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DISEASE PREVENTION AND HEALTH PROMOTION ACT OF 1978 HEARIN GS BEFORE THE SUBCQMMITTEE' ON ~ HEALTH AND SCIENTIFIC RESEARCH OF THE COMMITTEE ON HUMAN RES'OURCES UNITED STATES SEI ATE NINETY-FIFTH CONGRESS SECOND SESSIOAT. ON S. 3115 TO ESTABLISH A COMPREHENSIVE DISEASE PREVENTION AND HEALTH PROMOTION PROGRAM INI THE UNITED STATES AND RELATED BILLS MAY 25 ; JUNE 7 AND 9, 1978 Printed for the use of the Committee on Human Resources U.S. GOVERNIVIE\T' PRI\TING OFFICE' 30-536 WASHINGTON : 1978

2 FORMULA GRANTS FOR PREVENTIVE HEALTH SERVICES SEC. 102. Effective October 1, 1979, title III is amended 3 byy adding after section 314 the following new section and 4 5 6 7 heading thereto: "FORbtULA GRANTS TO STATES FOR PREVENTIVE HEALTH SERVICES SEC. 315. (a) The Secretary shall make grants to s' States to assist them in planning for and in~ meeting the 9 oosts of providing (through such States and through grants 10 or contracts or both with public health authorities of political 11 subdivisions~ of the Stat'es, other public entities, or private 12 entities ) preventive health services. 13 "(b) No grant shall be made under subsection (a) 14 unless an application therefor has been submitted to, and 15 approved by, the Secretary. Such an application shall be in 16 such form and be submitted in such manner as the Secretary 17 shall by regulation prescribe and shall provide (other than 18 in an application for a planning grant) - 19 "(1) for a detailed plan of' a program designed to 20 reduce, through the primary or secondary prevention of 21 causative conditions, the mortality rates for one or more 22 of the five leading causes of' death in the State; 23 "(2) the amount of Federal, State, and other funds 24 obiigated by the State in its latest annuaL accounting

( Text of : S. 3115------------------ S. 3116------------------ S. 3118----------------- CHRONOIA COMMITTEE ON HUMAN RESOURCES HARRISON A. WILLIAMS, Js., New Jersey, Chairman JENNINGS RANDOLPH, West~ Virginia JACOB K. JAVITS, New York CLAIBORNE PELL, Rhode Island RICHARD S. SCHWEIKER, Pennsylvania EDWARD 1L KENNEDY, Massachusetts ROBERT T. STAFFORD,, Vermont' GAYLORD'NELSON, Wisconsin ORRIN G. HATCH, Utah THOMAS F. EAGLETON, Missouri JOHN II. CIIAFEE, Rhode Island ALAN CRANSTON, California S. I. HAYAKAWA, California WILLIAM D. HATHAWAY, Maine DONALD W. RIEGLE, JR., Michigan STEPHEN J... PARADISE, c3eneraL. CounselandStagDirector MARJORIE M. WHITTAKER, Chier, Clerk DON A.. ZIMMERMAN, MinorityCounael GaEaoRY Fusco, Minority Staff Director SUBCOMMITTEE ON HEALTH AND SCIENTIFIC! RESEARCH EDWARD M. KENNEDY, Massachusetts, Chairman CLAIBORNE' PELL, Rhode Island RICHARD S., SCHWEIKER, Pennsylvania GAYLORD NELSON; Wisconsin JACOB K. JAVITS, New York WILLIAM D: HATHAWAY,,bfaine JOHN H. CH'AFEE, Rhode Island HARRISON A. WILLIAMS, JR., New Jersey (ex o8'icio) LAWRENCE HOROWITZ,. ProJesaionalStaff Member DAVID WINSTON, Minority Counsel Ford, Hon. Wendell H., a U.S. Foege, William H.,, M.D., Dirt Kretchmer, M.D., Director, Human Development ; and and Health, Department of! «'olfe, Theresa and Moira I O'Malley, Mark Adams, an,~ School, and James Valeo, Be Evans, Richard I., Ph. D., prof~ Houston, Tex., accompanied Public Communications Cent president~, Green Dolmatch ALeffall, Lasalle D.,, Jr., M.D., accompanied by Donal& Youl ciety, and former medical dir M. Daugherty, Jr., M.D., Ph, American Heart Association ; chief counsel, Action on Smo, AIcGinnis, Michael, \LD., Deput: Health Initiatives, aecompan Cisntrol'; and Taylor Quinn, :ldministration ------------- I'ielding; Dr. Jonathan E., comi of JPassachusetts___-__-____- Steen, Lowell H., M.D., repres( accompanied by Harry N. Pe American Aiedical Associatiol Arno)d! Dr. Charles B., presid Medicine ------------------- Lazar, Dr. J. Brett, health office representing the National A~ Pulilic Health Association___ 1'.Irquhar, Dr. John W., profess( of Medirine_________________ Manoff, Richard K., chairman, -1Ianoff rnternational, Inc____ Hanneman, Gerhardi J., associat Schooli of Communications, U

1 2 3 4 5 6 7 8 19 20 21 22 23 24 6 3 period for the provision~ of eachi program described in paragraph (1); a description of the preventive health services provided'by Ghe State in each such program.in such period; the amount of Federal funds needed by the State to continue providing such services in each such program, if the State proposes changes in the provision of the: services in any such program, the priorities of such proposed changes; the reasons for such changes; and, the amount of Federal' funds needed by the Statee to make such changes; (3) for, at the option of' the State, a detailed' plan of a program designed to reduce, through the primary or secondary prevention of causative conditions, the bur- den of illness associated with~ the five leading causes of morbidity in the State ;. "'(4) the amount of Federal, State, and other funds obligated by the State in its, latest annual accounting, period' for the provision of each program described in paragraph (3) ; a, d'escriptioit of the: preventive health services provided by the State in each su& program in such period; the: amount of Federal funds needed by the State to continue providing such services in each such program; if the State proposes changes in the provision of the services in any such program, the priorities of such 1 2 3 5 6 7 8 9 10 11 12 13 14 proposed change: amount of F'edei such changes; " (5) that t and (3) - ta (A) ~, tion prograj cable, all re "(B) r program or particular a: /( (C) , relevant rai of'morbidit, 15 " (D). 16 reduction i~ 17: where app, 18 «(E) 19 tions com? 20~ 22 shall incluc how the cc tronic med~ poses of th( "(F).

8 I 2 3 5 tity in the~ State that will be responsible for ac- complishing through contracts with privateentities~ and other means the requirements of paragraph 4 (E) ; and 5 6 7 "(G) shall contain such other information as the Secretary may by regulation prescribe; "(6) for assurances satisfactory to the Secretary that the preventive health services which will be pro* vid'ed' withi funds under a grant under subsection (a) will be provided in a manner consistent with the State health plan in effect' under section 1524 (e) ; "'(7')for assurances satisfactory to the Secretary that the State will provide for such fiscal controll and fund' accounting procedures as the Secretary by regula- tion prescribes to assure the proper disbursement of and accounting for funds received under grants under sub- section (a) ; "(8) for assurances satisfactory to the Secretary that' t.he:State will make such reports (in such form and containing such information as the Secretary may by regulation prescribe) as the Secretary may rzasonaltly require and keep such records and afford such access thereto as the Secretary may find necessary to assure the correctness of, and~ to verify, such reports : c E " (9)' for assurancE that the State will con imposed by this section, " ° (10') for such ott may by regulation presc "' ( c ) (1) The Secretar} 1 2 3 4 5 6 7 ties undertaken by each St, under subsection (b) to d, grams are operating effecti 8 9 10 poses, and if the State comF with the application. The 11 application submitted undei tary determines- "'(A) that the pr effectively to achieve tl " (B) that the Str vid'ed with a prior ap 12 13 14 15 16 17 18 tion ('b ) , an& 19 20 21 "(C) that' he is ply with the assurant under consideration. "'(2) Whenever the 22 23 and opportunity for a heai 24 to funds paid to it under ; 25 the program or program~ 3U-36 (1i- -,8 - 2'

VIII Artieles, publications, et cetera-Continued Trends in U~rban Mortality in~ Relation to Fluoridation Status, by Eugene Rogot, A. Richey Sharrett, Dlanning,Feinleib, and Richard R. Fabsitz„lldational Heart, Lung, and Biood Institut'e, Bethesda,1Id., Page from the American, Journal of Epidemiology, February 1978L------- 484 Two Days in January, an explanation of the 300,000 deatll, statistics,, from the Tobacco Institute_____________________________________ 278 Communications to : Blumenthal, Dr. David, staff member, Subcommittee on Health and Scientific Research, from Wali~am DL Kane, executive director, Asso- ciation for the Advancement ofHealth Education, Washington, D.C., June 15, 1978-------------------------------------------------- 406 Califano, Hon. Joseph A. Jr., Secretary, Department of Health, Educa- tion, and Welfare, from Michael Pertschuk„Chairman, FederaLTrade Commission, Washington, D.C., May 24; 1978--------------------- 113 Kennedy, Hon. Edivard M., a U.S. Senator from the State of .iias- sachusetts, from : Biemiller, Andrew J., direchor, Department of Legislation, American Federation of Labor and Congress of Industrial pr- ganizat'ons, June 1, 1978----------------------------------- 405 Kornegay, Horace R., president'4 the Tobacco Institute, Wash- ington, D.C., July 12, 1978------------------- 239 Soloman, Joel W., Adiuinistrator, General Services Administration, from Hon. Joseph A. Califano;,Jr.,,Secretarg, Department of Health, Education, and Welfare, January 7, 1978_________________ Selected tables: --- 11G Carot'ene„Ascorbic Acid„Thiamine, Riboflavin,111iac'n; and Pantothenic Acid Contents of Selected Canned Foods, by the National Canners Association -------------------------- --------- 737 DISEASE PREVENTIC A( THIIRSE Si'BCO]r_IIITTEE O,_\ HE=1I:- OF' TIM C( The subcommittee met, pur. sen Senate Office Building, a nedy (chairman of the subcom Present: Senators Kennedy Committee staff present : Da J.D. majority staff; Davicj minority. Senator CtI AF"EE. Ladies an ing. Senator Kennedy is unal statement that I will insert in [The opening statement of OPF, NING STATEMENT 0 Senator KEV:vEDY. Today tific Research opens hearing: vention and Health, Promoti week with the cosponsorship lation proposes & series of pr, for the first time in its histor prevention of disease and tbi zens. Today's session, focuses ~ to cigarette: smoking,, and p:smoking among our children. Over the years this subcom of health issues, but none ha turbs me more deeply, than th of parents in this country- for one t.hing, above all other cal health will permit them beinb . For many American, parer hopes may never be realized. disease, but by an epidemic of From 1968 to 1974, there of 12 to 14 year old girls wh(

, byy d R. J1d., Page _ 484 ties, --- 278 and _sso- ).C., ---- 406 uca- -ade 4as- 113 enic ners 737 DISEASE PREVENTION AND HEALTH PRO'1I0TION ACT OF 1978 THURSDAY, MAY 25, 19"78 U.S. SE`ATE, StiBCO-MJCITTEF: ON HE:ILTII A\I) SCIENTIFIC RESE.IRCII OF THE CobIDiITTEE OY HUMAN RESOURCE3,, tiVash,ington, D.C. The subcommittee met, pursuant tocalli, in room, 4'232of the Dirk-sen Senate Office Building, at 10:14 a:m., Senator Edward AI. Ken- nedy (chairman of the subcommittee) presiding. Present : Senators Kennedy, Schweiker, an& Chafee: Committee staff present :David Blumenthal, M. D., Robert Wenger, .I.D. niajority.staft; David Winston and AIai•yFrances Lowe, minority. Senator CHAFEF. Ladies and gentlemen, we will now start our hear- ing. Senator Kennedy is~ unabieto be here until later on,,but he has a statement that I will insert in the record at this point. UThe opening, statement of Senator Kennedy follows :] OPENTIIrG STATEMENT OF SE\ATOR FiDNVARm M. KE.'v,NEDY Senator KExxEDY. Today the Subcommittee on Health and Scien- tific Research opens hearings on S. 3115, the \Tat'~ional Disease Pre- vention and Health Promotion Act of 1978; which I introduced last week with the cosponsorship of sev eral of my colleagues. This legis- lation proposes a series of prob ams which would provide our Nation for the first time in its history -with a comprehensive strategy for the prevention of disease and the promotion of health among our citi- zens. Today's session focuses on the provisions of S. 3115 which relate to cigarette smoking, and particularly, on provisions for d'eterring smoking;among our children. Over the years this subcommittee has heard testimony on hundredss of health issues, but none has more personal relevance to nae, or dis- turbs me more deeply, than the topic on which we focus today. liillions of parents in this country-and I count myself among them-wish for one thing above a1L others. They hope that their children's physi- cal health -will permit them to realize their full potential as human beings. For many American parents and'formanyof our c'hildreny those hopes may never be realized. They are endangered not by war or by disease, but byfln e.pid'emic of'another sort. From 1968to1'974, there was an eightfold increase in the number of 12 to 14 year old girls who smoke cigarettes. During that time, the 1! (1)

ure to r sub- it, the ts will -retion tisfied ?ly or satis- s dis- t. by a g for Sep- 'tary, 30:20 State: ntive d by atloll Sep- it of 1 2 7 20 21 22 23 24 25 1,1 8 Stat'e and local expenditures for preventive health services supported by grants under subsection (a)' within the State in the State's fiscal' year which ended on or before July 1, 198'1; in the case of' the fiscal, year ending September 30, 1983, 7~ per centum of the amount of such, expenditures in the State's fiscal year which ended on or bef'ore July 1, 1982; and, in the case of the fiscal year ending Sep- tember 30, 1984, 10 per centum of the amount of such expenditures in. the State's fiscall year which ended on or before July 1, 1983; and "(B) may not be less than the prodnct of $0.50 and the population of, the State. "(3) The total, amount of grants received by a State under subsection (a) to assist'~ States in meeting the costs of operating the health communications component of their preventive health services programs for any fiscal year shall be determined by the Secretary, except that it may not be less thaa the product of $0.10 and the population of the State. Notwithstanding paragraphs (1) , (2), and (3) , if for any fiscal year the amount appropriated for that fiscal year under subsection (1) is less than the amount needed to make grants for that fiscal year ini accordance witlu sucIi paragraphs to all States, the total amount of grants for that fiscal year for a State: shall not be less~ thani an amount which

9 tor ac- 2ntities igraph ion as retary e pro- will will health, retary 4 and :~gula- )f and ' sub- etary :1 and y by ialily ccess t'1ie C 6 1 "(9) for assurances satisfactory totheSecret'ary2 that the State will comply with any other conditions g imposed by this section with respect to grants ; and! 4 (10) for such other information as the Secretary 5 may by regulation prescribe. g "(c) (1) The Secretary shall review annually the activi- 7 ties undertaken by each State with an approved application 8 under subsection (b) to determine if the program or pro- 9 grams are operating effectively to achieve their stated pur- 10 poses, and if the State complied with the assurances provided 11 with the application, The Secretary shall not approve an 12 application submitted under subsection (b)' unless the Secre- 13 tary determines- 14 "(A) that the program or programs are operating, 15 effectively to achieve their state& purposes, 16 "(B) that' the State complied with assurances pro- 17 vided with a prior application submitted; under subsec- 18 tion (b) , and 19 "(C) that he is assured that the State wiII com- 20 ply with the assurances provided with the application 21 under consideration. 22 "(2) Whenever the Secretary, after reasonable notice 23 and opportunity for a hearing to the State, finds wit'h respect 24 to funds paid to it under a grant under subsection (a),, that 25 the program or programs are nit operojZg-*ctivelg to 9©-aa6 0 - 7. N -_ O W ~ © Cn Cj N

7 lescribed in itive health program in Aed by the each such e provision ,riorities of' i changes;. . the State bailed plan e primary , the bur- causes of :her fun& ecounting -cribed in ti-e health ogram in 'd bv the N'h such r,rovi.ion ~ Of snch 4 1 proposed changes; the reasons for such changes; and„ the 2 amount of Federal funds need'e& by the State to make g such changes; 4 "'(5) that the plans described in paragraphs (1). 5 and (3)- g "' ('A ) shall describe a comprehensive preven- q tion program which utilizes, to the extent practi- 8 9 10 11 12 13 14 15 16 17 18 19: ' 20 ft I'. cable, all relevant professional disciplines; "(B) may, at the option of the. State, describe a program or programs that are targeted toward's a particular age group ; "(C) shall set forth quantitatively the current relevant rates of mortality andy where appropriate, of morbidity in the State; "(D) shall set forth the quantitative goals for reduction in the relevant rates of mortality and, where appropriate, of morbidity in the State; "(E) shall have a separate health communica- tions component in the program or programs: which shall include, but not be limited to, a description of how the communications media, inoluding, the elec~ 22 tronic media; will be utilized' to effectuate the pur- 23 poses of the programs; 24` '' "'(F) shall identify -a specific" instith.itional en-

10 1 2 7 achieve their stated purposes or that there is a failtzre to comply substantially with assurances provided under sub+ 3 section (b) with respect to the.receipt of such grant, the 8 Secretary shall notify the State that further payments will not be made t'o it under such grant (or in his discretion thatfurther payments will be reduced), until he is: satisfied that the program or programs will operate effectively or there will no longer be such a failure. Until' he is so satis - g fled, the Secretary shall make no payment' or, in his dis- 16 17 18 19 20 21 22 23 cretion, reduce payments to the State from such grant. "(d) (1) The totaU amount of grants received by a State under subsection (a) to assist States in planning for preventive health services for the fiscal year ending Sep- tember 30, 1980 shall be determined by the Secretary, except that it may not be less than the product of $0:20' and the population of the State. "(2) The total amount of' grants received by a State ttnder subsection (a) to assist States in providing preventivee health services' for any fiscal year shall be determined by the Secretary, except that it- "(A) may not exceed the lesser of- "(i) the product' of' $0.75 and the population of! the State, or 24 "(ii) in the case of the fiscal year ending Sep- 25 tember 30, 1982, 5 per centum of the amount of 1 1 2 3 4 6 7 8 9 10 8 State and local: ex services supported within the State ii ended on or before fiscal year ending centum of the amo. State's fiscal year 1 1982; and, in the c, tember 30, 1984, such expenditures befor d d on or e 11 en 12 13I 14 "(B) may not be h the population of the & " (3) The total amour. 15 under subsection (a) to a: 16 of operating the health cotr 17 preventive health services p 18 be determined by the Secrc 19 less , than the product of S, 20 21 22 O 23 W 24 © C.~ 25 W State. luotwithstandixig par for any fiscal year the am, year under subsection (1) to make grants for that fisc paragraphs to all States, th fiscal year for a State shalll i

V Page a U.S. Senator from the State of Kentucky________ Hon. Wendell H. Ford 94 11 , , Food Marketing Institute, Dennis M. Devaney, counsel; prepared A ' statement --------------------------------------------------------- 884 )r Page Foote, Emerson, former vice cha;rman of the board, American Cancer Society, prepared statement_________________________________________ 214 410 Georgia Department of IIealth, Joseph A. Wilber, M.D., director for adult prepared statement_________________________________ health services 526 ie I; , Giant Food Inc., Janet E. Tenney, nutritionist, office of consumer affairs, prepared statement------------------------------------------------- 690 .Ie. id Green Dolmatch Advertising, Inc., New York, N.Y., Paula Green, president, preparedi statement------------------------------------------------- 192. id 'd, al -_ 00 Haas, Ellen, director, consumer division, Commun_ty Nutrition Institute; Robert O. Nesheim, Ph. D., vice president of science and technology, The Quaker Oats Co., representing the Grocery Manufacturers Association ; Michael F. Jacobson, Ph. D., executive director, Center for Science in4he he 39 Public Interest ; Ira I. Somers, Ph. D., executive vice president and director of laboratories, \ationaliFood Processors Association; and Janet E. Tenney, nutritionist, office of consumer affairs, Giant Food, Inc., accompanied by H. Edward Dunkelberger, Jr., counsel, National Food cts Processors Assoc:ation, a panel_____________________________________ 600 --- 208 Prepared statement'----------------------------------------------- 608 Ird 514, Hanneman, Gerhard J., associate professor of communications, Annenberg School of Communications, University of Southern California_________ 398 )H ___ 836 Hart, Hon. Gary, a U.S. Senator from, the State of Colorado, prepared statment ---------------------------------------------------------- 305: _-- 854 Health Education Foundation, Morris E: Chafetz, M.D., president, prepared D. statement --------------------------------------------------------- 538 , 221 International Foodservice Manufacturers Association~ prepared statement 918 or Kellogg Company of Battle Creek, prepared statement (with attachment) 881 , _ 218' Lazar, Dr. J. Brett, health officer, DiontgomeryCounty Healt'h~ Depart~ment, ive representing the, National Associ'Qtion of Counties and the American Public Health Association 374 -_- 372 __________________________________________ D:, 685 Leffall;, Lasaile D., Jr., M.D., president-elect, American Cancer Society, accompanied by Donald Young, M.D., member, American Thoracie So- ion, _ 08 ciety, and former medical director, American Lung Associationq Robert, M. Daugherty, Jr., M.D., Ph. D;, cha^rman, subcommittee on smoking, ical American Heart Association; John S: Banzahf III„ executive director and chief counsel Action on Smoking and Health a panel 198 lof , , , ------------ Prepared statement 208 Aor s E. 10 _______________________________________________ Manoff, Richard' K., chairmany Richard K. Manoff, Inc., and president, Manoff International, Inc___________________________________________ . 83' _ 412 Prepared st'atement----------------------------------------------- 390 Jr., -- 915 McGinnis, Michael, 'M.D.,,Deputq Assistant Secret'aryfor Health for Special Health Initiatives; accompanied by Donald Millar, Center for D'sease Ired ---- 3'-'0' Control; and Taylor Quinn, Bureau of Foods, U.S. Food and Drug. Administration ---------------------------------------------------- 328 Prepared stat!ement_______________________________________________ 339 National Association of Broadcast'ers, prepared stat'ement______________ 844 rli__ llifi National Food Processors Association, Ira I. Somers, Ph. D., esecutivee vice president and director of laboratories, prepared statement_________ 717 17!) President's Council on Physical Fitness and Sports, C. Carson Conrad, !aooI EaecutiR•e, Director, prepared statement_____________________________ 412 - :{71) Public Communications Center, Pelhazn~ Manor, N.Y., James %V. Swinehart, +lrll Ph. D., director, prepared; statement_________________________________ 187 U.} !2i; Quaker Oats Co., Robert 0. \esheim, Ph. D., vice president of science and technology, prepared statement______________________________________ 676 rn Richard K. AIanoff, Inc.,,Richard K. Manoff, chairman, prepared statement 390 1Niil Steen, Lowell H~, M.D., representing the Amer`c•an~ Jledicall Association, aceompanied by Harry N. Petersonl director, department of legislation, Ameriean Medical Association______________________________________ 368 129,

Page es and ient as House ------ 93 Lent___ 8'0 icology Dedical ~nt---- 315 ------ 240 --- 887 ,fessor ------ 179 epared' 900 Jlartim • High~ anei__ 159 rssional 690 ,he \ a- 736 iter fbr ---- 499 by- '.versity, 178-_-- 466 )rtzllity istitute utes of )c'ated 3chatz, ------ 98 ' - 5599 avid: I. Tomm Health --- -- 62' Water ,tectiou iary of --- 31 )'vaui:r :.heard >1.\dm, - 37 .Y., Lv „~ nf 11,77 .13".." 'nnt I.;i -17s ~ VII Articles, publications„et cetera-Continued Guidelines for Preparing Nutrient Statements for: Page Canned asparagus-------------------------------------------- 738 Canned cut green beans-------------------------------------- 742 Canned beans (waY)---------------------------------------- 747 Canned beans (lima) ---------------------------------------- 750. Canned beets------------------------------------------------- 753' Canned carrots..---------------------------------------------- 756 Golden creami style corn______________________________________ 759 Canne&yellow whole kernelicorn_______________________________ 763 Canne& sweet: peas------------------------------------------- 771 Canned spinach--------------------------------------------- 775: Canned sweet potatoes---------------------------------------- 779 Canned tomatoes--------------------------------------------- 782 Canned stewed tomatoes-------------------------------------- 785 Canned tomato juice----------------------------------------- 788 Canned tomato paste----------------------------------------- 796 Canned tomato puree----------------------------------------- 799 Canned tomato sauce----------------------------------------- 803 Apricot halves----------------------------------------------- 807 Apricot nectar----------------------------------------------- 813 Canned fruit cocktail_________________________________________ 816 Clingstone peaches------------------------------------------- 821 Freestone peaches-------------------------------------------- 826 Canned tuna------------------------------------------------- 832 Health Education Foundation, description of organization----------- 575 HEF News, Voh 1, No. 11I, from the Health Education Foundation„ Washington. D-C----------------------------------------------- - 5~7 Ineffective Filters in Reducing Carbon 1lonoside Through Filtration__ 118 lfortality in Selected Cities with Fluoridated and Non-Fluoridated Water Supplies, by J. David Erickson, D:D.S., Ph. D., Chronic Diseases Division„ Bureau of Epidemiology, Center for Disease Control, Atlanta, Ga., from the New England Journal' of' DZedi- cine. May 18, 1978---------------------------------------------- 446 NA's Survey Result's: What Consumers Want (And Don't Want), To See on Food Labels, from, Nutriti'on~ Action: June 1978------------ 692' Overview-Heait'hi Consequences of Smoking, from the U.S' Department of IIealth, Education, and tiCelfare; Public Service, Cent'er for Disease Control, 1975___________________________________________ 313' President Carter Expresses Personal and Administration, Support for Fluoridation„ telegram to Dr. Frank Sheler, president, American Dental Associatlion, Miami, Fla., October 1077____________________ 996 Proposed Label by the National Food Processors Association-___---- 734: Proposed Labeling Under S. 3117__________________________________ 735 Public Health Service Smoking and Health________________________ 124 Reid Brothers, a partnership, 1977 crop year net income------------ 97 Research Shows \oi Mutagenic Effects: From Fluoride, by the ChiefS Laboratory of Developmental Biology and Anomalies, \ ational In- stitute of Dental Research, National Institutes of Health, September 1977 ---------------------------------------------------------- 495 Safety of Water Fluoridation, by Ernestl \ewbrun, D.M.D., Ph. D.,, professor of oral~biology and cha'rman of the section ofbiologicali sciences, University of California, school of dentistry, San Francisco, Calif., from the Journal of the American Dental Association, Febru- ary 1977------------------------------------------------------- 427 Selectedi Corporations and Public Authorities Conducting Employee Heaith/FithessProgTams, from the President''s Counc?1 on Physical Fitness,and Sports--------------------------------------------- 595 Statewide Antifluoridation Initiatives: A\ew Challenge to Health \Vorkers; by Caswell A. Evans, Jr., D.D.S., .ILP:H. ; and Tomm Pickles, D.M.D., M.P.H.,, from AJI'H; January 1978______________ 472 Surveilltinee of Nutrition Labeling in the Retail Packaged Food Sup• p1P, by Raymond E. Schucker___________________________________ 619 "Tar" and Nicotine Content of C'garette Smoke in Relation to Death Rates, by E. Cuyler Hammond, Lawrence Garfinkel, Herbert Seid. man, and Edward A. Lew, department,of epidemiology and statistics, American Cancer Society, New York, \.Y------------------------ 2261

CONTENTS Text of : Page S. 3115---------------------------------------------------------- 4 S. 3116---------------------------------------------------------- 52 S. 311'8---------------------------------------------------------- ---------------------------- usylvania it ansylvania t CHRONOLOGICAL LIST OF' WITNESSES MAy 25, 1978' Ford, Hon. Wendell H.,, a U.S: Senator from~ the State of Kentucky______ 94 Foege, William H., \IID., Director, Center for Disease Control; \orman Kretchmer, M.D., Director, \ationali lnstitutes of Child Health and Human Development ; and Johni Pinney, Director, OfHce of Smoking and Health, Department of Heaithj Education, and Welfare, a panel__ 109 Wolfe, Theresa and Moira Reilly, Immaculata High School; Jiartin O'\Ialley, Mark Adams, and Charles Grif6th„ Gonzaga College High School; and James Valeo, Bethesda-Chevy Chase High School, a panel__ 159 Evans; Richard I., Ph. D., professor of psychology, University of Houston, Houston~ Tex., accompanied by James: W. Swinehart, Ph. D., director, Public Communications Center, Pelham Dianor, \.Y. ;, and' Paula Green, president, Green Dolmatch Advertis=ng, Inc.,, New York, N.Y., a panel__ 166'. Leffall, Lasalle D., Jr., M.D;, president.elect, American~ Cancer Society, accompanied by Donald Young, M.D., member;, American Thoracic So- ciety, and former medical director, American Lung Association ; Robert M. Daugherty, Jr., JLD:, Ph. D:,, chairman, subcommittee oni smoking. AmericalrHeart AssociaVon; John S. Banzahf fII, executive director and chief counsel; Action on Smoking and Health, a: panel_________________ 198 Jv:Nn 7, 1978 McGinnis, Michael, M.D., Deputy Assistant Secretary for Health for Special Health Initiatives, accompanied by Donald Millar, Center for Disease Control; and Taylor Quinn„ Bureau of Foods,, UIS. Food and Drug Administrateon ---------------------------------------------------- 328. Fielding, Dr. Jonathan E:, commissioner of public health, Commonwealth of Uiassachusetts--------------------------------------------------- 364 St'een, LocvelL 11, M.D., representing; the American Medical Association, accompanied by Harry N. Peterson~ director, department of legislation, American Medical Association_______________________________________ 368 Arnold, Dr. Charles B., president, the American, College of Preventive Medicine ---------------------------------------------------------- 372 Lazar, Dr. Js Brett, health officer,, Montgomery County Health Department, representing the National Association of Counties and the American Public Health Association------------------------------------------ 374 Farquhar, Dr. John, SV., professor of medicine, Stanford Univers: tw School of 3ledicine-------------------------------------------------------- 379 Jianoff, Richard K., chairman, Richard K. 'Manoff, Inc., and president, Manoff International, Inc___________________________________________ 383' Hanneman, Gerhard J., associate professor of communications, Annenberg School of Communications, University of Southern California--------- 398

4 93TH CONGRESS 2D sEssioN St 3115 1 FORMULA dR.AT 2 SEC. 102. Eff ' 3 by adding after s INTH E SENATK OF THE UNITED STATES heading theret'o : MAY 19 (legislative day; MAY 17), 1978 4 Mr. KENNEDY (for hlmself,.jfr. WILLIAWa, Dfr..CxAFEE,.Air..RANDaLrx,,Mr... 5 "FORMULA GRAN PELL, Mr. RiECLE, Mr. McGbvEaN, Mr. HART, an&Mr. LEAHY) introduced the following bill; which was read twice and referred to the Committee On Human Resources 6 7 SEC. 315. (: A BILL To establish a comprehensive disease prevention and health promotion program in the United States. 1 Be it enacted by the Senate and House of Representa- 2 tizes of the United States of America in Congress assembled, 3 That this Act may be cited as the "Disease Prevention and 4 Health Promotion Act of 1978". 5 TITLE I-FORTMULA AND PROJECT GRANTS 6 FOR PREVENTIVE HEALTH SERVICES 7 SEC. 101. Whenever in this title an~ amendment is es- 8 pressed in terms of' an' amendment to a section or other pro- 9 vision, the: reference shall be considered to be made to~ a ~.. 10 section or ot'her provision of the Public Health Service Act: 10 11 12 6. 13 (b) No gr:~ 14: unless an applica 15 16 17 18 19 20 21 22 23 O 24 W ~ O W 8' States to assist t: g costs of providing or contracts or boi subdivisions of' th entities) preventi- approved by, the such form and be shalll by regulattiof in an application f, "(,i ) for reduce, throuk causative conc of the five ler "(;2)the' obligated by

15 individual th a grant -h individ- 1i informa- discl'osure lorisre- of a State, m may be ; or to an provisions: vhich are .vice pro- ;rams as, ident for , and' on ie ext'ent onditions on (b) , 12 1 on the amount of funds obligated under grants under subsec- 2 reception room, conference room, or hearing, room in any 3 operating programs: to prevent the diseases and conditions 4 referred to in paragraphs (1) and (3) of subsection (b) ; 5 and on the effectiveness of the programs assisted under 6 grant's under subsection (a) in preventing such diseases and 7 conditions. 8 "' (k) (1) For purposes of paragraphs (1) and (3) of 9 10 11 subsection~ (b), the term 'primary prevention of causative conditions' means the prevention of the development of the conditions in healthy individuals. 12 "' (2) For purposes of paragraphs (1) and (3) of sub- 13 section (b) ,`secondary prevention of causative conditions' 14 means the early detection of the condit'ions in~ asymptomatic 15 individuals. 16 "'(3) For purposes of'paragraph (d) (1') (B), the.term 17 'State and lbcal expenditures for preventive health services' 18' means expenditures by State an& local public health authori- 19 ties for preventive health services supported by grants 20 under subsection ('a) but excludes expenditures by such 21 authorities- 22 "(A) spec:ificalNy required by Federal statutory 23 law as a condition to the receipt of Federal financial 24 assistance, or

23 proceedb onnection it of that'~ by ot4er r effective 'eneral of !presenta- exa.mina- ds of the pertinerIt individual _i a grant iu individ- formation closure is or is re- 4 a State, ;ratn may 1, or anv such 20 1 "(h)~ Nothing in this section shall limit or otherwise 2 restrict the use of ftimds which are granted to a State or 3 to an agency or a political subdivision of a State under 4 provisions of FederaL law (other than this section) and 5 which are available for the conduct of~ preventive health 6 service programs from being used in connection with pro- 7 grams assisted through grants under subsection (a) . g "(i) The Secretary shall submit to the President for 9 submission to the Congress on January 1, 1981, and on 10 January 1 of each succeeding year a report on the estent. 11 of t'he problems presented by the diseases and conditions 12 referred to in subsection ( j); on the amount of funds obli- 13 gatied under grants under subsection~ (a) in~ the preceding 14 fiscal year for each of the programs listed in subsection ( j); 15 and on the effectiveness of the activities assisted under grants 16 under subsection (a) in controlling such diseases and 17 conditions. 1s "(j) (1)~ For payments to States under grants under 19 subsection (a)' for establishing and maintaining programs 20 for the screening, detection, diagnosis, prevention, refer- 21 ral for treatment, an& followup on compliance with treat- 22 ment ofhypertension, thene nre authorize& to be appropriated 23 $30;000,000 for the fiscal year ending September 30, 1980; 24 $35,000~,000~ for the fiscal year ending September 30, 1981,

loubled. Among ore than~ a pack itane of teenahe >ut at, a disturki- of these y oung will be marred rlier they start i at age 16, and rrlierthan their he lung, mouth, )re emphy.sema, cart attacks and ire catastrophe. o a habit which generates for a re a number of ; or encouraging h programs are ning. Deterring in dealing with ly hazardous to ivironmental or ~e in death and heard extensive cing debate. «'e fourth has sttb- ,e cListinb i'shed zed the bulk of ewed! all of the ~ett~e smokinh is )cen raised from ence concerninnal problem. The iScouu•a~ing cig. hildren are pri, >ae aclear role kerh tlicilr clril- "ountlr~sOther railroacl f liik f„r dnig ~ nsake cr•rt,lin ~~„f tli1• al„. Today ws will explore the phenomenon, of childhood smoking, and we will examine some potential strategies for dealing with it. I am confident that with the'help of the kind of witnesses we will'hear from, today, we can organize effective, acceptable and noncoerciv.e programs for blunting the epidemic of childhood smoking in thiscountiry. Before proceeding, Iwouldlil:etoexpress myregi•et that the tobacco industry was unable to provide a witness to represent its point of view at this morning's hearing. When S. 3115 was introduced 6 dayss ago, we invited the Tobacco Institute and'several tobaceo companies to appear at this sessionL They informed us that this was not sufficient warning, and that they coukU not find a single individual from the Institute or from any of the companies who could appear today. I would only point out that among the witnesses we have with us today are several who~ were not told until 3 or 4 days ago that we wanted them to attend. Senator Ctr A M-E. I am cosponsor of this bill which we are consider- in« today, -whichdeals with the area of prevention. It seenas to me that there is something off-kilter in our whole system of expenditures for medical care in thejTnited States in that we pour billions of dollarsinto, taking care of people who are illa--andthat is proper and right- but 'wepour about 2 percent of that amount iiitotryingt'o keep people healthy, in the whole area of preventive medicine. And so this bill,, which Senator Kennedy was the primary sponsor of and which I am a cosponsor of, deals with this particular area. The bill has several see- tions. The area we will be considering today deals with the subject of deterring, smoking amongst our children and relating, to thezvhole problem of cigarette smoking. Now, over the years this subcommittee has heard testimony on hundreds of healt~h issues, but it seems tomefezvof them liaveconcen- trated in the area of preventive medicine. What we are considering today, is the subject of cigarette smoking and its damaging effect~s on, the health of our entire citizenry, and wearepart'~icula-rlyconcerned no.cwith the young people who are smokingin, increasing numbers. tiVefirst have a statementlfrom Senator Schweiker, and then we will proceed with our first distinguished witness. Senator ScFrwErt.En. Thank you very much, Mr. Chairman. I am not a sponsor of thispartieular bill. Idid agree to sponsor the billi on t'hehealth education, program on which anotherheamng will be hel'd,, so I«ould like the record to show that I did not cosponsor S. 3115, thee c.oinprehensive bill, or S. 31117 or S. 3118, because I have some unre- solved problems on both bills. I amia sponsor of S'. 3116, aa bill which expandsformula grants and project grant programs, andcreat'es a new program on health promotion and diseasee prevention. I come here with an open mind and will be glad to heart'hetesti- mony: today. Thank youi very m2uh, llr: Chairman. [The texts of S. 31115; S. 3116, and S. 3118 follow :]

13 d for such nount ap- .mt needed such fiscal ~ made for ,ar period ning, after :nd'er such limates or s justment's d in such~ he Seere- 'h a ants. , hich is=a -duce 'the or equip- nd truWl ernmeat ny ot~ter ofpieer ` o r tli e 10 1 detail of such an officer or employee is for the convenience of 2 and at the request of such State and for the purpose of pla.n- 3 ning or carrying out a prograan with respect to which the 4 State grant under subsection (a) is made. The amount by 5 whi& any such grant is so reduced shall be available for g paymentl by the Secretary of the costs incurred inn furnishing 7 the supplies or equipments or in detailing the personnel, on g which the reduction of such grant is based, an& such amount g sli,all be deemed as part of the grant and shall be deemed to 10 have been paid to the State. 11 "(g) (1) Eu.ch State which is a recipient of a: grant 12 under subsection (a) shall keep su& records as the Secretary 1,3 shall by regulation prescribe, including records which fully 14 disclose the amount and disposition by such State of the 15 ,, proceeds of such grant, the total cost of the undertaking in 16 connection with which such gra,nt was made, and the amount 17 of that portion of' the cost of the undertaking supplied by 18 other souxces, and such other records as will facilitate an 19 effective audit. 20 ." (2) The Secretary and the Comptroller General of 2j. the United Sta#es;.. or *Ay of,their duly authorized representsi- 22 . tives; shsill have a+oce.ss for the purpose of audit and egamicuti- 23 tion to anvy books, doc=ents; pa.pers, and records of each 24 State which is a recipient of a grant under subsection ('a). 25 that are pertinent to $u<sh grant.

12 9 1 bears the same ratio to the amounts determined for such 2 State in accordance with this section as the amount ap- 3 propriate& under subsection (1) bears to the amount needed 4 to make grants in accordance with this section for such fiscal 5 year to all States. 6 "(e) Each grant! under subsection (a) shall be made-for 7 costs.for preventive health services in the one-year period 8 beginning on the first day of the first month beginning after 9 the month~ in which the grant is made. Payments under such 10 grants may be made in advance on the basis of estimates or 11 by the way of reimbursement, with necessary adjustments 12 on account of underpayments or overpayments, and in such 13 installments and on such terms and conditions as the Secrie- 14 tary finds necessaryy to carry out the purposes of such grant,. 15 "(f~) The Secretary, at! the request of a; State which is~-a 16 17 18 19 20 1 detail of such an officer or e 2 and at the request of such ~ 3 ning or ca.rrying out a pril 4 State grant under subsecti 5 which any such grant is. 6 payment by the Secretary 7 the supplies or equipment g whioh the reduction of su,1 9 shall be deemed as part c 10 have been paid to the Stat~ 11 1° ('g) (1) Ea,ch Sta under subsection (a) sha shall by regulation pres, disclbse the amount an •proceeds of such gran't,. recipient of a grant under subsection (a), may reduce Ihe 16 amountl'of such grant by- 17 "('1) the fair market value: of any supplies or equip- 18 ment furnished the State, and - "(2) the amount of the pay, allowances, and travel 19 2fj 21 expenses of any officer or.empioyee of the Governmei~t 22 when detailed to the State and the amount of any o&r 23 costs incurred in connection with the detaili of such officer 24 - or employee, 25 when the furnishing of' such: supplies or equipment or 'tke 21 the Uaited States,-or A s connection with which of that portion of the other 'sources, and suc: effective a.udit. "(2) The Secret; 22 . tives, sha]1 have apcess 23 tion to any books, dc O 24 State which is a reci ~ 25 that are pertinent to s W W U1

25 eptember 30,. L)' for estab- iize children poliomyelitis, here are au- te fiscal year ie fiscal year for the fiscal ~or establish- L flhoridation ted $5,000,- 30;, $5,000,- 1'981, and r 30, 1982. or establish- ,vent illness~ ronment of tances, and are author- I year end= fiscal year 22 ending September 30, 1981, and $12,000,000: for the fiscal: year ending,September 30, 1982. I "(5) For payments under subsection (a) for establish- ing and rnaintaining programs to prevent diseases borne by rodents, there are authonized: tb: be appropriated $14,000,000! for the fiscal year ending,September 30,, 1980, $14,000,000: for the.fiscal year ending September 30, 1981„and $14,000,- 000 for the fiscal year ending September 30, 1982. "(6)' (A) The Secretary shall establish, after consul- tation witk the President's Council on Physical Fitness, 3 4 5 6 7 8, 9 10 11 12 "(B) For payments under subsection (a) for establish- 13 ing and maintaining comprehensive physical fitness pro- 14 grams that are consistent with the standards established 15 pursuant to paragraph ( A), there are authorized' to be 16 appropriated $10,000,000 for the fiscal year ending Septem- 17 ber 30, 1980, $12,000,000 for the fiscal year ending 18 September 30, 1981, and $15,000,000 for the: fiscal year 19 ending September 30, 1982.". 20 (b) Section 503 (a) of Ptiblie Law 91-695 (relating to 21 authorizatfions for lead-based paint poisoning prevention pro- 22 grams) is amended by inserting bef'oretheperiod at theend 23 thereof: ", $14,000;000, for the fiscal year ending Septem- 24 ber 30, 1980, $14,000,000 for t'he fiscal year ending, Sep- standard's for camprehensive physical fitness programs.

24 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16' 17 21 and $40,000,000 for the fiscal year ending September 30, 1982. "(2) For payments under subsection (a) for estab- lishing and maintaining programs to immunize children against diseases (including measles, rubella, poliomyelitis,, diphtheria, pertussis, tetanus, and mumps),, there are au- thorized to be appropriated $35,000;000 for the: fiscal year ending September 30, 1980, $35,000,000 for the fiscal year ending September 30;, 1981„ and $35,000,000 for the fiscal year ending September 30, 1982. "'(3) For payments under subsection (a): for establish- ing and maintaining community and'school-based fluoridationi programs, there are authorized to be: ajtpropriate& 85,000;- 000 for the fiscal year ending, September 30, 1980, $5;000;- 000 for the fiscal year ending September 30; 1981, and $5,000,000 for the fiscal year ending September 30, 1982. " °(4) For payments under subsection (a) for establish- 18 ing and maintaining programs designed to prevent illness 19 20 caused by factors in the inanediate living environment of people such as localized exposure to toxic substances; and 21 improper storage of solid waste and fuels, there are author- 22 ized to be appropriate& $12,000,000~ for the fiscal year end- 23 ing September 30, 1980, $12,000,0W f'or the fiscal year 1 2 3 4 9 10 ending September 3C year ending Septembc "'(5) For paynu( ing and maintaining rodents, there are aut: for the fiscal year eni for theIscal year end 000 for the fiscal yea: «(6) (A) The tati.on with the Pre 11 standards for compre; 12 " (B) For paym( 13 ing and maintaining, 14 grarns that are con: 15 pursuant to paragral 16 appropriated 810,000 17 ber 30, 1980,$12, 18 September 30, 1981. 19 ending September 30;. 20 (b) Section 503 . 21 authorizations for lea( 22 grams) is amended b, 23 thereof: ", $14,000;C 24 ber 30, 1980, $14,0( 0 - 78.- 3

34 ;e of any or flavor- ition that' ; on the of such ecretary irtificial ients of Isult in iall by ,duire- ealed: ;raph id in rma- tion lud- 1 "(A) the total number of calories and grams per 2 serving, 3 "(B) the percentage per serving of protein, fat, 4 sugar, starch, and akohol in terms of caloric content, and 5 "(C) the grams per serving of protein, saturated 6 fat, unsaturated fat, sugar, starch, alcohol, sodium, 7 cholesterol, and any other ingredients as the Secretary 8 g by regulation~prescribes~ "(2), The Secretary is~ authorized, where appropriate, 10 to prescribe: by regulation~ a system of symbols, figures, or 11 other devices which will enable consumers to readily eom- 12 prehend the nutrition information required to be placed on 13 labels by paragraph (1) . 14 "(3) To the extent that compliance with the require- 15 ments of subparagraphs (1) and (2') is impracticable, the 16 Secretary shall by regulation prescribe exemption from such 17 requirements.". 18 PREEMPTION 19 SEC. 303. Chapter IV is : amended by adding after sec- 20 tion 411 the following new section~: 21 "STATE AND LOCAL FOOD LABELING REQUIItEMENTs 22 "SEC. 412. (a) Except as provided in subsection (b), 23 no State or political subdivision of a State may establish

32 1 2 3 4 5 6 7 8 9 10 29 into arrangements with recipients of grants under sections 315 and 317 for the provision of' appropriate an& necessary technical assistance, and (2)', shall develop and disseminatee to suchi recipients approaches, methodologies, policies, and standards for delivering preventive health services. `° ( d) For the purpose of making payments pursuant to, grants under subsection ('a) , there: are authorized to be appropriated $10,000,000 for the fiscal year ending Septem- ber 30, 1980, $10,000,000 for the fiscal year ending, Sep- tember 30; 1981, and $10;000;000 for the fiscal year ending 11 September 30, 1982.". 12 CObiIIUN ITY B ASED DEM!O1 STRATIONS OF' 13 PREVENTIVE HEALTH SERVICES 14' SEC. 202. (a) The Secretary of Health, Editcation, and 15 Welfare shall undertake or support (through grants or con- 16 tracts or both) five intensive and comprehensive community 17 based programs for the purpose of demonstrating and evalu- 18 ating optimal methods for organizing and delivering compre- 19 hensive preventive health services to defined populations. 20 (b )' The Secretary shall submit to the Committee on Hu- 21 man Resources of the Senate and the Committee on Inter- 22 state and Foreign Commerce of the House of Representa- 23 tives on January 1, 1981, and on January 1 of every second 24 year thereafter a report on the programs undertaken or sup- 25 port'ed ander subsection (a) including, but not limited to, a 33 30 1 detailed description and an eva 2 each such program. J (c) For the purpose of :} d'emonst'rations and evaluatinns ; there are authoriied' to be », 6 each of! the fiscal years endiu,~ 7 ember 30, 1981, Sepember 34 8 and Sepember 30, 1984. 9, NATIONAL DISEASE PRE' 10 SEC. 203. (a) The Secrr 11 tional Center for Health Stai 12 submi't to Congress on Januar 13 of every third year thereafter„ 14 data profile in order to provi& 15 implementation of this Act an, 16 of the prevalence, incidence, 17 ventable causes of' death and ~ 18Suclt profile: shall include at'a i 19 (1) mortality rates 20 (2) morbidity rate~ 21 diseases; 22 (3) the physical 'c 23' population of the U.nite O 0~ 2} between these determina

1 2 3 4 5 6 7 $ 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 14 11 "(h) All information obto.ined' about any individual under any program that is being carried out with a grant made under subsectioni (a) shall not, without such individ- ual's consent, be disclosed, e$cept that (1) such, informa- tion may be disclbsed without such consent if the disclosure is necessary to provide service to such individual or is re- quired' by a law of a State or political subdivision of a State, and (2) information derived' from any such program may be disclosed- "(A) in summary, statistical, or other form, or "(B ) for clinical or research purposes, but' only if individually identifiable personal data of any such individual is not disclosed. "(i)i Nothing in this section shall limit or otherwise re- strict the use of funds which are granted to a: State or to an agency or a political' subdivisim of a St'ate under provisions of Federal law (other than this section) and whi& are available for the conduct~ of preventive health service pro- grams from being used in connection with progranus as- sisted through grant's under subsection (a) . "(j) The Secretary shall submit t'o the President for submission to the Congress on January 1, 1981, and' on January 1 of! each succeeding year a report on the extent of the problems presented' by the diseases and conditaons! referred to in paragraphs (1) and' (3) of subsection (b ); i 1 on the amount of funds oblig 2 reception room, conference 3 operating programs to prev- 4 referred to in paragraphs (I 5 and on the effectiveness o 6 grants under subsection (a), 7 conditions. 8 "(k) (1) For purposes~ 9 subsection ('b) , the term `I 10 conditions' means the preve 11 -12 13 conditions in healthy individ " (2) For purposes of 1 section~ (b) , 'secondary pr( 14 means the earl{y detection o 15 individuals: 16 "( 3) For purposes of F 17 'State and local egpenditurE 18' means expenditures by Stat~ 19 ties for preventive health 20 under subsection (a) but' 21 authorities - 22 " (A ) specifically 23 law as a condition to 24 assistance, or

td'ding atthe ;ubparagraph. ate not more Ith program 'REti'E1T- N Sem•ice Act by sectiun~ I nd heading 1T-~ the Sec- viding such < ()f grants c; conduct- <t-effeative- :rams; and ui& stand- tiecretalrY vntitics~ in x centct;,; 'ripliiiaa•t- 31 28 1 health promotion. Tb the extent practicable, the Secretary 2 shalll provide assistance under this section so that at least 3 five such cent'er.s will be in operation by October 1, 1981. 4~ "('b)(1)Nograntmaybe made ander this~section for 5 planning or dev eloping a center unless theSecreta~rydeter- 6 mines that when itl is operational it will meet the reqtiire- 7mentslisted in paragraph (2)~ and be! able to provide 8 assistance and dissemination of information to recipients of 9 grants under sections 315 and 317as provided insubsections 10 (a) and (c) . No grant may be made under this section for 11 operation of a center unless the center meets such require- 12 ments~ and is able to provide: such assistance and dissemina- 13 tion of information. 14 "'(2) The requirements referred to in paragraph (1) 15 are as follows : 16 "( A), There shall be a full-time director of the NCenter who possesses a dt;monst'rated capacity for sub- 1& stantial' accomplishment, and leadership in health pro- 19 motion, an& there shalli be such additional professional 20 staff as may be appropriate: 21 " (B) The staff of the Center shall represent a 22 diversity. of relevant disciplines. 23 "(C)Such additional requirements as the: See- 24 retary may by renulatiion pr.escribe. 25 "(c)' Centers assisted underr this section (1) may enter

33 under sections and necessary nd disseminate , policies, and -ices. lents pursuant thorized to be iding Septem~ .r ending Sep- al year ending vs OF i ,iducation,, and grants or con. ve community ing and evalu- -ering compre- populations. !mittee on Hu- ttee on Inter- f Representa- every second •taken or sup- t limited to, aI 30 detailed' description and an evaluation of: the effectiveness of each such program. 1 2 (;c) For the purpose of undertaking or supporting demonstrations and evaluations pursuant to subsection (a), there are authorized to be appropriated $10,000,000 for eachi of the fiscal years ending September 30, 1980, Sep- 3 4 J 6 ember 30, 19811, Sepember 30, 1982, Sepember 30, 1983, and Sepember 30; 1984. NATIONAL DISEASE'PREVENTION DATA PROFILE 7 8 10 SEC. 203. (a ) The Secretary, acting through: Nar 1i1 tional Center for IIealth Statistics or its, equivalent, shall 12 submit to Congress on January 1„ 1981, and on January._1 13' of every thir& yearthereaft'~er, a national disease prevention 14 data profile in order to provide a~ data base for the effective 15 implementation of' this Act and to increase public awareness 1'6 of the prevalence, incidence, and any trends in the pre- 17 ventable causes of death and disability in the United States. 18 Such profile shall include at a minimum- ~ 19 (1) mortality rates for preventable diseases; 20 (2) morbidity rates associate& with preventable. 21 diseases; 22 (3) the physical determinants of health of the 23 2-1 populat'~ion~ of the United St'ates and the~ relationship between these determinants of health~ and t'he ineidence~ O ~'

2 number of girls aged 15 and 16 who smoke more than doubled. Among teenage girlswho smoke, the percentage consuming,more than a pack of cigarettes a day has tripled. Fortunately, the percentage of teenage boys who smoke has stayed more or less unchanged-but at a disturb- ing 31 percent. Unless they find' the inner strength to quit, many of these young people will die prematureliy; and their declining years will be marred by chronic, d'ebilitating disease. On average, the earlier they start smoking, the shorter their lives will be. If they begin at age 116, and smoke a pack a day, they will die on average 6 years earlier than their nonsmoking friends. They will suffer more cancer of the lung, mouth, throat, bladder and pancreas. They willt contract more emphysema, bronchitis and vascular disease. They will have more heart attacks and! more ulcers. Our society is watching the makings of a health care catastrophe. We are watching our children mortgage their health toal habit which has no redeeming social value other than the income it generates for a very small proportion of our people. In the legislation we introduced last week, there are a number of provisions aimed' at discouragirlg adults from smoking or encouraging them to use cigarettes which are less hazardous. Such programs are important, but the real place to start is at the beginning. Deterring children from smoking must be our highest priority in dealing with cigarette smoking in this country. It will be argued that cigarette smoking is not truly hazardous to health, that the data is not conclusive, that other environmental, or occupational hazards explain the irrefutable increase in death and disability among smokers. In 1976, this subcommittee heard extensive testimony on the scientific issues involved in t'he, smoking debate. We heard from three vobeli laureates at that time, and a fourth has sub- niitted his views for this hearing. I think one of these distingui~:hed g'entlemeny Dr. Renato Dulbecco, accurately summarized'the bulk of this testimony when he said: "I have carefully reviewed all of the available evidence and' am fully convinced that cigarette smoking is the cause of 90 percent of lung, cancer. Doubts liav.e been raised f ronr timetot'imebut have on scientificvalidity** *." It will also be argued that, regardless of the evidence concerninZ the health hazards of cigarettes, smoking is a parental pro(',I~•n,. ''lii, Federal Government, some will' say, has no role in discoru:r1,in41 arettIe smoking among children. I am the first to agree that the smoking habits of ehildrmn :ur marily the responsibility of their parents, but I still 'rr a for Government in helping those parents who n'ish tn {:ee (v dren from smoking. First, the Government ways to protect the heal'thi of children. We ("1til f''ll"' tracks and' the sides of brid'ges. «`e t , ° ~th h ~ vide food for tho=e ~r r i t « ners: e p o con ~~ Second, the Fed'eral, GovernJnent lras t(le Cq'1e-,Al1"'"'" that parents and children receiv.e n fair and full (.:ct,irr rrls of cigarette smoking As long as the b", million a year advertismg its (~rMl°` ~' ~h~~ ~~~ f~ ;, ir for Government involvement in bn}nncin~ Today we will explore tl wen•ill examine some potE confident that withl t'he'hell today, we can organize effec( for blunt~ingthe epidemic c Beforeproceeding, I wou industry was unable to pr view at this morni'ng'sheai, ago, we invited the Tobacc to appea~rat this session. Tl .varning, and! that they co~ Institute or from any of t would only point out that a are several who were not t them to attend. Senator CHAr•EE: I am col ing today, which d'ealswith~ there is something off-kilte rnedicall care in theUnited. into taking care of people v but we pour about 2 percent, healthy, in the whole area which Senator Kennedyy wa cosponsor of, deals with thitions. The areal we will becdeterr.ing smoking amongs problem of cigarette smoki Now, over the years thL: hundreds of health issues, b trated in the area of preve, todav,, is the subj ect of ciga the healtlr of our entireciti now with the youngpeople«'e fi'i•st have a statementt proceed with our first distii, Senator ScFrwEncEx. Tha not a sponsor of' this partici the health education progra so I would' like the record to comprehensive bill, or S. 31 solved problems on both bil expands formula grants and program on health, promoti, I come here with an opei mony,today: Thank you, very much. ~ [The texts of S. 3115; S: 31

17 re facilities, con- populations shall figures avail'ablee payments underr in planning for ~ed to be appro- ; September 30, its under grants ig the costs of. are authorized .al year ending cal year ending cal year ending . the fiscal year ~nal' payments - es in meet'ing us component there are au- ie fiscal y ear lie fiscal year 14 ending September 30, 1982„ $35,000,000 for the fiscal year ending September 30, 1983, and'~ $35,000,000 for the fiscal year ending September 30, 1984.". 1 2 3 PROJECT GRANTS, FOR PREVENTIVE HEALTH SERVICES SEC: 103. (a), Effective October 1, 1979, section 317 4 5 and t'he heading thereto are amended to read as follbws: 6 "PROJECT GRANTS FOR PREVENTIVE HEALTH -7 8 SERVICES PROGRA:1fs "SEC. 317. (a): The Secretary may make grants to. States, political' subdivisions of States, other public entities„ 9 10 11 12 13 14 15 16 or private entities to assist them in meeting the costs of pro- viding preventive health services programs as set forth in subsection (j):. "(b) No grant may be made under subsection (a) un- less an application therefor has been submitted to, and ap- proved' by, the: Secretary. Such an application shall be in 17 such form an& be submitted in such manner as the Secretary 18 shalliby regulation prescribe and shall provide- 19 "(1) for a detailed plam of the program for which 20 21 22 23 24 25 the'applieant is seeking support under subsection (a) ; "(2) the amount of Federal, Stat'e„ and other funds obligate& by the applicantin, its latest annual accounting period for the provision of each program referred to in paragraph (1), ; a description of the preventive health services provided by the applicant in, such program in

26 23 1 tember 30, 1981, and $'14,000,000for the fiscall year Cnrlin,_e 2 September 30, 1982". 3 5 EXTENSION OF GRANTS TO S'r_YTE,S`, FOH' C('I]II'1t1SIIESSIVE PIII3LIC' IIEALTII SEItVICI•:S SEc. 104. (~a~)', Paragraphs (4)~ and'~ (5)! of'~ section 314 (d)', are amended to read as follows: (4) (A)~, The tot'a1~amount of (rrants received I)v State~~ health and mental health authorities nnder parag7apll (1) for any fiscali year shall be determined by the Secretary, 10 except that it'- 11 "(i) may not exceed the lesser of- 12 "(I)theproduct, of $1 and the population of13 the State, or 14 " (II) in the case of the fiscal year ending 15 September 30, 11980, 5 per centunn of tlieauiouiit. 16 of State an& lbcal expendithres, f'or colnprehelisive 17 , public health services withiutheState in the State's 18 fiscal year which~ elyded oni orbefbrcJuly 1, 1'979; 19 in the case of the fiscali year endiilgSepticnibm 30; 20 1981, 7~.,'-,,- percentumi of the,amount of such expeudi- 21 tures in the State's fiscal y.earwhich ended ou or 22 before July 1, 1980, and in tlrecaoe of the fiscal 23 year ending September 30, 1982, 10 per centuru of .24 the amount'; of; such expenditures in the State's fiscal 1 3 4 5 6 year whichen( "'(ii)), may not. " (I) the such authoritae> year ending Scli, " (II) the f th State 7 o e 8 Notwithstanding clause 9, appropriated for that fis 10 than the amount neede( 1'1 12 13 14 15 16 17 18 19 20 21 22 W 23 O 24 95 M in,accordance with such health authorities wit] amount of grants for t mental health authoriti, which bears the same such authorities in accor appropriated under su, needed to make grants such fiscal year to a11i S ities with approved app " (B) The Secreta mental health authorit grants to it under parag "'(i) the fair i ment furnishe& suc'

VI Page Sterling, Theodor D., professor, Department of Applied Mathematics and Computer Science, Washington University, St. Lou's, Mo., statement as present'ed to the Committee on Interstate and Foreign Commerce, Houseof~ Representatires, April 29, 19G9------------------------------------ 93 Articles, publications, et ,cetera-C' Guidelines for Preparing l\ utr Canned asparagus_______ Canned cut green beans _ Sugar Association, Inc., J. «'.,Tatem, Jr., presidpntl, prepared statement___ Temin, Howard M., American Cancer Societyprof'essor of viral oncology and cell biology, JlhArdle Laborat'ory for Cancer Research, the JIedical School, University of Wisconsin, Ziadison, Wis., prepared st'atement____ Tobacco Institute,the;,prepared statement'_____________________________ United States Brewers Associittion, Inc., prepared'statement------------ University of Houstbn, Houston, Tex., Richard I. Evans, Ph. D., professor of psychology, prepared statement___________________________________ Wine Institute, Arthur H. Silverman, Washington counsel, prepared statement ------------------------------ ------ Wolfe, Theresa and Jloira Reilly,, Iuuuaculata High School ; Martin O'Jialley, 'Mark Adams, and Charles Griffith, Gonzaga College High School ; and James' Valeo, Bethesda-Chevy Chase High Scbool„ a panel__ ADDITIO\AL INFOR.IIATIO\, Articles, publications, et eeterw: Adjuncts Report'ed! to be Employed in Brewing,,from the Congressional Record, `Ihzrch 12, 1973, page E 1'471----------------------------- Available Guidelines for Preparing \utrient, Statlements, by the Na- tional Canners Association; 1Vashington~ D.C_____________________ 850 315 240 887 179 900 159 90. 73G'. Canned beans (wax)___ Canned beans (lima)___ Canned beets:______-__-- Canned carrotis__________ Golden cream style corn_ Canned yellow whole kern, Canned sweet peas______ Canned spinach_________ Canned sweet potatoes___ Canned t'omatoes-_______ Canned stewed tomatoes_ Canned tomato juice____ Canned tomato paste____ Canned tomato puree____ Canned tomato sauce____ Apricot halves_-_______- Apricot nectar__________ Canned fruit cockt'ail____ Clingstone peaches______ Freestone peaches_-____- Canned tuna__________-_ Caries-Free Teenagers Increase with Fluoridation, by the Center for Disease Control, Jlay 1978---- ---------------------------------- Case Study of the 1976 Referendum in Utah on Fluoridation, a, by R_chard B. Dwore, assistant professor„College of Health, University of Utah,, from Public Health Reports, January-February 1978____ Claims of Relationship Between Fluoridation and Increased \Iortalityin Chile Not Valid, response from scientietsat the\ational Institutee for Child Health and Human Development, \ational Institutes of Health, on the paper "Increased D'eath~ Ratesin Chile Assoe'atedwith Artificial Fluoridation of Drinking Water", by Albert Schatz, Ph. D---------------------------------------------------------- F 499 466 98 Health Education Foundation HEF News, Vol. 1, No. 1-4, f Washington., D.C_______--. Ineffective Filters in Reducin Mortality in Selected Cities Water Supplies, by J. Da Diseases Divieion. Bureau Control, Atlanta, Ga., froi ciue: May 18, 1978_________ \A's Survey Results: What See on Food Labels, from, : act! Sheet onHealthy from theHealth, Education Foundation______ Fighting the Latest Challenge to Fluoridation in Oregon, by David I. Rosenstein, D:JLD.,, 11.P.H. ;, Robert Isman, D.D.S., .1l.P.H~; Tomm Pickles, D..1LD:, JIP.H. ; and Cra g Benben, B: A.,,from Public Health Reports, January-F ebruary 1978_________________________________ 5a9 462 ' Overriew-Hea1t'h,Consequenc of Health, Education, anc Disease Control, 1975__-__- President Carter Expresses P Fluoridation, telegram to . Fluoridation and Cancer: An, Analysis of Canadian Drinking Water Fluoridation and Cancer --NIortalit'y Data,, by the health protection brancht Departaient of Health and Welfare, Canada, summary of report ----------------- 31 Dental' Association, Miami, Proposed Label by the Natior Proposed Labeling Under S. ~ Public Health Service Smokil Fluoridtttion an(t3Iortality : An Epidemiologic Study of Pennsylscania Commun`ties, by George K. Tokuhata, Dr.PH, Ph. D. ; Edivard Digon, INIPH'SI; and Krishnani Ramaswamy, J1Sc, \iiSHyg, JiAdm, from Public Health Reports, January-February 197$_____________ Fluoridation of Water and~ Cancer Mortality ii>, the UIS.A. by 37 Reid Brothers; a partnership. Research i Shows \ o, Mutagen Laboratory of Derelopment stitute of Dental Researchy 1977, , Iticltard Doll and Leo Kinlen, department of regius professor of mecticine, Radcliffe Infimnary, Oxford, from the Lancet~ June 1977 Fluoridationof'Rater Supplies and Cancer: A Possible Association?by. P. D. Oldhamt _1IRC Pneumoconiosis Unit, L`andough Ho~;pitali Penarth, S. Glamorgan; Britain, and D. J. Aewell, University of 3"2 --------------------- Safety of Water Fluoridatio professor of oral biology a, sciences, University of Calif Calif., from the Journal of ary 1977------------------ \ewcastle upon Tyne, Britain, from~ Applied, StatistFcs; 1977____ F luoridation 1: The Cleveland Experience;, an epideuwiological Classic and theStat'us in Ohio, bsCharles A, Clark, D.D,S:, _II.S.,, JI.Sc., 3I.P.H., chaicnman, depart'mentl of community dentistry and assistant, prol'essorof community health,, school of medicine, CWRU_______ _ 451 7S' Q L„ Selected Corporations and P Health/Fitness' Programs, 1: Fitness and Sport's_______- Statewide AntiBuoridatiom Ii Workers, by Caswell A. I cp~ Q ~ Pickles, D.M.D., M.P.H., fr Surveillance of Nutrition Lai ply, by Raymond: E. Schuci "Tar" and \icotiine Content ( ~ Rates, by E. Cuyler Hamn ~ ~ man, and Edward A. Lew, d American Cancer Society, :

~isonahle notice 4ent, finds with the program is ed purposes or %vith~ assurances to the receipt grant recipient ider such grant il be redticed)i, rate eff'ectivelv he is so satis- in his discre- tion (a) shall ;rant shall be i the one-year month begin- de. Payments i the basis of ith necessarv verpayrnents, conditions as purposes of 21 18 1 "(e) The Secretary, at the request of a recipient of a 2 grant under subsection (a), may reduce the amount of such 3 grant by- 4I 5 6 7 "('1) the fair market value of any supplies (in- cluding vaccines and other preventive agents) or equip- mentJurnished the grant recipient, and "(2) the amount'~ of the pay, allowances, and 8 g travel expenses of any officer or employ ee of the_ Gov- .0 ernment when detailed to the grant recipient and the 10 amount of any other costs incurred in connection with 11 the d'etnil of such officer or employee, 12' when the furnishing of such supplies or equipment or the 13' detail of' such an officer or employee is for the, convenience of 14 and at the request of! such grant recipient and for the pur- 15 pose of carrying out a programi with respect! to which the 16 grant under subsection (a) is made. The amoula by which 17 7 any suchi grant is so reduced shall be available for payment 18' by theSecret,aryof the costs incurred in furnishing the 19 supplies or equipment,, or in detailing the personnel, on 20 whichi the reduction of' such graa is based, and such amount 21~ shall, be deemed as part of the g raut and shall bedeemc& 32to havebeen pai& to the grant,recipient. 23 "'(f) (1) Ench recipient~ of a grant under subsection 24 (a)shall keep such, records as the Secretary shall' byregu- 23 lhtion prescribe, including records which fully disclose the

16 1 2 3 14: 15 16 17 18 19 ~ 20 21 ~ 22 23 24 r 13 "(B) for operating inpatient care facilities, con- struction, or mental health programs. "(4) For purposes of subsection (d) , populations sha11' 4 be determined on the basis of the latest figures available 5 from the Department of Commerce. 6 "(1I) (1) For the purpose of making payments under. 7 grants under this section t'o assist States in planning for 8 preventive heaith, services, there are authorized! to be appro- 9 priated $55,000,000 for the fiscad year ending September 30, 10 1980. 11 "(2)! For the purpose of making payments under grants 12 under this section to assist' States in meeting the costs of 13 providing preventive health services, there are authorized to be appropriated $150,000,000 for the fiscal year ending September 30„ 1981, $175,000,000 for the fiscal year ending September 30, 1982, $200,000,000 for the fiscal year ending. September 30„ 1983, and $200,000,000 for the fiscal year ending September 30, 1984. "(3) For the purpose of making additional payments under grants under this section to assist States ini meeting the : costs of operating the health communications component of their preventive: health services programs, there are au- thorized to be appropriated $25,000;000 for the fiscal year ending September 30, 1981, $$30,000,000 for the fiscal year 1 ending September 30, 1: 2 ending September 30, 1! 3 year ending September 3 4 PROJECT GRANTS FOR 5 SEC. 103. (a) Effet 6 and the heading thereto 7 8 9 "PROJECT GRANT sERRv "SEC. 317. (a) TI 10 States, political, subdivisi, 11 or private entities to assi .12 viding preventive healtl 13 subsection ( j ) . 14 "(b) No grant ma3 15 less an, application therc 16 proved by, the Secretar 17 such form and be submit 18 shall by regulation prescr "'(1) for a det. the applicant is see! " (2) the amour obligated by the apF period for the provil paragraph (1) ; a , services provided b;

i 36 I 2 3 4 5 6 83 tion that the common or usual name of a spice or flavoring be on the label for the purpose of provid- ing health information to consumers; " ('B) a declaration of' the percentage of any specified' ingredient (ot'her than a spice or flavor- ing) if the Secretary determines: by regulation that, such ingredient has a significant' bearing on the quality, nutrition, acceptability, or cost of such food, and " (C) a symboI as prescribed b y the Secretary by regalation to signify the presence of an artificial flavor or eolor. To the eztent that compliance with the requirement's of, subparagraph (2) is impracticable or would result in deception or unfair competition, the Secretary shail, by regulation prescribe: exemptions from such require_ ments. ". (2) The second sentence of: section 403'(k) is repealed. (c) Section 403 is amended by adding after pa.ragraph (p) the follbwing new. paragraph: « (q) (1)' If it is a food for human consumption and i n package: forms unless- its la.bel bears such, nutrition, informa~ tion relating to the food -as the Secretaryy by regulatson prescribes to provide health information to consumers i l nc ud 25 it~gat~least~the~~following~: 3 4 5 6 7 8 9. " (A) the t serving, «(B) the 1I sugar, starchs ano "(C) the g fat, unsaturated cholesterol, and by regulation prc " (2) The Secrc 10. to prescribe by regu~ 11 12 13 14 other devices which prehend the nutritio. labels by paragraph "(3) To the es 15 - ments of subparagra 16 ' Secretary shall by re 17 requirements.". 18 19 SEO. 303. Chap 20 tion 411 the followin 21 "STATE AND LOC. 22 "SEc: 412. (a) O 23 no State or politica

119 ieeded by the vices m each sanges in the m, the priori; ans for such Is needed by ~e Secretary wM be pro-' ion (a) will State health' t those cases vioes will be r oonsistent', bj (1) and e Secretarv,cal control ' tretary by , sbursement~ 'ants under . Secretary > such form :_' rymayby 2 3 4 5 6 7 8. 9 16 regulation prescribe) as the Secretary may reasonably require and-keep such records and afford such access thereto as the Secretary may find necessary to assure the correctness ofy and to verify, such reports; "(6) for assurances satisfactory to the Secretary that the applicant will comply with any other conditions imposed by this sect'ion with respect to grants; and "('7) for such -other information: as the Secretary may by regulation prescribe. 10 "( c)•(1) The Secretary shall' review annually the activ- 11, ities undertaken by each -recipient of a grant under subsection 12 (a) to -determine if the program~ assisted by such -a, grant 13 is operating effectively to achieve its stated purposes and 14 if t'he grant recipient complied with the assurances provided 15 with the application. The Secretary- shall not approve an 16 application submitted under subsection• (b) -unless the Secre-. 17, tary determines- 18' 19 20 21 22 23 24 "(A) that the program is operating effectively to achieve its stated purposes, . "(B), thati the applicant complied with assurances provided with a prior application under subsection (b) ,., and . - "(C)' that' he is assured t'hat the applicant will comply with the assurances provided with the applfca-. 25 -,• tion under consid~ration.

