Tobacco Documents Online

C 3 The oroblem of smoking and health is urgent because: * smoking causes at least 80 percent of all lung cancer deaths and is the number one cancer killer among men and fast approaching number one among women; ^ smoking is also a primary contributor to cardio- vascular disease, the nation's single largest cause of untimely death; * smoking results in a growing burden of death and disability due to emphysema and chronic bronchitis-- diseases that turn the prime of life into premature old age. These distressing facts do not need to continue into the future. These statistics can be reversed. Nor do we need to continue to suffer the enormous economic consequences of cigarette smoking. Just two months ago an article in the New England Journal of Medicine suggested that the costs of cigarette smoking are more than $8 billion annually in direct medical costs and nearly $20 billion more in lost production and other costs. _, As this Committee so well knows, personal health care expenditures have been rising at wildly inflationary rates and reached $142.8 billion last year. It would ~ appear from the New England Journal estimates that some- d- W thing more than five percent of these costs are directly CP attributable to cigarette smoking. ~

STATEMENT BY DEPARTMENT OF' HEALTH. EDUCr1T1O'NI. AND WELFARE WILLZAM Fi. FOEGE, M.D. DIRECTOR, CENTER'FOR DISEASE CONTROL, BEFORE' THE SUBCOMMITTEE ON fiEALTH AND SCTENTIFIC' RESEARCH'. COMMITTEE ON HUIMAN RESOURCES UNITED STATES SENATEI FOR IRELEASE Oy'LY' ON DELIVERY' E, THURSDAY, MAY 25, 1979

c MR. CHARIMAN AND MEMBERS OF THE SUBCOMMITTEE : I appreciate this opportunity to appear before you this morning and to present our Department's view on the Smoking Deterrence Act of 1978, S. 3118. I would like to introduce to you the two witnesses who accompany me, Dr. Norman Kretchmer, who is Director of the National Institute of Child Health and Human Development, and Mr. John M. Pinney, the Director of our Department's new Office on Smoking and Health. This legislation,as a major component of your National Disease Prevention and Health Promotion Act (S. 3115), seeks to advance the Nation's health by focusing on ways of preventing illness, ways of keeping people out of hospitals, and ways of preventing unnecessary disease and avoiding premature death. On behalf of Secretary Califano and Assistant Secretary Richmond, I congratulate you for the leadership you have shown in this area. We share your deep interest in improving the preventive components of our health strategy. it• 0

- 2 - The concept of health care in this country has for too long been dominated by the images of doctors, hospitals, and the acutely ill. Prevention, as well as treatment, is a vital element in our Nation's health care system. S. 3115 is broad and covers many aspects of health care and disease prevention and touches on many programs now conducted by the Department of Health, Education, and Welfare and by State and local governments. We will comment on this comprehensive legislation in detail at a later date. Tcday I would speak to the particular hea lth problem of cigarette smoking and express my own personal gratification for the endorsement which S. 3118 provides to the Department's smoking and health initiative. It seems unnecessary, Mr. Chairman, for me to speak at length here of the needwess toll of disease and death exacted by cigarette smoking. You have demonstrated again and again your commitment to prevention. As one so committed, you are aware that cigarette smoking remains the single most urgent and potentially rewarding target for preventive action. As Secretary Califano phrased it in his address of January 11, when he announced our Department's smoking and health initiative, it is Public Health Enemy Number One.

It is extremely difficult, of course, to assess the impact of the warning label, both on cigarette packages and in advertising. A continuing reminder-- seen over and over again, wherever cigarettes are. being promoted--may, in conjunction with other messages, help some smokers form the determination to quit and act upon it. Certainly it can be argued that some form of official warning is not only appropriate, but * necessary in discharging the Government's responsibility. The ten separate warning messages would attract greater interest, through both novelty and variety, than the single message now used. Several of them-- for example, the one on damage to the unborn child-- would have the further advantage of calling attention to specific threats that. may not yet be widely recognized. If the decision is made to require a variety of messages, the specific wori ing of each needs to be carefully considered. I would hope that the conditional "may be" could be avoided, and that, in every case where the evidence is supportive, that the force of the statement "is dangerous" could be retained. I would emphasize that warnings should be required in advertising, as well as on packages. ..

