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Comprehensive Smoking Prevention Education Act

Date: 05 Mar 1982
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~OCU~-fV_NT COXTP, OL PROJECT DRAVER/ITE~I SHEET DRAWER NO.~~ ITEH NO. 10 ) COPY ALL DOCUHENTS. ) COPY ONLY DOCUHE~[TS IJ CP~,~,C~ FILE FOLBEBS. ) COPY C~$L'~ D,3C'J2:E][TS ill [~Ef'/EET,~ CRA?$Cg FILE FOLE'EP,-¢.
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I__ COMPREHENSIVE SMOKING PREVENTION EDUCATION ACT HEARINGS BEFORE T~ SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT OF TIgE COMMITTEE ON ENERGY AND COMMER#E HOUSE OF REPRESENTATIVES • NINETY-SEVENTH CONGRESS ~ " SECOND SESSION - -~ ON H.R. 5653 and H.R~ 4957 BILLS TO AMEND THE PUBLIC HEALTH SERVICE A~T AND ~m FEDERAL CIGAB~'TTE LABELING AND ADVERTISING ACT TO ESTABLISH A NATIONAL pROIf~R.kM UNDER AN OFFICE OF SMOKING AND HEALTH TO INFOI~A THE PUBLIC OF THE DA]W. GE~S FROM SMOKING TO CHA~GE THE LABEL REQUIREM~,NTS FOR CIGARF21~ES AND FOR OTHER PURPOSES Serial No. 97-106 @ Print#d for th~ use of the C~m mi.ee on Energy and C0mme~ k C "4
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EDUCATION ACT HEARINGS B~FORE T~ SUBCOMMITTEE ON HEALTH AND TttE EINVIRONMENT OF THB CONMITTEE ON ENERGY AND COMMERCE HOUSE OF REPRESENTATIVES ~]NET~ ~E~NTII CO~rGI~SS SECOND ~ESSION ON H.R. 5653 and H.R. 4957 BILLS TO A~IEND THE PUBLIC IIEALTtt SERVI~E ,kCT A~D TH~ FEDERAL CIGARETTE LABELIXG AND ADVERTISING ACT TO ~T2~BLI~I~ A NATIOi~AL PROG~;I~ UNDER AN OFFIC~ OF SMOKING AND HBIALTH TO INFOR31 THE PUBLIC OF TH~ DAN- GERS FROM S~IOKING, TO C IrIANG ~] THE L,kBEL REQUIREM E~'T$ FOP* CIGARETteS, A.*¢D FOl% OTH~I~ pIIRpOSES MARCH 5, 11, AND 12, 1082 Serial No. 97-106 ® 94~M7 0 printed for the u~ Cf the Committee on Energy ~tnd Commerce U.8. GOVERNSIENT pRINTI~'G OFFI~]$ W*%$HIN t]~:ON : 1~82
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CONTENTS Hearings hem nn Page March 5 19~2 ................................................................................... 1 March 11 1q82 ..................................................................................... 27"1 March 12, 19~2 .............................................................. 35] Text ~f" HR 4957 ................................................... l~ H.R 5653 ......................................................................................... 3 Statement oL American College of Cardiology .................................................. 331 Ay~rs, Stpphen M, MD, chairman, Smoking or Health Committee, American Lung Assoziation ..................................................... 41 Blaekwelb Roger D profe~.'mr of marketing Ohio State Univorsity ............. 474 Blake Amanda, on behalf at American Cancer Society .... ............. 30 Blau, Theodore H, Ph. D., Ponnsylvania State University .................. 486 Brandt, Edward N, Jr, M D, A~sistant Secretary of Health, Public Health ~er~ice, Department of Health and lluman Services .................. 278 Cuban, William G, M J3, on behalf of Pm~erican Cancer Sozlety, Inc .......... 60 DaugherW, Robert M, Jr., MD, Ph D, chairman, National Interagency Council on Smoking and H~al~.h ............................... 182 I)eVita, Dr Vilmeat T., Director, National Cancer Institute, Public He.1 it h Set, ice, Department of Health and Human Serxdcez .................... ~8 Eysenek. H,ns J. Ph D. D SO. professor of psycho}ogy. Institute of Psychiatry, Uniwrslty of London ............................ 443 P~her, Edwin R, M.I), pittsburgh, Pa ................................. 5,13 Forsythe, John, Beverly Hills, Ualil ............................................ 29 Fur~t. Arthur. Ph D. director emeti%us. [nstitule of Chemical Biology. Unlvevsity of San Francisco ......................................................................... 511 Hnrriga~, Edward A, Jr, chairman and chief executive officer, R. J. Reynolds Tobacco C~ ........................................... 352 Keeshan, Robert. an behalf of American Lung Assneiation ................... 33 Kcop, Dr C Evm~tt, Surgeon General, Public Health ~rvice, Depart- ment of Health and tIumau Services ............................................. 281 Kornegay, Horace R, chairman, The Tobacco Institute, Inn ........................... 352 Light. Larry. Ph D exevutive vice president. Ted Baton Worldwide. Ine ... a52 Minton, David, Washington council, Mage~ine Pablishezs Assocmtmn ........ 232 Oates. dQhn A., M D. chairman. Subcommittee nn Smoking. American }lear t Association ........................................................................ 53 Pallia, Dr William, Dit~-tor, National Institute on Drug AbusG Public Health Service, Department of Health aud Haman Services .................... 278 Robin, Erie, counsel, Outdoor Adver rising Association of America ............... 219 Summers, Sheldon C, MD New York Cit , N.Y ................. 500 Stealing. Theodore D., r~search profossnr, ~imon Fraser Unive~ity ............ 522 Terry, Luther, MD, Philadelphia Pa ..................................... 195 Watersnn, Michael J, oa behalf of American Association of Advertisillg Agencies American Advortising Federation. and As~0ciatlon of Nation al Advertisers ..................................................................................... 211 Wind, Yoram, J, profosser of marketing, Wharton Sehoul, Uniwrsity of Pennsylvania ................................................. 459 Wi . Sa ue B , , vi~ president secretary and general counsel. R J Reynvlds Tobacco Co ............................................................... 352 Additional material submitted for the *~:ord by: Amerlcan Cancer S~eiety, lnc, attachments to Mr. Cahaa's prepared statement: Cigarette Smoking Among Teenagers and Young Women .... 71 Dangers nf Smoking, Benefi~ el Quitting ................................................. 10~ qH~ ¢J1
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COMPREHENSIVE SMOKING PREVENTION EDUCATION ACT FRIDAY. MARCH 5, 1982 HOUSE OF REPRESEz~TAT~VES, SUBCOMMITTEE ON HEAI2rlI AND THE ENVII~ONMENT, COMMITTE~ ON ENERGy AND ~OMMERCE~ Washingtor. D C. The subcommittee met, pursuant to call, at 9:59 am. in room 2123, Rayburn House Ofllee Building, Hen. Henry A. Waxman ichairmany presiding. ~r ~VAXMAN. The me~ting of the subcommittee will gome to order. This morniug the subcommittee will receive testimony on H.R • 1957 and H.R 5653, legislation designed to improve public aw~we hess about the health efT~cts of smoking. I doubt there are many Americans, including smokers, who don'~ ku~,n tb~ a~n~itlnn "Warning: TLe Surgeon General has de%er- mirled that cigarette smoking is d.~ngereus to your health" This warning is now required on all cigarette packages and advertising and has bee~ the local point of the Federal Government's smoking education cainp,~ign tbr over a decade. During this period we have learned much about smoking and its eflect on human health In lhct, the Surgeon General's 1979 report on smoking characterized the weight of scientific evidence against smoking as overwhelming. Just last week Surgeon General C, Everett Koop issued a chilling report which documented clear, convincing evidence about ~he rela- tionship between smoking and ~ar most feared dise~s~--can~er The report provides a tktrther confirmation of the tragic fact that ~moking is the single most preventable cause vf death and illness in this country. The known facts about smoking ~lnd health are many: Smoking can reduce life expectancy by as much as 8 yeBrs. It dramatically increases the risk of cancer, and lung and heart disease. I~ can ki- crease the possibility of high risk births or even fetal death For wonlen using oral contraceptives, smoking substantially increases the risk (ff heart attack and stroke. As i see it, there are two aspects to this legisiatien First, i~ ~ my belief that the present cigarette warning b~bel is lint as eflhctive as it could or should be It should be strenff~hened. It should be replaced by a series of health '~arnings which express the facts about smoking and health in a clear, straightlbrward manner, (1} C .,I
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3 ! H. R. 5653 LN" TIlE HOUSE 0P REPKESENTATFfES blAJ~CH 1, 1982 Mr. WAX'MAN in t r~:luced the [ollo~4n~ btll; which was referred to tim ('ommittee O~ ~nor~ sud Co~¢rce A BILL To amend the Public Health Service Act and the Federal Cigarette Labeling and Advertising Act to estabhsh a ha. lional program under ~n Office of Smoking and Health to inform the public of the dangers from smoking, to change the label requirements for ~garcttes, and for other pur- ]~oses. Be i~ enacted by the Senate a~d House of Re'presenta 2 tires of the ~i~d States of A~n~ca in Congress assembled, 3 That this Act may he cited as the "Comprehensive Smoking 4 Preventinn Education ACt of 19li2" 5 SEC. 2. The Congress finds thatL t~ ,,j b$
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O 21 22 23 24 4 2 (1) nigarette smoking is the largest preventable cause of illness and premature death in the United States and is associated xtqth the unnecessary deaths of over three hundred thousand Aanericans annually; (2) smoking is the number one cause of lung cancer in the U~ted States and is the major cause of chronic obstructive inn8 diseases such as emphysema; (3) heart disease accounts for nearly one halt of the deaths in this country and one third of these deaths are attributable to smoking; (4) pregnant women who smoke are at E higher risk for the possibility of spontaneous abortion, still births, premature births, and child weight deflciendies; (5) women who take birth control pills mad smoke are more llkelv to s~ilfer a heart attack or stroke than women who don't smoke; (6) certain neeupatinnal hazards in conjunction with an indlx4dttdi's smokia8 increase suhrt~ldaily the risk of disease and death; (7) present Federni, State, and privam initiatives have been insufficient in eonve~n8 these hrnith mes- sages ~o the American public; (8) it is esthnated that nigarette smoking related deaths and disabilities result in $25,800,00~h(X)0 annu
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5 3 l slip kl Ios~ productivity to the United States ecor~omy ~' and $13,600,000,000 in medical cost~; and 3 (9) because of the abo~e flndin~s, a new strategy 4 should be undert~en to educate and provide informa- 5 lion to the Amerlean public to allow them to make di- 6 formed d~c:~slr, ns as to whether or u~t the), should 7 smoke. 8 SEC. 3. (a) Title XVYI of the Public Health Service Act 9 is amended by adding a$ the end the followdi~g: 10"SMOKINO ~%ND ~EALT[[ I 1 "SE~3. ~ 711. (~) There is established in the Department 12 of Health ~,nd Humml Services the Office of Smokfilff aad 13 Health (hereinziter in this section reterrad to as the 'Office') 14 which sh~dl be under the Assistant Secretary for Health, The 15 Seeretar3, shall appoint a Director to head the Offi,'e. 16 "Ca) The Secretary, acting ~hrough the Office, shall es- 17 t~bl~h ~ ~dnfi~ister ~ program ~ hiI6rm th~ p,sbiie ~g the 18 dangers to human health presented by cigarette smoking. In 19 earrfing out the program the Secretary sh~[] "(1) coordiaate an research and educational pro grams and other activities ~vithJn the Department which relate to the effee~ of c~garette ~moking on human health and coordinate, through the Interagency C~mmO~e ~ Srooklug and Health, ~ueh activities ~th similar acti~ties ~ff other Federal agencies; O~
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6 4 1 "(2) establish and maintain a liaison ~,th appro- 2 pilate private entities, other Federal agencies, and 3 State and local public agencies respecting activities re 4 ]ating to the effect of cigarette smoking on human 5 health; 6 "(3) conduct research on the effect uf cigarette 7 smoking on human health, develop materials for in- 8 forming the public of such effect, and provide assist 9 anee for education programs on slaoking and health; 10 "{4) calinct, analyze, and disseminate (through 11 pulilications, bibliographies, and otherwise) hfformatain, 12 studies, end other data re]ath~g to the effect of alga- l3 rett~ smoking on hmnml health, coordinate the dove] 14 opment of nlaterinls on smoking and health, and dove]- 15 op standards, eriteSa,, and methodologies for improved 16 iafonnatlml programs related to smoking mid health; 17 and 18 "(5} compile mid raake available information on 19 State mid local laws rclatiI~ to the sale, distrilintinn, 20 use, and consumption of cigarettes. 31 The Secreta~" may carry out paragrapli (3) dlrectlp and 32 through grants. 23 "(c) To ca~ out the eoordilmtlon activities under the 24 program estab]islied under subsection (b) there is established 35 an Imcrageney Committee on Smoking and Health to he O~ ,.5 .,J
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~a .j t~
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8 6 ] SEC. 4. (a) 8echon 4 ot the ]~ederai Cigarette Labeling 2 an~ Advertising Act (15 U.S.C. 1383) is aruen~ecl to read as 3 throws: 4 ~LA~I~LINO 5 "'SEe. ~. (a)(l) I~ shall be /tnlawinl Ior any person to G u~uffacture~ packag~ import, or ~xport ~r sale or dlstrlbu ti~ s~y cig~et~ th~ p~ck~e of ~h~ch fal[~ ~ h~ar, in ~¢- voraance w~th ~ requirements oi subsection (b}, one al t|~e 9 label statements listad in the following paragrtlphs: 10 11 I2 13 I4 15 17 18 19 20 21 22 23 24 25 "(A) For information on the Specific Dangers of cigarette smoking, write t~ the Surgeon General, United States Publio Health Service, Washingtont D~- tric~ of Colarabia 20201. "(B) Warring: (~igareLte smoking is the numhcr ou¢ c~.~.~¢ of ~ra~k~'~m~ ~ad Lung ~aucer. "~C) Wamlng: Cigarett~ smoklug is ~ ~j~r e~e al tIeart Disease. "(D) Smokers: No m~tter how long you have smoked, quitting new greatly re{luces the risl~s to your health. "(E) Warning: (~igaret~ smoking ~ pregnam women may r~su]~ in ~irth D~/ec~s or Sporttaneous Abortion. "'@3 Waralng: 0igare~te ~moking m~y c~se
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19 2O 21 ~2 2~ "(D each brand of cigarettes and tile advertisix~g for each brand of elgatettes shall, in each s~vca-year pe~od beginning gf~er the system is made applicable to it, bear egch of the label statements ]isted in subsection (a)(lh f.q .,5 g~
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! 10 8 1 "(2) no brand of cigarettes or its advertising shtdl 2 bear one of the label statements listed in subaeetion 8 (a)(1) for a period greater than one year, 4 "(~]) in any year, each label statement listed in 5 subsection (a)(1) shall appear on subalantlal]y the same 6 nmmber of brands as determined under the system, 7 "(4) the label statements shall be located in a 8 conspicuous place on each cigarette package and in 9 each cigarette advertising and shall appear in eonspieu- 10 ous and legible type in contrast by typography, layout, 11 and color with all other printed or background material 12 on the package or in the advertising, and 13 "(5) the label statements on packag.s of ciga- 14 rette~ for export from the United States shall be print 15 ad in the princyal language ~rf the cotmla'y to which i6 the elgare~tes are exported. I7 "(e) It shall be unlaw~l for any p~rson to manulacture, 18 package, import, or export for sale or distrilaitinn any niga- 19 rettes the package and adver6sing of which fails to disalose 20 the lave] of-- 91"~1) tar, 92 "(~) nieofme, and ~3 "(3) carbon monor~de, ,,j g~ ¢,0
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15 16 I8 19 20 21 22 2,~ 24 25 "(A) before the ex]~wmion oi sixty days after the plaintiff has given notioe of such didiation (1) to the ]~ederal Tr~o Commission, ar*d (ii) m ~e person who is a]higed to have eoromitte~ such violation, or ~'(B) if th~ A),lomey G~z*~r~l h~ts ¢ommer, ced a~d is ~igently prosecuting a olvil actloa in a court of the United l~tate~ to re*l~hre compllanee vAth ~eefi~n 4 (~r 6, but if such proceeding or eidil action ~s commenced a~t~r the glv~r,g ~ ~o$i~¢~, ar~y persor, gi~g ~ck no~i~e raay intervene &8 a ma%ter Of right ill ~ueb pro- ¢eediwg or ~tie~. .,,I g~ g~ cA cA
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13 11 1 Notice miler this paragraph shall be ~ven in such manJxer ~s 2 the Federal Tra~ Commission shall prescribe by role. 3 "(3)(A) I~ a~ action i~ndcr paragraph (1), th~ Fcderal 5 of right. 6 "~B) The court, it1 issui~ ~ny final order in a~ action 8 ~nd reasonable f~es for ~t~orneys and expert witnesses if the 9 collr~ detormines that such an ~war~ is ~]~ropri~c. Any 11 su0h an order, m~ ~wa~'d cost~ of suit ~n~ r~sonabIe ~s for a~tor~ys if the court ~termin~s that such an award is 13 ~proW[ate. 14 "IC) Nothing in this section sh~n respect any righ~ 15 whi~h any perso~ (or class ~ff persons) may h~ve ~l~ler any statute or commoll law to seek elll~orcemont of section ~ or 6 17 or ~ sock any other relief 18 "(D) ~rhell two or more c~| ~cti~ns brought under 19 pa~Fe~ph (1) invol~g the same defendant and th~ same 20 issues or ~o]~fions ~re pending ia ~wo ~r more ju~¢ial ~s- 21 ~s, ~1~ pen~g ~ms, upon ~]?plic~on M su~ ~c~en~- 22 ants to such ~ctions which is made to • eot~rt in which any such ~ction is brought may, if such co~rt ~n i~s discretion s~ ~4 387 O ~ ~ 2
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! 14 12 1 all parties reasonable notice and opportmlity "~o he heard) nf 2 such court and trled in- 3 "(i) any district which is selected by such defend- 4 ant and in which one of such actinns is pending, 5 "6~) a ~listnet ~vhieh ~ ~.greed up<m hy ~tip~latloa 6 between all the parties to such actions and in which 7 one of sl~ch actions is pending, or g "611) a 6isLrint whleh i3 sein~led by the cram uad 9 in wlfich one of such actions is pending-. tO The eour~ issuing such an order shall give prompt notificatlon 11 oI the order to the other courts in which the rivii ~etions 12 consolidated under the order are pending.". 13 (g) Section 11 of such Act (15 U.S.C. 1840) ia repealed 14 an~. section 12 o[ such Act is redesigtlated as section 11. 15 S~C. 5. The amendments made by section 4 shah take 16 effect upon the expiration of the one-year perind beginding on 17 tim date of the enactment of this Act. During such (me year 18 period, the Federal Trade Commissin~ shall promulgate such 19 regulations as may he necessary to implement the ame~d- 20 monte made by section 4 on their effective date. f2
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! 15 I 97rll COI~GRESS H.R. 4957 To am ell~l the Public Iiealth Ser~ie* Act and the Federal Cigarette Dabc]]ng cad Advertlslng Act to establish ~ nation~/ program under an 0ffiee of Smoking and Health to infnrm the pub]lc of the dangerl from smoking, to change the ]abal rBtitaroments for mgarotte~, ~ald for othor purpose~, L'¢ TEE HOUSE OF REPRESENTATIVES NOVEMB]~B 12, 1981 Mr W~X.'tA~, introaueed the folio'a~ng bill; whi¢h wa~ referred to the Committee on Ettergy ~ld C~m me n.,~ A BILL To amend the Public Health Set,dee Act and the Federal Oigarette Labeling and Advertising Act to est~hlish a n~ tional program under an Offie~ of Smokimg and Health to inform the public of the d~ngers from smoking, to change the l~bal requirements for ~ig~re~tcs, ~nd for other purposes, Be it enacted by the Senate and House of Representa- 2 tires of the United States o[ Amen~ i~ C, ongre~s assembled, 3 That this Act may be cited as the "Comprehensive Smoking 4 Prevention Education Act of 1981". 5 SE¢. 2. The Congress finds that
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1 2 3 4 5 8 9 10 11 12 13 14 15 16 17 18 19 20 2I 22 23 24 16 9 (1) c~aret~e smo]fing ~s the l~gc~t preve~t~le cause of illness and premature de~th in the Unitec] States an~ is ~sso~ate(l ~rlt]l the ~necessary de~ths of over three h~dred thousan~ Ame~cans ~nnaal]y; (2} ~mol~ ~s file number ~nc c~¢ of lup.g ~c~r L~ the Um~d St~t~ ~d i~ the ca~Qr c~se Qf the d~l~ m ~s ~oun~ry ~nd one t~fi ~ ~ese de~h~ ~e att~LJJ~c t~ smoking; (4) pr~an~ womea who amo~e are ~ a higher ~s]( ~r ~he poss~ili~ of s]~ontene~us ahor~on, sill] births, premature b~h~, ~d child weight deficiencies: (5) women w]lo t~ke birth om~trol pills end sm(~kc a~ T~or~ J~e]y to ~LL~fcr a he~t ~ttac~ Iir 9~oke ~e.~ w~men who don't smoke; (6) ~c~am o~eup~i~ne~ hazards in oo~u~c~ion with an ~n~cLuM's smoking increase s~bst~tial]y the risk of d~se~se and ~Leath; (7~ present Federal, State, ~nd p~vate initiatives have beon ins~c~ent ~1 conve~J~g Lhc~e h#alth me~L ~eges to the American public; (8} it is es~m~ted that eigarotte smoking reigned ¢]eaths ~n~ d~]itles rosult in $25,800,00~,C00 ~u !
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11 3 1 ally in ]ost ]lroducti~tF to the United States ecunemy :~ and $13,600,000,000 in medical costs; and :~ (9) because di the abo~'e tindings, a ne~v ~rategy 4 s]]odid be t~nqlertakc~ to educate and pro~d~ informa- 5 tien to the American publin to allow them to make in. {3 ~rmed decisions as to whether or not they ~hodid 7 ~ca~k~, SEc. 3. (a) Title XV]] of the PulJli~ Heait]~ ~er~Sce Act 9 is amended by adding at the end the following: 10 L~S~,IO~INC- AND HEALT]4 11 "SRC. 1711. (a) There is esLablished in the Department 1.0 ef Health ~nd I~uman Services the Office of Smoking and 1.'1 ~[ealth (hereinafter in this s~ctinn referred to as the 'O~cc') 14 "+hi~ ~]~ail be under the .~'~a~t ~c~a~y f~ l{~alt]a. Tb, e 15 Secreta~ shall a~pobl~ a Director to head the O~cc. 1~ "(b) The Secretar~r~ acting thro.gh th~ Office, shall es 17 ~abllsh ~nd adininister ~ i)regram to dii~n the public o~ the 1~ dangers to haman health I!rcs~n~ed by cigarette s~/oki~. In 19 carrying OU~ the progrm~ the ~ecret.~ thall-- 20 ~(1) coordblate all research and educational I~ro~ 2'~ gr~m~ and ~th~r actin~t~ w~bl "~h¢ Del)ar~r~e~t ~2 which relate te the effect of cigsr~tte s~l~)king on ~ hum~n health and coordinate, tltrough the L~teragency 24 Committee on Smoking and Health, such ac~i~d~ics ~5 with ~imilar acti~tles of other Federal agencies; 0o !
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18 4 ] "'(2) establish mad maintain a liaison with appro- 2 prlat~ private entities, other Federal agencies, mad 3 State and local public agencies respecting activities re- 4 laffmg to the egeet o[ cigarette smoking on human 5 health; 6 "(~) conduct research on the effect of cigarette 7 smoking on human health, develop materials for in 8 forming the public of such effect, and provide assist- 9 ante for education programs on smoking and health; 10 "(4) collect, analyze, and disseminate (through 11 publications, bibliographies, and otherwise) information, 12 studies, and other data relating to the effect of elga 13 re~e smoking on hmnan health, coorddnate the devel- 14 opment of materials on smoking a~d health, and devcl- 15 up standards, criteria, and methodologies for improved 16 infonnatlon programs related to smoking and kcahh; 17 and 18 "(5) compile and make available information on 19 State and loeM laws relating to the sale, distribution, 20 use, and consumption of cigarettes. 21 The Secretary may carry out paragraph (3) directly and 22 through grants. 23"(e) To carry out the coordination activities under the 24 program established under subsection Co) there is e~tabllshed 25 an lnteragency Curare[tree on Smoking and dIealth to he t~ ¢,,q "O ga, t,D
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I 19 5 1 composed of one representative from each of the fo]lowing: 2 Tho Federal Trade Commission, the Department of Educa- 3 tlon, the DeparLin~rl~ o{ L~bor, god any other Federal agency 4 dcsiffaa~ad ~ the Secreta~. The Gommittee shall inter at 5 foaal four times each year and the Director of the Office of 6 Smoking and Health sh~ll ser~e as the Chairman of the 7 Committee. 8 "(d) The Seereta~, acting throug'h ~he Office, shall 9 ~ransmit a report to Coilgr~ss not later thait ,fanuary 1 of 10 each year which shall contain 11 '~(1) c~rent hlformat~on on the health consc 1~ quences of silaolflnff; 13 "(2) an overview of the activities of the Office 14 dtzflng" the previous year and ~n a.~ses~mcn~ of the 1~ Feclerai ~tivlties urdtertaken to inform the pt~ie of 16 the h~th coiasequences of smoking; tutd 17 "(3) such recoronacndatlons for legislation tts the 19 (b) Seetfon 1701(h) ~ff the Publle Health Sorvice Act (42 U.S,C. ~00u(b)) is amended by alriking out "and 1709" and 21 insertin~ m licu ther~of "lTOP, art?z lTlt". 22 S~. 4. (a) Section 4 of the Federal {3ig~rette I,abofing and Advertising Ae~ (15 LT.S,fL 1333) is amended to read as 24 follows: O~ #,
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2O 6 1 "IaABEIJIN(t 2 "SEe, 4. (a)(1) It slmll be uninmffdi for any person to 3 msaluiacture, package, import, or export for sale or distribu- 4 flea any cigarettes file package of which fails to bear, ill aC- 5 cordanee with the requirements of subsection (~o), one of the 6 label statements listed in the in]inw;alg paragraphs: 7 "(h) For information on the Specific Dangers of 8 cigarette smoking, write to the Surgeon General, 9 Unlted Stutes Public Health Service, Washington, Dis 10 trlet of Columbia 20201. 11 "(B) Warning: C~garette smoking is tim numher 12 one cause of Enlphysema and Lung Cancer. 13 "(C) Warning: Cigarette smoking is a major cause 14 of Heart Disease. 15 "(D) Smokers: No matter bow long you have 16 smoked, quitting now greatly reduces the risks m your 17 health. 18 "(E) Warning: Cigarette smoking hy pregnant 19 women may result in Birth Defects or Spontuneous 20 Abortion. 21 "(]¢) Warding: Cigarette smoking may cause 22 Death Item ho~rt disease, cancer, or emphysema. ~3 "(2) It shall be unlawful for any person to advertise any 24 cigarette unless the advertising bears, in accordance with the ka
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21 7 ] requlrements of sltbsection (b), a label statement listed in 2 paragraph (1). 3 "Co) The ]~ederal Trade Commlsfion sh~l~ establish ~, 4 ~stem under which-- 5 7 8 9 l0 11 !2 13 14 15 16 17 18 1!} 21 22 '23 24 25 "(l) each brand of cigarettes and the advertising f~t e~eh brand ol c~garel~es shML iu e~h six year period begirming after the system is made applicable to ib be~r each of the label statements listed ~ subsection "(2) no brand of cigarettes or its advertising shall bear one of the label statements listed in subsection (~}(t) ~r ~ ~ri,J~t gr~.ter than oue ye*x, "(3) in any year, each label statement listed in subsection (atID shall appear o,~ substantinl]y the same number of brands as determined uader the system, "(4) the label statements sh~]l be loe~.ted in a conspicuous place on each cigarette package and in each cigarette advertising and shall appear in conspicu- ous and legible t:,Te in contrast by tylmgraphy, layout, and color ~x~th all o~her printed or background m~*tefia] on the package or in the adverheing, and "(5) the label statements on packages of ciga- rettes for e~pDrt frem the Uinted S~a~s shall he print- ed in the principal ]aaguage of the eo,m*ry to which the cigarettes are exported. fdl i'¢
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l 22 8 1 "(e) It gtxai[ he u~.lgwful for gay p~r~ot~ to monu~acttire, 2 package, ~mport, or export for sal~ or distrJbtltion s.ny eiga- 3 ret*.es tho 1)aekage and advertising of whleh ~ails t~ diseloso 4 tho level of- 5 "(1) tar, 6 "(2) nil~otinc, ~nd 7 "(3) e~rbon mm,o×ide, 8 produecd by th~ cigarette ¸when ~moked. The ]eve] of tar, 9 nlcotlne, mad c~rbDn monoxide shall be ~ased o. thc levels 10 estaMished anuual]y by the Federal Trade (3ornmi~sion.". 11 (b) Section 5(a) of such Act (15 IJ.S.O. 1334) is araend- l~ e~ ~0y inserting b~furc the period the ~ollo~ag: "~r in any 13 cigarette advertising". 14 (e~ Section 7 of s~ch Act (15 17.S.C. 1~6) is emend~ 15 ed-- 16 (1) by ~tr3fmg out sub~eetlo~ (a), 17 (b) by ~triking out "Except as prov~led in st~,see- 19 ~her~of "Nothing", and 20 (~) by redesignafiag subsections (h) ~md (e) as sub- 21 ~¢¢~io~ (~ and (h), ~pe~i~-eiv. ld) Section 8 of ~ueh Ac~ (1~ U.S.C. 1~37) is amended 23 by striklng out subsectiol~ (~O and by strlking out "(b)'~. mm ¢.q ,,5
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9 1 (e) Seetio~ 9 of s~ch Ar~ I15 U.S.C. 17,38) is ~r~e~ded 2 by striking out "$10,000" arid inserting in Eeu thereof 3 "$100,000". 4 (~ ~ 1¢~ ~ suc~ A¢~ (15 U.S.(~. 1~) i~ ~mer~ed 5 ~ hlsertlng "(~" after "SEC. 10." and by adding at the end 6 the followiDg: 8 may co.hence a ¢i~dl action against any person who is a]- 9 leged to ~ in violation of section 4 or 6 to res~'ahl such vi~[atlom Any ~i~l a~tloa m~er t~ 9~r~apt~ ~all he brought in the United States district court for the district in which the alleged ~iolatlon occurred or in whioh the defend- ant r~side~ or in which ~c defendant's principal place of busb~ess is locked. The district courts of the United States shall have ~urls~iction over sult~ brmtght under this para- graph wit~ou~ reg~,~d to the amoml~ i~ controversy or the c[fiwn~hip of the parties. I~ an)' civil action under this p~ra- ~ph, prooess may be served on a defendant in any judlcial disttic~ in wMeh the defendam resides or l~ay be found a~d subpoenas ~or wlmess~s may ~ served in ~n~ ju~ci~l dis- "(2) No civil ~fioB m~ be commenced under para- graph (1) to restrain a ~do]ation of seetlo~ 4 or 6-- plaister has given notice of such violation (i) to the [0 11 12 13 14 15 16 17 19 ~0 '21 22 23 24 25 gl ,,,I d:* r
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W 24 10 1 Federa] Trade Commission, and (11) to the person who 2 is alleged to have committed such vlol~tion, or g "(B) if the Attemey General has commenced and 4 is diligently prosecuting a civil acif[m in ~ court of the 5 United States to require eompilance with section 4 or 6 6, but fi such proceeding or civi] action is commenced 7 after the giving of notice, any person giving such 8 notice may intervene as a matter of sight in such pro 9 eeeding or action. 10 Notice under this paragraph shall be given in such manner as 11 the FedBral Trade Cominission shMl gresefibe by ral¢. 12 "(3)(A) In any action under paragraph (D, the Federal 13 Trade Commission, if not a part)', may intervene as a matter 14 of fight. lb "(B) The court, in issuing any final order hi an>" action 16 brought pursuant to paragraph (1), may award costs of suit 17 and reasonable fees for attorneys and expert witnesses if the 18 court deternfines that such ~n award is approprhiLe. An), 19 eoorL in issuing its decision in an action brought to re~qew 20 such an order, may award cosLs of still and reasonable fees 21 h~r attorneys if the court determines that such an award is 22 appropriate. 2g "(C) Nothing in this section shall restrict any right 24 which any person (or class of persons) rmvy have under any call g~ g~
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25 11 1 statute or common law to seek enforcement of section 4 or 6 or to seek any other relic[ 3 "(D) When two or more civil actions brought unc]cr 4 parngroph (1) involving the same defendant and the same 5 i~su~s ur violations are pending i~ two or more judicial dis- ~ tracts, sack pending actions, upon application of svcli dc~nd~ "; ants to such actions which is made to a court in which any S such action is brought may, if such court in its discretion so 9 alcaldes, be consolidated for trial by order fissued ~fter giving 10 all parties reasonable notice and opportunity to be heard) of l 1 such eot]rt ttn~] tticilin 12 "(i) any dlstiict which is selected by such defend- 13 anL and in which one el such actions i~ pending, 14 "(li) a district which is agreed upon by ~pdiation 15 between all the ]parties to such actions and in wlilch 16 one of such. actions ~s pending, or 17 "(ill) a district which is selected by the court and 18 in which one of such action~ is pending. 19 The court issuing such an order shall give prompt notificatinn 20 iff the order to the other eottrt~ in which the ~ilvil aetioIt~ 21 ¢onsalldated under the order are pending.~. 2:~ (gi Section 11 of such Act (15 U.S.C. 1340) is repealed 23 anti section 12 of such Act is rcdcslgnated ~s see~inn 11 24 SEC. 5. The amendments made by section 4 shall ~ak~ 25 ~ffcct upon the exl)iration of the one.ear period beg~nding on f~ ,Q ga,
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26 12 1 the dat~ of the enactment o~ this Act. Dac~lg s~eh one-year 2 po~od, tim Fedcral Trade Com~li~sion shal] promulgat~ such 3 r~gu]alioas as may ~e necessa~ to ~npl~ment the aalend- 4 ments made by section 4 on ~heir ef~ee~ve dat~. ~J
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2? COSPONSORS "Comprehensive SmokiNg PreveDtion Education Act" H.R. 4957 - H.R. 5653 Joseph P. Addabbo (D. NY) Les AuCoin (D. Oreg) Michael D. Barnes (D. MD) Anthony C. Beilenson (D. CA) JOnathan B. Bingham (D. NY) James J. Blanchard (D. Mich) David E. Bonz0r (D. Mich) Don Bonker (D. Wash) George Brown (D. CA) Shirley Chisholm (D. NY) Cardiss Collins (D. ILL) Baltasar Corrada (P.R, Res Cem) James A. Courter (R. NJ) George W. Crockett (D. Mich) Norman L. d'Amours (D. NH) Ronald V. DelIums (D. CA) Ren De LUgO (Virgin IlS-DEL) Lawrence DeNardis (R. CT) Thomas J. Downey (D. NY) Mervyn Dymelly (D. CA) Bob Edgar (D. PA) Don Edwards (D. CA) Glenn English (D. Okla) Allen Erdahl (R. Minn) Walter E. Fauntroy (DC-DEL) Vie Fazio (D. CA) Millicent Fenwick (R. NJ) Thomas S. Foglietta (D* PA) Edwin B. F0rsythe (R. NJ) Barney Frank (D. MA) Martin Frost (D. TX) Samuel Gejdenson (D. CT) Richard A, Gephardt (D. Me) Sam Gibbons (D* FL) Newt Gingrich (R. GA) Dan Glickman (D. Kansas) James V. Hanson (R* Utah) Cecil Heftel (D. Hawaii) Earl Hutto (D. FL) Henry Hyde (R. ILL) James M. Jeffords (R, VT) Dale E. Kildee (D. Mich) John J. LaFalue (D, NY) Tom Lantos (D. CA) ~illlam Lehman (D. FL) I
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6~0574449 0
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! 29 Mr WAXMAN. | am pleased to introduce our first panel of wit ness~s. Professionally each has distinguished himself ~l" herself in the field of entertainment. They are also re|unreels wtl~ have ~-iven of thoir time to w<~rk at reducfug the deaths and illness assc ¢iated with cigarette smoking. John l%rsythe has a long list of TV and film credit~ and current- ly portrays the character of I3]ake Carrington in the TV series Dy- nasty Amanda Blake charmed many of us in the role of Miss Kitty in Gunsmoke, RobeiL Keeshan need~ no introduction to those who have known and praised hi~ work with children through Captain Kangaroo. Ori behalf of the ~ubc~ml~ittee, I would lfke to welcome each of you to our hearing today and a~k you to come for~vard, if you would¸ | fee] like I should say after maay years, good morning. Captain. Mr. KEE,~HAN. An eilue~tted Congressman Mr. WAXM^N We ~re delighted to have each of you with us today to shaw your views and persona] perspectives on this impor- tant su~ect. Mr. Forsytbo, why don't we s~art with you. ST.~.TE.'.IENTS OF dO|IN FORgYTHE. BI]VEI~LY IlI|,Lg, CAI,IF,: AMANDA IILAEE. ON BEItALF OF THE AMERICAN CANCER SO- CIETY: A?~ID ROL~/dR'l' KEE~IIAN. ON RIEI4ALF OF THE AMERICAN LUNG ASSOCIATION Mr, FORSYTHE. Mr~ Chairman,, membors el the committee. I want to thank you fer inviting me to testily this morning. Gentlemen, while I am llere as a concerned citizen and a |hther of¸ three children~ I else am aware that I ~tnl here because I am an actor, and actors have a certaln viell~ility. This visibility and the affection that audfenees may feel for us because of our work we realize can o~en sway and influence large numbers of people. So, as a group, we actors are tic| unmindful that this influence can be misused. Many of us who try to u~e this influence constructively realize that we bear a very heavy responsibility to do our homework and to be as evenhanded as we can. I am also aware that I am nc~t a scientist, that my opinfens are based on material | have read and largely from the Surgeon C~ener- al's reports | am aware, too. of ~,he importance of the tobacco i~- dustry to our very shaky economy today. | am also very sympa~het~ ic to the plight of the small former in these wry harsh times. tIaviag said that, I must tell you that I have very strong feelings about the ~mportance of this bill, HR 495?¸ ] was fortunate enough to have stopped smoking some ~0 yeal~ ago on the advice of a dear friend, who will appear on this panel later. Dr. William (~aban. He is a surgeon specializing in lung cancer, and I will ne~er stop being grateful to him fur having advised me to stop. Two other members of¸ my immediate family were not quite so fortunate¸ My y~unger brother and my younger sis~er~ both moder ately heavy cigare[te smokers, wouldn'~ or couldn't sfop, and they both died of luilg cancer within the last 4 years¸ 34 3~i 0 ~ . 3 0~
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! ~0 To watch a beiutiful, vibrant wom~m m the prime of her Hie w~st£, e~w~ly s~ t}lat ~]~e was al/1]ost unl-~!l:l~gllizab]e Js so devasta~Jl]g that it is very hard for me to talk about Almost the same situatio~ held true lot my brother. It was not long Ed~el¸ those two back-t~b~ck blows that I decided to use ~haCever e]otzC that I had as a reasonably well-knolvn ac~r to hell~ My ~eling is ~hat ifI can be iniluenti~l during my ~ifetime in f=~l.tin~ even ~0 te~'nagers not to start cigarette smoking, I ~ould haw done much more than having entertained ~0 mil]iorl peopfe throtagh s~me televisfen series, So now i talk with some regularity t.o gr~ut~s ot¸ young people¸ I try to assist the American Cancer Society a~d the American H~art Association il~ any way ] can To deserfoe my feelings about smokiag to you now in speci~es 1 think would be dimcult and time consuming. I would prefer, if you will laermit me, Mr Chairman, to read to you i very slort editor - a, if 1 ma~, ~m tl~e Los Ange es Times It ~s date~J February ~4, 1982, It says: In iarevlous report~ r*n ~nl~king atld hea~l~L, Ihe U~ Su~eon Genera] s olfic~ ha.s described cigarette ~mokin ~ ~1~ "a~o~ated¸¸ with or ' 1elated'' to bladc~erl kidney and paijcrl~ c.~m'c~rs In his ~l/~ r~pr~t, I*]e .qglJqeoal O~*ne~-a] ~ f~'ther Slno~J~lg is nu~ cited as a '~coll~ihlltory fae~0r" in ~he~e diseases¸ as well ~ the priIr~ry c~tu~e in ~3 percent o~ the 90 (1~}0 deu~hs that o~cur annua]~y from lull~ cancer What a~l this m~ans is lhal the heallh ~iska flora sm~kL~g haw now offi~iall~¸ beell iderttilied ~ I~eing rr~ore extenl~e ~uld luore demortst~at~d Ehan ill ~he ]past¸ Smoker6 ~re mot~ likely ~ die trurn ~oenach ca~oer or Oerv~val c~n~c ~h~rI are n~nsmokers ~mokers are m~re [ike!y ~o ~uifer ~om prema~ur~ c~rdiov~s~u[~l¸ dis eases {han are I%onsmoker$, I~ alll ~urge~;l (~e~era] {2 ~ve~ett Koop rep~t~ smoking is respoll~ible ~r all es- timat ~d ~4/b,(){10 de~[l~ in ~he Ur tired States each ye~lr Srr*~k~nl4'~ costs exceed these ~ any na~r'al ~fa~(r~ph~: ~Z~ billion a year i~ health care exp~ns~s l~s~ income, ]~st pt~dt~ction All use of ~b~eco is da~gerou~ Ci)¢~s and p!pe sm~kint4 are ]inked to some can eers, as are che~ hlg t obac~ ~nd snuff The bes~ tli~d mosl, ~b~ious ad~,i¢ e tot a~.~ one who rises tolaac~ i~ to ~top. The best advice in every other ca~e is n~ver to table /tp tobacco use i~ t~le f~rst p[g~e Hel'e ai leas~ there are encouraging ~igns Slllo]4ing aln~f/g 5oun~ people htl~ ~l~ patently bean d~¢li[ling In I,q77 2~ percent of }l~gh 8¢ho~ ~enior~ said ~hev snloked dai[y In 19~1 tkle figure W~s down to ~(~ pereen~ Ant~ ~haee~ education ¢~mptigns ~llght t~ b~ int~ilsihed. Children sh~tl]d he ta~aght early to avoid ~o}~aceo as theY wo~ld avoid rabid dogs¸ The Surgeo~ General's z~por~ a~ain underscores %he ,xbaurdlfy o~¸ Federal ~ubsl dies--~7~ mlUi~l~ worth thi~ year~o th~se wh~ grow a crop that is a public hea]th ment~e. T~is mRkes ~ nl~h rflora~ sense a~ givln~ gov~l'nmei~t support ~() a can- neyy ~]~ prod~ci~ ~re r ~gta]a~ }e ~on~amln~e:J ~ ~}le btR~]ism hac~J)us. Whist the ~url4e~n Genera;] says abo~lt the loerils of tobae¢~ ought t~a be taker~ seri ously by ~h~ public, cer tainly, and for a cha~ge lay Congres~ They are strong words, but that editorial echoes my sentiments compfete}y. Mr. WAXMAN. Thallk you wry much. Ms. Blake, we would like t~ hear ~om you. STA'f E~E/~T OF A~ANDA BI.AI~E, Ms. BLAKe; Mr C]%airman and members ~f the committee, I am privileged to have this opp~rtunlty to represent the American Cancer Society and to volce our support for H.R. 495~, the Compre~ hensive Smoking Prevention fJdueatio~ Act of 1981. -J b~
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31 This task is made especially pleasant in that l am able to testify today with my good friends John Forsythe and Bob Keeshan and dlat we are here together representing this very exciting new con]i- ilan of the American Cancer Society, American Heart Assoclation, American Lung Association and the National Interagency CoUncil. That these organizations have joined togett, or to fight as a com- bined force on this issue must surely highlight to us all the over- whelming importance the voluafary health agencies and the medi- cal community place oll smoking as a health hazard On February 22 of this year, the U.S. Surgeon General, in hL~ report entitled '°the Health Consequences of Smoking--Cancer," issued the fhllowing warning: {'igarerle smokang is the major single cause oI cancer mattali~v in the United States. Tnhacco's coiit~ibuLiOn to MI cancer deaths is estimated to be 30 percent This means we can expect that ]29,0F)0 Americans ~vill die of cancer this year be~ cause of l]~e higher overall cancer death rules tha5 exist mnoa~ smokers as cnm- pDred to nonstnokers. ghgara*tte smokers have ~otal cancer cleaLh l'ates two times ffteater Lban dO non- smokers. Heavy smokers have a ,~ to 4 times gi'eat e r excess risk ol cancer mor~alltv I was particularly interested in the Surgeon General's statistics on oral cancer and larynx cancer contained in that report. He said that these cancers would strike an estimated 40,000 people and will cause approximately lg,gg9 deaths this year in our count~ry. He went on to say thaL an estimated 50 to 70 percent o~ oraI and lmyngvnl cancer deaths are associated with smoking. I am a victim of oral cancer, a victim of cigarette smoking. Clearly had I kno'~n what it was going to cost me to be a smoker when 1 lit that first cigarette, I would never have struck the match Gentlemen, how do l explain in a way that you can understand the fear of t'mding out you hays cancer. They tell me that cancer is the mos~ feared disease, and I believe it. In our minds, cancer has come to mean death. It has come to mean pain and disfftguremerLt. When my doctor told me I had cancer of ehe mouth, 1 didn't be- lieve it. I had never even heard of cancer of the mouth, yet I had it. I arn an $1cLress. and l found oLlt catlcer of the mouth meant 1 was going to have to have surgery that would affect my face. I w~uld also ha~'e in l~arn to %a~k ~galn What w~rso could y~u tell an uctress? I thought, what if i~ is in my larynx? Wha: if they have to remove my vocal cords When I woke up from the surgery, I remembe'r I made a delibe~ ate erfurt to moan and I thought thank God, I still have ray voice box. The nurse came and o~ked me if ] needed pain medication, and I heard myself say yes. That simple word meant tha~ I could sfiil talk, that I could [oa~x again to practice my professiom I w~s lucky. But the emotional pain snd the fenr were monumental, and the memory of it will he with me for the rest of my life, After relating my experience to the members of this committee you musL surely understand why I am so disheartened to learn that the percentage of smokers among young girls ages 17 and 18 b.as gone uP. I am evml more disheartened to learn that in~g cancer will outdistance breast cancer as the No 1 cancer killer of women by as early as nex'c year and tha~ many doctors and Irledi o~ O~ ,,} t¢ I
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82 col researchers attribute this to the increase in smoking among WOITI£' n We may have come a long way, baby, as the cigarette ads say, but I doubt sincerely that where we women wanted to end up was with higher cancer mortality rates caused by smoking. Still, we do know that our education efforts have not overall been a failure. According tc the American Cancer Society statistics, there are still some 54 miilisn smokers who smoke more than 630 billion cigarettes each year. However, there are also 33.3 million ex-smokers, up from 3h5 million 3 years ago. Even the level of teenage smoking, which only a few years ago was going up at alarming rates, has started to drop in recent years Teenage girls who smoke now constitute 13 percent of thai paga]a- tion as compared to 15 percent in 1974 and teenage boy smoker~ are down to 11 percent from 16 percent. Now, I am not an expert on advertising. I am not a doctor or a research scientist, I am a cancer patient wish a partisu]m kind of cancer that is heavily associated by my doctor, by many U,S. Sur- geons General and by most of the respected professionals in the country vdth smoking, t smoked two to three packs of cigarettes a day for about 36 years. That, in my mind, was probably a major contributing factor to my cancer. I am here be~ause I want to spare as many ynu.lg An]eric~ns ~s I can the painful and frightening experience that I hail. I find it in- credible that anyone can slt in this room or in any room and say that since we do not have enough information on the effectiveness of cigarett~e labeling we sh(mldn't tr~ a new labx,ilng technique which might increase that number of ex~smokers. I am sure that we have all seen a report by the FTC that tells us that most people don't really know what could happen to them if the:* smoke I surely did not. If we save just a few thousand people from having to suffer through surgery~ radiation tberapy, and chemotherapy and from havlng to face either the prospect or the reality el premature death and of disfigurement by simply changing cigarette labels, no ciga- relic company is going to be able to convince me that their cost is going to be too great to make it worthwhile. I simply will not accept it. Last year the tobacco industry made aver 86 bi]lisn on inhaceo products alone--S6 billion on a product whose additives don't have to he listed anywhere, not even with Government researchers; $6 bi]llon on a product that many US, Surgeons General say causes cardiovascular disease, lung disease and cancer and other kinds of cancer; $6 billion on a product asso~iined with over 300,606 premm ture deaths a year and wlth $25 billion in lost productivity; $6 bi] ]ion on a product that caused me to go ~hrough ~u~gery and exten sis'e rehabilitation treatment. Since 1974 the Federal Government has spent over 8215 million to strengthen that $6 billion a year industry Every year the Gov ernment spends money on tobacco price supports and tobacco re- search and marketing, That industry can surely afford to spend a little more on its labeling, or even a lot more on its labeling, Therefore, I, for one. wholeheartedly endorse the legislation of- fered by the chairman whatever the cigarette industry may claim 8 ¢¢
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33 it is going to cost. 1 do not believe any cost-benefit analysis of this labeling proposal will prove to be supportive of the tobacco indus '~ry~ position. I belivve that I would not have smoked had 1 seen a label on a cigarette package or in a cigarette ad that said, "Warning: Ciga- rette smoking may cause death from heart disease, cancer, or em- physema." That simple message would have saved me y~ars of ~ri~f in dealing with an illness that jeopardized my e~reer and my !ilk I urge the members of this committee to overcome whatever po- litical considerations exist with regard to the tobacco industry and io show the courage and public dedication that will be needed to pass th£s l~gis {~tton. I understand how difficult this will be for some of you. I also be- ieve you will have failed in your commitment to your constRuenzs and in your duty as representatives of all the people if you do not, !t the very least, glee our people an opportunity to make an in- formed 4~ision ~b~t cigarette smoking, an opportunity m know what it is they do to their bodies when they smoke. I am prepared ~o assist you, Mr. Chairman, and the other 88 ~oorasors of this legislation in lay w~y I can to insure pa.~sage of HR. 4957 We must succeed for the sake of the health and safpty of Mr. WAxmAN. Thamk you very much for your very effective testi- 'nony~ Mn Keeshan. STATEMENT OF ROBERT KEESHAN g~r. KECSHAN Good morning, Mr. Chairman, Congrcssmell. I am most happy to be here this morning and representing the American Lung Association, I could just as easily be representing the American Cancer Society or the American Heart Association because I dolgght in the ~ignifieance of this coalition, which has come together to more effectively inform America about the dan- gers inherent in cig~¢rette smoking. I am grateful for the opportunity that you afford me to appear before this committee to express my views and my concerns about a health haaard whith threatens the well heine ~nd event~a[l~ the lives of millions of young Americans. I believe most of you are aware that I have spent the last ,g5 years on television and radio educating young Americans, helping to develop them intellectually, physically and culturally in order 'dmt the), may become h~althy, we]leducated, stable contributors to our society. The human being hegii~s the learning process at birth Much learning, e~!x'cially in the earlier years, is by observation and irr, i- tation. For example, we learn language by observation and imita- tion g~s we grow older, observation and imitation remain a mgnificant part of the learning process and the models of ,mr observation extend beyond the family. By laretee~ and t~n yoa~s, many of the most intluential mudel~ for young people are their pr, ers It is at ~q ta
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J 34 this time that that demon, peer pressure, plays a significant role in the development of attitudes, actions and habits. Peer pressure is probably the mo~t slgnifica~t influence in caus- ing a young person to light a cigarette for the first time It is an un~at~r al habit. Bl~w some cigarette amoke in the face ~f your dog or eat one of these days and note the reaction. We have to overcome this natural antipathy for cigarette smok- ing, and peer Eressure plays a very great role It has been es~imat ed that over 0,000 children light up for the first time each day Many of ~he~e children are q or 8 years of age~ purl of our hurried generation, anxious to be grown up and, most unfortunately, equat- ing smoking with maturity. Why not? They are modeling the be- havior of those they view as sophisticated adults. Almost 15 percent of teenage girls smoke cigarette~, sl[ghely more than teet~age hays. The increase m cigarette smoking by teen age girls in the last decade is alarming. There has been much spec- ulation as to the reasons for this increase, Perhaps smoking by young women is no longer frowned uJj~c on, Teenage girls have, indeed, been liberated from social taboos They are now ~s free as any other group to endanger their health and to shorten their bfespan, We all know the pains suffered by the long-time adult smoker who decided to quit the habit, and we are mos~ sympathetic, hut would it not be a better idea to appl7 an ounce o~ prevention to the y~u~g American, to arrest the devePopment of America s most pre- ventable cause of death? This bill of yours, Mr. Waxman, which is the subject of these hearings, is particularly ~tttractive to me because it calls for the or- ganizations, the marshaling of forces to educate all Americans ,as to t fie dangers inherent in cigarette smoking in a much more effec- tive maturer than we had done so in thep~ast. Educating young Americans, telling ~hem the facts, disabusing tfiem el" the notion that cigarette ~Tr~oking is a sign of maturity, helping them to resist peer pressure by developing proper attitudes at an early stage in life, are all programs that can creatively and effectively relich young Americans with the message cigarette smoking, feeling good and living long do not go together. l have become convinced that on our program Captain Kangaroo, whicb is produced for preschool and early schoaI age children, it is now time for us to develop programs tkat will help young people develop attitudes toward smoking, that will help them in a ibw years, later in their life, to resist peer pressure that is such at sig- ffff~cant cause of their lighting up for the first time Our programs in this regard wifi begin m the fall of ~his year. As a direct result of ~hls eoalitiol~ which comes before you today, we must reach preteens and teen$ with the llfe-s~ving message, stock- ing can kill y~m Let's help tho~e older Americans wh~ are vietim~ ~f the habit t~ give it up, but let us turn our great efforts to our children, who have the most to gain and the longest to live. If we can effectively reach young men and women and prevemt thsm from beginning to smoke, if we can reach them successfully, then we may all say with ¢~nvieti~l~, y~u have e~me a l~ng ~v~y, baby. Thank you, sir. l
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35 Mr. WaX~AN. Thank you. Let me s~y to the thre2c of yt)tl, you have been 8bsoluLe]y fant~- ~i¢ ~ co, me here. ~ thi~k y~u~ *~e~im~ny ~ a~ ~ffecti~e ~ an~ 1 ~ve ever heard as a Mcmber ~f Congress. I think you have ex- plained to us and brought a visibility to this issue tha~ | think w]lI nave an effect beyvnd this room. I think i~ will m~ke it far. far easier for us to pas~ this fagisfativn. Each of you has been working as a v~fonteer, talking to young iJet~pfo, talking to organizations about the d~l~gers of smoking, Mr. Forsythe, why don't 1 direct this to you What reaction do y~u gat when you talk to chtlclren, young people ~nd teer~agers about smoking? Mr, FOP~YT~ 1 agree most whcleheartedly with B~b that that should be our thrust because as cruel as it may seem~ we can try to help the older peo~e The young people is where everything is at. It is quite remarkable the kind of pressure that istcnsified edu catlonal campaigns have brought about in sch~|s, the way appa~ cntly the ~trongest p~nt in the antismoki~g campaign has been chl]dren coming hame, telling their parents, "pleas~ ~op smoking, Daddy, please stop smoking, Mother." I would think that our efforts mad our moneys cou]~t bes~ be ~pent largely in that ~rea~ Mr. WAXMA~q. When wc discouarge them from taking up a had habit, it has an additional impact? Mr FO~¥T~E. A double-ended thing, yes. Some people may corn p[ai~ abe~ frightened children, but 1 think it is a more rea[k~tic a~proach t~ life, even though they may he slightly frightened. Mr WAgM~ The three of you are involved in the medi~ Yo~ krmw what is effective in communicating to peop]e, you know what i~ effective i~ reacl~i~g ~he~. How do you see the role ~f the media in~ci arette adver~.ising and in the sub~|e ways their role models are established ~n programing, m influence people to takc up this habit? Do any of y~u w~n~ to t~lw~r~r*t O12 ~Ir. K~S~AN. I think there is no questio~ that r01e modeling is very persuasive with young people¸ When a character who is obvi- ously s~phistica~ed, glib, well spoken, admired, in a dramatic corn ~, |et u~ say, is a ¢lg~re~%e smoke~-, %he %wo hcc(~me ~or~fused. There is n~ question tha~; a 7- or 8~ea~o]d will associate that one ~lttribute of the ch*)racter, the use of cigarettes, with the other at- trlhutes of that character--the glibness, maturity, admiration which he earns. I think it is incumbent upon us--I would never tell a producer under no circumstances s~lould a character smoke ~ cigarette be- ck.Use %her~ ~trc times whe~ for dramatic ptlrposcs it is necessary. a~ ~here are t~mes when ~or dramatic purl~oses iL is necessary to p~tray vi[lians. B~*~ if it is gratuitous, if it is merely a gratuitous action on the part of the character. I think ~here is absofately no excuse for It. ]~]r~ WA~MAN~ D~) You k~low whether producers o~ programs or films either i~ te~evi~on or motion pictures will purposeig pu~ in a plug for cigarettes or a brand of cigarettes by ~sing it as par~ of the scenario of part of the perfarmance? !
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i 86 Ms, B~xE. t have never encountered that I think inserting of smoking of cigarettes to make a store point or portray a dramatic moment, I think that has been decreasing, very much so, in the last years. They are using other methods of showing or pumping up a dra- matic moment rather than [ightlng up a cigarette. I have found a decrease in it. Mr. FORSyTItE. I ha,'e not come across it, either, As a matter of fact, 1 have something good to say about the tobacco industry in one sellse. For 5 years I had a teleolsfon series called Bachelor Father, and our sponsors were tobacco people. I indicated to them that I never WaIlted $o make a commel'cial~ | never wanted to ap~oesr in any commercials. They were kind enoug]~ never to force me to appear, So on that level, ! thtek they have been good¸ On some other levels I could question that. Mr~ KE~SHAN. I have to add to those kind comments¸ | ~nust say, Mr. Chairman, that no cigarette company has ever asked Captain Kar]garoo to slnoke. Mr~ W^XMAr~. Well, I want to thank you agaim I want to recog- nize my colleagues to ask qtlestiens I want you to know how much l appreciate your tesitmony Mr Bliley Mr~ BLILEY Thank you, Mr. Chairman. Mr~ Keeshan, would you say from your experience, children begin smoking because of observing it i~ someone else, their pa~ ents, their peers, or do you think they do it because of advertisfog? What dn you think i~ the primary purpose? Mr. KEES~AN. A decade ago or more, Mr~ Bliley, I might have been able to say to you that I think advertising influenced them because I think the medium that advertises or affects children and by children I mean preteens and y~unger-~would be the telev~ sien medie It has been a generation since we have had such adwr- rising in television. It can be influential in magazine advertising, but I do think the greatest pressure on young children 8 and 9 and 10 and 11 years of age ],o smoke comes from peer pre$$12re. T~at is why I think oducetiona] programs with the young, that will deve]op attitudes toward smoking, make them aware and in- formed as to the dangers of smoking, are very important in order that they may be able to resist peer pressure. It is not the only action that peer pressure causes them to engage in, hut peer pressure is very significant with young peeg[e. Mr BIJIT.~Y. From your tostimony I gathered thet ol] three of yvu have smoked at one thne or another, some perhaps longer than others~ I know Mr Forsythe testified that he gave it up. I assume the others have~ too. He indicated, I believe, that it was consulta- tien with his physician tha~ caused him to give it up. How about yo~r~4e]f? Was iL the warnings on the ]abe], for expire- ple, what we are considering here, o1" was it consultation with your physician? Mr. KEES~AN. |L was consultation with my physician He made it very clear to me that I was risking my health in continuing snlok- ing. I must say that as important as the reason for giving it up was *4
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87 the reason [ took it up in the llrst place. I think it wL*s more than anything else an aflt~ct~/tion J remember very, very clenrly doing it because every other teen age kid tha assocaed ~ L dcl ~, and if you didn't do it you were a sissy¸ It was just peer pressure thaL caused me to Lake it ug, remember that as a teenage experience ver'~ plainly it¸ I had be~ the benelieia~y of an education prog~'am, a~ ~r young peopl.~ can be toclay, 1 don t think I ~ould have taken up cigarette smok- ing in tile lirsl place I would have resisted tha~ peer pressure. Mr. BLILEY Thank you. Do you have a comment, Iris. Blake? Ms, I~II.AKE. Yes. I took up smirking because I thought it wa~ g]amorous. .l~r I:IIJLEy -~Iy question was, what caused y~tl t~ stc~p? Ms 13LA~E It was because I had a sore in my mouth e~nd when I went t~o the doeLor he said, you are goin~ to quit smoking, aren't you? I said, well, the h~rse has already escaped from fine barn, but I arn qin~ing smok~n~ If yuu east ~a~e my life, I pzornise yn~ I wi[~ never smoke again, Mr. BLILE¥. Thank you very mueln Mr. WAXMAN, Mr l~oger~ Mr I~oc~s Thank you, Mr Chairman¸ I appreciate ~be chair man's kind courtesy in allewing me to sit nn thls panel today and pElrtieipate in Lhe 9roceedings. I would like, Mr Chairman to say thank you to these three people in the public eye for .joining u~ i~ere today on this very im- portant cause. There are some of us who, although aware of tb.e possiblo d~ngers of smoking, are al~o somewhat concerned about th~ f~c~ ~.h~t thi~ l~i~latio~ may b~ o~,er~ea~b.ing in .s~)me ~|" the const.ittltional asp~k~ arid philosophical l~.spects of what Govern ment. should and should not cto There ar~ some of us who ha¥~ a little concern ab~l~t the ¢eritr~l 13overnment seLting up, in effect, a brainwashing organization ~o sway people, ~ee poople, ~m what they sl~ollld do or no~ do, Some of the aspects of ~,his bi)l bring to minct possible fears of whether or not tile Central C-overnm~n~ should be involved in swaying public att~itudes fer or against a matter that is essentlally a private choice a]~d the dangers that that might bring to the fa~t that the Government possibly could enter o~her areas of public per- ~uasior~ oil ma~tec~ that o.re, [l~ a dem~craey~ rn~t~rs of prfea~e choice This bill, in [aet~ would create a very large bureaucracy in the Go~'ernment with ~nspeuified, open-enclecl funding. It would sub- stantlally place a very large load on the Federal court system, which ~lready is almos~ ~wamped in litigation, by permitting any person ~o bring a civil suit ~ith pe alities o~ $100,1)00 for a|lege¢i violations of the reginatinns with even one pack of cigarettes. The United States District Court amount for bringing suit would be waived under these proceeding~ Two, I think ~hi~ bill would divert a~.tention from all other envi- ronmental and occupatinnal factors which may have human hea]th side effects by lbeu~ing exclusively on ~moking. The Chairman's proposal is really premised on an FT(I study th~,t claims that Americans are not aware of the health warning on cn o~
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88 cigarette packages and in advertising The 6month comment period for that staff study bas not yet expired. Yet. we are being asked to take actien before the lhcts are in i~om that stall¸ report by the Federal Trade C¢~mmission This change Hies in the ~ce ol¸ a November 20 stalemenl of last year by the Health Secretmy~ Mr Scbweiker, who s~id and I quote, "A Gailup Poll this year found that the percentage of smok- ers in the United States is now the lowest in the 37 years of the Gallap Polls. 90 percent, 9 of 10 people, agree that cigarette smok ing is harmlhl." The present system I think of providing health in~rmation to permit peilpfo L(I rntlke their own dec[siiln, Ixl m~ike ~ fre~ choice On ~hether or not to smoke appmentiy is workfog because 90 gercenl of the people understand and agree that cigarette smoking is harm fuk Would we, in this bill, be providing a lot of possible danger to our democratic system, in addition to the Ihnding costs, in addition to the huge bureaucray involved, in addition to Lhe economic costs in- volved, and would we be perhaps loading up on the Government's s~-cal]ed responsibility in this area at great cost? I wonder wha~ your thoughts might be, any of you who would care to comment on that line Mr KEESHAN. Mr Rogers, 1 agree that we should be eolleerned and that we should permit every American to make a flee choice, to make a decision as to whether to smoke cigarettes or not to. We are not talking about banning the sale of cigarettes, but I think that we also must be certain that every American is able to make an informed decision For that segmen~ of the populatgm in which I am particularly interested, and my friend Mr. Rogers is particularly interested-- the other Mr. Rogers, Mr. Rogers--we are concerned that our young Americans are not able at this point with the information they have to make a fi'ee choice when they are subjected to peer pressure and modvling at u later age of 9 and t0 and 12. The Ameliean Lung Association, for e×amp]e, hEL~ ~1 marvelous program which is called--i~ is in an experimental stage at the moment--well, the Seattle program in the Seattle area in which they do emphasize many health hazards, cigarette smoking only one of them Other concerns that you exp~ev.~cd this n/or~ling~ o~her environ mental concerns are also emphasized in this program. The program is designed for kindergarteners, first and second gradet's. These young people will be intbrmed. So, they will be making an in- formed judgment. I think that is what we should be concerned about, that when that t)cee judgment is exercised by all Americans, as we like so proudly to point to our ability to make free choices, that that free choice will he intelligently made, lust as we txy to inform them every 2 years when we run for Congress so that they can make an intelligent and informed choice among candidates. We want them to make an informed choice as to whether they should smeke or not smoke I want my young people to be in formed. I think this hill will go a long way to help m inlPrm those young people. g~
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89 Mr FOrSYTIqE. Mr. Rogers, in spite of the Ne~ Federalism I am old-fashioned enough to believe that the Governn e t has a very, very strong rvsponsibility when a public menace is as evident as she Surgeon Genera] makes this appear When you have this k~nd of incontrovertible proof that it is not allied or relaLed to, but contributory, then surely Members o1" Can ~ress have a very heavy responsibiliLy in th~s matter. I am not uite a~ worried aboLlt the bureaucratic results as yotl are, Ms. BLAKE don't think can top that¸ I think you ha~e said it all, John. Mr. ROn~RS. I am wondering since you apparently belier., all cf you, that the United States Gove~mment, the Central Government. should have a heavy responsibility in convincing our citizens of our country not bo smoke, would it be also equally as much of an obli- gation of our Government n your view that perhaps we should re- quire advE'rti~ements for power hlwnmowers to disclose that push ]awnmowers are relatively safer? Should Volkswagen be required to put in their advertisements that Volkswagen passengers are more likely to be injured in the event of an accident than passengers in other kinds of cars'? How far should we go with this new ground that we are breaking with this bill? ~ir WAXMAN W II my co eague 3' ~ld o me fbr a second? I want to address the question as tim author of the bill. It is an interesting paint you are raising about the obligation of the Gov- ernlnent in this regard. The Constitution provides that the public health and saibty is a responsibility tbr the Government of the United States We are l~ow paying billions of dollars for the health care costs of people ~'ho have been affected by cigarette smoking. The Government is already spending millions of do]lars in tobac- c(~ subsidies. We are already involved. Since we are paying all of these costs, pa,rticul~rly the billions of dollars in costs that take Care of peoples health, it seems to me the Government has to figure out what to do. In protecting the public health, we can ban cigarettes, as we call ban an[ other item that is clearly so dangerous As a policy that wouldn t work We found that out when we tried to have a prohibi- tion against alcoholic beverages We want to assure people's right to make decisions for them- selves, but when we have advertisements that are paid by people who stand to profit, ~hat try to make cigarette smoking attra¢- tive--I hold up this advertisement as one of man5' examples it seems to me that someone has to counter the heavy propagandil- it~g, brainwashing, that is going on paid for by the industry Indus- try stands to make billions of dollars from their investments in promotional advertising to try to persuade people to take up a habit that will do a tremendous amount of harm to their health. At minimum i think the government ought to be trying ~o make people aware of stocking's health risks so that they can make a free and informed choice. I even think we ought to go far beyond just asking the industry to change their labels. I would like to see us pay tbr advertising on
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f 4O television to counter the years of advertising the| have built up over time to convince people that ~moking is glamorous We ~lre not going that Mr. We arc suggesting chat the Govern- meat ought to let people know what is at risk [br them, Now, Ifind it a peculiar argument to ~ay on the o~e hand Gov- ernment should not be involved in telling people one thing amd on the other hamd suggest that 9 out of 10 people aire~ldy know it I want to be stlre that everyone knows that when the~ pick up a cigarette, when they decide far themselves to smoke, ~hat they arc endangering ~hetr he~ltE, F~therm~re they are endangering n~t just themselves, bu~ they present & risk to their fhraily due to their illness and possib]e death, they cost the taxpayer who pays for their treatment and they cost society in the loss of productivity. Mr. RoGs~s~ Reclaiming whatever time I may have remaining, ! think the American Lung Association and the Americtin Heart As- sociation and other privately ~nded organizations are d~ing ~n ex- cellent job of educating and warning I think that ~hese privately funded organizations are the proper groups tn fund these effart~ because they do not get into the consti- tutlonal and philosophlca] questions (~f a C~ntra] Government brainwashing its citizens Mr B[JI~y. Since this is a bill, Mr. Chairman, 1 wonder if I might ask you a que~on. Since 9 out of l0 peop]e--morc than 9 out of 10 people1 according to the Gatlup Poll--already realize that smoking may be harmful to their Ix~th, ~h&~ ~nc~ea~ed percentage d~ y~u thhik thi~ biLL, should i~ become law, will add to tha~? Mr. WAXMA~ Any ~ncrease in public knowledge is worth the price of having stronger ]~be~s. ~aylng to someone they may die from heart dlsease~ lung disease or cancer raises in their minds what kinds of risks they are taking when they smoke. It is well worth requiring the industry tha~ i~ earning billions ~f dollars ~rom selling this product to a~ least take en tha~ obligation c~f inib~mlng the public m~ to the risks inherent in this produc~ Mr BL~LEy. N~t to prvlong this, Mr. Chairm~n, but 1 know the pena~tle~ have been ~n~ea~ed ~0 times i~ this b~l, from $t~,0O(~ ~ $100,000. It i~ my understanding that since labeling was required on cigarettes there has never been a case brought of a vlol~t~on~ was wort~ering t~ y~u ini~ht educate rae as to why ~he atcrease~ if we have never had a violation be~re. Why increase it? Mr. WAXMAN. Let's get into tha~ down the road as we look ii~t~ the sections of ~he bill | think we ought to have effective s~nc~ions to assure comp]iance with the ]~lW Let's hear ~rom otzr wltn~sses ~nd ~o in|c) the questions of why the ]egislation is needed or not needed. ~V~r. BLip. Thank y~u. Nlr. C]~a~rman, but ] thought we were a~ ready doing that. Mr. RoG~S. l yield back. Mr~ W~x~.N Let me af~ain extend my ~ppre¢ia~i~r~ ~ y~ it's been very helpful to have you here, and l think the fact ~hat you are here is o. dem~nstratiol] ~o ~ not just ~f Your sli'ong ~eelings and sincerity, but the hnportance of this matter. Thank you. Our next panel represents a |~ro~d spectrum of v~]untary public health gr~ups~ tec]uding the Americcnm Heart Associati~, the
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41 American Cancer Society, the American Lung Association and the National Interagency Council on Smoking and tIealth. I am particularly pleased t~ese gentlemen could be here ,vith us [his morning to share their special medical and scientific expertise tm this important subject. Steven Ayres is the chairman of the Department of ~Viedicinu at St Louis University School of Medicine. Dr John Oates is profes sor of medicine, Del~artment of Medicine and Pharmacology, School of Medici,,e, ¥anderbilt Uni~rsltg'. Dr ~tubert Daugherty is the dean of the School of" Medicine, University of Nevada. Dr. William Cahan is attending surgeon at ~he Memorial Sloan-KetterJng ~iance~ Center. We will make your statements a part of the record. You may proceed a~ you ~ee fit. gTATEMNNTS OF STEPHEN M. AYRES, M.D., CIIMRMAN, SMOKING (IN HEALTH COMMITTEE, A]~INRICAN LUNG ASSOCIATION; .IOHN .g. ~ATES, M.D., CIIMIk'4AN, S',!I~C~MM|TTF~E ON SMOK- ING, AMERICAN IIEART ASSOCIATION: WILLIAM G. CAHAN, M.D. ON BEHALF OF AMERICAN CANCEI~ SOCIETY. INC.; AND IIQI~ERT 31, DAUGIIERTY, ~R.. M.D.. P~I. D., CD.AIR~,I gN, NATION- AL INTERAGENCY COUNCIL ON ShIOKIN'G AND HEALTH Dr. AyRES l~r. Chairman members of the committee, I thank yog ['or the opportunity of presenting the views of the American Lung A.~ociation and chest physicians throughout the Uniy.,d States on the issues of cigarette smoking It is important to recog- ~]ize that the physicians here represe~t a broad fabric of American ~!cdiclne, physicians specializing in heart disease, cancer, and ]ung disease I would like to emphasize that the modern physician would prefer to prevent disease rather than to treat it. It's veiy clear that a l~rge percentage of the almest 2 million death5 each year are re /ated to problems that are potentially preventable, related to oar ious habit forming, unhealthy human behoviors. Cigarette smoking clearly causes lung disease, heart disease and ~ancer K people did not smoke, many people who die of those diseases would not die of those diseases Chronic respiratory disease is a condition that leads individuals to become progressEely short of breath. ~/ou might visualize it as hrea~hing through a narrow ~traw for many years of life, unable ~o receive life-giving air. There are about 47 million people ia the U~ited States who ha~e chronic respiratory disnase and the cost of care for these people is approximately $4g billion. Cigarette smoking is a m~or cause of this problem During this past year, 60,000 people died. There is no r~al controversy regarding the relationship betwee~ smoking and disease. Over 30.0g0 studies have been published, and almost all of them have demonstrated some aspec~ of this positive relatioltship. There h~ heer~ ~,,er t4 reptlrt~ ]~r~vided by %he ~lt'gmm ~er~er- al repre-~enting the Federal Government. The National Heart, Elood, and Lung lnstLtut~ in 1978 published a document ~n which they elmcluded that ctgaretf~ smoking is ~he single mes~ iraportaut risk factor for disease of the lung. Reduction or ideally, elimination of cigarette smoking would h~ve a ~*]ajor impact on national health
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42 and on the social and economic costs that are a conseque~ce of smoking related diseases. Now this is the National Institutes of Health speaking, the most prestigious research organization in the entire world. Part of this legislation is designed to coordinate the findings and activities of the Natmna] |nstitute el" Health with physicians al~d health educators throughout the United States. The only way to modify unhealthy behavior is through educa tion. There has been considerable speculation about the impact of the label and other activities on those people who say they know about the health effects of cigarette smoking. Knowledge and belief are two different sides, We feel tha~ knowledge can only be converted into belief by con- stant reminders, by constant health education by what some would call brainwashing. Each year, there are many new studies which confirm these relationships. I have presented some of these to the committee in the formal report. Very ~w studies ever suttee that doubt this relationship. We are concerned about the imbalance that exists ~tween those forces clesigned to get people started smoking, and those meager forces of we physicians, he~ith educators, and others who try to modi~ and prevent smoking, Let me just give you one example taken fec~m a report writtcn by the Ted Bates Advertising Co, in a chapter which they wrote, they said, and the title of the chapter was "How to Reduce Objections to the Cigarette " They pointed out that since cigarettes do not have any real, abso- lute positive qualities, that it's very importanl thgs cffoctive adver tising reduce objections¸ Then further in their report they pointed out what I believe to be the real heart of the issue in terms of the overall approach to young people¸ They point out, this is the Ted ]]gses Orga~/izatfou spoakhlg; for the young ~moker the cigarette is not yet an integral part of lifo, of day-to-day life; in spite of the fact that they try to project the image of a regular, run-of-the-mill smoker¸ For them a cigarette and the whole smoking process is part of the il]iist p]c~nsure category, in a young smoker's mind a cigarette falls into the same category of drinking wine, beer. thav- ing, wearing a boa or purposely not wearing one, Demonstration of independence. For a young starter~ a ¢igarett~ is an introductfon to sex lifo, courtship, smoking pot, and keeping late hours, It then recommends a ~trahi~" for attracting young people to start smoking, We feel iabelin~ is only a beginning¸ Cfoarly, label- ing by itself will only continue the process of attempting to hlferm young peopfo and older people concerning the hazards of cigarette smoking. We aim to have a social milieu, a fabric ~n which un- he~tithful behavior becomes socially acceptable. Consider, if you wiIl, tha~ this ]egislaiton really represents the role of the foot soldier in an entire ~rmentari~n. It is the begin ning, not the end I would point out, gentlemen, that these are di~ ficult economic times. The Federal portion of the over $200 million in health costs are rising¸ Medicare health costs are rising, If Americans were to stop smoking ~morrow, it is very likely that the budget could be balanced consider~*hly earlier th~n is presently projected. Thank you for the opportunity. [Dr AFre's prepared statemei~t and illustrations follow:] C~ C ~J w~
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i. ,i ~J 9 Z ° ~ z ~Z 8 z
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44 C~n~u~ ~i~h ~n emphasis ~n pure drink~ ~er and s~nitar), ~t~ ~LN,~I~q~ED~E ~L~I) BELIEF (,Jl
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46 ~l~v=~,~n pro~rlm±n~ a~ ~ m~m~ure "~n~~' om c~r~ a~d
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~ an~ly~i~ ~ho~s ~h~t for ~ac~ LO0~O~O p~p~l~i~n sam~ie 0 ",I
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47
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48 mm
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---
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6S0574471
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In this country 340,000 people die prematurely every year from the effects of c=garette smoking. t.\ N 1 l~l~ l( ;,\ N 1 ,L* N( ~ .\S~ )( ;1 ATI( )N
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52 POLLED AMERICANS UNAWARE Smoking causes mo~t cases of bronchitis and emphysema 60% did not know 20% did not know Smoking causes lung cancer Smoking causes many heart attacks 50% did not know O~ C ¢, -3 Co
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~B Mr. WAX~4AN Thank you very much. Dr. Oat~ STATEMENT OF JOHN A. OATES, M,D. Dr. OATES, Mr. Chairman, members vf the committee, I ~rn Dr. John Oaten, professor of medicine and pharmacology at Vanderbilt University, and chairman of the subcommittee on smoking of the American Heart Association. I appreciate the opportunity to testify on behalf of the Heart Association which is a nonwofit, voluntary health organization with 119,000 members and almost 2 million arbor volunteers who are dedicated to the reduction of premature death and disability from cardiov~scu]al disease. Cardiovascular diseases kill nearly 1 million Americans each year. This year, some 1'/2 million Americans will h~Jve a heart attack and about 5~,gl)0 of them will die from this cause. Another 174,000 people wilt develop peripheral vascular disease, a major disabillty. These figures have special significance because cigarette smoking ho.s been firmly established as a major contributor to the occurrence of hear~ attacks, sudden death, and peripheral ~ascular dlsease~ Cigarette smoking is the rnos~ preventable cause of death and disability from these cardiovascular diseases Compared tv the non- smokers, cigarette smokers are m~re likely tu suffer heart attacks, to die tYom heart attacks and to die suddenly from coronary artery disease. Fortune,Icy, quitting ~moking reduces the risk t~ward that of the nonsmokers Cigarette ~moking pertlcular/y increases heart a~tacks and stldden death among younger Ine?/ and women. Tho American Heart Association attd the Co~littcm on Smoking on Hea~th are committed to helping smokers who want to quit and preventing children from starting to smoke Accordingly, we wholeheartedly support the passage of H.R 5653. The provision of statutory standing of the O~'f]ce of Smoking and Health is very imperZant The proposed role of the Office of Smok ing and Health will be instrumental in comblding and coordhla~ing the efforts of the public and private sectors to address the problem of cigarette smoking Thus, a relatively small Federal eitort can be used to mobilize enormous private sector resources to address a major health problem Requiring the rotation of new warning statements on cigarette packages ~md advertisements is needed to better inform the public since the current warning statement is overexposed and %am out This should Come as no surprise since any message presented in exactly the same way will soon become so familiar teat it will lose its effectiveness. Moreover, two optometrists in a stud}' of cigarette tailboards found that while the brand name was highly visible, the warnblg could not be re;~d. Clearly there is a need for varied ~urning sta~emeu/~ and a format that is visible Yet the tobacco industry argues that the warning labels should remain the same in every ad. This is ~ntra dieted by the practices of the industry itself which changes adver- tising copy frequently t~ sell cigarette~. .Q
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54 For example, here are copies of a very successful adverti~ng campaign which made numerous change~ during the course of a single year. It's obvious that the message muct be changed to at- tract attentfom Cigarette advertising uses a multitude of different images, to appeal to different markets. The logical extension is that the warning must also be tailored to appeal to diflPring consumers. For example, smokers with a history of heart disease in their forailies may lind a warnii~g on smoking and heart attack a much more personally relevant matter than a general, vague message. The American Heart Association has insufficient access Lo the media to inform the public adequately on the hazards of smoking¸ The nulnbcr of anLismoking public service announcements on t~]e vision since the ban on cigarette con]merciais has been drastically reduced with hardly any being shown during prime time. Informa tion in the print media has been equally scarce. It has been sug- gestad by some that heavy advertising by the tobacco industry serves to discourage coverage of the hazards of smoking in the prlnt medga This potential for intimidation was reinforced when a cigarette advertising account for a half million pound sterling was abruptly withdrawn from the Sunday Times of London after a r~port on heart transplants which named the brands of cigarettes smoked by patioats~ For whatever reason, the broadcast and print media do not provide the public with full information on the dangers of smoking. Accordingly, the warning labels would pruvide all assurance that all citizens have access Go at least a minimal level of information. It would provide an important means by which the Federal Gov- ernnlent at no cost can effectively assist the private sector in edu- cating the public about the hazards of smoking. The decision to smoke is frequently made before the age of 21, usually without full awareness of the odds against escape from the smoking llubit. This legislation would be an important step toward assuring that this is an informed decision. Mr WAXMAN. Thank you very much. [Dr. Outes' prepared statement follows:J l
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55 TESTIMONy OF JOHN A OATES. M 0 CHAIRMAN ~C~COMMITTEE DN SMO(ING AME~ICAR HEART ASSOCIATION Hr. Chairm~ and members of the 5ubconmittee on Health and Envirorme~t, my ~a~e ~ Oobn A Oatos, M D. i am ProfQssor of M~dic~e ard Pharmacology at Vanderbilt Uai~Irsi:y and CB~irman of ~he S~be~ittee on Smukfng of the Ame~icBn ~ea~t Ais~cia%1on I appreclatg IEe ~pportJrI%y Be appea# before t~is Subcommittee on behalf o[ the American HeJrt AssociaBion t~ testIFW in supoort of ~he ICD~eh~P$iy~ Smoking Act OF 1381 ,t As ycu may ~n~, t~e ~mericaa H~art Association ~ a nonprofit vo]unI~ry health organization with eve- IIg~OOG members and alm¢~t mHlior other wlunteers who a-e d~dicat~d to Bhe red~tS~n of pr~matur~ o~ath ~d disab~]~ty from cardiovascular ~iseases.' Car~vascol~r di~aseB kill n~l~ one millie~ ~lerlcans ~ach year, ]hls i~ more thBn all ether c~us~s ¢of~bined Heart a~tacks, Bhe ~atiDr~s nunOer one k~ll~, c:ai~s ~DSt pf these li~e~ This ~ea~, as many as I 5 ~i~ion A~erlcans can ~ expected to hav~ a h~-t a~ta~k an~ abO~ ~!~000 ~f the~ wi]] di~ The ~v-~I~rs ~fl~ jo~n over ~ millim~ ~e~ica~s who have ~ ~Ist~W of ¢orDna-y d~semse~ The~e f~pres ~ave special s~nificanc~ ~ecmuse cigar~tBe ~moa~ng h~s been fi~ly tmp~iza~ as ~ ~ajor conBribu~oF t~ t~ occ~-renc~ ~f ~e~-t ~t=acks~ s~d~ea d~th, peripheral viscul~r dismase and it 3~eat~ aggr~v~tel ~her f~rms of cmrdiowscuT~r d~eases. Cigarette smoker~ are mor~ Ifke]~, than non-smokers, ~O s~fer a he~r% ~ttack, more I~]y to dfe "rom the~e ~ttack~ ~nd m~r~ li~e~y to ~'e sud~rI~ Th~ effect ~s d~re~ly r~lated to t~e amoun~ smoked ~4th heavy smokers being a~ three %~es Bhe risk of noq-~mokers, Based o~ dat~ ~ron Bhe Fram~ngham ~e~t S~udy', we e~timate t~t ov~r II¢,000 ~er~e~t of t~e~e people wi]] be ciabeti~s, 70~ mf the rema~O~r ~I] b~ ¢f~mrottg smokers ~ Moreov#~' ~f~b~t~ who also smoko ~re at even greater r~k' The l~k of E~arette s~oki~ tc ~m-~her~l V~scular disease is c~n~istent ~nd inde~rdc~t of d~abete~ ~nd other r~sk ~ctor~ a~d related ~re~ly ~ the numbe~ cF cigarettes sn~E#~ , Perhaps most s~gnlfIc~nt i~ the fac~ ~hat when ~eop]e stop snokin~ t~eir r~B of t-e~ card~=vascv~ar ~i~eases g~ad~ally re~urns ~o n~rma] The risk of fatal and nor fatal haart att~s amo~ ex smokers is similar to ~on-~m~er~ ~n about ~0 ye~r~'-~ The risk cF Defipher~l vascu:ar dis~se IS ~i~ila~ly redseed to t~zt cf a n~n-smo~er ~n ~out ~ years~' The evidence incriminating ¢~ar~tte sm~k~n~ aB a major r~k fmc~or for heart atBac~ an~ peripheral vascular dlsea~c wa~ judge~ by an ex~e~ panel of th~ A~ricar Hear~ Associ~tlon tD b~ ~onclus~ezz T~W furBh~r C~cl~d tha~ ~eor~t~c~l~, c~arette ~mokin~ ~s ~he nest preventable cause ~f ~h~$~ C~rd!ov~c~Imr d~SEaSes and mc-tality thmre~roo"' I~ sp~B~ el ~he overwhelming ev~Oe~ce 1~rg ¢~et~e smoking C~rd1~vascular and other diseases, o~er 5~ mil~or ~eric~s a~e st~ll sm~kin~'~ How~w~ ~wo thirds of th~se smokers WOUIC ]~ke to 4uit add ~ost QO
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56 h~ve tr~e~ to ~ s~+~l ~ol~o~i~ an u~u¢ce~ful ~ttempt to ~uit, ~y ~I the~ ~ok~rs t~nd to ~wit~h to low tar ~nd nlcoti~e ciga~ette~~'~ T~i~ i~ 60.~of ~ll ~ale~ i~ 19~II~ TH~ ~vel~p~e~t ~ ~la~g ~e~au~ th~ ~videnc~~ ~ug~e~t~ ~hat many p~o~le ~ s~it~h to lo~ ~a~ ~n~ ~!~o~ine in ~ e~or~ t~ l~er thei~ ri~ of a~v~rse ~Ith ~f~e~t. Whil~ switchi~9 ~ th~e ~i~ar~ttes ~y l~ner ~he ri~k f~r some ~i~ea~, there i~ ~o evide~ of a re~c~on ~ ri~k for cardiovascular ~ise~ i~ ~ f~tb r~c~nt ~v~de~ frem t~ Fra~i~gha~ ~e~rt $~d~Li, ~ug~s~s tha~ ID~ tar ~n~ ~c:t~e ¢i~arette~ ~ eve~ i~c~a~e th~ ris~ ~ ~ova~ul~ ~sease. T~$~ ¢~uld be • very d~ger~ d~ve~p~t ~fnc~ m~st clg~rett~rel~ted Geath~ ar~ fro~ ~e~rt a~acks , The ~merica~ H~art Asso~l~t~o~ ~ ¢~m~t~ to ~Ipi~g s~ok~rs w~ ~a~t to ~u~t an~ ~revent~ng ¢hi!~re~ ~r~m starting to ~e~ Ac~rdl~91~ ~e ~o~ehe~r~e~ly ~port the pas~ of ~ R, ~, th~ "Cc~pr~hensive Smoking ~r~ventFon Educat~o~ ~t of 19~I~' Th~ pTovision ¢f statutory s~rdf~g t~ the O~ce on ~moki~ ~nd Healt~ i~ very important The p~opos~d ~¢~e of the Of~i¢~ ~ ~o~i~9 a~¢ He~It~ will be instrumental in ~bi~in~ Bid coo~dina~i~ ~he e~or~$ cf the public and private sectors ~o ~d~ress the ~eder~l eff~r~ ¢~ ~e u~ed to ~biliz~ enormous private ~ec~oF ~esou~ce~ to a~r~s~ ~ ~ajor ~al~ ~r~blen The ~rov~s~o~ ce~ul~i~ the rotation of six ne~ ~rn~ statements D~ ~ig~r~t~ ~a~k~g~s anJ ~veF~m~nt~ i~ ~ee~ec to be~er i~f~r~ the p~blic of the ~pe¢~fi~ c~ger~ Df ~gar~tt~ ~oKing The r~t~c~ale fo~ the req~e~t o~ ~ ~rnln9 Statement f~ th~ first ~ce, was t~ ~or~ CDnSu~rs ~f th~ h~alth h~ard ~ever~ t~e ~C~ h~ r~nt~¥ ~on~lu~ed that th~ curr~nt warnln~ statement, which ~a~ ~÷e~ u~d Dn packa§~s and a~vertise~e~t ~,~c~ study by !~r~ ~css~ge Report Service ~h~ch fo~ that o~l~ ~ 4~ of adults e~e~ to ~arett~ ~ds ~a~ the ~urge~ ~cer~l'~ 1,r~rni~gs T~S ~h~ul~ bec~ SO f~fllar that ~ ~ill )os~ ~ts elf~ct~v~e~,''-'~ ~u~the~ore, sinc~ cig~tt~ ~c~p~n~s v~r~t the copy Df ~eir ~verti~e~ent~ t~ ~,oid th~ re~uri~ ~ l~ss~ Brodsky ~c My~owitz,~' in a ~tudy ~ cigarette bil!b~rd~, f~d the ~a~n~ t~at us~ ~ ~ew~pap~r ~nd ~9~es I~divi~ual ~etters f~ th~ ~r~n~ ~o~is~e~t'~ ~eared the sa~e, i e • re~u~d detail Wh~ ~o~p~red w~th th~ detail ~d ~ze of ~h~ ~ett~s in tle ~an~ ~e, the t~o l~r~ ~serv~ warnln~ st~t~nt~ were 3~ ~C 17 ~ sm~H~r T~ two op~D~etri~ co~lu~ed f~o~ their t~t t~t wh~)e the br~d ra~e ~s visi~le, t~ ~rnin~ was not~
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57 This ampl~ s=pports thl reed for varied warn:ng statements in ~ f~r~a= that ~l visibIc HG~over, the Tobacco Iasttt~te'1 i~ r~sponse to the FIC Staf~ Report, argued that the effec~iyeness of the c~ga~tt~ advertisement a~d w~r~lng stBtement ~ust b~ j~ged bY differen~ criteria The ~atla~ale is that ,'th~ fDr~er CQd~ert~sement) must achleve consumer recall for a particular brand among numerous other brands, al" ~? ~h~ch pres~r~ com~ing and ccn?li~ting ~essa~es w~!]e th~ latter (warning) a~pe~rs ~on~ist~tly t~ the c~nsum~r in ~ery advertisement ~no c~ every pack ~l cigarettes" This dual criteria i~ no~ o~]y unsupported but ~sup~r~able ~ the ~r~ing ~Bte~e~r~ h~s be~ "r~m~rkably t~fe~t~ve" by ~etng presented consistently =h@ ~a~e way th~n it ~U]~ ~een t~at brard ~ecall waul~ d~ ~hanced if lhe pgrt~ay~d lnage ~as ~{nt~i~d unchanged over t~e years. ~r exanple, t-~ ~ar!b~ro advertisement ~hould b~ mo~t ~ffect~ve ~f the ~r~glnal ~d co~ w~ continued Yet, t~e ¢~ i~ cha~ec z~ ~ha~ged fre~uenty Di~ferPrt ~owboy~ ~e u~d fn d~fferent sett~gi Additi~B]~, Brown dnd ~ila~s~ mac~ seve~l ~ha~g~ 1~ its ve~ ~u~cessfL] Barclay ~ampa~g~ last year¸ ~ images to appe~ ~g different ma,ke~s This is inde~ c~n~ste~t ~ith the concept of ~ar~e~ s~mentation The logical extenslo~ ~f ~h,s is tna~ th~ warning must also be ~]]~red ~o ap~ez] to dlfferl~g COnsumers. Fo~ ~a~p]~, o~ smoking an~ h~rt attack ~uch n~r~ pers~na]l~ ~]~vant than a ge~e~al messag~ • edia ~h~le c~ns~ers are ~xp~sed in ~]i medi~ t~ information on ~1~ hazard~ ~f smoking is ~i~leadtn~. The number of anti-~mokin~ ~A a~red o~ television ~i~ce the ban ~n cigarette c¢~l~erci~ls has b~e~ c~astic~lly redu~e~ ~th s~i~ ant ~a]th in t~ print ~d~a has ~e~ ~q~ally scar~ It has even b~n ~uggeste~ bY some=~'' tha= the tDbaCC~ indust-~ n~y be u~g t~ icwr~isi~ a~ a lever~ t~ d]sco~r~q~ c~verage on th~ h~ZB~ ~f smok~n~ i9 ]~r~]~ ~nacc~ssi~/e for i~f~rmi~g ~h~ pub~iz ~f ~he ~a~ge~ of sm~Kirg. ~e~H~le t~ so c~llcd brard adve~t~sln~ ~es o~ at the tune ~f on~ b/lIc~n ~ /~s 9~r ~ea~ /, R~ard/es~ c~ ~he i~te~t, ~c~1~k~rs ~d ch'~d~e~ ar~ ~eavlly c~¢osed tn t~is ~dw~t~sing It ~uld be V~ difficult tD argue ¢o~vi~clngly t~at so~e ~n-snDkers, e~pe~iaHy children a~d t~e~ag~rs, are no~ a'f~cced ~ ~is ¢~ns~an= ~t~ay~l of smokers as b~ing young, at~ractiye, ~ ~b~rd~en~ ~ no etf~c=~e ~o~at~r, it i~ n~t h~rd tc u~darstan~ ~hy ~3~ of sm~ke~ d~ not k~o~ or believe that s~o~in9 c~u~s many ¢as~ ~f hea~s att~cx ~ F~ the ~b~ve reasons, =he wa~,~ abel bec~m~ ~ ~ery i~or~nt ~diuY =p get ~T~ inf~rmatl¢~ to t~e p~}c T-E Ancrlca~ ~e~r~ Assocat~n has ~ac~ ant ~l; continue tD m~e e'forts =o bett~ inf~r~ ~h~ p~)l~c a~oJt h~zarc~ ~f t~ Z~l]y in'cr~ the ~]i¢ Our efforts wi~] have a greaLer :hanc~ ~t success If the ~leari~ de=ep~ve Intention ~f cigarette aovertfsi~g is attenuated by i~clu~in~ an effect~v~ ~r~in~ T~ ~rn n~ i~ y~t arother ~ay, at po cost, ~ w~lch th~ federal g~v~n~En~ can ~ffect~v~ly as~is~ the prIvat~ sect~ f~ e~ucati~g the pL~]iC z~ut t-~ hazard gf cigarette ~noki~g. T~erefDre ~he ~meri~n Heart ~s~oci~ti~ strongly ~upp~rts the adoptioa of the ~IX specific ~r~lngs proposed in IIR 49~2 We further propos~ the ~nE~rp¢~atior ~f the I'circle ~rd arrow" f~r~t, Teco~enc~d by the ~TC~, ~D disp]~ the ~rnlng on advertisements This ?ormat wou d signif~cantl~ enhante not~c~abl~ty of ~he v~rnn~ FinaTly, req~lrfng that ~-e warn~ letters measure at east 2~% O= the ~aximU~ braad n~me letters and be of tha sam~ proportionate ceta ] ~ould ~i~=h ~mpr~ve its visib~it~.L' TheS~ simpl~ measur~ ~t n~ cost, woeld ccntr~bJte ~reat}y t~ ths education eflurt~ of th~ ~i~a~e s~ct~r
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58 1 ~1~an Heart Association, ig~l ~atic~al Anmual Re~rt National C~nt~r: OalIa~ T~×a~ 1981 2, American H~ar% ~ssociato~, Heart Facts: ]~$2 Natic~a] CEnter: Da]l~i. Te~ 1932 3 KannEi, ~ ~ ; O~yle, J,T ; Fredrlcks~n, 0 T and Harlan, W R Re~ort of th~ AD HOC Committee o~ Cigarette !m~k~n~ a~d Cardfo~a~c~l~r Diseases: Fo~ HRal%r professionals; ~o: 71-~01 ~ ~eri~n ~ear; A~soc~atio~; O~11as, T~x~s l~i Shurtleff, Dewey~ Some Characteristics Re'atec t~ the I~cid~c~ of Cardiovascular D'se~se and get,h: Framir~h~m Stud~l~ e~ear F~ll~-u~ Fr~ingh~m Study; Sec~i~ 30; OHEW ~blicatlo~ NO~IH) 7~ 5~9, February, 1974 We1~, \ S "Cigarette ~mokimg a~d Arteriosclerosis Obl~ter~n~: An Ep~demJol¢~Ic Approach", ~erlca~ Journal of Epid~Io~ gs(l]; 17-~5, 197~ 6, Weinro~h LA, a~d H~cz~tein, J "R~lationship Df TDbaCC~ aad Snoki~g t= Ar~Rri~sc]ero~is Oblitera~s in Diab~te~ Me~litus," Journal of %-~ Amerlcap Medical As~Dclation l~i(~): ZOO, May, 19~5 7, ~amn~l. ~ B "~pi~emi~log!c ~t.~le~ ~ S~ki~ 19 Cerebral a~d 2EriphR~al Vascular Ois~a~e" in ~nde~, E L.~ Ho=f~an, 0; ~or~, ~G (E~itDr~) pr¢ceedlng~ of ~he Third World CDaferance on Smok~n~a~d ~aa:th 0o~l, ~ a~d Pet~, R "~ortal~y in Relat~s t~ ~oking: ~0 yea~' (60~i) 15~-15~, he,ember ~5, 1976 9 Go-don, T ; Ka~ne W B ; Mcgee; ~a~her TR ; "~th ~m¢ C~rnmary A~¢kl in M~n AI%~r ~Ivi~ Up CJga~tteI: A Report from the Framingham Study" Lancet ~:13~5-13~ ~ece~b~r 7, ]974 I~ Koch, A "Sm~ki~ and Peripheral Ar%er~a~ ~sCase," !a: ~ynde** EL; Hoffm~r, D; Gori, GB, (~ditorsl Proceedi~q ~f the -h~rd ~orid Gonf~ence oa Smokin~ and H~alth BHE~ P~bHcatio~ NO ~NIH) 7h ]2~i i ?81 783 Ig7B II Ka~l~ W B ~ Doyl~, JT,; Fred~r~k~un, ~T and Harlan, W R ; Re~ort of ~ Ad Hoc Committee o~ Smok=n9 a~d Cardi~vascu~a- D~e~s~s N~ 51 ~ A, American H~art ~ss~c~atio~: Dallas, Te×a~ I~74 l
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59 to th~. N~ti~na] Hea]tm, Inte~iE~ Survey " kl~, 1~8I 13 14 15 ~I~e]:, d C '~Ci;~r~tte S~le~ Lp i~ l~ik, A~e~tfsi~£, p 72, 0ece~be~ i, 19~1 ~c,~ma~a, P~ aq~ K~nrel ~ B "The Fi~r ~i~arette ~rd Cor~y Near= Oi~e~s~: T~ F~m'~gh~ ~ud,/,¸¸ .ance~ 2 (@23~): :0~113, Myers, ~ 0 I~oe, C ; Jennln~s, :arol; ~enox, ~; ~ln~y, • and 5~¢ks, A St!iF ~t o~ the C~ettc Ad,~tf~ Z~e~=ie~ti~r F~der~l T~de C~rnT~ss~n h~l, [98i ,]~qll Ad~e~t~lno Research, August, 1978 19 Craig, ~t &l "Adye~tf~in~ ~'ez~ou~; A~ ~×~er~m~r~] Analysis" ,Jcur~t] nf ~rketi~ ~es~&~Eh, N~wmb~r, t~'6 P~ca] Optics E8 (Z]: :l;~?bebr~l-- The T~3~C~ !q~'tLte C~m~ent~ of the Tobacco Institute o~ t~e FTC ~t~nr-~rcI~e Adve~tl~,q- in~1o] '~d~hil~to~, Smlt~, ~C "The M0~azinesm Smp~ing ~it" Col ~mbia ~ourn~li~n ~evle~ 16 !~): 2~ ~I J~nua*~ebru~r~ 19;~ ~rhelan, E; Sh~r~G~, M; Nei~ter, K end ~os~er, B "~nalys~ of CDye~a~ of Ti~acEo Nai~rds ~ Women's Va~az n~ " ,]eurq~ of 9.blic Hea]~,qPD]~cv The Roper Org~qzatl:~ 0~milu~ S~dv #72~ for the Fe~eFa ~r~e Co~f~fon,!98U yjV~d7 ,,,} CD
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60 Mr. WAX.'~AN. Dr. Cahan. STATE31ENT OF WILLIAr~I G. CAHAN 1 Dr. CAHAN. I first thank you for the privilege and honor of testi- ) tying before this committee 1 would like before my testimony begins to submit two periodicals which I think would be of impar tanoe. One is titled, "Cigarette Smoking Among Tennagers and Women." Another is called. "Dangers of Smokiag, Benefits of Quit ting.' Mr WAXMAN. We will be pleased to receiae those. Dr CAnAN. For 40 years 1 gave been associated with Memorial SloamKettering Cancer Center. It is the earliest cancer institute in ! this country. It is one of the rnos~ prestigous The last 33 years of I those 40 I have been a chest surge/in on the tbclracic st!rvice, de81- inga great deal with malignant tumors elf the chest and thoracic cavity. Cancer is an extrmrdinary dise~me It's ~twesome and awful There is hardly any among us that has not been touched one way or anvthel either by family or friend with this particiar disease so we have had some inkling that there is that extraordinary ~llter- ? ation in one's life, one's hopes, one's dreams by its onse~ All the statistics we have been hearing are certainly suggestive of the con- nection between smoking and cancer and other diseases. What is often lost !n numbers I think is the human element which presents itsc]f to us who are in the world of" cancer as a daily diet, if you will If you have sat where I have sat seeing patient after patient with her or his cancer, and seen the destruction this makes in their lives, you would 1 think become dedicated, to trying to find out wha~ the mechanisms are and how you can prevent these disasters. In this 30-year period we have seen many changes in cancer which I think are germane to this discussion. For one thing we i have seen a little over 30 years ago the reintroduction of cigarette smoking as a possible cause It's hard to believe in this day and age, ~hat in those days people were very skeptical, suspicious cf and rather reluctant to believe the connection. Since that time. we have seen an extraordinary maturatlon vf this idea unisl there is an unequivocal relationship. Other observa- tions made in this time period that even with the improvemen~ ¢f surgical and radiation therapy we are still unable to cure many cancers, in particular, catlcers ussociated wilh the cigarette smok ing habit. For example, at our best we can cure one in three lutlg cancers. But unfortunately, the osera]l average is just 1 in 10. Again, in the same period of time, we have seen that which you have already heard from other panelists, the remarkable rise in the incidence of women's lung cancer. Where we used to have a rati() at Memorial S[oan Kettering Cancer Center of at least 12 males to 1 female, this is now almost even in a short period of 15 years arid bodes well t(~ pass the men in incidence. These are not women who work as "R¢)sey the Rivl!tcr" i*r in industrial hazards. These are housewives, office workers, teachers, and the like for
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fil whom there cannot be, I think by any stretch of the imagination. the equivalent c~f a man's exposure to industrial exhausts. We are familiar with a well-popularized cigarette slogan mell tloned today, I ~uld like to ~raphra~e it a~4 h~e it read, "¥~ have come the wrong way, baby" In any event. I thought it might be of interest ta yeu if ! present- ed an X ray of a chest showing a cancer o[a lung fu ~ woman. I will put it on the viewing screen This 59-year-old woman~ wife. grandmother, m~er, with a~l t~e Ye~on~ in ~he world ~ ~tay ali'ce, was a heavy smQker for 20 or more years. By deJ~itfen, beavy smoking is ~ pack a day for 20 or more years. She was very careful to have periodic chest X~rays to monitor her con~itiorl and each tiIne a 12egatlve chest X r~y canle from her erase she breathe~ a ~i~gh ~ r~lief ancl went ~ut an~ kept smoking. Her family was n~turally quite concerned about this ~nd tried to stop bet. One day she cotlghed up a little blood and had this chest X-ray taken She came to my office, bringing it with her, as ]]ave so many thousands. This is a chest X-ray showing the heart, the ribs. and her left lung which is on th~s side and appears norJnah What I would like to draw to your attention is the shadow in the right upper lobe of her lung. She sat there--and the drama is re- peated over and over again--locking at her own X-ray with that shadow. She smoked untl] the day she came to ray office, and saw her own partisubtr tragedy in the making and stopped on a dime Trying to stop peopfe from smoking is one of the most difficult problems we have to face today. There are many methods: physi- cians' advice, smoking clinics, acupuncture, hypnosis, and so farth. ~ut we h~'e a better than ~O-percent take on stopping people from smoking when they view their own chest X-ray and see the shadow for the first time This i$ the hard sell, but by then, the horse has left the stable. What we are tofaing about, is to avoid reaching that pargicular peint, by any and all means. Another major problem is the question of children smoking. We have already heard about this today but I want to give you the cancer point of view. We are now m~re and more aware tfu~t growing tissues arc mo~e ~nsitive to carchl~gens, caneer-formi~g age~ta, than are adt~lt ti~ sues. We have seen ample evidence of~this in children who to be irradiated for a large thymus and then went later on as adults to develop thyroid cancer in the field of rad]atlon. We have also seen it in children who had radiation ef bemgn bone tumors and later developed cancers at the trradlatad ~i~e. Similarly. young tissues exposed to carcinogens in tobacco smoke might well be more sei~sitive to them and more liable to devefop cancer. If that is ~he case, al~d we think it is. we have a d~sma] pro- jection to m~Ae; within 25 to 35 years in conslderatien that chlh dl~l~ a~e st~qki~g ~.t atl ~.~fier ~e, ~ c~9.tt e~pect ~/ en~rlr.oll~ epidemic, of lung cancer and smoking-rehttod diseases, particularly ill WoYflen. 1 ~ry to stop people at all times from smoking, anywhere and ev- erywhere l have often said I have been invited to the best of houses once. I think [ have als~ been quoted as ~aying I ha~,e saved -,]
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62 more lives at dinner tab]es than I do at the ~perating tab]es-- which is no reflection on my sllrgery but it i~ ~ form of preventfarl of R IN diseus~g th~ l~bel~ Mr. ~i~y, yo~ mad~ ~ p~i~ ~f~r al~ ~e already have a label and if we change the label, what difference would it m~ke, I think ~n the cessation1 of smoking we need maay, many efforts to ¢/'ea~e a climate¸ Some ~lrc gerleral and some ~ll'e ~ry perusal ~ thi~k ~meb~d~ pi~g Lip a cigarette packet a~d lighting it each day with a warning that is more than the present slap on the wrist wou~d be r~uch be~ter a]erLed than the one~ we presently have. [~ short, c~eer ~ a dread dLSe~e Any of yogi who have had cot~- tact wi~h it can b~ar that out bcyond belie~ You have heard Amanda Blake discuss hers, you have heard Joh~ Forsythe talk about his family memhers If there is any way at all within the realm of the law ~ prevent it~ it would be doing a great act of hu m~ni~ f~r the rest of the people of thi~ c~untry, Thank you very much. [Testimony resumes on p. 1~2.] [Dr. Co.han's prepared statement and periodicals follow:l -5
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63 TESTImONy OF W~LLIAM G. CAHAN~ M.D. Mr. Chairman, member~ ~f the C~mmitt~e, • feel privileged S~iety, a vol.ntary health o~aniz~t£o~ w~th over 2 ~±llion active v~l~nteer~, ~edic~te~ ~ f~h~ing c~n~r. Heca~se of th~ iJ~A~te ~ the ~l~ic~n Cance~ Society it is L~t fl~t~n~ tha~ we ~f~r o~r testimony ~ str~ng ~upgo~t ~f ~.~. 495~, the C~mpreh~siv~ Smoking Present,on Education Act o~ ~981. I a~ professor of Surgery ~t t~e COrnell ~ivers~ty Medical C~lle~e, an~ ~erve a~ at~en~in~ sure.on, Th~ ~'hora~ic S~ViCe of Memorial H~spital, i~ the Memorial Sl~an K~tterin~ Cancer Center. I am a lon~ tlme active volunteer of the American T~acco ~nd c~ncer of the Society'~ National BOard of D~ctors, ~n~ curren~l~ serv~ o~ ~e Su~t~'s Ad ~OC Co~E~itte~ ~n ~bac~ Habituah~n. I f~el that i ~an ~ddress the problem o~ tobacco an~ can~r from a r~her ~pecial perspectiv~. In addition to m~ i~rest¸ in T~ra~ic s~ery, I h~ve also had an inte~ interest in experiments i~ animal~ w~ich ~stabli~hed ~hc ~a~sal r~latio~hips ~etw~en smoking and ~ance~. 0~
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64 I would like t~ commend you, Mr. Chairman, for ~ou~ leadership and ycu~ foresight in s~ng t~ important p~eventive health ca~e m~asure. I w~ui~ also l~ke to ~ay h~w pleased I am t~ be able to testify a~ part of th~ distinquished panel. ~he wor~ that ~he Ar~e~±¢~ Callcc~ Society will b~ doiElg on this bill tug~th~ with the AJ~erican Heart Association, the ~e~ica~ ~un~ A~U~[at~on a~d the National Interagency Council on Smokinq a~d Health~ i~, ~ hope, just the beginning of a coalition ~edicated to educating A,//ericans t~ the d~ngers of ~mokin~. We ar~ all extremely exc±~ed ~hout the potential impa~t on the smoking p~bl~m in ~his country resulting ~rom the joini.g of forces of our o~ga~izations. The reason we are t~stifyinq together i~ to underscore t~e amount of energy ~hat our o~ganizatio~s ~re willing to e~t t~ ~ncourage t~is vital hea~th e~f~t. The ~easons for our dedicat±o~ a~e clear. T~da~, 54 mi~ionAl~ericans will light up a cigarette a~d we know that smoking w~ll contribute t~ the ~eath of ~v~ 3~,000 ~£ ~h~ this year alone. 43~,~00 /~le~lcan~ will di~ f~om ~ll forms of cancer in 1982~ According t~ the ~ebruar~ 22 ~urgeon General's report Pn the Health Consequences o~ Smokin~ 129,0~ of th~se d~aths will be caused by ~he u~e of tohacc~ products.1 ]
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6~ 85% of ~he 111,000 lunq Cancer d~a~hs thi~ year will be smoking relaL~. We ~now f~o~ the Su~g~ Gener~'~ r~ort appro~imatoly duuble ~ose ~ nGnsm~k~ ~d for ~male smoker~ ~he d~th ~ate i~ ~pp~o~lma~ly ]0 peru~t ~gher. T~e Surge~ ~neral found t~at cig~rette smoking w~ a m~jor cau~l of l~n~. l~rynge~l, oral C~vity, ~nd esophageal Cancer. It wa~ al~ ~ou~ ~o be ~ c~ntribu~ory f~ctor t~ ~ladder. kt~n~y and pan~r~a~±~ c~cer. In ~dditi~n, h~ ~o~e~ cigarette ~Oki~ and ~toE~a~ cancer t~ a p~ssible ~ci~ti~ ~etw~en ~m~ ~nd u~er~e and cervical c~nc~r. What i~ eve~ ~rs~s th~ cancers ~t cl~s~l~ associate~ wi~ ci~a~ett~ smoking Ilung, es~?hage~l~ laryngeal, ~al ca~it~ and ~ancreat~c c~nce~l, can be t~e mos~ difficult o~e~ to ~reat, ~h~ can~s w~th the l~st hope ~r survival. For ~xampl~, t~e Qv~rall 5-y~ar ~ur~±~l ~te for l~n~ can~er is ~nly 10%~ ~or c~nc~r ~f esophagus, 4% ~nd for ca~er ~f t~e p~cr~, 2~.2 ~£ t~s y~r, t~ Pre~d~nt of t~e A,l~e~i~a~ C~n~ Society, ~r. Robert Hutter, ~±d: Q~ p~ C~
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66 "~th~n w~ hear of a bad a~id~nt £nvolvinq 20 o~ 30 people everyone i~ horrified and offi- cials @ta~t clamoring fo~ m~e COnsumer pro~ tectio~. Hu:e ~e bare a sit~ati~n in which two to three h/in~ed people a day ale be~n~ killed by robac~elated can~ a~d these people have been given v~t~al~y no p~otec~ AS a physician who mLJs~ care ~or victims of ¢i<Ja~et~e sm~kincJ, I can ~t~Lt~ wi,th cr~rl~.iction to th~ members of th~s Committee that d'~i~lq f~c,r~ lu~lg c~r~c~r is one ~f the ~J~Js~ r~.aful ~xp~lJ'iences a h~l~lar~ bein~ c~tn cIo th~oLl<Jh. ,i,l~ pe~mit t~eor, le to klJ.~, themsel%.e~ 1:his ~ay ,~it~lo,Jt nta~ing ~-h~ hazards ~l~y clear le~.sl~lt<~-s, ~lus,¢ l~,t all~L~ t~L cc, rltin~Je. The ~leri~a. Cance~ society s~:on~ly s~ppnr~s the efforts ~ ~be ~ponsors @f ~h~ legislation ~ m~J~a~n a £~m~l ~ffice ~f ~llloking an~ H@~lth. S~¢h ~n office ~ed~c~ted solely ~0 e~u~atingA~le~icans to the da~ge~s of smoking an~, in a~diti~n, wo~ing to eliminate the AJ,erican ~m~kinG habit is v~t~ to the V~IU~C~ry ~alth sec~ ~ r~l ter~ aa ~11 a~ ~ymb,~l~ca~ly. W~ ~ed a ~roup of I~owle~gable p~es~on~ls a~ th~ federal lev@l in such an ~ff±ce c~u~itted h~ ~his ~ause. ¢D
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V 67 we a~e al~o pleased that the Chai~m~n h~s ~h~wn a~ interest in adding to his legislation an amendment whic~ wou~d require that all cigarette c~mpa~ies li~t w~t~ the secretary ~f H~S all t~ba~CO additives. We a~e ~o~ a~k~ that the t~de sec~t~ ~n th~ tobacco ~ndust~y be ~e~eale~. Howe~e~, t~e AC~ questions why th~ ~i~a[et~e ~nd.~t~y ha~, fo~ so long been exempt from a~ ~eq~rem~nt to list thei~ additiv~ wh~ m~st ~the~ ~onsu~ab~e consume~ goods ~ave ~t h~ such an e×emptio~. In ~dditlun, we a~ well awa~e that c~a~ette ~m~k~ng ~s ~an~ous. It i~ vital, that at t~e very leas~, g~ver~ment scientists be given an ~ppE~rtunity ~o tes~ the health impacts of burning and ~nhalin~ such fl~ori~ additives as cocoa husks. The scientific an~ m~a~ c~L.l,unities must also be allowed to ~est these a~dit~ves S~ a~ t~ ~r~t~t the 54 ~llion ~m~k~s ~nd fo~ t~ose ot~e~ millions wh~m we a~e n~t re~hing t~h e~ucati~n eff~s wh~ ma~ ~t s~t tu s~ke. I ~n~w the la~elin~ provisions ~f the legislation raise s~me g~est~ons. ~ cannot ~ay fo~ suze that six rot~tin~ la~els listi~ exactl~ t~e ill effects o£ cigarette ~mokin~ will ~ak~ the difference. I ~a~ s~ that in 1979 13.5% o£ b~ys aged 15 an~ 16 ~d 11.8% of girls that a~e a~e ~e~ula~ smoke~s2 I ca~ ~ay that at ages 17 and 18, th~ incidence l~c~eases to 19.3%
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68 for b~y~ and 26.~% for g~rls. AI~O, the ~e~c~ntaqe of ~i~ ag~ 17 and 18 who smoke hal risen sharply sin~e 1974. On~ further p~i~t, by 1983, acco~dinq ta statistic5 from th~ National Cancer Institut~ lunq cancer will o~t4i~tance ~r~ast can~e~ as %he nu~be[ on~ c~n~er killer of wnm~n.3 our children a~e risking their lives, po~ibl~ because of cl~v~ ~ver~ising, combined ~th the ~arious re~ns that influenced ~o many p~ple ~o be~i~ smoking ye~r~ ago~ ~e~ pleasure, peer imitation, ~ayi~g it looks SO ~ophis~a£ed, grown-up, etc. ~ the ve~ l~as~, we mus% gi~e them ~he ~est information ~ho~ the ~aza~ds o~ cigarettes to ~e~mit them t~ m~e an i~formed decision. An ~TC staff ~tud~ ~a~e ~o ~he f~llowln~ conclusi~n~ ".,.many [smoker~1 a~e una~ar~ ~ %h~ existe~c~ of th~ ~elati~nshi~ between ~mokin~ and ~ome ~f ~t~ ~t s~ri~ a~d ~idesprea~ ~l~th c~,nse quence~, s~h as heart dis~e...Som~ of ~he health con~eque~ce~ ~f smoki~, s~h as lung ~ow~ve~ even for l~g cance~* the mo~ w~ll known health ~ff~ct, som~ s~b~tamtial g~p~ • i~ consumer ~nowled~e are evident.~ C ~n C~
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69 We have an obli~t±o~ to fill those ga~s, especially fo~ tho~e 17 year old gi~ls ~ho ar~ lighting up a c~g~rette today co~preh~d that they ~o~ld get oral c~v~ty cancer ~nd wo~ld h~e t~ underg~ the difficult ~nd painful ~h~b~litation that is necessary t~ overcome tl~e d~sabilities a~oci~ted ~h t~t disease. ~t eno~gh~ Mr. Chai~a~, th~ Collgress's own resed~ch a~rk~y, t~l~ Of~ic~ of Tecnnology Assessment, in i~s A~ESSMEN~ OF TEC~OLOGIES FOR ~ET~Y~NING CANCER RISKS F~OM T~ ~NV~ONMENT, ~ted J~n~ 198~, ~t~tc~ that tuba~o ~luuking ~i~ th~ ~ingi~ ill~e~ d~a~il~t~, and de~th ~n the U~ited ~tate~." The OTA ~epo~t ~t~s a WHO ~fc~en~ st~ti~ ~'~okln~-r~lated di~ea~ ~re ~uch ~po~t~nt C~uses of d~sa~il±ty and ~em~tu~e de~th ~n d~eloping co~trie~ t~at t~e c~ntroi of cigarette s~oki~g co~trie~ than ~ny ~±mgle a~tion in t~e ~o~ fi~l~ of ~e~enti~e medicine.~ Q~
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L~ "B9 99 ~ L~ :~p~sn~ S~1~ ~ sn dl~~ ~ OL _L
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V 71 CIGARETTE SMOKING AMONG TEEN-AGERS AND YOUNG WOMEN US DEPARTMENT OF HEALTH EDUCATION, AND WELFARE PUbhC Hestlh Service NatLona~ InstJt ut~ of Health C
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Contents 73 Introducbon ..................................................................... 3 HOW the Study Was Conducted ................................... 4 Summary ......................................................................... 5 Findings in Brief The Teen-Age Smoker .............................................. 11 Young Women Smokers ........................................... 16 The Balance Sheet ........................................................ 91 Charts 1 Cigarette Smoking Trends .................................. 22 2 The Gids Are Smoking More Than The Boys .............................................................. 22 3 Antiemoking Message ......................................... 23 4 Pervasive Smoking .............................................. 24 5 Saw Or Heard Anbsmoking Commercial ........... 24 6 Teen.Age Girl Smokers More AdvllnCed ........... 25 7 Self-Gonfident Teen-Age Gid Smoker ............... 25 8 Cigarette Smoking and Teen-Age Girl Rebelliousness .....................................................26 g Smoking As A Social Asset ................................ 26 10 Schools With Smoking Areas ............................. 27 11 Smoking Among Peers ....................................... 27 12 Most Teen-Agers Think ...................................... 25 13 Kinds Of People In Ads ...................................... 28 14 Barriers TO Smoking ............................................ 99 15 The Militant Nonsmoker ...................................... 2g f5 Most Antismoking Education .............................. 30 17 Young Women Smokers vs. Nonsmokers ........ 30 18 Heavy Smoking Among Housewives ................ 31 lg Who Encouraged You TO Quit? ......................... 31 20 Potential For Quitting ..........................................9f Note: The findings reported in this pamphlef are part of an extensive research project on smoking among teen-agers and young women conducted in 1975 for the American Cancer Society by YP.nkelovich, Skelly and White, Inc.