22 19 1 amount and disposition by such recipient of the proceeds. 2, of such grant, the total cost of the undertaking in connection 3 4 5 6 7 8 9 with which such grant was made, and the amount of that portion of the cost of the undertaking supplied by otlter sources„ and such other recoi~ds as will': facilitate an effective audit. "(2)' The Secretary and the Compta•oller General.of the United States, or any of'their duly authorized representa~ t2ves„ shall have access for the purpose of audit and examina- 10 tion to, any books, documents, papers, and records of the 11 recipient of grants under subsection (a) that are pertinertt 12 to such grants. 13 ."('g) All information obtained about any individual 14 under any program that is being carrie& out with a grant 15 made under subsection (a)' shall not, without such individ- 16 ual's consent, be:disclosed, except that (11) such information 17 may be disclosed without such consent if the disclosure is 18 necessary to provide service to such indiv idual or is re- 19 quired by a law of a State or political subdivision of ai St.rte, 20 and (2 ) information derived from any such program may 21 be disclosed- 22 "(A) in summary, statistical, or other form, or 23 "'(B)' for clinical or research purposes, 24 25 but! only if individually identifiable personal, data: of any such individual is not disclosed. 2' 1 " (h) Nothing in this 2 restrict the, use of funds v 3 4 5 to an agency or a politic provisions of Federal law which are available for tl 6 service programs from bei 7 grams assisted through grai 8 " (i) The Secretary , 9 submission to the Congre 10 January 1 of each succce, 11 of the problems presentec 12 referred to in subsection ( 13 gated under grant's under 14 fiscal year for each of the. 15 and on the effectiveness of 16' under subsection (a) ii 17 conditions. 18 " (,j ) (1) For payme 19 subsection (a) for establ 20 for the screening, detect 21 ral for treatment, an& fo ~ 22mentofiliypertension,ther 23 $30,000;000 for the fiscall 24$35,000,000 for thefisca,

40! 37 1 2 3 4 5 6 7 any stairway, elevator, hallway, conveyance, waiting room, reception room, conference room, or hearing room in any such facility. (',b) Smokers shall be effectively separated from non- smokers in any restaurant, cafeteria, snackbar, other dining facility, recreation room or lounge in any Federal facility. (c) Ea& instrumentalit'yof the:United States shall use reasonable efforts that do not~ result in excessive: costi or administrative disruption to effectively separate: the work- places of its employees who do not smoke an& who wish to be so separated from the workplaces of its emplbyees who do smoke. (d) In planning, designing, purchasing, leasing; or 14 otherwise obtaining new facilities, each instrumentality of 15 the United States shall, to the maximum extent' practicable, 16 insure the: effective separation of smoking and nonsmoking 17 emplbyees in such facilities. 18 "NO SDiOKING" SIGNS' 19 SEC. 402. In every area in any Federal facility where : 20 smoking is prohibited under section 401, "No Smoking" 21 signs shall be clearly and conspicuously posted in sufficient 22 numbers and prominence to give notice to any person enter- 23 ing or occupying such area that smoking is prohibited in 24 such area. 5 6 7 8 9 10 11 12 I SEc. 403. (a) Tht tive officer of each instr be responsible for enfo Federal facility in zvl offices. (b) Not later thaz ment of this part, the e officer of each instrun publish in the Federal ment of sections 401 a: appropriate sanctions f 13 comparable to sanction: 14 applicable regulation r 15 16 17 18 19 20 21 22 23 O W 24. Q9 O 25 being, of! the public or SEo. 404. For the (a) the teru} possession of a ligb a tobacco product; (b ) the term aration of areas . ii which smoking i: minimizes, to the from the: smoking

;arette) of' in or im- conditions,, iuch deter- ommission this para- is are first .edures for those ap- ing svhi& •nt of this :ETJRy.- i calendar all certify nt of each ,orted into 11 be used tax to be ning with iing after calendar an, shall f testinQ, 45 42 1 certifying, and imposing taxes under this subsec- 2 tion on new brands of cigarett,es introduced for 3 sale.". 4 (b) The amendments made by subsection (a) shalU 5 apply to cigarettes which the manuf'acturer or importer of' 6 such cigarettes removes (within the meaning of section 7 5702 (k) of such Code) within 120 days after the date of 8 enactment, of this part. 9 (c) The Commission and the Secretary of the Treasury 10 or his delegate shall promulgate regulations for the purposes 11 of section 5701 (b) of the Internal Revenue Code of 1954 12 within 60 days after the date of the enactment of this part'. 13 SEC. 407. There are authorized! to be appropriated for 14 the fiscal years ending September 30, 1981, September 30, 15 1982, September 30, 1983, and September 30; 1984, those 16 amounts determined! by the Secretary of the Treasury to be 17 equivalent to the taxes received~ in the Treasury under sec- 18 tion 5701 (b), of the Internal Revenue Code of 1954 for the: 19 purpose of making additional payments to the States to. 20 assist' them in meeting the costs of providing preventive 21 health services under section 3 15 of the Public He<nlth Service 22 Act. The amount of payments to the States shall be det'er- 23'mined, on a per capita basis:Provided; That onlythoseSt'at'es 24 who are receiving grants under section 315 (1) (2) of the

2 '3 4 5 6 42' 39 (c) the term "instrumentnlity of the United States" means- (1) an executive agency, as defined in section 105 of title 5, United States Code; (2), the United States Postal Service; (3) the Congress; . (4) the courts of the United States; and (5) i the governments of t3ie: territories and pos- sessions of the United States; ('d) the term "Federal facility" means- (1) any building, installation, or facility owned by the United States, excepting private residences, or; (2) any part of any other building, installation, or facility, which part is owned or leased by the United States, excepting private residences. EFFECTIVE DATE SEC. 405. This : part shall take effect ninety days a#ter the daze of enactment of this part. PART B-ESTABLISHMENT OF A HEALTH PSOTECTION TAx SEC. 406. (s). Subsection (b) of section 5701 of the Internal Revenue Cb& of 1954 (rclating to the rate of tax 24 on cigarettes ) is amended to read as follows : 25 "(b) CIaAnETTss.- 5 6 7 8 9 pr 10 pr 11 12 ti( 13 << 17 18 19 << 20 CONTI 21 a. 01)

27 I ~ section 3'1-1 ived ly State ran-raph (1) le Secretarv, populatliou, of year endiQi); the anloniit Ilnpreheu."i.•e 11 tlleState's u1y 1, 1i;)71), ptenibcr 3(Y, ucll expendi- ended on or oftlle~ fiscal •r ceutnnl of "t,lrc's fiscal 2 3 4 5 6 7 24 year which ended on or before July 1, 1:981; and "(ii) may not be lesstlian the greater of= `° (I)thetotal amount of grants received bysuc.h authorities under paragraph (1) for the fiscall year ending September 30,1979„ or "(II1) the productof' 50.50and the popnlation of the State. 8 Not«•ithstandingclause(ii) if for any fiscal year the amount 9appropriatedl f'ort.hat fiscal year under paragraph (7) is less 10 11 12 13 14 15 17 18 19 than the amount needed to make granto for that! fiscal year in accordance svith such clause to all State health and mental health authorities with, approved! applications; the total amount ofi grants for that fiscal year for State health and mental health, authorities shall not be less than an amount which bears the same ratio to the amount's determined for such authorities in accordance with such clause as the amount appropriated under such paragraph bears to the amount needed to make grants in accordance with such clause for such fiscal year toalll Statehealthand mental health author- 20, ities with approved applications. 21 22 23 24 "(B) The Secretary, at the request of State health and mental health authorities, may reduce the amount of the grants to it. under paragraph (1) , by- "( i) the fair market value of any supplies orequip. 25 ment furnished such authorities; and

20 1 2 3 4 5 6 7 17 "(2) Whenever the Secretary, after reasonable notice and opportunit'y for a hearing to aI grant recipient, finds with respect! to funds paid to suchrecipienty that, the program is not operating effectively to achieve its stated purposes or that there is a failure to comply substantially with assurances provided under subsection (b) with respect' to the receipt of such grant, the Secretary shall notify the: grant recipient 8 that further payments will notl be tnade to it und'er such grant 9 (or in his discretion that'. further payments will be reduced!), 10 until he is satisfied that the program~ will operate effectively 11 or there: will no longer be such a failure. Until he is so satis- 12 fied, the Secretary shall make: no payment or, in his discre- 13 tion, reduce payments, to the grant recipient. 14 "( d) The amount of a grant under subsection ( a)', shall 15 be detennined' by the Secretary. Each such grant shall be 16 made for costs f'or preventive health serv.ices in the one-year 17 period beginning on the first day of the first month begin- 18 ning after the month in which the grant is made. Payments 19 ttnder such grants~ may be made in advance oni the basis of 20 estimates or by the way of reimbursement, with necessary 21 22 23 adjustments, onaccount, of mid'erpayments or overpayments, and in such installment's and on such terms and conditions as the Secretary finds necessarytb carry out' the purposes of 24 such grants. 21 1 2 3 4 5 6 7' 12 18 " (e), The Secretary, at the grant under subsection (a), maNgrant by- " (1) the fair market eluding vaccines and' other 1 ment furnished the grant rec " (2) the amount of travel expenses of any off ernment when detailed to amount of' any other costs : the detail of such officer or ~ when the furnishing of such ~ detail of such an officer or emp'. 1-~ and! at the request of such gr<. 115 pose of carrying out a progra 16 grant under subsection ('a)' is 17 any such, grant is so reduced ~ 18 by the Secretary of the cos 19 supplies or equipment, or it 20: which the reduction of such g 21 shall bedeeme& aspart', oft 22 to have been paid to the grant 23 "( f) i(1), Each recipien O W 21 (a)shall keep, such records ~ O W Q5 25 lation prescribe, including r+ tiA CJ

41 .ng room, a in any nom non- er dining 'acility. shall use cost' or ~e work- -,ho wish vees who ising, or Itality of rcticable,, ismoking y where moking" sufflcient ,n enter- bited in 1 2 3 38 ENFORCEMENT SEc. 403. (a) The executive head or chief administra- tive officer of: each instrumentality of the United States shall 4 be responsible for enforcing sections 401 and 402 in any 5 Federal facility in which such instrumentality maintains ~ 6 offices. 7 (b) Not later than ninety days after the date of enact- 8 ment of this part, the executive hea& or chief administrative g officer of ea& instrumentality of the United States shall 10 publish in the Federali Register regulhtions for the enforce- 11 men.t of' sections 401 and 4:02 including, but not limited to~, 12 appropriate sanctions for noncompliance with, such, sections 18 comparable to sanctions for failure to comply with any other 14 applicable regulation affecting the health, safety, or well- 15 being of the publlc~ or the work force. 16 DEFINITIONS 17 SBC. 404. For the purposes of this part: 18 (a)~ the term "smoking" means the smoking or 19 possession of a lighted cigarett'e„ cigar, or pipe containing 20 - a:tobacco product; and 21 (b ) the term "effectively separated"' means the sep- 22 aration of areas in which~ smoking is permitte& and in 23 which smoking is not permitte& in a manner which 2} minimizes, to the egtent' practicable, the drift of smoke 25 from the smoking area into the nonsmoking, area; _..~;:~.1h; 01 - 78 - 4

29 ,is, and travel Government al health au- i incurred in or employee, ment or the convenience iental health a program -aph (1) is i so reduced of the costs it, or in de- f such grant part of the to the State i)' (TI), the: nsive public local public health serv- Apenditures atutorv~law~ 26 1 as a condition tbthereceipt of Federal financial assist- 2 ance, or g "'(ii) for operating inpatient care facilities, con~ 4 strucaon, or mental health programs. 5 "(D) For purposes of' subparagraph (A) populat'ions. 6 shall be determined on the basis of the latest figures avail- 7 able from the Department of Commerce. 8 "(5) The Secretary may make payments under grants 9 under paragraph, (1), on the basis of' such, estimates and ini 10 such installments as appropriate with adjustments for any 11 previous overpayments or underpayments.". 12 (b) Paragraph (16) of section 314 ( d) is amended by 13 (1)' striking "a State's allotment" in, clause (A) and in- 14: serting in lieu thereof "the amount received", (2) striking 15 "of a State's allotment" in clause (B) (i) and inserting in 16 lieuthereof "'received'underparagraph (4)',", and (3) strik- 17 ing "State's allotment" in clause (B) (ii) and inserting, in 18 lieu, thereof "amount received under paragraph (4) ". 19 (c) Section 314 (d) (7) (A) is amended by striking 20 "and" after "1977," and inserting before the period 21 thereof: ", $107,000,000 f'or the fiscal year ending Septem_- 22 ber 30, 1979, $125,000,000 for the fiscal year ending Sep- 23~ temller30; 1980, $140,000,000 for the fiscal year ending 24 September 30; 1981, and $150,000,000 for the fiscal year 25 ending September 30, 1982".

48 1 2 3 45 by paragraph (a) (2) appears on 10 per centum of all cigarette packages. PART D-ESTABLISHMENT OF PROGRAM TO DETER SMOK- ING AMONG CHILDREN AND ADOLESCENTS SEC. 409. (a) The Secretary of Health, Education, and Welfare, after consultation~ with appropriate' public and private entities; shall establish a comprehensive program designed to deter smoking among children and ad'olescents. Such a' program shall include- 14: (1) the undertaking or support' (through grants or conthacts or both) of biomedical and behavioral research designed t'o increase understanding of the biological and behavioral determinants of smoking among children and adolescents, with special emphasis on children aged 15 twelve or below; 16 (2) the undertaking or support (through grants or 17 contracts or both) of demonstrations and evaluations of 18' comprehensive community and school-based programs 19 designed t'o deter smoking among children and adoles- 2& cents; and 21 (3) grants to States or political subdivisions of 22 States to assist them, in meeting the costs of operating 23 comprehensive community or schoolrbased programs 21 designed to det'ersmoking among children and 25 adolescents,- 49 1 2 3 46 (b) With respect to gra the Secretary and each grant comply with the provisions c 4 (e), (f), (g),and' (h) of see 5 6 7 (c) (1) For the purposE undertaking or support of rese: there are authorized to be apl, 8 fiscal year ending September 9 fiscal year ending September : 10 the fiscali year ending Septemb 11 (2) For the purpose of n 12 13 14 115 116 17 118 19 20. 21 22 23' taking or support of demonsi paragraph (,a) (2), there are $10,000,000 for the fiscal ye< $10,000,000 for the fiscal yee and $10,000,000 for the fisc 1982. -- (3) For the purpose of'. under paragraph (a) (3),thc priated $10,000,000 for the fi> 1980, $10,000,000 for the fis 1981, and $10;000,000 for t ber 30, 1982.

49 ,)er centum of all TO DETER S-M0g- LESCENTS h„ Education, an& riate public and -hensive program and adolescents: hrough grants or havioral research he biological and ong children and r children aged irough grants or d evaluations of based programs ren and adolo~s subdivisions of ts of operating ased programs children and 1 2 3 4 13 14 15 16 17 ~ E 18 ~ . ~ 19 20. 21 22 23 46 (b)~ With respect to grants under paragraph (a) (3), the Secretary and eachi grant applicant and recipient must comply with the provisions of subsections (b), (c), ('d), (e), (f), (g),and'(h) of section 317. (c) (1) For the purpose of making payments for the undertaking or support' of research under paragraph (a) (11) , there are authorized to be appropriated $10,000,000 for the fiscal year ending September 30, 1980, $10,000,000 for the fiscal year ending September 30, 1981, and $10,000,000 for the fiscal year ending September 30, 1982. (2) For the purpose of'making payments for the under- taking or support of demonstrations and evaluations under paragraph (a) (2)i, there are authorized to be appropriated $10,000,000 for the fiscal year ending September 30, 1980, $10,000,000 for the fiscal year ending September 30, 1981; and $10,000,000 for the fiscal year ending September 30, 1982. (3)' For th& purpose of making payments for grants under paragraph (a) (3), there are authorized to be appro- priatedl $10,000,0001for the fiscaliyear ending September 30, 1980, $1'0,000,000 for the fiscal year ending September 30, 1981, and $10,000;000 for the fiscal year ending Septem- ber 30, 1982.

39 tapplicable to any )n to any labeling section 403. a political subdi- ilation after notice mpt from subsec- be prescribed in of such State or nines that there- >1 oonditions and to be in violation nded to read as or man or other her animals, in- )everages,". ctions 802, 303, ch is intioduced commerce after ;his title. 1 36 .. :; OTIFICATION TO AIvTD REPORT' BY THE FEDERAL TRADE ~, COMMISSION SEC. 306. (a)~ The Secretary of Health, Education, and Welfare shall notify the Federal Trade Commission of the t; S 3 nutritional information that is require& to be placed on food labels pursuant to section 403 (q) and recommend to the Commission which (if any) of such information should be required by the Commission under the Federal Trade Com- nussion Act to be included in the advertising ofl such food. 1i)' (b) The Chairman of the Commissioni shall report an- 1,1 naalty to Congress on (1) any recommendations made to the Commission by the Secretary under subsection (a) ,('2 ) 1:3' in those situations where the Commission accepte& a recom- 1 2 ' 14 inendation, a description of any action taken to implement 15 such recommendation, and (3) in those situations where i t; the Commission failed to accept, in whole or in part, a 1T recommendation, a description of the reasons for such failure. 1s TITLE IV-PROGRAbiS DESIGNED TO PRO1,i0M 19 IIE'ALTH THROUGH SMOKING DETERRENCE ')OI PART A-REGULATION OF SMOKING IN FEDERAL 21 FACILITIES RESTRICTIONS ON SMOKING IN FEDERAL FACILITIES 23 SEc: 401. (a) Escept' as provided in subsections (b), ~ (c), and (d), smoking, shall not be: permitted in, any en* or :.':, closed area open to the public in ar~yjFeder"6i~y in 21

~ 1 2 3 4 5 6 7 , 20 21 22 23 24 25 44 41 content (',oalculated in milligrams per cigarette)' of each brand of cigarettes manufactured in or im- ported into the United States. The conditions, methods, and procedures for conducting such deter- minations shall be promulgated, by the Commission in regulations issued by it for purposes of this para- graph. Uintil such time as such regulations are first' issued, the: conditfions, methods, and procedures for conducting such determinations shall be those ap} proved by the Commission for formal testing which are in effect on the date of the, enactment of this: subsection. °`(B)~ CE'RTIFICATION TO THE SECBETARY.- During the laAI calendar quarter of each calendar year, the Chairman of the Commission shall certify to the Secretary the tar and nicotine content of each brand of cigarettes manufactured'in or imported into the United'States. Such certifications shall be used by the Secretnr,~ to determine the rate of tax to be imposed on cigarettes for the period beginning with the first day of th^ calendar year beginning after such certificatior, imade, and during, such calendar year. "('C)TheCommission and the Secretary shall, promulgate regulations for the purposes of testing. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 G 23 ~ O 24 certifying,, tion on n sa1e.". (b) The amc apply to cigarette. such cigarettes re 5702 (k) of such " enactment of'~ this pz (c) The Comi or his delegate shal of section 5701 (b) within 60 days afti SEc. 407. The the fiscal years end 1982, September 3 amounts determiner equivalent to the t-. tion 5701 (b) of thc purpose of making assist them in mec healthiservices unde Act. The~ amountl 0 mined on a per capit who are receiving

gram in I by the ch such rovision rities of hanges; -e State ?rev en- practi~ escribe, ,vard a •urrent priate, ils for • and, 1niCa- ,vhich : ption 55 5 of, ho.vthecommunicatiorm media, including- the electronic media, will be utilized to effectuate the purposesof the programs; "(T+')shall identify a specific institutional en, tity in the State that will be responsible for ac- complishin(r through contracts withprivate, entities and other means the requirements of paragraph (E);and (G) shall contain such other information as the Secretary may by regulation prescribe ; "(6)1 for assurances satisfactory to the: Secretary t'hnt the preventive, health services which will be pro-vided with funds under a grant under subsection, (a) . will beprovid'e& in a manner consistent with the Stlate, healthiplan in eff'ectund'er section 1524 (c)!; "(i), f'orassurances satfisf'actory to the Secretary that the Sta,tewill provide: for such fiscal control and itindaccounting procedures as the Secretary by regula- oioni prescribes to assure the proper disbursement of and' accounting for funds received! under grants under sub- ~ection (a); "(8)' for assurances satisfactory to the Secretary tliat the State will make such reports (in such form and' ronta:ining, such inf'ormation as, the Seeretarymay by regrulation prescribe) &s the Secretary may reasonably

1 28 1 2 3 4 5 6 7 8 9 25 "(ii) the amount of the pay, allowances, and travel expenses of any officer or employee of the Government when detailed to the State health or mental health au- thority and the amount of any other costs incurred in connection with the detail of su& officer or employee, when: the furnishing of such supplies or equipment' or the detaill of such~ an officer or employee is for the convenience of' and at the request of the State health or mental' healt'hh authority and for the purpose of carrying out a program 10 with respect' to which its grant under paragraph (1) is 11 made. The amount by which any suchgrant is so reduced' 12 shaili be available for payment by the Secretary of the costs 13 incurred in furnishing, the supplies or equipment, or in de- 14 tailing the personnel, on which the reduction of such grant 15 is based, and such amount shall be deemed as part of the 16 grant an& shall be deemed to have: been paid to the State 17 health or mental health authority. 18 "(C) For purposes of subparagraph (A) (i) (TI), the 19 term 'State and local egpenditlzres for comprehensive public 20 health services' means expenditures by State and local public 21 healtha.nd mental health authorities for public health serv- 22 ices designated by the Secretary but elcludesexpenditures, 23 by such authorities- 24'"(i) specifically required by Federal stat'utory law 1 2 4 5 6 7 8'. as a condition to thc ance, or " (ii) for opera struct}on, or mental l: " (D) For purposes shall be determined on t able from the Departmen, "' (5) The Secretary. 9, under paragraph (1) on 10 such installments as apj 11 previous overpayments o. 12 (b ) Paragraph (6) 13' (1) striking "a State's 34 serting in lieu thereof "i 15 "of a State's allotment" 16 lieu thereof "received un, 17ing "State's allotment" 18 lieu thereof "amount rect 19 (c) Section 3'14 (d 20 "and" after "1977," 21 thereof : ", $10 7,000,00 `'2her 30, 1979, $125,000. '?3t'e.mber30, 1980, $140 September 30, 1981, a] ending September 30, 1'S

35 ind dis- of the 'ut not habits, ionship ~ ~idence hl and' qection ter for ith a11' Public: t©VI- _1ND PRO~- is ex- other to a and 2 3 4 5 6 14 12, 13 14 15 16 17 18' 19 , 20 21 22 23 '_"1, :.',r 32 NUTRITION IN'FORAIATION AND OTHER LABELING REQUIREMENTS SEC. 302. (a) (1)i Sect'ion, 401 is amended by striking, out the fourth sentence thereof. (2), Section 403 (g) is amended to read as follbws: "(g) If it purports to be or is represented as a food, for 7 which ai definit'ion, and standard of identity have been pre- 8 seaibed by regulations as provided by section 401, unless 9 (J)it'~ conforms to suchi definition and standar&;and (;2 )' its 10, label bears the name of the food specified ini such definition and standard.". (b), (1)~ Section403(1), isamend'eds to read a& f'olloavs,: "(i) Unless its label bears- "(1)' in the case, of food whichi is not subject to par- agraphi (g) of this section, the common or usual name (if any) of the food; and "( 2) in case it! is fabricated from two or more ingredient.s- "(A) the common or usual name of each such ingredient in the order of its predominance; except that any spices or flavorings which are notl sold as such shalll be designated as artificial spices or natural spices and artificial flavorings or nattzral flavorings, as the ca.,emay be, without naming each such ingyedient, unless the Secretary requires by regnla-

51 ,ViTa TA$ ONLY I JrctA- ,and tudy with and con- this ults (a) tive. 9:,TII CONGRESS 2D SEBsION S. 3116 IN THE~ SENATE OF THE UNITED STATES MeY 19 (legislative dhLy, MAY 17), 1978 .\lA'.,KENNEDY (for himself, Mr..WILLL4MS,,Mr.C$AFEE„Mr.,RAtiDOLPH,,Mr.. PELiy Mr. CifiANBTON, Mr. RIEGLE, Mr. JAI'IiTS, ,11r..SCII\I'E1KER, Mr. .STAF- FORD, Mr. MCGOVERN,.'lr. rI<LRT,,and .~ir. LEAHY) IntroduCed the fol16Ning bill; which was read twice and referred to the Committee on Htrman Resources A BILL '1`b amend the Public Health Service Act to provide assistance through formula and project grants for preventive health, programs, and for other purposes. 1 Be it enacted by the Senate and House of Representa- 2 tives of: the United States of America in Congress assembled, 3 SHORT TITLE; REFERENCE TO ACT 4 SECTION 1. This Act may be cited as the "T+'ormula ~ and Projects Grants for Preventive Health Scrvices and 6 Resources for Disease Prevention and Health~Promotion Act' 7 of 1978". II

43 les" 1 2 a,ion 3 4 5 6 7 pos- 8 9 10: ned 11 ces, 12 13 ion, 14 the 15 16 17 :ter 18 ON he ax 40 "(1), IMPOSITION OF TA%.-There shall be im- posed on every cigarette manufactured in or importe& into the United States, regardless of weight, which contains- "(A) from 10 to 19.9 toxic units, a health protection tax of $0.0025; "(B) from 20 to 29.9 toxic units, a health protection tax of $0:0075; "(C) from 30 to 39.9 toxic units, a health protection tax of $0.015; and "('D) 40 or more toxic units, a health protec- tion tax of $0.025. "(2) , DEFINITION OF TOgIC : UNITS: For the pur- poses of subsection (b) (1)~ above, the number of `toxic units' means the sum of- - "(A) the number of milligrams of 'tar', plus "(B ) 10 times the number of the milligrams of 'nicotine' which are contained in su& cigarette. 19 "( 3)', DETERIMIN;ATIO:P OF' TAR AND NICOTINE 20 CONTENT.- 21 "( A) TESTING BY FEDERAL TRADE COMbiIS- 22 sION.-The. Federal Trade Commission (hereinafter 23 referred to as the 'Commission') shall from time to 24 time (but at'least once each calendar year) deter- 25 A mine or cause to be determined the tar and nicotine:

18 1 2 3 15 such period; the amount of Federal funds needed by the applicant': to continue provi&ng such services in each such program; if the applicant proposes changes in the 4 provision of the services inany such program, the priori= 5 ties of such propose4 changes; the reasons~ for such 6 changes; and, the amount of Federal funds needed by 7 the applicant to make such changes; 8 "(3 ) for assurances satisfactory to the Secretary 9 that the preventive health services which will be pro- " 10 vided with funds under a grant under subsection (a) will 11 be provided in a manner consistent witL the State health 12 plan in effect. under section 1524 (c) and in those cases 13 where the applicant is a State, that such services will be• 14 provided, where appropriate, in a manner consistent 15 with~ any plans in effect under paragraphs (b) (1) and 16 (b) (3) of section 315; 17 "(4) for assurances satisfactory to the Secretary, 18 that the applicant will provide for such fiscal control 19 and fund accounting procedures as the Secretary by,, 20 regulation prescribes to assure the proper disbursement 21 of and accounting for funds received undcr grants under 22 subsection (a).; 23 •"(5) for assurances satisfactory to the Secretary _ 24 that the applicant wili make such reports (in such form; •- 25 and containing such informatron as the E'xeret", may by 19 2 3 16 regulation prescribe) as t'f require and' keep such re thereto as the Secretary r 4 - the correctness of; and to v 5 " (6) for assurances that the applicant will con imposed by this section wi "{7) for su&,other may by regulation prescril " (c)-(I) The Secretary s 11, ities undertaken by each iecipi' 12 ('a) to -determine if the prog 13 is operating effectively to ac 14 if the grant recipient,complie 15 with the application. The S 16 application submitted under s- 17 tary det'ermines- . . 18' 19 20. 21 22 23 24 25 "(A•) that the prog achieve its stated' purpose "(B)~ that the appl provided with- a prior ap and "(C~) t'hat, he, is a comply with the assura tion under considQration.

57 Ford such access essary to assure )orts; o the Secretary other conditions grants; and is the Secretary nnuallyy the ac- approved appli- the program or We their stated the assurances Jary shall not subsection, (b) s are operating ;, assurances pro- I under subsec- ;te will compliy plication under isonable notice 7 1 and opportunity for a hearing to the State, finds with respect 2 to funds, paid! to it under a grant under subsection (a) , that 3 the program or programs are not'~ operating, effectively to 4 achieve their stated'purposes or that there is a failure to 5 comply substantially with assurances provided under sub- 6 section (b) with respect to the receipt of such grant, the. 7 Secretary shall notify the State that' further payments willi 8 not be made to it under such grant' (or in his! discretion that 9 further payments will be reduced) , until he is satisfied that! 10! the program or programs will operate effectively or there 111 will no longer be such a failure. L ntil he is so satisfied, the 12 Secretary shall' make no payment or,, in his discretion, re- 13 duce payments to the State from such grant. 14 "( d) (1) The total amount of grants received by a 15 State under subsection (a) to assist States in planning for 16' preventive health services for the fiscal year ending Septem- 17 ber 30, 1980, shall be determined by the Secretary, except 18 that it may not be less than the prodtrct of $0.20 and the 19 population of the State. 20 "(2) The total amount of grants received by a State 21 under subsection (a) to assist'~ States in providing preven- 22 tive health services for any fiscal year shall be determined 23' by the Secretary, except that it- 24 "' (A) may not exceed the lesser of- ~d~d-SLAfi~ OI• S8~_ ~.

47 1 eive pay= 2 3 iErrrr 4 5 of enact- Labeling g 7 .ended to 8 9 )erson to 10 Aribution 11 12 r the tar 13 in milli- 14 15 Lr one of 16 17 FROM ig 19 rOUTH, 20 CIGA- 21 22 ESULT 23 4'4 25 44 " (D) CIGARETTE SMOKLNG MAY HURT YOUR HEART; "(E) EMPHYSEMA AND CHRONIC BRONCHITIS b1AY RESULT' FROM CIGA- RETTE~SMOKING; `° (F ) CIGARETTE SMOKING DURING PREGNANCY MAY D ADIAGE THE UNBORN CHILD; "(G) YOU OWE' YGUR BODY SOME' RE- SPECT-DON'T SMOKE'; "(H) SMOKER'S COUGH IS AN EARLY SIGN OF LUNG DAMAGE; "(I) IF YOU DIUST SMOKE, INHALE LIGH'TLY-TH'IS MAY REDUCE THE RISKS TO YOUR HEALTH; "(J) DON'T SMOKE CIGARETTES TO THE END-THIS' MAY REDUCE THE RISKS TO YOUR HEALTH.". (b) The statements required by subsection (a) shall be located in a conspicuous place on every cigarette package and shall appear in conspicuous and legible type in contrast by typography, layout, and color with -other printed matter on t'he package. (c) Cigarettes shall be packaged for sale or dist'ribu. tion in such a manner so that each of the statiirtegtu•require& ©

popula- linJ Sep- mount of :e health tion (a) ir which ise of the i3 per es in the e July 1, ling Sep- mount of ar which of $0.50 : a State the costs t of their :-ear shall Lw not be tlre State. if for any ear under 59' 1 2 3 4 5 6 7 8 9 10 11 9 subsection (1) is less than the amountt needed to make grants for that fiscal year in accordance with such paragraphs to all States, the total amount of grants for that fiscal year for a State shall not be less than~ an amount which bears the same ratio to the amounts determined for such State in acT cordance wit'h this section as the amount appropriated under subsection (1) bears to the amount needed to make grants in accordance with this : section for such fiscal, year to all States. "(e) Each grant under subsection (a) shall be made for costs for preventive health services in the one-year period beginning on the fust' day of the first monthi beginning after 12 the month, in which the grant is made. Payments under such 13 grants may be made in advance on the basis of estimates or 14 by the way of reimbursement, with necessary adjustments on 15 account of underpayments or overpayments, and in such 16 installments and on such terms and conditions as the Secre- 17 tary finds necessary to carry out the purposes of such grants. 18 "( f), The Secretary, at the request of a State whi& is a 19 recipient of a grant under subsection (a), may reduce the 20 amount of such grant by- 21 "(;1) the fair market value of any supplies or equip- 22 ment furnished the State, and 23 "(2 ) the amount of the pay, allowances; an& travel 24 expenses of any officer or employee of the Government 25 when detailed to the State and the amount of any other

1 2 3 4 5 6 7 8 9 56 6 require and keep such records and afford such access there`o as the Secretary may find necessary to assure the.em•rectness of, and to verify, such reports; "(9) for assurances satisfactory to the Secretary that, the State will comply v-ith any other conditions imposed by~~ this section with respect to grants; and "(10) f'or such other information as the Secretaryy may by regulhtion prescribe. "'(c) (1) The Secretary shall' review annuallay: t'he ac- 10 tivities undertaken by each State with an approved appli- 11 cation under subsection (b) to determine if'the program or 12 programs are operating effectively to achieve their stated 13 pm'poses; and if the State complied with the assurances 11 provided with the application. The Secretary shalll not 1 and opportunity for a b 2 to funds paid to it und, 3 the program or progr, 4 achieve their stated pi 5 comply substantially i 6 section (b) with, resp 7 Secretary shall notify 8 not be made to it unde 9 further payments will 10 the program or prob . 11 will no longer be such 12 Secretary shall make i 13 duce payments to the S 1I " (d) (1) The tot. 15 approve an application, submitted' under subsection (b) 1.5 16 unless the Secretary determines- 16 17 "( A) that the program or programs : are : operating 17 18' effectively to achieve their stated purposes, 18 19 "(;B)', that the! State complied with assurances pro- 19 20 vided with a prior application submitted under subsec- 21, tion (b) , and 22 "'(C) that he is assured! that the Statie will, comply 22 23 with the, assurances provided with the application under 2 3' 24 consideration. O W 21 25 "(2)' Whenever the Secretary, after reasonable notice 0 W .~ Cd State under subsection preventive health servi ber 30, 1980, shall be that it rriay not be les population of the State. (2)The total ai under subsection (a). tive health services foi by the Secretary, excep " (A) may no

30 27 1 (d) Sectioni 314 (d) (7) is amended by adding at the 2 end thereof the following new paragraph : 3 "( C) Of the amount appropriated under subparagraph 4: (A) for any fiscal year the Secretary shall obligate not more 5 than $1,000;000 for the uniform national health program 6 reporting system referred to iniparagraph (',2) (C)' (ii) .": 7 TITLE II-R ESOURCES FOR DISEASE PREVEN- 8 TION AND HEALTH PROMOTION 9 CENTERS FOR HEALTH PROIIOTIOYI 10 SEC. 201. Title III of the Public Health Service Act 11 is amendeiI by adding after section 315 (added by sectioni 12 1'02of thisAet)~ tltefollowing, newsection and hcading I 13 thereto: 14 "CENTERS FOR HEALTH PROMOTION 1& SEC: 316. (a)Forthe purposes of assisting the Sec- 16' retaryin~ carrying out sectfions315 andl 317; providing, such 17 technical and consulting, assistance as recipients of' grants~ 19, 20, 21 22 23 24 25 under such sections may from time to time reqtiire; conduct- ing research, studies; and analyses (including cost-effective- ness analyses ) of preventive health serv ice progranis ; and developing approaches, methodologies, policies, and stand- ards for delivering preventive health services; theSecret, ry shall Uygrants, assist puhlicor private nonprofit entities ini mcetingthecosts ofplanninnand de welopi2ig new centcrs; and operating existing and new cent'~ers,for multidi;wi}ilinar.N ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 O 23 W 24 4 h 25 Co1 W health promotion. Tb th( shall provide assistance ~ five suchi centem will be: "(b) (1) No grant i planning or developing a mines that when it is, olments listed in paragra assistance and! dissemina grants under sections 31._ (a) and (e) . No grant operation of a center un1 ments and is able to pro, tion of inf'ormation. " (12) The requirem, are as follows; " ('A ) There sl C'ent'erwhopossessc stantial accomplishn motion, an& there s staff as mayy be apprc "(B) The stai diversity of relevant " (C) Such a( retary may by regull. "(c~)~ Centersassisto

50 47 PART E-STUDIES OF' HEALTH RISKS ASSOCIATED WITH 1 2 3 4 SMOKING CIGARETTES OF VARYING LEVE'LS OF TAR AND NICOTINE AND WITH SUBSTANCES COMMONLY ADDED TO COMMERCIALLY MANUFACTURED CI(}A- RETTEB SEC. 410. (a) The Secretary of Health, Education, and Welfare shall conduct, or arrange for the conduct of, a study or studies of (1) the relative health risks associated with smoking cigarettes of varying levels of tar and nicotine and (2) ~ the' health risks associated with smoking cigarettes con, taining any substances commonly added to commercially 8 9 10 11 12 13 14 manufactured cigarettes. (b) Within two years of the date of' enactment of this part, the Secretary shall report to the Congress the results 15 of the study or studies conducted pursuant to subsection (a) 16 and any recommendations for legislative or administrative 17 action. 95ra CONGRESS 2D SESSION IN, THE SEN: MAY 19 Mr. KExNEDY (for himsel PELIy,Mr.. CRA'xBrON,.- FoRD,Mr. McGovER:., =bill;, which was read Resources To amend thePublic through formula programs, and foi I Be it enacte, 3' tives o fthe Un:itE 3 sIIo 4 SVCTioN 1. :, and Projects Gr G Resources for Di 7 of 1978" II

58' 2 8 "(i) the product of $0.75 and the popula- tion of the State, or 3 "(ii) in the case of the fiscal year ending Sep- 4 tember 30; 1982, 5 per centum of the amount of State and' local expenditures for preventive health~ services supported by grants under subsection (a) within the~ State in the State's fiscal year which ended on or before July 1, 1981; in the case of the fiscal year ending September 30, 1983, 7l per centum of the amount of' such expenditures in the State's fiscal year which ended on or before July 1, 12 1982; and, in the case of the fiscal year ending Sep- 13 tember 30, 1984, 10 per centum of the amount of 14' such expenditures in the State's fiscal year which 15 ended on or before July 1, 1983 ; and 16 "(B) may not~ be less than the product of $0.50 17 18 19 20 21 22 23 24 an& the, population of the State. "(3) The totaU amount of grants receive& by a State under subsection (a) to assist' States in meeting the costs of operating, the health communications component of their preventive health services programs for any fiscal year shall be determined by the Secretary, except that it! may not be less than the product of $0.10 an& the population of the State. No tw.ithstanding, paragraphs (1), ( 2), and (3), if for any 25 fiscal year the amount appropriated for that fiscal year under 1 2 g 4 5 6 7 8 9 10 11 12 13 ~ ~ 1-1 ~ # 15 ~ 116 il 17 18' 19 :..' 1 subsection (1) is less grants for that fiscal yeai to all States, the total a for a State shall not be 1 same ratio to the arnour cordance witlh this sectio subsection (1) bears to t accordance with this sect 20, amount of such grant by- " (e) Each grant' u for costs for preventive h beginning on the first da the month in which the ~ grants may be made in : by the way of reimbursei account of underpaymei installinents and on such tary finds necessary to ca "(f) The Secretary, recipient of a grant und "(1) t,hefairm ment furnished the S -3 " (2) the amoutl O C5 ~} expenses of any ofi7cc W Q7 when detailed to the (b N

3gteIIt litions (b).; r sub- Statps dition.s ~ (b~,; undcr, ;iseases (3) of usative ; of tl}e of sub- tditions':. )tomatia he tem ;ervices'. authox- grants by such tatutory 63 13 1 law as a condition to the receipt of Federal financial 2 assistance, or 3 "(B) for operating, inpatient care facilities, con- 4 struction, or mental health programs. 5 "(4) For purposes of subsection (d)', populatbons shall 6 be determined on the basis of the latest figures available: q from the Department of Commerce. 8 "(1) (1) For the purpose of making payments under 9 grants under this section to assist States in planning for pie- 10 ventive health services, there are authorized to be appro- 11 priated $55,000,000 for the fiscal year ending Septetrt- 12 ber 30, 1980. 13 "(2) ', Fpr the purpose of making payments under grants 14 under this sectioni to assist States in meeting the costs of 15 providing preventive health services, there are authorized 16 to be appropriated $150,000,000 for the fiscal year ending 17 September 30, 1981, $175,000,000 for the fiscal year 18 ending September 30, 1982, $200,000,000 for the fiscal year 19 ending September 30, 1983, and $200,000,000 for the fiscal 20- year ending September 30, 1984. 21 "'(3') For the purpose of making additional payments 22 under grants under this section to assist States in meeting 23 the costs of operating the health communications component 24 of their preventive health services programs, there are 25 authorized to be appropriated $25,000,000 for the fiscali year

46' 1 2 3 4 5 6 7 43 Public Health Service Act shalll be eligible t'o receive pay- ments under this~subsection. PART C-CIIANGE.S IN LABELING FOR CiIGARF}T'TE PACKAGES SEC. 408. (a) Effective one year after the date of enact- ment of this part; section 4 of the Federal Cigarette Labeling and Ad'vertising, Act (Public Law 89-92) is amended to 8 read asIallbws: 9 "SEC. 4. (a) It shalli be unlawful for any person to 10 manufacture, import, or package for sale or distribution 11 within the United States any cigarettes- 12 "(1) if the package for which fails to bear the tar 13 14 15 16 17 18 19 20 21 22 23 and nicotine content of such cigarettes stated in milli- grams, and "(2) if the package for which fails to bear one of the following statements : " (A) CANCER MAY RESULT' FROM CIGARETTE SMOKING; "(B) CANCER OF THE' LUNGS, MOUTH,. AND THROAT MAY RESULT FROM CIGA- RETTE SMOKING; "(C)' HEART DISEASE MAY RESULT FROM CIGARETTE SMOKING; 1 " (D) CIC. 2 HURT YOUR H 3 `°(7+J) EMI 4 BRONCHITIS' _ 5 RETMSMONI; 6 "'(F) CIGA 7 PREGNANCY i1 8 CHILD; 9 "(G)i YOU ~ 10 SPECT-DON'T' 11 "(H) SMOE 12 SIGN OF LUNG 13 «(I) IF Y" 14 LIGHTLY-THI 1& TO YOUR HEA]i 16 " (J) DON". 17 THE END-THIi 1:8 Ig ( b ) TO YOUR HEAIi The statements : 2') be located in a conspicuous ''1 22 21 and shall appear in conspi~~ by typography, layout, an on the package. (c) Cigarettes shall " tion in such a manner sotb.

65 or the fiscat year 'or the fiscal year 0M for the fiscal 1LTH SERVZCES 979, section 317 ead as follows : :ALTH SERVICES make grants too er public entities,, ting the costs •of rams as set forth .der section (a) iubmitted to, and ~plication shall, be i manner as the A shall provide- )rogram for which r subsection (a) ; State, and other it~s latest annual of each program 'escription, of the 1 2 3 15 preventive health services provided by the. applicant in such program in such period; the amount of Federal funds needed by the applicant to continue providing 4 such services in each such program; if, the applicant 5 6 proposes changes, in the provision of the services, in any such program, the priorit'ies of such.: proposed changes; the reasons for such changes; and, the amotrnt 8: of Federal funds needed by the applicant to make such 9 changes; • C; 10 ' "(3) for assurances satisfactory to the Secretary 11 that the preventive health services which will be pro- 12 vid'e& with funds under a grant under subsection (aj 13 . will be provided in a manner consistent with the State 14 health plan in effect under sectiion 1524 (c) and in 15 those cases where the applicant' is a State, that such 16 services will be provided, where appropriate, in a 17 manner consistent with any plans in effect undei para- 18 graphs (b), (1)' and (b) (3) of section 315; 19. "(;4) for assurancessatisfactory to the Secretary 20, that' the: applficant will provide for su& fiscal control 21 and fund accounting procedures as! the Secretary by 22' regulation prescribes to assure the proper disbursement. 23, of and accounting for funds received under grants 24 under subsection (a) ; 25 "(5)! for assurances satisfactory to~ the,, Secretary

ciy second ,rtaken or iot limited , effect'ive- rting dem- -tion (a),,. )0,000 for 0; Septem- 30, 1983,. 'OFILE ;h the \ a- , shall sub- nuary 1' of' prevention effective awareness ie prevent- ted States. cases; ~~reventablce 81 31 Iulation of the! United States and the relationship between 2 these determinants of' health and the incidence and prev- 3 alence of preventable causes of death and disability; 4 and 5 (4) the behavioral deteiminantsofhealth of the 6 population of' the United States including, but not lim= 7 ited'i to, smoking, nutritional and dietary habits, etereise,. 8 and alcohol consumptions and the: relationship between 9 thesedeterminants,of health andt'1ie incidence and prev- 10 alence of preventable causes!of'dcath and disability. 11 (b), In preparing the profile required by subsection (a),. 12 the Secretary, acting through the National Center for Health 13 Statistics or its equivalent, shall comply with all relevant 14 provisions of' sections 306 and 308 of the Public Health 1 5 Service Act. of the pop-

n such ;cretary lay rea- rd such isary to reports ; ecretary mditions ; and ' 'ecretary a the ac- nder sub- by by such l! purposes inces pro- 1 not' ap- (b) un- ectiM1 ely too assurances ,ction (b) ,, 67 17 1 ply with the assurances provided with the application 2 under consideration. g "(2) Whenever the Secretary, after reasonable notice 4 and opportunity for a hearing to a grant recipient, finds with 5 respect to funds paid to such recipient, that the program 6 is not operating effectively to achieve its stated purposes or 7 that there is a failure to comply substantially with assurances 8 provided under subsection (b) with respect to the receipt 9 of such grant, the Secretary shall notify the grant recipient 10 that further payments will not be made to it under such 11 grant (or in his discretion that further payments willi be 12 reduced) , until he is satisfied that the program will operate 13 effectively or there will no longer be such a failure. Until 14 he is so satisfied, the Secretary shall make no payment or, 15 in his 'discretion, reduce payments to the grant recipient. 16 "(d) The amount of a grant under subsection (a) shall 17 be determined by the Secretary. Each such grant shall be 18 made for costs for preventive health services in the one-year 19 period beginning on the first day of the first month begin- -20 ning after the month in which the grant is made. Payments 21 under such grants'may be made in advance on the basis of 22 estimates or by the way of reimbursement, with necessary 23 adjustment,s on account of underpayments or overpayments; 24 and in such installments and on such terms and conditions it will com-

62 12 1 January X of eaCh succeeding year a report on the extent 2 of the problems presentedl by the diseases and conditions 3 4 5 6 7 8 referred to in paragraphs (1) and (3) of subsection (b),; on the amount of funds obligated' under grants under sub- section (a) in the preceding fiscal year to assist the Statps in operating programs to prevent the diseases and conditions referred to in paragraphs (1): and (3) of subsection (bk; and on the effectiveness of the programs assisted under 9 grants under subsection (a) in preventing such diseases 1 2 law as a condit" assistance, or 3 " (B) for o 4 struction, or men 5 " (4) For purpo 6 be determined on tN 7 from the Departtnent 8 " (1I) (1) For ti 9 grants under this seci 1o and conditions. t. 10 n "'(k) (1) For purposes of paragraphs (1) and (3) of 11 12 subsection (b), the term 'primary prevention of causative 12 13 conditions' means the prevention of the development of' tf}e 13 14 conditions;in healthy individuals. : 14 15. ,"( 2) For purposes of paragraphs (1) and (3) of sub- 15 16 section (b) ,`secondary prevention of causative conditions', 16 17 means the early detection of the conditions in asymptomatio 17 18, individuals.. 18 19 "(3) For purposes of paragraph (d) (1) (B), the ter{n,, 19 20 'State and local expenditures for preventivo health servieeS'. 20 21 means expenditures by State and local public health author- 21 22 ities for preventive health services supported by grants 22 23 und'er subsection (a) but egcludes egpenditures by such 23 24 authorities--" O 24 2,5 ° •"(x1) specifica~ly required by Federal statutory W 25 © ventiv.e health, servi{ priated 05,000,00+0, ber 30, 1980. "(2) Farthepu und'er this section to providing preventive : to be appropriated $ September 30, 198 ending September 30. ending September 30, year ending Septemb( "(3) For t.he p under grants under t; the: costs of operating, of their preventive: authorized to be appr M

34 1 2 3 4 5 6 7 31 and prevalence of' preventable causes of death and dis- ability; and (4) the behavioral determinants of health ofl the population of the United, States inclndin;, bat not limited to; smoking, nutritional and dietary habits, esercise;, and alcohol consumption, and the relationship Uet'nveen these determinants of health and the incidence 8 and prevalence of' preventahlie causes, of death and 9 disability. 10 (b) In preparing the proFille required by subsection 11: (a), the Secretary, actingtlnrouo;h tihe \at[onal Centierfor 12 Ilealth Statistics or its equivallent, shall comply with all 13 relevant provisions of sections 306 and 308 of the Public A Health ServiceAct4 15 TITLE III-A:IDEND_IIENTS TOTIIE FOOD PIIOVI- 16 SIONS OF TII E FEDEII AL FOOD, DRUG, AND 17 CoS1IETIC' ACT TO FOSTER HEALTII PRO- 18 MOTION 19 S>;c. 301. Whenever in tliistit.le:an amendment is eg- 20 pressed in t~ermsof an, amendment to a sect~ion nr other 21 provision, tlrereferencesliall beeonsidered tobemade tio:a 22 section or other provision ofl the Federal I'ood, Drnm;, and 23 Cosmetic Act. 1 .V 3 .t 5 6' 7 8 9 10. 11 12 13 14 15 16 17 l:i 19 Nt'TIt1TU'1N' INFtitttlttA: St•:r : :;iY!. (n) (1) 1., uut tfit+ fourth !,entcncr thrt (2) ti,•t ti.in ,*u:1/R1 .. (Py If it lourryw,rt, wI'iich a definitiou and •ta ,i•riV,ed bv n•Kulatioa. a. (11 ) it t•ouG"nn. to "a(.h ~'. lititel Itcar4 tltr ntuttr of t. and -untlani.". (Ir) ( 1 )1-4•cti-m 4413 it.l.)Pcl t • (1'y in the ca.e agraph (g) u( tbi:s « (if unh•) of the food: <<(2) in ca.c i; in;:redlents- , (A) tlte 0 int=redient in th, that any sj)ice+ ~ ~uch 4011 Le d.. 2 t

53 GRANTS FORR rICES iendment is ex- ection or other to be made to Health Service .TII SERVICES !; title III is following new "TIVE IIE 1LTII ake grants to i meeting, the hrougll grants ities of politi- ies, or private bsection (a) itted to, and, tioni shall be. as the Secre- )vid'e(ot'her :1 3 "(1) for a detailed plan of a program designed to reduce, through the primary or secondary prevention of causative conditions, the mortality rates for one or more of the five leading causes of death in the St'ate;. . "(2)', the-amount, of Federal, State, and other fundn, obligated by the State in its latest annual accounting period for t'he provision of cach program described in~ paragraph (1) ; a description of the preventive healtt services provided by the State in each such progra.m in 'uch period; the amount of Federal fund's nced'ed' by the State to continue providing such services in each such program; if the State proposes changes in the provision of the services in any such program, the priorities of such proposed changes; the reasons for such changes; and, t'he amount of Federal funds needed by the State to make such changes; `° (3) for, at the option of the St'ate; a detailed plan of a program designed to reduce, through the primary or second'ary prevention of causative conditions, the burden =I of illness associat4with the five leading, causes of mor- hidity in the State; "(4) the amount of Federal, State, and other funds . obligated by the State in its latest annual accounting period for the provision of each program descrihed' rm Paragraphi (3) ; a description of! the preventin•.eliealth,

64 1 2 3 4 5 6 7 8 14 ending September 30, 1981, $30;000,000 for the fiscal year ending September 30, 1982, $35,000;000 for the fiscal' year ending September 30, 1983, and $35,000,000 for the: fiscal year ending September 30, 1984.". PROJECT GRANTS FOR PREVENTIVE HEALTH SERVICES SEC. 103. (a) Effective October 1, 1979, section 317 and the heading thereto are amended to read as follows :• "PROJECT' ORANTS FOR PREVENTIVE IIEALTH SERVICES 9 PROORA3i9 10 "SEC. 317. (a) The Secretary may make grants to 11 States, political subdivisions of States,, other public entities, 12 or private entities to assist them in meeting the costs-of 13 providing preventive health services programs as set forth 14 in subsection (j) . 15 "(b) No grant may be made under section (a) 16 unless an application theref'or has been submitted tb; an& 17 approved by, the Secretary. Such an application shall be 18 in such~ form and be submitted in such manner as the 19 Secretary shall by regulation prescribe and shall' provide- 20 "(1) f'or a detailed plan of the program for whi& 21 the applicant' is seeking support under subsection~ (a)', ; 22 "'(2)i the amount of Federal, State, and other 23 funds obligated by the applicant in its lotest annual 24 accounting period for the provision of each program 25 referred to in paragraph (1) ; a~ description of, the 1 2 preventive heal in such progran: 3 funds needed b 4 such services ir 5 proposes chang. 6 any such prog 7 changes; the re; 8 of Federal fun& 9 changes; 10, «(3) for ~ 11 that' the preven 12 vided with func 13 will be provid'e( 14 health plan in 15 those cases wh- 16 services will b 17 manner consiste 18 graphs (b) (1) 19 "(4) for t 20, that the applic; 1 and fund accoi. 22' regulation presc. of and accoun, under subsectio " (5) for :

73 ar ending iscal year establish- borne by 4,000,000 4,000,000 814,000,- r consulta- ess, stand- r establish- i programs )ursuantto )propriated - 30, 1980,. - 30, 1981',tember 30, ( relating to ention pro- at the end i7 Septem- ng Septem- 23 1.ber 30; 1981, and $14,000,000 for the fiscal year ending 2 September 30, 1982". 3 E%TENSION OF GRANTS TO STATES FOR CObiPREHENSIVE 4 PUBILIC! HEALTH SERViCES' 5 SEC. 104. (a) Paragraphs (4) and (5) of section 314 6(d)~ are amended to read as follows: 7 "(4) (A) The total amount of grants received by State 8 health and mental health authorities under paragraph~ (1) 9 for any fiscal year shall be determined by the Secretary, 10 except that it- 11 "(i) may not exceed the lesser of- 12 "(I) the product of 81 an& the population of 13 the State, or 14 "(II) in the case of the fiscal year ending 15 September 30, 1980, 5 per centum of the amount' 16 of State and local expenditures for comprehensive 17 public health services within the State in the State's 18 fiscal year which ended on or before July 1, 1979,. 19 in the case of the fiscal year ending September 30, 20 1981, 71 per centum of the amount of such eg- 21 penditures in the State's fiscal year which ended 22 on or before July 1, 1980, and in the case of the 23 fiscal year ending September 30, 1982, 10 per' 24 centum of tlre amount of such~ expenditures in the' 3fi»3Si~~. U- '~ - 6~

71 data of any or otherwise a State or to under provi- l.nd which are i service pro- ;rams assisted' President for 1981, and on on~ the extent md conditions of funds obli- the preceding ;ubsection (j) ;. :d under grants _ diseases and ,r grants under ining programs -ention, referral with treat'ment ue appropriate& 21 1:$30,000,000: for the fiscal' year ending, September 30,_ 1980, 2 $35,000,000 for the fiscal year ending September 30, 1981„ 3 and $40,000;000 for the fiscal year ending September 30, 4 1982. 5 6' 7 8 9 "(2 ) For payments under subsection (a) for estab- lishing and maintaining programs to immunize children against diseases (including measles„ rubella, poliomyelitis, diphtheria, pertussis, tetanus, and mumps) , there are au- thorized to be appropriated! $35,000,000 for the fiscal year 10 ending September 30,, 1980, $35,000,000 for the fiscal 11 year ending September 30, 1981, and $35,000,000 for the 12 fiscal year ending September 30, 1982. 13 "(3) For payments under subsection (a) for estab- 14 lishing and' maintaining community and school-based fluori~ 15 dation programs, there are authorized to be appropriated 16 17 18 $5,000,000 for the fiscal year ending September 30, 1980, $5,000,000 for the fiscal year ending September 30, 1981, and $5,000,000 for the fiscal year ending September 30, 19 1982. 20 "(4) For payments under subsection (a), for establishing 21 and maintaining programs designed to prevent illness caused 22 by factors in the immediate living environment'of people. 23 such as localized exposure to toxic substances, and improper 24 storage of solid waste and fuels, there are authorized to be 25 appropriated $12,000,000 for the fiscal year ending Sep-

38 35 1 or continue in effect a labeling requirement applicable to any 1 2 food which is different from or in addition to any labeling 2' 3 requirement applicable to su& food under section 403. 3' 4 "'(b) Upon application of a State or a political subdi- 4 5 vision thereof, the Secretary may, by regulationafter notice 5 6 and opportunity for an oral, hearing, egempt' from subsec- 6 7 tion (a), under suchi conditions as may be prescribed in 7 8 such regulation, a labeling requirement of such State or 81 9 political subdivision if the Secretary determines that the re- 9! 10 quirement is required by compelling local conditions and 10' 11 compliance with it would not cause a food to be in violation 11 12 of a requirement under section 403:". 12 13 Ai,COHOLIC BEVERAGES 13 14 SEC. 304. Section 201 (f) (1) is amended to read as 14 15 follows: "(1) articles used (A) for food for man or other 15 16 animals, and (B) as drink for man or other animals, in- 16 17 oluding distilled spirits, wines, and malt beverages;".. 17 18 EFFECTIVE DATE 18 19 SEC. 305. The amendments made by sections 302, 303, 10 20 and, 304 shall apply with respect to food which is introduced 21 or delivered for introduction into interstate, commerce after `? 1 22 oAe year after the date of the enactment of: this title, 22 23 O 24 ~ ~' 25 ~ CT~ ~ NOTIFICATION TO AND R: cW SEe. 306. (a), TheSec Welfare shall notify the F nutritional information that labels pursuant to sectiou Commission which (if anti required by the Commissio mission Act to be included (b) The Chairman of nually, to Congress on (,1) the! Commission by the Sec in those sithlations where tl mendation, a description o su& recommendation, anc the Commission failed to recommendation, a descript TI!TLE IV-PROGRAIf IIEALTH THRODUII' PAlzrr A-REGULATIO: F. RESTRICTION s ON 8110 SY.c. 4011. (a), Escel, (c~),, and! (d) , smoking - closed area~~ open to the jp

he purposes of recipient ofl a anount of su& pplies (includ- )or equipment ices, and t'raveU ie G'rovernment : the amount of ith,the detail of uipment or the ,he convenienoe mt and for Obe eot -to which the nount by which ble'for payment nishing the sup- onnel,, on which ~eh amount shall deemed to have .1 69 1 2 3 4 5 6 12 19 shall keep such records as the Secretary shall by regula- ,tion prescribe, including records which fully disclose the amount and disposit'ion by such recipient of the proceeds of such gra.nt, the total cost of the undertaking in connection with which such grant'~ was made, an& the amount of that portion of the cost of' the undertaking supplied by other sources, and such other records as will facilitate an effective audit. "('2) The Secretaryand the Comptaolller General of the United States, or any of their duly authorized representa- tives, shall have access for the purpose of audit and ega.minar tion to any books, documents, papers, and records of the 13 recipient of grants under subsection (a)', that are pertinent 14 to such grants. 15 "(g) All information obtained about any individuall 16 under any program that is being carried out with a grant 17 made under subsection (a) shall not, without such individ- 18 ualfs consent, be disclosedy egcept that (1i) such information 19 may be disclosed without such consent if' the disclosure is 20 necessary to provide service to such individual, or is required 21 by a law of a State or political subdivision of a State, and 22 23' 24'. ( 2) information derived from any such program may he disclosed- "(A) in summary, statistical, or other form, or r subsection (a)

66 1 2 3 4 5 6 7 16 that the applicant will make such reports (in such form and containing such information as the Secretary may by regulation prescribe) as the Secretary may rea- sonably require and keep such records and afford such access thereto as the Secretary may find necessary to assure the correctness ofy and' to verify,, such reports; "(6) for assurances satisfactory tb the Secretary that the applicant wilt comply with any other conditions imposed by this section with respect to grants; and "(7) for such other information as the Secretary may by regulation prescribe. "(c) (1) The Secretary shalli review annually the ac- tivities undertaken by each recipient of' a grant under sub- section (a) to determine if the program assisted by such 15 a grant is operating effectively to achieve its stated purposes 16 and if the grant recipient complied with the assurances pro- 17 vided with the application. The Secretary shall not ap- 18 prove an application submitted under subsection (b) un- 19 less the Secretary determines- 20 "( A) that the program is operating effectively to 21 achieve its stated purposes, 22 "(B) that the applicant complied with assurances 23 provided with a prior application under subsection (b),, 24 and 25 "'(C) that he is assured that the applicant will com~ 1 2, 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 O 24 W ~ O CJ ~ (b 40 ply with the assi under consideratic "(2) Whenever and opportunity for a respect to funds paid is not operating effect that there is a failure t provided under subw of such grant, the Sec that further payments grant (or in his disc reduced) , until he is E effectively or there w he is so satisfied, the in his 'discretion, redu " (d) The amount be determined by the made for oosts for pre, period beginning on t ning after the month i under such grants 'ma, estimates~ or by the R adjustments on aocoun and in such installmei

72 22 tember 30, 1980, $12,000,000 for the fiscal year ending September 30, 1981, and $12,000,000 for the fiscal year 1 2 3 ending September 30, 1982. "'(5) For payments under subsection (a) for establish- ing and maintaining programs to prevent diseases borne by rodents, there are authorized to be appropriated $14,000,000 for the fiscal year ending September 30, 1980; $14,000,000 for the fiscal y,ear_ending September 30, 1981, and $14,000,- 000 for the fiscal year ending September 30, 1982. "(6) (A) The Secretary shall establish, after consulta- tion with the President's Council on Physical Fitness, stand- 4 5 12 ards for comprehensive physical fitness programs. 13 "(B) For payments under subsection (a) for establish- 14 ing and inaintaining comprehensive physical fitness programs. 15 that are consistent with the standards establishe& pursuant to 16 paragraph (A), there are authorized to be appropriated 17 $10,000,000 for the fiscal year ending September 30, 1980,. 18 $12,000,000 for the fiscal year ending September 30, 1981,. 19 and $15,000,000 for the fiscal year ending September 30, 20 1982.". 21 (b) Section 503 (a), of Public Law 91-695 ('relating to 22 authorizations for lead-based paint poisoning prevention pro- 23 grams) is amended by inserting before the period at the end 24 thereof :`;$14,000,000 for the fiscal year ending Septem- 25 ber 30, 1980, $14,000,000 for the fiscal year ending Septem- 1 .ber 30, 1981, and $14,0 2 September 30, 1982". 3 E%TENSION OF GRANTS '_ 4 PUBLIC E 5 SEC. 104. (a) Paragr G('d')', are amende& to read a 7 " (4)' (A) The total a 8 health and mental health 9 for any fiscal year shall " 10 escept thatiit- 11 "( i) may not esc~ 12 "(I) the pro 13 the State, or 14 " (II)in the 75 16 17 19 ,)0 21 02 2 3 24 I, Iu - ::1 - " September 30, 19 of State and local public health servic fiscal year which e in the case of the ;'. 1981, 7j per cen: penditures in the on or before July fiscal year ending centum of the amc

52 2 TITLE I-FORilIII'LA AND PROJECT GI1AN TS FOR PREVENTIVE HEALTH SERVICES SEC. 101'. Whenever in this title an amendment is ex- pressed in terms of an amendtnent to aseetion or other provision, the reference shall be considered to be mad'e to 1 2 3 4 5 6 asection or other provision of the Public Ilealthi Service: 7 Act. 8 FORMULA GRANTS FOR PREVENTIVE III;.ILTII SERVICES' 9 SEC. 102. Effective October 1, 1979, title III is 10 amended by adding after section 314 the follbwingnew 11 section and heading thereto: 12 "FORMULA GRANTS TO STATES FOR I'RE\'ENTIVE HEALTII' 13 SERVICES 14 "SEC. 315. (a) The Secretary shall make grants to 15 States to assist them in planning for and in meeting the 16 costs of providing (through~ such States and' through grants 17 or contracts or both with public health authorities of politi* 18 cal subdivisions of the States, other public entities„ or private 19 entities)' preventive health services: 20 "(b) No grant shall be made under subsection (a) 21 unless an application therefor has been submitted to, and 22 approved by, the Secretaly. Siich an application shall be 23 in such form and be submitted in such~manner as the Secre- 24 tary shall hyregulation prescribe and shadl' provide(;other25than in an applicat~ionJor aplanninggrant)- 2 3 4 5 6 7 8 9 " (1) for a dc reduce, through t of causative cond', more of the five l+ "(2) the~amc obligated by the period for the pr paragraph (1) ; ~'~ services provided 10 such period; the ., lli State to continue program; if the S 13 of the services 14 15 proposed changes amount of Federi. 16 such changes; 1; "(3) for, at 18 of a program desi 19 secondary preven of illness associat bidity in the Statc " (4) the an' O~ 1 obligated by the W p~ 24 period for the p O ; W 25 paragraph (3) Cn ~ CP

® administrative itates shall' be i any Federal ; offices. date of' enact- administrative I States shall r the enforce- imited to, ap- such sections. : ith any other 'ety, or well- smoking or pipe contain- means means the mitted and in anner which rift of smoke area; 85 1 2. 4. (c) the term "instriVumitality of the United' States" means- 3 (1) an executive agency, as defined in section 4 105 of title 5, United States Code; 5 (2) the United States Postal Service; 6 (3) the Congress; 7 (4)_ the courts of the LTnited States; and 8 (5) the governments of the territories and 9 possessions of the United States; 10 (d) the term "Federal facility"'means- 11 (1) any building, installation, or facility owned 12, by the United! States, excepting private residencies, 13 or; 14 (2) any part of any other building, installa- 15 tion, or facility, which part is owned or leased by 16 the United States, excepting private residencies. 17 EFFECTIVE DATE : 18 SEC; 6. The provisions of this Act shall take effect 19 ninety days after the date of enactment ofi this Act, 20 ESTABLISHMENT OF A HEALTII PROTECTION T AC 21 SEC. 7: (;a)~ Subsection (;b)of section 5701 U the In- 22 ternal Revenue Code of 1954 (relating to the rate of tax 23 on cigaret'tes)is~ amended to read as follows: 24 °L (b) CIG ARETTES: 25 "(1) InIPOSITION OF TAS.-There, shall be :imposed

77 ral statutory law I financial assist- e facilities, con- (A) populations est figures avail- ;nts under grants estimates and in .tstments for any ) is amended by .ise (A) an& in- ved", (2) strik- ( i ) and inserting, (4) ", and (3). ( ii ) and inserting paragraph (4)") nded by striking Jore the period year ending Sep- iseal year ending e fiscal year end- i 2 3 4 5 6 7 27 ing September 30, 1981, and $150,000,000 for the fiscal year ending September 30, 1982". ('d)~ Section 314 (d) (7) is amended by adding, at the end thereof the following new paragraph: "(C)', Of the: amount appropriated under subpara- graph (A) for any fiscal year the Secretary shall ob- ligate not more than $1,000,000 for the uniform na- tional health program reporting system referred to in paragraph (2) ('C) (ii) .". TITLE II-RESOURCES' FOR DISEASE' PREVEN- TION AND HEALTH PROMOTION 12 CENTERS FOR' IIEALTII PROMOTION 13 14 15 16 17 18 19 20 21 22 23 24 25 SEC. 201. Title III of the Public H'ealth Service Act is amended by adding after section 315 (added by section 102 of this Act) the following new section and heading thereto: "CENTERS FOR HEALTH PROMOTION "SEC. 316. (a) For the purposes of assisting the Sec- retary in carrying out sections 315 and' 317; providing such technical and' consulting assistance as recipients of grants un- der such sections may from time : to ~ time require ; conducting researchy studies, and analyses (including cost-effectiveness analyses) of preventive health service programs; and' devel- oping approaches, methodologies, policies, and standards for delivering preventive health services, the Secretary shall by grants assist public or private nonprofit entities in meeting

1 2 3 4: 5 6 7 8' 13 74 24 State's fiscal year which ended on or before July 1,. 19$1;and "(u) may not'be less than the greater of- 1 "(I) the total amount of grants received by su& authorities under paragraph (1) for the fiscal .t 5. year ending September 30, 1979, or G "(TI) the product of 50:50 and the population of the State. Notwithstanding clause (ii) if f'or any fiscal year the amount appropriated for that fiscal year under paragraph (7) is less than the amount needed to make grants for that fiscal'_yeas in accordance with such clause to all State health an& mental health authorities with approved applications, 14 the total amount of grants for that fiscali year for State health 15 and mental health authorities shall not be less than an amount 16 which bears the same ratio to the amounts d'etermined for 17 such authorities in accordance with such clause as the 18' amount appropriated under such paragraph, bears to the 19 20 21 22 amount needed to make grants in accordance with such clause for such, fiscal year to all! State health and mental health authorities with approved applications. "(B ) The Secretary, at the request of State health and 23 mentall health authorities, may reduce the amount of the24. gcants to it under paragraph (11), by- 7 "(i) the fi menb furnished " (ii) the : expenses of' an.i when detailed authority and in connection v 8 R-hen, the furnishin 9 10 ].1 12 13 14 15 16 17 18 19 20 21 22, detail of such an o of and at the requ authority and for with respect to w made. The amount shall be available f, incurred in furnish tailing the personn is based, and such grant and shall be~ health; or mentaU he " ('C) For pur term 'State and loc healtlhservices'me.health and mental ices designated by by such authorities,

d into the -Iontains - a health & health k a health th protec- r the pur- r of 'toxic 'tar', plusligrams of - zrette. N ICOTI` R CONi1IIS- (hcrcin- •halt, fromdar year) e tar and her ciga- ictured iiu 87 6 1 or imported into the United States. The conditions, 2 methods, and procedures for conducting such deter- 3 minations shall be promulgated by the Commission 4 in regulations issued by it for purposes of this 5 paragraph. Until such time as such regulhtions are 6 first issued, the conditions, methods, and procediires 7 for conducting such determinations, shall be those 8 approved by the Commission for formal testing 9 which are in effect on the date of the enactment of 10 this subsection. 11 "( B) CERTIFICATION TO THE SECRETARY.- 12 During the last! calendar quarter of each calendar 13 year, the Chairman of the Commission shall certify 14 to 'the Secretary the tar and nicotine content' of each 15 brand of cigarettes~ manufactured in~ or imported 16 into the United States. Such certifications shalll be 17 used by the Secretary to determine the rate of tax 18 to be:imposed on cigarettes for the period beginning 19 with the first! day of the calendar year beginning 20 after such certification is made, and during such 21 calendar year. 22 "(C) The Commission and the Secretary shall 23 promulgate regulations for the: purposes of testing,, 24 certifying, and imposing taxes under this subsec- I

LRh' (a)(1) (1), ),for the ),000 for the $10,000,000 ,nts for the 1 evaluations to be appro- ing Septem- iing Septem- ;ye1g ending ts for grants to be appro- eptember 30, ing Septem- year ending CH SMOKING ~' AND NICO- Y ADDED TO TTES lucation, and ~!t of, a studyociated %rit'h 93 1 2 J 4 :l 6 12 stnolcii~a ciaarelltes of .-aryinalevels of tar and' nicotine and (:?)' the healtli risks associated Nvitliisuiultiira' ciaarettes' con- taiuing any substances counuonlyaddedto . coinniercially imaiufucture.d cigarettes. (h)Within twoyears of tliedate of enactment of, this parts tlrc Secretary sh:llli rehorttot'die Congress the results 7, of the~study orstltdies conducted pursuant to subsection (a)~ S ancU any recommcnrlations for lcgihlativeor aduiinistrative9 action.