- 9 - Section 9 of S. 3118 would require that all cigarette packages list the tar and nicotine yield of the cigarette. It would also substitute for the current warning -- "The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health" a set of ten different warnings, each of which would be-required to appear on ten percent of all cigarette packages. Tar and nicotine levels should, in our opinion, be listed on the cigarette packages. We would suggest, however, that provision be made for: -- inclusion of the information in all advertising, as well as on the package; and -- listing of other hazardous compounds as they may be identified in the future by the Secretary of Health, Education, and welfare, and determined through appropriate testing methodology by the Federal Trade Commission. One of the elements in cigarette smoke that may have significant effect on health is carbon monoxide. Yesterday, Chairman Pertschuk of the Federal Trade Commission informed Secretary Califano that the Commission will begin testing domestic cigarettes for their carbon monoxide levels, and will begin pubi~ishing the results early in 1979. The Chairman's letter announcing this important action will also be submitted for the record. The Department, through its Office on Smoking and Health, will give wide publicit_v to the results of these tests.

To coorrdinate this effort, the Secretary has established the Office on Smokingiand Health and hass a knowledge of', andt commitment to prevention and health education. manager and analyst of health programs~, and possesses appointed' Mr. Pinney as its Director. Mr. Pinney brings to this position ten years experience as a permitted,as well as areas in which smokers and non- j=isdiction are listed in which smoking will not bee of S. 3118' deal with the regulation of' smoking in Federal facilities. Specific areas of facilities under Federal One of the important elements in the Department's initiative is to move further in protectingithe rights and health of those who do not smoke. The first provisions Soloman will also be submitted!for the record. Clearly new regulations allready promulgated within HEW,~which am submitting for the record'. We have urged other Department and Agency heads, and organizations, such as the General Services Administration, to adopt and' enforce similar restrictions in the facilities uAtier their control. A copy of my letter to Administrator These provisions correspond very closely withithe non-compliance. smokers must. be separated'. It also provides instruments for enforcement of these restrictions and sanctions for

this policy to other public agencies, as we11 as organiza- the 50 States for their consideration in efforts to We have circulated a model "Clean Indoor Air" bill to tions~,in the pr~ilvate~ sector for th~~e: ir review. protect the non-smoker. to notify World War II shipyard workers and'other asbestos review of' the medi:cal and behavioral aspects of smoking since the original Surgeon General''s report of 1964. The Department is now engaged in a nationwide effort Agencies and work has begun on the preparation of'the 1979 S'urgeon General's report. This will be the most extensive Dr. Richmond1has assigned'responsibilities among the workers of the heaSthirisks they face. exposed to asbestos, contracting,llung,cancer as a non-smoker who has not been exposed to asbestos has up to 90'times the risk of This campaignn emphasizes that an individual who smokes and who has been therapeutic drugs~. One important interaction recently reported was the combined effect of smoking; and oral the published reports on the interaction of smoking with The Food andiD'rug; Administraltion is now reviewing contraceptives which produces a marked increase in cardio- vascular disease and deaiths. Warning notices must now accompany all such pills when they are first prescribed to the patient.

It was because of the human and dollar costs of' smoking,that Secretary Calif'ano announced the Department"s initiative on smoking and health on January 11. Under ob j ectives of S. 3118. the Department--all of which we believe addres.s the this initiative, a number of steps have been taken by Together with the Federal Trade Commission, the audience. This petition is now being considered by the FCC. the information would be made available to the widest public service announcements,, including,prime time, where Department has petitioned the Federal Communication C~ommis,s~ion toopen~ more broadcast~,o~pp~~ortunit~ie~s for have sent additional information and digests of'smoking Secretary Callifano and Commissioner of Education Boyer and' educational materials to the chief school offices the 501 States and to all 16,000' school districts. Dr. Boyer has also invitedichildren from all ouer.r the country to and shuttle buses, and calls for separate work areas for The Department has drafted a new policy on fmoking in HEW-occupied build'ing,s, which bans smoking in, conference rooms, classrooms, auditoriums, elevators send us posters and essays on their feelings about smoking. smokers and no-n-smokers, where practical. We have submitted

In summary, Mr. Chairman, the Department is deeply gratified by the continuing support of this Subcommittee for disease prevention, particularly efforts aimed at smoking and health. As you knowi„ the Department presently has broad authority in thi:s area and has recently undertaken a major initiative aimed at objectives that closely parallel those of S. 3'11&.. While in many instances, specific authority may not be required to advance our mutual goals, this expression of' support from the Congress will significantly aid our efforts.

