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c importance of state and local action in health matters and we are encouraged' by thiis proposal'. (lt is beneficial that the formuilla grants proposed under S'. 3115 would be targeted to the l'eadi ng causes of mortali'ty and' morbiidi'i ty within the state. Such targetiing can prevent the dissi,patilon of these new funds over too broadl a range of activities. However,, twoissuies,d'oco~ncern us., The filrstis the proposed level offund i ng whii ch m i'ght not be suff i'c ient toe reduce the rates of morta l i' ty or morbidity in a state effectively. It would i'ndeed be unfortunate for Congress to develop a major disease preventioni ilniiti'ative, yet to fund' it i'nadequatelly a d'iisproporti'onate amount of fund'i'ng, leaviing iinad'equate resources to be used for as i nd'i cated iin your remarks upon i nitroducti'on of the b i l.' 1, P1ir. Cha iirman„ take a t remendous to ll l i n l ives„ i'nf l i ct w i des pread i nj',ur ii es and cons t ii tute tead i ngi causes of mortal'i!ty and' i'njuriies iin many states. We are concerned,, however, that difficulties inherent in dieating wTth these problems milghit qlucckl'y absorb Our other concern ils the sheer scope of the program. As we saiidi earl iier, this is a wide-rangi'ng and, ambitious undertakiing i'n iits goals. We would suggest that i'nitiall'y these funds be concentrated on d4sease prevention programs. We certaiinty recognize that such things as automobi 1le accidents and homiciide,, so that the effort might not get off the ground. We urge the Subcommittee too seriously consider enhancing the funding available for these acttiiivilties. other areas of'di'sease prevention where desirable results are al'so sought and where such funds might have greater ilmpact. If it is i'ntended that formula i t may be wilse to piace a percentage 1 i'mi tation on use of fu,nds for such . purposes~~ --~ at least until states gaiin more ex~~perilence~~ in such~ prev~en~t~iv~e~~ grant funds be usedito attack such problems as automobile accidents and homicide, activities in these areas..

-2- particularly supported'earlier fed'eral' programs in d'iisease prevention and we are pleased to see an extens ilon and expans ionlof suchiact i v ii t iies . Your consi'd'eration of S'. 3115 at thiis time iis propi'ti'ous si'nce it can focus publ'iic attention on the health issues to be consi'd'ered at the July conr fe~rence "'Fo~cus~ on Pos~i'ti've Heallth St~ra~teg~i'e~~s1°',, joli~~ntly s~~ponsoredi by~ you,-, N1ir. Cha i'rman, and' the AMA. H'opefu l l y a 11T these act iv i't i'es wiI lll encourage the publ'ic to be more aware of the benef i ts of diisease prevention and' the iind!ilvi'dluali's important role in preservi'ng, hi's or her own health. hea~l'th~ p~romo~~tiioni and~: heall'thi ed~ucation~ throug~hi long prow~~en~ s~uccessful' co- operative federal-state activities. The billl also includes ingredient and'' and' nutritional label'i'ngion food products and ilncreases the present efforts S. 3115 i s a wi'd'e-rang i ng! ef fort to, re i nforce programs of' d isease prevent i'on, Antended' to deter smok iing . At this t ime, Mir. Cha i'rman, we woulld' 1' i ke toladdress speci f'iic prov i s lonsof' the l eg i s l at i on. UJh ii 1'e we support the overa l l, g,oaIs of thii s b i ll 1' and' the thrus t of ma jjor prov is iions of the b i' l ll , certa i n prov i's i ons do ra i se ques t i ons that we~~ be~l~iieve~ should be~ answered early i'~n the~ consideration ofthe~ biilll.~ Certain modiiifi'cati'ons would enhance the beneficial intent of the biU1'. FORMULA AND PROJECT GRANTS FOR PREVENTIVE H'EALTH SERVICES' Title II woul'd' provide ainew program of federaJl formula g!rants to states to assist them i'n meeti'ng the costs of planning andl provi'di'ng preventive heal'tfi services. These state programs woulld' be diil rected at reduci ng, the f ilve llead i ng and prevention of these conditions. A state could aTso receive formul'a! funds causes of mortality withlin the state through systems of earl'y detection, screening for programs des i'g,ned to reduce the f i've leading causes of morbidi'ty withi'n the state..

