March 2018

National Tobacco Reform Initiative (NTRI)

In October 2013, Core Team representatives and the tobacco control leaders of a dozen of the major national voluntary health organizations met in Washington, DC to explore ways these groups could celebrate the 50th anniversary of the U.S. Surgeon General’s Advisory Committee Report. At this meeting, the interagency group approved the 10-year goal – to reduce the smoking prevalence among adults from 18% to 10% by 2024.

At a January 2014 National Press Conference, seven of these organizations formally called for a new national commitment and bold actions by the leading voluntary health organizations, and all levels of government, to achieve the 10-in-10 goal. 

The Core Team was then enlarged to include additional distinguished independent senior tobacco control leaders to help focus the tobacco control community and other stakeholders on the need to elevate the bar on efforts to reduce adult smoking in the U.S. , proportionate to outreach initiatives aimed at kids and young adults.

On September 3, 2015, the Core Team convened 16 tobacco control leaders from the major national non-profit public health organizations and governmental agencies, mostly from the Atlanta area. Included were leaders from the ACS, ANR, Truth Initiative, CTFK, OSH, GSU, UCSF, etc. This was the first in series of special meetings organized by the Core Team to review the current state of tobacco control, and to help identify ‘areas of opportunity’ in a re-energized collaborative nationwide movement driven by the 2024 goal.

Seven (7) priority areas were identified for follow-up action:

  1. Elevate the importance of tobacco control with a stronger ‘sense of urgency’ and calls for action;
  2. Increase the investment of substantial resources in tobacco control;
  3. Focus on marginalized population groups;
  4. Develop a comprehensive policy on nicotine;
  5. Understand hostile political environments;
  6. Build relationships with opponents; and,
  7. Hold the tobacco industry accountable for lives lost needlessly.

The plan was to replicate this meeting at different locations across the country; however, mainly due to the lack of resources, it was subsequently decided to ask key tobacco control leaders across the country to provide feedback (via a special study) on what they believed were the four (4) highest priority actions, by order of importance, for the tobacco control forces to focus on nationwide going forward.

In early 2016, the Core Team provided the first-ever opportunity for 120 tobacco control leaders across the U.S. to help determine national priorities for saving adult smokers from the deadly cigarette. A total of 180 carefully-selected individuals were invited to contribute to this survey.

In processing their valuable input, three (3) Priority Actions were given the highest ranking in terms of their potential impact in reducing the prevalence of adult smoking. These are listed here in their order of importance: 

  • Increase the federal excise tax on cigarettes, and cigarette taxes in those states with the lowest rates;
  • Encourage health and life insurers, employers and health professionals to actively promote smoking cessation measures;
  • Establish a more rational tobacco, nicotine and alternative products regulatory framework based on their relative risks, and that is adaptable to the increased speed of innovation in new technology development.

Distributed the Executive Summary Report of study findings and recommendations to more than 1,500 national public health organizations, governmental agencies, leaders of key congressional committees and staff support teams, professional associations, public health and tobacco control leaders at all levels nationwide, and other important stakeholders.

The Executive Summary Report was also provided to the 120 study participants; more than 35 of these special individuals returned strong letters of support and appreciation for the chance to be part of this effort. Examples of these responses are: “The highest-ranked Priority Actions are very important, and the ESR is quite compelling. I very much encourage you and your team to continue this advocacy” – EVP and Chief Medical Officer, CVS Pharmacies. And, “I laud you for this insertion of new energy into the tobacco control field. It is another health problem that continues to mystify me … costly to society, a tragedy for families, preventable, and yet passively and actively condoned” – Bill Foege, Consultant, Bill and Melinda Gates Foundation; Former Director, CDC.

Answered hundreds of requests for information and guidance on tobacco control issues via the National Tobacco Reform Initiative Web Site:

The Core Team’s membership was then enlarged with the addition of six (6) tobacco control experts covering all the key areas of expertise required to represent the comprehensive tobacco control effort; and, its name was changed to become the National Tobacco Reform Initiative or NTRI Team.

The NTRI team is made up of 10 senior tobacco control leaders who, collectively, have provided over 400 years of service to fighting the tobacco epidemic.

The team then approved the following “Mission Statement”: The NTRI will look for special opportunities to individually engage in and facilitate dialogue with others, including, but not limited to, public health organizations, health care professionals, the research community, governmental agencies, policy makers at the federal, state and local levels, consumers, the media, tobacco and nicotine product trade associations and manufacturers, where appropriate.

The NTRI was the first entity to call for and encourage development of a coordinated national strategy (delineating responsibilities, timelines, resource commitments, measurement and reporting requirements) to reach the 2024 interagency goal.

Put in place a process to identify the major deficiencies and barriers holding back tobacco control in the U.S., and provide recommendations on how to resolve. This process was utilized to call for a first-ever national strategy on smoking cessation, and the need for a Consensus Conference for a 21st Century Strategy on Harm Reduction.

In the spring of 2017, the NTRI Priority Action on Harm Reduction led team members to take the leadership in urging (in person, by letter and email) FDA leaders, Commissioner Scott Gottlieb, and Mitch Zeller, Director of the Center for Tobacco Products, to put in place a more rational nicotine and alternative products regulatory framework based on their relative risks, and that is adaptable to the increased speed of innovation in new technology development.