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74 Introduction. Why do some teen-age gids and young women smoke, while others do not smoke? This is a major question facing the antismoking forces in the country. FOr all around th6re are signs that even as the adult population of the country is beginning to cur~il its cigarette smoking, the nation's young, specifically teen-age gids and young women, are now more likely to smoke and to smoke more than in the past. Many theodes have bean developed to explain this phenomenon, including; the women's liberation movement, the increased number of young women entering the work place, and the intensive advertising efforis of the cigarette industry targeted at this audience. Yet, Iglle specific information has been available from the young people themselves--including the extent of their cigarette smoking, who are the smokers and nonsmokers, their attitudes towards and motivations for smoking, and most important of all--present and potential barriers to cigarette smoking. With the belief that this kind of information was vital not only to their own antlsmoking efforts, but to concerned parents, educators, public health officials, community leaders armd government authorities, the American Cancer Society sponsored this study. It's purpose is not merely to assess the incidence of cigarette smoking among these groups, but to understand the dynamics of what is Occurring and what steps the American Cancer Society and nthor angsmoking forces c~.n ~ke to reverse this trend. h ¢, ¢J1
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76 How the Study was Conducted The study was camed out in three phases: Phase I: A Literature search of articles and research studies concerning cigarette smoking ~mo~g teen-agers and young women. Phase I1: Focused group discussions with bOth teen- agers and yOLmg women--smokers and nonsmokers--for the deveropmerlt of initial hypotheSes and the development of the questionnaire, phase Ill: The study itself is based on a national representative sample of 3,009 households, from which were selected projectable s~bsamples of respondents for the following group~: Young Women (18 to 35 years of age) Total 559 Smokers 227 No,strokers 227 Former smokers 105 Teen-age Girls (13 to 17 years of age) Total 267 Smokers 125 Nonsmokers 142 Teen-age Boys (13 to 17 years of =ge) Total 246 Smokers 127 Nonsmokers 119 In all, a total of 1,072 teen-egers and young women were ~te~tawed in ths~r homes v~ith a ~er~thy ~nd detai~ed Questionnaire. In no case was more than one respondent interviewed per houSehold Interviewing took place during the months of October and November, 1975, C t J1 ¢=
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76 Summary The results of the study point to several important trends and some surprising findings, 1. Cigarette Smoking Is On The Rise Among Teen-Age Girls: From 1969 to 1975, cigarette smoking among teen- age girls has increased at the rate of 23%, Today/ 27% of all teen-age girls smoke cigarettes either occasionally or heavily compared to only 29% in 1969 Translated in(o people, this increase means that half a million more teen-age girls are now smoking. Oudng this same period of time, however, cigarette smoking among boys levelled off and remained at the 30% level. What has clearly happened is that teen-age girls have nearly caught ~p with their male counterparts (See Chart I), 2, Teen-age Girls and Young Women Are Smoking More Heavily Than In The Past: Dt~dng this same 9eriod of time, pack-a-day-or-more smoking has increased fourfold among teen-age girl smokers. In 19691 10% of all teen-age girl smokers smoked at least a pack a day compored to 39% now. Boys, on the other hand, continued to smoke at the same levels as before. The smoking scene among young women more closely duplicates the psttern for teen-age girls. For while smoking incidence has shown onty a slight increment among young women (34% in 1965; 36% now), the proportion of heavy smokers--particularly really heavy smokers--has accelerated sharply. According to the Uniled States Health Survey, conducted in 1965, one out of two young women smokers (51%) were smoking at least a pack of cigarettes a day, By 1975, the figure was 61% with the sharpest increase among the more-than-one- pack-a-dey group (up from 9% in 1956 to 25% new), Currently, then, the locus of the smoking problem is among teen-age girls and young women, {See Chart II). b t~
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3. Yet, The Antlsmoklng Message Has Been Heard: This increase in the numbers and intensgy of cigarette smoking among young women and teen-age gi~ls has occurred at a t~r~e when these young people were at least intellectually fully aware of the hazards of smoking. For a substangal majority of the group the message has come through loud and clear: • $i/~kin9 is ~$ ha~ml~l ~oi vl~ as f~ ~ (74% teen-age girls; 80% young women]. • Smoking is as harmful for young people as well as for older people (71% teen=age girls; 71% young women), • tt is rot sate to st?,oke ~w t~ ¢igaret'~e~ (56% teen-age girls; 54% young WOnlen). • Smoking during pregnancy can harm the fetus (58% teen-age girls; 62% young women). Among young smokers, 56% of the teen-age girls and 62% Ot the young women believe wholly or in part thai smoking is as addictive as Illegal drugs. (See Chart III). Yet they still smoke and start to sn~oke in greater numbers and with more frequency tllan in the past. The question is why? These trends help to explain the reasons: to
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4= 78 The All Pervasive Smoking Environment: While young people continue t~ be aware of the antismoking message, the situation all around them and their own perceptions of who and how many people smoke more than counterbalances the impact of what they have seen, heard or read about the dangers of smoking. For example, among teen-age girl smokers: • 62% of aU teen-acje ~ids think of teen-agers as smokers rather than nonsmokers. I Two out of three believe that more women are smoking now than a few years ago. • 72% of the gids with boyfriends report ~hat their fellows are smokers. • 66% say that half of their friends or more smoke, • 87% smoke with their parents' knowledge; 34% with their parents' approval • 84% have fathers who smoke or smoked; 64%, mothers, Add to this the fact that: • 49% of the teen-age girls who smoke report that their schOOls have special "smoker" rooms where it is permitted to light up during the school day. • And 68% of the teen-age girls who smoke indicate that their own doctors have not warned them against smoking. ¢=
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79 5. Fewer Antismoklng Commercials: Another key factor too, is that awareness of antismoking television commercials, has been cut drastically as a result of the retrenchment of free matching time following the barring of cigarette advertising on television, In 1969, 88% of all teen- agers reported that they had seen or heard an antismoking television commercial in the past 4 weeks. Currently, only 48% are exposed to this type of television spot. On the other hand, the kinds of people identified with cigarette advertising include the following: attractwe, sexy, enjoying themselves, young, well dressed, and healthy. (See Chart V). 6. Changing Moral Norms: Further bolstering the impressions of the all pervasive smoking environment and especially helping to explain in pad the sharp increase in smoking among teen+age girls, are the cbs.nges in the prevailing social norms¸ For compared to tha teen~age girls, teen*age boys have changed less th~n the girls in their attitudes, needs and feelings about themselves as tar as these relate to smoking, With teen-age boys, cigarette smoking continues to go hand-in-hand with social uneasiness, the need to be popular with the opposite sex, the urge to prove one's masculinity. It is an intrinsic part of adolescent boy rebelliousness--as it has always been @'I C~
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8O With teen-age girls, the picture which emerges is very different. For in this instance a real change has occurred in the prevailing social norms and the differential between boys and girls has been blurred. The teen-age girls, for example, are socially considerably more at ease with their own peers, mQre "sophisticated" than their mate peers, and less in reed of see/el props. Itldeed, the rebatli~usness against adult aociaty--once far m(bre the province of the boys--is now very much a part of the girls' environmer~t as well. Girls are joining in with the boyS and smoking pot, drinking alchohot and getting in trouble with the authorities¸ ~t is nQt just in cigarette smoking that the teen-age ghls are catching up with the boys. 7. The New Vaiues: at genera}, the taen-sge girls he, re bee~l more influenced by the new youth values than the boys. These "New Values", Originally generated by college yOuth in the sixties and now permeating the majority of aft young people~ represent the breakdown o~ previous motsI norms and are characterized by the rejection of Buthority, emphasis on the emotional rather than the rational, freer sextJaL morality, a strong accent on se(f and self-fullillmentl the acceptance of illegal drugs and a more informal life style. The new youth values do not necessarily cause more young people to smoke--hut they make it easier to do what One wants to do and to resist arguments against doing it. ,~The New Mot a[ity" by Daniel yanketOWCh McGraw.Hill, 1974
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8. 81 Opportunities for Change: Yet, interestingly, opportunihes for curbing smoking among young people are also intrinsically tied in with these same new values, For the very emphasis on the importance of salt, the need to be an independent thinker, the importance of physical well- being can provide more effective incentives against smoking than the more tradg~onal threat of future health hazards These, then, are the major trends revealed by the study. What follows in capsulated form, are additional significant and interesting findings relating especially to the increased incidence and volume of smoking among teenage girls and young women. tO 1°
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82 Findings in Brief The Teen-age Smoker a) The Self-Confident Teen-age Girl Smoker:, Even among her girl peers, the teen-age girl smoker stands out as more confident, outgoing and very much at ease in her own social grouping, Parties are her metier. One measure of both her sophishc~.tion and her value structure is the fact that 31% of the girl smokers (ages 13 to 17 years old) have already had sexual relations. Instaid, it is the teen-age girl nonsmoker who tends to be quieter, have Les~ setl-contide~ce, or sett-esteern, ~nd is shy wdh the boys. The nonsmoker is a more devoted television viewer and reader. Sexually, too, she is far less precocious than the smoker. Slightly more than a third (3B%) ha'~e boyfriends and ~t B% ha'~e had sexual relations. (See Chart VII). b) Rebelliousness and Smoking: Cigarette smoking among teen-age girls, however, does appear to be highly identified with an antiauthodty, rebellious syndrome in terms of the adult world. This cuts across parents, school~ institiJgonsmand even impacts receptivity to antismoking messages emanating from adult authorities $ One out Qt ~o ot the teen-age g{rl smokers (53%) are annoyed by the so-called experts who tall them what is good for them (34% teen-age girl nonsmokers). II= Half of the teen-age girl smokers agree that there is too much regulation of people's lives (39% nonsmokers). • Almost half of the teen-age girl smokers want to do something entirely different from what their parents want them to de (26% nonsmokers). 11 cr~ G1 cJ
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83 12 • One out of three of the teen-age girl smokers (32%) hate school (16% nonsmokers); 29% have been suspended or expelled from school compared to 4% of the nonsmokers. c) Cigarette Smoking, Alchohol, and Marijuana: An even more overt indication of the rebellious nature of the teen-age girl smoker is her use of alehohol and marijuana: • Among teen-age girl smokers, 81% drink alcohol compared to 42% ol their nonsmoking girl peers. • Almost a third of the teen-age girl smokers (32%) sometimes drink to get drunk compared to 4% of the nonsmokers. • One out of four of the girl smokers (25%) use marijaana compared to only 3% of the nonsmokers, Among teen-age boy smokers, the same trends are apparent. Yet for all of these current forms of rebellion, the old wood shed image of smoking as a symbol of assertiveness apparently ~ingers or= among teen-age smokers--while the concept of nonsmoking as proof of nonconformity or rebellion against the adult world, society, advertising or big bLJsiness has not caught on. (See Chart VIii). d) Smoking as a Social Asset: For the teen-age boy smokers out to prove their mascstinity, cigarettes are s511 regarded as a social asset. This is not the ease, however, with the teen-age gid smokers. Instead a majority (52%) consider smoking to be a social drawback¸ This may make it easier for her to quitmbut is also one other sign of her flaunting and rebellious spirit. (See Chart IX). C
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84 e) A Permissive Adult World: Smoking as a form of adolescent rebellion becomes more difficult to comprehend in a society in which many adults take a very lenient, if not telerant posture, regarding teen-age smoking, parents know about their teen-age daughters smoking (87%] and 34% condone it. Many schools are providing special "smoker" rooms in line with changing times--even though there are signs that the availability of legal smoking places in the school plant appears to be directly correlated with an increase in teen-age girts smoking. Among teen-age girl smokers, 49% report that their schools have regular smoking areas compared to 32% of the nonsmokers. (See Cha~ X). f) Doctors and Smoking Among Young People: Nor do most members of the medical profession play an active role as antagonists of smoking among young people. For example, 70% of the teen-age girls and 73% of the young women repori that their personal doctor or clinic has not cautioned them at all aPou~ the dangers of smoking. g} Peer Pressure: Peer relationships, long identified as a meier factor in teen-age smoking, continue to operate as a dominant iofluence with teen-age girl smokers, for e×ample, flocking together • Among teen-age giP smokers, 69% report that half or more of their male friends and 66% report that more than haft of their female friends smoke. Among teen-age girls who do not smoke, only 32% claim that half of their male friends smoke and 19% more than half of their girl friends smoke. • Generally too, among the girls and young women, smokers USLJelly come in pairs 13 :.,I
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85 • 72% of the teen-age girl smokers have boyfriends who smoke compared to 27% of the nonsmokers. • 68% ot the young women smokers hBve boyfriends or girl friends who smoke, compared to 41% of the nonsmokers. (See Ch~.rt XI). h) Everybody Smokes= The all pervasive smoking environment, according to the teen-agers, is not limited to their families and friends--but to the whole world all around them. Most teen-agers--smokers and nonsmokers--consider smoking to be a rnalority phenomenon among their own peer group, as well as among most adults. Teachers, executives, housewives, femir~st leaders---all are thought o( as smokers. Doctors and athletes are the only two exceptions, [See Chart XII). Then, too, there are the cigarette ads which help to reinforce the image of the cigarette smokers as attractive, (68%); enjoying themselves, (65%); well dressed, (62%); sexy, (52%); young, (50%); and healthy, (50%). [See Chart XIII) i) The Smoking Rationale: Teen-age smokers, like adults, have developed their own rationale for continuing to smoke. Sure smoking is bad for you--but still and all: • The dangers of smoking are exaggerated for my age grou~ (52% ten-age girt smokers; 64% teen-age boy smokers}. • There's too much talk these days about things that are bad for you [43% teen-age girl smokers; 48% teen-age boy smokers]. • And then there's air pollution which is just as ~mpottant a cause of lung cancer as cigarettes (teen-age girl smokers, 67%; teen.~ge boy smokers, 51%). 14 ~3
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86 j) Battlers to Smoking: Teen-&ge girl nonsmokers divided into two almost equal groups--the Traditionalists and the Vulnerables~ it is easy to understand why the "traditionalists" do not smoke. They are strongly religious, respectful Of authority, and net accepting the new values. They also shy away from their peers who smoke, drink or use marijuana, The other group of nonsmokers, the "vulnerables" are very different, for they share many of the same values as the smokers, and are highly exposed to the total smoking environment. On the surface, the vulnerabtes appear to be ready candidates for the next wave of new smokers: • One out of twG of the vulnerables report that half or more of their male friends smoke. • A third indicate that at least 50% of their girl friends smoke. • A majority of them have one or more parent who smoke, half have siblings who smoke. Yet, the "Vulnerables" do not smoke, Instead they have found, consciously or unconsciously, some strong barriers to smo~ng. These are: • The importance of being in control of one's life. • Emphasis on physical fitness and well being. • Concern about the addictive nature of cigarettes. .15 O ",3
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~Z 16 l And, perhaps most of all by becoming militant antismokers--people who are angered by other smokers, upset by smoke filled rooms, and ready for inoreased regulation of smoking. In o~ber wo'(d$, they are fining ~. new c~.~e and ~= peer identification. (See Chart XIV). k) Antlsmoklng Education: Many teemagers have attended antismoking programs including 48% of the teen-age girl smokers and 49% of the nonSmokers, A large maiority (84%) have found them meaningful, inCluding, however, most of those who are now smoking. The problem is one of timing. Six out of ten girl smokers, for example, have started to smoke before they are thirteen years of age--but have only a~lended smokin9 education classes o~ ~ro~-~ms in the seventh, eight, ninth, or tenth grades of school when if is already too late. (See Chart XVI). Ih Young Women Smokers a) An Independent-MIndett Group: Many of the same qualities which distinguish teen-age girl smokers from nonsmokers are atso apparent--but to a lesser degree--between young women smokers and nonsmokers, The women smokers also tend to b~ mote social a~d ¢~tgo~g, antia~th~riW and strongly subjected to the total smoking environment and "peer" pressure. Over two*thirds of all young WOmen smokers (6E%) have boy thends or husbands who smoke compared to less than half (41%) of the nonsmokers. Their friends also smoke--and they are somewhat more tikely to have come from homes in which one or both of their parents smoked. Compared with their own nonsmoking peers, the young women smokers are readier to: • Have fun now and forget about the future (46% smokers; 36% nonsmokerS}. O~ ,,,} ¢= Oo
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7 88 17 I Rationalize that everything you do these days seems to give you cancer (46% smokers; 32% nonsmokers). • Feel that there is too much regulation of people's lives (41% $mokers; 32% nonsmokers), • BelLeve we are close to tinding a cure for cancer (50% smokers; 45% nonsmokers). Yet they also have one stTong charactedstic which could be used as an integral part of any atlfis~'noking effort--61% of the young women smokers express a strong need to be independent compared to 52% of their no,smoking contembo~a~ies. (See Chart XVII). b. Working Women: Contrary to the theo~ that the increase in heavy smoking among young women is correlated with the greater number of women who are now employed, the findings of the study show that it is ti~e h(~usewtve$--not the working women--who are more likely to be the heavy smokers. Among young women smokers, 39% are employed toll or par~ t/me--and 61% are housewives (or L~employed or students). The pattern for nonsmokers is parallel (37% ~re employed; 63% are housewives) A )ook, however, at the in¢i:Jet~ce bt heavy ~mo~ing-- and the myth about cigarettes and working women is refuted. • Among housewives who smoke, 66% are heav~ smokers; among working women, 53% are heavy smokers. Interestingly, it i$ also the working women who afford the best opportunity tor converting smokers into nonsmokers, accen~uatir~ the desirability of antismoking campaigns directed at the workplace. (See Chart XVtlI). ,.j c~ CD
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89 The myth about the Women's Liberation movement encouraging cigarette smoking is also not substantiated by the findings of the study tot equal numbers of young women smokers (70%) and nonsmokers (69%) identify strongly or partially with the Women's Liberation movement, ¢. Smoking and Pregnancy: A critical period to reach young women smokers is not only during pregnancy but in the months after the woman has given birth. A majority of young women smokers (62%) believe that smoking can harm the fetus. Even more important, during pregnancy, 67% of the smokers have either cut back (32%) or stopped smoking (35%). Unfortunately, however, the abstinence does not hold up--for here they are back smoking once again d. Smoking and Children: Several years ago, when antismoking commercials were far more widely available on television. YOung children were reported to be among the main crusaders ~gainst their mother's smoking habits. Today. over half of the young women smokers with children (56%) report that their children are bothered by their smoking--but there is little evidence that the children are as militant in their efforts as in the past. Among former smokers, for example, very few mention that their children were a major influence in getting them to quit. e. The Former Snlokers: While progress has been made in getting some young women to quit smoking--the main success has been among the light rather than the committed smoker. Most of these former smokers (63%) smoked less than a pack a day. There are, however, important lessons to be ie~tmed from the former smokers: • MOst did quit of their own accord, (50%), some were encotJraged by their boy friends or husbands (28%), a handful by their doctors. 18 ¢t3 O~ ¢, ¢1
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90 • One out of two used willpower rather than substitutes such as candy or gum • Almost none of this age group of young women smokers reported that they gained weight, • Most found immediate gratification from quitting. The feeling of being in control of one's fife, an increased sense of physical wellbeing, the end of cigarette bad breath and smell, and money saved, proved to be stronger reinforcements than even the insurance they are buying against future disease and ill health. (See Chart XIX). f. The Potential for Quftttng: Most young smokers want to quit. Among young women, 70% can be classified as "potential quitlers"--smokers who express concern over their smoking and some eagerness to quit. Among teen-age girls, 58% of the smokers can similaby be classified as "potential for quitting." (See Chart XX), Only a minority, then, are committed to continued smoking. This group expresses little or no concern over their own smoking and tends to deny the dangers of the habit. Indeed. everything about the group suggests that they wgl strongly resist any or atl altempts to get them to give up their cigarettes. The potential quitters, on the other hand, are half way there, but Still need help to conquer their smoking habits: • Two out of three of the potential quitters (65%) believe that once you start smoking it is impossible Io stop. • A majority (60%) agree that smoking ts as addictive as illegal drugs. • Over half (57%) are worried about their weight. 19
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91 • Two out of three (67%) have boy friends or husbands who now smoke, suggesting the need for more emphasis on "quitting couples." • Potengal gLJiffers among the young women smokers also are more likely to be employed, pointing to the advantages of antisrnoking programs directed at the workplace. They are also more involved with clubs and group activities again indicating the desirability of widespread antismoking efforts. Most of all, however, many of these potential quitters are asking for the help offered by more strict regulation of their own and other edopqe's smoking. Among the potential young women quitters: • 55% believe that it is important to take special measures to protect our health. • 46% want to see stricter regulations of where one call and cannot smoke in public. • 31% want to see cigarette advertising in newspapers and magazines regulated. They are, in other words, looking for allies and support from the ali-imporlant militant nonsmokers who support the same causes even more strongly. EO ¢b G~ -3 $I
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92 The Balance Sheet Teen-agers and Young Women The Plus Side • Smoking is a minority pheFlomenon • Teen-age girl smokers do not consider smoking to be a soci~.l asset • Smoking is not a necessary social prop--at least for the girls • The "evils" of smoking are known • The militant ilonsmoker--a new form of peer pressure • Most smokers want to quit • Most young smokers are not yet committed • The New Values: emphasis on self, self- control, self-fulfillment • Impedance of physical appearance and fitness • The example of the former smokers • Pregnancy and smoking • Children as allies • Fear of gaining weight is not an inhibiting factor • "-he readiness for antismoking regulation The Minus Side • The increase in smoking • The all pervasive smoking environment • "Everybody smokes" theory • Health hazards are seen as exaggerated for teen-agers • Relaxation of restrictions at home • Boys still smoke to express their masculinity • Smoking rooms in schools • Cutback in television antismoking adverlising • Peer pressure; smokers come in pairs and groups • Parents who smoke • The advertised image of the smoker • Doctors don't speak up • The New Values: Antiauthority, emphasis on the emotional rather than the rational • Belief that smoking is addictive makes quitting harder • The problems of being a housewife encourages young women to smeke • "The cure is just around the corner" crutch for smokers ¢= CJ
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-4 I11 Q b~ > ~D~D W m 0 rn Z .i m 0 ¢) g~ e~ J ,
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1 ~m 0 M I11 0 C) ~&~059
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~D
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96 CharL6 TEEN-AGE GIRL SMOKERS ARE MORE ADVANCED SOCIALLY THAN THEIR MALE PEERS TEEN-AGE SMOKERS Girls Boys % % Going to parties and da[~ces is a tavorite 75 81 leisure time activity It's Importanl to me to be popular with the 4~P 61 opposite Sex Smoking is a social 37 55 ~$$et M~+eting new people an~ being [n e Mew sit uat[on makos me 32 45 I~ervou$ Chart 7 THE SELF CONFIDENT TEEN-AGE GIRL SMOKER TEEN-AGE GIRLS Smokerl Normmokem % % Paltie$ 8re 8 favoritO 75 58 leisure time activity Havea boy friend 64 3~l Reading is a I~vor]te 39 61 iei~ure time activity I often feet I~nt not 34 SO very good at things Meeting new peoF>lo makes 32 46 me rlorvou8 I have had $e)Cual relalVJn6 31 B 25 ',3
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97 CIGARETTE SMOKING AND TEEN*AGE GIRL REBELLIOUSNESS Chart 8 Drink alcohol 81 42 Sometimes drink to 32 4 9et drurlk Have been ~ uspended or 29 4 expelled from school Use marijuana 25 3 Ran away frcm home 25 10 SMOKING AS A SOCIAL ASSET Chart 9 TEEN-AGE SMOKERS Girls Boys % % Srnokingisasoctalasset 37 5S Smoking is a drawback 52 31 Neitherone/both 13 11 26 C h~
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98 SCHOOLS WITH SMOKING AREAS 49% 32% THe-Age Girl Teen.Age Gid Smokers Nonsmokers ChartlO SMOKING AMONG PEERS ~oyf fiend smokes Half of maJe f fiends Smoke HaJf Cl fomale friends smoke Chart 11 TEEN-AGE GIRLS Smokers Noll,mokerl % % 72 27 69 32 66 19 27 C~
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99 MOST TEEN-AGERS THINK ALMOST EVERYBODY SEEMS TO SMOKE Chart12 Usually Think of as TEEN-AGERS Smokers Rather than Girls Boys Nonsmokers % % Teen-agers 82 84 Women execulives 69 70 Housewives 67 54 Feministleade~ 64 "76 Doctors 30 30 Athletes 9 11 Teachers 68 67 Chart13 KINDS OF PEOPLE SHOWN IN CIGARETTE ADS Teen-age Girl Smokers % Attractive 69 Enjoying thernselves 66 Well dre~,sed 66 Sexy 54 Young 50 Healthy 4~ 28 I/1 ,q
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1nO BARRIERS TO SMOKING Chart 14 How "Vulnerable" Teen-age Girl Nonsmokers Differ From Smokers Dilfnrenne belween '=vulnerable" non* Snlokerl and current $1tlOkell I am the most a~ismokittg ++.p.F+ pamon in my family Beingin e smoked firmed +÷++ /onto annoys me Believe smokJn~ cigarettes +.F.F+ is a serious h ~allh hazard ~eirtg around smokers i$ a serious heaJth hazard ++ + Enj°y sP°de ++ Would welcome more emphasis on physical ++ fitness Support regulating smok n~z in public ++ Each ~ represents a I O% ¢ilffer elr¢ e of "VulnnrabJe" nonsmokoPs over smoker8 THE MILITANT NONSMOKER I find being in e smoke filled room v~ry annoying I favor regulating where Smokers Cart and cannot Snlok~ I faro r regulallng adv~+l S ng of cigarettes in n~w~aper$ end m~gazine$ Being arOUnd people who smoke I$ e serious h~alt h hazar.d Chart 15 TOTALNONSMOKERS Teen-age young Gid$ Women % % 6O 70 58 65 47 42 29 30 29
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101 Chart 16 MOST ANTISMOKING EDUCATION IS TOO LITTLE AND LATE TEEN*AGE GIRL SMOKERS % Started to srn eke before 60 13 years of age Attended antismo,dng 48 education program in sch(301 Attended antlsmoking 4 education in 6th grade I12 years o~d) Chart 17 YOUNG WOMEN SMOKERS VERSUS NONSMOKERS Have A Strong We Are Close To Have Fun NOW Everything Need TO B~ Finding A Cure And F¢ rgcl you DD Th~se Days ~ndependent For Ca~cer About The Future SEems TO 30 Give You Cancer ¢T: C r J1 b;
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102 HEAVY SMOKING AMONG Chart 18 HOUSEWIVES VERSUS WORKING WOMEN Smoke A Pack Or More el Cigarettes A Day % Housewivea 68 Working Women 53 WHO ENCOURAGED YOU TO QUIT? Chart 19 % NO one/did on own 50 Husband/boy f rien(} 28 Relative (parent, sister, etc.} 13 Dockor 3 Friends 2 ChiFdren 2 Olher 2 Chart 20 POTENTIAL FOR OUITFING Confirmed ~ Confirmed Smokers Smokers FotBntial p0tentJa L~uqtlers Qujtlers Teen-age Girl8 Young Women C~ Ca
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108 DANGERS OF SMOKING BENEFITS OF QUITTING & RELATIVE RISKS OF REDUCED EXPOSURE REVISED EDITION An up la date summary of'tile key scientific and medical studies, plus new mfonnatkm ol/ economies, psychology, pharmacology and other aspccts of tobacco smoking and health. American Canoer Socqety, Inc. 777 Third Avenue, New Y~rk, Ne*v York 10017 ~q -O #h
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104 IABLE OF CONTENTS TITLE ]ntmduetion Dang~-i s Be,milts. Relative Hi~s l M{~rtali~y, Disabflit y and Chronic lIhless II I,uog Cancer llI Other Cancels IV IIeart Attacks, Circnlatnr~ Diseases and Strokes V Er Iphysema Chronic Bronchilis and Other Nor>Cancerous Lung Diseases VI Smoking and PI e~rlancl, Drug Melabolisnl, Medical Tests VII Tile Smoking Hal)it: Psychology and Fhsu ma~ology VIII SnlnklngEconomi(simdStatislics Bibliography Appendi× Subjec~ ludex ~mth(n Index 5 7 10 16 29 84 89 46 55 62 7,5 7(, 7g 8(J
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105 INTI~ODUCTION WiLlliIt the past 15 years, the habit of star,king tobacco rr~nly in ¢~garettes-has been universally condemned by author~ t~bve medical group~ and government medical ot~cers ~s a leading cause of death and a major public health problem in developed &llltltrles: ~ "A~ impor tent a cause of death as were the great epid¢~c diseases that al{eeted previous generations in ~hi~ country." [British Royal ColIege of Physicians, 1971]1 ~ ~e largest preventable cause of dealh in America." [See- retary Joseph A. CaIifano, Jr~, US Department of HealS, Eduea- tlon and Welfare, 1979]~ ~ "No longer any doubt..., a rnajvr and certainly removable came of ill2~ealfh ~nd premature death~ [World Health Orgaaiza- ~on, 1979]~ The purpose of this booklet is to summarize the latest m- formation about smcJking and health, dcrived from thousands ~ epidemlo[og~cal, biological, pharmacological, pathologlcal and other shldies. The present booklet is an update of the one published by the American Cancer Society in 1972 ~nder ~c title "The Danger~ of Smoking, The BeheSts of Quitting" which smlaaafized key stadies, beol~, and major surveys starting with that M thv land- mark report Smoking and HeaI~h of th~ Advisory Committee to the Surgeon General of the U $ Public Health Service i~ 1964, On the 15t,h anniversary of the famous 1964 report, ~anu- ary, 1~79, tile pre~ent Surgeon Ceneral, J u]ius 1~ Richmond, M.D~ issued a new report tltlcd S MOKING & HEALTH composed of 22 dela~led seien tit;c papers ~mpiled by 12 agencies ia the Depa~b ment of Health, Education and ~,Velf ar e and reviewed by scientist~ re~gnized as experts in the di~erent ~3 e hts The then Secretary of HEW, J'oseph A. Califan~, Jr, wrote in fl~¢ in~roductlon that the new repc~t ~dcmol~shes the elabns t. Smoking & 11 ,a]ta N~, ~t,aa oE I~n~al ~:~1~- ~ Phrs~an~ of Load~ ~I'ttmln l'0
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106 n~' by Cigal'~tt~ lJlunufac2tu¢crs ~lld • • other~ . • . that the ~c~ ~ntil~e cvidencl~ was ~kctchy; that n~ lin[~ between slnokln~ and is ~ru]y s]ow-motion suicide." ]'his booklet 1he Dun~¢m o~ S~oking, the Benefits of (~i~tir t ~ ~ttd ~thxced bSxp~r¢ a~ds, ~ tll~ ~ria[ ~'¢e~e3, ha th~ original The Dangers o~ Sm~klng, Th~ B~nefi~ o~ Qui~ting, the l~test ~thng~ in th~ 1979 Surgeon C, en~ral's rPport, and other t~EW rc~I~Orts published sin~ 197"2, pIus those of ~hc 1~)79 report, "Controlling th~ Smoking Eplderai~," ~f the World Hea]~ Organ i~a~on, an~ a n~m~oel of i e~n~ in divldua~ $lu~. Only the ra~t ln~r~Jnent i~v~ti~tlon~ ~Te ~it~c[ and~ in many c~ses, the findings o~ nla~,y ar~ merged. V~rher~ a ~tuglc sludy Js described d~recfly, the re~renc~ is given in ~ footnote; w]lere ~wral are abl'idged or described flora ~nother source, a g~nc~l l~age r~ierence is giwn to ~he survcy p~blleatlon ill wl~ieh the raat~ial aI~pe~rs g~nerod references n~l~d [SC,] [Diehl] [lloyalj [WHO]. [ ga .q
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107 DAN(;EBS, BENEFITS, lIE LAT~rE RISKS Fo]lo~nng is the ~rst chart to codify in simplified terms the dallgers of smoking, th~ ben~t~ of quitting, and the r elaln ve risk~ of smokkng low tar/nicotlnc/£1ter-tlpped clgarettes. All tobacco-smoklng damage seems to be dof~ related: tn the age at which ~e smoker shorted, t~e number of cigarettes, pipes or cigars smoked per day, the length of tame smoking has take~l place, whether or zJ~t the smoker inhales, hew deeply the smoker inhale, h~w m~eh of the elgarette (or pipe ~r c~gar ) is smoked, the tar an({ meet/he content ~f the smoke. Thus, any diminution, or chaiLge, lu ~Jy of the variable elements wnuId affect th c smoker's ri~k; an~] I/ui~ing entirely ~[1 reduce risks progressively over a period of time, prov/dlng irreversible tlssuc changes }lave not ta]~ea place. The smoker wh~ qufff also achieves many immediate health behests. The ~rst is a rapid dec]ine in the ca~on monoxide level in the blood within twelve hours. Ileadaches and stomach ~ches c~used by smoking (]isappear SLandna alld vigor improve¸ Ofte~l e~. S[lloker~ [i oilce a keel]er ser~e ¢1~ t~ste a~ld Smell. Bnt there are rosiny rrlt~re h~por tlltlt, long term hea]th ~nd llfe saving ~enefl~s ~rnm qtHtting ci~ret'es See chart on the fo~- loving two pages -,]
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108 RISKS OF SMOKING Risk: Sh ode,led life expectancy, 25-year-old 2- pack a day smokers haee fife expectancy 83 years shottor tha~ ann-smoking COntCffl pDrafies. Other smoking levels: proportional ris~; Risk: Lug cancer. Smoking cigarettes ¸'major cause in both men end wome~¸¸ [SO 1979) Risk: Larynx cancer, In all smokers (including pipe and cigar) it's 29 to 17.7 times 1hat of nonsmokers. Risk: Mouth cancer. Cigarette smokers have 3 to 10 times as many oral cancers as non- smokers. Pipes, cigars chew ing tobacco also major risk factors AIcoboJ aesms synergistic caroi~ogen with smoking Risk; Cauccr of esephagu=. Cigarettes, pipes and cigars inereaser=skofdyingofesoph ageal ca~ccr about 2 to g times Synergistic relationship between smoking and dido hol. Risk: Cancer of bladder, Cigarette smokers have 7 to 10 times r~sk of bladder cancer as noremokers Also synergistic with certain exposed occupations: dye- staffs, etc Risk: ~nc~r el pancreas. Cigaretle smokers have 2 to 5 times lisk of dying of pan- erratic cancer as nonsmokers. SENEFITS OF QUITTING Benefit: Reduces risk of premature death nomnlatJveFy After 10 15years,e,l.smokers¸ risk approaches that of those who'ee never Smoked¸ BenefJt:Gradualdecraasein risk After lgq5 years,risk approachealhatnflhnsewbo ReverBraDked. Benefit: Gradual redunllon af risk attOr smoking ceseatiou Reaciles nelmal after 10 yeall;. BeneRi: Reducing or eliminat- ing smoking/drinking redness iisk in first few years; ri=~k drops to level nf nonsmokec$ ia 10-15 years. BIUIIIi: Since risks are dose [elated reducing or eliminat- ing smoking/drinking aheuld ~leve ri~k-redaBing elleef. Benefit: Risk decreases gradually to that @f non- snickers over 7 years. Beiefit: Since there is evidence of dose-reraled risk reducing or eJiminating smoking sJlouid have risk reducing effeot RELATIVE RISKS: FILTER-TIPPED, LOWT/N BRANDS Redgced risk of death frunl certain diseases Isee below) implies increased life ex- pectancy Flit er tips reduce risk, b~t it is stiIJ 5 times that of non smokers Low T/N brands reduce male risk by 20%. female risk Oy 40% FJlt er trps ;educe risk 24 to 49 pelcent, NO identified henBfit No identified bennfil No identified benefit Na identified benefit 08 ¢,I "4 Z~
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RISKS OFSMOKING Risk: Pupils ulcer. Cigarette smoRer$ q~ mor~ pept[c ulcers and die mDre often of t~em; cure is more difficult iu smokers. Risk: Allergy amd Impairment ef imlliile System. 109 BENEFITS OFQUITrlNG Benefil: Sharply decleases risk after one yean After 10 years eX Smokers risk is same as that nl those who n~,er Smoked Benelil: Cough and sputum dbappear during first low weeks Lung run,lion may implnml and ~t~ ol d~criora- tiDn slow ~O'~ Benefit: W0m~n who stop smoking beinre 4L~ month of preg ~aney eliminate flsk M slillbi~ h a~ low blrlhwe~hl caused by smoking ~nel~; SiBCe childlan ~ aan smoking motb~rs are bigger and more adwaced socially, i~lerenee is fh~ not $~lolllng d~fin9 pregnam©y might avoid SBeh inderdevelop~ child roll. Benefit: E×-smo ker~ g~t ucler$ but Ihuse are mort lilly t~ heel ~pldly a~d oDmpl~ely th~n those of ~mo~r$. Beme~il: Sinoe these are direct immediate effects of smoking¸ thn~ a~ obviously a Voldlible by nut smoking, Bandit: MDoflty ~ blood Iwmpo~nts el~aled by imel~ leg i~gr~ hi nQrmll illlllt oo~satlOn, Nonsmoker~ on PiR have much lower risks el thrombo~i~ RELATIVE RISKS: FILTER-TIPPED LOWT/N BRANDS LOW T/N male smokers had 12 percent Iowel CBD rate, lemale ro,v T/N ~nokers 19 percent lower than high T/N Smokers NO identified benefit NO identified benefit NO identilied benefit NO identified benefit "~o identilied benefit 08 01 6a
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110 I-MOlqTALITY, DISABILITY AND CIIRONIC ILLNESS The most direct result o~r srooking is visible i]1 the differ. en~es between the death ra~¢s o~ smokers at~d Emnsmo~rs ~n the same age groups; grid in the diffezences ha Ihe number of years o| Iife between the two grotJps "Death rate~ azc ~l~dfformfy |figher among srcoker~ th~la ai~ong nonsniok~rs, in both sexes, and whatever the age at death. The e.'c~ea~ ro~rt~,l~ty of clg~Tette z~ok~ ~ larop.or~io~eIy gr¢~ter at ai~s 45-~ than lit yo~nge~ or older ages A s~oker doubles hi~ r~sk o~ dy m g ~ethve ~ge c:6" ~WI40 1 ~c3, ~. t~ D~th l~ales Amoog smokers, the d~th rates ~rorn all cau~s ~ncreRs¢ • ,vl di the number o~ cigar ett~s smoked per day, the number of years th~ snulker has smoked, and the earlier the ~ge at which smoking ~dr~ed Othe~ vari~51es ine]uffs depth ~f inhal~Jon~ tar and nico- tine ]evgh of tile smoke aud the number of puffs per eigareite AII of these c~Rtrihut¢ to tha de~ee ~ ri~k ~[v~d ~t~ smo~m~;~ ]pl~, ci~arett~ srn¢~ing Js associated wilh ~ ~1 per~ollt Rvcr~ge ~c~¢as~ in over~ death ~a~es. ~iu ~ tw~ most vuh~a'ols age groups, 8,~.44 and ,15.5-!, the dcaflI ~ates of smokcrs are 86 per~lt higher gnat 1~ per eel*t h~gher, respeetlvdy. ~G 1~7~, p, ~11] The d~a~h rate for a given number o~ ~igar~tt~s smoked is higher am¢~g inhalers than among tho~e who d~n'~ i~ha~ Is~ffs'mlc heart disease, ]ang ~anccr, and chrome obstructive lung disease are not as likely to develop in individ~a]~ who do not inhale tol~a~co smoke. Der~ l~ales~ Ma~e F~r g~xq3s ol re~l~ ~r~ki~g ~we~ tha~ ~ ~ig~re~tcs Iy~T da'¢ of the types preva]e~lt ~ntil the 1~0"~, tile death rate is about ~1 p~etr~ higher ~an ~crt ~r~nsmoke~; b~ 10 ~d ~ ~lga~e~le~ per day, it is 70 p~reen¢ higher; between 20 aod 89 cigarettes per day, the death rate is ~ per ceJlt higher, and lot ~]ose wh~ ~mo~ge ~,,,~l~y ~ ~ha~ r nu~,h~ ~. ~ nde~ed *a ,~is~Jn~,~h th~a from #he 10 .q ¢/1
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iii 40 cigarettes or more a dr;y, the death rate is 123 percent higher lhan for nonsmokers [Ifoinmnond, E. (3~, HonL 1)~ Sin~kJng and Death 13ates--llepor l on forLy four months ~f follow-up on 187,7~1~1 men. Pail I, rI oral Mot tality; JAMA 1~6:1159 ~2 1958] The death rate oF smokc~s is sul~,tant~ally higher for men who stal tecl before age 2(I, than fer th~e wla~ ~l~.~ Led ~te~ ~ge ~5. gt~v¢ tar/nicotine t'igam~tte smokers have lower mr)r£ali~y ra~s than medium or high lar/nicoti~e cigarette ~mokers~ how- ever, overall death rates ~t fow tar and nicotine (]~ts than 1 2 rng nicotine and less ~ha~l 17f~ mg tar) cigarette smokers are 52 per cent ]31~her tlq~iI ~llr nOnSr~o'Kers. D~ath lfetes; Female Women who smoke cigaretles have a sigl~ilicaL~tly higher death rate lhan those who have never smoked regularly As with men, the relationship t~elwd~en death ~nd smokin~ is directly re lated Lt~ the number ot cigarettes and the duration of the smoking habit Th~ overall inLir Lal~y tales are ~omr~w}3at Iowir for wom~n sraokex~ l~/~n for ~/ale ~kcIg t~ ~he sarn~ age. Thi~ ~e0,ect~l~'e,~ p~st ex]~llsiir~" to cigarette smoke, such a~ staltill~ smnl/~Jng ]a~r~ smoking cigarettes with Ir~we~¸ lar and nict~tine ~,untent, and sm~k inlg ~ewer cigarettes ller tl,~y ¢]latl nlen. As ~oroetl fire be~imltlin ~ tl/~moke e~ flier and smoke moee, }lo,,vever their sm ~ldn~ rc'l~t~l jllIlesses are increash/g Normal Dealh Hate and ~x~ess Dealh~ For e~tch age group ~]lere is an exllected f~eat~l rate ~l~r 100,000 popu/alion Iol¸ pers~n]s who have never srn~ked The differ encc bct~eell ~}le number ot ~[eal}ls ¢~t smokers, an~ the number o~ dear}is cKp~[e~l }lasl~ll or/ no~smokers' death ~ates aie ~'~xc~s$ c[eat}ts." For n~en between the ages of 85 to 4~ whtl ~mr~kod ciga rettes the e~¢ess number (ff deaths is d3 percent; fer ages 45-51, more than 413 percent¸ hi other words¸ ff nr~ one smoked, there would he ~lt least g5 percent fewer lnale deaths between ages ~5 and 54. I Flarmnond El C. Smoking in ~elation Io the death rates of one milIion men and w~men In Haen~z~l, W (Edlt~r) Epidemi- o/oglda/ b_ppr~aehes to the $1udy ~t Career and Ot~,et Chrome Disease. US Pt~blie Hl!alth Service, National Cancer Institute ¢D IS1 .,,I ¢m
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112 Monogta/th 19, 19136, pp. 127 204 Kahn. H. A The Dorn stltdy of smoking and mortality among U.S. veterans: report on 811 yea~s of ohservation In Haenszal, W. op clt, pp 1-126] Smoklng-Related Deaths ~lt has been eaI~ulated that in ~3ontries whero smoking has been a wldesprcad habit, it is responsible for 90 percent of lung cancer deaths, for 75 percent of bronchitis deaths, ~md for 25 per- cent of ischemic heart disease deaths under 65 years of age in men. In women the proportions may be somewhat less" [WHO 1979, p. 10] Life ExpectaTwy A 25 yearn]d, two-park-a-day smoker of cigarettes of the type prevalent until the 1960's has a life expectancy 8.3 years shorter than his nonsmokang colin terpar t For groups of nleo smok ing fewer than 10 cigarettes per day, thl. Io~ of years of life expeetaney is 46 years; smoking 10 to lg cigarettes a day shortens the ]if~ expectancy by 5.5 years; and smoking 20 to 89 cigarettes a day, by 6.2 years, [H~mmond, E. C Lilt. Expectancy of Ameriean Moo in Relation to Their Smoking Hahffs, J N.C.I., 4a: 951-962, 19691 ( See Table ! p 13 ). Pipe and Cigar Smoking p~pe alad eis~ar smokers have mot taliW rates similar to those of cigar etle smokers for cancers of the oral cavity, pharynx, l~r ylm, and esophagus; hut they have much lower dealh rates tttml eiga rette smokers (but higher rates than nonsmokers) for cancer o~ the lung, isohemie heart disease, and chronic obstructive long dis- ease The diff~reIlces are thought to be related to differei~ees in inhalation of smoke Pipe and cigar smoke is chemically similar to cigarette smoke, except that the former is alkaline. Since alkaline smoke is irritating to the respiratory tract, it deters many pipe and cigar snlokers from inhaling When cigarette smokers switch to pipes or r,igars, however, the tendency for some is to eontlnue inhaling. DL~abil~y As in moitality, there is a normal or expected rate of dis- ability A National Health Survrw by the US. Public Health Service ealenlated that in a single year cigalette soloking caused an ad ditlo hal or excess of: 12 MORTALITy, DISABILITy AND CtlRONIC ILLNESS C U1
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113 Table I !~ URVIX ORS HIp OF MEN AGED 25 IN REI.ATION TO CURRENT N UMBER OF CIGARETTES SMOKED PER DAY: BASED ON BATES ADJUSTED I'O THE 1959 6I US LIFE TABLE FOR ALL MALES Never smoked Smoker s: NO, of eigaret t es daily Age All men regularly 1-9 10-19 29 g9 40 25 100.0 1~)00 I000 100.0 1000 10OO $0 99.1 994 99.1 99.1 991 988 '35 98,2 987 981 98.1 98,0 97,3 40 968 97.8 96.6 96.5 98.5 951 45 94.6 96.4 94.-0 949 938 910 50 9L1 94.4 90.6 900 893 856 55 85.6 909 85.9 838 82.5 777 60 78.1 855 77.8 753 735 67, [ 65 (37.8 77.7 673 684 611 54,0 70 552 667 524 477 45,9 400 75 412 523 362 33'3 803 25,7 80 267 85~ 206 186 18.1 143 85 ] ~¢ 6 192 7,8 8.5 72 65 90 4,9 7.0 22 2.2 22 21 95 1.0 1.5 0,5 05 0.5 04 [Me expeetanc~ 702 78g 690 68.1 07.4 fl58 (ags) Life expectancy 452 48.6 440 431 42.4 40.8 (yr) Difference from N,S.~. $4 0 4,6 55 fi 2 83 (yr.) SOURGE Ha ~r, tond, E C, Rogot, E (SG 1979, I~, 2 12J 03 t~ ,D, U1 r.O
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r 114 •.. 81 mi[hoJ1 ~er~on days [~[ from work. ... 145 miJ]ion person-day~ spent i]/in bed ISG 1979, pp. For men be~een age~ 45 and 64, m~Ire than 25 pere~t of the number of days of di~bi]ity were associated with c~rctte ~mokin~ Another study aI~Oll~ womcrl~ hotIsewive~ ~nd L~oose ~th ~'ent more days ill in b~] th~n womell who hav~ never smoked. Heal~h, Public Hcalth Settee, May 1967] Ch~onlc 1~Ine~s T~kin~ the rate of chri~nie IHne~ of pcop]~ who had ~ever smoked cigarettes a~ file baseline, in i~6~ the N~onal Clc~ring- "~['h~re are ii million more chronic ~es ~f il]~cs~ year]}' The saltl~ estimate repcr~ed lhat: "T~ are ~ fti0~e persons ~'~o r~or~ a h~ ~on~li- fio~~ and e~matcd ~ile million n~ore ca~ o~ chronic broa~Jitis an~/or ~rn~em~: ] ~ roll]ion more e~s o[ ~inusltls; one mi]l~ on mere c~ses of p~tlc ulcer than ~here wolt]d be ~f no one cv~ smoked ei~r~tes l~id] Q~t~ng R~d~ces R~k There is ample evidence that ~ving i~ ci~:~s reduce~ of }'~ar~. After ten to ]5 year~ of ~r~okin~ ces~on, L~e ex~moker~' have never s~oked, as i~ the fo]]ovAng chart ( Fi~u~e I ) : 14 M~TALITY, ~1SABILIT'I AND CHRONIC rLLNE S S U1
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115 F~me / 90 80 7.0 6.0 50 40 80 2.0 D = 0.~ ~ 0.~ o,7 o.~ 0.4 0,3 02 d -- - Ne~r Smoked ~ Ex cigarette smokers Stopped 10 14 years Maximum amount smoked 2 [ 59 clearer t~s per day Smoking 21 39 ~garettes per day I I I I I I ] I I I ] I I I ] I 2 3 4 5 t] 7 tl 9 I0 11 12 13 14 15 18 Years o[ Follow Up f~OURCE: Roger, E, Smoki~tgan¢t Mortolily A m~Jng Lt S Ve~rans Y~I~. C~)~ii. Dise~sf~ 2 ~ ~9 ~02{{19Z4)
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116 II-LUNGGANC~R Smoking ciga*ettes has be~:n identified by oi~cial coff~m~- sions and scientific studics in many countries ( Austraha, Car*aria, I)enmazk, Finland, France, Ilo]land, New Zealand, Swc~len, United Ki~ gdom, the United State~ ) as the cruise of the enormous zise in the incidence of lung ca~cI~r iu these countries since World War II, a ~ise so steep that it has been called an el)idcrnic. Lung ~ancer is f~tal in about 92 percenL of maIe case~, and ~n 88 percent of female case~, lnorea~e ill Morgalit7 In lgl4, the death rate from lung cancer wa~ 0.7 per 100,0110 polpnlation i~ the United States alld Great Brila~n for both men and women. By 1950, the lung cancer death rate thr U.S, men I~a~l risen to 18.4 pet ~ 9a3,~?g~/$ ear h ~9e4, it had mu~n~et~ to 37/~ and in 1877, to 54.S, Comparable ~gures ~r white females were 4.0 in 18SS~ 59 in 1864 aed 149 in 197~. In 1950, there were 18,~1~ U S [u~g cancer deatlJs; in 19~14, there were 45,8,58 lung cancer deaths and in 1877, 90,~10 died of thes~ ~mors For 1980, the prediction is lf)lfl00 such deaths. Some of this increase is due to ~n aging population [Vital Statis~¢s of the Umted State~ i~)~ 10~4, 1877¸ US. Cov~rnment PrilLtlng O~ee.] However, ~he US. Surgeon Genera] reporli~d in 1971 that " • . t'i~ate~{c smokill~ is the lllaln ('allse of lll~ ~e~ll c~r in reel1 . . . m wome~ (i~) aooou~t~ for a smath~r portion ot the cases tham in men" [SG 1971,p 11] In the Iq79 Surgeo~ General's Report, this conclusion was strengthened: "Cigarette smoking is the major eanse o~ lung c~ncer ~t~ both men and women.~ [SG 1979, p ,_~,3] ] An inc[eased risk of lung ca~cer has been found ~or every smoknig habit investigated Ther~ are dose-respoi~l,e re]atiollship~ fo~ duvelo~itlg lurtg ~aneer. That is, the number of cigarettes smoked per day, the duration of smokin ~, degTce rd inhalation, ~ar and nicotine contellt of cigarettes, al] contributed an i~reasecl ri~k of developing lur~g eanc~r The age at wlSeh people ~iart smoking is also iel~ed to the ili effecLs; men who ~tarled smoking before age 1~ had a ~]cath rate 18 ,,d fa ¢0 .,.I
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117 from lung cancer nearly [O~r times higher than those who began after age 25. Pipe and cigar smokers have higher lung caneer mortality rates than noasrnokers, hut considerably lower rates than cigarette smokers. [SG 1979, p 5-23] Sajely h* Sl~pping The risk of developing hmg cancer increases with age, for both smokers and nonsmokers; however, the incidence of lung cancer in cigarette smoker~ is much higher. A cornier ting corollary for those who are able to stop ~mok ing cigarettes: "There is a decrease in risk of de~eloping lung ¢anem, whleh occurs over a period of several years." ~Mter 1.0 to 15 years, the risk of dying ot hmg cancer tor ex smokers has decreased to the point where it is only shghtly abo~e the iith for nonsmokers of the same age M1 of the n~jor studies show this reduetion in risk Figure ~o on p 18 shows the different incidences o[ blon- ohial cateinonla ill snlnkers and e,x smokers, according to years stopped, and nollSiilokeF5 Male~Female D*fferences in Lung Cancer The difference in lung cmlc'er ineiOetwe and inorta]ity be tweet* nlale and female smokers has often been cited by critics as ea~ting doubt on the eonneetien Ix~twt tn elgarctte smoking and lung cancer. However, it usually takes 15 20 years o[ smoking to produce lung cane/r in a human being, and heavy S Hlnkil] g altlO?l g wolnell is cx~ncen~t ated in the age gIoups in which lung cancer is least ]pievalent. Differeut~" in hornmnal makeup may also play a part in tile differene~ in the hnlg eaneer rates hetw~ en male and female smokers Wometl generally smoke less Of each cigarette than men, thus avoiding the heavy concentlation of ilicotine and tar in th~ htst part Of tlle eigarl tie. On the aw!lage, wmnen also inhale less frequently and less deeply than men, and smoke filter-tiplx~d eiga reties with lower tar and nicotine Rapid Increase of Fe~*uIle Lung C~ncer However, lung cancer mortality is increasing in wolnen more rapidly titan any other cause of death, The Iung cancer death rate in woiu~n has risen nearly 1,000 percent since 19,$0. The US. 17 oe co
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inddence as p~rc~nt o~ rale at time of stopping {log scale )
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119 lung cancer death rale is rising f~ster loday among women than among men, as inole aiid Irlorc women smokers move into tile age groups in which hmg cancer becomes prevalent. [Royal, pp 5g-NI SG 1971, pp 2.51 252] In 1~4, lung eana, r was the Fift]~ leading cause ot death item cancer in US women, It rose to fourth place in 19fl7 and to third place in 196'9, passing cancer of the ut.rns. In 1977, lul~g cancer mortaFity passed that of ca Ileal of the colon and lecture a~ the second leading cause oi deatb [rnm cancer in 13 S. women, i~ present tlends are not reversed, tinting the next decade lullg cancer will become the leading cause of cancer nlortahty In US. women, exceeding deaths fronl cancer of the breast Sex Differences in Smoking An English doctor calculated in 1964 that the lifetame con sunll~ion nf ci~,qlelte~ at3long 47-year old men was four times as great as among 47-year-old womell, and that the male lung cancer death rate between ages 45 and 49 was Five times as great as among women. [ltoyaI, p. 60] The British note that smoking has been in creasing mine rapidly among British women than amnng British men [Royalp 59.1 Today, al@m*u gh there are still {e~,er U.S. w~nen ~rnoking than U,S, men, the gap i~ rapidly narro'.~ing Cigarette smoking among U.S teenage girls has been increasing steadily, so that as of 1974, equal percentages of boys and girls are smoking cigarettes. Bm there have been recent decl61c~ ~s show~ in Table II on the follov, ang page Over the past decade, there has been a ~.6 percent decrease in the number of adult US. f~males w]m smoke cigarettes, wherea~ there hns been a 136 percent rednelion in the number of adu[t US. males slnOking cigarettes Filter T*ps The public began to become aware of the connection be- tween cig~rett( s and lung cancel and other diseases in the early 1950"s witFi the publiclttion of the earliest prospective smoking ~ald health studies. This g¢owing awareness has had a strong impact on the smoking habits of people all over the world. In the years in which key studies and reports were issued, there were drops in the overall cortsumption of cigareltes. And smokers have switched in I~UNG C &NCJF2~ £g ua ,,,t ui
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---
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121 alassJ~e 13 t H13 hl i's ~O filter-tipped ei~;ut t~t s tm the aNSi IlllpliIHl that amc~xing some of the particulate mattm (tar) and gases frnlrl smoke oug}lt to/owtr t}lc lisk T<Kht), m/ire than ~1)'3 prle(!nt nf cit~m ettes sold in the United States are ifltm tipped: 25 yems ago, f~ltl,r tips rellresented less than three i1~ rcenl of the ~u~l ]~e[. Manu hlcmJers have steadily changed the tyl*s of tuba<co in cigarettes Ind as tl I L fuIt h~ve decreLLsed the alnouut Of Id.i cllic] DiCOlhle iII all hlandx "I]ius tod,L~ malty brands with~mt hltt~s gi~ ~Jff less ta~ uld nieotille thai1 S UlIi (' ]]ltl i -til)lle/l bl alldS (lid LI dozen years tt i~t i (Seep 22) F dt ~ r6 : Lung Term B(,m fit rl'he ]mtg [erm ust ( It} years ~r more) uf filtol cig,uettes is associated with lower dcalh lares Irorq [uug carleer than that asstl elated with an equal numhcr of nonfilt er cigarettes 1 his conduslon enme~ f~rm] gl nltlab~F of StIfflieg In a study of 552 patients with lung cancer matched with 522 c~ii It o]s, Wynder e± al, found that thusc wit~ I,,ld switched lo filters 10 ycays earlier had a Iowrr risk of hmg canoe, than flmse ctmtlnulng to smok~ the satlle ilUln})er of rtoil~]ttt ei~,uettes [SG 1971,p 275] l'ar and N icotine in a recent large prospective study, 897,8~5 men and women sulokers ill 2~ states were divided into fluee categones a cord~llg lo tar and nicotine leve]s~, and exatllil3ed with respect tll I/UI~ (~&ll cPi Tha r~,mtts me shr~m m TaMe 111, pagt 22. Bt, halw, R~sk~ o~ Low Tor For males smoking t}m same number oF cigaaettcs per day, there appears to be a 19 percent reduction in risk of dc~eh,ping lung cancer with the use 05 low TN cigarett~ Fol femah s, there iS a 40 ]percent red u¢~ti Oil in risk. Ilowever, 1[1 ~ separate matched group analysis, the uumber uf eigaroltes smoked pel day was fcmnd to be relatively mor~ illlportant than the tar and ui~'tltJne mntent of dgaret~es In the last 25 years, there has been a ~)eat drop in the tar and nicotine content of the smoke from cigarettes eollsuIr/(~d /II the olllg}, ta, and ~=ot ~ne ITN ): ~5~ t~, ~37 m~ ta~¢ ~ (} to 27 mK nicalin ~ Medmm ~tl 1~ than in. ng id Othle LUNG CANCER 91 ga,
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122 Table/II AGE.ADJUSTED LUNG CANCER MORTALITY RATIOS" FOB MALES AND FEMALES BY TAR AND NICGTINE IN CIGA,BETTKS SMOKED Males Females High TIN L00 L00 Madi~ TIN O.cos 0,7~ Low T/N 0,81 O.fl0 °The mot t~]it? ratio for the care or,; with htgllc~t ri~k was matte L00 thae the relative reductiom in rig t.nth the ume of lower T/N cigarettes tepid he vttualtze J. Sot~ve: Hammond, EC,, Garf~cel, L, Seld~an, lff*, Lew~ E.A. Some reeem ridding* co~em~ng ~t~'tte ~mokmg. In: tt~att, H H. Watson J.D., Win~ten, }.A. r/~ilors) Dri~t, jmo~ F/umo~ Cu~er Bo~ A: lnetJe~ce of C~er t'~ H~ma,~ New YOT1:. Co/d Spring H~,~o~ ~ore, 1977, e2 O~ ¢,o
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123 Unit~ d Stats A recent autopsy study asked: are there dii[erenet s in lung damage in smokers who died (of diseases other than lung caJicer) in the period 1955-1960 (Group A) as compared with those who dhd in the perled 19711 U¢77 ( Group B ) ? In fact, structural changes of various sorts cells with atypi cal nuclei (having the appearance o~ cancer cell nuclei), lesions 'a~th no cilia and basal call byIJerlll~-sia were found far more fro- qnently in the bronehiat cpithe]inm (lining) of Croup A smokers than in Group ]B. [gee Figure $, p. 24] This encouraging sign has prompt ld the authors o{ this autopsy study to p*~diet that at some future date, there should be a decline in the death rates of eig arette smokers from lung cancer. [Auerbaeh, O, Hammond, E. C., Carflnkel, L. Changes in Br ouckial Epithdinm in Relation to Cig- arette Smoking, 195g 1960 vs 1970 1977. The New England jnur i~al of Medicine 800 ( 8 ) : 881-886. lgrO] Dang#rol~ Occupations Lung cancer is caused not rally by cigarettes but is also associated with exposure to certain Ill]ner¢-Is and chemicals, and, in a very small degree, with polluted air However, aithnugh the risk ~f lung cancer is four times as great, among (say) cigarette sllxokin g urannlrn miners as in the general cigar elle smoking popu- ]atinn, it is 10 [[ine~ greater amo,)g /n'allinnl miners who smoki than among nonsmoking nrauium ntiller~ In a 17-yeaI follow up stndy ot g,414 uranium rrliners, there were (}2 Inltg CallCe[ deaths- hut only two of these were of nonsrnokirs [SC, 1971, p 256,] Cigarette snicking altd occupational exposures are said to be synergistic, acting together [n a cump[icated way. Most hazard- ous occupational lxposnres invo]ve 8ing]e xuhslauees or only a hw Cigm'l't t¢ srnoklngo however, results h* exposure to mm e than 2,000 chemical compllunds, among whidl are c/rchloKens, tinrltlr initiators and promoters [SG 1979, p_5-27] Thus the number and type of intelactions can be very large. Asbestos workers ha~e eight times t]l~ brag cancer risk of the g~neral popnlatiIrrl But al[/ong ~tsbes[ns workers who snloke cigarettes this risk has been estimated to be 92 thnes the risk of uonsmokcu s who do ~ot wnrk with asbestos I Selikoff, I I, Bader, II. A., Eader, M, E, Clutrg, J, Ilanunond, E. C. Asbestosis al~d neoplasia The American J~mrnal ot Medicine 42 (4}: 487-496, LUNG CANCER 28 -,I #, ga ga
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1 r- >p ~rJ PEBCENTAGE OF SECTIONS c~
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125 LUNG (2ANCEI1 25 g~
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126 A number of dclgs died during Lhv experlme~t, buL none was a nonsmoker, At tim ~nd of the experiment 40 dogs were sacriI~ced A iltl21ibe. ~)f txlrrlorf were fcqznd [n the ]utl~$ of the alllmal~ Two eigh~ ~onsm~ki~ g dog~ (g5%) bad ~ro~s; f~. fd 1~ d~g~ (40%/ who ~moked falter.tipped cigarettes had ~mors; five of l0 (.50~) of a g~ oup of noJ~ filter smokers ( who smoked only half as many clg~ ret~es )~ a~d 12 of 12 (100~) of the full-quota nonfi]ter group, had tumors. Onl~ irRer~stil/g fueL: ~e ot~y itl va~,lvl: ttlrqor5 ",~er e f OuTlet Jn fLllI-quoLa Non~]~er sltiok~r~, nnd two of the$~ Were carcinomas simi]ar to ~11e tying, molt oftt'n seen in mcl~ Dogs" hlrl~s weye also azla]yz~d ~or ~rft]Dhys ema~ and I~s~/le ~nd eelhl/ar ~lan ges. By far ~le largest ~um~ler ~}~ p,~ ~1o] ogies were Pound In the dogs who had sfr~oked the fuIl ql~ota of nonl~]Ler ciga- rettes, consideraldy h~wcr ia those who smoked o~Iy hair as many rlOn~]t~rs, verv fexv such changes in ~]t~r ~ip stn~r~ and nol~ in the no~smoklng dogs¸ Compaaing the reslz]~s ~adth those of studies of the lungs of men the authors conclude: ".. , ~hv types of hlstol~glc changes produced in the lung pareuchyma ( nla~n lung tissue) were found to be the same ~n the bea .~le as ~n mar~; in both species lherv i~ a doae rel~th~nthip; iii both • , the degree vf damage . inc~ea~e~ with il~crc~sing duration of cig~reLte ~moking . ": Extrap~]~t/ng the be~g[e study ~ m~n the authors state: "Findings in th~s study strongly suggest If~at smoking clgt~rrqtes with an efflclent filter u.~ll produce ~ess darn~ ~e~ to tt~e human hlng parenci~y~t~ tha~ #m~lclng identical ~ga~ttea wi~ou~ filters~ (autl~r~' ira]its) [lIamr~ond~ E C, Auerbach, O., KiLman, D, GarfinkeI, I. Effects of Cigarette Smoking on Dogs, Archives of Environmental Health December, 1970, p. 752 ] Pro-Smoking Cri~iei.wns Defenders of cigarette ~mokdng r~ise three other objectmn~ to the cause and-effect relationship between cigarettes and lung catlcer: Ohiectivn I The evidence is only statistical Answer: This is I~OL true. ]fundrcds of cpid e miolo gqca], ex perimcnta], pathulogica], and clinical studies all demonstrate t]lat cigarvtte smok~ftg is hazardous. H~:altll st aListies are the basis of most llisease control, And all b~l)mt'dical research, whether ill l~xpi~rlmcnta[ allJJ~als ~T huInall 2{3 ]hUN(~ CANCER ,,,I ga, ga .q
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127 populations, must use statishcal tvvhnique~ to analyze and reach sound, seientit/e conclusions. The Royal College of Fhysicians pnlnts out: " . it is pos- sible to observe what is, in effect, an experiment in which millions of people who have been smoking cigarettes often develop lung cancer while millions of others who lmve abstained seldom do so." Llhiyal, p. 61] Obiectlon 2 The associatibn is nonspeelfle in that many different diseases are associated with o~garette smoking, Answer: The great fog of London in 1952 increased the death rate for many diseases, particularly respiratory and coronary disease, Cigarett~ smoke, like tile London fog. is not a single ehem~ eal, bul thousands of chemicals, many of them known to be h~rm- ful It is unreasonable to suppose that exposure to this range of chemicals would increase the risk of only one disease. Objeclion 8, The genetle tbe~rry: penpIe inherit a tendency toward lung cancer and a desire to smoke cigarettes Aiaswer; While there are some psychological and physio- logleal differences bclween smokers and nonsmokers, there is no evidence of an inherited tendency toward lung cancer, x.Vllen many Britisb doctors stopped smoking, the hmg canner death rate for flint profession went down~hich contradicts the premise of an inborn desire to smoke, and an inborn tendency to lung cancer. Other easily disprovable criticisms are: 2~nat (he rise in lung nancer is fietitk~ms, caused by ]fetter diagllos/s; disproved by the fact that the r/sc has been greater in men than in women~ both being dlag~losed the same way. [Boyal, p. ~.1 Thai the rise in lung cancer tuay have resulted front a fall ili the TB death rate; disproved by the fact that while the fall in TB mortal.it) has been greater ill WOlllen, th( ri~r ill lurlg eancl r h.Kq been greater in men Strnie Conchtsioas 1. "Cigarette smoking is the major cause of lung cancer in both men and wmnen This fact has bc~m supported by prospective and retrospective eplderniologlecl studies, clinical studies, autopsy shidies, and experimental studies in animais. The conclusion is based on evidence which exceeds by several times the evidence available when this same conclusion was first reached in 1964. LUNG CANCER 27 ga
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128 $. "Llxng ~all~er l~l>rta~ity is an("fe~s~ng in wQlllen rflore raj)iclly than any other cause of death If present Irends enntinue, Lung can~er ~ill be t|~e ]t'~di~g callse of ,~aneer tfcatla aanlmg wollI ell in the next decade $ "Tl~ Ic~g~enn u~e ( 'tO yeax~ ~ nlf~re ) ~f f~lttet rigarcltes is associated with Io'.~er death rates froIrl ]tltlg CI/IICII" than those ~ff l~orson~ w~ sm~k~ an e~lual number of a~m~l~er cig.~ etl~, 6 ". The rilk of deveIoping Imlg cancer for ex smokers doi~eads ~tl tile type Of smllkcr I~ o~ ~hl~ used t~ be { ~md i~ 15T~>~- tional) to the number of eigare~tes previou.~ly smol<ed per day, deg~r ee ~f inhalations, the a~e v:hen ~m(~kmg was ~t~r ted and dura- tion of smoking. 1¢ takes from 10 to 15 years, however, .nlql the tick ~± deveI~pin~ luttg ca~tcer {l~( e~ ~mkersl aplm~act~es treat ~f nonsmoker~ " [SG 1979, p. ~81 ] 28 LUNG CANCER O1 UI ga
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Tobaec~ smoking also cztLses, or is stroJle]y assoeiat~q with, cancers of the ]&rynx, rn~mth esophagus, ~rinary bladder, pan creas and possibly kidney, Cancer oj the larynx A t .~13i¢al patient with cancer o~ the I~Lrynx is a 60-year old male who has ])Cell ~ hl,~lvy Cigar ctte s~okcr a~td also a tiliidt~te- to hea~3' alcohol drinkcr [Marks, IL D, PuL.ev, l ]., Scruggs, H J, ynx. Journal of the Scmth Carolina Medical Association 7] (11): 3~-8~6 1975] The rcI~tfive risk ~or develoI~ng laryllgeal cancer is 1~8 for ma]e cigarette smokers and 9 {I for female cigarette ~mokers. This large sex difference is ilow diminishing, i~robably beeausc o~ the increase in temale cigarette smo~crs [SG 1979, p. _5-S~] Pipe and cltgar smokers ha~c a risk similar t~ that o~ ciga- rette sTrlok cos ~ t~evd~pmg la~5~gea~ ~m~c~'r I6G ?t£tT~3,p 5-~ The number of cigarettes smoked per day is strotlgly related to the risk of developing cancer of tile larynx. In one study r~Iative risks for ma]~s r~ngecl from 2 9 ~or short torrn light smokers, to 177 ~or h~vy l~Jng.term smoke~s [Williams, 1~ B, Ilorn, J. W, A~so ~'i~ tion O~ ¢an¢¢~ sites will] t 1/]3ae~o al~d aIcohol ~2on~t tm~tioll and so¢ioe~l~/omlc $1attts ii~ p;itlerltS: Itltevvicw sl/idy f~orn ~he "I~lird National Calicpr ~/irvey ]ourlla] o~ the ~&liiinal C~l~¢er Institute Autopsy ~t~dies rcvea] a clo~lTM dose r elafionshap bctweet~ the ~ultlb~r of cigarettes smoked and atypical ccllu]ar changes in the 1 ¢~ry~lxe~ ot [Ilen w]lo t]i~ no[ i]il~ ot ~ynx c~l~c¢l Every ~1~ o'ger o~ a pack or-more-a day ~tucticd had atypical ce]hflar ehmlgef the iYlor ~ ¢i~aret tes SXtll~ed, the more suc]l c~]l c]q ,1Ii ges Biit 75 p~rcent ef the nonsmokers ]~d no al~lormal eclls~ ar~I those who did, had very fete Of the men who hall quit ~m~king, 41/percent had ab uorraa[ cells which v/ere disttttegyatiu~that is. disappear rag. and bci~g replaced by norin~l e~/Is [Auer[~ach, O., Hammond. ]E C. ~arflr~k¢l, L, Histologie C]~allges hi Ihe Larynx i~ Relation to ~qmoking H~it~ (:ancer 25: pp. ~ 10~t, I anu~rv 1~7~1 A distluct syn gcrg~sm bet w~en nlcoho] ~nd tobacco iu laryn- ¢.q
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130 geal cancer h~s been ¢onl~rmed, w rifying the ]ink noted in over 14 earlier studies. [Wy,dcr, E. L ~ Covey~ L. S., Mabuehi. L, M/tshJn sial M E~vironment~/ factors in caJlc~r of the I~rynx A secotld look. Cancer ~8 ( 4 ) ~ 1591-1~i, October 19761 Long term cigarette smokers, both thales alld temtdes, wbo nse ~ter-ttp~, reduce their risk of laryngeal cancer by from 9~ to 40 percent, and the risk nmong ex-sztll2kers drops gradually slier c~s sati/m. After ttpproxirnately ten y~rs ex-smokers' risk of larynx cancer t~pproathes that of no~srnokers [SG 1 ~79, ~-~1| Cancer of the larynx is often cured, usual~ by st~rgery and generally by tt~Tnoval of the larynx, the main organ of speech The patient thus curet] c,~ be ~attg~lt a new methol] of speech, anti must 1lye with a p~li~anent opening in bfs throat. A new expels- rnental opel~]oil (2an somctllne~ cpeatc a tlew ~vocal co~d" Out of pbaryageal tlssnc that makes re I~;irning speech quicker and eas~er Sur~on GenemI~ (£tmclusion ", . •/dpidernio]ogJca]~ experilnen~I and a ultopsy sbldies in- dica~ ~hat elgnrette smoking i~ ~1 sight,cant causative factor ill the cleve]~pment of callcer of the larynx The task of develop~n~ l~ryn. Real cancer in pi~ and cigar smokers is siml]ar to) that for cigarette szaoke~s, [andJ mu~h greater for heavy smoker~ who also drink heavily, ~Jm~ared with individuals who only have exposure to either ~uhst anc, e. There is a $ubs/antlal decrease in r~sk • • • witil the long-term use of filter cigorettes /10 year~ or mole) compared to the use of no~fllter elgar~tes, [andl a gradual redueti~m in risk of ~8i InryngeaI cancer after eessation of smoking." [$G 1979. pp.5 37, Mouth Cancer Analysis of a ]arge nxtinbnr of studies reveals from three to te~ ttme~ a~ mar~y mouth cancers ( can~s '~f the lip, tt~l~g~e, ~c~r of the mouth~ hard and soft palate, ete, ) in cigarette smokers as ill nonsmokers. Pipe smoking has long h~el~ reeogl~ized as a cause of bp eal~cer; pipe and cigar sllloking a~ we~l as tobacco ehewln g, also contribute to cancer ~tt other sites in the raout}l. Afoah~ll ~r~sum~tlc~ and 9ossthly p~c,r d.enti~ als~ ap pear to be risk factors In otle stud~ 7~ percent of oral cancer in mafos was attributed to the illteraction of tobacco and ~dc.oh oL The ~o Oq~HEI~ CANCERS A
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131 risk for tile heavy drinker who also smokes is from six to 15 times grealer than for tile individual who does lint use tobacco or alcohol [Itothman, K, Keller, A The ei[eet of joint exposure t~ alcohol and tobacco on risk of cancer of the month and pharynx. JournM of Chronic Disease 25:711-716, 1972 ] Mouth cancers are often cured because they are readily seen and treated at an early stage Of one series of 117 patleJ~ts tured of mouth cancers, 4g quit smoking but 74 em]tinued to smoke. All remained {roe of sympton/s fur three years Then ~ of the 71 smokers developed new oano~ rs of the mouth; hut only fuur of the 45 who had quit smoking developed call(xlr a ~(~lxlnd time Thus, the repeat rate of mouth cancer was four times as great among smoke]s as among those who stopped smoking. [Moore, G, MultipIe Mouth-Throat Cancer, Arnenenn Jnnrrml c~f Sm Rery, pp 534-53g, October 1965l Sur~eot~ Generol's Conclusion ". Smoking is a significant causal factor in flit dove]op- nleII l Of cancer of tile olal cavity the use ot pipes, cigars alId ¢ hewing tohafleo i~ associated wifll cancer of the oral olvity. 1lie risk of using these forlns is the same general 01a ~nitulh' as that fir ~lSit]g oi~alettes . The use of alcohol und tobacco together re suits hi a l]igher ri~k of dew:l(~piug CaJlcer Ihan ft om the: use tff r~ithl,r xuhs~aner alnne" [S(; I~79, p 5_4f, J Cllnel~r o] the 15sophagux ( ]igaret tt smokers have a risk of dyin ~ of esophageal cancer about two to llille tlnles that of Ilnn~ll~okl~lS~ d(~petldillg oil the numlger (d cigarettes lrnoke J and on the n~lo/in I ill llh2nh ol drunk The k~o w~l c~ncer eausi]tg chemicals in ¢igarett e smoke dissolve ill alcohl~]; md ill this form they more reada]y i)en~trate tissues Thus, wh{n swallowed, they are apt [o ~ll[ei ll]e walls of the esnphagus 'This }xas }looll de/rlonatrated expL rinl~nta][y in tutlnl~ll~ [$G 1079, p.,%44, 45] A stndv of the esophagi of 1 2&~ men wire died of causes othe~ than esophageal f2~lI]¢er showed tl/a~ ahnolma] cells pre- callcer(ms cells were found much mn~e freqnenfly nl the tissltts of srnnkers than in nonsmokers. [Auerllach O, Stout. A, P, Ilam mond, E C, (;mfinkt~l, L, Histologie Changes in Esophagus in Ile]ation to Smokhlg Ilabits, Archives ill Envilllrnneut tl [leallh 11 OTHER CANCEIIS ~I Ol ',,I U1 U1
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132 (1) : 4-15, July, 1965.] Surgeon General's Conduslon "... Cig~ette smoking is a si~ffifieant causal lacier in the development of cancer of the esophagus, q~e risk.., [in] pipe and cigar smoking is about the same , . . as that for e~garctte smokers studios aIso indieat o a synergist fo reMtlonahlp between the use of alcohol aud tubac~o ~.nd cancer of the esophagus, [SG 1979, pp. ~44, 4g] Cancer of the Urii~arpj Bladder ai~d Kidney A number uf studies have shown n lagher blcidt nee of can. cer of the urinary bladder among smokers, and a higrmr death rate from this disease among smokers than anlong nonsmokers. The increased risk as compared wit]l nonsmokers-of cm,traeting blad- der canccr r~llges IlI~ to inore dl~rl seven tidies ai~/nilg all salokegs~ and is ~en times as great in heavy ~mokers. About 40 percent of male bladder cance;s and ~1 percent ot ~emale bladder cancers may be attribtLted to smoking cigarettes. In ex smokers, the risk of d'~vc[oplng bladder cancer de- creasct said approaches that of nonsnlok~rs about so~. en yt~Rrs after eplltting smoldn g. [Wynder, E I~,, Goldsmith, B The epidemlology of bladder calmer. A sexual luok Cmlcer 40: 1246-1268, I977] Smokers alsn have a higher risk Iff kidney calmer, ~angang from about one and ¢meIbali to two and tmeIbalt times normal Certain oceupaffona] exposures to dyestuffs, rubber, leather, printing hlks, paint, D~rOICUlII~ and other chemicals incIease the risk o~ dcvdoping bladder cancer A number o~ substances, in the chemical ~ami]y of aromatic amines, ha~e been identified as risk faclor~ in Ilum~n bladder cancer and aie alsu brand in cigarette 5 iilOkl~* ~bUS, cigarette smoking alone, or m cnnec~ t with uecnpa- tSonal exposures can act as ag~ots in lhe deveIopment of Bladder cancer [SG i979, p.547] Su~geen Gelu'rat's Conclusion "Ep~demiologi~a] studies demonstrate a significant associa- tion between ~4gar~te ~rn~kh~g ~nd e,~c~r ~ ~he ~rlna~y bladd~ in both men and worn erl Cigaretlc smoking acts fi Jependent]y as a cause of Bladder cancer and probably acts synergistically ~ith tltbl,r D~k {acio~$ ~;~leb gt~ ~'. ~lpati~ al e~pee,o~e to cer t ~ix5 a~:x~ ~ 8~ O'l IIEH GANCERS UI ,<t
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133 OTI IER t2ANGERS ~8 -,I ~q ~q
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134 IV-IIE ~Hl¸ A'I TAC:KS, CIIICULA 1 OIlY D IS EASES AND STROKE Ci~aiet tc SlflOkilJ~ cau/es i ]]J~hcr death ra[e {i ot/1 c0rcmary ]leal t dlsea~e ill L]ll, [ Jnit~d States It has be011 eh[~nlatcd that n/ole t]~lll 120,000 excc~s deaths horn this disease each year in Ibis lleilm't of Ad Hoe C.mnlit~ ou Gigaette Snxok i~ and Cardln x ~culm Disease, Am [I(art \ssoclaNou ])ocum~ut 11/10/77] S~dles of mor~ ~han two million indi%d/~als show that clgIo/'lie !llloking illcreases t}ll~ i~sk of ~i](ldcil cardJdc dt,atlls, al}d at]ll?roscler05}5 (I(,~{ims, p[J]ut~ and occlu~olit of ,Irtcric$, heaFt ahd II(h~r InStil/s}. Hiilviv~r ~hc allocllth~n between d~lctto S[lloking tlll~] ~Nokl~5, l,ld all ~ina ]]¢ctcli5 t C[le'~ paiui is i1o~ coil du~i~e; and tller~ Js no apparent Idationship lutw~en smoklng and the incidence of hyper~ensi~m (higll blcmfl p~t'ss/tre) Neve~ ~hp]csl ~lyiIcrlens~on and ci~arot~c smokin~ wben pleSe[It (o ~ether.multiply risk (scc below) ~)ultting Sho~ II[ff I~('lht~e4 Risk Stopping tracking harply decreases th(' risk of heart at tacks, and other cirtndatory diseas( s Tiffs begbls to happcn .~thm ol]~ !c~r af~(r ~tOllpin~ and after 1(/)eros, the ex smoker's risk is [Hammond, E C. Galfink¢[, I. Corona,y Ilearf Disease, Stloke and Aortic Ancurysm Factors in the Etiolug). Archives of gn ~ [vo nmell~,~l H~ ~(th lt3 { ~) : lC~.l ~, AuCust i~3 ~ c)I In a study of all British doctors a~e K5 (~4 since 1951 H:my O~ I}lt~sl phys/cJazl~ I/ale g[vtn tip cJ~lrette snloI<Jn~ ~u[ ft v;-cr ~i~[l met in gcnm~ hax~ stopped sm~&ing ci~an'~les In 1!~8 deaths fr ella all Iw,ut and blood ~ esse] fliseaaes amoug tbese B~itish doctors had <bopped by six pe~ce,t since 1955; while the dear]is ~ronl these diseases lit ,dl British men had inoeased b> 111[112 per vent.[Royal p. &S] ~hC mosL Iul~lllt [~Y.~ ]l/~orMKt~iOn Oil 5moklDg ¢~'~llt[oIl ill the follo~h~g r~,l)ll! shaws significant flec~eases in tte luobabflit~ Ot I]c;lth ~f01n (o~01tal y ]ll'gr~ disl,a~e tor thos( who b~ e stopp/'d smoking rv~ We or more y~ols ( See Tab]~ IV, p. 35 ) Several maIor "~i~k flcto~s" ]rove been klentilhd in heart 34 ,,d ¢n
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185 TablelV ANNUAL PROBABILITY OF DEATH FROM CORONARY HEART DISEASE, IN CURRENT AND DISCONTINUED SMOKERS, BY ACE, MAXIMUM AMOUNT SMOKED, AND AGE STARTED SMOKING Agest~edsmoklng 20~4 Maximum Cltrrent Disc~atlnued Oar r~ilt Discontinued daily number smokers for five or .rnoke;s {or fiv~ or ot ¢igarel~es more ears moxe ye~ Age smoked . Pro ~a fihty • ]0r ) 55-64 0 501 SO1 10-30 798 5t~ 811 551 21-~9 969 766 872 698 65 74 0 LOIS 1,015 10-20 1,501 1,169 1,478 1,213 21 39 1,710 1,334 1,57~ 1,098 1For age grouz p 65 74, probabflilS~ for discontinued smokers ale to I0 or more years oldi~nttnumace sil~c¢ data for the 5.9 yezLr discozlLinuan~ ~roup are not given* SOURCE: U.S public Health S e~v/cc. The Health C~.~equences o[ Smoking A Re[er~c~ Edition: 2976. U.S. De~a~t.~n of 11ealth, Lduc~tlon, and We ~a e~ Pubic Heallh Servlc~, Can~ f~r Disease Control HEW Publica- tlon No ( CDC) 78-~57,197 6~ 657pp 95 ~q
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136 attacks. The three leading risk flctors arc 1) cigaretlg smoki.g; 2,) high blood pres~ur~ ( hypcrr~ nsion ); and 8) high bl~Jod eholes- teroh Each of th~$c ~islx ~eactor~ increases [% person's chance5 o~ having a heart attack¸ P~opl~ who smoke cigar~ttes~ bL]t haw neither ~f the ~ther t~vo ~aetort, have ~ deafl~ rate trorn h~art at- tack ~ pereeot ~leater than that of llonsm~k~rs If alI three ri~k factors are present, the llsk goes up to 800 perceiIt that of pe] tops withom any ~Js/~ tactllrs l/i~k is also related to .~g~ ~ld l]l~" am<*nnt of ~po~ure Arte~ D~se~:~ ~l~ing ~he aTl~i~ o~ ~g'aretl~ ~mt~ a~ mlll~Vsy, p~ thologis~ have seen that the blood vessels of smokers contain great number of larry p]~ltuc~, which adhere to the walI~ and c1~ arteric~el~rosis, aT~d i~ thoug]Jt t~ predi~pose the su~[er~r ~ heart attacks In a study o~ ~ds type, tt~e arterioles (~m~ arteries} a~d al ter~e~ o~ nearly 2,000 mef~ who died ot all causes wer~ examined BJor)d v~sels were ~ell~llv~,d ~om vo.riou~ p~lrt~ of ~ho body: th~ trachea (willdi~pe). ~ro~c~llal tubes, esoph~Lg/n~, stomach, p~n ¢l~a~ al]d adr ~n,~] ~q]a ~ cls The seicl/li~t ~ did l/or kuow the ~ml/~:Jll~ hahi~ of the men until after they exalnilled these tissues alld r~corded their ~ldin~s, It wa~ fl~tmd that the wa~ls oi th~ I~l~I~d vessels in1 all lh~e ~rgans tended lo ~hick~n wiLl~ age in ~1[ ~lb- jells ~lut ~hiekl~ili~ wa~ ¢oiis~dcl~tbly ~,r~zt~r iEl ~lllldccrs thai in nonst/ll~l~r$, .lil~ wss dit (~clly rt~te(~ ~ll ~ n~tll~uez ~3~ ¢~igarekt(~ smoked '~l/egardless o~ the ~e~}~auism. it seem~ likely thJt the thic]<~nin~ ~lf t~le ~an~ o~ ~i'te*ri(lles al~ll s[]l~ll ar~l'rie5 ]~cat~c[ f~ art ~r g~%n 11~ ~ I e.q~ t ~. slimily dcleh~riclus e~ ec~t itpC~rl llla~ or~N1" [h(~ :Li]t]lor~ conclude(] 'If wide,Dry,it¸ i~ iIl~y pllt ~orne st]~iil t~pol] the cgrdiov~seu],~r systl~m as a whoI~ I[ so, [hi~ m~y h&'~e chsea~e~ with advancing age ~nd with amount ~t eig~r~2tte $iI~ok- iTi ~." [Au~rh~eh, O. lI~mmt)J~d, EC , Car~ukcl, L , Thicksl~i[/g of Wa/lf of Arteri~les .~Jld bm~di Arteries in l~elallo~ ~o Age aud Smoking Ha}~its, N~ England J'ou~a] o~ Nl~dleinle 27;5:9B0 9~4. May 2.196~.] ~lli~ l~nl~ly w~l~ latel" exlenldet] Ill a roiel~sc(l~ii~ ~.xilrnln a llo~ $6 HE.% }~ 1 AT l ACK~, C]]~CULATO~¥ DTSEASE~ AND STROKE o~ ,q UI .q
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137 uf ~rterioles of heart inusde. Fibrous thickening> in the walls of • esc small blood vessels were four~d in 90,7 per~en[ of those who had smoked two or more packs a day: in 484 percent of those who had sr.uked less Ihan rJne pack .~ day, and in n~le of those who had never smoked reg~flar/y [Auerbach, O, Carter~ H W,, Gar finke], L. i[~ml/Iond, E. C Cigarette smoking a~d corof}ary arl~ry dlseases: A inacr~copic a~d microscoFic study¸ Chest 7(1(6) : 897- 705, Dcccrnbcr 1076 ] Nicotine (~ut~ ( )xtj gem and Speeds Heartbe:rt Cigarette smoking st~mulate~ eertalr~ ~lands to release ~drenalin and other powerful h~rmoncs which causc fl,e walls of tht. }lf~a~t to cont Facet mol-e strongly aHcl lilt)re of [ell~ [tic/ease the heari rate. and thereby increase th~ Ii¢~rt's nl~elt tot oxygelI itlld otht2~ nutiiellt$. Cer~ail~ bloo~ vessels collt~act ftlongly ulqd~i the ill]h J f'l~ ('e of thest~ ]lormones. But at flJe same time, the carbon rc onf~xlde (CO) in e£gar ~tt(: $.3oke i e placdes :ts BUell ~ts t wl'I~,e percent of the o×ygei£ whic[~ would noLmaIly bc ca~ r~ecl by the ~ed cells in the blood with car- boxyhe~nogh:13~n iCOFIb ~ t~ht I:~nd of CO and h~Jt/oglobin ) So, wllile the ~l,~ok(~r's heart l~eods riioru o×y~en, it ~tl I~s. llle lack of oxygen in the b]~od m,~y cow,tribute to the development of atheroscler~is [SG 1971, p. 3b] F~xp~ed Occul~a~ion~ A sttldy {IF p:~lq~it~n h/×i itr Jvl~rs s~ov~ed th~[ SITIO ke~s ~ 15 cigarettes a clay h~d f<)ut times the level of ca rbnxvh~'mt~l(~bin as those smoking fewer than five cigareltcs a day Blast furnace work. ~s wtJr~ te~t ell ~lt the el~d of theli slli[t; nollsll/o]<¢t $ fad betwee~ 40 and 49 percent of total ear boxyhe;nog/obin Tho!c whq~ sntoked more than 20 cigarettcs a day hall bloocl low,Is ~f ~ 5 pereent 'it is c'¢ident that if air pollutiot~ is a pathogenic factor it is smr~ll ~n comparison with sli~killg.~ [WHO 1979,13, 27] Smot<in~ Fi~ts tl~rk D~aCh A 4,5 Veer old m~te ~ir plane p~hlt who ~ml)kll~ L~0 i.~ar ettes a day ha~ ~ risk of ~lrkIen d~th ~8 tim~s ~r~at~r than t]l~t of a nonsmoking pi]/~t~irrespec~ive of other risk factors T~}~cco smoke slgnifc~tn~l¥ ii~terfeles with the physical ~nd mental abili(ies that ar~ ~o itl~ort~l~ ~or pilots, The liiiiJt~tt[olks [tl~lu(ltt V~SttL~I ~tllp~tif- IIEART ATTACK S, CIIIC ULA FOI~y DISEASES AN I3 ~FROKE 87 -j O~
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138 ment, tlv ing or temper td ircipairment, ann itnpail Joent ill decision- iI~.lkio~ a~ld cootdJilatJDtl }v~any ~re the rehtdt Of increased Far b~xyhemoglohin ]ew~l iT~ the blood IWIIO 1979~ p .°7J Other E~ecls Smokillg eJgaruttes alst~ damages breathing capgelt y; thus, a smoker l~kcs ii,/cos alt ~uh eadJ brcalh tbitTi ~ III++~31~~'k++T ~fl~s fmthei diminishes thc amolint ei oxygen available to the over worked heart of a smoker ISG 19~1, p 14fi et seql Anoth~l inechanism related {ll crooking affects the platclets --a [ractlon OF ~}ll hhJod which causes clots. Smoking seeJllS 1o cause th~ platelets to adhere %dfich might contlibnte to acute thrombus (dot] tmnmti+m ]SG 1~d71, p 9] Co+l¢Iles~o~ls ".. Smoking fs ot~e of three maioi independent risk factors ~or heart aua~ks, lbofld l~aaI and nor,ialal , and sudden catthac death in adult men and women Moreover, the effect is dose re. lated, and s}~lcrgistie with othe~ ~isk ~aetr/]s for heart attack • ." ~.. Cigarette mneking is associated (m linfited autopsy sludie$) with lllllre sIwele and extealsive it~heroselefosls O~ ~i~ aorta and cofontffy arteries than is fou~ld among nonsmokers . . , While more data might bc desirable there is no rcasc~lla]lle douht that ciqa, ette smoking enhances athsrogeJles [estahlishingl it fundamental ralioli;lle for the ~qndJiigs on ~[I< incidence o~ bearL 'ltt ark, inp]udin g sudden emdiac deatll, J~or tie aneurysm, and peri- pheral va~'u[ar disease in ~clatiorl to ~l~lokillg It is s(nllewhat nil+ err tail~, lint llkelv, that smoking has ari adverse effect on the rceur- renc~ of heart itt~wk amoug survivors of a prier myocardial infarction," ", , . Epldrmiologic dala on tin association between ~igar- ~t!e 5Ino!¢illg arid gl]gllla peetoris alia c~l~hrovilseols-r disease (stroke'} are not conc]uhlvc . There ts no apparent relationship between smoking and the fi/clder~ce of hypertension, lalthough] smoking joins with hypcrtension to affect the patient with the car- diovassular burden of both risk faeto~ s "It should he rloted, however . that ~isk (llf Coronary healt disea~<) in sfflokels reverts to llormal or Jlonsmokers' levels after they cease to smoke ." [SG 1979, pp 4-e3 6] 88 ~IEAIITATTACKS, CIBCULATOItyDIsFASESANDSTROK~ O~ .q ed't
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139 ~EMI~HYSEMA, CHRONIC BRONCHITIS AN D OTHER NONCANCEROUS LUNG DISEASES "When patients with bronchitis a~e asked i{ they }lave a cough t}Jey ant infrequently rep]F "yes, lik~ everyone e]se' They d~ not rea}izc that people with healthy hmgs have no cough and produce no phlegm.~ [IIoyal, p. 69] Sillok~2£s c¢)llgh more than hflnsl[to]<~r~ and prodnl~c fftore spuhlm Th~s CaI~ oeclar very soon a~ter the ollset of smoking and even when the numhe~ of clgaretle~ smoked is very small. [Smok- ing Or Health Third }lell(~rt of College of Physioi~ms. Pitman~ London. 19"t7. p 771 Respiratory, infectaons, including postopera- tiv~ ones, are mo~e co1~111Oll in sil~oker~, w]u~ t~c ]c~ngcr to rl~eovcr (:igarct te smoking acts independently of and syncrgistlca]ly ~th the (~ther risk f~ctors contributing to bronchitis¸ In de veloped ¢ountrles it is now the mo$[ illl[lf~r[arl[ i~al/~t~ i)t l~hrtm~t~ bronch~tls." [WHO 1979, p 20] Definition~ Chronic bronchitis and pulmonary emphysema are often /inked. because they are hcqucntly Iound Io[~ther. aald h~cause they ~eem to be produced by similar causes and meehan~ms Clinical]y pure Iorml of chronic hrcmchltis and emphysema .~rc lhc exceptinn~ rat h~r th~n the ~u]e, and ]uilg cancer is oftcB also seen in the sgme patients. Chronic hlonchiti~ is d~lled a~ t]lt~ "~ironic or re~llrr~:llt cxeessiw mucl]s sccr etioll of fl~t~ hr~nLchi~t] tree " [S(~ lqTI. p Lqg] It is identifi,:d ~ two symptoms. (1) chronic c~gh which pro- 4uces (2) ~putum. The sputum may be clear, but often coat,ins pus because peopJe with chr~l~ic brvnchitis a~e hi~ly suscepuble to ltmg ill f~( tiolls. "~e[i a~rs, who smtlke ~qs few as ~ve cigar ettes a day, cou~h and slsit a]lr/flst af rnllo}l ~s all ~dt~l[ h~a~y slltoker The longer a person "adth chronic bronchitis smokes, the worse ~he condition becomes. The all¸ passage~ in lltc Juries bt~ ~o]~e plogiesslvely iJ~rro'.vcd~ mfl.kil~g it ]l~rc~or and ~arl]cr tc~ breathe. This is o~ten w~r~cncd by the I.qct that ~o many people v.qth bronchitis als~ have emphysema. Pulmonary cmph~cma destroys the tiny all sa~s in the lung w]lere oxy~l~ is absvrbed into the body¸ A~ the walIs between the s~es are destroyed, thl~ ~acs hi,come larger ]~ut. ~ce;~use fewer in 89 .,j U1
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140 number, tlmy oiler less ~ut.fl surface from which oxygen e~rl hc ab- sorbed llel~ce, lno~ atlll more bre~khs arc reqllired. A IIolmal adult expetld~ about 5 percent of h/s en~r gy in hr~a~ing; a person with advaJlc~d emphysema uses up to 8() percent of his strength just to breathe He is const,autly exhausled, gaspln~ for ~ir, Deaths fflm~ ptdr~mn~lr y emphysema and chr ollic bronchitis (known toclcther as COLD--Chronic Obstructive Lilng Disease) have increased ~eally in th~ U~ited S~tes in r~ent years. In l!~cl, ~ele were ol~ly 2,~8 s~ch deaths listed in ~he Unlted States. [Diehl, ~ ~]0I In 1977. the figure had rlst~n to ~8,000 de~hs p~r ]lear. Chrou~e }lrol~cl~t~s ~d ~'w4~by~e~a ~k ~l'cl on]}' to coTonary ~rtery disease a~ a cause of ~l~cia] Seourity compensated disability [SC 1979, p, 6 7] 1. lhe U nitcc] Kiuclclom, ~th a pop~aHon only o~e ~our~L that of the United Stale~, tl~er e arc more than ~0,(}()0 such deaths each year; and ,~5,000,000 man-clays are ]o~t ~rnrn v.ork armually as th~ r~lt of emphysema and chronic bronc]lili~, This is ten to 12 tir~ the number o~ d~ly~ lost throuclh industrial disputes¸ [Royal, p, 00] Sm~e~ V~lnerabl~ to COLD Deafh Cigarette ~rnoklng is the m~st important cause of COLD¸ Cigm ctte smokers I~ave higher morlallty rate~ fr(~ra chronic bron ~lJcls and ~nl~hy~ma~ ~ii increased prevalence of respirattlry synlpton~s, ~1~1¢] C[il]liil~sht~d perforl~anee on pu]ulonary ~lletion tes~irlg enrflpared to non~l~lo]~ers These di~t~l~n~$ ber211~l/e more marked as the nnmber oE cigarettes incre,ase~ [SG 1979, p. -6 7] Th~ most recent data from a 20 year followup ~f ~4Al0 British male physioia~ls ~o/md a 1 5-fold ]higher de~lth ra~ frnm COLD ill smoker~ who in]laird th~n in smoke~ wh~ did not inhale¸ scrvations on male British doctnrf Brilish Medical ~ourna] ~: 15~ i5~6 1~79] A ~un~b~r ~( ~e~e~ ~l~ ba~ e~ab~sbecl a l~i~ pre. v~lcmee of r~ph ~tory 5ynlptnnls ~rl ~doIc~¢~nt, tcl~nllge: and ylnmg adu]~ $ mokc~r ~ as eoirlpar cd with nonsln~llKt,~s. In ~ study of 14,(K~ churl smoke~s ag~d 10 to 12',i in fi~e Unite¢~ Kingclom, more were found than their nonsmoking classmate,s [Bew]ey, I3, Hlaud. J M., Smoking and resphat~ry symptonl~ in two group~ ot ~choolehi] dren Preventive ~,Icdicin ~ 5: 63-60, 1976] EMPHYSEMA CHI/ONIC Blq ONCHITIS AND OT~IER NONCANCEBOb'S LUNG DISEASES fd~ Cat
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141 p~rt, d that rcgu]al cough, phlegm produclion and whe~ zing cot related strongly with c~gareLte sln~king. IRu~h, D Changes in r esglr[l~ory symptom~ rclated [o ~[J]l~lxlng in a tccn~t ge po~)u]~ti~n: Jh[~ rCSLLltS Of ['~/o linkc~l 5/lrvey~ s['parfltel] by one ycar Jiil~,rna- tion~l J~u] hal of Epidemiology 5 ( 2 ) : I78d78, 1976] New ~[it[2~ts i[i 1~l~,2su~i~g I~n~ ~u~c[[oli now m~k~ it possibI~ t{) pinpoint early changcs iJl ~ln~l] airways of the t~ache~- CJ~areO~ ~D/ok~r8 ~how ~b]]orm~l cha~g~$ ilL [h~ Sm~l/ ;dtw~s which ~1 e at~n~ ~om th~ lungs o{ nonsmoke] s C[g,~ret~c su]okiI/g p~ot hlci~ g si~i~can( ~i~rls ~h~II (:[in/'plitio~a[ lnethods i)~ Trll'a~llr ing ]Jul~orlaly fLInct J(d~ ~r(~ used Ev[dezl~(~ If olzl a ~l~lb~r of dlf. ~rcn[ X~L[lOr~torlP~ all/~ C]~iC~ indfcs[~s d~lll;I~ It) snl~q]l ~i~w,~ys i[J from ~5 ~o ~ p~rcc;lt o[ ~lSyElip~orll~tic (~q Iet[l~ S ~lO~el'~. ])~ln ~Lg(~ to ~11~ small alr ~aTs ]ills 8[so hilt/ rel)ol ted ~ ~cnagc ~[nok~r~ with histoli~s of smoki~]g :~s brlef as one to ~vc years [S~ ]979, pp 6-10.22] ing early sign~ of emph)sema alld chronic b~nchitis I~e~rc the ps[Je[lt dc~c]i>p~ syul~olll5 Air Po~l~ior~ d~ei]t times ~nlo)]~ wol]<e~s pXl~llge~ to high co)]c~llL~t~0n~ of p(~llu~ed all ~t v.ork A][h~ugh ;dl th~c w<~rke]s have ln~r~ ]lLng di~csses []l~ll Jlz fll[~ r(~s~ o~ the" populutioil, ~]1~ grl~( iJl epolzl[~r~qrlc~ o[ ~u~Ii di~e~ts(,~ is illvarf~ly [(lurid tls i~t hnl~ (~anc~i¸, ~ii~ong c~aTe[t<~ ~l~loke ~s S(tldi~ of w/~rk~s i)1 t}l<, r~t'~hani~d chculic~[, ul~r:lm~(~, [ound[y (~r Tillable l~ur[i-Fili]~, I~llin~, til@ C/I[LII]~, [~DeSt~)~, clnl- ~LrLIction, ~Pl~l~llt~ rubDcl¸, cork ~ll~ u[ller ill£[t istri(i$ ]/~vl~ ~o~1/ a tlJ~hcr [[lcld~nce (if ~l'spiratory d~a~l~ ;tlllO[l~ sl/iokcls []]gzJ ;(mong llo~Dio~r~ ~×Dosed ~o ch~ ~nl(~ (~ccu~i~Jl]~ h~zaI'd~ [WIIO 1979,1) ~] OTJ JEll NI)NCANCE]/O U ~ LUNG DISEASES 41 4~
