FP Report -- December 1999
From acceptance to opposition: Tobacco fight evolves at AAFP
The days of AAFP Board meetings in smoke-filled rooms with overflowing ashtrays are long gone. A visit to the Scientific Assembly's exhibit floor will no longer yield free cigarettes. In fact, the Academy's position on tobacco use has evolved from passive acceptance to active opposition, and the organization now plays a leading role in promoting a tobacco-free lifestyle.
How did it happen? What did we learn, and where do we go from here?
The early years. Browse through the Academy's archives, and you'll find stacks of photos from the fledgling years when it seemed everybody smoked. CME presenters had cigarettes hanging out of their mouths. Candid shots show physicians chatting, cigarettes pinched between their fingers. Wide-angle pictures feature doctors and their spouses eating dinner with smoke rising from ashtrays. Smoking was part of the social fabric in the United States, and the American Academy of General Practice (AAFP's predecessor) wasn't about to rip apart the seams.
From 1949 to 1969, tobacco companies exhibited at the Academy's Scientific Assembly. This exhibit description illustrates that era's state of mind: "Welcome to the R.J. Reynolds Tobacco Company Exhibit! You are cordially invited to receive a cigarette case (monogrammed with your initials) containing your choice of Camel, Winston Filter, Menthol Fresh Salem or Cavalier King Size Cigarettes."
You've come a long way, baby!
1969 -- a physician smokes while presenting an Assembly casting workshop.
Now -- the winning poster in the 1999 national Tar Wars® poster contest.In 1964, the AAGP Board voted to adopt the AMA's policy on tobacco, essentially refusing to endorse the Surgeon General's Report on Smoking, which had been released earlier that year. In 1965, the U.S. Congress passed the Federal Cigarette Labeling and Advertising Act, which required the surgeon general's health warnings on cigarette packages.
Three years later, a resolution introduced at the AAGP Congress of Delegates aimed to ban the exhibition and free distribution of tobacco products at Assembly. The resolution was tabled after some delegates voiced concern that it "would be a slap in the face to tobacco firms currently exhibiting at the Academy meeting." However, a similar resolution passed the following year.
The tide was turning.
DOC, delegates push for change. Two significant forces pushed the AAFP toward more proactive anti-tobacco initiatives, according to Herbert Young, M.D., Scientific Activities Division director.
Starting in the late '70s, one impetus came in the form of DOC -- Doctors Ought to Care -- an organization of physicians considered radical at the time for their irreverent approach to educating the public about the major preventable causes of poor health and high medical costs. Rather than focus on the dangers of smoking, DOC put the blame squarely on the tobacco industry and urged patients to think critically about tobacco's misleading advertising messages. DOC --which is still a leader in the anti-tobacco effort -- also pressured the Academy to play a key role in preventing tobacco use, especially among young people.
"A lot of what AAFP subsequently did was spurred by DOC's activities," Young said.
Family physician Alan Blum, M.D., now director of the University of Alabama Center for the Study of Tobacco and Society in Tuscaloosa, founded DOC in 1977 and recalls battling the Academy's reluctance to take on the tobacco industry. But his passion and enthusiasm were contagious, particularly with the specialty's up-and-coming leaders -- medical students and residents.
As a family practice resident at the Academy's 1977 meeting for students and residents, Blum tried to announce his new organization and invite his peers to participate. He was told he didn't have permission to speak at that time, but was later assigned a room in which to address interested conference attendees. "We got about 30 people packed into this little room," Blum said. "They were fascinated. Our breakthrough was focusing on patients' attitudes about smoking and, above all, bringing humor to a very serious health issue. Our slogan is 'Laughing the pushers out of town.'"
The message resonated with students and residents, who went home inspired and began implementing the strategies and skills Blum promoted. They shared the DOC concepts with the next generation of FPs-in-training, and the momentum continues to this day.
Pressure to take a stand on tobacco also came from an ongoing grassroots movement among constituent chapters, said Young, with FPs across the country crying out about tobacco's destructive impact on health. Starting in the early 1970s, members raised the issue with their AAFP delegates, who in turn brought a plethora of tobacco-related resolutions to the annual Congress of Delegates.