In July 2017, the NTRI commended Commissioner Gottlieb for the FDA’s rethinking the risk-based regulation of tobacco and nicotine, and the agency’s new, bold and innovative plan to address the enormous toll of smoking combustible cigarettes announced going forward.

Started the process to establish a comprehensive review of the cost-effectiveness of the multiple informational, smoking cessation and treatment interventions to help smokers quit.

The NTRI is one the first independent groups of tobacco control leaders to encourage adult smokers to switch to E-Cigarettes as an aide in helping them to adult smokers to quit, and to help save the 480,000 adult smokers who will die prematurely each year. Although millions of adult smokers are now using E-Cigarettes, and this number continues to grow, the National Public Health Organizations still oppose their use under any conditions. This difference has caused considerable and unnecessary confusion and a growing misperception on harm reduction, which urgently needs to be addressed sooner than later. The NTRI is seriously considering how to deal with this major concern.

Developed a definitive breakdown of current adult smoking incidence across the high- risk categories of adult smokers who are poor, uneducated, have mental health issues and substance abuse problems. This provides a deeper look at smoking incidence across these groups expanding the data provided by the Office on Smoking & Health.

A special Advisory Group of distinguished and influential national public health leaders was formed, and will be enlarged, to provide special counsel and advice to the NTRI Team, and to critique and react to proposed new initiatives before they are officially launched. This Group has already provided significant input and support in the development and implementation of the NTRI initiatives.

In the roles of a facilitator, catalyst, advocate and convener, NTRI members continue to start conversations with leaders of key national organizations, agencies and other stakeholder groups and individuals about the urgent need to advance the three (3) Priority Actions identified by the NTRI study.

Although the NTRI has no relationship with the Foundation for a Smoke-Free World, it is kept abreast of this evolving newly-established entity which is indirectly funded by the PMI.

Team members presented Updates on NTRI Strides and Plans at six (6) strategically-important tobacco-related meetings (FDLI, SRNT, Summit on E-Cigarettes, World Conference on Tobacco OR Heath, FDA and CTP meetings, etc.) which were attended by hundreds of tobacco control advocates, activists, organization and agency leaders, researchers, etc. from around the U.S.

On March 21, 2017, a comprehensive, highly-informative and compelling NTRI article with the headline – “National Health Leaders call for Immediate Actions to Curb Smoking in the United States” was published in the Washington Journal , with copies of this circulated to news outlets and national organization publications nationwide.

Representatives of the NTRI helped to review and contribute to the development of the 2018 Surgeon General’s Report on Smoking Cessation being produced by the Office on Smoking and Health, CDC. This important process is still underway.

Letters and phone calls have been addressed to the CEOs of major National Public Health Organizations and Governmental Agencies to inform these key individuals of NTRI strides and plans going forward, and to urge them to help advance the three (3) Priority Actions through their respective affiliates at the national, state and community levels nationwide.

NTRI members have participated in various Webinars, radio interviews, etc. to advocate for the advancement of the priority actions, and to describe the important functions of the National Tobacco Reform Initiative.

NTRI representatives have interacted with innovative tobacco control leaders in the UK to better understand how the Royal College of Physicians, Public Health England and the Heart, Lung and Cancer national organizations were able to collectively get electronic cigarettes embraced as an aid in helping UK smokers quit. Curiously, the adult smoking prevalence in the U.S. (15.8%) and the UK (15.9%) are almost the same.

Of course, the goal would be to get the public health community in the U.S. to follow the UK’s lead. This concept has been discussed with the Director of the OSH at CDC.

The NTRI has proposed to the Office on Smoking and Health that it replicate the UK’s recently-approved national strategy on smoking cessation. This is something the U.S. should do to enhance the efficiency and effectiveness of smoking cessation efforts nationwide, and to create new and innovative modalities, to help save the lives of 40 to 50 million current adult smokers.

The NTRI has committed to the development of a proposed framework and key ingredients of such a strategy (a pattern) which OSH and the tobacco control community can use to actually build the plan.

NTRI team members contributed to the NIH and ODP request for recommendations related to the advancement of tobacco control that should be included in the ODP Strategic Plan for FY 2019-2023.

On January 30, 2018, the NTRI issued another Press Release with the headline –“NASEM Report: Bemefits of E-Cigarettes and Harm Reduction Products VS. Combustible Cigarettes”. This Press Release represents the NTRI’s measured response to the January 24, 2018 Report of the Study Committee on E-Cigarettes sponsored by the National Academies of Science, Engineering and Medicine. A focus of the Press Release is that “E-Cigarettes Are Saving Lives” and the urgent need to counter the alarming misperceptions on harm reduction”.