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142 Poland but these studi~s were poorly control]ed fear socioeconomic s~t~ a~d ~m~k~r~g habits. D~ a ~t~dy ~t ~c'phll~e l~lstall~s ~l{ repairmen izl Baltimore New ~ork CRy, WashillglorK, De., and ~iid a.y relation hetween pulroonap/ symptoms and de~t~e o{ ilyb~lni~atloli o~/3hqee of wor~ or refide~lce ~y wele, }lllwever~ able to establish ~ str~ng col relation between sm~k~ng habits and pulmmlary symptoms [Camstoek, C. W., Stone, I~ W., Sakal, Y., Matsuy~, T, ~kmaseia, J A., l(espiratory ~qlldin gs and l*~han living Archives of Env~ronme.ta] IIet~lth 27 (¢3): i4~ 150, September 197,~ I In a 1964 survey in the United States and a. earl]c'r one (1951) in the Unlted Kingdort/, rates el su¢[t i[[nefses as chrome }IFOlIC]]I~iS~ asthma, and emphysema, were gr eat~'r among those i11 lower scc~c~omlc ~e~p~ I~ew~tbl, h~lwevel', a ~ttvd'~ ~ ~;2~6 r¢sider~t~ o{ Teeumseh, .~iehigan, fon.d that mo~t el the differ- enees in in¢iden ~e o~ chronic br tme'nitis i. people o~ di~Iering oc etlpational, edtlC.~ti¢mal or income classc?s were attribulatde ~o d~ie~ ences In smokhng ha}Jits Comp lred with smok~n ~. poor occo p~ttlol]~ edtlcatillll II h~'kgroulld, arid ~eotlolrlie ~irou rhstm~ces had only a weak deleterious e{~ec~ [Iliggiizs, M %V Keller, J B, Metz nfr, I{ L, SFl2flkill~, socioecollOrlliC ~t~lflls and chronic" respiratory disease Am~:rican Review of Rcsplratory Disease 116: 403-411), IW7.] AS a resu]~ o[ these and o~h~r s Ludies, it i~ concluded IILtE if air pollutiov increases risk of COLD. this increase must be small eompered to thai related to elgarelto ~mokin g u~der ¢onditlons of air po/lutio~l to which the awra~ person is exposed [SG 1979, p._~ as] pohllt Wog~e, $ A Polish ~rudy o{ 280 wlrrke~ in the EIeeDtrmeda mlea] (~OOl~erativt: ill Waraaw, c~ltleellt~ating~ on those who had smoked a pack (~r more a day for telt y( ars, revealed thB ~: 1, SllloktTs become ill ~ 5 [ilIR!$ f[s (lttcil as i]onstlltlkl!l s and that abseitteeism caused by smokJn E-related disemse was up to We thnes ,is frl~quen{ arnollg smllker~, N or~sl/~f~k{~l s ~c~{ [~ ~[me~ gs im f~xtm¢ t~l ¢olds ~,; starch. ers Sr~oker~ "o~rten became the [~ra~ to collt] to( infl/l~llza " ~11 II}1~ ~TS h,lx~e ~Wi¢i~ a5111./1~y f}ll I1%£~ java aceld er~l$ a5 ram- EMPI]'I'SI,~,fA CHIIONIC BI{ONCI{ITIS AND 4E O I ilr~t~ N/}I4~;ANCEIIt ~ES t ~JE(; I)ISEA~E~ ca 6a
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148 smokers [Job Absenloeisnt amol~g llabit~lal SmokeJs, Korsak, A, World Srn~ing and Hcalt]~, Vol 5 N~ 9 F~II~ 1077, pp 15 17] In~erzl~tlo~l Bettt;t'en S ~lol.~[4 onlI O~ctlp~tloI~aI Ex~giJ~l~'e8 ]~oth s~oki[] g rtlld/icctlpatiol]al exposlll es al.e known to con- ~ai[~ute lo dise~t~e m~du]y Jn~olvhlg the ]un~, cardiovascular sys- teTn, k]~lttt~ys~ }~],ldder, ~md ~Tllr~l ~[~rv[Jl~ sysleltl Now aLt~ltion is t/eili~ ~]ven to the w,ly~ tllese two ~actors itl fly a~t t oget~]cr : ] Tob~le~'o pror]uct$ itlay $1~rvt~ a~ vectors by becolllin~ eol/tamh/atcd with toxic agents; ol 2 worLplace ¢henllca]s nlay be ~r~ln~tll rn~cl h/~o ~lOr~ ]nai ~/fl/] ~lgont~ })y th~ i~]n [~nli~a] s ][i stl]oke Ccltain toxic agents nlay be found both in the workplace and Jr/ tol)acco~ increasii]~ i~xpllsllre catl~irlg arl additive or. in some [~as~ s, an ~xp~]n~nt~a] ~,IL ~ ~ Sr~lc~klng rna! ~ds~t c~[~tribute ~o acci- dents m the workplace "FILe Natim~aI Institute ~ Occupational S~fety and Health (NIOSH} has identilled a number of potential ~uiLLa~iLinants foml([ ~r~ tollac~f~ pr~d/z~ inc]/idill~ ilLOrgai]ic" fluori~Jes arid mcr- emy, [cad, dillitro ortho-cleoso], formaldel]ycte~ bo~n trifluorlde, orgatlo{it], melhy] ll~raLl]io[J, ~LIJ~] call~aryI, hi adr~ilion, hydrogen cyanide has been f~und in cigarette smoke in significant ~,~l~c~,x. tlol]~, alld 121~arette ~mo~ing a]sll COll~llbu~s to i~tcl'cascd ex p~sute lo carbon monoxi~le O~1~] ]~all~/f~] chemical agellts fo~:nd wlt}][n t~13a~x~o and ~n the W~I~/~LC~ iI~c]ud[~ ~Lcelo[le, ac~oleln~ a]dehvdos, arsenic¸ ~'admium, forula]dehyd~', Iwclr~gon ~lllfad~ ke Lorles, ]cad, i,a~thv] nftrlte, nlcot[ne, tilt logell dic~xldtL p]lcno], and p~lycycllc c~mpc~unds [SG 1979, p. 7-7-9] I[J a ~udy [~f l~sL~Ji~ fire tig]LteJS both occttpation and cig- ar~t~ ~ii1D],ir/g eclntritllltod tl) chr~311[c rtolls]l@ciflc r ~splr~ltory d~s ease [Sidor, R, peters, J M, Prevalence rates of chronic non. specil]c respiratory disease in I]lc I~ghters American llevle~ of IlesDhatorv Disease. 109 i2}: 255 26I. Fc]~uary 1~74] NIO~t~ l~s re~olt]lrlt'ndcd that 1,¢111~'1"i C~XlIO~[~l] t~ t~r ta]i~ stl}~s~ances rof~ail] froTrl s[llol~i~g~ bu~ ~}lat t]lis clll'tal]n/ent should alto "oe a~2coTn] i~ ni/~d by silllU]l~tlZt'otts col~lloi of ot'clll3,q~ional ex. po~urt~ to toxic physical and chemical a~nts. [SG 1~79, p !718J Llmg Pro~ectlor~ A~.qong Lh~ main pr~t~ctlv~ lnecha[llsi]ls of the ]urtgs are I~MpI IYSEMA. CIIRONIC BI~©N CIIITIS AND O i illSH N fJNCANf:EItO( !S LUNG DtSEASES 4~. -,.l
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144 the cilia--tiny hairlike structures which fins airways and beat, llke a ~'/aving [/e]d oF gr~tirl, trt~vi~g the mucus blanket constantly out- ~r~. ~is p~oee~s xi~ th~ ½u~s ~ ~D~i~r~ ~p~le~ Inhale6 ~xoke ~ag~; t]lc ~lt~vercLe~ o~ ci/i~ .u~d gr~t~cdly dest~y~ them. The re~t2ir~tor¥ mucus blan~.et is, itscl~ scc~ cted by goblet ceils. Whea the lining cells of t}lc lun ~ ~re dc~uded, the ~mber of goblet eel]l increases ~ls does lilucu~ production T~is is thou~h~ [o b~ o11~ iitccllanisl~l tiler ~uiIiat ( s "broF~lills in slno)ccrs ~o~ (he ~¢tivit~ o~ ta~cr~ph~, a W~e ~ ceil ~h~sc ~e- riot/ is ~o ing~st hlrclgr~ Tnatter ~nd transport it, ~i~ Ihc hlo~d or ]y~llph sy~l~m~, to one ~ ~he body½ e×o etory or gar~ T}lis ]3rocess is k~owll as phaguey~usi~ The acLiv~W of the m~croph,~ges is also i3~bibited })y c~ga~e~tc smok~. [SG 197~, p. 176] [SG 1979, p B31] Ocher F, ffe~t~ ~f Sm~ke Two other m niter I)osslhilitics o~ how sInoking ln~, damage the brags ate: l Al~r~ng*D~2~a.ce Andprolea~ I~al~ice EraE~hysema i~ ¢har~cterlzed by irreversible dosLru~t~o~ of ~ss/~c, Yoai~ly o~ th~ p~oteill t~lz~st~3/, ~1~ il~poY'~nt cu]l~p(IFl~t o~ hm~ col~llec~ivc ~ss~c, J:~las~i~/can bl~ atl~cked ,~/d destroyed by enzymes called 1)~o~e~se~ ~eased I~¸ ~vhite "blood ~,ns and nl~cto- ~1 ot~c~lls, ~out~d ~r hll~r~l!¸i/~ lllt~o ~ ~c~r/lrtL s~rv~ to ~h(*ck ~t o[l~ase~ If, fl)r ~ll~y ~e~SOil: ~}lls h/]~iice i~/tps~ ~lld ~x~css l)rl)t~a~ a~tl- .~nl csr ge~ r~sllJt ~ tory ~i~ ~pac~s Sm ok'iu g i~ the nl~ljor ~aetor i~l/Ipscllil~g lhe 'ood~ly })alILn~ inaclophat~es, t~ whEch cig,lre~!e s/nc~e ~s ~o~{e ~,Vben these c~Is are ini~l led by ex.oo~ul c tll sln(~ke, Lhcy die, r~leasitl~ lance qu,~ntl- ~ies o~ p~htt~$~ ill thl¸ //roccss Ful~hc~r~oi~1 ~ll~ipltlte~se~ ~r~ bTuimn~ nlc~lanlsnls in boLh anirsals and pc'o~e T}le a'oi)ity o~ EMPI]y~ff].'~IA (]IIlIC)NIC BRONC~[IT]S AND 4t O{~IIEANONCANCEBOUSLUNGDISEASE5 .,1 w~ ¢,A
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145 maeruphages to eilgul~ ha~erla alid other ~or eigu stLbstanees is im ~&ir(~d in xmokers~ and the total inlmher o[ rnacTophages is in creased Cban~(~s lit theix ul~rast ~icture have also been observed in snlo~ers, w~ich are absent in nons~okei~ Lymplmeytes ( white ,vlls ), inllmr rant in the body's defense system have been recovered in ~eater lmmbcrs (by ]lulnfl[l bronchopu]naolhary ]avage) from smokers t]lall ~r¢)m nonsnlokers. These observations indicate consider able phvsioh/gica] im paimlen t of immune ml eh,misms lit 81tlokers. [SC i979, p {~8(} ,'321 Conclusions "(ilgar(tte ,m{)king, nwm in young ag< groups, plodnoes hmg damage Cessation of smoking leads to at Iiast padlal resolu timi of symptoms, Pulmonary [nn¢ti<m and hist ologie abnormalltles have been observed in young smokers, confirming ellnieal susp£ dons of lung damage in this gronp " "... puhnonary ~unetional abnonnabties, believed to repre- sent snlal[ airway dysfunetirm, oeenrs (sle) in smokers , It has been Sllgt4estcd that such changes rrag lee precursors o{ mr)r( extensive a~la[o]lllC fnnetiollal abiiorilia]ities i{ snaobil,g were cent blued." ". A number of recent invcstigatiol~s have su gg~,~ted that destructive lung changes . . may resull fiom excess lil~er Itlnn of or fai]ure kl inhibit, proteases in tile lung Cigaiette sJrmke has been demonstrated ¢o impair a variety o£ }unellmls of the hunlall alveoIar maerophagc" "Most of the di~crences in the pl evalal~ce of chronic bron- chitis in s~,bjeets of diIfcliug occtlpatiolla] edt/c ational, or income classes can be attributed to dif~ereneus in smoking habils7 [8C 1079, pp _6.89-42] EMpH3'SEMAI CHllON[C BIION¢]HITIS AND OTIIEI1 NONCANCEROUS LUN(: DISEASE~ 45 ¢/1 da rdl
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146 VI-SMOKING AND PREGNANCY DRUG METABOLISM, MEDICAL TESTS PregT*a.cy a.d In[ant HeaTth More aild mor. dala shuw that cigarette smokJr, g during pregnancy h~ls a sign]laeant adverse ~fieet ul~n lhe well bl~it~g of the fetus, the health of the newborn baby~ ,q~d the fl~tur~ develop ment of the input and dllld. Stillbirth and Low B irlhwoigh¢ Wolileii who smtlke duri[ig prt~gilantty ]lave siguiEcantly moIe stlllbirths, and more of their ba'oles die c] u ring the first month of infancy, than those of non-fmoking m~thers O~e study of 2,fill0 pregnant women concl~lded that 2.(I percent of the unsuccessfal pregnancies "would have been successful if llLe Ji~t]~er had not bcen a regular ~moker." [Russell, C S, Another ltaz~rd o~ Sm~k- ingo New Scientist, 41 (f~ql) p 64 65, January, I965] A prospect~e British study o~ 17~000 births showed thai "the mot tality in babies of smokers w~s si~ni~t~y hig)u~r than in those of nonsmokexs" The reason: "the e×cess of ]~lw Bit t]lweight babies" [Butler, N. R., Alberman, 12 D., Prenatal Pr~]blems, Ed~n- burgh, E. & S. L~vings~n~, Ltd. 19~9, p. 72-84] "Low birthweight" refers t~ babies prelnature I~y w~gbt, ( und~r ~ pounds. / [n a st~ dv o~ 100,0~0 births, smoking mothers' babies weighed ~n thc ~vcrage 61 ounces less tha~ those of non~ smoking n/~thers. [SG 1971, p. ~J89, also Table ~, pp 397 g991 L~w birlhweight is related n/or~ to smoki~l~ t~aan t~ any other ~ctor. And it is related to the length ~f t~.ll~ Ihe pregoant woman smokes beldre giving birth¸ In 4/q,0II(I prl~naneie~ the mothers wllo did I~ot smoke ~aad die largest babies; these who s[llo]~ed durlJl~ oizly 0~ fiJst parl ~f the/J¸ pre~r~ancy, had sm~ller I~a]~ies~ ailt] th~e who s~iL~ked during the e~tlre pregnancy h,ad the smallest babies¸ [SC I~71, p ~89 ~3901 T]q~ more ~ worfl~n ~l~okes during pre~zlftllcv, the g~e~t~r the reduction m her iofaal's bir~h weight, accordi~lg t~ a I~rge zltql~b er of st ud[es However, if ~ wo~ a,~ giv,.s up smoking during pregnancy, her risk of th~liverlng a I.w birth weight baby be et~mes ~imilar ~o that of a no~lsmoker. [SG 1979~ p, 8 1"2] In o~e I~rge sl~ldy, t]~e rqost ~rni~ca~t cldlt'l ~lllke~ }3~fw~en smoking and r.onsm~kiug pr~grmT~t w~m~r~, in r~sk ~F "]3cri~l~tar' 46 0~ .q
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147 dc~Lth (ill th~ dt-velulJed feht5 of 5oox* a(tll bifih} ~nd in prcg ]laney complications, were fOtllld to ~K'eur al tire ge~hi[i0tlal a~es f,~tl1:10 weeks to ~2 to 38 weeks, lM~ycr, \i I~ , "lcmaseia ] A, ~ ] aterl~a] smukin g, ill e~llancy eonlp]ic;~tlon~ al~d i~cril~at a/inortal- itv: American j~urllal of Obstetrics and (~yl.:c dugy 128 (3): 4N- 5!)2, July 1, D77] Ph ysldo lc E~clt~ it~ ;'.,2nar~cL* ~nl~kill~ ¢~{/ises &fl i[Icred5~ ill the amom~t d cait)oE J]2onI oxide in the bllllld, and, thercfure, ~ @crease in its oxygen content ~Vh~ii a ple~]LLIR We:fibril snlOKCS Ibis oxy~lq/ po0Y ])lood elf cu]ates through Lhe fdus DI L D Longo stated that 'the de ~llas*:d availability nt oxygen . . is pr(ibab]y irliur[ous Lo [eta/ tissue." [Carbon Monoxide in the Pregmult Mother ,lnd Fetus, Annals i)f the N.Y Ac, ldun~ of Sciences 174 ( l ) : 818-841 October 5,1970] W]Len fats and rabbits me exposed lo nicoLine or ci~,'lrelte sn*okc, thly have more unsuecess[ul prcgt]auuies and smalhr off ~prin~ than clmtrol anita*rig Sludies ill rnJcl, have ~]/owed t]lat nicotine (alld its metallo]ites} accumulate i1~ t}Je placenta the mL mbr;me around t]le f tus and pass inh~ die ~etns [SC 1971, pp 407 and 4J 5] In one <d the few studies of SilnU[att d m uiiuan t st, raking in animals, it was reported thtt gulnca lligs exposed to mar@lana smllke showed an in,re tsed iuaterii a] ]le,~r t rat~ durizl ~ the smock. ing 13erloll, and changes wine obs~ rved in bolh maternal and fetal tqeetmvnc¢~phah~!!rams [Singer 1' IL, Scib/tta, J J, J%~s~n, x.l. C Simulated marijuana srnol in~ in the in~h,rn iI and fcta[ ~uinea pig. Amel~can Jouri~al of O]/stetlies md G~nu:l:o]og5 117:,~31 ~O, October ], 197~1 Long Tel n~ Eff¢ct,~ i~ Children A long term follow-ltp shldy s]lowed that when thl motl~ ix had bt'cn heavy Sll~ukers dmiJ~g p~egnanc) did* hi]dreu at the [l~e of seven weril shorte~ ill stature and had I~tarded reading ability and lower ratings on social ~K[jllstn/ent" than thl children of nons~loking m~)tt*er~ 113uth.r, N. K A National Lo~lK-Tcrm StudI d Perinatal IhzarG, prescntc~] at 6th World Congress of Gynl'~ohlt~y Ohstetfim, New Y~k, April 12 1S, 1970. 11 pp.] Anothm long tetra study & mtmst~ ated som~, sigld[ilcant dif- 47 U1 ga UI O~ 00
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148 terences in favor of nonsmokers' children with respect to behavior ratings and school placement [Dunn, H. G McBunncy, A K, Ingrain, S, Hunter, C M Maternal cigarette smokitl g during preg- nancy and Ihe child's ~ubsequen% develnpment: 1I Neulologleal and intellectual maturation to thl age cff 6~ years. Canadian Jour na] of Public Health 68:43 5D, January/F~br uary 1977] Pt~ptlc Ulcer Male cigarette smokers get more stomach ulcers ,rod also die of peptic Ldeer more ofttn than do nonsmokers. Antacid treat n/en~ for s[onia~h /dct-[ is less ~f~'~'~lve ii] SlrlOker~ thaii itl nn[i smokers, and beallng is slower. ISG ] 971, p 428] In one study, the intenelatiorL~hipf among coffee alcohol, and smoking were examined in 36,656 men al,d women, aged 80 tu 59; 2,597 of them had a bistnry of peptac ulcer disease. Men wh~ ~muked had a 2 l-fold grealm frequency of ulcer disease than those who did not smoke and women had a 16 told greater fro quency. Neither coffee drinking nor alcohol consumption alone was related In increased o~eurrence of peptic uleel disease [Fried man, G D, Siegclallb, A B, Seltzer, G C Cigarettes, alcohol, coffee and peptic ulcer. The New England four~ml of Medicine 290 ( 9 ) : 469 5 478, February 28, t9741 In studies done at difflrent times and in four different ~'otmtries (Britain, Poland, Israel, and the United States), peptic ulcer was found 70 to 9'3 percent more frequently in both men and wonlen who ~uloked l]lazn ill IIOlISU tok~rs EX-Slnokcrs alsu had consistently greater evidenee of peptle nicer. [SG 1979, p ~8] Allergy and Phallnacolog~t Tobacco and its pruducts, indlldlng ~ltlfd~e, ¢2.t[1 affg~t Ihe immune system in two ways : as antigens, whr'r~ they interact with the iffimllne system to inffu( e specific responses sufb as production of antibodies mr sensitized cells; or as irrRanh pharmacologic, and toxic agen[s, intetaetlng with [}to hos[ defetlse sys[elil ~fld il/- fluencing the functional a bilit3 o| these elements There is cv~dt nee thlt tnhaeer~ h:af and its products are antigenic in animals and man, but the evidence that tobacco smoke is antigenic in man is meager and controversial at present [SG 197~*, p 10-9] Nicotine is lint the r espoasible antigcnic component of tQbaccn l~af, but We plant prottlins h;tve been isnlated from SMOKING AND PREGNANCY 48 DRUG~.IETA2JOLISM, MLDICALTESTS 0~ ¢D
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tobacco leaf and tountl to possess ~ht: property of pre¢ipitallng human sera. a lest for anfi~:nieity [Pa~ayotopoulos, $, Gotsis, N., Papazt~ff,,lou, N.~ Cc~couns, L. Antigerlic slud.y of uicotiana taba corn and research on pfeclpltlns agaiflst tobacco anti~ms in the serum ~f smokers and nonsrc okers. Allergologla et Itnmunopathc- logia2 (1/~ lll-114. January/Fcbruary 1974] Asthma or hay [~ver affect as nauch as 15 to 17 percent of ~he population in tllE~ Uoited Stat~s S~dies of active anll passive sin.king have sho~ that al]er~ie ir~dlviduals, especia]ly th~se with asthma or thinitis, may, in fa~t. be more scnsitlve to the nl~n- specaqc noxious elfec~ t~f clg~Lr~tt e smoke t}lan healthy indivlduals [SG I979, p. 1024] Effect ~ Passive Smoking: Pharmacology Tobacco smoke can la a significant souree tff atmospheric ~o] Iillioll [iJ ~ii¢21osed &r~a~ The total s/nolKe exl)o//l~ of Ilonsmo~ ers is multi smaller thall that of smokers, but the alubienI smoke may be qtlaIitatively ~ichel¸ izl cerLals~ compounds, such as nicotine, carbon lrlono×ide a?kd firomoflia. Th~ll~ flrt~ i/o d.ql~ liil~Kirl~ ~12. ~r ~,~s~t~ ri~k of l~ng ~a?l~'l~r ~o I)~ssive irlhaIation of ~1~b,~¢¢ o stllok~. INi~l I~in ~ i~ lhe air i$ of ¢oii ¢:erl i because it is ¢oll~idc'r ~¢i 1o h¢" one o~ the f~t,Dr$ c~ltllbl/lhl~ [o al]l~r t~d~)~ic c~diov,~sc/t]ar dist~as~ irt ~igarettc~ 51iioker~ Hiiwt~vel", 131 irla~y rl~otln~ rn ('~q ~tlr ~d [11 ilonsrr ok~r~ und¢l¸ ¢oiidltiinl~ ill s~vl'r~ t o b~t ~'o smoke po]] LJlion showed .~ltt~ ~/ltl~n[i~l[]¥ b~]ow t]~os~ for urilqa~y nicot[l/¢ i1% smok~r~ [Rus~elI, "~! AII., Feyerabend, C, BIood and mJ~ary nicotil~e i~1 n~sll~okers Lancet 1 ~79~10): 179-181, 1975] ~.thol/ mlllloxid¢, at l~v~[~ occasionally fount] ~lk illlokl~ ~]Ied l~r~vjl olltll~ii[s, ~tI1 pl odu~l~ sl~ ~tlt ~¢t('l"iora tioll iii &~telitlv~ iI~s~ and ¢ognitlvt~ [llrl~tiorl ~/it ¢ffe~ls of carboll iIloltoxiil~ ~l l~ve]~ 101111(] ill molor vehicles, fol ~x~l/IpI~. wel~ fl)Hr~d to [ll~ in. significant¸ The c~mbinelI ~I~ect ~ff aIcohol ancl carbon monoxide could he demonstrated¸ IMedical (~lh~ of Wisconsia Exposur~ of him/all5 lo c~r]ll~ri mclllo~i¢[¢ com~inl~d wilh ~¢1~5tioll of ¢2thyl al~l}llll ~d the ~'ornparJson of humall ]p¢l ~or m~n~¢ whell ~xpclsl~ll for varying periods of time to carbon monoxide. M~di~al Colleg~ of Wi~¢ilnsill, I~e/lartl~ll~iiI of Env~rtrDm~l~ta] M~t]iiirlc Mil- waukee. 1974, ~9 pp I SMOKING AND pR~GNAN/?y DRUG iqEqgk~OLIS~I, MEDICAL T~ST~ 49 .,0
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Adult ICea~lit)rls to Passive Smo~,ing ~L 1~75 tt~[ephlllle survey, 8mo~¢r s ~nd rlonsra~x$ w~t~ asked; "Is it arlnoyillg [o b~ n~ It [~t~r~lltl who is ~moking c[gar- ~te$~" Thirty live perce~t ~f ma]~ slnlllx~r~ alld 34.~ [~erce~lt of female sn~ers replied 'Yes" as clld 77 pement ~f males al~d 805 percent of lcrnalcs who h~d newr smok~cl Fffeets ~f ambiet~t smoke vary ~th th~ i~di~idual, ra~ging fr~ minor eye an~ throat irritations to an~na] ~Lttaeks. [National C]~arlnghous~ f~r Smoking and IlealtJl. Adult Use af Tobacco 1975 US. Departr~l~lt of Ht~llttl, Edu~allt~n and W~Ifale, Public IIcalth Service, C~riter for Disease C~mtr~l, I~ure~u of H~allh Education, Natlc~n~ I~tl [kites Of Ht'illth, Xatiol~tl CB r/l~l~r [ Nstlt lite, N atlolla] Cle~rill gtlousl~ for Sn~oking aJ~d Health, ~une 1976, 9~ pp ] P~slve l~alatio~ i~ Children "Th~ ri~k of a yomlg i~nt dcveh~l~i~g bro~clfitis ~r pll~ ~1- monia in the [[r~t y/~l of li~ is d~ut~ed if it~ parents sm~e The risk is iarreased if th~ par~t~ts al~o eot~gh and i~t!~duce phlegm ~Vlle~zin~ ill ¢]li]l!ren up to ~ ~v¢ i~ illor e ¢o~ moll if ~]/~ i~r~lt~ ~moke. A study of ~LI)(10 Pari~ schoolchildren a~cl students ~ge~ 10 ~0 shawed th~ t adlloid~elonly and] or tonsillectomy, ~lsidered a5 an iiidex o{ rcpcatt~ tll)p~-r r~pira~lry tra~t di~a~ ilt e~ly ehiIt~lood, was v~y significantly ~el~lcd to the amount o~ sm~ki~g by ~a~:tt i~ar el~t [ WHO 1979. p 22] Ir~emctio~ ~ S rooking witll Ot~er Subsm~ce~ ~nce Cigar etle ~moke is ~ ¢ol~[l[~x iNix~ll~e o~ ilox~oll~ ~ub stances, it is l]o[ siirprisin~ that i~ ¢~11 a~[~ct ¢~£1d Jlltc~ll~t with ¢]rll~ ~)od COllsti[ut~nls and re~poll$~ to dlaKIlosli~ tc~t~ ~ltl~ll of [h~ ~xp~rill/~nt:ll wllr I~ itl iltall, allilna]$ and ti~sue~ il/~li~at~ t]l,/[ the dolni~*~ll t tit tlg-intl~lalfflo~ e{~2¢[ o~ ~tllt J]~ltg iil~ o[vc$ cnzyilw~ in the liver. Ph~acetin a~ Theoph yli~le ~, the frequcn~y of n]t~rt~] ~]isi~sltiol~ a~d p]3~lrmacoIog- ~at c~garette ~ing ~hould ]3e ~sicl~ as on(~ of the prlm~Lry sources of drug interactions in man " [SG 1979~ I) ~o~] AS one exampll~, stlldi~ ill mall alld ~tniol~/l~ glveil p~lt'n ~¢ l~lill, a colilitlon pain ki[]~l¸, ~]t~w lower 1~ ¢1~ of p]~en:lcetin io ~mokers that~ ill ~lon ~MOKING AND PgECNANCY 50 I)RUG METAB()LI ~ M, MI~DICAL TESTS
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smokers IRescarchvrs attrilmtcd this ~o inereas~d metabolism of the r]rug by enzynl~s "Clgaret~e smoking m~y n~!eessil~tc inodl- ~cation of ~lrug therapy and ]~er organ function or reSl)on~iw- ness~ [SC I979, p 1~281 "Poe do~lng of theophyline, ~ broneh~- di]alor with a narrow ~hcrapel~ti¢ ~ange, is seriously affected b v smoking¸ A~lrtlgc~sic ~Ind ~y~lo~ro#ic Drt'~qs "Srar~l;¢rs cllflcr fl'c~l~ i/on~lllokers irl th~ir p~En thrcs[lold, Of ~ullst~n~s ~11¢]1 a~ nic~o~n¢, ~]lJeh r'aul~ colrlp~in~ ot¸ ~l~]l]i~lx ¢j in Vr ~ating pain or anxiety ,r iSc 1979, p, 1.9 45] ~,[ariilla~a ~mokiu~ ~]so ~l~t~ li~,~r enzymes c'ol]c~lll~d wilh ~tlu~ disposition II hax iccen~ly been e~il~al~d tt~Lt 1~ rail- ]inn pl'op]e ~ the lluited States now ~J/iok~ ~nariiuana [Abramo- wi~z, M (Editor),),laliiualla ~'~¢~dle~] I ctter ~n ¸'Drug and Thc~apeutles 18 ( 17 ) : ~ ~0 A~/~lst 1~, 1~8] Th~ Pill lr~ 19~, a reporl was published stating fl~at clgareth" scaok- illg llli~ht ~l~]l~ii/,c th~ li~k ill ~hl oil tbl;elrlboli~ m lit c~l(]iovas¢/l[,~l" p~rt ~howed ~hat ~o~n~lL who ~<~k tile ill]] a~d smokeJ ~tJt~ [~a~k ot cigarettes per d~y had :~ ~llO percen~ i~cr~sed risk of a strok~ ICo]labo~ative G~mp for ~he Sl~tdy of Stroke in Y~ung Wolll~n OTa~ coIl~ral~l~l~ti'ces *~lld ~1o~ iit ~lg wollqlYr : Assr3ci~ttcd I1~ factor~ Journal of the A:neriean M~!dic:~l As~oeiatio~ "291 ( 7 ) : 718- 722, February 17, 1~75] In another stt~dy cf ola] corstr~e~p~iv~ Ii~r~, the r~]a ~i,¢~ ri~]¢ ~ llo~tr t ~tt ~1~$ ill~Teascd from I ~ in wome~ ~l~3okitl~ ft.w~ thtul ~ c~arct ~s at day, tll 4 I ill woml~ srollkJn~ 15 tO 21 ¢i~rcttes a day~ and to |1.~ in womerl snloklng ~5 or mo~ cigarettes a day [Malnl, J. L. Vesse~ M P. Thorogo~d. M~ D~II, oral eo~ltrac~p~ive prac0ee British Medical JL~l~rnal ~: 241-~45, May ~. 1~)75] A thi~ study showed excess ~l~ntla i dearies of 1 p¢~ 10.000 for or~d o3nt~ aceptive uscJs who had ~lui~ smoking aEid I per ~ ~dOKfi~G AND P~EGN~NCy D~13 (~ hlI~TAIJOL1 ~M, 1.1EDIGAL R~I~S ~1 0~
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152 Obe~'ztF Althollgh m,~ny individuals who have g~v¢~ up .moking report signi~c~n~ weight gains, there is no measureable change in resting metabolic rate J~ former smokers "~q~o have quit¸ [Sims, b:. A. H [Lxp~r~m~ltal oh~slt y~ ~li~tary in~lu~t~d th~rmc~e f Jes]s, and their clinical implications. Clinics in E~docrinology and Met~tbo lism 5 ( 2 ) : 577 '395, July Ic~ 6] At~lbhj~pla, O~leoporo~is, Vilalni~ Smoking is linked wi~ amhlyopia (an eye disease) and osteopor~sis (lo~s of calcium from the body). ~'Smoking e~uses changes in plasma and leukocyte concentrations ~f vit,~min C and impairs biochemical funcLi~n~ of this vitamin. ~tamin B-12 is smoking¸ Some heavy ~mokers dew!op an amblyopia which is re- versed hy ~it]l~r ¥ilaiTl~rl B 12 t/lp~ielll~Iit~tillii or terllliil~LlOl~ of alter the metcholisl~l of ]ipids, ~a~[)ohy~rates~ proteins, and other vitamins such as v]t~tmin B-8" [SC 1970. p. ~2~8] Testing nor n~a] in~]ividuals, ~ot suf[~rlng trom any smok~ l~]~tc£l ~]Js~,a~e or ,lrly n~h~r {]is~as~, re.~rcllers h,2ve found th.~t "smchjn g ~l/lsc~ si~/~i~nt c~ h.2 ii ~2~ ]~/~he ~llo~la]' l,:~hles in van. clinical laboratory" ~;uch tests ~lelucle white blond cell counts (smokers "~h~wed inc~.cas~s in ll~n~ogT~hin, ]uem~t~crit and ~nea~l corpuscular vclurne") So~v~e studi~s h,~ found higher cl~oles tl~ro~ [~v~is ill ]le~v}~ fllxoh~rs~ ot]l~rs ha¥~ ~ot. Srnokiil~ seer.s ~t~ decr~a~e cr~t]lli~J~ alhul~/ill alia{ g]o~/llii~ t~ve]s; ~l~re~se uric acid¸ Platelets~ a clottin~ f~or in blond ~o up in ~mokers, as do other b]ood viscosity factors: fibr~nogen plasma viscosity, ~nd red cell aggregation [SG 1070, pp. 12-79, ~2, 85, $4, $8] Cazcinc~einl~ry~m~ aill~gen (CEA), a mar~r ~o~ ecl~aiu c~ncers used to monitor txeatment, is elevated in sraokcr~; the blood levels of CF, A dcchl~ to normal ]ew'ls thr~e m~/ll~h~ aft~r quitting sm~king Arn~ng the Sur g~oI~ Cenera]~ c~nciuslon~: ~'1 ]~e illaior~t y ~f Ihe bh~od ~nmt~niJen~ ele~at~] due to ciga- SMOKING AND pI~EGNANCY $R EIRUG METABOLISM; MEOICAL TESTS ¢D UI
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rettc smoking appl ar to revert to approximately nmmal ]~w]s after cess~tiorl of ~mokin~, "The smoking statu~ ~f an ind~v~du~I should }~e ~ne]uded in reports of elinieM / din~ostlc tests per formed on ~a~ indlvidu~l," [SG 1979, p. 1287] Smokln~ anrl F~re~ In 1979~ the Natlona[ Ffre Protection Association INFrA) re ]~clr ~/,d ~at rflore f~taI ~c~ a~ caused by cig~ret te~ t}l=~ll }iv ally ot]ler ~OUyCe of combus~ioll ~lt~sl~ I~rcf r~lll~ ~n ~n estimated o_,~00 deaths each year in the Ullited States In a special analysis of the igllltion of fatal fires reporled to the Association ~or the years 19~1 1978, the ~FPA ~und that cigarette c~us~d firu~ accouJit f~r 40~2 percent ~f fatal ~res wilh known ~gn~ion sources allcl ~49 percent of enrr t'~pr)ndillg ~re deaths¸ The next I~adlng aeclden lal ignition source i match, lightci, calldl~ ) a~cou.ts for 9.0 percerLt ~ the fatal ~ret ~nd 9~3 perl'c'f~ o[ ~he fire deaths. Many of these a~e also reIated to smoking. Tile Natlona] Fire Prot ecti~n Asfoeiation analy~d the most common ar~!L~ of ~re origin ,and materials ignlt~d in fatal fires s~ar'ed by cigarettes in I~able V~ p. 54. In additiiJn to ~lc [atalitles, an NFPA a~lysis ~und tha~ at le~s~ 25~000 peop]~ wt~r~ injured during 1977 in residential fires ignitc~d by cigarettes and t[/c~t appt~ximately 8~1/3 i/l/Iliol~ ill p~op ~r~ was lost in thes~ ~res CaIifoJnia SLatu Fire ~{ar~hal l~hil~p C F,avro ~estifLed on Mal ch 22 [977 ~ ~he hrst s~Lsslon ot tile American Ca~leer Soeiety~s Nati~mal C,~remi~sioT~ ~n Smoking a~ld llub~ic P~icy~ held in Lus Angeles. t]l~t of more than 12 ml]linn t~1e5 in the United S~a~es in 1975, about 19 pe~ cent, or 225,000, we~ caused hy smoking. SMOKING AND PI{EC:NA*~Cy DP.UC METABOLISM, MEDICALTESTS S~ 0~ 0~ ¢dl '.d g* U1
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1 154 Table V FATAL FIRES STARTED BY CIGARI~TTES T}~e Top Ten Ignitlon Scenarios Material Set Area Where Perc~:nt Per~nt On Fire Started of Deaths of Fire Upholstered furniture Livillg r ot3m 48~9 40.1 Bedding Bedroom 80.8 ;24.8 Upholstered furniture Bedroom 2.9 3,1 Bedding Living room 24 2.8 ~bb~sh Kitchen 2,3 lY/ Clolh~ on a person Be&nora 1,9 2.7 CIolhes o~ a person Living ruum I 5 2.1 Soft oodsotherthan bed~ng or clothes ~1 ~person B el:It c~m 13 1,2 Clothes oa a person Kitchen 10 1,4 Fudlitltre (t~e undetermined ) IA~ing room L0 07 Suttrcv: N~OI~I Ftrg p~oteetiofl Ax~oct~ion Bas#d on 3,037 death~ in 2~131 accidental fires in the ~]nited States r¢~r~ed to lhe Association for the year~ J971.197cq. The t~a scenmio~ in this Table CA ,0 CA
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158 VIl~lIE SMOK[ \'C I{ABI f: PSYCHOLOGY AND PHARMACOLOGY Smoking is a compIcx act invotvii/g learned behavior, plea- sure or redRetion Of un[J]easant situati(~lls a stlrnnlatlng an~t pos. sibly habit uatilJg ~nd/or addiutlve drug (nicotine), and a variety of other chemicals with an enormous nunlbcr of physiological effect~ Most research in helplng smokers quit has ilsed learning theory, based un bdlt~vior modification¸ learning theory regards smoking as behavior ac~llred under social reinforccment, typically peer pressure since most ~IIl~kcr8 bc~ill as leena~ers w]kf*n poet pressure J~ lrl~s~ potent At first inhaling tobacco smoke is repugnant. Eaell puff increases physical tolerance, and builds the hallil Eventually, sn~oki. ~ pro ducts enough reinforcement to sustain i~elf with~.t s~elaI 13res sures. The nunlbcr Of etllo~ona] eveci~, [iol}t po~ilivc and lle~a tire, that e~Zl i~ueuce sm~kin ~ is pot entlal/y ~ry great¸ Fd~ moodily ~mokln~ behavior may require a varlcty o~ intervcntiol3 tedln~quc$ in a spcclrum of s~mations And it is complicated by the ~ct that smoking provides instant reinforcen/enl from the physiologically powerful drug, nicc~tln ~ [SG, 1979, pp. 16-5-7] N'ieotlne Nicotine flom aa iuhaled cigarette rcamhea the brain in ~even seconds ([wiee a~ fnst as froi~l an intravenous hli¢ctioll) A pad, a day smoker takes mmc than 70,000 puffs a year, a frequency o[ "shots" unmat c~/ed by any other drug taking. Thus, the habit is tremendously ~overlearned." And its serious ill eflects~ of which ~mokers are aWale, Co~rt~ years later; ~hns seem very ¢8n/o1~. Ni¢oticie is the most ]powerful pharwac~logica] agent in ¢~aret[e ~llloke; other h/~l¢~]il~ that exert chemical e~¢c~s oil the l~ody are c*q r go ci iIiOltOXlde and tar ( particulate lxt~t t~r, a llxix - tllre of ~evera] t]loUSalld chemlca]s ) Olte $~udy hi w]tldl tdr aiic~ n~oathle were varied acid dissouia~ed, s]lowed ~hat the rlnm]lor (1~ ci~lreltes stllci]~ed w~s re]alod to the nic'lltlne conteilt llut not to* the taz. [Glausel, S C, Glnuser, E M, ]Rcldcnberg, M. M., Busy, B IV, Tal[arlda, fk J Metabolic effect in nlan of the cessation of smoking. Phar ma¢ologist 11 ( 2 ) : 288, 1969 ( Absb act )] ga, UI ",3 O~
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156 The r~suK~ are consistent wiOt the [det that let I)ph sn]oke tobacco to obtain nicotine although smokers will smoke nicotine- free cigarettes. Many report that they smoke wht.n ~lres~ed Sunle hlvestl gators cotlstdt r tlla[ Ilicotine is the prinlary leinforf'fl bef, ause of its role 111 redlll:Jng lellsiou and distress, associated with nicotine deprivation. But the evidence is not conclusive [Jarvik, M E., Biologacal factors underlying tlu smoking h:d~it, lu Jarvik, M E, Cnllen, J. W, Critz, E I/, Vast T M, VtZcst L.J. (Editors). Re- search on Smoking Behavior. NIDA Researcb gfonograph No 17. U.S Department el Health. Education, and Welfare, Public Ilealth Ser~qce Alef~hol, Drug Abuse and Mental tlcalth Admin istratSon. National Institute on Drug Abuse, DIIEW Publication No. (ADM) 78-581, December 1977, pp, 122 148] [SG 1979, p. 15-8] Genetic Prediepdsitlon An ongoing stud) using idelltical twins has reported evi detlee of a gluetie predislmsltion to smoke }Iowevor, this seems doubtful The most recent review concludes that "the theory of genetic predisposition is disproved by the smoking discordance among monozygulic [identical] twins." [Ramstrom, Lars, M., Ph.D., "The Swedish T'aln Study@uhlieity & Criticism" World Smoking & Health, ,3 ( 2 ) : ] 4-19,1978] Hormonal Factors Hormonal changes ltl puberty, oeellr at shunt ~he Sallle time that indlvidua]s stair sumking; thus. endocrine responses and stool,trig have been examined for passible links "oAth smoking (~gJwth hormone and ACTH were mcasured in nonsmokers after smoklng two cigarettes A rapid increase in both hormones was observed, but no signuqcant change in others, eg. Lid (lut ein- izSng hormone ), FSI-t (follicle ulinmlatlng hormune, TSH ( th}roid stimulating hormone), and tegtost/rone (male hormone) levels [Winternitz, W W., Quillen, D. Acute hormonal response to cigar- ette smoking Journal of Clinical Pharmaoalogy 17 (7): gSgg97, July 19771 Vasopressin (a hormmle affecting the eoutraetilm of bloom vessels) levels are also armed hy nleotine Smokin< Ceasa*lon Significant physiological changes occur immediately on TIIE SMOKING HABIT: 56 ]?SYCIIOLOG~ ANLI PHAI~MACOLfJGy 1 ",I ~a .q .,4
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157 SInoking ~essatJun in heart rate, dialtolie b]ood pressure, excr~ tiou of adr enalln and norq)inephtiue, EEG, cur tlcal alpha activity O~ ~he bra~n~ 3~d eardiupLLbnoilary ~uiIctloil tests. Many cx-smokers report fe/Iings of well bcilJg and iln- pro~ed health, but others experience a ~ide vanity of temporary unldeasant side ei{eet~ irmhlding r'raxing for tobacco, irritabi]ity, restlcssnels, dullness, s]eep and gastroint/stiaa[ dlsturhanees, ~qlxieDy, impai3 nlcl/[ o[ eoucenLra[hnl, iud~[II~JIb al]d pSy(hOl]~ot f3[ per focnl~nee. "Wit h dr a ~al lymptonls of ~ arying severity ~olh/win ~ ecsla- tfon are the principal rea.~ons cited for relapse [o smoking, x3,%m eu are more likely to fdl in smoking cessation efforts than men, and it i~ pmsih]e tbnt there is a sex di~l fence in withdrawal symptoms. [Guilford, J S., Factors Belated l~ Successfnl Abstinence from Smoking Pittsburgh, American Institutes f~r ]~e~c'arch, July lgC',fi, I71 pp.] Smokin~ in Adolescenta ~nd Children The decrease in adult smokiug shlce 1904 is paralleled to a lesser degree among teenage boys and younger t~enage girls, al ffmugh am~mg older teenage ~r]s (17-15) R eonthlues to increase sharply Hundreds of studies have been conducted by behavioral scientists in an effort to understand the complex factors invoh'ed it1 Lhe initiatiolt of snlohiug iu this groaF Such infurrrlatiurL is essentla] to create effective programs to persuade )eung people *lot to start s~oking. Between tile ageg of '~ to 9 or 10, children accept the fact that smoking is hazardous to health. At this age they express anxiety when they observe a pare*~t or older sibling smoking Yet ,as they approach adolescence, tnany of these sau/e children ~nay begin to smuk~ Adolescent Transltlon Adolescence is the tlme of transition from se]~-detqnitaon as a f a~r~ily nlelnber ~o identification xUth the peer group as a source Of s~t~* ~e~lnl~J~ a ~[iJuk~r inay have the ilil[]l~dl~[~ v3~u~ Of being accepted by peers, of feehng more mature because smoking is an adnlt behavior forhichlen file ehild~ and i~lay also serve as an act tff de~ance to autbotity fl g~:res The smoking parent becomes a rnod~l for tbe child. If both TIIE SMOKING IIABIT: PSYC I I OLOGY A ND p h'AIRM ACOLO Gy 57 ==
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158 parents sm*~kc, there il a greater likelihood that the child wiP bcpiI~ smokinp tlian if only one or neither par~llt sraoke~ On thc other hand, parental disapproval cf smokin~ is not a slgnilie,~nt factor to the te~lJag~ Both smokillp and nonsmokhlg junior hig]l school slt~dent~ irl one slu~y rccognlzed tha~ their parent~ ths api~r~w~li of their sraoking behavior. [SG 197~ pin ~-1~, 14] Teer~age I'aflue~ces The sllJ~Jklng behavior o~ olclcr siblingt is a possilile in liaelJee on wunger ehildrert. Twenty eight lo ~/ percent of the h~w and 25 to ~6 peroen l of Ihe ~rls who report rogular smc~kin g also have older sibIings who smoke¸ If an older sibling an~, both parents sin~kc, ~ child is f~r times as llk~ly to slllok~ a~ a child 'Mau ~as n~ ~rn~}king m~Seli~ the family. ~liG ).97~, p 17141 Teenagers who ar~ emiIloyed outsi¢le ~he liofo e are t wic*3 t~ llkely to fmoke ~s teenagers who ~re not employed¸ Sstudentl who plan to g~ to coth~g~ are the ]vast lik ely to sn~oke Chil& en in lower statt~ eorrelat e~ less with sl~ok~ng than with parerttal smokinp or poor ~¢//olasl~o per~ormace The influence of t~e ma~s media in ~hc initiation o~ sTrloking is ¢Iffl]cul~ to establish. Teenage smokers seldom consider the decMon t~ sinok~ a wls~ ~n~ In an American Cancer Society study, ,~8 percent of 4th ~rader~ asso~ia~ecl sl~ok~n~ with ¢~anizl~r Sl~vt~l~y-~l!ven pcrCe~lI o~ teenage ~rnokers De]ieve t]laL it i~ better n~t to start amo~in g than to h~ve to quit¸ Eighty [our p~r~ nt say ~mokhl~ is habit forming, an¢~ 6~ percent think that it is a 'oat] habit. ISC 1~7~, p. 178] In vle '.v ~f thf~, the US Public ]~Iealth Service s~ggests: "It is futile to continue to telI teenagers th.~t ~mok~ng is harra f~l .... T]~e in.st e~lective thing that we can do is to h~p t~lem tt~ under- ~tand the liell ellis ~f ~mokinp as eomparet] with the costs and d~n- gera so that they w~U have the facts that they n~ed to make a tholl~htt111 decision ~$ to whether ~¢~ 5niobe or Ilot to smoke.~ ~q~nal ~sti~es o~ ~lea]~ Teeua~e ~rn~inp ~'~on~ ~P~l- tern~ ~ Cigarette Snlokil~gl ages 12 throu~',h 18 ill 1972 and 1974 US. Depar tlner~t ill Health. Ethloation ~ nd ~a,'elfar~, ]Publi~ Health Servi¢G N~ion~l Ifl~tlt~lte~ of Health, DIIEW publication, No. ~NIH/7~ ~SL 197~ l~5pla l "P~rhap~ the real question to be answered i~ why d~ we THE SMOKING I]A~IT: ~3 PS,y C]IOLOI~y ,~kbIlD pI ~ A I~M ~.GOLOGY -~ k L--Z - .-.- C ,,j
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159 kl. J~ ~ly r'a~ t*se ~o ez~ga ge it* sel~ destr uC~a~ e b~h a~'ic¢ when so mnt.h of our energy is dir coted Ioward preserving our lives?" ISG 1979, p, 17-25] Fsycbosocial tr,fl~nc~s Personality Traits oJ Adult Smokers Many studies have attempted to correlate the smoking habit with various persouality traits. A large British study ~tound that smokers are greater rlsk-takers, more impulsive, mote prone to divorce and job changing, more interested in sex a~ld in.re likely to drink tea, coffee and alcohol [Cherry, N.. Kieman. K. ]?ersonah ity scores and smoking behavior. A lon#tudinal study, British Journal o[ Preventive and Serial Medicine 80(2): lk3 181. June l~q~6 ] in general, smokers seem to tend to,yard c xtToversion~:rav- ing exeitelnent, willing to fake tasks, kkmg parti¢s; they ase sodable, carefree and easy going, and nlay he aggressive. Non- smokers tend to he introverts-introspective, retirltag, bookish, pmde~.t, emoti~nal(y ecsr~tr~l/¢d.. 'pa~gi~e. ~.¢.d. reliaBle. Internal-External Uontrcsl Four of five studies showed smokers to be more externally controlled than nonsmokers Internalized-contro]Ied individualg tend to believe that they are masters o5 what hapl~ns to them; externally controlled persons tend to look to fate, hick or things beyond their control to bring them their rewards. [SC: 1979, pp 3.8-6,9] Drug Taking Of six personality factors in drug taking, two most lillked with smokang were 1 ) genera[ tendeney to use drlags and 2) "fear of per~ona] reaction to drugsf Smokers of tobacco e0nsume more marijuana, more psyeho~ropie drugs, and mow aspirin than do nonsmokers of tobacco. [SG 1979. p. 18-10] Ex-Smokers" Personallty Forme~ ~mokers exgress aggression ~nore oper,fy than either nonsmokers at smokers who never tried to stop; flae)' also have ~t strouger need ~or rtehievcment than any other group, 0. lesser need for close tics with peers, and more behavioral stability than the other groups. Nettrotlcism and extroversion are associated with the ahdity Io abstain from smoking Such individuals are high in ex- THE SMOKING HABIT: PSYCItOLOCy AND PIIARMACOLOCy 5i~ 2 UI
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160 t r oversion and ]ow h/ neuroticism. Male quldela ale mrlr( sociable and inu[~ extrovor ted in their behavior. N(I re[atiolls}llp h~ been found between edtlealion level and snacking e(~satlon Successful qnlt~crs ale more likely trl be maks than females [SG i979, pp. 18.17-i9] Fotce of H dbit Thel'~ is xnollnting evidence that thl number of cigarettes smoked p~r day is directl}, mid (filCh markedly, related [o inability to quit smoking [West, D. W, Grabam, S., Swanson, M, Wilkin- son, G Five year follow-up of a smoking withdr twal clinic popIlla tion. American Journal of PubIie Healfl/ 67(6): 586-544, June 1977I How to Quit It has been estimated that 9,5 p~rcent of the more tha[l ~[) milliun smokers mho ba~e quit ~h~ee lt364 ba~e dose so on t~eir ow~. About one third or fewer of smukers who are motivated to quit are i]Jt( ws ted in formal program% a potentia[ audience of per haps 15 ~rfilli~)ll Arn~rlcans. J h~wtwer, only L sraa~[ mnmn~y of Ibr~e who express an inter t~nt in quitting actually att etld such programs, perhaps because they are n(~t universally available. The American Cancer ~oci¢'ty has eH~anded its activities in this area since it is known that about ~0 petewlt of smr*kers who participate in such programs art still not smoking one year later. The:~ have been great advances in iu formation about smok- ing cessation mctl otis in recent years, mainly based on ]at go-scale L'or ODa~ preventiogl ±rials allld iosearch clinic experience The ill(~t critical concerti ]s the validity of the self report data This has been questionl d ill up to 2D percent o[ eli:fie par ti¢ipanks Carbon monoxide in file blood appe,Lrs to be a more reliable measure of smoking bllhavior (finn self.reporting. Education and Ptv't'ention Vast lnlm]3e~s of a II~sl/lokiilg proRrams exist for bot]l young people and adults Never dleless, it is still not kno~l what forms of education ~re ttm~t e[[ect[ve irt ker'ping y(ILlng people from ttm vln~ from < xperlme illaLion with elgarettes to bfeOltling hablhla] smok. ea's And it is still not known how best to IJe]p adult~ give up the sm~ku~g [rabit TI~E $MOK]N (~ llABIT : 60 PSYCI~OTOGYANDP~ARMAGOLOGY .... Ili, i " CA (Z
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161 TIIE SMOKING I ]~',B rr: PSYCHOLOGy AND p/~AI~MACOLOGY 61 t~
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162 VUI--SMOKI NG ECONO3tiICS AND STATISTICS "Smoking results in a considerably increased morbidity rate, • ¢dth it~ c~n~cqueut I~s~ t)f Workhlg days, absenteeism a~tl exLes sive demands on medical scrvlces~ bath fur primary and for hospital ea~c. The cost to the community of premature death, increased, ill- ness, atld loss of productlve capacity resullin~ from cigarette smoking i~ very high In countries where the habit has been coatmon for al~g time?' [VeHO l~Tco, p. 10] :In the Ulllted States, it was e~tlmated in 1976 chat the average smoker spent S0240 ~ year for SOS paok~es of cigareC'es Total retail e ~:pentittt~re ~ ~r to~oacco ~c<~uttted ~r ~pproxkt~te~ 15 per~nt of thsposable income. [Smoking and Mcoba] Abuse; Lucc, B. IR ~nd Schweitzer, S. O World Smoking and Health ~4o~. 8. No 2, Summer 197S, pp 27-81] Per caplt~ coJt ~¢or smokln~r~ated disease is estimated at $4~ an~u~ly in ~he U~ited ~tes Tot~l ec~t m the Uafted State~ for major smoklng-ro]at ed disease and f~xes, inclodiuS he~di care, lost earnings through morbidity and mot t allty, and property costs was estimated at $27.5~9,700,¢~)0 in 1976. This Is 11.~ percent of the compar~b/e aggregate costs of all US, illness. Tot,a] out-of pocket health care oust o~ smoking-~e~ated diseases v#as e~tim~,teti at $82 billion in 1976, approximately 7.8 percent of zJl U.$, baalth cam c~ts. (ib/d). Tobacco Falrn~rl~ Peak pexlods ¢~ tobacc~ growirLg cotucld ~ ~dtb times when agricultural labor is needed for other cropsl hence, tn developing countries tobacco farming may irderfere with the ~ood supply. Farmers in such countrlt~ arc genclally trl dcllt to ptiv~tte corn parties; a large proportiot~ of their income ~oe$ to transnadonal t(~o~,~o ~t~t~pa~.ics S~ t~ost c~ltutties exl~rL lttt[e of t}xeir tobacco cr~p, it doe~ not aid their balance of payments [WIIO "Tobacco-growing is balpi~g t0 spread deserts, because huge quantities of ~re'.vcod are cut annually from threatened thres~ to pr~ide he~t thr c~rlng the ~bacca7 [Wq~O, 1979 p, ~t3l U ~. Tobaccm Eootmmic~ Tobacco is a cash crop in 16 state~ of this countt3', aud ~2
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168 dominates the agrio~]ture (:4 severa], most no~ably North Carolina and KentuckyI It is also a major induslry~ ~,vhtlst custolnets s]polt $18 hi]lion for its manufactured products m the US. in 1978, of ~41ich $16,589,000,000 went for cigarettes. Federal, state and local governments collected $6,270,[X](},0(D in tobacco excise, sales and customs taxes in fiscal 1978. U.S. tobacco exports were valued at $2,i20,000,000 in that year. Tobacco imports the same year totaled ~428fl~ 0O0 exclusive ol dutyL The U.S. Department of Agriculture has spent well over $1.5 billion im t(~bacco programs since 1983 Current tobacco price support loans of tbc Dcpar tlnont'~ Commodity Credit Corporation total $750 million. Total of all such lo~m since 193g is about $6 bil lion. Almost n~) interest has been paid on thcs~ loans to the govern- merit, although the Department of Agriculture paid well over $500 million in interest to the U.S. Treasury through Ju~e 80, lg74, to borrow the money. N~t losses on loau principal totalled 855 million by 1974s Department of AgrlcnIhlre budget for tobacco loan ser- vice, tobacco inspection, inarkeling n~ws and tobacco research wa~ $54 million its fiscal 1978~ It is interesting to rmte that all legislation thus far passed has exempt r~d U S clgaretles x/lid in export from usin g the warning label, except those shipped to the U.S. Armed Forces overseas. Consumers the world over spend an estimated $85 to $100 billion each year to buy four trilllun cigarettes, about LOgO etgar- I:ttes tot every man, woman and ehihl in the world lEAk EcldJohn, Woddwatch Paper 18, March 1978, Woddwa tall Institlltc, Wash ington, D.C] Cor~ur~ption From ] 9X5 to I qS0 the per capita consumption of cigareltes of persons 18 years old and older in the United States rose steadily, from 1,285 to 3,522 cigatl ~tes per )'ear. There was a thp in 1954, the year when the Americas Cancer Society first published results of its first maior prosp( ctSve study of the effects of smokin g on health ( see p. 77 ). US pcr capita consumption reached its peak in 't 9,g~8 h T~bd~o m ~he Nat~ot*~l E¢otlom~, U S l)¢x~arlmcnt ef Agr~fat~, ASCS, Ma~h, 1970, p 2 ~ r,h~e o Sit ua~ioo, Maleh, 1979, p 17. T~b~¢~ ~d.'~,r$ ~ot~leteama, Jan ~7~0, 1~d75 ~h~r~est~n, ~C. IJ~/aubH~hed D~I~ o~ Ag,lculhl,~ d~,zmeut 0~ s~
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164 at 4~3~6 cigarettes, z~ltd declived in 1964, Ihe your of the first '~Sut- ge~ G~r~cral's Report" It declined again between 19~8 and 1970, the period of intensive broade~sllng of anti soloking ules~ages by file na~r TV and radio networks and stations ( The vale f~f these messages iu commercial time was estimated al $75 million,) [SG 197~ pp. A~, 6. 7] In the last four yeats, U.S per capita cons~tmp- taon has declin~l In 1979 ~t was at ~he Iowcst point slrlee 1958¸ It is assumed that the cventf mentioned in coui~nction with th~ declines ii/per ~Lpit~ corlsumption w~re operatiw factors, but there is no ¢¢ay t~ prove ~i~. UnHl 1967, the vnly iissay~ of tar and nicotinv conte/lt of eert,~in popular brands of Lr.S c~garettcs available to the p~bhe were published in R~ac/er'8 Diges~ ma~azine, and Consumers Union l~epor ts In 1967, the Federal Trade Commission l~h~ratory began publishing its o~vn ass~tys of tar and nicotine ~n ~11 U S. ¢iga- re~t~ [~raud~ a~Jd h~s continued [o do so ~v~ry ~ix rooliQa$. P~r Capita ~nd Total Declir~ l~oth the pez capRa .~nd total cigarette consumption have dcclined eonsisten~l~ in the U~lited States sln~ 1978. reversillg a go,iota] 9~0.year tr~d. Th~ esl~mated pcrcentages Of m~ and women over age 18 who ~mokc cigarettes have als~ declined. Among me~, 52,6 percent of adu]t~ smoked in 1955; this has droppec/tt> ~.~ perec~t in 1975¸* T]I~ percentage of female smok ers ~ose from 24 5 peIcent in 1955 t~ a peak o~ "~:~ 7 percent in / ~lfl/~ and rctreate, d to 289 peJ~ent in I975 Percer~tagcs of ex smokers anlonb~ men have ~sen fr~nl ~0 9 percent in 1~55 to 292 p~rcctlt in ]c~; anmng won~en tr~m 3,9 percer~ in 1~55 to 14~ per~c~t ~n i~78. FSG igrt9 Tabl~ ~, p A-101 Al~cl~gh tile percentage of the, U S population thai smokes ~s s~l~a~er th~n it was a de~t~e ag~ ( see bclo~v), 01e ~3 hired St~tes retains its longstanding title as the world's pr~mler cigarette. slriokill g cottl~l~y: ill (hl~ mid-s~v~ntics, ~l~nH~] [~ S. c~gal'e[~ ~on sump~vn was 2.7~ cigarettes per capita ~or all citizen~ ol a~l ages; Jap,~n was seeund with 2,600, How ManF $uwke~ In absolute nurab~rs~ there we, re an estimated 58.~ million 64 SMOKING ECONOMICS AND STATISTICS .q
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165 "CS cigmetle smokers in 1~J65, and 541 im]lson k* I~S el whom 48 mi]lion were ,~vl'r the age of 18 Thls sinai] numerical growth trailed behind the increase fil population; it repr~ sent% in ahsnlute nnlllhers. 55 percent f~wer I~la]e sn/okers an~ 11.1 percellt more female su~.e~s [SG lg7~, I~ ~-i I~ ,~,{ost current clgarltte sraokers hegall smokhlg in their tccnf Today, m Llle U.Red St~s, thor~ are 8 ~ ml]lfim regular o~ this a~e ~oup This is a drop of four peree~ltage points ~inoe 19~4, meorillng to Secretary Joseph A Ca]ifallll, Jr, of }[I~%'V He ~vcs his sourcls al surveys pertorrned by lhe National C]carb/g houfc for Smoking and Heakh ~n lfl~S and 1974, and the National ]nstff/tte of Educafirm Cr, 1979 Amo~g teenage smokers, girls 'ft.7 million ) n~w outnumhcr boys ( 16 milllen ), See tables presented by former Secrctmy Joseph A Cah- lane, Jr of the trends in flnoklng in di[[erent t~enage grouI~s: (See pp ed, 6~,67) Who Snlt~kes A, ilsl]t maIo smoking is Jn inverse r~ttio ~l) ~:mlily income, whi[e adult L~m~le smoking incr~as~ wilh family income Smok- ing is rc]ativc]y mlcol Linen ~moog pro[essionals o[ both sexes [S~ 1979, pp A 14 15] But among managers and admil~istraLive persolmvl the Ilcrecnt~tge of female smokers i~ higher tlmlt that of rnales. [SG i979, p~-161 Male white collar workers [professionals and teehr,ical workers) hive the ]nwcst smoking rates~ bhl~ collar worker'; (l'~ borerl am] craftsmen) have the highest. Women show the oppo- site correlation Upwardly re.bile men tend t(~ smoke less and dowrtwatd]y ntqlKl~ trtert are more likely to bc htavy smokers, [SG i979, pp. A 15 16] A sh~d~-of four health professions (physicians dentists, pharmacists, nurses) ill i975 found on[y ~1 pl ree~t of physicians smoking in that year; 30 percent had been smoking in 1987 Twenty-three perclnt of dentists, and ~8 percent o~ pharmacists were s~llokers; both gro.ps showed snbst ar~lial declines hJ slnl}king lsets~e¢n I0~,-68 and ig76 Otdy among retries had smobang in- crense~l, flora $7 perclrtt in ifl69 tn ~9 l~rcenl irt I~75 Rut the great majority of all health prldcssionals agrt'ed tll[ll they s}~oll]Cl set a SMOKING ECONOMICS AND STATISTICS 65 ca 00
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166 Tah]e V[ ( IC~RE IrE SMOKING A~,ION[~ YOUNG PEOPLE ACE It2.14: • Fo boys the percentage of regtllar smokers 'aent ~raln 2 9~ in 1968 to 4~o~ m 1974 t~ ~2~in 1979 • Ft~l girls, the percel] [age O[ regtl]ar smokers went from 0 6% in 1968 to 49~ in 1974 to 4&g in 1979 • To sam up a sharp drop among bo}~ since 1974, )utol~;i shg]lt drop mong girls 66 L1 ,,,I
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t,1 © b~ © L~
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168 lable Vrl[ CIC,,A REq~ TE S\[OKINC A~,IONG YOUNC PEOPLE AGE 17 AND I8: • For boys, the percentage of ] eg/~hr smuker~ wen~ ~Yom ~0 2~ in 1968 [o 3 [.0~ in 1974 to 19~ in 197~r • FOI ~i¥15, fhe p~rcenl l~e o{ Ie~ulal sl. O]g~[~ %venf ftorn 1865 in i9f18 to 259~in I974 to 26 2~ in 1979 • To sun1 rap: a sharp drop au~ong boys--but a dtsturt~ing, eonthmlng rise ae.ong gicls 09 t~ ,O ;/I
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169 good example by not smoking. And the majorit% except pharnw.- eis ts, never smoked in front of patients. [Survey of Health Profies sJonals, 1975 Department of Health, Edocntion and Well.c, National ClearkJ@house for Smoking and Hcalth, Atlanta, Georgia S03S$1 What They Smoke From 19Sz0 to 1960, the market share of flRcr-tip cigarettes increased rapidly from 1,6 percent to 50,9 percent. By 1975, ~5 per- cent of current regular sinoker~ consumed filter e~garettes In 1979, the mar ket s tmre of filler-tlp eigarettes exceeded 90.3 percent. S,'des of U S cigarettes with 15 mg or le~s of tar h~tve i~- creased from 3 percent to over 80 percent during the period I970 to 1978..klon g with this ir~er ease, there has bc~n a decline in sales of relativeIy higher "tar" and nicotine grands. From 1954 to 1977, the sale-weighted average "tar" ( par tie~isde matter in smoke) p~r U g cigarette de,lined from appr ~xanvately °.6 mg tt~ I ~ v.g ~r fes~, for both ~ltcr-lip and nonfilter cigarettes. A dechne in the sales- we~ghhd average nieotlne per cigarette was also ~isserved, and is now at the love[ of 1 mg or less in many brands [Table IX, p 78, Table X, p. 74] Parallel r~ductions in tar/r~icotlne have taken pkiee in other developed countries. In Gloat Bt[talrt, lung cancer rateg are now decreasing, and in tim United States, deaths }ron/cardiovagc~a]ar d~scases have beglln to decline Both effects ma~" ise attributable, at least in part, to smoking cessatlon patterns and to switching from high to low tar/nicothle cigarettes, Cba*~ges in Lung Agnormagfies Some proo~ of th~se ~ fleers comes from a recent histologlc study in the United States which has ~ho'.~ a thamatic drop hi lttng abnormalities in fmokers who died (of diseases other than lung cancer) in the period 1970 1977~ as compared with those who died in 1955 1960 ~. much lower proportion of abnom~ah itles nf various sor':s ceils with a~pica] nuclei, leslon~ ~ith on cilia and basal ce][ byperplasia were fouud in the bronchial epithelium of smokers who died between 19T)-77 than in those who ched between 1~55 60. Those who died in 1g~'~0-1977 must have smoked lower tar and nicotine cigarettes than the earlle~ Stoup because a[f israr~d~ had decreased ~a~ a~d ~i~l~e ¢.~nt~t SMOKIN~ ECONOMICS AND SThT]ST]CS
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20-- 170 Figule 4 PERCEN'TACE OF CUH~ENT. RECULA~ TEENAGE SMOKE~S, UNIIED STATES, IN SELECTED yEARS, BYSEX D Male • Female 711 UI ',.l
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171 The author$ of this work view the findings a~ a very encouraging sign a~ld prl~dic~ that, at so~e future date, there should be a rette sraoker$ /see h~llg c~ml~cr Section 11). [Aueib~'h, O., llaln- mond, E. C,, Gar~l~kel, L Changc~ in Brlmchial El~the]ium i~ I~ela~h~h~p tl) CigaT~te Sm~mg~ 1~55~1~3G~ ~. 1~3~f~-1577 The New EIl~and Journal of Mcdiclnc ~t10{8); ~1.~6, 197"9.} S mo~ers Smoking More The actual number ~f ~mok~r~ has de~lined more th~n the per capita Consumption ~/~ cigarettes Possible c×planations: I} Those w~o s~n~k¢ least, ar~ most apt to ct/li~~ Icavhl~ a highc~ incrermmt of heavier sm~kcvs; 2) Tbo~e who contint~e ~moking may be sm~,ing mare; ,~) New smokc~s may be smoking m~e than lon~[eJEJJ ~moker~ ISG 1979, p. A-171 S[n~ thi~ maior c]lall~e lit ~l~oki~3~ p~tte~Ii~ hits oc¢:urled e~inciden[ally with a s~eady drop in ±hc sal~s wcigh[ed ~ar con- tent ~f US }/r:mds ~f ci~arett~:s (mcbidiu~ a ~tro~3 hi nicotine, which is u~/ta]ly in a ralio ~r l:10 to tar), t~eories arc that the remaining imokers nlay b¢ ~mok[ng r~ore clg,~rc~les ai~d inha]{ng t~or~ dew,Iv itl or~c~ to ct~m~Prl~te ~or [~ [¢~wered b3r/ll'l~[n~ contenl i)f ~]]@ir }lrnli(]s. Howover,. ~11 expethn~nt t]l~i~ed ~o te~t these tht'i~ has indi~2at~'/] I}lal ~m~)k~'r~ i~av illcr~ase t~l~Jr stu~kln~ ~elIiporarth, w~en swtcb.m~ ~o a I~w T/N brand~ but that they return to habilual lew~]s wlt]~i~ a ~]l~rt ~ime. 'llter~ i~ the fttrthcr fact ~hal the dec:line in tar/nicothle was mor~ railed be~w,een I957 ~nd 1965 than betwcc~ 1966 a~d K)77 [SG 1~79, pp. A 18 19!~01 s MOKING E(:ONOMICS AND STATIS~ ICS Tl
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~igur~ 5 To~ IQDDIO@DQD@DDlllOI@Q~ pOe@QQOO e@@DO@ODOOD • • • • • • • @ Filter t/@ eg° I0,50 5~ ~ ~5 70 75 YEAB I~re~mir, a~'y - S~(10 fm
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9:- I I I I Io
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174 Table X MARKET SIIARE OF CIC~,RETTES "~VI TI~ ,TAR,, 15 MG OR LESS 1967-19e?~ (1978 J~RC)IECTED) 20 10 V 1967 ~3 69 70 71 72 73 74 75 76 77 78 Year S~urce: Max~cel~ ]C C ~17 ~0 5'1
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175 BIBLIOGRAPHY Pulllieations referred to repeatedly in this report are iden tiffed by a simple code, as follows: [SG] Smoking al~d Hea]Ih: flepor t ~f the Advisor y C~nmit tee to th~ Surgeon General of the Public Health Scrvi~(~ ld S l)e parlment of [tea]t h, Education arid WeI~re ]Public I Ieallh Service IMblication ~No 1105. 19G4 [SG 1967] l~ne lIealth C~nscqnenees oF Sml~kln~ A Fublic Healt]l Service Eevicw: 1967 US. Department of IIeaIthl Educa- tion acid V~Te]Iar e. Public Health Service ~ublicati~Ti No ]~6,19~18 LSG 1 ~)fJ~] The Health Consequences of Smoking¸ 19~ Sl/p- plernent to the 1967 Pu}~l~c IIeaItll Service I~ev~ew~ US Depart menl of Service ]PubIication No 1G96. i969 [S(.~ 1~] The Health Consequence~ of Smoking U.S De- partment of Health, Education and Welfare. 1969 Supplcmeat to Public Hea]Lh Servie~ PuhHL~;lt~(m Nl~ 1 l~a~J 2 197~) [SG l~ll The Health Consequence~ of Smoking A I~eport of the Surgeon Genera]¸ 1971 US, Department of Health, Educa- [io~/and Wolfare Public Fle~lllh S~rviee DIIE~V P/~blicnl~on Ko ( H~M ) 71-7~1~ ISG L9791 SMOKING AND IIEAL~[I a report of the Sur geon General, US. Department ~f Hea]ll~ Edu~aLi~iL a[Jd Wel- fate, Public Health ~erviee O~ec of the Asaistant ~ecret~ry for IIeaIth, OfBre ~1~ Sm~kin~ and IIeaI~h, DIIEW ~?ublleation N~ (]PIIS) 79 50<]66 U S Govcrnme~l P~intin~ Of~ee. Washington, DC 20402¸ Note: Th~s document is paginated by chapters, rather thar~ eonse~t/(ively [Dieh/] Tobacco and Your ttealtl~ by tlaro]d S. Diehll M A,, MD., SeD, Si)ec~a] {~(msnhant h~r t~ ~r eh and Medical A ffai~, American Cancer S~,eiet y, [nc, MCGraw Hill Book Gompany, New York, 1969, 210 pp ind/~di~g index plus xl pages of introduction. FRoyall Smoking and Hea]lh Now--A New Report and Sum mary on "Smol~ng and ILs Effects on HeMth" from the Royal Col ]cge of l~hysicians of London Pilman Medica] and S~fienbfic Pub Iish~ng Co.i Ltd i London, England 1971. [WHO i979] Controlling the Smoking Epidemic, Report of the ~,VHO Expert Committee on Smoking Gontro], Technical IRcp~r t Series 086 Wodd Hea[Ih Or ga~izat[oll, Ceneva 1979, 87 pp. (~Sw. fr.) 78 ",,.1
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176 APPENDIX The results of seve~ prospeetlve studies of large popula tions, tutaling nearly se~en million Derson-ycars, are frequently gronll~ d in this and other repDrts Great weight has been given to ~hese $~udies IYla de 2n thYee ~ou/It [icsI because of tbeiY Lonsi$ tenc y. These ~eveu comphse all file large pmspeetive smoking studies known. The first started in October, 1.951; tbc latest, in October, 1959 Several are continuing In b, ief, file seven greups are as ffJUows: ( 1 ) British dnetors, a queslionnair e having been sent to all members of the medical profession in the United Kingdom [Doll and lii11, 19511 (2) White American men in nine states. These men were enrolled by a htrge number of American Cancer Socic'ty volun- teers, each of whom was asked tt, haw, tim questionnaire filled in by I0 wblte men between tim age~ of ~) and 69. [Hammond and Horn] (3) o de s of U S GoveJnment Life lr,surance policle~, available to persons who served in the armed torees between 1917 and 1940 [Dorn,eontinued by Kahn] (4) Men aged 85 to 64 in nine occupations in California who were suspected of being subiect to a higher than usual ecru pational risk of developillg Iung cancer [Dunn, Linden snd Bres low] (5) California members of tbe American Legion and their wives. [Dnnn Buell ,rod Breslow] (6) Pensioners of the Cmadian Department of Veterans Affairs, i.e., Veterans of World Wars I and lI and the Korean War. (7) American men and women in ~5 stat~s, enrolled by volunteer researchers of the American Cancer Society, each o~ whom was asked to enroll about I0 famibes containing at least one person over 45. IHammend] See Table XI, p 77 for dates and nn tubers. ! ',4
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Table XI OUTLINE OF PROSPECTIVE STUDIES OF SMOKING AND MORTALITY Authors Doll Ham~ond (Dorn) Dunn, &Hill &Horn Kahn Linden, Brcslow Subj'ects British Whlte men US Ca]iEorttia Doctors Jn 9 seates vet ergla~ oco lp~,- ti~nal gnoups Number of 34,000 188,000 248,~00 67,000 usable replies Dateof Oct 1951 ]an.Ma~. an 19~4 Nov 1958 enrollment1952 & j~an. I957 and May 1957 Age range 35 75 + 50 6!) 85 84 ~5 6"9 Months f~ll~wed 120 44 l~0 about 48 Noofdeaths 4,534 II,870 46,£70 1,714 PersoIt-years 269,000 668,000 1,8 I~IO00 222,000 ef erp~tu~ Dunn, Best, tlammond Buell, Josie, Br e.¢l c~w Walker California Canadi~a~ M&F in American pensioners 9~5 States Leg;on (veterans t~ membersdependents) 69,868 78,00D 1,057,000 May-Nov. Sept 1955- Oct. 1959 1957 July, 1956 Feb 1960 25 75 + 85.75 + ~84 8672 70 5,404 9,070 45,211 386,571 383,000 3,764.57] To ta] nuraher of slthj eels: 1 ,~/41,868--Total laualber of person-years of exposure: 6,955,142
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.,,I
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Pipe a:t~/~i~ar ~:~c ].i11~ 12. I ? 29 3i) 32 ~raoker~ ~]~il~] ren 57 pi[~)ts, ~7 t~n~'orl 1!~ 2I~ ~,~0 t] ~ nlo].in ~ ! lec Cigar~ t!e ~m~illg ]'il~e and ~:ar ~m~ingI ~,,lukin~ c~satioEl ( sec QLlilting ) Stllc!i(~ 7~ 2~ C~]if(*r ni~ Alnico, ~n Legion C~li!~Jrni~ ~,c~¢(ipa ti(~n al grou~, 7C) ~7 Cnr,adia~ ~EL~,)aer s, ~, ":7 Male ~,~,~ Ic:::a[e ~n twenty ~vc stale~ 76 T~ Tccn~e ~m~i~ ~ 211 ~9, 40, 41 57 5~, ~1, 65 66 6~, 7(I ] ol)a~,c,: ~r ruing, ~2 ~2 3~ ill pregnancy, 9 4~ 48 ~1 ~nl~aee~iv e ~PI[L/ user~ O, ~l 179 .,J
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180 AUT~IOR INDEX Fla~ n~z~l, W, I1 L2 HamnloJld~ F~ (~ I I~ 12, 13, 2~.~ 2~, 25, ~a~l~w~.i~z, ~d 5 L ~f~ 21],~ t, 4 :~6, ¢~7~ 71.75 76 77 Ad~Jns, W Y, 2~ lffJ~ t I, ~I Hr 22 A1bezr~an, E,D, i~ lh~Lli~ M ~,V,, 42 A nlerl<.a?~ I~ear t As*ocJ~Ik n ,31Hill, All,, "~6, 7~ AIlerl3ach, F) ~3. 24, 26 2!}, !/1 qG, Ho]l~h, A 1 33 ]IonL I W, 2t~ B:d,,~, M E, 2~ Homer, CM, 18 BesL ~%V R, 77 Ingrain, S~ 48 Be~ley, B 40 Bland, ] M 40 Ja~.ik, M E, 56 Bt~]ow, L, 76, 77 Joule, GH, 77 BIIt]er, N B,, 40, 47 Kahz~, ~ A, 12, 76, 77 Kv]Jer, A, ~I C~rler, H~V, ~7 IGer n~n, K~ 59 C'her~y, N, 50 Kir~mn, D,, 26 Churl~ I • ~'~, ~5 Korsak, A, 1~ C~mstvck, G W, 42 f~on~mer's U~ion, 64, 73 Lindem, G, 78, 77 Ol.hl, H S : 40, 75 M~bucid, L, 30 DoI1 R. 18, 40, 51, 76 77 Nil BurThen,, A K, 48 O,,~n, H F, 12, 76~ 77 Mann, J I, 51 DuTm, H ~. ~$ Ma~k~, I~D, ~O El~nn, J E, 76~ 77 51a~ ~uya, T 42 Maxwe]], J CC,, 7~ 74 E~b~hn. E, 65 Metz~r, ~IL, 4~ Me}et, M B , 47 Feyerabend, (], 4@ Moore, C, 31 Fr,edm:m, CD, 48 Mushln~ki, M, 30 Ga r fillkc-l, [, 22, 2~, 26~ 29, ~1, ~4, Natirmal ~'~r~ p~ot e¢~icm Asslmlatio r, ~6, ~7, 71 (N I" I'A ~, 53, 54 ~i~u~r, EM, 5S Glau~er, SC, 65 Owen, T.B, 73 Gotsls, N, 49 P~mayotopoulo~, S, 40 (~ra]1~m, S, 60 P~paxo~klu N, 49 Gro~e, E, 6~ Pet., R, 40 Guiliord~ ] S, 57 Phillp i~lorrls, ]me, ~ putnel', IJ , 2S 8O = o~ U1
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181 QmIien. D, 56 }lanlst rom~ L~I.~ 56 Reade¢'~ Digest. Reiik nbezg, M.M. 55 l~ichm0~d JB, 5 IIosen, M G, 47 l~othman, K, ~I Iloyal College of Physie~ as (London),~ Eu~]l. D., 41 RUS~e]], C5,46 II.sse]], C S, 46 Russell, M AH, 49 l~usy, 8 F, 55 Sakai~ Y, 4~ S~ II~ eltzer, SO, 62 $cihet ta, J J. 47 scnlg~, I I J. 29 Sellkoff, I ~, 28.25 Seh~r. C C. 48 $idor. R. 4~ Si~-gelaub, A.B, 48 Sill'e~ b eI g, E, 33 Sims, EA H ~ 5~ Singer, PR , 47 Standard and l~c~,r~ Corp, 74 Stout, Ap, 31 Swan~m~, M, ~0 TMh;ida. l~ J, 55 T~,~goad, M, 51 Tobacco Sit uation, P~ T~m~ia J h. 42. 47 U,S, Department of AgncNhnr% ~, 72 US, Federa] Trade C.,umfission, 64, 7B, 74 U.S. National Clca~ghouse for Smoking and Heahh, 14, 20, ~d, ~S N&ti~a] ]I~sti~ut e of ~du~5o~, ~5 VogL T.M. ~ Wakeham, H, 78 Walker, C B, 77 Wallace, K M, ~0 Warm, JD, 22 W~ber, KH, 18 W~t, DW, We~t, L.J, Wilkinson C, ~0 Wi]li~ns, RB, Win~len, JA, ~2 Winterllltz, WW., 5~ Wisconsin, Medical Co]legc of, 49 Wynder, E L, 21, 30, 32, T~ 81 C
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182 Mr. WAXMAN Thank you Dr. Daugherty. ~TATEMENT OF ROBERT M. DAUGHERTY, SR., M.D., FII. D. Dr DAU~HERTV. I am Dr Bob Daugberty, dean of she school of medicine at the University of Nevada and chairman of the Nation al lnteragpncy Council on Sn~oking and Health. It is in that latter capacity I apDear b~lbre yo~ today t~ urge sup port for H.R. 4957 and now H.R. 5653, also known as the Compre- hensive Smoking Prevention Educatim~ Act The National Inter agency Council on Smoking and Henhh is a voluntary association of health education and youth leadership organizations having re- sponsibility or concern with the problem of cigarette smoking on human health The interageney council seeks to provide a coopcra tire ~md independent force In hfiorm the ]public of the harmful ef- fscts of cigarette smoking Currently there are 30 national organi~atlons that comprLse the membership of the council, The Coaht~o~ on Smoking aud He~fth which was announced here a-~day will serve as the public policy arm of the National Interagency Council and will work closely with the three majority voluntary health organizations represented at this table with me today, American Cancer Society, American Heart A~sociation, and the American Lung Assoeiation, Last month, the Tobbacco Institute launched its biggest cam paign exer, ~ campaigl~ estimated tr~ c~t well in excess of $1 mil- lion includes nine insertions in national editions of Newsweek, People, Sports Illustrated, Time, TV Guide, and US. News & World Report. I am holding a cop)' of the campaign that now ap- pears that most people have seen Considering the conclusive evi dence linking cigarette srooking to disease, we agree with the theme, weigh both sides before you take sides, which is why we urge in fac~ rotation of the warning inhelb that provide up-to-date facts on the hazards of cigarette smoking. On the Office of Smoking and Health, maintaining the interlhce with the Federal sector is sequential. The Interagency Council is determined to play its role as coordinator in the private sector However, the commitment of the FederM Government to perform its role h~s become a source of great concern. As you know, the OMB has twice tried to line out the Office of Smoking and Health Fortunately, Secretary Schweiker has been able to get the funding restored Ceitainly the $2 to $3 million budget of that Office is mt~Pscule compared to over St bitlion used to promote the sale of cigarettes Yet this small amouot provides the necessary lhnds to carry out essential governmental functions in smoking and health. Requiring the rotation of six new warning statements on ciga- rette packages and advertisements we believe it is critical. Since the FPC has shown convincingly that the current warning is worn eut, ~mmediate actim~ is needed ~o make this al~ effective medium to reach the public with inlhrm,ntlon on the hazards of smoking The Tobacco Institute has referred to the rotational warning as a cumhe~ome sysbcm imp]ylng a burden to the industry, ltowever, if you look at the ads of cigarettes this claim is ridiculous. Cigarette 3 0~ ,,J C~
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18S ad copy is changed and changed frequently. On the far wall are seven samples of a Marlboro ed collected from national magazines in one 4 week period during one month. Are wc to believe changing a simple label is cumbersome and a bul~len? Their argument that this represents increased regulation on an overragulated industry also seems to lack merit. It overlooks the fact that tobacco and t~bacco products are exempt by agency deter- mination or specifically by statute from those laws which were en- acted by the Congress and in particular this subcommittee to pro- tect the health and well-being of the American consumer. Passage of H,R, 4957 would assure consumers r~ceive the neces- sary information on the health hazards of cigarette smoking. No one is being denied the right to smoke. No one is being restrained on selling cigarettes or distributing cigarettes. We are not imposing restrictions. The ]e~fis]ation simply seeks to provide the consumer with the right to lolow. Thank you. [Dr. Daugherty's prepared statement follows:] 00
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TE~TI~C~ Rf~E~T ~I. DAUGHERTy, JR, H.~, P~ 0
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185 ~.~, ¢957 wDuld ~ssure that 0$~ co,tinge ~O provide ~hi~ vitll func~ A s~cure e~lst~n~ ~o~ O~H with d~lineat~d ?~¢ti~s and objectives, ~,~UI~ ~]~o b~ a ~i~n~f~can~ ~tfm~la~ to ~he p~t÷ s~c~or~ The ~t~bHsh~e,t of a~ Inter~c~ Committee wi~hi~ ~$~ ~o c~ord~nate ~l H ~ 4957 B~ requiring federal a~e~c~es ~o coordinate, ~s ~h~ ~r~ate ~enc~e~ ~,~do, w~l f~rther enhance ~he qu~Hty ~d e?f~c~n~y of feder~ pe~form~e C~ld~Fing the d~m ~r~pe~t ?or ~nc~a~ federal ou~)~y~ i~ ~hl~ a~ea, efficiency ~ critical. The ~©vfs~ of H R 495~ requ~ing th~ rot~tl~ of ~x ~ wa~nTn~ ~atement~ Dn c~g~rette p~ck~e~ and ~dve~semen~ ~s ~mm~ ~m~ort~nt The FTC~ h~ ~h~n convincingly that ~he ~rrent w~n~n~ i~ "~O~n OU~,,. ~r~r~Id~a~ a¢~i~ l~ ~ee~ed to ~k~ th~ ~n effect~v~ m~d~u~ ~ ~eac~ the ~bHC w~th f~f~r,l~i~n on ~h~ hazard ~f ~ok~ Th~s requireme~ I~ s~th~ ~Mch the federal g~ve~n~en~ ~a~ do, ~t ~ ¢~st, to supplement ~r~vat~ ~fforts It~ l~ort~ce c~nnot be o~e~mph~z~d sin~ the b~adca~~ ~nd prf~t'-' are I~rge~ ~nacce~s~ble f~r cDmmu~it~ I~form~fDn on Lh~ The T~b~c~o l~t~t~te' ha~ referred to the .otat~onz~ wa~n~ ~ a "cumb~rsor~ s~tem~'~ ~ply~,~ ~ burden t~ ~h~ ~d~try H~weve~, ~ ~b~rv~n¢~ ~ the Brown ~d ~llia~on'~ Barclay ~d cam~a~g~ u~d ~t }ea~ ~ven co~e~ely d~ffere~ or Var~ ~ the CDpy Th~S W~ ~at~d o~ of ~h~ "~O~ ten" ¢~pai~ns f~r 19~1.~' l~ a~cor~ance with ~hi~ pr~v~o~ in H R~ 4gs~. th~ p~nt i~ that c~T~e ~d ~opy ~ cha~ge~ ~nd ch~d fr~que~tl~ ~ avoid The TObaCCO ~n~titute ha~ ~ a~d that th~ r~pr~ent~ fncrea~ed r~gul~tio~ O~ ~ ~er-regu~ed ~du~tr~. rh~ ~n~ ~l~o I~cks r~r~ I~ Dverl~o~s ~e ~ct ~t ~ba¢co ~d tob~c~ ~duct~ ~r~ ~ther exempt b~, ~enc~ d~t~r~on or specf?~ca~l~ b~ s~tut~ f~ ~ho~e la~ ~h~h wer~ ~n~ct~d bY ~he ~ngTe~ ~nd ~ ©articular th~ Sub~or~te~ ~ protect th~ healt~ a~c ~ell be~ of ~h~ A,,e~ca~ con~um~ The ~d and ~u~ pr~du~t~ ~r~ ~eft~er ~o~d~~ no~ 'dr~g~~ to be regulated u~r ~he Fo~d, ~u~ ~d ~o~m~ Act 1he Consumer p~du~ ~af~t~ A~ ~p~f~c~lly ~x~m~ bY ~gul~e~ vn~er that AC~, ~he F~era~ ~z~u, Subst~n~ A~ ~pec~ffc~lly ~xempt~ t~h~cco and t~bacc~ p,~duct~ ?~Dm b~g ¢~ered ~ "h~z~rou~ ~roduc~" u~r that ~c~ Tobacco ~ tobacco product~ ~r~ ~l~ ~ Fe~ulat~ Un~t~¢ St~t~ ~ d~clared c~r~te~ t~ be ~g~rDU~ t~ D~ ~÷~lth, tobacco and ~obacc~ p~ducts have escaped be~g ~ulated ~rc~r th~ Act~ wh~zh w~ enacted bY ~he ~ngre~ t~ ~p~f~ca]~ prot~c~ con~r~ fF~m h~]~h an~ ~afe~v ri~ks~ WHI~ t~bac~o ~d ~ob~¢¢o produc~ ~a~ot be c~sSder~ t~ ~ • food und~ ~h~ F~d, ~ru~ ~d ~Dsme~C ~C~, I f~nd it so~ek~at iro~ that f~ c~r~i~ue~ ~O be e~po~ted a~ ~ f~d u~der th~ F~od f~r pe~ce pr~gra~ The ~rgu~t tha~ ~he provision of more d~sea~ ~ec~f~: war~g label~ Is ~h~s l~isla~l~n ~e~en~s a ~ln$~ Df gD~er~me~t re~l~t~on esp~l~ wh~ con~id~d ag~rst t~ ~pt~ t~ the ?~e~a~ liws I have just toted. ~.R, ~g57 w~u~d give ~he ~nsu~r ~he n~¢ess~-y ~forma~ion o~ the ~p~i~c health hazards o? ¢~g~re~ ~oHng ~ ~hat th~ co~m~ W~ld b~ ~ble ~¢ make • n ~fo~ed Choice a~ to wh~th~r ~r not h~ ~ S~Ee ~ked~ N~ ~n÷ J~ ~lng d~n~ed t~ r~ght to ~mDke under th~ I~gf~a~i~ ~r ~T~ ~F~V ~t~ on Th~ ~e~la~,D~ seek~ ~nly ~ pT~e COn~Um÷-~ the r~ h~ ~o know a~l o~ ~h~ he~th haz~d~ oF ~g~e~e s~k~n~ N~ ~h~ and ~embe~ ~f th~s 5ub¢om~i~tee~ the ~t~l Intera~e~cy £D~C~l ~ $~Dk~g a~d N~l~h sta~d r~y t~ d~ their part~ f~ w~rkfn~ closely w~h ~he Congress ~d th~ F~d~F~l gDver~ent ~n a ~tron~e~ p~rtner~Hp t~ ev~'yw~ere~ Th~nky~u,
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18B REFERENCEg Thl C-allup goll, Th~~ Smo~ Repor~ N. ]eD. gr~ncetmm, N.J., July, ]SBI Offlc~ on Smo~la~ an~ HeaILh,~Hf hll ht~ F~am ~he 198D 5u~)emen~ %o th~ Smokin~ anti tBe Tobacco ZB~ In 197g~ Volume 1, May ]978. 4 Advertising A~, ~lTobac¢o ~roup Oelve Se~'. Ad~e~, page 80. Oanuar~ i8. 19B2. Boline~s Week, mH0w Cffgare~te Makers Aim To ~lee Up Silosa, Bus~#ess ~eek p~ 65-70~ Oecember 7, 1~81 ~ort on the~ver~*$in lnve~, Fede*a] T~lde 7. M~eTaa. E.; Sheridan. ~.; ~eistee. ~.; aod ~oshee~ ~, ~nalysls o9 Coverage of Tobacco Haztrd| *~ ~offenls ~gazfnet." Joornal of p~bli~ Retlth ~o]icZ, ~(a):~ Mar=h, I~SI, B. ~th, g.~.; "Th~ Magazfne$' Smokin~ BabTtI' Co~u~b] Joornal]sm Review, 16($):~9-3i,danuaw-Februae¥, i~7B. T~I T~bacco ta~itut~. Co*~e~ts of t~e Tobacco [~ttttate ~ th~ g~C ~t ~ are*~rtl~n In~es~f atio~. ~gtoa,~,. January 1~,]~2 c~p-~2O 311/~2 O~ L~ .4 .4
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6S057460S oo
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188 Mr. ~AXMAN Thank you very much, Each of" you has come here with your own proibssiona[ expert" enee and expertise. Rut you are also here representing three of the major health organizations that¸ are concerned about smoking, the Heart Association, the Lung Association, and the Cancer Society, I want first ~f all to e~mmend you fur estabti~t, lng it,% coalition or- ganized to try to work together in this one area of trememlous public health $igni/]cunce. I hope this will be the beginning of eoali tion activities in other areas as well. Each of you represents a nonprofi~ organization receiving volun t~ry eontrihutioos from the public. As I understand the ~urposes of your organizations, you have other priorities in addition to trying to bring public attention to the problems of smoking Parts of your budgets, maybe the majority of the money collected by your organization, goe~ to funding activities such as research. If we placed the full burden on voluntary nonprofit organizations to fmld programs for people to have contrary information on wha~ is being sent to them through very skilled and expensive industry ad- verttsiug eampaigna, aren't we asking nonprofit, volunt~ry organi- zations to divert scarce resources from research and other aetivi- tins, and lsn t this going to be an lmpos~lble task because you can never counter the millions or dollars of advertising spent by the tc~ bocce industry? Dr. Daugherty, ! would address that to you, if I might. Dr DAIJGIIBRTY. [ agree with what you have said, Mr, Waxman i think most of my effort with one of these organizations is with the American H~art As~eiatton I guess otxe of the reasons we a~ here today is that cig,nrette smoking is one of the major risk factors for coronary artery disease As Dr. Oates pointed out, it is the leading cause of death in the United State today and cigarette smoking, if we could get people to stop, could prevent that. There are lots of things involved by the Heart Association il~ terms of resea~'h on hypertension, cardiovas- cular disease including stroke, and we need to continue to do that. You are correct [~ saying that if ~e had to dewte all of our rc~ sources to this, all of our resources wouldn't even touch what the industry has available to it in the course of a year Mr. WAXMAN 1 find it ironic t}mt some of our colleagues with us today sent a letter to Members of the House of Representatives urging them not to join in support of our bill Mr. Rogers referred to the concern he has that we are going to divert attention fl'om nil the environmental and occupational factors which may have human h~alth eftec'~s by recasting exclusively on smoking. Three days out of this week and the next couple of weeks this subCOmmittee is marking up a bill to chnnge the Clean Air Act. I expect the result, as I see things going in our subcommittee, wit] be that our committee is going to present a bill to the Congress that wiU dramatically weaken the protections of the Clean Air Act which has been set tip to protect public health. Once we have this bill out, I don't think it's going to become law. I don't think it will paea gut if the Con~g~fress h~llox~ed the return mendations of some Members who are offering this legislation, we are going to weaken effbrts to try to clean up the air, Shouldn't we then put in even more effort to try tO stop cigarette smoking? 7 ¢B
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q 189 I)r Cahan maybe I coald address tilis to you Arc we talking ~foout I~ings that can be segregated~ con~idel'ed sep~tr~llc~y, ov is there a syller~i~tic ell~ct of air pollutiun, cigarette smokirlg, ~lnd other ei2virolllileiiL~i] ~:pos/lres~ Dr. CAHAN. Well, an ideal alrangement, would bo to take the rna~or carcinogenic m~terJals thz~t we breathe, imbibe and ~ut Of ~ur culture B~t in a realistic sense. I think ~/at il may be difficult I~ accomplish both and you therefore may not accclm[l/ish either I don't know how these legislative mechaal~ms wo~k There is tlo question, h~voF, in discussing the envfronnlel]~ C~ncer spl!l!illt ist~, eschew any and a]l thing~ which cause cancer¸ "We have a strong [ee~ing that ~e person~ envfoonment, namely, smoking, is the p]'epond~rant c,~use of oLlr ~rtic~lar ~ntere~t, which is cancer. Therefore, I think the concentration would be in that direc~fon i think there are many llves t~ be ~aved in b(~th. But that fo my ~ni~d, w~ald have prime interest. Mr. WAX~A~. ~her~ is a combined impact? ~here is a ~ynergistic impact to these expostlre~? Dr, CAHA~. Yes, the syilergism, is called ¢ocarcinog~niclty. There i~ no question that otle p]us one equ~l]s ~hree, r~ot two. For exara- pie, radiation plus some other carcinogen painted on animal skin ~ou~d cau~ cancer r~ore predictably than ~ne afone. An asbestos racily worker who ~mokes. has a marked i~crease in l~is ct~tnce of developing cancer ol¸ the ]ung th~ln if the asbestos worker does ~loL ~moke. Mr WAX.~AN. I guess ~he poiilt I ~Jm drawing out is that we should no~ d~ert our efforts in a~y area. a~d we shoaled no~ expect that one ar~a alol~e is worthy of¸ ~l~r attention as representatives ~n Governmen~ today. The tobacc~ industry frequently characterizes ~he report~ and statements of the US Surgeon General as merely one man s ~pini~n it ~ugges~ tr~le res~&l~l~i$ ~s ilptloscd to pr,'~c- ~cing phy~lc~'ans a~e ]~ot qu~e a~ confident as yo~ gen~eme~ ab~t the health effects of smoking. Hvw would you respond to that commen~, Dr. Oates~ Dr. OAT~ The Heart Association has examined these issue~ ex- tremely carefully a~d repeatedly with expert groups o~ scientists examinatio~t~ that there is no question regarding the data Mr. WAX~AN DO you find researchers a6 well as practicing phy- sicians have come ~o the same ¢~nclu~ion? Dr. OATES, These are indeed the researchers who have come to vasca]ur di~e~es Mr WAX~AN Among physicians that you have c~me in ~ont~ct with, how umch of a differing opinion do you find? I~ this a wide ~pread consensus, ~r is this oi~e where maybe there is ~nly a slight majority ~f views that cigarette ~raokin~ i~ harmful? Dr. Dau~herty Dr. DAU~H~Rq'y. I think the~'e is widespread consensus /L~ a matter of f~ct physichins is the one groul~ that has the ]~ighest per- centage of people who stop smokil~g I think that afore is evidel~ce that the practicing physician believes the data that has come from the researchers, which incldenta]ly the Surgeon General i~ one person, but he has put together the data from many. many inve~ti-
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190 ga{ors It is not one man's c~pinion, It is in tket facts compiled by one man to present to the public. Mr WAX~A~, A~d lhe~ let me j~t ~k ~ cuuple of queslion~ be- cause t think it is important to bring these points out. Dr Ayres. can a smoker reduce the risk to health by qui~tlng, even after years of heavy ~moklng? Dr A¥~ES. ]~hat evidence, that quitting ~rnoking reduces the inei dence of disease, is part of the evidence that points to the causallty ot Cl~¢~rettes, One exa~lple~ a large n~lmbel Of phy$1cl~n~ in ~]reat Britain were followed for a number of" years. Over half of them ~opped smol~ing, ~nd the reduction of deaths ~oln ¢hroofc lung disease was ~4 percen'~ colnilar~ to oIlly 4 percent In th~ g~nera] po uiation ~ the~e i~ ~ ve~'y ~ubstantial hody of literature de~loptng this point. There are ~be~ sttldie~ in Americ~l ~pu]atiorl8 tlul$ ~how that after a number of years of abstaining from smokbclg, the desth r~t~ froT~ lu~g ~is~ ~r~d ~a~t d~ase ~re st~h~t~.r.~ially re- duced¸ That i~ very impo~t~nt ~nd even people with ~rnptomatie heart disease or ~yrapfomati~ emphysema can be i~pr~ved if they s~p ~nu~ng. May I ~lk to that? • .Mr. W~x'aAN, Yes, Dr Cahan, Dr. C~,R~. One o~ the ~oph~rie~ w~h which ~mckevs amo~e themselves l~t!quel~tly i8 ~h~lt it is "too hire to stop¸" This has no recoiling in a scientific sense ~e do not kn~w where that point ~f no retur~ is, where that cell beaten On suddenly waves Lhe white fl~g of" surrender and ~ys all right, if you fo~is~, I am going to he~ome GarlC~FOI]~ There is no questio~l tha~ the sootier llr~ st0ps~ tb~ bett~r the chance one will not get to this [Joint o~ ~o return. This is ~ message we ~h~uh] co~ey ~ people wbl~ sraoke f~ ~ny length ut t~r~e~ There is unquestionably a renewal, ~ healing, a recove~ of the mucus membr~nes o~ the trachea] b~onchia] tree once the irrit~- ~n f~ctor has ~topped. Thiz renewaI can ~eturn in time almos~ to its origii*a] pristine state, after a p#riod of 10 or 15 years, and to be equated with those ~h~ never smoked. Mr WAX~AN. What role does carben monoxide in cigarettes play in the risk of heart disease andpz regnancy oatcome? Are carbon monoxide leve/u lower in low-tar-ni¢otiue cir~rettes and is there a safe or safer cigarette'~ ~)r. AyRES ~he carbon monoxide issue is an interesting one, it is interesting it ~*~s not mentioned in eredier reports It is only in recent years that it has been recognized theft when carbol] monox ide combine~ ~ith her~globin that there is a deprivation of the ox gea available to the heart muscle. ~hvre is excellent widener that smoking cigarettes decreases th{~ exe~'~e tolerance ~f patient~ v~itt] c~r~ary ar~ory di~e~e. One of the problems with the methods of reducing tar and nicotine is that the), do not reduce t}~e gases in clg~retfo smoke a~d carbon monox- ide is one ~f the gases of ~-e:~t eo~cer~, h~eidet~tally, carbon mono~ ide is not a required labeling issue and there are many ~*f us who believe that the carbon monoxide content shouid Mso be on the cigarette packng~
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191 Mr. WaXMAN. Why would that information be vatuable to some- one7 Dr, Ay~ES If smokers wished to select what they believed to be a healthful c~garette and we incidentally do not be]feve there are any healthful cigarettes, they need so have a complete listing of the ~iangerot~$ elements so they can m~k~ an infin'med choice, Dr OATHS. The evidence does not show ]ow tar and nicotine ciga- rettes provide any protection ~oln the risk of heart attacks. Mr. V~rA~I~IAI~. ~o ~ iD~-~.r/few-ilicot~lln- c~gar~tte n'L~ ~3t h~ve low danger ]evc] for the smoker if he thinks he is gaiilg ~o have a safer cigarette. Is that correct'? Dr. OATE8 Furthern]ore, there is a well~:t0cumeLlted Coillpell~ tlon with the low tar/fow-nicotine cigarettes in which smokers will smoke more and inhale morc deeply to gain higher leve]s of inco tine and other substances in the smoke. Mr. WAXMAN, ] am going to call on my colleagues tc engage in some questions that they might h~ve for you, But I wan~ to ask a question and I am asking it rheforlca]ly This Government spend~ money on ~accinating children. We had some hearings indicating that s~me of the cuts in the vaccination prod'am are poorly thought out and endangering many children with the possibility of getting some dreaded diseases Bu~ I do not know that when we encourage children to come in for vaccinations, ~hat that Js any more br~inwashatg than it would he to try to inform people that smoking clgar~ttes is going to be hazardous to their health, dangerou~ to their well-being. And 1 think in both cases the Government has a responsiblity to try to educate the public as to the danger~ of why they should avoid smoking on the one hand, ~nd why they ough~ to get vacci hated on the other. Mr, Bliley, Mr. Brz~y. Thank you, Mr. C~airman Thank you. gentlemen, for appearing toclay, Dr Ayres, does the American Lung Association have any re- search results that positively show that extensive labeling will de- crease the incidence of smoking in the United States? Dr. Ay;~ES. Tile American Lung Association supports research umong ~he scfentif~ community, but is not a research institution of itsel~ I do not believe there i~ very much good m~rketing informa- tion about the impact of labeling. | think there is a strongly held belief that it is an important aspect of our total fabric in the at- tempt to p~rsuade people t~ ~t~p o~ to not ~rt. Mr. BLIL~. Thank you. Does anyone e~se want to comment? Dr. OATHS. I think one could view the labeling not in ~erms of proved marketing effectiveness, b~lt in terms of the righ~ to know when someone purch~es a lethal preduct, Dr. CA~AN. Mr Bliley, in light of the fac~ that cigarette smoking has increased in the f~ce o~ the current label suggests i~ is indeed foe~c~ual, and is all the more re~son, a~ our advertising brethren would say to stop that particular campaign and gct a better one I think the daily reminders tha~ a good campaign might produce are very importanL, as ] said before, as a persisteDt repeated reminder. There are those warnings that come as a block sized headline such as the Surgeon ~eneral~s report. But daily reminders I have 0~ .Q
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192 found in my attempts to stop people are just a6 important. The na~glng wife, for the h~th~d who pemists in ~rn~ki~g; the w~ter dripping on stone. All these things, finally do add up. This, would also be ~ way of a~proaching it and estimating its value. ~'v[~'. BL~Y WelL, Dr C~,han~ sip.ce y~u have sa~d that you d~ not know whether it would work or not, tha~ the changing of the labeis or wha~no~ wotl]d h~tve an effect, should we not await the research ~u this before we rcquise it? In other words, should we not get the evidence in before we require a procedure? Dr. CA~AN I think that these are very hard things to c~timate before you really ge~ into the experiment, if you want to use that. We cannot prejudge it of cv~rse. On the o~her hand, 1 do think that the idea behind i~ has a paralfoi, in an offect~ve campaign used ~n teisviston, where so mt~ny children stopped smoking when they v~ewed an~ismoklng televi~isI~ commercials which have largely been discontinued. That is the only p~ralle] I can judge as far ~s that is concerned. But in all probability, multipIe labels will serve up a multipJici~y of personal warnings t~ fit some particular individual; for e~arnple, the pregnant woman looking at that particular ~lbel. It will do a great deal more than the 9~diid one that we have at the present time. As somebody h~ts said, it has become a p,~rt of our backgroun~ alre~dy~ like a hydr~nt in front of the house or a picture you no longer se~ ~n the w~ll The idea of changing ~hern is iutercsdng and peopis will be more likisy ~o read them. Dr AYRES. Mr Bli]ey, we just d~ not have th~ resources tha~ the tohacccl t~dustry d~ea to perfor~n the~ marhetlnd ~tudies, We know the tobacco in~l~stry invests hundreds ~f millions of dollars with each campaign to see it ~t particular ~nes*~,age is effective. We have to re[y basically ~n some predictmns that it may be effective I happen to beheve that it would be ine~bet~v~ and preheblv ~m inappropriate use ~f private ~nd Federal l'~nds to ~nvest a bi~llon dollars to see if the ]abels worked. It would be more appropriate to follow the judgment of expert~ a~d ettempt the labeling approach and then lvok at c~garet~e ~aies dow, the road and see if it is ~l~ec~ tlve. Mr. BLIL~Y YOU are cert~in]y entitled toyour opinion Dr. Oaten, ~ the bt'st of your kn~wtedge h~ the Ar~erisa~ Hea~'t Association p~rtornlsd ¢qny research evahlating the ef~ec£s of rotat- ing warning isbels on human behavior with regard to smoklng? Dr O~s. We ha~'e ~ot eva~u~ted the ~pecidc ~pec~ of ~arpin~ labels, but we are quite familiar with the dat~ that re]~te~ to the level of knl~w|edge that ~hese warning l.~be]s would attempt to cor~ r~Ct. For examp[e, atnon~" people who ~urrenr v ~lre sn okors, on ,~ percent know that s noking ~ a cause of ~lny heart attacks ~ ~s our {eeildg with respect to ~he label that the person who purchases these produc~s should know in specific what are the risk~. And ~his rlgh~ to k~o~ is irrespective ~" marketing surx, eys in terms of ef- fects on behavior. We think that the personalized ~lspeet of the messages as indicat- ed wall speak r~re specif~c~ll~ to ~he people ~h~se ~ami~ies h~ve hear~ dise~se~ women who ~re on birth control pJ[is, ~nd people O~ ~D
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193 ~i~l ~¢o~e f~ili~r witi~ t~.e mul~ipl~,clty cf the dreadful effects ~hat occur fl"om the cigarettes We think there is a right to--knowledge of ~hesc things and that it ~s something of great value. Mr BLtl.~y Since you gentlemen are in the health fie]d a~d are concerned, genuinely so and righfful]y so with the health of the ~ltion, ~ we are as member~ o[" this sllb¢ommittee arid members of¸ thi~ Congress, we already h~ve legi~|~ion that requires w~rning ~n cigarettes~ with which you ~n~y agree or may not ~gree. But there are other pI'oducts th~ are for sa~e. Alcohol ~pe¢ifical- ly ~on~es ~o mind¸ Th~ t~r~ainly ha~ health ha2ard~ asscciate~ with it. Yet we do not require warl~ings on tha~ advc~isi~g or re- st~ictlon~. Ill t~l~ limited time ~nd re~ollrc~s w~ h~x'~ i~ the c(~m- m~tee, ~ou[d we ~ot be ~o~g at this are~ before we go to in- crease war~ling label8 ~ere, when ~he rest~ect~d Gallop Pol| says over 90 percent of the people in the country believe already tha~ smoking may be harm~l ~o their health? Dr. AyREs Well, we are in a crisis situation, sir I think that ~he m~gnltude of the smoking related deaths a~d illness so exceeds that of ma~y of the other issues that have been r~ised that we ~h~l~ begin there. Now I p~rso~ly h~v~ ~o pr~lt.n~ ~ith a ~iml- Jar warning oll alcohol. But m~ny of ~he oth~cs, Mr Roger~ men- tinned power m~wers, certainly that is sigi~ificant. But I think it is ~1 little u~realistic to take the number of f~ngers ~nd the deaths ~om power mowers ~nd compare that with the number of deaths ~ora ¢i~rette smoking¸ So it is really a ma~r of beglnni~g where our efforts will be most important. Mr. BLILE¥. Do you have ~t~tlsti~$ oll other products, ~ny of you, as to what effects it has on health? I)r. O~z~. ~ think ~s pLysici~s ~e are ~ery ~mi~i~r wit~ ~ m~ltiplicity of laclors that have effects on he,d~h. And all of us are here b~ause we feel that this ~ne pa~ticu]~lr ~ctor represents an epidemic of major pr~[~ortions that is thre~ilcni~g American health and i~ is a particularly dreadful epidemic because it is i~tlicted inl- tially, mos~ ofte~l, on children who e~tel¸ itlto a dit~cult toYoreak habit without adequate information Mr. ]BLILE¥. ~ DOCtOr, is teenage ~c~)~olism r~o~ reach~l~g epi- demic proporti~ms in th~ country? Dr. OASES. Exactly. But ~ do flot think our choice here is to corn p~re ~i~g~ that ar~ b~h ~errib~ b~d I ~hink that ~ are ~eeh~g deaths due to cigarette smoking ~tm~ cxceed th~se in most m%c~r w~rs of this world. Mr. W~X~AN Will my colleague yield at tha~ point? I ~hou]d point ou~ just ~r the record that to ~]le credit ~f the alcohol indus try they do spe~d money to discourage children l~0m drinking. They talk about drinking alcoholic bevcr~ges as something lbr adults only. Thcy are al~o ~ regulated in~]ustry The ¢igalette i~dustry is not regulated. They do not put money into discouraging ymlng people from smoking¸ In fact. riley do the courage yo(~ng people to ta~ iL Up.