girants are one means of accomplli'shing this. However, before such acti'vi'ties are insti,tuted,, we would urge the Subcommittee to review carefuillly existiing federal' activities under the auspilces of the tVational' Institutes of' Health, other arms of HEW, and' other agencies such as •EPA to determine iif, i'n fact, resources are not already avaiilable tolthe state. If indeed they are already avai'llabl'e in a satiisfactory manner, we woul'd suggest that the funds ear- marked'for this Ti'tle be usedlfor other acti'vities such as the grants under Title I. Si'milarly, concerning the proposed national' disease preventionidata profi'le, we recognize the need for adequate stati'sti'cs to guide the devel'opment of these programs. However, iit is not clear from thiis provi'sion i'f'a new data colllectilon system woul'd be created or if existing federal resources would be used to prepare the abstract. I'nsofar as existi'ng federal data systems are adequate for this purpose, we encourage their use. shoulld be avoid'ed.. Dupi'ieation,of mi'ssion and resources At this time we wi'll' turn to the proposals for nutritional iabel'ing of food's and' anti-smoking activities inc]ud'edl in Ti'tles III and IV. NUTRI'TfOw LAB'ELI''WiG Title III would amend the Food, Drug and Eosmetics Act to mandate that , ingredient and' heallth andi nutrition iinformation appear on the label ing of a1l'. 4F packaged foods. The bi l l, wouilld al'so amendl the defini tion of food to i'ncl'udee alcoholic beverages, thus specificallly bringing the labeli'ng requirements of alcoholi'c beverages under the jiurisdiction of FDA. The American Medicall Associ'ation commends efforts to increase pubil ilc awareness concerning theingrediients aM the nutritionall' val'ue,ofthe fao~ds, they consume. _However, nutritional labeling or information presented' to the

-5- We allso note thatt each state recei'ving, aigrant would have to set up a special health communications uni't whose purpose woul'd'be to encourage healith, promotiion and education using all med'ia, especial'ly electronic. We think this proposa l has mer i t. Of ten the iinforma t i'on needed by the pub l' i'c i s not suff i c i ent l'y d'iss•emi'nated,, especi al' llyin the area of heai th,. Heal thcommurn i~cat ionsunii ts~ coul'd~ be one answer to th ils probl em. However, we must aga i n stress the need to fundl these activiitiles adequatel'y so that 'the message wi til be delliveredl effect iwelly. This Ti'tl'e ailso, extends the f'undi'ng for section 31''4(d) grants for compre- hensiive publ ic heal'thiservi'ces. These funds, in essence a block grant to the states, have represented a ma jor source of money for a var i'ety of' state and l oca l' publi i c health activities. They could also be used to suppliement the new ilni'tiatives' iln health promotion andi d'i'sease preventi'on under S. 311'5. We have supported this block grant program since ilts ilneepti'on and support i'ts extens ion. Title III proposes a federal support system for the foregoing state programs and' we wi l ll diisc ss these at this time. RESOURCES FOR D[SEASE PREVENTION AND~HEALTH PROMOTI'ON The federa 1 government wou 1'd estab l iish f i've centers for hea ll thipromot i on." The purpose of these centers would' be to provide technicali assi'stance to the ~ s~ta~~te~s, i ni ca~~rry i~~ng out~ their p~ro~grams~~ for "p~~r~event i~~ve~ hea~Tth~ serv~ii ces!"' ou~~t~l i'ned in~ Tilttet. The~ S~eereta~~ry~ wouId'~ a~llso set upcommunity-bas~~ed~ demonstration projects to tes t methods for organ i'z i ng! and' d'el i ver i ng, comprehens i ve prevent i ve health services to d'efilned popul'ation . We concur wi'thi the need to disseminate to the states additional iinformati'on on disease prevention and healthipromotion. The proposed centers andid'emonstrati'on