In early 2018, it was decided to identify a short-list of “Essential Elements” for each of the three (3) Priority Actions. The 15 or so “Essential Elements” essentially represent the specific major actions or program of work to be undertaken with the greatest potential impact for moving the three (3) Priority Actions forward during 2018 and beyond. They are listed on the pages that follow:

The “Essential Elements” for Taxation include:

  • Carry out research to establish the proposed timeline (last increase in federal excise tax on cigarettes took place in 2009) and step-by-step processes/protocols for preparing to seek the next federal tax increase;
  • Hold off on any attempt to pass a large differential federal excise tax until after the fall of 2018 elections;
  • Poll Congressional lawmakers on their attitudes about raising the federal excise tax on tobacco;
  • Carry out systematic, coordinated and sustained advocacy efforts to educate lawmakers, especially for appropriators, about the huge economic costs of smoking-related death and disease, and the economic value to the U.S. of aggressive funding for cessation services and technologies;
  • Show how a large federal tax increase on combustible cigarettes, offering differential policy alignments proportional to the risk ratio of each class of tobacco products, would drive a switch with fast reductions in related deaths;
  • Earmark $250 million of the funds accrued from an increase in the federal excise tax on combustible cigarettes to support a National “Moonshot for a Smoke-Free USA by 2030” patterned after the cancer control effort led by VP Joe Biden;
  • Carry out polling of state-level tobacco control advocates to a answer the question of readiness for increases in local and state excise taxes on tobacco;
  • Place major emphasis on the 34 states with current cigarette taxes below $2.00 per pack;

The prevalence of smoking among adults has been shown to decline faster with increased spending for tobacco control programs, with the most prominent examples in New York City, California, Florida and Massachusetts. The NY tobacco control program reported adult smoking prevalence declined 16% and smoking among high school students declined by 40% over a six-year period, resulting in more than 600,000 fewer smokers in the state over the intervention period. Currently, only two states (Alaska and North Dakota) fund tobacco control programs at the level CDC recommended levels;

  • As part of an increased federal cigarette excise tax, plan to compensate states for their excise tax losses;
  • Popularize the lost revenue of the southern states that they could have if state taxes go to 80% of NYS, MA or Californ
  • A special effort will be made to learn more about the value of pushing for a change in the Master Settlement Agreement (MSA);

In fiscal year 2015, the 50 states collected $25.6 billion from the settlement and taxes. But, they will spend only $490.4 million, or just 1.9% of it, on programs to prevent kids from smoking and in helping adult smokers quit. Tobacco companies spent $10 to market tobacco products for every $1 the states spend to reduce tobacco use.

The “Essential Elements” for Smoking Cessation include:

  • Launch a “Moonshot for a Smoke-Free USA by 2030” patterned after the Obama effort dedicated to cancer control built around its chair, former VP Joe Biden;
  • Develop the “Framework of Key Components of a Comprehensive National Strategy for Ending Adult Smoking by 2030”;
  • Encourage health and life insurers, employers, and health care professionals to actively promote smoking cessation measures/services;
  • Significant funding from the “Moonshot’ effort should be made available to launch an aggressive hart-hitting TIPS-type Media Campaign sustained for the entire 12-year period to wipe out adult smoking in the U.S.;
  • The NTRI should get serious about encouraging the entire tobacco control community to encourage adult smokers to switch to electronic cigarettes as a first step in quitting, and to save millions of lives over the long haul;
  • Develop the concept of involving the 52 million former smokers (21% of all adults) and one-third of all U.S. households that have suffered the loss of a family member to reach out to and help save the lives of the 38 million current adult smokers;

The ‘Essential Elements” for Harm Reduction include:

  • All tobacco, nicotine and alternative products should be regulated by the FDA based on their risks, relative risks and intended uses (continuum of risk);
  • Reducing the levels of nicotine in cigarettes, but only as part of a comprehensive tobacco harm minimization effort;
  • FDA/CTP processes for the review and approval of science-based reduced-risk products should be reconfigured and streamlined;
  • Consumers and the public should be given complete, truthful and accurate information by both public and private sector organizations, but is not limited to the FDA, CDC, NGOs, health care professionals, retailers, wholesalers, and manufacturers;
  • Adults should have ready access to alternative noncombustible lower-risk tobacco and nicotine products that are ‘consumer acceptable’;
  • Good science (regardless of who is conducting the research) should be driving policy and regulatory efforts;
  • Innovation, technology, research and incentives in the development of alternative lower-risk products should be encouraged in both the public and private sectors;
  • Greater engagement and dialogue between stakeholders should be encouraged and undertaken in both the public and private sectors.

Special NTRI teams have assumed responsibility for ensuring that the previously-listed actions for each of the three (3) respective Priority Actions are moved forward at the earliest possible time. As advocates, catalysts and influencers, NTRI team members will strive to engage and start conversations among the tobacco control community that result in follow-up actions to move the agenda forward.

NTRI team members communicate on a regular basis via email and telephone; reports of progress in addressing the “Essential Elements” are considered on Team Conference Calls which take place every other month.

The Web Site – – continues to be provided with fresh materials on the work of the national tobacco reform initiative and the over tobacco control movement in the U.S. which should be of interest to a wide audience. A detailed plan outlining how web site traffic might be enhanced and of greater service to the tobacco control community across the U.S. is now being developed. All background materials, press releases, plans, etc. have been downloaded on the Web Site. Plans are now being considered to promote the Web Site widely via Facebook or Twitter.