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194 I)~. Ot.T~. Ia these tiraes of fiacal constratafa it is impur ta~t that we arc wastlng billiorls of dollars of the health budget m care ~r the morbidity and mortality of the use of tobacco¸ Mr. BLH~Y. No further questions. Mr. Chairman¸ Mr. WaX:~AN Thank yc~u, Mr. Bliley. Mr. Rogers. Mr. Roctes Thank yo~, Mr Chairman I served as local chairman of the Ameriean Cancer ~ociety and ATnerieaa Heart Association campaigns to raise ~'unds ~roJt;e~ vohln- teer~, fund the programs that you so eloqueat]y promote in your different organization And I was honored and proud to do so, and still am. A~d it is ihe that reason that I think the organization that you represe~lt can best sell the American people on the hazards of ~:aokhxg, And not the U.S Governmet:t l.t is my ~piaioa that the Government can best do the research and support the scientific re- search, and to then let and ]~elp in any way possible the privately funded voluntary cwgaaizatlon do the selling, tMe prop~gandizing and, if you will, the brainwashing, because it ha~ the army of people ~nd the hundrefl~ of people we involved iv, the campaik,m to raise those funds. It has the army of peap]e willing and able to take on the task it properly motwated and armed aad equipped with the proper mau.~ rial l am told lhat the American Lung Aasociation spet~ds less than 5 percenT, of its total budget, 5 percent or less, in funding re~ search I frankly 1.hulk that is a little bit embarrasslt~g for the folks that I ask money out ~f back home for that program, I do not think they ar~ aware of +~hat. l was not either. Frankly, the orgaalzation and the Heart Associ orion arid the others l think are well equipped to sell the concepts that you have described here today But President Reagan and this administration and thm Government intent upon reducing the cost ~f the size of *~he GoverrLment that ~e have, and ~ailuve to do ~a, could possibly render us in very severe economic problems, So the president and many others seem ~ leei that private organization, voluntary organization such as your own should be given more of the responsibility for what many in the last 5 or 6 years perceived to he public se~wice, g~v~rnmental programs Wo~ld it m~t be more appropriate for the Central Government to fund the scientific re- search on smoking and the hazards, al~d then to let your organiza- tion and others take that scientific research and do with it what ~ou do best, and not establish another huge bureaucracy up hero evote~ ta teili~g Ix'ogle n~t to smoke? Would that not be th~ best route t~o take, given the circum- stances we are in? Dr. Ayres. Dr Av~gs Well, I suppose I should first respond to the issue of the 5 percent on research. And l suspect I know where those fig ~res came from. We feel a~. the American Lung Association that we have accomplished much of our goa~ because we have been at- tacked so freq~aently by the tobacco industry, and we give oursolves aa A on the report card for that,. We support research, but we also use our budget for the support of p~blic education and professional education, and we have a large rtumber of affiliations, a~ you klmw, in many States throughout the United States, all the States. The issue about how much to put into
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195 biornedlca] research and how much to put in beh~lviora] research is a very signiticant issue¸ My own view is that we have done ~heut as much hlomedlca] ~e6oarch as we need ~o do. It is the tobacco in du~try that keeps saying d~ more research. They would like us to find out something that we h~ve not. already found. So I Lhink we have done enouEh biomedica] research~ no~ Qui~e enough, we now need to put those dollars into behavioral] research. into helping physicians and ~lthers unders~nd how we ~an promote hea[thfei habits. Mr. ROG~:R~ If I may interrupt you, why do you not pblt more Of tho~e moneys into tel]ing t/~e American people not to smoke? Why c/o you n()t have advor~iserneats such (ns M~rlbot~ over ~hero t~]ling people not to smoke? ])r. AYR~. Well, you know the budget of your Lung A~soclalion as well as ours¸ When y~u thiak of that $1 biU~o~ figure, | dD not ~hink there are enoug}] Christmas seals that will ever be printed that can equal their ~]gure It is the ul]equfi] balance that concerns us. A.n~ I share ycl~r concerns about Oovernmcrtt. | think we all do Bv.t at some point, you gentlemen have ~o decide wl~ere Governmeat should take a s~:~nd a:nd where it should trot. And we be[feve th~ art op[demEc that ki[[s as m~ny AmevLcan~ as cigarettes do is ve~ worthy ot~ a Federal and coordinated ap- proach. Dr. OAT~:S. We are f)art~cular[y ittfere~fed Ln ~l~is tss~e oC how much we can do in tile Heart Association for informing the public about smoking. We find that we are in a vet5 ~ustrating and hexed in ~osition in ~e~:ms of bein~ ~b]e t~ be effective in this area. There h~ve been some esti]~ates ~f the cost of a 30 second spot to make ~ne single message on te]e~'is£(~n It i8 in the neighborhood of" $80,000. The£ is about equivalen~ ~(~ the annual budget el" the Smoking ~ubcommittee o~¸ th~ IIeart Ass()ciation at the moment. ~uch a public service mess~ge~ by our past experience, is fikely to be shown at about 2 a.m in a not very interesting programing fl~rmat This is one of the re,sons why the Heart Association finds that it needs to work together with the Federal Government. We w()uld not ask that the Federal Government assume ~1 of ~hls re- sponsibility, but feel that with a small amoun~ of money in the Office of Smoking and Health that this could bring t(}ge±er forces that could accomplish this ~ob in a way that they singly could no~. Eerhap~, the bes~ ox~rnpfe of this is in the area of hypertension which is another risk factor for cardiovascular disease, where the National Heart~ Lung, and Blood Institute ha~ been exceedil~]y c~ fectivo working with the private agencies to bring ahetlt a remark- able el~ange in the treatmor,~ of hypertension, and veo are very gratified tha~ the incidence of stroke is felling remarkably. So ! think this is an area where the Fodera] Government with a sm~ll e~f'ort working with private groups has been exceedingly et= fective and that is a made1 we could Ibllow Dr. CAHAN. I am not an economist but I de not think it is asking too m~ch to project that the problems of v~lun~ry organization aio g~}ing Be he increased as far ~s funclraisin~g is concerned in light of our present economic ~ituatio[l, and that this wi~} become -2 deepert- ing one. ¢n
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_~_~-.-..=--um=I 196 ~t with the estate tax differences and what with diminished incomes, v~hmtary agencies are going to suffer along w~th others. So J think at this partisu]ar time it would be appropriate fbr the Guverrtme~t to help. Mr. Ro~Eas. Yield back my time, Mr, Chairman. Mr, WaXMA~. Thank you very much, Mr, Rogers. Gentlemen, thank you very raucb for your tostlmo~y today. It has been very helpful to us We appreciate your taking the time to be with us. The introduction of our next witness is a special pleasure. From 1961 ~o 1965, Dr, Luther Terry played an integral role in identify- ing and substantiating that cigarette smoking is a major human health risk. We have learned much in the 18 years since Dr. Terry sounded the alarm. It is app~-opriat~ today that we solicit the vise, s of the man ~'ho made the position ~f Surgeon C~'n~ral synonyr~ous with ~rnoklng prevention. STATEI~IENT OF LUTHER TERRY, M.D., PHILADELPtI[A, Pg. Dr. Tsatty. Th~nk you, Mr. Chairman, members of the commit- tee. I appreciate your inviting me here ~o speuk on this very impor. tart ~uhject. I recognized this as ~n important ~uhjeet, dating back to 196'~ when I was Surgeon General. Prior to that [ w~s successful in appointing a very fine scientific advisory committee to review the subject, and es a result, on Junuary 11, 1964, we published the results of that committee's study, of over almost g years. And it has been a hallmark in the field of the recognition of tobacco smoke iu relation to dlsease I am very gratified that in these 18 years since that report wins released, that none of ~he significant findings and conclusions of that committee have been repudiated As a matter of fact, the main tiling that has h~ppened over more recent times is tha~ there has been further sttb~tan~iation of In, any ~f those facts tha~ were brought out i~ the ~ri~inal Advisory Com- raitt~e's repurt, and we have c~:tended our information with regard to sraokisg and health into other areas that were not known; for instance, the effec~ on pregnancy, women, and birth control pilIs and even some more substantial scientific information on ghe sub- ject of heart disease, and partisu]arly coronary disease. So that I are very gratified that this information has been fur- ther substantiated and that it is readily avaihibIe to the public and is strongly e~dorsed by" the medical protbssion l am also indebted to you, Mr. Waxman, tbr having so succinctly in the November 12, 1981, issue of the Congressional Record, to have c~psulized the information on the subiev~ to file extent of bringing oat the importance of the subject. At the risk of being redundant, I will have to say again what sev- enfi of our ~ther Witnesses have said, that ~moktng is the most pre- ventable cause of disability and death in the United States h~day. What more challenging statenaent c~tlld be made iu terms of re- ~panslbflity ot the American people to do something about?
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197 At thls st.u~e I w~uld like to s~y ju~ It ~ld ubout Secretary CalJ [a~ be~au~e [ ha~e ~cb. great ~dw.~rat~[a~ [or him ~nd. ~r the stand that he toQk. Prlor to his creating Lh~ O~l'ice o~ ~m~king and H~llth. we had a clearinghouse ~'hic~ wa~ cr~e~ i~ ~he P~li¢ H~ S~r~ice. which ~erved in the ~am~ gen~ral direction. The fac~ ~h~L Mr Call- .no ~'aised ~he status ~f this ~e~ment in t~rrns o~¸ it~ loclttio~ and importance ~nd ~affing and ~n~s i ~]ni~. ~a~ a grea~ lii~. f~ ~ ] have be~n greatly concerned by ~h~ rumors ~hat the Office of ManagemenL and Budget wlsb.es to Cu~ down or eve~ cut out tile funds for ~his~ anti 1 feel that we shoul~l be appreciative, at ~ew~ to ~ siff~ifica~lt flegree, to ~ecret~ry $~hweik~!r in l~eepi~g this prc~ gram alive Now. if I may, I woukl like to speak speci~cally about a tew o~ the ]e~is]atlve pr~i~osal~ ~vhich are b~fore y/~u I think ~he first ol~e ~hat I would like to tak~ ~p i~ ~he questi~ll ~f the ~t~utory cre- ~l~ion Of an Office on Snloking ~nd H~aJth. As you k~ow~ at the present time this ul~it is a~ administratlve cr~ion of the Secret~ry and c~u]d be wiped out with th~ sweep of a p~n. At the same tim~, ~his 8ubjec~ and ~hls ~rgalli~ion is so ill~.~r~nt ~hat th~ Conffress sllvu]d r~anif~s~ its interest in this to ~.he d~Jree far cre~t~i~g ~. ~t~t~lry ~e~e~ i~ ~ur Government; namely1 the Office on Smoking and Healtl~ | would also like to emphasize the fact that I ~hlnk the ~imot~nt in any respect. When yot~ think that ~he Clearinghouse, the ~r~de cessor of th~ O~fic~ ~n Smoking and Health had a budget of ~bo~t Sg milllon b~ck in 1~ ~ and loday we expe~ tl~at Office ~o operi ate on a third of ~he number 0~ emLp~loyees ~nd about $2 million. Ima~ne wh~ $3 n~illi~n wa~ in 19~1-72 in comi~arisoa to $2 mil- lion ~w, a~er 10 yea~ ~ inIl~tion. Frankly, 1 would be delighted if the C~ngress would authorize an appropriation level for the O~¢e vn Sm~klng ~nd He~J]th, ~nd ~vould per~o~l/ly recommend t~at a I.evcl of $10 millio~ a year¸ over the next few year~ would be proper¸ Furthermote, I wc~u~d hope ~hat th~ Appr~:priations Committees would respv~d to such ~n authorization alld giw us the st~pport that we need ~r the pr~gr~im. l~ rel~tion to other aspects, | think the def~niti~l~ o1" l,h~ re~nsi bLlities of tt~e Office on Smoking and Health which ar8 it~cluded in the b~lls is par~icu]arly ~mportan~. O~e thing I would like to espe ~:i~l]y em]~h~size is ~he re~uiremen~ of atl anl~ual ret)or~ of the Publi~ Health Service ~tnd the Depa~tmel~t of Health ~nd Human Services to the Congtes~ ~n the scientific ~spect~ on sm~klng and health¸ I well recall back in 1965, when the first Smoking and Health Act ~vas i)a~sedl that one o~ the a~h~ri~ations ~nd r~luiremen~s I a~ not sure tl]at we ~v~uid have accumulated ~he amount ~f information or go~len th~ amount of supp~r~ that we ~¢eded in the quired by the CoI]gress that the Department ~llbmi~ an annual report ~J
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198 l think this issue is too important to alh~ iI to slip by nud that this should be continued There is a qlc~tion of our near,ling more rcse~rch fa the field of ~muk rtg and ~a Lh lhe tobacuo industry rJver the years has rc peat~:~ly said I'we need more resenrch, the fa~ts are not all in." I think mcs'~ ~f us in ~b.e ~c~entil~ ~ield k~ow that this is c~m pletely irresp(msible, that there are enough facts to poin~ in the di rec~ion we need to go ~ would a~so sayl yes, there is ~ustification in having mere research The research, however, shouht be prlma~J~ directed, now that we know smoking af~cts these certain organs a~d e~uses cer~aiIl disease condJtion~, so thltt we e~ln learn n~(lle about exa~ly how it does it, and we should kno'~'. Ho,~ev~r, I ~hiak p~'oh~b~ the m(~ imgorta~, thing a~d area in which we need research in smoking and health ~day is in relath~n to beI'~avioral s~udies, ~u ~mder~t~.nd ~'hy p~p~e ~:onlinue sn~oki~. In other word~, we need fund~ fhr this lype of resea,eh ~[ also applaud the provision irt th~ bill for requiring a health w~lrnfog on clgaret~es th~ are exported for consumptforl For S~v- eral years 1 served as the chief of¸ our delegation to the World Healt~h Organization More recently, I serve~[ on an advisory co~n mltteo to ~be World Health Organization on the subjcct Fra~k[yl [ have hee~ embarrassed t~ ~hi~k ~hat ~e wo~ld l'e quire such a health warning on cigarettes for c(~nsumptlon by ~ur own n~C.iollal~, and ye~ n~ requi~ it ~'or o~h~?Y e~ntr~es. I~ is true that in most of tile more advanced countries they t~ow by their own ]aw~ require hea~th warnings. I3ut one of the areas I t]link of ,-i grg.~t concern t~? r[lany of/is is tremendous movemellt on the p~rt oi" the tobacco indua~ry to develop, s~imula~e and expand the market in the developing, or the Third World countries Those coun~rie~ in general~ d~ not have Lhe s~ien~itic excclfo~ce nr el}~ciency to evaluate the problems Consequently, I fel~r that we are focding epidemics of death ~o some of (mr developing fi~reign n¢ighhers, wLere we shea[d he helping with f(~od and ot~er thi~g~ in ~heir normal developnl~nt. I ~ould like to ~omme~t ~us~ b~i~fiy abeu~ th~ tluestio~ of fo~- ing the F~der~l C-overnmen~ out of this and lettlrtg volurtteer orga nlzations ~nd local au~hm'ities take c~r(, of ~t. I think most of us realize that this i~ really no~ a reasonable ~p proact~. Yeu kn~w very well that if as of ~his week tbe Federal (l(~vernmen~ dr~/pped its requirement on the health warning on ~d- verti~Jng and on packages, they would be discontinued, a~d none of our mun~il~a~l.i(~ ar evet~ ~tat~ cou.ld he eff~ct~e in re~luirlng that ~rt Of requirement. S~, there a~e certain thing~ like thaL which the Federal G~v~r~- me~t mns~ do in ~timulating and ~nssisting~ bu~ ~lt the same tim¢~, I ~ea~ize ~hat many of ~he pvob~er~s in relation ~r~ smoking liavt" a very important aspec~ of local action, both volunteer and local gl~v el'nnlen~ action I think one of the best examples in this respect i~ what ~'e call illv~l~ntary smoking, or the secondary effoc~ of ~moking on a rlon- smoker In that regard, I think this is rto~ an ~rea in which the Federal Government can ac~ very effectively, exccll~ in relation to Federal buildings and instaLla~fons
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199 I think that we have seen o~er the country the a~'tions that have been taken by local governnclents, and that local organizations has been very active in this regard It is sonlething which they can do i think the Congress, in it is v~ewing the problem ~Is it relates to many aspects of smoking and health has to careflllly decide which of those things the Federal Gov~rnnlent alone can do, or pl~domi- nantly can do, and which they cannot do as well and thereibre should not take action in that direction I realize there are lots of aspects of the problem, Mr. Chairman and members, that I have not Eouvhed on l think my printed report to you goes inLo more de~ail, but at the same time I did want to touch on some of those ma~ters which I ~eh were ot great- est importance Thank you, sir [Dr Terry's pl~pared statement follows:] ~n 19
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206 Mr WAXMAN. Thank yotl very much, Dr, Terry. In your xde~,, what is the most significant flew info~matiott we have learned stbout the health etlbets of smoking since your report Dr. TERRY. I think the confirmation of the el]ects on coronary ar- teries and coranary heart disease is by far the mo~t slgnificaut, tt is the rnost significant because it invo]ves so rnany more people and is such a ~ and de~b me~uce i~ s~ many i~s~ce~ There are others that are of considerllble importance, particuh~r ly in re/atiou to smoking and preguaney But the uumhcr of people involved, the potential dangers and deafb even in this important ~rea of p~gn~ncy is n~t ~nythi~g to zompsre with the problem in relation to cardiovnsctl]ar disease. Mr. WAX~A~ You mentioned the Office of Smoking and HeaRh that was, 1 believe, started in the mid-sixtles Is that correct? Dr q'~aY Nu The Clearinghouse on Smokin~ and Health was set up by me, as a matter of tacL when I was Surgeon General, and if, opt"rated under that name and in that eapacfiy until Seeretar3" Califano changed the name, upgraded its status from the Public Health Service to ~he Department and changed it in that respact There has been a continuing program. As you knox,, there have been reports regular]y from the Public Health Servtce to the Lon gress. l~]r, WaXM~ The Office of Smoking and Health, which is new part of the Department of Health anal IIuman Services, is some- thing that this bill would make statutory We would authorize it to be part of the Government and to be funded each year by the Con- gress. As it is now, the Office coufit be abolished if the Secretary and the rest of the administration agreed to it It could be abolished by the Office of Managemen~ and Budget, just striking the itrm from the budget. Now, you worked with the Congress You know this is an author izlng committee. We set up an age~cv or we set up a program. I~,ut then the funding must go through t[~e Appropriations Committee. You indicated at one time $~ million was the amount given to this eflbrt by the Federal Government Now tile Office is funded at sg million, with 12 employees. I am wondering if that in.any.~'udgment could be considered a huge government bureaucracy to uea ~ith a prob em of th s mag nitude; second, and whether from your experience of working with the Congress if we authorized a statutot~ agency could we expect that the Apprepr,ations Commktee would increase appropriations above the $2 million in the current budget? Dr TE~. Mr. Chairman, I think, to be quite frank and realistic about it, the recommendation from the dl~partment recently and from the Public Health Service, if you are h~terested in the ~umber of employees needed in the Office of Smoking and Health and arnoui]t of thnds needed, is absolutely ludicrous. Obviously it is a decision that is handed down from the top of the department. Who else participates in it, 1 de not know, but I think the relatively recent resignation el the d~rector, the head of the Office of Smoking and Health, Mr. John Penny, is an excellent ex- ample of what he thought was the direclion in which it was going ..... ~ .... r, .- .... -q
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207 by ~hi~ cu~ in the l]~mber ~f emp[oy~ arid e\,e~ ~he m~ag~r amouat of funds available Mr WaXMAN. ¥~u ~ouched on the other aspect of the bill that should get soJne att~niion, and that is ~he export of tobacco prod ucts from the U21ited S~atc~ overseas, particularly to Third World developlng count ties it is unllkely their governments have any kind of proffram ~r making available to ~heir citizens in~rmation about th~ dangers of ~moking ] doub~ very much that t}/ere is u voluntary hear~ associ ~ve h~vc in this ~ountry. We have permitted cigarettes to b~ ~xpoltet] ~o the~e ~oun~ri~s without any health warning Do you have any ~sis ~o believe that except by word of mouth, occasionally, some i/~ thc~e people could have a~y ~ea ~hat this habit being pushed upton them i~ a danger- ~u~ rue and that ~hey will live~ maybe die, to rcgre~ it? Dr. T~RR¥ It is a very 00replicated question~ if olze can character- ize i~ a~ a question. the first place, ~ ~l~k tb~ere a~e a fe~T ~f the m~e educated, the move advanced people ~ those countries thaL d~ recognize it. I don't think the vast majority cf them do. I am not sure how mal~y would be informed, bow many more would be informed with a health warning on c[garettc packages and labels. On the other h~nd. l am ~ure some more would be. Frankly, as a loyal American citizen | would be much mo~e happy to think my Government r~quired this ~ort of labe]ing for its ~reign neighbors as well as i~s dom~.stic const~mptlon. O~e ~ther ~hL~g m ~t ~espect. I ~i~k tb.at there isn't mu~h ~hat we c~n do as American cltlze~s ~thcr than requiring such a warning for all American products ~ those co~ntrie~ But 1 think wo have to depend a grea~ deal on the World Health Organization and its various organlza~ions, like the Pan American Health Organization, wbi~ is the regional office lot WHO in the Americas, 1 think we have to work, support, help WHO and i~s ve~onal ¢~ rices a~d activ~tles. I think that this is the thing that we can do b~at a~d m~st effectively The, I tk~nk, ~ already ~l~der~ay, tl~at the World Health Organization hns an expert committee on smok- ing ~r health¸ They first cre~ted that particular phrase, "smoking or hea]thf' Furthermore, last year smoking w~s taken ~ the World Health subject of the year. and ~orld Health Day was ~ew~ted to the ~ub- ject of smoking or health¸ So, I think there are o~hcrs who wiIl be working on it. 1 think tha~ we need to assist ill that cli~ection, but there are certain things that are o~r definite and direct responsibility, such as the labeling of our cxport products. Mr WAXMAN. Mrk Bliley. Mr. BLI~y. Tbank you, Mr. Chairman. Thank you. D~. Terry, ~or appearing today. ~ct~r, i~ ~ time ~f ~l~ca~ restraint that we ~re i~, ~'t y~ think it would be more prudent to evaluat~ the use of rotating cigarette labels befbre we require them?
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2O8 Dr. I~RR* I am not convinced that I know what you are talking about when you talk shout fi~aai avtsVerltF" ~,nd r@ati~g label~ for the simple reason that 1 do not believe that the rotating labels would pose i~ny real appreciable increased cost Mr. BLILE~. You don't? Dr. T~RaV. No, I don't. I can't see why, if you were changing the health warning label once a year, to think that changing the presses to chang~ the wordage of that label for that particular manufacturer would cost anything very much. I can't believe it. Mr. BLILEV. I think you would find plant managers who would teil you that when you shut down equipment and machinery and stop people to make changes, that it does cost considerably Dr TERRy, [ c.n't conceive a plant having to be shu~ down very long lbr that particular ch~nge~ sir, Mr. BLILEY. I see. The other part of my question is we couldn't know what this is going to do, so why put it in? I mean, as a physician you wouldn't recommend a procedure for treating a patient until it had been evaluated, would you? Dr, Tvaa~. i don't think the question yon pt~se to me i~ quite a proper one or could be answered directly. As a physician, I would recommend to my patient anything tha~ [ thought ~uid improve that person's health, whether it was of a preventive or a curative type. I am quite convinced that this would add some more to the effec- tiveness of the health knowledge of the American people, if we }rod a more specific warning, if we had a warning which was rotated. Frankly. I would like tO see, Mr Bliley though I don't believe yo'.I were ill the C'ollgress at that time, n~t on this committee. anyhow--back in 1985, wben we were ~estifying betbre this com- mittee we presented to the committee malked up cigarette pack ages in which we had very prominent wordage across the front of the package and recommended specific explicit warning. The Congress, in its ultimate wisdom, decided not io do that and decided on a less explicit warn[ng on tbe edge of the package. Even that we were grateful for, because it was the first time ~bat the Congress had ever officially recognized smoking as a health danger I think we have come a way now, that there is reason tu believe that m~re explicit warnings, more prominently displayed and rotat ing in type, would be more helptub For instance, we don't have any final results, hut the ~vidence in Sweden is strongly suggestive. Sweden requires a rotating warning. Some of the studies there recently have suggested that a larger number of the people are aware oI a health warning oil the pack- abe since it became a rotating try'pc of warning. On the other band, I think frankly that we do not have enough evidence to say it is clear from the Swedish experience that so add so and so and so. I think there is strong evidence that it suggests that such warnings ate he]ptul. Mr. BL. ~Y. Finally the message is getting across in this country George Gallup's poll says 92 percene That is a pretty high rating. If any member of this body has a 92 percent name ID, they don't worry too much about the other 8 percent. Ca t2
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209 Dr TEaRy 1 am not disputing a fact of Mr. Gallup, hut Mr. Ga]lup has been wrong before on some of his polls. Mr. BLILE'Z. Are you suggesting he might be wrong here? Dr, TERRY. I am suggesting he is wrong. I don't believe 92 per- cent oi¸ the people are aware of the meaning of the current health wurrdngs Mr. BLlUEY. What do you base that suggestion on? Dr. TERRY. On my observ~italns and discussions with people Hr. BL~LE~. I See. Doctor, moving on to the su~ec~, the bfocllng itself, the public ~eems fully aware of what you and other Surgeons C, enel'ai h~ve sa~d all,Jut, ~;mokJng, as has been documented repeatedly in pubiic ~pinfon polls. Doesn't this show that¸ the Goverllme~t andpri~.'ate organizations haw succeeded in ec]uc,~tting Ih~: Anlerfo~n public? Dr. TE~Ry. I don*~ think they h~lvc succeeded in educating them enough. Mr BLILEY. I see. Dr. TERRy I think yes, there has been some informalion~l, edua- ~nal effect. [ ~n't th~k it is enough. Mr BLIL~Y When you were the Surgeon General in 1964, thc report uf yl~ur Advisory Committee emphasized that smoking, and I quote~ "should be labcled 'habituation' to distinguish it clearly from ~addiction ' " Since that time llumerous scientists have repeat- ed this distinction including, for example, Dr. Ernest Wende in 1979¸ Don't y~Ju believe in view oI¸ the scientific uncertainty in this area that the warnfog related to addiction proposed by this bill cannot be justified? Dr TERRY¸ I don't want to argue about the details of each specff- i~ ~avt~m~. Ou the ~ther lxaud, ~et me say ~er~ directly lhat it has been my [~er~onai conviction that cigarette smoking is addictive¸ Mr. Bt~LC¥. ~n spite of what your Advisory Committee said in 19647 Dr TERRY. There are many things we know now that ~he Adviso- ry Committee did no know ] 19t34. Yes, regardless of what the committcc reported at that t~me. Mr BLll~V In spite of what Wende said in 19797 Dr TERRy, What did the committee say about cardiovascu]ar dis ease in 19~d? They pointed out a h[~her mortali~ ra~e among smoulders At that time they were ~'e]uctant to attach a c~use and effect re[at[~nshi~ to smoking and coronary disease. On the other hand, ~ thinl~ the evidence since that time has quite clearly demonstrated that the~'e is a ~:a/ise and effect relationship aud this was clearly brought out in the 1979 rep~t of tile Surgeon Genera]¸ Mr. BLILEY SO yOU Would chan~=W and say it is now addictive as c~ppo~d ~ rAe~ely Dr T~l~¥. I said it is my conviction that cigarette smoking is ad d~ctive to many people Mr. BLJLEY. Thank you, Doctor. Mr WAXMAN. Mr, Y{ogers. Mr. ROllERS. Dr. Terry, have you any traialng or experience or background in behavioral research or behavioral science? O~ ~q .,3 g:. ~z
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I " Dr TERRy. I am having difficulty hearing you Mr. ROGERS, I am sorry Have you any background or training in behavioral science or behgviora] research? Dr. TEeny. That is a difficult question 1 have not had [ormallzed training in psychiatry, psychology" or behavioral research of that sort. Mr Roce~s. You have not bad practice in that area, either, have yo/l'! Dr TERRX. I don't think any physician practiced medicine, as l did f~r ma~y, ma~y year~, ~th~u~ l~ractlci~g in full recognition of human behavior ~lr. Roc~m~ Well. [ am & lawyer. [ practice helmvi(~ral science iu practicing law We ~ll practice behavioral science in our way o[ lifo. As a medical doctor, have you had any trainmg or practice in behavioral science? Dr. T~naY. 1 have had a lot of experience in behavioral sciences in dealing with patients and their problems Mr. ROTORS. I am wondering why you don't address the subject here today because this bill really addresses behavior and behavior research of the American people. ] happen to agree with George Gallup. At lea~t he is in the ball park. Until you show me semething different I am going to believe that 9~ percent of the population of the country agrees that ciga- rette smoking is harmthi and don'~ need to be warned anymore The que~tmn is h~w go yea make them behave according to the science that they know? That subject has not been addressed by any witness ~ere this m~rnmg, from & baekfiroutld ia that science, and I would wonder why there are no behavioral researchers here this morning to tell us the answer to that. Gallup also says that the percentage of smokers in the countzT is down to the lowest point in hist~*ry in 37 years. It seems to me what this Congress adopted a f.w years back, and your report, which started off the debate, it seems to me that what is being done is working. Can you argue with that? Dr T~R'~. It has been tntermlttent ~nd spasmodic over t]rmse 1~ years. At the same time, l think nverall we have made progress, ~nd I am very happy for that, I thi~k ~e should keep t~p what we are doing, but we need to do more. Mr. Ro~as. Thank you very much Mr. W~XMA~, Thank you, Mr. Rogers. Dr. Terry, again, my appreciation for your being with us You were very helptul to us. The subcommittee will now recess until 2 [Whereupon. at ]2',15 the sabcommittee recessed, to recon~ene at 9 p.m,, the same day.] AFTER IIECES~ [The subcomnfit[ee reconvened at 2 p.m. Hon Henry A. Waxman, chairman, presiding.] Mr. WAXMAN, The meeting of the subcommittee will please come to order. I I [ ] I I I I .O
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211 Our last panel today represents the advertising and publishing trade associations Eric Rubln is Counsel for the Outdoor Advertis mg Associ~tion of America,. Michael Waterson is iReseareh Director of the Advt'rtising Association and represents the American Associ ation of Advertising Agencies. David Minton is Washingt~n Coun set for the M,ngazine Publishers Association. We would like to welcome each ~f you today to our he~lring Come forward, if yeu would, please. Without objection your foil prepared star,remits will be made 10art of the record~ We wou~d like to ask you to summarize those statements in a~ brief a period ,~s po~ible so we can have an ~>pt~ortunity for questicns~ STATEMENTS OF MI(~ltAHI, J. WATERSON, ON BCItALF OF A~',IERI- CAN A~qgocI:%TION OF ADVERTISING A(:ENCIt~S, AMERICA~; AD- YERTIgINC FEDERATION, AND ASSOCIATION OF NATIONAL AD- "¢ERTISERS: ERIC RIUBI~, COtI'~S~L, OUTDOOR ADVERTISING ASSOCIATION OF A.',IEII[CA: AND DAVID ?,I|NTON. WASHINGTON COUNSEL, MACAZINE PUBLISHERS ASSOC1AT[ON l%~r. W~T~SO~ I '~'ould ~ike to %ha~k th~ ~hairman ~r gi~fog me time to testify today on behalf of the American Association of Ad vertising Agei~eies, ~he American Advertising Federation, and the AssociaLion of-National Advertise~ I would also like to introduce myself[ I am Research Director o|¸ the Advertising Association, based in London~ I am also a member o~' the Council for Nalional Academic Awards. The function of the Adwrtising As~oriatlon is to see that t~he in terests of manufacturers, adverLising agencies and the media are represented in the United Kingdom and European parlian~ents, and to insure that issues such as the one under discussion here to~ are debated fairly, and in ~ne |igh~ of all a~alfubfo research evidence. We have worked closely with the EEC Parliament, with the Council of Europe, and ~he British Government on the questions concerning the advertising of alcoh~>fu: drink, advertislng to chil- dren, and the incidence of fMse advec~,i~in~ cbnims. |t is also relevant for me to point out Lhe the Advertising Associ- ation did no~ deiend cigarette advertising without ~frst researching areas whe~ ~e ~lt uncertain of our posit~on If our research had indicated meas of concern, | would not be here today¸ In short, the Advert~i~ing Assoc~atfon would not jeopardize its h~trd won position of ~espec~ in Europe, l~y defending a doubtful cause¸ | do believe that there are good~ grounds fo~ rejecting the measure~ proposed in |I.R. 4957¸ My re~ons derive from the research evidence available which show~ that restrictions on clgarette advertising do not have any effect or[ ove~aC ei~,qrette congumigtion, [~estriction8 do h~wevcr slow down th8 ~ratl~!r o~ smokers ~o low-|at, low-nieotin8 br[~nds. The evidence ranges [r~>m eeonometrlc studies, which isolate the impact of foctors such ~u~ price, and health campaigns on consump tion~ ~hrough to appraisals of l~rcep~ion of cigarette ads and anti~ cigarette ad~, through to comparision ~udies of the different mar- k~ts • 00 ~a -,I ¢D
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212 In my ~pfnio~ ~ kit ~( in(brmatkm can be got h'om this data~ since the position varies Iroln gounlry to country For example, in Swi zer and there is ~ rtual]y complete freedom to advertise tblrow- inag a recent referendum, in No.ray und Poland hm~s on cig~aru'tte advertising exist I~ Norway a massive health campaign has ac- companied the ban. Yet per capita cigarette consm~iption has hardly varied over the 5 years beibTe the ball or the 6 years since, In gwede~ lg health v, arulugs r~t~e o~ cigarette pack~, but no effect can be detected. In Finland ttlc main effpct of the ban has been to slow down the transrm" of smokers to low-tar brands. The research e~idence suggest~ c}earlv that the governments that kave tried to reduce smoking h~ restricting tobacco ads llave no~ been soccessfu] The reason is simple, cigarette i~ds do not sell the idea of smok- inn C~gmetle ads sell brands an~ most importantly, I~w-t~r and low nicotine brands. The evidence from econometric analysis backs up this common- seiise view, Many st/oh studies have .ow been conducted in t~urope on cigarette and similar markets. None show ads ~xert~ng any in- i~ttence other than at the brand level. This explains why health messages on packs don't work. It is reP ativeiy easy to se|i a new brand It is vlrt~mlly impossible to make petiole smoke n~re cig~retts or use n~ore gasldiI~e thr~t~gh adverti~ ing. Similarlv, modi(ving the behavior of sm0kers not to smoke ~s extremely unlikely to remllt from }len[tb warnings on pack.~ or ila ads. In addition to thi~ aspect, henltb warnings ~re shown by the evi deneo to b~ ignored becaose they ~re messages smokers don't want to ~eceive. In the l~nited Kingdom it is almost impossible to [i~d a ~moker wh~ doeth ~ klm~v t~e health h~czard. Yet it i~ also alnmst impossible to 17nd a smoker who kno~,,s the winds used in the pack warnings, The ~act is, thl~t other parameters ~ucb as i~rae and price level ate far rnoro i~portant For examp]e, i~ Britain~ cigarette con- sumption fell by I5 percent last year due t(~ a large price rise. ]¢or these reasons, d is my view that It.1~. 4557 wiB not contrib- ute to ~ deelitte t~ cigarette ¢ot~sumptlor~. If h is enacted i~.to low, i~ will however, contribu~ directly to ~ lull in ~he rate of conver- sion of smokers from high to low-tar brands. The research evidence sho~ that comitrie~ such a~ the U~d~d States and West Germany where cigarette adve~-'is[ng is permitted h~ve experitnced a i]]oi*e rapid converslon,, rate ~o low tar ciga rettes, than countries such as Norway and Poland where advertis- ing i~ batxnex~. Any interference ~lth the effeetivem~s~ of brined ad- vertising, such as that proposed by IIR. 49,~7, will certainly slow gown this conversion process. ]~inal|y, I ~t~uld submit that II.R. 495% ~f passed, will ~e% ~ dan- ger(llls precedent In ever'," country in Ettrope and ~mposition of cigarette advertising regtllations bus signaled the start of demands that the advertislng of other prildttct groups be restricWd [ w<~t~Ld sugge@~ tha~ if HR. dgg7 is enacted, it will form the ha~i~ for demands for the restriction of the advertising for many o~ber products in common usage today. As such it ~t]ikes at the heart of th~ market system ol ~he United States. ~n ....... r ....i'-rr :: - ' "
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213 To conclude, I believe that H.R. 4957 will not succeed irl its aims if passed To quote one of the most recent studies produced by a major re- search organization in Germany, "every country in the world that has tried to reduce smoking by restrictlng tobacco advertisements has been unsuccessful," The experiment has been tried, and has failed. In Italy cigarette advertising ts to b~ allowec[ adain after a 20 year b,nn, during whlch period consumption l~se by 60 pe~ent In all probability however, the bill. if enacted, would have unfortu- ~tlte ~ind /lillooked fox* corlseqtleiices t~f o. 8~l'ious ii,ttul'e I will be happy to answer any questions, but before I do I would like t~ ii~e~ti~ th~ copies of my reg~ o~ thi~ ~l~ect h~ve been foserte¢] for the record, and made avail,~ble foI' ~nembers of" ~he ~ommittee I will be happy to s~pply the committee with copies of uny other research evidence I have referre~] to Thank you for your time, [Mr. Watexson's prOpared ~atemcnt folicav~] O~ ga
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214 Tes~imon~Mich~el J~ WateTson for the and the ~viro~me~ o~ ~he Conm~ttee ~n Energy a~d Co~merco on H.R.4957~ The Compreh%nsive ~mokin~ Preve~i0~ ACt of 19BI Msrcb 5, Igs~ ] would like, firs% Of all, ZO thank the ~h~irman for gtvin~ me time ~ te~t~£y t~day on behal~ Of th~ American Associa- tion Df A~er~ising A~nci~s, ~h~ ~ic~ Adv~tis~n~ Fe6e~a stTicti~ ~i~r~tt~ advertising. As you are aw~r~, the a£vertJ~in~ ~n~ustry is h~avily J~c~ud by recommendations i~ your legislation. W~ we~com~ ~hls 0~oc- t~ty ~o ~pp~a~ b~fo~e y~u~ Committee t~ illu~trate the pr~c ~ical e~£e~t~ 0~ such action which may he c~u~er prod~tiv~ to th~ ver~ n~ure of your inte~. I ~m Research D~re~tor o~ ~he Adv~rti~i~ A~sociation~ ba~e~ in th~ United Kingdom,' I h~v~ a~ h~noTs de~le¢ i~ ~on0metric~ ~nd a m~s~rs degree in Marke&ing. The Adv~rt~si~ ASSociat~D~ h~s ~xi~ed lot note ~h~n 50 years. Its ~u~t~ is to en~ure ~ha~ tJ*e joi~t interests ~f ~a~f~c- ca
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215 ~ureT$, adv~rtis~n£ a£encies and th~ medi~ ate f~irly repTe~ ~ented ~ ~he United Kingdom and ~rope~n ~arllam~nt$. Our purpose is ~o wor~ with goYernme~ts, to ensure tha~ issues ~uch as the cn~ ~ndeT discussion here todaT ~re debated fairly, a~d i~ the ]igh~ OF 811 ~v~l~ble Tese~rch evidence. For e×~lnpl~, w~ work~ CIo~l~ ~i~h ~he British government to research exhau5%ively th~ incide~c~ af ~15~ a~d m~le~ adv~rtlsln~ ~l~ims, i~ conjunction with leadi~ consumer ~rganl- za~io~s. ~e ~ave woTk~ ¢los~Iy ~i~ the ~uropcan ~ono~i¢ Co~unity. Parliame~ and Co~li~ion, a~ wi~h leading ~rop~an Consumer grou~$ to research the questions ari~ln~ abou~ advertl$1~g ~o ~hildren. A~dweha~¢ ~or~d i~ harmony wi~h lcadi~ oT~a~iz~O~S ~ Europe Concer~ed wi~h ~lcoho~i~m. w~h th~ Council Of ~urop~, the EEC Collgaissio~ a~d the British Department of Health on the questions concerning the ~ertisin~ of alcoholic drink. I feel i~ i$ also rel~a~t for m~ ¢o point ou~ ~ha~ ~he Adver- tising Association did not u~derta~e ~he ta~k o~ defendin~ the p]ace o~ Ci~&~ette ~dverti~ing in ~ur~e without ~irst research- i~ the i~SUeS ~nv~l~ed. ~e spen~ ~wo yea~s debating the vaTi~u~ poin~ with our mem~er~ and re~earchi~ ~re~ where ~e ~e~t un CcrtRin Of our p~iti~. I~ ~l~r r~se~rch h~d ~ndica~ed ~rea~ of Concc~n. ~uch as suggesting ~he~ cigarette Bd~erti~in~ was a f~c~or i~ pTomotinE total sales Of cigarcttcs. I would ~ot be her~ to~y. ,,,I
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216 In short, the A~ver~Ising Association would not be pre~arod to circle~ in Europe~ by defending a lost or doubtful cause. I d~ ~l~e~ ~hat ~her~ are goo~ ~ro~n6$ ~o~ rejecting measures such as those proposed in H.R+4957. My reasons derive from the research evidence I h~ve ¢olle~ted in recent yeats, ~hich ~how$ ~hat restrictions o~ oigarotge a~vertising do ~ot h~ve any effect on o~eral~ cigarette cnn s~mptian. Advertising restrietion~ do however slo~ down ghe transfer of smokers ~o low tar~ low-nicotine braads. I~ my opin£on H,R,4957 may well result in a decline in Clg a:egte advertising+ denying valuable product information~ p~rticulsrly relating to new low-t#r brands, to ~onsumers. and metric stud~es~ which atzempt to i~olate th~ impact of various [~ctor~ such as income. ~rice, an~ health camoaign~ on cigarette censumprion; through ~o appraisals of consumers' .ercenti~ns of c~garet~e adver~is~ment~, anti-cigarette advertise.tents. ~nd aOver~isem~nt$ ~efen~ing cigarette ad¥ortis~ments; through to comparison ~tud~es ef the di~qeren~ European markets where many d~ff~ren~ types of att~:~pts have been made ~o cu~ smoking, I~ my opinlun a great deal of useful ~nforme~i~n can he derived from thi~ mass ~£ data. ~iace :he position varies so grea~ly from country to country Jn Europe. For example, in ~witzerland there is virtually complote freedom for the manufacturer9 ~o a~ver~ise ~here aad how they like~ follow~n~ a rece~ referee+ d~m o~ the issue. In Norway, Sweden and Fi~land ~ co~ple~e campaign k~s ao¢ompanled the cigarette advertisi~ ban. Yet pe~ c~i~a cigarette consumption has hardly v~rie~ over the t +FIT- .........
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217 ~vc yea~s before th~ b~n OT ov~r th~ 3~X yc~r~ ~nce. ~n Sweden~ no less than I0 health w~rnin~s rotate on cigarette packs, but no e£~eet can bc detect~. In Finl~nd the ~aln effect of the advertising ban has been to slow down the trans fcr of ~mokers to low tar brands. In ~iI~ UK cigarette advertising is ~ll0wed~ ~ut ~onsungti0n dropped by IS~ l~st year d~e to a v~ry l~rge pri~e increase. The research evidence augge~ts ciea~ly that of the government5 that have tried to reduce ~ekin~ 5y ~estric~in£ tobacco ~ds er by i~re~[n~ tk~ nu~er ~ health ~rniil~, ~e~a~ hee~ [he rea~o~ ~ si~le, cigarette ad~ do ~ot ~ii the ~ea of s~0ki~g. ~garet~e ads s~ll bra~s and mo~t i~iporta~ly, low-tar ~lld low ~icotine bra~ds. Ihe evidence fro~ ~roperl~ conducted econo~e~ri~ a~al}'~is hacks up thL~ co~m~n se~s~ ~iew. A iarg~ nu~Iber of s~ch s~dies hav~ now been ~on~ete~ in ~urope on ¢igarett~ a~d similar markets, No~e show ~ds exevtin~ any influence other than at £he bran~ level. This partly expl~ins why hoal~h messages on ~ack9 don't work. It is relatively easy £o ~ell a new brand, It i5 ¥i~u~lly imp6~ibl~ to ~k~ ~eo~i% 5m~ko m~r~ ¢~r~t~e~ or -~6 nor~ g~soline through advertising, Similarly ~odifying th~ be- havior 0~ smokev~ not to s~oke is ~Atrcmcly tl~likcly ~o result from health warnings on p*cks or in ads. I~ sdditios to t~is aspect, health warnings ~re shown by re search evidence to be ignored because the}- are messages smokers don't want to receive. ~ the United Kind~o~ it is almost im- ¢n ~n
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218 ~ossible to flnd ~ smoker wh~ doesn't know t~f heai~Ji h~z~rd, or who has n~ a~ some stage tried ~o giv0 up $~okin~. Yet it ±$ al~o almos~ impossibi~ to find a sm0ker who knows ~h~ wcrds The f~c~ is, that the only factor we call findas~oci~ed with f~l|ing cig~r~tt~ c0ns~p~i~, i~ the pri¢~ ~ cigarettes. ~ these r~gs~$~ it ~s ~y view that H.R.49~7 w~il no~ in any way ¢~ntribute ~o a decline In cig~ret~ consumption i~ th~ U~A. T~ it is ena~e~ into law~ ig wi21. bowevc~ to~t~bu~ directi~ to a {all i~ th~ Tare of ~nversion ~f smoker~ ~rom high t~ iow- The r~$e~rch evlde~e shows q~it~ c~early ~hat ~u~Ties such as Fi~land a~d Norway wi~h ¢Ig~rett~ ~dvertisi~ ba~s. or proportion o~ the pop~lat~on smoking i~w ~ar and low nlc~tine cigarettes. Co~nt~ies s~ch ~s the USA ~nd West ~er~any where cigarette a~vcr~isin~ is pe~itted hav~ experienced a ~uch m~re wlth the ef~ctlvcne~s Of br~ adver~isittg, suc~ a5 that prn- po~ed by ]I.~.4957, will certainly ~low dow~ t~is ~o~Yersio~ ~roce~s. F~nally, I w~d s~bmi~ that ]i.~.4957j i£ paised, I~ every cow.try i~ £urope wher~ clgar¢~t~ advertisln~ is ~e. stricted 0r h~n~ed~ th~ Impo$itie~ o£ ~eg~I~io~s h~ ~±~n~led the $%~r% o~ ~h 6em~5 %h~% ~h~ ~er~in~ ~ ~h~r ~r~I duct ~rou~5 should be re$tri~ted. ~h p[l i .... .,
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219 would suggest that if H.R.4~7 i~ successful, ~t ~i]l form ~he basis £or ~em~ncs fez the restriction and regulation of the a~werti~iag f~t ma~ ~[ ~1/~ ~ther p~dicts in ¢orar~om us~e %~,iay, as such it strikes at the heart of the market system o£ the USA. ~o conclude, I believe that b[.R 495 will not ~uaceed in its • i~S if passed, To cuote o~e of the ~ost recent studies ell the ~llbiect. pr~duer*d by ZAI~ in germany, concerning data [ro~T 14 cc~tries "ever~ country in the world th~/ ha~ ~ried to reduce ~moking by restricting ~obacce advertisements h~s been unsuc- cessful.'~ Therefore ~her~ is n~ reaso~ for the United S~at~s already been a~temn~ed in Western Europe withou~ uccess. In ~L£ probability however, tee bill, if enacted, ~ou]d have u~ £ortunate and ~nlooked fo~ consequences of a serious nature, such ~s di couraging ~ale~ o£ new products or product improvements. I'll be happy to answer ~ny questions, but before I do I ,~ould like ~a men~ieIt that copies of my rcpor~ on thi~ ~ub~ect have ~een illserted for the Record, and made a~-ail~bls ~or members copies of al!y other research evi&ence I have refer~ed to Thank you far your time. Mr ~ ~x~x~ Thank you velS" ninth, Mr. ~"a~crs~n ~Ir Rubin STATE'lENT OF EIfIC RUBIN Mr. RUmN I am counsel to the Outdoor Advertising Assoviation of America (OAAA) OAAA is the trade association of the standar~ ized outdoor advertising industry I am also a partner in an out~ door adver sag bus aess located n Lynchburg, Va, and am testl- lying before the subcommittee today fr(im ~hat dual perspective. The OAAA appreciates this opportunity to testify regarding the advertising restrictions that would be imposed on cigarette ~dvc~ ~i~ing by II.R. ~957 and ~ ~ta~e its opposition to those provisio~s. HR. 49,57 is predicated ell the sponsors conclusion that cigarette smoking is a heakh hazard and that curren~ Federal, S~ate, and private initiatives have been insull~cient m inlbrm ~he American public of ~he health consequences of smoking. In this regard, the biH largely parallels an extensive series of staff recommendations aheady under consideration by the Federal Trade Commission. [n the OAAA's view, the question of whether the warning tex~ should he revi~'d has been largely eclipsed by the public's virtually universal underst mding el the potential hazards of smoking. The FTC staff report itself ~oints out that 90 percent of the American public now understands that cigarette smoking is potentially dan- gerous m health t~ U1 -d
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220 Frolrt a practical starldpoint thole is a serious question whether the additional disclosures mandated by thi~ bill would have any percep~ibh" impact on cigarette consumptbm. This is borne ottt by" testimony presented by the first panel this morning and is dof'u- monied by the empirical data p:eseuted in Dl Waterson's testimo- rl~' today'. It is diflicu k to understand hew more specific adver ising d sales res would achm~e a level of puol c a~areness hat has not already been attained given the plethont al detailed p;odacr infor- mation generally available and alread2~ comprehended by the public The advertising regulation plovisions of II.R 4957 are trouble- some from a legal, as well aspolicy, standpoint, it is essentlal to recognize that cigarelws are a iawfal commodity and that current cigarette ~dverfisil~g incorporating the Surgeon GeneraFs warning i~ ]awtul c(Jmmerclal speech thai; is protected in the first amend- meat. As a result, despite its substantial interest in public healtb i~sues, the Congress does not have unlbttered dis¢ietion to impinge on that advertising. It i~ easy to lose sight of these principles when consideling dra- matlc issues such as smoking,, and health. Nevertheless. the sub- committee must confront the fact that IIR, 4957 imposes specific prb)r restraints on protected speech and that the courts have em- phasized that every such restraint is inherently "suspect." Tile uperative constitutional standard is that any governmental restriction of protected speech must be the "least restrictive means" a~ailahle to achieve thl! governmental cfi~jectlve Giver~ the efi;~ctiveness of the current health warning ~ystem, the imposition of a new, more burdensome diaclosure scheme as almost by definl- lion not "the least restrictive means," Finally, i~ sh~ulg al~o be n~ted Iha~ ~epara~e first amendmvn~ problems are raised by section 4(d) of this bill which would increase the penalty from $1q,0(10 t~ $1g~,0(10 I~r each violatio~ ~f the C~ga- retie Labeling Act With a proletariat penttit~ nf this magnitude ihr noncompliance, it is easy to see how these provisions could themselves become a de- terrent to otherwise lawftd speech This potential "chilling effect" on speech alone would represent all infringement on first amend- ment protections, Indeed, [f enacted into law, the constitutional fate of this bill might well be sealed if even one cigarette manui~cturer decided that it was compelled to abandon or even ~ignificantly reduce its advertising in order to diminish or avert the potential exposure to criminal penalties. Finally, the OAAA would like to address itself briefly• to that part oI the leglslation which require~ the conspicuous display of the health warning. Certainly until very recently, this was the most se- rious issue with respect to the dissemination of cigarette advertia- ing in I;he outdo(w medium. BU~ in July 1981. the F.T.C, filed five cornpalMon consent judg- ments in US Dis¢ricI Court which resolve this issue by establish- ing an entirely new and unique warning format that is to he used solely for billboards. These con~ent judgments abandon the tightly containe~l warning rectangle iormat that has been in use fro" ten -,I FI r fFF) l I [
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221 yc~ars and ~equire instead that a greatly enlarged Surgeon Gei~er- ~['~ warning be displayed within a ,¢egregated banner that extel~d ~cro~s tile entire ~en~th of each Mgn ~y lovely assistants here w~ll slmw you t,w examples¸ This is tile actua] billboard copy, was unti! last Mo~ld~y, the warning disp!ayed o~l poster size billboards which were 12 by Z4 posters. The right b~md side is the warning which now appeal~ as ol¸ Monday when the cl~lseJlt o~llet' finally came into effect~ You can see the distinction and differenc~ beiwct~n the two wI~rning~ is rely graphic¸ That is the actuM size Indeed the new warning ~rrnat already provides the tyl)e of con spicuous dlslosure on biHboards that would be required by thein- stant lcgiMation The OAAA appreciates this opportuaity to present its views. Thank you [.air¸ Rubin'~ prepa~ecl statement ~blb~ws:] 0~ .O g~ g.* tO
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222 T~STI~O~? OF O~'D~0R ADVE~TI~IN~ ~S~IATIO!I OF AMERICA R~RD~NG H.~. 4957 My n~me is ~rle Ru~in. I am a~ ~ttorney ~ private p~tice in w~hingtonj D.C. and c~unsel t~ the Outdoa~ hdverti~ing As~oclatlon of ~eri~a IOhAA)~ ~A~ is the trade ~s~ou!~tlon of the stan6ardized Dutdoor advertlsing i~austry. I ~ also p~rtn~r in ~n ou~4oor ~wrtisino b~ne~s located in L~nchb~r~, Virgini~ ~nd ~m testifying he~o~e the Subco~itt~ ~oday from ~hat ~ual 0erspeetive. The O~ a~precia£es this opport~nity to ~stify reg~q the ~d~ertis~g ~estrlction~ that ~oul~ ~e lmpose~ on ciga~tt~ ~ve~tising hy H.R. 4957. • he OhAA is compri~ of one h~n~red ~nd seventy membe~ c~mpsnies £hat ser~e 7,900 distinct local ~dvettl~lng markets through~t ~he ~nlted States. The O~'S members are principally ~1i, locally based, family-owned businesses opc~ati~ in ~ sinqle lo~litv~ or in ~veral ¢ontiguo~$ ote~ withi~ ~ por~icula~ sh~he. 0the~ OAAA members age re~tiv¢ly large companies which op~¢~t~ on a r~ionai or national bas~s. Like all other media, o~t~oor ~du~is£ng is OU~Chase~ by bo~h n~lon~l ~nd local ~dverti~r~ For the dissemination ~f ~ll types ~ ~o~e~cial~ political a~ ~ocia~ messages. ~n 1980, outdoor • d~ertisin9 represented 16~64~ ~f media e×pend~s f~r a~v~rtisin~ ~ff th~ 15 /e~lng cigarette br~nd~.~/ D~ring that same period, ~i~a~ette ad~ertis~n~ represented approximately 15% of all ~s ~issemlnated on Oatd~r ~ver~lsinq, Thcs~ comm~nic~ti~n~ are l/ L~dlnq ~tion~l ~ve~tiser~. Media Deelsions. October, 1981, P~ge 174. ~5 5~
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223 pr~nt~ in two b~sic standard-sized billbnard ~¢~ts. ~ "poster panel, is a 12 f¢ot by 24 f~t ~i~n upo. which a pr~-printed message £s poste~. A "pointed b~lletin• is a 14 foot by 48 £oot s~gn which contains a ha~d~painted message. Post~r~ a~ m~lntalned in ~ne ]ocati~ and advertising c~py is periodically pasted 0nto the surface of Lhe sign. The painted bulletin ~ign face is hand- painted at a central produc¢ion facility ~nd is then trsnspo~£ed in sectlons and affixed to a ~r~ent!y in~tall~d s~p~ort framework. A bulletin wfll remain ~n ~,e l~catlo, for ~ perio~ of ti~e. usually two months, an~ i~ %hen d~sassembled a~d replaced b~ ~nother • ~e while th~ fir~ message is relocated t~ another billboard structure. In ~his way, the ~ame h~nd-painted message ~s mo~ to series ~f ~i~ferent slte~ i~ a metrOpOlitan area ~ver a six ~nth or twelve m~nth period. I~.R. 49~7 is predicated on th~ sp0nsurs' c~nc~usion that cigarette ~moki.9 is a heal£h hazar~ ~nd tha£ ~urrent Federal, State and p~iv~te inltia~i~es hav~ b~n insufficient to inform the ~er=can p~b~ic of the hea~th con~qu~nc~ of ~m~king. Thus. the bill ~ul~ !mpos~ a $~rie~ of .~w boile=p~te health warnings ~or insertion in cigarette advertisements to ~du~ake the A~erican public. These warn~q~ w~l~ be rot~te~ between the adv~rtlsements f0~ each cigarette br~n~ ov~v a ~ year period of hi~. ~ this r~qar~, the bill largely parallels an ~x£~nsi~e ~erie~ o£ staf£ ~o~end~tions alre0dy ~nder consideratlo~ by th~ FeAeval Trade Commlss£on. At first gla~e~ the p~oposcd ]egislationwould s~m t¢ a~v~nce a ~elatively h~.i~n public public policy. ~ut in a ~erV r~al ~ens~, it se~m~ i~ngr~o~$ that the very complex ~nd ~tionall~ ~n -5
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224 q~*estion of how f~r the ?overnm~nt should go in ~ttempting to curb ~iqareLte ~moklng should b~ played OUt within the ~rrow context ~f a~v~rtl~lng regulation, I~ the O~A'~ v!e~, the qu~stlo~ o[ whether the w~rnin9 text should be revi~d h~s ~een largely eclipsed by th~ publi~'~ virt~lly u~ive~sal understandin~ o~ the potentlal h~r~s of smoking. The F,T.C, St~f£ R~p~rt itself poi~t~ OUt thBt 90% of the ~erlcan public ~w understands that =l~rett~ smoking is ~tenti~l~y d~nger~s t~ he~!th. ~eed, the re~ort re~se~ !~st w~k by ~he Surgeon ~ener~l no~es that s~=e 195~ ~he p~¢~ortion of ~vic~s who smoke h~ decreased from 42~ to ~2~. ~ut i~licit in H,R, 495? is a p~llcy wh{c~ extends b~yo~d a cognl¢i~e ~,~ie. The apparent p~licy cf th~ bi~ IS ~h~t if ~i~r~tte ~vertislng ~tBlle~ th~ po£~nti~! h~zs~d~ of s~oklng to ~e~lth then p~ople wouldn't smoke~ if ~erh~ps the ~arning lust ~ llttI~ ~ore d~stic~ ~ecple~u]~ ~e sc~red ~nd would quit. In OU~ vie~ there is fal~ ]~gic iurk!n~ in thi~ view. From a p~eti~l stBnd~oln~ ~here is a ~erious que~tio~ wheth~ the ~dd~t~on~l ~i~¢]~su~es ~andat~d by this bill ~ould hav~ any perce~tibl~ im~ ~n clg~rette consumption. Cle~ly¢ ccnsumer ~emand f~r th~ ~r~ucts i~ ~]~p~d ~V ~ ~mulex s~ri~s o~ f~ctcrs, ~ndeed, ~t b~ it is unclear w~ethe~ consumers would ever rely o~ ~dv~si~g ~or ~ore th~n t~ general type of inform~ti¢~ ~ontained in th~ cu~n~ w~rn~ng system. The bill simply presumes ~h~t new a.~ more sp~ci[~c advertising disclosures ~OUld ~hi~v~ ~ ]~vel of -J
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225 publlc ~w~rBness that has not a£t~[ned ~esp~e th~ ~lethnv~ of det~fled product ~nform~tlDn generally av$ilable ~nd ~]ready ¢0~Rre~enaed by th~ public. Perhapl ~he FTC itsel~ best ~rtl~l~ted the li~it~tia~s of wb~t can reas~n~bl~ be ~¢¢amplished through adve~ti~inq d~SClOSU~a when in fir~ ]o~k~ at the problem in 1964 at a t~me wh~ p~bli~ awareness ~ f~r le~s perva~e~ "Z, attempting ~ ~u1~11 it~ stat~tor~ ~ep~nsibilitles to p~event u~{~r or deceptive ~±qaret~ advertisin~ a~4 l~bel~ng, ~he Commis~i0n ~h~uld not ~e un~e~stoo~ as ~t~e~t~n~ ~mprehe.si~e solution t~ ~he premium. 5~h~lin~ Ind a~verti~in~ re~t~ction~ c~l~ n~t, ~n ~ny me~iez] ~nd economic Issu~ ralse~ by ~h¢ wide~prEa~ ~nc~dcnCe of ~he smoking habit...~ S~t~m~nt uf ~g La~ellng ~f clg~rettes In Relation t~ th~ ~e~ith ~azard~ of Smuk~ng 11964) at p. 7. tr0~bleso~e ~ro~ a l~g~l~ a~ well ~s policy, standpoint. It is ~h~ current ci~ar~tt~ ~d~er~nq in~rp~ratin~ th~ S~eo~ the First ~endment, A~ a result, ~es~i~e its s~hst~ti~l ~nterest in ~ublic ~eal~h issue~, th~ C~qr~s d~s ~t have unfe~%~r~ ~isctetlon ~n the ~lec~l~ ~f the measures ~ effect that p~r~o~. ~q~er~ ~he ~ea~s ~ h~s selected £mpac~ on ~r~£ecte~ s~ech, the Congres~ cle~ly ¢~nnot ~erci~e lt~ $~thorlty ind~?ende.t of F~St g~
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2~ I~ ±s ~l~y to l~e slqh~ oE ~h~ ~rJn~p~es ~hen c~sl~r~ng i, - ~r ir f~r~t ~ •.r,.. • . •
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Q~ Q~
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r
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229 ~.ou~s of Ci~¢ult cm~t ~eei~icn~ Limit~n~ Afgir~t~ve Dis~l~ure orders of the F.~.C, T~e 6upreme C~rt ~i~st ext~nd~ Fir~ A~endme~t ~rot~ctlon to =prlm~r¢i~l speech in ,~i~ ~rla St~e BOard n~ Fharn~u~ ~it~zen's Cons~er ~un¢~, 425 U,S~ 74A I19~51. In s~bse~uent d~is~ th~ Ca~rt h~s ~velop¢~ ~ cl~r CUt standard fDr reviewing q~vernm~t rest~icti~.s c~ ~dvertisln~: government re~!ation of t~uth~[ commer~i~l sp~ec~ for ~ l~wful ac~i~ity must ~irec~ly advanc~ ~ s~bsta~t~l government interest and be no mo~e extensive Publi~ Servit~ Co~misslon~ 4~7 U.S, 557, ~65 I1980), ~he incorporation of ~mmercial speech wi~hln the penumbra the Circuit Cnurt~ of th~ substantial prior ~estr~ints that ar~ inherent i~ ~I ~ff~rm~t£v~ di~c1~s~re orders. Th~ ~s~u~ was clearly drawn ~ khe ~hlr~ ~ir~ui~ in ~e~¢lal 7~r .~, ~C.~ 5~2 F,2d 611 13~ Cir, 197~}, c~rt. ~en. 430 U.5, 983 [197~) ~here~ the court h~ted th~£ ~r~in~r~ly ~t was obl~aed ~o "~efer h~oadly to t~ Commission's ~¢~ise of Informe~ ~i~etlon in ~ming re-~i~l orde~ that b~a~ so~e r~ional r~lati~nship to the r~mov~l or ~r~v~ntion of an ~stablished vioI~tion,~ I~. ~t 618. ~ever~h~less, ~ C~rt ~r~w a ~istinc~i~h with r~pect t~ e~mercial spee¢~ ~emed~es~ ~But we are d~ling in this e~e w~ fhe g~ver~ent regulation of ~ f~rm of ~peech, ~he First ~mend~nt r~qui~es, w~ he~]eve, an examination of ~h~ C~ission~ ~ti~n that is mo~e ~earchin~ than in Other c~ext~.' ~d. ~t 6!8-19~ ~5~ ~hlrd 5~
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ill I I li i-- -~ i~I - - _
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~J
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L l 23~ ~f. WAXy|AN Thank yoa. Mr. 5+qintoJ~. STATEMENT OF DAVID MINTON Mr MI~TOI~. I am I)~'id Mi~n, Was]~thgton c¢>~n~el ¢=1~ l]~e Magozine P~blishers Assocla~ioTl I think the magazine which you displayed this moraing showing the two-page ad from the 3"~bacco |nstittlte is the s~lme m;~gazine which carried ~ two-page article On the Surgeon Ge~erki's Report ~ln Cigarette Sinokil~g. staadpoinL in cigarette advertising, I belicve we bare ~'tt]i]l]ed the tnission to i~for~l the ~u~ic ~s to t~lE! iss~e~ of th~ day a~ they re]at~ to cigaret~=e s]~oking ~lld oth~er ~u~ects. | have nothln~ t~ add ~c) wh~.t h~s bven said e×~:ep~ that our con- ~r the ill you perceive is e~'ec~ivc. ~e belicve that the evidence is Fairly over~le]mi~g ~hat warnings ]~bels ~nd ad~'ert]~izlg warnings do not have the effect tho~e who desigrl them wi~h thcy would have. I did a olae-r~an ~rvey last week with a ~o]~ ¢)~ Rol~ids. I pa~=~ed the~ ~ut to my 2~ c~l~eague~ in my office. Elc~,e~ ~ ~[~em t~ok it without noticing what i~ wa~ lhey were tki~ing, other than il was ~ c~dy mi~t. T]lere is a ~ w~)rd warning l~lbc~ on ~ packable of Rolt~i~]s ~hat star q~rterba~ks dorl'~ m~n~ioll wlae~ they are ~ld ver tising thel~l If y~u are on a ~rtain kin~ of diet or taking a ccrtkin kind of dru~" yo~ sht)uidTl't ~ake R~Jlai~ I i"e~llize t~at is .a cliff'event kind of report al'ler repor~ aider ~+~=port il]u~tr~l~e, that p~oplt! dr) 1lot p~y tha~ muoh ~Ller~tio~a to warnl~g~ ~i'hev p.qy attentioll to big warn- in~, as 5,~o Uclall remarked at the timc ~f Three Mile Island If Ihey say that everybody w~thin 150 mi]e~ ~f this place ~+i]~ be ex- terminated within ~}~e next i0 day~. peop]e pay attenti(m, Btll they ItIJrl~ ~lway~ p.~y a~ten~ion to I~se:" t~rea~ adnlinistratio~. Th~ Depart~n~!nt of the T~'e;l~ury and Dep~i'tment Of ~alth a~d ~uln~n ~er~'ice~, in studying the problem of ~l]cohol i~nl, devoted a ~re~lt de~l of .al'l;ention to ~e ¢~tivezaes~ ~ warn ings, c~rette label warnings ai~d advertising warnillg~, Thl! (~rter adl~tirtl~tt~at~n ~.~td~t" ~e~r~tary C~ifa~o. =~udy car~t(~ ~:~ thc conc]~sioil that ~aere was no evidence t~l~l cigare~le labclir~g ~nd c~a~e~te advertising ha:t had a~ appreciable efl'eO. ~n the Overall decline in smoking which h~s occurled ~)ver the last 2(~ear period. So. iL is our view. as de~nders of the rlgh~= to publish pvct~y ~rluch what you wallt, ~h~.i: if there is defnon~=l'abl~ evi~erl~ lhat yoar 13~/~poski wth n~- work. the~ ~e hnpe tha~= y~u ~il]. ce~ect at length on whether ~t should be enacted ~t i~ e~ ~ en~c~ a bil~ ~nc[ ~ay, oh, wel~. 1~ the =%upreY~ C~)~lrt decide it. MaYbe this will work or maybe it w~n't, Bui as defende~ oi¸ a]| of c~ar co~stltuti(~nal rights I am sure that ~embei's Of Coil gress ar~" ¢onc~'ned about ~h~2 preceder~ti~I eit~ct of p~tssing law~ to ¢:ontrol human behavior¸ The!re is a wide variety ~f' proposa]s the many dif~rent mter~t gwups t~day, w~l~at~s re[at~r~g ~o ,J, . ,, , i •
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233 teenagers using contraceptive devices, cigarette warnings, drug warnings, and other kinds of warning The warning i~he] on a hammer was illustrated in a Department of Health and Human Services study¸ One hundred out of one hun dred people in a te~t never noticed that a hammer had a label al- though the label on the hamnler said. "Do not use this hammer" So, if there is evidence, not just lbom the Tobacco Institute, but fi'om the government itself, that labels don't work. and if there are more ef}~ctive remedies you might pursue in other areas, then ~he Supreme Court suggests that you pursue remedies in other areas and that you do not infldnge upon a constitutional right that exists under the first amendment, That is our position. [Testimony resumes on p. 247] Mr. Minton's prepared statement follows:] ¢n (2 ~q ,.j c~
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284 TEST][MO]~r OI" DAVID ~IIN'~ON, WASJ~INGTC~ COEJ~SET~, S~]BCr~T'2~E ~L~ BF~J~JTI~ AND E~I~IRO~EE~T ~JN ~.I~. 4957 MarCh 5, 1~ Ti~ MaE3azine ~Llblis~l~rs As~ci~ll~£~n is ;in o~-gaTlizat£on ~rl~ f~i~tllre *~ag~2ines, j~,l~nrla~s of ~r±~e~r~ltllId~ a~JE~ ~i~i~l±on, ~cial lnteJ'est pll~c~l~c~ns ~n .~'~tc~c~llT~, every aspen% of human beh~lvic~', ~Lr~d a ~,a~'±ety of ~he~" ~l~jects~ The A~eri~an peoE~e s*~l~c~.iJ~ ~c~ 25r~ i,ill£~n collies o£ ~ach i~s,~e o~" ~IpA Jl~g~lz~nes. AS ~n ~Jrgan~zatiorl, ~[PA ha~ tes~Lifie~l bl~fore ~.~llero~Js ~n~re~sion~L1 co~ittees ~lnd a,~inist~',~tive ~lgerLcles on ~lub- lects ~f ~e,lerai and ~pec~flc concern to the p~bli~hing in~ust~y, ~ln~ T~ hope ~la~" our cor.trih,~-i,~L to the leg±s~.ahive and ~d,~ini~tra*liv~ i~rocess h~L~ h~le~l cc~s~'L~c~ive. TO~,~ T~e ~p~r t~ ~Jl-eaerLl- o~r v±e~,~ ~r. ~he iSSUe~ in }I.1~. J~957 which1 ~'e]~te direc~l~ to the l~l~lishi~lL~ ±~l.%stry. ~LC~Ve~'~LI~II~CJ ,~ ~ncl~ude sp~iJ~c st~,~.e]aer~l~s cf health war~JirL,~ f~,t J~e~l ~- the F~I~'rL1 la~,elil~I r~qL, i~-e~1~lt f,~r c±~'et,~. I~LC]~JCS bec~mrle ef~ec~i~,~ ~l~LrL~l~y J~, I966, =Lr~,~ ~J~ ad~i~cr~ ~f th~ w~LrJ~i~g l~tbl~2 tLJ ~l~verti~irL~ began J.n 1972. Sinc~ I972, 1
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235 there h~s been ~o leg±~lative consideration of expanaing hhe requirements of the present ~ga~ine advertising label. The rotat±ng wa~nin~ p~op~se~ ~n thi~ legislation i~ a far br~a~er ~quir~ent tha~ the c~rrent stat~e.tn h~eve~, an~ comes ~ter the Supreme Court ~s more clearly construed the constituti~al li~s of ~ermiss~ble ~ov~rn~ent regul~tion o£ cc~rcial speech under the First ~n~ent. ~t also come~ after s~s~anti~l e~r~ence and research ia measuring the effectiveness ~ w~rnin9 l~bels, Including ~ho~e ~ppli~able t~ ciga~ttes~ ~his ex~rience plays a part in dete~ning wheth~ gover~nt control o~ ~erc~al ~peecn ~S const~u- ~onally permis$~l~. S~. ~n a ~c~e, th~s is ~ f~esh a~os~he~e for ~on~iderinq the ±s~e, and we hope that the s~i~ee will welgh c~reful~y the p~inclples ±nvolved in light Of these deu~lop~nts. The Ma~a~i~ ~I~he~s A~sOciat~on opposes section 4 £or two rea~on~ we think it exceeds ~h~ permissible ~imit ~f government regulation of adver~i~n~ ~s tha~ llm~t ~a~ be~n establl~hu~ by ~he ~preme Court ~f the U~ite~ states, ~n~ we ~hlnk that even if ~t were no~ ~nc~nstitution~l~ it will not achieve ~C goal ~'~u ~p~ear tu b~ pur~uinq -- persu~d~n~ people to stop ~oklng. If there is r~m to diff~z as to ~he
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V~len~Ine ~ Ch~t~ns~n, 316 U.~. 5~ I194~I . O]
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2~ Bz~ea~-c3 vs. ~ile=~Inc1r~la, i~1~,c~Ivin,~ dc~o2--to-r~ooz- sale~rl 1~ed ~1~.ing wJ.t]1ou,,~ a plez~i~c. Bill- ~ir~ce B~learcl, ~..i 1951. ,~he CoUt-£ has not denied l~rot.ec'.ion t~ cof~ez'ciat speect~ o~i theft bas~s rifle "has n~l- ~11rv~ved ~-~f~ectio~1 .2/ In 1975. the Cot~-~ r110t~ed s~*a~pZ~. ~r* ~he o[~p~s&'~e c~±rec1=ior~. I~ ~ vs, ~, a V~i~i~±~ia stat~Jte ~aki~q the new~- paper adv~rt.iseme~it E~f a~ortion j-efe~-~-al s~rvices a cr~n~ was st~lUCk down ~LS an ~,rt~r~:~tt~tion~LJ~ ~nfz-~igeT1ent .ip~rL the F~.t~st A~lerldr~en~. If there were lirl~jez~.~ig do1~bt~ as tc~ "purely" ~o~er~±,~l speec~L,$ st:at~Js tlnc]~.l~ ,Lite l~ir~t AtllenC~ent because t~Je ~ cas~ ~n~ToJive~I abr~r~£c~1 services a pt~blic ±~sue ~ranscerldi~1~j ~le~-e cot~itel-c~lal s~eec~1 -~ t]~ ¢o~irt's decision in ~a 1~ha~1~acy :.~i 1976 laid atl dcJ~bt8 to rest. J11st~ce Blac}~r~lJn, si~eal~in~ for ~i~e CuT4:rt, c~efi*L~c~ ~'he ~sue ~-o be whether ~ ~o~L~Lerclal s[~eech was ollt~ide the Iprot~ect£o~1 ~Jf the 1~irs~ Arlen~IJ~ent. "0~- a~j~%.er ,, ,]L~stlce J~lackm~rl said. ~'is t,~a~ it :[~ zlot ~h3/ ~/ ~eard vs. Alexand~a, 341 U.S, 622 (195~)~ Justice ~ouglas's ¢orlnent ~ found in Camrlaramo vs. Unite~ States, 358 U.S. 524. at 534 (~959)* 3J" ~ow w. vir~ ~21 U.S. 809 (1975) ; ~ S~ate Board ~ Pham1~a~v vs. vir int~ C~tize~ Consumer C~nc11j 425 U.S. 748, 7~2 (197~.r Subse~en~ de~uphoZd±ng th~ ~ Phaz~ac~ ~le ~nclude. among others. Bates vs. State Bar o~ Arizona. 433 ~.S. 350 (1979) and Care ~ ~vTcce~nationa~, 431 U.S. 678 (19~m O~ "4 O~
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238 The Court has nsvertheles~ recognized legitimate avenues f~r regulation o~ C~e~cial speech, just as t~ere are legitimata grounds fcr ~h~ reg~latien Of p~litical speech~ The Securitle5 and Exchang~ A~t, the 5herman Antltru~t Act, a~d a number of other law~ regul~te com~rclal s~eech, b~t the interests ~f ~o~i~ty in th~ p~s~ti~ ben~f~t~ c~ tho~ l~glsla%ive aim~ have been considering an "~ver~idin~" p~bl£~ interest, Pha~mac~ itself prescribed tha~ pur~y c~ercial sp~ec~ ~ould be regulated t~ be "c~ean" as ~ell as "~re~." A clear ex- or misleadin~ advert±~ing. In 1980, ths Supreme Cour~ ~fined in ~etail the con~t±t~- timbal protectio~ of commercial speech in Contral Hudson ~as. Th~ eaJe involved a ~ew York State rcgulat~on which ba~ed cor~erc~al ~@ver~slng by a p~lic ~tility which prompted tha p~rchase of ~atur~l gas. Justice Powell laid ou~ the r~l~ to be f~31cwed t~ te~ Co~stit~tloDall~ p~iss~bl~ requ]af~on o~ a~crti~i~. H~ said. If the co~t~u~i~ation is neither misleading me~t'~ p~wer ~s mQre c~rct~scr~. The state ~ust ~sse~t a ~bstanti~l interest t~ be ~h~ b~ restriction Dn ~rci~l speech. Moreov~r~ t~e regulatory t~ch~lque m~t be in proportion to that intexes~. The lim~ta~io~ ~n expression mu~t be ~e$ig~e~ c~refully to ~ch~Ve the stat~,'s ~oal. C~m~ pl~ance w~th this re~uire~nt may be ~a~ by two criteria. First, the ~est~icti~n m~st Ill I I
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229 directly ad~,ance the stat~ interest involved; ~'he re,~l~lation may not be ~ustain~d if it provides anly ~T1effecti~,*~ or re~te support f~r thc gover~m~entts p~rpose, second, ~.~ the ~Jove~nmental interest cC,uld be serve(1 as w~ll by a more limited r~str3cti[,n on commercial speech, the excessiv~ restriction cannot ~r rive .4/ Mr. Ch~irrlan, we believe that the r~.st~-ictiorls propE~sed in section 4 o~ }~.R. 4957 do not me~t the requirements pre scr~ed in Hudson Ga~. They do nE~t, becau~ the e~fectivcncss of advertising and label ',~arnings do rLct have a favorable impact ~/pon public behavior, most particularly whcre personal hab~.ts are invCJlvcd. Most likely~ t~e effectiveness wuulf~ be l~.~easL~rabl~. Finally, th~ ~co~l which yoi~ seek to achieve may he more effect±rely achieved by means n(~ invol%.~ng fL:rther r~strictions upon t:h~ FreedOm of ~peech~ W~ hope ~ha~. this subcor~mittee'~ commitment to tha~ liberty o1~tweighs its in%eres~ in p11rs~ing the unexplored potential of ~urther res~r~ct~on~ upon co~-cial speech. In, ~letermining whether the proposed restriction violate~ the rule so cle,lrly enttnciate~ in ~Tud~on Gas, we must first ~]e~rmine wh~er cigaret~.e advertlsin9- is free of l~islead~n~ ~cntent. TO mi~e~d, as Webster ~/~£±nes th~ word, i~ "to lead in a wron%, direction or into a mlstaken act±on; to lead a~tray* 4_/ central Hudson Gas vs. N~w York Public Service commia~ion, 100 ~.ct. 234] (198~)~ Mr. Just±c~ RehnqulS~dlssen~e~ in both this ~se an~ ~nia Pharrlac,~. ,.j
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24~ S~e decsive/' ~ceivc,"Webst~r ~aysr "is LO caus~ ~ ~liev~ t~e false. - The ~edera! Trade C~±ssion ~ta~f in i~s ~ec~nt report contended t~at cigarette ad~ertisir~q is ~ec~ptive'l because it fail~ to provide sufficiently- d~taile~ i~oz~ation as ~o ~he harmful effects 0,~ ~ok~ng. Tha~ i~ cal~d deception by ~r~si~n. ,~h~ Cotillion staf~ w~t ~o great l~n~h~ to ~tt~mpt to prove this ~eca~ ~m~ess they ~o~id pr~v~ d~c~tio~, ~he FTC cannot act ~n~er ~urzcnt law. Th~ staff's ~a~ic W~S to c~nced~ thah the public is some~e~ v~uely aware t~at smo~ of p~£b~e harm. va~o~ z~r'~ys in which people failed to ±~e~ify correctly ~atis~ical information ~b~ smoki~ alleqedly proved ~he point, so, the staff C~ncluded, ciqarette a~v~r t~ ~inq ~e~eives. ~he staff'~ ar~ent has severa~ weaknesses. ~r~ ~f all. aJi ~ t~e mos~ ze~o~s a~er~nt~ of t~e ~ta~f's cause w~ul~ concede ~ha~ t~ p~li~ £~ aware of the ~i~e~read p~ici~y abo~ t~e ~ote~tial harm wh~c~ can resu!~ from s~kln~, an~ i~ ma~e ~ore aware e~.er~ ~ay ~V ~overnmen~ re~o~, ~ews~ap~r arti~le~, ma~a~n~ ~rts ~nd by the te~evisicr~ n~ws p~rams. ~hls week's Time ~vot~s a lengthy ~rticl~ ~ L i i
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241 secorl~lly, every F.mC or jIJdiciaI case uz~d b~r the comlll~sslci- staff to ~l~pl~E~rl: its claims ~f decepti~lr/ involved ~ldver~iseme~/ts c~t ~ very c~±fJ~e~e~t ~ort, ~lll of which1 r~ac~e ~firm~Ltive c/~air-s. "Won~i Bre~ builds ~leal~.]~y L><J~lie~ 12 wr~ys.'~ ~I~l~sehol~ ~'±n~/ce ~lakes "Irl~ta;it "~E~X ~efL~r~s. ,, That is a p~sitive clai;/ o£ sor~e tl~i~J ~jc~oc~ t',~~. w~l1 ha~pel~ if yoL1 bL~y WOnder I3~ea~ or take yoL~" tax r~tl~rn to H~L~nh~]~ ~n fact, ~r wa~ not ~o~ SO J~he a~rertisem~n~s were oJ~¢lelnec~ to I~c i~t.%¢lr~L~ Ciga,~ette advertisi~q E~C~ not r/al~e ~lf~lirnl~t~ve claims in regard to the cffect el~ sf~klr/g i~p~-11 ~l~ll~h -- ~.r;~£~1 is the E~Jly re~lsoi~ ei~vl~er the I~TC o v the COngress ±z i11vc~]veL~ i;/ tl~is ~'atter. r~he ~ r~i~J~l ~J£ h~alth in any cigarette ~ldv~rti~en/~IIl~ is the declarati~ stutterer '~',~F~NG: TI~ I~ANG~O~TS TO YO[~I~ I~JTH.,, C~rett~ a~vertisi~l~ pictures %hi~l~js -- cowboys, ~Jrettv gi~rls~ and ~o O~L; b~lt thr-re is 1~o clai[~. T~Jere ~ stcli-emeJ~£s o£ perl~inen~ fact: l~±cotl.;le and ~-ar ce/~ten~, dete~'r~i~Led ,!n~le~n ~TC stan~al~Js. There are alum cl~i~ns that th~ ,~r~Ld advertised '~t~l~t~s betteln, ,, which ls E1 rna~e~, of o~irlic~n. In ]'ec~J~t ~i~n~-s, tar and n~col~ine coJ~t~*lt have beco~'ne a m~lj~Jr a~]v~rti~±ll~, featL~rc for most brands, and E~erhal~.~ L~ ~-easo~k for sl~i~Lc~lin~ bran~s. Thdt ir~ itself der~o~Lsi-rate~ pl~bllc awareness. C±~jal~e-~e ~la~l~fact~Jrers 11o ~o~lge~n advertis~ ~he c£~aretl~es w~i~h dn olde][ ge~Jcratior~
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242 or Ch~sterfi@ld~, a~hhou~h people who Drlfer th~se brands conti~ tu buy them. An adv~tisem~n~ which make~ no af£~ativ~ claim to anythlnq and which has a htalth warning ~n plain sight and plain words ~s not deceptive, and ther~fQre is witnln the bouad~ry of protection fo~ ~o~ez~ial speech ~r~cribed hy the SUpreme ~o~rt. The ~ec~nd ~ss~¢ is whether ~he remedy proposed i~ l~kely tv ~e c£fective, o~ wketh~z the r~sul~s will b~ ineffective or ~e~t~, t~ereby ~ai~ing ~he Court's ~tandar~. The FTC staff ~onclud~d that the current c~garett~ label ~s ineffective, ~pp~ren~ly because ewryhody ha~n't quit smoking. Since it ~ppears that t]~e goal is the eliminatiun o~ c~garc~te Smoking ~n th~ unite~ s~ate~, th~r~ may be many programs which woul~ fail ~o meet ~h~ staff's test. A~vertis~n~ labels may b~ one o~ them, b~t the claim that th~ ~l~c ±s not aware d~ie~ co~on ~e~e ~d the Surgeon General'~ mo~t recen~ report. The 19~2 ~port o~ th~ $~rgenn ~eneral sh~ed ~hat ~oday 5~ mill±~n people s~n~e,~out the ~e number as 2O years a~o, That i~ n ~£~nific~nt decline in the p~zcentag~ of th~ population. Thvre were abo~f 1~0 mill£o~ peoDl~ in t~e United S~at~$ in 196~* an~ there are about 230 million m
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243 today. The pevcentege cf adult s~k~rs has dropped from 42% tu 33%. Public attitudes have changed; medical advice h~s change~. Radio and televis:on advertisi~ig is no longer avail able, in testing who+her ~.R. 4957 complies with the standards ~eL Cu~ in Hudson Gas, the relevant question is whether in- ~reased restrictions will have ~ d±re~t impact upon achiev:ng =he legislativ~ goal. We believe that the correct answer :s either ~n~,, cr "nobod~ know~." In either ca~, we believe ~hat the prudent advocate o~ constitutional freedom~hould refrain from restraint upon free speech ra~r than i~:pose further c~estion~ble restrictions. ~ecent studies ot the effectiveness ~f w~rning advertise mcnts and labelin~ show ~haf the p~lic tends to ignore them. In their Nove~ber, 1980 ~eport to talc ~csident and the congress, ~he Departments cf the T~easur~ and Health a~d H~a~n Serviccs £o~d that "the public g~n~r~ly is 'over ~arned' by the Government" an~ that the effectiveness o[ warning declines as U~e de~e~ and frequency o~ warnings ~ncrease. ~ersona~ attitudes, experience, and h~bit play a highly ~ignif~c~nt role in dete~ning whether a pe~n ~ays aftenti~n to war~i~gs, regardles~ of the ~onsequences. The Report specifically ~oun~ that "fear statements, are "~eneral£y ~o~ as effective.., and may cause th~ audience to feel ovcriy threatened ~nd, ~s a -5 g~
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244 r~suIh, ~cre~n ~ut the m~ssag~."~/~h~ ,.size,, of the problem is x~la~ t~ t~e effectiveness o~ thn warning, too, ~ny p~op~e gwitched from aerosol ~p~ay ca~s to carbon dioxide spray cans when alert~d to ae~osul'$ thrcat t~ the Iev~l ~ ozon~ in ~he stratosphere. R~id~nts nedr Three ~ile Is±~nd move~ Out ql~ickly. Th~ widcsp~ea~ fear o~ stronti~ 90 in cow's ~i~k ~ a zig~i~ca~t [~cter ~ ~Lic ~u?~ort f~ ha~in5 nucIe~r tcst~ng i~ the ~%~c~ph~re. ThO~e are b£~ ~hreats ~f al~t incomprehensible pro~ortloos -- which appear to ~hrea~en li±~ on e~r~h. As ~e~resen~a~Ave U~all remarked • t t~e ti~e ~f Thr~e ~£1~ island, en~mle~ you c~n't SC~, ~eel, or h~r, arouse a ~eeper fear ~h~n oth~rs~ W~n i~ co~es d~wn to the personal level, ~hc eff~ctlve- ing aspect o~ %~e ~ic~n character ~h~t most ~op!e don't bellev~ wh~ ~b~ new~pap~rs oz the g~ernment seys. Th~ re~ula ~on o~ personal b~h~v~o~* particularly p~r~ona~ habits* is ~x~nem~ly difficult. Ma~y ~anuf~c~urer warning~ o~ instruc~lon~ ~o hoe appear to W~rk. Controlled e~per~m~n~ ill~trate t~e ~roblem. on~ expnrimen~ involved the u~e of ha~r~ -- the ~evice you drive na£is w~th ~- which had been carefull~ labelled to w~r~ of danger, or to instruct th~ u~er not to us~ the t~ol ~/ ~e~ort ~o the president and the Congress on }[ealth Hazards As~ciat~ wit~ Alcohol and M~hod~ to Info~athe General Public ~f t~es~ Hazards, U.S. Department of the ~reasury | - ||l q
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IIII II II
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247 if they opposed £t, take it to the Supr~e c~rt. They did, ~d t~ey won. It is our hops that every advocate for ~he pre- ~ervat±on ~f cher±shed although not always popula~ fxeedoms does nob have to resort to litiqation to preserve those rights. There a~ other ~rsas of concezn where legislation would prove effective. Should Co,~g~es~ requi~ the Adm£nlst~at±o~ ~ ~fo~¢~ the 55 m£1e per-hour ~pe~d l~mit? ~he~'e is ~ver- whelminq e~x~ence of th~ dire~t relationsh±p of ~pced t~ t~afflc de~ths. Fifty thousand ~e~ple died in ~reff~c accidents last ~propria~ed no funds in F¥ ig82 ~O ~nf~rce the s~atuto~ Speed limit. That ~t Z~I problem in~cl~$ no con~titutio~al question, The Supreme ~urt ~as p~escribed n~ ~le. ~u~ in the ca~ of further ~st~icti~ns upon commer~ia~ speech* th~ Court has, and in our opinion H.~. ~957 transgresses that ~ul~. We ~cpe that you will re¢onsi~r. We hope, ~ Ju~tlce Douqlas put it, t~t the adVerti$inq ~estr£ctions proposed i~ ~ect£on 4 "will not ~urv~ve ~fleeti~n.~ Mr. W~XMAN. Thaak you very much, Mr, Minton and Mr, Rubin, you are both attornpys, is that cor- rect, representing the Outdoor Advertising people and the Maga- zine Pub]ishers? Mr. Mm~ Yes, Mr. RU~IN. Yes, Mr. Wa_~tA~, Mr. Waterso~, y~u were referred to ~ Dr, Water son. Mr Wa~'~SON. I think that was a mistake Actually I am Mr. Waterson. I have two degrees but one of them is not a doctorate. Mr W~XNAN. You are research director of the Advertising Asso ciatmn, you have been invo]ved in research on advertising and its eflhct? Mr WATEP,~ON. Yes We have b~n %hrough these qaestions in Europe many, many times over the past 5 years They have been rathor more ¢urretxt in E~rope than they have here So, I have a great deal of evidence at my disposal which maybe has not been worked on in the States. Mr. W~XMAN. Mr. Minton, you referred to this Newsweek maga- ziDR Mr MINTON. Time is the magazine I was ref~raing to, but if it was Newsweek---- Mr x~]AXMAN, | ~hoIl~ht yOU r~ferred to Newsweek ,O ~o
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248 Mr. Mz~ro~. I am sorry. | d}da't see the cover cf tke~ magazlae this raorni~g but I am familiar with bath the Newsweek and Time ~rtfele~L-- Mr WAX~A~ The March 8, 19S2, i~sue of Newsweek contains a dory on the Surgeon General's recent warning abou~ the health e~ feces of smvking "The risl~ asgociated wiLh smoking, the most ira- pnrtan~ public health issue of our time~" There is a box on page 89 wkh the plcture and text of the article. In the same issue of Newswec'k I noted that 1"here are no fewer than six fu]l-pag~ color ad~ promoting various brands of cig~arettes ! would ]ike to put the ar~icfe referred m by Dr. Koo~ as ~ll a~ the ads in the recerd, W~thout objectloa tha~ will be the order¸ [The material re~erred to fellows:] ~llml F -,I
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1
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25O MEDICINE .,d
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6S057467~
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GS0574674 tr~
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1
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25,5 99% tar free. The pleasure is back. BARCLAY
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256 C II I III I
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257 .J
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258 the ~rsL tipae. But there h~5 been ~t least one case ou it every year from the S~prenle Court. Celntr~] Htidson is the most recent--- Mr. WA2(MAN. YOU haven't filed any lawsuits? You haven't cha] lenged the eonstltutional~ty of the present restrictions? Mr. Ruat~. I have no reason to. Mr. WAX~AN. But you would have reason if the rotating label system was passed or if the label were of a different size or the war*~ing a different substance? Do you think that would ~rigger %he boundaries between what is consfitutloaa] and what is not? Mr. RUSIN. AS Mr Minton says. you start from a base level of what now exists. Aild the proscription is on additional restraints in a context where they are not th~ lea~t--~hey are not the least re- strictive means. And the least r:~strictive means is the u'st The question is whether, if you are not ~oing to achieve anything more with %he new imposition on prc~cte6 speech, the question is ~hether that is valid under the first amendment Mr WAKMAN. Do you }lave arty opinion you would ol]br? Mr RUBIN. ~ lhink I testified that I think it comes within the area where the:'e is s~bstandai ~lues~ion Mr. WgtXMA~-. De, any 0fyvu have anything to offer to us by way of either your expertise Or knowledge on the aHegatious sbollt the danger~ of smoking? Is that beyond your competence? ,Mr. MrNTON, It i~n't the subje~< of my testlmony. Our objection to your bill is directly related m provisions of section 4 regardlng imposition of restrict:ons on advm¢Jsing. Mr W~,x~,~. Mr Water,on, y~u ruised ~he noti(~ that thi~ ne,s restriction will have the ~mpact of forcing cigarette marmfacturers to stop advertising Then you claimed that would be unfortunate because, sms~g other reasons, the advertising of low-tar and nico- tlne cigarettes would sot be available tt~ the pubiic Is that a correct statement? Mr. WACFmS0N. I didn't say it would force them to stop. ] merely suggested any increase in regulated activity wouId probably d~ crease the eifectlvesess of brand advertising. That is my ballet: Mr. WAXMA~;. Of brand edvertising~ Mr. "~ATEI~SO D[. ~ares. Mr. WAX~. I see. And i~ it your olpinioa that there i~ a p~blic v~ue to having brand advertising because of the low-tar and nico- 6ne content of one brand versus allother? Mr. WA~a%oN. The government~ throughout the Western world have tired to e~courage low-tar advertising. Certainly in Europe and, I believe, in this country as well, Mr ~AXMAN, We have had some testimony this morning [rsm some ernmtnent medical prof~siomals and researchers who seem t~ indicate that there may be a problem with carbm~ monoxide Carbon monoxide is nssociated wi~h heart disease, higher risks to pregnant wom~n and is present in high arng~nts in many Io~-~ar nicotine cigarettes Is that something with which you are Ihmiliar? Mr. W~TI~gsol'~, All I would say is tha'~ every go~,ernmen% to my knowledge in Western Europe, ha~ tried to enc~)urage the cl)nsurnp- lion of low tar nieo~toe cigarettes at the expense of hlgh-tar nico- tine cigarettes. gn ~2 I IIu
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259 I do not knc~w mucil about carbon monoxide levels but I do be- lieve the offJci~q] government position in Europe is that, as I stated, ]o~r-tar is bettor Mr. WAXMAN. So, you~" argument is that because other govern ments try to enc~ur~go this. that we should take that into consider- , ation and weigh it ag~linst what scientists are now telling us? Mr. WATERS0N No, that is simply the limit of my knowisdgo Mr. WAXMAX. Simply the ~imit of your knowledge¸ Now, I 'van~ ~o show you an ad from the New York Times m~lgazine. I can show it ~orn here¸ If you want a closer look, we will be Rlad ~o }~r[ng iL to you. It is an ~dvec~isement, a copy of which we will make avai]abi~ for l.he record. It is a picEure of ice cream and i4.ent cigarette~ IThe advert iselnent referred ~o follows:l
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6S0574GS1 i
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.~Ir. WAXM.~N I assume wm ale hm/iliar with the kinds (/i themes aclVel'ti~Jng people l~nk alJout tu encourage the i)ub[ic to buy their prodact What maio~ themus do you think are present in thi~ ,~d and w~qat ml~rrnltTil)n I)f v~lhI~ doe5 the m~llufocttlrer or ad agency tend to convey to the public. Do you think they are saying smoking is a~ wholesorae as e~ing ice cream? Are they trying to say tu p~ut~l~ the'- it¸ they ~to~ smoking they will get fat? Mr Warm,soN My expertise is limited to highly detailed knowl edge of the effect ol¸ .~dwrti~ing on consVtmlation levels Ihroughout many product areas. [ have no idea what went Ihrough the mind ~f Lhe advertiser when he made up the advertisement¸ Mr. WAXMAN, Do you think advertising [llay~ a role in increased smoking by young people? Mr. WATt.SON Every shrucl of evidence we have. and you have copy of m¥ munograph on tho su~eet in your record, suggests that Lhi~ is not ~o. l'here is no evidence at all ~o my i~n(~]ed~e through ~m~ ~uro~e or indeed in the Sta~s to s~*gg~st that advertising en eotlrages young people to smoke¸ Mr WAXMAX, DO you think advmtising ~l t~rod/lct m~kes it more like]y that people who are the target nf the advertising are more likeiy to buy a product? Mr WAT~RSON. 1 ~imply tt~ink it is impossible ~r advertising to stimulate t~e consumption 0[¸ ~1 ~rudu~s s~muItaneouskv Youag p~ot~le are sold drink~ and 1 million ~ther product~ | think it is slightiy naive to think they can be sold all tile~e things simulta- neously £111d ~or~sume ~i[ of ~honl more a~ a rt~su[t o[" udverLis[llg¸ Mr WAXMAN In ~ hearin~ of our owrl Sub(:onlmitt~e,e on Over sight and !nve~tiga~ion~ there was a quote lhom a r~!oo~t by th~ Ted Bates Adw!rtisin~ Agettcy obtained by the Feder~ Trade Corn ~r th~ voun.~ smllk~r the cigarette is nol vet all lilt egE~[ I~UCt ~f ]i~e Of d~y tO da~ lile, in s~ite [~ th~ l~er ~hat they try to project the JrIl~ ~f !/ r~l~l¸, run of'the mill smoker F~r ~h~m, a cigarette gtnd the wl~le ~rnoking io/oee.-.~ ~ ~ part of Eh~ illicit /ale~stlre c~lteg~ry In the v~ung ~moke~'s mind ~ cigaretl~ fali~ i~to ~h~ ~o cuteg~ry with wine, beer, sha~ing, weaf]n~ a br~, or Cpurpos~]y not wearing er, ~ cigarette i! a~eial ed with int r<)duction to ~ex ][l~, with tour t~hip, with sr~nk in~ [Joi" and ke~plng late studying hours Wouldn't one tend to think ~hat this proposed advertising cam- paign was ~arg~tect to ~ particular group, particularly teenage girls, who appear to be taking up smoking at a faster rate) lit effect ~hey a~e proposing tt~ targt'L no~ ~1~ t~ a ~ran~l, a~ yo~ said in y~ te~ timony, hut to t~iking up a n~w habit? Mr. WAT~SO~ I have been ~onnec~ed with advertising for 15 ye~trs, products like drink, particularly, in your ~ugge~tion, target ed to yoking people | have never once see~ any campaign include a statement to the effoct that Lhere was a desire or hope of increas ~n tl~e tota~ m~rket for ~hat I~r~du~t b~ brand ad,-¢~rtising. ~f s~irn kings ~ell mor~. somebody else s~lls le~s It is as simple as that in my beliet~ Mr. WAXMA~V. YOU indicated Swe~hm has had a number of label changes but ha~ had no decrease irl smoking ti~arette~ Would y~u furnish for us for the record your data?
