Vigilance urged for patients' lifestyle choices

AMA policy signals a renewed commitment to fight smoking, obesity and underage drinking.

By Victoria Stagg Elliott, amednews staff. July 7, 2003.

Chicago -- Don't smoke. Don't drink. Watch what you eat. And get off the couch.

Though it's all been said before, it needs to be said again -- and with renewed commitment. At least that's the point made by a series of policies adopted at the AMA's Annual Meeting last month. The actions encouraged physicians to stay focused on patient lifestyle issues, and called for public and private efforts to buttress these messages.

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"It's part of an overall resurgence of interest in public health," said Yank D. Coble Jr., MD, AMA immediate past president.

Issues regarding tobacco use prevention and cessation, point-of-sale restrictions, and tobacco product labeling received considerable attention -- consistent with the House of Medicine's long-term concern about the health effects of smoking.

"We have allowed companies to create an entire subclass of our society that are neurochemical slaves," said William P. Gibbons, MD, a pathologist from Aurora, Ill. and a delegate from the Organized Medical Staff Section. "These are our patients, and they're dying."

On tobacco control, the AMA urged adoption by the federal government of the Framework Convention on Tobacco Control Treaty and announced its support for recent recommendations of the federal Interagency Committee on Smoking and Health. The ICSH called for the establishment of a National Tobacco Quitline network, an extensive anti-tobacco advertising campaign that calls for all federally-funded health care programs to cover evidence-based counseling and medications for tobacco cessation, provide training for clinicians to help their patients quit, and implement a cigarette tax to fund the measures.

Canada, Australia, Brazil, Thailand and the European Union require pictorial warnings on cigarette packs.

The AMA also wants it to be harder for consumers to buy tobacco products. Specifically, the organization voted to encourage businesses such as chain drug stores that dispense medications to recipients of federal medical insurance to stop selling tobacco. The Association also wants to ensure that smokers pay full price and that tobacco taxes are implemented and exist as a impediment to people starting or continuing to smoke.

Opposition to tax-free tobacco products also was raised.

This issue emerged because several Native American nations are selling or are planning to sell tax-free tobacco on their land and over the Internet.

"We've lobbied heavily to increase cigarette excise taxes because studies have shown that when the price goes up, consumption goes down," said Michael Migliori, MD, an ophthalmologist from Providence, R.I., who proposed the resolution. "By eliminating the tax, this undermines the efforts to reduce the number of smokers and reduces state revenue that should be used to offset the cost of treating smoking-related diseases."

On the labeling issue, a policy was endorsed that called for laws banning marketing terms such as "light," "ultra light," "mild," and "low tar," and declared them deceptive.

"These cigarettes give smokers a false sense of security and less motivation to quit," said Ronald M. Davis, MD, an AMA trustee. "And the use of these terms deceives millions of smokers."

The AMA also will seek enactment of legislation requiring that the contact details for smoking cessation services be printed on cigarette packs along with picture warnings.

Such illustrations may prove to be stronger deterrents against smoking than just words, particularly for those with low literacy or limited English comprehension.

"In Canada, Australia, Brazil, Thailand and the European Union, these warnings have already been implemented, and the data clearly suggests that the impact on the minds of smokers is phenomenal," said Jeffrey Palmgren, MD, a delegate from the Resident and Fellow Section who proposed the resolution. "And this goes right along the AMA's push for pictorial patient information to improve health literacy."

Looking beyond the smoke

Delegates widely recognized that smoking was by no means the only lifestyle factor impacting health. Alcohol and obesity also got their due.

According to new AMA policies, the organization will work to create a higher level of awareness about the harm caused by underage drinking and encourage more research in this area. Taxes on tobacco and alcohol should be increased to fund health care and health education.

Several physicians gathered to form an alcohol caucus to push these issues to the fore.

"We have no interest in prohibition, but we are particularly concerned about the growing use of alcohol among adolescents," said AMA President-elect John C. Nelson, MD, MPH, who led the meeting.

AMA delegates also called on the organization to study and recommend changes to the government's food pyramid to reflect racial, regional and ethnic differences in diet.

"We really don't know how to eat," said Kevin McKinney, MD, chair of the Minority Affairs Consortium. "And until we learn how to eat, we will never be able to get rid of a lot of the disease we have right now."

The AMA will collaborate with other agencies to create a multidisciplinary task force to review the public health impact of obesity and recommend measures to better recognize and treat obesity as a chronic condition. The task force will create "National Obesity Awareness Month," encourage the reestablishment of physical education in schools, push for the creation of obesity prevention programs for the whole family and promote the inclusion of obesity prevention in medical school curricula.

A minority of physicians felt, however, that there was too much emphasis on environmental factors in these lifestyle issues. In the case of obesity, some questioned whether declaring it a chronic disease would mean individuals take less responsibility for what goes on their plates and how they spend their time.

"This would validate people not playing a role in their own care," said Pino Colone, MD, an emergency medicine physician from Howell, Mich.

There were also questions about whether the true villain in underage drinking is advertising or peers and parents, as well as some interest in researching the possible beneficial effects of moderate drinking that are reported periodically.

"The major factor in alcohol abuse by youth is actually the deficiencies of parents and peers," said Raymond Scalettar, MD, former chair of the Board of Trustees and an adviser to the Distilled Spirits Council of the United States. "There are also medical benefits to alcohol which have not been addressed."