More to do on tobacco control

The American Medical Association reaffirmed its commitment to tobacco control at its Annual Meeting in the wake of recently passed legislation supporting the organization’s long-held position that the Food and Drug Administration should regulate cigarettes and other nicotine products.

But the organization is also calling for several other steps that would make a further dent in smoking rates.

The House of Delegates approved a resolution calling for the stoppage of the sale and marketing of tobacco products in pharmacies. It also agreed to work with government agencies and pharmacy trade groups to remove tobacco from the shelves and push for relevant legislation toward this end. Delegates said it didn’t make sense for businesses to both sell products to improve health and ones that damage it.

“There’s an extraordinary conflict of interest in the sale of cigarettes at one end of the store and the filling of a prescriptions for the consequences of smoking at the other,” said Carolyn Lopez, MD, of Illinois, a delegate for the American Academy of Family Physicians.

Also, the AMA is seeking to reduce the number of places people can smoke. The house passed a resolution to urge the U.S. president to issue an executive order making all federal workplaces, both buildings and campuses, completely smoke-free.

“There’s no safe level of secondhand smoke. There’s no safe or effective ventilation mechanism to remove the effects of smoke from the environment,” said Arvind Goyal, MD, MPH, of Illinois, a delegate for the American Assn. of Public Health Physicians. “I think it’s acceptable for the federal government to make rules that would prohibit smoking in public spaces and protect the rights to breathe fresh air for the workers.”

There was wide support for this move but also questions about how expansive it would be. It’s unclear what facilities the order would cover.

With regard to physicians helping patients quit, the AMA house also voted to advocate to collect information from patients on tobacco use, secondhand smoke exposure, interest in quitting and any prior attempts. Electronic health records should be designed to capture this information along with that on other behaviors.

“We encourage physicians to query about smoking habits, and we encourage electronic health records that will allow physicians to record this information,” said AMA Secretary Joseph Annis, MD.

There is also significant interest in technology that could make smoking cessation more likely, so delegates also voted to study the potential role of electronic cigarettes in this process.

“We have very little information on this new device,” Dr. Annis said. “We know that nicotine can have adverse consequences, particularly cardiovascular disease. Does this [device] have more adverse effects than the nicotine patch? We don’t know that. The big question is whether this is a way of surreptitiously getting people to continue their addiction to nicotine under the guise of being an aid to smoking cessation.”

These products were, until recently, marketed as alternatives for those who want to smoke but have fewer places where they are allowed to light up. The FDA is currently reviewing the data on them and has been refusing to allow importation of such products on the grounds that they are unapproved drug delivery devices.

“None of these products are covered by a [new drug application] or by an investigational drug application. Because they have not been submitted to the FDA for review, we have no way to know the amount of nicotine provided. The agency has no information on the manufacturing process,” said Janelle Derbis, PharmD, who spoke for the FDA and is the health programs coordinator for its Office of the Commissioner. “The FDA is concerned electronic cigarettes may introduce young people to nicotine and that their use could lead to the use of other nicotine products and other problems.”

The annual report on tobacco also will continue to be produced. The board proposed that it be produced only when something significant happens, as part of a general movement toward reducing the number of mandated annual reports produced by the AMA. This was voted down.
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