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i L 262 Mr WATERSON I can give you Ihe to'~d consumption levels in Swede~ which show no drop aftei¸ imposition of ]6 health w~rn ings ] can ~Jvc it ba~k ~ far ~s you like. I don't have i~ wil]n hie bu~ I can furnish it Mr WAXMAN. HOw long h~ls Sweden h~d that w~rnlng ]abeI rt~ t]~iremen~ Mr WATE~:SON~ ~ am I~OL l!]¢'~r Of precisely h~w long Mr WAXMAN. If it ~'ele ~/n/y a ~w y~ars would you think per haps it is too early to moke ~ conclusion? Mr WATERSON ] can ~ubmlt [ have under nly~ ill my files da'~a ~ hterc~y maybe 5(~ d~t~r~t ~u~ries I ca~ ~ubmi~ i~ ~i~b, ~he clare. [ c~ft remember pricisely what it ~hows | do krlc~w in a]] ot¸ Scandinavia ~here is n~ evideilce Io ~ugg~:st tha~ either the imposi- tion of ]~ealth warnings or indeed inassive sta~e canlp~iigns against smoking, as in Norway, has had any impact on t~al levels of con- sumpt[on. In Norway the ~ituat~on ha~ most cle~rIy shown where they have spent in United ~ingc]om ter'm~, 2I~ million p otJ~lds, ~10 million, you multiply ~ha~ by 5 in US. ~erms, over ~ID0 million over a period of¸ 5 years~ This has not had the impact or decreasing con- ~umt~t~on Mr Wa.XM~N. ~low do you explai~ the decre~i~' in ~igarette coo somption in this countr:~ ~vcryone ~eems to acknowledge il" it ~S not cl~e ~o greater awareness of ~e d~ngers of cig~lr~t~e smocking due to a~tici~arette ¢~.rnp~igns, ~v~rning labels, aIld mor~ press iI~t~r- rnation? Mr. W~TE~SON. I am not s~ying that [~n~t the rea~un for it. ][ am simp]y sayin~ ~pecit~cally in~l-l~la~ion on labels ~nd ~pecificaliy the N~r~l~au campion b.ad n~ i~p~t ~. d~ believe i~ the Uv,~e~ I~ingdon] tbr ex~lrnple, the theme oJ¸ newspapers, bomb~ld~neut of¸ health campaigns ~nd ~o on, has had an e~I~t ~ don'~ believe the w~rnings sp¢cihca/]y have been sho~n to h~ve any ei~c~ aL oil They are ignored because ~he smoker chooses t~ iguore them ~ud [~rge. No matter how m~r~y yo~ have. Mr WAXMA~. But yOU do acknowledge the fact that there has been a decrease i~ cigarette ~moking in the l~ni~ed Kingdom, and a~so here. How do you e~p~ ~in it~ Mr. WATEI~ON Because o~ tile bombardment of I~eal~h informa- tion over the p~lst 10 or 15 years I presume¸ Mr. WAXMAN. DO you think people~' knowledge comes only from one specific ~ource ~lr~([ that there is i~ot ~1 growing aw~rene~ ~s differellt sources? Mr. WATE~CSON. Research cvidenc~ su~e~s to me people ~on'~ read the packs¸ That i~ all. ~ do believe that ~ey take in over a period of¸ y~rs ~he health campaigns that have been launched at them in this country and in the United Kingdom. They apparently have not at ~111 in Norway. Mr WAXMAN Do yclu think we would be more effective if we n',a~d~e~l ~ou~er-a~r ti~n~ ~f cigarette s~okiu~'! Mr. WATERSON. I do not know becau~ ~ h~tve no data based Oil counter advertising campaign~ except in Norway¸ [ ~m clear The ~ituati~n here i~ very dlfferent from -Xorwa~ In N~rw~ly the spe¢i~ I III
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ic campaign does not appc'a[ to have had any impact at all as op- posed to t]]e sorts of artic]t!~ my col/c!aglm 1 ~1 red to Mr WAXMAN. If you can se]l a product by advertising, why can't you reach people with information about the dangers of that prad- uc~ ~ advertising? Mr WArI'J~ElSON As I explaincd in my testimony it is wry much ~asier hi sell a sin~]~ brand, to get a brand trial is a wry much silnp[er thing than to ~itlempt to modi~ human behavior which is a~ enormously c~rnp]ieated subjcc~ li is very difficult to do as in drink moderation camp~igns, ~r e×ample II is very difficult to get acro~s concepts oF that so~t. At lea~t it is much more difficult Mr. WAXMAN If there is a difficulty in getting across a n~essage, is the best way to approach that problem by abandoning any ef]brt? Or. to try to be as effective as you can, to reach as many people as you can? Mr WA~'~I~SON | Lhink you have ~o depend on "~he research evi dance and I think that r(.s(~lr(:h ~videnc~ s}~ows that ~he bill a~ composed is extreme]y likely ~o be inef~ec[ive. Mr. W~X~AN. Wha~ would be effective? Mr. WATERSC/N. 1 have no idea, in this country¸ I thi~k in the UniL~.d Kingdom the continuation of the present situation as it is is provin~ effective Ii~ this country -- Mr. WAXMAX. IS that based on the high price of cigarettes? Am I correct in assuming ~om wha~ you have said earlier that the effec- tiveness of discouraging smoking in ~he United Kingdom is based to a g~eat d~ee oil the high price ~ff eit4ar~tt~!s~ Mr. WATERSON. That is difficult to say In the shor~ term. car tainly it" you i~¢rease the price you will decrease ¢¢~nsumption, In th~ lon~rm we don't haw enough evidence to su~'gest that ~hat consumlJti~n decline won't go back new ye~r. There is also the pl'O]~leltl Olle can see t~.ofll Norway, wht!ro yell al~ompt to con[re[ ~he product by that, jacking up the price 10 to a(} percent, you en- courage people to import i]legallv. In Norway, 30 perce]lt of spirits consumption is illegally distilled which is in kself a considerable health haz~ird Thirty percent oi¸ the spirit~ consumed in Norway, ~his is a Government esL[maLe, not mine, again [ can lhrnish de ~ails. Mr, WAXMAX. I mi~ed ~he point ~f that. Mr. WATERSON, Attempts to control oon~urnption levels by mas- siv~ price increases ~r advertising bans and so on Mr. WAXM~N I see C~rtainly the free market system indicates if you want a product and have to pay a high price in one place you w~]l go to a place where you can pay a lower price. Mr WATERSON. Exactly, that is my point. Mr. WAXMAN Tha~ is reasonable to expect. I go to y~u as an e×pert in advertising and say we have a big public health problem in this country. People are dying (~f cancer and lung disease and heart disease. I~ appear~ to be that cigarettes are a leading cause¸ What would you recommend to me as an advertising expert know- ing how to ~ell things ~ people? Your answer would b~ Mr. WATERSON. This really i~n't my field at all but l would su~ gest that as a purely personal impression, I think Captain Kanga r~(~ is righ~ That you ~eed more education Mr. WAXMA~. Mr. Bliley.
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264 Mr, BLmI~Y. Thank you, Mr. Ch~frman Thank you very much, gentlemen. Since we g,~ve Newsweek an opportunity Mr~ Ch~lirman, I ask unanimous consent we incIude in the r~cord a rei~orI from the Sul~ Ke~ Get, evil that was ~ Time ~n ~'~]ar~h ,S. I~ t~nd~ t.~ c~n~rm a lot of what you have said, Mr. Waterson And I will quote one pas sage from itr "Surprisingly, 95 percent of the penp]e who broke the smoking haSi~ ~hd so xvithout the hell) of organized programs." Mr. WAX~AN Without objection we would like to make ~he alti cle ~om the Marc]~ 8, 1982 i~soc of Time Magazine on the Surgeon General's repcrt, as wei] as, ] a~]] sure the genL]cman Wou]dn'~ dis- agree, ~is we]] as Stll cigareL~e advertisemelxt~ in that [~sue., ~ par~ of the rc~ord Mr BLIL~y. Certainly. [The article and advertisements referred t~o ~bllOw:! ~A
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~'Tt Mr. BLrLEy Mr W~tterson, have you conducted ally research studies supporting the notmn that rotating warning labels reduces cigar ~*t te smoking? Mr. WATeRSON We have looked at the UK situation where the number of warnings increased. We found no evidence at all Mr. 1]LILEY. HQW many? Mr. ~VATERSOI~'. One tel three There has been no evidence at a]] this has had any impact. We have trl~d to research it econvmetn call:,' and second, using surveys of peoples' knowledge and impres- sions of the health warning. Mr. BLILF~V DO you know of any studies by anyone el~e, that have been conducted that would support this? Mr. WATERSON. ] dOrl't believe there is any evidence at all to slip port the notion health warnings have any eflbct at all on packs .f cigarettes Or advertisements. Mr BLILEY ~ see. Do you think that ooe of the reasons for the decrease, in eigare*~.e smoking in the United .c,~.al~" might be due t~ the fact ~bat the US population is becomhig more educated and, hence, perhaps more rational? Mr WATERSO~" It could well be. I don't have special knowledge required t~ comment but I am ~ure that is part of the res~clv.. Mr. BLIIEy. *I'OU mentioned Norway Do they allow cigarette ad vertislng in Norway? :~Ir WAn~:~ox. No, it is banned Drink edvercising too is balmed. Mr ~LILEY. It has cut consumption in n~itber instance? Mr. WAT~r~qOr~ Zero Nothing at all. The only effect of both bans we can see is a big incz ease in illegal distillation of spirits ~r. BLILEY I see. Mr WATERSON Ther~ has also been an increase in smoking tc~ bacco. Mr. BLILEY You also mentioned Italy How long has Italy banned adver tlsingo Mr WATERSON. Twenty years Mr. }~I~I v.~ You ~y ~on~mpticn ha~ r~c3en hy 6{1 percent Mr, WATERSOI~'. The specific Governmel*t data is in the back of my submission to you Mr BLILEY ~O now they are thinking of-- Mr WATERSON. [continuing] Reinstuting advertising. Mr. BI ri.~y. Are theyp~ lanning to have required labels? Mr, WATERSON. The &bates are still going cm I think they will carry health warnhigs. Mr BLILEy. ~ see. Mr WATERSON. The situation [s parallel to a number of o~her countries, especially Poland, wi~re a ban has been in existence since 1972, and again consumption has risen ~,ver that period from approximately 70 million cigarettes to 90 ngl]gm cigarettes over tha~ period. Mr. BL~LEY. It iS your opinion, backed by your research, that ad ditional warning labels would have absolutely no effect on con sumption? Mr. W~TV.~SO~ Tha~ i~ my c~n~idered ~pi~fi~, ye~, zero Mr. BLIL~. | see. Mr. Chairman, I want ~o thank the witnesses again, and l have no turther questions. -J
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272 Mr. WaX~aN You all believe one effect vf this legislation wiJl be t~ adversely a~fec~ the economic interests o[ ~bc advert~slng agem ci~ and Lhe advertising industry? Mr. R~RE:¢. ][ don't even know how to answer that question, hon es~]y l have no knowledge or that. M~ WAXMAN. DO yeu feel that there would be harm to some extent b~cause of the concern about liability? Mr. Rus~x. Cigarettes are advcitised on bilIbeards, ju~l ]ike atlLomobiles and iocal hardw~le stores, but ~ have ne knowledge aL all or no expertise at all oil what the e[~'ects of this wou|d be in terms of their desire to continue adver~islng one way or atmthcr. Mr. BLILEY Would the chairman yield on that poin~ Mr _Ruben, ~ou in your testimony brought up pena}ties. ~ro~, as an outdoor ad'¢er~iser--] ul~de~t&nd you ha~:e a firth. As you un- derstand the legislati~ln witl~ regard to the penalties, would your firm, sa)', if yo~ I~rg~t to cha~ge ~,~e ~abeling duri~ ~e of the time periods, could yo'~ possibly be held liable? Mr, l~J~ There are all sorts of ~iabi[ities I arn s~re the adver tlser ~ld h~ ~s Itab~ Iava n~t ~u~c w~e~er ~e ~ld be ~e~d liable o~' not I don't k~ow. Mr BT~JL~Y. Thank you, Mr. Cbeizman ~Mv ~X~A~. Did e~ther of t~xe ~ther t~o have ~" c~n~l~entu to make about my question? Do you ~el that the advertising business '.~ould suffer economically if¸ this legislation is adopted? Mr. WAT~aSON. I believe the most serious a~pec~ o[ the! [eg~la- tion is no/ the immediate ~donomic impa0t, but the mc~ that ~t is /ikeJy to ~/e used as ~i s~c~ping stolle ~y many o~er pressure groups t~ impose health warnings, advertising !estril:tio~s in other areas. This is precise]y wha~ happened in Europe¸ Mr. rVl!NTO~ I have no e~pcrtise in that field, Mr Chaillr~an. Our interest is in ~ny lmp0si~ion of any goverilmen~ regulation upon advertising; th,~t is, at least where it trar~s/:l~nds what appear to be the bo~ndari~s ol" lawfu~ regulation Mr WAXMAN. YOU are af,~aid oi¸ other pressure grot~ps W]~ere ha~ it led in Europe? Mr WATERSON The ~]uropean Parlian~l!n~ next week ~s to debate ft~rther restrictions on drink adver~Jsh~g, ~r example. The Council o~ Europe is a|.~o debating restrictions on drinking adverl~sing, Mr WAX~AN Whal; respor~sibilities do ~dvertising agencies have in promoting th~ const~mption of pro)ducts which are un~a~? I~ir. W~s~ I feel many p~odu~ts in this co~tvy ~d Europe .~.ir. WAX~A~. DO you feel that advertlsillg ~gc~eies h~ve any re sp~ns~bility m thi~ record~ Mr. WaTE~SO~. I think i~ is a Government resDonsibil[ty as to what should be ~eely sold alld what ~s not. Mr. WAXMAN. Freely sold? If it is and there J~ Tlo prohibition, you l~el it should be fully adw~rtised? Mr WATERSON. [ think th~ gllver~rnent should decide theze mat ters in each ]ndlvidua[ coul/l;Iy. I dou't thillk it is the respo~lsibility of the advertising agency to suggest that restricllons should bs ap- plied.
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273 If the Government feels that a restriction should be applied, then that is the way it is. /3ut it is their responsibility, not the adder~is- ing industry's Mr. WAX~IAN Are you a citizen of the United States? Mr. WATE~SO~ No, United Kingdom. Mr. WAXMA~ Are you a taxpayer here? Mr. WATE~SON Yes, indeed. Mr. WAXMAN We have a lot of people who are getting very sick, many dthem are dying due to cigarettes~ It is costing the taxpay eJ~ of this countr~ millions of dollars to treat their illnesses. We have a budget dcflck We don't want to spend so much of your money in ta×cs I assume we are taking more than you like in [axes. We arc all concerned about people's health. It ~s a moral concern that everyone should have¸ We want to discourage people ~'om smoking¸ It is a [act ~igarettes are legal and there is no prohlbitfon. No rational person could have the idea thai. we should sa~ an indi- vidual shouldn'L be allowed to smoke if they wish. It is legal tc~ smc~ke, it is l~gal to sell cigarettes, it is legal to ac]- vertise cigareLr.es. How ~hould we, it¸ you were in the position of ad- vising us, try to lessen the consumption ~f clgar~tte~? How would you advise us to do it? Mr. WAVI~RSON. 1 think y~u have a reLll l~rohlem [ think if you add up the cost of all of the products advertised in this country, if you add up the cost--- Mr WAXMAN YOU can't equate that, A car is nut a patently dan gerous thing used ~r only one purpose. A car is used in a ve~ beneficial way S~)me people can argue that cigarettes relax them, but l don't think there is any medical expert that could say there is a Value tO smokil~ a eigal'e~te, even if som{2one receives some psychological behest We are selling people the idea of smoking, and the only ~hing that can come ~om smoking is bad health. Mr WATE~ON [continuing]. The whole point of my testimlmy is that we don't know about selling smoking. Mr WAX~AN How do you account for the increase in smoking when advertising is so widespread? Mr~ WATE~SON. HOw do you account for the fact that smoking in Eastern European c~mnlrfos has paralleled that, with no advertis ing? Drinking has done [h~ ~ame thing¸ Mr WAXMAX. HOW do you account lbr it? Mr WATEXSON Because advertising has no impact on total con- ~umption We have shown it over and over again There are a number of factors which go into increased consumption of any one individual product It may he a whole strfng of things¸ It may be television, pictures, I don't know. We are cfoar of¸ that¸ Every shred of evidence through~ut the world suggests it is not advert~ing that is a basic mo~.ivator of that type of factor. If it was true, we w~uld buy cosmetics and every- thing else in the United States because they are advertised ten tin]e5 Yl~oFe. Mr. WAX~I*N I am not an expert in advertising. We are politi cians. We toni lbr o~e and try to sell ourselves to ~he puhllc. -3
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274 Every time we have ever seen a campaign or election, ~bcre there has been no campaign, and he nly thing on the ballots would be a race for Congress, the vo~er turnout is low When there is a cempetition to try to ~el] one candidate versus another, the total v~Oer turnout increases, Why couldn't 1 assume from that tirol it" there is a campaign lo sell ~ lot 0~ dlflbrenr brands, making smoking a bland of cigarettes more attractive, and each brand competLag with ~ht" other to make it appear more attractive, that that will increase the total con ~o.mptgm of th$t particular product? Why shc~Md I not make that assulnption"~ Mr. WATERSON There are two points there. I can only g(~ on the research I have uetn personally'. I have never seen research on an American pc tical campaign. Ex'eI3' evidence I have which covers the tobacco markets of Europe shows that thcxst fbrms of advertis big do not increase the c~nsumptLan of cigarettes In Europe at least the pebtical advertising is outside of the con trol system so you can lu~ke claims that you l!~tn't make in brand advertising You can make chdms that are wild and unrealistic, which you can't there. Mr. WAXMAN. I have never told anybody that voting for me will make them sexy, healthier and more active I claim v will he happlier. I ~ave nothing further. Mr. Bliley, do you have anyfhiag fur ther? Mr BLILEy. I just wanted to say I thought we were discussing whether or not we should increase the warning lagels on there, I think the testimony from these gentlemen, partisularly from Mr. Waterson~ was that it does not have the effect of reducing con- sumption, artd for that I am ~,mw glatefl~L I look fhrward to read ing the additional t vidence you intend to smld us Thank you, Mr. WAXMAN. I am certainly interested in reading the ~dditional information and evidence yell send us. i mus~ admit it defies my knowledge of what I expect human behavior to be. I am not saying it is the only reason why people smoke but it is certainly one I want for the record to read the whole paragraph from the Time Magazine article to which Mr. Bliley referred The paragrap}~ sharks, "Since the 19fi4 report, almost ~0 million people have man- aged t~ give up smoking. 'Quitting cold turkey appears to be a more effective strategy than cuttinh down without trying to stop emire]v Surprisingly, 95 percent of the people who broke the smoking habit did so without the help of organized programs.' I think that would ret'er *~o ~rga~ized ]pro~rums to he~p people stop smoking People ~ho- want to quit, quit ihat is the ~ay I did it and the way most other people do as well Again, let me thank you gentlemen for your t~stimony today. We look forward to receiving additional information Mr. BL~LEY. P~etbre we adjourns, might I h~ve an indication what ~he schedule will be fbr this subcommittee? Mr- WAXMA.nl We tire expecting to try to work out the fulLawing schedule: To hear irom the administration next T]mrsday morning and then to h~ve Frfday's hearings devoted tv the testimony that ~e will ~ork out with the Tobacco institute in order to hear a number of witnesses.that day relative to this legislation. 5~ -d
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COMPREt[ENSIVE SMOKING PREVENTION EDUCATION ACT TIIURSDAY, MARCll 1L 1982 HOUSE OF REPRESENTATIVES~ SUBCOMMITTEE ON P[EALTH AND TIlE ENVlRONMENT~ COMMITTEE ON ENERGY AND COt~II~IERCE~ Washington, D.C. The subcommittee met, Imrsuant m notice, aL 9 am. in room B ~18, Raybmn House Office Buihting, Hon Henry A. Waxman (chairman) presiding. Mr. WAX)aaN. The meeting of the subcommittee will please come to order. This morning, the subconmlittee crmtinues hearings on the Corn prehensive Smoking Prevention Education Act. Last Friday, we heard testimony fbm~ a pane] of distinguished physician research ers who presented evidence that smoking is the No. i health risk factor lhr Americans. We also heard from a panel of prominent eitiz~ens who expressed their personal concern over the hpalth el forts of smokin~ as it touched their lives and those of their fami- lies [ regret chat nlore members could not have heard theil presen- tation. It ~as truly moving, mtd I think clearly sets thrth the reason why this legislation is so necessary Today, we will hear from the administratton. Recently, lhe l)e partment ol ltealth and Hmnan Services released an exeel/eni repot~ oil ~he health consequences of smoking as it rCated to cancer In releasing the Iepor~, the Surgeon General characterized smoking as the ('hicf cause of preventable disease and illness in this country. This alone shmdd make passage of Che Comprehen- sive Smoking Prevention Educati(m Act a toll pliority The pending legislation is designed lo make Americans more aware of the serious risks smoking poses to their h( alth, and in the case of pregnant women, to the health of the unborn child Smok mg is a sell:destructive habi¢. It is des*.ructive of human lile and is resp~msible fl~r an almost unimaghmble to]] in terms oi lost produc ~ivity to the ecorlolny and excess medical costs Prevention of smok- itlg through every nleans at our disposal is in ~mr personal and na- tional best interest, I want to make it dear that changes in the current warning labei ale not the only st{ Ils necessary to make a major diffhronce in the smoking behavior of Americans. It is also) importan~ that the Federal Government, through the Office of Smoking and Hcallh, maintain a prominen~ role in developb]g new educational mateli als, wink closely with the voluntary health sector and maintain a vig~)lol/s research presence I believe the combined hnpact of these strategies call }lave a powerful effect in ellcOUrliging curretlt srrlok- d27~b
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278 ers to Tai~ and dlsco~ragh~g ~tential smokers h-~m su'~kh.g ~Lat firs~ match. Our first witnesses this molnhlg are a distinguished panel of physicians: Edward N Brandt is AssisUmt &.cretary for Health of the Department of Health and Huma. Services. Accompanying Dr. Brand~ are Dr. C. Hvere~t Keep. U.8 ~urgeon General; Dr. Vincent T. DeVita, Director of the Natkma/ Cancer Institute; Peter L. Fromer, Acting Director of the National Heart. Lung, and Blood institute; and William Pdiin, Director of the National Institute on Drug Abuse. I would like to welcome each o[ you to our hearing today and I will ask my colleague. M'I Biiley, is there any comment you would like to makp? Mr. BLnEy. NO statement Thank you ver~ much. Mr. WAXMAN, ~h" Brandt, we are pleased ~o have you with us 1 would ]ike t~) call on you at this time to make ~our prcscntaLion to the committee ST.'xT~ENT~ OF EDV,'ARI) N, BRANITI', JR., M~. %S~,IETANT SF~C RETARY OF HEALTH. AND DR. (, EVERETT KOOP. SURGEON GENERAL. P[BLIC fiEALTH SERVICE, DEPARI'MENT OF ItEALT]I AND mISIAN SERVICES. A(COMPANIED BY DR VIN- CENT T. DeVITA. |)IRE(TOR. NATI/INAL CANCER INSTITUTE. AND DR. WILLIAM UOLLIN, DIRECTOR, NATIONAh INSTYI'UI'E ON I)RUG AIII3SE Dr BRANDT. Thank you very much, Mr. Chairman. I am pleased to present to you the statement of the Department of Health and Human Services on the heahh eil'pctu of l:igarette smoking. These heahh effects and tileir signiilcanoe to the American people must necessm-i]y provide the rationale and justi/icatkm fgr whatever action your committee m~y take in regard to the hill befbre you AS you mentioned I am accompanled t,3 DT Hoop, Surgeon G~n- erah Dr. Vincent DeVi~a, National Cancer Institute; and Dr Peter Frommer of the Natimml Heart Lung, and Blood Institute. Let me begin by prese~ting a capsule description of the health effects of cigarette smoking Then we will give you a more detailed description of smoking and can(or ~nd in regard to pulmonary dis- ease. I will also address research e~fbrts by the Natiorlal Institute on Drug Abuse, on the addictive characteristics of cigarette smok- ing In summary, clgare~te smokir, g is ¢learb; ~he single most impor- tant preventable cause of premature illness and death in the United States Estimates of the number of deaths related to smok- ing exceed 300,000 annually. One may compare this figure with the 105,000 deaths that occur each year ms a result of all injuries, the 2O,00O deaths from homicides, or the dO,0{10 infant deaths. Ciga~ct~e smoking is one of the three major independent risk fac tots m coronary heart disease; a m~or cause of cancer of the lung, cancer of the larynx, oral cavity ~nd esophagus, and a major cause of chronic bronchitis and emphyser~a. Maternal cigarettes smoking is associated with regard~ fbta] growth and increased risk /or spontaneous abortion and premllal 0~
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279 death, and slight impairmeds of growth and development during early childhood, Cigarette smoking acts synergistically with oral contraceptives to enhance the probability of coronary and some cerebrovascular dis ease. It acts also with alcohol to increase the risk of cancer of the laryrtx, oral cavity, and esophagus; with asbestos and some otber occupationally encountered substances to im'rcase ~he likelihood of cancer of the lung; and with other risk factors to enhance cardio- vascular ri~k. Mr. Chairman, cancer wa~ the first disease to be associated with cigarettes As Dr. Keep pointed out in introducing our 1982 Report on Smoking and Health a i~w weeks ago, reports linking smoking and lung cancer began appearing in scientific literatule ms long as 50 years ago. The evidence which links cigarette smoking with ]un~ and other cancels was reviewed in most careful detail in the i9S2 report just issued, which will be summarized by Dr, Keep in a few moments. A subject which was hardly touched upon in tho 1964 report is the effect of smoking on women, and in the case of maternal smok ing ~ts effect on the f~tus and in~an~, In 19~0 this was the topic of the Department's report to Congress. Its conclusions were that women are not immune to the d;tmtlging effects of smoking, and that the lesser occurrence of smoking related diseases among women smokers is a result of their having lagged about a quarter cemetery behind ff~e~ in tbeis widespread ue~ ~ eigar~ttes. The 198(~ report established that cigarette smoking is a major threat to tbe outcome cf pregnancy and the well being of the baby Another public health question, now enormously important, re- lates to the use of the new low-yield cigarettes. This was the sub ject of the Department's 19~1 report. Tbe report's conclusions were that although there is no safe cigaratte, smoking cigarettes with lower yields of tar and nicotine poses a lower risk of lung canceT than smoking other cigarettes, provided there is no compensa~ry change in smoking pattern. As you pointed out. Mr. Cbairm;m, the 1982 Report of the Sur- geon General lbcu~ed upon cancer The *(,port noted that more than 10tl diseases that we call cancer have come ~o be the second leading cause of death in the United States. Tbe report also made a number of other important points, which again will be summarized by Dr. Keep in a few nmments. The National Cancer Institute's ei]brt in smoking research has ~cown from a $1 million program m 196~ to one costing about S10 million in 1962. Our program now focuses on preventing smoking and involves, first, behavioral studies to e×amine why people smoke; second, epidemiological studies of populations with high rates of king and otber smoking related cancers to identify cofbc tor~ ~uch as ~c~pation and alc~ho~ ~sumptiou: toxi~ol~J studi~s to examine the content of substances is toda~"s low tar and nice- sine cigarettes that initiate and pronlote cancer; pharmacologic studies to determine which looters in tobacco might be addictive; and tinnily, a program to help smokers quit by encouraging pbysi clans, dentists, and other healtb professionals to distribute infor- mation on smoking cessation to tbeir pa[ients .,) g~ .j
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280 This past year, NCI-supported investigators identified how Lhe body handles two eareinogeus found in tobacco ~moke. They are now de[~rmlnLng whether these ~arc[nogens affect specific organs or tissues. This research is relevant beeause this particu]ar c]ass of carcinogens, called niLromlminc~, I~ou be reduced in smoke with the use of better filters. Often when people ~hink of the health co.~equcn~es of smoking dgarettes~ they think of lun~] cancer Yet rile nulnber¸ ~[ cigarette related de~ths re~tlting from noncancer{~u~ puhnonary and ooril- nary heart diseases is lilt greater. Chronic obstructive pulmonary diseases today represen~ the fast es~ growing of the m~or eause~ of death, now ranking i~fth ]n 19~0, 55,{I0~ Amuricans died of pulmonary disease. A]most 3 roll- ]ion Afner]c~ins now suffer ~om emphysema, a terribly debilitating disease¸ The eviden<'e is ~ubs~r, ntia] and u,~equiv{y2a] ~ha~ cigarette smoking is ~he chic[¸ cl~]prit in the onse~ or exacerbation ~f these diseases. During the past i0 years we have ~]so obtained a far better un- derstanding of the m~chanisms of lu~g damage, im'ludi~l~ the de- strue~ion ~ elastln, ~i~e m~or structural protein of t~e long, whbh is adversely af]~c~ed by cigarette smoke¸ Despite a dramatic decline in m~rtality duriug the past deeade~ coronary ~eart disease re ~nah~s the No. I k[]]er in this country~ d~iming three q11arters of a rail]ion lives in the United Sta~es each year The scope of the problem is indeed enor]~us. Ci~areLte sr1~oki~g i~ orl~ ~[ th~ three ~r]~]'or r[~k [~Ictors to goror~ary artery dis~e. the other two bel.g high blood ~ressure and high serum cholester- ol. Epidem~ol~ica] eviden~e clearly I)]aces the smoker a~ ~ greater risk Of h~yt disease than the nonsmoker, F~Irth~r]]lore tht~ milri! one smokes, ~he greater the risk. There is also. however, ~r~unate ly. evidence ih~t STE~okinz cessation can decrease that risk. On t~e basis ol¸ chu~ d~!peudence and the addictive properties of cigarette smokin~ ~nd on the basis of research condLLeled by ~he National Ins~iLu~e on Drug Abuse, it is ~ur view that ci~areLte s~1~king represents ~ proto~pic dependence process and is, i~i ~act~ the mosL widespread example of drug dependence in this country¸ It is import~n[ to note that DSM IH, the standard diagnestic manua] of psychiatric {~i~rders in the U~ited S~ates, and ~.he World Health Organization's hlternational Clsssifieation of Dis- ease, both include tobacco dependence as a dependence disorder. Th~ key findin~ ~o date indicate nlc~doe as the mai~ factor in estab]ishing and maintaining dependence on tobacco. This results, in part, from i~s multiple, powerful biological and p~cholo~4cal e~ fects, which include stimulation ~f the release of a uumber of hor- monal sub~ances~ such as 11or~pinephrin~, epinephrine, growth hormone, cortisol, vasopressin, and probably beta endorphin; the production of behavior arousa] and EEG aler%ing pa~erns; and ~he fact that it is oue o[¸ lhe mo~ rapidly metabolized of all sel~admln- i~tered substances. Mr Chairman. at ~his time [ would like to turn my attention t~ the bill before your subcommittee, ILR 49~. This bill w~uld e~ab- fish an Office of Smoking and Health within the Department of Ilealth and Human Services We ~ppose this pr~vision. Such an office created by stat~ would not provicle the flexibili~ that pe~
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281 mits us, as wc have at present, the opportunity to alter the pro gram if need c~ Since 1966 the Department has maintained am active smoking component which has worked c~sely with S~ate ~nfl local go,'ern- ments and with voluntary health and educatkmal agencies to help bring about great changes in the smokil~g behavior of adults and teenagers alike This admini~,trati~n, m,d in particular ~ur Department, has placed great emphasis on prevention. We are concerned about the health problems that smoking causes, and we will continm~ iv oper- ate an effective program. We support the bill's ret~uirement.s for stronger" health warnings because we believe they would increase the public's knowledge of the hazards of smoking and make it possible for smokers and po- tential smokers to make belle1 informed judgments as ~o whi.ther to continue smoking, or to begin smoking We believe, however, that several modifications should be consid ered. We would strongly suggest Lh~li in the proposed section I of Ihe Federal Cigarette Labeling and Advertising,. Act the Sec]etary uf Health and Human Services be given the responsibility fur de- termining and modifying the actuai wording of the multiple warn ings We believe that the sbstelI] recommended in proposed section l(b) might be more efihctive is all of the proposed warnings appear on each brand simultaneously, so that tile smoker does not know which warning may appear on the packages he h.ys This is the sys~ern in use in Sweden, where 16 different warnings appear on packages at a given time, [n addition to greater effectiveness, ~bis system would nfinLaaize industry expense and compliance oversight reguirement~ We would, h~wever, want the flexibility to adopt other systems should this prove to be inefL~etive Cigarette nlanufa/turers are currently allowed to cite ]eveis of tar and nicotine as determined by the method specified by the FTC when new or reformulated brands are advertised which have not yes been tested by the FTfL Such a provision we would recommend be added to the proposed section l(c). At this rime, Mr. Chairman, I would like to turn to Dr. Keep and ask him to summarize the 1962 Repolt of the Surgeon General on the Health ConstNuences of Smoking STATEMENT OF DR. C, E VERIbTT KO{}P Dr. Keep. Mr Chairman, I would like to do this by calling your attention to l;he two charts, lirst looking at the one on your left You have already heard that cigarette smoking is a major cause of cancer i f the lung arynx, era ca~ v, and esophagus, al~d these proportional charts show the percentage of deaths from cancer of these ~ites to all cancers that we know about in the human body They compare 1950 with I977. The whole pie is MI cancer, and the size of the slice reprcsents those cancers we are concerned about that are sraoklng-related Y~u can ~ee from the size ~f the slice ef these trap pies that from 1950 to 1977, the percent more them doubled Lt went from 12 to 27 percent, l would also cal[ your attention to the Ihct that these rep- resen¢ fuur cancers only They do nc)t count the smoking rela~ed -d -d
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282 cancer deaths tha~ we know nDW c(~me from bladder, kidney, and pancreas, some proportion c~[¸ which can be attributed to cigarette smoking, If you now look at the cba~t oil your right, it shows the remark- able increase in lung cancer deaths in rela[ion t(~ total cancer deaths. The tap red Iine thews the steady increase in the number of deaths from cancer ~on] 19~0 to i978. And the lower red line shows the equally remarkable decli~le in ~]] cancers other than cancers of the [ul]g This line has its remarkable slope primarily due to our added ability to band]e c~ncers of¸ the prostate, the colon, the rectum and breast c;mcers And because the survival of lung cancer has remained unchanged, you can ~ee that that blue line in the middle has the same slope as all cancer¸ And indeed, if you will luok at ~he time between 1975 and 1978, you will sei. lhat the two lines, the red llne for all cancer and the bluc Gne for lung cancer only, parallel each other almost exactly, and this coincides with the same period of time when 1be red line at the bottom is absolutely flat, There is much more that could be suid, Mr Chairman, but this puts that report in a nut,hell Dr, BRANDY. Th~tt concludes uur s~atement, Mr~ Chairman. We would he pleased to respond to any questfon~ [Testimony resumes on p. 294.] [D~ Brandt's prep~lr~d statement lbllows:] &n .Q .j 50
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283 STAT~'JENT L~y ED~'~A~! N FRANDT, J~., M.D '~ ~SISTAb'~ ~C R ET '~ ~y FQR H~ALT~ O~ .Q
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289 ~e N~t JonaJ Cancer Ins~it ute is interested in pursuin~ some new leads. There i~ a ~r~'~in~ body o~ evidence that p~op~e ~ho ~moke loaf t~r and ~icotine ~at et te~ adiu~t ~h~ir ~moking b~h~vior--Jnhal~n~ more deeply cx cover~nE ~h~ ven~i~a~on ho]es ~n ~he ~a~et t~ filter ~, ~ is ~hou~h~ to be an a~t~mp~ to ¢ompen~ lot the dec~ea~cc nicotine yield. ~e plan IO t~ke ~ ~ok ~ ~hi~ que~;ion. II ~e~e preliminary l~d[~ ~re c0n firmed, il ~o~d imp]y lh~t ~mo]~ers of todays' cigarettes are not decreasing :heir exposure ~o nicotine and in Izc~ may ac~a~ly b~ incr ~n~ their exposure :~ h~r ~I~l c~mbu~ t~o~1 prod~c~s ~uch ~s hydoca~bons and car b~n ~onoxlde~ Smokin~ and Ca~dio ~uJm0~arY D~sease Ver~ ~ften, ~hen p~ple lhlnk of ~he health consequences of smokLn~ circlet ~e~ ~hey thEnk ~I ~un~ ~ar~er. yet, the nL~mber o~ c~ar ette-r e]ated deaths r eSULI~ from (noncancerou~l pulmonary ~d coronary h~ar~ ~i~e~e~ LS f~c gr~a~er. Ch:~n~ obs~r uc ~iv~ puli~onar y di~se~ IC~PD) to,lay represents the f~te~ ~r owin~ of the mai~r cau~ o~ death, no~ r~nkEn& ~I~h. In ~9~0, ~C0 ~m~r ica~s died o~ ~ulmon~y dise~se~ ~Imos~ three mi11~n Am~r~c~ now ~u~ler I~om emphys~ m~, ~ I~r r Jb]y cebi~i~tin~ ~ise~se..~.Ior ~ than ~ve~ re[Won h~e chronic bronchi~i~. Chronic r~spir~ory diseases account for apgroximat~ly ten percent o~ di~abd~t y beneI,~s ~cr i~t ~o~k h~urs. ~nd~ ~e evidence i~ ~u~t Bn~i~[ and un~u~voC~I ~ha~ ci~ar ~e ~mokin~ is the chJ~ Cuipr i~ in ~h~ ~n~et or exac~r b~ tion .Q .Q
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290 Re.arch con ELnues in t~l~ are~ ~o ~iv~ ~ ~ better basis ~£ ~nowledge in ~rder t~ pr event ~r ~rre~ the pr~te~ ~l puJmonar ~ di~eas~. Stu~J~ have demonstrated th~ be~i:~ ~f ~moki~ cessation, inc~din~ impalements i~ lu~ ~r f~rman~ ~ ~an only h~ to ret~ ~t~ p~ress~on, l~ves~i~a tot $ ~re work[n$ towards st~ ~o i~er~ene and r~v~r s~ ~h¢ pr ~e~. At t~e saH~ tim~, re,earth c~nt~nues ~i~ce ~rr,ok~n~ pr evenri~n or ~e~atlon r~pr~s~n~ ~he ~y effec~ inter ~en~on mea~u~ we now ha~ De,pit ~ ~ dr a~a~[~ ~ec~in~ ~n rr~r ~a~y ~r Jn~ th~ past d£~ad~, coronary heart of a m~lli~n ~e~ i~ the Un~ed $~ate~ e~h year, FOr e~ry mlnu~ o~ the da~, t~er~ ~re ~b~ul thr~ Amer ica~ ~vho su~fer a ~l~r~ a~ta~. ~hlJ~ the pr~re~ in r ~d~ci~£ ~or onarT h~art dis~a~ a~d other cardlova~c~lar d~a~hs durin~ re~ent ~ar~ is hear ~nin~, the ~o~e oJ the p~oblem remai~ ~n~rm~. L
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Cigare*te *rooking is one o~ ~h~ three malor r~sk £aciot s [~r coronary heart disease; ~he ~%her ~w~ belrl~ high blood pce~re ~rld high ~erum c~lester o]. Epide mlological evidence ¢~r ly pl~¢~ the ~moker at B ~L~h~r rls~ of heart dlsease th~n ~e nonsmoker. ~e r~or~ ~ne ~mokes, the g~e~ter ~he ri~k, "f'rle f e is al~ e~'J(te nc e that ~ ~oklrlg ce~a~on ca~ de~re~e :he r~k, Alt~r ~n]~ orle year fr~e ~I cLg~ret t~s, ~ [~r m~c ~mo~r may be able to reduce t~e ri~ ol heart di~ea~e to ~Jcse within T~e exact me~har~i~ ms o~ how c~garet te smoking ~ffec~s coror~ry he~r~ disease ~re s~il[ ur@~own a~d are ~he subject of considerable re~drch now u~C~r w~y. Never t~e[e~, the evlden~e ~ed on epide mioloBi~ ~nd autopsy studies clearly linkir~g t~e amoun~ ~f ~m~king with Fi~ffe~ irmidenc e of ~eart d~se&~e, i~ Lr~deed impr e~sLve. Add gtive Proper t]~s cf Cigarette Smokin~ On ~he i~ue ol drug d~pendel~e ~r~ the afldict]ve proper ~ies ~[ C$~r et~e srr oki~g, • n~ on the ~is ~f r ese~rch ~ond~ted by the National in,tit ute on Dru~ Abuse (NIDA), i~ i~ our view that ~igar~t~ smok~n~ r epresen~s • pc~to~yplc ~epen(ience process ~rg in f~c% is the r~ot: widet[)re~d e~ample of dr~ ~epc~dc~ce in lhis c~u~ ~y* ]~ is Lmp~r ~t ~o no~e ~hat D~M I][, ~h~ s~nd~r~ diagnostic manu~ o~ psychiat ric disorder ~ in the U.S.,~nd the World HeaLth Organ~za~[~'~ I~t e~n~t]onal Classification of Disease bo~h include t~b~cc~ depe~erce ~ a dependence c:~r der, NIDA re~ear~hecs ~ce ~xpioci~ ~h~ same quest ~a~s that we a~k ~£ ar~y at~er ~ru~- usL~g be~avmr: what t~ctors (ll de~er mlne initial exper m]e~tat~o~ of use; (~) ~he progres~io~ [rom ¢~s~l retreat ionBl ~se ~o Cegu]ar, compulsive u~e; 13) the ~chi~v~m~t ol ab~ :inenc~ and (~) ~he high tale o[ rel~p!e, ~e ~e~ flndi~gs to d~e ~mplJc~te nL~c~ine ~ ~e main ~tor En establishing ar~ ii~int~nLng dependence on tobacco. ~l~is resukts in par: from L~S m~l~[ple, cn N,
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~2 ~)owerf~i bJologicml and psycholagical ef fe~ts, which i~lude 5tlmulatJon o~ (he re1~a~ of R num~}~r ol hor mon~l ~ubstanc~ (norep~ne$~rln~, epineDh~Jne, ~ro~th hot n~ne~ ~r tls~[~ va~{Ire~u~ a~ ~c~bab~ b~t~ e ndo~t@hin} ~ th~ ~i~uct ~ o~ behavJora~/ar ~u~ll ~nd EEG aler ring pat terrls~ and the fact lhat h Es erie of lhe ~s~ la~i~ I~t~i ~ all ~i~r~i ~ab~e~. It ~S ~ne es%ab/~s~lment oi trlbaCCO ~c~e~e~e ~ ils COnsequent impairment ~f ah ir~iv~d~ al's ~bil~t y to ~asJ~y (~is¢o~t in~e be~lvlur ~ha~ h~ or she in~elJ¢c~uali}" kr~aws [~ ~f ~anla~Jn~ w~ich ~ead~ Ic the mul~ip~ ~av© heal%h consequences ~at I hav~ previously summarlze~, The exien~ ~ te))a¢co~ ability I0 ~ this i~ m~s~ easil~ ¢omprehen~cll ~vhen e~ ~'~ t ~s ~hat wher ~ the ~ar~e rna jor~t ~ e£ ~rnerL¢~ ~v~ u~ alcohol are ~o~ie~t~vely az~ objc~tiveJy ~b~e I~ SalLStactoriJy Conlr oL t~Lr [ev~J of u~e, ever 7~ ?ercen~ o( tob~ce smokers wo~d IJk~ l~ quil bui 1lave ~Jt flcuLty in d~in~ ~, ~ba~ ,v LtJ~ a~L t]~ dev~at~n~ hea[t~ ef feels ~hat are a Consequence ol t ¢,b~cco srn~kin~ is ~he ~ae~ ~ha~ we are t~[kln~ abou~ Mr.Chair m~in~ in Closing~ [ ,~ould like i~ turn my a ~len%ion 1o lhe bill before your T~iS b~]L ~v(}u Id egtabksh an O~!iee ~ Smoking an(~ HealIh wit ~bl t~e Depar Ime~ o~ Id~alt~ ~u~d H~rna~ ~,~r ~ces. ~e Oppose th~s provi~r~, An ~IIio~ Crealed ]~ ~$alute ~vou~d ~oI }~r(~v~de IlexJbi~ly. ~,~ pre~nI~ ~e can alt~i t[~e prog~a m comgonen~, ~Vhi¢~ ha~ ~vor ~ed el~sel), ~vith ~ate and Ic~al ~over~ts ~d wi~h vo~un la~ F~ea~lh and ed~Jca~ioea~ a~ ~cies ~ ~el~ blln~ about ~reat Chan~e~ in ~h~ ~moki~ beh ~vicr ol ac~t~ an<J t~ena~¢rs alil( e. I~i~ Ad~nini~ I~& lion ~ ~d L~ ~&ItEc~l~ ~L~ ~e~azt~, ki~ F*LaC,~ ~re~ ~ T~2bi~i~ ~ {If ~ e~L~Lu~. ~e ace e~ncer ned abou~ the ~e~1~h problem~ ~ha~ ~rr~o~in~ ca~es, and ,ve will con ~inue tD Ope~a%~ a~ e~t~ e ~e~rarn, ~b -,} C~
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293 We su~por t the biers r equlr em enls fo~ str~n~ heelt h ~al n]n~ beeriest we believe they w~uld lnerea~e the public's knowledge ~f the h~z~rd~ ol smoking a~d make it pc~Ible for ~tnokers trod ~otenti~l ~mo~r~ ~ make better informed jud~rn~ht~ a~ to whether to co~ti~lue ~mn~iz~ or begin ~m o~:[n~. ~e believe however, that s~wral mo¢~ficati~ns are neeCe~ We weul~ ~ Ir on~l,/~u~gest ~hat i~ propOSed ~ectI~n 4 of t~e 3~ede~i Cigar etle Labeling ~nd Adver rising Act, !he Secretary of Hea1~h and Human Services be ~iven the r e~p ~$1bil!ty f~r d~lerminin~ ~n~ modifyin~ th~ ~etual woldin~ ~f the multiple warning!~ We b¢l~eve that ~h~ Syst e r" recommended in pr ~p~sed section 4(51 mi~}3t be m~re ef feztive if all of lhe praposed warning~ g~peat on each brand simultaneo~slv, • o that the smoker does ant know which w~ra~n~ may appear on th~ packages he bu~qs. T~s i~ the s~st enq in usa ~n Sweden, ~he~e I6 d[f ~r e~t warning~ aptp ea r ~ paeke;~es al ~ glVen time. In addition to ~rea~er ef f¢¢llveness, this ~y~tern would minimize indust ~ expense an~ compliance oversight requirements. ~e Wbuld h~¢ver, Wa~t the ~]ex~bility In ~d~t ~ther ~s~ ~ms ~h~uld ~his ~rove Io be it~e f ~ctive. C]garette menufacturers ere cur r en~ly a~ow~d ~o ~ite le veL¢ of ~er and nicoti~e a~ d~t ermined b~ the rne~d~ s~¢¢ified by th~ FTC when new or r efor mul~ed br~n~ are advertised which have not X~ be~ tested by t~e ~TC. Such a provision ~hould be ~dde¢l t~ propc~sed ~¢Iio~ 41c) • Mr~ Chairman, ~hi~ ~ncLud~s my ~tetemenL W~ will be ple~se~ t~ respnn~ t~ ques~ion~ y~u may hsv¢.
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294 Mr, WAXMAN. I want to thank you both for your statement. We appreciate the fact that you summarized it, and without objection your full statement will be made a part of the record. 1 would like to ask some questions of you, Dr Brandt. You and the others with you may be ~t~le to answer yes or no t~ these ~luest.i~n~, but if you wish to elaborate, reel free to do so I wcmhl like to know wbethel¸ the following statements are scien- tifically valid: Cigarette smoking is the largest preventable cause of illness and premature death and is associated with the unnecessary deaths of over 3~)0,{)00 Americans annually¸ Dr Baa:~iyr Yes, that is the scientilic evidence¸ Mr WAXMAN Smoking is the No I cause of lung cancer in the United States and is the major cause of ¢hronis obstructive lung disease, Dr }3RANDT. Yes. Mr, WAXMAN, Cigarette smoking is ~bo No. 1 cause of empbyse- llla. Dr BRAN~T. Yes. sir Mr WA;4MAN He~lrt disease accounts for nearly one hall" the deaths in this country aIld it is estimated that one-third of these deaths are attributable to smoking, Dr~ BRANDT. If yOU amend that to be cardiovascular disease, the statement is correct Mr WAXMAN Cigarette smoking is the major cause of" heart dis Dr. BRA~DT. Yes. Mr. WA×MAN. Pregnant women who smoke are at higher risk for the possibility of spontaneous abortion, stillbirths, premature births, and child weight deficiencies than women who do not sInok(% Dr. BRANnT. Yes, that is correct Mr. WAXMAN. Women who t.~ke birth control pills and smoke are more likely to Suffer a heart attack or stroke than womel~ v~bo do not smoke. Dr~ BRANDY. That is correct. Mr. WaXMAN Certain occupational hazards, in e~ajuneLion with an individual's smoking, increases substantially the risk of disease and death. Dr. BRAt4DT. That is right. Mr. WAXMAN, Cigarette smoking may cause death from heart disease, emphysema, or cancer. Dr. BRAider That is right Mr. WAXMA~. Cigarette smoking is addictive and will injure your health Dr. BRA~DT. That is right. Mr. WAXMAN. No matter how long one smokes, quitting greatly reduces ~he risk to their bealth~ Dr. Br.ANDT, That is correct.. Mr. WAX~AN The tobacco industry has made a number of¸ s~ate- meT~ts about this legislation ~q~lll about the health problems that many claim are associated with smoking It has been suggested that requiring specific warning statements about heart disease or lung cancer will send a signal t~ young pros-
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295 pective smokers that smoking will only cause d~seases that affect older people. The implication of this position is that the current warning label is more meaningful than those proposed in the legis lation. Do you agree? Dr. BI~ANDT. I think that the warning labels that name specific diseases will influence younger people to recognize that in the first place, we have to gPt across to everyone that the disease, is a result of cigarette smoking, is cumulative and dose-related. And I think if we can emphasize to young people not only the fact that it is harm- fu[ to their health but also causes specific illnesses, that would be more effective. Furthermore, it depends on how young thpy are talking about, but the proposed warning about women who are pregnant and smoking would certainly get to a younger group of people. Mr. WAXMAN. Over the years, the tobacco industry has chal- lenged the Surgeon General's statements about the relationship be- tween smoking and health. They have suggested that she Surgeon General's warning, however well intended, is more conjecture than scien¢ific fact For example, in a 1982 review of scientific literature entitled "Cigarette Smoking and Cancer: A Scientific Perspective", the To- bacco Institute writes, and I am quoting them, "The claim that cigarette smoking causes lung cancer has not been proven scientifi- cally. The charge iglmres unresolved scientific questions concerning animal experiments, smoking patterns, and lung cancer rates, diaw nostic variables and many confounding factors" Would you care to respondq Dr. Br~ANnT. The question of what is scientific proot: 1 guess, is the issue that is being raised, and the argument has been raised that until such time as you can show the physiologic mechanism by which cigarette smoke transforms a normal cell into a mahgnant cell, you cannot claim that smoking causes cancer We know of very few mechanisms, that result in disease, yet we do know a lot of causes and we do kn¢lw that ir you can get people to quit smoking, their risk of lung c:~ncer and heart disease will di- minish. I think Dr DeVita may be able to address this in some more detail Dr. D~VITA. Dr. Brandt put it well, Mr. Chairman. My own per- sonal feeling is that the scientific evidence is irrefutable in the sense that the strength of association of smoking and lung cancer is overwhelming. The dose response relationship between the inci- dence of smoking and the number of cigarettes smoked and the time and duration of smoking is irrefutable, and the fact that you could cease smoking and reduce the mortality from lung cancer is one ~urther piece of e~ddence. 1 tbtak tha~ the animal data shows that you can cause cancer from cigarette products. l believe that the statement you just read would not stand up to the test of scientific facts. Mr. WAXMAN Do you believe that we must fully understand the etiology of cancer befbre we can determine the role of smoking in promoting the incidence of cancer? 0~
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296 Dr. DEV]TA, l do not believe we have to understand the etiology of any disease to prevent it. History is replete with preventina of disease without knowind the causes for examplel smallpox and cholera. We know that ¢igareLtes cause lung cancel-~ so if we can prevent smoking, we can do a for to alleviate the cancer problem in this country. Mr WAXMA~. Frequently you read in tobacco industry publica- tions that the f~eld of epidemofogy yields only statistics, not Facts from which ~cienti~c eonclusfons can he der~ed Would yc)u ex- plain the role and importance of epidemiofoW; in e~tablishing cau- sation ~n a disease like ltlng cancer? Dr. D~VITA. Well, epidemiology is like a doctor for the entire country ~isteinng to what is dolng on in the country, as opposed to what is going on in an individual patient and is a largely used method of case control ~tudfos; that is looking at individual dis- eases and tracing back to controis that do r~ot have the disease and l~ki~g at the ~r~ables that seer~ ~ be t~f~u~nst~ the in~ibe~ce of cancer. What is important for an opldemfofoglcal study, which is ~ very sound scientific method, is the strength of the association to the partinular factor, and i[ you put ¢t n~mber of ~u~pocted carcino~en~ ~n a ~cale and looked at the rel~tfonship between, say, cigarette smoking and any number of other materiais that we are investigat- ing at the present time, the difference in the association is really what is key The reIatlve risk o£ lun~ cancer for a heavy stacker is about tenfold what it is for nonsmokers. F~r a very heavy smoker~ two packs a day. you are talking about a 20 to 25~fold increase in risk. The~e are very sound methods of associating certain agen~ with the incidence and mortality ~om disease. Mr. WAXMAN, We often hear the sv.dgestfor~ that ~enetics i~ay be respon~dile for illness associated with smoking. Some people are more predisposed to can~or or h~art disease. Can gelle~ies explain the correlation between ~rooking and chronic lung (l~sease? Dr. DEV~TA. ~n my opinion, n~ The~ are some twin ~udles, identical twinsl with one smoking ~nd one not. and only the smok ing twins get lung cancer; the nonsmoklng twins do not. And that "~'ould ~)e continxaafiy eonl~rmed. ] see no e~ideace to the conirary~ Mr. WAXMAN I want to recognize my colleagues ter questlons. I might have some ~ddi~fonal ones later. Mr~ B[ifoy~ Mr. ]3LIly. T~a~k y~u, Mr. Ch~ir ma~, Dr. J(oop, in your recent press conference announcing puhlica tion c~f this year's Surgeon General's report, you claimed that, and ! quote, "Smoking is re~ponsibfo for sore(~ 340,000 deaths in this collntl~y a~lnu~i][y " Are yo~ aware that this figure was manufactured withot~t any scientific basis by an advertising man. Emerson Foot, b~ck ill 1965, who publislzed the first Surgeon's Genera[ report? Dr. Koo~. No~ sir. | am not. Mr. BLILEV. Where did you get your figure, 345.1100'? Dr. KooP. We got our i~formatfon from the Na~{~nal Center for Health Statistics. L .j .d
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297 Mr BI.ILEY Dr. Keep, one of the poinLs made in this year's Sur- geon General's report was a statement that about half the cigarette smokers who quit do not resume the habit, and that about 95 per cent of the quitters do so on their own. without help ~om outside SOUrCe~ Doc~or, do you not think these figures contradict the statement in the proposed warning label regarding addiction, which suggests it is near~ impossible to quit? Dr. KeeP. No, I do not think so, sir Studies that you just quo~cd also indicate that it is the motivation beyond the ilaiLfar's response that is tile important thing¸ And if you h*nve Lhe kind of a person who can be sail~rewarding, then his motivation is highE!r For example, ray father, a two pack cigarette sm~ker, fa~d ~1 ler- rible chronic cough¸ My mother asked me one day if I could do something to help him slop I said he wilt never stop because he has not got the guts. He was standing right behind me, and he never smoked again in his life He was the kind of a nlan who had a sell:rewarding kind of a p~rsonaiiLy I think that is what coml~ in the motivation of these people Mr. ]3L~LEY. i see. Doctor, io your extensive medical backgrotlnd, }]a~'e you had any training in behavioral sciences? Dr. Ko~P. Specific training that comes in college and medleal school and gTaduate school, and the fact that you cannot haip but ]earn something by watcfang people in medical practice over the years Mr. BLILEY But yOU have not b.ad ~lny sl~cci|~ training9 Dr Koo~. l~o, sir Mr. B~LEy. Thank y~u. Dr, Brandt, have you had any ~rainlng in behavior sciences? Dr BRANDT, I have had no tbrmal training in behavioral scien- ties Mr BI.II,EY I see. Are you familiar with this report, this report to the President and the Congress on health hazards associated with alcohol and methods to in~m the general public of these haz- ards? It was published in November 1%0. Dr, BRA.XDT. i am not familiar in detail; no, sir, Mr. BLILm¢. I see. Well, in that repor~, ~ war~t to read you some statements While it was concerned primarily with alcohol, it d~es take or~ tobacco¸ We were ¢oncern~t] ~})o~lt th~ ~v~ru~e of ~ne of the C, ov~rnment's most impor~an~ ~orm~ of health tfiert, ~ g~neral h~hth hazar(] warnlng label, if it is posslbl~ to corn munica~e ~he information adequately through other m~ans. If, a~ a number o~ corn mu~icat]o~l$ ~xDerts ~d~i~e* ~he pith]it is be¢om[n~ jaded over (]~v~r~me~ warn ing~<, ihc Government should use health hazard warning labels with caution. The second s'~atement: Labeling alc~h~llc beret ~ge~ with ~l ~erie~ Of ~peci~c health h~zard war~ing, rotating fab~]s, such as we are Lalking abou~ herem V4as ~Ls~ ¢ons~dcrt'd a~ a po~a[bl~' m~hod t~ cnnv~y ~ l~lr~ number ~f ~pecifie h~alt b. w~rn~ngs to th~ alcohol collsuIoin~ p~bli¢ The depart ments believed r~tating 1~b¢1~ for alcoholic beverages wotl]d confuse the public, c~use them t~ believe tha~ ~ne p~r~icular brand, lee¸ example wi~h 5t~perceut ~lcohof' might cause alcoholism, while a~other prodt~ct wi~h 12 percent alcohol might Cause birth defevts, and s~ ~n Also, such a requirement would pos~ potentially dimcult administr~tiv~ and en. forcement problems, especi~] ly ~ffeeti~g imported p~t~luc~ g~ .,3
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298 pregnant women in ehildb0arlng >ears confront multiple hazards il~ the safb corn pletion af pregnancy. Among the~e are cigarette smoking, alcohol consunlptinn, ex ~ve a~,~u~t~ of ¢~[C~ine, ~xd hxad~qu~te diet A etrate~ b~e~. otx i~divldt~L warnings directed toward each he,Mth risk may simply have the effect of o~er- whelming the woman arid hor family t,qth prohiDitlons, [f everyt hlng appears to be h~,rmful, ~ ~a~ zd,JpL ~Ke fatalistic view and oa&*~ue ~tf~ L~biLs ~m/ iLt~ styles IL is our judgrnent such in formatinn can be more s~cce~fully eon~ eyed through a p~hli~ iB~r mo.~nn ~oI~pa ~R cuverltt g all sigrtlf~C~tt*L CISI~ to ~regtlancy rather t~n thTough a labeling effort directed toward the single ri~k of alcohol cansmnption wish corollary efforts singling out smoking and caffoine. ~AthJatlgh sav~kin~ levels have darlined in public ~arenea6, the health hazards have increased The depal tmcn L collelud~d, after z eviewing available studie~, that k is impossible at this time to i~olate the impact of any ~pecil]c commnnicadon tech nlqne on smoking behavior, including the cigarette warning label ~n the ctgarette ~mackage. Do you agree with ~hose statoments? Dr. BRa~DZ Well, i cannot agree with all of these statements, Y~r. Bliley. I think that in ~he first place, we are trying to be selec- tive. I would agree with the statement that you can overwhelm the public with information about everything being harmful, and that it is important to select those things that have the g~-eates~ risk to the public. If one looks at the causes of death, and in particular if one looks at the l~ss of years of productive life, tha~ is, premature deaths, deaths before the life expectancy, and selects from that Iist those agents that have the greatest influence on persons losing their lives, and selectively warns on that, then we will acc[)mplish the most. Clearly, cigarette smoking leads that list, We fee] that therefore we most x~arn the public. Now that does not mean that that is the only thing we will do. Certainly, public education efforts must continue. Certainly we have to continue our research, particularly on how people can quit smoking. So I think we will be selective. I do not disagree that we should be, but I think cigarette smoking is certainly right at the moment the mo~t important thing we can ~ddress, Mr. BLmEy. Well, Dr. Brandt, you cited the Swedish experience. Dr BRA~DT. Ye~, sir Mr. BUL~. We had testimony Friday afternoon at our last hear ing, so far unrefuted, that in 11 years, 5 years before and 6 years since rotating kibels went on the packs, there has been absolutely na change or virtually no change in consumption in Sweden, In Great Britain, where they have had rotating labels for 8 years, there has been no messurabie change in consumption, before or after. In Norway, where they have totally banned cigarette advertising, and there has been a ma~sive campaign by the Government to edu- cate people on the dangers of smoking, there has not been any change. In Poland, where cigarette advertising is banned, there has been no change in consumption. And indeed, in Italy, where cigarette advertising has been banned for 20 years, consumption is up 60 percent. Now, we are not in this bill today talking about health hazards. It is not designed that way. It is designed to potting labeling on to
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300 [The following infurmation was received for the record:] In 1981, 640 hi]lion cigarettes or 32 billion package~ (20 c~arettes per package} were so]d An eight cent F~dera] excise tax per package generated $25 billion Jn revenue m 19~1 Thus, the Federal excise tax would h~ve to be raised to 43 een~ pe~ l~ckage to generat~ revenues of $13 6 billJo n I~mning ~2 billion paek~ge~ ~re sold) To gener- ate $25 bhlllon in revenue, the Federal excise ~ax would have t~ be raised to 78 cent~ Per package [assuming 32 billion packages are soldi Mr. WmTrAXER. l would appreciate it. An[] in addition, I would also like to ask wha~ amount above that level of taxation would be required to recoup the estimated $25.~ bdlion c~st~ for premature death and disability? So if you ceuld bring that to our attention, l would appreciate it. Dr. BRANI}T. Yes, sir Mr. Wmvr~.KgR. What has been the experience in otber countries with increased levels of taxation on cigarette products in minimiz- ing or discouraging increased consumption of tobacco? Dr. BRANDY. WeII again, it is difficult to attribute change to any one variable. The most recent data from England is that cigarette smoking is dropping at a very rapid rate in that country. There has been a signil'icant change over the past 2 to 3 years in the con- sumption of cigarettes in England. Some persons attribute theft pri marily to the uae of the warning labels. Some attribute it to the increases in tmxes The most recent event that has happened in that country with respect to cigarettes has been an increase in the level of taxes. Whether or not one can attribute any change in human behavior to any single event is somewhav problematic. That is the one coun try about which we have inibrmatiorl at present. Mr. Wmvr~r¢. In my reading, England is the most recent coun- try to implemen~ a high level of taxation. Is that the only country that has implemented that in the last decade? Dr. BgAr~nT it is the only country that I have firsthand experi ence about, Mr Whittaker. Let me see if anyone else on the panel knows that information. [Pause] Dr. BRAND'I' No. Well, we will be happy to look at that and pro- vide you with that information. [Testimony resume~ on p. 313.] [The tbllowing information has been received fur the record:J ~m
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301 Background da~a on the experiences of other countries on the taxation of cigarettes and ~iEarette ¢~ns~mption patterns, Source: Roem~r~ Ruth, Legislative Action to Combat the , Wor~4 Smok~ EpidetalcI A Repart to the Wo~]d Health Oraa~iza~ion, Chapter X~, "FIBcaI and Economic Measures." Dr~ft report~ Univ~rsEty of Callf~rn£a, L~S Angeles, CalEforn£4, 1982. LEGISLATIVE ACTION TO COMBAT ll~E WORLD SMOKIN~J EPIDEMIC . A Report to the World Health Crganizaton by Ruth Romner, J.D. School of Public llealth Uniyerslty of Galifor,ia tos Ange)es, Callfor,ia July, 1981 "4 -4
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302 Chapter X[I, Fiscal and Econ~l¢ ~as~res There are 5~1~ who alle~e that GoverMentS have a vested tnterest In za~o~n9 ~C~US~ of the va~ cev~ue that ge~ Caught by t~e Chart. ¢ellor's netl ] can assure ~o that t~l$ 15 nonsense. It ~ould be quite po~l~]e to raise this revenue In some etker wly. ~-D. ~a]s, ~ecretary of $tate fo~" Health. United ~tngdo~. P~per ~re~en~ed to the OxfOrd He~l¢~] SocleLy. 27 ~tobe~ 1976 T~e ~o~acco In~u~r~ k~ large st~kes I~ ~e~eatle9 efTort$ to ¢o~t~ol the tTa~sna~lonal t~acco ¢o~910mera~es. de~cTlbed I~ • ~978 repor~ of the t~tted ~t~or~ Conferenc~ on TTade and Cevel~p~nt,157 presents a fom~dable edye~- $ary tO go~trr~en~s ~r~9~Ilng to discourage thetr ~ung people frct~ taking up ~no~tng ~r~ to persuade ~mo~er~ ~o free ~e~ye~ frc~ ~accD d~pe~e~c~. Ranged on the sloe of ~he tobacco ~nteres~s ~e their enomou$ f(n~cIal Te- ~our¢e~. their c~ntrol Df I~d~s~Ttal tec~n~lOg~ lot ~odu¢l~g. manu~c~urtng, and packaging ~b~co pr~uc~, thetr ~a~tery of sophisticated ~rke~ln9 ~echnl~ues~ ~n~ ~1~ Secret ~apo~--the addicttye h~ture o~ tobaccO, t~ S~Jl~ ~l~. g~ver~nent$ have a $~n~fl¢~t E~onomtc lnter~$~-~ le~ving aside humanitarian ¢or~n$-*Jn*prote:ting t~lr people I~ainst pcema~e death an~ chronic d~s~billt~ fron Smoking re~ultln9 in Ions of pr~- duCtl~l~. Against the m~h-wun~ed economic benefits of ~obacco p~oduCtlon m~$t be we~hed the ~t~h costs of smoking. In ~he L~l~ed $~tes, the econ~l¢ consequences of ~mok~g weTe estimated In 1976 to to~al $27.5 billion, of ~hlch 18.2 billion re~esented direcL health ca~e ¢o~s.|SB ]f 9ove~men~s and ~n~-smok~n~ forc¢~ are t~ ¢onba~ the powerful amamemter~u~ of the tobacco ©~pan~e~. ev~ strategy tha~ ~lds promise for dl~ln~sht~g~ and eventullly eliminating. SWOk~ng in socfe~ m~ be explored. ~e cen~ellatton of ~eas~e~ ~a~ has I~e~ used tn onl~ ~ 1~ w~Y |$ tha2 Of f~ll and economic ~tu~s. T~ese Include policies o~ taxlng~ O~ ~3
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303 Baste Reasons The baste reasons for adopting fiSCal tr~ econQ~ll¢ measures 4~e: To dlseo~Tag~ s~klr~ tn general and sa~kln9 of more harmful brands In ~rtloular. TO decrease pr~luctton of tobacco and to provide lncenttYes for preductton of tess h&~ful crops. 3. TO discourage sq~klng by young people. 4. TO finance s~roklng L~duC~tlon. smoklng cessatlon activI:~les, nnd research on s~oklng, Ralslng Taxes and Prlces Three t~vpes of tLxtng policies are descr~bL~ tn Guidelines for 9nOkln~ ~nOrol~-a genera] tax Jtlcrelse. differential taxes favDrlng ;ow tar and nico- tine ¢191rette$~ and Inclusion 11~ the tax structure of a levy to finance sr~Ok. 1rig educatlon, s~ng cessation activities) and research.159 General Tax I~crease. Raising taxes or prices seres to decrease cofls~ptlon of tobacco.160 According; to the Royal College of E~ystelans of London. "~hen ~he price goes upt the cor~umFLlofl goes do~11.TM Experience In the tlnlted Xlngao~ sho~3 tha~ five tax |ncreases tntrod~C(d fr~ 1974 to 1978 ye~e as~,oclat~ ~th a 9 percen~ reduction ~n cigarette sales and hasLen~rrg the move a~a.v from high tar cigarettes.162 In Belgtu~, ~he Federal Republlc of Germany. Luxe~lbourg, the NetJ~rlands. Zrdta. and ]~alv, price Increases reduced sates t~ sore i~ent.163 Gr~nted that total per ¢~plt8 spendl~ IS rare Influential than prices on per capita ¢lga~et~e c~s~f~on~ as one stud~ of 47 ©ou~tr~es sho~,]54 nevertheless hlgbsr taxes ard consequently h~ghe~ ~rlces appeer to restrain consumption.165 Thee ts, however, ~me ev|derCe C~ O~ -3 ~C
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304 ~n
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805 Objections my be offered to tax Increases. ~ne 15 t~e Idver~'. Impact on In.Income smokers, possibly a blessing In disguise, k~other is that in- creased taxes may have on1Z a t~porary tefl~ence on s~les~ affecting In~l- "sldtl~l daily ¢ons~r~.ion but not the p~ev~lence of stoking ~n e sDctety, as I~ntlone~. Nevertheless. despite these objections, more experience IS neede~ with this strategy. A representative Of the ~tlonal Board Of Health of Finland tn describing the strong ~oktng control l~Is7atlen t, Ftnlend stated Ca~ldly: One element ~n a truly health-oriented smkfng control policy is (qts!;fng--na~leJy pl"lCe pOll~. There IS gro~ing evidence on the importance of price po11~y as a determinant Of cigarette cons~ptton, esFeclally a~on9 young peo~le; and my I~rs0nal guess I$ that the time will be ripe for ~ew legislation on price policy ~n a few years. ~an~ile wtce pali- C~ r~asures that can be car~t~d OutU~e~ the current I~g~sl~';ton will be used so far as ~1itleally possible."~ F~nland had proposed t~o ~easures--~bllgatory price checks o~ cigarettes twice a ~ar a~ di~fere~tlal taxation ba~-~ on harmful SL~stances. BOth ~easuTe$ 1reCeived bro~d approval, but action was postponed ~ecause overall re~$~on of excise taxes was ~nder co~lderatlon by a national commission. Lev~ for AntiSmokin~ Activities* AS m~ntlo,~[ earlier in connection 1¢4~h tla~atln9 health e~u:atlon, ]¢eta~d requires th~ tee state ~obacca m~nopol3 spend t~ percent o~ gro$~ tobacco sales on lnf~tio~ ~n televlstnn, radio. in ne~p~pers. ¢l~flas. and othe~ places ~arning against the hazards of smok- II*~, In Finland 0,5 ~ercent Of tobacco tax revenue ~ust be a11oeat~ In the national budget for health education~ re~earch, and eval~tlon tn smoktn~ con- ~rol. In Venezuela, par~ of the toSacco tax IS used by the National Tobacco Furd for development tn ~he rural ~obacco gro~lng eeglons.173 in the Unite~l States. the Health ~cretary of the S?~te of ~ennsylvanla advocates a penny a pack InCrease 1~ the State cigarette ~ax tO financ~ a ¢anceT re<JIStFy a~ t~e beginning o~ c~ncet screening* de=ectlon, and prevention progr~$.174 .j
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3~ ].s~anCe ]nce~tlve$ a~d DIslncentlvGs Ano~.l~r fore of ~1c measure affecting smoking tS the gro~ng ~actlce the insurance Ir~ustTy |n the Untted States or extendfmJ ([iscoumt.s on |tfR |~urance ~tum$ to nonsr~ker's. T~IS l~nov~tlon ~jan in 19~1. ~ 1.h~ $*cate ~utual I.lfe ~.~suran~e Company of ~r~rica offered a new lSfe tns~ance polic.v ~c~ust¥~l.v to ~rson~ ~o. ~t t~ time ~f al)pli~ation* had n~ s~.~d¸ ¢|glrel.tes for a ~ar. In |~76. 1.1~ ¢~p~ ~nd~ Non~k~r ~l$¢Ount~ on ~r~lums tO ~l |t~ l.dlvldual n~-~nsSon 11~ Snsur~nce poltc~ he]derS ~ho ~re ~on~T~. After ~4 ~ars~ ~p~r[enceI an~ls o~ mo~-a]l~v differ. en¢e$ ~tw~en fo~ur~ s~o~r~ and r~0k~$ reve~ed the l.~gl¢ f~ct ~hat the ¢~'S ~ker ~1~ helde~$ ~re eXl)~rl~nctng ,~rt~]t~ almost ~ a~d ;~lf *cl~s thet of thefo no~s,~k~r ¢o~t~rpa~s,175 Since lg~4. 54 ¢~te~ ;~ave b~g~ t~ off~ ;x~tu~ on 11~ insurance policl~ to non~k~rs at lo~er ~n sta~ard r~tes.17~ These ¢~]~ie~j a]~o. have ~11 ~ou~ the mort~tt)" r~ am~j their ~o~er$ ~uch Io~r Lh~n ~.h~t ~f ~h~ir $~r~ker ~]l~.~ holderg, In f~t, th¢~ tnsLr~nce co~tpaflt~s have b~n SO ~r'uck b~" the m~gnf- t~de of dif~re~¢~$ I~ ~rtall~ T~e$ ~t~, s~oker$ ~ nons~k~rs that the ~'nlle this ~x~rlen¢~ 15 s~lll ©onsid~rL'd ~l~t~d~ Insurance execu~lve~ b~ iew ~b~t the ,~tall~ differences bet~n s~l~er$ a~d n~ns~c~rs mus~ ~e taken tnto account for indtv~u~ tns~r~e undeT~rlt~n~ and prt~tng p~- ~S. A prtnctp]e tn ~t~bltshing un~eT)ffit(ng classifications ($ that 1.;~ standard group Should be th~ llr~est group, a~ those ~ a~e either pr~ferr~ or sub-s~l~ar~ should be fo ~he mlnortt)', ~¢ordl~ to t~ lg7g Report of the U*$. $uTg~on G~eral, ~n~ok~rs are no~ the ~a~ger g~ou~* ¢~lslng 67 p~rcent ©f the U*5. Fc~pul~tlon. a~ ne~ 1tf~ lnsuran¢~ bu~l~e~ ~efle~s this m I
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307 d~In|nce o~ ~$~ker~.~7 Therefore, non~ker$ can p~'o[Er]~' be COnSidered as tl~ popula~Ion that d~finel "~.tlr~ard* riskl, ar~ ~kers shou}d bQ defln~ is zub-stan~ard~ The ~perlen¢~ of State H~ua] i.I~ /~s~ar~e C~pany ~dth • ~eml~m di~ount~ ar~i with of~rlng ~19h dlvldend~ to ~n~m~e~s has sho~ for Carre$~ndln~ $~okers. The pr~t1¢~ of ~1~in~ Ins~r~n~e ~u~entive~ b~ O~ ~o~$~n~, I~ Widely |dopted, may prDv1~ ~ddit1~na] ¢~onc~I¢ ]evera~ In ~he ~trug~1~ t~ ¢~bat t~¢ ~r~kln~ e~id~i~. ]n~nce ~¢enti~es ~d dislnCent~e~ ~,~II enlarge ~he role of the In~ur~n¢~ In~u~t~y ~r~ t~t Of ~ctuar1~1 ~ fln~n¢i~ ~n~r- ~er to th~ of a~iw ~r~ic~Fant I~ the ~for~ ~ c~ange people's be]~v1~r to ~re ~ea]th~ul ]i~ st¥]e~. ~bo11~n9 Sub~id~s for T~1~¢~ Is the q~e~ion of agr1¢ult~al s~b$idles ~ tobacco ~o~u~tlo~. The ¢~n~r~- d1¢tlon ~¢t~n prc~ding q~e~tqv¢~ ~ t~ba~o production and t~ publlc he~h objective of ~nokln9 ce~5~o~ I~ ¢]ea~. Yet, ~ba¢¢~ ¢~Itlvdtlon I$ ~ and ~ri~u]~ur~ (]rg~tlo. h~$ p~Int~ out~ I~ i~ ran9 the fle]d crops Input rcqulr~¢nts ~I¢h m~e I~ dlff1~uIL tD $~t~ t~ other crops,178 ~P~ler$ 111 varlou$ ¢o~trie~ ~la¥~ beg~q ~ ¢~I] ~r ~ r~u~1on, a~ u~ate]y ~olIt1~n~ ~ sub~Idle~ for t~ba~co~ The first ~¢r~a~ no~ker~~ |roars and u~ of the ~u~ ge~ecat~ for a latge-~ale C~p~I~ a2aln~t
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3O8 SmOkln~ In E~rope~ SchOolS. In Ig80~ thls r~comr~fldatlon was renet~d~ and ~n" apl~,~] was sent to the C01~ISSlOn of the E~ropean C¢~nmltles |~ B~'us~,els fo~" ,* ten percent r~luctlon tn subst~le~ fo~ tobacco gTo~ers. In 1;h~ UnH;e~ .s~a~s~ the Natlonal ~ssion on ~oki~ and ~alth, a b~y of dlst1~sh~ cltfzens ap~Int~ to ~ropo~ ~tton~1 ~o]I¢¥ on thi~ subject, recommended that Subsld~ o~ tobacco in th~ present ~bacco price support s~t~ In the llnl~Jed $1.e~e$ be phase~ out over ~ ten-~eer Period.179 pawe.ts should be made to farmers fo~ not 9ro~n~ t~bacco. ~s~stlnce s~uld be ~ovld~ famers to gro~ less h~rmfu~ kin~s of tobacco. ReSearch on nor~h~mful uses of tobacco should be exp~r~e~. In June, ]~ the t~erlcan fled1¢~1 Assocla. ~lon. reversing a ]5-~ear poltc.v, passed a resolul.lon recor~r~Bdlng the e~d of f~'~eTal subsidies to L~ tobacco Industry* ~le r~sol~r~on Was IntrOduced by a 1.hl~d-~e~ me~ic~1 student.~0 M~l, hout minimizJng the cOmpl~t~es a~ problems of achieving a ¢~ange In national and inLern~ional economtc ~licy oh tObaCco production, ve may nevertheless heed these vell*coosldered recor~endetfons of concerned conscezer £~oup$. Both the ~:dO ~xpe~t Committee on ~n~ ar~ Health ar~ the ~orld Nealt;1 Assembly have urgL~J ©ooperatlon of lnternatlona~ a~enctes to achieve crop diverslflcatlon and develo~ent of substltute ¢~ops. %~aglna~Ive provl- $1on of econonlc Incentives for producI.lon of alternative crop~ may be a waS to begin to close t~ gap be~-~n econc¢1¢ ~o1~les a~d publlc health Ob~ ~¢K I yes. O~ ~C d
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Ftnland, SUpTa note 149 at 8. iS?. MaTl(etln~ and Oist~IbvLioe of Tobecco, Study pTepared b~" 1,he UNCTAO $~TeLarlet, United ~at]on$ ~onferer~e on Trade ar~ ~evelor~, 16 J~e 1~76, 1S8. B.R, Lute and $,0, ~h~lt~er, ~5~Oktmg a~ ~lcOhol Jbuse: A Comparls¢~ pf ~h~lr ~cono~f~ ~o~sequ~n~e$," ~ ~land ~ouroal Of Hed~clne, vol* 29B, F. 570, March 9. 1978~ 159. Guldel ]nes for S=ok~nq Coetro1, 2d edition, ed~te~ b:/ I]$gel Gr~ end HIchae~ Daube, pp. 1~3-1Z5~ International Un~on agatnst Cancer, 6enew, 1980, ~, p~to "price an~ Cogsum~lon of C|gare~tes: A C~Se for l~tervent~on?" Br~tt~h Journal of P~even~lve an~ $oclal Medicine ~_8:241, )g74; M,A.I~. Russell~ "Cha~lge$ tn ClgareLte F~ice and Consemptto~ by Hen |n Britain 194~ Lo 7|~" Br~tlsh ~ourn~l af Pr~wnt~ve aed Socle| ~ed~clne: ZT: 1, 1973, O~ C~
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310 161. ~, A Report frQm the Royal College of physicians of LOndon* p. 119, pt~rlafl Hedic~l PUblishing ~i . Ltd~ , T~br(dge Vells. 1977. " |6Z. Guidelines f~r ~mokin9 Control, $uwa note 159 at 124, 163. Tobacco*Ha~rds to ~ealth and Human RepT~ducttan, pO ula'~len Re rts, $er~es L. ~, 1. p. L~I, March 1979, cltl~ U~t.ed St~t.es Dep6rt~ent of Agr~cul~cute, FD~elgn AQ~lcultural Servt¢e. ~Orld Cigarette p~OdUCt~on ~nd T~ade tn 1977, Washing~n. D.C.. USD~* July 1978 {Foreign ~Jrtc~l° ture Ctrcular FT-3-78). 164. A.L. Paktala. "Living standard Influences Degree of CtQarette Smoktng. Tobacco Renorter 103 (?):55. 72* Jul~ ]976, 165. Tol~accC-Haza~ds to ~ea~¢h ard I~u~an R~pr~uctl~Jn. suwa ~oCe 163, 166. PerS~nal ¢¢r~n~lca~ion from I)r. Lars H. Re,strop. IHrector ~ener~l, t~stlonal Sr~k~n9 ~d I~.~l"ch A~so~la~lon. $ved~n. e~n~ a $~edlsh s~ud~: A* Barrol and L.H. Rmsl~ro~. "Tobaksvanorn~ ~ S~er19e" ("Sqloktng Habll$ ~n S,~edsn~) in Tobo~s~okn~nq eller h~ls~ ~. ; K~¢Scnal ~ard or- ~ealth and ~lt'ar~,, S1.0ckhOlm. 1979. 167. Personal communication frm Dr. Lars I~, Ramst~o~. D~re~tor gener~l . ~|Li©nal S~k~n~ ~z:d Health kssocla~Jon. S~eden. CJ
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311 168, p6trl¢la Buchholz, "]_egal Aspects of the Control of Tobacco," .~, Vo], 4, pp. 14-34 at 21D Spr|n~, 19~0. 169. Guidelines ~or ~ktn~ ~ntro), supra note 159 at 123. 170. CIgare1.~e Tax Law Regular.Ions of Kew Yor~ Ctt.v F~ance ~tnts~r~or, Article 2.A. upheld In People v, Cook. 34 q.Y. 2d 100. 312 N.E. 2d 452 (1974). 171. ~o~val College of Ph~/slcta~. supra note 1~1 at 120. ]72° Legislative and kcmln~Itraf:tve Action ~or Control of T~bacco-~oktn~ tn F~nlard, supra hole 156 a~. 9. 173. Tobacco-~z~rd$ ~o Health and ~+uma. I~product~oe, supra ~ote 163. 174. The Nation's ~eal~h. p4 4. December 1980. 175. HIchae~ J. Cowell. Vlc~-Preslden~ mr~J Chief ~ctuar~. State ~tual Ll~e Assuraac~ Conpan)" o~ ~aertca, vlr~rlnce Incentives and OIstnee~tlve$~ In Hea~th EducaL~n~ ~r~ Pr~otlon~ ~e~da f~r ~he El~hL~e$, A Sun~ary of an ][ns~P~e Industry r.onference oq Heal*.h ~d~catlon and promo~r~n , (Heather J. ~(otz a~ Jonathan ~. ~|e]dl~. Ed$.l, sponsored b~ the gealth ~hsurancl Association af ~merlc~ American Councn of L~fe InS~AnCQ ~ 1980.