Major actions taken by the Congress in the '70s and '80s included making AAFP and its meetings smoke-free, recommending that smoking be banned in hospitals and other medical institutions, opposing cigarette sales within health care facilities, commending publications that refuse to accept tobacco advertising and circulating a list of those publications to AAFP members, and accepting a challenge from the American Medical Association to promote a smoke-free society by the year 2000.
Members' booming interest also led to development of the Academy's popular Stop Smoking Kit in 1987. The kit includes brochures for the waiting room, forms and stickers for patient charts, a physician and office staff manual, a patient guide, audiotapes, and other motivational and educational materials for patients.
Tobacco today. As the number one preventable cause of death in the United States, tobacco use now has become one of the Academy's top concerns. For example, AAFP members and staff have testified at state legislatures and the U.S. Congress on the need for laws that protect people -- and particularly youth -- from the hazards of smoking.
Family physicians are leading the charge in many ways. Some examples: Surgeon General David Satcher, M.D., Ph.D., uses the credibility of his office to promote a tobacco-free lifestyle. Karin Husten, M.D., heads the Office of Smoking and Health at the Centers for Disease Control and Prevention. Carlos Jaen, M.D., of Buffalo, N.Y., serves on the task force drafting clinical policy guidelines on tobacco use for the U.S. Preventive Services Task Force. Tom Houston, M.D., is coordinating the AMA's upcoming World Conference on Tobacco. And Robert Higgins, M.D., has spread the anti-tobacco message across the globe as president of WONCA, the World Organization of Family Doctors.
In addition, hundreds of family physicians throughout the United States and abroad participate in the Academy's Tar Wars program, which takes a pro-health tobacco education program into elementary school classrooms.
Family physician Jeffrey Cain, M.D., of Denver launched Tar Wars in 1988 with support from DOC and the Denver Museum of Natural History. "At that time, the approach to tobacco education was 'don't smoke or you'll get cancer when you're 65,'" he said. "That's not very effective with fifth graders."
Tar Wars is a specific tool based on the DOC philosophy, said Cain. Children learn about the short-term consequences of tobacco use and analyze the misleading images portrayed in tobacco ads.
The AAFP endorsed Tar Wars in 1993 and, in 1997, signed a four-year agreement to operate the program. Cain said family physician involvement skyrocketed when Patrick Harr, M.D., of Maryville, Mo., was elected AAFP president-elect in 1996. In a speech at the Assembly that year, Harr challenged every active member to donate "one hour of one day this next year to teach a tobacco education program to a local fifth-grade class." A subsequent letter from Harr to the membership generated more than 15,000 requests for the Tar Wars curriculum packet. The number of AAFP constituent chapters sponsoring the program also has jumped from eight to 32.
Although anyone interested in preventing tobacco use is welcome to present a Tar Wars program, Cain said the involvement of FPs is crucial. "Family doctors are the only physicians who see the initiation and the consequences of tobacco use," he said. "They see the whole life span. As generalists, they also have an overarching perspective to understand the role of tobacco in the family, community and society."
Want more information?
Tar Wars® -- (800) TAR WARS
AAFP Stop Smoking Kit -- (800) 944-0000
Doctors Ought to Care -- (800) DOC-9340
Where do we go from here? The Academy can glean lessons from its history with tobacco, said AAFP Past President Harr. "The main thing is that this is a slow process," he said.
He applauded the Academy for its strong promotion of Tar Wars, but said other at-risk groups must be targeted, too. For example, strong initiatives that promote smoking cessation among teens are essential, he said. "More teenagers smoke now than ever before. The number of young women who smoke is increasing at an alarming rate."
Harr also said he hoped the AAFP will keep the issue of tobacco in the spotlight. "The tobacco industry settlements took some focus away from dangers of smoking and put more focus on the litigation," he said. "People think that the lawsuits took care of the problem. But the industry is still targeting kids, despite what they say. We just have to accept that challenge and step up to the plate."
By Sharon Dent, Associate Editor
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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