78 28' the costs of planning and developing new centers, and oper- ating exist.ing and new centers, for multidisciplinary health~ promotion. To the extent practicable, the Secretary shall provide : assistance under this section so that at, least five such 5 G 7 8' 9 10 centers will be in operation by October 1, 1981. "(b) (1) No grant may be! mad'e under this section for planning or developing a center unless the Secretary deter- mines t'hatl when it is operational it will meet the require- ments listed in~ paragraph (2) and be able to provide assistance and dissemination~ of information~ to recipients of 1 "(C) Such ; 2 tary may by regul 3 " °(c) Centers assi 4 into arrangements wit 5 315 and 317 for the 1 6 technical assist'ance, ai 7 to such recipients apj 8 standards ~ for deliverinr 9 " (d) For the pur 10 grants under subsecti( 11 appropriated $10,000;( 12, ber 30, 1980, $10,00( 13 tember 30, 19811, and t, 14 September 30, 1'982.". 15 COMMUNITY BASED 11 grants under sections 315 and 317 as provided in subsections 12 (a) and (c) . No grant may be made, under this section: for 13 operation of a center unless the center meets such require- 14 15 16 ment's and' is able to provide such assistance and dissemina- tion of information. "(2) The requirements~ referred to in paragraph (1) 16 HE 17 are as follows : 18'. "' ( A)' There shall be : a full-time director of the 19 Center who possesses a, demonstrated capacity for sub- 20 stantial accomplishment and leadership in health promo- 21 tion, and there shall be such additional professional staff 22 as may be appropriate. 23 24 17 ' SEC. 202. (a) The 18' Welfare shall undertakE 19 ~ tracts or both ) five,intc 20, based programs for the 21 ating optimal methods 22 prehensive preventive li "(B) The staff of the Center shalt represent a W 23 diversity of relevant disciplines. v 24 W 25 ~ O N (b) The Secretan . Iluman Resources of thu state and Foreign, Con

54 4 services provided by the State in each su& program in such period; the amount~ of Federal funds needed by the State to continue providing such services in each~such program; if the State proposes changes in the provision of the services ini any such program, the priorities of! such proposed changes; the reasons for such changes; and; the amount of' Federal fhnds needed by the State 8 to make such changes; 9 "(5) that the plans described in paragraphs (X) 10, and (3)- 11 "(A) sha11' describe a: comprehensive preven- 12 tion program which utilizes, to the extent practi- 13 cable, all relevant professional disciplines; , 14 "'(B) may, at the option of the State, describe 15 a program or programs that are targeted toward a 16 particular age : group; 17 "(C) shall set forth quantitatively the current' 18 relevant rates of mortality and, whereappropriate, 19 of morbidity in the State; 20 "(D) shall set forth the quantitative goalf; for 21 22 23 25 reduction in the relevant rates of mortality and, where appropriate, of morbidity ini.the St.ate;, "'(E) shall have a separate health cominunica- tions component in the program or programs which shall include, but not be limited -tq, a description I .t 51 of! how the comm~ electronic media, ~ purposes of'the pro " (F) shall id tity in the State complishing, throur and other means (E),;and ~~ " (G ) shall c, l~t the Sccretary tnal'I L "(;6)for assuran, t}~at thepreventivi lif vidh& %N•itli funds und, «61i be provided in a h~;flth E,lan iu ,•1Tect uu ( ~ ) for a--uratt Htnt the stntr pill pt : ttui af c~,untin•^ hr„c.. :;,,tf prr-t rii~cs tn a•.~~ ,u,j„r ':in , ,.. „ .:~

IV JuNE 9, 1978 Conrad, C: Carson, Executive Director, President's Council on Physical: Fitness and Sports; Robert H. Griffiths, D.D.S., member of the board of trustees, AmericanDent'a1 Association;,Joseph A. Wilber, II.D., director for adult health services, Georgia Department of Health ; an&\Iorris Chafetz, MlD:, president, Health Education Foundation~ a panel______ Huns, Ellen, director, consumer division„ Community \utrit`on Institute ; Page 410. Robert! 0. \esheim„Ph. D!, vice president of science and technology, The Quaker Oats Co., representing the Grocery Manufacturers Association ; Michael F. Jacobson, Ph. D., executive director, Center for Science in the Public Interest; Ira I. Somers, Ph. D., executive vice president and director of laboratories, National Food Processors Association ; and Janet, C. Tenney, nutritionist, office of consumer affairs, Giant Food, Inc., accompanied by H. Edward Dunkelberger, Jr., counsel, \ational Food'Processors Association, a panel________________________________ 600 STATEMENTS American Cancer Society, Elnerson Foote, former vice-chairman of the board, prepared statement__________________________________________ 239! American Cancer Society, Lasalle D. Leffall, Jr.,, M.D., president-elect'S prepared statement------------------------------------------------- 208'. American Dental :>issociation;, Robert H. Griffiths, D.D:S:, member, board of trustees, prepared statement_____________________________________ 514 American Dental Hygienists' Association, Jeanette S. Buchanan, RDH president, prepared statement--------------------------------------- 836 American Frozen Food Institute, prepared statement___________________ 854 American Heart! Association, Robert \I. Daugherty, Jr., JLD:,, Ph. D.,, chairman, prepared statement______________________________________ 221 American Lung Association, Donald Young, former medical director, prepared statement------------------------------------------------- 218 Arnold, Dr. Charles B., president, the :lmerican College of'~ Preventive Medicine ---------------------------------------------------------- 372 Center for Science in the Public Interest, Michael F. Jacobson, Ph. D., executive director,prepared statement------------------------------- . 685 Community \utritiow Institute, Ellen Haas, director, consumer division, prepared stat'ement'------------------------------------------------- 608 Conrad, C. Carson, executive director, President's Council on, Physihali Fitness:and Sports; Robert H. Grifliths, D.D.S., member of the board of trustees, American Dental Association ; Joseph A. Wilber, M.D., director for adult health services, Georgia Department of Health ; and Morris E. Chafetz, JLD:, president,, Health Education Foundation~ a panei______ Prepared stat'ementl---------------------------------------------- Distilla?d Sp=rits Council of tiie United States, Inc., Sam D. Chilcote,, Jr., 410 412' president, prepared st'atement--------------------------------------- 915 Dulbecco, Dr. Renato, Nobel, Laureate, scientist, and researcher, prepared statement --------------------------------------------------------- 320 Evans, Richard' I., Ph, D., professor of psychology,, University of Houston, Houston, Tex., accompaniedi by James W. Swinebart, Ph, D., director, Public Communications Center, Pelham Manor, Zw.Y. ; and Paultl Green, president, Green Dolmatch Advertising, Inc., New York, N.Y., ai panel-- 166 Prepared statement----------------------------------------------- 179 Farquhar,, Dr. John 11'., professor of medicine, Stanford University School' of 3ledicine-------------------------------------------------------- 379. Fielding,, Dr. Jonathan E., commissioner of public health, Commonnvealth of Massachusetts --------------------------------------------------- Flavor and Extract Jlanufacturers"Association, prepared'statement______ Foege; William H., M.D., Director, Center for Disease Control ;\orman Kretchmen .II.D., Director. National Institutes of Child Iie;alth and Human D'evelopment ; and: John P'nney. Director, Office of Smoking and Health~ Department of Health, Education, and Welfare, a panel'______ Prepared statement_______________________________________________ 304 926 109 129 Ford, Hon. Wendell H., a U'.S. Senato_ Food, Marketing Institute, Dennii statement ----------------------- Foote, Emerson, former vice chairr Society, preparedi st'atement______- Georgia Department of Health; Josel health services, prepared statemen Giant Food Inc., Janet E. Tenney, n prepared statement______________- Green Dolmatch Advertising, Inc., Ne prepared statemenf---- __________- Haas, Ellena director, consumer divi: Robert 0. Nesheim, Ph. D., vice pr4 Quaker Oats Co., representing the Michael F. Jacobson, Ph. D., execu3 Public Interest ; Ira I. Somers, I director of laboratories, National F' E. Tenney, nutritionist, office of accompanied by H. Edward Dunk Processors Assoc_ation, a panel__. Prepared statement______-_____- IIanneman; Gerhard J., associate pro School of Communications; UniTer IIart„ Hon. Gary, a U.S. Senator fi statment ----------------------- Health~Education Foundation, Morrh statement ----------------------- International Foodservice INfanufacti Kellogg Company of Battle Creek, pi L:Azar, Dr. J. Brett, health officer, Mo representing the National Associ: Public Health Association_-___-_- Leffall, Lasalle D., Jr., M.D., presi( accompanied by Donald~ Young, li ciety, and former medical director. - :Vf. Daugherty, Jr., M.D., Ph: D., American Heart Association; Joh and! chief counsel, Action on Smol. Prepared stat'ement_________-_- .llanoff, Richard K., chairman, Ric)! Manoff International, Inc_______-- Prepared st'atement________-____ McGinnis, ;llichael, 1LD., Deputy Assi~ Health, Initiatives, accompanied b. Control ; and Taylor Quinn, Bur Administration ----------------- Prepared st'atement-____-_______ \ationali Association 4f Broadcaster\ational Food Processors Associati, vice president and director of laboi President's Council on Physical Fit EkecutiveDirector, prepared stat Public Communications Center, Pelh: Ph. D., director, prepared st'ateme Quaker Oats Co., Robert 0. Nesheim technology, prepared statement-__- : RichartI K. -Manoff, Inc., Richard K. Steen~ Lowell H',, 11I.D., representin, ~ accompanied by Harry N. Peterso: W, American Medical Aissociation__- ~ ~ ~

. 1 2 60 10 costs incurred in connection with the detail of such officer or employee, 3 when the furnishing of such supplies or equipment or the 4 detail of such an officer or employee is for the convenience of 5 and at the request of such State and for the purpose of plan- 6 7 ning, or tarrying out a program with respect to which the State grant under subsection (a) is made. The amount by which any such grant is so reduced shall! be: available for payment by the Secretary of: the costs incurred' in furnishing the supplies or equipment, or in detailing the personnely on which the reductiom of such grant is based, and such amount 12 shall be deemed as part of the grant and shall be deemed 13 to have been paid to the State. 14 ' "(g) .(1) Each State w'hich is a recipient of' a grant 15 under subsection (a) shall keep such records as the Secretary 16 shall by regulaation prescribe, including records which fully 17 disclose the amount and disposition by such State of t'he 18' proceeds of such grant, the total cost of the undertaking 19 in connection with which such grant was made, and the 20 amount ofi that portion of the cost of the undertaking sup- 21 plied by other sources, and' such other records as willi facili- 22 tate an effective audit. 23 "('2 ) The Secretary and tbe : Comptroller G'eneral of the 24United States, or any of t'heirdWy authotnzed: representa- 25 tives, shall have access for the purpose of audit and examina- 1 2 3 4 5 11 12 13 14 15 16 17 18 19 20 21 22 23 W 24 0 25 ~ ~ W tion to any I State which that' are perti ({(h) .A under any p 6 made under 7 ual's consent 8 may be disc 9 necessary to 10 byalawof (2) inform disclosed- "( "( but only if ~ individual i: "(i) h strict the u agency or of Federal able for tbi from bein through gi " ( ] ). submissior

68 18 1- as the Secretary finds necessary to carry out the purposes of 2 such grants. 3- "(e) The Secretary, at the request of a, recipient of a. 4 graut under subsection (a), may reduce the amount of such 5 grant by- 6 7 8 9 10 1 12 :13 .. "(1) the fair market value of any supplies (includ- ing vaccines and other preventive agents) or equipment furnished the grant recipient, -and' (12) the amount of the pay, allowances, and travel expenses of any officer or employee of the Government .when, detailed:to the grant Tecipient and the amount of any other costs incurred- in connectioin with :the. detail, of wch offiCer or employee, 14 when the, furnishing of such supplies or equipment or the. 15 detail Af such an officer or employee- is for the convenience 16 •, of- and at the request of, such grant recipient and for Yb,e 1.7 -,purpose af carrying out a program with respeot to which the 18 - grant under subsection (a) is made. The amount by which 19_ :amy ' such grant is so reduced shall be availahle "for payment 2} by the Secretary of the costs incurred' in furnishing the suL)- -21 _' plies nr, equipm,ent, or in de tailing. the i persolmel,; on which 22 the redtiction, of • such grant is b®sed, 'and such amount shall 23- be deemed as parfi of the grant andd shall be deemed,to have y4„' been paid.to the grant recipient. ;• 25 "'(ff (1), Each recipient of a grant'under subsection ('a). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18' 19 20 21 22 23 O w 24 0 CJ shall keep such tion prescribe, amount and disl such grant., the with which sucl portion of the sources, and' suc audit. "(2) The ~ United States, tives, shall have tion to any boa recipient of gra to such grants. "(g) All under any prog made under suli ual's consent, b may be disclos necessary to pr by a lawofi a

86 5 2 7 8 9 10 11 on every cigarette manufactured in or imported int'o the. United Stat'es,, regardless of weight, which contains- "(A) from 10 to 19.9 toxic units; a health protection tax of' $0.0025; "('B) from 20 to 29• :9 toxic units, a health , protection tax of $0.0075; "' ('C ) from 30 to 39.9 toxic units, a heal& protection tax of' $0.015; and "(D) 40 or more toxic units, a health protec- tion tax of' $0.025. "(2 ) DEFINITION OF TOXIC UNITS: r' Or the pur- 12 poses of subsection (b) (1)' above, the number of 'toxic 13 units" means the sum of- 11 "(A) the number of milligrams of 'tar', plus 15 `° (B) ~ 10 times the number of the milligrams of 16 'nicotine' which are conta'ined' in such cigarette. 17 "(3) DETERMIN:ATION OF TAR AND NICOTINE' 18. CONTENT.- 19 "(A) TESTING BY FEDERAL TR,YDE C•O5i1IIS- •20 sloN.-The Federal Trade Commission (hercin- 21 after referred to as the `Cbnunissiou') shall fi•ont 22 time~ tb time (but! at least once each calendhr year)~ 233 determine or causeto: be deteiunined the tFir and 21 nicotine: eontent. (calculated in milligrams per ciga- 25 rette) of each brand ofcigarettes manufactured in 1 2 3 4 5 6 7 8' 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 O~ 24 W ~ or imported into tl methods, and proc, minations shall be in regulations issu, paragraph. Until ss first issued, the cor. for conducting sur approved by the whieh are in effect this subsection. " (B ), CEBTIF During the last cE year, the Chairmai. to 'the Secretary th, brand of cigarette into the Unit•ed St used by the Secret: to be imposed on ci with the first day after such certifica calendar year. "(C) The Uor promulgate regulat certifying, and imi

%a. )efore July 1, 1 1 of- received! by for the fiscal he population cal year the er paragraph rants for that. 1' State health applications, r State health an an amount Aermined for lause as thee bears t'o the ;e with such i and mental .t 5 rc 7 25 "(i)~ the fair market value of any supplies or equip- ment furnished suchiauthorities, and "(ii), the amount of the pay, allowances, and travel' expenses of any officer or employee of -the Government when detailed to the State health or mental health authority and the amount of any other costs incurred in connection with the detail of such officer or employee, 8 when the furnishing of such supplies or equipment' or the g detail of suchi an officer or employee is for the convenience lo 11 ]2 13 14 15 16 17 18 19 20 21 te health and! 22 aount of' the / 23 24 25 of and at the request of the State health or mental health authority and for the purpose of carrying out a program with respect to which its ! grant under paragraph (1) is made. The amount by which, any such grant is so reduced shall be available for payment by the Secretary of the costs incurred in furnishing the supplies or equipment, or in de- tailing the personnel, on which the reduction of such grant is based, and' such, amount shall be deemed as part of the grant and shall be deemed to have beeri paid to the State health or mental health authority. "(C) For purposes of' subparagraph (A) (i) (II), the term 'State and local expenditures for comprehensive public health, services' means expenditures by State and local public health and mental health authorities for public health serv- ices designated by the Secretary but excludes expenditures by such authorities-

92 7. 8 11 undertaking or support of'research under paragraph (a) (1), , there are authorized to be appropriated $10,000,000 for the fiscal year ending September 30, 1950; $10,000,000 for the fiscal year ending September 30;, 1981, and $10,000,000 for the fiscal year ending September 30, 1982. (2) For the purpose of making payments for the undertaking or support of demonstrations and evaluations under paragraph (a) (2) , there are authorized to be appro- 9 priated $10,000,000 for the fiscal' year ending Septem- 10 ber 30, 1980, $10,000,000 for the fiscal year ending Septem- 11 ber 30, 19811, and $10,000,000 fWthe fi@%t;ye* ending 12 September 30, 1982. 13 (3) For the purpose of making payments for grants 14 under paragraph (a) (3), there are authorized to be appro- 15 priated $10,000,000 for the fiscal year ending September 30, 16 1980, 810,000;000' for the fiscal year ending Septem* 17 ber 30, 1981, and $10,000;000 for the fiscal year ending 18 September 30, 1982. 19 STUDIES OF HEALTH RISKS ASSOCIATED WITH SMOKING 20 CIGARETTES OF VARYING LEVELS OF TAR AND NICO- 21 TINE AND WITH SUBSTANCES COMMONLY ADDED TO 22 COMMERCIALLY biANUFACTURED CIGARETTES 23 SEC. 11. (a) The Secretary of Health, Education, and 2-1 Welfare shall' conduct, or arrange for the conduct of,, a study 25 or studies of (1) the relative health risks associated with 1 smokina cianrettes~ of vary (2)~ the liealth risks,associ;~ taiuiog any~ subst'ances~ cu~ 2 3 4 manufachu•ed cigarettes. (1)) Within t«-o y,ear~ part, the Secretary shall n of thcstudy orstndies coni and any rec:omnienrlatiou. (fi 7 S 9~ action.

82 95aIl CONGRESS 2D S£.SSION S.3118 IN THE SENATE OF THE UNITED STATES Dsnr 19 (legislative day„M4s 17), 1978 3fr. KENNEDY (for himself,,lir. Wna.Ianis, 3ir. CxAFeE;,.lir. RAVDOLra,,lir. PPI:I,,,Air. RzEcn,E, Dfn blcGoe7.aN, bfn I-IAaT; and Mr. I.FaxY) iintroduced the following bi1l;,which was read t'R-ice and referred to the Committees on I:nviionment, and Public Works, Commerce, Science, and Transport'ation,, and Human Resourcesjoint0y by, unanimous consent 1 any stairway, elevator, 2 reception room, confer 3 such facility. 4 (b) Smokers shal 5 smokers in any restaur 6 facility; recreation rooi, 7 (c) Each instrum( g reasonable efforts that 9 ABILL' 10 To create programs designed'~ to promote health through 11 smoking deterrence. 12 Be it enacted by the Senate and Hause o f Representa- 1 13 2 tives o f the United States o f' America in Conyress assembled,. 14 That this Act may be cited as: the "Smoking Deterrence 3 15 Act of 1978". 16 AREOULATION OF SMOKING IN FEDERAL FACILFPII'S; 17 6 R.EBTItICTIONS ON SbiOKINCi IN FEDERAL FACILITIES 18 17";. Slic. 2. (a) Except as provided in snb,ections (b), 19 8. (;c),,` n.nd ('d), srnokingshall not be permitt~ed in, any en- 20 9 closed area open to the public in any Federal fraeilitq or in 211 II 22 administrative disruptit places of its employees be so separated from t do smoke. (d) In planning, i erwise obtaining new i United States shall, t, insure the effective seF employees in such facilii NO SEC: 3. In every smoking is prohibited .such area. signs shall be clearly a numbers and prominew ing or occupying such

84 3 1 ENFORCEMENT 2 3 4 5 6 7 8' 9 10 11 12 13 14 15 SEC. 4. (a) ~ The executive head or chief administrative officer of each instrumentality of the United States shall be responsible for enforcing sections 2 and 3 in any Federal facility in which such instrumentality maintains offices. (b)', Not later than ninety days after the date of' enact'- ment of this Act, the executive head or chief administrative officer of each instrumentality of the United States shall' publish in the Federal Register regulations for the enforce- ment of sections 2 and 3 including, but not limited to, ap- propriate sanctions for noncompliance with such! sections comparable to sanctions for failure to comply with any other applicable regulation affecting the health, safety, or well- being of the public or the work force. DEFINITIONS 16 SEC. 5. For the purposes of this Act: 17 (a) the term "smoking" means the smoking or 18 possession of' a lighted cigarette, cigar, or pipe contain- 19 ing a tobacco product;,and 20 (',b )t'he t'erm "effectdvely separated" means the 21 separation~ of areas in which smoking is permitted and in 22 whi& smoking is not permitted in: a manner which 23 minimizes, to the extent practicable, the drift of smoke 24 from the smoking area into the nonsmoking area; 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 ~ 8 19 20 21 22 `,3 Q Q:. Q w `?q'! 25 O (c) the te means- (1) f. 105 of tith (2) t: (3) t; (4)_ ti (5) possessiow (d), the te (1) ai by the Un or;. (2) ~ tion, or fa, the United SEC. 6. The 1 ninety days~after th,~ ESTABLISIIME~ ~ SEC.~~7: (;a)! Si ternat $evenue Co; on cigarettes) is: an i` (b) CiIGARET" «(1) IMP(

70 1 2 3 4 20 "(B) for clinical or research purposes, but only if individually identifiable personal data of any such individual is not disclosed. "' (h) Nothing in this section shall limit or otherwise 5 restrict the use of funds which are granted to a State or to 6' 7 8 9 10 11 12 13 14 an agency or a political subdivision of! a State under provi- sions of Federal law (other than this section) and which are available for the conduct~, of preventive health service pro- grams from being used in connection with programs assisted through grants under subsection (a) . "(i) The Secretary shall submit to the President for submission to the Congress on January 1, 1981, and on~ January 1 of each succeeding year a report on the extent of the problems presented by the diseases and condit'ions 15 referred to in subsection ( j); on the amount of funds obli- 16 gated under grants under subsection (a) in the preceding 17' fiscal year for each of the programs listed in subsection ( j); 18 and on the effectiveness of the activities assisted under grants 19 under subsection (a) in controlling such diseases and 20 conditions. 21 "( (j) (1For payments to States under grants under 22 subsection (a): for establishing and maintaining programs 23 for the screening, detection„ diagnosis, prevention, referral 24 for treatment, and follow-up on compliance wit}l treatment 25 of hypert~ension; there: are authorized to be appropriated 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 O 24 W Qj 25 O G7 C: tD W $30,000,000, for th $35,000,000 for th and $40,000,000 f .1982. "(2) For pay lishing and maint: against diseases (i diphtheria, pertussi thorized to be appr ending September year ending Septen fiscal year ending S( "(3) For pay lishing and maintah dation programs, tl $5,000,000 for the $5,000,000 for the and $5,000,000 for 1982. " (4) For paym, and maintaining pro, by factors in the in such as localized exp st'orage of solid wast appropriated $12,OC

83 STATES 'r. RA_Nnoi.rx,,.lfr. .FAax): introduced the Committees on id Transportation,, 2 1 any stairway, elevator, hallway, conveyance, waiting raom,, 2 reception room, conference room, or hearing room in any 3 such facility. 4: (b) Smokers shall be effectively separated from non- 5 smokers in any restaurant, cafeteria, snackbar, other dining 6 facility, recreation room, or lounge in any Federal facility. 7 ~c)' Eaeh instrumentality of the United States shall use 8 reasonable efforts that do not result in excessive cost or 9 administrative disruption to effectively separate the work- 10 It1I throuai~ 11 12 of Representa- 13 gress assembled, 14 :ing Deterrence 15 16 FACILITI'ES ; 17 , FACILITIES 18' 11bsections (b), tted in; any en- •al fueilitv, or in places of' its employees who do not smoke and who wish to be so separated' from the workplaces of its employees who do smoke. (d) In planning, designing, purchasing, leasing, or oth- erwise obtaining new facilities, each instrumentality of the United States shall, to the maximum extent practicable, insure the effective separation of smoking and nonsmoking employees in such facilities. "N0 SMOKING" SIGNS 19 SEC. 3'. In every area in any Federal facility where 20~ smoking is prohibited under section 401, "No Smoking" 21 signs shall be clearly and conspicuously posted in sufficient 22 numbers and', prominence to give notice to any person enter- 23, ing, or occupying such area that smoking is prohibited in 24 such area.

79 ~rs, and oper- )linary health Jcretary shall least five such l. iis section for cretary deter- t the require- _e to provide )i recipients of in subsections his section for such require- ;nd dissemina- aragraph (1) irector of the )acity for sub- health promo- ofessional staff 11 represent a 29 1 "(C) Such additional requirements as the Secre- 2 tasy may by regulation prescribe. 3 "(c) Centers assisted under this section: (1) may enter 4 into arrangements with recipients of grants under sections 5 315 and 317 for the provision of appropriate and necessary 6 technical assistance, and (2) shall develop and disseminate 7 to such recipients approaches, methodologies, policies, and' 8' standards for delivering preventive health services. 9 "('d) For the purpose of making payments pursuant to 10 grants under subsection (a), there are authoiized to be 11, appropriated $10,000,000 for the fiscal year ending Septem- 12 ber 30, 1980, $10,000,000 for the fiscal year ending Sep- 13 tember 30, 1981, and $1''0,000,000 for the fiscal year ending 14 September 30, 1982.". 15 COMMUNITY BASED DEMONSTRATION S OF' PREVENTIVE 16 HEALTH SERVICES 17 ' SEC. 202. (a) The Secretary of Health, Education, and 18 Welfare shall undertake or support (through grants or con- 19 tracts or both) five intensive and comprehensive community 20 based programs for the purpose of d'emonstrating and evahi- 21 ating optimal methods for organizing and' delivering com- 22 prehensive preventive health services to defined populations. 23 (b) The Secretary shall submit to the Committee on 24 IIuman Resources of the Senate and the Committee on Inter- 25 st'ateand Foreign Commerce of the House of'Rcpresenta-

129 al content~ ld remain )pe would ~ are inter- I :no~~ledge j nt on the .e bem in e Depart- r research 1'and bio- ~quest for wed your lion-plus, ;lad to see ea, and I FOR RELEASE ONLY ON DELIVERY DEPARTMENT OF HEALTH.EDUCATION;.AND WELFARE STATEMENT BY WILLIAM H:. FOEGE, M.D. DIRECTOR,. CENTER FOR DISEASE.CONTROL SUBCOMMITTEE ON HEALTH AND~SCIENTIFIC RESEARCH COMMITTEE:ON HUMAN RESOURCES UNITED STATES SENATE

W 1 2 3 4 30 tives on January 1, 1981 and on January 1 of every second year thereafter a report on~ the programs undertaken or supported under subsection (a) including, but not limited to, a detailed desci-iption and an evaluation of the eff'ective- 1 ulation of the United f 2 these determinants of 3 alence of prev entablc 4 and 5 ness of' each such program. 6 (c) For the purpose of undertaking or supporting d'em- 5 (4) the behavio 6 population of' the Un 7 onstrations and evaluations pursuant to subsection (a), 7 8 there are authorized! to be appropriated $10;000;000 f'or 8 9 each of' the fiscal years ending September 30, 11980; Septem- 9 10 ber 30, 1981, September 30,, 1982, September 30, 1983, 10 11, and September 30; 1984. 11 12, NATIONAL DISEASE PREVENTION DATA PROFILE 12 13 SEC. 203. (a) The Secretary„ acting through the \a- 13' 14 tional Center for Health Statistics or its equivalent, shalli sub- 14 15 mit to Congress on January 1, 1981, and on January 1 of 16 every third year thereafter, a national disease prevention 15 17 data profile in order to provide a data base for the effective 18 implementation of, this Act and tb increase public awareness. 19 of the prevalence, incidence, and any trends in the prevent- 20 able causes of death and disabilityin, theUnited, States. 21 22 23 21 25 Such profile shall include at a minimum- (1') mortality rates for preventable diseases; (2): morbidity rates associated with preventable diseases; (3) the physical determinants of health of the pop- ited to, smoking, nutri and alcohol consumpt these determinants of alence of prev entla.ble (b) In~ preparing the the Secretary, acting throu Statistics or its equivalen provisions of sections 30 Service Act.

DURING PIIIE RISKS ETTES T0 PIIE RiS4S (a) shall ~e -ette package )e in contrast rinted matter or distribu- -t.l.tcments re- )ci. cc it[un of ~ ~. [:ItiG AMONG , t . ducation, and 91 10 1Welfare, after consultation, with appropriate public and' 2, private entities, shall establish a comprehensive program de- 3 signed to deter smoking among children and adolescents. 4 Such a program shall inchzde- 5 (1) the undertaking or support (through grants 6 or contracts or both) of biomedical and behavioral re- 7 searchi designed to increase understanding of the bio- 8 logical and behavioral determinants of smoking among 9 children and adolescents, with special emphasis on 10 children aged twelve or below; 11 (2) the undertaking or support (through grants 12 or contracts or both) of demonstrations and evalua- L3 tions, of comprehensive community and school-based 14 programs designed to deter smoking, among children 15 and adolescents; and 16(3) grants to States or political subdivisions of 17 States to assist them in meeting the costs of operating 18 ' comprehensive community or school-based programs 19 designed to deter smoking among children and 20 adolescents. 21 (b) WitL respect to grants under paragraph (a) (3)!, 22 the Secretary and each grant' applicant and recipient, must, 23 comply with the provisions of subsections. (b) ,(c) ,(d) , 24 (e) , (f'), (;g),and (h) of section 317. 25 (c) (1) For the purpose of making, payments for the,

90 1 .2 3 4 9 " (F ) CIGARETTE S~iOI~I\ G' DURING PREGNANCY MAY DAII AGEMIE UNBOlI,N' CIIILD; "(G) YOU.O"'E YOUR BODY S0;1IE_IIE- 1 2 3 Welfare, after consultati, private entities, shall estal signed to deter smoking ;; SPECT-DON'T' SMOKE;; 6 "(II) SMOKER'S COU GII IS ANEARLY _ 7• SIGN OF LUNG DAMAGE; g, "(I) IF YOU MUST S.MQKE, INIIALE 9 LIGIITLY-THIS IIAY EEDUCE THE RISKS 10 TO YOUR HEALTH; 11 °`'(J) DON'T' SMOKE CIGARETTES T0 12 THE END-TIIIS MAY REDUCE TIIE IIISI~S 13 . TO YOUR IIEALTH.". 14 (b) The stiatements, required by subsection (a) shall be 15 loeated' in & conspicuous place on,ev.ery cigarette package 16 and shall appear in conspicuous and legible type in contrast 17 - 1)y typography, Itiyout~, aud color:with other printed matter 18 on the package. 19 (c) Cigarettes shall, be, packaged for- sale or distribu- 20 tion in such a manner so that each of the statementsre- 21i quix'ed by paragraph (a)~ (2) ahpc.r5on, 10: per centum of 22 all cigarette pachages: 23 ESTABLISFI11iEhTT' OF PP.OGRAM_ TO DETER SMOKING ADiO:~G . . , . 24 CIIILARE:; AND ADOLESCENTS 4. Such a program shall inclu~ 5 (1) the undertal 6 or contracts or both) 7 search designed to ir. 8 logical and behavioral 9 children and adolese 10 children aged twelve 11 (2) the undertall 12 or contracts or both;; 13 tions of comprehensi 14 programs designed tc 15 16 17 18 and adolescent's; and (3) grants to S States ~ to assist them comprehensive comm 19 designed to deter 20 adolescents. 21 ( b ) With respect to 22 the Secretary and each gr p 23 comply with the provisior Cw C9 24 (e), (f), (~g), and (h) of 25 SEC. 10. (a)' The Secretary of.IIealth, Education, a.nd k..d 25 ~ o (c) (1) For the purl N W

96 As Presidential Health Adviser Dr. Peter Bourne pointed out last year :"No matter how much one may favor prohibition of tobacco products, such a move is 300 years too late." The choice rest's-asit should-with the individual. Those who want to use tobacco will'-those who prefer not to, won't. You' cannot legis- late choice-that's what living in a democracy is all about. There is one finall point that needs to be made, Mr. Chairman. Thee sheer economics of this situation dictate finding a solution rather than abolishing the industry, which, in effect, this legislation could do. Tobacco is a multibil2ion-d'ollar business. More than 600,000 farm families (more than 90 percent of small family farms in: my State albne)' derive much of their income from tobacco. Throughout the years of exhaustive debate over tobacco, no one has come forth~ with an alternative crop that these families could grow which would keep them self-sufficient. I have no doubt that okra, Bibb lettuce, cucumbers„ and hundreds of other crops would thrive in' the rich farmland of my State and else- where. But the cash receipts to be derived from any of these alter- natives would be far from sufficient to support either a family or thee farm. Mr. Chairman, I don't want to see the Congress, through this legis- lation, be a willing accessorvto the further demise of' thefamllyfarm-because unless we find a suitable alternative, that's what will happen, and these people are going to be left with only two choices: Leave tlie family farm or end up on welfare. [The following was received' for the record':] Incomd 0:)era~t.Tin~~ ~i~nena~~s. er;~irs ntF ~9t. ,rr ,r• Lv~so _ ; ' ~L, ulll ,y ~ ~ L ,°: ,r ;nee :1iti n:3 i !it«'pcus:in. ~ ^c;11a.n-ms %-r'•tract Lab,r x Tr ur^ ex, . . uvel l~.c,,,onc 1Tue8. :;t-~claCt redtti Ol: ltaid Bros. 1977 Crop Y Pon 3ch F' :'orm 1065 `1".17,, ~o !+o,,^_ 33. ) '•) 1E0 1`30?? :oU C n` n; ral Lnc„) 1, ^J~. 190'"c7',CO~ +bb a1'd h. inai.•idua~ ti~f ~a un _ b;; in.'Sv.Yeuu:'I nurtnaw. u'i ~ ar"tnersi,; ~ Invc:4ment y335yu

The concept of health care in this country has for too long been dominated by the images of doctors, hospitals, an&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 Welifare and by State and local governments. We will comment on this comprehensive legislation inidetail at a later date. Today I woul&speak to the particular health 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 needliess to11i of disease and death exacted by cigarette smoking. You have demonstrated' again and again your commitment to prevention. As one so committed'y 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 l'11, when he announced our Department's smoking and health initiative, it is Public Health Enemy Number One.

Ineffective.Filters in Reducing.CarbonMonoxide Through Filtration Present day filters found on most commercially available cigarettes are ineffective in reducing carbon monoxide through filtration. Some of the other manufacturing techniques used inilow tar/low nicoti'ne cigarettes are effective in reducing carbonimonoxide. These include the selection of certain types of tobaccoland mechanicali variations such as porous paper and' specialized additives. As a result, with only a few exceptions, low tar/low nicotine cigarettes tend to be appreciably lower in carbon monoxide emissions. Senator CHAFEE. DOct'+ question here-but is it reduce the incidence of Dr. FOEGE. The ans, time in coming, but it 15 percent in persons n as compared to person arettes, so that we thini rates because of low tar Senator Ci3aPEE. All Dr. FOEGE: It ls' exti of the warning label, I Some form of official i in discharging the Gov( The 10 separate wai through both novelty Several of them-for child-would have t'hee cific threats that may If the decisioni is ma wording of each needs the conditional "may where the evidence is dangerous" could be re; be required in advertisi Section 10, Mr. Cha: of the legislation, Thie ment. It is also the are the past. We can poil smoking among adult:' males. But with child Stnoking, among boi most recent figures, .~ mer, show that 5 perce. 201 percent of boys 15 a cent of boys 17 and 18 established, and we th Meanwhile,smokinr the 1960's about twice age level girls are sm Senator ,,~CHWEIKER (lence at all to indicate teenage girls?' Dr. FOEGE. "'e' are partially to the new e( Mle hoping, therefore, (ro down. Senator ScHwEIKERDr. FOEGE. That's ri recognizes the import nwed to learn more ab; ticularly regarding sni

115 ires depends, HEW has on the .n use your -tance of of FTC "s "r", nicotline, that will le project Senator Scawr,igER. Doctor, let me interrupt there 11 minute and ask-we have heard always about tar and~ nicotine; what is the scien- tific indications in, terms of monoxide and how does that compare to tar and nicotine injuries? Dr. FoEaE. It's difficult to quantify how much injury carbon, monox- ide causes, but there seem to be both immediate and long-term effects. The immediate effects are that carbon monoxide levels are increased' in cigarette smokers. Carbon monoxide, has a greater affinity for hemoglobin than oxygen and therefore part of the oxygen-carrying capacity of the blood is removed because of' carboni monoxide. Thiss cut.s down on the amount of oxygen available, therefore, for instance,, to the heart muscle. And it is expected by some people that this may be one of the con- tributing factors in coronary occlusions, or insufl'icient' oxygen to the heart muscle. This is animmediat'eeffect. There appears also to be a long-term~ effect where the mixture of carbon monoxide in hemoglbbin may help increase t'lie laying down of plaques in the arteries which would promote the development of arteriosclerosis. So there appears to be both an immediate and a long-term~ injurious effect on health. Senator SCHWEIKER. Do any of the present filter mechanisms impact at all on removing carbon monoxid'e ? Dr. FoECE. If they do, it is not a sufficient impact to eliminate carbon monoxide as a problem. Senator ScxwEixEx. But it reduces it a little ? Dr. FoECE. I am not sure on whether it reduces or how much it re- duces,,but I would be glad to get this for the record. Senator ScxwFSKEx. Alll right. [The information referred to follows:]

61 f,: such officer ment or t'he nvenience of pose of plan- :o which the e amount by available for in furnishing personnel, on such amount ,11 be deemed nt of a grant the Secretary Is which fully L State of the e undertaking nade, and the derGaking sup- i as will facili- General of the. :cd representa- t and examina- 11 1 tion to any books„ doc,un¢ents, papers, and records of each 2 State which is a recipient of' a grant under subsectfon (a) g that are pertinent to such grant. 4 "(h) - All information obtained about any individual' 5 under any program that is being carried out with a grant 6 made under subsection (a) shall not, without such individ- 7 ual's consent, be disclosed, except that (1) such information 8 may be disclosed without such consent if the disclosure is 9 necessary to provide service to such individual or is required 10 by a law of a: State or political subdivision of a State, and 11 (2) informat'ion derived from any such program may be 12 disclosed- 13 "(A) in summary, statistical, or other form, or 14 "(B)~ for clinical or research purposes, 15 but only if individually identifiable personal data of any such 16 individuali is not' disclosed. 17 "(i) Nothing in this section shall limit or otherwise re- 18 strict the use of funds which, are granted to a State or to an 19 agenoy or a political subdivision of a State under provisions 20 of Federallaw (other than this;section) and which are avail-. 21 able for the conduct of preventive health service programs: 22 from being used in connection with programs assisted~ 23 through grants under subsection (a). 24 "(j) The Secretary shall submit to the President for 25 submission to the Congress on January 1,, 1981, and on

133 - 4 - se: al l liung .ncer killer one among to cardio- largest ' death and _c bronchitis-- .nto premature :e smoking :dical iuction and health _nflati~onary _t woulid that some- -e directly It was because of the human and dollar costs of smoking that Secretary Califano announced the Department's initiative on smoking and health on January 11. Under this initiative, a number of steps have been taken by the Department--al'1 of which we believe address the objectives of S. 3118. Together with the Federal Trade Commission, the Department has petitioned the Federal Communication Commission to open,more broad'cast opportunities for public service announcements, including prime time, where the information would'be made available to the widest I audience. This petition is now being considered by the FCC~. Secretary Califano and Commissioner of Education Boyer. have sent additional information and digests of smoking, and educational materials to the chief school offices of the 50 States and to aDl 16,000 school districts. Dr. Boyer has also invited children from alil over the country to send us posters and essays on their feelings about smoking. The Department has dtafted a new policy on smoking in HEW-occupied buildings, which bans smoking in, conference rooms, classrooms, auditoriums, elevators and shuttle buses, and calls for separate work areas for smokers and non-smokers, where practical. We have submitted

101 Page 10 4 76 Columns 1977 COSTS PER GROUND ACRE FOR DIVERSIFIED FARMING IN FISHER COUNTY, TEXAS Ln (1+2-3) 1977, Net ITEM COST ITETI COST. Cro Income 00 75373'.00 Labor f 13.64 Interest Z 2.96 Supplies 7.48 Taxes 2.37 00 Repairs 7.02 Dues & Fees .07 0 75373'. Fuel 6.15 Office Expenses .12 ,410 . 00 Seed 3.79 Vehicle Licenses .10 Utilities & Phone .42 Hand Expense .50 Chemicals 2.80 Storage .19 Fertflizer 1.60 Insurance .96 (,0 9399.00 Leasesd. Rent 32:15 Equipment Payments 26.36 00 226.00 Pest Control 20.13 Mi'scellaneous .13 00 Machine Hihe .66 3.?13.00 Feed .26 TOTAL $129.87 9397.00 00 182)19 Vpt .02 . 00 ?215.00'. 00 !E1-1 }9.00 .00, 19N7.00 MINIMUM MAJOR ITEMIEqUIPMENT LIST NEEDED FOR 1000 ACRE DIVERSIFIED FARMING .00, 1767.G0 OPERATION (65% COTTON, 10% MILOi 10% WHEAT, 15% LIVESTOCK),IN FISHER COUNTY. 487.00 2089.00 .00 620.00 00 198 ITEM NEW'PRICE AVG. USED PRICE . 4l;. 00 1 00 593 2 Tractors 100'H.P. f 311000. f 19.600. . 326.00. 2 Cultivators Com,plete f 4.800. f 3.200. 21 02.00 2 Planters Complete f 1,770. f 1,300. 2 00! 1, , 0 2 14'"Too1 Bars Complete f 3,600. f 2.400. . 1 4 Bottom Plow & Rake f 3.650. f 2,400. 00 1 (6298.00)Los3 2 14' Tandem Disc & Rake f 7,960. f 5.000. . 1 90" Shredder f 1,690. f 750. 2 300 gal. Spray Rigs f 3,150. f 1.900. 1 1000 gal. Water Trailor f 2,200. f 1.600. 1 14' Chiesil f 2.100. f 975. 1 Big Ox 9 Shank f 1.800. f 850. 1 Cotton Stripper f 10,500. f 6,800. 10'Cotton Trailers $ 24.000. $ 20,000. 1 Cotton Ricker f 3,100. f 2,100. 1 Grain Drill f 2,300. $ 1,600. I Combine 14' Header $ 45,000. f 29,600. I Grain Truck $ 19.400. f 14.000. 2 3/4 Ton Pickup Trucks f 10,950. f 4,900. 2 Fuel Storage Tanks S 1,400. $ 1,100. 1 8 Row Rotary Hoe f 3,950. $ 2,600. 1 8 Row Sand Fighter f 1,970. $ 900. 1 12' Hay Swather f 6,540. f 3,700. 1 Stack Hand f 10,700. $ 6,400. 1 Stack Mover f 4,800. $ 3,500. 1 Metal' Barn w/Shop (40'X1001) f 9,700. f 6,000. 1 16' Stock Trailer f 2,800. E 2,100. Farm Shop Equip. & Tools 5 12.000. b 9:000. Livestock Misc. Equipment S 8,500. f 5,400. $241.330. $159,675. TOTAL rp

98 PaCe 7 Breedi Stock Cost dveraGe Yarm uper 900 Acres ---500 oraes 15100.00 :; t• I i t 54 aulls $1;9698.00 qu pmen nvea ment 693 Cows ;i16'3 026.00 t1 Heifars , '' 125.n0 OperatinE, Cost uf i,qttipnient Tota 1950 Grain Truck v i ~ , 375,UO: }60 fialee of cotton at .40 Dis, Plow 175.00 Loasoperatin` Co~t D. Tractors 2 4020 J 8 635.00 ' . 3reaking,Plow , 450.00 L et Inceme; of'farm=3r that o Pac"or 215.00 6 Cotton Tra?.Lers 113/41. 00 ;aturrn on~ In.re3tr.,int 2Fi2'J.D. Jtriaaor 5350.n0 ^ Lar d crnU ii d air com-ressor Iir, .00 , . i o 1o72 J.D. Tractur 4320 6400 600 :' f l • t d (at 1/ 5 Bbttom Br•ea'.;iik; Flow 1791.00 ar mer ren s an 3anddigger 2} row ].LJ47. 00 ' 292 J.J. Strimper 73n1.o01 f.iwunt of rlrc-) to t,,j o1i jr J.D. Stripoer 33, b'.00 'ota7 Les3 h f 1l -ihi 4630 J.DL Tractor ''. 2N0.00 ,~ ore e ~ e Gf_°set Disc. J.D. 51-D0',00 Grain Drill'J'.D. 1450.00 ;stimated 10 year Werogn y, ~ h & + ' 1!1~1 1NT. Loader 685. uo w en us nUs 2 oli.tnttn,_ 2 4630, J.D. Tiractor 23J71.00 Ilroak e rm n f n t 2 Ssddlas 1057.00 ve o er,m o i 2 Addiri~; machines 413.90 u ^ ~se ft • s r nll c 3quiD. ?ostor 5000.00 . i we e oori g o e Planters 9i Lister Bou:ns 3quip. Fjster 6o2r.oo 9500.00 :e .i;xUonsion 3crvmce In °c shredder lOn5.00 C 4630 J.D. Tractor 1'6,300. 00 ounty Axea r.:c4;,inS Butane tank 12r.00 o~ fi l 2-12 tow lini'viitG 3i~s 2325:00 © gures were compl ei 2-1.? 30w Plantors 2325.00 II Al i - H il t N 2-12 2ow Cult7vators 23)r'OO o ow rt , a - Ou - c C. B, .tadios 1198. 00 Gooseneck Trailer 1500.00, Saddle &c 1:quip, 500.00 Scratchers 213.00 Water line 2847.00 Water Troi.tghs 955.00 Pipel!1'no 778.00 11969 Case Combine 2000.00 1'955 Chev. Truck 1600600 Saddle 72.00 3 Cotton brailera 179'>.00 Water tank 16~-.oa PortaLle 'iorkinz , cl utP 10Cr. C-0 .J1 ndmi 11 r"00. 00 Tota . _•01 r9. ToTAL v343o 8.00

117 s leader- population. :u own em- lize their , I have 3N Occupied3king in , and cing in ;etting igSe :he -d are is that ernment ~etnmente IIICCl SURNANS I IOATe Mr. Joel 1J. Solomon Page two I shall be announcing the new RSt7 smoking policy in a epeeeh Wednesday morning conmeoorating theannivorsary of the ieeuaneeof the Surgeon General's Report. If you are agreeably, I would like to indicate GSA's adoption of the new policy and/or the convereion of the GSA guidelines on smoking into regulations. If it is not possible for you to reach a decision by uedaesday, I suggest that we form a joint GSA-EEW Task Force to study Smoking Policy in government-occupied facilities and that I limit ryy ennouncemeat to,that effort. .. Obviously. I would prefer to make the stronger announcement, but believe that we should:at laast signify our readiness to work together on this oLatter. Sincerely, Joseph A. Califano, Jr. P~nepare&by DASH (SHI)cLVOgel/HMeGinni's/PBell/'LMiller:gp:1/7/78 OS Reading. Return signed copy to 605-F FC8 W DAT. •i,CE iURN4N! OaTC O-Ce SURNSNe. OAT 1' / ESS ~: ~ Bih„ lil~n

134 - 5~ - this policy to:other public agencies,, as well as organi~za- tions im the private sector for their review.. We have circulated a model "Clean Indoor Air" bill to the 50 States for their consideration in efforts to protect the non-smoker. Dr. Richmond has assigned responsibilities among the Agencies and work has begun~on the preparation of the 1979 Surgeon General"s report. This will be the most extensive review of the medical and behaviorall aspects of smoking since the original Surgeon General's report of 1964. " The Department is now engaged in a nationwide effort to notify World War III shipyard workers and other asbestos workers of the health risks they face. This campaign emphasizes that an individual! who smokes and who has been exposed to asbestos has up to 90 times the risk of contracting,lung cancer as a non-smoker who has not been exposed to asbestos. • The Food and Drug Administration is now reviewing the published reports on the interaction of smoking with therapeutic drugs./ One important interaction recently reported was the combined effect of smoking and oral contraceptives which produces a marked increase in cardio- vascular disease and deaths. Warning notices must now accompany all such pills when they are first prescribedi to the patient. • To coordina established the appointed Mr. Pi brings to this p manager andianal a knowledge of, health education One of the initiative is tc and health of tn of S. 3118 deal facilities. Spe jurisdiction are permitted,as we] smokers must be for enforcement non-compliance. These prov- new regulations am submitting f< Department and : as the General ; enforce similar their control. Soloman will al ~ ,: ,-

1 2' 3 4 5 6 7 8 9 10' 11 12 13 14 15 16 17 18 24 25 88'. 7 tion on new brands of cigarettes introduced for sa1e:". (b), The amendments made by subsection (a), shall apply to cigarettes which the manufacturer or importer of such cigarettes removes (within the: meaning of section 5702 ('1~i) of such Code) within 120 days after the date of enactment of this Act. (c) The Conimission and the Secretary of the Treasury or his, delegate shallpromulga#e: rea lations for the purposes of section 5701 (b) of the Internal Revenue Cod'e of' 1934 within 60 day s after the date of the: enactment of' this Act. SEc. 8: There are authorized to be appropriated for t'he fiscal years ending September 30, 1981, September 30, 1982, September 30, 1983y and September 30, 1984, those amounts determined by the Secretary of the Treasury to bee equivalent to the taxes received in the Treasury under section~ 5701 (b) of the Internal Revenue Code of 1954 for the purpose of making additional payments to the States to assist them in meeting the costs of providing preventive health services under section 315 of the Public Health Service Act. The amount of payments to the States shall be determined! on a per capita basis: Provided, That only those States who are receiving grants under section 315 (1) (2) of' the Public IIcalth Service Act shall be eligibletb~ receive payments under this subsection. 1 CHANGES IN LABELI 2 Suc. 9. (a) ElfectiN nient of' this Actl, Section 4 and AdvertisinbAct, (1' 5 read as follows: t; "SEc. 4. (a) It! sh, 7 niamtd'actnre; import, or 8Ivithim the United Staies a 3 " (1)' if the pat 1'~G~ tar and nicotine~ coi 11 millig-t•ams, and 1.: " (2) if! the pact ~ 13 the ~ following ~~ statemei 11' «(A) CA~, ] 15 . CIGARE`1'TE S: 116 ~ "(B) CA\C ll; ,,5 ANI)'1'IIROi1T RET"1'E' S_lI0KL tU «~(C)~ IIEaI _1 FROM CIUARE "(I))' CIU _t O ~. HURT YOU R IIi " (E )~ E.l1P BR()\ CHITIS 1 O W ~ RETTE' S'.lliOM M+ N

.istinction who I ,ntucky, Senator 'orward to your .S. SENATOR xpecting t'hedis- and some of my airman, and so if he Senator from aim I will! be glad vou to know that because we have .aughter.] ~- frre,but if there, I will be glad to ;land, if that will ird this mornsng, id myself sitting I daresay it won't o get out of these ou maintain your iny trouble at all _ent in the Senate. - anya-rguments I •ecognize the sub- raise:are carefully forward with this have no problems ion which pertain -1 to this e-tl'ect-if! tion which is now i tsi . ontinue to~persist -e thatho,proper ~.onsis not througlrh. 1 elements, if theyChrougir research, risks found to be intaining the eco- stabidity"--of this s. 95 In fact, I find it ironic that we have to even consider a renewal of gov- ernmental assaults on tobacco at the very time the marketplace is so rapidly dealing with the problems~ that smoking adversaries talk so much about. Tar and nicotine yields have been cut in half in recent years. The cigarette industry is involved in the most vigorous and ex- pensive competition in its history to convert smokers to the low-tar brands. The end result is that we are seeing a classic illustration of the value of freedom of choice-the free choice of smokers on t'he one hand to srnoke cigarettes that critics say are safer, and the free choice of the manufacturers on the other hand to respond! competitively to that growing market. Now, it appears that the Federal Government wants to recognize the industry's initiatives-re«•ard the industry's efforts to produce a safer product-with punitive legislation. Why must this be the direction we take ? I's it that unreasonable to consider supporting-instead of under- I nining-what I perceive to be a sincere and intense effort to save an industry that provides billions of dollars of income for millions of Americans ? As I have reminded my distinguished colleagues~ many times, to- i5aico is a~ pliable product, a product from which impurities can be re- moved in as short a time as two growing seasons. That flexibility facilitates research such as the kind which is now being conducted on smoking and' health at the University of Ken- ~'ucky's, Tobacco Research Institute. Since the Tobacco Research In- stitute's creation in 1972, more than $3.7 million annually of State funds has been directed' into massive research and' study. That re- ~earch helped develop the current low-tar and! low-nicotine cigarettes which are now on the market. Yet my repeated calls for increased research initiatives at the Fed- (?ra1 level continue to fall on deaf ears. According to Health, Educa- tion, and Welfare Secretary Califano, the onliy budget increase for research on health-related aspects of smoking will amount to a mere ~I million in fiscal year 1979-an amount just slightly more than what is~ now being directed to research in one State-with non-Federal drnllars~as well. The dividends to occur from tihis research will be far more reward- iiilo, and productive than to pump millions and! millions of dollars into antismokina initiatives and, punitive legislation which have no guaran- tee of success. Another question that must be addressed is why tobacco has been in0ed out as the focal point of this subcommittee's preventive health Prol-ram. IV, hy aren'tt similar efforts being directed toward the thousands of 1Sew chemicals which are poured! into the environment each year? 1t'hy isn't equal enthusrasm being directed toward the estimated 1'-:>0(2 substances in the workingplace which HEtiV suspects to be can- "ercansintr? 1'm all for findinn new ways to cut down the high incidence of cancer in this~country, but,I'm not convinced that the approach you have pro- Posed will produce anysubstantiveresult's. A tlhird and fundamental issue at stake is thequestion, of individual rneedom of choice. I I I a

the areas that .ve: have identified as top priority. The actual content of the research proposals and the peer review system~ would remain totally intact, and I would have no influenceover that.Btiit. we would be influencing those researchers, who we hope would! turny for example, to doing quality research in the areas weareinter- ested inL We are trying to identify mainly the gaps in our knowledge about smoking, and target our resources towar& those. Senator ScxwEixFR. Doctor, maybe you want to comment on the same question. Dr. KaETCx-MEx. I don't have too much to add. We have been in contactt with Mr. Pinney and our programs do relate to the Depart- ment's act'iivitiesin smoking. TlieNICHO responsibility is for research on t'hehealth of mothers and! children in both thebehavioral and bio- medical fields: Mr. Pinney is aware of our issuance of a request for research grant applications in those particularr areas. Senator ScIiwraicFR. I didn't mentiony but we also approved your budbet yesterday. We did give you that money for the $4 mnllion-plus, sotioushoulklo havetlie wherewithal to do the job. I am just glad to seeH)JNbeingso well-coordinated and integrated~ in this area, and I commend you for it and I certainly promise you my support. That'sa12I have.lir. Chairman. [The prepared statement of Dr. Foege and additional material sup- pliedn fotLolv :] DEPA DIRI suscornK.

89 :roduced for n (a) shall importer of ; of section the date of the Treasury the purposes 'od'e of' 1954 of this Act. ["opriated for ,ptember 30, 1984, those •easury to be. ,asury tinder ; of 1954 for the States to ~ preventive ablic IIealth _at'es shall be at only those 13 (1) (2) of le to receive. 1 8 CHANGES 1N LABELING For CIGARd:TM rACr_WE'S 5 ~ ~ Eff ft 9 ti ~ h d ~ f~ 3 J . (a ) t'c: v~e one vear a er ate ~ o ec t e eiiact- nient, of this Act, Scction 4 of the Federal C-i~arctte La~l~elina 4 J 6 7 b and Advertising Act (PublioLaw 89-9?)~ is aiuended to read as follotivs : "Si;e. 4. (a) It shall be unlawful for anypeison tomanufacture; import, or packa;e for sale or distribution -witbiiii the Vnited States any cirarettes- 9 "~ (1)~ if' the~ package for which fails to bear the~ 10~ t'ar~~ and nicotine~ content of such cigarettes stated in 11 ntilligl•ams,~and 13' "~(?')~ if the package for ~~ whicln fails to bear one~of the following statements: 14 "(A), C A\CEI{; :lI A1 RESULT 1'IiUH 15 CIG ARE`1'TE' SHOhING; 16~~ "~(~;B)~ C'A\CER OF TIIE LUNGS, .1IO~UTII, 17 AND TIIR~OAT~,lIAY ~ RESULT 1'Rd1I CICa A- 18 RETTE SJIOIiI!\ U ; 19 . "~(C) IIEART DISEASE MAY RESULT ''0 FROJI CIGARETTE S\IOhI\ G ; 21 . °` (~D)1 CIUaR ,,,hTE~ SHOKI1U'~ IIAY HURT YOUR IIEART; 23' ~ EIIPHYS " ~E '~ O ( ) E_lT A AND CIIR~OV IC W :.'-1 BRO\CHITIS MAY RESULT TRO_li CIGA- O `'5 RT:TTE S.)DOIiI\ 6 ~ ; W ~ N

99. PaCo 7. Page 8 AveraCe Farm u„^eratlon For Howard County 900 Acres ---500 Pound Projadted Yield 1;Quipment Investment dc_3137,1}0c.00 Operatin(<; Cost of PsqUprient 1 59,913.00 ~~0 Ha1e9 of cot-t-on at .40 400 Ponnds Per Acre w72,000.00 LaseoperatinG Co-,t y 59,913.0p Net Zncome of fermer that ouna hi^ Lsttd p 12,187.00 teturn on Inve3tr.-,nt 6.17~ If lard ccninted l.fln r If far~nor rents ]iand (,at 1/l~ rent) HZs loss t.a ~ r,,313,n0 Amount of ri.ro~) to hs c1i',1ts1e fo,• defioncy payment Tota7 los3 h.;fore e1lGilrle for any Government Paynent_w 3l},f>13.00 Eatimated 10:year "+veroi;e yield ( when us!ng, a~&2 al:nti.n,r,; p,itLern over 900 Acres) 400 Poimds/Acre To Plroalr oven fermo,,m+iot recvive 46/ per LB. Those figui•oo, were coririled by Gary Condron- The Aroa Economist for the ;xtanoioni 3ervice in °ort Stoclston6 and six avera_i~e faiRnors frorm ?ibwardi County Area rL:r4;ing in :.,go from 21y-60 These figpres were c-,mpiled considering there were Ideal conditions 'io Hail- DIo Plowin. Out- No Insects- And No Flooding Etc. I R M

114 Secretary Joseph 11. Cal'ifanoy Jr. Page Two The usefulness of FTC carbon monoxide figures depends, of course, on an informed public. In the past, HEW has made significant efforts to educate the public on the subject of cigarette smoking. We can once again use your assistance in educating smoke.s about the importance of carbon monoxide in cigarette smoke, the meaning of FTC's carbon monoxide figures, and the use of FTC "tar", nicotine, and carbon monoxide figures in selecting,brand's that willi lessen the health risks by cigarette smoking,. I have high expectations for this worthwhile project and liook forward to our joint efforts. Sincerely, Michael bertschuk Chairman Enclosure Senator ScxwE_ ask-we have heal tific indications iI to tar and nicotine Dr. FbEGE. It's c ide causes, but the The immediate e8 in cigarette smok hemoglobin than~, capacity of the bl cuts down on, the to thehearG' muscle And it is expect tributing factors' i heart muscle. This There appears : carbon monoaidee of plaques in the arteriosclerosis. So there appear effect on health. Senator SCIiWEI at all on removing Dr. FOEGE. If carbonmono$ide a Senator Scxw<EI, Dr. FOEGE. I an duces, but I would Senator ScawEil [The informati(i

all cigarette he cigarette. .ing -- "The Smoking, ferent warnings, ten percent Anion, be Le Secretary d determined +qy by the .at may noxide. 'rade e tes for ublishing ter submitted ffice on o the 139 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 working 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.

116 DEPARTMENT OF HEALTH. EDUCATtON, AND WELFARE Mr. Joel Page two I aha11 Yednesdaof the S like to conversi If it is suggest Policy i announce Mr. Joel W. Solosrn Adminietretor Ceneral prieoe~¢Q,Lpiptrattna. 18th and F Streets, N. it. Washington, D. C. 20605 Dear Jay; I appreciate your readiness.to cooperatexith uson,the smoking and health issue. Clearly, this ie a matter of great importance, since smoking is the leading preventable cause of disease and disability in thia country today. I believe that the Federal Covernment should provide leader- ehipin the effort to reduce smoking in the general population. At the same time, we have an obligation to assure our own em- ployees a crorking environtlent which does not jeopardize their health and vall-being. With these thoughtsin.adnd, I have approved a new HEW Policy.Statecent on Snoking.in BEW.OccupiedBuildings and Facilities. It not only prohibits smoking in conference rooms,.auditoriums, libraries, elevators, and shuttle vehieles„ but also protects nom-smokers vorking.in common tork areas. A copy of the manual sa anc setting forth that Po1lcy.ie enclosed. Because of the preponderance of evidence that smoking is harmful to health „ I would encourage you to review the existing CSA guidellnes on smoking vith a aiev toward atrengthening them along the lines of the Policy we are adopting,, andis.suing them as regulations. lfyhope is that such a uniform ercoking policy within the Federal Government might be regarded as a modeL for state and local governments and for institutions in-the private sector. I OFFdCE AURNAYE DATE OF,FICE EWANAME IDATE OFFICE lUMHAM6 DAT~ Obviousl believe together Prepared OS Readir Return,si Es5

138 - 9 - Section 9 of S. 3118 would require that all cigarette packages list the tar and nicotine yiel~d 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, eachlof which would be required tolappear on ten percent of al!1 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 Welifare, 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 publishing: 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 om Smoking and Health, will give wide publ!icity to the results of these tests. It is extreE the impact of tY' packages and in seen over and' o~ being promoted-- help some smoke, act upon it. CF of official war necessary in di The ten se greater interes than the single for example, th would have the to specific thr If the dec messages, the : carefully consi "may be" could the evidence i: "is dangerous" that warnings s well as on pac}

97 d out last f tobacco who want not. legis- man. The :ther than i do. - ,000' farm my State ;hout the orth with ould keep hundredg ; and else- tese alter- .ily or the this legis- fle family what will o choices : Page 6 itaid Sros. A 1'artnership 1977 Crop Year Nat Income Columns (1+2-3) Income Per 3ah F Add 1977 Less,1976 Crop Year Form 1065 Item:y in Items in 1977 .1978 1977 Live3tuc'" Salos u"7.vl8.(10 Cost of Livest)("'. 3old 1 ?j Calves 9J17G. _)0 Cotton 49233- "1 29046.00 9rain 2009J.00 103P3.00 Tlach?ne }1or1` 4?10.~0' .?3rm. Fro;;1'z:m. 1'apr,ents Q1V 38:;6.00 Tutal Total 1n304..0U 321jin.00 103 }.C0 D erattn~ 3x eu~ c a or- m o;~cee ''3Q05.001 i?epairs 7'+6^2, J0 373.00 104L''.00 Interest 11V).JOi (x)11>21:0,G0 lont or Ler,so "1?R 2. J0' Fea1 1'Ill'36,00' ?2r6.00 ?2l}9.C0' Seed ,r00,u0' Fer"i11~igr- Insrsctic4do "1';!}.Q0i liachlne ?i1re r7"9'.10' 70.00' Ouppli'co j00?.00 2f1.00 66.00 Vet. :c 1•edicine 1603.:.!0 )F17.00 Gas, ~a1, Cili ]nrn3.?0 CI 0.00 11,f10'n0 Taxes 1773.u0 Insurance 2201.s0 Uti4ities 1"•l4u.00 7reit;ht+:Truclii.m. W7.00 Drtiscal!lan-nis Contract Labor 13071.00 Picku7,w Tr-cl-V ex•. ^~ 20 1~29.00 '56,00 'Pravel ^"•n.n0 " 1991IPf,,00 11r9"09'.Q0 (i017,6.00 7A279.00 9707.00 4210.00 3866.00 2156117. 0' 23205.00 13947.00 20359'.00 21282'.00 IrIJJ}3L00 9500600 21j4.00 57119.00 2965.00 1186.00 1'8963.00 1773.00 2201.00 1R1~9,00 977.00 988.0[) 13071.00 4361.00 289.00 TeLenhono ^3?. 00 932.00 Accoaintinn ':Le,;ul i ='iJ 1n15p.00 OffIce ._ Does ~'nU ~.00 tierr Jo~ s Crodi t `)00. JO °00.00 Decrec~atl.on( i)ec11 nln,• r,a1!uno o) 1; 7! p 0'~ ^J' - li71y60.0m) ~ebal - 1i '•J,n7.CO ?: 77'.00 ,, 6.0 : 209 .00 llot Incime 3'+"1.J0 7235.00 '~!797.001 r925.00 (x)'at,d h„ indivddunl~ un,behclifof rart'nershYip~ (1), ~Zeceivel b;, in'ivildtc.11 nnrtners Total Partnersl,ic Inves,>rrcent y336,UUJ.00 deturn on Invectment of 177%

130 MR. CHARIMAN AND MEMBERS OF THE SUBCOMMIiTTEE: 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 i~s Director of the Nati~onal~ Institute of Child Health and Human Development, and Mr. John M. Pinney, the Director of our Department's new Office on Smoking,an&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 d'eath. 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. The concept of healtt long been dominated Y and the acutely ill. is a vital element i: S. 3115 is broad and and disease preventi conducted by the Dep Welifare and by State comment on this comp later date. Today I problem of cigarette gratification for tt- to the Department's It seems unnecessar} at length here of tr exacted by cigarettE again and again your so committed, you ai remains the single rr target for preventi% phrased it in his a< our Department's smc Public HeaLth Enemy

112 A copy of Secretary Califano's letter to Administrator Soloman will a1sobesubmitted for the record. Clearly you feel as we do that the Federal Government has an opportunity and a clear responsibilityy to set an example for all organizations andl employers. Congressional support for this policy should encourage its establishmentn-het'her through legislation or administrative action, Sections 7 and 8 of! S. 3118 provide for the establishment of a"health protection tax." The principle of a gradt.iated! tax based on, tar and nicotine in~ our opinion deserves serious consideration. The question of earmarking tax revenues for special purposes= even the best of purposes-raises many economic and tax policy ques- tions which require further analysis. However these questions are resol'ved,,it is the view of our Department that Congress and the Aneri- can~ people should be aware of the economic burden which cigarette smoking phtces upon the taxpayer in terms of increased hospitaT and medical costs, the cost of days lbst in produetion,, and other costs. The revenues obtained from cigarette taxes atthe present rate, or even under t'he rates proposed by S'. 3118', do not begin to approach these costs. Thus, in effect, nonsmokers are required to subsidize smokers by means of increased', health costs, increased insurance premiums, and increased taxes. Section~9of S. 3118 wouldlrequire that all cigarette packages list the tar and nicotine yield of the cigarettes, and provide 10 differentt warn- ings, each of which would be required to appear on a~ L0: percent sam- ple of all cigarette packages. Tar and nicotine levels should, in our opinion, be listed on the cig- arette packages. We would suggest, however, that a provision be made for inclusion of the information in all advertising, as~ well as on the package, and the listing of other hazardous compounds as they may beidentlfied in the futurebvthe 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 effects on health is carbon monoxide. Yesterday,, Chairman Pertschuk of the Federal Trade Commission informed Secretarv Califano that the Commission will begin testing domestic cigarettes for their carbon monosidelevels, and «•ill' begin~ publisliingthe results early in 1979. The chairman's letter announcingthis important action R ill also be submitted for the record. The Department, through its Office on Smoking and Health, willl give wide publi'city to the results of these tests. [The information referred to follows:] o..,- o. TNE C-.nMAN Secretary Jose Department of and Welfare Room 615F SP 330 Independer Washi~ngton, D. Dear Joe: In respoi you that carl: begin publish: in the smoke c Our invo several years Cancer Instit• Laboratory to of testing ci, ~ time that the• With that mac: carbon monoxi,significant c, I believ- figures is im who choose to that will les the availabil encourage cig monoxide outp in relation t should be a g carbon monoxi, share their a Our expe conclusion. Ntar" and nic nicotine leve has decreased

140 - lil - Section 10 of S. 3118, Mr. Chairman,, is the portion which is to me the heart of the legi~sliation. This section:provides for a program to deter smoking among children and adolescents. This is the area of greatest concern to the Department. 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 mal'es and recentliy, encouragingly, among females. But with children and youth, the picture is different. Sinoking,among,boys has hardly changed in the last d'ecade. 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, an&I think this is shocking. Meanwhile„ smoking among girls has increased dramatically. In the 1960's, about twice as many boys as girls smoked;; now at every age level~, gisl's are smoking at the same rate as boys. The legislation which you have introduced recognizes the importances of research in directing our efforts. We need to liearn more about smoking behavior than we know now, particularly regarding smoking,behavior among chsldren,. Perhaps almost all children can be expected to try cigarettes - at one time or a: while others do smokers whil~e ot no apparent trou bound youngsters to colliege? And who are populations, and chilidren 112 to 11 have tried a1coY as likely to ha, likely to have - In the Pre requesting $4 m Child Health an childhood'd'eter logical researc histories of di research--to fi can do a better decisions--wi-11 intervention pz 0 w ~ 0 w ~ ~ w

76 1 2 3 4 5 6 26 "(i) specifically required by Federal statutory law as a condition to the receipt of Federal financial assist- ance, or "(ii) for operating inpatient care facilities, con- struction, or mentalhealth~ programs. "(D) For purposes of subparagraph (A) populations 7 shall be determine& on the basis of the latest figures avail- 8 able fromAhe Department of Commerce. 9 "(5) The Secretary may make payments under grants 10 under paragraph (1) on the, basis of such estimates and in 11 such installments 12 13 14 15 16 17 18 1'9 20 21 22 23 24 as appropriate with adjustments for any previous overpayments: or underpayments.". (b) Paragraph (6) of section 314 (d) is amended by (1) striking "a Stat'e's allotment" in clause (A) an& in,- serting in lieu thereof "the amount' received", (2) strik- ing "of a State's allotment" in clause (B) (i) and inserting in lieu thereof "received under paragraph (4)"; and (3) striking "State's allbtment" in clause (B) (ii) and inserting in lieu thereof "amount received under paragraph (4) ". (c) Section 314 (d) (7) (A) is amended by striking "and" after "1977," and inserting before the period thereof: ", $107,000,000 for the fiscal year ending Sep- tember 30, 1979, $125,000,000 for the fiscal year ending September 30; 1980,, $140,000,000 for the fiscal year end- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18' 19 20 21 22 ~ 23 W 2 4 ~ W GO 25 ing September 30, 1981 year ending September 3(1 (d) Section 314 (d:)' end thereof the following, "('C) Of' the ai graph (A) for any ligate not more tha tional health progrec paragraph (.2) ( C ) TITLE II-RESOURi TION AND = CENTERS FC SEC: 2D1. Title III aniended by adding, afW, of this Act) the followii "CENTERS F "SEC. 316. (a) F( retary in carnying out st technical and consulting der such sections may ft research, studies, and a analyses) of preventive oping approaches, metlt deliv.ering preventive h grants assist public or

141 _s the !gislation. This .oking among a of greatest area in which ast. We can ases in smoking 'Itly, encouragingly, t, the picture _mthe last _1 be updated rcent of boys ent of boys percent of boys moking,is pretty ing. eased dramatieally. girls smoked; t the same ed recognizes r efforts. We need a know now, ig children. to try cigarettes at one time or another, but why do some kid's keep on smoking while others do not? Why do some teenagers become regular smokers while others are abLe to give up the habit with no apparent troublie? Why does it appear that fewer college- bound youngsters smoke than those who do not plan to go to college? And who are the real chance-takers in the child populations, an&how do we identify and help them? [lmong children 12 to 17, children who smoke are twice as apt to have tried alicoholir beverages as non-smokers, four times as likely to have tried marijuana, and six times as likely to have tried hard drugs. In the President's budget for FY 1979, we are requesting $4 million for the National Institute on Chi1d Health an&HumamDevelopment to investigate the childhood determinants of smoking behavior. Epidemio- logical research will, be critical to tracing the smoking histories of different groups of children. Educational research--to find out how parents, schools, and'communities can do a better job in helping children make wise health decisions--wUl enable us to designimore effective intervention programs.

u, .nd 1977 r, iister. shea. ;, fu.l. elso- t110.00 psr ton. per ton~- r Lale were esed. - ao havo the sika, er bsls. er tal.. 11. l. f oil. ns are true. 103 Senator Fortn. Mr. Chairman, I will be delighted to attempt' to answer any questions that you might wishi to pose to me this morning. Senator CxaFEr. Thank you very much, Senator, for your thought- ful and perhaps not.surprisi'ng testimony. I think the last point you made,, of course, about the family farm is something that concerns the entire Congress, and, indeed, the country. I think it has been shown by constant votes in the Senate that, wearec.oncerned about preserving the family farm to every extent possible. But somehow I think the choice vou presented,, that unless they are 4rrowing tobacco the choice is tlo give up the f!amilyy farm or to go on, welfare, is a little limited. Senator FoRD. Well, Senator, let me ask you :What crop would you suggest thatl the 600,000 farmers in several States start producing to substitute f or tobacco?' Senator CnAFF-E. Well, I suspect that there are many family farms i'Riithe \ ation that are not solely dealing with tobacco. Senator Foxn: Well, let me give you one State, Senator-I am not sure that you understand tobacao and tobacco States, because I doubt seriously that.you raise too much inyourState. But in my State there are.165;000 farms,;,t'hat represents165;000 families, Of that, 103,000 of those farms raise tobacco. Of that 103;000, 90 percent are small family farms. tio.v, you give them a subst'itute,,and'then you~ start relating to tobacco prodtict's-and you, go into the manufacturing of those prod- ucts. Now, it's a far-reaching rippling effect-you stop the growth of tobacco, and you look what you have done : you have not only elimi- nated the best income for small farm families that they can have; you have also eliminated industry, and probably some industry in your State when you have unemployment and y ou would like to have it there. Senator CHAFEE. `Vell, we are very conscious of that, alt'hough, as you know, this bill does not eliminate the industry-you have obviously l ooke& over the bill. Senator FoRD: I understand, but if you look at what it is trying to do, and',you look at all four bills; and you get imtoall the ramifications of the legislationy then it is far reaching and it does do damage to the industry, and to the people-the people I represent. And. 8Ir: Chairman, I want you to take one item: consider- ation. We have, been trying to solve our own problems in~ Kentucky without a dime from the Federal Government. And whereweput an average since 1972 of $,3.7midlion intoresearchL And the chairman of this snbeomnsitteeadini'tted thatwehad~thetoppeople, not only in this vout3t.ryV bnt probabl'Vin the world, heading up that'research institute, tryinr; to solve the problem without Federal dollars. We are trying to solve that, Senator, without intervention from the Federal Govern- ment. And here, with onlythe addition~ of $~-1millionfor research. I think this is the answer-not billions of dollars. And why tax one cnop-asbestos, for instance ;, that is cancer-causing--and llet this be a t)Veventative measure? Senator CriaPEE. Welly I think that the evidence is very, very clear tliRt 90 percent of lung cancer is related to smoking. Senator FORD. What about asbestos? What's the figure:on that? Senator CxaYr•_n. Well, it divid'es up the balance of the101 percent. But when, you have afigureSenator'Forzn: You can get any reseacher you want-and I think you ~'an find something to refiiteth~it. There is alsaa plust'~o tobacco, if you

among the of the 1979 t extensive smoking, 1964. de effort er asbestos mpaign o has been of not been •i~ewing, ing with~ cently oral in cardio- st now scribed • To coordinate this effort, the Secretary has established the Office on Smoking and Health and has appointed Mr. Pinney as its Director. Mr. Pinney brings to this position ten years experience as a manager and analyst of health programs, and possesses a knowledge of, and commitment to prevention and health education. One of the important elements in the Department's initiative is to move further in protecting the rights and health of those who do not smoke. 'The first provisions of S. 3118 deal with the reguliation of smoking in Federal facilities. Speci~fic areas of faciliities under Federal jiurisdiction are listed in which smoking will not be permitted,as well as areas in which smokers and non- smokers must be separated. It also provides instruments for enforcement of these restrictions and sanctions for non-compliance. These provisions correspond very closely with the new regulations already promulgated within HEW,which I am submitting for the record. We have urged other Department and Agency heads, and organizations, such as the General Services Administration, to adopt an& enforce similar restrictions in the facilities under their control. A copy of my letter to Administrator Soloman will also be submitted for the record. Clearly

Filt,ration~ .y availablie )xide throughi tiques used .n r.educing .ertain types :s paper and ew exceptions, abliy lower 119 Senator CxAFEE. Doctor, I may be duplicating Senator Schweiker'ss question here-but is it clear that the reduction in tar and nicotine does reduce the incidence of cancer? Dr. FOEGE. The answer on this, a definitive answer, will be somee time in coining, but it appears Ahat mortality rates do decrease about 15 percent in persons who are smoking low-tar low-nicotine cigarettess as compare& to persons who are smoking high-tar high-nicotine cig- arettes, so that we think we are already seeing a reduction in mortalfity rates because of low tar and low nicotine. Senator CxnPEE. All right, thank you. Dr. FoEGE. It is extremely difficult, of course, to assess the impact of the warning label~ both on cigarette packages and in advertising. Some form~ of official warning is not only appropriate, but necessary in discharging the Government's responsibility. The 10 separate warning messages would attract greater interest, through both novelty and v.ariety, than the single message now used. Several of them-for example, the one on damagE to the unborn~ child-would have the further ad'vant~age of calling attention to spe- cific threats that may not yet be wid'ely recognized. If the decision ismade to require a variety of messages, the specific wording 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. Section 10~ Mr. Chairman, is the portion which is to us the heart of the legislation. This is the area of greatest' concern to the Depart- ment. 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, among fe- males. But with children and~ youth, the picture is different. Smoking among boys has hardly changed in the last d'ecade: Our most recent figures, which will be updated during the coming sum- mer, showthat'5 percent of boys between 12 and 14I smoke; just under 20 percent of boys 15 and' 16 smoke; and somesvhat more than 30 per- cent of boys 17 and 18 smoke. By age 18, the habit of smoking is well established, and we think this is unfortunate and shocking. Meanwhile, smoking among girls has increased dramatically. In the 1960's about twice as many boys as girls smoked ; now at every age level girls are smoking at the same rate as boys. Senator ScHwE1xER. Doctor. do we liave any information or evi- denee at all to: indicate why, ;.vhat's the reason for the upsurge among teenage girls? Dr. FOEGE. We are not: certain of this, but we think that it is due partially to the new equalily of the sexes that we are seeing, and we are hoping,,therefore, that iiowthat we are equal these votes will also go doivn. SenatorSciiwEifiER. Fquali right~s~ to~ getlung cancer toqet'her?Dr. FouGE. That's right. The ledislation which you have introduced recognizes the importance of researclr in directing our efforts. We need to learn more about smokina behavior thani we know now, par- ticularly regarding smoking behavior among children.

