local efforts to enact useful regulations; and
3. opposes any efforts by the government or its agencies to actively encourage, persuade or compel any country to import tobacco products and favors legislation that would prevent the government from actively supporting, promoting or assisting such activities

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