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312 I/ho ~ttes ~r~at 4n t~fe ]nsuranc~.~ A National u~eT~lter publl¢a~lon. lgB1. 178 • 179. food and ~grtcultuYe ~9enlzatlon. Tobacco - ~e Esser~t~1 F~C~ (,,dat~). A ~ltional Dile~la: Ctg~re~t~ SnIDktrl~ GF tJ'a Health O~ ~rmrlca~ls, Re.~Jr'£ of the Nation&l C~nlSSlOn on ~okJng at~ pub11¢ F~llcy to "~he BoaTd Of Directors. A~ertcsn Center Society. Inc.. ~htllp R. Le~* ~c~tn~ Chalk- man, J~nu~ry 31~ 19?8. See als0 Wal"cer $. Ross, =Let's Stop F~[~r~tng the ~noklng Epidemic," ~orld ~okin~ ar~ He~th, v01, 5, no. 3, pp* E9- $2. A~n 1980 (a~apte~ from "Let's $~op Exerting the ~okTng Epld~lc=" ~ ~ay 1980). kn~tca~ public HeeIth Assocl=tton, W~shlnq~o~ ~et~ Letter, No. ~t p. 6, June. 198I. l~;erpretatlon of ~he Nor~glan legislation re1 tes on three articles by K:te11 ~ar~velt= Cha~n~n, It~lOn~l Cou~l on S~oklng a~d iteal~h: "The Ko~veglan To~e¢¢o Act ." Ne~lLh I~d~c~lon ~lourn~l, ¥ol • 36, NO. I. pp. 3- tO, 1977. "The Norwegian TobacCo ~c~ (Introduction)," ~_C~dlnavlan ~o~rnal of Res~l~e~or~ Dtsease~, $upp, ~o. 102, pp. 14Z-146, 197a and =Government~l ~:tlon on SmOklng a~d Ilealth," B~11. of the International Union ~]~t~st Tuberculosis* v01, 53, no. 4~, pp, 334-339, December 197B. O~ c~ `3 -3
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313 Mr. WIIITrAKER. ]n your opinion, and I will ask the same ques- tion of Dr. Koop, in ~ur opfaion what would be the most effective, and I hate to limit this to the single best method, but in your opin- ion what would be the best method in which to recommend to the legislature that we could provide a disincentive to increased tobae co usage? Dr BRANOT l think Ih~lt you have ~ split ~fait up into ]eng-lerm versus shortterm [ think the Ion~term soiutioi~ is gahlg to be for us to mlderstand why it is that people smoke, and to understand what can be done ~o assist people ]n stopping smoking. That. I think, is our best solution. I do think it has sixown remarkable suc- cess t~tus far from a whole variety ~f ways that we must begin to work on In the short term, 1 think our best api)roach is to continue to alert overybedy c~ust~lnt]y to lhe kind~ of h~lz~lrds they arc run ning. and the cos~ to our basic economy, particularly to our he~t]th care expenditures, of cigarette smoking. Let me turn to Dr. Koag, Dr. KOOP I would agree with what Dr. Brandt has said, essen- tially The words that you used, that we could iagislate, [ think limit what one's answer might be Therefor, I woul~ go along with Dr. Br~ndL that what we are doing, intensified, is the best way. | think that Lhe primary thillg T wnuld like to see accomplished if we could is to stop young people tYom starting to smoke, and the way to do that is to study the meanings or motivation, how they can avoid peer pressure and that sort of thing. But how that can be legislated, I do not know¸ Mr WHI~'JAK~I~ You mentioned in your testimony, Dr. Brandt, and I have forgot~.en which agency you refatec] it t~, but there were behavioral studies going into the origin of people beginning to smoke. Do you have any projected date or knowledge of when that study will be available? Dr BRAN~. We have two sets going on, one in the National In stitu~ of Drug A|mse. and | will ask Dr Pollfa to address that question. Dr. Po~J~I~¢. We have an ongoing series of studies, Mr Whittaker¸ It is not any one single study. We have found, along with other agencies studying this problem, tha~ wi~h regard to young people. for example, techniques which point out to them that initiation of smoking actually limi~ their freedom of choicc, rather than~ as they often conceptualize it before they get started, thinking of this as a means of asserting independence, pointing out the ]imitation on subsequent freedom of choice, pointing out that they are sub- jeered to peer pressure and helping them to resist peer pressure has been shc~wn in a number of carcfa]ly controJled studies ~o be quite effective; and further, investigatiot~s of how to strengthen and apply this knowledge are currently under way, both with regard to cigarettes and other d~u~s Mr. W~tTWAKER. Thank y~u. Thank you, Mr. Ch~lirman Mr. WAXM;t.'~. Thank you, Mr. Whittaker, It has been suggested that a major benefit of clgaret~e advertis- ing is |he promotion of low tar and nicotine brands. The implica- tion is that tfa~ cigzirettes ¢'lre so~lewh~t ~]er Are the so-called light cigarettes safe? .Q ¢¢
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314 Dr. BRANDT. That question deserves two responses. There is no question that if a person switches from a nonlight cigarette to a light cigarette without changing their smoking habits, that the risk will be reduced. However, unfortunately the preliminary evidence is thal many people who switch to the light cigaretle first i~wrea~e their consumption of cigarettes and second, inhale more deeply and therefore, expose themselves in the same dose of tobacco smoke and the carcinogens it contains. So the answer to your question is yes, they are safer if the persel~ continues to smoke in the same fashion. Mr, WAXZaA~. Is it also the case that even if they are ~aihr, you would not consider them safe? Dr+ Bm~NDT No, sir I think all of the evidence indicates that the only way you can reduce your relative risk from lung cancer, heart disease and other diseases associated with smoking is to quit smok ing entirely Mr, WAXMAN ~PI~. 5~g3 ~quJres the dJsclosare of ingredients used in the manufacture of cigarettes Does the department cur- rently have a comprehensive listing of ingredients manufacturers use in the production of cigarettes? Dr, BI1ANI~T. \~'e do not now have a comprehensive listing of those ingredients We are. however, in negotiation with represenin- tives vf the tobacco industry for their voluntary disclosure of those tO US, Mr. WAXMAN How long have those negotiations been going o~? Dr. BR;~NDT. They have been going on for several months. Mr. WAXMAN SO as of this point, the cigarette industry has not disclosed the i~gredients it uses in cigarettes to the department. Dr. BRANDT, We have not yet received that. However, I am con- v~nced that the tobacco industry has negotiated with us in good taith and is making all attempts to be responsive to our r~.tuests. Mr VgAxI~IAN. Wou d yOU agree that in the case of a product as dangerous as cigarettes, ingredient disclosure would be appropri- ate? Dr B~ANDT I think that the question really is whether or not the ingredients are harmful. [ think if the additives to ~igarettes are safe, then the issue of whether or not they are revealed to the public is one of advertising and marketing considerations. I think on the other hand, if there are additives in cigarettes that are harmful, then there is no question in my mind but that they should be revealed, Mr. WAXMAN Do you support the provlsian in H.R. 4957 requir- ing listing of tim carbon monoxide content of cigarettes? Dr. Br~XNDT. Yes, we do. I might say if I could, Mr. Chairman, on March 31, we will release the advance report from the health and nutrition examination survey, which shows the blood levels of carbon monoxide in smokers to be strikingly higher than that in nonsmokers, irrespective of location of sampling or other variables. It is clear that increased levels of carbon monoxide put you at greater risk for heart disease and for certain other illnesses. It may be that this finding will lead us to other ways to under- stand the mechanism by ~hich this occurs, but it is clear that there is a strikingly higher level of carbon monoxide in smokers than iu nonslYlOkel$. J
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315 Mr. WAXMAN. The NIDA Division of Research sponsored a meet- ing in 1979 ~ evttlu~tte whether or not cigarette smoking was an addiction¸ What was Lhe conclusion of the L~k ~rce, and do you know of any rccent eviclcncc conlradicting tlTe lusk ftJrce c~nc]u- sions? Dr POLLIN Tha~ task ~rce concluded that cigarette smoking met all of the requirements to be considered as an addictive proc ess, and to my knowledge, there has been no Subsequent evidence which contradicts that finding¸ Mr. WAXMAN. And would you describe for us the recent policy recommendation of the Nztt[onai Advisory Council on Drug Abuse regarding clgarette~ Dr. POLLIN. Yes. The Advisory Council recommended that the wording on the [abel be changed so that it include the words "Ciga- rette smoking is addictive and dangerous to your health" Mr. WAXMAN. Dr. Brandt, the Office of Smoking and IIealth has been without a permanent director for a considerable period of Lime. When might¸ we expect announcetnent of a new director? Dr. BKANCrr. i hope that we will be able to announce the new di rector in the new few months. I must admit to you that the lack of having a permanent director at this time is my responsibility. Quite frankly, we have been trying to get this report out, and that has been the whole problem. We are beginning our search in some depth at the present time. Mr. WAXMAN. What is the current and proposed 1983 budget for the Office on Smoking and Ilealth? Dr. ]3RANnT. The current contln~ing resolution level for the Office of Smoking and Health is $1.9 million¸ Our I983 request is for $2.1 million¸ Mr. WAXMAN. I would like ~o ask that an article ~om the No- vember 1981 issue of "Current Sweden." suggesting that the Gov- ernment's smoking prevention acLivi~ies have in fact reduced the percentive of adulLs and ehihtren who smoke, be mude part o~ the record I would like to share that with my col]cagues. [Pause¸] Mr. WAX~AN. If there is ne objectien, we will make it a I:ar~ of the record and leave the record open if an2~o~le should wish insert any commenLs with regard to Lhat study. Hearing no ~bjection, Lh~t will be Lhe order¸ [The ~llowing information was received fur Lhe rec~rd:l ~j
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~OVERNrlENT-AP~O[~T~D COM~I£SION PRESENTS flE~ PLA~$ ~OR A ~5~¥~A~ PROGraM pA~L ~SR~SREH co ,,j
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317 Th@ Swedish §avcr~ment began it~ anti ~moki~q work i~ 196~t Wllefl fu~id~ ~rB ~ppropri~t~d far ~bc rJr~ time to p~ovlde information on th~ h~rmful effecLs @f tobacco. A more a~bitious ]anq-~r~ progra~ involving m~ny diffever~L Lyp~ of ae~iv~ie~ ~ ~re~ented in a ~Y~ repor~ from a ~p~c~ research grodp ~n toh~cea within the N~t~onal BOard oE Health ~d ~f~r~ (Soc~Is~yrel~en~. This r~ort, ~hich ~ec~me x~tern~taon~Hy kro~n as "~der~'s 2~ year progr~ ~g~n~t ~maklng," e~t~a~ed ~ ~ajor inten~ificaLion ~ ~nform~t~a] ~ork on the p~c~m~n~ of ~rrllrlg ~×~ ~nd declara~i~e of cont~nt~ on ~abaceo pack- ages. 5ome~hat ~ter~ another la~ ~ p~u~cd ~hich i~po~ed r~n~rle~on~ o~ tobacco ~dver~islr~g. ~t ~h~ ~a~ior~al ~ev~l, ~n[orm~ion on t~c~ h~ primarily been ~h~ r~- ~pon~ibili~y ~f t~o bod~e@; thc N~ional ~ard nf He~th and ~el~are ~nd the N~ion~l Smg~ing an~ H~1~h A~oci~icn (N~tlon~if~reningen ~r u~p- ~0 non-prufi~ ~q~nizataons. An~l-tob~cco campaign~ ur~ u~uo corri~ o~ h~ o~h~r ~overnment agencies, such as Lhe ~ional Board of fdu~in~ (~kolovers~yrelse,~i. A~ the regional le~e~, they are handled h~ the county cuun~i1~ and ar~ part o~ thezr preventive ~ea]~h c~re effort~. I~po~t~nt contr~u~*on~ ~ ±nformaL~n~l ~ark ~re also ~,ad~ b~ certain privat~ ur- ga~a~t~un~, m~t no~ably the S~ed~h ~ncer 5~c~ety ~nd the ~r~-~oo[~ ~ntinq childrer~ ~nd youn~ pcopl~ from s~rLin~ to ~moke. Froc the ~ime ~J~ flr~t ~t ~heir Ice~ ma~er~i~ cnre ~enter, future p~r~r~ are expu~ed to ~nF~rn~ion oh the ~rmful effect~ of smakln~ ~n cunn~c~ion ~ith pregnanc~ and childbirth, lhi3 infurma~Jn~ i~ nffered to ~ether ~i~h pru~r~ designed to h~Ip ~eo~le ~tnp ~m~king, ~ch county th~ N~ion~l Board ~f Hea~th nnd ~if~r~ has arranged re~innnl ~dvnn~ed ~ralning c~fer~ncco to ouppor~ an~ inten~iF~ ~hese efforts, r
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6S0574739 m~c mm~ c~m~ m m ~ ~c c×m o ~m~ ~oc-~m c~a ~ ~ m m mo c~ m o~ ocx , . m.
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319 Tobacco related ~nfe~rmtlon la yaunq people ~ ~Ino provided outside the ~oho01~, fo~ ~x~ple i~ varies ~outh ~LUhS. VISIR h~s a separ~t~ youth leBgue~ currently with ~bout 10,000 members in sch~l clubs throughout the country. During the past three years a speeia~ c~p$ign ha~ also been carried out in tb~ mass media. Its ~im ha~ been LD "adverLi~ n~n-~mokin~ . In other ~ords, it has refrained entirely from mentioning the hazmfu~ gf- fce~ OF s~ok~ng and ha~ in~¢a~ ~imply p~ea~n~d **the no~ ~moking Mte~- t~ve" as something ne~, youLhfoL, ~n6 modern. A s~p~rate organization has b~n f~d fo~ thl~ campaign. ~own as the Foundation for ~ Non-Smoki~ Generation~ ~ ~ open.arid b~ the S~edi~h ~nc~r 5ociety~ NTS, VISIR, national and regional ~ovevnment agencies, insurance cempanies and other enterprises~ etc. UM~q outdoor ~csters, advertising Films in movie huu~e~, campaign newspapers, postcards, rodie and W spots, decals, campMgn sweat- • h~rt~, debates and school ~n~ee~ endorsements by ~o~th eelebrities~ rock c~ne~rts, ~nd other modern ~rla~keting tc=hn~ques, the feundaticn h~s Work emcn~ Inform~tionB1 activities are al~o the mosl ~mporL~.t element of campaigns ~gainst the tDb~Co0 ~ab~t ~mong adult~. BU~ onIy a small proportion of this l~f~rmatien is diasemino~o~ vi~ direct mass cu~l~n~o~le~ From n~tionB1 er~aniz~±ons lo the publle ~ L~rqe. ~e~o~ ~formot~n o~ the harmful effects of tnba~co i~ provided ~o smok- ers ~ia warning te×ts on tchacce packages and i~ tobacco advertisements. Bo~h ~he N~t±onal ~eard of He~lt~ and ~elf~re and NI~ as ~e~ a~ o~hez o~ga~iz~tions, el~o p~od~:ce ~eneral ~ormatiena~ ma~¢~i~l ~n the furm o~ breohures, posters, deems, book~, fil~s, etc+, ~hieh ar~ av~±~ble ~o any~ ooe. 5ometlme~ auoh ma~er±a~ ha~e been dietr±buted Free in ma~s edition,s. A few year~ a~o, for e~m~]e, ~he Nat±ohM ~oaed ~ Health a.d ~]fare pab]~shed B sm~l~ brochure entltled "~dv~e~ to ~mokera" (R~d t~l r~k~e) ~hiohwa~ distributed Free of charge via aL~ pharmacle~ ~nd po~ o~fieee ~n ~*lede~. Of course, teIevinSon, da±]~ newspapers, m~d oLher media aurl,ellme~ conducL ±nfor~at~on ca~pa~qn~ ~cout ~m~in~ on ~he~r o~n init±ative. [n the f~ll of 1980~ For e×amp]e~ 5~eden's largest morning newspaper, ~, ~ttra~ted a lnt n~ ~tte~[i~n ~th ~ ~er~es o~ articles ~bou~ the medical effects o~ smoking, wi~h ~he theme "5~oke S~ L~ve*' ]t was illustrated ~it~ p~cture~ b~ the famed ~e~i~h med~oa2 photographer Lennart NIIsson. Information to the puoJ~o also aesume~ other Forms, such ~s ~h~ local VISI~ cJubs apons~r 2ectures, e×h~bit~ons a~ lib~aries, arid the ~kv. But ~er~eraJ in~ormation is ~ot s~¢io~ent and erueiai ~n actually p~r- ~uBd~F*~ people to Stop soakir~. Fur th~ ~e~u~, U~ orq~n~za~±on~ h~ve chosen to allot ~re funds ~s bu±]dil~g up programs uf local in~oen~on. The £oea ~$ ~at ~] smakara Jr1 a ~±vec v~c~y ~ho~ld be able ~o ob taia ~nfarmali~l~ ~ ~k~n~ ~s ~11 as~elp in ~uitti~thehBbi[ -- for ~ns~c~ via ~ersona~ eo~taets~ith the ~ff Of t~r ]o~ol ~a~h eB~e cen~r ur ~iU~ ~eupL~ a~ ~helr o~n ~orkplaees. An important t~sk ie [h~s ~o reeru±~ end tr~i~ t~e "ke~ peopl~,~ ~ con e~rey out ~uch work ~n Local ~ Fat ~ number oF years, the National ~ard of Health and ~a]- ~re a~ ~eIL es ma~ oou~t~ cou~i]a have trained "~obBoco ~nfcrmetion off~¢er~." lheac are people ~ho -- by virt~e ~¢ their pns~nn as teachers or as officia]a of trade union~, study ~ssociatJons, or other "popu~ar ~ove~n~n,, -- can organize i~forne~iona~ ~c~ivi[ies and ~mp~e ~ul~smok~nq
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32O G~ Ox -3
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321 are regulated by e nunber o~ rule~ Such ~ds may not appear in wee~/ magazines ~nd the llkv which are primarily i~tn~d~d for people under 20. Nor m~y tab~nno ~dverti~e~nts appear on the sports p~em of newspapers or in sports magazines. Full-p~ge tobacco ads ~re nat per- mitted. In 5woden, one no longer ~ees tobacco ~dverti~ement6 of the glamourizing t~pe using modn1~, '~tatus objects" e~e. The I~ a~o vtipulate~ that the ~arning Ee×Ls required on tobacco packages mu~ aide ~ppeor in tobacco ado+ Smokinq on the decline Sweden ha~ n~ver been a heav~-amoking ~ount~?. The increwe in smokia~ ~hich did occur fo~lo~ing ~ar]d ~ar I[ ~nd~d a~ound ~70. Since then~ the percentage of p~ople ~ho are habitual amok~r~ ha~ declined among men end has not inc~a~vd ~mong ~omen. In ~he p~t couple o~ year~ decline ha~ also been noted among women. S~nce 1976~ NT~ has conducted ann~al~ nat~oaally represeatalivv su~ve~ nf ~making ~abits. The results show e ~te~dily declinisg pe~uvntage of advlte aged 18-70 who are smokers (see Table 1), table I. S~okl.g habiLs among ~dult~ each year, 1976-19B0, in percent 1976 1977 1978 I~79 1980 Smo~e daily ~ 34 39 31 3~ ~ ~7 32 ~I 26 Smeke occasionally 8 7 9 8 11 10 9 7 10 7 Oo~'t smoke ~9 §9 52 60 ~I ~6 5~ 61 ~9 66 NO reD1Y 0 0 0 0 ? ~ 0 0 0 0 ]he number o~ daily ~muNers ~mung rn~rm ~a~ ~ll~n conLinuuu~ly duri:~g the~e five ~ear~, Item 43~ in 19~6 t~ 3q~ in 19B0. Thi~ decline h~ gone on ~ince the ~arly 1970e~ when the p~op~rtiaa of men who ~mo~ed da~ly wan around 50%. As for wonlen~ Lh~ nun,b~r OF ds11~ srnuk~c~ h~ rel~ain~d s[atlonar~ aL ~uaghly 3~ since the early q~70~. Dur~n~ the pa~t two year~, no.ever, there has been s steady drop tc the current figure of 26%. 1he ~ercentage oF men ~he smoke ~aily i~, on the whole, larger than th~ per- centage o~ wo~en ~ho do so. This is Dr~aril~ because men, but not wo~en. include pur~ pipe and cig0~ amok~ro, The Dcrcontnqc of men and women ~ho smoke c~gsrettas is, h0~ever, the same~ 26%. Pure pipe and cigar smokivq in oreasa with u~c. As a c~nscqu~nce, a larqcr porc~at0~e of oldie me~ than ~oun~er men smoke, ~hJ~e among ~omen the smoking habit ~s the most wide spread in younger and eopecially ~iddlc ~gq~ grouse (Cf. Table 2)~ One m~ght also note that in yaang age oategorzea, S~oking is mo~e common emorg women than ~nn~ mnn, whnrna~ the oppo~ltn ~ tTun ~f older ~ge ~tn~orina. lh~re ~re ~lae subs~eatia~ d~fferenees between ~r~LJpS with different educational levels. F~r hath men and ~nmen~ ~mo~ing is cons!der~hly l~s~ nommnn ~mong the highly educated than a~ng othnr~.
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322 Isble 2. Smoking habits. 1980~ bF age and sex~ in percent A~e 1B-24 25~3Q 35-54 55 711 All M W H ~ H '~ Smoke d~ily 25 27 5q 3Z ~1 ~0 33 16 31 26 Smoke oecasi~ilally 16 13 13 111 10 5 5 4 111 7 Don't smoke 59 60 55 ~7 58 64 63 80 59 &6 Nu r ~pJ.y (3 O 1 D 1 [1 11 0 E1 O The smoking habits of the yo~nqest ~ge categories have been surveyed since 1971 in large-scale studies eonducLed annually by the Nat~oT~al 8~ard or Educmhion. These stu~zes have sho~ the folio~ing trend (See Iab]e 3). It should be observed hha~ thos~ who ace classified hu~ ~ "~rnokers" are those who answered Yes £e the qu~s£1on "Du you smoke?" In other word~ ~his category includes b~Lh d~ily aod occasional smo~er~, ~abl@ ~* Smoker~ in ~hc nine year compuls~F s~h~l, p~rcent Bo~s ~ir~ 6o~s ~irls 19Fq 14 q~ ~1 47 1974 111 12 31 ~5 ~977 9 ql Z5 ~O 1979 6 B 2q 3~ 19BO ~ ~ 21 3~ The c~eline in ~moking ha~ also been re£]ceted in the sales figures for tobacco products during recent year~. But ~ho~l~h c~ret~e sales, fnr inst~nre, ~re nnw ~]e~r]t l~wer in terms of~, tr~ ~umher of el~a rettes sold is virtus]ly unch~mged. ~ne explanation for ~h~9 ma~ be that the d~dlin~ number oF srr~ers nonetheless smoke r~re cigarettes than p~e~iously. 1his should be seen aq~inst th~ backdrop o~ ~ s~ron9 sh~ft durzng the 1970s to small, less po~en~ cigarettes, lhose ~ho st£1] srmke appear to have become note "carcfel" in their ~hoise o~ wha~ tc snoku. Ne~ piaes fo~ the fuLure A parliamentary commission of ~nqu~ry pre~e~ted a Fzn~ r~p~t in 19~1 e~titl~d "the Deolinin~ Use of Iohacco -- Final Report of the Commission o~ Tobacco.' ~ts r~s~n~enda£1ons imply a~ ~ndor~¢~nh und ~n ~u~mer~a~i~n of the £hrust of anti tobacco work he date. Above all. informational wor~ should be given greater funding, ~u~ the commission also recommends some addi~ion~] ]cgi~]otion. Broader information Host of the commission's recommendations for action ~hus concern infor- m@t~onml sc~vLt~es. ExJstin~ ~nforma~i~n mu~ be broadened in a number J C~ ¢n ~J -3 C~
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of ~aysp the ~ommie~ion bcliew~. It is not enough to provide inForm~li~ on the h~rmful ~fFect~ of t~ba~co, hut i~stead other kinds OF information ~re needed to~. For examplc~ information on different methods oF quilling 8moklngp hD~ tB deal ~tth v~rioos ~ithd~a~l ~y~pt~xms~ ~the~ ~ay~ oF ~is f~in~ the needs pre~iou~ly mel b~ smoking, etc. In th~ ~ame ~ay~ inFo~@- tion fo younq people must be b=~adened ~o that it helps the~ @void starting to ~moke. In ~ddition, there i8 ~ ~eed ro~ informafion~l aoti~ilies dealing ~ith the d~mage that o~okii~g may cause t~ y~ung pe~le, and makioq it clear by ~hat meohani~m~ people a~e persuaded t~ beqin ~oking. In g~ad~s 4-6 of the ~om- pulsoD~ School I~Oes ~0-12~, ~st pupils a~ firmly oor~irl~e~ ~ha~ they do n~t ~nt tB start sr~king~ but only a fe~ ~er~ later, ~any Of tho~ hove nonetheless done so. ~hey have not been prepared For ~ho ~ay it h~pp~ns. They cannot s~e through l,abil-Fut~ing machanism~, ~nd they h~ve received too lit~ t~aining in ho~ to choooc thei~ o~n attit~d~ ~nd v~lues and ~tand up fo~ them when subjected to peer pressures. In the s=hool ~y~tem~ health educ~tlon should be allotted an ~ven stronge~ position than oo~. ~corcil~g to th~ c~rnmission, all leaohe~8 ou£ht to re ccive baSlO tr~inlng in health education, either as pamt o? their regular undcrgraduale s[udlo~ or through on the-job ~nl~T~e~* In addition, ~ more cxtcnsiw supplementary t2~ining program Jn h~alth edun~tion Should be pe~- m~e~tl~ c~lablished, rt i~ imoortent tha~ there be posltions f~r healDi eduo~tnr~ holh ~ifh£n the s~hoo) system and Lhe county board~ oF education. ~chool p~emlses arc emong the public p~ees [see belowl ineludeo i~ th~ commission's proposal fus ~ l~ on resfricli~g s~oking. But this is not sufficient. The schools are "[he ~nvironment whore tssnage~s ~n acute danqer of begJnrli~g lo snake s~nd a ver~ large pa~t of lhcir time." The ~chool ~Lelll thus be~r~ a speci~l responsibility. Rulss on Smokln~ var~ from schoo~ to ~chool, T~C uo~rlni~ion p~OpOGCG that th~ ~u]e~ gradu~l]~ be ch~n~cd, or~ the basi~ uF ~ nation~id~ ~ecommendoti~n on "tobacco £~ schools." The National 8o~rd o£ Edu~allon uhould ~ceive greater funding f~r thn p~ po~e oF ptovidlng granL~ to cn~0u~a~e youth org~ni2~tilns to undertake special ar:ti-Eubacco procr~ms. ]hess ma? ussume the Form o£ ~ttitu~e chang- ing campaign~ such as "A ~on ~r~lukin~ ~cneT~tion~u ot Bthe~ le~s ~p~ta~Ll]~r erF0tts 9S ~art of [he ~c~ui~t ~ctivii~es Of the£~ o~ganizafions. tong lerm, pu[Jcnf in?o~ma~Jonsi ~o~k and trea~ine~t at the gress~r~ots l~v~l ~Jll yield good res~Jts~ the eo~ni~oic~ bcliDv~s. Sn~ukin~ i~ of courso, already ~n the dccJJnc. If the commJ~ion'~ ~im~ ~ ful~il]~d~ redeem th~n 15~ of Sucdi~h adults uill he uning tol~cco in 20 2ears. The "Final DbjBetj~e,, of the o~m~nnion i~ that ',use of tobacco be redu2ed to a level ~hJ~h i~ OS ClOS£ to [ot~l ~ho]~ti~n An IS practically possible," A societ~ that ~ou~e4 r~duced tobacco u~e The commi~s]on ha~ a elenrl~ exlressed desire to avoid r~tricti~e ~asures ~s m~Jch a~ possible. Out so~e res~ict±on~ ~e noncthel~s~ necessary, 2t bslieve~. One oF [he commission's demands is that ~dvert!sing by the state~ o~ned Sv~ns~e Tob~ks AU ~nd by ~Ii other tobacco CO~p~IIISS b~ subjected [o rules as strict as those ~Iread~ appllcabl~ lo uI~ohol advertising in S~ed~n. In o~he~ ~ords, a tota~ ban on Icbacoo ~d~.
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1
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~25 The tax 9~o~d also be u~ed to ptomot~ • shill ~way fruln ~x¢~i~cl¥ str~n~ ci~re~tes~ Stron9 clear, Lies should be ~ubj~cted to ev~ l~rgcz ta~ hikes ~h~n ~eak one~ The au[~1~iLJ~ should be ~iv~n po~cr to ~n ~h~ very strongest cigar~tte~ th~ co~ni~ion stales. Reduced Lub~c~ u~ a "m~@t,' ~h~ c~mmi~sio~Is prop0~l~ for ac~ hBV~ been ~t out t~ ~r~OUS ~OV~ ernment ag~, pri~at~ ~rg~n~z~ons~ companle~, ere. for ~he~z wrltt~n comments~ ~hich ~re duc b~ November I~ 1981. 0~i~ after that ma~ the C~bl- ~ dc~id~ ~he~h~r tn present a 0ili ~ Parliament u~l ~11~ ~ubje~t. Th±~ will p~h~ps ~ccu~ nD ~arli~r t~an ~h~ f~1 I~B~ ~es~ion. In any ~v~n~, the r~cu~men~i~s Df the c0mmi~i~n ~±II le~d ~ ~n~n- sJ~ied ~rk L~ ~ombat the ~ of ~bac~7 even if t~ £~±net should Th~ c~mi~ion i~ a~re thst its ~e~om~ended program ~f ~¢t~orl ~ill ~nt~il increased presgure on to~cno is~rs. But the panel bel£e~e~ that there are ~0 ~tc~native~. Ih~ h~rmful effect~ oF ~obacco are alar~in~l~ gr~t. Kno~J ~d~e ~f ~h~ is in~rea~In~ all th~ t~m~. T~lis f~ ~1~e c~n~Litute~ ~rce 0£ beery pressur~ ~n smoke~. It i~ ~ors~ to ]eav~ Lhei~i L~ thcir fate ~h~n f~ the p~blic ~ector to ~mplement ~l~ aggressive p~ogram of ~c- ~i~ ~i~ the use of t~bacco. Mr. WAXMAN Mr l~J~Jey. M~. BLI[,E¥. Dr. ~r~ndt, in response to a question ~f ~y co]- |ea~ue, Mr. Whi~aker, you indicted that statistics showed the drop in consum~tio~l Do ~ou haw those statistics with y~u? Dr. ]]RA~T. No, ~ir, [ do no~. Mr~ B~LEy. Will you submi~ ~h~m ~o us, because ~h~ is at var~ a~ce wJt~ testimony we h~ve he~rd b~re. [T~e fo]lowin~ info~ina~i~n w~s received ~br th~ record:] -d -G
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t 326 S~O~[NG PREVSLE~ICE SELECTED COUNTRIES WITH SHf~KI~G CONTROL gCTIVITIES O~ .q
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UNITED KINGDOM Surveys o{ sm0ki~g in the Unite(~ Kingdom haw been conducted by a varie%y of or ~anizations. The Tobacco Re,arch Council provides data up to ]97~ ho,~.e v ~r more ~urrent informati~1 on prevalence is provided by the General Household Surveys which are of ficiaily supported and conducted by the U. K. ~overnrnent. The per centare of smokers h&~ decllned amon~ both ma]es and females in the United Kingdom. ]n ]960, 61 percen~ of males and (~2 percen t ~f f ~males ~,ere elassi lied as smoRer$. By 1978, the percentage had deer ined to It5 p~r cent males and 37 percent females. These declines are remarkably simi Jar %o those observed for rrl ~Jly olher Countrles~ particul~ly i1~ Canada and the United St ate~, The table below pro~des prevalence ~or various surveys an(( time periods toe males and lemales irl the Ubited Kingdom, ~eIIta~e of Smokers in th~ United Kingdom iDT Males and Females for Various Years, 196(] through 1978 1960* 1965. 1970- 1975,* 197~** Males 61 }~ 55 ~}~ ~ Femal~s Q2 ~2 ~ ~9 37 Tobacco iRese~r ch C0uncil ~ur~ey ~ Getler ~ Household Survey UNITED STATES The percentage of the United States pol)utation ivho smoke cigaret te~ regularly i~ at its l~west point in many years. [n 1950 ~1ightly ~nder one-third of adults were cigaretl~ smoker~. Over 36 percent of adult males smoked (36.7 percent) and ~n]y 2~.9 percent of a4ult ~emales smoked. Corre~pondlng figures for 1979 were ~3.5 percent males and 3].i percent females. These declines a~e remarkable when they are compm'ed to figures of smoking prevalence /or 19~ ~he first year the 6oVemFnent oflJCially be1~an collec~ing nationzd ~rnol~ jn~ behevior Jnlormation, E4milar deeline~ have b~n observed among teenagers in the [ fnited 5rates. The table belo~v ~ive~ an over view o( Ion~term trends of smokin6 behavior ~or adult $ in the Unlt~d S~ates. Est}ma~ed percentage ~f regular t'Jg~r ette smokers amon~ adu]t~, l]nii~d Sta~es~ 195~ through i~$0 19~ 1965 1970 198(] Males 52.6 ~I.I ~.~ 3~.? Females 2~. ~ 33.3 31. i 2~1.9 ~b G~ Cn .J .j
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328 WEST GEI1MAN¥ Over allt ~mok~ng arn~ adults ~r~ We~t Germany has decli~d between 1~'6~ and 19~0, The percent of all adults who smoked w~s ~6 percent in 19~;~ and this decreased to #0 ~ercen~ irk 1980, D~'li ~e s have b~n more pronounced among males ~han amon~ ~em~le c[g~'e~ smoker s* I,I 1965 ~ [ per~n~ o~ males ~re regtl[ar ~i~al'et~e ~rno~tf Cor~par ed ~ 2~ p~rcent for ~emalesl ~is h~d decreased to ~0 p~Icerl~ amon~ men in ]97~ ~nd ftlr~her dec[it.d to ~ per~nt in 19~0. In f~ma]e~, ht~ever, an i~crease was noted be t'~eer~ 196~ ~d 1975 (2~ [~,rcent ~o 29 per cent) wi~h no chart~e r~ed between I97~ and 1980, The ~,~ble be~w presents d~,~ ~cx adt~l~ for th~ three time periods. Percent oi Adull C[garet t e Smokers Among Men and Women in West Germany Ior 19~ 197~ and 19~r~ 195~ 197~ 135~) Males 61 50 ~ Females 2~ 29 29 CANADA The /)reva~ence of smokin~ araon~ Canadians clQsely parallel~ that in the Un~d ~t~s b~t~l ~n Ir ~nds ~wr t~lne as ,~ell ~s the per centage of the adul~ population who srnoke, C~n~di~s~ however~ tend t~ I]av~ a slightly hi~h~r poreen~a~e o£ $caoker s th~ ~oes t~e United States, In 1~ $~i~h~]y Over ~ percenI of the male pop~JaIJ0n 20 y~ars of age allcl Older were teguJar ci~aretle s'~oker~ (~6,2" percent), By 1~7~ thi~ had declin~ci ~o ~,~ ii~rcent and by 1979 ~a~ lurlher decrease(l to ~0.~, The decline among females, however, ~s r~ 5ee~ as ec~am a~ic a5 amon~ m~les, a ~rend often ~o~d in other cou~Iies~ [ncludin~ the United Sta~es, For females 3~,9 p~rcent were r~lar d~are~te ~moker~ in 19~6. T~S decreased ~ 32.fl peTcent in 1~75 and 3fl.7 pelcent in i~79. Similar ~li~e~ were n~teel am~n~ teenagers in C~n~da (~es ~5 t hnau~,h 19)~ I~ovs te~d to have slightly hi~e~ percent a~es of ~moker s in the teena~ greuo ~mpared t~ f ern~]es, however, this gap Ix na~r o~ln~ Wlth girls ct Jrr~nt ~y srn~k~n~ a~ approximately the same tale as boys (i.e., 29.5 perc~n~ versus Z~ percent) P~tcent ol Regular Ci~rett ~ Smoker s in the M~J~ and Femal~ Canadian POpulation ~ Years of Age and Older 1~66 ~70 197~ 197~ Females 3e, O ~3.6 32.~3 3D.7 t~ O
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~T 329 ~ED~4 The percent of the adult populat[o~ in Sweden who are cigarette $~okers ha~ declined over ~he last live year period* [976 through 19$0. This d~line has been observed ~or both males a5 ~II as females. Malm~ have shown a steady, consiste.t dmeline Item ~3 percent in 197,% to 31 percent in 19~0. Corresponding lig~lre~ lot temales are 3L ~uld 26 percent* [n ] 970 ~he prevalence of ~oily smokir*g among smokers was ~2 percenl add lot fer, lales 3~ percent. Th~ percentage ol cigarel~e-only streakers among m~les was ~6 percent in 1950, ~he same cigarette smokinK rate as for l~m~les. Ado]es~l ~moki~g has also decI~ned over the period 1975 through 1979~ ho~vev~r girls are ~moking at higher rates than boy~, a trend noted in sevepal other countries, ir~'l~di~ the United States. Twelve percent of 13 year old h~vs srooked in [971 respectively. In Ig7~ 32 percent of ~6 year old boys were ~mokers compared to ~ per Cenl el girls. These ~igures had decreased ~o 21 a~d 3~ percent for males and le~0a~es re~pe~'tive/y i~ 1979, Table 1 add Table 2 give these a~ well as ~i~ures tot Jn~rmittent repot ring ~eriods ~er the ~bov@ grc~s. p~p~la t ion~ a6es I 8 to 70 years of age~ 1970 to 1980 * 1970 1~76 1977 1978 1979 19~0 tAa[es ~ ~3 39 3~ 37 31 Ferlales 3~ 3~ 31 3~ 32 26 TBh[e 2 percent o$~Qo~eseent sI~d@nT fmo~els ages 13 and 162n ~eden for 1~7~ 1977and 1979 197~ 1977 1979 ~oys age 13 [2 9 6 5oys~agel6 ~2 2~ 21 Girls. age 13 I~ IL $ Girls ~ age 1~ ~5 80 3~ *~ales = includes ~mc~ker s ef p~es, eigar~ and dgarette~ Females = Cigarette ~mokers only
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330 Mr B~Y. Dr. Kocp, do you not think, in the final analysis, that the ~n~n tha~ warning labels ba~'e not been as effective as they might is that when people m~lhe the decision to smoke and they go to tee macktue, they are just ~.~tarestexi th gettir~g their brand. They have already made their decielon, Much the same as you ~aid that your father would never quit, they have made thi~ decision and they do not stop to read the warning labo]s an)~vay~ Dr. Koop. My fauher has been dead for about 20 ye~trs. He never l~ad tee advant~'tge of a warning ~ahek l have no idea how he would have responded if he had seen one, especially if he had seen one teat wa~ ~pecif~c a~l ~.a~ked abuktt cancer ~f tEe lung ~r emphy~a- F/1EI. Mr. BLII.EY In fact, you do r~ot k~ow how aayone else would re- spond if they see one, do you? Dr. KooP. No, I do not. but I do not think---- Mr, BLILEY. Thank you, Dr, I¢oop. That is all of my questions. Mr. WAXMA~, If the genfieman would yield to me--- Mr, BL~L~ ~ ~OUld be glad to yi~fld. Mr, WAXMAN Dr. Koop. did you want to say anything m~re? Dr. Koap. [ just wa~ted to say that I do uot te~uk we can ~ay flatfoatedly that the war~ing on ~garettos h~s no~ bee~ effective. Mr, WAXMA~. Mr, Whittaker Mr, W~rerAKER. Thank you. Mr. Chalrm,~. I, too, wanted Dr K~op to have az~ opportuni~ to finish hi~ answer. Mr. W~MAN. G-eritlem~, thank you wry much¸ Thi~ ~est~rnony hm~ been ~ery helpftlh I want ~o congratufote you on the work you are <l~t~g ir~ th~ area, a~d I hope ~ve ,n~l be abfo ~o w~rk togetEe~ to t~y to deaI with this preve.~tab]e cause of so many serious ilh ness~.~s in this country. Dr. BRA~DT. We will be pleased ~o work ~vith you. Thank you. Mr. WAXMAN Without objection, the testimony of Glenn G, Me- Namara, M.D., president of ~he American College o[ Cardiology, will be made a par~ of the record. With no ~bjection. that will he the order That conclRdes otlr business today. We will meet tomorrow at 9:45 in room 21~3. We stand in recess. [Mr McNamara's statement and additional material subrni'Red by Chairman Waxm~n follow:] -d
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Amerlcan CollegB of Cardlolog¥ STA~ENT H.R. 5653 ~res±d~t ~or~c~n Colle~e a£ C~rd±ol~rly ~oncrablG Henry A. W~
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~32 Dear Mr. Cha~a~ and Members of ~h~ S~c~itt~e: I ~ Dan G. M~Na~arat M.D.r F.A.C.C., Professor of Pediatrics a~d Chief of the Card±olog~ Section, Baylor College of Medicine ~nd Texas Childzen'~ Hospital. I am als~ President of the American College of Cardiology, ~ professional m~di~al ~pe ~ial~y society ~presen~inq ~ver ~1,5~0 ~sician~, ~ci~tis£~ ~d ~d,~c~t~r~ who ~.ci&liz~ i~ di~ea~e¢ ~f the heart a~.~i~culahor~ system. ACC is dedi- ~ate~ to ensuring ~ptlmal c~re for persons with cardiovascular ~isease and those with the potential for d~velop~ng cardiovascular disease ~nd, ~r~u~ educational and s~cioec~nomi¢ activities, ~o contri- bute signiflcantly ~o t~e prevention of cardiov~s-
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333 cular disease. It is in my capacity as President of the College that this statement is made on H.R. 5653, the "Comprehensive Smoking Prevention Edueatlon Act of 1982." One main concern of the College is whether consumers receive sufficient and accurate information on the deI~nstrated relatio~shlp3 betwee~ cigarett~ smokin~ and cardiovascular disease. The College believes that consumers are prcvlded with insufficient infor mation oD the demonstrated relationships between cigarette smoking and cardiovascular disease and that this lack of information weakens a physici~s role in alterinq a patientts smoking behavior. AS the Federal Trade Co~%ission noted in its "Staff RepQrt on the Cigarette Advertisinq Investiqation" (May, 1981), which we co~ented on (attached), a "substantial portion of the public remains uni~- fo~m~d about the hazards of smoking," and that FTC tests "indicate that the (current) warDinq is neither ~oticed nor read by the vast majority of people.~' Even thouqh the current warnlnq indicates that the $~rgeon General has determl~ed that eiqaFette smoking is dangerous to onels health, 17% of all s~nokers and 24% of heavy smokecs do Dot know that smokinq
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884 is hazardous to health. Additionallyr as noted, consumers themselves agree that the current warniDg is inadequate. Why not provide the pLtblic with the type and quality of information souqht? As the FTC report notes, nearly "two out of every three questioned during the 1978 ROper survey f0r the Tobacco I~stitute, believe that the current warninc is not "adequate" and indicated they preferred a health warning that describes the specific health risks of smoking." A 1978 Gallup survey of smokers and nonsmokers found that 32% were not aware of the statistical r~l~tionship between cigarette smoking and heart att~ck~ that 37% of smokers did not kn~ this relationship; and that~onc heavier smokers, 40% did Dot know the increased risk for heart attack associated with cigarette smoklnq. The 1979 Chilton Study, conducted by the FTC, found that 25% of the general population and 31% of smokers did Rot know that smoking greatly increased their risk of heart attack despite research that concluded that it doubles a person's risk of heart attack. In addi- tiont const~ner k~owledg~ of the relationship among ciqarette smoking, birth control pills and heart -J
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3~5 attack is low, despiLe the fact that women who smoke and take birth control pills have approx imately ten ti~s the risk of a heart attack of wo~en who do n~ither. ThereforeI tho College agrees that th~ c~rr~t cigare~t~ warning is not effective relativ~ to ~ p~bli~'s ~ed to know and ac~ on th~ stro~q sclentif±cally-validated ~tatlstical relationship between cigar~t~ smoking ~nd ca~dlovascular disease. The College agrees with the need to improve on the type and Content of the required ciqarette war~ing labels. Therefore, in r~viewing the FTC r~port and its Co~l~sions, ~he College ~ildorses the concep~ of rotational warnings as be~g more effective than th~ c~r~nt w~i~gb The College b~lieves that the labeling approach ~nd sp~cific warnings contained in H.R. 5653 (as modi- fi~ b~l~ ~or s~ient£~ic ~ccept~bilit¥} will ~sslst consumers in making conscious, more inforrm~d deci si~s abo~L s~king~ because they Will have more de~initive information on the specific health con- sequences o~ s~okin~. ~his typ~ Of info~ation~ al~o,w±ll assist cardiologists# other physicians a~d G~ ~q
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336 other health professionals in co~unicat±ng the risks of smoking to their patients. The College would rcc~r~end that "Warning: Cig- arett~ ~moki~ i~ a M~j~ Cause ~£ Heart Disease" be amended a~ foll0ws~ "Current scientific ~vldence indicates that Cigarette Smoking is a Major Ri~k F~¢tor ~or Corona~ Heart DiSease.~1 The Coll~e would also rec~nd ~hat "cigarette Smoking may caus~ Death ~r~m ~ear% Disease, Cancer or E~ph~sema" b~ revised as follows: "current scientifi~ evidence indicates that ciqare~te smokers are predisposed to suddent death," and "current scientific evidellce indicates ~3~t there is a significan~ rel~tionshlp or emphysema." I~ addition, the College believes that one aspect of the wordlng of t]~e bill relat±nq to the coordi~ authority o~ the Secretary tc c~rry out t~c pro~ visions ~f this bill through grants, may ~eed clar- ciqarette smoking ~ff~cts being conducted by NHLBI, NCI and other Institutes a~ NIH~ If coordination ~e~s ~e i~ffplementatiD~ o~ ~ systematic ~hanqe
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337 of information On the research b~g ~pported by different &genci~st this would be useful. If, howevert the ~urpose is to provide the Office of Smoking and ~ealth with authority to direct the research of Institutes, the College believes it w~d b~ ~.a~r-p=~d~cti~e ar~ ~n~irahle. However, authority to c0nd~ot typas of research that do not =all clearly under the autb0rity of the categorical Institutes Gould be appro~ria~ for the o~fice of Smoking and Heal~l. Examplos of ~ch ~i~ b~ i~ ~oy!nq n~ti~nal trends of ciqarette co~s~pt$on in different aqe groups, $~rveilla~ce of the composition 0~ tar~ micot~ne~ carbon D~o~oxide and other potentially harmful constltue~ts of ciqar~ttcs ~n~ maintaining the periodic re~ort~ng o[ new research findinqs. In addition, the Coll~qe also believes that the Congress should revie~ all Che cuzr~zt ~ate~J~l on the connection betwecN c~qarette s~okin~ a~d the costs to society through i~crcased ~edical costs an~ rmduccd pro~uctlv~ty in Order to provido a basis for further ¢iqarettc s~okln~ prevention efforts. I trust that these co~ents that relate to our s~pporh for yo~r efforts in this area will b~ of asslsta~ce to you an~ the Co~it~ee. We would be pleased to provida yell with any other assls- hanc~. O~ &n .j
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A,,,~J Drug i,b*,~ ~d ~lr~ Ls, 19~Z ~en~lH~i~',~,~
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L~ 339 ~ ~isherl L~D
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340 NATIONAL TNST~ C~ ~UG ABUSE ~CIL~IC~L ~VIEW 0.~ CIGAP~ SMOKING ~ ~ ~DICTIO~ Thirdly ~ud ~r~day, AUg~ 23 a~d 24, 1979 T EFIN~ ~pC~TI NQ~m~n A. Kr~ne~r~ Ph.D. INTRODUCTZON T~ l'~po~ ~u~mm~z/zls th~ T¢chni~ Re~n~w ~n c~arette Smo~u~ a~ Add~ctmn that lOOk place ~n Thursday ~u~ Friday~ ~u~n~s~ 23 aud 24, 197~. This ta~k for~ me~/ng was sponsored by the Na~/onal In~luI~ ~n Drug Ab%~se (yLDA), DiW~n of Re~ch, [~ ~val~at~ the s~i~nt~i~ e~udence th~ ex/~ts fo~ and a~'a/nst cig~r~t~ smoEi~ ~ am ad'J~c~cn and ~ arrive ~ ~ con~n~s on ~ qu~t~n ba~ed On ~h~ avai~l~ scicn~fic ~den¢¢ ~a~ro Sy~I~m~, Inc, ~a~is~ed N[DA ~n ~he ¢omd~ct of ~h~ meaun~- Thi~ • u~/uary r~port w~ w~tt~ by Dr Char~s R S~hu~t~r ~f ~h~ U~ver~l!y of Ch~caEo The App~nd:x p~'escat~ ~.h~ a~'end~ f~r the mee~in~ ~u~ ~ I/st ~f the CD .J
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341 T~CKNICAL p~EVIEW ON CIGARETTE SMOKING AS AN ADDICTION: ~2OP~T ON TI~ TASK FORC~ O~ SMO~lg~ ,,d
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3~ that ob~e~ed ~th ~c~hol ~d h~m use It ~ Of ~rest Io n~l~ ~E iudl- vidur!s Y~bo us~ h~lh herom ~nd cig~re:~es r~po~t that rh~y would ~h:d i~ ~a=ier =+ DE~INITIO:N" OF ~rJICTION AND AN ADDICTING SUBSTANCE Before p~e~chn~" T~ consider whethez curr~nt evldence aJ/ow~ ~he ca~e- gor~aT~or~ oi" cigarette smok:n~ as ~n ~dCacT;on, we must de*#~ lh~s t~m [~ ~ ~;~a~t ~ens~, ~dc]/cT;on is a state ch~r~le.~zed by ~he repe~i~d ~io~ ef ~ ~ub~t~c~ tha~ ~ t~-c ~ud le~ds tc ~:;~irabl~ socL~l ~cnsequences ~h!s ~h as abuse, habi~tlon, ~nd depend~nc~ An adch¢:h]g ~ubstance is ~e that has: (i) pharma~o~g~cal pro~r~es ]~adlc.~ Io ~m~i~e u~e; (~) ~ Ca~° ~>~hly o[ ~roduclug or~Bn ~r~d/~r b~h~oral ~ym~ity; ~nd (3) ~ use parley. ~s!oc,~d ~lh ~dver~ so¢~ c~nsequer~c~ In ~dd~Iiom, this lerm :! ~euer~l~y ~ph~d ~hen th~ u~$T~n o~ such subtracts is viewed h~ ~ Lirg-~ ~e:t ~f ~h~ society ~s u~$~rable 3. A.~I~ALSTUD~ES -5
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ii 343 Ther~ has a2~o been hm~[ed r~e~rch on a¢~u~ ci~ette smok~ ~ sni~a~s r~ther spora~c fashion. CerVera animal, how~, ~ regularly smo~:e and oh~alu ~e blC~d I~V~L~ compar~l~ ~ tho~e ob~d by h~xaan c~are~ ~mokers. 4. HUMAN STUDIZ$ Although it u~ $~D/ not unequivocally dear that n~co~i~e is ~he only a~ent r~sponsihle fo~ the development of physics/ dependence on toSaceo or ~he mau:. tenan~ ~f ~mok~n~ heha~or, it is c~r~an~ th~ le~ding c~nten~er, pr~o~ of n~cotu~e*s prlmary r~le stlq3 ~w~dts a d~m~ns~ra~on thal ~he ~i~ar~ ~iLhdrawal syndrome i~ s~mlL~p ~ ~he n~c0~ne ~vi~hd~aw~l syndrome¸ How~verl there h~ve -4 -j
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~44 been ~.wer~ studies ~mpllca~iug ~otane's role n% the ~bj~etRv~ aspects ~f ~ok- mE as well as the frequency. For Inst~ce~ subieets have hee~ ~n cigarettes withcul n~co~ne (or ~h ~r~tl~ diminished mc~Lne) and ~hey fro/ to report the~ ~Iston%~ry enioymei*~ of s~;klI%~.. Some subiects ~e~m to enjoy r.he ]ow- m~oli~e cigarettes, but tE is po~e ~hat L~ey are able to ext2act more nico~/ne by chang t~e~ man~e~ ~f ~olcm~- (eg, Lncrea~ed ~nhalat~n) ~o~er type of ex~erlment in~o]v~s delivering nlcotlne t~ su~ject~ vla ~o~her route ct adm/nL~trst~on besides ~/~/al/~n. $~/b!ects ~f these exper~en[~ do ne~ ~xpefl- once the IIS~tA dew'Tee of s~r.sfact~on Lhal t~ey ~et f~o~ t.~elr =~$tomary c~a- re:~es, aluhou~h u~ some instances ~he~, do ~c~ort some set.faction from L=e n~cotme F~r~er e~denee =nplic~in~ the ~'le o~ ntc~t~r.e in c~gare[:e s~ok~g is p~vlded by ii~ ~n~d/~s that have d~mecdv ~leas~rad ci~'srette smo.~ behaver These sD/dlcs ha%.~ shc~Zn: <i) ~ncre~ses cr descraases in n~coIlu.e dose ~ ci~are~ss are associated ~-{t~ compeflsarory chan~=s in smokul~ which lend to mam[aln n~cot~ne blued l~vsl$ wiuh/n certaln h~its; (2) ma~pulaL1on of ur~ary excre~on ~f nkot~ne eiLhe~' upwards o~ iO~TI~]a/~dS is ~&ISO assoc~led w~th ~pensat~ry changas ~ ~mo~E wb~e~ ~end ~ ~a~II~dn =/co~ine blood level~ ~nth~ cel'tmi~ limits; (3} l~rOtreah~ent ~nth nico~ne (u%tr~veno~sly or crazy) produces c~mpen~r~ry decreases m smokang; and ~) pre~rea~mea~ wlth a o~coliue anta~n~s~ produces elevation in $~okiug. ~. ~Y$1CAL DEp~qBE.NCE A~D TC~LKg.A.NCE AS wlth o~er classY; dm/g~ of ab~e s%~ch as the op.oids ~d sedat/ves, Io]era~ce ~d pbyslc~d d~pendence are import~n~ chal'~clerlst~cs of a drug becaus| they ~ay exaeeeDate Lhe USeC'$ leudency to contmnue i~s use. Tolerance, for in$~ce, eedi~c~,s the ph~rm~co~Jg%c~l effecz~ et drugs mad may /Cad to ~ore frequ~t ~d~2a~/on o[ b/~her doses of ~.he d/u~, whach ~r~ [%%rn rosy prod.co Treater ri~ks of ~x/mly or uu~ward effects ~n ~he use~ Tole~m~ce has b~n d~monsTmsted for t~e effec~ of smoki~ ¢i~are[~es and a/~ to the ~fee~s o~ m~y of the components of cigarettes Nause~ ~nd o~ CA
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345 d~2~xe$$ L~ co--On among= ~ovvce smelters, b/it ¢L~appears ~th. elf!~erfenOe Metabolic ~Ivr~e c~ be d~onstra[ed ~ smokers to yarners compo~er~t$ of cigarette smoke (e g , zlicotSr~e+ "tar". benzypyrene, carbot~ monoxade, other ¢o~pounds) as wtll as to a ~eTe vazaety of drugs suck ~s barbit~%es a~d chlorpromaz~ae. Receptor ttolermnee can be demenstraled :~ some extent to cer- ta~ e~rap~aents of tobacco 5make. For iastaz~ce, rAeeune laven intxave~r~usly haJ been sho~7., to have a greater physlologlcal effect ~pon nonsmokers ~*n on mmvkers ~im~Lar~ ~e]era~ce ~o ~eil~x~Lv, ~u~.h as acX~i~5 [e~ei, ~az tee'~ demonsIc~ted ir. ~ ~de ~r.e:y of s-~x~a: ~uc2es I3elz~x~ora3 ~o[ecan:e :o nice- :me Mso ass bee~ demo~$~ra ed in m~L'n~, ie aramaic l~r. :o cora~e~s~te f0$ decrements ua performance ~lazle ux=der ~.e mf3uenee a~ ~he drug. There is al~ evidence of :phT~mal dependence to I.~bacco Clear ii~s of wtthd~aw~l appear ~nea heavy smokers abrup[3y quit, el=hough there ~ppe~rs to be ¢or~$iderable *'alaa~illty m tts mmzlf~st~tl~;:. ~lhen ~ s~oker stcp~ ~m~I~=ng suddenly, he/sht~ frequently" shot~ a decrease :~1 hear! rate, scmetxme~ ID ~:ood ~r~ssure, az~c. a decrease m excreted ep=le~:,rme mad ~erep~epnrnae ~d ::s metatloi2r~e~ Ocl~er e~adoci~a~ol~acal eha~ge~ may aide o¢c~i" Furtherm~'e. there i~ ~ decrease m me~ E~G frequency. ~ xr~crea~e lZi appetite ~flad ~e~glzt) a~l a~ ~pa~m~ez~t ia performmace on psychemo[or ta~ks end m eonoe~rr~on I]l~tUrbazxees ha ~ousal atua sleep may occur; a2aci ma~e~, irvat~bility, m~d ~ecreases wath time Despite ~ reported L~crease la cr$ving, the ext$zzt to w]alch physical dependence o~ tvbacco or r~¢otlme iaflue=ct*~ the frequency of ~ok~ag- ~e~ lo be detetmxl~ed H~ma e;~pe~me~ m~cate that, fvlIowing per~od of depz4v~t~a, irriLabillty a~ad t.he probabllfft~" of smoking m~e~se I~ ~o~mar~, although e-~:~eeimenta] findings are limlt~d, it ~ clear tha~ tolerate a~d pi~'sical depen2~nce do occur w~th cigarette smo3ung, but the rol~ they pla~ in ~e rnaintenzmce of s~ol~zlg remaxns to be e~l~lOrecl. CIGAIq~TT~ SNO~NG AS AN A/~DICTION IT "aould se¢m c3ear from ~he e~dence presented that tobacco smoka~-g p~= d/~ces pharmacological eff~s ~'ba~k ¢$text lead to c~mpuL~i'~e use A~ sl~ted O~
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346 prewlQusly ~ ~ur def~km ~ adchc~n, it ~S necessary ~o d~m~nsLrmte That an ~ddic~g sub~t~J~ce p~d~s 0~ ~dlQr beh~or~ to,nelly AlIhot~gh ~e acute behav~r~l effects ~f ~okiml~ s~e m~d m c~m~arl~c~ to those produced hy most ad~c~ug sulzst~ces, the mul~p[e delete~vua heath effects of c:g~re~e ~mo~g, including m~r~d~t~y azd c~L~ab~ty ~ ~he~r ~t so~ial coas¢o ~uemces, ~re no~ wel~ establLshed~ Fe~ quesldon that t~e regl~Llc USe o~ ~oBacc~ leads to ~ w~cle r~uEe Of org~'~ to~c~I7. CONCLUSION~ I~ was lhe open of the ~p a~ler re,~e~cg :he eWde:~ce c~ard~c~ ~he compulsive u~e, ~T~e lox~¢iIy, ~d the adverse soc~ cvn~eq~emces, thai c!~'arei~e smol~ng behavior should be considered a for~ ~f addlc~on, a~d tobacco ~ the ~ ~f cigare~es, ~ addic~nff s~bs~ce 8 :MPLiCATIONS REGAI{DI~'G CIGARETTE S)IOKiI{G AS A_~- ADD[CT[O~ (I) T~mon¢]uded that clg~re~te sz~o 'k~=g is ~n adddct~n. The hr~ade$~ /ml~lica~n ~ ~ ¢oz:c~u~r~ is tha~ ei~ar~I~e s~k~u~ ~h~uld r~w ~e r~.~.am/11~ /n I/ghl o~ the r~ ~f ~o~cy ~on~id~raOo~s which a~ preseatly con$/d~r~d ~r~zu~e ~o the c~s~i~ fo~ ~ dru~ a~dicra~n ~u~.~ (2) G~'ea tha~ ~a~t~e smokln~ is ~onsider~d an ~ il could be ~ou~d allow the apl~Ii=ahon of th~ m~hods ~nd conceptual ~mulatlOn~ ~ pubhc health ~ he a~i~d to the smok/n~ prolalem. (~) B~c r~$~rch e/forts ~h~uld 1D~ ~eu~ed on the anal~si~ ~f cigarette b~hav~" ~n h~ns. Re,earth pr~r~m~ shoU2d eluC~da~a the nauo~ and ~/on of c~Ea~ett~ sm~k~u~ behavior. The l~hS O~ n/c~Line ~n th~ irmt~/~n ~d ma~tenance of ciEaretle smok~g shollld be explored ~fects
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347 (4) ReseaJ-~h On ~svc~o~cu~ m~ue~ces ~hould not be de~m:~has~ed, but ~h~ rep~rl has 5tx~r~l~ed the T~c]:~lc~tl ~¢~lew Dn C~'~lze Smol~" a5 Ad~n Addl~nai ~f~a~1on ~out the me~tl=~ m~y be obtained from Dr pier~ ~ema~t, REDA Oi~ion of ~s~arch. O0
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348
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349 ~c~ ~ ON CrC, A Rz~rx SmO~C'A S AN AD~C~ ~C~ ~ Re~t~ M,D. 9~--387 0 1 ~2 w ~3
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350 [Whereupon, at 9;55 a,m., thc subcommittee was adjourned.J
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COMPREHENSIVE SMOKING PREVENTION EDUCATION ACT OF 1982 FRIDAY, MARCH 12, 1982 HO[)SE OF J~E]PRESE~TATTVES, SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT, ~OMMITTEE ON ENERGY AND ~OMMENCE, W~Lvhington, DC. The subcommittee met, pursuant to notice, at 9:50 am., in room 2123, Rayhurn House Office Building, Hon. Henry A. Waxman (chairman) presiding. Mr. WAXMA~. The meeting of the subcommittee wfi] please c¢)me to ordei, Th~s morning bpgins the third and final day of public hearings on the Comprehensive ~moking Prevention Education Act. Yesterday we heard from the Department of Health and Ihman Services, which on behalf of the administratiou indicated their ~up~L't fur this legislation. The administralion I~ow joins a large and growing number of Congressmen. Senators, and public health organizations in support of a bill of immense importance to the public health of ~his coun try. I would llke at this time to expross the subcommittee's ~lpprecia tion for Lhe many letters oI support we have received from volun- tary" health organizations all across the country. These letters, in addition to tile written statements of organizations which due to the time constraints were unable ~o present oral testimony, will be made a part of the record at the conclusion of our hearing Today we set aside time to hear from representative~ of the t~ bacco and cigarette manufacturing industrp. Witnesses invited to testify were recommended by the Tobacco Institute, a Washington- based trade as~)ciation. Our first witness is Edward A. Horrigan, chairman and chief ex- ecutive officer of the R. J Reynolds Co. He will be accompanied by Horace R, Kornegay, ~muel B. Witt, and Larry Light. Would you please come forward~ Before recognizing Mr, Horrignn for his statement, I understand that Mr. Kvrnegay would like to make an opening statement. I am pleased to recognize you at this time and welcome all of you to our subcommittee hearing. (351) g~ -5 ",5 ]L
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352 STATEMENT OF EDWARD A. HORRIGAN, JR., CIIAIRMAN AND CHIEI~" EXECUTIVE OFFICER, R. J. REYNOLDS TOBACCI) CO.. ACCOMPANIED BY HORACE R. R/)RNEGAY, CH AIIU~IAN. THE TO- BACCO INSTITUTE. INC,; SAMUEL B. WpPT IlL YICE PRESIDENT, SECRETARY, AND GENERAL COUNSEL R. J, REYNOLDS T(IBAC- CO CO.: AND LARRY LIGIIT. PH.D.. EXECUTIVE VICE PRESI- DENT, TED BATES WORLDWIDE~ INC. Mr. KOgNEGAV. Thank you verb, much, Mr Chairman. I appreciate the opportonity to introduce the spokesman fi)r our panel. It is a privilege for me to introduce to you and the suboom- mittce the chairman of the executive comlnitt~!e of the Tobacco In- stitute. Edward A [{orrigit~, Jr. Mr, II~rrlga~ is also the chairman and chief executive officer of the R, J Reynolds Tobacco Co. and executive vice president arm director of R. J Reynolds Industries He is a graduate of the University of Connecticut and the Hat yard Business Sehooi's advance management program During the K~roan c~nflict, he ~er~ed a~ al~ Army infanlry ~ffieer and received the Silver Star, Purple Heart, and combat infantryman's badge. He entered the hu~ineas world in ]954 with Procter & Gamble and fhen later became vice president of T]lomns J Lipton, Inc. He then moved on te become chairman of the board and president of the Buckingham C.brp, Ke j~d~ed R. J. Reyn~td~ Tobacco Interna- tional, Inc, in 1978 as chairman and chief executive officer and was promoted in 19~0 to chairman, president and chief executive officer of R. J. Reynolds Tobacco Co. Mr. Horrigan ha~ received many husines~ and philanthropic award.% among ~'hteh are fi~c[uded ~he prestigious K~ratio Alger Award, the American Jewish Committee's Award, and the Pop Warner All American Award for service to youth Mr Horrigargs activities as a civic leader include director of Sulem College, the board of visitors of the School of Business Ad- miai~trattor~ at the Utlt~ersity of C~m~ecLicu% and as an honorary board chairman of the Touchdown Club of America Mr. Chairman, it is a pleasure Lo present to yoll and the subcom miztee Mr. Edward A. Horrigan, ,Jr. Mr HoaamaN. Good morning, Mr. Chairman. Mr. KornegaF has it~treduoed me t~ the eommRtee a~xd y~u have i~groduced those members to the panel who will be assisting me here in our presen tation this morning. My name is Edward Horrigan. I am chairman and chief execu tire officer, R. d Reynolds Tobacco C~ and the chairman of the ex- ecutl~ ~ corot rio. ' . 'tree of the Tobacco kt~ttute, mx association <If tobac- co manufacturers. With me today is Horace Kornegay, chairman of the Tobacco [n stitute; Larry Light, executive vice president, Ted Bates, Inc.; and Sam WitL vice president, genera] counsel and secretary, R. d. Reynolds Tobacco Co. We are here at your invitat on o express he ndus r post on on I-~.R. 5653, the'Comprehensive Smoking Pre~enUon ~ducation Ace of 1982. 1 respectfully submit that tEis hill is um]eeessarE because virtu- ally everyone is aware of the claimed dangers t)t smoking. The bill also represents a waste of taxpayers' money because it would re- .,I -O ,,3
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, H ,,, , ,i, ~0~9
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g~ Yet consider the language of some of the warning labdels pro- posed in this bill. "Cigarette srnnking is the number one cause." "is a major cause," "will injure." What credibility can such statements have in view of the millions of people who have smoked througbout their lifetimes and have not gotten any of the ailments mentioned, and the milfion~ who have not smoked who have gotten them. The tobacco industry is recognized as a leader in ~eking the an- swers to the questions regarding smoking and health In the past three decades, the industry has committed, without fanfare, over $1110 million for unrestmcted smoking and health research, spend- ing gvealer than the tobacco-relattd research expenditures of all the voluntary health agencies combined As worded, the bill purports to settle by congressional edict evolving medical and scientitic controversies, Therefore. it may divert scientific taisnz and resources from the basic research neces sary to solve the enigmas of chronic disease We are aware that there have been some effort to build support for this bill with claims that its poovislons would serve as a deter- rent to ~va~king amend yotlng 9eople, and that i~dustry advertising and promotional practices are intended to encourage youthful smoking. Such ~harges are without foundation. Last Friday, two w tnesses speak ng in support of tb s b 1 --Mr Keeshan and Mr. Forsyth--both acknowledged that peer pressure and not our advertising provides the impetus tbr smoking among young people. Expert testimony this afternoon will slm~v this belief is correct. Our ae]vertislng is targeted at smokers and is intended to encour- age switching from competitive brands. The available e~qdenee clearly shows that our advertising is not designed to attract new smokers of asly age and is not baviug that effect Our industry has acted responsildy in the past and we see no reason ~his bill is ~eeded to Parther regulate our advertising prae~ tises. At th~s point, 1 will return m specific provisions of this bill. Our objecLions to them are stated in detail in om written submission to the committee, so I will only highlight some of tbem now. The rotattional warning labeling requb'eraent~ this bltl prapeses are technically unworkable and unwarranted. There are now ap- woximately 209 cigarette brands and brand styles on the market, With new brands being added and old ones withdrawn regularly, and vast differences in sales volume and advertising patterns, it would be virtually impossible for cigarette manufacturers or the FTC to insure compliance with a system of seven rotating warnings tn appear on "substantially the ~ame number of brand~" at any given time. There is also nn reason to believe these multiple warnings would increase public awareness of smoking and health issues. There are persuasive arguments that such a system is not working in Sweden, upon whose system this prol~sal is based. In fact, accord~ lug tu the Swedish Government, cigarette consumption b~s risen there annually sin~e the new system yeas imp emented in 1977 The bl]l's requiremei t of disclosure of *'tar, nicotine and carbon monoxide levels un packages and in advertising is unwarranted~ -d C J1 J
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~55 **Tar" and nicotine Ievels have been readily aval]able to smokers in every cigarette advertisement since 1970. With respect to carbon monoxide, expert scientific testimony today will show that carbon rn~noxide exposure through cigarette smoke is not a significant health issue. Furthermore, there is no generally accepted method of carbon monoxide measurement which would make any data presemed on packages and in advertisements subject to question. The recently added provision requiring listing~on cigarette pack- ages of ingredients is totally unnecessary and ill-conceived, Cigarette manufacturers use a variety of mgrodisnts to enhance flavor and appearance and preserv~ shelf life. These ingredients are among each manufacturer's most closely he]d trade secrets. There is no justification for denying cigarette manufacturers the tT~d~ secret pru~ection extended to every othe~ c~nsumer product [ndustry You should also consider that as ibis provision is drafted, the list of ingredients, combined with the proposed health warnings and tar, nicotine and carbon monoxide numbers, would turn cigarette packages into fittle textbooks, likely causing smokers to ignore it With regard to the labeling requirements for exported cigarettes, I will only say that the result would be confusion, chaos, and com- petitive disadvantag~ for Amerisa¢l products in many overseas markets. (Attachment AJ [See p. 385.] Turning tO the enforcement pro~'is~ons, I can only conclude t)mt the underlying rationale for these proposals is to make it legally hazardous tbr dgarette manufacturers to advertise their lawful preduct~. The tenfold increase in the fine for violation of the labeling act, combined with the complexity of the labeling requirements of this bill, is grossly unfair as inadvertent violations are almost a certain- ty. Furthermore, the provision for an entirely new civil injunctive ~ctisn bv anyone wishing to claim the law has been violated is an unwarranted" delegation of the Government s enforcement powers Lo private individuals. These provisions are inconsistent with e5 forts by the c~urts and C~ngress t~ limit F~,dcral uri~dicti~n and ease tl{e overburdening of Federal courts. Finally, we do not believe that unbiased scientific research and dissemination of factual itlfurmation regarding smoking issues re> ~uires the establishment of a statutory office of smoking and ealth, an antismoking organization within the Federal Govern iTLent. Since such an organization was created in 196,t, its w¢~rk has done little to resolve the smoking issue questions and has in filet been slanted toward disseminatiol~ of antismoking propaganda largely unsupported by thctual evidence In conclusi~m, we are firmty opposed to this legisl~tisn because we believe it to be unnecessary, mlsleading, and, mos~ importantly, because the medical and scientific assumptions or findings undelly [ng it are incorrect and unsubstamblted. I am sure that many people will ask why the ~oba¢co industry is resisting this bill? What's the problem withputting u few neon, warnings on cigarette packages and advertising? -,t .,3 I
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3~ We are not opposing the bill because we wish to exploit the youth market as ~me have falsely charged; nor are we opposing the hilt because of the p~ten~al co~ts of compliance. We oppese this bill becsuse, despite the appearance of good intentions, this is bad legislation lbr the American public and for otlr bldustry. This biI1 tYeezes science in its tracks and may divert scientific talent and resources from the basic research necessary to resolve those q~csttons k a~so ~eri~u~ly ero6es she principle ~f free choice in a democratic society. In denying a person's right to reject official information, this bill betrays its fundamental prDhibitionist mo- tives. It says, in effect, that Americans are expressing their basic freedom of choice in rejecting the arguments of antismoking activ- ists, and that Gvvernment finds this unacceptable Therefore, steps must he taken to make Americans conform and to encourage prohibitl~n of smokitt~. [ do not believe the American people will accept ~uch a rationale. We are a responsible and concerned industry Manufacturing a lawful product which provides pleasure and satisfaction tv 5~ mil- lion Americans. Our industry contributes more than $57 billion an- mmfiy to the greys ~ati~nal pr~ct a~d Ke~erates $22 billion in Federal, State, and local taxes of all kinds We view this proposed l~gislatlon as an unwarranted interven- tion by the Federal Government into the private lives of its citizens and a thlnly veiled effort to further herass and ultimately elimi- nate an imp~tant American industry [Testimony resumes on p. 390.] LMr. IIorrigan's prepared stamment and attachment follow:] .Q -J j
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B~ Statement of Edward A. Horrigan, Jr on HR. 5653 Before The Subc0~ittee on Health and The Enviro~ent Of The Corm~ittee cn Energy and Co~erce My n~ i~ EdW~ K. ~rigan, Jr~. I a~ Chai~a~ and Chief Executive Officer, R.J. Reynolds TObacco Company. I ~ also the Chairman cf the Executive Committee of the Tobacco Institute, an association of tobacco manufacturers with headc~arters in Washington, D+C With ~e today ar~ Horace R. Kornegay, Ch~i~a~ Of the Toba~oc ~ti~ute; Dr. Larry Llgh~, E~ec~tive Vice President, Ted ~ates, I~C.; a~d Samuel B. Witt~ Ill, Vice president, W~ are her~ at yogr i~vitation to e~press OUr Indus~ry's po~itlon on H~ 5653, ~e "Comprehensive Emcklng prevention Education Act of 1981." The purpose 05 th~ bil~, and I ~c~e, is to "establish a national pro~am under an OEfic~ of Smoking and Health to in~o~ the public Of the dangers from sm~kln~, zo change the label re~Ire~m~t~ for cigarettes, an~ f~r Other p~oses," I re~pec~f~lly su~mit tha~ ~Is blll is unnecessary be- cause, in fat%, virtually everyone is aware o~ t-he clai~e~ dan~ers of smoking. Tl~e hill also represents a w~ste Of ~a~- a bureaucracy tha~ will serve no use/ui purpose. A 1981 C~llup ~urvey, reported by S$cre~ary Schweiker to la~g~ ~ssem~ly ef vol~tary hsa~th org~nlzations in November
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858 of that year, fsu~i %hst "Ninety percent Of the population agrees zhat cigarat:e smokinq is harmful 11 In his 1978 ~epor~, ~he U.S. Surgeon ~eneral ~ald that "notable ~hanqes" had ~aken place in public awarenes~ cf claimed ~mokl~g hazards ~nd expressed doub~ tha~ a higher level of awareness could have any e/feet on smoking ~ehavior. We share this skeptlcism. [~deed, the level of awareness about Imoki~q ~d health far exceeds publi~ awa~enes~ cf most if no~ all of t~e major rontempQrary ~ssues facing ~his ~i~ ~hat les~ :nan 25 percent o£ the public knows w~at t~e Fi~t Amendment ~s or what i~ d~als wi~h, Othe~ resem~ national at Three M~le Island; ~5 p~r~ent a~e ~ot aware ~hat the U~l~e~ states mu~t impor~ oil to m~t i~ ener~ryneedsl ~5 ~e~ce~t do tl~n; a~d one th±~d de ~ot]~rtow ~hether ~%~ ~ederal ~u~get is balanced. of th~ ~llegation~ thag smog±rig is danger~ to health, This Ievel o£ awarenes~ demonstrates r~.e succes~ of the current effforts of public and private organ±z~ions The ~ederal ~lgar~te Labeling a~d AdVer~l~an~ Act i~ 0{3 -J £
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359 pevple are in a poslti~n to ~ak~ a f~e@ and informed choice on whe~er or no~ to smokl. system £or the present law? There ~s ~o need tv e~abli~h yet critic web o~ requla~ions targeted ~t ~n icdu~tr~ which ~anu- I submit th~ this bill will have l~ttie i£ any impac~ upon the rem~inln~ few Amerlc~n~ who may be uaaware o~ claims m~d~ aq~&nst ~moklng £ollowi~g al~o~t three decades o~ govern- merit and private ~arnings, t~e S~rqeon ~ene~al'$ st~teme~ on cigarette packages znd advertising, and bro~ ~is~emination of a~ti-t~accp prop~gands through the p~Dl±c ~ed~a. ~n reality, th~s Dil~ is a pt~n~tive me~sure dl~e~te~ a~a~ns~ ~/*e ~anuf~ct~r~r~ o£ a lawf~ ~ro~u~t an~ appears ~e~gn~ t~ lea~ ~owar~ the pr~nlb±tio~ ~£ ~mokln~. Th~ £~ct the al~os= u~ver~a! awareness of the al~eg~t~ons regar~in~ h~s l~ th~ to c~clu~e that those wh~ reject a~ti-s~okinq ~r~v~s a~ c~in~e ~o e~erc±±e ~exr freedom of choice ~ill, desiqned to £orc~ smokers to conform, and ultim~e~F to 2 -j 0
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Let .me ~ake a ~W minutes to rev~ow so~e o~ the p~e~ises used to ~upp0rt tY~is ~ill and the Ghar~es l~vel@d at the Tobacca ~Ddus~ry~ A ntl~oer ~f v~ry b~oad, sweeping st~te~ent~ rela~in~ to smoRinq, dislase ~d addiction are included i~ the particulars of 5he blil. Certainly t/~e statement that smoking is addictive is ~ontTadic~ed by the 1964 S~rgeo~ Generalls Report a~d the conclusions reached by many experts since 1964. Of course, the=e are ~tio~s r~ised b~ statistical ~seciati~ rel~t~ng to smoki~q a~d diseas~ which m~t be a~swered. But the truth is that all Qf the s%atementu that are presented ~s esta~!isb~d fac~ in this bill have bee~ challe~ged by ~he research Zindi~gs of many emlnen% s~-en%ists, some o~ wh~m y~ ~ll hear fr~ later in todmy's proceedings. ~sre are mor~ than ~hirty h~hly respecte~ ~ ~owl- edqeable witnesses wi~h expertis~ in the relevant medical and scientific d~eipli~eB who we ~derDtan~ WOU~d h~e been willing ts testify about ~he broad range o~ the so-caLled "findings" l~s~ed in Sect:on 2 of the bill, Oaly the sbcr~age of ~i~e for ~hese he&rinqs prmvented t~eir testimony. Given ~he ~pp~rt~n~ty, ~ney would clearly have been able 5s distln- 8~lish hypoth~sls a~d speculation from ~bj~tive medical a~d scientific fact, and w~uld have raised serious q~esticns ¢on~rnlnq Zhes~ "fi~dln~$'I ~e ~esp~ctf~lly submit that ~he time ~as Gome for this Cor~ittee an~ ~!%e Csnqres$ t~ be f~lly and ~ai~ly informed ~J
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361 a~out the smoking and health controversy. We have Been ad. b~ll must be Lmlted to one ~ay. Unf*rtumately ~hlF is ~ar ~hort of hhe time re~,lir~d a6eq~tely to t~gorm :he Committee, ~e available to us. In 19~9, when th* Federal Cigarette L~bel~ng and Adver- commit=ee i~ a part h~Id extensive hearings over a period ~n e~cess of two weeks. It heard test/many from Members Of ccn~r~ss, szate offlc~als, qoverrgne~t health an~ re~lla~ory ~ge~cy offl~ials, vo~k~itaKy health ~Na~ati~s, a~ ntt~e~o~s e~pert w~nesses in ~he fields #f medicine, biomedical re- search, s=a~istics~ amd other scientific ~is¢ipl~ne~. OnCe b~s of the~e exte~s±ve hea~nq~, the full C~m. mittee c~ncluded eha~ "no~hing new has been de~e~ined with respect to ~e relat±onahip betwe*n cigarette smokin~ and h~Nan healtN since it~ hearings in 19~4 ~d 1965." The C*~xtte~ wegt on to say that ~-~e argument~ p~o and ¢~n with reNDect to cigarettes ~r~ the same now as ~hen, thouNn *upported bN a lar~er statistical ba~e." That conclu- s~ is as ~rue t~day as it w~s in i~59. A£ter ~hree ~ecades ~£ investigation and millions of do~lars invested by the N~ver~ment, =he ~obacco Industry ~ o~her pri~ate orNanizgtions, the sm~kxnq and health controversy r~ain~ unre~*lved The net resu2t cf all of this egfort has
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We are awa~e that th,re have Been some effo~s ~o bUlld support for this blll with claims ~hat its ~rovision$ would serve as a deterrent %0 smokinq ~o~g yeung people a~d that encouraqe yeu*~lful smoklng. Such chargeB ~r~ without foundation. Last Friday, two witnesses speaking in suppor~ ~f this b~ll--Mr. NeeshanandM~. goxsyth --both acknewl~ed tllat peerprassure ~d not our adv~rtislngpr~vi~es the impetusfor s~oking,~ong young people. you will he~r more ~bcut thi~ point this af%ern~n ~rom the experts wh~ W~[I be ~esentin~ t~etr t~tiaon7, They will cle&riy p¢int out %hat the ~rovislo~s o£ this legizl~%~on ca~ in n~ way be justified by the *mot~on~lly a~peal~g ~ut ~nsup~ port~ assert±on that ¢igaret~ adver~isinq enceuraq~s a youngster to ~raoke. Smoking ~s an adul~ practice g~ ~e considered o~!y by those mature enough to make an informed decision. ~ 1965, ~or eN~llple~ cigarette ~ompani~ ~toppcd all advertising and prcm~tion~l ac~lvigi~s in s~hool and college publications and on cmmpus We also s~opp~d using c~lebritie~ ~nd spor=~ ffl~es xn advertising. itin~ advertis±ng, marketing an~ sampllng d~re¢te~ at young ~eople. Even though the a~inis~rasive provi~z~n~ are ao ~o~ger im effec=, ~ach company still a:~u'ner~s ~ the principles .,d ',,t
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~4 of ~hls code, I wm~Id, wlth y~uT per~iBslon, like to submlt a su2amary o~ these principles add a copy of OUr Ciqlr@tte Sampling Cede for the record. rn 1969, we offered to cancel all radio and tslevlslmn advertising because 0£ broadcastrs u~ic~/e reach to ye~q people, and ~n 1971, pu~suan% to ~ede~al legislation, lef~ the broadcast med~a. C~ir a4~er%iz£~ ~s tar~ete4 at ~mmkers a~ ~s ~ter~ to ~n=0u~ag~ ~tch!ng £~m c~mp~%l~i~ brands. %'n~ a~ai~ab~e evidence clearly shows t~.a~ our adverzisinq is net designed t~ attract new smoke~s of any age and is not hav~ng that effect, The same Ga~lup p~ll I ~e~i0ned earlier also reported that the percentage of $muk~s f~nd was the lowest eve~ recorded by ~h~t 0rqa111zatlon. Looking a~ the broade: picture regardl~g clqa~ett~ adver- tlsing, the re~er~ clea~ly shows that our Industry has been responsible in its practices. O ~ i~5~, t~ m~et p~bi~ ~e~an~, ~e be~a~ to ~ver%~s~ Im I~SD, aZtex the ~TC stated that it had determined that ~qch a~ve:ti~i~ ¢~uld be construed as a heal~h clai~, we voluntarily ~gzeed to eliminate frem c~garette advertisinq all re~er~nce$ ~ "tar" 8nd nicotine. o In 1956~ when th~ FTC reversed its position we agreed that cigarette edverSisi~g would di~cl~se "t~r" an~ nzc0ti~e content. i C~ Ca
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O ~ 1967, we baqa~ a continuin~ proqr~ o~ scie~ti£ic and ~Goti~ testing. 0 I~ 1970, we beqan to ~¢lude tn aur b~and advertising, %he ~£C "tar" and nicotine m~as~rements. o I~ 1971~ we v~l~mr~d to depict the cigarette pack,ge in all adv~r~Isl~g in such a way as to dlspl&y legibly th~ wa~n±nq l~beI. o ~ 19~2, we e~tere~ i~o a~ aqree~D~ with t~e FTC o~ unifo~ term~ of con~plcuous~y dlspl~yi~g the warning ~abel i~ adver~isinq c In 19@1, we r~ache~ a~ ~q~eement with the FT~ oD an incr@ase i~ ~he size of the warnings. In shot%, O~r I~try has acted re~pons±bly i~ the pa~% a~d we se~ n~ reason anyone ~hc~ld feel ~ we will n~t continue t~ ~o so in th~ future. Nor do we se~ why ~.%ls bill i~ neede~ to retrial@ £~rthe~ ~r advertising pract~c~ in ~ny Getting back to the specific p~visien~ of the bill, t~e labeling re~.~lremen~£ it proposes are ~nworkab~e. The bill dlr~C~£ ~e FTC to establish ~ rotational war~i~q procedure which ca~ ~t bes% be described a~ a "R~e Goldber~" each of ~ ~even ~e~±red warnings for no ~ore %h~ ~ne year ~ri~g every seve~-~ar period. Then the~e is the ~dded ~rovison that a~ an~ given ti~e ~ach of ~h~ seven w~rnings must appear ~ "s~be%a~lally the same nu~r of braDds."
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367 each year since the new ~ystem wa~ implemented i~ I~77~ I also c~ll yo~r ~tze~ion to the fact that the rotational warn, ng system in SwCdem was part Of a total preqra~ des±~ed to ~olis~ smoMi~g; which is the ~ltimate goal -. d~spite de~&Is -- o~ many o~ ~he ant~-smokl~g organizations which support this b~ll. In li~h~ of Zhese facts, a~d your statsment that the purpose Of thi~ legiFlation i$ not to prohibit smoking, the ~bvi~us question ~ri~es: IS the proposed ro~a~iona~ ~ystem necessary or appropriate? W~ ~re aoP~vlnced that the answer is the% it is heir.her. A~SO ~rA~r~a~ts~, ~n ~Z opin~, i~ %he b~li's x~ir~- ment for di~losu~e 0~ "tar~" nicotine, mnd carbon monoxide leve~s o~ pa~k~qes ~d in a~l ~dv~tls±nq AS ~ndicate~ ~rlier~ si~c~ igT0 oigaretts ma~2~fact~rers have volun%arily dls~losed ~he ~tarM an~i~otine l#vels in ciga:ett~ adver~±~. Th~S ~nformation ~S w~dely ~vailable t¢ ~he public. Smokers who choose their brand on the basis oZ fro~ cigarette advextlsi~g. As S ma~%er Cf £act, t~he aversqe "tar" yield o~ cigarettes sold i~ this country ha~ dr~pped from 38 milligrams in 195~ to 12.5 ~lligr~/~s in I~81 Almost seventy perce~t Of ~ii eiqa- rette$ sold ~re in ~he low "tar~' category. With ~e~ect to carbon m~noxid~, there ±a no purpos~ ~
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368 the scientific ro¢ord w111 show, the ¢o~1~5~on that exposure to carbon mo~o%id~ from cigarette ~okinq i~ significant in to~s of health im u~warranted. Furthe~mor~, no singll methcd of carbon mono%id~ measurement in Clqarette smoke has ~ained ~ny da~a pr~e~s~, Dy any meth0d, will be ~ub~e~t ~o ~uesti~. The~e ~s~e~ should be resolved in th~ scientific cupidity. We ~i~mly bel±~ve thst a requi~d disclosure of ~arbo~ mon©x~de ySelds i| lll conceived. req~i~e ~ch p~ekg~e to iis~ "a~y Che~i~sl s~bst~c~~' tha~ may become a co~pc~ent mr otherwise affect ~be oharaete=zs$ics of could ~o% determine what substances t~ey were re~i~ed to disclose. A~y attempt to ~SS th~s ia~al~q req~Lremen~ ~o~ ~iqa- provislom a~d the rela~ed pr~vl$$o~e ~f ~e~t$~n 4 ~$d ~e to turn ~ig~rotte package~ Snto little ~ex~beoMs. ¢o~sider wha~ the bill wo~ld require on every package -- a war~i~ statement, a li~±n~ o5 "ta~," ~±Cotine~ c&rbon monoxide, a~d "ch~mic~l s~bs~ces." It seems la~ely that consumers, c0~fr~nt~d with s~ch a welter of detaile~ infcr~ation, will simply iqnore all ~hi~ p~ovi~ion wo~id al~ require ~igar~gte ma~f~cturer~ to disclose tra~e s~e~te that menuZacturers 05 other ~on~umer .% J
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369 products are not ~c~ired te disclose. C~garette manufacturers u~e a vgr~ety of substances in thei~ products to enhance flav~ and appearance an~ te preserve shelf li£e. The identity cf additives used by eac~ ~anufactl~rer is among the most =losely~ard~d of their ~rade secrets, f~r s~ch ingredients ~lay a ~s~antial role ~n maintaining censurer ~¢eeptance. Manufacturers ~£ other consumer prod~c=s are not re~red ~0 disclose trade secre~ of thi~ kind There i~ no justlfi- sation ~or denyin~ cigarette manu£aeturer~ the trade ~ecret pro~e~%ion thaZ is available to every other cons~er product industry. Th~ basic d~fect in this provlsion, an~ indeed in all of section 4, l~ that L~ ls an attempt te pr~vLde a c~lek ~t~ easy "s~lu~ion" to a problem tha~ has not yet eve~ been ade- ~ate[y defined. We have been and co~tinue ~ be en~age~ in o~ns~ruczive and £r~ful discussions with As~stan~ 5ec~etary ~randt ~nd other ~S officials on this mattez with a view to making available neceseary in=or~ation ~o H~s under appropriate procedures and ~afequards. Secretary ~randt has r~cently sta~ed =hat he is "~lea~e~ wi=h" our "c~eperatlv~ spirit" and that he is "~o~ident that subs%~ntial future p=ogres~ ca~ be made" i~ resolving ~hl= ~estion. The ~resen~ bill WOUld short-c~c~i~ this effo~ UC res~ive any ~ concerns. In o~ wo~s, the effec= cf the bill is to "sh~0% first an~ 0 L~ -J 0
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to exported cigarettes. The presJnt law wisely leaves packaqe i~i~g t~ the g~v~r~ant ~f e~ch imp~r~i~g co.~ry. ~zny cou~les requi~ s~atemen~s re~a~ding s~oki~g and heal~h ~o n~t. danqero~s." Iceland had a compulsory war~ b~t a~ando~ed warnings, Sweden is ~ique i~ requiring a s~orga~b~rd of Thi~ ~ill wo~id req~/ir~ A~eric~ experts ~o ~arry ~ U,S, WaT~ ~t~m~nt, ~hiie ~De~itiv~ ~ran~ i~many f~r~iqll marke~s would carry none. In ~un~ries which ~equ~re their o~warn~n~ label, U.S, cigarettes ~eu!d h~v~ ~o carry two or m~r~ wa~ning statements. In s~me cou~rie~ ~he sale ~£ cite° ret~esbearlnganywarni~qs~a~me~ther tha~ thaZ ~equired by legal law ~ay b~ p~hib~te~ In ~ny event, th~ resul~ weuld be chae~, c~nfusio~, and co~petltive dlsadvant~qe. U~iSed stete~ to de~ide for the rest ~ the w~Id wha~ state- ~ent~ ~h~ul~ b~ i~clu4e~ o~ c~aret~e ~acka~e~. I would now like t~ address th~ ~ropose~ amenct~e~ts ~0 th~ enforcement provis1~ns of the present law, Mr. Chairman, I ~m forced to o~ncl~de that the undezlyin~ ratien~le i~ s±~ply to make i~ leq~lly h~z~dous f~r cigarette manufacuurer~ to advertise their lew£~l produous.
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371 The bill would increase the fine for violation of ~he Act from $10~000 ~e $10D,O00. In the seventeen years the present law has been in e~fect, there h~ve been no violations. "/hat ffact alone ~rgnaes against any increase a~ all in the penalty -- much less a tenfold increase. ~rthe~more, in view of the complexity of the new prc- p~sal, the increase ~ als~ gro*s~y unfair. Inadv~rten~ violations Of ~he complex rotational warning system, which is likely to be further complica~ed by FTC req~Irements~ are almost a cer~a±n~y Suppose~ £or example~ that ~t is d~termined thet one manu£acturer had pr±nted warning statement "B" ~n the packages of two of it~ brands fer a tetal mf ~e yea~ and eke mcnt2n, while w~rnznq statement "D" wa~ ~rinted on the packaqes of th~se brand~ for on~y eleven m~n~s. ~ha~ manu£ac~urer w~uld ee ~n v±o~at~o~ of ~he Nrohlbi~icn aga~ns~ presentation of any ~n~ off the warning ~tatements ~r more than ~ne year in a seven-y~ar p*r~ed~ it w~uld ai~ b~ in violation ~f the r~- q~lireme~t that all ~tatem~nt~ be given equal ~ime. Even ~ou~h the ef£ect ~f ~'ae~e vi~iation~ weu~ appear to be at mo~t trivial, the manufacturer would be subject to huge p~ten- =ial penalties. A law that permits such mousetra~p:ng can ~nly be cal~ed ~nequ±%a~ie and punitive in intent. In a~diti~n, an even qreater opportunity f~r abuse l~ cre~ted by ~h~ ~r~vi~ion ~hat establishe~ an entirely new civil injunctive actio~ ~0r anyone who wishes to claim that .,d
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372 dele~a~lon Of ~/%~ ~ov~rn~e~t'~ snfo~c~m~n~ powers to p~iva~e i~divi4ua~. ~t is ~o~ cnly defective from legal and policy • ~vo~i~g the J~ri~ic~ic~ o~ ~h~ ~e~era~ courts ~u~t s~ow ~ha~ i~ has perso~a~y ~ere~ ac~ua~ o~ ti~eatene~ i~j~y as a to challen~e action~ ~o which they ~r~ phil~o~h~cally o~ p~li~ically o~po~ed. ~t ~e~m~ cl~ar, ~en, ~ha% th~ c~vil C~nqr~s~ ha~ ~e~gni~e~ ~hat the ~era~ ~our~s ar~ seriously overburdened, and ~&s ~gl/n ¢o ~ake ~tep~ ~o !im~t tho~ courts ~0 unlimited ~itig~tion over th~ ~rca~e d~&ils c~ ~e b~l~)s ro~at~o~a~ ~a~n~ng ~y~tem, ha~aBs~e~ s~xts a~ai~st ~i~a~e~te ~an~acgure~ b~ ~ndlvidu~l~ ~n~ ~ro~ps opposed ~o ~oki~g i~ gener~l. ~e va~e a~d Of a~arfl~ o~ coz,s and a~ey~~ fe~ provid~ ~y ~h~ b~ll,
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373 lawsuits alleging the host trivial violat10ns Gfthe law will be encouraged. Surely that is neither a fair nor appropriat~ ~se ~f our judicial syste~ We must also register our vigorous 0pp0~ition to the bill's elimination of the six-moD%h Congressional review period with resp0cz %0 trade regulation r~le-making proposals In eDactlng the Federal Ciqarette Labeling add Advertising Act, Congress s0~ght "to establish a comprehensive federal program to deal with cigarette Imbel~Dg and advertislng+" The legislative hist0ry and lan~age 05 the ACE and its $~bse~aent amendments make it ~bu~da~t!y clear that Conqress ~etermi~ed that such a comprehensive unifmrm policy should be ~- ~for1~ulatedandarticul~ted. Eiiminatio~QfC0ngres. sional overview Of the FTC on ~issu~ of s~ch national impact would be iacen~istent with this sst~d policy Le~ me now ZUr~ to Section 3(a) ef the bill, wh±ch wo~id establish a statutory Office of Smoklng ~ne Heal~h. As I s%ated earlier, Zhis Industry has always favored objectiv~ sclentlfic research and t~he dissemination of [actual health information to the public. ~ow~v~r, we do not believe %ha~ ~hese goals call for an anti-smeki~g organization within the Federal ~over~ent. ~hen such an 0rqa~ization was Created in 1964, th~ Senate Appropriations Co~i%~ee q~esticned whether ~he funds might b~ better spent on research rather than propa- ganda. A ~blio Mealth S~V~Ce offici~l assured the Committee that "the money would not be used to propagandize, b~K o~ly to mak~ the health facts available to the people."
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874 ~as that pl~ge bee~ carried out? Let m6 prQvlde o~e example which is not itypical. Last year, the Offfice of ~mQk/~q and Health produced a $68,000 publicity zlmpaign. It was built arour.d fcur television Go~vcials ~eaturln@ Breoke Shields, The theme was that ~moklng is u~gla~oro~s or as %he teenage starlet put it ~ cne sh~rt ~ssa~e: ~If the~e*s ~nythin~ I ~te, ~'~ ~a~h~ ~¥ h~ir ~.4 the~ b~in~ with people who smoke, yecch" H~rdl~ a ~ess~qe of health fa~ts, you will agree. of ccurue, zhe Office of Smoking and Health~reduc~s mor~ ~han adv~rt£~ing campazgn~. ~t also pUblI~L~B anmual r~p~rts abo~ 2he health co~sequ~ces cf smokinq. T~,e tlming Of the report~, h~wever, bea~s virt~al!y ~o ~ela~cnship to ~he ~0n~ct of ~ientlfic r~search or the p~b- lica~io~ ~f results ~die~ ta~e years tc ~0~plete. Eve~ o~ ~omp!etion, their findings ~re ten%atlve and ~ub~e~t %O v~ri- ~acka~ed te meet a ~h~uled annual report. As a result, r~e ~epoy~s ~o Congress have been use~ as m~4ia evenzs h~gh in ~ropaqan~a content and low in ~cien~ific sub~tanue, Add~2icnall~, b~resueratic ~rcssure to show "proqress" ~esults i~ escala~inq %he rhe~orlc~l style o~ th~se reports ~o ~v~r~ome ~heir s~i~i£ic ~hortcominqs R~ther ~ha~ pr~s~ntin~ balanced view of all available information an :he complex quest±on~ ~nder stndy, the reports consistently ~ave omitted ~n -5 -5
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-3
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376 other ~oveZ~-~ent aqen~. Thls bill woul4 s~b~ec~ even ~he National l~tit~tJ~ of Heal~h to such "Goordinmtien~ J~It how the decis~-maki~9 procssses a~d p~er ~eview ~ys2~ms Of th~ NI~ would be "coo~dinate~" is unclear Th~ poz~ial fo~ mi~hlef i~¢ however, obvious. I~ co~cl~sion, we a~e firmly oppes~4 ~o t~.£s leg£slatio~ because we ~eliev~ it to b~ u~eces~ary, m~slasdinq a~d, most importantly, ~eca~se the medical an~ scientific as~pt~ofl~ ~r "ff~di~qS" ~n~erl~l~ it are ~n=crr~ct and u~¢antlated. I am sure ~hat many p~ople, after scannin~ the h~adi£ne~ or lis~i~ ~o ~he eveni~q mews, w~ll ask: Why is the T0ba~co l~u~ry resist£n~ this ~ill? ~4ha~'s the ~ro~le~ w~th put2£~9 ~e ar~ L~t ~pc~Ing~e hill because ~ ~h t~ $~lolt the y~uth market ~s some have f~isel¥ ¢ha~ed: nor a~e w~ o~pos~q the Dill becaus~ o~ the poeefltial costs of ~mplying wi~ i~s retirements. We O~pose this bill because, despite 2he appe~raflce Of qo~d in~e~t±¢ns, thi~ is bad legisl~l~n -. not ~nly ~or our I~dus~ry but ~he ~eric~ p~b!i~ a~ well ~his blll f~eezes sc&ence ~ It~ ~r~cks. It purser,s t~ set~la by Congressional edict medical an4 $~ientif~¢ ¢~n~re- ver~i~s tha~ are still evolving, an~ thereby it may d£ve~ -5 l
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~7 This bill aluo seriously erodes the prlnciple o~ ~ree choico in a democra%ic society. It says, in effect, that if you~on't conform, you are ~n~nformed, and that the Oover~le~= must take ~orrective ~¢tlo~. In denying a person's right to reject "offlciali~ information, the bill betrays ~ts fundamental prohib~tlo~ist motives. The propone~%~ Of ~ne ~iii object to the ~act %hatAmericans are expresslng their Da~ic freedom o~ C~OiCe iD rejectin~ the arguments Of anti-smoking activists; they flnd this Independe~c~ unacceptable, and therefore, propose s~eps i~teDded ~!tim~tely tc result in the prchibi~lon of u~oking. We are a responsible and concerned in~stry~ ~anufact~r~g a i~wful product which provides pleasure and ~a~i~factio~ ~© ~iilions. 0~r ~n~ustry co~tributes ~or~ th~ f~f~y-~eve~ billion dollars ~nnuali~ %0 ~e Gross National ~roduct a~ generates twen~y-%wo billio~ ~iIars in Ee~eral, sta~e and !ocal ta~es o£ all kinds. Thl~ proposed legi~latlon is a~ uzwarrante~ intervention zens, ~n~ a thinly veiled effor~ further %c har&ss add ~it~- merely ellmina~e a~ important America~ I~dustry, Q~
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~8 ~.$. ~er~izori~1 ~ossessions. i. N~ advertising shall~pnear in p~hlic~i0ns ~irected prlmaril%, to those ~n~er 21 years o{ aKe, Inclu6in~ school, college or ~versity ~edi~ (~uch a5 athletic, theatrical er @theT p~oKzamsl~ comic ~oks Qr comi~ .suppleme~ts. 2. N~ one d£picted in Ci@s~¢Tte a~ver=islnz &h~ll be or es~en~ia~ tO social promlnence~ distinction, ~U~Ce~S ~ sexual a~tr~ct~on, no~ shall ~ piczure ~ p|~son smoking i~ a~ exaggerated ~a~er, 4. Ci~?ette a~ve~tisi~ may p~cz~re at~rsc~iv~, hea!~hy .l~oki~ persons provide4 t~ere i~ ns ~u~es~io~ their 8~tractiven~5 zn~ ~ood ~a~th IS ~ue to ci~sreTte s~ki~g C~r~ZZ~ a~ve~tisinK sh~ll ~o~ dep~c~ ~$ ~ smuker a~y~n¢ who is or h~s been well kno~ as an aZhlete, nor shall i~ show a~}' sm~ke~ participating in, oy ~bviou|l~, just h~ving particip~te~ i~, a Dhvsic~l acti%'it~ req~r~ stamina o~ a~hleti¢ ~di~ionih~b~yo~d that of ~or~l recreation. .6. No ~c~%s o~ ~leh~'it7 testimonials sh~ll be used or ~ho~e o~ others who would ~ave spcci~] appcsl ~o ~erso~s under p%TSOnS who cn~Z~ in ~spl!n~ ~hzll ~ef~* to ~ive z s~mple ~o a~F ~ersom who~ ~hey k~o~ zo be ~nder 21 y~ars p~ ~ o~ ~h~, ~i%h%ut Tez$~n~ble i£~nti{i%~tie~ 1o the contyar}'. ~ppe~rs to be les~ th~n 21 )'ears o~ s~e. %. S~mplinz 5h~ll no~ he cold,tie{ in any pu51~c ~l~¢e within plsy~o~ds~ schools, college ~smpus~s. or frsZerni~), or s~rori~)" hous~. 9. p~rsons w~o en~a~ in sampl~n~ sh~!l nnl nz$~ ~ny ~6ul~ 21 yeaY~ of ~e of over zo ~ccept a sample ~f ~he ad~it d¢cl~ne~ or ~e~us¢$ to aec~t such $~mple. -% .j
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379 Code of Cigarette Sampling Practices O~ ,a.