132 - 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 cardi~o- vascular disease, the nation's singl~e largest cause of untimely death; * smoking results in a growing burden, of death an& disability due to emphysema and chronic bronchiti's-- diseases that turn the prime of life into premature oUage. These distressimg,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 welli knows, personal health care expenditures have been rising at wil'dly inflationary rates andireached $142.8 billion last year. It would: appear from the New England Journal estimates that some- thing more than five percent of these costs are directly attributable to cigarette smoking. It was be smoking that initiative on thi~s initiati the Departmen objiectives of Together Department ha Commission to public servic the informati, audience. Th the FCC. Secretary have sent add= and education~ the 50 States has also invi; send us postez smoking. The Depart in HEW-occupie conference roc and shuttle bc smokers and nc

mong lople. ndus- t. also )lved. 1.re. a the ges- whole ssibly Auct, `er of I own ealize -a1, as that's )ut it, idual, n the L1 iental leage, i, but lution t that :~rt,ain here's s bill. ; here ~ry to is 300 ;co, it arch ; Auct, :u can 'k are ev to there ig for loney thing I you 107 Senator CHArFE. I don't quite see why you say that. Part of this bill looks intot:lieveryeffectsof reduce& tar and nicotine in cigarettes and d'oes research in that area, which is exactly what yoit are asking for. Senator FoRn: But the research in HEjV is only 4' mil2ion~ more in 1979 in this related field. And I don't believe I detect in here that the money is going intoresearch; it's going into studies and preventative- tell them how not to smoke, you know, how to get off of cigarettes. Senator C,xAFFE. Yes; there is one section on that. Senator F©rzn. So there is really no research. Senator CirAFEr. No; there is one section on that. There is also a section to study the health risks associated with smoking cigarettes of varying lev.els of tar and nicot'ine, wh,ichis exactly thesub- ject you are concerned with. In other «-ords, what are the effects of commercially manufactured cigarettes of varying tar and nicotine. Senator FORD. Well,,if you are proposing that we go to low tar and nicotine cigarettes, that's eaactl .~•hat the free and'~ open market is d'oingtodayw.ithout punitive amageby t'tieFederal Government,, or interventiom That's what's wrong with "big brother" today. I have. heard y.ou stand on the Senate floor and fuss about regulations, get- t~ing into privat'e business; doing thingsin, our lives-and you are opposed to that very vehemently. But now you are cosponsoring a piece of legislation thatis going to usurp w.hatt private industry is trying to do for itself. And' I think in that vein alone that you are making a mistake. I think you areflying in the face of trying to eliminate Federall regu- lation, but, on the other hand', you are moving in that direction with theother hand with this piece of legislation. Senator CIiAFFu. «'ell, as youl know, there aretag incentives here to achieve the very goals that you are discussing. Senator FoRn. Yes;, but why tax a fellow to do it when free enter- prise is.doing it themselR-es ? Senator CHAFEE. Iiut the tax incentives hopefully will encourage- as has been pointed out, tliemanycigarettemanufaeturers who will have a reduced Federal tax as a result of this legislation. Now,, I think that, that is~ something you would encourage. SenatorFoan. «~~'elly Senator, you and I have a different view of how to help industry and how to help people:And I don't believe taxing an industry to turn around and'spend that money to try to put that industry out of business is the proper procedure. If that business is, causing a problem,that is, automobileindilstry-I don't want too put t'heautomobilesoffthe road; wecan't afford to. But in asmalder scale, you can't afford to put 600,OWfarnt families out of business either. And i'f you view the. farm problem in, this, country in the last few months, and if you take a survey of this country and the crops that are not ini the ground yet, the farmer is not goi~ng1 to fare very well thisyear. And this is one crop-one crop- that thevcan look foi ward to, borrowing sonie moneyat the bank, being aule~~ to buy fertilizer and do thosethiIligs for other crops on their farmL and tobaecois thevehicle to saa•ethe small farm. Now, if tliey did not have tobacco, that'm~wbrimgthem as high as ~;3,0001an aere--substitnte that'~ forcucumbers, that willgivethem about ;j-100an acre-then whatare you goin„ to do? Then look at the rippling ef}ectthat would have: on t'hetot'al industry:

123 for Disease Control, e O'fHceand in fund- =Moking and health. his monev fr.om the id from ihe ,ye ; there has been a _tutes and a major 41 game, y ou know, ay this out, and we that is, reprogramed )ney. ther money, thc $24 _ money p1us- itil we reappropriate ave been used for if of' research would it esearchL It is money ! institutes. iat were allocated for n identified for smok- what what is it, Dick,, that _llion of totally new t is what I am~ trying _imendable,but I am~ _her resources. Is that )eing directed toward 1 for smoking. Nbw, t is being, carried on )ns that Cancer, for pment are exploring. , gives an illhistration Kretchmer can speak of their research is in a spillover int'oqnes- ~l, ian terms of the ad- '6million new money. • 1978 is $110.1 million. Senator ScxwE~rnrER. But for whichi category of what~?' You know, «-e've got three different categories here. Mr. PiNNrr. _1 little over $4 million in research and $6:1` million- Senator ScIiWE~ixFx. That- is. in~ the National Instlitute~ of Child Health ? Mr. PrNtiEY. That is t'he, National Institute ~ of Child Health and Human Development,, and minor increases~ for Cancer, Heart, Lung,, and Bloodl Senator~ SCFiWrrKnx. That's $4 million. But~ t'~he~ $6' million is not'~in, that. Mr. PiN:vrg. No; t!he~$6, million, is in the Center for~Disease~Control I nd' for the Office on Smol.ing and IIealth. Senator ScxwEn.Fx~. F©ir~~ the grant' program~ to~~ the Statesi _11r. PiNNEF. Right; yes,,sir. Senator SciiWEniErt. And that's where we took it up to $15: million yesterday. And y ou ask for how muchi?' Mr. Pi-\NFl. $6,1 million. Senator ScHwEileER. OK, you are up to $115 million oni that. Senator KENNEDY. «~"ell~ you gave us a breakdown, but I would l!ilte~ to~ know~ in dollars where the transfer~ comes throuhh each of these a10'~encies, if' you, will supply~ that for us,~ OK ?~ I)i•. F©r:Gr:. I might say, DIr. Chairman, one of the problems with doing~thIls-the National Institute of OccupatibnallSafety~and Healthy 1'nr~~ instance, .rithi every criteria document that we~ put'~ out at this hoint, we do look at the smoking effects, so: that moneyy is not allocated there specifically for~ smoking,, but we have to~ look a~~t smoking,~ Like- Xise;~ with every occupational study now done; we hav.e~ to correct!~for~ ~iuok~ing in order to know~ what~would the~rates have been in: smokers, mndl nonsmokers, so that a! certain, amount of~ money now goes into~ ~4mol.ing from those souz•ces. [The information referred to follows :] 0

111 problem of ion for the s smoking mtion, you urgent and ry 11, when iative, it is 3 of cancer These sta- 3mic conse- t:icle in the of cigaret'te. il costs and This means •ibutlable to llar cost of ent's initia- nitiative, a f which we irtment has open more ~, including ~ the wid'est ~r are work- 1 materials. ie 50 States gencies and Teneral's re- cal and be- TeneralPs re- °t to notify 'kers of the i indieidual! to 90 times ias not beeni ie published 'ngS. he Office on yy as it~s Di- ,rienee as ai knowledge `smoking in lry with, the hIamsub- mitting for the record. We have urged other Department and! Agency heads Senator CfaArFF: I)r. Foege, could I just interrupt for one moment. G'oing back to the subj'pct of asbestos-the point you make about expo- snreto asbestlos and being a~ cigarette smoker increasing the chancess of lungca.ncer 90!percent-I must say that is asliockingfigure: But the opponents of the bill mightwsll say, zvell, that is t'~hefault of tllieasbesto;don't expose people to asbestos. \ ow, it seems to me that the key thing we are dealing with, here is the risk of those who smoke cigarettes. I guess the point you are making is that there are other factors involved which increase this factor by the square or geometrically. But I do wond'er about other factors, like pi11s or asbest'os, because the opponents say, get rid of thee asbestos, for example. Dr. FOEGE. We think it's important-people who have other risks R-hichi may be additive or synergistic should! know about those risks. With asbest'os, for instance, a nonasbestos workerr who smokes will have about a tenfold increase in lung cancer as compared to a non- asbestos worker who does not smoke. If you, take asbestos workers only, asbestos workers who do not smoke have only a slight increase in lungcancer, as compared to nonasbestosworkers,who do not smoke. But it is the combination of cigarette smoking and asbestos that in- creases the risk from tenfold to nmetyfold. And we think it's important that asbestos workers know that, be- cause the one thing they can do right now is to stop smoking,in order to reduce the risk. Senator CfrAFFE: Well, that second point'you madc about thenon- suiokers'esposnre toasbest'os; you said his chances for lung cancer go up very slightly. Dr. FaECE: Very slightly. Senator CHAFEE. In other words, the asbestos alone is a minor factor. Dr. FcEcE. That is right. But it is the synergistic effect somehow of cigarette smoking and asbestos that makes this very dangerous. Senator CxAFEE. And the same is true with oral contraceptives and so forth? Dr. FOEGE. With oral contraceptives, there is, a slight, increase in cardiovascular risk in women over the age of about 35, even if they d'on't smoke. But this becomes greater if they do smoke. And it is in this area where people do not know about the additive or synergistic effects that we think we have to give informat'ion. Senator CFrAFnr: Well, now, thereis a whole series of theses}-ner- gistic effects «-it~h, say, pregnant women, where smoking and liquor aredainagiih?~ Or is that not so? Smoking alone, or the lfiquoralone, is thedamaging factor in the fetus? Ir: Fonc,F. I think we really don't know in~ howw many areas thereiuirilitbe sv,nergistia effects, and we are just. ibelieve, at tlsebeginning, tltethresholdh of this sort of knowledge. «'e]:noav with coal mio1ers, nranium miners, an& so forth, that there is this addit'~ive and syner- Tistic effect, but there may be many ot~her things also. Senator C1IArEF: Thank vou. Dr. Forc:n. We havee urged other department; and agencyy heads, and organizations, such as the General Services Administration, to adopt and enforce similar restrictions in the facilities under their control.

144 - 15 - The final section of S. 3118 calls upon the Secretary to study and report back within~two years on the relative health risk associated with smoking cigarettes of varying levels, and the relationship of tar, 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 General'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 effort, the agencies will be looking at the changes which have taken place in the cigareate 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 information will be available before the end of two years. Regarding addi some 300 substances to cigarettes for f not even know what : would recommend you language requiring, and other additives justifi~ed for the p they are at lieast e In establishing Secretary Califano E the National Cleari: was formerly a part Mr. Chairman, that t no means signals the smoking. The budget now before the Congz to the States which effectively for the on a significant scc development and proa in close collaborati apply its epidemiolc with smoking to a gx of lifestyle educati one of the principal with hypertension, c grow.

136 you feeli as we do that the Federal government has an opportunity and a cliear responsibility to set an example for all organizations and emplioyers. Congressional support for this policy should encourage its establishment whether throughilegisiationlor adininistrative action. Sections 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 onicigarettes ranging from five to fifty cents a pack,, based on "toxic units' which are derived from the milligrams of tar an&nicotine contained in each brand of cigarettes. The proceeds from this tax woul'd' be used, beginning in Fiscal Year 1981, to support payments to the States in the form of 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 raise this tax on (and:presumably thus the priee of) most cigarettes by substantial amounts, but would lower the price of those cigarettes with the lowest toxic yield. The principle o: nicotine in our op: particularly the dc example, a lowerincc cigarettes, as is Je encourage more smor hand, very hi~gh~ ta: might have no effec thus have little mc Department is pres operation with the these important qu provide a basis fo near future. We w The question o purposes -- even t economic and tax pc analysis. However is the view of our American people sh den which cigarett in terms of increa costs of days lost revenues obtained rate, or even unde not begin to apprc . -.,' () - 78 - i,

The principl'~e of a graduated tax based on~tar and nicotine in our opinion deserves serious consideration, particularly the design of the tax schedule. Fbr example, a lowering,of Federal taxes on low yield cigarettes, as is proposed in this legislation, might encourage more smoking by young people. Onithe other hand, very high taxes on the highest yield cigarettes might have no effect on confirmed smokers and would thus have little more than punitive significance. The Department is presently undertaking studies in co- operation with the Treasury Department to answer these important questions and hopes to be able to provid'e a basis for such technalcal judgments in the near future. «e will keep you advised of our progress. The questi=of earmarking tax revenues for special purposes -- evenithe best of purposes -- raises many economic and'itax policy questions which require further analysis. However these questions are resolved,, it is the view of our Department that Congress and the American peoplie should be aware of the economic bur- den which cigarette smoking,places upon the taxpayer in terms of increased hospital and medical costs, the costs of days lost in production, and other costs. The revenues obtained from cigarette taxes at the present rate, or even under the rates proposed by S. 311B, do not begin to approach these costs. ,r.e 0 _ 7 M- in,

124 N,aUior,al Instiitutcs of Heal!±h: Pub4ic Health 5arvice SmoSing and Healthi National Cancer institute: bsse .................................,.... increase.. ......................... Total, NCI .......................... National Heart, Lung, and Blood~ Institute: base ..................................... increase................................. Total', NHLBI ........................ National Institute of Envi'ronrental Healt'h Sciences: base ..................................... increase................................. Tota1, R1EHS National Inst'it'vte of Chill!d Health and Hur..an DeVel'opcent_ base ..................................... increase., ................................ Totali, f;ICHD base ..................................... increase ................................. Totall, NIH Office of t!:e ASsistant Secretary far Health: Center for Disease Control: base ..................................... increase ................................. TQt_ , rLI <............................. .. base ..................................... increase .. ...... ......................., Total, OASH ......................... Alcohol, Drug Abuse and Nental Heailth Ad7inist'ration: base ..................................... increase ................................. Total, ADAMHA....................... To?-21 Public Health Servioe: base ..................................... increase................................. Totali, 'HS .......................... 1979 S(2,4o7). t---), S(7.500) C--) $0,100) t---l l ,l OJ~ S (---) (4.007) $17',pDO S 4,003 $21,030 $ 100 T-1 oo $ 1,500 1,507 Senator KT•.\ NEDY. - bill that , require in Fcnonsmolkingareas se provision? Dr. FbEGE. Yes; we Senator KE.N\EDY. us what your positi administration. Dr. FOEGE. This is v( Senator KENNEDY. Dr. FOEGE. To the 7 buildings, that there , ing whenever possibl Senator KE\ NEDY. Dr. FOEGE. It does~I freedom to have area Senator KENNEDY. Dr. FOEGE. The SeC ing them what our ru al l I Federal buildings. Senator KENNEDY. ting rules out in terrr support legislation th Dr. FOEGE. I think Senator ScxwEIgE_ rooms in that? Senator KE-NNEDY. Senator SCIIWEIgEI Senator KEN\EDY. what' we are trying t approach, without rc( obviously, with regan makes sense to you? Dr. FOEGE: Yes, sir. Senator CHAFEE. F have been the results Dr. FOEGE: Our ex IDisease Control, thatt understanding is, frc been major problems. Senator KE1iNEDY. think it was last year reform, with regard additional Federal r, ]ower t'~arand nicotin(i Do vou have an es hospitalization for 1 i'n the lungs attribut: tlhat ? Dr. FOEGE. There .Tournal of -liedicine in this countrv were. «utire health cost cc

ltor Soloman will as we do that the ear responsibility zrs. Congressional ,lishment whether timent of a "health based on tar and on. pecial purposes- id tax policy ques- iese questions are' ess and the Ameri- n tivhich cigarette ~ased hospital and id' other costs. The sent rate, or even to approach these )sidize smokers byy ce premiums, and e packages list t'he. 110 different warn- a 10-percent sam- listed on~ the cig- provision be made , as -%relll as on the unds as they may h, Education, and tint;, methodol'ogyy y have significant airman Pertschuk ary Califano that ~s for their carbon ,ttts earliV in 1979. action 'will also -)ugh its Office on ie results of these o..- o. rr+c " IA.nNnr. FEDERAL 7RADECCMMISSIONWASHINGTUN,.D.C.20.580 May 24, 1978 Secretary Joseph A. Califano, Jr. Department of Health, Education, and Welfare Room 615F SP 330 Independence Ave., S.W. Washington, D.C. 20201 Dear Joe: In response to your inquiry, I am pleased to advise you that early in 1979 the Federal' Trad'e Commission begin publishing figures for the amounts of carbon monoxide in the smoke of domestic cigarettes. Our involvement with carbon monoxide testing began several years ago when a $50,000 grant from thc National Cancer Institute enabled the Commission's Tobacco Research Laboratory to obtain a cigarette smoking machine capable of testing cigarettes for carbon monoxide at the same time that they are being tested for "tar" and nicotine. With that machine, we will'be,able to publish figures for carbon monoxide -- widely regarded as the third most significant constituent of cigarette smoke. I bel~ieve that the publication of FTC carbon monoxide figures is important for several reasons. First, those who choose to smoke will be better able to selecL- lirands, that will lessen their exposure to a harmful gas. Second, the availability of comparable carbon monoxide data should encourage cigarette manufacturers to lower the carbon monoxide output of those varieties whose output is excessive in relation to that of competing brands. The end result should be a gradual reduction in the environmental burden carbon monoxide poses for smokers as well as for those who share their air space. Our experience with "tar" and nicotine supports this conclusion. Since 1967, when the FTC first started publishing "tar" and nicotine figures, the weighted average "tar" and nicotine level of all cigarettes sold in the Uni~ted States has decreased significantly. 113

142 - 13' - At this point, let me emphasize that the primary goal of our prevention programs with children, as well as adults, i~s,to provid'e ed'ucation 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 an&not discourage healthful behavior. But we cannot take from young people their right to make choices as to~thei:r own conduct, so long as this conduct does not infringe upon the rights of others., As stated before, we believe that if our citizens--especiaLly those in their teens and subteens who begin smoking for the first time--are given all the facts from Government 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 to inform children and young people is through health education in the schools. Some excellent school curricula have already been developed and tested for eliementary school chil!dren. One of the best, I am personally pleased to say, has been developed by CDC and is now in place in some 350 school districts in more than half the States. But there ar country. To reac teachers and admi' materials develoF between school ar others who can h, new i'nitiative, working closely There is a p+ programs for tee~ knowledge, we mu teen-age attitud learn. Surveys Eighty-fc that smo' Sixty-ni: them dow Two-thir as their And half their ch These are F promising apprc which CDC has t contract with Smoking and He

157 xliinit X1-60-1, GENERAL ADMINIiSTiF.A9 I a pa9e Z I . ' _ ..01 5..To.develop general health education actiNitdes with emphesis on smoking and'healthpractices in hospitalis and'clinics. 6. To cooperate with.othercommmitygroups in thedevelopment and impleauatationof.cosmunity-wide activities dealing wi'th'.the cigarette smoking problem. Signed byp /s/Iouis M. Rousselot„ M,D. Js/Wil2iam H.,Stewar,t M,D. /a/'H. Mi Engle, M.Di. u a . ousae ot, . m H. Stewart,. M.D. H. M. Eng1e,.M:D. Deputy Assistant Secretary Surgeon General . Cliief Medical Ditectorof Defenae U.S. Public Health Veterans Administration. (Health~and Medical). Service Date: April 24, 1969 Date: April 21, 1969 Date: May 5, 1969 HEH TH-7g.2 (1118/78)

Page 4 r.,:ater 1-fi0, GENERAL ADyi (3) (3). Libraries. Smoking shall not be permitted in libraries except in such areas as may be designated as smoking areas. 4) (0). Elevators. Elevators shall be.designated as no- smoking areas. (5)Shuttle Vehicles. Smoking shall be prohibited in "' 5) shuttle.vehielesunderHEWcontrol A No Smoking" sign shall be posted in each,vehicle andd the driver should inform all passengers of thiss requirement. C. work Areas (1) Separation of Smokers and Nonsmokers In consideration of thee rightss ofnonsmok'ers in work areas, ttiey,will, within practieaL limits, be given the opportunity.to be assipned to offices.or workplaces separate and ph'vsically distdnctfrom those of employees who smoke. The following provisions will apply in making these determinations:. Efficiency of work units or administrati^e effectiveness shalt not be impaired. -2- Excessive costs will not result from providing physical separation. -3- Addikional space will not be required.. (2) in, conuooin wuin a .... - . ,., . ... . ~.. -, ployees are asvigned, supervisors will'prohibit smoking if an employee objects in writing totobaceo emoke in the immediate workenvironuent on the basis that it is having:an adverse effect upon.his or her health. (5) D. Cafet be es contr This respm then, and n nated non-s shoul futur on ex exhau where HEW IN=78.2 (1 18. 8) -5-il

108 So I think the procedure here,, that what you ought to db, you ought to put it in research and try to isolate that problem. We are going to have the Space Shuttle before long, and one of the.fine things about' the Space Shuttle, as I und'erstand it-you can isolate cells. And you will' be there for 2«eeks. And you can fuse metals that you cannot fuse here oni Earth. And so maybe there is an opport'unity for us to develop some research. It is an opportunity to try to save an, industry instead of being punitive to it. Senator Scxw.Eixrx. One of the provisions of this bill, Senator Ford, is that it does segregate smoking and nonsmoking areas in lounges, public, dining facilities, and recreation, areas. Are you opposed or supportive of that? Senator Foxn: I am opposed! to it. About the only, time I getl to ride on an airplane is a seat bvt'helavatorywith no window, under the motor. N'ow, we used to~haveproblems about segregation in this country-and we are now being segregated in a different~ areaL But if a cryi~ng baby is sittlingnext to: me, that's fine, that doesn't make any difference. The fellow that has other kind of problems sits next to you, that's all right. But, you, know, I can't sit equal on the airplhne, for instance. Senator S'cHwElrER. Of! course, a baby may give you a little noise pollution. Senator Foxa: That's right, but I can und'erstand that. But, yotu know, I have seen people jtist raise cain because the baby is crying; the baby is going to cry,, it has problems. But we know where we are goingwhen we gett oni that airplane. And I think that it ought to be equal on both sides. And the ventilation of the airplane is much better, and the stability of the plane is much better, if you have them side b,y side, in the circulation, rather than have it all in the back. Senator ScnWEixEx. Well, if you don't have segregated areas, you certainly don't, have freed'om of choice, whichi you say you advocate. Senator Foau, That's,right. Senator SeHwEIKEx. So you are advocating freedom of choice; but if I, as a nonsmoker, sit nelt to a smoker for a 4-hour flight to L.A., I have no choice at all. So your freedom,of-choice argument, doesn't hold up on that one. Senator FoRO. Well, it may not, but I think rather than being segregated to the: back of theplane; underneath the motor, by the la~ratory-thatis something else. And I dbn't think that's right or fair. Senator ScHwErvnn. I would rather put youi in a; front, seat any- way, because those seats in front usually get the worst in a crash. You can have the front'~, as far as I am concerned. [Laughter.] Senator FopD. I want to telll you, Senator, that may be fine, but I can't afford first class, so it's going to be back in tourist before they get to me. And I want to tell ti•ou, if that is what your concern is, I will s«ap: smoking areas .vith~ vou. Senator SCHwmaux. Well, Senator Kennedy is going to outlaw first- class ~ seats anyway. Senator Foxn: Well, I am for that. I don't mind that. I'll be glad to vote and support that piece of legislation. Senator CTiAFFE. W(211, obviouslv; this is t'hefirst round in a 15- rounder. [Laughter.]I We look forward t'o heai which will come along lat.ei arguments that y ou have mc Senator Forn. Mr. Chaii it's going to be an int'eresti forward to you coming to!:. I just want to make one and nicotine might be in tl think it's still a 5-cent tax- amended it or changed it. - Senator CxAFEE: Yes; bui poi'nt. Some are going down Senator FoRD. We12, you not in~ this bill ; this is addi already have. And! it bring in;- the balance of payment: Senator CHAFEE. If I colcurrently is 8 cents. In this SenatorFofin: That'srig] i tiTo matter how low the taii think my statement was wr tax then, regardless of the t,- . Senator CUAFEE. Yes; bu with the tax going down. Senator FORD. No; but th; Senator CrrAFF.E. «~~''ell~ R•., . Senator FoxD. j'Vell,, I w.-1 deter you from being a dote: Senator CirAFEE. Oh, I e: coming. The next panel will be m the Center for Disease Cot fi•omthe National Institut inent, and John Pinney, Dir, in HEN. Gentlemen, we, welcome Foege. Why donit we start. c STATEMENT OF WILLIAM DISEASE CONTROL;, NOR TIONAL INSTITUTES OF MENT; AND JOHN PINN: HEALTH, DEPARTMENT A PANEL 1)r. FoECF. Thank you, : «-onld idisert, this for the re( t e ~timony. Senator CxAFEE. Fine. 1>r. FoFCE: First, 11Ir. Cb `ceretary Richmond have a }iip that ~•ou~ have shown~ in Improving the preventi-

100 PaBo 9 C1uy, s9elma Rei~d Jii. 1977. Crop Year Income 1977 COSTS PER GROUND ACRE FOR DIti' Per Sch F Add' 1i977 Less1976 Columns 1+ ) Income Form 1065 Items in Items in 2-3 ( 1TEM COST 1 7N 1977 1977 Net " ' Crop Income Labor $ 13 64 ~4~56 . Ca ves 00 11~~747 75373'.00 Supplies 7.48 11F;71-7.00 7537 3. 00 ~• ^ 7 02 Cotton Trailer Credit•t 17fL~'0 1 ft 00 0 3?3'.~0 Repa i 1 . s Fuel' 6.15 yoty l-lr 3•uu ,, .2 Seed 3.79 Ut'dl!ities 3 Phone .42 Chemicals 2.80 0' erat.in* '~cnunse.3 ' fi1~+10. 00 Fertilizer 1.60 a oe 441;1.C1J ' 00 '9 ` Leases & Rent 32 15 ~0 '~0 27 ~Q' "20.00 . 93 • . Repairs2quip. rest t I 11.! L. . 4Ol~!•00 Z26.00 Pest Control 20.13 Machine Hir 66 e n ?9ed 2 I • 0 254.00 3213•00 e . Feed .26 3oed ~ 1%•n0 9397.00; Vet .02 ^urtili::er 00 1021' 9 llachi:ne hlre , . 15 00 li 314_00 185.00 22 . e, Su?p Oil l cl ' (i • I ~ ~.(ti0 %1!1.00 1?5.00 4119.00 00 A , . a- , ucea l t; ert Yro 0o 13l~.00'~ 19 7~. F 00 MINIMUM IMJOR ITEM EQUIPMENT'LIST N , ; , Insa.nnce 1;? F5.00'~ 7,. 17 4a7•00 OPERATION (65% COTTON, 10% MILO. 10% IItilities 2089:00 G tt clto itk; 21'3`?•`t0 an pP 00 6 o " 00 126 139.00 20. ITEM Piokup,car ~ Gruc, . 001 198 Telephone 1 ii•0J 4J;.00 u Suba . LE1" 00 2 Tractors 100 H P . Dues L©g,il.. wAccoi,tMn«1,9.j.00 Office in IIome 3'6• 00 - 593.00: 326.00 21362•00 . . 2 Cultivators Complete 2 Planters Complete ".00 77 30 IDe-,rec _ 2 14' Tool Bars Complete . Total nr0 _>..00 `,° 8' , 0 1l3 2.00 1 71•00 1 4,Bottom Plow & Rake Idet Income (Loss ): 36578.00 7,5105,00 117981i•00 (6298•00)Loss 2 14' Tandem Disc & Rake 1 901" Shredder 2'300~gal. Spray Rigs 1 1000 gal. Water Trailpr 1 14' Chiesll 1 Bi9 Ox 9 Shank 1 Cotton Stripper 10 Cotton Trailers 1 Cotton Ricker 1 Grain Drill 1 Combine 14' Header 1 Grain Truck 2'3/4 Ton Pickup Trucks 2'Fuel Storage Tanks 1 8 Row'Rotary Hoe 1 8 Row Sand Fighter 1 12' Hay Swather 1 Stack Hand I Stack Mover 1 Metal Barn w/Shop (40'XlOO') 1 16' Stock Trailer Farm Shop Equip. & Tools Livestock Misc. Equipment TOTAL'

rimary goal 11 as ad'ults„ that will nform examples we ch will promote cannot take s to their nfringe e believe teens and are given and they stilli : hazardous, nokers, 'sd to Lth L iI for am 7 CDC > in 143 - 14 - But there are some 16,000 school districts in the country. To reach a major share of our youngsters, teachers and administrators will have to be trained, materials develioped, and close cooperation encourages between school and health officials, parents,, and others who can help do the job. Through the Department's new initiative, CDC and the Office of Education are working closely together to accomplish these purposes. There is a particularly urgent need to develop ediicational programs for teenagers. While we are gathering new knowledge,, we must also appliy what we aliready know about teen-age attitudes toward smoking and about how teen,agers learn. Surveys have shown, for instance,, that: -- Eighty-four percent of teenage smokers admit that smoking is habit forming. -- Sixty-nine percent realize that smoking slows them down in sports. -- Two-thirds believe that smoking is just as harmful as their doctors and teachers and parents say. -- And half of them hope that when they have chijldren,, their children won't smoke.. These are positive attitudes on which we can build. One promising approach is peer education-kids teaching kids-- which CDC has been supporting,on a small scale through a contract with the National Interagency Council on, Smoking and Health.

Regarding,additives, we understand that there are some 300isubstances which cigarette manufacturers add to cigarettes for flavoring and other purposes. We do not even know what many of these substances are. We 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, incl'~udes 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 promulgationiof school health curricula, in close collaboration with the Office of Education and will apply its epidemiological expertise to problems associatedd wilth smoking to a greater extent than heretofore. Ptograms of lifestyle edticatlion, in which smoking is incliuded as one of the principal risk factors closely inter-related with hypertension,, obesity, and others, will continue and grow.

146 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 know, the Department presently has broad authority in this area and has recently undertakema major initiative aimed at objectives that closely parallel those of S. 3118. Whilie in many instances, specific authority may not be requiredito advance our mutual goals, this expression of support from the Congress willl significantliy aid our efforts. o.ncE or TME.CHAIRMA". FED! Secretary Joseph A. Department of Health and Welfare Room 615F SP 330 Independence Ave Washington, D.C. 20 Dear Joe: In response to you that early in 19 begin publishing figg in the smoke of dome Our involvement several years ago wh Cancer Institute ena Laboratory to obtain of testing cigarette time that they are b With that machine, w carbon monoxide -- w significant constitu I believe that figures is important who choose to smoke that will lessen the the availability of encourage cigarette : monoxide output of t in relation to that should be a gradual carbon monoxide pose share their air spac our experience conclusion. Since 1 "tar" and nicotine f nicotine level of al has decreased signif

1979 S(a,to0) (---) 3TE."4a~. S(7,5oa) (---) 5(a,t00) (---) ~ti_ S (--) (4,sca) S17,000 S 4,000 $21,000 S 100 ' ~oo S 1,500 1,509 125 Senator KENNEDY. Now. you are familhar withi t'~11eprovisions,of the ~ bill that require in Federal facilities that there be smoking, areas and ~ nonsmoking, areas set aside. Are you familiar with thatgeneral, prov.ision.? ! Dr. FOEGE. Yes; we are. Senator KENNEDY. jFhat is the administration's position-or tell' us jvhat your position is, and then we will ask you about the adhninistration. j Dr. FOEGE. This is very close,.Mr. Chairman IY Senator hFxwr:nr. If you've got a differentposition: ~~ Dr. FOEGE. To the rules that HEW has now put out for all HEW buildings; t!hattherewi11 be separate areas for smoking and nonsmok- i ing whenever possible, so that'«-e arein favor of this. Senator IiE-NxnoF. Does that make senset'o y.ou ? Dr. FoECF. It does make sense to us that nonsmokers should have the freedomi to have areas where there is not smoke. Senator KENNEDY. Shouldn't that applty-,to: all' Federal buildings?~~ Dr. FOEGE. The Secretary has, in fact, ~ ritt'en a; letter to GSA telll- ~ ing them what our rules are and suggesting, that they look at this for all Federallbu2ldings. ~ Senator KENNEDY. Well, if he thinks it's a good idea and lie i's put- ~ t'ing rules outl ini terms of GSA, is there: anvreason that you wouldn't ~ support legislation that would require it in~Federall buildings?I)r. For;cE. I t'hink that this is in, fact a very good step to take. Senator ScFWuixER, Can we include Senate office building hearing rooms in that? Senator IiE-NN-Fnr. Which: part of the room is going to be smoking? Senator SciawErKES. This is a ban, a total ban. Senator KENNEDY. But, in any event, it's completely consistent with what we are trying to do in Federal buildings, elevators etc. And t'1ieapproache without reg ard to the particulars-you have suggestions, obviously, with regards to the language-but in terms of' approach it makes sense to pou? Dr. FOEGE. Yes, sir, very definitely. i SenatorCxaPEE. Has it caused much confusion and reaction~? What ~havebeen the result& as far ast'hepeople are concerned ?Dr. FoECE. Our experience has been, particularly at the Center for(' IDisease Control, that this has been a very smooth transition, and our understandingisg frotit other buildings in HEW, that therehavenot been major problems. Senator KEa-NFnY. 1'ow, we also-as vou are a-ware, last vear-I think it1 waslast vean--had the amemdrnent on the tax reform, l'976 tax reform, with re~ards to -thefinancial inaent'ivesto trvand provide additional Federal, recoveries on taxes for high tar and nicotine and lower tar and nicotine. Do vou have an estimat'eof the cost to the Federal Government forhospit'nlization, for people that go to the hospital from complexities in the Tungs attributable to smoking? I mean, is thereany.estimate on0 that?W Dr. For,r,F. There was an article 2's months ago in the Vle«-England~' i~ Journal of Medicine. They estimated that the total direct health costs ~ in this countlry-were SS billion per year, so thatabout', 5,percent of thew entire health cost could be attributed directly to cigarette smoking.,;~, OD

153 Page 4 (3). n ignated (4): no- ,d in king" (5)~ driver nent. i P .•u :nt 'ect ; -I?ter 1-60~ CENERAD ADMINISTRATIONPage.5 " ---- - - -- • Recognizing the rights off smokers who continue to smoke, supervisors will establish areasin which smoking ispermStted. Such areas wilL b'e. c.onspicuously.posted. be enforced by all levelsof management and supervlsors.. Violators of these regulations and procedures will be sub']ect.to.disciplinary, action under the provisions of'Section 73.735-1101 of' the Department'sS'tandards of Conduct. Smoking~will be.prohibitedlin those work environ- ments in which the comb'ination,of smokingan& special occupational factors presents a particular hazard to.the.h'ealth and safety of employees. The safety an&health regulationsand procedures established under C.. (4).above, whicti~prohibit.ss smoking.becauseg of occupational'exposure, will (6) Inadllition to the prohib'ition of smoking in..accor- dance with paragraphs.C. (1), (2).,.and (4)labove„ an employee who occupies aa private office iss authorized todeclare that office a no-smoking area. (7) As a general rule, amihimumrate of 5 ctmof' fresh air per person,is recommended:toremove~ smoke from a work area and provide an environ- ment reasonably freeofcontaminanta.. D. Cafeterias or Dining Areas. No-smoking areas shall be established in cafetertasnr dlninv n.eas under contract to MEWiu Jep--,,.,. , .,. U , ,., „- „„,,. This may be.accomplished by agreementbetween the responsible HEW offic.ial and the concessionaire, and then included asa.provision,in future amendments and nevcontracts.A..no-smoking areaa shall bedeeig- nated and postedibased on an-stimate of smoking and non-smoking patrons served. Careful evaluations should be made afterdesignaning,separate areasand, future adjustments as to,size should be made,.based on experience. Improvements to air-conditioning or exhaust systems will also be considpred'in such-reass where ventilatiom is poor. 0 HEWTN- 8.2 (1 187J8) M'

heart', attacks and~ )n right nohv : ~~ This you~ say there, are nol.in~ is helpful', statistics-I don't 'nmiliar with frac- n for several days. my committees. from the Tobacco re oni Thur-sday is 'ubject. )acco is beneficial, Senator. And not 1? e protein that has. ,orward! «ithi that. . that vou can take. Ilion families with ve y our cigarettes. t it out of bu5iness ,msas it relates to imarily to provide ioney,~ then, t~o put. ~ Federal Govern~- kar cigarettes. ir prev entat'~ive in- ,r areas in andl let dles, for instance. help? H'ow much (;o dowm iow without Fed- )ctween industries by tas, to force lg. enence of opinion g htcd to debate it witnesses on that uggested. We are u other points y ou 105 Senator Foran, «'ell~ Senator, I will just say. I look forward to your coming and testifying before me at my committee, as a cosponsor of this legislation. Senator CFiar•EE. Fine. Well, I hope I emerge as well' as you have here todaw. Senator ~Foan: Fine. Do you have~ any f urther questions of ine?Senator CHAFFE. H'av.e you any questions? Senator SciitvErxFa. I just have one question, Senator. If' the tax on tar and nicotine were not in this bill, would your views about the bill change to any est'ent?Senator FORD. That is just onepartof it. The labelling you get i'aito-I' think that!is in three of the four bill's that I have had an op- portunity to read. That's one reason it went to Commerce, the labelling an4 alll the ramifications:You set up a new section-I believe it's 305 that you ref'er to-inthe bill. And what we need is to try to hellpthe indnstryput 600,000 farmfamilie.s~out of business, t'hosethat areem- ployed' by prodkicts from that crop. And you have the potentiial of this (rreatl protein that willlbe availableto this cotultrythat isprotein,short. ~ So instead of trving to be punitive here. I think vou ought to find some way-if nothing else, if you are going to tax just cigarettes=let 1~ome of the other industries that will have stronger testimony than against tobacco as relates to cancer-c~cusing, problems-let them share part of the load. But in the Senate, you know, yoir put a tax in the l,ill, the only way you cait tackit'on-you have to tack it on to a House ibi11; the Finance Committee can't even consider a new tax, in my opinion. tienator Sc~iwrrxrn. Maybe you didn't understand my question. _llyqttestion was SenatorFon». No, sir, I would object to the bills if t~he tax -wasout. Senator ScuwrirEa. What particular features of the bill, other than tlre tax, which you say ispunit~ice. What particular features ofrhebillido vou~objectto?Senator Fonn. Well, you are elkminatingbeing able to smoke in vari- MiM facilities. You aresayinfr that people are not free to do this~or to,do that. You~ are saying, no, you can't.. And that is part of the bilL I' thinl:peoplle ought to havea flree choice. And if you don't want to bearonnd~ a person t-hatsmokes, move; if you d'on't want to be3round a fellow that, drinks, move. You know, they always have that '>phortunity: Even if you have to,go outside. You take in most of the ,(•liool~ now, I think that they have an area for the kids to smoke. Back \~-lhenI was going to school', ti-ou had! to g et' off the property to smoke. liut now, in onreducationall systems-and this may be leading to what You are trYing to do-but they provide an area,,or they can smoke on lcliool groiznds. This is their freedbm,of choice. And that is tlie:reason tliov allowed them to do it. So you are flying in the face of problems I lon't tliink you have thoughtthrough'very well. Not you particu- 1:»'llv. because,you didn't cosponsor it. ;~nator ScxwFUKrx. Yes; it's not my bill. ,"enator FORD. That's right, it's not vour bill. Senator CxraFr•,F. Obviouslvwe have got'some difficult problemsIiere. Whetheryon agree with the statistics or not, I t~hinkthat it is. V<'i'vapparent that the overwlielming-and 90 percent, savthose who ~>>ow-:1Opercent' of cancer in, the lhings is caused bysmol:ing. Look _" - ~ I.i, U- i.. - i4 V I 0

gratified disease :ndlhealth. :hority ii~tiativeS. 3118. = be on of ~ur efforts. TME CHAIRMAN FEDERAL TRADE COMMISSION WASHINGTON, 0. C- 20560 May 2-0y 1978 147 Secretary Joseph A. Califano, Jr. Department of Health, Education, and Welfare Room 615F SP 330 Independence Ave., S.W'. Washington, D.C. 20201 Dear Joe: In response to your inquiry, I am pleased to advise you that early in 1979 the Federal Trade Commission will begin publishing figures for the amounts of carbon monoxide in the smoke of domestic cigarettes. Our involvement with carbon monoxide testing began several, years ago when a $50,000 grant from the National Cancer Institute enabled the Commission's Tobacco Research Laboratory to obtain a cigarette smoking machine capable_ of testing cigarettes for carbon monoxide at the same time that they are being tested for "tar" and nicotine. With that machine, we wil~l be able to publish figures for carbon monoxide -- widely regarded as the third most significant constituent of cigarette smoke. I believe that the publication of FTC carbon monoxide figures is important for several reasons. First, those who choose to smoke will be better able to select brands that will lessen their exposure to a harmful gas. Second, the availability of comparable carbon rnonoxi~de data should encourage cigarette manufacturers to lower the carbon monoxide output of those varieties whose output is excessive in relation to that of competing brands. The end result should be a gradual reduction in the environmental burden carbon monoxide poses for smokers as well as for those who share their air space. Our experience with "tar" and nicotine supports this conclusion. Since 1967, when the FTC first started publishing "tar" and nicotine figures, the weighted average "tar" and nicotine level of all cigarettes sold in the United States has decreased significantly.

148 Secretary Joseph A. Califano, Jr. Page Two The usefulness of FTC'carbon monoxide figures depends, of course, on an informed public. In the past, HEW'has made significant efforts to educate the publiic on the subject of cigarette smoking. We can once again use your assistance in educating,smokers about the importance of carbon monoxide in cigarette smoke, the meaning of FTC's carbon monoxide figures, and the use of FTC'"tar", nicotine, and carbon monoxide figures in selecting brands that will lessen the health risks by cigarette smoking!. I have high expectations for this worthwhile project and look forward to our joint efforts. Sincerely, Encliosure r./~''Ll~+Ll,~~ Michael' Chairman -(} - - 1) /__ ~ , , ~ '• ?" "" ,"„ ertschuk A. it isthepo: nonsmokers(tstrictingsss and facilitir individuals t life orprops to, nonsmokerf H. In recognitic health of sac creates a hee_ diaease. restobacco amolo, be irritatin their privil tobaceo.smokcvide an envir 1,60-20~ Applicabilityanc A. The pnovision elements oft: buildings anc HEW TN-78.2(1.18 78).Supersedes CA: rurv~L ...... GENERAL 'PAer 1 .., General ADMINISTRATION POI NEW' OCC1JpI 1-f 1-60-00~ Purpose The purpose of t: onsmoking, intEC General Administr "Policyy onSmokir 1-60-10. Policy

156 . ~Ie.neral Adminlstration POLICY ON:SMDKINCFOR MEDICAli.CARE FACIIJITI'ES OF THE Exhib ct. a1-OL.- _ DEPARTaENT oFDEFENSE, PUSLIC HEALTH SERVICE.,.AND VETERA.tiSADMSIv'ISTRATION~ In viev.of the established fact that cigarettee smoking iss directly.related to considerablee excesss morbidityand.mortality,and that ciga.rett.e:smoking const- t:utesone of thee nation'smajpr preventive health problems,.it shall be the policy of'.the Department of Defense.,,the Public Health Se.r.vioe, and the VeteransAdminstration in.n all medical care facilities under their jurisdiction:. 1. Toeducate professional and non-professional staff about the nature andd magnitude of.the health hazards of,cigarette smoking, the behavioral changeramificationso9 the smoking practice, the educationallapproachesto.preventingor alleviating the problem, and the exemplar influence of health-orkers and healtH~service fac.i~lity.environments. 2. Through firm administrative poUieies, toestablish a health facillity environment vhichdiscouragescigarette smoking and: which reihforcesnon-smoking practi.cesamong.employees„ patients, and visitors. This effort shall include: a. Proscription of th.e.receipt of,freeoigarette.s:; b. Restriction of cigarette saless ict hos.pitals, clinics, and other direct care facilities to canteens or simiilarr areasvhere other produoc:, ..,.c. -lZ; c. Discouragement.of smoking by.professioaal personnel! and staff uh'illein the presence of patients; and d. Restriction of smoking.to visitor's waiting areas, patient day rooms, staf8 lounge;s,.private offices, and special7ydesi~gnated'areas. ]. Aggressively.to initiate and eontinuesmoking cessation activities spec.iallygeared to high risk patients and to.all other patients.and~ employees whoo vish~to stop,or modify.their smoking behavior. 4. To encourage all medical service personnel to.avoid the use of cigarettes vhen.makingformal public and professional appearances. HEW TN-7g.2' pl 9~ 7~:. . _=.xhibit X1-60-1!, GENERAL A: 5. To.developgeneral he e.oking and health pr 6. To cooperate vithh oth~ isqelementation of coas cigarette smoking pro! Signed by:. /s/'Louis M. gousaelot, M.D. Dl' u s , onsse ot, , . Deppty Assistant Secretary of Defense (Health•and Medical). Date: &ril 24. 1969 11EIi TM-7a:2(1/1g/7a)

TESTIMONYPRESENTED : RESEARCH ON MAY25, HEALTH PROMOTION ACT My name isJame the past 15 yearss my the field of health I favor all the like to comment part deterrenceofsmokir. 0~ This section of, smoking and support course, one should V before undertaking knowledge provides : expanded if control, Forexample,r w• relatedto smoking.' has two parents who close friend who sm friend is associate suggests that a det aduitro:le models r As part of a p were asked whytheythe jargon of biome ground and provide ••I,•m younE. "I don•t~i~ "My folks

154 Ch_pterl-60;.GENERAL ADHINISTRAT!ION_ Page 6 E.Corridors„ Lobbies and Restrooms. Normally, smoking in corridors,, lobbies and restrooms of HEN-controlledbuildings will bee permitted, except as follows: (1) Large lobbies or entrances that are used for waiting rooms, etc.,, willibe divided into smoking and non- smoking areas. These areas will'be properly.postedy to assure that all persons can.easilydetermine where smoking is permitted. In addition, there will be no ashtrayaorreceptacles in the designated no-smoking area. (2) If lobbiesorhalllwaysare utilized bysmokers.to a degree that results in employee complaints, the official in charge is.responsible for evaluating the conditions and, ifnecessary.,establiishing,.themf in a whole or part as no-smoking areas. (])It is determined that the air.changes are not.s.uf- ficient to assure reasonably clean air. 1-60-50 Education and Training In view of the dangera to health caused by smoking, super- visors and employees will be given training,on the dangers of,amoking,.methods of breaking the smoking.hab'it, and'the provisions of the chapter.. The Assistant Secretary for Personnel Administrat,ion,will provide.for such trafning,in, supervisor's training programa and employee orientation sessions. In addition, within applicable regulations, employees will.be provided with reasonable tlme.off during working hours to attend established'training programs.that aesist in breaking the smoking fiabit totheextent that the efficiency.of work unite will not beimpaired. The Assistant Secretaryy for P~r:n. .... DepartmenC guidance covering suchh training. 1-60-60Grievances If an employee feels that the provisions of this policy are not being.implemented the employee is entitled to utilizee either the HEW agency grievance procedure, or.a negotiatedgrievanceprocedured whichever is applicable.. Employees who file a grievance undlrthese procedures will not be subjected to restraint, interference, coercion, discrimination or reprisal by virtue of having filed such a grievance. HEW TN-78.2(1/18/78) ~ l't.-,nrer 1-60;.GENEBALADMINISTBAT 1-60-70 Noticesand Sip A. Notices to plementing employees.cprovisions B. Signs., (1) Suitab rooms Where a card neares placed possib (2) The nu depend two sh for la (J)', Signs- cludin Genera high f:. for ls: (4), The aa., may be in no indicai. 1-60-80 Referral of Que: Technie~l l ,;.;esti tional materialecigarette smokir referred to the the Assistant Se Edocation, and L HEW TN-78~.2~(1/,18/78)~.

THREE :cAR LcEJGrPULINAL STUGY SOCIAL-PSYCHOLOGICAL DEPCRRE;TS OF SMOKING IN SCi1O0LS PROJECT 14.96 Mean Part Per Million Nilotine in Saliva 6 -'-) 3.53 ` - - - 1 1 Nonsmokers Experimental "Hard-core" Smokers Smokers N=14 N=15 N=_i6 ~ FIGURF 3. . Analysis of a randcro sample of saliva specimens fran students participating in the study durinq the fall 1976. Z40SE09E0 1975 PILOT $1 UDY REPORTED SmOkINr BEHAYIOR 1 TocnT1AFNT I 1 CONTROL GROUP

11 "H d ar -core .,- I o- r.,.,'..;-..., i - Smokers Smokers N=14 N=15 N=_i_6 P £I6UR£ 3. Analysis of a rarxlcr sartp1e of saliva specimens €rom students participatirg in the study during the fall 1976. 1975 PILOT STUDY REPORTED SrnOKING BEHAVIOR TREATMENT 20% 15% I 10% I I I I a ~ l9 a 1-1 I Z CONTROL GROUP I I I I I J U V N=80 N-93 N=97 N=104 eaeEO9Eo F[~il1RF 1, PERCENTAGE OF STUDENTS WHO BEGAN SMOKING (ONE OR MORE CIGARETTES A MONTH) DURING THE FIRST QUARTER OF THE SEVENTH GRADE, AS REPORTED AT THE END OF THE TERM. - - TREATMENT VS E%PERiMENTAL GROUPS x2 = 4.51, P_-.O5

182' These re.sultss suggest that'~ such.i'nterventi~ons may.prov.e mo.reuseful in d'et.erring.smoking,among junior high stud.enitsthan merely instructing them im.thelong-termdangers of smoking. k.longitudinal st.udyy ini't.iallyinvolv.ing approximateliy 4,5:00 students ispresentlys underway, tracking,these students through thes.event~hy,eight'h..,.and ninth grades. Through.itssec.ondh year, prel.imina.rydata analysis suggest.ss asigni'~ficant impact of the interventions. (.SeeFigure 2). The saliva specimens ofaf randomsarnple.ofl forty-five (4!5.) , sevent.h..grad'e students in the study were analyzed for nieo:tinee content byy a mass spect.rom~etrilc technique developed by. Dr-EVan Horning.,.Baylor College of'. Medicine. Students were representa- tive of nonsmoking, "experiment'al" smoking, and "regul.ar"smo'aingsub-gr~oup.s within our larger study directed att preventing.theonset of a.ddictivee smoking in adolieseents.. Results of the analysis showed that nonsmokers had less nicotine than "'exp.erimen- tal"'and! "regular" smokerss with 3•.5.3„ 5•0T', and 14,.96 ppm o:f'ai:cot.i~nei:n the salliva of thea.verage subject from each of these respective. groups.. Eventhou.gh Low.lieveis off nicotine we:r.eobserved~in nor.- smokers„ the presence of any nicotine repre.sentsthe effects of' "second-handismoke"' - - influence of ot.herswho smoke.. (With this mean of 3.•53,, nicotine levels of up~to 10.ppmwere observed in thisgroup..)3ee Table 3. Tihis may be one off the most extensive demonstratio:nsof how"passivesmokingp1or "seoond- handismoke" do.es,,indeed,.effect the nonsmoking adolescent.., 4! We should! encourage esophistieat.ed i:nocu.latioc=programs in lieu of the fr information eent:ere3 progrproductive.

150. l:P.irinoer 1-60GENERAL'ADMINISTRATiION B.. These provisions are also applicable to HEC elementsoccupying.Government owned and leased spacee which,is assigned.byGSA, and space obtained onause permit, or nominal rentaliorr rent-free basis. Insueh cases, the Department policy will apply.witAin the eonfinesof the assigned,space over which HEW has exclusive custodyand, control. 1-60-30 Responsibilities A. The Heads of,POCe(fortheii headquarters,.regional and; . field components), PROS (for the organizational elements under their direct control)j andDarector.,.Office of Management Services, OS (for the Office of the Secretaryy at headquarters); are responsible and accountable for implementing the provisions of this chapter. Theywill:. (1) . Prepare an implementation plan setting,.forththe provisions of this chapter and methods to insure compliance within 60 days of its effectiivedate. A.copy.ofthe plan will be submitted to the Assistant Secretary for Management and,Budget for review. (2) Includeih the plan,provisions for the following: Page 2 a. In Government owned HEW occupied buildings and~facilities,, ttiesenior HEW official has the responsibility for implementing the 9ecretary's policy as it relates to space under.his or h'er jurisdiction,and control as implemented by his or herappropriater head- quarters. Where two or more HEW.organizational olements o~-. na„ and the officials.are of the same rank, thesee officials will share implementing responsibility, and issue a single directive.covering HEW employees oecupying,the building or facility. b. In buildings that are controlled byoth'er Government Agencies, such as GSA or non- Government organizations or individuals,, the Secretary's policy.wild be applied when the space is being utilized exclusivelyy forHEWactivities. If an agreement with the occupant, owner, or lessor can be reached on the control ofsmoking, officials are.authorized to jointly.issueimplementing directives. . 1-60, GENSRAL.ADMINISTRAT C: In -oh He of Se th 1- B. Heads of St this policy. Director, 00 implementat Personnel areas.ofre guidance an 1-60-00~ Implementation A. General4 H enforcethe(seeparagre volved. B. Smoking sha (1)i Confer and cl meetir, purpos and ih this d as con spnne. t:raini.. the no Prompt Smokin aehtra of cig (2)i Auditoaudito approp sha11 may be visito become HEW TM--T8.3ZI]'I8]7$J HEW'7N+78.2 (1l18178),

120 In the President's budget for fiscal year 19 7 9; we are requesting $4 million for the National Institute on Child Health and Human De- velopment to investigate the childhood determinants of smoking behavior. At this point, let me emphasize that the primary goal of our pre- vention programs with children; as well as adults, is to provide educa- tion and to conduct research that will enhance, not' reduce; personal! choice. Nemust understand that an 18-year-old smoker does not neces- sarily represent free will. That smoker may well represent bondage d'ueA to insuflihient i'nformationto make a deliberat~einformed choice. Do our teenagers truly understand, as emphasized by Secretary Ca1i- fano, that smoking is indeed slow-motion suicide?One of the most effective wav s we have found to inform children and youn;peopleis through health education in the schools. Some excellent school curriculum havealready been developed and tested for elementary schoolchildren. There is a particularly urgentt need to develop educationall programs for teenagers. «''hile we~ aregatheringnew knoivledge, we must also apply what wealreadyknonv about teenage attitudes toward smoking, and about how teenagers learn. Surveys haveshoR-n, for instance; that 84 percent of t'eenagesmokerssay that smokingis habit forming; 69 percent believe thatsmoking slows thent down in sports; two-thirds believe that smoking is just as harmifull as doctors and teachers and parentssay; and half of tlliernhope that if they have children,their children will never smoke. The, final section of S. 3118 calls upon the Secretary to study and report back within 2 years on the relative health risk associated! with smoking cigarettes of varying levels, and the relationship oftar, nico- tine, and various ad'ditives,to health risks. These two: questions, in our opinion, are among the mostt important public health questions of our tivne; We are now beginning work on the 1979 Surgeon GeneralPsReport. This vr ill be the most important review of information on smoking since the publication of the original'report nearly 15 years ago. As part of this effort, the a„n,encieswilll be looking at the changes which, have takeni place~, in the cigarette itself, and will' attempt to evaluate the health significance of these, changes. On the basis of't'his information, HEW will focus attention on manv aspects of'e the ques- tions posed in S. 3118, and it is ouz• hope that this information: will be available beforetiheend of 2,years. Senator Scxw,r•,tKFx. DTa.y I interrupt just 1 minutie? «te just marked up the Labor-I+IEW, bill y.esterday, and on the health education, smok- ing, section-we raised it from $2.5 million above both the administra- tion's requestt aiU the Hottse. So we did put $15 million in the Labor- HF.W appropriation bill in healtheducationh on smoking. I thought you would be glad toknow that!. Dr. FoFCn, That certainly is good news. Regarding additives, .ve understan& that there are some 300 sub- stances which cigarette manufacturers add to cigarettes for flavoring and other purposes. lV'e do not ev.en~ know what many of these sub- stances are. «7e would recomme_nd! y our consideration of additional language reqpiring the disclosure of these flavorings and other addi- tives: If ingredient knowled it seems to me that they arc inhale. In summary, Mr. Chairm the continuing support of particularly efforts aimed < Department~ presently has centlv undertaken ai major parallel those of S. 3118. V may not be requi'red to ad- support from the Congress If' bubonic plague would 900 people per day in the T: to bea; crisis and! demand smoking has developed ins And yet it is a modern an crisis, and yet every 22 takesup smoking. We are pleased that yo and counteract this 20th cei Thank you. Senator KENNEDY [pre~ to our witnesses, and theleague, Senator Ford, wh on this subject. An& we a. The administration, as correct? Dr. FOEGE. Yes. Senator KExNnnY. Dr. verv warmly. We remem' of the committee had doN on legionnaire's disease, a ccntersin the world. At ~rclationshipbetween Gov~ ,-onheadn one of the trul}~- Cxovernment, and I comm So you don't mind now Dr. ForGr•,. Thank you i, Senator KENNEDY. Yo hud ;et request. Now,, as already been previouslyanr I correct? J1r. PiaNFV. 11r. Cha li~cal Yean•1978'. budget a rmiaiest isfor ~.'30 inallton Senator hnxNr:nY. T. Mr: PrxNF:r. $24 mill~ i,r'1'ilUlle(l Il]olleVan(1 new histitntcas of Health, tl' .1(luioiilistration, andithervlate(1 activities in the> in netiN, nirniey for the \ [ )ei-elopment has been i 3„ ~. ( - ' A: - .

> db; you :. We are ne things late cells. that you unit'y for r save an Senator areas in et to ride inder thei in this ~a. But if nake any ~ next too airplane,, Ule~ noise~ But, you i crying; -e we are 7ht to be ~is much av.e them back. reas, you idvocate. oice, but to L.A., t doesn't in being ; by the right or eat any- a crash. ie, but. I ore they etn is, I aw first- ~glad to in a 15- 109 We look forward to hearing testimony from the Tobacco Institute which, will come alongla-ter, and weappreeiat'eyour forceful and' able argument~s4hatyou have made here. Senator FORD. Mr. Chairman, I thank you for your courtesy, and' it's~ going to be an interesting few months in front of us, and I look forward to you coming to my committee and discussing it'there. I just want to make one closing point. No matter how low the tar and~ nicotine might be in the cigarette, this bill adds a nickel. And I think it's still a 5-cent tax-I believe that's correct, unless you have amended it or changed it. You don't have a zero figure in~ the bill. Senator CxAFEn. Yes ; but there is a tax already which is t'~hestarting point. Some are goinU dbw.n and there is a zero tax. Senator FORD. Well, you still have the Federal tax on cigarettes- not in this ~ bill ; this is adding it on ; this is adding it on to rvhat you already have. And it brings about $6 million rn-it's $2 billion help- ing the balance of payments, and that's bad enough. Senator CHAFEE. If I could just'clearthe record. TheFed'eral tax currently is 8 cents. In this bill, some of the tax goes down to 5 cents. Senator Foxn: That's right, so it's bound to be-that's what I said : No matter how low the tar and nicotine is, it's still 5 cents. I don't think my statement was wrong. So the record is clear with the 5-centt tax then, regardless of the tar and nicotine. Senator CHAFEE. Yes ; but we rarely find people who are dissatisfied with the tax going down. Senator FORD. No:; but the 50'cents on the other end is horrendous. Senator CtrAFFN:: Well, w.ehope that will be-a deterrent. Senat'or FORD. Well, I want to tell' you, I am going to see if I can't deter you from being a deterrent. Senator CiiAFEr. O1i,, I expect that. Well, thank you very much for coming. The next panel will be made up of Dr. William Foege,, Director of the Center for DiseaseCont-rol in Atlant'a, Dr. Norman Kretchmer, from the National Instlitutesof Child Health: and! HumanI)evelop- ment, and Jbhn Pinney, Director of the Office of Smoking and Health in HFWGentlemen, we welcome yow here. It is my privilge to know Dr. Foege. IVhy don't we start o$1 with Dr. Foege. STATEMENT OF WILLIAM H. FOEGE, M.D., DIRECTOR, CENTER FOR DISEASE CONTROL; NORMAN KRETCHMER, M.D., DIRECTOR, NA- TIONAL INSTYTUTES' OF CHILD HEALTH AND HUMAN DEVELOP- MENT; AND JOHN PINNEY, DIRECTOR, OFFICE OF SMOKING AND HEALTH, DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE; A PANEL Dr. FOEGE. Thank yoii, ',\Ir. ChairmanL With your permission~ we would insertl this for the reeord~ and read only selected portions of our testimony. Senator CirArnE. Fine. Dr. Forcr•,. First, '_1Ir. Chairman, Secretary Califano and Assistant Secretary Richmond have asked met'ocongratulateyou for the leader- shipthat you have shown in this area. We share your deep interest in improving t'hepreventive components of ourheadthst'rat'egy.

183 We should encourage effortss too tiuild.in.to school curricula s:ophisticat.edlinoculat.ion~s-agai'~nst-social-pressures-to-smoke pr.ogramsi.n 1ieu.ofl the frequentlyy used high.fear arousal, ilnformationn centere3.programs, which may well even be counLer- nroductive.

178 unrealistically believe you can stop allichildren from starting to smoke or eliminate all addictive smoking, but begin to at least cut into this smoking problem, it will begin to: feed! on itself, a new climate will begin to emerge. It will soon become a lot more `°in"for children not to smoke than to smoke. If t'lie goals are modest and we don't err as «as done in the area of delinquency or the «-ar on poverty w liere it was proposed to eliminate all delinquency and pov.ert'ry•,,if wetalk realistically and suggest modest results, I thinlt ws«-ould have qttitea high probability.of success in deterringsmoking based at least on our data so far. Senator KEvN-RvY. OK. Thank you very much. [The prepared statement of Dr. Evans, Dr. Swinehart, and Ms. Green follows:] Summary c . To The Uhd 0 (Dr. Evans is also. Dire College of~ Medicine Nat L`emonstration Cente.r,,H of the NSliB?-s.upported in Schcclls Pro,;.ect.j Social psychologiis basic laboratory resear gical issues. During t teen inc.reas.ingl~ychaL1 relating.to signifi.cantt pre,judi~cea.r,d discrimir morerecent'~ chaIlenggfmedici'ne,.e particularly contribute to morb.idity smoking,.which has beer: in cardiovasculardise2r areaa of behavioral invekas been upon the addio'_nvestigation milgnt bedeterring,theonset of ,;ected' t'~osocial press: a:different set of t.he< those encounteredlim . a* addicted smoker.

I imagine that is verage taxpayer. id up with non- rance premiums. * principle that 5t smokers? Ij'( 'eaching the con ,y for it, it isn't °e for it? Doyoa point ? have the feelsn; nd study the al- iat our position rawbacks if one! rere in any way, 2ausethereis a have to look at way or the other arettes the teen- i cigarettes now, y IlliRy.swltch to one of the ques- is goin(r to try -hat kind of in- .oming smokers. ,)m some of the icotine-say we i the higher tar I or in suphort ; with~ this teen- idea of a zradu- y carefully and not prepared to tions? We hope ity's initiative, ,le issue of con- lie effectiveness •entivet'o move have raised in~ from a public tar loirer-nico-;lnrl I'our bill we clonrt l)ave ~ will'be study- priority to~see i 127 if we can do something now to keep teenagers from starting, up smoking. Senator KENNEDY. Well, just finally, don't you have the scientific information about the high,tar high-nicotine and the hibher incidence of cancer? Mr. PiN-VEY. There is no question that there is a dose response, based on tar and nicotine contents. The questions come at the lower levels, and the questions come in terms of compensation, as smokers move downwards, as they change their smoking habits. There is data on that: there aree somc studies. We believetihere isaiotenoughnowto de.- simn at'~ax which will be effective. Senator ICiJw~NEDY. Well', couldn't we agree that it is wiser for them to smoke the lower tar and nicotine until we get the facts? _llr. PINNEY. Absolutely. In the absence of conclusive evidence, our policy and oturposition has been very defiilitely toencotn•ageIpeople to smoke Ibw.er-tar and lower-nicotine cigarettes. Senator KENNEDY. OK. Senator Chafee? Senator CF;ArEE. Dick, do you have any questions? Senator ScHwFU.Er,. .Tusta couple. Firrst,I do want to commend CDC' and~ HEjV for their work in this area. I am strongly supportive of the~ sections of the bill dealing with clean indoor airand nonsmokers' rights. I think this is long overdue, and whille I have some problems with other sections of' the bill~ I don't have any problems with those sections and' I strongly support them. I assure you that in terms of the nppropriationsaspects, we will give you the money to do the job; I would like to ask one or t.wo questions. Dr. Foege, you mentioned on pa,,,e 1i2--or you ask the question, which is a darn good one :"Wh,y does it'appear that fewer college-bound youngsters smoke than thosewho do not plan to go to col9ege??'' I was astounded recently to see that in, a~ survey at Princeton, a smaller percentage of college men smoked compared, to when I was in colileoe; I just couldi-<<t believe the statistics, but apparentllS- thev are true. And the question I have is,, it seems to me there is an awf'iil, lot to learn about the peer group pressure on the col7e(ye maleand why hee isn't smoking, and the peer group pressure of the young teenage -a1' and why she is, because peer group pressure seems to have worked in completely contrary ways. I would assume that would be part of your survey. Is that correct. Mr. Pinney? Mr. PiN-:,-EY. Yes, sir. Senator SCFTIVr:rQ:Fr,: How will vouintegrateu thou,()'h, with the'Na- tional Institute of Child Health, because thev havet-ei-v separate ))rocertures on peetrrevicws oflrriojects? I ain all for the int'egration-- lbttt isn't that going tobe tiproblem? .l'Iir. PraNr•.r. It is not' a problem, Senator. Thephilosophy on whicli t'~~1ie~ofl'iceis based is one of project management. In essence, the Secre- t,trv felt that there~r;rs not enongltiattention at liis le~-el on tlieproblem oil ~suiokincr andl health. There was a lot~ -oingr on in each~ of the In- 4itutes, but the question was: Are rVe directing what resources we l'r,iveto the hes' possible means and ends? And, forexannple;witli the N,ttionil InstitWeof'Chfild Health and HumanDevelopment,isrn-role wortld he one, ofdiscussinl(, Nvitlt Dr. hretc}imerwlrat his program annorrncetnent would saw in terms of elicitingbood~ sonnd research in

187 TESTIMONY PRESENTED BEFORE THE.SENATE'SUBCOFPIITTEE ON HEALTH AND SCIENTIFIC RESEARCH ON MAY25,. 1978i CONCERNING THE N'ATIONALDI6EASE PREVENTIONANDHEALTHIPROMOTION ACT OF 1978. . ~ My name is James W'. Swinehart. I am a social psychologist, and during, the past 15 years my.work.has.involved teaching, researchyd and practice in the field of health communications. I favor all the provisions of'~ the bill underconsideration, but would~ like to comment partieularly.on that part of Title IN,which concarns deterrence of smoking.among children and~adolescents.. J Thiss section of the billiproposes research on~the determinants of smoking and support for community and school-based.programs. Ideally,,ofcourse, one should know.agreat deal about the determinants of a problem before undertaking.effortsto controL it; in theease of smoking, our present knowledge provides an admquatebasis for program planning but needs to.be expanded'if control programs are to be made more effective. For example, we know that modeling and peer influeneeare closely re.latedto smoking,behavior. The boy or girl most likely to begin,smokinghas two parents who smoke, an older brotherror sister who smokes, andd a elosefriend who smokes; the presence of a.nonsmoking parent or sibling or friend is associated with markedly lower rates of smoking in childten. This suggeststhats a deterrence effort should address parents, teachers, and other adult role models rather than focusing exclusively on children andi adolescents. As part of a project carried'out by young people inSan Diego, teenagers were asked why they smoked. The eight reasons given most.oflten are not in the jargon of biomedical orbehavioral'research, but they cover a lot of ground and provide obvious clues for the designof control programs, "I'm young now--why not smoke7I can quit later." "Idon't inhale, so smoking can't hurt me." "My folkssmoke--why shouldn't I1^

149 ses depends, GENERAL ADMINISTRATION' ~FAaT 1 .. General CHAPTER 1-GU. POLICY'ON SMOKING.IN HEW OCCOP.IEDBllILDINGS AND FACILITIES HEWhas on the 1-60-00 n use your 10 tance of '20 of FTC "s 30 r", nicotine, 40 50 that will 60 70 80 Ie project 1~-60-00, Purpose Purpose Policy Applicability and Scope Respons ibilities Implementation Directives Education and Training Complaint Procedure Notices and Signs Referraliof Questions The purpose of this chapter is to provide a'.Departmentwide policy on smoking in HEW-occupied buildings and facilities... It'supersedes General Administration Nanual Circular 72,1,, dated'Fetiruary 7, 1972, "Policy on Smoking in HEPf-Occupied Buildings". 1-60-10 Po. licy. A. It is the policy of the Department to protect the.riglrstsofnonsmokers(both Federal'employees and the public), by're- stricting smoking in oertain areas of HEW-occupied buildingaand~.facilities. TheDepartment.also recognizes the rights of individuals tosmoke, provided such action does not endanger life or property, cause.diseomfort or unreasonatile annoyance. I to nonsmokers or infringe upon their rights. B. In recognition of the fact that.emoking is dangerous to the health of ssqkers+; that tobaeco.smoke in,a confined area creates a heallthhacard tononsmokers suffering from.heart . disease, respiratoryy ur-a- . , --,.- . -.+-uu wtobacco smoke; and that smoke in a confined area may be irritating and annoying to nonsmokers and violates their privilege of breathing airrel.tively.free from tobacco smoke contamination, every effort will be made to pro- vide an environment reasonably free of such~contaminants. 1-60-20. Applicabil7ty,and Scope. A. The provisions of this directive apply'to all organizational elements of HEW that.occupy Government owned.and.leasedNEN buildings and facilities. FEW TN-78.2'(1/.1877"upersedba 0,}Rcula~7.2,~d'ated~~2/7 JS

126 Senator KENNEDY. Who ends up paying for that'? I imagine that is~ in premiums and thatisaNoi general' revenues, the average taxpayer. Dr. FoErE. That is correct, andl we do in fact end up with non- smokers subsidizing smokers through taxes and insurancepremiums. Senator KENNEDY. Well, doy.ou feell as a matter of principle that there~ should befinancia~lincentives working against' smokers? A~-~"s are not talking about banning smoking, but at least reaching the con elusion that if' the rest of the society is going to pay for it, it isn't unreasonable to expect smokers themselves to pay more for it? Do you have trouble with that as a theme or as a philosophical point? Dr. FOEGE. -N-o; w.edo not. But this,entirearea we have t!he, feeling that we have to get with the Treasury Department and study the al- ternatives before we can really definitively say what our positioni would be. For instance, we can see some possible drawbacks if one would lower the price for low-tar, low-nicotine. Is there in any way, then, an encouragement for teenagers to smoke because there is a cigarette they can get at lower price? «'ethink we hal~-e to look at t'hese issues to see-can we find scientific evidence one way or the other before wemake a statement? Senator KENNEDY. Well~ do know what type of cigarettes the teen- agers are smoking? If they are smoking higher priced cigarettes now, you think that if wepassecU this, kindl ofi'ncentive they maysu-itclr to the other ? Mr. PINNEY. We don't know, Mr. Chairman. That's one of the ques- tions that theinbtiative that theSecretary launched is going to t'ryy to find'~ out what kind of cigarettes, and therefore what kind of in- centives could work on teenagers to keep them, from becoming smokers. Senat~or KENNEDY. Well, we are going to: hear from some of the teenagers later. But with: regards to the high,tar nicotine-sayy we skewed' it in such ai way that. the tax was increased inthe higher tar and nicotine, and those revenues were used for research or in support of local community activities in encouraging or coping with this teen- age smoking. Doyou have any conclusions on that? Dr. Fo~^~rE. We donrt have conclusions. We think the idea of auadu- ated tax is an attractive one that we do want t'o study carefully and tiryy to give you as much science as we can. But we are not prepared t'o do that now. Senator KENNEDY. When will you have recommendations? We hope to move this bill along. Mr. PINNEY. Mr. Chairman, as part of the Secretary's initiative, I atn beginning now a series of studies~aroainde thewhole issue of con- sumption of clgarettes, which includes this element, the effectiveness and the dr2~~bac1>5, t~o using agradaiatedl tax as an incentii-eto moce tolVar(t lbnv.er tar,u"d lowernicotineai!zluettes. N'ow, there is a second public health issue which you have raised in the bill most appropriately, and't~hatistivhetheror not, fromapublichealtli point of view. Inoti•nIg smokers toward lower-tar lower-nico* tivlc cigarettes is in fact niovin;r tliemto~ rediiccdrislc-and' voior bill vercV approl)r.i:Itelv recognizes that theit is solm,thing n-e don't have a1V the xnsAver5 on. either. So these things must be taken. I believe, in concert. Wewill, be studv- ing the smoking habits of youtli,thout~li, with a high priority t'o see if we can, do somethiii smoking. Senator KEN NEDY. ~. information, about the hi of'cancer? Mr. PIN -,-EY. There is on tar and nicotine con and the questions comc down-wards, as they chi that ; there are some stu sign a tax which will be Senator KENNEDY. jV to smoke the lower tar a; Mr. PINN EY. Absolnt policy andolu• position smoke lower-tar and lov . Senator KENNEDY. 0 Senat'or CIIaFEE. Dicl Senator ScHwEIIiI3n.CDC and HE«' for th, rDftlle sections of the bil ri'p~hts. I think this~is I N5-ith other sections of ections and I strongly ;ThI'oPriations aspects.. I would like to ask oon page 12-or you ask does it appear that f'ev %%-ho do not plan to go t'.c I was astounded rec -analler percentage of' c ~~l~lete; I just colildn't true. And the question io learn about thepee- i e isn'tt smoking, and' al and why she is, bee irI completely contrari Yrnir survey. Is that' correct. Mr. I _llr. PINNEY. Yes, s4 SenBtoI' SCIIWEIIiEId: 1iioual Instituteof Cl ;~rocolliu,es On peer rev t isn't that goin(rto I .lir. PlxarY. It is nc 1I,. office is,based ison1 ",,n•v fe,lt that there wa~ '1t` ;me~l.in~ and healtll + itntes, bntt the quest ! ;e \-etio the best possil` 1\~atirnial Instituteof tn11lei be one of discl uinonncelnent «-olilc1 ~

192 Green D01n1atch Ilie. Advertising 500IifthA.cnue \cw1i)rk \:Y. 736-0505 A New Leaf By Paula Green President and Creative Director Green Dolmatch Inc. May 25, 1978 It is wrong for us to believe that people start smoking today just because of advertising. Today, advertising is only one factor. We've been a cigarette culture for about 60 years now. Three generations of Americans have grown up smoking themselves and watching other peoplie smoke. And considering it a perfectly acceptable pleasure and habit. • We only learned the worst 114 years ago. 14 years ago the Surgeon General issued his famouss report, andi we found outthat'~cigarette smoking, one of our dearest pleasures, was a;thief of health, a destroyer of life. We also learned something else in these past 14 years. We learned that we could use teievision advertising, to do more than sell products. We learned to use advertising commercial techniques to telliAmericans the terrible news and get them to act on it. And for as long as the Fairness Doctrine pertained, and cigarettes were also advertising on radio and TV, we were highly visible and very successful. We got millions of people to stop smoking. Cigarette smoking declined. When we banned cigarettes from radio and TV, we lost our mandated prime-time exposures, our mandated frequency, and we lost a visible enemy to pit our- selves against. And cigarette smoking began to climb.