- 12' - at one time or another, but why do.some kids keep on smoking, while o~th~~ers~ do:no,t?~ WhX~ •~d'o~ s~ome~ te~enage~rs~~ be~~c~ome~ regular ~ smokers while others are able to give up the habit with to college?' bound youngsters smoke than those who do not plan to go no apparent trouble? Why does it appear that fewer colleg,e- I requesting $4 million for the National Institute on as likely to have tried marijuana, and six times as likely to have tried hard drugs. In the Pres!ident'''s budget for FY' 19179, we are And who are the reai1 chance-takers in the child' populations, and how do we identify and help them? Among children 12 to 17, children who smoke are twice as apt to have tried alcoholic beverages as non-smokers, four times Child Health and! Human Development to investigate the childhood determinants of'smoking behavior. Epi:demio- decisions--wi;ll enable us to design more effective intervention programs, can do a better job in helping children make wise health research--to find out how parents, schools, and communities logical research will be critical to tracing the smoking histories of different groups of children. Educational 4,

The~ princip~]le~ of al gradua~ted~ tax based on tar and nicotine in our opinion deserves serious consid'eration, provide a basis for such technical judgments in the Department is presently undertaking studies in co- operationwith the Treasury Department to answer these important questions and hopes to be able to thus have little more than punitive si:gnificance. The cigarettes, as is proposed in this legislation, might encourage more smoking by young people. On the other hand, very high taxes on the highest yield cigarettes might have no effect on confirmed smokers and would particularly the design,of•the tax schedule. For . A.. ' ' .... . - . example, a lowering of Federal taxes on low yield t near future. We will keep you advised of our progress. The questi:on of'earmarking tax revenues for special purposes -- even the best of purpo es economic and tax policy questions whicli require further costs of days lost in production, and other costs. Thee revenues obtained from cigarette taxes at the present rate, or even under the rates proposed by S. 3118, do in terms of increased hospital and medical_costs, the American people should be aware of the economic bur- den which cigarette smoking places upon the taxpayer analysis. However these questions are resolved, it is the view of our Department that Congress and the not begin to approach these costs.

you feel as we do that the Federal government has an opportunity and a clear responsibility to set an example for all organizations and employers.` Congressional support for this policy should encourage its establishment whether through legislati'onlor administrative action.. S'ections 7 and!8'of S. 3118 provide for the establishment of a"'health protection tax."' These provisions would, in effect, amend the tax codes to create a varying tax on cigarettes ranging, from five tolfifty cents a paick, based on "toxic units' which are derived from the millligrams of tar and nicotine contained in each brand of cigarettes. The proceeds from this tax would be used, beginning, in Fiscal Year 19'8'1,, to support paymentss to the States in the formof formula grants to assist them in meeting the costs of preventive health services. The present Federal excise tax is eight cents a pack. The schedule set forth in S. 3118 would raiseth~is ta on (and presumably thus the price of)' most cigarettes by substantial amounts,, but would lower the price of those cigarettes with the lowest toxic yield.

Regardingi additives, we understand that there are some 300 substances•which cigarette manufacturers add to cigarettes for flavoring and other purposes. We do not even know what many of these substances are. would recommend your consideration of additional language requiring the disclosure of'these flavorings and other additives. If ingredient knowledge is justified for the products we ingest, it seems to me they are at least equally justified'~for products we inhale. In establishing the new Office on Smoking,and Health, Secretary Califano and Dr. Richmond have used as a nucleus, the National Clearinghouse for Smoking and Health, which was formerly a part of CDC. I would like to assure you,, Mr. Chairman, that the departure of the Clearinghouse by no means signals the departure of'CDC from concern with smoking. The budget request for CDC'for Fiscal Year 1979, now before the Congress, includes a proposed grant program to the States which would engage official State agencies effectively for the first time in anti-smoking activities on a significant scale. CDC will continue and' expand its development and promulgation of school health curricula, in close,~co~Tlab~oration,with the~ Office of~Educat~ion and will apply its epidemiological expertise to problems=.associated with smoking to a greater extent than heretofore. Programs of lifestyle education, in which smoking is included as one of the principal risk factors closely inter-relaited with, hyp ertens ilon , obes ity , and others,, will continue and