-3- Specilaill project grants wouldi al'so be available for the foll'owing heal'th servIces: 1) detectioni of hypertension; 2) immunization of chi'ldren,;, 3'), communi'ty fluorild'ati'on progirams; 4), preventi'on of i'llnesses caulsed by envi'ronmental factors; 5) prevention of'rodent borne di.seases;, 6) physical fitness activities; and 7) liead-based paint poilsoni'ng prevention. C'ertai'n, of these activities,, such as immunization of chil'dren„ detection borne diseases, are currently in effect. The American Medical Association has of hypertension, llead-based paint poisoniing prevention, and prevention of'rodent supported' these act iv i t i es and cont i'nues to support them il n the i'r rev i sed form. Moreover, the AMA, recognizing the need for expansion of' prog,rams for iimmunizatilon, of chil'dren„ has developed draft llegilsliaitioni that woul'd~ increase the level of immunizationn. We submit a copy of that bil!l and commend it to you. Iln al li the forego i ng act i v i t i es „ Mr. Chaii'rman, the resources and~ serv i ces of the private sector shouldi be utill i'zed to the maximum. Another factor bearing on publlic heail'thiad'dressedl by S. 3115, physical f'iI tness, is deserv i'ng of greater nati ona l' attent ion and we support il ts i'nc Lus i on as pa rt~ of' th is program. We~ hope~ that the language ~ g i v~inglauthori',ty~ for the~ ~ Secretary to set standards for physical fi'tness program will be clarif'ied' to avoid its being ilnterpreted as authori'ty to establ i'sh nati'onall personal physical. Environmental factors also pllay a large rol'e in disease and their adverse effects shoul'd' be mtniimiized. H'owever,, because off' the scope of suc.h an and' the llimited funding authorilzedl„ we bel i'eve the program~ should be initialUy recognized as experi'mentail' or demonstration with extension on a broader basiis resulits become available. Coordlinati'on with exi'stiing environmentall quality as programs shoul'dI aillso be soug,ht. a3603,a,33_ We are especially pleased' to see that the state would' have a major role in determi'ning priorities for the disposiiti'on of fund's. We have long stressed the

STATEMENT of the AMER I CAN MED I CAL ASSOC I'AT1 ON to the Subcommittee on Heaithiand Scientific Research Committee on Human Resources lJni.. ted! States Senate Re: S. 3115 "The Disease Preventiion and Heal thiP'romot i'on Act of 1978"' June 7, 1978 ; Mr. Chairman anndMembers of the Subcommittee: My name is Lowell l Hi. Steen, M. Di. I am a pract iic ing phys i c iian i'n Hammond,, Ilndiana„ and! II am a member of the AMA's Board of Trust'ees. With me today is Harry N. Peterson, Director of AMA's Department of Legislatiloni. in public health have come about through advancements in the methods of qreventing d1sease, such as immunizations, improved sanltation and better nutritionrn. These have been achieved through a cooperati'ue effort among federal, state and local the qwa 1' ity' of our env i ronmen t, and' the ed'uca t ion of hea li th R rof es s iiona l's , among many others. 036031331 Mr. Chaiiirman, it is well recognized that many of the greatest improvements in6uriing the safety of foods and drugs, support of biomedical' research,, improving to improve the heaUth of each and every citizen. These efforts have included The American Medical Associiationi is pl'eased' to present its vilews on S. 3'1115,, the D isease Prevent i on and Hea l th Promot iioniAct of 1978. Since its faunding, in 1847, the AMA has sought the betterment of the public heaIlth. We have supported many efforts,, both private and governmental, designed governments, the medical profession, and the public. To that end, the AMA has

C eonsumer wouldl be of l i ttle value without coord'inatedl programs i'ninutriition education. Furthermore, the format of such liabeliing must be designed so that it iis easilly understandable and can be properl'y interpreted' by the consumer. W'il thout nutr i't i'onrn educat ioniand an effect i ve format for the i nformat iion, we bel i'eve that the laud'ablle resu l ts antiy e i pate&by th i's prog,ram wou l d be unrea l' i zed. Currently, the t).S. Department of Agriculture and the Food' and Drug Admi'niistrationiare conducti~ng joiint publ ic heariings to determine what types of' informati'loniwo~uld:bemostbenefilciall to appear inifood 1'abel' ingi and' the format that the i'nformati.onis_houild take. We suggest that consi'd'eratiion of Ti tle tl t t' be delayed unt i'l1 the resul ts of th i s jo int study are avalil labl'e. SM'OK1 N'G DETERR'ENTS. Title IV'woul'd initiate new programs to deter smoki'ng and to protect non- smokers. F'i'rst,, the bi H would' prohi'biit smoki ng in al l publ ic areas of iindoor federal facilities except i'n designated smoUng areas. Separate areas for smokers and non-smokers would' be establ i'shed in al ll food service areas iinifcderaiT facil!itiles. -Tolthe maximum extent possibl'e, federall agency officers would be required to separate smoking employees from non-smoki'ng emp:l'oyees. The American Nledical Association commends these efforts. It ils widely acknowlledged' that carbon monoxiid'e, tars and' nilcoti'ne from cigarettes, plipes and R cigars can affect not onl'y those who are smokiing them but allso non-smokers i'n, the immediate area. We therefore concur that efforts should be made to separate smokers from non-smokers and to l'imit smoking to ceriainispecilfi'ed areas. At p the AMA headquarters, we had already begun such a pr©gram by establ i'shingi, ~ 0 smoking and non smokingiareas in our cafeteria. We are also plleased toinote that these provisions wouldicover not onl'y the executive agencies but also the Congress and' courts.