94 Senator ChAFFE• Thank you, Senator Schw eiker. And now our first witness is a Senator of great distinction who I am delighted to welcome here, from the State of Kentucky, Senator Wendell Ford. Senator, We are glad you are here and look forward to your testimony. STATEMENT' OF HON. WENDELL H. FORD, A U.S. SENATOR FROM THE' STATE OF' KENTUCKY Senator Foitn. Thank you, Mr. Chairman. I was expecting the dis- tinguished Senator from Massachusetts to be here, and' some of my statement is couched ini the vein that he would be chairman, and so if you will forgive me I will not let you look liketheSenator from Massachusetts. Senator CHAFEE. Well, any broadsides you loose, at him I will be glad to absorb, because I am a cosponser of the bill. Senator FORD. I understand that, but I just wanted you to know that the terms of my statement were couched otherwise, because we have been adversaries before-and youi are a new one. [Laughter.]I I haven't studied your tactics yet. Senator CxnrEE. Well, I don't want to divert yourfire; but if there are any shaft's you wish to throw in this direction, I will be glad to receive them. Senator ScxwEirEx. They are both from New England, if that will help. Senator FORD. OK; I will not put him on my petard this morning. Mr. Chairman, this isn't the first time I've found myself sitting across the aisle from~ you to talk about tobacco-and I daresay it won't be the last. I' don't know how much enjoyment you get out of these sessions, but I can guarantee you that as long as yow maintain your strong interest in this area, I'm not going to have any trouble at all convincing myy constituency that idle time is nonexistent in the Senate. Quite frankly, I do not expect you to be sway ed by any arguments I might make this morning, but I do hope that you recognize thesub- committee's responsibility to insure that the points I raise are carefully considered and' given their due process as you move forward with this legislation. Let me make it clear at the very beginning that I have no problems with~ theintent, behind the provisions of! this legislation which pertainn to children and smoking: I would support legislation to this effect-if that were its sole intent. Unfortunately, that is not thecase, and the legislation which isnowbefore this subcommittee goes far beyond those limits. I will be the first to admit that serious questions continue to persist about tobacco, But I will also be the first to declare that the proper and! logical response to findinganswers to these questionsisnot throug4 punitive legislation, but through accelerated research. Through research we can work to identify harmful elements, if they are found to exist in tobacco, and then remove them, Through research, we can make important strides toward lessening any risks found to be associated with smoking,, while at tlie~ same time maintaining t'heeco- nomic stability-and I might underscore "economic stability"-of this industry which is so very important to so many States. 9r In~ fact, I find it ironic that we hav, ernmental assaults on t'obaceo at th rapidly dealing, with the problems rnuch about. Tar and nicotine yielc ,~ -ears. The cigarette industr~ is invc ~~ensive competition in its history j,rands. The end result is that we are seein of freedom of choice-the free cho, ;rioke cigarettes that critics say an~ iranufacturers on the other hand rowing market. Now, it appears that the Federa ' 1 ie industry's initiatives-reward safer product-with punitive legiE Why must this be the direction wc Is it that unreasonable to consic ;!aning-what I perceive to be a si ;ndustry that provides billions of :mericans ? As I have reminded my disting acco is a pliable product, a produc 11oved in as short a time as two gro,,; 'I hat flexibility facilitates resear ing conducted on smoking and icky's Tobacco Research Institutc t1itute's creation in 1972, more th nds has been directed into mas: ~<<rchhelped develop t'hecurrent I hich, are now on the market. Yet my repeated calls for increa level eontinueto fall on deaf~ion. and Welfare: Secretary Calil "r-earch on health-related aspects ; N million in fiscal year 1979-an ai now being directed to researcl: <<511ars as well. The dividends : to occur from thiE. ;-and productive than to pump n ~ n~ t~i~moking initiatives and' purntiv of success: .lnother question that must be : - led out as the focal point of th '~ rram. ~V1w aren't similar efforts beins 0helnicals which are poured \V1~1' isn't equal enthnisiasm~ be C ..;rir~ ~1lbstances in the workingpla W -1' oaiisin(r? ~ I11) all for findinn new ways to ci ~I)i.~ co~~ntr.v, but I'm not convin, «il l produce any subst'~antiveN: _~ i'Ihird and' fimdamental issue a of choice.

ri from starting to smokee to at least cut into this self, a new climate will )re "in" for children~ not' was done ini the area of as proposed to eliminate cally and sug est modest' ~)robability of success' in so far. ,h. Dr. Swinehart, and Ms. 179 Summaryofi:est.imonyTo.Ee. Yre.sent'edToTheUnit.rd 8:tates S.enat.eSub-C:onmitt.ec on Health on Mhy. 25,193$ Iiy.. Irhnrd I. Is, Ph.l- . __- ~i,rs.^" r r~fl I'.-. ,v.hul-[^/~ Un~i~versity~ of~ Ilouston. Houston, Texas ~Dr. Evans isal'so.Direct.or ofthe Smok.inS..S.=ction.of the Di_r.ler ^n1Ilege of MedicineNatilonaliHea.rt and.Blood. Vessel Fes=_aro:and D.emonstratiloni Center, Houston, Tiexas and is Pr:.ncipal In•iestign.torof the. N}iLSI-supporf~ed'~Soeia.l Psychologilca~l. Dete.rrent~s.t.o Sm~oking, in Schools Project). Social psychologi.stshave tiraditionally beenenesged.i.n fairlyy b.asic laboratory,researeh dealingwith theoretieall and :nethcdblio- gica.l issues. During the past several' years.,, however, they, haveheen increa~si'~ngly, ehallengedt:odeveliop:and.e:valuate interventions :.elatiing tosignificant.social problemssueh asm~e.ntal iilness prejud'~icee and di'scri~minat'ion,, poverty, crime, and d'elineuer.cy,. A :r.ore recent chal'lenge for socialpsy.choliogistishasbeen behavioral medicine, particularly as it rel'ates to modifying,li'.fest'~yles which contri~bute.to morbi.dityy and mortality. Controll of cigarette smoking, which has been weiil establiishe.d as a,crucilai "riskfactor" i~n cardiovascular disease and'cancerisa particuliarlyy significantt area of behavioral' inv.esti~g3ti:on,. Although the previous.focus has.been upon thead'dicted adult smoker,.a more fruitful 1'~ine of investigation mightbet to address the more fundamental problem of deterring the onset of smoking,. Deai~iing~ wit.h~ chi~ldiren who ar~ee sub- j.ected; to, sociali pressurest.o initiiate smoking behavior presentss ad.ifferent set of theoretical and~methodol.ogicai issues tharn those encountered in attempts to alter the behavior of the already addicted smoker.

they know, and they've 3 of millions of dollars :rtise. igy keep their campaigns. ~ble in every medium 3y decide what aat. iimplicit ad for smoking. habit. ance. e we call it advertising rty word -- we have been a a concerted mass- abit, or on a persuasive habit -- the habit of ord. children, call it -acation, health education take a leaf from~the dule :30 second "lessons", nd "Lessons"'or 2-minute e to expose our "lessons", our "students". her materials for then buy time? edantic, authoritarian, "health educator" lessons. and smart and memorable ng around -- yea, even as -4- Let us apply the Sesame Street experience (which by. the way took its cue from TV commercials -- the right length of time for the attention span of kids, and right in keeping with what they're watching on TV anyway). And let us schedule our lessons on the right programs at the right times, let us repeat our lessons, remembering that there are new kids joining the audience every day. Let us think of television as the great new classroom -- surely the eritics of TV do: consider the sex and violence controversy that rages right now, the sugared cereal, the idea of banning TV advertising tolkids completely. And let us start some new ideas about smoking coming into kids' lives, let us give them counsel and support a new climate, a happy, informed, non-punitive non-smoking healt!h, environment. Let us build a good habit and the seif-respect and self-worth that goes with it. That means buying time, planning schedulies, creating TV campaigns, being as professional and effective in our efforts against smoking as the cigarette people are in promoting it. Why TV? Why not just the classroom? We have sex education in schoolis and yet our unwed teen-age mother population grows. We teach hygiene in schools and VD is on the rise. We teach the dangers of drugs (and kids today know more about drugs than.their teachers, I'm sure), and our drug probliem persists, and is now reaching a younger and younger population. We may not like it, but school is not where kids learn their basic values and ideas. As a matter of fact, it never was. We have always learned from our home and our friends, an&today in the home,'TV iss perhaps the greatest inflpence of all. So if you

193 May 25, 1978 t people start ertising. ctor. r about 60 years ve grown up ther people smoke. ceptable pleasure s ago. issued his famous rette smoking, a thief of health, these past 14 years. vision advertising mercial techniques ws and get them to :)ctrine pertained, ing on radio and TV, Iccessful. smoking. li'o and TV, <posures, our mandated .nemy to pit our- >king began to climb. -2- Since then, anti-cigarette spots have been basically confined to the ghetto of the Lat'e Late Show, catch as catch can, to compete not against cigarettes, • but agadnst' zoos and adoption agencies and a wholie passel of other worthy causes. The irony is, the cigarette companies continue to spend milliions an&millions of dolQars every year advertising cigarettes, while public health is a beggar, depending on free hand-outs from the media, unable to mount a serious steady campaign.against smoking, unable toltarget a market or build a: schedule, an audience, or most important, the non-smoking habit itself. Now it is very tempting to believe that somehow the cigarette companies have,in their deep dark files mysterious secrets that enable them to manipulatee us into smoki'ng. I don't believe it. r believe we know as much about smoking behavior, smoking appealis, peer group pressures, social leaders and'.followers, emotions et al as they do. The National Clearinghouse for Smoking $ Health: has been collect,ing data, the Armerican Cancer Society has beemcollecting data, the NCI and all sorts of socialipsychologists, sociologists and other interested parties have been interviewing, surveying and collecting data. For years. And we have our own observations over the years to go on. AndII dbn't believe that if we ever do get the cigarette companies' studies we will suddenly have the keys to turning off the habit in the American public. (By the way, while we''re waiting, we're,noro simply letting them prosper, we're delaying our own fight). No, I don't believe they have a devilish secret. What I do believe, indeed what I know, is that they are devilishly good, very smart and very professional:

162 Mr. VALEO. I have thought about it, and it would have to start reallyy at an early age. When I ivas young I was totally against smoking and I got my father to quit smoking. Senator. ILExxEnY. How young was that ? 1ir. VALEo. I am talking about 9 and S; in that area. Because I had! teachers back then~ also that would say how bad smoking is, and, you know, what it couU do to you as you gotiolder, and so on.But! then as I g ot into junior high school„the emphasis om smoking- the onl,y thing we heard was you can't smoke in~ school; that was it. But we never heard why. And so it almost became-just to defy authority, we would smoke. And if they kept the emphasis up, because, you~ know, it's a: pretty impressionable age, even~ through high school- if the emphasis waskept up on why you shouldn't smoke, not just tliat you can't smoke, I think that it would makeabigdidference. Senator ScxwEZS.ER. Jim, how did you get the money to support your habit? That can run~ several hundred dollars a year. Did your folks give you your money? Didn~t that get a little expensive after a «hile,? Mr. VALEO. I don't,like to take an allbwance from my parents unless. I have to, when I am not working. I try to work at ski shops, what- ever, as often as I can,,because I just think I would rather be able to support myself, at least as far as spending money goes or anything albng those lines. Senator CHAFEE. Could we just have a show, of hands-how many of you have ever seen in your schools educational films on the bad effects of smoking? Butyou are in the same schoolL Miss REILLY. Different cl'asses. Senator CxaFEF. Different classes. What did you see, a film ? Miss RmLr.g. A filhn,, in physiology ; it was on t'he, body, things like that. And occasionally they would! have topics in the science course where they review cancer and smoking and things like that-that's just one trimester, out of the whole year. Senator CxaFEE. And if you didn't happen to take that course in physiology, you wouldn't see the film ? Miss REILLY. Right. Senator Cfi ArrF. And none of the rest of you ha& any educational films in assemblhes or anything like that ? Senator SCHWEIKER. Or physical' education or health elasses?' Miss REILLY. No. Senator IiEN xEIDY. Let me ask you-what would be your reaction to the school providing this information? Would tiou consider it, well, they d'on't want us to smoke, so therefore they are jamming it down~ our tihroat, a continued plot, of the foreesof' authority in our lfives; or do you think,,if this health message was providedi in a scien- tific and no-nonsense way, that it would make a difference in, terms of their decisions? Mark, what do you think? 11r. ADAMS. «'ell,I think that would make a bigdiffereuce, because most peoplewho startsmoking don't really know what cancer is like; and if they were given more examples, like showing films at an earlier age than junior high school~ I think that that would really prevent a, lot of smoking. Senator hr:T ti EnY. Charles ? Mr. G_ who are age-ank, \toira ai term eff You knc ofl it. Ar t1re, effe( who is 6i1 Senat. when yc( try tot:~ have an Jim ? Mr. A and I i smoke, smokin: to me, just pwSena Mr. _ said, it can do Sena 11isss weren't Sena Miss you sm they c: you kn we woi Sent asking decisio from i and fl] «-ould _llis: and e( paren! they s and d( Sen it any llis Sen fectiv you I mates more

190 print media, such as news stories, featurearticles,e editorials, cartoons, and letters to t}ieeditor. Commercial advertisers typically place their materials where they will be.seen or heard by personss in the market for their products. It makes.sense for smoking control programs to db~the same. Some examples of media which, reach children and adolescents, inaddition.to those listed above, are comic tiooks, posters for schools (and for kids' roomsathome)y shorts or "trailers" for use in movie theaters, placemaUs in fast-food'restaurants, bumper stickers, buttonsp milk cartons, and Ti-shirtimprints. All of these could be used in a comprehensive community program--nott to provide detailed information but to serve as reminders and perhaps to.help establish nonsmoking.as a norm.. A sp,eci~al note should be added here regarding,the scale of adVertising and related elements of smoking control programs. In an environment where a tobacco company can spend $40 million to.develop.ando promote a single new brand of cigarette,and~.where well over $250 million a year is spent to ad- vertise vertise / the top,20 brands, the odds are slight.that a small counter-effort' can have much impact on~the "climate" regardingsmoking, By, the age of 12 a childihas experiencedia long period of exposure to cigarette advertisingg and the example of adult smoking; thus it seems unrealistic to expect sig- nificant results from fragmented programs of small size or duration.y Whatever.the nature of the interventions employed, all programs funded under thee proposedd bill should be required to (1)) characterize in detail the methods and approaches.used; (2) use evaluation~designswhich meet specified criteria for appropriateness and scientif'~ic rigor;; arttl(3)use outcome measures which include behavioral assessments aswe1L wellas self-repfrom~childten. The purpose of these.requiiements would be to make program resultss cumulative; that.is, to make possible an accurate det~erminati'on of the relative value of various approaches so that those.foundito be most effective can be impiemented~ on a wider scale. In~summaryy~ the foli • Plans based on acand attitudes ro[ • Use of specific c, results evaluate< • Extensivecoopern agenciesp and ott • Involvement of h, and dentists • Use of a variety . Emphasis on~imnebehavior, and av • Involvement of c of materials • Pretesting of ma • Use of athletes • Use of multiple related to physi • Controlledd place • Reinforcement of • Use of rigorous assessment of di It has been estimat arises because oftobacc accounted for only one-t ttiis country last year, cost savings that could apart from the values ii enormous..

ce with onal Clearing- n indeed d women to mi'nation: own on rettes, direction eveloping .ce with~ the nion that itive to listen el, and s dedicatedly ising pro- fessionals,the best we can get. 2. We are willing to do what the Army and Amtrak f andithe cigarette companies andipoliticians do, and'that is treat the problem seriously and budget the money to target, plan, schedule, and sustain our efforts in the media. I've spoken mostly of TV. But I include anything -- from radio to pet rocks -- on a sustained, committed' basis. If we believe we have an urgent job to do, if we're to prevent the diseases of smoking by creating a good non-smoking generation, we should be willing to pay for it. Not just for conventional educational approaches. But for the new and vital educational tools of today.

160 Mr. VALEO.One of mine. Senator KENNEDY. One of your parents. H'ow about the ones that don't smoke, do your parent's smoke or not smoke? Martin, what about that? Mr. O'L~IaLLEY. One of my parents smokes, but lie is nota consistent smoker; lie just has some every once in a while. Mr. GxIFrrrx. Both of mine smoke. Senator hEINIXEnv. Ancll you don*t smoke. Mark, what about'y.ou? Mr. A eithel~ of my parent'~ssnroke. My mother used to, but she quit. Senator KExxEIDY. Do your friends think at all about the health implications of smoking, or do you sort of think about it and think it is not going, to happen to me ? What kind of! a sense do you or any of' your friends have about whether it really is going to make much: of a difference in your health or not? Both your own view and what you hear souie of your friends talk about. Mr. O'MALLEY. tiVell, I would say that kids my agearen't really concerned with the health issues; they talk about it maybe. But the main thing that they are doing it for is, youi know, just to fit in with the crowd. Smoking is something that most adults do. So: I think the reason wliy the kids do it is just so they can get a feeling of, you know MIsS REILLY. Maturity. Mr. O'\IaLLEY. Yes, maturity. But I donrt think they are really con- cerned that much~ with the health issues. Senator KEVNEnY. What about it, Jim ? Mr. ValEo: Well, when I first started to smoke I used to think it couldn't happen to me; I couldn't get ill from it, I was immune to it or something. But now that I am older, I have been thinking-I can see how itihas affected my ability to run~ any length of distance,you know, my wind'~ Senator KESti r.nY. Andl you don't smoke. .1Lark, what about von? Mr. VALEO. Well, I used to run track, I used to sprint. When I sprinted, it didn't make a difference, because, you~ know, a hundred yard6-t!hat's nothing. But I am talking about going out to run 2'or 3 miles-I don't know whether I could do it anymore without huffing and puHing at the end of it. But now, you know, I have made a vow to myself that I am going to quit smoking, because I can see the effect that it has had on rne as far as that goes. SenatorScxwEIaEr;. Are yougoing, to quit cold turkeyy how are you going to quit, Jim ?. Mr. VALEO. Well, I have tried~ to cut down,,andit just doesn't work, because there are too many times when a cigarette tastes good-that's what it boils down to. But I am just going to go all the way, quit cold turkey «-itih i', when I quit. SenatorCfiAFEr:. Charles, I notice that youd'on't smoke and both your parents smoke. Now, are you involv ed in althletics or for what particular reasonAoyou not smoke'?Mr: GRiFFIrrx. I didn't smoke-alot of'my friends started, to smoke back in 7th and 8th grades, and my parents srnoked, and I jRrst wanted to:be difierent. I like to be independent. Senator KE about the sm{ Does that mai iNlISS REILL seniors. Our 1 public high s do about it. there's not mt Senator Kii think that m, much attenti(i little older tl on it, or wha- ilTiss WOLF me, it didn't can see that I d'on't think Senator K think much a Mr. AnAri, figure, you k: like when I t11 But now, a Senator K to stop ? Have som( show of hanc( ing? Jim, yo Senator Su Senator K the factors tl Is it again R d'oyou t'hinl. tions encour; What do , of grettingte( :tI'ISS REIL healthprobl, 20 years yot when you ai 1onr-term ef ing about-7But you R wliere most school, then would'ni't be ~ Senator h and that' is- from gettinr What' sug .Iim~

C 102 Paoe 1'1 Roaparisona of pcpenses and Incose =ot' the years 1950 and 1977 Howard County, T- I In,1950 a four row tractor, fully weighted, with oultivator, lister, and planter sold for $3.9?0:00. . In 1977 an eight row tractor with no extras sold for $269732.00. In 1950 a~ ton pickup sold for $1.550.00. In 1977 a ton pickup sold for $6,442.00. In 1950 good faxa labor cost $5 per day with nothing furnished. In 1977 fara labor coat $30 per day in additlon to housing, fuel, elso- ~- In 1950 cotton aold for $0.42'per pound and seed sold for $110.00 per ton. In 197? cotton sold for $0.41 parpound and seed for $67.00 per ton. In 1950 after paying the ginning,seed checks of $25.00 per bale were recieved. • In 1977 ginning cost an additional $10 per bale above the seed. In 1950, after rent cotton netted $140:25 per bale. In 1977, after rent cotton nstt. 10 . 0 p.r bal~• ~ In 1950 hand picked cotton cost: $34 per bale to harvest. In 1977 sachine stripped cotton coat $30 per Isle to haareet. In 19501 before nst weight trading, wrapping that weighs 21 lbs. per bale was sold for the same price aa the cotton. In 1977, since not weight trading, wrapping coating $14 per bal,e goes with the cotton and the prodUOer buys the wrapping and recieves nothing for St. 0 tt old on grade and staple. on s In 195 cc In 1977 we have many different grades and staples. Yb also have the aike, all of which lowers cotton prices. In 1950 charges for selling a bale of cotton wsre $1.85 par bale. In 1977 charges for selling a bale of cotton were $6.60 per bale. In 1950 a bale of cotton would buy about 114 barrels of oil. In 197? a bale of cotton will buy 12 to 14 barrels of oil. In 1950 s bushel~ of wheat would buy about ~ barrels of oil. In 19?7 a bushel of wheat would buy about ,' of a barrel of oil. Aooording to ay research and records, the above comparisons are true. Clay Bo: 51 ~ tricity, and trans rtation to and f k. Senator FORD. :1ir. Chairman answer any questions that you m Senator CHAFEE. Thank you v ful and perhaps not surprising te,, I think the last point you mad something that concerns the enti' I think it has ~ been shown bycoi concerned about preserving the But somehow I think the choicc Ifron•ing tobacco the choice is to «•elfare, is a little limited. Senator FORD. Welli, Senator,,ll uggest that the 600,000 farmer: ~ubstitute for tobacco? Senator CHAFEE. Well, I suspil inthe -Nation4hat are not solely d Senator FORD. We11~ let me gi sure that v.ou understand tobacc serionslyy that you raisetoomucd tre 165,000 farms; that represen tliose farms raise tobacco. Of th:. farms. Now, you give them a sul tobacco products-and you go ii~ ncts. Now, it's a far-reaching ri, i obacco, and you look what y ou nated the best income for small have a15o eliminated industry, State when you have unemploym Senator CxAPEE. Well~ we arc ~'ou know, this bill does.not elimi Iboked over the bill. Senator FORD. I understand, I do, and you look at all four bills ,d the legislation, then it is far i lindiistrv, and to the people+-the _1nd,~ _lIr. Chairman, I want Mi ion. ~~ehave been trying to : ',vitihout a dime from the Feden . :.reraoe since 1972 of $3.7 millic siibcommitteeadrnitted that .111rntrti-v but probably in the wor g, tosolvetheproblemwi- ~-Olve that, Senator, without i` And here, with onlythe : I thinkthis is the answer-nc "«T-a6besti.os, for instance; th: !11!"ventative measure? SonatiorCxAFEE. Well, I thin ~':It 90 ) percent of ltuig cancer is `enator FORD. «'hat about as Senator CarArEE. Well, it div ~ ~'11twhen vou havea figure ,~('natorFoRn. You can get an'ro tioidl solnething to refute tha

110 Today; I would! like to speak to the particular health problem, of cigarette smoking, and express my own personal gratification for the end'orsement of' S. 3118 provides to the Department's snoking and health initiative. As a committee committed to prevention, you are aware that cigarette smoking remains the single most urgent and potentially rewarding target for prevention 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 No. 1. The problem of smoking and health is urgent, because of cancer deaths, cardiovascular deaths, and chronic lung disesase. These sta- tistics can be reversed. Nor do we need to continue to suffer the enormous economic conse- quences of cigarette smoking. Just 2' 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 nearlly $20 billion more in lost production and other costs. This means that about 5~ percent of our health costs are directly attributable to cigarette smoking. It was because of the human and dollar cost of smoking that Secretary Califano announced the Department's initia- tive on smoking and health on January 11. Under this initiative, a number of stepshave been taken by theyDepartment, a11 of which we believe areconsist'~ent with objectives of S: 3118. Together with: the Fed'eral Trade Commission, the Department has petitioned the Federal Communications Commission to open more broadcast opportunities for public service announcements, including prime, tlime; where information would be made available to the widest audience. This petition is now being considered'by the FCC. Secretary Califano and Commissioner of Education Boyer are work- ing with the 16i000 school district's to provide educational materials. We have circulated a model "Clean Indoor Air" bill to the 50 States for their consideration in efforts to protect the nonsmoker. Dr. Richmond has assigned responsibilities among the agencies and work has begun on the preparation of the.1979 Surgeon General's re- port. This will be the most extensive review of the medical and be- havioral aspects of smoking since the origina-1 Surgeon General's re- port of 1964. The Department is not' engaged in a nationwide effort to notify World War II shipyard workers and other asbestos workers of the health risks they face. This campaign emphasizes that an individual who smokes and who has: been~ exposed to asbestos has up to 90 timestlie risk of contracting lung cancer than a nonsmoker who has not been esposed to: asbestos. . . The Food and DI rug Administration is now reviewing tlhepublished! reports on the interaction of smoking with therapeutic drugs. To coordinate this effort, the Secretarv has established the Office on Smokingand! Health and has, appointed l'I~r.John Pinney.nsit'sDi- rector. Mr. Pinney brings to this position 10 years' experience as a managerand analy stof health programs, and! possesses a knowledge of, and commitment to, prevention and health educat'ion.The,first provisions of S. 311I8deal withtheregnlation of smoking in Federali facilit'ies: These provisions correspond very closelvwiththe new regulations alreadypromulgated w ithin HEW', whichI am sub- mitting for the record. We heads Senator CHnr• FF. Dr. Foa Going back to the subject o sure to asbestos and being of lung cancer 90 percent- But the opponents of th( of theasbestio; don't exposeN ow, it seems to me thatt the risk of those who sm( making is that there are c factor by the square or ge factors, like: pills or asbest< asbestos, for example. I)r. FoncE. We think it' which may be additive or With asbestos, for instanchave about a tenfold incrc asbestos worker who does onlv, asbestos workers wh( in lnng cancer, as compare( But it is the. combination creases the risk from tenfol And we think it's impo cause the one thing they c: to reduce.the risk. Senator CHAFEE. Well, 11 sinokers'etposiretoasbebo up very slightly. Dr. FOEGE. Very slightly Senator C11AFEE. In ot'he Dr. FoncE. That is right c6garette smoking and ask SenatorCxaFEE.And tl so forth? Dr. FoncE. With oral c cardiova.scular risk in wo: ~lon7t smoke. But this becc And it. is in this area wor svnergistic effects that. Senator CHAFEE. Rr'ell, -istic effects with,, say, p" :u.(, daaliaginr?' Or is that the damaging factor in t I)r. FOEoN. I think we l~1ld_rbt be st'nerglstlceffect r li(~ tharSholkl, ofthissoirt liranium miners, and so I _ i .4ic eifect, but there inav tienator Crr:.rEF. Thank I)r. FoecE. We haveur'.( 1'~wlizations, such as thf and enforce similar restr

:hanrer 1-60, GENERAL ADMINISTRATIONI Paze 7 1-60-70 NoticesandSigns A. Notices toPmployees. Officialls resnonsiblefor iin- plementingreGuirements ofth'is chapter shall inform employees under their jurisdiction in writing ofthe provisions applicable tothem, (1) Suitable "No Smoking" signs shall be mounted:ina1'1 rooms and areas where the no-smokingpoiicy applies. Where common or public smoking areasareestablished, a card:or otherdevice willigivedirections to the nearestn area. ThesediTectional sigDs will be placed adjacent to the "No Smoking"'sign whenever possible. (2) The numbersof,signstobe posted or displayed will depend on the sizeofth'e room or area. Generally, two should be sufficient for small rooms and four for large rooms. Signs placed in,designated no smoking areas (in- cludingrooms) will bear themessage "No Smoking"'. Generally, the size of lptteringshould be one inch high forsmall roomsor areas and two,incheshigh for large rooms and areas. (4) Theaccepted international symbol for no smoking maybe used on doors or appropriatelydlsplayed in nosmokingareas, in additiontothesigns indicated above. Technica8 er,tinns n - " - ' ' ' tional materials, or suggesned metu- .,i.u .agin-o. cigarette smoking in Government buildings, should be referredto the Office on Smoking and Health, Officeof the Assistant Secretary for Health, Department of Health, Education,and Welfare, Waahington~ D.C. 20201.

209 Mr. Chairman, a clear need for preventive medicine is shown in official statistics on cancer death rates. Among,patients diagnosed during the years 1950 through 1959 and included in the National'Cancer Institute's'end results study, white five-year survival was 39%, but black was only 29Y,. The same thing showed up with patients diagnosed during the years 1960 through~1966t White five-year survival' was 40% and black was:28%. I includ e the table here, but will' not orally quote it allt :. Relative Survival~~ /-------- Year Of Diagnosis---------- / Rate 1950-59 1960'-66 1967-73 White L-year 60 61 64 3-year 44 45 47;_,. 5-year 39 40, 41""' Black 1-year 51 501 54 3-year 34 33 37,.,. 5-year 29 28' 32~`" *"Relative takes into account that some patients would have died from various,causes Incomplete even if they didn't have cancer. Sources National Cancer Institute Mr. Chairmany I personally happen~to have been involved in a study comparing patients here andlin Africa which shows that these excess black deaths are, in fact, not racial, that is not

214 Testimony of EMERSON FOOTE Former Vice-Chairman of the Board American Cancer Society Before the Health Subcommittee of the Senate Human Resources Committee Senator Edwvard' M. Kennedy, Chairman c regulating cigarett~ I ~ not the adbert'~isingtremendbus influer smoking and in inc in "hooking" peopl, man who spent his the potency of adve I tobacco indtistry. in~saying that ciga- anot'her and does ni but airy and self-s C is this oft-repeate, development of the this country were: cigars, snuff -- w, c May 25, 1978 Washingtony D, C, sales have grownit

210' related to~their genetic make-up6 Rather something is happening to U.S. blacks which is,not happening to U.S. whites to produce a cancer effect greater in the blacks. Specifically, measurement of all cancers in the U.S'. on a:sample basis during the years 1950 to 1969 shows that the death rate from cancer among white males was 1174.04 ' but nonwhite males suffered a death rate from cancer of 184.28, or 5.9% higher. Among nonwhite females the excessive cancer death rate was 7.0%. Sbrne the the big problem areas are in prostate cancer where the nonwhite death rate exceeds the white by 53.5%. In pancreatic cancer the excess is 5.6% among males and 5.8% among females. In stomach cancer the nonwhite males suffiet a;57.9% excessive cancer death rate and the women suffer a 38.877 higher cancer death rate than white women. In . cancer of the bladder and other urinary organs the black males suffer a 34.2% excessive death rate and females 27.6%'. cancer sites studied ss genetically based,,itl so that preventive med' future that are tragic needed, where preventi smoking. is the most obvious cL cancers are related tc practically no room fc I are very closely simil and for women 0.3'/,'. f must be made among bLa published dgta showiq but only about 17%'of

Testimony Of LaSALLE D~ LEFFALL, JR., M.D. President-Ellect, American Cancer Society Before The Health Subcornmittee of the Senate Human Resources Committee SENATOR, EDWARD M. KENNEDY, CHAIRMAN Mr. Cr is shown in official statis Among 11959 andiincluded in the Na white five-year survival wa The sc during the years 19801throi and black was 28%. I inc7 it a11s Relative Survival• Rate. White 11-ye ar 3-year 5-year Black 1!-year 3-year 5-year *'Relative takes into acco various causes even if t ` Incompllete Sources N2tion Mr. C i~nvolved in a study compar that these excess black de May 25, 1978 Washington, D.C.

189' -,r I.it on something smoking risks onal attractive- itp ing,what shouldi11T. How would Tuestionswi'SL ae following ol systemss s which cover hown promising evarietyof could enable viors harmful to exposure to, this will.somehowSi'nce the only once, efforts or periodic basis the specific effects at they are clearly ere is a need to supplement this information with non-health appeals, since most teenagers who start smoking do so because this provides other values which seem to outweigh the perceived health risks. Nine out off ten teenagers believe that smoking is harmful to health,p but.they are in a conflict situation because they also see smoking as a source of peer approval and a symbol of adulthoodL The design of control.programsin this area ismade especially difficult by the fact that the positive consequences of'~ smoking (such~.as peer acceptance) are immediate,.while the negative health consequences may not appear until years later. It may be.necessaryto devise forms of immediate reinforcement of nonsmoking behavior if control programs are to become genuiaelyef~fective. New.community-based programs should involve greater.eooperation on the part of school.sys.tems, health departments,p affiliates of voluntary health organizations (such as theAmeriean Cancer Society, American Heart Association, and American Lung,Association), and other appropriate community groups. Whenever possible, children~or adolescents should participate in the development of new program materials directed to them, and.such materials should be tested~for appeal andef~fectiveness before being.produeed in quantity. The number ofanti-smokings.pots broadcast on radio.and television has dropped.sharplyover ttiepast few years. Rather than re3ying solely on public service time contributed.by radio and TVstations, which~is extremely limited (espeeiallyduring time.periods when a large audience is available), community programs should be permitted to,purchase time and thus control the frequencyy and times of placement. Persons responsible for these programs should seek to supplement paid commercials through~appropriate use of talk shows, editorials, segmentss on news shows,docuunentary features, and special children's programming. In the same wayy local control programsshoulid be able to purchase space for display advertising in newspapers and in metropolitan magazines. Compre- hensive programs should also include.attempts to utilize othervehieles in the

194 -3- they know what to db with what' they know, and they'vee been~willing to invest hundreds of mililions of dollars doing it all these years. . They advertise, advertise, advertise. They never quit. They keep their messages fliowing, keep their campaigns coming, keep their product visible in every medium open to them. They target, they schedule, they decide what they should say where. They repeat and repeat and repeat. They know every cigarette is an implicit ad for smoking. They build image and rei!nforce habit. They are the one constant presence. They put us to shame. For somehow -- probably because we ca11i it advertising whichlin many quarters is a dirty word -- we have been unable to get the money to make a concerted mass- media attack on the smoking habit, or on a persuasive presentation of an alternative habit -- the habit of not smoking. I think we should change the word. Let's not, for the sake of our children, calli it advertising. Let's call it education, health education if you will. And then let us take a leaf from the tobacco people and let us schedule :30 second "lessons", :60 second "lessons," :10 second "lessons" or 2-minute "lessons." Let us buy the time to expose our "lessons", to plan our schedules, target our "stud'ents!'. We are not opposed to buying other materials for educational purposes, why not then buy time? And let our "lessons" not be pedantic, authoritarian, establishment, or, forgive me, "health educator" lessons. Let our "lessons" be as bright and smart and memorable as the most engaging advertising around -- yea, evem as good as cigarette advertising. Let us apFI the way to length of right in l And let u, at therir that ther. Let us th surely th controver the idea Andilet u kids" liv climate, healith en habit anc goes witY That mear TV campai in our ei people a: Why TV? V We have : teen-age We teach We teach more abo our drugg younger We may n learn thh fact, it home and perhaps

196 -5- want to get to the youngsters,you've got to go where the youngsters are. Can you "sell" a health habit the way you sell a product?. I believe that toothpaste advertising has done more to build the habit of brushing (and with it, better dental health) than all the schools and dentists combined. I believe that soap adbertising has done more tio build cleanliness--from our bodies to our homes-- build personal hygiene and with it a kind of social eontroL over communicable diseases than schools and doctors. And I know from my own personallexperience with f the American Cancer Society and the Ngtional Clearing- house for Smoking and HeaLth that youican indeed infulence health behavior: I've persuaded women to have Pap Tests, to learn Breast Self-Examination: smokers to quit smoking, smokersto cut-down on smoking, to look for less hazardous cigarettes, and even, Ilbelieve, have influenced the direction that cigarette companies have taken in developing low tar and nicotine products. And'.L know fromimy own personal experience with the International Ladies' Garment Workers' Union that you can get a new and difficult and sensitive message across, that you can get people to listen to a union message, look for a union label, and even get them to sing a union song. Can you "seT1" a health habit? Yes, you can. Yes, we can. Provided that: 1. We do our job as professionally and as dedicatedly as the cigarette companies, using advertising pro- fessionals, 2. We are w and the cig and that is to target, efforts in I've spoken from radio basis. If we belie if we're tc creating a we should I Not just fc But for the C W M' 0 w aa~ ~

-2- 188 "If L donFt spend'the money on cigarettes, I'd spend it on something else." "Smoking makes me look grown up andi.mature." "Smokingcan"t hurt.me--I smoke.filte.r cigarettes." "Smoking is better than putting on a lot.of weight." "All my friends smoke--why shouldn't I?"' These commentss confirm the view that teens' understanding of smoking risks is.of'.ten superficial, and that they are concerned about personal attractive- ness, being accepted, being"normal," and beeoming independent. Given some knowledge.of reasonswhys children begin smoking, what should be done in commmityprograms developed under the proposed bi117Now.would they differfrom~programs nowoperating7Opinions.on,thesequestions will vary, but I believe most health professionals would regard the following answers as reasonable. Many controliprograms are now being implemented in~school systems throughout the country. Some of these, particularly the ones which cover smoking as apart.of a general orientation to health, have shown promising, results. Newprograms should: be encouraged to utilize a.wide variety of approaches, including the development of coping..skills which could enable children to resist pressures to engage in various otherbehaviorsr harmful to health. A number of current programs offer onlyy a single brief exposure to information about smoking, presumably on the assumption,that this will somehow "innoculate" children against subsequent pressures to smoke.. Since the decision not to smoke must be madee periodically rather than only once, efforts to support this decision should be provided.on.a continuing or periodic basiss from the primary grades through~high school.. Programs which provide infor~mation~about physiology and thespecifie effects of.smoking are.appropriate as part of a general education# but they are clearlyy inadequate as means of deterring.smoking,in adolescents. There is a need to supplement this info who start smoking do outweigh the perceiv smoking is harmful t theyalso.seesmokin~ The design of c by the fact that the are immediatev while years later. It may of nonsmoking behavi New community-ti~ part of school systeorganizations.(such and American Lung As Whenever possiDb development of new pp should be tested for The number of ~~ dropped sharply over service time eontrit (especially during t programs should bef and times of placeme to supplement paid c segments on news she. In the same wa} for dispilay advertie hensive programs shr,

-rstio.n ''kirs...._s- rade, .r.g=.rcu.s, n lar.ge-y or ccl- !dt'.he mass • the -^'_orattons. - f.indiln,zs., -_cn to. snti- .- tra:^... control -nt;I cn~n th~e. 181 study, and: now.through,thesecor.d yea.rr of a three-year longitudinal study which wiLl follow students through the seventh, eighth, and nilthgrades) predicated on thee folilow.iing.theoretical nation: ifl student.ss can be "nu.rsed" through thee particularly vulnerable- to-sociaii-pres.sures-to-smokejunior hi',g1lischoolyears,they will be fortified su~ff.icientlyso that the heavy„ addli:etiv.e smoking which is generaLly first found as students progress into high s~^hool, wii.l less likely, occur. Sythen, students,maybemere independent, and may be less likely to r,espondito~these socilal pressurestobe.gin smoking. We would encourage the development of programs whic.F.useh f'~ilms andd reLated reinforcers.(~posters., etc.)iand feature s.cenes of thest.udentst.hemselves demonstratinghow.theysay "no" to p,ress:uresto smokeratHere than authority.figu.readults presenting high feararou~sal messages. Such an approach alsoim.aybe pot.en- tiallya maxima:llycost effective strategy to detler smcking.:h.isi',s in contrast to smalll-group.face-to-face training which nas the dilsadv.anta:geofnote being readily exportable to other localie.s:, variesconsiderabiyi!n.howskillfully, it is.execu.tied,s and'c.ancot be too easilystandari'zedi.for evaLuati:on~purposes.. To: ampLifyour methodsand:resul't's„ first a ten-week inv,estilgation was completed with 750 male and female studentsentleri.ng,s.eventh grade.Rates of onset of smoking in~the.flull.tirea.tment,.thefeedback:, and the testing,onliy gr~oups wer:esignificantly lowe.rth.an the onsett rates in the pretiest-singie pcstt'~est controL groups (s'ee :.i g u re 1).

212 4. ex-smokers, but only about 16%,of the blacks. And non-filter cigarette smokers numbered about 12 percent of the white males compared to 24%' of the bliacks. So you can see the real excessive hazard among blacks. (Data from one study; not necessarily accurate for the entire nation.) The American Cancer Society has scheduled for next January a conference on the subject of cancer and black Americans. At that time we think we will learn a great deal more than we now know about the disease's impact on minorities, and about the perceptions of minorities with regard to cancer cause and prevention. We will no doubt have new insights on the problem of cigarette related cancer among blacks. Meanwhile, we see in busses, in magazi,.es and' newspapers cigarette adve_,tising explicitly directed'by content or medium to the black community. The data already cited represent strong evidence that this advertising is effective. Mr. Chairman, our Society has just recently received a report from a special commission headed by a former i-IEW assistant secretary for health on the subject of cigarette smoking. With study of that report, committees of our Society have already begun adoptling some of the recomrzm iiniseveraS cities Dssues Committee hh differential tax o content; has recor warnings onicigare Public Issues Comr. week in June. Cancer Society wil seeking to strengd proven effective i proliiferated6

191 -s- .lss cartoons, here they will It makes sense -f'f media which -boves aree comic rts or "trailers" . . bumper stickers, In summary, the following should characterize new community programst • Plans based on accurate andd current knowledge of children's beliefs and attitudes regardimgsmoking(dcrived'from surveys, focus Croups.o ete.), • Use of specific objectives, so that efforts can be kept on track and results evaluated'clearly •Ektensive cooperation among,school systems* . voluntary and public health agencies, and other interested groups • Involvement of' health professionals, particularly practicing physicians andidentists e Use of a variety.of media uld be used in~a . ~rmation~.but to • .s a norm. of advertising • .ronment where a • a.singlenew • .s spent to ad- • :ounter-effort the age of 12 • :eadvertising • :o~expect sig- iration. y ,rogramsfunded :ein detail the i meet specified ;eoutcomemeasures fromchildren.. ~sultss cumulative; -labive value of :an.be implemented~ Emphasis on immediate personal and sociaL reinflorcement of nonsmokingbehaviorg andiavoidance of exhortation~or sermonizing Involvement of children and adolescents in program planning and design of materials Pretesting of materials with revisions.madeasneeded Use of athletes and other valued figures as nonsmoking exemplars Use of multiple appeals, including social and personal themes un- relatedito physical health Controlled placement of advertisements in~print and broadcast media Reinforcement of basic messages over a period of years. Use of rigorous evaluation.techniques which.permit comparative assessment of different approaches and programs It has been estimated that one-fifth of the cost of inedicalicare today arises because of tobacco and alcohol abuse. Even if smoking-rel'ated problemss accounted for only one-hundredth of the $160'bilLiomspent on.healtti~carein this country last year, that would be $1.6 billion. Clearly the potential! cost savings that could result from effective smoking control programs.p apart from, the values in terms of personal health and! productivityj are enormous..

switch smokers sales ever rise he most magical .' sixty thousand 3 times -- with e! i any shadow of or in building the y, with an~annual ways. It is es on a stagger- of cigarette-induced , is 290, 000 per -]g every 2 minutes he American wrong -- one erage -- as part it its present Andlthe cigarette industry is now, spending well over 300 million dollars a year in an effort! to:expand sales still further. Can~ we not' at least blunt the pointl of the inst'~rument they empioyto:"hook" people on cigarettes, the end result of whichi is more d'eaths? Can we not at Lea3 keep a larger proportion of our young people from getting on the long assembly line whose finished product is lung cancer? The AmeriaaniCancer Society has takenithe public position that there should be no models ini cigarett'e advertising. If this could be ac- complished it~ would help al great deal. Because the glamorous people of both sexes, with whom young people like to identify, would no longer be associated with cigarettes. Ih this statement, however, I shall not attlempt t'o tell the Congress what to do about cigarette advertising to make it less lethal. A full answer to this question would be beyond the capacity of any one person. A eommittee of advertising experts would surely be helpful. I will simply say to tnis committee, as urgently as I can, please start to do something -- as soon as you can~ -- to reduce the deadly effects of cigarette advertising as presently practiced. Remember, people will keep on dying every 2 minutes and 6 seconds until something, is done. 30-536 O-7&'-16,

OfRce. of Smoking and Health and for the Center for Disease Control, primarily in the arcai offundingoperations of the O'fliceand in fund- ing a progranl of grantls, to St<Ites tal~geted on smoking and health. Senator KENNEDY. Well, you took some of this money from the cancer program and from the heart program and from the Mr. PINNEY. No, sir, there has been no change; there has been: a slight increase in each of the research institutes and a major increase Senatol KI:xNEDY. Well, it's obviously a shell game, you know, moving the money around'y it's important we 1hy this out!, and we find out where you are getting it: it's old money that is reprogramed or it's Mr. PI~N-EV. No, sir; the $10.1 million is new money. Senator KFNNFDY. That's new money. Mr. PINNEY. Yes, sir. Senator KENcNEDY. I am talking about the other money, the $24, million. Where did that come from ? 1ir. PINNEY. The other money is continuation money plus--- Senator KENNEDI. Continuation money? Mr. P'INNEr. Yes; sir. Senator KENNEDY. It really isn't continued until we reappropriate it in the Congress. What would that money have been~ used for if it wasn't used for this program? What kind of research wouU it have been used for? Mr. PINNEy. It would be used! for smoking research. It is money identified for smoking-related research in those institutes. Senator KEN--NnDr. Are those the only funds that were allocated for those types of research in the institutes ? Mr. PINNEr. Those are the funds that have been identified for srnok- ing research to~- Senator KEN ti EDy. Well, how much into Cancer ? Mr. PIN .NFY. I believeit is $8.1 million. Senator KE,NNEDi. You~ mean of the whole-what is iti Dick, that you appropriated yesterday?'$850-odd millfion Senator SCxwEIKFIt. We gave them $10 million of totally new money they hadn't asked for yesterday, and that is what I am trying to find out, where they are going to use it. Senator KENNEDr. Well, I think that is commendable, but I am trying to find out exactly where you got these other resources. Is that tlie only money ini tlhe cancer program that, was being directed toward smoking? Mr. PINNEY. Yes, sir-specifacally identified for smoking. Now, the problem becomes one of other research that is being, carried on which willl in faet- hav.evalnetothe questions that Cancer, for example, or Child Health and Humani Development are e.ploring.. Child Health and Human D'evelopment, I i hink. gives an: ilhlstration of where a great deal of their research-and Dr. Kretchmer can speak to this more accurately than I can-a great deal of their research, is in the area of prenatal impact, and sothat. will have a spillover into ques- t ions~relatel tothe eti•ec,ts of Sn1okin- omthe fetus. Senator hEN NEDY. «'ell,.veare totulderstand', internls of the ad- ministratiorrs ren;uest, that it wasreally just forS0million new money. MI•. PtN~N Er. The totall increase over fiscal year 1078'is $10.1 million. Senator SCHWErKER. E we've got three different Mr. PIN:.EV. A little oi Senator SCIIw.EIiKER. Health ? Mr. PINNEr. That is Huunan Development, ar and Blood. Senator SCIIwEIBER: I that. Mr. PI--\-NEY. No; the 1* and for the Offrce on Sm Senator SCxwr:IlcER. - Mr. PixtiEY. Right; y( Senator ScIIwEIhER. - yesterday. And y ou ask f Mr. PI~~FV. $6.1 mii Senator SCI3R'EIIiER. ( Senator KENNEDY. 11 like to know in dollars i agencies, if youlwill supf Dr. FOEGF.. I mSght ~ doin,(r this-the \ ationa forri'nstancer with evei, point, we do~look at thetherespecificaldy for sn n-ise, .v rthi every occup, ^nrokirla in order to kn• lmcl nonsmokers, so th smoking flnom thosesou [The infomnation ref

165 v makes the most iTn- aeonewith a littleau~ set an example. But. )king and has experi- someone that is more 1. combination~ of all' of~ is young, if~I had had', ne, don't smoke-that ~ need~~ the support, of ld need their,support ~ ~iem~ for~ a irhilh---be- 1 parents also. Every- -and I would just be. -Jiim mentioning that A the support of the I suppose tiha~t you v activitv whether a izations;" that they be is a sensitized com, :ards of smoking. t of television ?You evision, but you see ers-does that have gged man or woman V is serious enough it more serious. inter-adVertisiirg on f some value, too?' ~ you influenced by-,~spapers and mag~, )us 7 Does that look idiculous~ as far as vou see ads every- get get away from it. have a cigarette- t get away from it. and persuade your ngt'~o him. I mean, uldn't run upstairs active l life 1u1til he l, if Yoeeparents smoke, you, should try to get them to stop, because it is really bad for them and so on. Between tltosereasons; that prompted met'o help- to tryy and help anyway. Senator KENNEDY. Well, we thank you for bein« with us this~morn- ingand for your answers. Is~there anything elseyoulwould like to say to Lls ? Mr. VALEO. In listening toyoul all discussing adding the tax t'othe highertar and nicotine cigarettes and lowering the tax on low tar and nicotinecigarettes-«ell, to me personally, it «-ouldn't'maket al difference. I mean, I smoke~ one brand and it is high in tar and! nficotine-I am going to stick with that brand! because I lilcethe fla- vor-I have beeni smoking the same for 3 years, because I like the flavor and I don't like the flav or of any other cigarette. Senator ScflWFiKEU. You are sayi'ng if they raise the tax, you would pay the money for the taste. Mr. VALEo. Sure, yes. It R-ouldn't' make a diffcrence, because it's al- ready gone up; I can remember when they were 50 cents a pack, now it's65cents-and I am still paying the price. Senator liENxEnY. What about! any of'the others on the, cost- 14iiss~IInILLr. I agree «•ith what he said. It doesn't matter how much, you pay for ci9arettes, if you smoke; you are just going to buy them anyway. And I don't think that too many people look at the tar and nicotine quantity of the cigarette when they buy their packs; you know, it' just clependson tlietaste-if'it's gota lotof tar and nicotine, then you will smoke it with a lotoftar and' nicotine. If those are too harshy then you srnokelow.-tarcigarettes. There is not nnich d7fference: Senator Cx AFEE. Does the price of smoking-in other words-have no effect on your consurnption ?Mlss REILLY. No. SenatorCiiAFEU. It doesn't seem a heavy burden to you tolpay now 60~or 65 cents a pack? lliss REILLY. Well, in someplaces~ you can buy a pack for50, cents, other places it's 75 cents, othei~~ places it°s, 65 cents. So you justpaywhatet-er vou have to. Senator Scr11WEIKEIt: Where do you get the money to support it.?' Your parents? Miss REILLY. I work. Senator KENNEDY. That's a pretty stron g indication of' the degree of desire for the cigarette, that you would pay what'ever the price is in orderto smoke. I think it is probably a reasonablh measurement of' the degree of real addiction to smoking that, young people have, and makes it more vital that wetry and encourage peoplo not to get start'ed on it. OIi, is there anything else any of you would like to say? We want totlinnk all of vou, and thank Pat'lier Wardi fromGonzag a for his help incoordina.tingt'hese activities.1"hank vou verv, very much. Miss REILLr. ThEinl: vou. Senator CiTArnF: Cood hick, Tim, with kicking the habit. Senator KENNEDY. We have got our next panel, I believe, with Richard Eo•ans-llr. Evans, llr:Swiaieharb,and Paula Green. Dr. Evans?

211 ; happening to U.S. 3e a cancer effect cancers in~the shows that the it nonwhite males iigher. ;ive cancer mabes sufSet a 57.9% ,8x higher cancer ier urinary organs d females 27.6%. 3. Now that we have definite data that, at least in cancer sites studied so far, the excess deaths among blacks is not' genetically based'y it is clear resarch,is needed to find the cause so that preventive medicine can be used to salvage these lives in the future that are tragically liost now. One area where work among all ethnic groups is needed, where preventive medicine is need'ed, is certainly in cigarette smoking. As this Health Subeommittee knows, lung cancer is the most obvious cancer corollary of smoking, but bladder and other cancers are related to smoking as well in statistical degrees that leave practically no room for doubt. In lung cancer the white and non-white death rates are very closeliy similar, the excessive white rate for men being 3.6% and for women 0.37. But it is clear that special efforts on smoking, must be made among,black groups. The American Health Foundatian in 1976 published data showing that about 247 of white males were non,smokers, but only about 17% of the bl!acks. About 267.' of the white males were

161 How about the ones that noke ? Martin, what about , but lie is not a consistent . -Mark, what about you?~NIy uiother used to, but '~i at all about the health iink about it and! thinkit of a sense do you or any y is going, to make much your own view and' what. :ids my age aren't reallyy about it maybe. But the. i know, j ust to fit in with adult'&do. So I think the ~an get a feeling of, you think they are really con- smoke I used to think it i it, I was immune to it or been~ thinking`I can see ;-th of di'stanee, you know,Mairk, what about you ? used to sprint. When I se, you know, a liundred ut going out to run 2 or 3 anymore without hufling nyself that I am going to t it has had on me as far cold turkey, how are you1 and it just doesn't work, irette tastes good-that'e ~ goiall thewav, qhit cold )u don't smoke~ and, both in, althletics or~ for~ «-hat~ friends started to smoke noked, and I j ust wanted Senator KExxEnY. Let me ask you about the attitude of the schools about the smoking. Do your schools permit it', do they discourage it? Does that make any difference ? j17hat about it, -.lfoira ? lliss REir,Lr. Most Catholic high~ schools, I would say, allow it for seniors. Our highischool didn't allow smoking at all. Generally, in most public high schools, there's so much smoking, there is notliing you can do about it. But I would' generally say that most' schoolsallow it;there?s not much you can d'o, so many people smoke. Senator hEa sFnY. «'hatl about this health issue, Theresa? Do you think that many of the voungerpeopletliat get started give;that very- mlich attention or much thought, or d'oyou find out when they get a little older that they begin to give it more and then~ are they hooked on it, or nhat?;1liss! WoLFF. When yon, first start smoking, it doesn't-at least «-ithme; it didn't take effect until like a couple of years after, like now I cani see that I can't run as much orpartrcipateas much in activities. Idonrt think t'heyreallylook into it, the healthi conditions of it. Senator KENNEDY. Mark, .0hat do you think? Do: you think they think muchabout the health factors in smoking?lir; ADA-3zs. «"hen I first start'ed, yes, I thought about that', but I figure, yowknow, that Iwouldhrt be smoking my -%i•hole life; I figured like when I t'urned, 1S I would stop or something like that. But now, as time goes by, y ou know. Senator KENNEDY. You are thinking more about it, about whether to stop? Have some of you, thought about stopping smokin ;,?Let me see a show of hands. How many of'you have thought about' stopping smoh ing? Jim, you thought about it. Senator SciiwEigEia. He's going to do it.. Senator KENNEDY. He's going to do it. What do you think are really the factors that wouU make a difference in whether you can stop or not? Is it again what is happening with your friends; your colleagues?Ord'oyon think the fact that _vou know more about- t'~hehealth implica- tions encourages you to stop smoking?What , do yow think are the things that can~ help the most in t'erms of getting teenagers to stop? Miss RErLrLV. lTost teenagers aren't really well informed' about the hea~lth problems. You see commercials and' ads that say, you know, in 200 years you might develop lung cancer or something like that. But when you are young and'vou start smoking, you don~t think of the S long term effects ; yoularel ust thinkingabout now and you are think- ing aboub'-I will just try smoking for a«•hileand then quit. But' you would have to start at' the schoolsprobablys becausetliat is. «here most people start. And! if von can stop people f~rom smokingatr school, then thevare just not~ going todevelop a. hnbit. An& then ita-ouldn't be as hard to stop. SenatorKF:wxEnY. I think you putl your fingeron~~ the key question,, Wand that is-aretlierethings,that canbedone to prevent, voungpeople Qy, from getting started?© What suggestions do you have on that ? Dlaybe we will start with Cj Jii m. Q (Z 04

221 positive cognitive -off.effects in the ibiie thePr.ihnary_urricula in programs z.ed in the bill iss valuabledemons-trations estudiesof the about thehealthzing used. theresource.s made been extremely.s.a11 reason webeLieve legislation will CHAIRMAN SUBCOMMITTEE ON SMOKING AMERICAN HEART ASSOCIATION Before the SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH COMMITTEE ON HUMAN RESOURCES UNITED STATES SENATE MAY 25, 1978 TESTIMONY OF ROBERT M. DAUGHERTY, JR., M.D., Ph.D.

106 at this chart here that shows the increased incidence of smoking among teenageb rls, the overall ir creaseo f smoking, among young people.Now,.ve can say forget about that'problem, because we have tlieindus- trv and the labor of 600,000 people involved'y as y ou suggest. But also wehar:e the healt6 of an awful lot ofpeoplein this Nation involved. Anct it isn't that we are singling out the tobacco industry. Senator FORD. You certainly are-for tasing; you certainly are. Senator CIIArEE. Well, you can see what we have done in t!he Public Works Committee in dealing with the automotive discharges- t.he discharges from automobiles; we are taxing on them. The whole effort in that instance is, to try to clean up the air that could possibly be cancer-causing, and now we are dealing with anindiistry, a product, that clearlyy has a cancerous effect on thosewhousea.t'.Now; we can throw up our hands and say, well, it's a matter of choice,, and if somebody wants to commit sulcide that's, their own business-and forget about it. Or we can worry about it and realize that those who become sick become a burden on society in general, as well as losing their own health. We can say forget about it and that's a matter of free choice-it's a d'emocracy; or we can worry about it. I personally think it's a matter of concern not just for the individual, but for the Nation as welL Senator FORD. Well, Senat'or, let me say this :We didn't ban the automobile; we tried to research that to put certain environmental---- Senator CHArEE. With aitax on the automobile. Senator FORD. Not on mileage-I don't think on the environmental problem; I think where they were above or below a: certain mileage, they got taxed. I don't want to refute what staff is telling you, but it may be that there is some tax if they don't meet the air pollution stand4rd. I thought they took themi otf the market; I thought that the tax was if they didn't reach a certain mileage. Senator CIiaFEEI No,, I said! we required theni to meet certain standards. Senator FORD. But,, Senator, you didn't ban the automobile;, there's no attempt to ban the automobile. Senator CITAFEE. And! t.here's no banning of cigarettes in this bill, Senator FORD. I know, but the process t!hat you are following here will ban-why don't you put the money int;o research and; try to eliminate a problein that, as Dr. Bourne says, has been with us 300 years, if it's ai problem. And if you want to start banning tobacco, it should have started! 300 years ago. What I am trying to say to you is let's put the money into research; let's try to find a problem, if there is one. Tobacco is a pliable product, volu can grow any impi.irity out of it in two growing seasons; you can take it to a warm climate and do it in 12 months, Now; these are statistics that I don't think canbe refuted. So instead of being punitive, why don't you add the money to research instead of putting it into an educational program. If there is a problem, you can prevent it by research. And we are trying to do our part in Kentucky and not asking for a. dime from the Federal Government. It comes out of the tax money eollected in Kentuckv, and thelast 5 years we have put in somethiinglike$1& mil0ion, Andso we are trying t& find the answer, an& you are tr7ing to prevent us from evenhaving a chance. Senator CHAFEE. I d looksintothe very effe does research in that . Senator FORD. But t 1979 in this related fie money is going into res tell themhoavnot to s: Senator CiHAFEE: Ye Senator FORD. So the Senator CIrAFEE. '.\-c section to study the lr of varying levels of ject you~ are eoneernedl commercially manufac Senator F+ oRD. Well, nicotine cigarettes, tht doiirg, today without 1~ or Intervention. That's lieard you stand on th ting into private busi opposed! to that very plece of legislation th~tlying to do for itself. And I think in that t hink you a~reflyingiilation,'but, on the othcthe otherliand with thSenat'or CHAFEE. W( t o achieve the very goal Senator FORD. Yes;, 1>rise is doiaigit themseil Senator CHAFEE. Bui <<-~ has been pointed ou. ~i<iw, a reduced'Federal tilaat that is, something Senator FORD. «'ell~ li~>N~'tohelp industry ~;i Xingan industry to ti11at iQidiistry out of bu~ ~~ causing a problem, ;1nt the avtomobilesoff l;utin aa smaller scab . 1,11t of business either. the last feand the crops ~ "r ~~oing tlofare ~-.erv~ '~atthevcan look flor "'111„* ableto buy.fert \fal fi tle And ~)s l did no ~;;.1)t)c) ana¢re=sub- i,rMt' `, ;}00,an acre-th•.(I'i),I,IiR1g efl°ect that Nvo ~ C~

151 Page 2 ments -ch is rmit, cases, fines ive Gj)'_pter1-60 GENERAL ADMINISTRATION onal and elements :e of 3ecretary .e for iey, wi17: .A the -60-40 nsure date. et for owing: Igs has -e ,i as !ad- :ational these sibility. W employees vely I :als -1ng HEIi~TN~-78.2 (1/18/78) C. In addition to.the actions.required by this -chapter, officers in charge of all Public Health Service facilities shall implement the"Policyon Smoking forMedical Care Facilities of the Department.ofDefense., Public Ilealth Service and VeteransAdministration"'within their respective jurisdictions.. (See sxhibit 1-60-1) B. Heads of Staff Offices will'support the provisions of this policy and assist the Heads of POCS, PROS, and Director, Officeof,Management Sorvices, OS, in its implementation. The ASDfB:andAssistant secretary.for, Personnel Adminletration will providee within their areas of responsibility supporting.funds and training guidance.and assistance. Implementation Directives Ps age 3 A. General. HEW officials are directed toimplement and enforce the smoki'ng,policy in areas under HEW control (see paragraph 1-60-20).aecordingco the type ofspace in- volved. B. Smoking shall not be permitted.in: (1)Conferenee rooms and classrooms. Conference rooxnsand classrooms are defined as aroom~designated:.for meetings and training sessions or forinstructional purposesand,arenotuseds as anmoffice or part of and individuall's usual working area. Includedin this definition are multi'-purposerooms w)iile used as conference rooms or classrooms. The person.re- sp-ible for training session isalou. .,aurcing the no-smok'ingrule. Prompt action shall be taken to post appropriate."NoSmoking" signs in theseareae. Thereshall.be no ashtrays in these areas and receptecles for disposing of cigarettes, etc.., shall be placed at entrances.. (2). Auditoriums. Smokingshall not.be permitted im auditoriums. Prompt action shall be taken to post appropriate no-smoking signsih auditoriums. There shall be no ashtrays inthese.areae. Receptaclea may be placed juet.inside.the auditorium so that vieitors may dlsposee of cigarettes, etc., when theyy become aware of the smokingf restriction.,,

164 kind of welll known? What do you~ think real'1yy makes the most irn- pression?-0r a doctor? JliSs Rr:n LY. I w,ouU say Your peers, and! someone with a little au- thority,yotu know, a little ©14er, maybe could set an example. But. you know, someone who has ~onethrou~h smokin~ and has e~.peri'~ enced it andi can rel~itethose e~periences toyouy someone that is more your age-you would be more apt to listen to them. Senator hE.~ NEvY.W'liat about the rest? Mr. VALEO. Well, I feel it would really be a combination of all of them. I amiinpressed byathlbtes~; ancl when~ I was young, if I had had an athletc come up and say, come on andi be like me; don't smoke-that would make a big impression. But I would also need the support of my friends and whatever; if I did smoke, I would need their support, to help me stop, you, know, to keep~ rne off of themi for awliile Lie- cause it's a hard habit to break. And teachers and parents also. Every- body's input helps. SenatorIii•aNNEIDY. This is a good point here-andi IwouldJust be interested in the reaction of therest of y ou to it-Jim mentioning that You need the support of your parents and you need the support of the school, some health messagEs .vithintheschool. I supposethat. you are a1so~talking about other kinds of community activity whether a bovs clh.ib or agirlsAlcib or various kinds of organizations, that they be appl~~in~; themselvestolthis problem.What you are talking about, Jim, I suppose, is a sensitized eom- muni'tyy and local effort applied to the health hazards of smokinb. Would you, all a(yree with that as a thought ? Letmeask you just finally : What is the impact of televisioni?' You see all the advertising-excuse me, it's not on tellevision, but youi see, the other adv.ertisin- in magazines and newspapers-does that have much of an impact?You are always seeing a big rugged man or woman lightin; up acigaretltea Mr. lnaas. I don't think the advertising on TV is serious enough to get people to stop; I thinkthev should mahe it more serious. Senator KENaFnY: Do you thinl: if youl had counter-advertising on either radio or television, that! that would' be of some value, too? Probably aa tough questiom Senator SciiwFrKFn. Let me ask, how much are You influenced, bv the adVertisiurg about prosmokin~that you see in ne~spapers and mag, azines and billboards? Does that made it' l;lvnorous ? Does that look like it's,a mature grownup thing, to do?' lliss, RaiLi,v. The ads themselves: . arepr.ettyridiculons as far as, makin- You start tosinolce. But just the fact that vott; see ads everv- wherefor smoking, evervwhere;it's impossible tobet away from it. It reminds voiv of smoking, it makes you warrtt'~o have a cigarette- thin(;s, like that. That's jRtst so much of it,vou~can't get away~ from~it. Senator CirArrEF. Jim,,n-hat prompted you tolti.v and persuade yottrfatlher not to smoke? Mr. j'ALia. I could see then what it was doina to himL I mean. hejust wasn't a~g:ile;lrecouldn't run an-vmore, hecouldWt runiupstairs orany,thint; like that. ILejnst couldn't lead a really active ]i'feuntil lie Stopped ,moltirrg. _tncd nrn' teachcrthen had saicl, ifVour harentls. smoke, S- them an to trv an, Senat( ing and' to us? IIr:C hil-her t: nicotinee differem nicotine- vor-I 11 flavor ar Senat c pay the ii ltr. V ready gc( it's 65 c Senatil Miss I you pay anyway. nicotine know, it then yot harsh, tl Senat, no effect _l.iiss 1 Senat( 6t)or65 .lliss other pl whateve Senat, Your pa Miss I Senat( of desir is in orc ofthed and inal started'<OIs. i to thanl help in c Than] \Iiss Senav. Senat Richarci Dr. E

-3- 220 A'preliminaryevaluationof this programihas demonstrated positive cognitive gains andlattitudinal changes.in the children as well as spin-of'.f effects in th'efamiliies. There.isa crucial need for additional.funds to.enable thePbimary Grades Health Curriculum Health.Project andd other innovativecurrioula.in programs to reach all of our nation"s eh'ildren.If the amount authorized in th'ehiLliise made available,, it will be possible to take advantage of the valuable demonstrations initiatedb'y HEWand.others.. The American Lung.Associationstrongly supports definitive studiles of the health risks of cigarette additives. Not only is little known aboutt thehealith risks of additives, we do not even.know which additives are being used. An enormous task faces anti-smoking proponents. So f~ar„ the resources made available b'ytheFederal government to aid these forces have been.extremely sm.all i-comparision with thosee off the tobacco indust.ry,.. For this reason we believe the provisions of Title IV are long overdue and we hopethis legislation will be passed. I will begl~ad to answer any questions you.may.have. ROBERT M S AME SUBCOMMITTEE C4MM

' Health, Education 1975. :tes and'the Dev- 11-68, 1973. Infarctiom,, by Type of Smoking and n 44 Months of :1159-1172, 1958. i US Veterans. .udy of Cancer and :er Institute, Years Observations 476, 1964. Health, 1975. ent of Health, 76-1221). ks in Men After ham Study. ng Factor in of Carbon Monoxide Rabbits. J. ence of Card9o- ears Fol!1!ow=up. 225 -4- 13, Evans RI; Smoking in Children: Developing a Sociali-Psychological Strategy of Deterrence. J. Prev. Med. 5: 122-127, 1976. Americans. Policy to ary 31, 1978:

e requesting $1 id Human De- ts of smoking 3a1 of our pre- provide educa~ rdiice, personal does not neces- resent bondage formed' choice. 3ecretary C6,1i- rform children schools. Some_)ed and tested _onal programs , we must also >ward smoking instance, that it forming; 69 Is; two-thirds 1 teachers and children, their to study and ssociated with ipof tar, nico- iost important rning work on iost import'ant of the original it the changes *ild attempt to e basis of thiss ts of the ques- mation will' be. e just marked ucat~ion smok- ie administra- in the Labor- ng. I thought ~ome 300 sub- for flavoring of these sub- of additional d other addi- tives. If ingredient knowledge is justified for the prodircts we ingest, it seems to me that they are at least equally j ustified for products wee inhale. In summary, Mr. Chairman, the Department is deeply gratified byy the continuing support of' this subcommittee for disease prevention, particularly effortsainaed at smoking, and health. As you know, theDepa.rt'~ment presently has broad' authority in this area and has re- centlv undertaken, a major initiative aimed at objectives that closely parallel those of S. 3118. W'hile in many instances, specific authority may not be required to advance our nnutual goals, this expression of support from, the Congress will significantly aid our efforts. If bubonic plague would now stalk our country and if it would kill 900 people per day in the United States, thepublhc would perceive thiss to be a crisis and demand action. Because the problem of cigarettee smoking has d'eveloped insidiously, it has not been fully appreciated: And yet it is a modern and totally preventable plague. It is a health erisis, and yet every 22 secondS another teenager in this country takes up smoking. We are pleased thatvou are providing tlreleadership~ toident.ifyand counteract this 20th century epidemic. Thank you. Senator KENNEDY rpresiding]. Thank you very much. I apologize to our witnesses, and the previous witnesses, in particular my col- league; Senator Ford, whomi I alwaysenjpy eschangingviews with on this subject. And we appreciate your comments. The administration, as I understand, requested $,30 million, is that correct? Dr. FoEOt;. Yes. Senator KENNEDY. Dr. Foege, I first of all want to welicome you very warmly. We remember our very interesting visit that mcmbers of t'lie committee had down at the Center for Disease Control earlier on~ legionnaire's disease, and I think it is really one of the outstanding centers in the v-orldl Atl a time when people are wondering about therelationship between Govemiment and science and research and health, vou head one of the truly extraordinary examples of excellence in t'heCovernment, and I commend you and those wholare associated with it. So vou don't mind now if we go over a few points ? Dr: Foror:. Thank you very much-no. Senator KENNEDY. You have $30 million in the administration, budget request. Now, as I undlerstand further, $24 million of that had' already been previouslyprogramed, only $6 million is new money, am I corre:ct?' J,Ir. PraNEr. Mr. ('hairman, it is $10.1 million in netir nsonev. The fi,cal , yearr 151.7Kbuolriet anionnt -,i-as $19.8' nvillion. thefi6cal year 1!)7~A rer1rie5t is,for $:3/1 nrillion., Senator KENNEDY. Tell us where the $24 million camefrom?.llr. Pr~-~N:i-. $?-t! million would be a combination of'currentlY pro- irr,urred ruorrey and new rnoney prirnarili-frn• research in: theV<itionrrl Institutesof Health, the Albolrol, Drug Abuse, and Mental Health Adrrrinistrationk and the GenterforDiseas(, Control_ ("urrent smoking nelaterl ac ti%,ities in these agenci'es anionnt to$2lD milllion-S4rnill'hon ini new rnoneav for thc9Vational InstituteofG'hlld Healtlr anrllHrrrnan I)m-elbpnrerrthas beeni requested. An additional' $6:1 million isfortlre x, _::M 0 - ;3'-,

174 And for as long as the fairness doctrine pertained, and cigarettes were also advertising on radio and TV, we were highly visible and very successful. We got millions of people to stop smoking. Cigarette smoking declined. When we banned' cigarettes from radio and TV we lbst our man- d'ated' prime-time exposures, our mandated frequency, and~ we lost a visible enemy to pit ourselves against. And cigarette smoking,began~to climb. Since then, anticigarette spots have been basically confined to the ghett~o of the Late Show, catch as catch can; to compete not against cigarettes, but against zoos and adoption agencies and a whole passell of other worthy causes. The irony is, the cigarette companies continue to spend millions and! millions of dollars every year advertising cigarettes, while public health is a beggar, depending on free handouts from the media, unable to mount a seri'ous steady campaign against smoking, unable to target a market or build a schedule, an audience, or, most important, the non- smoking habit itself. Now it is very tempting to believe that somehow the cigarette com- panies have in their deep dark files mysterious secrets that enable them to manipulate us into smoking. I don't believe it. I believe we know as much about smoking behavior, smoking ap- peals, peer group pressures, social leaders and follbwers,,emot'~ions, and others, as they do. The National' Clearinghouse for Smoking and Health has been! ^ollecting data, the Americani Cancer Society hasbee-n colllect'ing, data, t'heNCI and all sorts of social psychologists, sociolo- gists and other interested parties have been interviewing, surveying and collecting data for years. And wehave our own~observat'ions overt'heyears to go on. And! I don't believe that if' we ever d6getthe ciga- rette companres''st'~udies we will suddenly have the keys t'o turning off theliabit in theAmericanpublfic-bythe way,,whileweare waiting, we are not simply letting them prosper, we are deliiying our own fight. No, I dbn't believe they have a devilish secret. What I do believe, indeed what I know, is, that they are devilishly good, very smart and very professional: They know what t~o dowit'h what they know, an& thev've, been willing toiolvest h2indreds of millions of dollars doing it all theseyears. They advertise, advertise, advertise. They never quit. They keep their messages flowing, keep their campaigns coming, keep their product visible iu every medium open to them. They target, they schedule; they d'ecidewhat they should' say where. They repeat and repeat and repeat. Theyknowevervcigar.ette is an implicit ad for smoking. They build! imageand reinforce habit. They are the one constant presence. They put us to shame. Forsomeliow-probably because we calli it advertising, which in many quarters isa dirty word-we have been, unab3eto get the money to make a concerted iuass-medfia attack on the smoking habit, or on a persuasive presentation of an alternative habit, the hnbitof notsmoking, I think we shoulkll change t~heword. Let:'s not', for the sahe of ourcliildren, call itl"ad~-ertlisiu-rr."Let's,calllit "education"-"health educa- tion,"if you will. And then let us take a leaf from t'hetobaceopeople and'let us schedule 30-second "lessons," 60-second "lessons," 10-second "lessons," or 2-minute "lessons." Let us buy the time to expose our I "lessons," t'o plan ou posed to buying otl then buy trm.e ? And establishment, or (f( sons" be as bright advertising around- Let us apply the kI it's cue from TV con tion span of kids, a on TV anyway). An at the right times, 1 are new kids joining as the great newcffi:sex and violence con the idea of banninr start some new ideas them counsel and s punitive nonsmokin and the self-respect a. That means buyi paigns, being as pro ingas t'hecigaretteWhy ,I'V ? Why r schools and' yet our u hygienedn schoolsun (and kids today kno and our drug probl] younger population. We may not liker-alues and ideas. A~, learned from our cc is perhaps the grea y.oungsters,, you've ~ Can you "sell" a h I believe that too habit of brushing (ai and dentists combinc to build cleanliness- bygieneand with it ~ ! than schools and doe And I know from Cancer Society and Health that you can women to have Pap qarit smoking, smoke ons cigarettesi and o cigarettlecompanies, Q products. W And I know f rom, (nLadies' Garment ZV- C and sensitive messa. W union message, look ~union song. ~

215 ~s Committee Can~death due to cigarette smoking be reduced by regulating cigarette advert'~ising to make if less lethal!?' I believe the answer is clearly "yes. " We are accustomed to thinking of'~ cigarettes as lethal, not the advertising of this producV. But cigarette advertising exerts a tremendous influence over people -- both im starting them on the roadlto smoking and!. in increasing their consumption once they have started. It is in "hooki'ng"'people in the first place that the damage is:done. and as a man, who spent his ent!ire business life in advertising, I can tell you that the potency of advertising in "hooking" people is incalculably great. I realize that~ this goes counter to the protestations of the tobacco industry. But the industry"s rather absurd! claims of innocence -- in saying that cigarette advert'~ising only switches people from one brand to another and does:not increase total cigarette sales -- are founded on nothing but airy and self-serving nonsense. One need not be a marketing expert to realize how silly is this oft-repeated "not guilty"'plea of the tobacco people. Before the development of the cigarette making machine in 1876, cigarette sales in t'his country were negligable. (Though tobacco in other f'orms: -- pipe, cigars, snuff -- was widely used. ): So, starting from virtually not'hing in 1876, cigarette sales: have grown to more than 600 billion units a year.

159 inzaga College High thesda-Chevy Chase ulata and Bethesda- n the formal witnesss the younger students ;Iink the Congress of ~y, of sources. In this R-ithan issue which -his country, perhaps interestis, the good rgly concerned aboutl _s so many scientists, , the scientific infor- or a type of health ions that have taken ni smoking continue. y what some of our )ointed out to this and means of work- _i and' your associates way we can work in er generation, of the realize it involves a )eople-and wetivant')u think is the nature -an best deal with it. is here this morning: «'ell, it's nothing to u in your own word's. have over here that' the very significant ,en 1968 and 1974 by ungest age, from 12, esponding increases, -ically dramatic con- )int, as we can see in tually even~ with the ls of' the use of ciga, s about the issues. ev-s; about smoking. ,)bviousiy, but we are nmes, y.our ages, and ,e to ask you a.bout ome otllerquesti'onsr teresa. Talk into the an4 R•hereNou go to I am Ted Iienned~', Island, and Senator Schweiker, from Pennsylvania, and we-are all members of the Health .Subcommittee that is concerned with thislegislation. So just give us your name, your age, your school, and then we will ,ome to some of the questions. STATEMENT OF' THERESA WOLFF AND MOIRA REILLY, IM- MACULATA HIGH SCHOOL; MARTIN O'MALLEY, MARK ADAMS, AND CHARLES GRIFFITH, GONZAGA COLLEGE HIGH SCHOOL; AND JAMES VALEO, BETHESDA-CHEVY CHASE HIGH SCHOOL, A PANEL Jliss WorFF. I am Theresa Wolff, I am, 17 years old,, and I plan on ,©ing to West Virginia Wesleyan next year. Senator CHAFEE. And you just gradilated from wliere ? Miss A'1"oLFF. Immaculata. Jliss REILLY. My name is Moira Reilly, I am 17, and I have just. ~_'raduated from Immaeulata High~ School. Mr. O'DIALr.EY. I am Martin O'Malley, 15, I am a freshman at Gon zaara CollegeHigh School. Mr. AnA.rs. I am Mark Adams, I am 15, I am also a freshman at l ionz4lba. Mr. GiiIFFrrx. I am Charles Griffith, I am 17, I am a junior at (l7onzaga. Mr. VALEO. I am James Valeo and I am graduating from Bethesd'a- ( 'bevy Chase IIigh School. Senator IiExNnoY. Could you telllus, maybe by just a show of hands, how many of you smoke? _ltavbee we could start with you, Theresa and Moira-when did you ~rilrt?' \Iiss WOLFF:. Around 14 or 15. ",enatior KENNEnY. 1jrhat about you, b2oira ? M1sS REILLY. 15. Senator KE.N-.-.TEnY. James~?JIr. VALFO: Yes, I was 13. `enator KE-N-NEnY. _llark ?' Mr. AnA-Ms: I was 13, Senat'or KE-NINrDY. I know that's a few years ago;, but do you think `~~~101- or not try smoke? ~~as t sort of a consc ous de asiod2d to start to Jliss REILLY. lVell, basically when people start smoking cigarettes, ir, is beca2tse of peer pressure; your friends start to smoke. And then it i, a choice of whether you want to be sort of left out by people of ~,nur own age; if you don't start smoking, you know, they sort of look '1nR-n on~vou. ~411i1<Itrn• Cir.%Prla:. What pe1•centa_,~'eofthe ~ii•Ik~ in clitss~,snnoke?AIiss REIr.LY. In my class I.~-ould say about 85 percent. "~t,nator KEN-N-EnY. What about you, Theresa, when you started to s ninke? -MiSs AVoLFF. I started smoking mostl~because I like it. I would say L~tarted snnoking probablyto fit in with the crowd. ~anator1 ICENNEDY. Let me ask the ones who do smoke-could I just. '00 your hands again ? How many of your parents smoke ? Botlli your E)arents smoke?