Section 10 of S. 3118, Mr. Chairman, is the portion which is to me the heart of the legislation. This section provides for a program to deter smolting, among children and adolescents. This is the area of greatest concern to the Depaztment. It is also the area in which we have been the least'successful in the past. We can point with some pride to significant decreases in smoking among adults -- first among males~ and recently, encouragingly, among females. But with children and youth,, the picture is different. Smoking among boys has hardly ctianged' in the last decade. Our most recent figures, which will be updated during the coming summer--show that five percent of boys between 12' and 14 smoke; just under 20 percent of boys 15 and 16 smoke; and somewhat more than 30 percent of'boys 17 and 18 smoke. By age 18, the habit of smoking is pretty well established, and I think this is shocking. Meanwhile, smoking among,girls lias increased dramatically. In the 19160's, about twice as many boys as girls smoked; now at every age level, girls are smoking at the same rate as boys. The legisliation which you have introduced recognizes the importances of research in directiingiour efforts. We need y to learn more about smoking behavior than we know now, particularlyregardingsmokingbehavior amongchiildren. Perhaps almost all children can be expected' to try cigarette

l. The final section of S. 3118 calls upon the Secretary to study and report back within two years onithe relative health risk associated with smoking cigarettes of varying levels, and the relationship ofltar,`nicotine, and various additives to health risks. :, These two questions, in our opinion, are among the most important public health questions of'our time. As I mentioned at the beginning,of'my testimony, the various agencies of the Department--the National Institutes of'Health, the Food and Drug Administration, the Office of Education, the Center for Disease Control, the National Center for Health Statistics and others are now beginning work on the 1979 Surgeon Generall's Report. This will be the most important review of' information on smoking since the publication of the original report,nearly 15 years ago. As part of this effart, the agencies will be looking at the changes which have taken place in the cigarette itself, and will attempt to evaluate the health significance of these changes. On the basis of this information, HEW will focus attention on many aspects of the questions posed in S." 3118--and it is our hope that this ;.nformation will be available before the end of two years..

But there are some 16,000' school districts in the materials developed, and close cooperation encourages country. To reach a maj'or share of our youngsters, teachers and administrators will have to be trained, between school and health officials, parents, and There is a particularly urgent need to develop educational programs for teenagers. While we are gathering new others who can help do the job. Through the Department's new initiative, CDC and the Office of Educationiare working closely together to accomplish these purposes. Iearn. Surveys have shown, for instance, that: knowledge, we must also apply what we alread!y know about teen-age attitudes toward!smoking and about how teen-agers Eighty-four percent of teenage smokers admit that smoking is habit forming,. Sixty-nine percent realize that smoking slows them down in sports. Two-third's believe that smoking is just as harmful as their doctors and teachers and'parents say. And half of them hope that when they have children, their children won't smoke. These are positive attitude's on which we caa build'. One wh~ich~ CDC has!b~~een supp~orting on a small s~~cale~ through a! contract withithe National Interagency Council on promising approach is peer education--kids teachling, kids-- Smoking and Health,.

At this point, let me emphasize that the primary goal of our prevention programs with children, as well as adu1'ts,. is to provide education and to conduct research that will enhance, not reduce, personal choice. We can inform children and young people, we can set the best examples we' can,and we can try to create an environment which will promote and not discourage healthful behavior. But we cannot take from young people their right to make choices as to their own conduct, so long as this conduct does not infringe upon the rights of others. As stated before, we believe thatif'our citiz~ens--,especially, thosein their teens and subteens!whobegin smoking for the first time--are given all the facts from Governm.ent or other sources and they still do not wish to give up a personal habit, however hazardous, then, except for protecting the rights of non-smokers, Government can properly do no more_ One of the most effective ways we have found toi inform chi]ldren and young people is through1health education in the schools. Some excellent school curriculalhave already been developed and tested for elementary school children. One of the best, I am personally pleased to say, has bee developed by CDC' _ c, . . and is now in place in some 3'S0 school districts i'n more than half the States.