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380 STATEMENT OF PURPOSE -1 Cigarette sampEng is a form of cigarette advertising conducted lheough the free dislribution of sampl~ packages of cigarettes dlr~tlS* to adult ~m~kers. The pur0ose of this Code is Io ensure that certain st~tr~d~ds ar~ ~|~serv~d in corme~tiorx v;~tk cigarette samp]ing, particularly avoicling the distribution of cigarette~ to mi~or~ ~r~d. the disruptiorl of pedestrian or vehicular traffic, and to provide a means wherebl, compliance with those slandards can be monitored and ~nforeed. j
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381 ARTICLE I DEFINITIONS 1. "Sampling" means giving or distribuling wiffiout charge packages of cigarettes in a public place for commercial advertising purposes ("cigarelte samples"}, but does not include isolated offerings of complimentary packages or the distributlon of such packages it] wholesale o~ retail ctlst omers oF to company sharehc]]ders or employees in the normal cvurse of business, 2. "Public place" includes any street, sidewalk, park, plaza, public mall, and the public areas of shopping centers and office buildings. Q~ I'¢
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382 ARTICLE Ill RESTRICTIONS ON CIGARETTE SAMPLING 1, Persons who engage in sampling sha]l refuse ~o gi~e a sample 'to ally p ~rsOI~ whom they know to be under 21 pears of age or who, without reasonable identi~cation Io the contrary, appears to be less than 21 ~'ears of age. 2. Sampling shall not ha conducted in any puhlic place within two blocks of any centers of youlh activities, such as playgrounds, schools, college campuses, or fraternity or sorority houses, 3. The mails ~hall not be used to distribute unsolieited cigarette samples 4, Persons who engage ~n sampling ~hall not urge any adult 21 years of age or over to accept a sample if the adult declines or refuses to accept such sample. ° 5~
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883 5. No cigarette samplas shall be distributed by a sampler in a public place 6. Persons distributing cigarette samples shah secure their stocks of samples in safe locations to avoid inadvartent distribution of samples contrary to the provlslons of Ibis Article. 7. Persons distributing cigarette sample~ shall avold blocking or otherwise significantly impairing the flow of pedesl1"ian trafBc. ~. In the ~ that ~i~ums~an~s a~ise at a particular ]or~tion that make it urllikely that sampling can be conducted in a manner consls~ent ~vith the provisions o~ this Article, ~ampllng shall ~a stopped at that location until such circumstance~ ~bate. 9, Persons di~ributirtg ~amples ~hall promptly dispose of empty sampl~ boxes ~r~d ~ha~ tak~ t~s~ahle ~t~p~ tc~ ~r~st~re that no litter r t~rn ains in the immedlat@ area of sampling a~ a result of samplln~ 0~
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384 ARTICLE HI COMPLIANCE AND ENFORCEMENT PROVISIONS 1. Each cigarette manufacturer that subscribe~ to this Code shall impose by contract on Bll independent contractors who conduct cigarette sampling on the manufacturer's behalf a set of samphng standards no less stringent than those contained in this Code. In addition, each cigarette manufacturer shali require such sampling contractors to inform all personnel emplo~'ed by the contractor who engage in salnpiing activities of the provisions o~ thiv Code, both orany and in writing. 2. Persons who engage in sampling shMl be monitored on a periodic basis by supervisory pe~sunnel of the ~igareit~ manufacturee and/or independent contructor for whom tile samplin$ activities are being cond~ed to erasure ~ompli~na~ with the provisions of this Code. 3. Each cigarette msnufaeturer that subscribes to this Code sha~l take all reasonable *teps to eusure that any person who engages in sampling and knowingly violates any of the provisions cff Ar tide II of this Code shall he dist:harged from employment as a cigarette sampler. ..j
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385 SUMMARY OF PRQELEM$ PRE~ENTE9 By ~KPORT PROYIS;ONS OF H.~. 5653 that t~ label st~t~m~t~ ~n packages of c£ga~ett~ ~ Ibl ~se~
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2. 386 requires rotating labei wa~in~s ~or cigarette e×parts. la) The pre~ant l~w wi~ely leaves pa~k~ labelln~ t~ t~e gc~r~men~ of each imp~tin~ country+ Many co~n~rie~ require It~tements re~ar~n~ smoXin~ ~md healt~ to ~e included in ~igarette ~ackaq~s ~nd advertising. Many ~o n~t. "~u~e i~ Dangerous." ~Celand h~d a compulsory warnin~ ~u~ abandoned it. ~n th~ United Kingdom Sweden i~ ~nique l~ re~uiri~ a $~o~ash~r~ of • ix~een ~ot~t±n~ w~rnin~s. (b) Smutian 4 (~)(1)(A] requires a wmrnin~ that "-hm convair wr~te to the ~rg~ Ge~al in Washington, D. C. f~ m~r~ £nforma~ion on "S~ec£~ic Dange~ cf
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387 Cigarette Smoking". T~is requi~enent is useless an~ i[I conceiv~d in it~ application to exports. ~'s hard to ~magine someone ~rom S~udi Arabia wr~tin~ ~he U.S. $~r~eon General. Would the U,S. Su~ean General re~p~n~ in ~rab~c? SQ~ foreign laws r~quire label warnings ~o be in tw~ ar even thr~e lan~a~es. F~r e~ample, C~n~da requires warnin~ i~ French and En~ii~h; ~l~i~ warnin~ are in F~ench, G~r~an ~nd Dutch. Since the w~rnin~s ~equire~ by C~na~a and B~I~ium ar~ dif~erent th~n anF o~ ~he warnings ~nd~r H~R. 5653~ ~he Canadian package may be r~quir~d ~o have t~warni~ ~a French an~ ~w~ in ~li~ and the 3elgi~m package may b~ r~quir~ ~o have s~x differ~n~ warnings. Tar.~icotine and Carbon Monoxide. Section 4 (~} req~i~s ~closure ~f £he lev~1 o~ t~r, nicotine a~d carbon ~ide un ~h~ pack. (a) ~.~F 56~3 require~ that ~he ~v~i cf ~art ni~ct±ne and carbo~ ~no~i~e b~ ~as~ cn the levels established ~nnually by ~h~ ~de~l Tr~e Co~ission. The I~ of ~ev~ral ~r~i~n ~ou~tri~ (e.9~ G~rma~y, Canada, Un~ed K~n~dom. E~ypt ~nd A~ra~ia) result÷ £~s~n~ m~th~ds ~Ch may result ~n ~-~r a~ ~icu~in~ I~v~ ~i~fsren~ than the level~ ~b~ai~ed ~ro~ the O
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4. 5~ ~8 Federal T~Rde Co~isgion m~hc~. Discrepancies betwaen the ~C method and ~b~ me~hod~ ~equi~ und~ the ~orei~ law~ ~oul~ con~use c~nsumers a~6 m~y expose U.S. ~nufac~rers ~o fines and prohibition O~ sal~ of thei~ p~oduc~s in ~ese countries. {b) ~e ~y~te~ in some c~untri~ do~s n~£ permit ~£~c~sur~ of t~r. nicotine ~nd carbon m~no~ide n~mbers o~ ~he ~ab~l. For e~ample, ~e Un~e~ Kingdom ~ivides t~r ~eveIs into fiv~ ~ro~p~ and ~he l~heI can ~n~y ~h~ %he t~ ~r~ and net ~h~ ~mber, Some countries have ~the~ ~ystems or reguiat±on~ re~a:d~n~ disclosure of tar and nicotine ~ ca~bo~ monoxide ~i~h ~onflict with th~ ~equirem~nts of K.~. 5653. ~on~ Pur~. ~ection ~ of th~ Cigarette ~e~in~ an~ ~ver~sing AC~ (~5 ~S~ 13~1/ is ~ot ~mended h~ H,R. 5653. Tha~ Section ~ta~es ~ha~ one purpose o~ ~he A~t was t~ nQt ~ede co~er~s ~y "diverse, n~nu~if~ and c~nfu~in~ ~i~a~tte Iabelin~ an~ a~v~is~ ~e~lations°~ ~e c0ns~m~ ~cnf~sion a~ c~fli~ ~it~ f~re~n l~w ~reated ~y ~,~. 5653 ar~ ~t~7 ~ t~ ~re~io~ l~te~- Soverei~ ~i~hts. K.R. 5G53 would £nte~fere with t~e ~o~e~iGn ri~ts a~d i~tr~ts uf foreign ~ations. L C)
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~89 Before actln~ to re~la~ expo~u~ in the manner ~bco~i~tee sh~ul~ a~k themse!v~s ~ow they w~ul~ reac~ re~ulati~ns whlch are a~ variance with U+S. po[ic7 and The questio~ of warnin~ labels on cigarette packages involves co~in~ national interemts and diffa~ences of ~er~pectlve on ~ndivi~ual ~n~ corporate r~t~ and ~e~po~sibilitie~. ~a~h society ha~ a ri~h~ tc ~trike what it ~ons~der~ to be the p~o~er b~lance am~n~ these ~o~e~in~ in~eres~* and i~ i~ ~s~ential[y irrelev~n~ + tha~ o~her sccl~ie~ might r~ach ~if£~en~ conclusicn~. I~ is ~ inherent ~i~ht ~f sovereignty to make d~¢~ions such as the~e without o~i~ interference. Conflict~ With ~.S+ ~ Admini~trstion Act. H.R. 56~3 ~d ma~ a majo~ aepa~ture ~rom ~+~. 1~ and ~olicy in ~t~ wh£~ have nothin~ to ~o wi~h ~,S. security, U.S. foreign.policy or d~es~l~ shortages* ~u~h a chan~e in cours~ s~id not b~ taken without thorough c~nlid~ra~±On by ~ ~n~s and ~ ~rincip~i c~i~tl~s ~ha~ have been isvoLved £n settln~ U.S. export pol~y ~or many
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390 Mr WAXMA~. Thank you very much, Mr Horriga~. far making your position dear ~n this legis]ataln It h~g been 1~ years since the f~rst Surgeon GeT~cra|'s report }ndi eating that cigarette smoking is ~ dallgcr to p~op]e's health ~irlc:c that time we have had let~rt after report, ir~cJuding the latest Sur ~eon Gener~ll's report re]atin~ cigarette smoking to cancer. We have had leading scientific experts in this c~mntry, the National C~i~ev [nsti~u~e~ al~d the N~t[~n~ll h~stitut~ oI~ Dr~g Abuse ~ll ~ that cigarette ~mokin~ i~ ~ddlctive Emd that it is a leading source of lun~ and heart d]seas~ In light ~f all that, how do you explain y~r unwillingness ta even make a c~nnectlon l~tween cigarette smoking a~d these health pr~blem~ Mr HORmGAN. Mr Chairman, to begin wit}l, we really do not b~' lleve that ~r industry is un~villin~ i~ any s~se o~ the w~)rd | meutioned in my testimony that we are a concerned and ~ re~pon- slve industry¸ That is supported by the fact that while the Surgeon General's report contil~u~:~ to p~blish ll~w statistics, our tobacc~ in dus~ry continues to earmark millions of dollars annually on all on ~ing bas~ i~ ~nr~r~cted, arr~'s-le~gth research ~ ~nswer ~l~c very questions raised in the Surgeon Ge~era]'~ report¸ One other point raised fa your question with regar~ to cigaratte~, with regard m addiction¸ There i~ abso~ute]y no proof t}mt ciga- rettes are ~ddictivc and tha~ was referred to in an earlier Surgeon Ge~era~'~ report~ Mr WAXMA~ YOU ,~re putting mo~ey into trying t~ prove or di~ pro~e an ~bso/~te scien~iiic ceT~ai~ly. Its ~ifSc~|t l~ es~ab|ish a scientific c~rtainty. We have to make judgments based on the evl- de~ce. '[he most respected scienti~c experts in this country have ~a~e a ¢o~c]usio~ b~sed on what they see a~ much mol~ than mere coincidence b~we~n ¢igaletle smoking and draalati¢ in cre~se~ i~ heart ~d l~ng disease, How do you explain the ~trong ¢orr~lation betwee~ those who smvke ~d those who seer~ ~o have th~ largest incidence ~f ca]~cer and heart and lullg di~ease~ Mr. b]O~IGAN. TImre are obviously new ~tatistical evidencc and links between various ~icknesses and cigarette sulokil~g. I cannot agree with you ~hat all of the scienti~c or medical commt~nity ~grces ~at]~ tha i~ter pretati~m ~ th~e fh~di~s This morning wc have a panel ~f scientist~ who will present their "~ie~s and i only w~sh ~hat all of th~se scientisls who wanted to participate thi~ morniug could have bee~ here, because the sci~nti~ ic communky is not ~naatmous ~n their judgments o~1 this point. l~r WAXMAN. ']'here seems I~ b~ a preponderance of opinion among the leading scientific experts in this c~un~ry tha~ ~re in- votved m p~h[ic health ~d heading ~p the major g~ver~m~ntal e6 forts to combat heart disease, lung dlsellse and cancer They have a|~ ~]n~ b~f~re ~s an~ said with~u~ a~y eqat~ca~lon, wilho~t any doubt i~ their minds, that there is a clear ]ink between cigarette smoking arid these i]]llesses You ~re telling us that L]~ere is no linkv is that c~rrec~? Mr. HORRI(~A:~. ] am S~lvin~ that scienct! to ~ate a~er much rc- see~ch includi~g ~e~ $1(~ md[io~ lhnded hy a~r i~d~ry, indi- cates that no cau~a] link has been shown. That is what I am ad- ~J
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891 vised I am not a scientist. Mr Wax]nan. That is why doctors asked or scientists asked to participate here this morning, 1o perhaps answer in greater depth the questions that you r~iise We share your concern. Thot is obviously why we earmark the dollars that we do ever}' year in research that builds nlore evi donee, not statistics, hut continues not to prove a causal link. Mr. WAXMAN You also earmarked a large number of dollars in order te promote cigarette smoking in this country, i~n't that cor- rect? Y~u do spend money for advertising and other promotional efforts? Mr HORRIGAN That's right. The free enterprise system, I think W~ h[Ive a ]awfll/ prodt/et ~tnd a right to compete hi tile n3Elrket- place for the smoking public Mr. WAXMAN Could you give us the figure lhat you would annu ally spend on advertising and also give us the figure of how much you spend on scientific researcil as to the danger or potential danger of your produc~ Mr. HOaRIC, AN. Yes, sir. First of all, [ don't have the numbers, obviously precisely by company, but on behalf of the industry, I would say our estimates of industry advertising is in the range of $900 million. The industry earmarks in excess of $10 million a year in research. I don't think we should truthfhlly relate advertising dollars to research dollars, but rather take the research dogars spent by many other organizations, health organizations, or indus- ~ries, and l believe that our numbers are recognized as underlying a ldr more significant commitment to this concern Mr. WAX,~IaN. Y~m indicate you have been having what you call constructive and truthful discussions with Assistant Secretary Brandt and other Department of Health and Human Services' offi cads on this question of smoking. Then, you express your unhappi- ness with their supporv for this legislation, You claim, in other words, the effect of the bill is to shoot first and ask questions later, Do you feel that the administration did not hear you out or un- derstand the arguments that you had to make against the legisla- tion that they are now supporting9 Mr HORRIGAN. I believe Mr. Korn~gay could answer that in greater depth. We believe we are having productive discussions with that agency regardiag that particular issue In that forum, we are getting u fair hearing 1 do think wit.h regard to the severity, the serious impact of this bill that our industry is not being given the proper time to air its ~iews properly and provide you with our responsibility to keep you as well-informed to answer all of the questions possible. The time flame on this particular situation, we believe, is very tight indeed. Mr. VgAXMAN. You are spending money on trying to corae up with a scientific certainty. Do you have any estimate from your sci- entific people as to a time when they will be able to tell us that cigarette smoking is or is not harmful? Mr. HOR~W.AN. l wish that I could, Mr Chairman. I think like any pursuit, any medical or scientific pursuit of any known disease, I don t think anyone could have answered years ago whether they would have found the answer to polio vaccine, l don't think science can work to a timetable The important thing is not to cut off medi- L~ ~J
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392 cal research and scientific research, but to continue in search of the ~s~. R~tt I realty can'~ give a timetable. Mr, WAX~AN Have you been influenced in terms of your own personal view ~ff the potential dangez~ of cignrettes frora a~l el¸ the evidence that has come about in the last ld years? Mr I4OIIRIGAN, I think my ~wn personaJ experience might bc somewhat unique ~nd approriate here I am not a so-called t~bacco industry executive who has spent his life in this business. I just j~[~ed the t~h~cc~ i~d~s~ry ~ ycar~ ag~. I~ ~ki~g at ~hi~ i~d~try, while the opportunity from a career standpoi]lt was a good one, but because of the publicity surrounding this industry I obvlo~sly had r~ ask myself a lot of questions abou~ it And I found out an awful lot about this industry that are little known facts. [ would l~ever have taken a career pOsLtiOn in th~ i~ dustry if I had any c~ncerns about the product that I was responsi hie for marketing. Mr. WAXMA~ You know, ~he prod~ct liability laws require man- tlfaettlrers tx~ war~l about I~e dal~gers ~ssociated wi~h a prodtlct. The Federal Cigarette Labeling and Advertisiag Act requires the current health warning displayed on cigarette packages [l¸ we were t~ repel./ that w~i~g ~r~ cigarette paekage~ ~r the *~ar~ing re- quired on advertising, what obligation do your lawyers tell yo~ that yo~ would have to advise the public about the potential ~an- gets of smoking your product? Mr. W~Tr Mr Chairman, i don't think ~he intention is ~o r~peal the obligation ~o have a warning¸ Mr WAXMAN We are obviously not trying t~ do that bu~ it was o~e ~f the sugge~ion~ i~ opposition of this legislation that ~he Go~- erntnerlb should no~. be ir~volved in this area. If we took yotl up o1~ the premise that ~e Government should not he involved in trying to urge people not to s]~eke arid struck from the law the require merit that there he a war~in~ that cigarette smoking is dangerous to y~ur health, you w~d ~he~ h~ve a legal obligation t~ ~,ar~ co~- ~umers if your product offered some dan~r to them. What. do your la'~'yer~ tell yo~ you ~o~ld ha~e to advise the public if the Government didn't require you to display the current warning label'? Mr WZT~ That is a very complicated question¸ If y~u would alIow me, sir, and if your staff would give ~s some direction as t~ reclsely wh~t sort o~ a~awer yo~z pre~r, [ will c~n~ul~- wi~h ~r ~atwyers and give you an appropriate a~swer }3~1. in ~he environ- rae~L we are acting ur.der a~ the monxent, ~ don't ~h~nk it'~ appro- priate for me to try," t~ speculate, givvn the fact that there is a sub starltia amount of product Iah ity i~igat on underway a~d give 1 the fact that it is, as I said, a very complicated ~nd somewhat dlffi- cult area to deal with ad hoc Mr. WAXMt~. Without objection from ray eotteagues, I witl have the record held open so that we can get that information from you at a later date. ISee p. 4151 But I would submit to y~u that ~ ade- quately warn the consumers under all of the product liability laws that l have seen from jurisdiction to jurisdiction throughout this country, you would have to give ~a lot more information and z~ sig- nificantly more detailed warning than what is t~ow required under the law ~q "0 4a ¢0
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393 I would think it would come pretty close if not exceed in detail the warning labels we are calling for in this legislation. See if your lawyers agree with that conclusion. Mr. WAXMAN. Let me now recognize some of my colleagues who have questions for Mr. Horrigan and members of the pane] Mr BLILEY Thank you, Mr Chairman and thank you. members of the pane] I appreciate you coming here to bring some light on this subject I have a tPw questions for Mr Horrigan. You mentioned a Gallup poll that found 90 percent of the popu- lation is aware of the health claims associated with cigarette smok- ing. Are you aware of any ether evidence polls, surveys, that show the extent of the public knowledge of this issue? Mr HOR~!IGAN Yes, sir There was a sur~'ey and a report or statement that goes way back to l~g8 where a Government official said that you could go to a roollop I forgot the exact quote and shout about the dangers of cigarette smoking and there would be nary a person that is not awm'e of the dangers of cigarette smok ing Furthermore, with l~egard to polls, ] think there was a poll back in 1979 or 1980, a Gallup poll. The specific breakout with regard to teenagers found that 96 percent of teenagers believed that snmking was injurious to their heakb You can tell by my accent I am a New Yorker, not from North Carolina. But we have an expresssivn down there: "If it ain't broke, don't fix it" We think your Surgeon General's warning is working very effectively Mr BL]LE¥ Your people who advise you and do s~atistlcal re- search tbr you in behavioral matters I know we will have some people later who are experts in this field tes~il'y is it possible, in yElur opinion, through changing warning labe]s or ~hrough the lan guage uf this hill, to raise the percentage of awcnreness as n result? Mr. HORRIGAN. [n our judgment, ~e do not believe yau could raise that level of awareness. If you take the business of market- ing, a 90-percent awareness level for any brand message would be regarded as an extraordinary success. There is another phrase called "singlemindedness versus clutter." Advertisers worry about being on television and the clutter effect in losing their effective- ~IOS~ But we believe genuinely that the singiemindedness o~ the Sur- gNll General's warning achieves that level of awareness, is accom- plishing what truly is 3~ur intention here. I think that to add per baps a mote broader perspective Lo your quesLi~n, I would like to ask Dr. Light to comnlent from his viewpoint on this particular question. Dr. LIGHT. Thank you. I don't have specific numbers on all adver fising campaigns, but I must say, based on my personal experience and judgment, this particular message has achieved numbers that would be truly considered to be remarkable Stone nf this is not surprising I don't believe ~here has been any single advertising message that has had the kinds of support that this one has had. There have been millions el impressions and rail lions of dollars spent. [t has appeared in alI tbrms since 1971, it has appeared consist- ently in the same g}rm since 1972 And the result oI all of this is -,J g~
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394 truly extraordinary awareness When I talk abou~ awareness, [ don't mean that people memorize specific words People do not memorize advertising What people do is they re member overall impressions And all of the research that I have been able to review suggests that consumers have registered the in- tended net impression of the warning statement I also think that there are a couple of principles we ought to keep in mind, advertising principles. That is this whole issue of singlemindedness and consistency. ]n the advertising business, we have some principles of bow" to produce eff.cti,'e messages. There are five of them. Keep it simple; make it clear; say it otlen; be con- sistent; be singleminded. The warning statement as currently structured, in my opinion, meets these guidelines, So it is not only that we bave had a lot of support for it over the years and a lot cf impressions made. but frankly, you have followed the principles of good communication So. again, I am not surprised that we have these extraordinary high awareness levels. There is a saying that fmniliarity brec<is contemgt. A lot of advertising people seem to buy that because they call it wearout. The truth is that familiarity breeds trust, not contempt, Consistency is what we are after in advertising, not variability. Variabilky breeds coniusion And. in my judgment, I think the ro- tational system that is pruposed wouldn't ilelp, it will hurt Thhlk of companies that when they built an awareness level ~f g0, 70, and 90 percent, how careful they are to make a change, They don't want to abandon some asset they have built over the years because they recognize any change will iswer awareness, no~ increase it. So, frankly, I see no benefit at all to this rotational strategy. My hypothesis is that it would probably hurt rather than help. Mr. BL.I,~v I~ your testimony, Mr Horrigan, y(lu referred tl) Sweden. You pointed out. I believe, that cigarette consumption, that is the number of cigarettes sold in Sweden, is not dovn~. But the chairman of the subcommittee introduced into the record yesterday an article published by thc Swedish institute called Current Sweden, deaiing with this subject. It was dated November 1981. I don't know if you have seen it or riot. My. HORRI~AN. I have not, sir Mr BuL~Y It was interesting to note that they agree with you onpage 7 in here, it states that the total number of cigarettes sold in Sweden has not changed. Has the total number of cigarettes changed in Great Britain, that is, to your knowledge, as a result of or since the rotational warnings went on there? Mr HOI¢IilGAN The market in the United Kingdom, l believe, is either fiat to slightly declining. I ti~ink it is a combination of rea- sons in that particular market, hut I can't really say precisely what these numbers are, Mr. BLILEY. They couldn't say in that what they werc, either. I believe the price of a pack of cigarettes in Sweden, with kronor value of 18 cents, would put it in the neigborheed of $2 a pack, which is considerably more expensive than it is in this country. L ~0 Ca
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395 I thank you. There have been several referencps in these hearings about the amount of money that cigarette manufacturers spend ol/ advertis ing and a large increase in that spending alter the industry ceased advertising on radis Emd TV I have been thinking about how the cost of everything else has gone up over the years I wonder if anyone [n the industry has ever compared what was spent to advertise cigarettes, say, 1(I years ago, to what is being spent today? Mr HORRIGAX. I have, Mr. Blilev, on many occasions, because I have to justify our marketing budgets to my hoard of directors. So we come up with comparisons to ShuT rates of advertising. That question is often raised, fm example, in a process such as this To put that in perspective, if you go hack to Mmut 1968, there were some 168, I think, brands or brand styles in the market You relate that to a marketing or total budget in those days or expendi- ture level in the range of some $,~00 million Give or take, it figures out to an average per brand in terms of marketing support of about $2.5 million per brand Now, it doesn't work out necessarily that wa:~ because you weigh your advertising. If you take the total dollars, that is how it came out Since then, there ha~ been a multiplicity of brands and bland styles introduced in the marketplace Given the nmnber of brands in the nmrke~ ptace today, and taking my nmnber that I quoted to the chairman earlier this morning of an excess of some 8900 million, which in real dollars compared to that $3~)0 million hack in 1970 would be more like one-half billloa dollars, then you are still talking about brand support on a per brand basis of ~2 to $2.5 million. So ynur rate of intensity on a per-brand basis ha~ not Jncremned Mr. BLILXY. Thank you. You also talked about the tobacco indus ;ry refkaining from sampling to adolescents. How do you go about aecomplishlng this? . ~r. H{3RRIOAN There is a cigarette code of sampling within ~he cigarette industry, which we all rigidly adhere to. We have written pamphlets with regmd to the sampling laws, for example, we do not sample in or near or around college campuses or schools, We have our own code hele with regard to the distribution of s*~mpies, the need to verily a certain person's age betbre cigarette sample is distributed I would tell you that our industry is so corn petifive that if, for any reason, as you move out and assign this re sponsibiiity to promotion firms or agencies, if there is any violation of this, at the local level it is brought immediately to the attention of the company who has that par~icu]ar problem. It is stopped imnlediatcly We very faithfully do this, Last but not least, I think it hdlows a series of changes over the , ~ =: " ~ ' d . - Mr. BLILgV. You say that the tobacco industr> sees no reason to b/elude the warning label on cigarettes that are exported. But, what about cigarette expe~ts to developing nationsV Don't you think they should be warned of the controversy surrounding smok- ing and health? )dr. HORmGAN. First of all, smoking is a behavioral patteln exer clsed or expressed throughout the world With regard to Third ",I
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396 World countries, there are certain requirements with regard to warnings and different governments have different requirements. They are obviously honored by all cigarette manufacturers. The cigarettes that are marketed in those countries, meet tile particu- lar pralhrences of those countries The trend toward lightness that we see hi America is emerging on a worldwide basis, bu~ it is not as mature yet in other countries of the world Mr BUL~" Do you know approximatel~ how much, Mr. Horrl- gan, it would cost the cigarette manufacturer annually to rotate warning labels. For example, how muck would it cost R J. Reyn- olds? Mr, HOR~mAN. Thero is an estimate developed on an industry basts, but to be very honest, as ] indicated in my testimony, our concern this morning is not one of economics. It is in the range of, I think, for the total industry a cost of some $40 milllon So it is not a question of lack of ability to do this, the economics of it are not. in our judgment, aa issue. Mr BLILEV I see But this $d0 million could go into higher em- ployee wage~ or some other factor, since it has not keen ~be~, at least m this member, that by rotating labels, that it has had any effect on consumption And I think that in Government. the burden o~ proof is on us, if we are going t~ put a b~trden or_ somebody, te in~xf~re with their rights to advertise, that we must show overwhelming evidence that it is g~dng to be effective, I thank you very much. I tha~_k the indulgence of the Chair and ray calleeLgues for altawiug me this time, Mr WAXMAN, Thank you, Mr B]i]ey Mr. Dannemeyer. Mr. DAN~MEYE~ Thank you. 1 ~ou]d like to ask the counsel Mr. Witt. a question ~r two, if [ may, Mr. Wkt, have there been any juries any place in the court ry who have on appropriate instructions of the judge, hroughl in a verdict of liability against the seller of cigarettes on the allegation of a plaintiff in a lawsuit thar~ the smoking ~f cigarettes impaired that ~laintiff s healt.h? Mr. W[TT. It is my understanding that there have been no ver- dicts brought i~ against the tobacco industry on that basis. Mr. DANNEMEYER You mention that there are some cases pend- ing ~r~Ltr~d th~ c~uutry n~ /kre there some avcaitil]g trk~l ~n thi~ issue? Mr. Wlvr. I can consult with my colleagues behind me and find a precise answer tc~ that Mr. D~.~z~. Wh~t [ .~ulcl like t~ d~, ~hen y~u eon~ul~. with them, is ascertain if pkdntilYs counsel have been successful in getting by a suit in a zivll c~.~e ~o the point where the judge has submitted the case to a jury If you h~we ~be answer ~o that, I • n~uld appreciate it? Mr. W~TT. Ity'ou would like, I will find ~he answer I don't want to take the subconmlttees .... woe to chat with my friends while other more important matters may be discussed. But I will find the ~,~',~'~er ~,Ed get it for yotl. Mr D&I~'NEMEYER [ would also like to km*w what il~struction plaintiff's counsel are giving or requesting the judge~ give~ to juries on the issue of approximate cause? That is the causal l~elutbm, epi-
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397 demfofogisally speaking, between the smoking of cigarettes and the onset of disease or debilitating disease to plaintiffs? For instance, I would llke to know, are judges including, in their jury instrtlctions, the statement ~ppt~aring on packages of ciga- rettes as it presently exists, when they instruct juries~ Do ~u know that? Mr. WITr. A broad answer, which we will be glad to expand upon if you wish, is that the instructions as you have put them have not gone to juries. In every case juries have found for the tobacco in- dustry. Mr DAN~EMEYER. | see. Interesting. Thank you I would like to ask this: Are you fo what [ call the advertising business, Mr. Light? Dr. LmaT That is Dr Light and that is what we call it. Mr. DANNEME;YER T anl glad to have the opportunity to meet one of the experts of your trade, sir. Because L too, am a consumer in America. And I have an opportunity from time to time, ] have chib dren in my home, llke most of us, ] suppose, and they turn on the TV--to view your work product. When the TV is on. I sometimes heal" these advertisements that you share with the American public, selfing the products of your clfont~ Would you mind outlin ing tbo~e specific things |hut you say se]i products to consumers of America again? The first was wha~ Keep it simple. Dr L~GHT What | was outlining there were some principles of communication for building awareness¸ Mr DANNEbIEyER Yes Dr LiGhT. Keep it simple, and I think that is, in my judgment, Ihe most, ftlndam~nL~[ one of a]]. in ~ICL, w~ h~tv~ ~t[l expressiOll tbat some of us use called KISS, kis s, it stands for "Keep It Simple, Stupid." Mr. DA~NEMEYE~ Yes ~qlat is the next one? Dr LIGH'r Make [t clear Mr DANN~M~YE~ All right, clear. Dr. LIC.HT. The Lhird is say it often. Mr~ DANNKMEYER Often, well now, ~hat is interesting. Dr. Lm~T. The fourth is be singfominded. And finally, be consist- cnt. Mr DANNEMEYEm And consistent Well. I den~l expect that nly COmments win change the tactics or nsses~ment ~f the ~dvertising industry one wit, sir, but one consumer to you, with a]] due respect, | think that the basic premise of the advertising industry of this country is insulting. I lind it {fffensive and demeaning to the intelligence el" the American people. And for whatever it is worth, in my assessmen~ of hew I will spend my money, for those products who advertise their wares on the principle of ot~en, where the theory is, | su~ po~e, |he more you beat peop[~ over tht~ he~d, tfi~ more you ar~ going to sell your products, it has the effect of consciously causing me to do deliberately the opposke. Perhaps that is all a part of your scheme. You want to invariab]y reach the psyche of the consumer to cause that P~vlovian response somewhere along the line. To ultimately breakd:twn and buy y~ur products. Perh~ps I ~im, you know, susceptible as well. 2
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r 398 Buu my [~iend, let me share with you, I am ~'ery sEncer¢ about it and I appreciate the oppor~uni~ of I~nding sorneoi1e ~om your in- dnst~3: and ~hari~g the~e thoug~ w~h you for ~hateve~ it is worth. There ~rc v~rlous ads th~It appeal to t~is consumer. Thel~ i~ one a~ Christmastime, I wouldu't name ~he product, but it ha~ a sleigh pulled by a horse going ~cross a snow scene I tell my wife when- ever ~ ~orc.e~ ~ut c3nC~ ~. year, "Yo~ h~.~e to ~o ~'P~ ~P~ ~uy ~orne of tha~ b~r because that, to me, ~ppeal~ to thi~ consumer's intellect." It i~ beautiful. £t is a story and ! suppose that the only time they come on is ~t Christmas. Whatever that i~ worth, take ~haz back ar~ ~hare i~ with tho~e ~xccutLve~ oil MHc~ison Aver~t~e ~ or~e COn- stlm~r of America to you peopJe ru1~ning ~he ~irwavo~ of our N~tion. Thank you, 19r LmHT. Thank you very m~ch ~r ~he advice. Mr DAN~Ey~R It i~ worth what you paid for Mr. WAXMAN. I se~em to be h~aring wha~ appe~.rs to be a contr~ diction i~ the testimony or~ at least one point. I understand, Mr Horrigan, that yo~ ~re claim£ng that these warning labels, this i~- ~rrnatio~ that we ~r~ l~r~o~in~ ~ h~e ~vm~h~ i~ ~ig~ret~e ~& v~rtising abou~ the specifiz he~th dangers of cigarette smoking, would not he e~Tective. i hear Dr Light saying thai the cigarette war~ing lahel we al- re~dy have i~ tremendously effective. I~ that ~ con~radlction? Mr. HORmGA~. I don'~ believe it i~. Mr. W~XMAN. Dr Light, why d~n't I address (hat to you? ]3r. LI~. I ~hi~k the key i~ y~ur de~nitio~ o[ eflhe~ene~. Mr. WAXMAN Are you c~inqilqg that mo~t peop]~ in thi~ country are ~ware of the d~Tlgers of ~mokhlg because of these warning label~ and the s~ccet~ of ~he warning labels is due to the lhct ~hat they are sir~ple, clear, and ~ing]eminded? Dr LIGHT. That is correct. Mr. WAXMA~. NOW, you ~ro s~ying they llre effective? Dr hG~T. Ab~lutel~. Mr. WAX~AN I thought M~ Horr~gan cl~imed that we should not ha'~e lh~s label changed because labels, per se, ar~ ~o~ effe~ive i~ informing people. Tha~ i~ the ~rgurne~t I have been heari1~ in the l~t Couple hearings, ~hat i11 Sweden and other pl~ce~, warniug labe]~ are not an e~ctive way ~ inform the public Mr HOnRI~A~. I ¢an'~ say th~L ~r. Chairman¸ Mr. HORm~A~. I ~aid th~it, it ks i~ my testimony, in my lengthier Mr WAXMAN If¸ we wa~t to inform tln~ public that cigarette sln(~king is a major cause o~" hear~ disease, ~hat cigarette ~m~king is the ~o I cause ~f lung cancer, ~nd tha~ cigarette ~moklng by preg- nant women m~y result ~ hlr~h de~ee~--whi]~ you might not a~reo w~h the me~age--~vouldn't walning I~.beI~ be u~ e~fective ii1e~ll~ to coilv~y Lhi~ il~forma~i~n~ Mr. bio~R.~c~.~q. We don'~ ~eli~e ~ w~uld he. Obviously. ~e ~re here this morning ~ec~l~ we ob~ec~ to this ]egis1~ion on several i
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399 bases~ not purely the method of communication. But on several bases Mr. WAXMAN. Your objection is to the substance of the warning? Mr. HORRJC.AN Our objections are based upon the mechanics of it, the fact that it is unworkable--- Mr WAXMA~ Why is it unworkable? You say that it is only a matter of economics--- Mr HORRICAN [continuing]. This bill, in its present form, has as- sociated penalties along with certain requirements. And with the multiplicity of brands and brand styles and this methodology or ro- tating warnings, the cigarette industry is being exposed very badly from a litigation stm~dpksnt. The mechanics of implementation, ~gardless of cast, are also burdensome. So those are just some--- Mr. WAXMAN [continuing]. I don't want to be unfair to anybody It seems to me if that is the problem, it can be worked out. We can talk about how you can implement what we would consider t6 be a legitimate wa~lb~g label because from our point of view, we want to inform the public as to the dangers from smoking. I understand you wouldn't agree with the message we have to carry, but as far as the mechanics of delivering that message, that seems to me to be something that can be worked out, if that were the only problem, Mr. HORRIGAN Aside from the mechanics, we have also stated clearly in our testimony that we object to this kind of requirement or legislation because the requirements of those statements as put iurth in the package are without foundation We have a right to be heard on that issue. Mr WAXMAN I understand you don't agree with the messago we have to deliver. I wane to clarify the issues we have before us. I have been hearing that you don't agree with the message we have to deliver and you don't think this is an effective way to deliver the nlesgage, We can dispose of this second item it appears you are in agree- meat that having warning labels is an effective way of informing the public. Mr. HOIlmGAN. We are saying that the warning label, as it is p~esently constituted, is delivering the message that you have a concern for. We do not believe that these will serve any useful pur- pose. It will add to the clutter and Lt is terribly simplistic to say it can be worked out mechanically, because, Mr, Chairman, it will be extremely difficult for your own FTC as well as the manufacturers. You are leaving us in an open field. Mr. WAXMAN. Well, it seems to me I am getting different mes- sages here. Maybe that is one of the problems, the message is not clear and consistent. Dr. Light, you indicated one of the reasons you think our bill ks deficient is that it violates one of the princi- ples of advertising, and that is to be consistent and clear and simple And therefore, you think the warning label already required fol- lows communications criterm for successful transmissfo~t of the message. Is that a correct statement? Dr. LIGHT, Yes, ~-ir. g~
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g00 Mr. WAXMMv. [ ~ould like in gek of you, why i~ it that the ciga- rette industry feels that it must frequently vary the formats of ad- vertlseraents and nut rely on the same one? Why do you change the pictures or graphics'! Certain thla~gs are eouslstent, hut why are others changed? lsn't it to tr'y to get and maintain public attention, because they d~ get tired of seeing the same advertisement over and over? [See p. 18<] Dr. Llcsv That is a very good example. If you look at it you will firtd e[emeIlts we keep cllnstant al~d there ai-e elemcttts we bare it is not true we have an ~td The intelltion is to keep the substance constant, &lid vary execu~ional context, Now, if yuu look at that o~mpaign, we consider it in fact a classic worldwide exaraple, not just domestic example, but worldwide uxample of consistency, not of inconsistency. Yes, it [~ true ttk~lt the pictures change It i~ also true there are elements that are coltsistent Bach has its own purpose. That cam- paign is an ex~mpie of consistency of message. It is not designed to say a different thing to the consumer in ad one, versus ad t~vo, versus ad three. If we did advertising research on any one of those ads~ we would e~:pect the same message tu come through. The message raay he ex- ecuted differently. Why? To get attentbm. Not to communicate di~ fm~e~t inter marion 5/It. W~Xx~N Hove much attetttlml do you think the puhllc is giving m the li¢tie label down here at the bot¢om that never varies? I~ i~ always the same and has what l consider a bland state- ment, "Warning: The Surgeon General hm~ determined that ciga- rette smoking is dangerous to your health." The dangers aren't clarified. The consumer looks at that aad snys, "Well. dangerous to yot~r haaith, sure," if thay see it at a]l Dr. LmHv. I don't know, but--- Mr. WAXMAN If yOU were hired by us to do ml ndvertislng cam- paign to communicate the message that people shouldn't smoke be- cause if they do they are risking their health, of course it is their decision, but to communicate that fact to them so they will be awme of it, would you reconlmend that the most efl~ctive thing we could do is to put the label down here at the bottom and never change it? Dr. Lie.He [continuingI You have a~ked several questions. Let me see if I can remember. ]~'irst, lo ~erms of co~sit~teney, let's take *he name Marlbero it is very consistent. Same type style, same layout, same n~me repeated over alld over again. ~he package design. There are certain things ~lient~ keep con- stant, name. logo, basic theme line. symbols or signs. Mr W~XMA~, ] don't under~tand which of my questions you are answering, it ~eera~ tu me, the que~ttons I w~uld like ~ou t~ answer are. one, d~ you think that the public, with that same warning label placed in the same Iocatiol~, lea]ly assesses that health mes- sage as e{fe¢~iveiy as they e(mid? At~d second, if you were advising us as an advertising expert on how to commtmicate the message we W~Ult $o communicate, would ,Q
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I 401 you recommend the current label as the most effective way to corm lnunicate this message? Dr. LIGHT. The first question as ] was trying to say, I believe that the consistency is not a proh]cro It is an asset. What it means is that the consumer cam quickly scan that page and by recognizing imniliar symbols without carefully reading every word, reminding them what is in that symbol. That is exactly why advertisers use symbols¸ Now, that white box with that type style is a symbol¸ I will pick an example of m~other ad. This is an ad in a language you might not understand. I believe it is Chinese¸ But ther~ is, because this ad appeared in the United States, a Surgeon General's warning in Chinese. But I believe th,at if we showed fuis advertisement to todav',s consumers and said. ' What do you think is written in this box? consumers who do not understand Chinese they would play back the impres- sion. the message associated with the Surgeon General s warn ng. Mr WAXMAN. The Federal Trade Commission said that fewer than 3 percent of the people who saw a cigarette ad read the warn il]g label How do you explaln that iact~ I am sure 10(] percent ¢:ould identif? these as Marlboro cigarettes. Dr. LIGHT That is probably not true But let's assume lhat if I show people an ad, my impression is that if I show people an adver- tisement and ask them what that said, they would play back the Surg(~n General's warnillg. I believe if we did the research proper- ]y and did it as traditional research, we would show them the ad- vertisement, and then not ask them what pieces of the ad people looked at on any given occasion People look at advertising campaigns, not at indiv]dua] ads. What we are after in measuring the eil~ctlveness of" the campaign is the cumulative tracking studies, such as the G;dlup survey, are what we use in our industry to evaluate ~hat the net impression is of an advertising canlpisgn tt sr.ems that that element, warning, that clgareLte smoking may be dangerous to our health, is dangerous to your health, has been commmlicated to 90 percent of the people That is a lriumph. Mr. WAXMAN. That is right Dr LIGHT Congratulations Mr WAXMAN. Conglatll]atagm t~ you. You are the ones who are triumphing You are making a tremendous amount of money, an unheard of amount of money selling a product, and yon are doing it very successfully w~th advertisements that communicate the message to buy one brand or another and in take up the ]habit of smoking. Don't congratulate us. We have ~ pay the bill fhr those people when they get lung cancer or heart disease. We have to pay for them when they get cancer and their insur ante runs out if they had any at all That is the problem we have. Please don't congratulate us I congratulate you htlok at this ad- vertisement This must be one of your favorites, certainly one of your lnos~ e[fecfiv~t. It shows Kent cigarettes as a carton of ice cream "Scoop on taste. Kent. of course," it says on the bottom Now is the message of this advertisement, I am asking re.re out of curiosity than any- thing else, thalt smaking cigarettes is as good as eating ice cream? Or is this advertisement saying to people if you stop smoking ciga 0~ 5q ..5 0~ iW
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402 rettes,qyou are going to get int because you are going to eat ice cream. [See p. 260.] Br. Lt~T. I doubt it is saying either of those two things. Is that a multiple choice? Mr. WAXMAN. What does it say to you ils an advertising expert? Is the message simple, consistent, et cetera'? Dr. LIGHT AS I kBOW, that advertis}ng campaign, they have been running each ad associated with variou~ food products. Research seems to sug~esi that iN the lo~ tar category, p~ople are concerned with that low-tar cigarettes don't taste very good. And Kent is obviously hoping with this advertising to communi- eats that this par tin~lar brand has go~d taste d~ii~ery, Mr. HOR~J~Ah'. Mr. Chairman, pardon me, but back in your statement a few moments ago, for the record, you made ~he obser- vation tha~ our ads are d~s~gned ta make people take up srn~klng. And that is not our objective at all, With regard to that particular campaign, I think, there is your picture, Mr. Waxman, Mr. ChJ~ir- rslai~, that is--- Mr. WAX~AN, I wilI take two of those. Mr. H6g~IGAN [continuing]. You present yourself to your custom- ers. your voters in a very ihvorahl~ way, With regard to our indus- try and our advertising tbr those millions of people who have made the decision to) smoke we present the product in a pleasurable way because to those who smoke, it is apleasurable habit So we present our prodoet in a pleasurable way in the same way you, l think, when you run fur office present yourself, but we do not urgee peopie ~o take up smoking ~]Jr. WAXMAN. I ~m not a~l expert in maay things, but 1 know more than most people ab4mt campaigns, I know if thare is an elec- tion going on a~d no contest, the voter turnout tends to be much lower If there [s a contest, competing caudidate~ are trying to sell themselves They are saying llfe is going to be more pleasurable if you vote for one as opposed to the another, Obviously, candidates are trying to sell their brand, get the public to vote fur them. But Lbe consequence, of that. campaign, is to Increase vo~er urnou More people participate In the election, l believe the impact of sdvertls/ng despite your claim it is only to attract smokers J?om one brand to another, increases the llumber of pet~ple who smoke Mr. ~ORRIGAT~. Having been introduced, you recognize my back- ground has been in ot]ler tadu~trins, let's say, where a far more open en~ironme.t exists to comp~te in the marketplace. Our indus- try competes in a very restrictive, inhibited environment and therefore, within thaL we know 5~r a fact what Js happening to the ~moklng ~p~lation and the incidenet" of ~rnoking So indeed, we have a ver~ competitive industry. But it is in fact one of us going *~gainst the other, and another company going against the other ang it is strictly a matter of brand preferene~ and brand switchlng. It is clear from t]~e statistics ~nd trend that we ~re not building the sracklng p~pu]ation of America, Mr WhXMAN Dr. Light, the Ted Bates Agency wrot~, in one of their advertising memoranda of a proposed c~mpaign to attract teenagers, y~ung people to cigarettes. $2 t¢
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403 The quote thz~t has been used ~1 nunlber of times in our hearings and came fhom a hearing of our c~versight committee when they eb rained the information from the Federal Trade Commission It as- serted that for the young smoker, the cfgarette is not yet an inte- gral part of life. of day to day life, in spite of the fact that they try to project the image of a regular, run-o~the mill smoker. For them, the cigarette, and whole smoking process, is parr el the illicit pier.sure category, in a young smoker's mind a cigarette fails into the same categos)" with wine, beer, shaving, wearing a bra--or purposely not wearing one--declaration of independence and striving for self identity. For the young starter, a cigarette is associated with introduction to sex life, with courtship, with smoking pot, keeping ]ate studying hours. This analysis is one of' what young people, generai]y speak- ing. think about smoking, and I would assume that this intbrma- ion is translated into an advertising campaign that can encourage them to take up this habit, with a particular brand in mind It becomes a lile lon~ habit Dr. LIGHT That a~umption is hlcorrecL Mr. WAXMAX. Oh. Tell me what is incomect Dr. LIGHT. Well, I had only arrived in the city and only joined Ted Bates several months ago. So I must tell you I only learned about the Viceroy Mr WAXMA'I What were you doing before that" Dr LmHT [continuing]. I was with BBDO But since the subject did come up, our legal counsel had briethd me on the issue I have read the materials yesterday. And I think, for the record, it might tie usetP~ to review what did happen to that paragraph, because l think the sU~tements you have made and assumptions you have made are incorrect. Not that it has been inaccurately quute~t, but it is incorrect that that quote was reflected in any advertising Mr WAXMAX. Where did that quote come from then? Dr. LIGHT. Well the circumstances were simple. The Ted Bates Agency as i understand, was apparently fn trouble on the V ceroy brand. There was no secret. The client had told the agency they were about to lose the account The account group, being nervous, and that is certainly not a surprise, they are al~o human, initiated some research The first thing I should point out is that it was not Ted Bates' research. It wrL~ resealch conducted by a company robed MARK, and the research repot t w~ written By a fellow called Cannon. This was qualitative research, and the research repoet was writ- ten by the moderator of these focus group interviews h~r WAXMAN. Wasn't the report written for the purpose of t[ying to figure out what would be a goad test or strategy to se]l cigarettes to young people? Dr. LmHT, The research report was written by a moderator who, I don't know what purpose they ran it. But I can sa~ that what did happen was Lhalt a ~r. WAXMAN: Why can't you imagine the purposee Why do you think they were doing that? Do you think they are soeiotogists trying to figure out what kids like? They are discussing tr>irtg tu sell cigureltes, saying what teenagers like ca .j
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404 I will certainly let you complete your statement. Dr. LmnT. Thank you There was a memo issued by an account execut~ wh~, c~ncerned f~r she j~b, ~ur~r~rizecl the results ~f ~h~ resle~rch an~ presented those restllta te ~he Client. Now, the key thing is your asstlmp~ion that advertising was then prepsrcd and guided by this r~isgukled research. ~ impression is, a~d I don't know, I haven't talked to Mr. Cannon, bu~ it is that, knowing that the agency was i~ trouble and the account person was in tr oub~e, m~ybe he was trying ~o ingratiate himself l~ any ca~e, Brown & W~l~am~n did n~C reclue~t ~ny ~dver~i~ng be prepared ba.sed on ~hat research. Advert[sln~ w~s no~ prepared or proctuced. The t~int o~ view in the document was not acted upon. No ads were ever produced based on ~hat research or based oa tho~e words which you have quoted And h~ my o~pinJon, whil~ the words ~o exis[ ill a nletao, they are quo~elt Oll~: ofccln~e~l: az/cl misrepresent the adx'erti~ng process, it sorer%imps happens th,%% there ~s I~n ~x'~'r~e~Lr~u~ ~eount ~(rc~up, IIl~yh~ a lllisg~i~e4 re- searcher, m~ybe ~omebody ~ryfag to save hi~ job, in fact, doing just the opposite. And unforLullately, an inappropriate memo is issued. But the ~ruth is there are enough ~hecks and balances on the clients side and on the ~gency's side to make sure that tho~e k~nds o[ ~hings do n~t happen. [~r. W~x~. I am going t~ ~n~err~pt you I understated ~h~ y~u said. You have said it ~,r ~he record. That is the assumption you malct~ Tho ssat~ment you have far us is ~ha~ this is not an ~tc- ellrate st$1tem~nt of ~lnythhlg other ths~ sonlebody who was trylnl~ ~o save his job, and it dkln'~ even lead to an advertising campaign hnsed on ~h~ rep~l't~ conchl~ions. Dr. Lzc, l~. That i~ ~ot--~he~ ~ n~ adverdsm~ redectod o~ that. Mr Wax~a~ ! would submit tha~ ! would think thls person made the inistake of putting down in writing what g~es on in ad- v~rtisfag agencies all the time. And wha~ goes on in advertising agencies all the ~ime is how are they going ~o sell ~ product~ and ho~ are ±he~ey ~oing ~o expand the ~arket. L~t me ask y~ a quest ~ along th~e tiues. We h~ve ~een ~tati~- tics thllt there has been an increase in ]un~ oancer wil~h woolen. We ~]sr~ see !.he ~2.tlstics thai; there has lateerl an ~ncrease in Cil~a- rett~ smoking among women. Nvw. I know it is just statistics and m~y well be a coincidence, bat can you ~ma~Ii~e ~a~ perhaps wumen were ps~inl~ up ~ra~kthg ill I~rg~r i~lvp, her~ o~T~r ~ ~ri¢~ ~ ~tme beg~ll~ ther~ "~a.~ ~rae calc~lfate~ e~)r~ to ellc¢lurage t}~em to take up sriloking? ~r ~Iorrigail, it ro~ks like you are anxious to answer that. Mr. HO~RrC~N. If)ou dont mind, Mr. Chairman, I vould llke to answer the ll~est~on, but lethe g(i bt~ck a step farther¸ i w0~]t) ~k~ to speak on b~hoif of the industry b~cause in ~o~ra~on~, ther~ ~re exee~t~e~ ~vh~ c~n get them~ve~ ~n trouble, in ~g~e~ there are ps~ple in Congress wh~l can get therasoives in trouble Do n~t---- Mr WAXI~AN i wan~ y~u to answer my qu~tion. Mr tt0~mAN No. a9
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4O5 Mr WAXMAN I am going VO have to interrupt yt~u [ don't want to be rude. I asked a specific question, ] really want an answer to it. Mr HOJIFllC3aN I will answer it. Mr WAXMAN Anything elsc you want to add, we will keep the record open. Mr. I]O~RIGAN Fine, With regaled to the incidence ~Jf women stocking, the incidence rate is, in fact, declining The numbers of lemales that are smoking is increasing as a function of population. Howevcr, when w~ ~ook at cigarette smoking amongst the female population, we c~innol look at that in isolation. There is a lot of change in social behavior with regard to ~emales in America¸ They are entering into the nlarketpface ~tnd they ar~ picking up other cha~ac~eristics~ The man who drank a ~otch at the airport and lit up 5 years ago now drinks whke wine but the working girl may stop at the same bar at the airport and have a c]rink and light up a cigarette¸ It i~ a matter of soclal behavior. Mr. WAXMAN Do you imagine the adverstising campaign, "You }lave come a long w~, b~iby,~' directrd toward women to encourage them to be more liberated and with it ~o take up smoking, may have had some impact on their decision to takc up smoking? Mr. HORRId;AN No. Mr~ Chairman. In our testimony, we continue to hold to the position our advertising is not geared to increasing 1he smoking market, but when those people make that decision, and within that universe that company chooses to make ~hat par- titular pr~3posit[on to) a ~ma]e slrlo]/cr, ilot ~t nun~n~ok~r If [ might--- Mr¸ WAXMAN. Yes Mr klORRI~A.'¢ Pardon me, Mr. Chairman. May ~ enter some ~hing lbr the record now? is i~ appropriate, or later ~n? Mr. WAXMA:~. I am sorry, what did you wan~? Mr. HORRIGAN. You said i wou{d have a chance to come hack and ~nter something in the record with regard to earlier con~l~ents Mr. WAXMA~ If yOU put it in writing, we will appreciate it Mr~ Ualtncmeyer Mr. DAN~EM~ 1 think it is appropriate to ask the witness how long the staLement he dcsires to make is Is i~ lengthy, or what, sir? Mr. HO~RIGAN A paragraph, r~r. Dannemever. Mr DANN~MEVER I think the gentlema~ should have the oppor- tunity of responding The chairman has pointed out he would have El chance¸ And that length of sta~emenh I don't think, will burden ~1~rot¸ us. The cha rman has been a little aggressive, and | th k hehas a right¸ to be, but I think the witness has a righ~ to respond, too Mr. WAXMAN I think ~he gontlemEin is speaking from the point of ~iew of urging fairness I will do this. I will recognize my ~]- leagu~, because i have taken up a ]o~ of time. Should either of my colleagues wish ~ yield durin~ their time, o~er any addltion~ ulllnments, they are t/tee to do so, Mr. B]i]ey Mr. I~in.~y Thank you, Mr Chairman¸ Mr, [Iorrigan, ~uppo~edly Ln this bill we were discussing rotation- a] labeling. But ~he ~ine of que~ti~niT~g that we have jus~ been
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40B going through appears to me i~ bs.~d on maybe a hart of adverti~- m~an~ it all %Ve had testimony yesterday, ~nd last Friday that, indeefi, clgl~rette advertising has bt,en banned in Norway and in Polaad. And Italy, Tile evLdence we were presented last Friday with regard to Norway and Poland, Lhat since Ibis ha~ occurred, there has beetl no change in the volume of cigalettes sold gl either Norway or Poland. qCha~ haly has har] ~tal ban vn cigarette ad~er- t/~ng for 20 years, but d~t coi~amptieo is ~p. FigUres we were given were d0 percent My question, Do you agree with tha~? 1%ir, H~)R~tlC~A~. Yes, Mr Bliley I do I have international tobacco retponslbi[ity a~d [ have had Con~ualer product experience at*oltnd the world for olher categories. Those s~me particular trends hold true. You ¢annut change human behavior or preferences as a func- tion of ~opping a particular adver~J~h~8 medium Mr BL~LEY, The second qltestioa. Are you aware Of aa) cotllttry that ha~ banned cigarette smoking in which fullowing the ban, there has been a change in consumption? ~r, HOR~I~AN~ I am not nwsre of any I am aware of ~he other re rt~ y~. ret~r t~h and die reveese eFfect, Mr~ Blile~,. ~r, B~lr,~:¥ I see Now, if you have a statement ~hat you ~anL to p~t into the record, yo~ can have it on In), time. Mr. ~OR~IClAN. Thank yo~l, Mr. Bliley. ~ deeply appreciat~ that, mentioned in my testirnolly that we are here this ~ornlng because we ale a responsible and concerned industry A sLa~ement made earlier, takmlg one particular m~lrketing staten~en~ out of coi~te.xt and making the g~e~ ~ss~mptim~ that that appii~ t~ ho~ ~ a~ an induatry market our produgts is grossly unl~ir as a mark upon our il]d o~try. Dr, ~rrry Light has commented ahou~ how we stay i~ place. We have hur~eds ol people i~ the tuarketi~g process au¢l we have checks and controls in place, And the integrity el the people wkhin our cortlpany and the respect For the laws and the we)' we ill~trke~ o~r product i~ of the highest order To ~ay that peopk" will not err within the process of the busines~ place, the business market, that is ne~ the way it is. ]]ut 1 do not want anyone to lea~e here this morning with a~y as~un~ption about the integrity of ~'ar industry or what o~r inten- tions are because that would be ~'o~sly unfair, *.aking one incldent out of contexL Thank you Mr BL~V. Thank you very ranch. ~peaking of out of context, Mr. Chairman, i had a e~py of a Iett~r delivered to me yetiS, rday, sent to you on March 10 by the Roper Organization and signed by Mr. ~urns, w th Roper say lg thaL lade ~d wh le his organization had been quoted and had done a stud~, that he didn't agree wiLh the con¢lu~io~ that v~er~~ placed on it ~y the FTC, arid ildaers, a~d asked you to include iIl the record. Do you i~tend Lo do so? Mr WAXMAN, I nm surprised you got ~he letter beidre ] did i haven't seen that letbc, r But I am Dlea~ed tt~ receive it. Without oh- jection, the T~ter addressed to me on the letterhead of the I~oper Organization by ~un~s W Roper, chairman, dated .%Iarch 1O, I9~2, will be made a part of the rer'or6 [The hO:er reFerr~ d to follows:[
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407 THE ROPER ORGANIZATION INc ~RNS~ AOPEA March 10, ]982 The Honorable Henx~ W~n Ch~i~n. Health Subco~i~tee co~itt~e on Energy ~d Co~eree U.S. Ko~se Of Representatives Washington~ D.C. 2~515 It ~s my ~n~ersta~d~C3 that your S~c~it~ee is c~re~tly holdi~ he~rlngs ~ ~ 5653. This is th~ bill that implements the cigarette labeling rec~uir~ent~ re~c~en~e~ i~ th~ F~dera~ Trade C~issio~ st~ff Report On ~ C~gar~tte A~ertisi~ I~vest~gation, ~at~ May 1981~ ~t le~s~ two su~y~ e~nd~cted hy th~ Roper O~ga~ z~t~on ~re cited extensively in that ~t~ff r~por~ in support of th~ repor~'~ contentio~ that strongmr and m~re varied clgarltt~ w~rnings ar~ r~quir~d both on cigarette ~a~s a~ in cigarette ~vertis~ng. One of th~ studies so cited is ~he r~ort ~f ~r~vat~ ~urvey we cand~te~ f~r the T~bacco Institute in 19~8 ~-hich w~ ~ttbpoena~d bY the ~C and ~bse~ently publicly zelea~ by the ~C. ~ secon~ wa~ a survey w~ conducte~ ~l~fic~ily for the ~I~C in ~9~0. In it~ staff ze~rt, the ~C doe~ ~ot directly ~tt~± b~te the conel~sions reac]~d Ina~l¥. that str~n~r an~ v~i~ w~rni~g~ ~r~ required) to ou~ organization. ~wev~r, thin fre- quent ref~re~cm~ to o~r data carry the impI~e~tion ~ha~ the ~Bp~ studies support the report's ~onclusions. I hav~ no objec~£ons t~ the way the ~C staff repDrted th~ resu~s of ~r s~ey~. To the ~ent that I h~e mhecke~ thos~ facts, they a~ c~rrect. I do, however, strongly disagree wi~h ~]~e conclusions th~ FTC stBff reaches based ~ those f~cts. B~C~use the ~ ~ep~rt reli~s s~ ~tron91~ on ~pmr d~t~ a~d b~use ~ d~sagree with thm±~ interpretations of ~b~ ~t~, r~peetfully request that ~his ~tter be ±~cl~d~d i~ the trans- cript of your h~r~n~. ~SE~TFORTY~ECa~DST~E~T • N~WYOnK ~EW~RKI~17 . 122~y~ -j
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4O9 An an~logy~ • ~uld subm£t that m~st Americans knaw their cars h~e ai~ pollution equlp~ent in~t~11ad in the, that ~sta~tial~ fewer know ~he7 h~ cat~lyti~ co~ters, and that very, very f~ know these catalytic ¢o~erters co~t~in pl~tin~. Does this mean we ne~ a campaign to ~cqu~int people with the presenc~ of pl~tin~ in thin c~t~iytic c~verters that constitute major p~rtion ~f the ~ir polZut~on equi~n~ in the£r cars? On pag~ 5-24 ~f the FTC ~t~ff rewort~ th~ f~Ii~a~n~ state- ment appears based ~n o~r 1978 ~ey for ~he T~bacco I~stztute: "Sixty~one percent ~f th~se polled and 69% ~f the n~n-~m~s polled favored th~ proposed ~ew w~r~ing. 0nly 34% ~f those p~ll~d a~d ~6% ~f ~he no~-smokers ~av~red the current warning.~ Th~ £mpZic~t~on of this citation is that this ~hows the need for • stronger ~r~i~. TO ~e. it ~h~s the reverse. Six~y- one percent w~uld n~t f~vor ~ st~n~er w~rni.g u~less they were aware of the ~ange~s. Many Pf ~he ~C staff's concl~s£~ns that the public i~ unaware of specific d~ger~ resulted fr~ the incidences ~£ 1,1nc~r~ect'r answ~zs--or guessed--on multiple-choice c~es~ion~ we • ske~ on b~h~if pf the FTC ~n ~ur 1980 survey. These were que~ tions that ~sked how ~ny times m~re likely a s~oker was th~n a nun-s~k~r t~ ~e~ dis~s~ x and then o~d four or five different ratios le.~., l~ss th~n ~wlce as l~kely, twice ~ lik~ly, five times as likely, ten tJ~es ~s likely, twenty tim~ ~s likely). In r~s~on~e t~ ~Imost ~ii of these questions, th~ qreat majority of p~uple ~er~d more l~k~ly, ~en if they did not pick ~he precis~ nu~e~ o£ ~imes m~ l~k~ ~h~t the ~C ~ys ~s correct. Where thc frame of reference wa~ reduced life expect~n<~, th~ qr~t m~jority ~n~e~ that ~he smoker e~perienced reduced li£e expectancv e~en if they were not ~ble to ~uess the exa~t If ~ wer~ t~ ask you if th~ sun is a lot ~rthe~ f~om the ~arth than the moo~ is, or a little f~r~he~ from the e~rth tha, the moon is, cr ~bout the sa~e dista~c~ ~rcm the earth as the m~on is, you WOuld h~ve littl~ t~ouble a~e~ing that it is ~ I~t f~r~hez, thus indicating ~ high gen~al ~reness ~f ~he ~el~tio~sh~ of th~ &q
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410 SUB and moon to the ~rth. BUt if I were to ask ~u whether ~le BUn is 42.6 ti~s as far from the la~th as the moon is, Or 121.8 ti~es a~ f~, ~r 266.3 tJ.mea ~s far, ~r 389+1 t~es a~ faz, 1~ is ~wsible you ~uld not select the ~rec~ answer. (I ~ld nDt citer, and in fact ~ didn't k~ what the exa~t z~tio ~ u~£1 I 1o~k~ ±t up and cn~puted ±t.) But • d~nqt think thl| meelns we ~ • r~ ~ucational c~a~n ~o m~ke p~ple a~re h~ m~h f~zther the S~ ~s from the e~rth t~n th~ moon ~s. Z ~ld not a~u~ that m~re severe a,~ ~a~ie~ warnings ar~u~ tha~ they a~e ~nlikely to ~nc~e~se ~he awareness much, for $t is already ~t a very high 1~el. main purpose, b~er, i~ ~o di~sociate Our f~m from I &~ ~eh~r~ cop~es of t~s letter to ¢~ch ~f ~he m~mb~rs Of ~ur S~c~ttee as well as to our ~o~t~cts a~ bo~h ~he F~er~l Tr~d~ Comm/ss~on an~ ~he T0b~coo Institute. I ~m ~i~o i~c1u~in~ copy of ~ letter I ~s~t to Mr. Andrew Sa~ of tha ~C a~ the time delivered ~ 1980 survey, a le~tez which has ~i~ce bee~ mlde ~1~c. In that letter i ~n~ic~ed that w~ concluded the survey RespectfUlly yours, ~_.~ . ~, _:.~ BWR/maa G~
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411 THE ROPER ORGANIZATION INC D~ce~er 5, 1980 Andrew Sacks, E~q, Fe~eralTradeCo~is~io~ 414 llth st~ot, N,W. ROQ~641~ Washington, D.C. ~0058 Dear Mr. Sa~ ~ach of mS three partLere and I {incidentally, t~ ~ckers, two non smoker~) have made a quick review o~ thn r~,~u]~ ~o ~r ~eck-on ~uesti~ns. it has be~ a q~ick revie~ because praised. ~everthele~s, qu~ck er ~ot, i~ ~s our J~!nt opinion that the results ~how a ~i~h ~ ~war~ness of the da~gcrs of smoking on ~ea~th ~t t~ 9ov~n~,~t, tb~ can~ Society an~ o~here have been p=~moting~ ~h~=e a~e excep~ea~ ~, {o~ ex~ple~but we woul~ call it a generally high a~,areness~ E~ere are ~om~ diff~re~ce~ bet~ee~ ~moke~s ~ ~u~-~mo- ke~. wi%h ~mok~r~ helng ~o~e,~nat toss incline~ to aeknow~ed~ smoking as C~SaI* but W~ are m~re impressed by the ~1~ilar~ of the an~wor~ 9~ven by ~moker~ and ~on~smokcrs than b~ the d±ffer~ ences. Ea=lie~ • ~o~£innn~ a high ~n~al'~ ~w~ne~. ~y th~b mean that ~ile many p~ople give te~,hai~lly w~r[~ ,~um~r£c,~l rel~i~a~hip~ Ie.9., "50 tim~ more l~ely", 110 t~me~ as likely", "5O% 9~te~,' ,,6 ~ 8 year~ loss", eta,), mo~t ~ay there is a ~iqnifiea~y 9re~ter chance of x* or a s~gn£f£~an~ re~uctLon ±n e~pec~ed !ongovi~, etc, ~n thi~ ~onnecti~n, w~ wculd p~i~t ~t something • men ~oned on ~hn phone when ~ ~p~e ko yo~. n~mely, the ef£ect of ~he alter~ative~ that are p~t ~o re~l~d~ wh~l ~h~y have u~l~
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412 a gene~a, ~n~wledge ~n~ ~o~ p.eciee information. ~DU wi~' re~er~er that we asked Q.3~b wi~h two different _~et~ Of answe~ option~ o~ ~he tw~ d~ferent h~lve~ ef ~he ~a~ple. Orle scale ra~ frcan less ~h~ twice as likely ep to ~ times as ~ikely~ ~he o~her se~ o~ Opt~on~ r~n £~o1~ £ive ~±mCZ ~s llkely L-J 5O ~mc~ ~e l~kely. ~n each q~e~£~n there ~c~e £1v~ option~, w~th ~he c~ect ~e~we~ (10 ~imes ~s l~kely) ~elng the n~¢ond optie¢~ [second lo~t f~equ~nt) £oz the Y sample 0nd t~e next LO last option (second iilOSt frequcnt) on the X hal~ of the simple. 'Phe effec~o ~f the eptlens poses to, ~espon~encs as ,,~ell ~s the measure of people's im!Jl:ecise knowted(/e :IS ~h~,n by ~he d£gfur~nce in response to L}I~ e~rrlct answer ~.n ~he two ~an, p~ ha.~vesl He~rly fou~ tJraea a~ many ~e:,ple g~ve th~ ~el~r~,¢t an~ur when it uas i~ the f~]~ei" two ~e~it~t?FI ~gl the J.ist ~s whoa it was ~n the ~ext t~ last p~it£on. ~t is oar vi*w tha~ th~ gene,-~llz~ld knowledge, Cat}~*~ ~h~n Iprr, cise kr~owledge, p~cb~2y ~xpla~le ~ ~Dd d~a! e~ the uneer- ~aint~ in e~hel" qucstir~ns thgt ulted hiqhly Ipeeif±c C2n~e fr~me~ ~r ~tlc~s, even tho~l~b ~/e 6o[llt have sp)it~aa~plec~ evidenc~ tc d~c~]rt~ thel~ ~eeling + 8i ricer ely your~ • ~rn~ W* ~opdr Mr. BL*L~V. I thank you very much. I have no [urther guestlons, Mr Cbairm~n. M[. WAK~A~I Mr. D~u~e~eyer Mr. DANNEMEyER I sit here and reflect on this warning label and reflec~ on the Fact, if I heard correctly, that 96 percent of the people, or was it teenagers il~ this country, were aw~re-- Mr. HOR~ICaN Yes, ~Ir. Dannemeyer Mr Dx~:~v~ (eontinlltng]. Of health hazards as~iated with sm~king, and still we are having a lot of cigarettes sold in the countD'. Maybe we adults ~houid recognize the deficleney in ot~r label k says the Surgeon General, and I think a lot of people wonder who the Surgeon General is. F~r ~ho~e '~'h~ kn~w, he ~ ~scciate~ ~ith the Federal G~vern- ment. I am reminded of that story about the person who comes to the citizens and says, "I am from the Government, and I wan~ to help you." The reaction ~1¢ a lot of people in this country today, unfortunate- ly, is to put their h~ds in their p~ket ~nd got ~)ut ~d ther~ quickly as vhey can If we would put a label on cigarettes that says~ince I come floe Fullerton, Calif., which is the home of the Califi~rnia Angels, I'll use a couple of people there whose names are associated rather extensively in the spores world If, say for in- stance, R~d Care~, retest valuable player l~t&ying for the CMtfornia Angels, said that, or ~f, Moha, t*med All or Reggie Jackson or some- body else--any of these names that are famous in American sports--put .their names on that label, we. might increase the atten- tion level ot people, l~fliybe our advertmmg community would have an ~pImrtunity of respo~ding. L
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413 ] If more women are smoking today, the £~let may be that it is the result of the women's liberation movement in our c/llturc Perhaps more women are working ou~ide the home and they feel whatever pressures there are that cause people to ~moke. My closing comment~¢ would be these, Mr. Chairman¸ I suppose that someplace in America, sooner or later, a meeting of the Ma~J high command would express the sentiment that ~olue day they hope some plaintiffs lawyer is going to hit the tobacco industry of this country with a product liability suit and win because they are astute enough bllsfeessmen to recognize that, as a re~l~lt, the legit[ mate tobacco producer~ would be driven right out of the industry, And this would just cause ~he gre~,tes~ interest on the part of those inLerestec] in the illegal production and sale o±¸ cigarettes because we would ~ back in probibitfen time again. So [ think we have an objcctive in mind of improving public health. It is laodab]e. I support ~hat. The label is there for people to read and rel]ecL c/n hopcful]y But y~u know, yesterday in this Chamber, we h~d a hearing on clean air I h~ve to ask, are we labeling coal consumed in power plants of America, the burning of which is d~lngerous te your health? After all, we taxpayers spend, what is it, ~Jbout $] billion a year on black lung benefits. And I have forgotten how many people we kill a year each year mining coal in this counLry ] am not aware we are labeling coal. Maybe we shou]d in order to ame]ierate human suffering, to ameliorate ~he adverse impact on people. Maybe we s~ould label every type of energy produced and consumed Jn America because when we are honest about it, every one o~ them poses a risk to our health. Tbenk you Mr WAXMA~. Would the gentleman yield? Mr, DANNE}aEy~. [ would be h~ppy to yfo]d Mr. WAXMAN. I have l~stened to whet the gentleman was saying quite carefully. There is a ditference it seem~ t(~ mc in what we are doing in the Clean Air Act, trying to ]imi~ the ~mount of emissions in ~he air that people breathe. There is a choice to be made when ~omeone picks up a package of cigarettes, decides to pull one out and light it up. That is a different situation than whether you are going to breathe the air or not. I think in the one case, the question of the air, we have an obli- gation to protect the public from breathing hazardous a~r. In the case of cigarettes, I lira net for prohibition. People are going ~o make a decision for themselves, buLI want pcep]e t~ understand that if they are going to take up cigarette smoking, they are sub jecting themselves to real health hazards. And there we have, [ think, the obligation to encourage the public to be as knowledge able as possible They certainly have a bombardment of advertising to make oiga rette ~nmk~ng seem attractive¸ I think they ought t~ be aware as they make a personal choice, where they }lave the ~pportuni~ ~o m~ke a personal choice, about the other side as well. Mr DA~NE~EYER. I apl~reciate the gentleman's comment¸ Mr. WAXMAN Anything fllrther by ~ny members of the subcom- rnittee? $. Q~ 5z
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414 i would c~m~ent ~hat ~he Ruper Organization's lette~. ~hich we n~a4~ p~rt ~ t~ re~ord,, ~a~ s~t hy e:~pr~ss mail We wi[| prob- ably ge~ aur copy ~Qo~ b~t it indicates in this letter that they criti cize the Fe.deral Trad~ f~ornmission staff conclusions that the public is inadequately in~rmed al)ou~ ~e dangers ol" smokln~, This, I un derstand, is only ~ne of five polling organizations that looked into pnbli~ opinion oJ~ the su~ect. Th~ Roper ~ette~ in~llc~tes ~hst in ~ survey they con~uc~e~ ~r th~ Tobacco Institute, they ~oun:~ th~ 9 ou~ o~ ~(~ An~e~ic~ns be- ~ie~e ~ha~ ~raoki~ is h~a~dou~. M~. Horrig~, ~. K~g~, ~' Wilt, Dr ~ig~, ~ th~k you and ~ anything else you migh~ want to add to the record, We ~o want ~o ~e ~s fair ~s we c~n be in geeing ~li t~e points of view before us bc~r~ the C~ng~e~s ~akes i~s decisio~ Than~ you very muuh Mr. HOI[I(IGAN. T}l~tri]~ you~ ~r Cha~rl~nan. ]V~r. ~)II~EGA¥ T~ln)~ you, .Mr ~'l~n, ~ery m~¢~ T~st~rno~> ~sUmeS on p. 44~. • ~'rhe f~ ~ ng [et~e~ a~d ~t~hed ~ater~a~ were s~bml~ted for the record:~ 5~
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415
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416 Under ~roduct liability law, ~anufaeture~a ale required %~ ~a~ c~a~uL~e~ about the dangers oF [i~ka &s~i~ted with t~e u~e Of hheir product~. Pleas~ ~bmi~ a legal c~i~ d~sc~hi~ the ~hliqati~ ~f the R.J. Rey~id~ C~m~any to warn consumers of the r~0k~ o£ ~mo~ing Federal Ci~aI~tte Labelln~ an~ Advertisin~ Act ~re ebliga~ed to ~i~losc ~o diseba[~ ~oar l~gal {2) ~ie~y d~z~ ~ll ~i~ar~tt~ ~ela%~ product ~iabili~ lih~ganio~ ~n which the R.J* ~y~nl~s Company and o~her ma~or ~.~. ci~ctte nk~nufautui~t~ ~ pxe~ently ~nv~ived. (3) In ~es~imu~y before the Subco~mitt¢~ you i~dlcatcd that ~here were approximately 2~ indlvi~u~l clg~tt~ brands ~larke~d ill t~e ~n~ed States* ~uhn~it a list of the~e br~dn and £n~iu~te th~ market ~are and ~its sold of each f0r t~e yea~ 198~ and 1981, In testimony before th~ ~ubco~Lmitte~ you ~ti~ated ~hat ~.~. 5653 could ~resen~ a~ additional ann~al cost to ~n@u~tr~ of ~Q million. Submit fo~ the ~ubc~mmittee a ~tail~d anal~i~ of how thi~ c~t £igure was computed. ~nd~cate how ~pecific costs rela~ing to chanq~ in p~ckag~ l~bel~ ~re isolated flem those attrlb~te~ to Idverti~inq* ~ith ~es~ect to ad~itiona~ ~dvcrti~in~ co~t~ Indica~ how such ¢ost~ ar~ allocated between uutdoo~ adve~tis~n~ ma~azlne advertising and nawpa~e{ ~dvertising* 15) $~bmit a list o~ these countries in ~h~ch the R.J* Indicate tho~e countries that r~qui~e a h~al~b w~ning Company uel] ~n G~eat ~ri~a~n~ Where are the packages ~n~ a~e~tiz~en~z ~u~ced a~ ~i~ted? ~ow man~ bzan~s Of cig~r~tte~ does the ~.~. R~no~s ~ompany sell ~n ~we~en? Wher~ are ~h~ cigarette ~ack~gas and ~ve~t~se~ents prod~ce~ and ~rinted? (8] Of the R*J. R~ynoIds coii~pany'~ three largest ~elling ~ran~s of cigarettes, how man~ d~rlt~qa~iILe and t~wspa~e~ adv~tisemen~ we~ ru~ ~n th~ 0hired ~La~es ~u~ing 1980 and I~81? (9} ~o~ ~ftea ale non-painted ~il]boaud adve~Laei~nta~ • pon~ored by ~he R.J. Reynolds Company, repla~ed or ~eg~ii~d? ~ ~t~ are ~in~ad biilb~ ad~e~ti~emen~ ~eplaccd or re~ai~ed? In an average ~ear ~hat i~ the ~tL~ ~ n~n ~aint~ ~o ~i~t~ h~llb~a~ advertisem~nt~? Describe t~e ~oduction p[oce~s u~e~ to d~t~bute ~a~azin~ a~ newspaper a~tlsln~ £~r ~b~!c~ti~n. ~hat is the average co~t o~ t~peect~ing t~e current ~a~nln~ l~bel ~o~paze~ ~i%b the ~oz~ of p~u~u¢ing an ~nd~vidual advertisement?
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Samu~l B WitLn~ vi0~ p~s10er i 417 R J ney~olds Tobacco Company Win~lon ~al~m, N C 27102 April 29, 1982 Honorable H~ A. w~an ~nalnuan, Su~ttee on HeaiUl ~d Ule Envt~r~nt United States Ho~se of ~[3~esentatives N~hing'con, D. C. 2~515 i ~er to y,~lr letter to Edward A. ~crigan, J~. dat~ ~il 8, 1982 m~ the lis~; of ~estlc~ attached thereto. Mr. I~rrig,~tn has ~,k~l that I respor~d to ~ur letter In ~kts =~t~n(~. *~ y(~ will recall, ~'~. Itorrigan aF,~eared before ~ur ~ithco ~ ~vch 12, 1982 in his capacity as Chairman o~ trle Exoctxtlve ~ln~it~ of ~t~ ~¢co Instit~lte. In that capaci~, be testified ~s st~l~,n for ~he tobacco indust~W and not as a repr~s~nt~t±~ of ~. J. I~3'n~l.ds Tobacco Company. ~uc letter. C~t~in ~cts of c~uesti~ns 8 thl'~b ID at~cb~d to your letter ",,~ul:l ~quire the di~,c~osure IW R. J. Reynolds 'Ibbacco O~i::,mW of hzgb~y ~n~.tive in~or0~tior~ £rc~ a c~oetitivra standpoint. For ex,m~ple, R. J. R~olzl5 Toba~ ~y has its o,m internal media deF~'~nt which ,,~ believe is able to ach±~ certain ~fflcf~p.c~s that our c~mpeti~ em~not, in addition, ~11 rlF~'s of ~ ~l~try colrtFe~ate their advertislng agent,s on different bases o~d we cor~idc~ it unfair to ~equlre c, lr Cx:~gany t~ di~c)ose infc, rmation of this P, ature. Accordingly, I t~espec~f~lly r,ectllest ~lat ~u r~n~id~c ~he ~priate~ss of question~ ~ through it) in vie,~ of i~. HOFf~cJ~S I~Sit±on aS an industry sl~ke~r~ and the i~atur~l ~f VetT ~ly '~urs, ~± B. Wltt, III, I~sq. At~cNI~n~ .,d
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418
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QU~STL~ ~ R6S~SEI ,,,I
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~&~O~9 r u
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443 Mr. WAXMA~ Our next panel of witnesses are Hans J, Eysenck, Institute of Psychiatry in London; Theodore Blau, a psychologist from Tampa, Fla; Yoram Wind, professor of marketing, the Whar- ton School of Finanee and Commerce,, Philadelphia; and Roger D Blackwe]l, pralessot of marketing, Ohio State Universit ~ We are pleased to ~elcome you to our hearing today. We have youl complete statements and they will be made a part of the record in full, I know the statements are quite lengthy. I also un derstand that you have been ialbrmed that we weald like you to summarize your statements We would lik~ you to keep it to as close to 5 minutes as possible so we will have an opportunity Ibr Questions and answers Dr. Eysenck, why do we not start with you, sir STATEMENTS HF HANS J. EYSENCK, PH. D,, D. SC., PROFESSOE OF PSYCIIOLOGY, INSTITUTE OF PSYCHIATRY, UNIVERSITY OF LONDON; Y(IRAM J~ WIND, PROFESSOR OF MARKETING, WHAR- TON SCIIOOL. UNIVERSITY OF PENNSYLVANIA; ROGER O. BLACKWELL, PROFESSOR OF MARKETING, OIiIO STATE UNI. YERSITY: AND TIIEODORE H. BLAU. PH.D., PENNSYLVANIA STATE UNIVERSITY Dr. EYSENCK. 1 am Hans d Eysenck, professor of psychology a~ the Institute of P~ychiatry, University of London and psychologist to the Maudsiey and Bethlem Royal hospitals in London. I received my Ph. D in 1940 and my D, So, in 1964, beth fi'om the University of I~ndon. I was senior research psychologist at Mill Hill Emergency Hospital from 1942 through 1946. In 1949 anti 1950 i was a visiting professor at the University of Pennsylvania in Philadelphia. Between 1950 and 1954, I was a reader in psychology at the Uni versisy of Londoa's Institut~e of Psychiatry In 19o4 1 was a visiting professor at the University of California at Berkeley I am a fellow of both the British Psychological Society and of the American Psychological Association, I have ibunded and edited three psychological journals, and l arn on the editorial boards of some 15 other international psychological journals I haxe written or edited for publication approximately 05 technical books and over 600 articles dealing with various aspects of the psychological field, particularly with respect to personality, intelligence, behavior theragy, and behavioral genetics I have conducted research in the area of smoking thr ever 20 gears and have authored two bcmks, the most recent of which is en- titled "The Causes and Effects of Smeki~tg," as well as numerous articles on this subject. I will not read my whole statement, of course, as you said, hut just /n3ke a low nlajor points A widely accepted theory asserts that cigarette smoking causes lung cancer, coronary heart disease, and many other diseases with which it is statistically linked. It is not always realized that (a) such a theory is thr from proven, and is beset by many anomalies and doubts, and that /h) there is an alternative theory which is based on undeniable facts which are not explained by "the causal theory.
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444 The present position seems to be that either theory may explain the tragic incldet2ce of lutl~ c~tncer arid coroRary heart disease--to which this brief account will be restrlet~d--or that both may be needed to complement each other. Oue important point I wa~t t~ make concerns the isolation ~f smoking from other correlated habits such as d~inking, living it up, staying ~ut late, wenching, et cetera; ~ha~ is ~(J say a certain style of life, the totality of which may increase tho rate of living so that smokers are bio]oglcally older than nonsmokers at a gzven age, for reasons only partly involved with smoking Nonsmokers are different types of persons from smokers, are generally more self-protective, and the personality traits and habits thus linked with nonsmoking may be more relevant to the longev- ity of ~mokers tha~ their refuel to smoke The most impressive evidence for the c~us~l theory has been the report that pi~sieians who ga~'e up smoking showed less lung cancer than naembers of the general public who continued to smoke. Thus, }t might appear tha~ giving up smoking has saved ~he lives of those who did so. But this proof is only acceptable if those who continue to smoke, and those who later on give up smoking, are essentially identical with respect to their health bolero some of them gave up smoking. C[early, if those who later on give up smoklng ~re already much healthier than those who later on continue to smoke, then the final differences iR health may he clue to th~ already e~i~ting difl~re~,~ before anyone gave up smoking, rather than to the cessation of this habit .Bat there is good evidence to show tha~ smokers and ex-srnokers a]Teady diflY~red wiib respect to thtdr heakth record bethre the ex- smokers gave up smoking Similarly, there is evidence that from the point of view of personality and genetics, ex-smokers are differ- eat them continuing smokers. ]'hus this alleged proof is based on all erroneotls assumption. These objections to the causal theory, and others made in my book, do not prove the theory to he wrong; they simply argue that it is still only a theory~ not a scientific law. l~lor~ convincing proof is required before the th~'ory can be accorded a more advanced stata~. But further than that, there ore ~mero~s fact~ ~uggestlng an alternative theory, and these facts cannot easily be integrated wkh the causal th~ry. Yet a proper theor~ demands that attention be paid to alI rele- vant facts, and thus again the causal theory is found wantlng. The alternative theory, first suggested by the eminent geneticist and statlstlcbin, Sir ~onald Fisher, suggests that genetic factors are important in causing lung cancer; tb~lt genetic thctors are active in causing people to maintain the smoking habit; and that pessib]y the same gm~etto factors may be inw]ved in both these trends~ thus producing the observed correlation between smoking and cancer--insofar as such a correlation is reak There is evidence that gene~ic fnctors do play a part in the causa- tion ~f htng cancer; th~s is not in d~uht. [ have brough~ forward evidence to show that genetic factors are relevant to the mainte- n~mce of the smoking habit Thu~ there is e~tdence for both the ~- sumptions on which Fisher's ~gumen~ was based &2 ".5 &a
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445 The origin of the smoking habit, on the other hand, is halxlly at all influenced by genetic factors¸ It appears ~om our g~nefic analy- sis and ~om the direct study of¸ the pr(~bism by Professor Spiel- berger that the origin of the sm()ging tlabit is due to peer pressure; parental influences pl~y a much smaller part, and advertising almost none¸ Mv own contribution has been to suggest $hat the mediating factor between cancer and smoking may be the personality of the people involved Thus it is assumed that people of a ccrfain person- ality are more likely than others to die of lung cancer irrespective of smoking¸ It is also assumed that people of a certain personality are more likely to smoke than others. Tberc is direct evidence for both these propositions. My original work with Dr. Kissen, an eminent British oncologist, showed very marked personality differences between lung cancer patients ~nd patients sufferfag from nonmalignant tumors, with the personality assessment made before dial.mosis. Since then, a large-scale study in East Germany has repbeated our findings. Other studies, als~ in dicating a relatisn between lung cancer and personality, arc cited in my book In a smli] ir wag, zny early work with Tarrant and Woolf ostah- llshed a corrclafion between personality and smoking, and many studies in different countries have since confirmed our findings, and added new ones We may thus say that the fhndamen?~l as sumption of Fishpr's genetic theory have found empirical support, and we may add that there is also some modest support for my t)wn attempt to integrate these two major fields. Unfertm/ate]y, there has been too little work along ~hese unusu al and somewhat unorthodox lines to say that the rcsult.~ are any- thing more than suggestive, and the theory linking them is still in a very elementary stage; nevertheless, as far as the findings go they support the genetic rather than the causal theory, although they do not necessarily contradict the lattez Recently some progress has been nlade on the theoretical devel- opment of the genetic hypothesis by linking it with research on stress, in particular the differential effects of chronic and acute stress, and the "inoculation" theory of stress However, in the ab- sence of large scale research into the re[inements of this theory, and more widespread thmi]iarity with the criticisms of its details, not too much should be chlimed for it other than that it presents a viable alternative to the causal theory. In the cast" gg coronary heart disease as in the case of lung cancer, proi)f for the causal influence of smoking is still lacking and is by no means as ciearcut and decisive as is often alleged. There is evidence i~ the ca~ of CHD of genetic £act~rs, and there are published correlations with personality; here, too. there ap- pears an important element of stress determining the appearance of coronary heart disease, and stress is intimately linked with per- scnality. No formal theory of genetis del.ermingsion of CIID has yet been put forward, bm it seems llkely that such a theory is needed as an alternative, or perhaps as complementary, to the causal theory for an explanation of the many gaps and anomalies in the latter. -4
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446 One important ~hnrtion of ~h~ genc~ic theory has been thai of ex- plaining the reasons why people smoke, and to /ink these reasons with their dilforent]u] personality patterns¸ Work .]ong these Hnes h~,~ had the [n~povl~nt effort ol¸ slldge~tind r~e~ ~i~ improved '~ys of teaching penple to give up smoking. The c~u~al theory of smok- ing causing disease has nothing to say on td{s topic¸ Another [ml~rt~n~ fumcdon of the genetic thcnry ha~ been to suggest better designs ~r research in this ¢~)mplc~ field; a good ex- ample is the use of ~he discordant twin meshed by Cederloi Lund- msn~ and other~, that is to say~ the [nvestigution af¸ the i[]ness pa~ terns of identical Lwins of whom one sm(d~cs, the other not. If this type of¸ research had been carried out on the large and internation a] scale required, instead of investing in the rcdundant ~nd scien~ tiflcal]y not vcry valuable repllcgeio~ and correlationa} studies, we would k1~(~w ~r more ~bout the re]ation between smoking and dis ~ase than we d~) ~ow. ~uch studic~s allow u~ to look at envilonrnental Ii~ctors, inc]uIllng th~se of smoking, while ¢ontrolHng for ~enc~ic factors; this is essen tial i[ any convincing results are to be u~hi~ved In ~ummery I would |]~e to state fhat the causal theory ol¸ ~mok ]ng as being responsibfo for lung c~ncer and coronary hear[ dis- case, while it has ~ound str~ing support, iS ~r from b~ing estab- lished, and ha~ many gaps, anomalies, an~ ¢ontra~ ~ndings to conLend ~vith; these are t~o fregucntly glossed over and dismissed E~s unimportant, when ~n reality they may 5e found t~ discrcdit the cEiusnl theory in who~e or ~n p~rl An alternatiw theory, based on genetics and implicating person- a]ity f~c[ors, ]s much ]ess well developed, more compl(!~, and at p~'e~ent not ied~ we[~ kno~vn to simony ~¢o~co~i~£s; ne'~erLh~le~ there are many wel]-established ~cts which suggest that ill part if not in whulc it ca~ account ~r the rn~jor findings. At the very [east~ th~s a~tecnative theory suggests ~vel research mcthcdlologies which would sorve ~o ~verconle the difficulties of the older me[hods and remedy their lack of proper cogero]s The possi- bility has also b~en r.~ise(l that the two theories may be comple- mentary, rather than oIlpusod to each o~her: this possibility too should be ]ooke~ into fl~om the experimental point of vicw. What is i~rtain is that at the momcnt no final decision can be made about whether or the degree t(J which cigarette smoking may cause lung cancer or coronary heart disease, how it intera~t~ with other [ac- ton~--stress, personality and so on or how can we best protecL ~he health of our citizens in relation [(~ these d~seases [Testimony resumes on p~ 459.] [Dr Eyscnck's prepared statement follows:]
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I ~m H~ $, Eysen~, professor of psychol~gy ~t the Institute o~ Psychiatry, ~niverslty Of London ~nd ~sychol~s~ to the Maudsle7 ~nd Betb1~m ~oval hospitals in Lo~on. ~ receive6 my Ph.D. in 1940 and my ~.SeL in ~9~ b¢~ ~rom t~ U~iver~ty of L~don. I ~ 8e~1or Kese~ psycho- logl~ ~ ~±]l ~II Emergency Hosgi~l f~Om i~ t~Ou~h 194~. ~n 1949 ~d 19~0 I w~s ~ visiti~ p~es~o~ ~t the University of penn~yl~ni~ in phil~delphi~. Betwe~ i~60 ~d 19~ I w~s ~ ~e~d~ i~ PsychOlogy ~ the ~niv~r~t~ Of pr~fes~o~ ~ ~he Unlv¢~slLy of ~aI~fo~i~ ~t B~ke~ey~ I ~m a Fellow of bot~ the British ~sy~holo~1~l ~ocie~y and of Lhe Am~ Paycholo~ic~l ~s~ocia~lon, ~ b~ve foU~Lded ~d edited Lhree psyabologIcal jou~l~, ~nd I ~cm o~ ~h~ ~d£~orial b¢~r~s of ~me l~ o~her In~r- n~io~l psychological ~urn~l~. I h~e ,In-lt~en or ~ited ~0~ p~bli~ion ~p~roxima~el¥ 3~ te~hni~l books ~Dd ~ver ~field~ p~r~eul~ly w~b respe¢~ ~o pe~son~!it~, iDle!license, .,J
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448 1~e~vlc~u~ ~Lhe~'~Jy ~nr~ beh~Lvio11r~l ~e1~cs. I h~L~;e con1~1~c1"ed ~nd i~ be~e~ b~ ~ny ~n~mali~ ~nd ~D~ts~ ~md ~h~t lhl ~her~ i~ ~ ~Ite~na~Ive ~eory w~i~ i~ b~ed on u~d~ni~D]e
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~uch ~f th~ evid~uce cited ia ~vour of the ¢au~l theory is statistical, but ~ny s~isti~i~ have severely suffffes~ed proofs as the correl~tiou betw~D ~mokxn~ ~nd lung cancer w~th~ ~ given couztry~ or bet~n l~n~ c~c~ and number ~f c±g~e~te~ ~moked ~'~aen ~ountrl~, ~re ~vid~n~ o~ c~elat~on, not o~ ~usation; one o~ the flr~ lessons t~e buddin~ ~tati~t~l~n learns ±~ that correlati~ doe~ ~ imply c~u~tio~. (Ther~ ~ ~ ve~ high correl~o~ cancer o~ the large lnt~ln~!)* Hen~ ~is m~thod ~f Thl~ would b~ ~o ~v~n ~ ~he ~g~l~ ~u~lly quoted c~uld ~ubtl~g ~eir accura~* The flgnlr~ ~uot~d are ba~ed ca clinical diagno~i~ o£ lung c~nce~, bu~ ~ese ~re ver~ unrel~aol@ ~n~ iinl~reclse. IL ~ ~k~ ~s our ~rit~r±~ ~'d~cps~ d~, a~d ccm~re the~
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451 i~ is often ~gges~ed that sex differences, wi~h males showing more lung c~n~r, are ~he pr~du~L o~ the ~en~ency ~f males in ~h~ ~ast ~0 y~ar~ or ~u to ~ke mor~. However, a~ ~e~e~al auth~ritie~ whom £ ql~e i~ m~ b~k h~ve 9~lut~d ~U~, similar ~ex ratio~ to ~hose ~serv~d no-~ ~re founc ~efore c~garet~ ~mo~.g b~came popular. ~g~in. ±~ is fou~ ~ha~ cba.g~ la the r~te ~f ~re~s~ of lun~ c~ncer di~gn~ occurred Slmul~u~uslV ~or ~e~ a~d ~men~ ~lthou~h ~he sh~ ~h~se c~an~s ~t a much l~ter d~e ~h~n ~u. If the ~aus~l theory is ~ru~, ~en ~e w~uld e×pe~ defini~ dos~-res~o~ relationship; ~8 o~her word~ ~b~ he&vy smoker S~Uld be stricke~ w~tn cancer earlier ~an ~he light ~r~ker. Yet the amount smoked ~c~ no a~preciable d~ffere~ ~o the m~an a~e at w~ich ~e pc?son £~ rc~r~ed first ~ th~ ~ll~lc~ A~in, i~h~la~lon s~uld ~ake ~un~ a~ncer~ca mQre li~ely ~n ~kln~ w~bou~ inh~li~ y~t ~he ~i~res s~o~ ~ ~aything a~ ~p~osite ~r~nd. ~e~e two observa~ozs ~re c~f~±cult ~ ~econ~ile wit~ the causal T~e ~s~ impressive evidence for the c~usal theory ~s been the r~p~r~ ~ha~ p~ys~i~n~ w~o gave U~ ~mokln~ ~owed le~ lunE c~n~r t~a~mbers of the general public ~o
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45~ The ~lZern~zive zheory, f~st su~esZ~d by the emineat g~ae%i~£~ ~d statistician Si~ Ro~ld Flshcr~ s~st~ that ~'enetic f~c~ors are important in ~usin~ lu~ c~c~r; ~ha~ ~m~k~n~ h~b~ ~ad t~at possibly t~e sam~ ~cnc~±c ~aeto~ m~ be involved £a boZh these trends, thus pro~cin~ ~he observed ~elat~o. bet"~een s~o~±n~ and caac~r /~nsof~r as such a ¢~rela~o~ is ~o~1/. T~ere is eviaen~e tha~ ~eneti¢ ~a~tors do ~l~y • p~rt ia ~he c~lls~tioa of l~n~ ~an~cr~ this is aot ~n doubt. ~ hav~ brought ~or~ara ~vid~ /in ~ddi~ion ~o ~re~y ~ery convinc±~ evide~ ~u~u~ed by many o~er people/ to sho~ tha~ ~ene~±~ fsc~ors ~e relevant to ~}Je ~aia~eaaace of the smOkia~ ha~i~. Thus ~ere is evidence for ~oZh the ~ssump~i~ns oa ~hich ~s~e~,s ar~Ll~ent ~s b~se~, T~ orz~in of ~e smo~n~ ~bi~ on th~ other h~n~ is hardly ~t ~ll ±~f!ue~ed b~ ~enetic f~c~s~ i~ appears from ~ ~n~%~ an~lys±~ ~nd from ~he direc~ sZ~dy Of ~hc ~roblem by P~ofesso~ Spielber~ ~h~ ~he o~i~i~ of ~he ~mok~ ~t ±s due ~o peer press~re~ pareatal influences My nwl~ contribution h~s beea ~o su~es~ Zha~ ~he ~diat- in~ f~or ~t~ee~ cancer ~d smok±~ may be the~ -J ~d L
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454 cer~ai~ p~r~on~lity are more likely than others ~o dio of lung ca~ce~ irrespective of Smok±~. ~ i~ ~Iso ~s~uE:~ th~ p0~ple of ~ n~t~i~ pe~ou~litv ~F~ ~cre llkcly to ~oke ~h~n oth~;s. There is evidence for ~o~h th~e propo~ition~. My Qrl~in~l ~ ~it~ ~. Kiss~u. ~n ~Jne~t Briti~ oncolo~sg. ~how~d very m~ke6 ~lit~ ~i~fere~oe~ betweeu lun~ ~noer patien~ ~nd ~atien~ 5u~erln~ from ~ou-~alig~ut t~ur~. with ~he person~li=~ as~es~me:~t m~de before dia~uos±s. ~ince t~e~. ~ ~arge-~e study in E~ G~u~y ~ rcollcated our ~nd ~s ~o~nd ~±~i~ar personality tra~s to those characteristic O~h~r ~t~die~. ~iso ±~dicatin~ a r~l~!ou between lung cancer a~d ~crson~iity, ~r~ ~!ted 1~ my book. I~ ~ similar w~y. my e~rly work w~th T~rran~ an~ Woolf es~li~h~ ~ c~rrela~±on het~ee~ pe~on~li~ and smo~i~. and many st~die~ i~ different co~tr!es have ~ince confirmed ~u~ ~i~dings. a~d a~e~ new one~. ~ m~y ~h~s Say ~ba~ ~he mo~es~ support g~r ~y o~ attempt ~o ±nit,rate ~h~ ~wo m~Jor ~i~Ids. Um~or~t~n~t~ly there h~ been to~ lit~l~ work i
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Recently some p~ogress has been made on ~he zheo~tical d¢velopmen~ o~ ~h¢ ge0ezi¢ hypothesis 5¥ liuking iz ~;h ~e~e~rch ou ~ss, io p~rtlc~lar Zhe ~iTf~r~nti~l ef£~ts of ~hronic ~nd ~ute s~re~* aria ~he 'inoculation" ~h~or~ ~ ~tress. However, In Zb~ absence of lar~e-~nale re~earch into ~he r~f~ne~eaz~ of th~s theory, and m~¢ wi~esprea~ ~millarit~ wlt~ ~d criticisms o~ it~ details, n~t too mUC~ ~itern~tive ZO Zae c~usa! theory, d±~e~se (C~), slmile~ crltlc~ms apply ~ do la th~ c~e o~ lun~ c~cer* The~ ~e ~onsiderable u.~ellabilities ia dl~O~s; there ~re l~r~ aum~er~ ~f f~c~ors ot~¢r ~h~n ~king w~ch havo been a~soci~zed and w~i~h aro n~t ~u~lly ~n
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The l~r~l ~onclus~o~ ~on!d s~e~ t~ be that ~n ~e c~Be o~ Ct~, ~s in ~he ~e O~ ]u~ ~ncer, Rroof fo~ the ',,I
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457 means ~s clear-cut ~nd decisive ~s is often ~lle~ed. Th~r~ evidence in the ~s~ o~ C~ID o£ ~ene~i¢ f~ctors, ~nd ~here are p~blished correlations ~±th person~(lty; here too the~e • ppe~rs ~n important elc~n~ of ~e~ d~erml~n~ ~he • ppear~nce Of C~ ~d ~S~ ~S ~t~e~y l~ked ~ith C~ h~s y~ b~ pu~ forward, but 1~ ~eems likel~ ~h~t suc~ a theory is n~d~d ~$ ~ ~lternative (or perhaps as comple- mentary) ~o ~he c~us~l ~heory for an explanation o~ the many gaps ~nd ~nor~lies in the l~e~, Ono lmpo~n~ fuQc~on ~f the ge~e~lc ~heory ~S been ~h~ oi ~p~i~in~ ~he re~sons ~hy people s~oke, ~d to link these re~ons wl~h ~h~ir differential personality p~t~rv~. ~k along t~e~e l±~es h~s h~ ~he imp~rt~n~ e~ect of ~h~ ~enetic ~heor~ h~s b~en ~o suggest better desi~n~ for research f~ ~his complex f~eld~ ~ ~ood cx~mp!¢ ~ ~h~ u~e Of ~he discord~n~ ~i~ method by Ce~erlo~, Lun~an ~a~ ~the~, i.e. the l~es~i~ti~, of ~be illness p~t~erns o~ ±~entic~l ~w~ns Of ~h~m ~ne smokes, ~he o~her ~C~. If ~iS type ~ research h~d be~ C~ried o~t o~ the !~r~e ~nd international S~le ~equired, instead of ~nv~s~±n~ in t~ ~un~n~ ~n~
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459 Mr. WAXMAr#. Thank you very much, Dr Eysenck. Dr. Wind. STATE:~IENT OF YORA~,I J. WIND Mr. WIND Thank you l am Yoram Wind. Since 1973 i have been a professor of marketing at the Wharton School I am the previous editor of the Journal of Marketing. I have been at Wharton since receiving my doer,orate from Stanlbrd in 1967 My specialty is marketing research, including consumc..r behav- ior. Over the years I have consulted to numerous companies Jtnd published extm]sively in various areas of marketing and consumer behavior. I have been asked by the Tobacco Institute to present my views as an expert in marketing and consumer behavior on the theoreti col and factual support for certain of tile provisions in the bdh I an1 appearing here tnday not only as an expelt hut also as an ex- smoker And I carl understand, therefore, the motivation underly ing ]he bill Yet, I find the ploposed ]abe]ing requirement to be conceptually unacceptable and empirlcal]y unsupported. The proposed bill suf- [ers from two major problems which if we will use a medical anal- ogy, can be viewed as, one, analyzing or giving the w~'ong diagnosis The bill is premised on the notion that consumers are not aware of the relations between smoking and health issues It seems to me based on the evidence we have, including FTC's staff report and other studies as discussed earlier today, that there is mxlple evi- dence to suggest that there is extremely high awareness of the problem The second problem is that even if we assume for a minute that the diagnosis is correct, that there is a lack of awareness, there is no conceptual nor empirical support to suggest that the labeling re quirement will have any effect on achiertng the oh]ectlve of the bill These are the two major problems vhat 1 will try to address myself to Concerning the first point on the current high leve] of awareness, it, as qude evident from my written statement and the earfier statements today, that there is enough evidence to suggest there is a very high level of awareness of the relation between smoking and health problems, The FTC report cites the 1978 Gallop survey which radical.s over 90 percent of the public believes smoking is hazardous to health A similar high percentage reaponds alfirmativtdy to more specific issues in many of the studies that were conducted. For example, 9() pt!rcl nt believe srnokillg during pregnancy call affect the smoker's baby, 87 percent of adults are of the view smok- ing has been found to be associated with cancer and so on The re- sponses at this high level are truly remarkable. A measured awarc~ hess of 90 percent can be considered de£iciency only if one takes as a staadlird against it perlhct tafurmation of 100 percent. This is totally unattainable, it is conceptually unreachab]e. It is imposslb]e, tIuman cognitive abilities, dilt>rences among people, se- lective perceptions, will never allow us to get on uny issue, 100 per cent awareness There are llUl]lerol2s studies, some of them cited in -J ~a
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460 my statement, theft suggest on other issues, more critical issues, you never get such high response rates. The FTC staff report, on which I believe some of file proposed bill is based, also misinterprets a fair amount of the data that it suggests as basis for its conclusions. There are basically six major problems with the staff report First, the staff improperly focuses on responses to specific ques- tions It establishes whether tl, e population knows or does not know a certain fact based on a response to a single iiem it is con- trary to everything that we know about measurement Lheory. No test is based oa a single item You are working un pattern of responses, yet all of the studies focused on a specific question. Can you measure your know edge of economic psycho ogy, humall be- havior, any area based on a slng]e question? Second, ~be ~tait" assumed that anyone that respond~ incorrectly to one out of a number of multiple response options ba-sicai]y did not know the answer. Imagine a telephLlne situation when yell are being interviewed, you are given like 5 diftk, rent options and if you miss the one correct answer you are classified now as basically' pro riding the wrong answer. Similarly, the staff interprets "do not know" in a quite erroneous mal~ner. Basically their definkion of do not know is anyone who missed the correcL answer. But there might be another interpreta- tion. MarkTwmnln LlfeontheMlssls~lppl ~atd, Iwasgratdledtobe able to answer promptly, and I did. I said I didn't know." Recognizing this specific problem, the Rese:irefi Center at the l.fixiversity of Michigan filr example poiilts out that the answer "I have no o linion on that" can mean merely, t am thinking and ad vises that it is a good idea to probe al] nf the "do not know' re spouses No probing was done in any of the studies thac I reviewed The third problem is that incorrect responses can he attributed to lack of tmderstanding of the specific question, or the options pro- vided. If you wiP ~xamine fully some o the questionna res that are the basis for the studies, you will see that it is extremely difficult to answer them. 1 urge you ~o try to be a iespoedent and try to answer Olem. The fourth problem relates to two very" basic issues. Ntme of the studies on the rdation between consumer awareness of smoking and health issues focused on either the basic question~ of the reli- ability" of the data, or wfidity of the d~ta Those are two critical components in any measurement; if we are trying to generalize from the findings to the gmmral population. Fifth, the stafi" report does net present a norm against which to compare several results Without a norm, given tile fact we ruled out betbre the possibility of 100 percent awareness as an acceptable or even a~;tainahle ohiective, we can never know wfiat does the number mean. Is it high+ low, medium? There are no norms pro- vided. Yet in any educational testing, or any other testing situation we always have tO have norms for comparison Six, and me.st f~ndamentally, the report's eonelusiorls are based to a large extent on confusion between tfie terms awareness, belief, at~d knowledge. And let me quote here tfie staff definition of awareness I think it is rely illuminating Their definitbm is, and I C~
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461 quote: "Those who say they do not believe, do not believe true statements. Believe false statements. Underestimate oN a multiple cbolce qlles~ion or answer ~do not know~ Or ~uncertaln.~p This suggests a major CoZllklsiOrl between belief aI~d awarene~ If I t~/ke positions of" belief as ~Laternent of t~na,varelless, I am ge~ing a complete coathsion that invaIid~tes all the ~nfermation provided in tern]s of percentage Of people who a]'o unaware. Ther~ are a number of exan!pfes I can quilts, you have them in m~ st~t~men~ an~ ~ will ~t ~ iuto thera n~, but you r~lgh~ ~a~ t(l refer to them or gc back to the original staff reports. These si× problems suggest tl~ me quite ¢onc]usively that the di- agnosis on which the bill is ba~ed, that there is no high awareness a~ to the rcfetion between cigarette ~meking arid health hazard is ~ncorrect. It seems to me tha~ there is a very b~h one The second point that i have is the ~act tha~ the warning ~ystem suggested wi]] not he]p us achieve Lhe objective. There is no way, of achi~vh~g ~hc objective of the bill The only basis, empirisa~ basis, tills that I am ~millar with i~ a s~dy done by Burke' that h~s four major problems. One, the sJ:udy ~stric~ed the warbling ~aterl2ents only to cig~l ratte a~verti~i]~g, ignored comp]ete]y the f}~ckage labeling. Did n~ test them at all Two, ~he sample ~va~ a ~onrepresontativ~ ~mpfe based ¢Jn select- iug people i~ mall~ as ~pl?o~ed to trytn~ to ]l~v~ a random probabil- ity saraple that would h~ve ~llowed us to generalize the re~uhs to !be population at large. Thee-e, th~ ~tudy i~c]uded ~l~ly ~o ~f the ~var~i~ge you are ~ ~idering tod~iy Even then~ worded difteren~]y. There is no defeasible empirical basis to suggest that any of the ~regesed labels ma]{cs any sense, that they will achieve their ob]ec~ ~ive Four, wher~ you ]~ok at the re~u]ts~ even with all ~hese limita- ~ions~ and if you control for the format--they te~ted i~ their study ~ur different formats and three meSsages--there is no signifiean~ ~ffere~ce be~vge~r~ the ~tre~e~ ~ the me~ag~ based ~tx the cur rent one, and their proposed ones, which hasis~]iy s~gge~t~ that~ even if you for~et all the probfems of the study, their data really do ur~t support the cor~ciuslo~ that lhe cornmi~.tee i~ mag~in]~ b~re. • s on ~hich in corlc]usion ttien, 1~ seems "Lo me tha~, one, the bas" the bill is based. ~he notion that we ~re in a situation as stated by !be go~mittee, that the ~:orlstlmer$ ~re unvlwar~ of the ~h'ln~er~ ~ ~mokJng is i~correct and unsupported by ~ct. Two, the hope that a prescri~tlon to replace the current Surgeoll General's warning '.with a ror~atfenal system of seven ~fff'eren~ warn~ ir~ will }lave ~l~y ]DOSitlYe effect ~n conslllner ,'lw~'erl~S ahel]~ sm~lkitt~ and health, i~ue is really speculative. We do ~ot have an~" sUpp~rt tbr this either co~cptt~ally or empirically¸ i urgt~ the committee ther~tore ~o reconsider the ad~'isibilitv et¸ the l~heli~g pr~isi~ns an~ ~ ~v~l he happy ~ ~n~'~er auy ~ue~t~ yo~ might have iTestimony resumes {mp 474.1 iMr Wind'~ prepared ~tatemen~ foliows:]
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462 STAT~MEN~ O~ ?KO~ESSOR y0~ J ~IN~ FOK S(~M~S$ON TO ~ SUBCOF~I~'~E ON HEAL~ ~ ¥or~ (Jerry) Wind. Since 1~73 I hav~ served as Professor o~ Mark~tinq ~ the Wharton School of the University ~f per~sylvaflia, and ~ ~e pa~t editor of ~h~ Journal of Market- ~. ] hav~ b~en o~ ~he fa=ulty at ~art~n since receiving my doctorate deqr~e from $tan~urd University i~ 19~7. My specialty is mark~tinq re,ear,h, w~th part£c~lar emoh~ls on ~e ~naly~ and m~asu~=~nt of ¢o~r b~havi~r. ~a~q ~e pas~ fiZ~een year~ I hav~ s~rv~4 as a re~ea~h consultant ~or various qov~r~en~ agencies and ab~t 100 c~mpan±~s and ha~e published extensively £n m~ny ar~ o~ m~rket~ng. A r~s~e Of my educa- of ~¥ ~li~at~on~, ar~ attached t~ ~is ~ta~emen~. I have hewn asked by ~e ~obac~-o ~nstit~¢~ t~ pr~sen~ my ~iew~, as an exp~rr in marketing and ~on~e~ ~havior, Cn ~-~ thecretlcal and ~actual sa~por~ ~or cer~ai~ ~ ~h~ pr0vl.~ions o£ ~.R. 5653. My ~stimony w£~l d~al with *~he p~op~s~d fi~in~ tha~ ex£~ting gcverr~n~ and pr£va~e prcqrams, in~udin~ ~he formed t~ p~bl~c a~ou~ ~mo~ing an~ he~l~ ~su~s~ a~d the ~roo~al t~ repl~ the cur.~n~ warn~nq ota~ement with a r~ta~ional ~s~-~ ~.~ ~even ~fferent wa~in~ ~ta~men~. My co~e~s are ~ased ~n an evaluation of a ~oc~aent i~u~ £n May 1981 by th~ Sta~ of th* Federal Trade ~o~ssicn entitled Re~or~ o~ tn~ Cigarette Adv~rt£~inq ~'nv~stiffa~ion, wh£ch I ~5
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466 This a~sumption i~ c~n~rary to ~e actual results of the studi~s cited in th~ repcrt, which 5how that mo~t p~ple are aware of all D£ the siq~l~lca~t ~laims abo~t smoki:l~ and health. It also vi~la~es ~un~amental principle~ abmu~ measure- ment o~ km~wledge ~r awareness, mn~c~ call Ecr the developmer~t of ~ o~rall ~owledg~ scots o~ ~co es based on response to multiple itemm. Can your ~wle~g~ ~f a ~j~t~ ~t's ~a~ r~spons~ to a single ~e~tion o~ each topic? ~et this is analogoas to the FT~C ~taff'~ relia~c~ on ~h~ r~pon~e ~o ~i~gle ~ti¢~ cn th~ h~a~th ef~ct~ of sm~(i~q. The second area ~f misinte~r~tatioa is the £zaff~ as~ptio~ ~h a~y~nm who respmnd~ incorrectly to m-a'_~_iple mhca~e ~2~e~tions ~nvolvlng uetailed ~ati~uica ~r medical k~cwl~4~e is insufficiently ~ware of ~ ~ct ~r ~s~ue in- volved a~ th~ c~sti~n. ~por.~em~s wer~ askad n~r~s ~e~tlcn~ i~volvin~ prec~s~ d~tails, ~u=h as '~OU~ ~f every hundred ~opl~ ~h~ g~t ~un~ ~ancmr, ~ow ma~y ~ie from i~," to ~ Staff~ anyone who p~cked oth.v than t2~e ~n~w~r that the $~a~f called correct -. 95 -- ~did not ap~reci~te the s~verity respondents ¢hos~ either ~5, 75, or ~S, indi~tinq ~at ~y b~ieve ~h~t lun~ cancer h~s a high mortaliuy rate of a¢ l~ast hardly ~up~orts ~h~ ~taff'~ ccncl~i*n.