2. Now, let's sharpen this a bit. At some point in the distant past -- the exact year is not important -- cigarette sales were at the rate of one billion units a year. Now, if all cigarette advertising does is switch smokers from one brand to another, how in the world did cigarette sales ever rise from 1 billion t!o over 6Mbillion?' This must have been the most magical marketing achievernent' in~all history! A sales increase of sixty thousand percent while the national population increased only, 4-1 /3'times -- with no assist from advertising, because it only swit'~ches people! Who can believe that?, In reality, beyond any shadow of doubt cigarette advertising has been the predominant factor in building,the present more than 600 billion unit a year cigarette industry, with an annual' sales volume of $15 billion. The cigarette industry is unique in many ways. It is the only industry whose existence requires human sacrifices on a stagger- ing scale. The most conservative estimate of the number of cigarette-induced deaths, which you can obtain from any non,tobacco source, is 250, 0Mper y~ar. This works out to one premature death from smoking every 2 minutes and'6 seeond's, around the clock, 365 days a year. Unless the U.S. Public Health Service, the American Cancer Society and the American Lung Association are all wrong -- one American dies every 2 minutes and! 6 seconds -- on the average -- as part of the price we pay to keep the cigarette industry running; at its present level of activity. And thc 300 million dollars a yea Can we they employ to"hook"pec more deaths? Can we nc people from getting on th lung cancer?' The Ar that there should be no n~ complished it would helpp both sexes, with whom y associated' with cigarett In this the Congress what to do A' fulli answer to this que A' committee of ad4ert'is: Lwill _ please start to do sometl effects of cigarette adve= Remen and 6 seconds until some 50-536O-1$- 15,

current FCC proceeding, but it's written in advance of any outcomee on that.. Ratlher thanrelying solely on public service time contributed by radio and TV stations, whfichis solely ettremely, limited, especiallvduring time periods when a large audience is available, community programs should be permitted topua-chasetime and thus control tliefrequency and times ofplacement.Pcrsons responsiblh for theseprograms should seeh~ tosupplement paid commercials through appropriate useoftadk shows, editlorials; segments on news shows, document~aa•y features, ancd special children's programing . In the same way, local, control proluranIsshould beableto purchnsespacefordisplay ad~vertising in newspapers and inmetropoli'tan magazines. Comprehensiveprograms should also includeatteiuptstotrtilize othervehieles in theprint niedia, such: . as neN~-s stories, feature articles, editorials, cartoons. and letters to the editor. Commercial advertisers,typicall~r plhce their materials where they ,i il2 beseen or heard by persons in themarket fort-heir productls:It makes sense for smoking controlprograms to do the same. Someesam- ples of media which reach children and ad'olescents, in addition to those listed above, are comic books, posters for schools and f'or kid's rooms at home,sliorts or `°trailers"for use in mov.ietheaters, place- mats in fast-food resturants, bumper stickers, buttons, milk cartons. andT-shirtianprints: All of these could beused in a comprehensive community program, not'toprovide detaile& information but t'oserveas reminders and perhaps to help establish nonsmoking as a norm. A special not'~e.should be added hereregardfing tliescale of advertisT ing, and related elements ofsmol:ing controli programs. In anenviron- Tnent wheree a tobacco companycan, spend $-10million, to develop and promote a single new brand of cigarette, and where, well over $2500 million, a, year is spent to adv ertise justthetop20 brands, the odds are slight that a small counter-eifort can have much impact on the "cli- mate" regarding smok~iilg. By the age of 12 a child has experienced a: long period of 'exposureto eigarette advertisii~g ancU the example of adult smoking: thus;it seems unrealisticn to expect significant results from fraginented programsof small size or duration-and in the past, that lias been too often what we've had. Whatiever the nature of theintervent'ibns emp3oyed,all prograrns funded under theproposed'bill should be recquired't!o(1)characterize in detail the methods and approaches used; (2)1 use evaluation designs R-hichi meet specified criteriu for appropriateness and scientific rigor; (;3'), use outcome measures~ which include bel6avioral assessments as well as~self-reports fromichihlren. The purposeof~ these requirements~ would be to makeprogram re- sult~scumulat~ive. Thatt is, to makepossiblean accurate determination of the relative value of various, approaches so that those found, to, bemost efective can beiQnplemented on a wider scale. In snmmairy, the fol9owin;should characterize new community prot_ri•ams : Plans based on, accurate and current knowled-e of children's be- liefsand attitudes regarding smoking (derived fronl surveys, focus groups; a nd so forth ); Yse, of specifia cbjectives, so that efforts cani be kept on tlrack and results evaluated clearl'y. Estensive health agenc. Involveme sicians and c Use of a v< Emphasis smoking belh Involveme desib i of m,, Protesting Use of atl Use of' mn late& to phy, Controllec media ; Rcinforce: Use of ri. assessment 0 It has bee: arises becau: problems ac on health c: Clearly the smoking cor. ~ health and r SenatorK lls. GRF.F.° director of ( In the past inghouse on agency proc under contrr of the publi and have se 1971. :liost i Cancer AdN things,I thi7 the preparec. It is ~ wror because of a Today,, ac for about 60 upsmokin- sidering it a We only Surgcon Gc cigarette sn a destrover j1'e also. that we cou We learneai cans the te on it.

213 4. :d non,fil.ter cigarette tles compared to 24% 1 hazard among blacks. ,r the entire nation.) has schedulied~for next .'black Americans. At that .n we now know about r perceptions of ition. We will no doubt ated cancer among , in magazi-:es and :ted' by content or cited represent strong 5. some of the recommendations of the commission, which held hearings in several cities to,get expert testimony on the smoking problem. For instance, a suticommittee of our new Public Issues Committee has already recommended for Society endorsement a differential tax on cigarettes according to their tar and nicotine content; has recommended endorsement of stronger death and~disease warnings on cigarette packages and in cigarette advertising. Our full Public Issues Committee will _onsider these recommendations the second week in June. There is no question in my mind that the Am~rican Cancer Society will in a number of ways join with this Subcommittee in seeking to strengthen the preventive medical measures that have been proven effective in tests or demonstrations and which should now be proliferated. We corunendlyou on your approach to these problems. is just recentliy received rmer HHW assistant smoking. With study 2. ~ ready begun adopting W. ~ ~ W ~ V

226 E. CUYLER HAMMOND,2 LAWRENCE GARFINKEL,3 HERBERT SEIDMAN,4 AND EDWARD A. LEWS Department of Epidemiology and Statistics, American Cancer Society; New York, New York 10017 Departrnent of Epide ""&Tar" and Nicotine Content of Cigarette Smoke in Relation to Death Rates' E6'% IRON SfENTAL RESEARCH t. "Tar" and' N E. CUYLER HAMMI Over 1,000,000 men am (with,fewexceptions)tr, smoking and various oti questionnaires on three J. the amount of'tar and nic< of two 6.year periods. An death rates„death rates f. somewhat lower for thm~ smoked "high" tar-nico tar-nicotine cigarettes w regularly. Many years have pas number of epidemiologic country and abroad (U.S death rates are higher in ~xposure to tobacco sm( (1) lung cancer andcanclitrynx, pharynx, esoph ,troke, and aortic aneuryy other diseases including The age-specific lung e ,.t as found to be about te never smoked; and this r. more cigarettes a day. I ::oronaryheartdiseasedF '.',.5 to3.0~times as high dt hrtrrdisease death rate 1 d t: ' From a paper given att the .~haratory; New York, Septe Sc D., Vice PresidenC ' V'1_A.,.Assistant Vice PtesM.B.A:, Chief of Statistic: t'.S.A., Consultant., ~ t`~right.<.: 19'6by,Atademid tYess.ll 1 'ih[, uf rcnrnhictinn ~manv fosm n M C

171 lerstood what I'm saying. first one to smoke a eigar- ,e the fi'rst one to take an be related to whether he's •eotype person You'ie tall:ingabotrtg the it were. more of afactor than, they pe who tends to do these iinly that cannot be ruled ier witnesses, and then «e anL ultation and research for ring the past 15 years my zcticein the field of health under consideration, but )art of'title IV -whsch, con- [dren and adolescents. ot done in collusion with you will hear some echos hi on thedet'~erminants of 1 school-based programs. -al aboutt the determinants control ib. In the case of :n adequate basis for pro* ~ontroll programs are to be Ipeer influence are closely girl most likelly t~o begin f'der brother or sister who ie presence of a; nonsmok- with markedly lower rat'es ild addressparents; teach- m focusing exclusively on people in San Diego, tcen- eight reasons given most r behavioral research, but ous clues for the design of ,nd it on somethinge1Se: Smoking cantt hurt me-l smoke filter cigarettes. Smoking ishetterthan puttingona lot of weight. Allim3' friends smoke, sowhS shouldn't I? Thesecoinments,confi'rm the view that teens"uncUerstandingof smok- ing risks isoft'~en superficial, and that theyare: concerned about per- sonal attractiveness, being accepted, being, "normal," and becoming indepenclent'.Given someltnoR-ledge of reasons why children begin smoking, what should be done in communityprograms deti=elbped under the proposed billl?' H~oivwould they differ from programs now oherating?'Opinions on these questions will vary, but I belieti-e. most health professionals would regard thefolloaring, ansR-ersas: reasonable.Dlany control programs are no~rbeing implemented insc11oo1 sys- temsthroughout thecountiy. Sbme of these, particularlyt~heones which cover smolkiirgasa part of ai general orientation tohealthy hat-esho«n promisiiigresults. A ew programs should beencouragede to uti- lize a widevariety of approaches, includingthe development of coping skills -which could enable children to resist pressures toengage 1111 various other behaviorsharmflut to: health. a number of current programs offer only a single brief etposureto information about smoking, preslmlablv on the assumption that this will somehow "innoculate" children against'~ subseqltent pressures to smoke. Simcethedecision not'tosmokemust bemadeperiodi'cally ratlher thani onlyonce.efforts to support! this decision should be pro- vided on ai continui'ng, basis or periodic basis from the primary grades~ through high school. Programs which provide information about physiology and t'hespecifnceffect's ofsniohing are appropriate as part'of a general edu- cation, but they areclearllyinadequat'eas a means of deterring smokin;~ in adolescents. There is: a need to supplement this information with nonhealtli appeals, since most, teenagers who start smoking do so be- ca2lsethis provides other values which seem to outweigh the perceived healthi risks: 9 out of 10 teenagers believe that smollina isharmfull to health, but they are in al conflict situation because they also seesnok- ingRs a sourceof peerapproval and a symboll of adult-hood. The,design of control progranis,iin this area is made especiallydiffi- cult by the factthatthepositit-econsequences of smokin'h such as peer acceptance-are immediate, n-hilethe ne~,~,at'~ivehealtli conse- quences may not appear until years later. It mawbenecessaryt'~o devise forms of immediat'ereinforcenrent of nonsnohingbehan-ior if controll prograuns: are to become gen2iinelyeffective. _A`e« conlnluniky-based programs should involve gi•eatercoopera- tion on the part©f school systems; health departments, affiliatles of rolnntaryhealth organizations such as the American Cancer.Societv, American Heart Association, and the American Lung Associntion, andd otlier appropriate comnnnnitygroups. Not thatthere has been zero cooherat'~ion, but it' should be greater. JI'henever possible, childrenoradolescent5 sbould pnrticipatein'tliedevelopjuent of ne-,V program materiaLs directed to them, and such ma- terinlsshouldbetested for-apheall and effectiveness before beingpro- ducecl in quantity. The number of'antismol:ing spots broadcast on raclibandltelel-ision has droppeil sharpl.y oN7crthepa:>tflew years; And the following com- me3it might be subject to change, clependinn on what happens in the

224 -3- REFERENCES 1. The Health~Consequences of Smoking. U.S. Department of Health, Educati'on and Welfare. PHS, CDC, US Government Printing Office, 1975. 2. Kannel WB, Shurtleff'D; The Framingham Study: Cigarettes and the Dev- elopment of Intermittent Claudication. Geriatrics 28:61-68, 1973. 3. Feihlieb M, Williams RR;, Relative Risks of Myocardial Infarction, Cardiovascular Disease and Peripherial Vascular Disease by Type of Smoking. In Proceedings of the 3rd World Conference on Smoking,and Healthti 1975, p:243. 4. Hammond EC, Horn D; Smoking,and Death Rates - Report on 44 Months of Follow-up of 187,783 Men:I. Total Mortality. JAMA, 166:1159-1172, 1958. II. Death Rates By Cause. pp. 1294-1308. 5. Kahn HA, The Dorn Study of Smoking and hlortality Among US Veterans. Report on 8k years of Observation in Epidemiological Study of Cancer and Other Chronic Diseases. W. Haenszel, Ed. National Cancer Institute, Monograph 19: 1-125, 1966, 6. Doll R, Hill AB; Mortality in Relation to Smoking: Ten Years Observations of British Doctors. Brit. J. Med. 1:1399-1410; 1460-1476, 1964. 7. Proceedings of the 3rd World Conference on Smoking and Health, 1975. Vol. T: Modifying the Risk for the Smoker. US Department of Health,. Education and'Welfare. PHS, NIH, (DHEW Publ. No.(NIH) 76-1221i). 8. Gordon T, Kannel WB, McGee D; Death and Coronary Attacks in Men After Giving up Cigarette Smoking. Report fram the Framingham Study. Lancet 2:1345-1353, 1974. 9. Aronow WS, Kaplan MA, Jacob 0; Tobacco: A Precipitating Factor in Angina Pectoris. Ann. Intern. Med. 69:529-539, 1968'. 10. Astrup P, Kjeldsen K, Wanstrup,P; Enhancing,Infl!uence of Carbon Monoxide on the Development of Atheromatosis in Cholesterol-fed Rabbits. J. Atherosclerosis Res. 7: 343-354, 1967. 11. Shurtleff 0. Some Characteristics Related'to the Incidence of Cardio- vascular Disease and'Death: The Framingham Study, 18 Years Follow-up. DHEW'Publ. (NIH) No. 74"599-1974. 12. A National Dilemma: Cigarette Smoking or the Health of Americans. Report of the National Commission on S:noking and Public Policy to the Board of Directors, American Cancer Society, January 31, 1978. 13. Evans RI; Smoki~ Strategy of Dete

218 STATEMENT OF THEAMERIQAN!LUN'G ASSOCIATION ON'TITLE IVOFS. 3115 TOTHE SENATESllBCOMMIT2EE ONIHEALTH AND.SCIENTIFIC'RESEAROHLPRESENTED BY DONALD A. YOUNG, M.D: I am~deliivering,t~hi~s statement on the smokingdeterrence provisions of S. 3115 for the American Lung Association as a member of that organization's Medical Section, the American Thoracic Society. I was theMediical Director of theAmerican~.Lung As.sociatiom for several years until Ileft in 11977. During that time, I wasint~imately involved with.the American LungAssoc.iation's.smokingand health programs. As.a physiciany I have ast~rong interest in anti-smokingact~ivilty because I am convinced that the smoking.habit isone.ofs the most severeroadblockst~o iinprovingthe nation's health. TheAmerican Lung Association's program is devoted to thecont:rol.ofpulmonarydiseases. Because cigarette smoking is related tochronie obstructivelung,diseases such as emphysema and chronic bronchitis, a major priorityy of Lung.Associations is smoking and health~probLems. Chronic obstructive lung conditions are now the 5th leadingcause:of death from disease and represent sigaif'icant burdens in medicaliexpense and disability.for ourr country. The Social Security Administration estimated years ago that disabi~litypayments for workers who had to retire prematurely.because of these:conditions amounted~tlo one-half biLliion dollars.. Todayy thesecos2s are be consid'erably, higher. This is.one of the reasons that the AioerieanLung Association supports an expanded Federal program as outlined in Title IV'ofS..3115. Pr.emature deaths and human suffering are even more compe.lilingreasons for our.support. We believe that smokers should be effectivelyy separatedd from.nonrsmokers in all public and closed places such as public buildings,.places of entertainment and the work plac.e... We believe that the Federal government should be a leader toward this endby, mandating,separate areass in its own facilities. On,t~he question,of ciga: which.is g.raduatedby the a are of the opinion that car off those toxic uni ts becaus We agree that the Federali T. cer2ifythe content of toxil Certainly, the effectivv questioned. Vhen any messa not to notice it..Rotatin€curiosityon~the part of sr and read the message. We have particular intc( snoking atmongchildren. T?often the end product of wiTh'is education,ofi the chilc notivated by the informatic various ages and social grc( research in the biological Demonstrations and eva~ anigranes to he1pSGates r. are.urgentlye needed. The . of Health Education, HEW,,: demonstration of thePrima~ of thec.ountry., Between 3- curriculum, Iit is an~exci~ variety of risk-taking beh .xbout his.orher health.

223 ime is Robert M. Daugherty, !dical School at the ttee on Smoking.of the Subcommittee on behalf 3port of the National 3. As you may know, the ry health organization key members and some the reduction of pre- ascular disease. ny thousands of prema- s high among cigarette s die of coronary heart ases an individual's g in 1964, the contri- heart attack and coro- 'irmed'and strengthened Ical evidence (1-7)h th the onset of perii- principal cause of both .re in turn the chief )ther types of heart :ases in proportion to ,f exposure to the habit. disease risk is inde- isk is greatly aggravated )od cholesterol.or diabetes :e place themselves in F smoking by smoking fewer -otine cigarettes, taking s to abstain from smoking it effective if the to cardiovascular disease rt Association applauds -ned' areducing the health -2- consequences from cigarette smoking. Therefore, we support the following proposed initiatives: 1. The institution of a differential federal, tax on cigarettes according to their tar and nicotine content. Since the current trend among, smokers is to purchase lower tar and nicotine cigarettes (12)',, such a system would not only aid smokers in selecting a less hazardous cigarette but would provide a financial incentive for them to do so. 2. Utilizing the strongest possible statement regarding the health risks of smoking, consistent with scientific evidence, as a warning label to be placed on cigarette packs. This could include the "revolving labelP" which is being used in Sweden. 3. Support for epidemiological.stud4es to determine the relative risks associated with the varying levels of tar and nicotine and other sub- stances commonly added to commerically prepared cigarettes. Continued biomedical research is needed to gain a better understanding of the mechanism through which cigarette smoking,eontributes to the dpvelop- ment of cardiovascular disease. 4. The establishment of programs designed to deter smoking among children and adolescents. Since the onset of smoking, specifically "experi'mental smoking"', is occurring at ihcreasingly earlierr ages (13), this inifi- at'ive is right on target. As smoking continues to decline in the adult po^ulation, there is a growth, in the number of smokers among this nation's youth, especially teenage girls. Therefore, we are parti- cularily pleased'to see the special emphasis on pre-teens and teen- agers. A review of the evidence to date linking,eigarett'es to coronary heart disease, peripheral arterial disease and chronic obstructive pulmonary disease indicat'es that smoking is a major and preventable cause of each of these diseases. Gains against this man-made hazard~have been modest considering the vigorous and effective actions being taken against other man-made environmental hazards, often based on less evidence of adverse health consequences. Effective action is clearly required. The American Heart Association stands ready to assist this Subcommittee and the Department of Health,, Education and Welfare in your efforts to: improve the health of this nation. Thank you.

202 While we are on that point, do the rest of you, in looking over the label provisions, agree in terms of their scientific accuracy of the la.bels ? Dr. YOIING. The problem of scientific accuracy is difficult without some hedgesuchas'`may"and wliatever. I think that the labelst'hat you have continue to question the firmness of data. I will give you an example. "Cancer may result fromi cigarette smoking." It is very dif- ficult to prove a causal relationship, and the "may" may incite a doubt in somebody's mind. Senator KENNEDY. tiVell,, isn't it an accurate statement? Is it an ac- curate statement? Dr. YOUNG. Yes; I think it is a veryy much an accurate statement as far as it goes, and the question is, Is the "may" strong enough, is there anot'her way of phrasing it that is even stronger than the ."May." Senator KENNEnY. I see. All right. Dr. LEFFALL. In the Cancer Society, we think that it is an accurate statement, and also we think that perhaps it isthe best statement now, based on what we know. Senator KENNEDY. All right. Dr. DAUGHERTY. We know that the odds are high if you smoke y ou are goingto have a heart at't'ack, Therefore we ought to say it. We also support the initiative t'o cont'inue biomedical research to gain a better understand7ng of t'hemechanismthroughwhichcigarettesmoking contributes to the develbpment of cardiovascular disease, but also to continue research~on why people smoke, especially young people. As we heard here today, we hear a lot of reasons; buti we need~ to con- tinue our research in that area. And certainly the: establishment of programs designed! to doctor smoking among, children and ad'olescents. As we have heard here t'o- day, this is & major problemi and' one [sic] that two wholeheartedQysupport. The American Heart Association stands ready to assist this subcom~- mittee and the Department of Health, Fducationy and Welfare in your efforts to improve the health of this 11 ation. Thank you: Senator KENNEDY. Thank you very muchL Mr. Banzahf'? Mr. B_aNZnaF. Thank you, Senator Kennedy. My name is John Ban- zahf, I ama, professor of law at the1rational Law Center of the George Washington~ University„ and also executive director of Action on Smoking and! Health (ASH). To paraphrase an old cigarette commercial, we are lhgal men nott medical men, so mytestimonv will beslantied a little bit differently from that of my medical colleagues. I alsodonotlinR-e prepared re- markstomake: I.rastold that I«-as toccrme and react to what I snwheret7iis morning; and I thought it would be somewhat presumptuous to prepare remarks beforehand. So I would like to simply share some of mv thoughts with you on itl. First, Senat'~~or, I t'liinkyou are to becongrabulated not only for introducing this bill, but also for holdin,tr these hearinas on the most important and, to me, t116emost• tragic aspect, of the problem ofl smok- ing, that is, t~heepidemic ofsmokillg among children. _knd I thinkthis appears as a, vervdramatic contrast to the inane ar~nments, of the tobacco industry about free will; that is, that Secretary. Calif ano's progi his m old k we ar Ford' we dc rnenti and a ticula the N%- efl'ect: I ti have: about pornc propc almos Yo, havee millic yet I : to the with curre: is illu is bei very Ser. 'i.oulc cannc both : of th(andr have wlieti. else. I of oui «'ee the sa pie a) those restri. regan Ser. Mr. ber o have effect!:' promi Th( have Trad( contiR

104 will recall. Thereare many plusses as relates to heart attacks and other thin~;s: And~ you have to take into consideration right now : This is a protein-short country, and fraction 1 Senator C1Ia:rFE. E'xcuse me, I missed that-did you say there are plusses to tobacco? Senator FORD. Yes; sir, the research says that smokin,u is helpful,, and there arepercentlages, and I can give vou the statistics-I don'thave, themi with me-but I certainly will. _Vreyoulfamiliar with frac- tioni 1 ? Senator CxAnEE. Well, these hearings are going on for several days. Senator FORD. Yes, sir, and they will beiir one of my committees. Senator CHAr•EE. «''ehaveinn-ited a representativefrom the Tobacco: Institute, but they felt the not!icewast'ooshort- Senatlor FORD. Well, notified oni Tuesdayt'~o be here on Thursdayisa litltle short for me. Senat'~orCHAr•EE. Well, you are prepared in this subject. Senator FORD. I hope so. SenatorCIIAFEE: But if there is evidence that tobacco is beneficial, we certainly wouldbe glad to hear t'lleen-idence. SenatorFoRID. I w,oul6 be glad~ to bring it to you, Senator. And not onlv is it beneficial-are vou f'amiliar with fractioll 1? Senat'or CrInFEE: No; I'm notl.. SenatorFoRn.Oh,well fraction 1, you see, is the protein thathas been discovered in tobacco. And t'hey,are moving forward with that right now in a prot~ein-shorb country. It is estimated'that t•ou can take the protein from tobacco-you can take care of 6(l million families with, what. is being produced now by tobacco, andl still have your cigarettes. And so you aretlyingt'o damage acro?~ here:and put it out of business that has an opport'unityto solve many of theproblems asits relates to llealthi in this country. SenatorCltaFrE. Well, this1ilh as you know,,is primarily to provide information; it's not putting peopleontof business. Senator FORD. Well, where are you getting your money, tllen, to put out tlie, informatlion ? Senator CIlAr•E.E. The money is coming from the Federall Govern- ment plus some of it from, an increased tax oni high-tar cigaret#es. Senator FoRa: So you are taxing one industry for preventative in- formation on all areas: «'llydon't you get t~heother areas in, and let'' themi share theproblem, if there is one-automobilhs, for instance. H'owmuch are you, goingt~o tax an automobile to help? Ho«muchare: you, ~;oing to tax the asbestos, peol;~le?Scllator CYIArr:r•.. With manv brands the tax r-ill godo«'n. Senator FoRn. Well, theindilstry is doing that noww without Fed- eral Government intervention~ There iscoiupetition between,iQldhtstries in thee open and free market, andl you are- trying, b,ytax,to foree peoplet'o do soinething that industry is al'ready doin~. Senator CIIAr•EE. Ij~el1~ wsobe-iously have a difference of opinion here. Senator FoRi). We certainly.do,, and I will be delfihlhtedi to debate it, with you,SenatoI'. Senator Cil.r•EE: We are going to have further «•itnesseson that! particullir subject, theprotvin siibjpct. that you sugrested: «reaI'e gratiefid for the views that you present. :1rethere any other points you .vouldllilce tomal.e$ Senator FbRn. Well, S coming and, testifying btthis legislation. Senator CHAr•rEE. Fine here t~odav: Senator FORD. Fine. D. Senator CHAFFE. Havr Senator SCHWEIKER. I on tar and nicotinewerebill cllangeto an,yextei Senatior FORD. That i~ int'o-I think that is int portunity to read. That's and all theiramifications. that voul refer to-in the i~ndustr,y put 600;000 fari ploved by.productsfrom(rreat protein that will be So: instead of trying tc soine wav-if nothing els : omeofthe other indust against tobacco as relates part' of the load. But in I,ill, the only way you can billi; the Finance Cbmm, opinion. tienator SCHWEII'iER. 1 AIyy questioni was- Senator FbRn. No, sir, : Senator SCFIwE37iER. I t han the tax, -,rllichyou : T l1obill do you object to?5enatorFoRD: W'ell, yoi W>s facilities: You, are sai do that. You are saying,; I think people ought tc t o bearound a person tl '11irnnnd a; fellow that drir OPPort:unity. Even if you -lioolF now, I think that t ::l1~'n I «-as, goingt'oscho,i 1" lit' non~, in our education ! (,rn aretlying to do-bub 1''aool -rounds. This is thi~ allowed'them to d'o i filon't t9sink vou have tl Yl ~-. becauseyou didn't cc `enator SCAwEIFiER. Ye ~~,uator FoRn: That's ri~ "~enator CIi*AFEE. Ohv141 11"lietherVou a,,ree apparent that the ov ''"W-`ttlpercentof canc , ~,, i „-~,,,I -..

30FESS0R 0F PSYCHOL- 1, TEX., ACCOMPANIED '0R, PUBLIC COMMUNI- . ; AND PAULA GREEN, 3ING, INC., NEW YORK, r commend the Senators~ like to invite you all to xactly the same thing. )od one after they lleft. if they knew what they e formal statement here, ne up which I could re- my my time. : Iam~ currently the di- or College of Medicine Lnd Demonstration Cen- Lung-supported,project, of smoking in children. y at the L niversity of art Cent'er and trying to blished risk factor in a ze that dealing with the. a payoff than: going intoo or,y?rngtodetert'heonset. ; ing,large groups of pre- ,vhole, range of smoking, ~ emergewhicli,interest,- ~ teenagers~t'hats you just aldren reach theseventht is dangerous. It seems angers of smoking very someone and they tryy to smoke: But on reaching )pen; they become very ch say yon are going to much to them+-they are lokingthat arenrt dying er pressure, -which waserviewed here extremely We have produced some ~esarelike and'how,for no: to them. Theymi~ht cizarette~ smoke. I3trt the nsive; t'he~teenaff ers want ~,d bv their peersso ver* V )rand that if both parents 167 smoke, the likelihood of children smoking is very high; if only onepat+entsmokesit issomewhat lessbut'still farily high; if neither parent. ~nrokes the likelihood of the child smoking, is,somewhatless. Another thing that came out, which I think is very inrportant: overtly, consciously, these * vonng teenagers usually are not really aware of how the media affects them, how the cigarette ads work. For ex- ample, we~ produced a sort of a; shortcourse, an early _llarshall lIc- Lulran, tryiil g to get them to understand how in fact the media worked, how they arerrppecU off bythemedia. (This is part of our films shown in the sclroois:)As a matter of fact, there's no dbubt about it',there is a covert influenceof tlldemeelia, Collectively and over time the same ~4lcills which adh ertising agencies can effect~ivel!vtrse in~ selding almost any proditct--and often selldng, the~~roduct without the consumer really knowing howw they are being infitrerrcecl-obviously can work in the area of initiating smoking. «'hat we are currently doing is engaging in a long-term investiga-tionin the Houston, Tet., school district'. We a2efoll'owingchildren, beginning in the seventh grade, through, lrighschooh We: havepro- dueed sorne films and messages wln& in fact aredirect'ed at training the children how to resist these pressures. Rather than having adult authority figures preaching to~ them in these films; we have children t'hemselvespresentrngtheinformat'ions lti'e actually have, learned from the children how they sav no, for esample, how these influenceswork. W'eattempt to transmit this inforrnation though a series ofshnrt fihns shown severall times during the year. Another thing that we found is very, very important-and it was interesting that it was brought out in the testimony from the chil- dren-is that if you can make a message indicate to the child thatt there is no immediate physiological effect of the smoking, rather than emphasize that at somelc.ter point they are going to get cancer or heart disease or what have you, that seems to be something that is not only effective, but our study shows that ninth graders, for example, would prefer this type of message. over the peer pressnre messsage. TheS-seemtogradually shift away from being primarily influenced by the peer pressure: To summarize what we~ are doing, in effect, is to try and nurse them through these. very formative years, when they are very vulnerabl'eto these pressures-say, ses~enih5 eighth, and ninth~ grades-and we believe, upon errtering high school, .vhen tlrevy become a good deal rnore indepenclent: and can now rnakee individual choices: logically. based on thereai fear of the disease that mav be caused by smoking, that presumablh .vecan cut into the rate or odds on, tlheposssrbility of! adkllictiv.esmoking.. Now, R-ithout getting into all of our data so f;rr, we are ratheren- coua•aged that in, a pilot study-and attached to the printed testimony we prepared are some charts relatin;- a 10-weekprlot study which 4hows thatR-e were able to actualltv decrease bvabont 50percent the number of teenagersthat begnn srnokinr. Followiarg this throtrgh.too theend of our 2'-year data, whfichwe are just beginning toanalyzc, the results, . al~olotrl: rather pronrising. In, fact, the results are a littletoo powerful, we don't quitebeliev.ethem yet. But right now it shows like about S0' percent of the teenagers in otur stucly we surveyed claim they were influenced by our filnts not to~ begin smoking,

200 The ALA has long supported the right of the nonsmoker to breathe ,a_ir that is not pol2uted~ by the smoke of! others. We believe t'hat the, Federal Governmentl should be a leader toward this end by mandating separate areas in its own~ facilities. We also support a tax on cigarettes which is related to the toxic unit'sin the cigarette. In addition to tar and! nicotine; we are of the opinion that carbon monoxide shoukl! also be considered in any eornpu- tation of these toxic units. We are especially pleased to note the emphasis on smoking pre- vention efforts directed toward children and adolescents. Much more information; needs to be gained to improvee our abilities in this diffi- cult area, and the combination of research~ and demonstration with evaluation will add to the knowledge base. Simultaneously, programs which have been tested and proven,,such as the primary grade.health curriculum project which the American Lung Association has helped develop, can be much more. widely im- plemented. An enormous amount needs to be learned in the areas of prevention, especially related to the use of tobacco products. Nidely applying this knowledgervill be an evenigreat'er task. Title IV of the Dlational Disease Prevention and! HealthPromotion, Act of 1978~isa good be;inning. I will beglad to answ erany questions you may have. Senator KENNEDY. Before we get there, let's hear from other mem- bers of the panel. Dr. Daugherty? Dr. DAUGHERTY. Thank you, Mr. Chairman. I am presently the dean of the College ot' Human lledicineat the University of Wyo- ming and chairman of the subcommittee on smoking of the American Heart Associatiom I appreciate the opportunity to appear before this subcommittee on behalf of the American Heart Association to testify ini support of the National DiseasePreventlion and Health; Promotion Act of 1978. I personally commend you; as a medical educator, I am pleased to see someone take a leadership position in the: area of prevention. As we look at the Nation of health professionals that we have educated who are more interested in the emergency room and coronary care unit, where the: heart attack victimi comes in rather than in the pre- vention of'the heart attack, it is encouraging to see someone take leadership in helping us prevent illness and', maintain health. Senator KENNEDY. We might get you back here on that issue another time, on the manpower. Dr. DAUGHERTY. Cigarette smoking has been held responsible for many thousands of premature deaths each year. Total mortality is twice as highi among cigarette smokers. as among nonsmokers. Many of these smokers die of coronary heart disease--that is,, heart attack, whic1l, istlleleading cause of premature death in this country. Heart attacks kill more people than anysingley disease in this country. Tliee majority of these people are men in the prime of their lives. They are the fathers and tlhehusbands,of families. It's interesting to notethis, morning,in Senator Ford!'spresentations he talks about'600,000fami- lies involved in the tobacco industry. This is less than theapproxi- matelv I million people killed each year in this country fromi heart attack. llost of these individuals~ arey husbands and fathers, many of them of families I am sure that raise tobacco. In f'act,, ciga developing car that shows a 1y certainly not I risk factors for Senat'or KEr [ All nod asse Senator IiE.N Dr. DAUGHE number of dea crease has occt We are seei: among women, crease, particul Since the fir contribution ol and coronary 1' strengthened' b evidence. Cigaj the onset of p diseaseincrease the duration o who stops smo the person who The effect, t: independent ol vated, howevei pressure or di; themselves in risk by smokii smoking. A sh former cigaretti In view of ; cular disease, Chairman, for consequences f following prop, First, the in: cording to theii smokers is to 1 tem would not' but would prov Second, util health risks of ing labeli to be the "revolh'ing Senator IiE.N scientifically ac Dr. DAUGHEI accurate. Howt scientifically ac Senator KENwould be glad t .. .-5a s~ 0 - 78 I - 1 i

aonsmoker to breathe We believe that the iis end by mandating ; related to the: toxic cotine, weare of the ddered in any compu- zsis on smoking pre- olescents. Much more abilities in this diffi- l demonstration, with -ted and proven, such which the American _uch more widely im- arned in the areas of cco products: Widely isk. nd HealthPromotioni .iave: tear from, other mem- I am presently the. r University of AN'yo- king of the American this subcommittee on testify in support of ~omotioni Act! of 1978. itor, I am pleased too rea of prevention. As hat we have educated -rn and coronary care ther than in, the pre- t~o see someone take intain health. : here on that issue _ held responsible for :r. Total mortality is ig nonsmokers. Many -that is, heart attack, n this country. Heart' >„ in this countiy. The f their lives. They are tteresting to not'ethis, :sabout600,000fami- ,ss, than the approxi- s country from heart and fathers, many of' 201 In fact, cigarette smoking greatly increases an~ individnal's risk of developing cardiovascular disease. We are not aware of any research that shows a plus for tobacco regarding cardiovascular disease, and certainly not in heart attack. Cigarette smoking is one of thee major risk faetorsfor heart attack. Senator KENNEDY. Now, do you all agree with that, statement? [All nod! assent.] Senat!or KENNEDY. Let the record show that they all agree. Dr. llALCxEnTY. In the past 5 years, we have seen a decrease in the number of deaths in this country from heart, attack. The major de- crease has occurred in males where cigarette smoking has decreased. tiVe are seeing an~ increase now in the deaths from heart attack among women, .vhie.h, as you know, is where we are seeing the in- crease, particularly in young womeny in smoking. Since the first Surgeon~ txeneral's report on smoking in 1964, the contribution~ of cigarette smoking to the develbpment of heart attack and coronary heart disease mortality has been further confirmed and strengthened by additional' epidemiological, clinical, and anatomical evidence. Cigarette smoking has also now been firmly connected with the onset of peripherall arterial disease. The risk of cardiovascular disease increases ini proportion, to i:he number of' cigarettes smoked and the duration of exposure to the habit. As a matter of fact, a person who stops smoking, immediately reduces his risk down very close to the person who has never smoked at all. The eltect, then, of cigarette smoking on cardiovascular disease is independent of other major risk factors. The risk is greatly aggra- vated,, however, if you have a high~ cholesterol and elevated! blood pressure or diabetes. Such high-risk persons who also smoke place themselves in serious jeopardy. The smoker can reduce his health risk by smoking fewer cigarettes, but the only sure way is to stop smoking. A shift to cigar and pipe smoking is not effective if the former cigarette smoker continues to inhale. In view of' this evidence linking cigarette smoking to cardiovas- cular disease, the American Heart Assoeiat'i'on applauds you, Mr. Chairman, for introducing legislation aimed at reducing the, health consequences from cigarette smoking. And «e would support the following proposed initiat'~ives: First, the institution of' a differential Federal tax on cigarettes ac- cording to their t~ar and nicotine content. Since the current trend among smokers is to purchase lower tar and nicotine cigarettes,, suchi a sys- tem would not only aid smokers in selecting a less hazardous cigarette but would provide a financial incentive. Second~ utilizing the strongest possiblestat'ement regarding the health risks of smoking, consistent with scientific evidence, as~a warn- inb,label to be placed on cigarette packs. Thiscertainly could includ'e the "revolv.ing label" which is being used in Sweden. Senator KENNEDY. Are you satisfied! that the labels in this bill are scientifically accu rat'~e $Dr. DAUGHERTY. The 1'abeis that you have in the bill are scientificially accurate. However I think they could be made stronger and still bee scientifically accurate. Senator hnti ti Emv. Well, if you want to make some. suggestions, we would be glad to consider them. 0 .- 7 )5 - 14

(1) We do our jpb as _te companies, usinrad- ind (~')weare willing igarette companies and Iriously and budget the ur efforts in the media. nything, from radio to we believe we have an -es of'smokimim by creat- be willing to pay for it'. ies, but for the new and a very interesting and =uggcst, Ms. Green, Dr. vsources?'« e are start- )int where we are start- make any impact and , we have got to walk iat you are doing; what 1, one of the thingsAllat films orwhatever cdu illv exportable. For ex- "Today" show several ceivecl'an average of 40cts around the United are not prepared Ycttohave our evaluation of thing quitemodestlvif types of luaterials that i (r(Yest problem of Fed'- to thetime When I di, on while thev alsohad l. and so On, and olle of 101 was constantl~~bein~ ~t'.heSurgeonGeneral's lnct adblescents. One of (l~- reiQivents the N+-hee1. ortant that the funding- . nie a bottomle~zs pitlof the same things. ~~-hen asveryrevealin,. Herearea, tvho are saYincr ir~)' \V-Ili(}h areprecisell = )ai,ton, in llinneal~~olis; il;rlizabilfitv about these:that it NN -oul(l be verv nuateriads that coiild he-ou!.rhthis very tedious 177 and slow-moving and not to mention costly process of every community doing it again. So in terms of resources, in terms ofl dollars, INvouldl say that- unless it'''s a; . bottomless pit'ot ftlnding I would argue that t'~heIlegisla- tion you proposewould seem to be a very, very good beeinning; but I also t'~hi'nkcrit~ica~1 re~-ie~~ s,shouldbe carried out tomakecertaln that these types of effor.ts, are focused so that the products of any given fimdd project could be used nationally,as .velll as, locally, ini at least some of its v,ielcL Senator Iin`NEnY. We1l,, if you are going, to purchase the time in counter ads and the other activities, we arest'i1l talking about terms of millions of dollars, aren't we? Ms. GxEEN. Well, I think we have to make a commitment, too, some- where down the line. When onecigarettecompanyintrodueed thela-t'~est brand of cigarettes, for their first 6-months' effort, they spent $I01mil~ lion. It.would seem to me that the U.S. Government would mount a national campaign for what the cigarette companies are doing on one brand alone-something like $30 to $40 million. IVe once prepared a media proposail fortheClearinghouseforSmoking and Health, which was veiry lnodest: It'began with a$'5 million expenditure and moved up eventually to sometivherearound $5b~ million, I think you can see re- sults from what you do at this level. I also believe that a, budget should benat'ional in its scope rather thancommunity, because I think that a community, first of' all, cannott use media effectively, and certainly cannot buy it as effectively. Even more important, with a community program, you, do not establish the same kind of climate for an idea as you do if y ou have a recognized national effort when everybody in the country knows they are all in it torether, and all at the same time. Dr. SwrvEi3AxT. I think that amount of moneyy is not unreasonable, since something on~ the order of $40 million a year is spent on the ad- vertising of fluoride toothpaste on television~ alone. o this seems a relativelyy modest scale, I think. I am not sure I would! agree w~it' hh Ms. Green, however, on the national scope of an initial effort. We may not. beat the point where.ve know enough to do it well and consistentlyy well. It might be worth it to try a pilot program in a number of com munaties on a morelamited basis-d7videthat money,, say, 10 kvays; that amount of money, for a 1-year period. Beyond that point where we learn somet'hing from the variations that would occurnaturallvacross those communities, I would agree that a probram national in scope would be more likely to be effective. Senator KE.XEnv. Let me ask you, Dn:Evans, just a final questiom If we pass this legislation-you~ say it is ani important begrinning- ]lowarewegoing to, do in this bat't'1e?Hoiv successful will we be, in rev.ersing these trcnds? Ur. Ev_~.s. We conlil speak on thebaseof onr cl<ita obtainecl in a lProJectiRr Houston in a schoolJdi'strict in this massive ;,reographicarea. I11 we can at least make sonleprojections~ fromtherelative, successwe1~ave lrad so far andl assnnie tlhat-anrl bvmoststandards this cost is rather nsodest.I Nvotald arTue thatvonr lel-islation would have,.a good payoil'. I tliink the (roals should notl be unrealistic. I.vould savif-we Could reduce t1ic1 onset of smokin- by G1percent:tlhat woulkllbealready ;t verypowerfull effect. tio: iftloe_roeilsarefairly modest, ifyotn don't

228 264 HAMMOND ET AL.. cancer is far more highly associated with cigarette smoking than is coronary heart disease. While this is true, it tells only half the story. Lung cancer is a rare disease in nonsmokers, whereas coronary heart disease is the leading cause of death~among male nonsmokers in the United States. Multiply- ing the high CHD death rate of nonsmokers by 1.5 results in far more "excess deaths" than multiplying the very low lung cancer death rate of nonsmokers by 10; Thus in terms of reduction in life expectancy the association between cigarette smoking and coronary heart disease is far more important than the association between cigarette smoking and lung cancer. While such information is of scientific interest, it is of no value to the public unless it can be utilize& to protect health and extend life expectancy. At the outset, several possible ways of putting the knowledge to practical use were discussed. Among these were: (1) Simply acquaint the public with the facts. According to the proponents of this idea, knowledge of the facts would be sufficient to persuade people not to smoke cigarettes. (2) Conduct extensive public education programs to persuade people not to smoke cigarettes. (3) Attempt' to develop a new type of cigarette which would have no harmful effects (or at least greatly reduced harmful effects) and yet would be pleasurable to smoke. All three of these things have been done. Presumably, due to application of the first two ideas, a great many erstwhile cigarette smokers have given ~ up the habit (U.S. Public Health'Service, 1976). However, millions of adult cigarette smokers have continued to smoke an&each year, tens of thousands of children and youths take up the habit. Many attempts have been made to develop a"safe" or "less hazard'ous" type of cigarette which smokers would find satisfactory. The only procedure along these lines which has as yet gained wide acceptance among cigarette smokers is reduction in amount of tar and nicotine in the mainstream smoke of cigarettes. Cigarettes with considerably, reduced tar~ and nicotine (often referred to as "low" T/Nl ciga- rettes) : have now been available for many years. We are concerned here with the question as to whether or not such cigarettes are actually "less hazardous" than are "high" T/N cigarettes. Some years ago, a: small committee of experts on the subject came to the conclusion that "the preponderance of scientific evidence strongly suggests that theiower the'tar' and nicotine content of cigarette smoke the less harmful would be the effects" (U.S. Public Health Service, 1968). (A short time later this was reported by the then Surgeon-General of the U.S. Public Health Service.) Their reasoning was about as follows: (1) Death rates from lung cancer, cancer of severaliother sites„coronary heart di'sease„and several other diseases increase with degree oflexposure to cigarette smoke. (2) Many experimental studies had shown that material condensed from cigarette smoke (usually called "tar") is carcinogenic when applied to animals. (3) The known acute effects oflnicotine upon the heart and circulatory system~suggested that the nicotine content of cigarette smoke was partly if not entirely responsible for the fact thatage-speci5c death rates are higher among cigarette smokers suppose that if the the harm done pe The term "stro conclusion might (1) If the tar anc smoke more cigar turned out to be in T/N to "low" T/P Hammond and G (2) Smokers o inhale the smoke their effective et exposure to the g (3) Itcoul&be harmful than the ' that, in certain ci certain gases, mc might increase t}: Therefore, ifal in age-specific de Since that tim studies (Bross ar that people who re people who smok panied by an in disease) led us tc. Between Octo can Cancer Soc- epidemiological ~ a lengthy questio: for 6 years, surv naire containing during the interv questionnaires v< series, Q4, were after June I, 19( The Society s 1964„and 98.'4CF traced' in the si discontinued aft eighth and last ? During the fir by Divisions of

242 Page 3 It is high time for decision-makers and guardians of public health to stop talking like generals and start talking,like leaders interested in getting,at the truth. To characterize tobacco as "slow motion suicide," to call it "public health,enemy number one," and to hold thfs single lifestyle behavior responsible for more than 300,000 deaths is not likely to increase our understanding. It very likely will have a chi1Ling effect on scientists who would prefer to "just keep learning." To others it may be taken as a signal that federal funds will flow to those who don't mind reaching preordained and officially-approved~conclusions. The Secretary of HEW said that smokers who ignore his advice are "whistlibg past the cemetery." He has characterized those who disagree with hi~s initiatives as "a self-interested minority." No wonder the press headlined his program as a declaration of "War on Smoking,." Tihis type of inflammatory rhetoric is an unfair andiunjustified attack on mil'lions of American citi~zens -- farmers,,blue collar workers,, manufacturers, wholesalers and retailers.: It suggests that they are the "enemy" who can and should be punished~in good conscience. Page 4 The truth is their forebears ar, will continue to t American society. rejecting the use people who, after say: "On a number views concer farm familte tobacco~... .T above all, b reallistical'_ fabric whici around cigar N'ow, 1'et me r various provisio! The tobacco position that sm has been that sm is mature enougt all available irr freedom of choic The industr self-regulation

Senator SciiRVrirEn. I don't think you understood what I'm saying. If the personality of a person makes him the first one to smoke a cigar- ette, his personality may also lead! him to be the first one to: take! an experimental drug or alcohol, which~ may not be related to whether he's addicted to something at all, It may be a stereotype person Dr. EvaNs., Ohy yes. I see«-hat Z-oii mean. You're talking about the obvious kind of risk taker who defies d'eatli as it were. Senator ScnwEirER. I mean, that could be more of'a factor than the point,of the Briti5hstudly. Here is a stereotype«hotends to do these things because tl:ey are atypical. Dr. EVANS. I see what your point is. Certainly that cannot be ruled out. Senator KFN.; Etrr. Let's hear from our other witnesses, and' t'hen, n-ee can come back with further questions: Dr. S-8vinehart ? Dr. S«-iNFriaaT. Tliank you, llr: Chairman. I am a social psychologist and! I do consultation and reseancli for public service communication prograins: Duri~ng, the past 15 yearsmy work hasinvol~-.ed'~ teaching, research, and practice in the field of health communications. I favor all of the provisions of the bill under consideration, but would like to comment particularly on that part of title IV which con- cerns the, detlerenceof smoking, among childreIi and adolescents. Although the followingstatement n as notdonein, collusion ssithDr. Evans or thekids.vho were oni earlier, you, will hear some echos as we go along. This section of the bill proposes research on the dhtermimants of smoking and support for community and school-based! programs. Ideally, of course, one should know a great deal about the determinants of a: problem before undertaking efforts to control it. In the case of smoking, our present knowledge provides an adequate basis for pro• grain planning but needs to be eapanded' if control programs are to be made, more effective. For esa2nple; we know that modeling and peer influence are closely related to smokrng behavior. The boy orgirll most likely to begin smoking has two parents who smoke, an older brother or sister who: smokes, and a close frienrL whosmokes. The presence of a nonsmok- ing parent or sibling or friend' is associated with markedly lower rates of smoking in chil'dren. This suggests that a deterrence effort should address parents, t'each- ers, and other adult role models,, rather than focusing exclusively on children and adolescents. As part of a project carried out by young people in San Diego, teen- agers were asked why they smoked. The eight reasons given most often are not in thee jiirgon ofbiomedical or behavioral research, but they cover a lot' of ground and provide obvious clues for the design of control programs-and here are the eight; I'm young now, why not smoke?, Ii can quit later. I don't inhale, so smoking can't hurt me. \iyfoll:s smoke:a-hy shouldn't I? If Ii don't spend the money on cigarettles, I'd spend'it on something else. Smoking makes me look grown up and mature. Smoking can't Smoking is bet All my friends These comn- ing risks is ol sonat attracti- independent. Given some should' be don, bill? I-Iow wo, on these ques. would regard Many conti tems through which cover s shown promi~ lize a widee va skills which various other A number 4 information : will someho« smoke. Since rather than c vided on a co throngh, higl. Programs, specific effect cation, butth ini adolescent nonhealth ap causetltis pri health risks: health,, but tl ing as a sour The design cttltt bv the 11 peer accepta duencesmay forms of imi, prorrams ar,. \ ewcomr., tion on the voluntary he American H, other appio; cooperation6 «'heneverdeve]opment' terials shoul duced in qiu The numb has dropped nrent niight

245 all advertising, :lege publica- ising,code '.i!ng directed to its principles. icel alil radio -oad'cast media's ;aken a variety rsumers; these ;s, especially .ine and Section 9' ntinuing program the Federal Trade "tar" and nicotine eir cigarette gs of their the cigarette to legibly =nt wi,th the Page 6 Everyone agrees that chiildrenishould not smoke, incliuding„ as its record demonstrates, the tobaceo industry. Few people„ however, know why they do smoke. Yet, this legislation calls for a'"shoot-first, ask-questi~ons-afterward" approach, proposing programs of deterrence before the problem is understood. The Chairman and~the Secretary of HEW'single out the role of tobacco brand advertising. Others are not so sure. Several witnesses at the Subcommittee's May 25 hearings, reflected'this uncertainty. Paula Green, president of Green-Dolmatch Advertising, who has been active in aiding the American Cancer Society's antismoking crusade, discounted the alleged power of advertising. She testiffed that: "It is wrong,for us to believe that people start smoking today just because of advertising. Today, adNerti'sing i~s only one factor." Moira Reilly, a high school student told the Committee that young people start smoking,because of "peer pressure."' As she put it: "Your friends start to smoke. And:then it is a choice of whether you want to be sort of left out, you know, by people of your own age."' Jiames Valeo, another highisehool student,, said that smoking became his way to "defy authori'ty." display,ing,

1s met with rted his le, but z~t of others. end'ent of ^y to give n education, entive health ant role.M s subcom- iamental rests wi~th as also re- ant ways in tion of the le record of co the taxation f tobacco con- )f retail outlets iicotine content sd spectrum of They can express -iocracy of the tax colilectors. 249 Page 10 The results of the free market mechanism should gratify those who believe that "the less 'tar' andlni~cotine, the better." (See Figure 1) o In slightly more than,20 years, the "tar" and nicotine rating of the average cigarette purchased has dropped by more than half. From 36.5 mg. "tar" and 2'.61' m,g,. nicotine in 1954 to 17.1 mg. "tar" and 1.15 mg. nicotine in early 1977. o Currently, there is no American brand on the market with a"'tar"'an&nicotine rating as high as the average cigarette sold in 1954. o Sales growth is now concentrated in what i!s called the low "tar"' segment, 15 mg. or under. In 1,976, one out of six cigarettes sold was in this segment; in 1977 it was one out of four;, by the end of 1978 it will be one out of three. In the light of this trend„ can we be sure that government tax reguLation will out-perform individual choice? Is it a sure thing that the tax collector willi prove to be more efficient than the free enterprise system? I~n other words„ if the legislative purpose is to encourage the consumer to smoke lower 'tar' and'nicotine cigarettes, then this legislation is not necessary. 30'.-i36'~. 0 - 78~ - 17~.

:bition~ , which of io are ieir ) suffer lcco. .ie ~duce But, Page 14 253 There i'~s much more to indoor air quality than someone's tobacco smoke. Other factors are building permeability, weather conditions, ventilation and~, probably most important -- outdoor air polilution concentrations. Why is it silent about any other sources of smoke inside or outside Federal buildings -- such as the automotive parking lots surrounding the Pentagon, for examplie. Hanging up "No Smoking" si~gns and segregating employees who smoke tobacco products will not improve the quality of life -- environmentally, psychologically or socially. The public smoking issue ils a red herring. The appropriate tool to clean up the air would appear to be the GlieaniAi!r Act, whflch has already been enacted. Careful examination of the scientific literature leads to an unequivocal conclusion. Many, physicians and scientists agree -- incl'uding,those who have conducted research on public smoking, those who have reviewed the medical literature, and even those who believe smoking is harmful to smokers -- that: There is no healith hazard to the normali nonsmoker from exposure to tobacco smoke in everyday situations. i M

250 Page 11 One example of the government's regulation of "tar" and nicotine suggests a degree of caution. In the late 195o's the Federal' Trade Commission banned all advertising,based on a brand''s "tar"' and nicotine content. In 1I966; the Commission reversed itself. Thus, for over six years, Federal regulators denied the ind'ustry the opportunity to advertise and make fully available lower "tar" and nicotine brands to tobaceo consumers. Therefore, it might be argued, Federal regulators postponed for years the decline in "tar"' and'nicotine y,ields. If the principle of a "Health Promotion Tax" is establiished for cigarettes, the field i's wide open for si~milar taxes on other consumer good's which have been embroilediin controversy -- for example, alcohol,, automobiles, motorcycles, sugar, dairy products, and foods with highicholesterol content. The transformation of our tax system from reven ue-rai sing, to behavior-control purposes is indeed hazardous. The concept of using the tax mechan,ism to control personal behavior is also highliy unfair. IJt is a regressive "Rich Man, Poor Man" tax. Its hiits cigarettes while it exempts other forms of tobacco. In particular, it hits hardest at those cigarette smokers, such as blue collar workers and working women, who are least able to pay for the ri'~ght to smoke whatever brand they choose. Page 1'2' By placing a new "he present cigarette tax bur de facto prohibitiom for income Americans. Like the other "Nob:also has the potential ot racketeers to supply conc legitimate market. New York City tried' 1971; and gave it up in New York's dismal experi, "This tax has not 0 enriched the bums who ar rackets. It has not y1e has not changed smoki'ng against the poor and it The T'obacco Institu and'nicotine legislation addi'ti'onal! points which previously: o Neither "tar", r ent or ingredients cigarette smoke haz d'i'sease in humans. o No one has esta'l level of "tar" and C W ~ Q W X -Z W

219! '_5TO~THE SENATE aLD A. YOUNG, M,D.. >vi'sions of S. 3115ion's Medical Section, ie American Lung t time, L was and health programs. tybecause Iam>locks.to improving 3ntrol of pulmonary ructive lung diseases Lung Associations tlions are now the atburdens in urity. Adininistrationi to: retire11ion dollars. Today asons that the asoutliined:in even more compeliling m non-smokersin f entertainment uld'be aa leadpr es. _2~_ On the question of'cigarette taxes, we agree thao there should be a tax imposed which is graduated.by, the amount of toxic unit~s in thecigarette. However, we are of the opinion~t~hat carbonn monoxide.should be also considered in any computation of those toxic units because of its demonstratedideleteribus effects on health.. We agree that.the Federal Trade Commission should be the agency to determine and certifyt~he content oftoxiosubstances. Certainly, theef'8ectivenes.s of thepre.sent label on cigarettes must be questioned.. :"henany, m~essageremains static for a period of time,, peopletlend not to~notice.it. Rotating a varietyof labels on~cigarette packages maylead to curiosity on the part of smokers and motivatemoretothem.to:examiine.trie.packageand read the message. We have particularinterest~ in Tit1eIV. as it relates to the program to detersmoking.amonge}iildren., Theind.ividuals decision~to begin smoking or not is often~the end product of what he perceives to hetheconseqpenc.ee ofsuch.action. Thiseducation of the child is top priority. I-or,der that he receive and be motivated bytheinformationhe receives, we need more insight into what influences various ages and social groups in their decisions. Therefore, we favor addi~tional resear~ch in thebiolbgical and behavioral determinants of smoking.. Demonstrations and evaluat~ions of comprehensive education programswith children andigr~ants to help States and communities to carry on anti-smoking programs are urgently needed. The American Lung Association in cooperation with the Office of Health Education, HEW, has been activelyy involved with the developmentt and demonstration of the. Primary Grade Health Curriculum Healtfi~Pboject in several areas. ofthef country. Between 300-4D0 teachers areournently teaching this innovative curricuLUm. It is an exciting "hand5-on" approach to the studyy of smoking and'avarietyd of risk-tiaking behaviorss to help the young childmake informed decisions about his or her health.

166 STATEMENT OF RICHARD I. EVANS, PhL D., PROFESSOR OF PSYCHOL- OGY, UNIVERSITY OF HOUSTON, HOUSTON, TEX., ACCOMPANIED BY JAMES W. SWINEHART, Ph. D., DIRECTOR, PUBLIC COMMUNI- CATIONS CENTER„ PELHAM MANOR, N.Y. ; AND PAULA GREEN, PRESIDENT, GREEN DOLMATCH ADVERTISING, INC., NEW YORg, N.Y.,, A PANEL Dr. EVANS. Yes; first of all I would like to commend the Senators on their questions~ of the teenagers. Iwould' like to invite you~ all to join our research staff, because we are doing exactly the same thing. Senator KENNEDY. I just thought of a good' one after they 1eft. How many of them woul& have not started if' they knew what they knew now? Dr. EVANS. `Vell, I am not going to read a formall statement here, because I think a number of things have come up which I could re- spond to thatt might be amore effective use of my time. First of all,, I would like to point out. that I am currently the di- rector of the smoking section of the Bayl'or College of Medicine 11 ational Heart and Blood Vessel Research and Demonstration~ Cen- ter. I am principal investigator of a Heart and Lung-supported 'project whi& is really directed at deterring, the onset of smoking in children. Academicalli I amprofessor of psychology a' tlteUniversity of Houston. Working with Dr. lliichaell De Bakey's Heart Center and trying to look at someof probably the most well-established risk factor in a number of diseases, smoking. I began to realize that dealing with the addictive smoker probably otF'ers a lot less of a payof£'thani going into an area that has been relatively unexplored, tiying todetert!heonset ofl smoking. W'hat wefound in our research bvinterviewing lazgegroups ofpre= t'eenagers and teenagers, and looking at the whole rangeof'smoking,, a model oftlhe initiation of smoking began toemergeR-hich, interest- ingly enough. is pret'~tv ivelll supported bvthe teenagers that yon just interView.ecll Tt seems that by the time the children rea.chthe sev.enth, grade, virtually alll of them believe smoking is dangerous. It seems that before their teeni yeansthey take the dangers of smoking very concretely, so they literally think it• can kill someone and they try to do things likepersuadethei'r parents not to smoke. But' oirreachingse-venthgrade, different thingsbegin, to happeni; they become veryy present oriented. Forr example, messageswhichsay yotu are going to getcancer when you are quit'eold don7t meanniuch to:thrm-they are living in the present. They see other kids smokingthatl areirt dying off immediately. Also, they now become influenced by peer pressure, R-hich was~ lirrnu"}it ornt bv t'hesee youn!,rsters 1-ou, just interviewed here extremelv well. This peer pressure is very important. We have produced some films v-hfich, actually show what thesepressures are like and how, for example, some youngsters learni hoR-to: say no to themL Tliev might make an excuse like I have got an allergI- to cimarette smoke.*But The peer pressures can be very hirh and treryv intensive, the teenagers want to belong. At this anv they I ~ant to beac•cepted hv their peers so,very much. Also, as! was already pointed out, we fonnd tliat ifboth p:2rents smoke, thc parent sm, smokes th, Anothe: overtly, cc of how tli ample, w.f Luhan, tr how they' in the sch a covert S skills Nvhi any prod rea11v kn, the area: ( What I tion in tl beginnin: duced soi the child authorit, themsel~ from the work. 11 short fils Anoth interesti dren-is there is emphasii heart di: only eff would 1 Thev se by the p To su through to these believe. moreir based oo that pri addicti~ \Tow, couragewe pre ~ shoacs I w numbei ~j the em p the re^ CJ too poN %I like ab ~ they «

.. Pinney, on Smoking ertising"s oked~into alcohol, a students :alifornia. ad'v,ertising 247 Page 8 A copy of Summary Report,, Surveys of Student Drug Use, San Meteo County„ California, San Mateo County Dept. of Publiic Health and Welfare, 3/2/77 is attached to be made part of the record. Although opinions may vary as to the rellative merits of the substances focused on in this study, one fact stands out: Advertising bears little relationship to their use or consumiption. Support for this view comes from a study funded in part by the American Cancer Society, which states that: "'Economists generally have eoncluded~that cigarette advertising in the U.S. has been a competitive weapon that companies have used to divide the national ciga- rette market among themselves; it has not been used as a means for expanding that market." [The Effect of Cigarette Advertising Bans on,Cigarette Consumption. James L. Hamilton, Ph.D.,, Associate Professor of Economics, Wayne State University, tn Proceedi~ngs of the Tltiird World Conference on Smoking anti'lH'ealith, DHEW publiication No. :NIH 7-1 13. 1 In other words, soap advertising, for example, is used to persuade people to buy "Lifebuoy" rather than "Palmo- live" -- not to persuade people to take more baths and, therefore, buy more soap. It ts tempti~ng to shoot at easy targets like advertising and smoking, but the truth is that the many influences shaping the various lifestyle behaviors of young people are not cliearly understood. It may be unwise to overemphasize just one.

Canyou "seld" a health habit? Yes, you can. Yes, we can. Provided that: (1) We do our jpb as profcssionally and as~dedicatedly as the cigarettecompanies, usiiigad- vertising professionals, the best we can cret; and (2) we are willing tod'owhat'the Army and Amt'rakand the cigarette companies and politicans do, and that is treattlheproblem seriously and'budget the money to target, plan, schedule; and sustain our efforts in the media. I've spoken mostly of TV. But I include anything, fromi radio, to pet rocks, on a sustained, committed basis. If we believe we have an urgent job to do, if we're to prevent the diseases of smoking b creat- ing a good nonsmoking ;eneration, weshoulde liewilling to pay for it. Notjust for conventional educationallapproaclies, butlfor the new and vital educational tools of today. Senatorhr:N _NF.nr.Thank you very much; a very interesting and usef'ulstat'ement. Let' me ask you about'-ifwe do~ zvhat' you suggest, Hs. Green, Dr. Evans, whatare we tall:ing abont in terms of resources? We are start- ing off'rather modestlvon this. We~ get to a point wliere we are start- ing off so modestly that we are not going to make any~ impact and people are going to: say«•efailedl OUviously, .cehave got' to wa]kbeforewerun. But to do the kinds of things that you are doing, what are wetalking abont in~terms of resources?' Dr. I]t-eN s. 111'ell, of course; as you sucr-este& , one of the things thatt wonlcl be verv, vet,v important is! to developfilhns or whatever- edu- cationa.l. meclinnr that isused thnt arenaax~imallv exportable. For ex- aniple. a5a resnlt ofnny appearance on tlie"'I'odav"show severaU weeks a-o,aliscussing, ourprojects, we have received an average of40. requests anoonthfrom va~ri'ous school, districtsaround tlieL7nitecll States wantin- to: useour filhns. We obvi'ous]v are not prepared yet t'oo staz,t, distributinv them widelvuntil ti~'ereall~- have our evaluation of tlleir long term iml>act completed. But, it seentstoaiieAtat we can, do this sort of thin~r cluitemodestly if we think in terms of trving: to develop these, types of materials that could bernaximalh• useful nationallv. The bi~,~~est problem of Fed- eral pro~i-anrs overtheyears-and I ~oback to tihetime when I di~- rected alar-edpl'hnc1nencv proaram! in Houstionivbile t1iey also had suchia proo;ram in \ew Y ork. Chicago, Bostcn, andl so on, and one oftllhething, tbatoften happened was that tliewheel was const'antlv being reinventecl. We are now preparing, a section aFtlre Surgeon General's reporton pi•evention of smoking, iiu clrildi•en and adolescents. One of tlhethin~-, we find in that litc rat nre is evort•bodv reinvents the wheel. It seents to me that it «-oulcl be very. very important tliat tliefruuling Avonikll he soiiocused sotlratitn-ouldn't becorue ai bottomless pit~ offfinrds al'lowivlg, everv sinale,contnnunity clbing t113esarne things. wlien inafcrial~- vorild be sliared. I think the testimony of the children here was very revealing. Heree are some cluldren frour the«'ashivrgton. I).C., area. wholaresaving tlrinl,ig-; ribont the iilitiadimi of ci'garettesmol:in~• whichi are precisely n•bat. we now know chil(liieni are saying in Homton, in _l~Liouneapolis. andin Palo _Uto, C'rlliif. There a lot of -eneraliiabilitc- about these influences to~ surokcr. ~_-;o. tlierefore. I tirou~ld say that it would be verv irulportant• to trv to floru, theseetl'orts, developamaterials that could lie clistriuutedt nationnrlly, and possibly not p;othrou,•h this very tedious, and slow-movin doinim it abain. So~ in terms unless it's a bot tion yotu propo~ also think criti these t.~~pes of fimc~led~ project some of its viel Senator XE-.\ counter adsan, of millions of d Ms. GREEN. `' n here down thc( brand of cigarc lion. It would nationall camp,- brand alone-s media proposa~a was very modlee eventually to s sults from wha I also believ than, communit use media effec more importai the same kind!, national! effort together, and a Dr. SwiNEx since somethin vertising of fl relatively mod Green,, howeve be at the poin well. It mightt munitics on a that amount o we learn som( across those c, scope would bc Senator ICE Ifwepasst how are we g- reversing thesR I)r. I:v.\sS: project in: Hoi If «-e c•an at ll have had! sof ratl6er modestt pan-off. I thin colilcU recluceta very po.veri

Page 9 For examplie, whenistate school officialls met with the Secretary of HEW in January, they supported his program to curtail smoking among young people, but indicated some concern about possible neglect of others. Their spokesmani„ Daniel B. Taylor,, Superintendent of Schools of West Virginia, urged the Secretary to give "equal attention to such things as nutrition education and alcohol abuse and similar kinds of preventive health measures in which school can play an important role.% It may well be, as the Chairman of this subcom- mittee has himself recognized, that the fundamental responsibiLity for the behavior of children rests wi~th their parents. HEALTH PROMOTION TAXATION Iit should be noted that the industry has also re- spondedivoluntarily in a number of significant ways i'n, meeting consumer demandi. Through the operation of the free market, ilt has establiishedia responsible record of performance which is particularLy relevant to the taxation provi~sion of the pending bill. In the United States today, mil:lions of tobacco con- sumers can walk into hundreds of thousands of retaili outlets armed with information about the "tar" and nicotine content of cigarettes and with assurance that a broad spectrum of brands will be available for their choice. They can express their individual preferences through the d'emocracy of the marketpl!ace -- without any nudging from the tax coLlectors. The results o those who believe (See Figure 1) o In slilghti rating of the aver than half. From _ to 17.1 mg. "tar" o Currently with a "tar"' and icigarette sold in o Sales gro the low "tar" seg of six cigarettes one out of four; three. In the light government tax re choibe? Is it a prove to be more In other words, i the consumer to e then this legislt

their forebears and their children have been, are and will continue to be a proud and productive part of American society. Presid'ent Carter,,for, example, in rejecting,the use of government authority to prevent people who, after notice, desire to smoke, went on to say: "On a number of occasions I have expressed my views concerning,the importance of the 600,000 farm families that derive their income from tobacco.... The strategy which we adopt will„ above all, be one that works„ and'deals . realisticaLly with the industry and'soci~al fabric which over the years has buiTt up around cigarette use." Now let me make some comments on 5,3118', and its various provisions. SMOKING AND YOUTH The tobacco industry recognizes and holds to the position that smoking is an adulit custom. Iits policy has been that smoking should be deferred until a person is mature enough to miake the decision in the light of all available information and on the basis of individual freedomlof choice. The industry's actions taken toward voluntary self-regulation substantiate its statement of policy.

244 Page 5 For example: o In 1963, tobacco companies stopped~all advertising and promotional activities in school andicollege publica- tions and on campus. o In 1964, they established arn advertising code prohibiting advertising„ marketing and'sampling directed toward young people. And they stilil adhere to its principles. o In 1969, the industry offered to cancel all radio anditelevision advertising because of the broadcast med'ia"s unique appeal to young people. Im addition, the tobacco industry has taken a varietyy of other steps to provide information to consumers; these initiatives are germane to your deliberations, especially with respect to Section 7 on "tar"' and nicotine and'Section 9 on labelling. For example: o In 1967, member companiles began a continuing program of scientific and technical cooperation with the Federal Tirade Commission, with respect to the Commission's "tar" and nicotine testing activities. o In,197p, they began to include in thei'm cigarette advertfsi~ng the FTC "tar" and nicotine ratings of their brands. o In 1971, they volunteered to depict the cigarette package i'nia11 advertising in such display the warning label. a way as to legibly ol In 1972, they entered into an agreement with the Federal Trade Commission on uniform terms of displaying the warning label in print advertising. Page 6 Everyone a i~ncluding, as i industry. Few Yet, this ask-questions-a of deterrence t The Chairr the role of tot so sure. Sever hearings, refl: Paula Gre, who has been a antismoking cr adverti~simg. S `It is wr smoking,today advertising is Moira Rei Committee that: "peer pressure "Your fri choice of whet know, by peop: James Va: that smoking.

241 CH 3! by the inflam- vould be itary isease 1!d! benefit 'waging war"' )aganda :he steady 'liounish ilitilons i11 Page 2 The fact is that at present we simply do not have enough basic knowledge to break through to the solution of a variety of major health problems. Dr. Lewis Thomas, presild'ent of the Memorial S1'oan- Kettering,Cancer Center,, put it well recently. "The solidest piece of scientific truth I know of, the one thing about which1I feel totally confident", he said, "'is that we are profoundly ignorant about nature. Indeed, I regard this as a major discovery of the past 100 years of bib3ogy." "In earlier tfmes," he added, "we either pretended to understand how things worked or ignored'the problem or simpliy made up stories to fill the gaps." He concluded with a statement that is particularly appropriate: "We will solve the problems of heart disease, cancer, stroke,,arthritis, schizophrenia, senile dementia.,,and all the rest if we can just keep learning." Unfortunately, a favorable climate for scientific inquiry does not obtain in the field of smoking,and health. The scapegoating of tobacco constitutes a diversion of attentionifrom the gaps tn our knowledge, which do, inifact, exist and which must not be ignored or covered~up.

would have to start really tally against smoking and a~ that area, Because I had - bad smoking is, and, you der, and so on. :he emphasis on smoking- :)ke in schooll; that was it. iost became-just to: defy t the emphasis up, because, ,ven through hig4sehool- )uldn't smoke, not just that e a big difference. get the money to support 11 dollars a year. Diidi your ;et a litfle expensive after ace from my parents unless 3 work at ski' shops, what- c I would rather be able to g money goes or anything ihow of hands-lio« many ucational films on the bad ichool. t did you see, a film? : as on the body,,things likee opics in the science course ad things like that-that's, )pen to take that course in )f you had anyeducationaL :ion or health classes ? iat would be your reaction i? Would you consider it, refore they are jannmsngit forces of authority in our ige was provid'ed in a scien~ make a difference in terms lke a big difference, because 'v know what cancer is like, ~ showing films at an earlier that'would really prevent a 163 Mr. Gx=ini. tiVell', I think if you had films or something of people who are maybe in their twent'ies or so, which is not far off from our age-and, you know, see the effects that it has had on them~ already, like AIoira and Theresa had trouble running, or James-and see the long- termi effects; they are there, but the short-term effects are there, too. You know, it's not that far off before you will st'art to feel the effect's, of it. And I think if you saw a young person not much older than you, theeffectithason him, itwoul& have more impact than somebody who is 60 y ears old and has cancer. Senator ScIIwEIxEx. I would like to ask of the people who smoke, when your parents found it out, what was their reaction? DU they try to talk you out of it? Did they say it's your decision? Or did you have an argument with themI What reaction did your parents give? Jim? Mr. VALno. AV, ell, -my parents never told me flat out I can?t smoke; and I never kept it from them either. They encouraged me not to smoke, and theyy kept using the example, well,, you stopped me from~ smoking, why are yoit smoking now?. They told me -what it could do to iue,but I didn't reallly,pay much attention t!oit. But t'heydidn`'t jjust put an iron han& downi and say no; I canlt. Senator SCI3ZVEIKER. MaI: k ? Mr. Au.ktiis. When my parents first found out, they really kind of said, it's your decision; if you want to hurt yourself, you lknotii, you can do it. But they encouraged me not to,, not to start. Senator ScawFIrEIt. Theresa? Miss AV, oLrF. They encouraged me not to, definitely. My parents weren't pleased at all. Senat'orScHWEIFEx. MoiraQilliss REILLY. Well, my parents-there's not much you can say when - vou smoke, you~ know-you are setting a bad example yourself. I mean, they can'tteld you not to do it if' they do it'. So alll they can say,yotu know, is it's your decision; you make the choice. But it is not what we would want you to do. Senator ScxwEIfiEx. Getting back to the,quest'ion that we are really askinb what is the most effective way that we can input on that decision?I ga,therif we were to ask yoit theq,uestion whether an inputflrom your parents, who «ould! take a strong stand, versus edticatlon and films and input from the school~ wha.t is your answer as to which would be most effective in your judgment for all kids1oIstopsmoking? Miss RFILLY. I would say that it would have to come from the schooll and education and the media sources, things like that. I mean, your parents will play arole in your smoking or not, smoking, but even if' thev say not to, there are so many times that you can just go ahead vud do it anyway. Senator ScxwEiNER. Right, and that is usually an ini-itation to do itanyw<ny, right?IIISS REILLY. Yes. Senator KENNEDY. On this point, what do you think isthemosts ef- fective in~ presenting this~ message to the students in the~ schools. Are youi better getting it from your peers, your colleagues, your class- mates? Are you better getting the messagefrom a teacher? Are you nuoreimpressed„ doyou think, if you get it from an athlete that is

e Graduate sburgh, ions of not kers. ty, pointed ealth,effects vels reached de con- w levels State ter„ said: published ey provide smoke is or that re has the presi- ded: t di~rection, moke on the t in fact, he American f_research okino, stated: an be influence s are too 255 Page 16 o Dr. Reuel Stal4ones„ University of Texas, who was an Advisor to the 1964 U.S. Surgeon Generall's Advisory Committee on Smoking and Health, said: In very direct terms, there i~s no medical proof that nonsmokers exposed to cigarette smoke in ordinary relation with smokers suffer any damage. o Dr. Gio Gori,, Associate Director of the National Cancer I'nstitute, pointed out: If you want to remain with fact and not with fiction, there i's little danger of disease to people that stay in the room where people smoke. CHANGES INILABELLING The proposali to present ten different warning labels is a Swedish import and has been,called the "'fortune cooki4" approach by the Secretary of HEW. Sweden requires stxteen alternating warnings. Other countries have a single warning, with different wording. Franee„ for examplie, requires the warning,that "Abuse Is dangerous." The current United Kingdom package label reads, "HM Government HealthiDepartment's Warning: Cigarettes can seriousl!y damage your heasth."' Our own country has yet another variation. Iceland had a compulsory warning but liater abandoned it. Some countries have no warning at aLl. These national differences demonstrate the uncertainty and confusion surrounding the use of warning labels.