determi~ne the bioliog,ic and' behavioral factors that encourage smokingi among chilldren and'adolescents. We support such a program. We bel' i eve that major efforts d i'rected' towards chillldren to d i ssuade them from ever beginning to smoke are highly desirable and' shouldi be i'mplemented as rapi'dly as possible. Stati'stiics iindilcate that more and more youngi child'ren are beg,inning to smoke. Perhaps a maj'or ad~ertising program d'ilrectedi at these impressionable individuals wouild serve to reduce thiis number. We are allso pleased to note the emphasis on state and' local programs in this areaiand we hope that school systems woul'dlbe brought into the program as early as possible. CONCLUS t OWI Mr. C'ha i rman,, The Amer ilcan Med i ca l Assoc i at i'on supports a comprehensiive program d i rected at prevent i ng ii l Iness. We bel'i eve that cont i nued' efforts in these areas, al'ongi wi'th programs to improve our envtronment and safety In the work place and the home, would substantially improve the publl7c healthiiln the United States. Programs such as those anticipated in the bi111 woulld buttress other ongoing activi'tiies. However, we shouldlnot be deceived i'nto bellievi'ng that these programs are a cure-aill. Basic to success must be a major and cont i nu i'ng~ ef fort to educate the A'mer i can peop l e i'n hea l thfu l' 1' ii festylles and the iimportance of prevent i've med'i c i'ne. Because resu l ts of' such act iiv i't i'es w.i 1 1 not be vi'si blie overnight, we recommend a 1'ong-termicomm,i tment to these endeavors. V h1'r. Cha i rman, we joi n with you i nisupport iing efforts des iig,ned to prevent [ll'ness and'I di'sease, andl intend to continue workiing with you and the Subcommittee i'n develloping programs to achi'eve these ends. We would now be pleased to answer any questions the Committee has.

C The bflll wou!l1d' a~l so~ amend' the ~ I nternal' Revenue Code to, ~ rev:i s~e~ the~ present provi'sions for federal tax on cigarettes by estabil iishing a, new system, for computing that tax. The new tax would be based on the amounts of tar and' ni'coti'ne iin cigarettes and' would range from 5~ to 5Of per package of cigarettes. The tar and nicottiine content of' al'll cigarettes iin the U'ni'ted States woul'd be determined annually, based'upon tests conducted by the Federal Trade Commission. The goals of thils proposed tax are commendable,, siince they are i'ntended to reduce cigarette consumption at least of higher tar and' nicotine ci'garettes. However, it must berecognilzed'that the proposed tax would' noittake i'nto: consideration other toxic factors rel'atedito cigarette smokinglsuch as carbon monoxide. Another ma jor prov i s i on of the b ii ll l wou l d amend the Fed'era 1 C'i'ga ret te ILabel i ng, and Advert il s i'ng!Ac t(,P. L. 8'9-92) to requii re eachic i gairette package to iist the tar and' nii'coti'ne content of' each ei'garette, stated iin milll igrams, andd to.contai'n at least one of ten &ifferent warniing statements regard'ing cigarette smoking andi adverse hsa4th effects. Each,of tfie statements would appear on at lieast 10% of al1' cigarette packages prod'uced. The American Med'i'cal Associati'on supports the label' warming concept ass part of the overall effort to increase publlic awareness of the heal'th hazard's of cigarette smoking. However, the effectiveness of the p1roposed' vari'ed' warning,s cannot be accuratel'y predicted and i'f adopted they should'be evaluated after a - ~ peri'od'of'use to see iif there has been any substantiial' difference in the public" awareness of heal'th problems associated with cigarette smokiing. The bi'l1, would also provide for a cooperative program among of Heal'thy ffducation and Wel'fare and'state and' local governments conduct programs witti special emphasils directed toward~ d'eterring, smoking in chii 1'd~ren andiadol'escents. Research programs would be the D'epartmentQ. W to develop and0! cigarette