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467 Similarly, ~e Staff interpreted "don't ~o~ ~swe~s t~ ~uch ~t£on~ as a l~ck ~£ awareness ~n th~ par~ uf t~e respondent. ~ut such an answer is ~aalIy s~s~e~tible t~ th~ in~rpr~%ati~n ~h~ the respondent ±~ ~ware of the statement presented but is unsure of ~he prec±~ stat£stics involved. In my previous ~xa~l~, a ~erson wh~ believe~ ~ha~ most people with ~unq cancer 4£e ~rom that ~s~a~, bU~ who wa~ ~ot sur~ ~he-~er ~h~ correct ~ropcrtio~ is 85, 90. 95, Or 97 ~t of 1~o, might answer "4on'~ k~ow " Th~ Report ~o~ld who "do not a~pre~ia~¢ ~e ~ever~y of lun~ c~n~er." still ano~z- interpretation of ~he "don't know" ~: "I was gra~i~ie~ to be able ~o a~swer promptly, and I did I sa£d I di~'~ kn~.~' ~ec~£zing this, ~e University ~f M/chiq~n ~lnts ou~ ~ha~ th~ ~n~er "2 hay~ no opinion on ~at~' can m~n ~erely "wait a m£~ute, I am "d~n'~ kn~w" responses. No probing was ~o~d~c2ed £n the studies r~li~ upon by ~he ~C S~ff. to ~he stu~ie~ ~ou14 ba.~e r~sul~ed f~om simple lack of under. s~andinq of ~h~ ~ti¢~s. ~.~ s~udie~ primarily r~Lied upon in th~ R~p~r~ on the i~ue ~f public awarcn~s~ w~r~ Dased on
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468 t~lephone surveys, in such inte~ie~s, l~ ~s not reascr.~le ~ expec~ a high percentage of cDrre=~ answers to complax ~e~t£Qns such as those that were asked i~ V~ studies. Let me give y~u an exampl~ ¢£ one such ~e~t~n Imagir*e tha~ I hav~ called you out of ~he blue, explained wh~ I am, aF~d ask you ~ lC, nq ser±es of ~es~ions. Even i£ y~u have remained ln~erest~d ~ alert throughout t~e inte~iew, y~u mu~ resRond ~o such ~es~ions as this one: RHCW m~ny ~ericans livin~ today will eventually die fro~ diseases rei~te~ to smokin~ ~i~are~e~? Non~* ~ne ~ o~ ~wo, ~ne out cf si~, one ~ut o~ t~n, or one o~t of a hundred?~ The a~i~ity of ~ ~h=aslng -- ~oes the w~rd "~erica~s" refer to all ~ericans or only ~se who ~m~ke? -. ~s w~ll as ~h~ precise statistical answers pre~ented tu~ ~uch surveys into ~ ~essing g~e ra~r than a t~ of knowledge or awareness. F~ur~h, none ~f ~he stuti~s cite~ im the Report 2h- eralded su~rtir~ data as to th~ reliability a~d ~al~dity o£ ~ei~ findings, Tha~ ~£, ~c svidenc~ was offered to ~how V~ the s~ries ~f ~estions asked were a reliable measur~ ~£ public awareness ~r ~owle~ge ab~u~ ~ny particular issue F~r ~x~ple, how many resp~m~nts w~u!d ~rovid~ ~he ~ame a~sw~rs i~ ~e¥ were reinte~iewed a -~ew w~k~ later? Furthermore, ~ valid~tion of the resukts wa~ provided. Indea~, g±v~n th~ focus of the FT~ Staff ~eport ~n s~stantive conclusions, if i~ w~re s~tt~d to a professional ~l~ca~i~F~ ~uh as t.%~
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470 smarch ~ the pre~ise "correct" answer ±s not r~a~onable, "don'~ ~ow~ is both ~ f~nct~on of tL~ ~sti~n wordinq and the i~em of concern; ~d uncertain~ doe~ not necessarily represe~ lack of ~waTeness. On~ ~xample af ~ faulty definition o~ "awareness" i~ the ~C Staff's misuse of the i98~ ~oper Study cl~ed £n th~ Repo~. That study a~ked people "how t~e you personally ~hlnk" ~ ~arti~ular ~ta~mcn~ i~. ~.e ±n~e~lewer wa~ ln- st~c~d t~ introduce ~hose ~ue~ti~n~ tu the r~p~n~n~s as follow~: "N~W I'm ~o~nq ~o r~a~ you some statements about smoking ~m~ heal~, a~d for each o~ I~d li~e y~u ~o ~oll me ~ abou~ how tru~ th~ s~atemen~ is." ~e~ponde~s w~re pe~itte4 t~ answ~ only "know ~'s urue," "think it's true," ~d~n't know i~ it's t~e " "~h~nk it'~ n~t t~u~" ~r lnq im ~be latter ~h~ee categories ar~ "unaware" ~ th~ ~n~orma- t£on convey~ by ~he ~pe~lfic statements made. It is ~vio~, however, that a resp~n4ent ~uld b~ aware ~ ~ claim (for exam~e, that ~mok~n~ increases tha ~isk of h~r~ attack) ye~ disagree w~th i~, The FTC St~f~ consistently mlsuse4 v~e stu~i~s in th~s respec~ ~o ~upp~rt i~s ~rroneoa~ con~s~on~ about awareness Let me ~e~d ~noth~r example from p~9~ 3-19 of~e ~epo~t~ "A~cor~ing ~o the Gallup Op~n£on Index, ~une. 1978, lg~ ~ the pc~al~tion do no~ believe that smok£~ cauues lu~q cancer .... ~ong all smoker~, 2~ d~ no~ b~[i~v~ ~mokinq c~u~ lun~ cance~ wh~£e arong heavier smoker~, nearly On¢.~3a£r~ -- 31% -- did n~t meliev¢ or
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471 know abou% the l±~k .... projected nation- wide, these da~a ~ggest that tens of mfll£ons of Am~rlcans, bo~ smokeru and non-smoker~, d~ not know that ciqaretue smoking cause~ i%tnq c~ncer.~ The Staff's o~nclusion ~imply does not follow fram the data This £undamen~al ~ype of ~rror .. con£u~inq cono~u~er a~a~eness wit+h ¢ons~or belle£ -- unde~m*_nes any reco~endation~ tha% might be base~ on a prsmis~ that the public is not ~dequately informed ~bou¢ s=okimg and ~eal~h. The ~ Staff R~port -- ~ pres~ably ~he present ~ill -- proceed from the pre~ise that t~h8 public ~B inadequately ~n£ormed abou~ s~oking and he~l'~h issues to the conclusi0~ ~a% a ne~ sy~t~ o~ ~rnin~ o~at~n%s ~s n~ary to ~eotify thi~ Inadequacy. As I h~ve ~tt~mpted ~o d~m~nstrat~, ~e available da~a do not ~uppor~ the premlse. Bu~ it i~ mque~ly di~rbin~ that the new system o£ warnin~ ~ta~ments ~co¢~nd&d by the R~port ~n~ by ~.R. 56B3 ~re not l±kely tu achieve any p~sit~ve impact on constn~r awarenems a~ut ~moking and hsalth imsue~, The~ is n~ evidence ~at s~eclf±~ warnl~s such ~ ~hos~ proposed i~ ~.~. 565~ would re~ul~ ~ any increase in p~lic awareness, The only s~udy of which I ~n aware that ~ela~es to ~h~s issue is a s%~y cunduc~ec~ for the ~TC Staff ~y Burke Marketing Research to test ~he r~call of dif~er~n~ type~ of proposed warning &ta%~ments ~nd fo~at~ T~I~ s~udy Q8 O~
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T 473 consumers might well concl~ that the S~rgeon General has changed his op±nion and no l~nger con~ld~r~ $~okl~ ~o be ~enerally hazardous t~ health. Moreover, by £o~ussing ~ ~pecific problem~, ~e warnings become significantly less relevant to various seqmen~s of the population. Teenagers, for example, are unlikely t~ be ~on~rned about ~mphys~a or heart disease; slngle m~n and older women are n~t likely to pay attention to a warn±rig ~ha~ smoking may c~u~e ~roblems during preqn~ncy. Neither the FTC 5t~ff ~epor~ n~r the pres~n~ bill appears to have given any oonsi~erati~n ~o ~s~ poten~-ial consequences o~ a rotational warning system In co~clu$~o~, nothing in =he studies cite~ by ~he F~C Staff or the rationale suggested in the b~ll itsolf sup- ports (a) the dia~nosis that the ~ub~ic is unaware ~ the claimed health hazards of ~moking and (b} th~ pr~cr~ption ~ha~ the replacement of the curren~ Sure.on ~n~r~l's warn~ ing ~l~ a rotational system of s~v~ diff~r~n~ warnin~ will h~ve any pos~tiv~ effect on consumers' awareness a~out smoking and he~l~ issues. The l~eling ~ro~esals simply ~r~ unsupported by facts or theories a~out c~nsumer behav£~. Hence, ~ u~qe thi~ S~co~i~ee to r~consider ~ advisability of ~h~ labeling provisi~n~ o~ H.R. 5553.
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4~4 Mr. WAxMhN. Thank you vexy much. ~re witl have questions in a minute Dr. B]ackwel] STATE?dENT OF ROGER D. BLACKWELL. PH. D, Dr, BL~CKW~LL. Mr Chairman, 1 am Roger BlackwelL a profes- sor of marketing at Ohio Stat~ University, specializing in the anal. ysis ¢~f buyer behavior and development of raarketi~lg ~trategy. My Ph.D. degree was earned at Northwestern University, with a con- centration in consumer behavior, I have authored, or coauthored, 14 books and over 50 articles published in professional or business journals that report research that i a~d others ha~e c~nducted c~ncerni~x~ the ¢oramunications process, consumer decision processes invo]wd in buying and using goods and services, and variables involved in marketing strategy. One of my most recent books is the fourth edition of "Consumer BehaVer," published this year. i have t~e~n ~ked to review section ~ of the hilt that would change the present labeling requirements to something else The rotational s~tmn of warnings proposed by section 4 is of course somewhat similar to the report and recommendations made by the staff of the Federal Trade Commission In my opinion, the change in th~ ~arning ~tatement proPe~ by s~ati~ ¢ i~ fundamentalty flawed First, the labeling provisions of section 4 would replace a hlghly successful program of informing consumers about the claimed health risks of smoking with a program of unknown and potential- ly counterproductive eol~sequenc~s, All of the studi~s conducted about consumer awareness of smoking an<] health issues lead to the conclusion that people are uoiversally ~ware oI the claims that smoking is hazardous tO hea]th~ and you can go back into the smoking section of a plane and simply verify that by talking to people and asking them. So why abandon this program io favor of a course that is not only unchart~i bu~. *~s 1 hope to demonstrate, likely to lead to re- sults quite the opposite of those apparently intended by the bill's spollsors? The other basic flaw in section 4 is tha~ the system of rotated warnings attributing specific health problems to smoking willprods ably lead to one of two ~lnh~ppy effects: Either consumers will er- roneously believe that the~ ~iil personally suffer the specific health problems identified in the warning statemeots and say yes, i will have a heart attack or get lung cancer, and if people did thal, and you know only some will, then Cengres~ is mandatkig o law which deceives some people Now that is one posslh]e consequence The other possible consequence, and probably the more likely one, is that people would read the ad and say, some people ~vill get heart d~sease, or tung disease. But we kncav that these are minority phenomenons, those are risk factors that only apply to a c~rtain proportion of the people Most of the people will, as human nature always is, say that is for the ether person Now let ale explain just a little bit about the point. .Q O]
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475 The poinl is imp¢)rtallt to whether people do h~lve (he informa tion ~b~ul whe[h(!r it ix folzElrdolJ~ (ir hill Pr(pfoss[Ir Wind h~l~ ilUile well summarized those data. al/d those data are described in 1oage~ 3 through 7 of my statement, so I would not repeat the]21, the prod ]ems with the assertion that peopie do not know the foot that a lot of inform~tlon is disseminaLed on this subject¸ Professor Wind and I did not interact before, hut ~ur analysis was very similar Mr Chairman, I think one ot¸ the most interest- ing things is, if you supplied these studies to all of¸ the leading con- sumer behavior profossors, or people who arc used to analyzing a panel ~f pco[J]c who would o~cctivcly cvafuatt" it, i just do not see h~w you w(ILI](] c~lm¢~ Io ~lny other (3onchlsions fl'om ~hos£. experts other than the ~ne tfott people do know, or do bclfove, that ~nlok ing rs hazardous. Now. so I will not repeat those slPeCi~cs. The5" are in the state ment But those are the empirical evic~ence. The other prohlt'm. and 1 think this is the one that bothers intellectuals, bothers ever~- body perhaps, that if" people know this they would act on i~. But it would be wrong to conclude that consumers are not adcqual.ciy in ~rm~t just because they do not act upon it As a Irl~tLter of fi~ct, the stuc]ics done by tht~ FTC, c~mmissioned by the FTC, flatly refute this position. The 19~0 Chil~n study came ~o the ¢on¢lt~ion as fo]fows, and I am quoting l¥om page 22, "Fact~at knowledge aho~at the healfu consequences ~f smoking was not found to be signiifo~ntly related to ~urrent sm~kfug behavior." In ~ther words, ~hc FTC's own commission studies indicate if people, hLld this illforll/atfoIl, rio rilor~ di['f~r~nl!e hi!l-~,t!(!n ]~now]t~(Jgc levels of" smokers compared with nonslnokers were found t~ be sig nificant at the 0.05 level of slgnif]callce than were to be expected by ~hancc So hasic~]ly my position is that il" yuu ~re [tying to pu~ in inf~r- matfon that would be more l~[evant to some people, those who are at risk in heart ~ittacks, you are by deflnition putting in fut~rma tion that is relevant to the people who do not consider themselves in those risk categories¸ My o~jeetion, all(] I a]21 ~ llO]2smok~'r ~nd I sIISpeCt I e;ilfl~thize quite a hit with the view of wal~ti~g people to not ~moke ,~s much, but my position is you woukl he creating a rule which said to many people, this is for people who are older, the ones who get heart at- tacks and the one~ who get lung cancer F[)r eX~lmt~]c, pc~ple over 65 have ~lmost 2.000 percent more like- lihood of ln2tligll,~ncy th~in yllun~ p~[)p]e W(! n[iw h~lve ~t symptom 112 which parents and peers, who probably influence the re~t/ deeisi~n to smoke~ can say the Surgeon General has determined that smok- ing is hazardous to your hea]th And wha~ wc are doing is ~rying to talk about a system that would repl~ice th~lt wi~h one that consequences that are uncharted, and everything in the empirical evidence that (foe~ c×is'~ ~md m consumer behavior theory indicates that there is no reason to be lieve that this will he more eflhctive, and in fact there are some wry strong probabilities that it would he counter to the intentions that probably many wel]-meani]2g people intend fbr this hill ']~.'~n k you [Testimony resumes on p 4~6.] [Dr. Blackwell's prepared statement foifows:]
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476 STA~NT OF DR. ROGER D. ~LAC~LL My name is ~ger ~. 81ackwell. I ~ Professor ~f MarketSng at the Gh~o State Unive~slty, ~p~cializi~g in the analysis of buyer b,eh&viQr and develo~ra~nt of marke+in~ ~trate~rg. My ~h+D. degree w~s earned ~h lgor'¢h~,~stern lJniver~lty, with a c~c~ntz~t}.~ il~ ~s~r b~h~Qz. I hav~ aUthOre~t or ceJ- authored f~t~teerJ b¢,~ks ~1t aver fifty ~ticles pttl=lished in pro~ssi0naI cr btlsinQs$ journals ~h~l: ~ep~rt research that I and Ohhers have ccnduated concerning th~ complications ~ro- cess~ cons~r decision processes :~l~l~ed in buyillg and usinq One of my ~ re~unt b~oks ~ the fourth edition Of Con~kr~r Behavior, p~hlishell ~i~ yea~. Tl~e book des0ribes psyci~l~glcal principles invC~l~d ir~ buying and consu~aption ~nd I.~ the ~st widely ad~pted ~extb~l~k in ~he field. ~ complete iI~t o~ my pttbi.~cation~ ~.~ sttl~i'~ted wt.l~ ~hl~ statement. •his is my ~rsor~al statement ~d s~llld not be con- c*~r inst,.turf.on with whicl~ I ~ or have be~ a~filiate~. I have l~es~ asked to analyze ~c~i~n 4 of H.R* 5653, which would change th~ present labeling requir~men~ for ~.gal~t~e pacRages and a~vertis~m~nts* The r~:aLlo~l system of w~ing sta~.~m~ts p~posed b~ Section 4 ~f the bill is ~imilar ~.o ~ rec~ndation made list: year by th~ staff Qf the Federal Trade ~valtt~d ~h~ £{ndin~B and ct)nclusi~ns of that Report as Well. ,,,I
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__. 477 In my opiniun, t~e ¢hanqe in the ~zning stat~nt proposed by Section 4 is f~n~t~liy flawed. First, t~e laDeling pro~ision~ o~ Section 4 w~uld replace J hilly ~cce~s- ful ~r~qrnm ~f in~o~min~ ¢on~ers about thB cla~ health risks of smoking with ~ p~Qgram of unknown ~ad putentially oo~n~erproduGtive consequences, AII of the ~tudies ~OndUcte~ about cons~er awareness of smmk£nq and health ~s~uss lead to that sm~kin~ is h~zar~us ~o h~alt~. Why ~band~n this program in f$~r of a cc~se ~at is nvt only uncharted but, as I h~pe t~ d~monstra~e, l~kely to ~ead to ~esults ~/i~ the opposite Of ~h~e apparently ~n~¢a~ed by ~he bill's ~ponsor~? ~f rotated warnings actributin~ ~pec±fic hsalth proble~ to s~k~ng ~±iI probably lead to one ~f two ~nha~py effects: either c~e~s Will e~roneo~sly believe that they will per- sonally ~uff~z t~ ~p~cifi~ h~lth pr~b~$ id~t~fie~ in ~ ,~arn~n~ ~ta~ment~, ~ven ~h~uqh such problems affe~ only a minority of ~he ~Oki~g and nonsmoking ~p~lation, ~n which case th~ warnings would b~ deceptive; or coasters will ger~c~ly perce~v~ tha~ only a ~mall proportion ~f the pgp~a~lon is a% risk from ~h~ sta~ed ~eal~h ~ble~, ~nd will thus coaclu~ that ~he Sur~n General ~d ~the~ h~alth authorities have now ~ec~ded ~ha~ smokin~ ~s no~ hazardous ~o all pe~p~, Since ~t appears tha~ th~ specSfie diseases ide~ti~i~ in ~he prop0se~ -J
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l 478 effect of the law muld be to reduce drastically t~e impact of th~ warning statement on yo~lg peQple. The rotational wa~£ng system proposed in the present bill ~d the FTC Staff Report apparently is based on the ass~p~ tion that present p~iic awar~¢ss ~f th~ claimed health c~n~e- quences ~f smoking 1~ "insufficienh." Finding 7 ~ S~cti~n 2 ~f H.R. 5653 states that "present Federal, State and pri~ate initia- tives have been insufficlant" in c0nveyin~ information about the claimed health ~nsequenaes of smkinq to the American public. similarly, the FTC Staff R~pQrt asserts ~hat "additional action d~signed ~ provide consumers ~itA~ ~re inf~rmat£~n about the health consequences of smoking is necess~." (Report ~t p. 21) F~r ~everal ~eas~ns, this ass~pfion is dubious. ~n the f~rst place, determination of what constitutes a "s~fi~i~nt" lev~I of ~wareness £n sach a com~l~ a~a is both difficult an~ s~bjecti~e, although ±t appears to me that, by ~n7 s~dard~ the level of awareness about the claimed health hazards of ~m~king i~ ~t~nishingly hiqh. A basic uuestion is the a~t ~f info~on a c~ns~e~ ca~ r~asona~ly be e~ecte~ to be aware of i~ collocation with a dec~slon tu us~ any particular prod~gt. Many of ~he questions posed in the su~eys cited by tha FTC Staff r~qu~r~d a d~ailed scientific ~owledq~ ~ut q.esticns ~f smOkinq ~nd healtA%, including a c~mpl~te awareness ~f e~e~ h~alth p~oblem that has b~cn attribute~ to smoking, the specific size of the increase cla~a~d ~n the risk of inc~rin~ each problem if ~ne s~kes, th~ perc~ntag~ ~f eacM particular health condition tha~ is attributed to smoking, a~d th~ proportion or number of
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479 people whc ~ fro~ a ~iven health cQ~dltlon. From ~e c~e~ vi~i~t, wh~t value is there ~n ~os~ing ~ch a c~mple~ array of info~tion~ WLen one ¢~sider~ t~ tremendQ~ ~nt ~f infQ~ti~n to which the con~r Is ¢xp~6ed ~very ~y, ~d t~ fact that c~ns~rs do not ~ssess ~l~it~d process±ng ~a~citles~ i~ clearly ~uld ~¢~m ~re f~cti~nal f~r the con- n~r~us b~t~ ~f i~f~i~ a~ the cla~med c~nsequ~n~s ~ information conveyed by ~h~ p~n~ S~rge~ C~eral~ w~in~ sta~ent. Proper ~val~a~i~ of the ad~u~cy cf con~r aware- ~ ~Is~ is ~p~ed ~y th~ ~ac~ tha~ there i$ ~o ha~elih~ ~r ~mOki~g ~d h~alt3a ¢~ar~ ~ the i~f~a~ion c~ns~rs p~s~ a~t the ~I~ hazards at~b~ed t~ other pr~d~c~ S~c~ as j~d~nts about ~h~ ~uffic~e~cy ~f the level ~f ccns~r ~war~na~s ar~ ~i~hly ~mhj~ct~v~ ~d c~n~t ~rv¢ v&lidly as a ha~ f~r ¢h~ f~r-re~hin~ chan~e~ ~bod~e~ ~a Section 4 ~ ~h¢ bill. M~re~ver~ an e~z~at±o~ ~ ~he ~tudi~ ~n ~hi~h the FTC re~e~ f~r ~ ~ruposit±~ that cons~r~ a~e n~ su~f~i~y awa~e ~f the d~rs asso~a~ w£~h sm~k~n~ ~veals tha~ ~se s~ud~e~ ~r~ ~fec~ive i~ ~vcral im~r~an~
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i 48O PerhKps most significant is that many o~ the survey measures assessed beliefs rather than awareness. The dlstin¢- ti~n between belief a~d awareness is a critical one given the existing controveray over the ~eal~h threats pressed to be posed by s~oking~ Considex t~e likely situation of a survey participant who recogni2es that smoking has been fo~d to be associated with partlc~lar health problems but finds the evldcn~e insufficient fDr demonstrating that smokinq causes these health problems. Thus, the person is aware of the clalmed link betwee~ SmOking a~d some health problems but does not believe that S~oking ~uaes the problems. As stated in the IS30 BUrke Mmr~ keLing ~esearch Poc~s Group Study co[~issio~ed by the FTC: MPurthe~ d~ubt a~ut the di~t relation- ship of s~king ~d canccr see~ to b~ related to the fact that these persona had k~own smokers who had lived long lives withou~ contracting cancer and non-smokers who had suffered from that disease.- ~Burke Study Analysis at p. 4.) Many of t~e m~asuros e~ioyed in the studi~s asked the respondsnts to i~icahe their aqreement with or the correctness o~ statements such as "smokin~ causes X.. Respondents who ~isaqree~ with these "su~posedl~ ~r~e,' statements are categorized as ,imawere. Al£eznatively, these rcspo~dentz may be aware o~ the ~edical evideno8 but have c¢4%cluded that while smoking ~a "related" to x, i£ does not "cause" X. Evidence suppor~in~ thls alternative explan~tlo~ is provided by t~e i~8~ Chilton study ~nducted f~r the FTC Staff. At one point survey participants
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were asked whether heart disease "had been f~d t¢ be asso~iBted ager$ ~d 9.3% ~f the ~dults i~rviewed ~wared ±nc~rrectly (i,e~, "~o" ~ "Don't ~ow. ~sponses) . Latar in the inte~iew, these s~ persons wer~ asked whether the statement "cigarette smoking is a major ca~$~ of h~art disease" IQUestion ~2] wa~ t~e or fal~e. 26.8% ~f the teenagers ~ 39.6% of t~e adul~ wer~ p~S~d ~o be ~aware" cf the ~lalm e~od~d in this statement. ~u~h response varistions between g~stion~ in~ivinq the sa~e diseal~, but which ~fer in posltin~ smoking as either the cause of o~ simpl~ associated with that d~sea~e, ~tronql~ suggest that m~y ~ers~s cl~sified as "~aware" in facf are a~are of s~ki~g's ass~rted r~lationship t~ vari0~s health risks. These ~ersons ~imply dD no~ believe that smok~n9 causes the~e health ~zoble~s. ~ues~io~ wording ha~ long been recognized a~ a critical area in su~y r~sear~h, ~ ~TC Staff Repo~ acLnowledqes ~hat more likely to generate a~reemeat .... ,, (Report at p. 3~} By the same toke~, ~tatements employi~q extreme wording ~r phrase~ ~re likely to inhibi~ agreement. ~hu~, the a~ounh of agre~ent with the statement "s~k~l~ i~ by far the g~eates~ cause ~f lung ~an~ex" used In the 19~ ~per ~h~dy was proba~l~ lower ~h~ ha~ the st~te~nt ~ee~ phrased "s~k~ng ~s the 9r~atest response patterns t~ a question, phxa~es r~p~atedly appearinq in ~he ~oper S~dy such as "by far," "~reatly increases," an~ O
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~2 "significantly increases," are very subjective. FOr example, some people ~ay pe~¢eivo a 30% riak increase as a significant ~norea~e, while others may not. It is in~erestin9 to note that th~ FTC Rep~t cites evidence that p~ple tend to iq~ore Qr discount stati£~ic~l information zn mak~nq ~ud~ments. (Report at pp. 4-14 and 4-15) G~ven this eviden¢$, it see~s inconsistenh to employ ~asures Of "statistical knowl@dge" for as~e~ing the level of awareness concern£gg the el~Imed effects Of smoking. Measures Of this type, ~ever, wer~ freqgently O~ployed as indicators of c~n- s~rs' awarene~ about the asserted danqers ~f smokil~q (~., "What ~ercent of long cancer cases are oaused by cigal~ette smokin~?" - Chilto~. 19B0~ "Si0~ker~ are at least ten times as likely to develop l~g cancer ~han non-shakers" - l~9~r 1980) . F~lr thes~ reasons, it would appear that cllrrent studie~ hays ~leresti~t~ ~nsl~0~rs' awa~eness alx~.~t the health hazards associ~.ted with sr0~k~.I~g. ~ere is, ,anf~rtunately, no way ~ff predi~lq how much ~mdere~t~ti~n error existz in these da~a. But in view of ~he fnct that these s~ studies ~onsiBterltly reNrt awareness l~llv~l~ in the 80 to 911 peacock: range, ~.t is ~air t~* ~or~elude t~a~- public awareness of tll~ variotl~ clrlims ~l~ll'~ isl~king ~ld health ~.s as a pract~.cal matter ~iver~al. It wc~,~id bs ~rr~ng to ~on~lude that e~nsurl~.rl are n~t adeqllately infold abc~ut the ¢ialm~ heai~h cons~..~:~uences c,£ s~l~ing simply because many con*~rs continue to I~ke. ~"t~e F~ staff ~pc~rt state~ several times that s,~mkers are not ~s
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488 well in~med ~s ncn~ker~, imp~yin~ ~at ~ch in~o~atiOnal differences are responsible for ~e deGisi~n whe~er or not to s~ke. That conclusion is flatly refu~ed hy hhe 1980 Chilton study, ~he ve~ study cited by ~e FTC Staff to demonstrate the sup~se~ difference ~n the level~ Of awarenes~ between s~k~rs and nonJ~okers. The con~l~sion reac~ by the Chilton S~udy was as fOlIQws : "Factual ~wle~qe abou~ the health ~o~seq~ences of ~m~kin~ was ~ot fo~d te be signlfi~antly related to ~urrent smoking behavior. NO m~re differences between knowledge levels o~ ~kers CQm~r~d with ~on-sm~kor~ were fo~d to b~ significant b~ ~h~oe." (pa~e 22} This important f~ndiag ~at ~on~umer kaowledqe hnm no relationship ~o s~kin~ ~ehavi~r refutes the no%~ that ~eople ~bo sm~ dc ~Q heeauso the~! ~r~ "~%~f~ed" ah~% th~ ~lai~o~ d~nge~s of smoking. The lack of a relationship between aware- ne~ an~ ~mok~nq ~Is~ ~e~r~s ~hat iner~aslng cons~rs' awareness ~ho~t the health hazards att~ibute~ to ~k~n~ is ~likel~ to infl~ence ~eir smoR~ng behavior, C~nse~en~ly, ~h~ ext~t th&~ ~e presen~ bill is ba£ed on a ~es~re t~ reduc~ s~ing -- an~ p~ttim~ a~i~e th~ cuest~on wh~ther ~ehavi~r ~odification ~s an app~priate ~al for goverr.~ent in this c~ -- th~ wa~nim~ ~%ate~ pr~p~ed by Section 4 ~re G~v~n ~ese facts, ~ ~h~nqe ~f the sort ~ntem~lated B~~ ~ectlo~ 4 ~hOuld ~t ~e ~de~takcn ~less there is si~n±ficant ev~denc~ that ~he p~posed system of ~t~e~ wa~i~gs ~uld better
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484 a~hie~ the 9oal of info~ng ~e p~blic, The li~le evidence ~at e~ist~ not only fail~ to ~up~rt that prop0~ition, but in fact c~ntra~i~ts it. initial stu~ for the FTC St~ff Was underLak~n in 19~0 by Walker ~esearch to assist in the selecti~ of specific w~ln~ ~tat~m~nt~, while ~¢b~z ~t~6y c~d~d by ~rk~ ~rketlng Resear0h examined cons~e~s' r~call of ~ari0~s wa~ing~. I~ort~tly, neither Study ex~n~ned th~ impact of such warnings on ~n~er aw~enes~. There are ~uordingly no ~ata to ~n~i~ate that a rotational syltem such as that proposed by the bill would meet ~he objective of pro~idin~ con£~ner~ w~th "s~fficient" ~ware~ess about the ~lai~d c~nsequ~nces of ~k~g, p~rticui~rly ~f su~ici~ is gauged by ~ very ~e~iled measures Used in ~e ~eys c~ by the ~C s~aff. What ~he studie~ do ~emonstra~e ~ tha~ cons~u~ex~ are likel~ to di~ w~rn~r~s ~lu~t l~nk s~kir~ t~ ~ci~i~ h~alt~ problem. ~n ±~s S~a~ of K~y F~dings, for example, ~he Burke FOCUS Group s~y s~ates~ pil~s ~d heart attack~ ~en~ t~ ~onfu~e the pa~cipants, wh~ dzd no~ thoroughly form ~he b~s~ of the ~ssage. ~ase t~o statements rela~in~ to c~al c~nt~s wer~ rathe~ ea~iVsomeo~e~m~ sed~isaS~ Th~ S~Udy '~hus uoncludos: .j
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485 "It seems ~t the birth ~ontrol m~sa~e could have relevance t~ a hiqhly select ~r~up of people who co~l~ be best ~e~ched through very specific media. Th~ ~ss~qe might be lost to t~e pop~laticn as a whole." (B~rke P~CU~ Group St~d~ A~alysis at p~ 6,) •hat s~ ~cn~lus~on appears to apply w~th 8qual validity to each of ~he spe~ifi~ ~isease warnings cont~pla~ed by H.R. 5653. Thus, even the pr¢li~na~ re~earch that ha~ been done tends to support the aomclu~ion that hh~ proposed rotational warnings wOUld be considered irrelevant ~y so~ cons~ers, as c~mpared to the present w~ing ~atement that anno~es to e~ry coaster the S~r~n G~neral'$ conclusion that ~$~k~g is dangerous to ~ heal~h." ~e$~ f~d~n~s ar~ particularl~ ~ignifi~t i~ ~iew of o~e of ~he ~j~r pre~ise~ of the F~ staff ~p~rt, and pre- lacy of t~e ~r~se~t bill~ tha~ co~s~rs s~o~id ~rcoive i~f~ma~oa comcer~i~ smok~nq and hsalth ~o b¢ personally r~le~. Since it i$ b~ic t~ h~m~ ~£ure t~ conclu~ tb~t r~ks apply to "the ~the~ person," specific wa~nzn~s that might h~ ~r~ ~r~lly r~lev~t to $~r~ consumers ~ou~ hy ~fi~ltio~ be personally ~rel~v~t t~ ~st other c~ns~m~s. FOr the sonally. ~hen the ~r~sed ~ew wa~nln~s would De less relevant. who may be ~akin~ th~ ~ecis~on of wh~th~r to ~oke ~g not. least i~ the ~resent situation pa~nts or pe~r$ can say to 0
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486 p~ple w~o are de~idi~ff to $~ke that "the surgeon General has ~ tha~ ~ok~ i~ ~r~rQ~ tQ yo~ health," Under the propos~ new warni~g~f the logical conclusion w~ld be that the e~lly ~heal~y, bu~ only ~he~I~y ~r certain olde~ secants As a~ analyst of ~on~e~ b~havi~r and decision ~kinge Z ~m of ~ ~ni~n ~hat ~.~ ~5] ~y we).), ha~ ~h~ ~i~ e~fe~t ~f that which ~pp~r~ k~ be intoned by i~ sponsors, I conc~rn~fl that H.~. $653, no ~t~er hOW l~ud~l~ t~e in~en- t~o~s o~ the spcns~r~r is not ~$ir~ble legisl~n if the ~o~1 £~ to h~ ~h~ ~eneral p~u~at£on, ~nd e~pec±a~l? s~kers, aware of the health h~ards ~hat are ~lleged t~ cCC~ ~rom ~m~kinq. Mr WAXMAN'. Dr. Blau. STATEMENT OF TIIEODORE ([. BLAU. PIL D. DI. BI~AU Thank y(m, Mr. Chairman, lbr the opportunity" el ap- pearing here today 1 will be brief and submit details of the re- search backgrmmd of my statements to vuur staff My name is Theodore Blau l hold a doctorate in psychology, re- ceived from the Pemlsylvania State University in 1951 I have been in tndependen~ practice uf clinical psychology m,d consulting psy- chology in Tampa, FI~. since 1953 Formerly, l was prlffesser of psychiatry at the Medical School of the University oi' South Florida, and professor ~f Fsych~i~gy at that school and others. I hold a diplomate in clinical psychology from the American Board of Professional P~ychology as well as the d~ploma from ~l~e American P~avd of Forensic P~ych~l 9gy I am a member aad past president of the American Psychoio~'i- eel Association and snl currently president of the American Psy- ch~l~gi~al Fo~t~d~ov.. I am al~ a member ~f the Evaluation Re- search Society and have c~nducted evaluation studies for p~iva~ corporations as well ~]s evaluation resealch fur various branches of the U.S. military a~d othe~ elemea~ of t~e Govertmvent 1 am the author of 1 book, a number ~f cimpters and approxilnate]y 50 articles. For several years, 1 have been involved m an evaluation of the research and ¢urreng state el knowledge about the psychological as- pects of cigarette smoking The evaluation include~ a ihorough review of historical factors, cur~ent ffmories and resemch, quality of the resemcb and publications pertaining t~ dependence, eddic. tion, laboratory and ~lpplied research and cultural aspects ot smok- ing behavion In addition to this ]iten~lure review, I have also communicated with active researchers working in Lhe area. 1 am presenLly writing .0
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487 the ~,ction entit]¢~d "Smoking Behavior~' that will be published in the "Wiley Encyclopedia c~f Psychology." It is my understanding th~iL proposed bill H.R 5653 would man date a warning on cigarette packages s~atiilg that cigarette sm0k ing is addictive I will address myself today to that conclusion For almost 400 years the smoking habit has been an ie~ue never lacking pr~poncnts as well as opponents S¢)me who smoke seem unable to giv~ Lip lh~ clg~rt'tte habit, a~ least during certain dec- ades of their live~ Others can ,~lJit with apparent ease. Few specific areas of aI0plied psychological research have re- ceived greater a~tention 1.hart the cig~ire~Le sm~king habih Despite this intense scientific focus on the behavior~d as wcIl as psysiolcgi ca] aspects of cigarette smoking', no gel]el'al agr~ernenl ~lnnon~ sci entists exists in answer to the questlol~ of whether cigarettes or their contents are addictive¸ The behavior and responses ot¸ cigarette ~¢mokers are quite ¢liffer ent than those observed in individuals who are addicted to heroin and other substances that are demonstrably adclictive, The scientific literature demonstrates the following: There is apparently nv difference in the seve~'ity of cessation re- ~pt)l]~ces be~weerl light ~mokers a~d ht'~vy ~rclokcor~ Rest'arch ~tl~o has show~ that these effe~t~ are felt more severely by those who reguced closages but did not stop c~mpletely than by those wh~ ab- stained totally. A third aspect reported by variou~ reseEtrcher~ is that ~mc~king cessation effect~ are relatiYe]y mild and in some cases n()n-existent. The~, are of a nature which might he expected to follow the loss of psychological rew3rd~ from any loved ~bject to which ~ person was long accustomed and which ¢~luld he conceived ~f as f~rmh~g an im- portan~ part of the way the individual sees themselves and th~fr behavior. It h~s been reported that many smokers ~re able to refrain from smoking for relatively ]~ng periods of time f~r pr~lctical, safoty ~r religious reasons and to d~ so without apparent discornfert. Some examples are coal miners wh~ may not smoke at the pitface, Orth~)- dox Jews who give up smoking at sundown on Friday and cease sm~ging u~il sundown on Saturday, and so forth Such behavior does not IlL conventional views of addiction¸ Whereas ~he effects of u~e a~d withdrE~w~l are comcistcnl ~lnd predictable with known addictive substances despite a ~ic]e ravage o~" uses, de~ri]Dtlons of ~obac~o effocts are extremely varied and in- consistent. In this regard, tobaccco use is more lille the use of caf- foiile rat.her than ~lcohol or opiates It has been reported by Cost~, ~n 19~0, that the continuance of smoking appears more re]atad ~ a wic]e r~lnge of psychosocia[ mo- tives such as pleasure, stirauia~ion, sensory m~JL~r manipulation, and reduction of negative effect ~han an add~ctlon factor. The U S Department of¸ HEW reported in 1977 that 95 percent of those people ~ho q~it smoking do so on t~cir own. This is no~ only a phenomena in sharp contrast to experience with demonstrably addictive substances but one which remains to be explorech Clearly, many areas o~¸ smoking behavior are as vet unexplored including why s~me smoke very heavily and some do not Carefully controlled animal studies must be done before a scientific descrip
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488 tion of the smoking habit can be expected Promising work with Rhesus m(mkeyn has been reported by giyoshi and Yanagita in Japan and researchers at the Southwest Research Institute Rogers have reported conditioning laboratory baboons to smoke cigarettes These developments suggest that we may be ab]e to study cigarette smoking in a prapvrly comrofied laboratory setting Until such controlled animal experiments with re]iable models of self-administration of tobacco can be devised and conducted as they have been with morphine, cocaine, and a]cohoh the concept of to- bacco addiction will probably remain a hypothetical construct only pardy underst~ed as suggested by darvik, 1977. And so, gentlemen, at this time the scientific data do not support the statemem: Ciga rette smoking is addictive I would very briefly like to Yell you my clinical experience with smoking During the past 30 years I have worked and continue t~J work with people who smoke cigarettes In reviewing my experi once with the thousands of people that I have seen profesiona]ly, many of whom were heavy smokers, I find some contkmed, some quit with stress, and some quit with llttle or no s~ress, These pa- tients of mine in no way acted like the patients that 1 have seen who struggle to be released fi'om the addictions of opiates or alco- hol or amphetamines. Cigarette smokms are very attached [o their smoking behavior The>- are often annoyed or distressc<l when they are not allowed te smoke. Hmvever, I have also noted people have equally strong at- tachments to tennis, jogging, candy, reck music, Coca~Cola, mere hers of the opposite sex, and hamburgers; particularly in my ado lescent patienk~. With children, one sees very strung attaebnlents to playmates, parents, certain articles of clothing, TV, blankets, and teddy bears. Removal from these activities, persons or objects can result in agi- taLion, sleeplessness, irritation, depression, and other uncomlbrt- able symptoms. They vary considerably in intensity and duraLion, as do the effects of abstinence tbom tobacco smoking I, myself, smoked cigarettes for 24 years, Two to three packages a day for the last 10 years of the habit I stopped at the age of 35, 1 year before the first Surgeon General's report, and have not smoked since. I was smnewhat uneomf(~rtahle for a short tmriod of time, but was never highly uneomfortrable. The craving never reached the level that I have experienced in medical weight loss programs or in alcoholic rehab clinics In short, although cigarette smoking is a common and perwisive habit. 1 can find no convincing basis in the scientific ]iteratme or in my own professional clinical experience to justify labeling it or treating it as an addicti~m Mr WAXMAN. Thank you very nmch, Dr. Blau Dr. Wind, I was interested in your evaluation of the FTC repmt You reached the conciuAon thai we shouldn't take that Federal Trade Commission report as the basis for this legislation. The people evidently, in your opinion, krtow about the dangers of smok ing; is that correct? Mr Wren Yes Mr WAXMAN They nevertheless still smoke. DO you believe, on the other hand, that the advertising campaigns by" the tobacco in- ",5 ga ¢0
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489 dustry have a causal reiationshfp to LhL, largo numbers of people that smoke9 MI¸, WIND. l don't understand your question. Mr. WAXMAN Do you believe a lot of people smoke beoause of ad~erti~emeat~2 Mr, WIND. I don't think there is any evidence to suggest what i~ the relative importance of adverlising Smoking like any other be- havior is a fanetion of many things. Thole are many factors affect- ing k t d~m't think th~ k~ed~ ~f the d~g~r~ strictly st~m~ from havfa~ the label there. Mr, WA×MAN. Listen to my question. P~ople smok~ ~r many reg- sons. Do yoo think one of the factors that encou~ag~ pcopfo to smoke Js the cigarette advertising? Mr. WIND. I doubt it. I have not seen ariy evidence to suggest the [mportance of advertising in gcmerating demand for smoking Typi caHy, the data that I have seen focuses on swltchiI~g, that advertis- ing affects the switehfag ~rom olle braml I~ another, to a lower tar cigarette and the like. l~Ir, WAX~A~;. Haw~ you seen evidence of this ~ffect? Have you seen studies? Are you J)asing these conclusions on scientific stud Jes? Mr. ~JNI~. '[here ar~ som~ studlos that ~ow basically ~hat ad- verti~in~ is rel~Lpd to brand switching. Mr. WAX~AN DO you think advertising at ~ny point helps market a product and increases demand lbr the product? Mr. W~N~. C~rtai~ly The i~t~o~cL~m of a~y ~e~ pro~t~¢t. But advertising is only one faetor, Ir~ any introduction of new product, demand is a function of your promotion, distribution, wo~[o~ mouth effects, experience with the product et cetera. Furthermore we have to look at one other lhctor Wc are talking abo~lt a fre- quently purchased and used product Adv~rtisfag Wpica]]y can help you in the in~roduction of such a new product, generate trial¸ The repeat is not a f~nc~Jon of advertising. The repea~ is typical ly a funetfon of the experience with the brand an~t everything else surrounding the other ~nputs peop]~ get Mr, WAX~AN. it's fair to say whi~e there are many factors that go into the i~roduetior~ of a new produc~, adverti~in~ is one foetor thai ~o~8 promote the t,riai of a new prodoet? Mr V4~ND. ~oxr~ct. Th~ i~ ~ypic~lly one ~f the e~fect~. Mr. WAXMAN. DO you disagree with that statement, Dr Black wpll? Dr. B1ACk'~LL. NO~ basfoal]y, no. Mr W~.xM~x So ~ oat~ have people try ¢~ga~ettes, and often times we ar~ ~nding young p~ople trying Cigar~o~ because of" a fa~ of different factors, one of which is advertising. Dr Blau sa~s that cigarette smoking is not addictiva; is that a ¢orroc~ statement? Dr. BI,At! There is no scientific 5asJs for a statement that ciga- rette smoking is addictive. Mr WAX~AN. Do you think that the use of cigarettes, has some kind of relationship to people wantmg to contfaue using them a little bit more than ~ther kinds of products that mJghL be used very o~ten9 D~ B~u. [ think tbat is a question of very serious ¢~neern, I nlad~ a visit 1~o Dr. Ev~s' faboratory in Houston¸ He work~ spe¢ifl-
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49O cally with the question of how do people start smoking, what keeps t~enagers smoking I see a group every week made up of seven people bet~een 7 and 13 years of age Durhlg the (last few years i have thserwd the ~n- e~is of the smoking habit. One thing impressive i¥om the researzh, l might point out, ks that there tire some indicatfans as to how these teenagers are drawn into the h~ibit The fir~ e[etnent is the ptlrental model, the second ks the sibling model, the third, peer group pres~,u r e I am quite t~t]cen by the fact tha~ many ~f my hea~k~t smokers, my teenagers thut I work with, don't read. They are very poor r~aders They are dropouts from school. Mr. WAXMAN. SO t~ere are digerent factors.9 Dr BtAU. Many factors Mr, WAXMAN. Orate they take up using 1:he elgarette product, isn't there some attachment ~hat keeps them smoking? More th~n j~st the oTigin~| rea~on~ to take it up? Dr. BLAU Yes, sir I think there are probably ~i muiti~ude ~f fac- tors that have been reported in the llterature. There are indica- tions that the habit, ~lftcr ~n initial aversive response becomes l~[eas~rab[e, for ~le it re[ieve~ ~e~ksn, it's ~ ~oeial grace in s~mt~ people's mind. For ~ small group of so-called diddlers, it's impor t~nt to have ~ometh ng to do v,,lth orlc~ s hand~, it arouBes ~ome. it t r a n~/alliz~2~; others¸ The amount of r~search which is done has stirred many ques- tions that must I~e e×plored and answered¸ I am fully confident in the future we will have ~ definitive answer a~ to how people learn to smoke, why they continue to sm~ke And from that, ~lear-cut di r~etions as to how to go about preventing the ineeptiozl ol¸ a habks. Mr. W~AXMAN. DO you believe the reason people continue to smoke after they ~t~rt smoking has less to do w~th advertising and mc~re to do with the~e other factors? Dr. BLaU. [ am afraid that I must plead inn(~cent on knowledge of t~.e a~v~r~i~i~g f~ct~r~ I can ~y speak f~r the ~ f~ctors [ think they are terribly strong, the psychosoelal factors in my ohscr vathm, and evaluation of the data, Mr, WAXMAN Let me ask the markaliJ~g people Dr Wind, what d~ you think? Do you think that the reason why people continue to ~lIloke relates more to the reasons thz/t Dr. Blau said, the plebiscite response, tranquility response? Once they try this new product, ad vertising is rl~t as important a factor? Mr. W~ND. I think it would be very dangerous to try to speculate here. Thks is ~u~ empirical question. ~£1~ere are procec]urcs today that allow us to find exactly what i~ the relative impact of advertis ing on behavior, in various areas, and I think what we have ~o do ks conduct a ~udy. I am not familiar with a speeifi~ study that looked at ~hi~ tt~t~s~on, coraparing the ~ffe~t of ~tlver~ising ~e~u~ peer group, parent ~nd others in terms of what is their influence¸ I tblak such a study can be ¢~nducted and provide the right guide lines. There k.4 (in(! other thfag ~o remember here, which ks that ciga- rettes in st]me resp{!ct are really not like any ol.her prDd~et, hiost other produet~ do n~t have counter communlc~tion, There is a tre- mendous amount of educational material, influential materi~l and d~
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491 communication against smoking. So the person, in making the deci- sion, is basically bombarded with beth pro and con arguments ~dr it. and makes his decision in some manner. So i would suspect, strictly speculation, that cma bc verified in empirical testing, that advertising would ha~'e less of a role here because of this counter communication than in other situations Mr WAXMA~. Because of the kind of communication? Are you speculating? Mr Wm-D That is speculation Mr WAXM&N You don't want to speculate on whetber advertis ing plays a lesser role in whether people continue to smoke? Mr. WIND It's a hypothesis that has to be tested. This would be a good hypothesis For a research project Mr. WAX]MAN Unfortunately, we have a limited budget so l won't cent:act with you for that study Perhaps the tobacco indus- try will do that lbr us Do you thh~k that if F asked you in your marketing expertise, how 1 could achieve the objective of discouraging young people f~om taking up the habit oF smoking, and encouraging people who smoke to quit, that there would be some efff'ctive way of doing that over and above what we are doing now, thr~*ugb the warning label that is on the package and thiough the messages that come through from hearings like this and Surgeon General's reports? Mr. WIND, My guess would be that prohEdfly yes, even though you are extremely eff~ctise today. You have n very high level of awarness. If you are trying to change people's behavior, and you are trying to influence people to change their behavior by reducing smoking, I think there are ways in which marketing can help in the h~llowing way: One, we ~i]l conduot a series o[ studies to find out why people smoke, why people don't smoke, why people quit Once we under- stand the reasons why, we will go to second step, which will be, let's try to generate a series of alternative strategies that we hope will lead to the right results. Three, once these are genelated g(~ back LO the consumers and try to test them to see which of these strategh,s is the best in achieving the right objective, None of these was done in the specif- ic situation here. The FTC report came with a number of suggestions They started g~nerating about seven options, but they are a relatively limited range ef options Why not try to open this? Why not base the op- tions on some insight and understanding why people smoke, why they eontlnue smoking? I think the whole approach is faulty. It's not a marketlng appr¢~ach to deal with the problem. I think there are approaches tha~ could help a~d provide guidelines. Mr. WAXM&N You think we should have marketing results to ~n dieate what would be the most effective way, not just of communi coting a message whlch you feel has already been communicated, but communicating a Iil~SS[lg{• in a way that would change behav- ior? Mr. WtN/~. That is your objective? Mr. WAX:~AN There are ways of doing that, I assume? Mr. WIND. Yes~ there ~lr( g.* b2
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492 Mr. WAXMAN. Just a8 there are ways of encouraging people to take up cigarettes? Iiave you done marketing studies o~ why people smoke, why they pick it up, what groups would be influ- enced most by kinds of smoking promotions? Is that done? Mr, WINn 1 personally am not aware of such studies, but if you are trying to do it. That is the approach. Mr, W~xx~A~ Ben% people come to marketing expert~ to figure out a strategy t~ promote their objectives? Mr. WIND. Yes, they do. Mr. W~XMAN DO you think that fhe cigarette companies and to- bacco companic~ go to marketing experts to try to figure c~t how to promote people to smoke citg~are~Ws? Mr, WI~D. I assume they do. They have marketing co;lsu]tants and research firms working f~r them. They ha~e their own market- ing research departments. I don't know whether they follow the procedure we just described before in trying to increase the sale of cigarettes u~ nonsmokers. Mr. WAX~aAN. If yOU have a lot of money, you can affbrd vo d~ a lot of differenv things, hire markeveers, outside experts, try things and see if it works and if not, abandon it. You can change your ad ~ertisemenvs or ~ry new strategies and ~bandm~ old on~s, The ~niy limitation on that i~ money? ~r. WiND Not necessarily You are assuming a symmetry. I said in response to the l]rst question that you had thflt you can prob ably, if you find out the causes for ~moglng versus nonsmoking, the causes that lead people to quit, to he able to design effective pro grams that will encourage and help you achieve your objective which i% redu¢ffton in smoking. Given ~hat there i~ so much pr~~. sure against smoking, ] am not sure that there is ~ symmetry here. That by finding the~e reasons, you will be able ~o design strategies that will increase the number of smokers. Mr. W~x~aaN There is a pressure to take up on smoking as well? Mr. ~r~'IND. ] thnd ~t very difficult to accept, There is no advertis- ing or other message fi~at wl]] convince me to go back to smoke. Mr. WfXMA~. I d~u't think advert[sing, as you pointed out so correctly, is the only factor that influences behavior. Mr W~a. I have difficulty--- Mr. Wax~ahra 1 r.hink seeing an athletic event sponsored by the R. J. Reynolds Co,, might well. it I am a youuger person interested in athletics, mt~uenee me Y~ know the R. J. Reynolds Co. spends a lot of money promoting various athletic eveng~ i would thhik that is one of {he benefits they get from that I think the marketing strategists can figure out a lot of ways to promoteproducts or devise a str~tegy to encourage sales of the product Dr, Blackwelh you claim those warning labels arc going to fool people, thw will be deceived into ~hinking that they will not get the di~ea~ or th~t onty old people ~ill get the di~easel ~ that correct? Dr BL~C~:WgLL. I claim there will be some co~fusion that will come from those among some people. There is some ev{dence of tha~, of course, in the FTC studies. Mr. VCAx~a~. Dr Wind says we shouldn't e~en pay attention ~o the FTC ~tudiese ,O Ca ¢o
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493 Dr. DLACKWELL. There ~rc many studies, T~le children's sLudy, the Walker study and -- Mr WAXMAN DO yOU think moss pregnant women understand that cigarette smok/ag may result in birth defecL~ or spontaneous abortions? Dr BLACKWELL Icontinu/ag] ] doubt that mothers do. That is not the same ~hing as saying therefor~ the way to correct that is that. The w~y to correct t]~at is to use specia]ized media with /aform~- tion in public releases, public /aformation~ rather than ~ televls/an ~dln~t a ~c~x,t~n ~d, b~t ~ prin~ ad that ~uld ~ t~ e~er~r*e and catl~e ~hos~ people Lo Consider that an ]rrelevanL mossa~e Mr. WAXMAN Dr. Blau, I have just two questions ~r ~11. Would you agree that the epidemiologic~ll evidence reveals strong sta~isti cai correlation between ~moking and various health ri~ks--let me ask this of Dr ~ysenck, you are p~hly better qualified. ~f there was epidemi~log~cal evidence that glws ,~ s~rong correlation be- tween ~moking and various health risk /actors, shouldn't thi~ p/ay an important part in public health policv? Dr. EY~CK'~ Evidence has bee~ pub[ished to that e~fect, But it has certain drawbacks¸ The units in which it dea]s are quite incom- parable. In ~ther word~, you are de~ling with d~agnose$. We kn~w at the moment ]ung cancer is be/ag over diagnosed. In other words, when you compare diagnoses with postmortem, then only a certain proportion of tho~e ~i~gno~e~ as ]~avin~ died of lun~ caocer, in facl. are found t~ ]~vc done so. And it was severely under diagnosed at the beginning of the cen- tury, in the beginning of the curves shown in the ~urgeon Gener ~ll's report, by a tremendous amount We fbundl for instance~ the peop]c actually ~ing from lung cancer, o~]y 4 percen~ were diag- nosed¸ Mr, WAX~AN. You don't believe epidemiolo~cal evidence reveals a strong s/atlstica] corle]ati~n between smoking and various health Dr ]~YSE~CK. it iS SO faulty it is very di~cult to draw any proper scienti~c conclusion t¥om ~he data¸ Mr. WAXMAN. Dr Bfou, you stated, apparently with s~mc conl]- dence, that there is nl~ ~leral agreement among scientists ~s lo whether cigarettes are addictive. The Director of the Nat/anal lrl stitule on Drug ~buse and the Assistant Secretary ~f Health made it clear th~tt in their opinion smoking w,~ in /act addictive, and this was a}so the c~nc]usian of the National Advisory C~Junt~i/ on Drug Abuse a~d a s~ecil~] t~k ~e of mdel)e~det~t researcl~ers convened by NIDA's Division of Rescarch. That soutlds like a consensus of opinion A~c ya~ ~king us to be- lieve ~hese dist/aguished phy~ic/an~ and researchers were wrong and you are right? Dr. ~u t ap~r befor~ you a~ ~n ~'~a~n ~cie~t~. ~x'a~u~- tlon i~ thc a~ses~ment ~f r~er]~ It's sort of like ~l~king the goats to guard ~he lettuce patch when you a~k scientists ~o mako ]o~lg rang~ general s~ateme~ts about their rest~rch The very essence of sci encc is caution. One of the outstanding researchers in ~obacco, Dr. ~tanley Sc~acter, a mcmher of the dist/agu~s/a~d boar~ that you jus~ men~/aned s~idl and I quote lr~m a Government publication, "Mo~t of us who do lest~al'ct) oll ~rno~in~ have at ~ome ti~e chaltl .j
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494 pioned the hyp¢~thesis that cigarette smoking with nicotine as *ha active agent is an addiction" Sometimes, however, it's dimcult to figure out why that convic- tion is so strong¸ The data supporting the proposition ;ire not par- ti¢~lo.rly g~/od I~ fact, looked at with a ruthle~ eye, they are rather flinlsy When sclentists are asked to weigh the evidence with care in terms of¸ the long range implications, they generally agree that we have a long way to go before we can give a scientific support to the statement, cigarette smaking is ~ddietive. Mr WAXMAN. Thank you very much¸ Mr Bliley Mr P~aL~ Mr. Cha~rr~an, thl~nk y~, gent~ernei~. I believe Dr Wind, that you said in your testimony that with 90 percent E)f the people knowing the dangers, that it would be very difficult to change. Do you believe that by going t~ a system of ro- tational warning labels, that i~'s possible to increase the awareness above 90 percent? Mr. WIND No; I doubt whether you will be able to find any pro cedure, any rrmrketing gimmick, strategy approach, that will in crease awal-~ness in general population more than 90 percent 1 am not thmiliar with ~my case -- Mr. BLILEy, [ don~t waIxt to interrupt you b~I [ dotl't want to ¢oll- sume too much time Are you saying thai the~e is nothing that we can do that MII increase the awarenes of the dangers, not just la- beling, but anything else that would increase the 90 percent9 Mr, WINIO lcontinuingJ YOU are correct In nil of my life as a re- searcher, scientist, in nil of the material I have seen, I have never seen a study that will document that there is l~ore than i~O-pereent a~-at-erte~ (if ~Ln~, ph~l~ctlxierta. Mr, BLILEy. Dr. B[aekwell, 1 have observed casually and keenly sim:e this legislation has come along, but for a numbt, t" of years, ob- served people including my wifk huying cigarettes. I have never seen a person pi~:k up a pack ot cigalettes in a store or a counter, reads a warning label and put them down ~ have never seen a person walk up to a cig:~rette machine, put coins in it, or about to ptlt coins in, re~d~ a xxartlln~ al~d D±rtl away at~d walk ttx~'a~,. I have seen ~hem walk away when they didn't have the correct change but not for reading any label. Have yoti done ~ny studies or are there any ~tudies that show tha~ indeed 1 am wrong in that people do come along and pick up these things and read warning labels and then discard IC Dr. BIACKWh:LL. No, That is ~t1~ astute obse~ration. I have seen no st tidies that wotdd re~ute that, Mr. BLILEY. I see. We have been talking about stud;es and re- seflrch to evaluate why people smoke and ~,~hy they stop, or not, as the case may be, llow much would it cost, in your opinion, Dr. Wind, to do a study for the benefit of Congress and this committee in particular, as to what causes people to smoke, and what causes people to stop? Mr. V¢IN~. I don't thi~k l will be able to ~l~er ~'ith a specific number, lt's not a single study. It's a progr~im of research You have to use different approaches to try ~o answer. ~olnt of them are not as effective in getting a valid onswer You have to commit yourself to a program of research that might cost, you know, a lkw Qe
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495 2 hundred thousand dolla±s over a period of time, to find out the causes and then to try: to lrtove into g~nerating strategies and then evahlatin~ them¸ Mr. BL]L~Y $400.000 or 8500,000? Mr, Wlxl). ] really cannot pinpoint the number. But I would ~ay ifs ]ikelv. Mr. ~*~AXMAN Dr Blackwelb Dr B, ACXWELL That would be a good start tm it, yes ?,lr. BLILSY How long, 2 or '3 years? Dr. BLACKWS~r. I don't think you wdl answer it definitively for every person, But you can isolate some of the major causes el major segments in a few yeals und at few hundred thousand dollars Mr. BLILEY I see. Mr WIND Time is difficult ~o assess because you are dealing with a program of research The next step depends on the results of the firsl one So it is an evolutionary problem You need a com- mltlnent, instead of coming with a proposal that is hal based on an empirical be*sis, and suggests seven labels, to commit yourself to say, 1 will make a bill based on empirical data that responds to a ieal problem out there, and that is the best way of achieving lily objective. Mr BLItlgy Thank ~u Thank you very much, Mr. Chairman It probably would cost us less money than setting up another bureaucracy at HHS and achieve better results in a couple of years, i yield tlaek the balance of my time, Mr. WAXMAN. Mr. Darlnellleyer Mr DANNEMEYER. I have a question for Dr Nysenek, You state that the personality at the people involved is a medlar ing thctor bet,ween cancer and smoking Can you present tbr this subcommitee a personality description of a smoker? Dr. EYSENCK. Well. in several different countries the people who smoke tend to be typically extraverted, social people, people who like to go out in the world~ mix ~ith other people, who like to have strong sensory experiences. People also tend to drink and have other social habits of that kind. that is one type of smoker Another one is the nervous and emotionatly somewhat unstable individual. They smoke for a different reason, of course, the extra vert smokes because he easily gets bored ,nd he has to have some kind of drug that elevates the level of arousal, whh:h smoking does. The more emotionally unstable type of person needs something to sedate him, to calm him down, a kind of librium more easily acces- sible and more pleasu.rahle than a drug. So he smokes Then you have people who are generally nonconformists, who are somewhat antisocial. They also tend to smoke. So you }rove dif ferent types of personalities that go in tbr smoking and they do so for different reasons. There is a large amount ot evidence available at the moment aleut motives for smoking and they are intimately [inked with personality Mr DANNEMEyI~R Thank you We previously ]tad a gentleman here from the advertising frat*~rnity, now we have two professors from the advertising fraternity, l can only assume that y~u have, i~ the e~urse cf wmr tenure in academia, had the privik,ge of in- structing students who tla~e found their wa:~ into the advertising
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496 community So I will ask y(~u gentlemen again: Do you believe that it advance~ the cause of the advertising community to respect these principles? Keep it simple, clear, repeat it often, be singlemlnded, and consistent? Dr. Wind, do you think that is a ~ir asscssme~Lt ~f what the ad- vertising ¢ommunlty should be doing? Mr. WIND. There is a distinction between what they should be doing and what they are doing¸ Should is a normative statement. It suggests that we hnvc a theory that tells us how advertising works¸ I~nfortunate]y, ~espite all ot t~le research that has been going on over the years in marketing and adver~isillg, we do not have, today~ a theory that tells us exactly how advertising works¸ There ~t¢c dJllerent models and hypotheses that suggest what are the ra- son~Jb]c ways of proceeding and getLing some output. Different agencies have di['fer~nt philosophies Dil~brent agencies use diffei~ ent approaches T~hat is the reason different manufacturers select different agencies that bring dil~rent philosophies¸ The notion of simplicity, yes. it has some merk Many years ago it was coined in ~arketirlg ~ the unique selling proposition, t)lat you are trying to colne up with a single message, with a single behest. There are studie~ in the cognitive psychology area talking abou~ the lim~tation of the cognitive ability of peopJe~ that typically people cannot process too lnuch in[ormatiorl So you are working on relative]y simple type of one or two m~Uor benefits But i think the key issue here is not s(~ much the ~act that ] have IL~ry Lere that gul@.e~ r~e to ~e ~g ~ith the ~in~ie ~irngle ~ proac]~, bu~ the ~cf that the market is heterog~leo~ls That we ~re not talking ~hout a homogeneous p~pulation out there that a single message will appeal to every one of them¸ If every single ~ld on TV will appeal to you, apparently they ~re doing something wrong because you are not the targeL segment of every one of these products What they are trying tc do, is deal withrl Mrk DA~NEMEyER. Why do so many exclude me? I must be different? Mr. W~n Ye~, I woulcl asssume that you don'~ buy all of ~he pve4~c~s ~6ver~ised ~n TV ~either 4~ 1 For ~he ~ ~u bu:~, ~4 verti~ing could hi,re been one of the inputs that prev~ded you some information. There ~tre a lot of comparative advertising that l~ro- rides you compar]sons ~imon~ brands¸ There ~re some sophisticated ads--look at industrial adverlising [ lhin]~ it is dangerous to gener- alize and say all advertising is po~r~ ,~1] advertising is insulting. I think s(~me is. But it's possible that s~me of the advertisin~ which is insatting is not aimed at us. And they placed it at the wrlm~ medi~ or they had ~ poor execution or someone did not know. Mr. DANN~;.MEyER. Dr [3]aekwell, wou~d you car~ to respond to that? Dr. RL~.CKV~L~. I ~ ~i~le~g ~ ~)r. e~lnL'~ co~nrnent e~n~ he qualified to say this wasn't principles o~ advertising but principle ~f communications generally. If one were giving a political speech, for e~alnp]e, ~r a lecture in the cla~srooyn~ Joe -~cGinness where book called "The Selling of A President" a few years a~ M~[~y newspapers have said the same thing¸ That is true of communlca .O -J
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497 tian in general To keep it simple, single mi~dcd, because of limits of cognitive processing. That is probably true for what might be called the middle 65 per cent of the total population¸ There are people on either tails of those dlstribu~ion I don't know which tail you would be on, but that is probably happening And Mr. DANNEM~Y~R. Ask our chairman, he will tell you where | am. Dr BT~ACKW~I~L There are many qualif/cations to those simple, basic communications. Advertising tends to be to the masses. In communication theory, there 16 ~orne~hing klloWn a8 one~sided corn munfoatlon and two-sicled communication, In a one-sided c~mmuni cation you only presenl, wh~t you want people to know~ In a two sided communication, you tell them wha~ ~s wrong with your prod- uct as well as what is right with it. Now ~s a generalization, it's more effoctlve to use a one-sided comrnunication with the masses of ~he population. But for people who }lave high education or high intellects ~ not that those are always the same far those ldnd nf people the two sided comrnuni ¢atfon may be more effective. Dr. L~ght was quite correct in stating the principals that are generally accepted for communications with the mtt~es But there are q~la]ifJcatfon~, of course. Mr ~)ANr~:M~:~k, III ~hank yOLL Mr WAX~AN. W~uld it 13e fair, then, to conclude &ore wha~ you are suggesting tha~, the cigarette advertising with the warning label that i~ carries t~day, may convey a dual message to ~ ra~her elite group ~f pe~ple? The dual mess,nge w~uld include n~t only the call to switch ~o this brand or take this brand, bu~ a~so that there may be some health probfom to taking ~p smoking and that this mess~g~ is not bein~ communica~d to the mt~sses or a larger group? Dr BLACI~WELL. I got a little Ios~ with the l~rst pa~t oF ~he qnes tlon Mr WAXMAN, If you are stating ~hat where t~e~e i~ a d~o.1 me~- sage communicated, it is communicated primarily to an elite group that i~ a ]il~le bit more wil~in~ to read and understand that there are two sides to the ~dverLisemen~, w~uld it be f, iir to conclude from that, that most people, in the more general popufo~ion, doll't get the dual message when they ~ee an advertiseme[lt for c~ga- l*e~es? I~r RLACKWELt.. The higher complex message would be better re- ceived with people with hig~ner education, in general The more Simple. direct oi¸ ol~e-sid~d, ~vhi~h ~r~ ther~ ~lr~ ~w/~ (it Lhr~ thir~f~s going on thel e, the very ednpfo message would comnlunicate better with the masses. That may have an application to this, For example, the present warning would be most effective, if you c~uld mak~ the ]~lp ~f foith ~orn general research to the specific here, the message as it is now constituted w~uld t~r~b~lbly be for more effective to the rnasse~ of" the popub~ti~n than ~he~e But for people with a high arno~n~ ~f education or the elite of the N~ti~n or something, they might have s~me more effe~'tiven~ss from some of these¸ So these ale tke kind of" i~sut~s Mr W~XMAN. Wouldn't it go to the question of whether any warnillg message get~ comtill~ilie~ed a~ all, whatever ~he c(3nt~nt~
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498 Aren't you saying only certain penffle pick up a warning message and most don't? Dr. BLACKWELL. I don't think I am saying most don't Most un- derstand this. A simple message is bettei Mr. WAXMAN YOll l~Fe not saying the reason most people under- stand that smoking is dangerous is because af the label9 Dr. BLACKWELL. f am saying people do understand it for a variety of re~ons, including the label Mr. W^XMAN. What [ am asking is whether the warning label, insofar as it is effective, is eflhctivc nnty with people who read it? Is it fair to say most pe~ple don't read all of the advertisements and that those of the higher inteEectual levels who have more time to read the advertisement at a particular moment are most likely to read the whole thing and get the dual message, while those who only get an impression from the ad do not get the dual message? Dr. BI.ACKWELL Once they get the message, there is no reason for them to continue to read it all ot the time. As Dr. Light said, they can ~e the ~ymhol and it tells them Mr. WAXMAN. Changing the message does not reinforce the cvtn- mualcation; is that a fair statement? Dr. B[ACKWELL f wouldn't say that. I would say repetition Mr. DANNEMEVEa HOW about if we put on there, like Reggie Jackson eaid it, rather than the Surgoon General. Or that Fred Lynn or Boh Gr[ch ~dd it. The~e are names that are kn~w~ in the sports world in southern Calilbrnia. So is Vince Ferragamo; why not put his name on ~here. Do you think that would improve the credibility of the message? Dr. BLACKWELL. No, because it really can't be improved If on vim knew the message, if people really didn't think cigarette smoking ~ms haz~rdous, your suggestion wemfd be perixaps ~tpptx/prtate. But how can you improve above 90 percent? Mr. W~ND. Can I interject a point? I think it's dangerous Lo try to generalize t¥om other areas Some 0£ the work on the two sided message was not really done in thi~ context. It was done in experi- ment~ primarily in ps~cholog~]. We are trying to project the results from there to the specific situati¢m here. " I would submit it is an interesting hypothesis [hat has to be tested. The same thing with the notion of endorsement by known personalities. There is an issue here, yes, a lot of personalXies are known by some. noL necessarily everybody, but even those familiar with them. what is their tredibihty with respect to smoking? Do they have the credibility to deliver a message ttmt people believe? Mr DANNEMEYER. They are athletes Presumably, to make a living, they have to preserve the ability of their bodies to perthrm over time ergo, smoking is inconsistent with theft. Theretbre, if you want to be like them, don't smoke'? Mr WiNe. What do they know about health? Not all testimonials are effective. What you want to do is test it, Test and see, to what extent--- Mr DANNEMEYEIC The advmtishlg world apparently selects ce- lebrities h-ore the entertainment industry or spor~s industry and they put their faces on ads, the intelence being that person is suc- eesslal, fherefbre if you smoke or buy the products, you will enjoy a! 2~ is o ~L ,I [[ :i -d
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499 the same success I don't know what they are getting after hut I guess that is what they seek co do Mr. WIND¸ John Wanamaker once said ~(~ percent of advertising is ineffective. Which hall? A lot of this is wasted, a lot of the ~clver tising is not very good. What we can do is experiment¸ Use ap proaches to test and see which personality, whether it's the ~ur geon General, whether it's a sports personality, a politician or who- ever, will be the best, most credible individual to deliver it. Mr. DANNIaMEyI:II. Put Jerry Brown on that labeL Mr. B~,~Y. I thank my colleague ~r yielding. A couple of times during the course of the hearing this morning the matter has come up about cigarette advertising and sports celebrities. In the ~tate- m~nt ~1¸ Mr. Horrigan, or rather attached to the statement, is a li~t of principals governing cigarette advertising. And No. G and t quote: "No stx~ t~ or celebrity testlmonial~ shall be used or those of others who would have spec al appeal to persons uader 21 years of age. So if anyone has the impression they are using sports ceiebrities in trying to improve their market with young people, i would just llke this to be a part otthe record. Mr~ WAXtaAN If the gentleman would yield to me, I think my colleague from California has the time. The I~ J. Reynolds C~. sup- ports sportibg events¸ Business Week reports that in 1!)82 the eom pany will ibcrease the number of¸ sports car races from 16 to 19, as well as support 32 golf tournaments. I submit that they do this be- cause | think they expect some promotional benefits to come ~om it, not just good will for the R J Reynolds Co as a good citizen Mr. BLILEY. If the gentleman would yield, the.v are not using players or participants to advertise the product They might spon- sor the events, but they are not using the partie/pant~, such as Reggle Jackson or I believe with a race car, Richard Petty might be more appropriate to advertise the brand of R d Igeynoids Mr W~XMAN. Anything further, Mr Dannemeyer? C.ent[emen, I want to thank you for your p~rticilJntion You have given us a lot to think about. I am particularly interested in the ideas of the marketing experts because it seem8 to me [hat we h~tve to do a lot more to be as effective as we hope to be In my opinion, that is in SUplport of the legislation, we ought to do something rather than merely l~ly on what we have done lo date. But we should also do more than what I am proposing in this legis[atlen. If we added to money spent on cancer research and de voted it to develop ell~ctive strategies to change hehavioi¸, we p~ob ably would be doing a lot of good in lessening ca[lcer rates in this courttry i would sIlbi~i~ ~h~l~ you ~lr~ ~ibsolt/Lely correct, DI Wind, a lot of¸ adverlising mrIn(!y is wasl~ed. 1~/1~ thP tob~ll!e() in(tu~try has a le[ of n~on~y ~o waste in prOlnot- ing t,heir pr~duct. We dont have a lot ot¸ money to discourage smokinl4. We will recess and come back at 2 o'clock [Whereupon, at 12:35 pm the subcommittee recessed, lo recon vene at 2 p.m., the sonic day ] 1
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A ~'I'ER RECESS [The subcommittee reconvened at 2 p.m, H~m Henry A, Waxman, chulrman, presiding.] Mr. WAXMAN The meeting of the subcommittee will please come to order. Our final witnesses will testify as a panel this allernoon. Arthur Furst is director emeritus o~ the Institute of Chemical Biology, University of San Francisco, Harvey Science Center Theodore D Sterling is from the Computing Science Prepare, Simon Fraser University. Also we have Edwin R. Fisher of the Shadyside Hospi- tal Pathology Laboratory. And, lmstly, we have Sheldon Sommers, of the Lenox Hill Hospi~ah N.Y. I would like to ~elcome you to out hearing today and have you come for~rfi. Gentlemen, y~ur prepared s~a~emen*~s wi[i be made par~ of the record in full W~at we would like to ask of you is to summarize your state- ment in around 5 minutes s~ we can have an ¢~ppartunity for ques- tions and answers. Dr. Furs% why don't we strut with you SIATEMENT$ OF SltELDON C. gOM:~IBRS, M.D., NR'~¥ YORK CITY, N.Y.: ARTHUR FERST, PH.D., DIRECTOR EMERITUS, INSTITUTE OF CItEMIC&L BIOLOGY. ~!N~VZBS|TY OF SAN FP.ANC|gC(}; THEODORE D. STERLING, RESEARCH PROFESSOR, gIMON FRASER U~|VERS|TY; AND EDWIN R, FISHER, 3LD., PITTg- BURGII. PA. Dr ~,~MEaS |tts my understanding that ~ am t~ ~]~k first, ~f I may. Mr WAXM~,N, ff you have worked out any arrangement, that is fine with us Dr. Sommers, please proceed. Dr. SOMMERS I an] Sheldon Sommers, MD., a phgedian specla]- izing inpatholag), currently c]inlcal professor of pathology at Co- lumbia University Cofiege of Physicians & Surgeons, New York, N.Y,, and University of Southern California School of Medicine, Los Angeles, Calfl: Also, I am consultant in pathology, Lenvx Hill Hospital N.Y ; eha~.rm~n, Ne~s Y~rk Sta~e Mental Hygiene Medi- cal Review Board; and president.elect, Arthur Purdy Stout Society el Surgical Pathologists. [ am past president ~f the New England Pathological Society and New York Pathological Society. Since 1936, except for Worm War I1 years, I have been engaged in medical research with partlcula~ r~ference to cancer, endocrine and gastrointestinal diseases, with over 3~0 p~blicadons--ab~ut 10 pe~ent dealing with lung cancer, and also some on pancreatic cancer ~ am coeditor of Path~)logy Annual and Diagnostic Gynecol- ogy & Obstetrics and serve o. the editorial boards of five other medica~ j~ur~als. My curriculum ~itae acd publicat[ou list are at- tached, For the past 6 months. I have served a~ scientific director, Coun- cil for Tobacco Research USA, Inc. This is a funding agency for blo- medical ~'vsearch in the area ~f smoking and healtlh funded by to- bacco manufacturers The budget for research grallts b* 1982 is gq million. G2 .,] t~
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501 Applications are acted upon by a Scientific Advisory Board, and those approved with a favorable racing are funded for up to 3 years with an opportunity for continuation grant~ thereafter¸ The Coun- cil lhr Tobacco Ilesearch exerts no influence upon the grantees, who may freely publish what they find as they choose About 80 active gran[s now exist in the United States and abroad¸ My appearance at this bearing is voluntary, and the opinions ex- pressed are personal, llOt representing those of any organization¸ They are the result of over 45 years of study, investigazi~n and pracLiec in the field of pathology and clinical pathologic correla- tions of diseases, some of which have been attributed to cigarette smoking. One approach to cancer causation investigation is ep~demiolog- ical and statistical Epidemiolegical statistics involves an experi- mental group and a control group For a valid comparison the groups must he alike as nearly as possible in all respects except for the item being investigated. In studies of cigaret~.e ~rnoking, matching smi~k~Ts and ~on-~mok ors by sex and age was achieved It has been assumed in all other respects the two groups were comparable This is not flrllc since in body build, exlroversion or introversion, marital history, alcohol use, use of non prescription medications, police records, military re cord~ and other aspects, cigllrcltc smokers are demonstrably dKi~r- ~llt B'OIyI I~C~ylSITI@A@T~, The lhHacy of one To-one comparis(ms of ~,mekers and non smok- ers with respect to mortality was pointed out in a monograph by Rose and Bell in 197I They studied predictors of longevity in war veterans in Boston reexamined at intervals One-on-one compari- sons placed cigarette smoking No 1 as a predictor of early death [ike many other ~tud[es Multlfactarial statistical analysis dropped smoking to somewhere below No. 30 as a predictor and dissatisf~m tion with job became Ne 1 The lesson is that in the present rein tlvely undeveloped state of epimiology, to beware of facile and sweeping conclusions Two other points about statistical epidemiology. Evt~T textbook states them, every active scientist knows them. Epidemiologic siud ies by the nature of the mathematics so lhr developed deal mainly with random populations but smokels are self-selected as are non- smat,.ers Comparisons of selected populations usglg mathematics, valid only for random populations, cannot be expected to provide valid answers. Second, epidemfo]og3' cannot prove cluse and eflhct All it can demonstrate is a relationship; the nature of the ~elationsbip, causal or o~herwise has to be worked out by other methods, usually ex perimentah The CouncB of Tobacco Research in /970 undertook a large scale research program to investigate whether cigarette smoking causes lung cancer in animals. Almost $14 million went into the plojecl in t2 years. To take ace~mnt of heredity, inbred mice were used and tested for and vaccinated against respiratory viruses. To show these animals could develop the major types of human lung can- cers, purl chemical carcinogens were introduced down their tra chea~. They were known to metabolize these carcinogens into the biologically active lhrms Abotlt 20 percent in younger mice and ,Q b2 t¢
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5O2 over 95 pereen~ in older mice developed "human-type" lung can cers as a cesuft of exposures to these pur~ chemical carcinogens Thereafter thousand~ of mice were exposed daily to ~esh whole cigarette smoke of¸ either low nicotine and high tar or hi~¢h nicotine and high tar content up to ~imximum tolerance during ~heir whole lives, up to 40 months in some cases At one polnt there were 11,000 animal manip~latlons per day including sham smoking and contrcd mice After all these years of cigarette ~moking practically zero lung cancers developed and not one case of the human ~pe cancer most o~en blamed on smoking¸ There was no question the cigarette smoke had penetrated into their lungs slnce this was worked out quantltatively In other ex- perirllents mice were primed with irltratracheal pure carcinogenic chemicals, then exposed to cigarette smoke dmh~g their whole lives¸ No increase in tung cancer occurred over the fucidence fotlnd after using pure chemicals Mime and in one experiment smoking was a~ocJated ~iLh a reduced lung cancer rate. The number of animals and conlputerized information are so abundant that sto~st~cal analysis by tno~ern e~perimental analysts is still continuing Some 40 publications have in part already ap- pear,K1 or ar~.~ in part in prospect. In the field of¸ science knowiedge is gained tfuough experiment and interpretation in the scientific methQ3~ a th~3ry i~ prow~ed. Therea~r experimen~ c~nf~rm or refute it. II" the latter, a new theory is developed It is a continuous ev~lu tlo~tar~ process and needs a critlcal a~d open mind. One must be constantly alert ~r uarpri~e~ a~ Gou~ Thom~ ha~ wrights. Lung cancer is high oil the li~ oi¸ sL~lt~ment~ fu the bill tIR, o653 aL~rib uting disease~ to cigarette smoking¸ There are two general methods of investigating the cause of cancers in humerus ~r animals One is the epi~emi~logic m~d sk~ti~ieal r~ethod already di~ussed 'Fh~ seccmd is the biomedical method Cause mlght be defined biological- ly as something both necessary and su~cient ~o cause a c~nditlon. Cigarette ~moking is no~ a necessary fuctor in human lung cancer wh~t~ e~i~ted ~r cen~rie~ ~n r~liuva miner~ he.re ¢ig~ reLte$ were irlventod. Lung e~ncer accolTlpail[l~s scarrirlg proceKse~ in the lung due to TB, connective tissue diseases and v~rious of her abnormalities in nonsrn~kers I~ ~l~ faiia to meet the cau~al cri~ri~n ~f being sufficient The fact is that the vast majority o~ smokerG more than 90 percent of even heavy smokers do not develop ltmg c~lncer Hence, cigarette smoking is neither necessary nor sufflcent in Ihe develo0ment of h~l~.n ~ung cancer and by th~ biological definh~on i~ not ~be cause¸ Like man¥ other diseases of older age lung cancec a ~ars to be mulfif~cto'rial which means the disease is associatedp with many things in addition to smoking. Practically ull ~cti~e r~search~rs now ~rt~, ~n this p~int. Fac tors include No I, heredity Families with a high incidei~ce ol lung cancer are known Sex and race. Men have thr~e times the lung cauc.r of women; blacks and orientals diflbr from whites in incidence. Urhm~ C~rtain urban area~ fuwe high lung cancer r~te~ which can't be accom~ted ibr by smoking. The~e areas are charac tcrized by in some cases severe winter weather nlvers{orl patterns with high air pollution. No. 4, occupation As already n~tted 0~ f.2
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5O3 some 20 occupations invdve increased risk. Some workez~ sm~lkc, others do not. Immune competence. Individuals with demonstrably reduced immunity have developed lung cancer¸ This may explain some familial c~s~s ~nd increase of cancer with age. Six, hormon~2s ]71ormol]es 9.cceie~'ate some nletabol~c processes ]eading to human lung cancer Seven, aging, the mean age of lung cancer diagoosis has been reported as abou~ ~7 years and said to be rising tu older ~ges in some populations¸ Currently ~esearcke~ do not know which if any of these or o~her factors play a role in the causation of lung Cancer. In summary, a massive experiment to demonstrate that cigarette ~moking can cause lung cancer ia anlma]s has prc)ved negative One kliows how impor~arit an experiii~ellta] mod~l is in c~naer re- search from the excitement that attended the c[aim~ years ago that cancers of lung or lary~l× had been i~reduced by cigarette smoke in anlmMs. However, no model so far developed withstands an objective analysis of the pathology of the alleged cancers. Lung cancer like many ether human cancers remalns a major biological mystery¸ Epidemieiegic studies report a suatistlcal association between ciga terse smoklng and lung cancer. However, the biomedical cxperi mentation does not support the smoking causation hypotk(~sis. [Dr. Sommers' prepare~l statement fellows:]
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i 504 STA~.Nh:qT O:" SItELDON C. ~O'l~l~Sr M.D~ 1C am Sheldon C. So~r~r M.D., a physician sp~c~.~liz!n~ £r~ pathology, c,lrrenl;~y Clinl.cal Professor OZ Pathology a~ Col.~nlbia Unive~sit,2 ColLeqe ~f Physicians ~ Surqe~ns, New York, N.~., and Un~VezsltZ of Southern California School o~ Medicine, LOs An~Jeles, Cal.~.forn£a. Also • axa cons~lJ.~n~. ~n ~athc~log¥, Leno~ It±ll ~ipit~l, NOW YORK; Chairman, ~ew Yor~ S~a,-e llcn~l ~ H~&ene M~d!~al ~view ~a~-d~ and P~e~i~c~ ~lec~., A~-thur Purdy S~C~u~ Scrimpy ~f $~rql.cal Patbol~i~ts~ I am paat ;residen~ of ~he N~w ~ngl~n~ I'a':hoIoqgc,~ Society and new Yo~k ~ath~lo~cal Society. Since ~9~6, excel,t for W~-Id wa~ ~ years~ I hav~ b~en en~aged in ne.:iical r~arch w±~.h 9~rl.A~ia~ ref,erence ~;c, ¢azc~r~ enrto¢~i~l¢ and ~a~roin~es~inal ~Ii~e~, w~h over ~0 publical.£ozs -- ~1~. ~0 percent dealln~/ ~,ith l~ an~ lun~ cancer, an~ al~ zem¢ on ~.~ncreatic cancer, r ~ ~r,e~i~r uf ~a~h~lc~gy ~mn~lal an~ Dia~n~,s~ic. ~yn~alo~y & 0bste~i¢~ an~i ~rv~ on the e~i~'or£a~ l~ards ~ ~.,~ ~r.h~r medica! ~ournals. ~ curriculum vitae and pullllcatic,n ~A~: al-~ a,~.ac!lo~l. For ~he ~as~" ~ mon~.hs, I have serve~ a~ ~ci~t±~i~ 0ircc~or, COUn~l.l for TOb~cc~ ~esearrh USA, ~nc, Tnls is a fun~ing a~ency for biomedical re~earch l.n the a~ea o~ ~r~k±nq a~ a~th~ fun~d ~y tobacco manufac~-u~ers. ,2h~ bud~e~ ~2~ research qrall~ in 19@2 is 7 milli,:r~ dollar~ App~ica~.~.~n~ ~r~ ac+-ed u~,n by a S¢~ent~flc Advisory Soaz~i, an~l ~.ho~ ~ppro~:l with a fa~abi~ ra~in~ ',,i
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506 abnormalities ~ nonsmoklz~. c~i~e~ion ~f beinq ~uffi~ent. The ~aut is *_hat ~he vast majority ~f ~mok~, mor~ ~an 9O| ~f even h~av, smokers, do not ~velo~ lunq can~r. Hen~ cigarette smoking is nelth~r necessary n~ • uf~ici~nt ~n ~he ~elo~n~ of human i~ng cancer, ~qd by ~he bi~lo~£~al def£n±~on is ~ the =au~c~ LI~ man~ o~er diseases o~ ~L~r ag~, l~g cancer a~ars to ~e mult~fac~rial, w~lc~ m~ans t~ disease is a~iated with C~h~r f~i~2e$ ba~ decreased lun~ funcuion. incidence. (~1 Urban. C~rtaln urban ar~as h~v~ high lunq cancer ra~s which can~ h~ ac~o~te~ ~or hy ~moki.~. These area~ are characterized b~ ~v~re %.~n~r weather ~nversi~. ~t~erns with ~41 ~uu~a~n. AS already ~ot~. ~ome *.w~n~¥ occupations ±nv~lv~ increased r~sk. ~ome w~rke~ ~oke w~!~ o~er~ ~o not. (5) ~e cor~eten~. Indi,~±~als w~th d~monstr~hly reduced ~-ty b~ve ~evel~ad !~ng c~ncer. Thl~ may expi~a s~m~ f~i~ ~ases, ~a~ ~he increase of cancer w~th aq~.
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507 161 HO~C~ Ad-en~l and sex h~cnes accelerate some met~bl~l£c i~rocesses leading ~_~ human lung cancer. (7) AgirLq. The m~a~ age of lung cancer ~ia~nosi~ ~,as ages ~.n m:~me populaLions. Currently, researchers ~ not knew ~h±ch, il~ an~,, a~ these or o~" gactors play a rc~l~l in tl~e causa=ior~ ~f lung cancer. The o~.:~er ape=each to ~a~c~r causation ±n,,~stlg~t,~o,~ =s eplde.~lioi~i= an~ s'~a~istical. Ed~idem~l~gi~ s~atisf-ic~ ~nv~lves an expe='~enz~! ~roup rand a control, g~:c~. I'~r ~ valid coerCer,.son, ~he groups must be alike e.s n~arlS, as ~sible in all rCSp~C~.S ex~e~t f~r the it*-m beinq iavestlc.at~0.~ in studie~ og c~-ette ~k±ng, matching s~ke~ and nons~ol~srs hy s~z ~nd a~e w~s ach~.~ve~, and i~ n~ been assm~ec~ that in all ~ther respects ~h~ t,,,~ ~ru~s w~re comparable. This ~.s n~= tmle, linc~ in h~dy ~uiI~I, extro.sa~sicn-£r~=roverl~ion, ~ri~.al history, alc~l~l use, us~ o-~ nc, n~r~scr~.p~ion ~edica~cns, ~olice reco~'~s, mllit~ r~cords mad o~r aspects, cigare~;c s~k~rS are ~em~nst=rabl~, 4if~eren~ from ~ons~c~r~. T~e falla~e. ~f a one to ~n~ coa,~ari~o~ of ~moker~ alld nonsm~ker~ with rellpe~ ~-o m~r~.ali~y ,~-as p~int~d o,a~ i~ a m~lacgraph by Pm~e and 5ell ~ 1971. They s~udie~ pr~£~.~rs ~f i~ngevl.~:y i~ war ~'~erans from ~oston, re-exa~in~ a~ in~rvalz. ~ne cn-~ne =omp~riso~s pla~ed ~igaret~.~ ~,~l~inq ~i as a p~'e~ictar cf ea~'Ly dea~.~, ~i~.a many o~-~ studies. ~iui~igactorial statis~!ca~ ~nalysis U1 ',,t
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509 d~gective lun~ cancer d~L~ ~rom ~eath certi.'ica~es, one other ey~n~ l~as ~ccurred whic.~l beaxs upon ~he ann~al quantification of lm~cj cai-~=. Th~ r,l~s l~v~ ~n cbanqe~ in the x~vi~ion of ~ne Inter-at±0nl~l Causes n~ rleath, ~th editxon, called ~C~-~ to IC~ 9, ~or re~rting ~r=~lity tl-e two r~b~i~ Prxlnary L~/g ca:~cer and Lurl~ Cancer Not 0~h~w~ Speci£1ed IN0$) were for th~ g±r~t ~-lx~e coml~±n~. L~r,:l c~ncer I~OS cou~.d beg2n isa lung ~r ,ave ~pre~a to l~n~ ~xum many ~f.~rent body ~tes, L~n~ r-eta~tase~ ar~ a~c,ng ~he ~2~=*~ most ~nl~n ~C cag~onz ~or al~ ~ intetl~al ~ance s. ;~ ~n essen~ ~CD-9 ~iJ.d was ta e/~arantee a cont~nu~,d inc eas~ il~ ~he r~por~e~ lung ~mcer mortai±ty, c~lvenlent!y dxsregar~:~q tha= half elf more of ghese c~n~ers be~n elsewhere in th~ b~c!- and spread t~ the lun~is. ~,~ las~ po~n%~ about ~katistiu~l epidemiol~y, Ever~ textbuc~k ~tates them, ]:very act~ive ~.¢£~nt~t knows them. Epi ~emi~l~ic studies b~ ~.he r~tur~l o~ th~ ma~hem~.g~cs s~ far devel~;pe~ as are =~smOkers. Compa~±~un~ of selec=e4 pop.~latior~ ~n~ mathematic~ val±~ o~ly fcr ro~,~,m pup~.la=i~ns cannot b~ expactea ~c~ provic~e vali~ an~u~r~. $ec~r~, ep~.derl:~ea/.0~j~, ~nne)~ [~rove c~ug~ and e~fec~, All it can d~aonszrat~ is a re!~i0nship, ePbe n,ature ~f the re- methods, usuail,~ ex~ermmentel,
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510 The ~ in 1970 ~d~r~ok a larq~ s~le ~e~r~h progra~ to inve~tiga~ whether cigarette smokinq causes lu~q cancer in anlma!s. Almost 14 million ~ollarl w~:t inSo t~le uro!ect in ~welve years. TO t~k~ &cco~nt o_~ heredity, inbred mice wer~ ~Sed, an~ they wer~ te,~t~d for ~nd v~er~ina=ed ag~n~ respiratory vLrus~s. 'fo show that these at~imals c~u~d dave~op th~ m~or hyp~ nf htJrat~ l~n~ cm~cer, pur~ chem~za! carcinogens were i~troduce ,~o~,n their trachea~+ l~io~h~nlcal~y, theee pa~tlcular lice were kn~,~n tc~ rle~abC, lize ~hese carcino~n~ /~t~ ~he blol~g~cali7 a~tive forms. ~u~ ~0% developed "h:man tyTe' l~a~ cancer's ~S a resu!= of ~× posure ~o these pure chemical car~noqens. l'hereagt~r, ~ho~sand~ Cf mice were exposed daily to fresh whole cLgarette sm,;ke uf either low n~co~-ir~, a.d high t01r ~r high nicotine and h~.qh t~r contcn~ ~p to maxLm~n t.o2~r~ince rl~ring ~h~ir whole l~ve~, UP to ~0 months i~ so~ cases At ~ne point, there wer~ ~1,000 ~nima! ~,~giouLatln~ her da~, includ~n~ sham ~aoxing and control mice+ A£~er a~± t~ yea=~ of clgar~tte ~eX~ke el~osur~ ~ractie~.~Z z~ro I.tl~q ~ancer~ devel~0ed, ant r~u~ one ca~l~ og squ~eu~ cell. ca~cin~ll, ~he h~man cn~ce~ most c~let~ bi~e~ I~n SmokL~,j, ,I,h~r~ wa~ no question t~t th~ ~-~g~rett~ ~lTl~k~ ~1 penetr~t~A ir~to ~h~ir ~II~gS, si~eo thls was ~r%e~ ~ut ~uant lt,~ive ly, In ~th~lr ~x~e~'n~s, ml.ce w~re ~'ne~ ~tl~ in~ratrllcteal pure carc~g~n~ ~hemi~a~ and ~en exposed ~.o cigarette sr~l~ du~ing ~e~r whc,~e lives. "~o ~nce~a~e ~n l~.a cancer cceur~e~ over t~ in~ence gottnd a±te~" u~ng p~r~ ~hemic~l~s alone, ant1 in on~ ~xp~rlm~nt the smokinq wa~ .ssociat~d w~th ~ re4u~e~ '.~lng zan~e,-
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511 rate. The n~bers o~ animals and the computerized info~ticn are so ~hun~ ~h~t sba~is~ical a~alys~s by modern experi~enta! me~hods is st=ll con~±nui~,9* So~e 40 ~u~llcat£~n5