232 268' HAAiMOND;ET'AL. TABLE I TOTAL NUMBER OF SI'BJF.CTS'.AT START OF EACHIOF TI%`OPERIODS, NL'.NBER INMATCHE'D'GROUPS, ANDAD,JL'SrED NUMBER OF PE.RSON-YEARS OF EXPOSI:RE TO'RISK ($Y"TAR" .AND'NICOTINE CONTENT..OFCIGARETTE): Sex Period" "High" "Medium"' tar-nicotine tar-nicotine "Low" tar-nicotine 1. Total number of subjects at start oflperiod Male 1 63,063 54:999 15;360 Male 2 29;157 40;090 6,832 Female I 44,137, 59',750 32,703 Female 2 22,909 49',193 16;803 2. Number ofsubjeetsini matched groups Male 11 57,346 50,698 14;897. Male 2 25,459 35,112 6;564 Female I1 43,062 58;538 32;357, Female 2 22;153 47;679 16,550 3. Adjusted person,years of exposure to risk Male 1 82,428 82;898 83,072 Male 2 35,974 36;0511 36,435 Female 1 174,619 175,088 175,744 Female 2 88;639 89l027 89;129 ° Period 1: July II, 1960-June 30;,1966; Period 2: July 1, 1966-June 30, 1972. ° Includes cases which were difficult to classify. two sets of numbers indicates the number of subjects who were excluded because some groups did not contain, at least one H, one M, and one L subject. The adjusted number of subjects was: 14,688 for males, Period 1; 6475 formales; Period2; 30;1I76forfemales; Periodi 1; and 15,342 for females, Period 2. Since a large proportion of the "low" T/N subjects were matched, the adjusted number of matched subjects was only slightly' less than the number of "low" T/N! subjects in matched groups. On the basis of the adjusted numbers ofsubjects; the mean ages of the subjects were: 53.6 for males and 51.6 for females at the start of Period' li; and 58.4 for males and 56.7 for females at the start of Period 2. Part 3'ofTable lishows the adjusted number of person-years of exposure to risk as previously d'efined' As shown in part 1 of Table 2, the adjusted number of deaths was 4735.5 for "high" T/N smokers, 4299.9 for "medium" /N smokers, and 3991.2 for "low" T/NN smokers. The difference between the "high'"' group and the "low" group is statistically significant (P<0.0001). Furthermore, for each of four sets of compari- sons (male, Period 1; male, Period'2; female, Period, l; and female, Period 2), the adjusted number of deaths was highest for the "high" T/N smokers and lowest for the "low" T/N smokers. In each of these four sets, the difference between the "high" T/'N and the "low" T/N gtoups is statistically significant (P<0!0005). As also shown in part I of Table 2, the adjusted number of lung cancer deaths was 318:4 for "high" T/N smokers, 285.5 for "medium" T/N smokers an&235.2 for "low" T/N smokers. The difference between the "highi' T!N group andithe "low" `"TAR' " TN group is statisticall, comparisons,(males an( cancer deaths was high T%N smokers. Part 2 of Table 2 sh number of deaths in the adjusted number of deal the mortality ratio for combined and 0.74 for mortality ratios of "loww for females and 0.83 for Period12). Mortality ratios were "mediumi' T/N and'"lc T/N smokers. These m Adjustedideath rates; if ofldeat'hs(part I ofTaU torisk(part 3 of Table Table 3 shows corre number of coronary h~: 1483:3'in "medium" Ti ence betweeni the "hit ,ignificant ('P<0.0001).. and females in Periodfi AD)l:STED. NE'MBER.•' DDRING E' AND Ni ,.E Sex Period Male Ii Male 2 S F emale 1'' I,- I~emale~ 2~~ 1,(1 T,tal 4;- \l.,le 11 `.7 n e 2 i cmale I! I emale 2 TSital I -01, " - ,R - ts

205 igress,has taken action Federal Trade Com- one of two forms. One an intended pnn-thee itly in the Wall Street nd financiall announce- ry to protect sophisti- is not tmreasonabl.e to in prohibit them from his morning, feattu•ing outd'oorscenes-scenes etract from the healthi messages happen to be. i are talking about? I of~ the~ kind of' ads, holding it up, because that ad'y as far as you itures two people who ,rred images, as leaders , very masculine: the:)doll forman,ywomenr good relationship. One outh znight even be the an, adoringlook. They,goody advertising pol- ;et their product across cept that if we look at that ad, do vou think? put them all to(re#her. completely unpolluted rain of sand disturbed. :ughter.] clear;t'he, air is clear. undlenmines that health that ad is saying toy.ou lctivity, i'tis associated ' guy who looks like hee runi 10 miles down the peoplla have. In other )v seekimo, to associatleliealtliful, and bvsng- fnl and robust outdboron of health. Nowy if you could hold the ad up just a little bit further, Senator, the. next point I think is important!. That is a di'splayad. From here, and I think probably from the back of the room, most everybody knows what is being adVertised and can see the picture.Btit even from hereI can't see theliealth.varning. I can see where I think it is. I certainllycan't see it or read it~. Yet the Federal TradeCommission hasheld' held'time aftethat it is an unfair and deceptive trade practice to advertise a; product wit.hout revealin g, a material fact. Certainlyy it is, a material fact with regard to those cigarettes that they can kill you. And yet that warning is not,clearand'conspicuous. And when we lookat them on billboards, Senator, it is often a challenge-I think even in Massachusetts, as well as in alt the other States-to find the health warning, much less to read it. The problem is, those kinds of ads should not be allbhv.ed't~o continue unless t'hehealth, warning is made clear and conspicuous- and here I am speaking about thebillboardds, the point ofdisplkayf ads, the ads on the sides of buses, and so on. Another thing .recan do now-and we cando~it today, and we,can even dloitwithout legislation-would be to limit various cigarette pro- motional tactics. Virtually not a week goes by when y ou can't clip a coupon out of a family newspaper or magazine and! send away for two free packs of this, that or the other cigarette. Now, you certify that you are 21 years of age and already a smoker, butt kids are smart enough to hnow that'they can send away for it and' get free packs of cigarettes. Also,, more and more cigarettes areoff'ering, premiums,premiums, for buy ing the product and for mailing coupons in. And increasingly tliose premiums are aimed at a youth audience. AV, hen you have a surf- boardl with a sail on it, when~ you~ have a T-shirt, when you have a beer cooler aimed at the beach crowd'-when you have these kinds of things-obviously those are of interest to kids, and here this very diffi- cult dCcisionthat these teenagers outlinedl for us this morning, tivhet'lier to smoke or not,.vhethert'o go tolbaver tar and nicotine, isintiuenced~ by the idea that if I buy ai few more packs of Zil~h cigarettes I may get that sailboat. That, to me; Senator, is, unfair and decepti:re. Certainly I woul& favor a return to theantismoking messages on~ radio and! television. I think also something should be done about candy cigarettes. ~Tany candy cigarettes are now being sold in packages «hich are virtually identical t'~o those of t'hereall thing. And these obviously are- used bvyour very, very young kids. Elementary psychology tells us that the oral gratificati'on that those kids get from smoking those cigarettes is going to be carriedi over. And presumably the one reason why the manufacturers allow their trademark and trade names,to be used on those packs of cigarettes is because they hope that some of that will st2vwith tlhe, kid, and that he will buy that pack when he gets older. We have presentecll a petition to the Fbod' and Drug Administration tolimstthe sale of ciuarettes. Finst, we think weought to gct them out of the unattended vending machines. A vervy important question was not asked thismorning, Senator: where do these kids~ get the cigarettes ? It's illegal in 1111 t'hearea j,uris- dietibns for kids t'obuythem and for them, to, be sold to kids. They must be buying them somewhere, and every indication seems to be- 0

vtATCHED~~GitOUPS'., K 'Low' tar-nicotine 15;360 6,832 32,703 16,803' 14,897' 6,564 32,357 16,550 83,072 36.435 175.744 89,129 lded because iect. !II5 for males, Since a large d number of N'subjects in mean ages of ?etiod 1; and ; ure t'o risk as ts 4735.5 for 2 for "low" w" group is of compari- 2riod 2), the d7owest for )ethveen the _0:0005). deaths was id 235.2 for I the "low" 233' TAR'AND N1COTdNE CONTENT OF CIGARETTES 269 T/Nlgroup is statistically significant (P<0.0005). For each of four individual sets of comparisons (males and females in Period's li and 2)I the adjusted number of lung cancer deaths was highest for the "high" T/N smokers and lowest for the "low" T/N smokers. Part 2' of Table 2 shows mortality ratios calculated by dividing the adjusted numberof d'eaths in the "medium"'T/N and "low" T/N group by the corresponding adjusted numberiof deaths inithe "high" T/N group:.As shown on the bottom line, the mortality ratio for the "low" T/N group was 0.84~ for all causes of death combined', and 0!74 for lung cancer deaths. It is of interest that the lung cancer mortality ratios of "low" T/N' smokers were lower for females than for males (0.57 for females and 0j83 for males in Period I and 0.62 for females and 0.79 for males in Period 2). Mortality ratios were also caltulated by dividing the adjusted death rates of the "medium" T/N,and "low" T/N smokers by the adjusted death rates of the'''high" T/N smokers. These mortality ratios were very close to those shown in Table 2. Adjusted deathrates, if desired, maybe calculated by dividing'the adjusted number ofdeaths (part I ofTable 2) by the corresponding adjusted person-years of exposure to risk (part 3 of'Table l)i Table 3 shows corresponding figures~for coronary heart disease. The adjusted number of coronary heart disease deaths was: 1616.8' in "high" T/N smokers, 1483'.3 in "medium" T/N smokers, and1392'.7 in "low" T/N smokers. The differ- ence between the "high" T/N group and the "low" T/N group is statistically significam (P<0.0001). For each of the four individual sets of comparisons (males and females in Periods li and 2), the adjusted number of coronary heart disease TABLE 2 ADJLSTED NUMBER OF DEATHS (TOTAL AND LUNG'.CA::OER)!ASV'D MORTALITY RATIOS Dl'RING EACHIOF Tw o PERIODS OF TIME BY SEX AN'DiBY"TAR" AND NICO'rmE CONTENT OF CIGARETTES US'UALLYSMORED To tal deaths Lung cancer deaths "High" " Medium" "Low" "High" "Medium" "Low" Sex Period T/N T/N T/N TVN T/N T/N I. Adjusted number of deaths Male I 1,543.0 1 L394.4 1,351.7 122.4 117.4 101.0 Male 2' 935.2 913.7 759.4 89.6 84.5 70:6 Female I 1,253:6 1,117.1 1,053.9 48.3 41.4 27.4 Female 2 1,003l7 874.7 826.2 58.11 42.2 36.2 Totall 4,735:5 4;299.9 3,991.2 318.4 285.5 235.2 2. Mortality ratios Male I 1.00 0.90 0:88 1.00 0.96 0.83 Male 2 1.00 0.98 0j81 1.00: 0.94: 0.79 Female 1 1.00 0.89 0:84 1.00' 0.86 0.57' Female 2 1.00 0.87 0.82 1.00' 0.73 0.62 Total 00 1 91 0 84 0 1 00 0 90 74 0 0 . . . . . . W ~ Q W Go 0 . 30-536. 0 '- 78 - 16 I

270 234 H A MMO ND ET AL. TABLE 3 ADfL'STF.D NU51BER OF DEATHS (CDRCI.\_aRl' HEAf[li DISEASE) AND MORTALITY RAT1O5DL"RIItiC EACII ()F Tw(D. PEIRIDDS'. OF TIMEBY SEX AND BY "TAR- AND t`IICnI-INE CONTENT OF CIGARETTES t.1SL'ALLY SSIQhED~ "High"' "Medium" "Low" Sex Period tar-nicotine tar-nicotine tar-nicotine 1. Adjusted'number of CHD~de•aths Male 1' 696.5 632:5 645:6 Male 2 336.0 345:6 274.2 Female ] i 318.7 277.5 257:41 Female 2265.6228;01 215;5~ Total 1,616.8 1,483.3 1,392:7' 2. Mortalitv ratios Male 1 1.00 0 41 0.93 Male 2 1.00 1.03 0.82 Female 1 1.00 0:87 0.81 Female 2 ].00 0.86 0.81 Totali I.00 0:92 0.86 deaths was higher for the "high"' TLN group than for the "low" T/N group. As shown on the bottom lineafTable 3, the coronary heart disease mortality ratio for "low" T/N smokers was 0.86. ADDITIONAL ANALYSES, Coronary Heart Disease As a further test of the hypothesis as related to coronary heart disease, a second matched-groups analysis was carried out including additional factors of significance or possible significance in relation to that disease. In this analysis, the subjectss within eachimatched group were alike with respect to age (same 5-year date of birth cohort, with respect to all the other eight factors included in the first analysis (as previously described), and with respect toallofthefollbwing,factors: (10) history of stroke (yes or no); (l1)historyof diabetes (yes or no); (',12)historyofhighblood pressure (yes or no); and (as,reported on Q1)(l3) usuallamount of exercise (none, slight vs moderate, heavy); (14) obesity (20% or more over average weight, yes or no); (15) coffee-tea (six + cups a day, yes or no);,(16)whiskey,gin, etc. (none, occasional vs daily drinking); (;17)aspirin (often vs not often); and (18) occupation (doctor, lawyer, teacher, nurse and other professionals vs other). Because of the larger number of factors on which the subjects were matched, there were fewer matched groups containing'at least one H, at least one M, and at least one L subject. The adjusted numbers of subjects were: 11,599 men„Peribd 1; 4996 men, Period 2; 23',584 women, Period l; and 111,450 women, Period 2. Since these adjusted, numbers of subjects were less than the corresponding adjusted numbers of subjects in the frst analysis (as previously d'escribed)'there were fewer "TAR' adjusted~.deaths.Neve results of the first ana' The adjusted numbcwas: 1007.5 for "high" for "low"'T/N smokei, group,is statist2callysi comparisons (males ar nary heart disease deat group. The coronary 0:83. Selective Effect' of Gii' In comparingsmoki distributed in 1972); w than of the "high"'T/~ could have accounted :. of subjects. To checkt Period 1. In this analy thereafter excluded't L thereafter excluded. T very close to the result up smoking did! not a( Many~ "Low"' TIN~ Ci; As shown in Tables cancerdeaths,,and co "low" T/N smokers matched on number c various other factors). studies (U.S. Public H cigarettes smoked pe subjects who smoked : or higher death rates cigarettes. Because of tions of number of cit cigarettes smoked, w( able to compare subjl subjects who smoked carried out a matched were alike with respec factors used in the firs before, thiswasdone time. The adjusted n Period 2; 12,275 fem~ The adjusted numt

240 STATEMENT OF THE TOBACCO INSTITUTE RE 5.311$ SUBMITTED TO THE SUBCOMMITTEE ON HEALTHIAND:SCIENTIFIC RESEARCH OF THE COMMITT!EE ON HUMAN RESOURCES UNITED STATES SENATE We are gratefull for the opportunity to comment on, S'.31!18, which pertains to tobacco and tobacco smoking, and to be able to do so under conditions which are rela- tively free of the emotionali~sm that often surround'~s this subject. The legislati~ve process i!s better illuminated!by the light of reasoned deliberation than the heat of infl!am- matory rhetoric. The level of public discussion woul!d~tie improved by strict limitations on the use of military metaphors in dealing wkth comiplex questions of disease causation and prevention. Indeed the nation would benefit if individuals and groups abandoned the myth of "waging war" against diseases or their allieged causes. Nature will not surrender her secrets to propaganda barrages. Nature will yield her secrets only to the steady advance of knowledge. Basic knowledge does not flourish in a lock-step society. It grows best under conditions of unfettered investigation and free, fair and full discussion. Page 2 The fact is that i enough basic knowledg< of a variety of major Dr. Lewis Thomas, Kettering Cancer Cent, sol'idest piece of sci thing about which I f "is that we are profo Indeed, I regard this past 100 years of bio "'Ini earl!ierti'mesr to understand' how thi or simply made up stc He concluded witl' appropriate: "We will solve tF cancer, stroke, arthr dementia, and all the learning." Uhfortunately, a inquiry d'oes not obtE health. The scapego; diversion of attenti( which do,,in fact, e or covered'up.

274 238 HAMMOND ET AL. voluntarily in the light of the fact that Ibng-term trends have been in this direction. We will end with a word of caution. In producing cigarettes with extremely little tar and nicotine, some manufactur- ers may use additives for flavor or for some other purpose. In our opinion, both additives and the cigarette smoke condensate (tar) should be tested for car- cinogenicity before such cigarettes are put oni the market. REFERENCES Bross, Il D. J., and Gibsun„R. (1968)Risks ofllung cancer in smokers who:switch to filter cigarettes. Amer. J. Pub: Health 58, 1396. IDoll. R.. and Hill. A. B. (1952)j ,A study'of ofthe aetiology of carcinoma of the lung:. Brit. Med: J. 2, 1271. Hammond. E. C: (1964). Smoking in relation to mortality and morbidity. Findings in first thirty-four months of follow-up inia prospective study started in 1959. J. Nat:,Cancer Inst. 32, 1461. Hammond, E. C., and Garfinkel L.,(1964). Changes in cigarette smoking. J, Nat. Cancer lilst. 33, 49 . Levin, M. L.. Goldstein, H., and Gerhardt, P. R. (i1950). Cancer and tobacco smoking. A preliminary report. J. Amer. Med. Assoc. 143; 336. U. S. Public Health Service (1964)1 "Smoking and Health Report of the Advisory Committee to the Surgeon-General of the Public Health Service."'Publie Health Service PublicationNo: 1103. U. S:. Dept. of H'. E. W., Washington, D.C. U. S. Public Health Service (1968). Public health service technical report on "tar" and nicotine. In "Hearings before the Consumer Subcommittee of the Committee on Commerce," United States Senate, A'ugusv23-25, 1967, p. 7. U.S. Government Printing Office. Washington, D.C: U.S. Public Health Service (1971). "The Health Consequences of Smoking. A Reportof ofthe Surgeon- General," DHEW Publication No. 71-7573. U.S. Dept. of H.E.W. Washingtonl,D:C. U.S. Public Health Service (1976). "Adhlt Use of'ilobacco--1975." U.S. Dept. ofH.E.W.. Bethesda, Md. Wynder. E. L.,,and Grahami E. A. (1950). Tobacco smoking as a possible etiologic factor in bron- chogenic caroinoma. J. Amer. Med. Assoc. 143, 3°_9: Wynder, E. L., \4abuclii„K., and Beattie. E. J., Jn. (1970): The epidemiology'of'ltmg cancer. J. Amer. Med. Assoc. , 213, 2221. TheHonorable. Edward PS. Kennedy United.Statles Senate Washington, D. C. 20`- Dear Senator Kennedy: EncLosed is a copy of regarding S. 3118 on ~ We thank you for the cc us to submit it for t': We are also attaching which we respectfully record. They are: 1. Summary Repo- Drug Use, Sa, 1977. 2~~.~ "Two Days In the 3001,000, 3. Statement of Hearings bef .. Commerce Cop 941. Enclosures TIE TOBACCO INSI ]776 K STREF.T. NORT'Hll'ESTiIS'ASMINGTON. OUR TOLL F'AE:L NUMBER I5: 800l424-9876 .

!' and cigarettes ;hly visible and )king. Cigarette e lost our man- and we lost a noking began to confined to the pete not against 1 a whole passeli spend millions tes,, while public ie media, unablla unable to target )ortant, the non- e cigarette com- rets that enable or, smoking ap- •s, emotions, and r Smoking and Society has been ologists, sociolo- wing, surveying bservations over do get the ciga- vs to turning off' , are waiting, we: r our own fight.. iat I do beiieve; very smart and't'hey know, and ' dollars doing it rhey never quit. rns coming, keep 'liey target, they Chey repeat and implicit ad for iiey are the one tising, which in to get the moneyrg habit, or on a .ie, habit of not the sake of our "liealtheduca- e tobacco peoplesons,7° 10Lsecond ie to expose our 175 "lessons," to plan our schedules, target our "students." We are not op- posed! to buying other materials for educational purposes, why not then buy time? And let our "lessons" not be pedantic, authoritarian, establishment, or(~forgive me)"healtli educat'or"lessons. Let our "les- sons" be as bright and smart and memorable as the most engaging advertising around-yea, even as good as. cigarette advertising. Letus apply the Sesame Street'experience('whiich by the way toOk its cue f~rom TV commercials-t1ieriglit'lengthoftinsefortlheatten- tion span of kids, and! right iit keeping with what they're watching on~TV' anyway). And let us schedulle our lessons on the right'programs at the right times, let, us repeat our lessons, remembering that thereare new kids joining the audience every day. Let' us think of television as thegreat new classroom-surety the critics of TV do: consider the sex and violence controversy that rages right now, the sugared cereal, the idea~ of banningTV adv.ertising to kidscompletely. And let us start some newideas about smoking coining into kids' lives, let us give them counsel and support, a new clinrate, a happy, informed, non- punitive nonsmoking healthi environment. Let us build a good habit and the self-respect and self-worth that goes wi'thit. That means buying time, planning schedules, creating TV cam- paigns; being as professional and effective in our efforts against snrok- ing as the cigarette people in promoting it. W'hyTV?AVhy,not just! the classroom? We have sex education in schools and yet our unwed teenage mother population grows. We teach hygiene in schools and VDis onitherise. «''e teaehthe dangers of drugs (and kids today,knowmoreabout drugsthan their teachers, I'm sure), and our drug problem persists, and is now reaching a younger and younger populatiom We may not like, . it, but school is not where kids learn theirbasic, . values and~ ideas. As, a matter of fnc:t, it. never was. Ij'e have always learned from, our home and our friends, and today in the home, TV is perhaps the greatest influence of all. So if' you want to get the youngsters, you~ve got to go where the youngsters are. Can you, "se11P'' a health habit the way you sell a product ? I believe that toot'lipasteadt-erth'sing has donemore to build the habit of brushing (and with itbet#er dental'health)than allltheschools and dentists combined. I believe that soap ad'vertising has done more to build cleanliness-from our bodies to our homes-build! personal klygieneand with ita kind ofsocial'control over communicable diseases than schools and doctors. And' I knowfrom, mvown personal experience with the American CancerSociety and the \~ational Cllearinghouse forShIloking, and Health that you can indeed! influence healthbehav.ior. I've persuaded women to have Pap tests, to learn breast self-e3amination; smokers to, quit smoking, smokers to cut down on smoking„tolool: for~less hazard- ous cigarettes, and even. I believe, haveinffluenced the direction that cigarette companies have taken in developing low-tar and low-nicotine products. And I know from mvown: personalietperiencewith the Internationall Ladies' Garment Workers' L nion that youl can get a ne.v and ditticult and sensitive message across, that you can gett people to listeni to al union message, look for a union label~ and even get themi tosingal union song.

HAMMOND ~ET~AL. tracing was resumed in 1971, 3 of these states dropped out for administrative reasons; and we decided not to attempt to trace those few subjects who were "lost" in the sixth follow-up. Thus„on October 1, 1971, we set out to trace 897.825 subjects who had been traced in the sixth follow-up and who were still living as of September 30, 1965. We traced 98:4% through September 30, 1971, and 92.8% through September 30, 1972. 1 This report is confined to experience during two 6-year periods of time: Period 1', July 1, 1960-June 30, 1966; and Period 2, July li, 1966-June 30, 1972. It is further confined to subjects 40 years of age or older as of July 1i,1960, who on Q1 saidithat they were currently smoking cigarettes regularly and had never smoked pipes or cigars regularly; and who on Qli state& the number ofcigarettes they currently smoked per day and their usual brand of cigarettes.6 Experience during Period 2 is further confined to subjects who answered Q4 and who on that'questionnaire said thaV they were currently smoking cigarettes, stated the number they smoked per day, and the brand of cigarettes they usually smoked at that time. MfTHODS' Information on the tar and nicotine content of the smoke from;various brands of cigarettes was obtained from several sources.' On the basis of this information, each subject was cl_ ssifted according to the tarand nicotine content(H, "high"; M, "medium~'; oriL, "low") of the cigarettes he usually smoked at three points in time as indicated in QI, Q2, and Q4. This was relatively easy for Q l, since at that time, although some manufacturers marketed two or more types of cigarettes under the same brand name they could bee distinguished by presence or absence of a filter or by menthol. For purposes of this report, we defined "highi' T/N as 2.0 to;2:7 mg of nicotine and 25.8 to 35.7 mg of tar. "Low" T/N was defined as less than 1.2 mg of nicotine; and! with very few exceptions, cigarettes which meet this qualification also delivered less than 17.6 mg of tar. "Ivledium" T/N was simply defined as intermediate between "high"' an& "low.' insofar as possible, we used'these same definitions for later years. However, some manufactureres marketed, under the same brandlname, two or more types of cigarettes which differed in tar and nicotine content. For thisreason; it is likely that some of the subjects who were placed in the "high" T/N category probably belonged in the "medium" T/N category and vice versa, There was far less difficulty of this sort in distinguishing the "low" T/N smokers from the other two groups. For the period 1966-1972, the three sets were distinguished! as follows: (1) "High" was defined as subjects in the"higfi" categoryinrthe 1959-1960 question- b,One additional analysis includes subjects who had never smoked regularly. ' Tar and nicotine content of smoke from various brands of cigarettes in various years was obtained from analyses made by Foster ID. SneII, Inc." and published!in the November 1959 issue of Readers Digest; in~the July 1961 issue of! Readers Digest; and fon 1965, interpolated from the Readers Digest August 1963'issue andltheFederalTrade Commission ratings published in November 1967,. naire (Q1)and as ei (2):"Low" was def"low"or "mediun and! Q4. "Matched grou divided into group: all of the followin (white or nonwhite or 40+); (4) age be, at time of enrollmc fumes, gases, chei womenwere matc school or above); i Q3, or Q4 (yes or r. Q2, Q3, or Q4 (y,tThis matching : Periods l and 2. number smoked f smoking was take smoked per day < Within each m three subgroups t discarded if itidid least one L subjec of subjects was i& adjusted number was then divided L)~toobt'ain three smallest subgrou; less than 1.00.) T corresponding ac subgroup: Likeu 6-year period) fo: factor to obtain tt to risk of a subje( alive at the end o up to the time of the start, of the r Having carrie( subjects, the fim Part l of Table of the two time I they usually smc included in matc

nable to idence 1'1 known ere is a iysical <nown ~art LC -557, 6 onal ether ons,. S. 261 Page 22 A review of recent scientific literature reveals that others, both in this country and abroad, have begun to d'i'~spute the asserted link between various illnesses and smoking. For example, in May of this year, Professor Phi~lip Burch of the University of Leeds in England, in an address to the Royal Statistical Society,, questioned the causal relationship between smoking and lung cancer,, and made the following,observation: "As we are all well aware, many eminent persons, committees and commissions have unanimously concluded that lung cancer 'is almost entirely due to cigarette smoking.' I once shared that view,.but having now studied'the evidence in more detail and from, new angles I feel unable to reach a defimitive conclusion„ apart from reject- ing the 'pure' causal theory,. Accordingly, I ftnd myself forced back to Fisher's (1959) earlier verdict: the data so far do not warrant the conclusions based upon them." To make valid deductions about the causes of disease the rules of statistical inference need to~be strictly observed; I hope that interested statisti- cians will scrutinize the frequent and often strident claims that a given habit or dietary factor causes a particular disease.", One final point on the scientific evidence. The smoking and health controversy is growing in intensity. After twenty years it is not dead; it is rising like a Phoenix. As an editoriall in the American Journal of Public Health -- a publication known for its anti- tobacco position -- put it: 0

We of' any outcome ont~ributed by radio.ciallv during time imunity programs itrol thc freqnency~e programs should -opriate use of talk atary features, and lie able to purchased in metropolitan, ittempts t~o utiliPees, fleature articlles,Aerials where they their products. It came. Some esam- nts, in addition to iools and for kid's ~-ie theaters, place- tons, milk cartons, n a comprehensive nationi but toserve )kingas a norm. .escale of adi-ertis- tins. In an env.iron- ion to develop and eree n ell over $250rnnds, the odds are mpact on the "cli- l has experienced a nd the example of significant resultsn-and in the past, )yed, all programs to (I ) characterize evaluation desinnsnd'scientific riror; 1ral assessments as make pro,ram re- rate determination those found to be enew community i~ of children's be- •om surveys, focus ]cept on track and 173 Estensive cooperation among school systems, voluntary and public health agencies, and! other interested groups ; Involvement of health professionals, particularly practlicing phy- sicians and dentists; Use of a variety of inedia;, Einphasis on immediate personal and social reinforcement of nonr smoliing behavior, and avoidanceofe exhortation or sermonizing; Involvement of children and ad'olescents in program, planning and! design of materials; . Protesting of materials with revisions mad'e as needed;, Use of athletes and other valued figures as nonsmoking examplars; I-;eof multiple appeals, including social and personal themes unre- lated to physical health; Controlled! plaeement of advertisements in print and broadcast media ; Reinforcement of basic messages over a period of years; and Use of rigorous evaluation techniques which permit comparative assessment of different approaches and programs. It has been estimated that one-fift]rof the cost of medical care today arises, because of tobacco and alcohol abuse. Even if smoking-related problems accounted~ for only one-hundredth of the $Y'i60billion~ spentt on health carein this country last year, that would be $1.6~ billion. CDearly the potential cost savings that could result from eflectivee smoking control programs, apart from the values in terms of personai health and productivity, are enormous. Senator Kr,xN-EnY. Thanks very much. Paula Green? lls. GxFFN. 1Iy name is Pa2ila Greeivand I ampresident andlcreativedirector of Green Dolmatcli, Inc., an~ adverbising agencti= in~ New York. In~ thepast'I have personally been a consultant to the Trational Clear- inghouse on Smoking and Health, and for a period of 21/2 years, our agency produced anticigarette advertising and'~ promotion materials under contract to the clearinahouse. I'm a fomnernatiional chairman of the public information committee of the American Cancer Societyand have served oni the national board' of directors of the ACS since 1971. illost rccently, I served the Governor of New York on his Breast Citncer Advisory Committee. I am ha1ftempted-there are so many things I think I would like to answer, but I think I will go ahead with, the prepared testimony anyway. I call'this "A New Leaf." It is wrong for us to believe that people start smoking, today just because of advertising. Today, advertising isonly one factor. We've been a cigarette culture for about 60 years now. Three generations of Americans have grown up, smoking themselves and R-atchin; other people smoke. And con- sidering it aperfectlti- acceptable plleasure,and habit. We only learned the worst 14 vears ago. Fourteen years ago the Surgeon General issued his famous report, and we found out that cigarettesmoltinEr, one of our dearest pleasures, was a thief of healt'h, a destroyer of life. We alsolearne& soulethin(r else in these past 14 years. We learne& t'hat we could use telhvision advertising to do more than sell'products. We learned t'o use, adv.ertising, co~nmerical techniques to tell Ameri- cans the terrible news about cigarette smokinIrr and get tltem to actt on it.

262 Horace ff. Kornegay President The Tobacco Institute July 12, 197,8 U.S. Sales-Weight "Tar"'mgs. 37.0 35.0 ', 34.0 33.0 32.0 31.0 30.0 29.0 28.0 27.0 I 26.0 25.0 24.0 23.0 22.0 21.0 20.0 19.0 18.0 ~ Nicot 17.0 ~'---- 1950 All brands on UIS: market. Page 23 "The persistent controversy regarding the role of smoking,in lung cancer cannot be resolved'merelyy by escalating,the force of arguments pro and con. That these arguments are becoming i'nereasingly sophisticated and more vigorous serves to demon- strate that the issue is hardly tri'~vial. Let us, therefore, carefully examine the nature of the problems we confront and seek to identify, means of approachimg them in the best interests of both the scientific communi'ty and the general population." [Ibrahim, M., The Cigarette Smoking/Lung Cancer Hypo- thesis. American J'ournal of Public Health 66(2): 132-133, 1976. There are additional arguments and still more evidence on the less popular side of the controversy. We respectfully request permission to submit for the record some detailed analyses essential to a better understanding,of why the tobacco industry is i~n opposition to 5.3118', and believes i~t is unnecessary in its purpose and'unwarranted in its premise.

Ki 222 Mr. Chairman and members of the Subcommittee, my name is Robert M. Daugherty, Jr., M.D., Ph.D. Lam presently the Dean of the Medical Schooi at the Universiity of Wyoming and Chairman of the Subcommittee oniSmoking of the American Heart Association. I appreciate the opportunity to appear before this Subconmittee on behalf of the American Heart Association to testify inisupport of the National Disease Prevention and Health Promotion Act of 1978. As you may know,,the American Heart Association is a non-profit voluntary health organization consisting of some 40,000 scientists, 65,000 other key members and some 2,000,000 citizen volunteers who are dedicated to the reduction of pre- mature death and disability resul!ting,from cardiovascular disease. Cigarette smoking has been held responsible for many thousands of prema- ture deaths each year. Total mortality is twice as high among cigarette smokers as among nonsmokers. Many of these smokers die of eoronary heart disease. In fact, cigarette smoking greatly increases aniindividual's risk of developing cardiovascul'ar disease. Since the first Surgeon Generall's Report on Smoking in 1964, the contri- bution of cigarette smoking to the development' of heart attack and coro- nary heart disease mortality has been further confirmed and strengthened by addiitional epidemiological, cl'inical and anatomicall evidence (1-7). Cigarette smoking has now been firmly connected with the onset of peri- pheral''arterial disease (2). Smoking,is also the principal cause of both chronic bronchitis and emphysema, diseases which are in turn the chief causes of pulmonary heart disease and aggravate other types of heart disease. The risk of cardiovascular disease increases in proportion to the number of cigarettes smoked and the duration of exposure to the habit. The effect of cigarette smoking on cardiovascular disease risk is inde- pendent of the other major risk factors and the risk is greatly aggravated when such factors as high blood pressure, high blood cholesterol or diabetes are present. Such high risk persons who also smoke place themselves in serious jeopardy (11Q,. Although the smoker can reduce the health risks of smoking by smoking,fewer cigarettes, switchimg to filtered low tar and nicotine cigarettes, taking fewer puffs and not inhaling, the only sure way is to abstain from smoking entirely. A shift to cigar and pipe smoking is not effective if the former cigarette smoker continues to inhale (3). In view of the evidence linking cigarette smoking,to cardiovascular disease which I have summari¢ed for you, the American Heart Association applauds you, Mr. Chairman, for introducing legislation aimed at reducing the health consequences from cigaret proposed initiatives: 1. The institution of a to their tar andinico smokers is to purchas a system would not on cigarette but would p 2. Utilizing the stronge of smoking, consisten to be placed on cigar label." which is being. 3: Support for epidemiol associated~with the v stances commonly adde biomedical research i mechanismithrough whi ment of cardiovascula 4. The establishment of and adolescents. Si'n smoking", is occurrin, ative is right on tar po^ulation, there is nation's youth, espec cularily pl!eased~to s, agers. A review of the evidence disease, peripheral arter disease indicate; that smc these diseases. Gains ag~ considering the vigorous , . man-made environmental ha:, health consequences. Eff, The American Heart Associz and~the Department of,Hea' improve the health of this Thank you.

259 Page 20 -- A 1977 study by Cohen, et al., strongly suggests that blie on earings stry =al:th 'I ° Smoking )f the .ng,that a cause ;hed -tion. he ion a common familial component in both lung,cancer and chronic obstructive lung diseases independ'en!t of smoking. [Lancet 2(8037):523-526, 1977.J -- A 1977 study by Forde, et al. found an increased risk of myocardta1 ihfarction in persons with family history of myocardial infaretions compared with persons without such family history. The authors also reported that "cigarette consumption~shows only very little variation in the different groups, and thus cannot be responsible for the disagreement." [IAmerican Journal of Epidemiology 105(3): 1'92-199, 1977. ]i -- A 11977, study by Parkash found that the inci~d'ence of lung cancer in Vienna has remained constant si~nce 1962 despite the fact that tobacco consumption has been steadily increasing. The author concluded that "there are other factors which pLay a miore important role in the eti~ol'ogy of lung cancer" than tobacco consumption. [Respiration 34 (5): 295-30u, 1977,.J -- A 11977 study by Lawson, et al., found no association between thromboembolism, smoking and duration of oraL contraceptive use. The authors stated that their "study provi'~des strong evidence against a major effect of smoking on the risk of thromboembolism inia group of otherwise , healthy women using oral contraceptives." [British Medical Journal 2: 729"730' 11977.1 N'

263 U.S. Sales-Weighted Average "Tar" & Nicotine Yields ole of •'Tar" mgs. 37.0 erely. J con. s1y 36.0 emonr et us, 35.0 the eans f bo1;h, 34A pulation." ncer Hypo- 33 0 66(2'): . 32.0 re 31.0 ersy. 30.0 29.0 is in 2B.0 sary 27.0 26.0' 25.0 24 0 ~ . 23.0 22.0 21.0 20.0 19.0 18:0 17.0 / 1 1 1 1 1 1 1 1 1 1 1 1 1 1 l 1 1 1 I f I I I I 1 I I I 1 1 Nic otine ;"T an" 1 1 1 l /\ \ \ \ \ \ \ \ 1 \ - 1960 1965 1970 1975 1980, 1 A 3.1 Niootine mgs: 3.0 2.9 2.8 2.7 2.6 2.5 2.4 2.3 2.2 All brands on U.S. market;. Data compiled by Philip Morris Inc.,- Jan..1978

As aa socral r,~:he,.':oyisti a:i•lressing h.m~self increasinglvn t.c, the probGem; o.ftlh~e u^ev.ent.ion andd control of~ ca:rrliovasc.ul-r disease par:iculiarlyy at. t.:hemcment,,smoki~ng„ it.wcuid a-zear ._ nethat. an import.antt direction in whiich~ we mignt,t go:_.z to foste- inocu.lati~on strategies.--wirichinv.oive trainr:na child,-en.t^ resist t.ne social pressures to~be.giro smoking or adva.cce:-oward £reqiaen.t.,n addictive smo:king. Our current findi'.ngss ini our FINLB'.-supportei suggest thatt f.ea~r arousal may be imef:"ective iia antii-m k.inF: r.es- ,.sges tio:children.Fy.the time theyreacn the seventh Frade,, even~though virtual7yall children believe smoking isdan¢erous, sariybe~.in smo'singanyway. O+.rin-depth in2~erviews with,a large populat-:onoS seventh.graders,.suggest t'~tlat, indivildua111yor col- lectiv.ely,.peer pressuwres, models o.ff smoking oarents, and the ma.ssmedia ;,e.g,., oigaret.tie.comp:a.nyadvertising)Ir.aye override the beliief cf^:aiidrenthat.s.mokingisdanerrous. :,ecent exrlorat:onscf this problere at y.tacfr_:-:iar.dMinne.sota corroborate ocr f~n3ir.zs.. ?urt'.he:aore, we nowhave somee:vid'encetaiat in addlit4cn *.ec depending too .`.eavilyy on fear as a deterrent bo.sm-iine„ ant.ii- smokink:nes,sag.esini sc.qrolsf.ail into a'*.',i;;e r.ersre^.t~ive" t.ra-.. That is,., t~heyy focusto- muchonh the: flitiure dianqers ef smo+:ins.. C ,::ildren are more likelyt:o~foc.u~s- ^n, the:presente r...essagesshoulids em~pFiusiae more i:n:me3ia•'.eef'fect.s cnildd or teer.ager.. Sir.~k7 aor."r^1. of' .,moki c_. on th=_. Wearean inocuiaticn-agai~nst-nress.;res-to-smor.=_stra:tegy (seemingiyquitc e~ff:ecti:vefirst in a ten-ve:ek. study,.an:L nowthrou.ghthesecor.study which will followstudent and ni.ntri grades) predicated on _f1 students can be "nursed" thr to-social-pres.sures-to-smoke.,jc be f.orti.fied su~ffiaientlyy so tS:, which is generaLlyfirst.found school, will less l.i~kely, occur. Sndenen:dent', and may be less 1?oressurestlc,begin smoking. wewould encourage thee dec fiim.sand related reinforcers (i : ofthe students themselves demr pressures to smoke.r.ather than riigtr.feararousal messages. Sti.ally a m.aximally costt effect. This is in contrast to sma:ll-gg has the disadvantage of not be locales,, vartes considerably i an~d cannot be too easilyy stand. Too amplify our methodss an~ investigation was completed wi entering seventhgrade. Rates of onse.tofsmokingt andithe.testi.ngonlygroupswe onset rates in the prete:st-sin :igu.re 1).

246 Page 7 On a telievisioniprogram recentl.y, John1M. Pinney,, the newly appointed director of HEW"s Offi~ce on Smoking. and Health expressed'the following view: "It is quite correct not to make ads the culprit in terms of why teenagers take up smokng. Advertising certainly ils not the culprit. If we can understand why they take it up then we can do a more effective job of trying to change that decision." But to the Seeretary of HEW, it is a "pernicious fact" that young people are being influenced to smoke "by halif a billion dollars worth of advertisirrg... designed~to convince them that smoking is glamorous, adult and sexually attractive." Research funded by HEW casts doubt on advertising's alleged power over youth. A ten-year study looked into the use of a variety of substances, including alcoholi, marijuana and tobacco by 7th through 1i2th grade students in public and parochial schoolis in San Mateo, Caliifornta. The resulits run counter to the theory of adivertiising asserted by the Secretary of HEW. The study revealed'an alarming,pattern. By 1977, more 11ith grade students were smoking marijuana and drinking alcohol than smoking tobacco. In fact, be- tween 11968 and 1977, student use of marijuana had in- creased more than 80 percent -- without the benefit of any advertising -- while tobacco smoking remained stable. Page 8 A ,copy of Summary Re San Mateo County, Ca of Public Health and be made part of the Although opini~c of the substances fo out: Advertising be consumption. Support for thi part by the Americar "Economists ger advertising,in that companies rette market ar as a means for of Cigarette Ac James L. Hamil Economics, Way' the Third Worl DHEW'publicati In other words, soa to persuade people live" -- not to per therefore, buy more It is tempting advertising and smc many influences sha of young peoplie arE unwise to overemphz

!!j tion of ti'on. In a banned j nicotine itself. s denied~the ake fully ) tobacco 'ederal in "tar" i~ Tax" is ie open for have been~ :ohol, icts, and :nsformati'on havior-control to control is a regressive es while it r, it hits blue collar e to pay for 251 Page 12 By placing,a new "health protection" tax on~top of the present cigarette tax burden, it comes perilously close to d'e facto prohibition for millions of low and middle income Ameri~cans. Like the other "Noble Experiment," this measure aliso has the potential of encouraging bootleggers and racketeers to supply consumers who are priced out of the legitimate market. New York City tried a "tar" and'ni'cotine tax in 1971; and gave it up in 1975. A ci'ty councilman summarized! New,York's dismal experience: "This tax has not only been a total failure--it has enriched the bums who are killing us with drugs and the rackets. It has not yielded anticipated revenues. It has not changed smoking habits. It blatantly discriminates against the poor and it has forced thousands out of business." The Tobacco Institute, in Senate hearings on "tar" and nicotine legislation in 1972'and 1976,, made the foll!owing additional points which are as cogent today as they were previously: o Neither "tar", nicotine nor any other ingredi- ent or ingredients i'm concentrations as found in, cigarette smoke has been established as causing disease in humians. o No one has established that any particular level of "tar" and nicotine is significant. m

257 The Swedish-type warning labels could have an unanticipated' effect. They have the potential of becoming the object of a teenage hobby, like col- lecting baseball cards or comic books. THE SCIENTIFIC BASIS S.311i8 rests heavily on a "single cause theory" of disease. That theory, however, can not support the huge regullatory scaffolding that its architects have designed. Recent research into environmental and oceupationali factors, for example„ is developing new data indicating that chronic disease may no longer be so readily and simply attributed to tobacco smoke as some have claimed. "0ccupational factors may very well play a far more significant rvl!e than is presently realized in the causation of the major diseases and health problems that confront us,"' according,to a report to the Ford Foundation, which added that: "Heart disease, the leading cause of death (accounting for... about 750,000 deaths), is only 25% 'explained' by known phystol'ogical and environmental factors, such as excess weight, hypertension, serum cholesterol, and ci'~g,arette smoking. An unknown but quite possibly sub- stantial proportion of the 75% of heart disease risk that is presently unaccounted for could be related'ito work and its attendant hazards, particularLy stress." [Crisis in the Workplace: Occupational Disease and~ In'ur . A report to the Ford Foundation, Nicholas A. Ash7ord, MIT Press, 11976, p. 10.] 0

alarlly the unat- ~~nah to reach up irettes. ~ He ~ can't ct and there is it, R'e. have sll„~',, zarettes to drugirs, all of' which roductst'o phar- =ame thihg, with to require in the tcigaret'~t'es may ce today is clear, has hardly been ;ed toward help- , thev have been tearing on smok- tells tells us that 9 madle a serious )Is-V to 11010 theseby the Govern- ive programs too is. And. indeed,, its~medical pro-~id'2ze it' through against teenage tI. It is aimedl at -on alone we en- ne a smoker, or'ction over tl3ere subtlereniinder es yOu sexually led', most people ther they would houglr 20to~ 30imure, the great rrr smohersdoes e rs. to have a very terms, Senator: ~ds; "Iiissin- a- a about appear-o'<-enlentwilll be ,sinb the differ- .ection of sllift- ~-ksof all of us. 207 And if cigaret'teswere tased at anything like the total cost of their use to the L`nited States, we would have more than enough money for alli the educational programs, smoking «ithdhawal programs, and everything else. We Arere talh~in«about S?0billion of costn•hichifairlyshould he borne bythose who, "enjo~-" ' the activity. Senator KENNEDY. You think iit's~ justified! justfrom the revenue- raising measures and the i NTr. B<~az_~FiF: More than enough. Senator, if I had control, I would take the total cost of smoking- and set a tax onsmohing sothato the income from that tax would equal the total cost. Dr. Yora o. Senator, I ami cyoing, to ]iave to excuse myself. I would be happy to answer any questions for the record. Sen:ltorIii;Nxr:os-. ~'es : thank you very much. Would all of vou agree that smoking has an adversehealth, iml,iact?You all agree on that'. And,second,, that' tlhere is no redeeming social effect of smohing- dbyou all a(ri•eeon that?Withtheetception? I'suppose, of the in- cometo4he particulalr industry, the profits on it-but in terms ofother social' impacts, you would agree «•iththat. And that it is, so faras your own professional and, scientific judg- ment~, the. Inostt important healtlh hazard that we are facinn interms of our society. Dr. Dau~hert~-, would } on agree v iththat ?Dr. DALrouEalTr. Fes : I would. SenatorhFNNrry. Andl Dr. Leffalli?' I)r. T.r:r>;ALL, Yes. lII•. B_~xz_~iIr: Certainly the most important and correctible one. I think in terms of n-herev-eput'our dollars and our effotrts; Senator, we llati•.e to loolc at', two things: One is the importance of the problem, the second is how cani welia~ve a long-terrn effect on it?ThereareInany diseases andi conditionsover n hichve may-not be: able to~ have control in theshort run. Smoking is not one of those. It is noton,ly the most important. but oneofthemost easil~correctible: SenatorrIir~a~Fnl~. I+inall~-, would you alsoagreet'hat at least in telrms of our society, ani area of ~~eryy substantiali concern, perhapsdleser~-in, of themost, ought to bechildhood~ smoking developmentt in our society. Dr. Li-,rrr•.>,rL, Yes, definitely. Di•. DArcllEr,TY. Yes : the preteelr andl teenaaet•. SellatorKraNnnY. OK. «~'ellaveirvited the TohaccoInstitutleto testift. They«•,ere una~ble,to „;ettheir material t.'.oyether for this,hear- in~ at thi5 timc, but 1ve~~i11 leave the recordl openi for n~hateti~ercom ment that fihe',- «rould like to make. We want to thank all of you, very much: A very, very helpful and informativahearinb. ['Tbe prepared, statenrents of Dr. Leffall, llr, Foote, Dr. Youn(r, Dr. I)ntlrllertv;rrncl nlatorinl sitb~erluentl~-snpplhe(liforthc~record fol~lows,:]

258 Page 19 Indeed, some scientists are growing concerned that the preoccupation with cigarette smokng as "one of the princtpal contributors" to the incidence of certai!nl diseases m,ay be ill-founded and dangerous -- ill- founded'because the scientific evidence onimany criticaL points is conflicting, and dangerous because attention has been -- and is being -- diverted from such suspected hazards as occupational exposure, environmentaL pollution, diet, heredity, and the like. Despite its frequent iteration, the statement that. "cigarette smoking is the single greatest preventable threat tolour nation"s health" remains an alilegation that ils not supported by "all the evidenee." In hearings before this Subcommittee in 197,6„ the tobacco industry submitted a detailed response to the U.S. Publi'c Health Service's latest analysis of scientific evidence on smoking and health, entitLed Health Consequences of Smoking -- 1975. That response, which was printed as part of the record of those hearings, marshalled evidence showing that smoking has not been scientifically established as a cause of human disease. Since those hearings, no study, has been published which would~require a change in the industry's position. Indeed, many recent studies demonstrate that "all the evidence"'does not support a smoking-disease causation, hypothesis. For example: Page 20 -- A 1977 study t~ a common famil'ia1 com obstructive lung dise 2(8037):523-526, 1977, -- A 1977, study risk of myocardial in history of myocardial without such family t that "cigarette eons: in the different gro the disagreement." 192-199, 1977.] -- A 197,7' study, of lung cancer in Vi despite the fact thz increasing. The auU factors which play ~ of lung cancer" tha: 34 (5 ): 295-3'ou, 197 -- A 1977 stud between thromboembo contraceptive use. provides strong,ev= on the risk of thrc healthy women usinr Journal 2: 729-730

te Smoke in RBERT SEIDMAN,4 Society, New York, 227 ENVIRONME':TAU.R'ESEAR'CH tZ,. 263-274 (1976) "Tar" and Nicotine Content of Cigarette Smoke in, Relation to Death Rates' E..C[DYLER HAMNfOND,2 LAWRENCE Gv1RFINKEL,}HERBERT SEIDMAN,a AND EDWARD A. LEW5 Department ofEpidemiology and'Statisrics, American Cancer Society, New York, New York 10017 Received September 10;, 1976 Over 1,000,000 men and women who enrolled in an epidemiological study in 1959-1960 were (with few exceptions) traced'for 12 years. They all answered questionnaries on cigarette smoking and various other factors at time of enrollment; and survivors answered repeat questionnaires on three later, occasions. In this analysis, cigarette smokers were classified byy the amount of tar and nicotine delivered by the brand'they, usually, smoked atithe start of each of two 6-yearperiod6. Among subjects who smoked the same numberofeigarettes a day, total death rates, death rates from coronary heart disease, and death rates from lirng cancer were somewhat loweri for those who, smoked "low" tar-nicotine cigarettes than for those who smoked "highl' tar-nicotine cigarettes. The death rate,s of subjects who smoked "low" tar-nicotine cigarettes were far higher than the death rates,of subjects who never smoked regularly. INTRODUCTION Many years have passed since the following was firmly established by a largee number of epidemiologicali studies earried out by independent investigators in this country and abroad (U.S. Public Health Service, 1964): First, and most important, d'eath rates are higher in smokers than ininonsmokersand increase with degree of exposure to tobacco smoke. Among the diseases involved in this relationship are: (1) lung cancer and cancer of several other sites, including the lip, tongue, mouth, larynx, pharynx, esophagus, and urinary bladder; (2) coronary heart disease, stroke„andlaortic aneurysm; (3) chronic bronchitis and emphysema; and(4) several other diseases including peptic ulcers. The age-specific lung cancer death rates of men who smoked cigarettes regularly was found to be about ten times as highias the lung cancer death rate of men who never smoked; and this ratio was considerably higher among men who smoked 40or more cigarettes a: day. Expressed in, the same terms (i.e., mortality ratios), the coronary heart disease death rates of male cigarette smokers were found to be about 1.5 to 3.0 times as high depend'Ing upon age and amount of smoking as the coronary heart disease death rate of nonsmokers. From this it might be conclUded that lung, ' From a paper given at the Conference on the Origins of Human Cancer at Cold Springs Harbor~ Laboratory, New York, September 14, 1976. = Sc.D., Vice President 11.A..,Assistant Vice President. ~ M.R.A., Chief of Statistical Analyses. F.S.A.. Consultant. W. ~ 263 Q .. ~ ~ C,,r~~nght 'e;.1'17h b. Academie Pre- Ine- / ~ W Vlingh[tof repnodi¢Iion in any torm reserved. ~ ~ , V I O W

ve been in this direction. -otine, some manufactur- 3se: In our opinion, both toul& betest'e& for car- a. who switch tofilteraigaretteso the lung.Brit: Med, J. 2;,1271. ty. Findings in first thirty, four t. Cancer Inst. 32, 1161. ;:J. Nat. Cancer Inst. 33, 49:, ,bacco smoking. A preliminary ne Advisory Committee to the ice Publication No. 1103. U. S. )ort on "tar"'and'nicotine. In )n Commerce,"'United States e. Washington. D.C. ;ing, A Report of the Surgeon- . Washingtoni D:C. i: Dept. of H.E.W., Bethesda; ,sible etiologic factor in bron+ alogy of lung cancer. J: Amer. 239 THE TOBACCO INSTITUTE 1776 K SiREET. NUH rHl'u'EST.'wAS61INGTON. O C. 20006202i457-4800 OWA TOLCF2iEE NUMBEA IS. eo07a24-9e76', HOHACEP.KORNHGAY' Resident 202/457-483C1 July 12, 1978 The Honorable Edward M. Kennedy United States Senate Washington, D. C. 205101 Dear Senator Kennedy: Enclosediis a copy of Tihe Tiobacco Institute statement regarding.S. 3118 on which you invited our testimony. We thank you for the opportunity you have extended to, us to submit it for the printed record of the hearing. We are also attaching to our statement three appendixes which we respectfully request to be incl'uded in the record. They'are: 1. Summary Report - Surveys of Student Drug Use, San.Mateo County, California, 1977. 2. "Two Days In January," an explanation of the 300,000 death statistics. 3. Statement of Professor Theodor D. Sterling, Hearings before House Interstate and Foreign Commerce Committee, Aprili29.,.1969, pp. 930 - 941. Sincerely yours,. Horace R. Korne///g~\\\attty'1~~~111 ~ Enclosures ~~

206 they get them out of the vending machines, particularly the unat- tended! vending machines. As soon~ as,akid ir;old enottghto reachi up. to the coin slot ofal vending machine, he can, buy cigarettes. Hecan~t buy alcohol, lie can't buy any other dangerous product-and tliereis no excuse for that. Even moreefi"ect-ive; I thinlt,, would be again what we havesug- gested totheFDA, would be to limit the sale of cigarettes: to drug stores. Cigarettes contain niicotineand a variety of tars, all of which, are drugs. We limit the sales of! far less dangerous products to phar- macies today. I see no reason, whyy we cannot do the same tlhing with regard to,cigarettes. We have also asked the Federal', Trade Cominission, t'o reqplire in the ads as well as onthepaek a warning t'~o the effect that, cigarettes mayy be addictingand/'or habituatang~. ~~'etllinkt'.ldeevi'dence tadayie cle.ar, but this is never mentioned in the ads. And indeed it has hardly been a topic of public discussion. We alsothinltithat additional effort should be directed toward he1p- ing people-nob only kids, but all adults-to quit once thevhavebeen hooked. Smokers-and this should be emphasized at a hearing on sinok- ing-smokers arenot the enemy, ;smokingis:HE«' tells us! that 9 out of 10 sniol.ers wouU like toquit; 6 out of 101have made a serious attempt. tadoso. Yet very littleresearchi goes into how tollelp thesee people quit;, there arevirtually no prog~rams; eitherby' the Govern~- ment or the various major health organizat~ions, effective pro_rams too help them quit. There should benaoresuch pro('rams. And, indeed,. the Government should subsidize such drivesthrough it'~smedical pro- graxns and the private health organizations shoultll subsidize itt through theirs. Senator, I think today the most effective program against teenage smokin,- is thegrowingnonsmokers" riglats!movement. It is aimed atprotectidtg the rights of nonsmokers, and' for this reason alone we en- dorseit. But I think, even more important, everytime al smoker, or eveni a nonsmoker, recognizes that there's a smoking section over there and a nonsmoking section over there, it's a, not-very-subtlereminder to him or her that smohiirgis not. a~ habit thatmal:es,you sexually sophisticated, and atitractivet'~o the opposite sex. Indeed, most people dort't like associati'n- wit'hsmokers and theywotlld' rather they wouldl stay away from them. And as your charts show, althougli, 20 to 30percentofteenagerssnol:e, which is,a veryserio2is figtu•e; the great majority do not smoke. And as those kids realized,,bei'ng smokers does not mtll.ethem attractlive tothema.jorit}-of nonsmokers. I think thenonsmolters' rights nrovement is going t'~o have ai very intportant effect. Iiidsare~s alrcad' v putting it in these tetnns, Senator:tlrey are, saying smoking isno lon--er :`cool."As an example of t'his.our best-selliiu<r~ sticker reads: "Iiissinr; a. Smolcer isLikeLiclti'nlg~O~ttt a~Dirty Old ~lshtrav.."Kids are so concerned about success witheacli'other, about appear- ing popular-I t'liinl;iit,thelongrun tlteltonsmohers'tnovement will be very iniportanti. 'I'hc final thing is we would commend you for proposing the differ- ential tar andi nicotine tax as a first step in the lon,- dircction of shift- ing back to tlhesmol:cr thecost that! he places oni tlllebaeks of all of us. smohers and' nonsmokers alike. And ifcigaret uset'o the L"nite( all tiheeducatio evervthinri else: should be borne Senator Iaa. raising nneasure: JIr: BANZAHF. would take the t the•income froml Dr. YouNG: S( be happytoans. Senator I1EN~, agree that smok tltat. And, second, t do vou alL agree conietothepart] sociall imlpact's, 1And that it is.. nient,themost i of 0111. society. I Dr, D.1i'GHERT Sen€ttor' IiE\ ~, 1)r. LEPF.ILL. Mr. BAa zaHr. I this7l. in terms wehaveto look . the second isho tuany diseases a1 control in the sh, most important. Senator hEN--, tierms of our so deserving of the eur society. Dr. LEFFALL. I)r. Da'rctrEI'.1 '-;enator ht:xa testifv. Thev we in(,- at this bime: iiienti that thev N We want totl iQrformative heai [Tlte prepareci I )<nig hertv -and n. ! ~i..~

On two days in , private, medically-: which were misLeadii known were unsuppor In 1977 alone,, r heart disease,,: Last year, smok from heart dise deaths from oth cancer of the e of the kidney a Cigarette smoki • more than 32 This contentior, smoking and health the figures vary dc how much~shock impi been quoted, repea, accept them uncrit-

256 Page 17 An essential feature of any warning is that it must be factuali and meaningful to the ord'i'nary reader. A warning,that lists specific diseases supposedly associated with cigarette smokimg could be interpreted in,two different ways by the public: that smoking alone causes these diseases or that smoking always causes these di;seases. Neither interpretation is supported by scientific evi'~denee,,hence the warnings may mislead the public and~prompt skepticism about such government messages in general. The rationale for a warning label, Swedish style or any style„ is the contention that the pubLic is not informed about the asserted healith risks of smoking. But can thts cliaim be taken seriouslly?: The public has many sources of information about tobacco products: mass miedia, specialized publications, individual healith professionaLs and~a deluge of reports and bulletins from both private and governmental agencies. As early, as November of 1968, ', the director of the HEW's National Clearinghouse for Smoking and Health conceded that the public was well informed~ on the smoking and health issue. "You coul:&stand on a rooftop andishout 'smoking is dangerous' at the top of your lungs" he declared, "andlyou would not be telling anyone anything they did not already know." Page 118, The Swedish-type war unanticipated effect. TYt becoming the object of a lecting baseball cards or THE SCI: S.3118 rests heavil disease. That theory„ h regulatory scaffolding t Recent research intt factors, for example, is that chronic disease may simply attributed to tot "Occupational factc more significant role ti' causation of the major confront us," according which added that: "Heart disease, th for... about 750,,0 by known phy,siolog as excess weight, cigarette smoking. stantial proportic that is presently work and'its atter, [Crisis in the Wor In'ur y . A report A. Ashford, MIT Pr

Page 13 252 o RedUction of nicotine content may cause an increase in smoking. o: A dramatic increase in price may cause a smoker to adjust his "tar" and nicotine intake by smoking themidown to a shorter length,,by puffing more frequently and by inhaling more deeply. REGULATION OF SMOKING IiNIFEDERAL BUILDINGS Thils provision could mark the return engagement to the American scene of two sociali tragedies: Prohibition and Segregation. Ironically, the Federal Government, which was the locus of their death, would become the place of their rebirth. Ironically, too, Federal employees who are so well protected against discrimination based on their race, religion, sex and age, would be singled out to suffer the new discrimination based'on their taste for tobacco. Of course, this proposal! would inflict a symbollic wound on government employees who smoke. It would reduce their status to less-than-first-class citizenship. But, what public healith purpose would it serve? Page 14 There is mueh mor somieone's tobacco smok permeabil:ity, weather probabl'y most importan concentrations. Why i sources of smoke insic such as the automotive Pentagon, for example. and'segregating,emplon wi~Ili not improve the c psychologicall'~y or soc The public smokir appropriate tooli to c: be the Clean Air Act, Careful examinat: leads to an unequivoc: and scientists agree - conducted research on have reviewed the med those who believe smo that: There is no heal: nonsmoker from e in everyday situ

279 TWO:DAYS DN'JANUARY On two days in January 1978 a public official and a large,, private, medically-related organization each issued statements which were misleading, inaccurate and which both~should have known were unsupportable: In 1977 alione„ more than 300,000 peopl's died from cancer„ heart disease, and lung disease attributable to smoking. Joseph A. Califano„ Secretary of Health„ Educationy and Welfare (1)i Last year, smoking,was a major factor in 220,000 deaths from heart disease; 78,000 lung cancer deaths, and 22,000 deaths from other cancers, including cancer of the mouth, cancer of the esophagus„ cancer of the pancreas„ cancer of the kidhey and cancer of the bladder. Joseph A. Califano, Secretary of .Health, Education, and Welfare (2) Cigarette smoking was related in 1977 to: a more than 320,000 deaths;, American Cancer Society (3) This contention of "excess deaths" has been pivotal to the smoking and health controversy for more than 15 years., Although the figures vary depending on who is giving them and when, and how much shock impact the "authority" wishes to create, they have been quoted, repeated and misunderstood so much that many people accept them uncritieaLly.

art disease, a secondi ictors of significance nalysis, the subjects e 5-year date of birth the first analysis (as ictors: (10) historyofiistory of high blood nt of exercise (none, erage weight, yes or eey, gin, etc. (~none, and (18) occupation her). iects were matched, r least one M, and at 1,599 men, Period 1; len, Period 2. Since esponding adjusted .d) there were fewer adjusted deaths: Nevertheless, the results of thissecond analysis were close to the results of the first analysis. The adjusted number of coronary heart disease deaths (in this second analysis), was: 1007.5 for "highi' T1N smokers. 929.3 for "medium" T/N smokers, and 834'.5 for "low" T/NI smokers. The difference between the "high" group and the "low" group is statistically significant (P<0':001). For each of the four individual sets of comparisons (males and females in;Periods l and 2) the adjusted number of coro- nary heart disease deaths was higher in the "high"T!N group than in the "low" T/N group, The coronary hearr disease mortality ratio for the "low" T/N group was 0;83. Selective Effect of Giving Up Smoking In comparing smoking habits as reported'oniQ1, Q2, Q3, Q44 and Q5 (which was distributed in 1972), we foun&that a larger proportion of the "low" TIN smokers than of the "high" T/N!smokers gave up the habitiat a later date. Conceivably, this could have accounted for the difference betweenrthe death rates of these two groups of subjects. To check this possibility, we made another matched-groups analysis for Period 1. In this analysis, subjects whowere not smoking as reported on Q2'were thereafter excluded' Likewise, those who were not smoking as reported on Q3 were thereafter excluded. The results of this analysis (in terms of mortality ratios) were veryclose to the results shown in Tables 2 and 3. From this„we concludeihatigiving up smoking did not account for the findings as shown on those two tables. Many'`Low" T/NCigarettes versus Fewer "High' T/NCigprettes As shown in Tables 2 and 3, the adjusted numbersofldeaths (total deaths, lung cancer deaths, and coronary heart disease deaths) were consistently lower among "low" T/N smokers than among "high" T/N smokers when the subjects were matched on number of cigarettes smoked per day (as welll as being matched on various other factors). There is abundant evidence from this study and many other studies (UIS. Public Health Service, 1971) that death rates increase with number of cigarettes smoked per day. For this reason, we wished to determine whether subjects who smoked a relatively large numberof"low" T/N cigarettes had as high or higher death rates than persons who smoked a smaller number of "high" T/N cigarettes. Because of limitations in the number of subjects with various combina- tions of number of cigarettes smoked per day and tar and nicotine content of the cigarettes smoked, we were unable to~make fine distinctions. However, we were able to compare subjects who smoked 1 to 19 "high" T/N cigarettes a day with subjects who smoked 20 to 39 "low" T/N1 cigarettes a day. For this purpose, we carriedlouva matchedigroups analysis such that the subjects in each matched group were alike with respect to age (same 5-year date of bi'rth cohort) and all of the other factors used in the first analysis except fornumberofcigarettessmoked'.per day. As before, this was done separatelyfor men and women inieach oflthe two periods of time. The adjusted' number of subjects was: 7971 males, Period! 1; 2785 males, Period 2; 12,275 females, Period 1; and 4841 females, Period 2. The adjusted number of deaths (all causes of death combined) was 1826.3 for

260 Page 21 -- A 1977 study by Stolley, et al~. was unable to account for geographic differences in the incidence of stroke on the basts of smoking or other well known risk factors. The authors concluded that "there is a strong possibility that environmental (both physical and~soci'a1) factors other than the presently known risk factors for stroke and atheroscl!erotic heart disease may account for the observed!geographic differences in mortality." [Stroke 8(5): 551-557, T977.] The claim that "few, if any, self respecting scilentists or physicians inithis country" holid' the view that smoking has not been established as a cause of human disease must be disputed. In this Subcommittee's 1976 hearings, we liisted some 4I6 eminent scientists or physicians who had either testified or submitted statements to Congressional committees in 1969', 1972'and 1976 qquestioning the theory that smoking is hazardous to health. A list of these scientists and physicians, together with their academic and professional affiliatfons, can be found in the record~of the 1976 hearings. Page 22 A review of rec that others, both ir. to dispute the asser and smoking. For ey Philip Burchiof the an address to the Rc the causal relation:: and made the follow:. "As we are all persons, commi unanimously co almost enti~rel D once shared studied the ev from new angle definitive con ing the 'pure' I find myself (1959) earlier do,not warrant them." To mak the causes of statistical ir observed; I hc cians will scr often strident or dietary fac disease." One final poir smoking and health, After twenty years a Phoenix. As an of Public Health - tobacco position -

265 1975 1976 1977 _0 COUN'TY; CALIFORN'IA- MARIJUANA - TOBACCO~ HIGH SCHOOL STUDENTS ls of student usage ics Section of the and Welfare under an. These annual ave bemmade in nd the priivate„ itionshave.produced'r each of the surveyed f use for each of~the a findings of the 1976 iing their own indivi- se. The original off p,oint - a ceiling ied. Inspection ofithe it was reached for of one school grade, survey. If pooled :sed for rate comparisons anging proportions of rates. Since no e standffirdized rates of the eight grade/ ta canialso be arranged )'can be traced There are many possible of, drug use, such as surveys. at is reasonably clear, Over the years a x rates are prod'uced! aach of two sexes and more than eighteen strong tendency for the upward pattern to repeat itself for the drug the next year. As an index grade, the eleventh grade has appeared to be most satisfactory, since there is a considerable drop-out after the Junior year. These drop-out students have more than their share of drug and'alcohol users. Therefore the eleventh grade is selected as being most representative. Although this report dwells upon what has happened over the past two years, shifts in usage must be considered in relation to the total ten year picture. The following table selects rates of use at different levels for Junior students to svnnariie major trends. Any Use Ten or More Occasions Fifty or More Occasions Males Females Males Females Males Females 1968 1977 1968 1977 1968 1977 1968 1977 1970* 1977 1970*'1977 Alcoholic Beverages 70.7 90.2 67.4 89.5 35.6 63.4 24.0 58.8 23.4 34.5 12.9 29.8 **Amphetamines 17s9 18.5 17.1 20.5 7.0 6.1 6.4, 9.3 3.9 2.6 2.9 3.4: Barbiturates 17.3 11.6 15.0 12.9 6.6 3.9 4.5 3.4 3.6 1.7 1.7 1.0 '^*"Heroin 4.9 4.0 3:3 2.4 2.4: 1.7 1.1 0:3 1.8 1.41 0.7 0.2 LSD 14.6 17.6 9.2 14.8' 5.7 4L2 3.6 2.4 2.6 1.7 0,8 0.7 Marijuana 36,9 65.2 31.7 62.8 22.5 46.7 16.7 41.9 23.5 31.2 14.4 24.6 Tobacco 56.7 53.6 57.4 611.9 39.4: 30.1 35.4 43:3 28.9 21.9 27:6 34.4 *Not avaa a e for 1968. ** 1970 data substituted. *** 1971'dita substituted. ~ALOOHOL usa ge has definitely increased. Not only have thirty-three out of a possible thirty-six,class/sex level rates increasedL but the amount of the increases were generally larger than had been experienced since 1971. This was a surprising finding since the data through 1976 had shown a pattern which had been construed as indicating a levelling off. The median can also be used to show what a student who says that half the guys drink more frequently than he,, and'the other half less frequently, did~ih the twelve months preceding the 1977 survey. A middle-ofi-the-road male Junior consumed alcohol on about four, occasions in 1968, and'twenty-nine in 1977. 30-536 0 - 78 .- 18

oronary heart disease is Jnited States. Multiply- Its in far more "excess te of nonsmokers by 10. ition between cigarette nt than the association no value to the public expectancy. wledge to practical use o the proponents of this ie people not to smoke )ersuade people not too vould have no harmful vould be pleasurable to .ie to application of the ave given up the habit dult cigarette smokers of children and youths -ss hazardous" type of procedure along these -e smokers is reduction ' cigarettes. Cigarettes :o as "low" T/N ciga- ncerned here with the 'less hazardous" than subject came to the >trongly suggests that less harmful'would be t time later this was "ealth Service.) lung cancer, cancer of ii'seasesincrease with al studies had shown 'tar'")Js carcinogenic ne upon the heart and ,tte smoke was partly ites are higher among cigarette smokers than among nonsmokers. (4) Therefore, it seemed reasonable to suppose that if the tar and nicotine content of cigarette smoke were reduced, then the harm done per cigarette smoked would be correspondingly reduced. The term "strongly suggests" included in the above statement implied that the conclusion might be incorrect. The major counter speculations were: (1) If the tar and nicotine content of the smoke were reduced most smokers might' smoke more cigarettes per day and thereby cancel the benefit. (This speculation turned out to be incorrect whenit was found that smokers who switch from "high" T/N to "low" T/N cigarettes do not usually increase the number smoked per day; Hammond! and Garfinkel, 1964.). (2) Smokers of "low" T/N cigarettes mighu (consciously or unconsciously) inhale the smoke more deeply than smokers of "high" T/N cigarettes. If so, then their effective exposure to tar and nicotine might not be reduced while their exposure to the gases in cigarette smoke would be increased. (3) It could be that gases contained in cigarette smoke are as harmful if not more harmful than the "tar"'and nicotine contentlof the smoke. Furthermore, it could be that, in certain circumstances, reduction in T/N is accompanied by an increase in certain gases, most notably carbom monoxide. An increase in carbon monoxide might increase the risk of coronary hearr disease. Therefore, if all this is true, the net effectlofreduction in,T/N might be an increase in age-specific death rates. Since that tiine, published evidence from two retrospective epidemiological studies (Bross and Gibson, 1968 and Wynderet al., 1970) was such as to indicate that people who smoke filtertip cigarettes have lower lung cancer death rates than people who smoke nonfilter cigarettes. Concern lest this desirable effect be accom- panied by an increased risk of some other disease (especially coronary heart disease) led us to carry out this investigation. MATERIAL Between October 1, 1959, and March 31, 1960„volunteer workers of the Ameri- can Cancer Society enrolle& over 1,000,000 men and women in a prospective epidemiologicallstudy (Hammond, 1964). Upon enrolhnent„each subject answered a lengthy questionnaire (hereafter referred to as Ql). Once every 2 years thereafter for 6 years, surviving subjects were requested to answer a brief repeat question- naire containing questions on cigarette smoking, hospitalization, diseases incurred during the interval between questionnaires, and several other factors. These repeat questionnaires will be referred to as Q2, Q3, and Q4. The lasu questionnaires of this series„Q4, were distributed on October 1, 1965;,but some were not answered until after June 1,, 1966. The Society successfully trace& 99.6% of the subjects through September 30, 1964, and 98.4% through September 30, 1965. Of those who were still living when traced im the sixth annual follow-up, 94.9% answeredl Q4. Annual tracing was discont'inuedlafter the sixth follow-up, but wasresume&on October 1, 1971. The eighth and last tracing was started on October 1', 1972. During the first 6 years, enrollment and tracing oflthe subjects was administered by Divisions of the American Cancer Society in 1121 counties in 25 states, When

_2_ 280 None who uses the figures can say accurately where they originated. One health official quotes a public relations practitioner as the source while the latter claims they came from "the government." Media occasionalliy attribute themito their newest source but increasingly provide no attribution at all. This paper will attempt to trace the origin of the "excess dpath" figures, show how they have been "tsarked up" (or dbwn) and, finally, will show how vuLnerable such statistics are to misuse. Where did the figures come from which Secretary Califano cited on January 11th, and the American~Caneer Society parrotedl three weeks liater? The "excess deaths" concept grew primarilly from various pre-1964 studies comparing smokers andlnonsmokers by two Britons, Richard Dolli and A. B. Hill, and those of Danieli Horn and E. Cuyler Hammond of the United States. Much of their data was used, in one form or another, in the preparation of the 1964 Smoking and Health report by the Advisory Committee to the U. S. Surgeon General. However„ as we will see„ that report wisely warned' against the concept. In her book, Smoke Screen, Tobacco and the Public Welfare, published a year before the Surgeon General's report„ Senator Maurine B. Neuberger quotedlDr. Horn as saying,it wouldlbe his "best guess" to blame smoking for "300,000:to 500,000...deaths per year." (?as an exagger~ deaths" estim< The Surgec of "excess dec causally relat cannot by accr Why did t1l Assistant Sur€ Committee, ga-, report was re' of trying to r many assumptic attempt this.. But othere the first anni Fbote, an adve called the Nat began a new rc release:, "Est studying the F are interprete be said with s for at least I Cigarette smo4 deaths per yee 3©-a36 0 - 78 - l'a

254 Page 15. Here are some relevant examples: o Drs. D: P. Bridge and M'. Corn of the Graduate School of Public Health,, University of Pittsburgh, Pennsylania, stated: ...our results suggest that concentrations of CO from cigarette and cigar smoking do not present an iinhalationihazard to nonsmokers,. out: o Dr. Gary L. Huber, Harvard University, pointed No data are availablie to demonstrate health effects of physiologic response to nicotine levels reached! in adult nonsmokers, and carbon monoxide con- centrations ininonsmokers are far below levels that are of known health hazard. o Dr. David~Owen, who was Minister of State for Health in 1i975 and is now Foreign Minister, said: A number of research papers have been published' on this subject. I am advised that they'provide no clear evidence to show that tobacco smoke is harmiful to normally healthy nonsmokers or that, a heavily tobacco smoke laden atmiosphere has other than a transient effeet... o Dr. Jonathan E. Rhoads, Chairman of the Notional Cancer Advisory Board~, and former presi- dent of the American Cancer Society, concluded: I do not have any, hard evidence in that direction [that there is a harmful effect from smoke onithe nonsmoker]. To my knowledge, it i~s not in fact, actually harmful. ol Dr. Ernst L. Wynd!er, President of'the American: Health Foundation, who has beem a pioneer of.research on t:ie alleoed _dverse healta effects of smokinp, stated: Passive smoking can,provoke tears or can be otherwise di~sagreeable, but it has no influence on the health. In that case, the doses are too small. Page 16 o Dr . Re. who was an Adv. Advisory Commi In very d that nons ordinary damage. o Dr . Gi National Cance If you wa fiction, to people smoke. The propc is a Swedish i approach by tF alternating ws withidifferent France, : "Abuse is danf The curr~ "HM Governmen can seriously Our own Iceland Some cou These na and confusion

289 ttegrity of t. Stewart 3ology of ne he did : estimate."'(16) :o the 300,000 E Minnesota's =ess deaths" id in a 1:968 11965, nearly ziated with half a. Yet a was disputed of Health, ated news- ng that co. (1i9) th center, r. Jesse lculating "Well," he said, "it's hard to get the exact number of excess deaths associated with cigarette smokimg. But there is no question that it is the major public healith problem in the U.S. today, both for men and for women. But, unfortunately, we cannot pinpoint exactly the number of excess deaths associated with cigarette smoking." (21) As recently as March of 1977 a Berkeley, California internist„ Dr., Stanford D. Splitter, communicated with the American Cancer Society's "National Commission on Smoking and Public Policy" to present some "evidence of the health conse- quences of smoking." But he warned the ACS, in the words of the 1964 Surgeon General's report, that "the total number of excess deaths causally related to cigarette smoking in the U.S. population cannot be accurately estimated." (22). Early in 1978, Secretary Califiano announced a new "war on smoking" by the Department of Health, Education, and Welifare. The blizzard of newspaper copy and editorial's which followed repeated, in almost every instance, the Secretary's claim of 320,000 "excess deaths." In some cases the figure was attributed to Califano; in many others it was reported as a fact which apparently needed no attribution. In his January 111, 1978;speech at a meeting of the National Interagency Council on,Smoking andiHealth, Califano stated that in 1977, smoking caused 220,000 deaths from heart disease, Z8',000 from lung cancer and 22,000 from other cancers ineluding, bladder cancer for a total of 320,000.

264 11968' 1969 E a 1970 1971, 1972 1973 1974 1976 1976 1977 SUMMARY REPORT - SURVEYS OF STUDENT DRUG USE, SAN MATEG COUNTY; CALIFORNIA ALCOHOL - AMPHETAMINES - BARBITURATES - HEROIN - LSD - MARIJUANA - TOBACCO TRENDS IN LEVELS OF USE REPORTED BY JUNIOR AND SENIiOR HIGH SCHOOL STUDEN?S' This is the last of a series of ten annual surveys of levels of student usage of drugs and alcohol conducted by the Research and Statistics Section of the San Mateo County, California, Department of Public Health and Welfare under the direction of Lilian,St. Clair Blackford'y Biostatistician., These annual surveys, funded by the National Institute on Drug Abuse, have been made in cooperation with the San Mateo County School Department, and the private, parochial and public schools in the County. The ten repetitions have produced a series of comparable rates showing independent trends for each of the surveyed' substances. These are basic data on changes in patterns of use for each of the seven substances surveyed. The addition of the 1977 data to the series strengthens the findings of the 1976 summary report - that several substances appear to be reaching their own indivi- dualiplateaus, levelling off, and~possibly decreasing in use. The originall premise of the study was that each drug had some levelling off point - a ceiling of use - and that at some point'.in time this would be reached. Inspection of the detailed tables made it appear thatithis levelling off point was reached for barbiturates and amphetarmines as early as 1971. Significant differences between rates for males and females of one school grade, andibetween grades were demonstrated in the ihitial, 1968, survey. If pooled data which inoludes more than one elass/sex,cell is to be used for rate comparisons from year to year it is necessary to standardize so thatichanging proportions of the class/sex groups do not produce'false directions in the rates. Since no precedenU was available, it was arbitrarily'decided that the standardized rates usedlih the tables would~ihelude equaliproportions of each ofS the eight grade/ sex categories in grades nine through twelve. This brief sumoary report emphasizes annual trends. The data can also be arranged so that the build-up of use in one particular group (cohort) can be traced b'eginming with its seventh grade through its senior year. There are many possible arrangements of data available showing various combinations ofi drug use, such as correlations between drugs, clustering, over the ten annual surveys. Summarization of this extensive body of data in a manner that is reasonably clear, and which exposes the more striking findings is difficult. Over the years a very simple predietion device has proved useful. Thirty-six rates are produced for each substance each year - three cumulative levels for each of two sexes and six grades. A rate can either go up or down. Ife there are more than eighteen rates that are higher than~the preceding survey, there is a strong tendency for the upward pattern to rep,eat its grade, the eleventh grade has ap a considerable drop-out after tF more than thein share of dt•ug ar is selected as being most repree Although this report:dwells upoc in usage must be considered'in ~, following table selects rates o, summarize major trends. Any Use Males Females 1968 1977 1968' 1977 Alcoholic Beverages 70:7 90.2 67.41 89'.5 **Amph'etamines 1P:9 18.5 17.1, 20.5 Barbiturates 17.3 11.6 15.0 12.9 ***Heroin 4.9 4.0 3.3 2.4 LSD 14.6 17.6 9.2 14.F Marijuana 36.9 65.2 31.7 62.E Tobacco 56.7 53.6 57.4, 61.' *Not avai ab'e or 8. '* 1970 data substituted. *'* 1971 data substituted. ALCOHOL usa e has definitely I possib e thirty-six class/sex increases were generally large a surprising finding since the been construed as indicating a show what a student who says t and'the other half less freque survey. A middle-of-the-road occasions in 1968, and twenty- 30-536O.- 98;- L8.

-4- 282 Once someone, no matter what his,or her expertise or objectivity might be„ had broken the ice and made the claim publicly, many others felit free to quote it. A month later, for example,, Dr. Horn, who had become chief of the Special Projects Section within H~E.,W.'s Cancer Control Program„ told school administrators in Atliantic City that "Emerson Foote, Chairman of the National Interagency Council on Smoking and Health, has stated that cigarette smoking is responsiblie for at least 125,000 premature deaths this year." (8) In March, 1965, the U. S. Senate began hearings to determine what legislation might be appropriate in light of the Surgeon General's report., Foote testified. Senator Thruston Morton told him that Horn had quoted "you as his authority." Foote laid the "baby" on the doorstep of the U. S. Public Health Service. SENATOR MORTON:, ..This interests me, that the scientist, the doctor, should be quoting you, the advertising agent. I suppose you quote him. That is the way these things get going. They support each other. MR. FOOTE: Absolutely not. created? May I correct the impression SENATOR MORTON: Certainly. MR. FOOTE: Would you like to know where I got those figures? Or would you care?' SENATOR MORTON: I would be glad to hear where you got the figures. I am merely saying that Dr. Horn is now quotingg you as the authority for these figures. MR. FOOTEc If he quotes me, that is fine. I didn't ask him to quote me, and I am not the authority for the figures. Would you care to know where I got the figµres? SENATOR MORTON: Certainly. ( MR. FOOTE: And they t As anothen American Cance table. But Di Committee, paes that Dr. Mortc York had giver "that among mi country attril 224',717 each • In additic University of published a s quarter of a 7 smokin g. " Horn was that the "exc death rates a was the cause went far beyo and came up w DR. HORN: estimate the exces over what same rate consists in which include c emphysew cancer of

mputation. (13)) can Cancer e were regularly, smokers. to lung .0, for a .d that .) to a11i the yo one to six, deaths" ,pulation I sixl •vation or alysis, the the :he 1964 public by _ himselif Terry pursued' ig of the hen ~ncy ;arettes i 287 -9- are responsible for at least 125,000 premature deaths, and maybe as many as 300,000 deaths, in the Unste& States a year. Exaggerated, the critics said. The Public Health Service believes these estimates are valid. Studies of mortality ratios of smokers an& non-smokers indicate that 240,000 men will this year die prematurely from diseases associated with cigarette smoking. About 138,000 of these excess or premature deaths will be from diseases clearly and definitely associated with smoking, such as cancer of the lung, larynx, oral cavity, esophagus and bladder, as well as bronchitis, emphysema and coronary heart disease. Another 102,000 excess or premature deaths will result from diseases where the relationship to cigarette smoking, while not so obvious, is nevertheless clearly indicated. This total of 240,000 premature deaths applies to men only, because in most cases the data for women are inadequate to make precise estimates. Where data:are available for women, mortality rati'os for comparable levels of smoking appear to be similar to those for men, but somewhat lower. A reasonable estimate of excess deaths among,women, added to the total of 240,000 for men, would bring,the overall total to 300,000. I consider this total to be a reasonable estimate."' (14). Terry's decision to disregard his advisory committee's judgment was one thing. Even more disturbing, however, was the casual way he added women to the illusory total, in the last three sentences quoted above. He gave not the slightest basis for his "reasonable estimate of excess deaths among,women." Ravenholt reappeare&briefly, applying his mysterious formula for the first time to 1966 U. S. deaths, in a 1967 speech to an anti-smoking conference in New York. This yielded' him 301,5601"excess deaths" among smokers. (li5) The 300i,000ifigure was satisfactory to Dr. Wil!liam~H. Stewart, then UL S. Surgeon General, when he appeared before a House Appropriations Subcommittee in 1967. He sai&that because early "excess deaths" statistics were based~only on~meny these figures should be revised upward for population~growth and I

204 the Federal Trade Commission nor the U'.S. Cbngress has taken action with regard' to that. We have proposed to the Federal Trade Com- mission that they substantially limit the ads in one ofl two forms. One the preferred one, would be-and this is not an intended pun-the tombstone variety of ads. You see them frequently in the Wall Street. Journal and other newspapers fbr commercial and financial announce- ment. If such~ an advertising format is necessary to protect sophisti- cated investors from being misled, I think it is not unreasonable to restrict cigarette ads to the samaform. If we cannot do that, Senator, at least we can~ prohibit them from putt'ingin avariet'y of! pictures, as discussed this morning, featuring handsome virile men, sedlzctive looking women, outdoor scenes-scenes which the F"I`Chas held again, and again to detract from t'hehealth message in thoseads, regardless of what those messages~ happen to be. Senator IiENNEnY. Is this the kind of ad~ vou are talking about?' [Senator Kennedy holds up a cigarette ad.]' llr. BaINZAxF: 'i hat would certainly be one of the kind of ads, Senator. Senator KEN NEnr. It's one of a kind. Mr. BANZAI3F. And I am very glad you are holding it up, because that leads to the next ppint,;and that is Senator KENNEDY. Well, what's wrongwith~ thatad, as far as you can see?, i Mr. BANZAirF. Just about everything. It features two people who~ are the kind who would be looked up to as preferred images, as leaders for young children. The man is very robust, very masculine ; the woman is obviously very attractive, a role model' for many women. The two of them are obviouslv having a very good relationship. Onee may assume, in fact, that the aigarette in his mouth might even be the reason whv she is looking up to him, with such an adoring look. They are seated on Senator KE:vNEnY. Well~ why isn't that just good advertising pol- icy ?Why shouldn't manufacturers be, able to get their prodlict across in the most attractive way?' Mr. BAN ZAHP. Nell, I think they should, except thatt if we look at that- Senator Senatlor KENNFnY. 1Vhat is deceptive about that ad, do vou think? Dir. B'ANZAuF. Well, if: canfinish, I willl put them all together. The_yare appearing ontivhat is perhapstheonly completely,unpolluted beach in the United' States-I see not even a grai'n of sand disturbed. SenatlorIirN-Nl:nv.It'soff-Vassachusetts. [Latighter:1 11fr. BAN Z_.nr. The water behind is crystal clear; the air is clear. All of which together does two things: first, it undermines that healtIt warning;if you look at the totialitv of that acl; that ad is sayingtlo yott that'smokingis associated with, clean outdoor activity, it' is associated with healthy robust people-that's the kind of 1-uy wholboks likehecould take ofl',and probably withi the woman, run 10 miles down thebeach. And that isJhe kind of image that the people have. In other words; theads iundercutthe health warningby seeking to associate smoking with things thought to be clean and healthful, and by sug- gesting that smokimg, is~ consistent wi'thhealthful and rolutst outdoor activities byy persons who are the personification of health. Now,,if you( next point I tl I think probai. what is being ; can't see the h can't see it or re Yet the Fed it is an unfaii without reveal; regard to those is not clear ane Senator, it is well as in all t to read it. The continue unles: and here I am the ads on the s Another thii e veni do it with motional tacti( coupon out of ; free packs of tl are 21 tiears of know that the, Also, more : for buying the those premium board with a s: cooler aimed things-obvioi cult decision tl to smoke or no, by the idea th,! get that sailbo Certainly I radio and! telev I think also candy cigarett identical to th your very, ver oral gratificati! isgoingtobe manufacturers those packs of! stay with the 1! Weha ve prc to limit, t'~hesa out' of the unat- :1 very imp wheredo these, dictions for ki must be buyin

272 236 HAM~MOND~~ET'AL. subjects smoking I to 19 "high" TIN cigarettes a' day an& 1923.9 for subjects smoking 20 to 39 "low" T/N cigarettes alday (mortality ratio 1.05). This difference is not statisticallysignificanr. The adjusted number of coronary heart disease deaths was: 670.6 for subjects smoking I to: 19 "high?' T/N eigarettesa day and~736:6 for subjects smoking 20 to 39 "low" T/N cigarettes a day (mortality ratio 1.10): This difference isstatistically significant (P<0:05): The adjusted number of lung cancer deaths was 75.8 for subjects smoking l to 19 "high" TIN eigarettes a day and 129:5 for subjects smoking 20 to 39 "low" T/N cigarettes a day(mortality ratio 1i.71). This difference is statisticallysignificant!(P<0.0001): For each of the four individual sets of comparisons (males and females in Periods I and 2); the adjusted number of lung cancer deaths was lower in subjects who smokedll to 19"high" TLN eigarettesa dky than in subjccts who smoked 20 to 39 "lbw'' T/NN cigarettes a day. "Low'"'TINSmok'ers versus Nonsmokers The next question which we posed was whether the death rates of subjects whoo smoke& "low"T/N cigarettes were appreciably different from the death rates of subjects who ha& never smoked regularly. To this end, we undertook a matchedd groups analysis matching on age (2-year date of birth cohort) and all of the factors included in the first analysis except number of cigarettes smoked per day and age subjects began smoking. Since subjects who had never smoked greatly outnum- bered "low" T/N subjeets„allibut a very few of the latter subjects were matched. The adjusted numbers of subjects were: 15;346 men, Period 1; 6822 men" Period 2; 32;702'women, Period 1; and I6,803 women, Period 2.Onithe basis of the adjusted numbers of subjects, the mean ages were 53.8 for men and 52.3 for women atistart of Period 1 and 58.7, for men and 57.3 for women, at start of Perio& 2. The results are shown in Table 4. The adjusted number of deaths (all causes of death combined) was 46703 for 'low"' T/N smokers and 3099.0 for subjects who; never smoked regularly. This difference is statistically significant (P<0.0001), The adjusted number of coronary heart disease deaths was 1674.3 for "low'"' T/N smokers and 1008.3 for subjects who never smoked regularly. This difference is statistically significant (P<0.0001). The adjusted number of lung cancer deaths was 258.0 for low T/Nl smokers and 39.4 for subjects who never smoked regularly. This difference is statistically significant (P<0.0001). For each of the four individual sets of eomparisons (males and females in Periods I and 2) for all causes ofdeathcombined'y for coronary heart disease deaths and for lung cancer deaths, the adjusted number of deaths was higher for "low" T/N smokers than for subjects who never smoked regularly and each of these differ- ences is statisticallysignificant. (The value of"P" ranged from <0.01 to <0.0001). As shown on the bottom line of Table 4, the mortality ratio (adjusted number of deaths of subjects who never smoked regularly divided by adjusted number of deaths of "low" T/N smokers) was: 0.66 for all causes of death combined, 0.60 for coronary heart disease deaths, and 0.15 for lung cancer deaths. TA ADjL'STFD.NL'MRER OF MnRTLALITS" (ZATI S.1ov Sex Period Male I Male 2 Female I Female 2 Total Male I Male 2 Female 1 Female 2 Total I Never smoked cigare It is quite appare smoke did not mak analysis, all of whoi Cigarettes wi'thirec (following the retros 1952; Levin et al:, I majority, of the femal I before that date. Tf smokers, were, wi "medium" T/N cig,- rettes. It appears th. incurred by smoking' increased the nurnbe to say that switchinl step in the right dire quit smoking fared! Whati of youths v They would be wL manythousan& ofn health of those whc Ocigarettes were ren- C.:

Footnote Reference - Page 2 292 116. U. S. House of Representatives, "Departments of Labor and Health, Education and Welifare Appropriations for 1968," hearings before Appropriations Subcommittee on Departments of Labor and Healith Education, and Welfare and Related Agencies, Part 4, Public Health Service, page 78„ 1947. 17. Schuman, Dr. Leonard M., University of Minnesota School of Public Health, Minneapolis, address to National Forum on Office Management of Smoking Problems, Chicago, I11., 4/11-12/68. 18. United States Senate„ hearings on Cigarette Smoking and' Disease, before Subcommittee on Health, Committee on Labor and Public Welfare, February 19, 1976, p. 183. 19. Steincrohn, Dr. Peter J., Washington (D.C.) Evening Star,. IR/22/68'. - 20. Fort, Dr. Joel, reported in the Pontiac (Mich.) Press, 12/1/70. 21. Steinfeld, Dr. Jessie L., U.S. Surgeon General', interviewed by Deena Clark, WRC=TV, Washington, D.G., 2/,14/71.. 22. Splitter, Dr. Sanford D., internist, Berkeley„ Cal'if., letter to Amer3can Cancer Society's National Commission on Smoking and Public Poliicy„ 3/22/77. 23. U. S. House of Representatives, hearing before Committee on Interstate and Foreign Commerce, Subcommittee on Health, 2/15/78. 24. U. S. House of Representatives, "Cigarette Advertising and Labeling -- 1969'," hearings before the Committee on Interstate and Foreign Commerce, page 1256. CIGARETTE LABE INTERS-, HOW April 29, 1969 sTATF.I OF A: TON The that W( do it to Mr. : Tlie ( Mr. fessor Science of bios versity Proces: Mathei inMat

-10- 288 include a guess about excess deaths among women. A challenge by Congressman Hull, regarding the imtegrity, of his claim appeared not to trouble Dr. Stewart at all. Stewart said simply that his number was "derived from methodology of Dr. Morton Levin and brought up to date from the time he did it." But he added that this was "admittedly a:crude estimate." (16) Most but not alil critics of smoking have stuck to,the 300,0000 figure. Dr. Leonard M. Schuman of the University of Minnesota's. School of Publiie Health took first place in the "excess deaths" sweepstakes, and stilil holds the record, when he said in a 1968' speech in Chicago that more than 860,000 deaths in 1i965, nearly half of all U. S. deaths, "were from diseases associatediwith tobacco use." The bulk of his numbers -- more than hal~f a million -- came from heart disease mortality. (17) Yet a causal connection between smoking and heart disease was disputed by the top health official in the U. S. Department of Health, Education, and Welfare as recently as 1976. (18) A year later, Dr. Peter J. Steincrohn, a syndicated news- paper columnist, quoted the Surgeon General as saying that 365,000! "excess deaths" were caused in 1965 by tobacco. (19) Dr.•Joei Fort, director of a San Francisco health center, raised;the number to 400,000 in 1970. (20)~ But by February, 1971, a new Surgeon General', Dr. Jesse Steinfeld, leaned~back on the side of caution in calculating "excess deaths."' "Well,"'' excess death no question U.S. today, we cannot pi associated'v As recer internist, I Anierican CS: Publiic Poli quences of the 1964,Su. excess deat population Early :' smoking" b: The blizza- repeated, 320,000 "e attributed fact which In his Interagenr that in 1! 78,000 frc bladder c.

199 aSalle Leffall„ presi- iulg;,nmembet~, ~Ameri- -tor, American Lung committee on Smo1t- inzalif, executive di- Iealth. , PRESIDENT-ELECT, BY DONALD YOUNG, :ETY, AND FORMER 7IATION; ROBERT'M. SUBCOMMITTEE ON ; AND JOHN S. BAN- F COUNSEL, ACTION car need for preven- icer death rates. 950-59y and included idy; white 5-year sur- ent. osed during the yearss nd black was 28per- cto submit, but will for blacks «-as con- M involved in a study rica which shows that that is, not related to )ening in the United ng to U.S. whites to a. c United States on a t tliedeath rate from bite males suffered a ;her. er deat~h rate was 77 te cancer;pancreat'ic i cancer sites studied netically based, itl is preventivemediciile ,'at are tragically lost k needed, where pre- smoking. 'r is themost' obvious ,r cancers are related practically no roonl In litng, cancer, the white and nonwhit'edeatlh rates are very closely similar, the excessive white rate for men: being 3.6 percent and! for women.3 percent. But it isclear that special effort'~s, on~ smoking, must be, made among black groups. The Alnerican H'~ealthFoundation in 1976 pubiished,'data showing that about 241 percent of white males were nonsmokers; but only about 17percent of theblacks. About26percent of the white males were ex-smokers, but only about;16 percent of the blacks. An& Ilonfilter cigarette smokers nwiibere& about 1'i2percent of the white males compared to 24 percent oft'heblacks. So you can see the real excessive hazard among black Americans. The American Cancer Society has, scheduled for next. February a conference on the: subject of' cancer and blacl: Americans. At that tiane we think we will learn a: great deal more than we now know about the disease's impact on minorities,, and about the perceptions ofl minorities with regard to~ cancer cause and preventiom We willl no doubt have newinsiglltson the problem of cigarette-related cancer among blacks. lleanwhil'e, we see in buses, in magazines and newspapers cigaretteadvertisingesplicitlye directed by content or medium to the blackconlmunity. The data already cited represent strong, evidence that this advertihing, is effective. ATfr. Chairman, our society has just recently received a report from a special Commi'ssion headed by a f©rmerHE~V, Assistant Secretary for Health on the subject of eigarettesmoking. With study of that report, committees of our society have already begun adopting some of therecommendations of the Commissiony which held hearings in several cities to get expert testimony ontlle smoking problelm. For instlancea: subcommittee of our new public, . issuescommittlee has alreadv recommend'ed for society endorsement a differential tax on cigRrett'es according to their tar and nicotine content. I make this statement having heard the report ofl the young students, who were here this morning. It has also recommended endorsement of stronger death and disease warnings on cigarettepackabes and ini cigarette advertising. Our full public issues committee .vill consider these recom- mendations the seconrli week in June. Theree is no question in mv mind that the American Ca~icer Society will inai number of wavs j~oin with this subcommit't'eein seeking to strengthenthe preventive medical measures that have been proven effective in tests or demonstrations and tivhich, should now be prol'iferated.Wc colnmend y ou on your approach to these problems. Thank you, _11r. Chairman. Senator KI:N Nr:DY. Du. Young? I)r. YouNC. Thank you, AIr. Chairmam Iifyoul will excuse me atthe end of myy presentation-this afternoon I am~ speaking on prevention in Buttalo; and I havea plane to catcll-I will beleav,ing. I am I)~r. Donald Y oung, a member of the American Thoracic societvandv formerlymeclical director of the American LungAssociation. I}rave-a statc-ment wlnchI will submit for the record. '1'be- American Lung Association strongly supports thediseasepre- vention provisions included in title IV of' the\ ationall DlseasePreven- tionandH'ealthPromotion Actlof1978.

1an 901 701 m tot ]oz 1970 5UR9EY ALL 6P.1B€S7CLASSCS :. .. uz ~ 7r.- --BTx - 9i. IOTH 117. 17rx 6MOE7CLASS PPEPAqEU AY: NES1ANfM t STATISIICS SECllql AERT. Of I[ALTN L 14lFAIlE SAN lNTLO COUNTY. CALIFOfpIA 1977 SUXYFY ALL 6W1~E$7C1A5$ES ~••fwln 904 IS) 30i zes ui BF. 9.x 10Ix GB7YE61S$S w1 ID l ._. . / ! ~ .~,......... /' 50. USAGE US i,. e:. ]tm 97x 10t. RA~ DE7[IASS LEVELS OF MARIJUANA USAGE SELECTED SURVEYS SAN MATEO COUNTY, CALIFORNIA, STUDENTS 12 CI4111N EMAR Um JIIIION CLASS BDq /Ob 7 llrx 171. FUX1EO 9Y: tlA110NAL IIISTITLTE ON DAW MUSE 4NANT kl1 M00091 lIL1AM ST. CLAIA BUC¢PoR9. PAINCIPAL IIIVES116AIUA r- -- - ..... ---- ~ IAY USAGE

198'. Senator KENNEDY. We have a final panel :LaSalle Leffall, presi- dent-elect, American, Cancer Society;, D'onald' Yoiuag, member, Ameri- can ThoracicSociet'y, and former medical director, American Luna Association;Robert Da~ugherty, chairnian, S'ubcommitteeon Smok- ing, AmericanHeart: Association : and Tohn Banzahf, executive di- rector and chief counsel, Action on Smoking and Healt'h.We will start with,Dr. Lefl'all. STATEMENT OF LASALLE D. LEFFALL, JR., M.D., PRESIDENT-ELECT, AMERICAN CANCER SOCIETY, ACCOMPANIED BY DONALD YOUNG, M.D., MEMBER, AMERICAN THORACIC SOCIETY, AND FORMER MEDICAL DIRECTOR, AMERICAN LUNG ASSOCIATION; ROBERT M. DAUGHERTY, JR., M.D., Ph. D.,, CHAIRMAN, SUBCOMMITTEE ON SM4KING; AMERICAN HEART ASSOCIATION; AND JOHN S. BAN- ZAH'F III, EXECUTIVE DIRECTOR AND CHIEF COUNSEL, ACTION ON SMOKING AND HEALTH, A PANEL Dr. LF;FrAr.L. Thank youy llr. Chairman. A_ clear, need forpreven- tive medicineisshowir in official statistics on cancer death rates. Among patients diagnosed duringt'heyears 1950-59, and incliid'ed in the, V'ational Cancer Institute's,end results study, white )~year sur- vival was 39 percent, but blaekwas~only 29 percent. The same thing showed up with~patients diagnosed during the years 1960-66 : Rhite ~i-year sur~•i~-a1 was 40 percent' andl black was 28 per- cent. I include a. tablehere, which I «ouldd like to submit, but will' not quoteit entimely, just say that thesurviva1 for blacks was con~- sistentlv lower thRn the survival for whites. \Ir. Chairman, I personally happen to have been involved in a study- comparing patients here in our country and in Africa which shows that these excess black deaths are, in fact, not' raci'al, that is, not relnted~ to their genetic makeup. Rat~her something is happening~in t'he, United States toblacl.~ Amerncans which is not happeningtoU.Sg wliitest'~o produce a cancer efFect'that is greater among blacks. Specifically, measurement of all cancers in the United States~ on a, sample basis,durinb the years 1950-69 shows that the death rate from, cancer among white males was 174.04 but non«-hite males suffered a death rate from cancer of 184.28, or 5.9 percenthigher. Among nonwhite females the excessive cancer death rate«as 7 percent. Some of' the big probl'em areas are in prostate cancer, pancreaticc cancer; stomach cancer, and cancer of t'lieblaclder. Now that we have definite data that at'~ least in cancer sites studied so far the excess deaths among blacks is not (yenetically based, it is clear research is needed to find the cause so that preventive medlieine can be used to: salvage these lives in the futuretliat are tragically lost now. Unearea where work anrong all et~hniegroups is needed, where pre- ventive medl eine is neededi, is certainly in ci,garettesmol.ing, As,thssHcalth Subcommittee lcno-,vs, lung cancer is the most obvious cancer corollam- of smokin,(r, but bliidder and otliercancers arerelated to smolcing as i i-ell in statistical degreestliat leavepracticallv no room for doubt. In lu similar women But - black ~ datash but on1 males v nonfiltc males c escessil The confere time w about t of mino doubt I among -AIean adverti commu: this ach 1Tr. (special Health commit recomn; cities to For i has alr, on eiga stateme herethi deat4 a adrerti~mendat, TherE will in strengtl effectil-c prolifer We c(~ -NIr. Cln Senat I)r. 1 end of I in Biiff ,i. I am : and for ]ia.-eas. 'I'lie ' vention tion and

285 -7- are, which =h Service aho has =duled to ich is included of deaths from itis and y, esophagus, als 138,000, imate of imated 1965 for these ulk of the .ave been .tatement for iarter million : definition ite, taking population, ie number of „000,deaths, ctality 3,000 deaths were excess sse, and ast number -- ae smokers. see table). on which his I i Excess Deaths Among Male Cigarette Smokers Age 18 and Over,. United States, 1962 Excess Deaths Among Total Deaths Cause of Death Cigarette Smokers Males 18 & Over No. ercent of 7{Tr Lung Cancer 29,472 83.5 35,304 Bronchitis & Emphy. 10,002 76.0 13,158 Cancer of Larynx 1,564 72.0 2,172 Cancer of Orali Cavity 2,873 58.6 4,900 Cancer of Esophagus 2,074 52.2 3,972 Coronary Artery Disease 91',797 28.3 324:,144: All other causes 89,470 17.0 525,972 All causes 227,252 24.9 909,622 Estimated from data or prospective studies: smokers' distribution, 1955; U.S.,population„ 1962; U.S. mortality, 1962.. Excess deaths over number expected from non-smokers' mortal~ity experience. Above is the earliest known tabulation of "sxcess deaths," presented by Dr. Morton L. Levin in a Congressional' hearing in 1965. Ravenholt, also cited by Diehl as a source„ did not testifyy at the hearing, but his 1964 statement to which Diehl referred -- actually a letter to the editor of a health jpurnal -- does reveal

ed out for administrative subjects who were "lost" iit to trace 897,825 subjects still living as of September 971, and 92.8% through periods of time: Period l', une 30, 1972. It is further 1960; who on Q l said that & neverr smoked pipes or cigarettes they currently erience during Period 2'is >n that questionnaire said' iumber they smoke& per that time. e from various brands of asis of this informationti : content (H, "high'"; M, ed!at three points in time igh some manufacturers rand name they could be io1. For purposes of this nd 25.8 to 35:7 mg of tar. ne; and with very few ivered less than 17:6 mg te between "high" an& • later years. However, te, two or more types of s reason, it is likely that RIN category probably ;a. There was far less :ers from the other tlwo ;uished as follows: (1)i he 1959-1960 question- ularly. i various years was obtained mber 1959 issue of Readers ed from the ReadersDigest' n November 1967. 231 "TAR" AND NICOTINECONTEdrT OF CIGARETTES267 naire(Q4)and as either "high" or "medium" on the 1965-1966 questionnaire (Q4). (2) "Low" was defined as "low" on the 1959-1960 questionnaire (Q 1), and as either "low7 "or "medium" on the 1965-1966 questionnaire(Q4),,ar as "low"'on both Q2 and Q4. "Matched groups" analysis was utilizedL As a first step, the subjects were divided into groups such thatwithin each group the subjects were alike in respect to all of the following factors: (1) age (same 2-year date of birth cohorts); (2) race (white or nonwhite); (3) number of cigarettes smoked perday (1'-9; 10-19, 20; 2i-39or40 f); (4) age began cigarette smoking(< 15,15-24~, or125+); (5)place of residence at time of enrollment(urbanior rural); (6) history of occupational exposure to dust, fumes, gases, chemicals, X rays, or radioactive materials (yes or no)~(menibut not women,were matched on this factor); (7):edUcation (no highischool vs some highi school or above); (8) history of ]ting cancer as reported on Q] or as reported on,Q2, Q3, orQ4l(yes or no); (9) history of heart disease as reported on Q1 or as reported on Q2, Q3, or Q4 (yes or no). This matching procedure was carried out separately for men and women in Periods I and 2. For Period I the amount of cigarette smoking was taken as the number smoked per day as specified on Q1. For Period 2 the amount of cigarette smoking was takeni as the higher of these two numbers:'the number of cigarettes smoked per, day as reported on Q1 and the number per day as reported on Q4. Within eachi matched group, as defined above, the subjects were divided into three subgroups according to tar and nicotine (H, M„or L). The entire group was discarded if it did not, contain at least one H subject, at, least one M subject, and at leastione L subject. Otherwise, the subgroup (H„M, or L) with thesmallest number of subjects was identified'. This smallest number willlhereafter be referred to as the adjusted number of subjects in a specified group.,The adjusted number of subjects was thenidivided by the number of subjects in each of the three subgroups (H, M, or L) to obtainrthree adjustment factors. (By definition, the adjustm en t factor for the smallest subgroup is 1.00; and for each of the other two subgroups itis either 1'.00 or less than 1.00.) The number of deaths in each subgroup was then multiplie&by the corresponding adjustment factor to obtain, the adjusted number of deaths in that subgroup. Likewise, the sum of the person-years of exposure to risk (during a: 6-year period) for each subgroup was multiplied by the corresponding adjustment factor to obtain the adjusted n umber of person-years . The person-years of exposure to risk of a subject during a 6-year period is (a) 6 years ~if the subject is known to be alive at the end of the 6-year period; or (b) elapsed time from the starUof the period up to the time of death if the subject died Iduring the period; or(c) elapseditime from the start of the period up until the time the subject was last traced. Having carried out'the above procedure separately for each matched group of subjects, the findings were summarized. RESULTS Part 1 of Table 1 shows the number of male and female subjects at the start of each of the two time periods classified by the tar and nicotine content of the cigarettes they usuallysmoked. Part 2 ofTable I shows the number oft'hese subjects who were included in matched groups as previously defined'. The difference between these

s< id 1923.9 for subjects t 1.05). This difference ry heart disease deaths tes a day and 736.6 for -[ality ratio 1.10). This number of lung cancer arettes a day'and 129.5 Irtalityratio 1.71). This the four indiividilal sets .ijusted number of lung I" T/N cigarettes a day !s a day. 1 rates of subjects who 'om the death rates of undertook a matched ) and all of the factors loked per day and age oked greatly outnum+ ibjects were matched. 1; 6822 men, Period 2; e basis of the adjusted 3forwomen at start of 'eriod 2. T deaths (all causes of )99:0 for subjects who icant (P<0.0001). The 674'.3 for "low" T/N rly. This difference is ung cancer deaths was mokedregularly, This and females in Periods disease deaths and for igher for "low'"' T/N I each of these differ- n <0;01 to <0.0001).. D (adjustedlnumber of ~adjusted number of th combined, 0_60 for iths. 237 "TAR" AND NICOTINE CONTENT OFCIGARETTES. 273 TABLE 4 ADlt'sTED NU\7BER (lF~ IDEATHti (T()TAL,.Cf)RDVA'RY~. HEA'RT~ DISEAS'E, AND~. LuNG CANCER) . AND M()Rr.aI:ITY' RATIOS DL'R11G EA(:11 (oF Two PERIODS'.nF TIME BY'~ SF`(;. "LOw" T/N SMDXERS'., AND Sl'BJECITS'. wHD~.NE\'ER SSt(1KED~.REGLIi.ARLY~. Total deaths Coronary heart disease Lung cancer Sex Period T/N Never smokeda' "Low" 7VN Never smoked° "Low" T/N Never smoked" I. Adjusted number of deaths Male t 1,522:3 864.8 742:3' 399.1 107.0 9.8 Male 2 853:0' 542.1 3111.0 238.4 77.0 7.1 Female I L288:0: 979.0 343.0 205.6 30.0 12.8 Female 2 1,007.0 713.1 278.0 165.2 44.0 9:7 Total 4,670:3 3;099.0 1.6743 1,008.3 258.0 39.4 2. Mortality ratios Male 1. 1.00 0.57' 1.00 0.54' 1.00 0.09 Male 2 1.00 0.64 1.00 0.77 1.00 0.09 Female 1 1.00 0.76: 1.00 0.60 1.00 0.43 Female 2 1.00 0.71 1.00 0.59 1.00 0.22 Total 1.00 0.66~ I.00 0.60 1.00 0.15 ° Never smoked cigarettes, pipes; or cigars regularly. CONCLUSIONS It is quite apparent that reduction in the tar and nicotine content of cigarette smoke did not make cigarette smoking "safe'" for the men and women in this analysis, alliof whom were over the age of 40 in 1959. Cigarettes with reduced tar and nicotine were not introduced until the mid 1950s (following the retrospective studies of Wynder and Graham, 1950; Doll and Hill,. 1952; Levin et al:, 1950): Almost all of the male cigarette smokers and'the great majority of the female cigarette smokers in our study began smoking cigarettes long before that date. Therefore, the subjects here classified as "low" T/N cigarette smokers, were, with few exceptions, persons who smoked "high" T/N or "medium" T/N cigarettes for many years and then switched to "low" T/N ciga- rettes. It appears that by so doing they somewhat reduced the serious risks they' incurred by smoking. (This does not apply to the relatively few who at the same time increased the numberofcigarettesxheysmoked perday.) Therefore, we think it fair to say that switching from "high" T/N to "low" T/N cigarettes was at least a small step in the rightdirection for those who continued to smoke cigarettes. Those who quit smoking fared considerably better. What' of youths who have not yet taken up the habit of cigarette smoking?' They would he wellladvised never to do so. However, in spite of all the warnings, many thousand.s of young people do in fact take up the habit. The threatto the future health,of those who make this youthful decision would be reduced if "high" T/Ni cigarettes were removedlfrom the market. Manufacturers may be willing to do so u H

I 291 TWO DAYS IN JANUARY Footnote References iearing, 1. .ronic 2. +ase , be 3. 'i'gµres. 4. ire fell why 5., abruary 6. of view 7. _on. 8. 1969 !nt. 9. :cusations , and 10. :es per 11. ictual 112. 113. 14. 15. Califano, Joseph A., letter to Members of Congress, 1/11/78. Califano, Joseph A., address to National Interagency Council on Smoking andiHealth, Washington, D.C „ 1/11/78. American Cancer Society, Report of The National Commission on Smoking and Publiic Policy,, New York City, 1/31/78. Neuberger, Maurine B., SMOKE SCREEN: TOBACCO AND THE PUBLIC WELFARE, page 15, (Prentice Ha, S9fi3~- U. S. Public Health Service, SMOKING AND HEALTH, Report of the Advisory Committee to the Surgeon Geneoal, Washington, D.C.,. 1/1176 Hun Adley, Dr. James M., ssistant U. S. Surgeon General„ transeript of news,conference released by U~ S. Public Health Service, 1/11/64. Foote, Emerson, Chairman„ NationaL Interageney Council on Smoking and Health, statement released by the Council„ Bethesda, Md.,, 1/11/65. Horn, Dr. Daniel, Cancer Control Program,, Division of Chronic Diseases, U. S. Department of HEW, "Cigarette Smoking in the High Schools," speech to American Association of School Administrators„ Atlantic City, N.J.,,2/17/65. U. S. Senate, "Cigarette Labeling and Advertising'."; hearings before the Senate Commerce Committee, 89th Congress, First Session, pages 123-4, 3/23/65. Ibid., page 107. Ibid., nage 133. Ibid., page 1145 andi148. American Journal of Public Health, Vol. 54, No. 11, November 1964, pages 1924-6. Terry, Dr. Luther L.,, U. S. Surgeon General, "Emerging,Anti- Smoking Activities of the Federal Government," a speech to the National Tuberculosis Association Annual Meeting, Chicago, IL1., 5/31/65. Magpitud'e of the Hazard,"'add+ress,to World Conference on Smoking,and Health, New York City, 9/lli/67. Ravenholt, Dr. R. T., Director, Population Service, Office of the War on Hunger, U.S. Department of State, "Cigarette Smoking::

158 Senator KE:. VEDY. Thank y ou very much. We will have a panel of high school students Gonzaga College High School, Immaculata Higli Sehool, and t'd'eeBethesda-ChevyChase High School. Through an oversight, the Immaculata and Betliesda- ChevyChaseHigh~~ Schools~were not' mentioned on the formal witness list, but they have been enormously cooperative as the youngerr students have. We want to lvelcome you to the committee. I think the Congress of theUnitedi States gets inf ormation, fronr a variety of sources. In this legislation before us now-we are trying to deal with an issue which I think is of enormous concern to parents all over this country, perhaps all over the world-parentis~ whose perhaps first interest is the good liealthoftheirchildren, parents who are increasingly concerned abouti tlheesplosion in the consumption of cigarettes. As so Inanyscientists, researchers, and family doctors have pointed out, the scientific infor- mation~ clenrlv indicates that R•eareheaded for a type of health catastrophe in this Nation~ if' the kinds of projections that have taken place between 1968' and 1974 among teenagers in smoking continue. I think all of you must have been~ impressed by what some of our distinguished researchers and doctors have pointed' out t~o this committee. And we are try.ing, as we should, to find ways and means of work- ing with~ local communities and working with you~ and your associates in the sc.hools to trv and find out if there is some way we can work in partnership~ to relieve this generat'ion, this y ounger generation, of the burden of smoking. We realize it's complex; we realize it involves a variety of different questions that affect young people-and we want veryv much this morning to hear from you, what you think is the nature of the problem and the ways and means that we can best deal with it. So we are very, very gratefnl to have you, join us here this morning. How many of you have ever testified before 2 Well, it's nothing to be concerned about, we want just to hear from you in your own words. I draw your at'~t'ention to the charts that w,ehave over here that show in those four different segment'ed areas the very significant growth in the numbers of regular smokers betR een 1968 and 1974 by various age categories. And we can see in the youngest age, fromi 12, 13, and 1i4-y.ear-olds, an eightfold increase. Corresponding increases, perhaps not percentagewise, but certainly numerically dramatic con- tinuing in the 15, and116, 17 to 18-and at this point',, as we can see in thechart that is just behind! it, the girls arevirtual7y even with the bovs in terms of use of cigarettes. This has been described as an~ explosion in terms of the use of' ciga- rettes„an& we w.ouldl like to try to gain your views about the issues. We would like to hear from you your own views, about smoking. We are not trying to make any moral judgments obviousl~*, but we are trving, to find out. Y oucan start o$" «-i'th your names, your ages, and~~ where you go to school. and then we .vould like toasky.ou about whether you smoke and wheit clid you st~art, and, some otiher questions.I think we will get started over here with Theresa, Talk into the, mikes, if you would, and give us your name, age, and where N ou go tlo school, just'initially we willl introduce ourselves. I am Ted hennedy., from Massachusetts,,Senator Chafee; from Rhode Island, and Senator Schweiker, from, Pe:. Sizbcommittee that i:. So just give us ycc come t~o some of the:( STATEMENT OF 7 MACULATA HIGI AND CHARLES GI JAMES VALEO„BI DZiss WoLFF. I an going to West Virgi: Senator CHAFEE. - lhss A`rOLFF. Imn- Miss REILLY. My g,raduated' from Imr Mr. O'MALLEY. I zaga College High ` Mr. ADAMS. I am Gonzaga. Mr. GRIFFITH. I Gonzaga~. Mr. V~ALr:o. I am. Chevy Chase High : Senator KENNEDY how many of' you sn:Ma -,be we could s start ~ M1sS `VOLFF. ATOl', Senator KENNEDY Miss REILLY. 15. Senator KENNEDr :1Ir. VALEO. Yes, I Senator KENNEDY ~'Ir. ADAMS. I was Senator KENNED7 you could try and smoke or notl to smol' Miss REILLY. We it is because of pee it is a choice of wh your own age; if ycdown on you. Senator CiIAFFFI. Miss REILLY. In n Senator KEN\-ED smoke $ :liiss WOLFF^. I st: I started smoking p- Senator KENNED, see your hands aga parents smoke ? ~

168 But' the real returns from this type of research are not what we find along the way, although it is very encouraging; it is what we will find out when we look at these children iQi, hirih school,, to see how rnanyfewer havereallv become addictive smokers. «'e find that virtual9y alll chilklren willi etperi'naent-smoking a few cigarettes is not the issue. But the real thing that has to, be, done; we believe strongly, is tost'op t~heacceleration toward addfictivesilok- ing-that's the point. In other words. graduallv they began smoking experimentally, and then they would smoke al~it't'Ie lhit more ;, finall~r, they would get to this point w.herethey are really hooked-and as we heard here;a 17-ve~ar-old can already ~ be hool:ed. SenatorSciiwEtxna. When ai•ethey hooked?How many packs per day ?nrhow many months of smol;in(,? Whereis the hooking point? Dr. EvAxs. T'he- "hooking• poiQit"' is probably,Nvhen t'hefrequencyof use begins to approach, for that agegroup, about half-a-pack a day or more. By the way, that raises an empirical question thatl I would hope that Jfr. Pinnev`ss research supportt program ~s~oulrl! look into much ~norecarefull!~~. ~I think tliat' weou~ht toprobablykno~v~o a good cleal more about that particular issue. Inour own researchi we looked in vain throuI (,h the literature for thekinds, of definit~ivedat~a on that very point. But firom our preliuiainary datai this is what it! , seems to be: Ifyoncani stop theacceleratic,n of smoking b^fore it getst'~o the fre- clueneywhere it approaches about; lialf-a-pacl. a day. and' you can at least maintain that' or hopefully liai-ethemi drop belbAv that, or evenmore desirably, not. to start in the first place, we can cut into this problem~ I-want. to caution that the results, in our study which are very dramatic, are just early results. We havet'~o be very cautious with this type of research. For example, inacldictive habits, one of the most commonly found finding,,~rhich is.ver~~d7sturbing,~is! R.hat'we.some- tiQnes call the regression effect orbaclisliding. What really happens with almost every drue-alcohol', nficotine; what have you-ist.hat within ayear nearly80percent fall back to where they R ere. In obesityand weight control, it'sprobably 99 percent after 2 years. So,in this type of research one has to be very cautious before claim- ing success. We, . shouldt not bepremat~urelyencouraged by results. But, at the monlent'our results are promisiolh. Senator5cHIVrai:rat. H'owlonga flnmefi•ame-would' y.on need to see tbat ~~on Motl to thatl backsliding st<age ?~ Dr. EvAxs. WhatI assume we're talkingabout here is not stopping children from smoking, hut stoppinr them from becoming addicted. In our particular study, I think that: if we could see continuing evi- denceat tlieend of the 9th grade and into the 1i0thgradethat the incidence of addicted smokin- hasdeclimed, we probabl.yhavesome confidence that these tFpesof conceptions may havesolnepromise. From the stand~~oint of stoppingacldicti~~e smokers, after havingj iist i ewielvec1 the literature very extensix-ely in this airea, it a1Pt?e<<rs to ]bern area, of only lii>>2ted, promise.,«~,~ehaaTe theseconimercial cliiiios that claim a lot o(' tliings, biat reallv. the (lata on their trnesioc(,ess~i's ioot re:ullV aN•ailablt By and lacgebacl.Sliding probRblyocclais aoiuong tdS~ ir ~ li~tits. It', onl Va Xc ivslu ill percentnge of peopl<.of smola i 4 wlioaire addirted and'cant ,top. So tlic5ih w.hy. I comulend thi, colmuittee: I thizilc it's I;reat that ti-oii recog»ire. as wchaiverrsearcliwise reeog- iiizcil'noa%T f'roiiaboitt :3'vear5, tliEtt the resl. noust pronti.-ing «•,av of going about, t~lii~ m~ight be to lure\-enttlieonsetof aciklioti~ e~,znolcialg. Senator : at the st,ati: be presentei school you' whereas, if going to col Now, oba. Why is the when, here formative t Dr. EVA d'hferenttpressure hrl . by incorre( doingsonu inclu onl1v As they college; pcpendence,C the i)svchc What pc peer grour- 'R?hat I delizhted could ad& ninth grac pressure t<. There's very impoo some et-id lil.elvtor. «-ell be th< So that w( onset'of sii Senator agreeing ' srnoke arc from the what thei respond ii, Couldn Dr. Ev- interestin enth or r abilitv to O saying yo W Risk t; ~ ~lc~nbt eb~ ~ to child'. whole rr ( ~ smoking CQ might' ca i 1,

293 CIGARETTE LABELING AND ADVERTISING-1969 HEARINGS Before The COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE HOUSE OF REPRESENTATIVES ~ -- --- - - ~ OF APPLIED MATHEMATICS AND COMPUTEB SCIENCE, WAl>HING- TON UlAIVERSITY, ST. LOUIS, MU. I STATEMEIPT OF THEODOR D. STERLIlRG, PROFESSOR, DEPARTII[F~T ~ The CkIAIRMAN'. TPe are happy to have you with us. We are sorrv that we have to run these hearings in the afternoon, but we have to do it to complete these hearings. Mr. S^rFaraxo. I understand, Mr. Cha.irma.n, The CHAIRMAN. Very well. You may proceed. Mr. SzERr.ixa. My name is Theodor D. Sterling, and I am pro- fessor in the Department of Applied Mathematics and Computer Science at Washington University, St. Louia I have been profeeAor of biostatistics for 8' years at the College of Medicine, at the Uni- versity of Cincinnati. I am the former chairman of the Biologic4l • Proeesslng Organization. I have served for 6 years on the American Mathematics Association Committee on Undergraduate Progra.ms in Mathematics. I am at present a member of the Committee of the

MR. FOOTE: Ii got them from the U.S. Public Health Service. Andithey had plenty of time to check the figures over. (9). As another source, Foote cited Dr. Harold S. Diehl of the American Cancer Society, who was seatediwith him at the witness table. But Diehl', in a written statement given to the Senate Committee, passed the responsibiliity to two others. He said that Dr. Morton Levin of Rbswell Park Memorial Institute in New York had given data at medical meetings in 1i9G4 which showed "that among males there are 224,,717 deaths annually in this country attributable to cigarette smoking." (10) Exactly 224,717 each year?' In addition, Diehl said, Dr. Reimert Ravenholt of the University of Washington School of Medicine in Seattle had published~a statement in 1964 which said that "in 1962 roughly a quarter of a million excess deaths in this country were due to smokin g: " Horn was at the hearing, and spoke up. He started to say that the "excess deaths" talk only had to do with reported higher death rates among smokers„ without the implication that smoking, was the cause. But then he switehedito assertions of cause, went far beyond the Surgeon General's report in this respect, and came up with yet another number -- 138,000: DR. HORN:, The figure of 125,000 -- which is a very low estimate of the total number of deaths -- which represents the excess number of deaths, occur in cigarette smokerss over what wouldihave occurred if they were to die at the same rate as people who ha&never smoked cigarettes. It consists of applying the 1962 death~rates to the diseases in which a causali relationship has been ind2cated. These include coronary heart disease, lung cancer, bronchitis anii emphysema, cancer of the oral' cavity, cancer of the esophagus, cancer of the larynx, and cancer of the bladder.

e .. s This figure is obtained by applying rates only for these specific diseases and only to men, since the bulk of the epidemiological studies which have been done have been done on men. (li1) Then it was Dr. Levin's turn. In a prepared statement for the committee, he placed the blame for nearly a quarter million "excess deaths" on smoking. He also presented his definition of the term: Dr. Paul Sheehe and'I have made such an estimate, takingg into account the age distribution of the malie population, the numbers of smokers and non-smokers, and the number of deaths from various causes in 1962. Over 200,000 deaths, about one in every four, are due to excess mortality among cigarette smokers. Of the estimated 658,000 deaths among male cigarette smokers, over 33 percent were excess deaths.,Lung cancer„ chronic respiratory disease, and coronary heart disease accountedifor the 1'argest number -- 131,000 -- of the excess deaths among cigarette smokers. Levin provided a tabulation~of his estimate (see tabl'e):. But he did not explain the basis for the numbers on which~his calculations depended. (12). 284 I am indebted to the original, set of figures here, which have appeared in statements of the Public Health Service as long ago as liast August, and to Dr. Levin, who has. publiished these figures and is, I believe, scheduled to testify tomorrow. The number of deaths from coronary disease, which is included in that, is approximately 80,000'. The number of deaths from ~ lung cancer is 33,500. The number . from bronchitis and emphysema is 1i6,500. Cancer of the oral cavity, esophagus, larynx and bladder, add up to 8,000 s This totals 138,000, I which is a little higher than the original estimate of 125,000, but is based on applying these to estimated 1965 I deaths from these caus Cause of Lung Can Bronchit Cancer o Cancer o Cancer o Coronary Disea A1D othe All caus Estimate 195:. Excess d expe Rav( at the f actuall

-a- 28fi the astonishing basis for his own "excess deaths" computation. (13). He began with a report from Hammond of the American Cancer Society which statedithat over a certain period there were 662 deaths among a group of men who had never smokediregulariy, and 1,385 deaths among a:similiar group who had been smokers. The "excess," as he noted by subtractions, was 723. Among the nonsmokers, 12'deaths were attributed to lung cancer, Ravenholt observed, andiamong the smokers 110, for a total of 122 and an "excess" among smokers of 98. With no explanationy he then inscrutably declared that because the ratio of all the lung cancer deaths (122) to all the "excess deaths among smokers" (723) was approximately one to six, all one needed'.to do to figure out how many "excess deaths" from smoking might occur in any year in the whole population would be to multiply the total lung cancer deaths by six! Thus, bormof invention rather than actual observation or expliainable logic, andlclothed'in data which defy analysis, the "excess deaths" concept continued its march through the history of the smoking and health controversy. Although the Advisory Committee which~prepared the 1964 Surgeon General's report had refused to misl!ead the public by guessing about "excess deaths," that Surgeon General himself fel~t no such reluctance. In May of 1965 Dr. Luther Terry pursued! the phantom numbers in a speech at the annual meeting of the National Tuberculosis Associatioa in Chicagoc Last January 11, there was a great hue and cry when Emerson Foote„ Chairman of the National Interagency Council on Smoking and Health, declared that cigarettes are and Stat The vali non- die smok deat asso lary as b Anot from whil This: only ina& avai 1 eve but deat men, cons: Terr judgment casual~ wu three se for his Rave formula speech t him 301, The Stewart, House AF early "e figures

-12'- 2so One month later, on February 15 at a Congressional hearing, he attributed to cigarette smoking,15,000 d'eaths from chronic bronchitis and emphysema, 175,000 deaths from heart disease and1100,000 deaths from cancer, and~stated this total' to be "more than 320,000." He gave no source for any of his figures. Neither didihe explain why or how the heart disease figure fell by 45,000 deaths between January 11 andiFebruarg 15y or why chronic bronchitis and emphysema were included in his February 115 total but not in~his January 11 total. (23) Undbubtedliy, invention of "data" to: support a point of view is tempting and'y- Yn~some cases, an irresistable temptation. Invented data can indeed persuade; they cannot inform. A statement by, a distinguished physician during hi.s 1969 congressional testimony on smoking and health is pertinent. Said Dr. Milton B. Rosenbliatt, "The widely publicized accusations of hundreds of thousands of deaths caused by cigarettes, and of shortening life expectancy a specific number of minutes per cigarette smoked, are fanciful'extrapolations and not factual data." (24) i 1. Califano, J I 2. Califano, on Smoking I 3. American C. ~ Smoking anc + 4. Neuberger, I WELFARE, p:. ~ 5. U. S. Pub1: ~ sor~ C~ A dvi - ~ ~ ~ " "'..." 6. Hundley, D ( of news co 1i/11/64. I 7,. Foote, Eme Smoking an Md'. „ 1/1i1/ 8. Horn, Dr. 1 Diseases, High Schoc AdministrE 9. U. S. Sen~ 10. before the Session, F Ibid., pa~ 11. . Ibid., naf 12. Ibid., pa,. 13. American . 1964, pa& 14. Terry, Dr Smoking A National 5/31/65. 16. Ravenholt 0 the War o Magnitude Smoking a W 0 W. ~ M"'1 ~ i

169 Ire not what ~ ; it is what high school, tive smokers. nokincr a feww o be done, we dictive smok- e~an~ snlokin~ more; finally, -d'---and as, we unv packs per )okin.z point 9 frequency of -pack a day or I would hobeokinto mualr sv a good deal we looked in data on that it seems to be : et.5 to the:fre- ad you can at that, or even cut into this ilich are very ious with this e of themost : hat we some- eally.happensv.ou-is thatt hey were. In ifter 2 years. before clFiim- )y results. Butt ou need to see ; not- stoppin~ )ing addicted.. )IltlnnlIlb :rade that t~he)ly have some ~ome promise:after havingit appeairs to. u'(Ircial clinics r)te success is occmni, an)nng J ' smolcers R-ho ri5 con)nrittee: clin•ise reco(r- : «-av of'(*oiir)M n1okII1g. Senator ScxwElhFR. One part I don't quite understand, if you look at the statistics that'theCancer Societyhashere-and I guess they'll be presented a little bit later-it indicates that if you don't go to1ighi school von, have the lbw.est rate of smoking among ~-oung people; .rhereas, if you go to high, school~, you have the highest. But if you're going tocolleac; it drops offa-ain. \otiv; obvIouslhpeergrouppressur..es areworking at all threest'agese Why is the high~school peer aroup pressure so important, particul'arlywhen here you're talking about the seventh, eigllth and nlnth, being a formative time ? Dr. Ev_»s. Well, I think that peer pressure begins to take on a different, type of charactler. For example, at, early agres peer group pressure has a primarily conformity componentt that is characterized bv incorrectlv perceivinir that it is a s)uall'gronp of peoplethat aredoing sometlrin;.r, thekids believe evervbody.is dbing it. Thiswould not only include ci!rarettesmol:inne but the u=e of clrngs and alcohol. As they get older and enter highschools and college, particularly in college, heer ~roup pressnre take on the character of stressing inde- pendence, of being yoursel'f, to do your own t'hing more. Obviously, the, wsYcholomcalnatnre ofpeerpressure goes tllroci' (Th an evohition. What perhaps I am really savin(r is that' you can't generalize about peer aroup pressure. It varies,overtime. What I armie, of course; in our research approach4 and which I'm delivhted to hear this comnlitteediscusse is t'hefact that! probably we could address ourselves to this anegronp~ in theseventh, eighth, and ninth "raclhs when there is a particular vulnerability to peer group pressure to smoke. There'sa 13 ritish stndvy tbat I)'r.111rances I3ewle.v did. which I think is very important and I hope this committeelboks into it. Shehas shown sonle e6Klence that if chihlren begin smokin(;,they are much more lil:elv to use alc:olloll heavil!v and move into other drn(rs,It. could very well be that fmrson)n teenafreiISIsmokinz is an addictive,entranceticket. So that n•o))ld be another \7ery important reason, I suspect, to deter the onset of smoking. Senator ScliwFii.FR. But couldn't that also be-anrll I'm~ not dis- agreein(r with vou-but it could also mean that people who tend to smoke are a little higher risk takers, a little more wIlliolrr to departt from the establishment, a little more willing- to: thumb their nose at what thein parents havet'~old them and therefore they're -going to respond in those ways? Collldn'tit also mean that?I)r. Well. Senator. I tllinlk tbat issneof Iisktakinn is a very interesting~ one: and I think it involves,a verysnbtle point. For a sev- entli orreinhtltinraclerr for example, this r'sl:tal:inn, miml)thetheabilityt'~o say"'no" and be able topnt upwit'h all of tlleseother kids sayili; ~~.on're ~hicl:en,and so~on, or yon're asissv or i~•llatever. Risk takinLr, of conrF:e, takes on t-;)rions cli)mn~sirnns. There is no rlhnht ~,3)nnt it, its mrulife4atinns wonld varv ameat deal fronl child to child. Inisomc cases yoniretllkin-a a risk hrs. Sa.vinff:`no."lfiecanFethewhole I-ronp is L'oinff to fall dhwn rnl von. In comecases you insistl on snnokinr that cigarette and' you'i•e takin- a risk liecause~ti,ou think it mi-orht cause cancer.

203 looking over the accuracy of the > difficult without at the labels that _ Will give you an~ ~." It is very dif- .iay incite a doubt nent ? Is it an ac- ccurate statement strong enough, is r than the "may." t it isan~ accurate ,st statement now, if you smoke you t to say it. ,dical research to ;h which cigarette scular disease, but, illyy oung peopl c. tt we need to con- ~signed to d'octor ve heard here to- -o wholehearted2y issist this subcom, d Welfare in your 3anzahf? ,ame is.John Ban- at~er of the George or of Action on~ irelegal men not tle bit differently iave prepared re- act to what I sa-what presumptuous implyy share some rted not only for on~ the mtost problem~ ofsmok- ron. _1nr1 I think rne 1rcriiments of, ,retarv Califano's~ program and your bill and others will attack free will. We saw here his morning, the data are very clear, that when 10-, 11-, and 12-year- old kidstake up smoking, when~ they are hooked bv 13 or 14' or 15, we are not, talking about free will. I"was aRnused! byy some of Senator Ford's, remarks on howhisindust'ry is aboutt'ogoout of business if', we do anything about the problem of smoking. One thing he didn't mention,,ofcourse, is that thetobaccoindiistryis rapidly diversifying, and also that more and more tobacco is being shipped overseas, par- ticularly to countries whichy unlikethe United States and'some of the western European countries, d'o not have or are not developing effective programs of public, health withregard to smoking. I think also it is worthwhilecontrastinr what we do or what weliave talked about doing with regard to smoking with what we do about other problems; because when we look at whab we do about pornography or alcoholl or teenage pregnancy or others, what we propose to do about smoking is so very, very srnalU in contrast and alniost minuscule. You were talking before about how much money R-ouU it take to havean effect'ii-eantlismoking programy and figures, of $30 and $40 million were thrown around. People were thinking this, is very high, yet I believe we spend somet'hing like $150 million already with regard to the problem of alcohol ; we are budgeted at HEW for $175 million with regard to teenage pregnancy: and even of the monev n-hich, is eurrentlybeingbudgetedl in smoking-and here I think t'~he~discussion is illuminating this morning, because nobod`y is quite sure how much is being budgeted for smoking-most of that is going int~o research, very little comparatively is, going into education. Senator, looking at it again, in part from a legal point of view, it would be my conclusion that educational programs; although valuable, cannot solve the problem-and this refers to educationall programs both ini the schools or on radio and television. Much as I am, in favor of the antismoking messages and having them return and continue, and much as I think thev are effective, I don't think that, we can havean effective antisniokinaprogram and solely rely on education, whether that is in the classroom, on radio and! television, or wherever else. Indeed, we do not simply rely on education with regard to many of our other major problems. We don't simply tryy to educate our kids about alcohol ;.v e restrict the sale as best we can of alcohol products. We don't simplywarn peo- ple about the dangers of a variety of drugs; we restrict the sale of those draigs:«'edo, the same thing with regard to pornography. We restrict the decisionmaking power of children insofar as we can with regard'tosesual activitycontacts and otherwise. Senator Iir._rN-r.nr. Would you do the same with cigarettes? Mr. B>>N zAnr. I R-ould, Senator, and I woul'd'like to suggest- a nurn- ber of tlltin;s ~•h~ichI' think can and should be done which ~soulal have amuch quicker impact and a much ;reater impact on a cost- effectiveness basis in the problem of smoking than, mere educational prozrams. The first would bet'o l i mit t'~he, ads, alll of the ads today, because thevhavesuch a dramatic impact on children. Year aftervear the Federal Trade Commission, has reported to: this Con;,•ressthat cigarett'eads continuet'o bewifaiir and deceptive trade practices, i-et to:date neither

Median occasions upon which alcoholiwas used by eleventh grade males and females: 1968 1969 1970 19711 1972 1973 1974 1975 1976 1977. Males 3.7 7.6 8.5 18.3 20.9 27.6 27.8 28.5 25.9 28.6 Females 2.4 2.7 5.2 7.1 9.8 10.6 16.8 17.01 18.2 22.1 AMPHETAMINE usage continued its downward trend with 22 out of 36 rates decreasing. The standardized rate for any usage droppe&from 15.3 to 15.1. Girls still tend to have higher rates, grade for grade, than boys, which may be due to the non-prescription use for weight reduction. The highest bracket - fifty plus - undoubtedly masks some heavier usage, particularly among males and'does not show whether administered orally or directly into the bloodstream. BARBITURATE usage which,is linked with that of amphetamines shows 26 out of 36 rates moving,downward. The standardized rate for any usage dropped'from, 12.4: to 11.0. Usage had apparently peaked in 1971. HEROIN usage cannot be evaluated by inspection,of rates fromithis survey. The percentage of users is so smalllthat even rounding of rates to one decimal point causes discrepancy, plus the various random factors other than real heroin usage that can influence the survey results. This data does not pinpoint small resur- gencies in specifiic areas. LSD rates continue their downward movement with 25 out of 36 rates lower than 779-77. The defini'tion of LSD in the original survey,,which for reasons of comparability it has been necessary to maintain, included some other occasionally used'hallucinogens including PCP. Many ofi these drugs whenianalyzed turned out to be LSD. We would have been interested in a more accurate count of POP. The 1976 survey which was expected to contain numerous references to methaqualude contained only three. The 1977, survey showed a consistent sprinkling of mentions of qualude which'ihave not been analyzed yet. MARIJUANA rates produced by this series ofistudies are of exceptional interest since they provide information that can be used in measuring the impact of California's new marijuana law (SB95). The liimited~analysis that time permits shows the contrast between conclusions that would be reached with only tiro annual surveys as compared'with an observation of the ten year series. TWO SURVEYS ALONE - 1976 and1977 - would form a basis for saying that marijuana usage is definitely up. The standardized rate for grades 9-12 increased~fromi 55.3 to,57,.5 for any usage, and from 22.5 to 23.3 for users on 50 plus occasions. Twenty-three out of 36 rates were higher in 1977 than 1976. We could also note that there was very little increase in the lower grades, and progressively larger increases in the higher grades. In fact, usage decreased among females in grades 7-9. The trend of'greater differentials in older groups parallels the findings on adults as showniin the January 1977 report~of the State Office of Narcotics and Drug Abuse. i TEN SURVEYS - 1968-197i unusua . Inialmost all class/sex between the 1968 and 19 and 1977. This is sunrr Number of Date of Occasions 1968 Any 31.9 Ten:plus 17.5 Fifty plus *15.9 *1970 figures. Fromithe detailed serit it is evident that mar the impact of the legi- unless a trend observe, levelling off had not c that'could have been cc years' experience. TOBACCO usage continues w en~ranges for females Simultaneously, rates i rates of usage on more mask the fact that rate there are clues this ye NONUSERS who reported!u fewer, with ten out of portion of st'udents who arbitrarily defined as occasions, and.LSD or a not exceed'.these limits tablp which shows a sta that this is largely du IN SUMMARY the series c since . There is r ularly for AMPHETAMINES downtrends since about and the 1977 figures gi females may be diminisli, over 1976. MARIJUANA r the Report of the State of the legislation beca:, Surveys are unde by additional copies may b Mat'eo County Department California 94403.

ie "excess ;or down) .s are to :al'ifano :y parroted 7arious two Britons, i and E. Cuyler ; used, in 3moking and Surgeon 7 warned _ Welfare, , Senator ild be his ) .,..deaths per year."' (4) Horn hiimselif apparently came to regard that as an exaggeration, and subsequently he confined his "excess deaths" estimates to 300,000 or fewer. The Stirgeon General's report itself rejected the theoryy of "excess deaths": "The total number of excess deaths causally related to cigarette smoking in the U. S. population cannot by accurately estimated." (5) Why did the Advisory Committee take this position? The Assistant Surgeon General, who was vice chairman of the Advisory Committee, gave the reason at a news conference at the time the report was release& "The Committee consideredithe possibility of trying to make such calculations,but it involves making,so many assumptions that the Committee felt that it should not attempt thas..." (6) But others ignored~this restraint. OmJanuary 111, 11965, the first anniversary of the Surgeon General's report, Emerson, Foote, an advertising executive and chairman of an organization called the National Interagency Council on Smoking and Health, began a new round of "excess deaths" speculation in a news reliease: "Estimates made by scientists who have spent years studying the problem, vary depending,upon the way that the data are interpreted." Nevertheless, he went on to assert,,"It may be said with sureness that cigarette smoki'ng i's today responsible for at least 125,000 deaths each year in the United States. Cigarette smoking may be responsible for as many as,300i,000 deaths per year in this country." (7) 30-536cD - 78 - 1J .

i 277 •ade males and females; 1975 1976 1977 28.5 25.9 28.6 17.0 18.2 22.1 of 36 rates decreasing. i.l. Girls still :h may be due to the icket - fifty plus - sles and does not show 3m+ s shows 26 out of 36 i dropped from,12.4 )m this survey. The ; to one decimal point than reall heroin usage pinpoint small resur- 36 rates lower than ich for reasons of some other occasionally n analyzed turned'out te count of,PCP. The ces to methaqualude sprinkling of mentions _xceptionaliinterest since impact of,California's oermits shows the contrast nual surveys as compared saying that marijuana 9-12 increased from s on 50 plus occasions. We could also note nd progressively larger among females in grades arallels the findings Office of Narcotics and TEN SURVEYS - 1968-1977 display the fact that the 1976-1977 increases are not unusuaT.- In almost all class/sex level cells the average annual percentage difference between the 1968 and 1976 surveys was greater than the difference between 1976 and 1977. This is summari¢ed by arranging standardized rates: Number of Date of Survey 1976 minus 1968 1977 Occasions 1968 1976 Total Average Surve 1977 minus 1976 Any 31.9 55,3: 23.4 2.9 57.5 2.2 Ten plus 17.5 35.4 17.9 2.2 37'.1 1.7 Fifty plus *1970 figures. *15.9 22.5 6.6 11.1 23.3 M From the detailed'series of marid'uana data, together with the graphs supplied, it is evident that marijuana usage increased between 1976 and 1977. However the impact of the legislation could hardly be considered explosive. In fact, unless a trend observed in,1976 that implied that marijuana rates might be levelling off had'not occurred, the amount of increase involved was of a level that could have been considered less than average, in light of the preceding years' experience. TOBACCO usage continues to fol0ow an interesting pattern,which began in 1970 w en r~T anges 7or females exceeded those for males and started a consistent climb. Simultaneously; rates for males have dropped consistently: The standardized rates of,usage on more than fifty occasions which have remained relatively stable mask the fact that rates for the sexes are moving in opposite directions. However, there are clues this year that rates for females are beginning to plateau out. NONUSERS who reported use of none of the surveyed substances to any degree became fewer, wiith ten out of twelve rates decreasing~ The same is true of the pro- portion of students who reported NO SIGNIFICANT USE. Significant levels were arbitrarily defined as the use of alcoholl„ tobacco or marijuana on ten or more occasions, and'-LSD or amphetamines on three or more occasions. Students who did' not exceed these limits for at least one of the substances formithe basis of the table which shows a standardized rate decreasing from 38.8'to 37.2. It appears that this is largely due to a more generale use of alcohol. IN SUMMARY the series of surveys show a rapid rise of rates for all substances since . There is recent indication of "peaking out" or plateauing, partic- ularly for AMPHETAMdNES, BARBITURATES and LSD which have shown rather consistent downtrends since about 1971. TOBACCO~usage continues a downward trend for males, and the 1977 figures give some slight indication that the upsurge of rates for females may, be diminishing~ ALCOHOL rates made decided and'unexpected'increases over 1976. MARIJUANA rates while increasing, were in line with the findings of the Report of the State Office of Narcotics and Drug Abuse in t'hat the influence of the legislation became progressively less strong, the lower the age group. Surveys are funded y HS esearc Grant Prior to Nove er 1977, additional copies may be obtained from Lilian Blackford,,Biostatistician, San Mateo County Department of Public Health and Welfare „ 225 - 37t'h Avenue, San Mateo, California 94403L I I I ~ ~ f ~ I W ~ ~ 0 I

SAN MATEO COUNTY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE CUMULATIVE LEVELS OF USE REPORTED 8Y JUNIOR AND SENIOR IIIGN SCIIOOL STUDENTS, 196g-1977 BY SCkIpOL GRADE AND SC% OF RESPONDENT. SPECIFIC RATES PER NIINDRED RESPONSES. TOBACCO LES - hEMALES ta n erdtre YEAR OF 7th eth 9t 10t 11[ 12t --7r -B[ 9t 1 [ llt 12" Rat e` Total Total•` SURVEY Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade G rade Grade Gra des 9-12 Responses Reporting any use of tobacco during preceding year. 1968 NA NA 57.1 54.3 56.7 58.3 NA NA 52.0 55.4 57.4 55.1 55.8 18,774 1969 43.6 51,0 51.2 50.0 55.0 58.2 39.8 50.1 51.6 55.5 54.9 57.4 54.2 25,883 1970 38.2 51.0 49.9 51.4 50,5 52.1 34.0 44.8 52.1 57,0 54.8 53.0 52.6 35,148 1971 41.5 50.1 54.5 51.1 54.6 53.1 36,0 48.6 56.2 56.3 55.8 53.7 54.4 35,701 1972 42.2 51.8 55.5 54.2 51.4 54.5 37.5 52.8 57.7 58.3 56.9 55.0 55.4 31,251 1973 50.4 57.4 61.1 58,8 56.4 57.2 46.2 59.8 63.5 61.2 57.5 56.8 59.1 27,388 1974 48.2 58.6 58.0 S6.1 54.1 56.9 49.0 60.4 64.8 61.1 58.8 56.2 58.5 28,232 1975 45.8 54.3 58.5 56.7 55.0 54.7 46.4 59.0 63.8 61.6 60.6 57,1 58.9 28,303 1976 42.2 51.6 5f.6 54.1 54.0 49.6 43.6 57.4 63.6 64,4 60.9 59.4 57.2 20,848 1977 ~40.6 51.3 51.0 _51.3 53.6 51.7 40,9 54.8 61.6 63.0 61.9 59.3 56.7 22,077 Reporting use of tobacco on ten or more occasions during preceding year. 1968 NA NA 34.0 34.6 39.4 41.5 NA NA 27.3 34.0 35.4 36.7 35.4 18,774 1969 17.4 25.5 31.3 33.7 38.8 42.2 14.0 25.3 30.5 32.7 37,7 39.8 35.8 25,883 1 970 12.3 23.6 29.4 33.5 34.8 36.8 11,9 21.4 29.6 36.9 35.4 37.5 34.3 35,148 1971 15.8 25.7 32.6 33.0 38.3 37.3 14.3 26.2 33.7 37.6 38.8 36.4 36.0 35,701 1 972 16.6 29.2 31.7 34,8 34.6 37.0 16,4 30.0 34.5 39.3 38.8 39.1 36.2 31,251 1973 17.9 28.5 33.8 34,8 3ti,6 37.7 18.6 31.9 38.0 37.7 39.0 39.2 37. 1 27,388 1974 16.0 28.5 30.4 33.3 33.1 35.3 19.5 31.8 41.2 39.0 38.8 40.7 36.5 28,232 - 1975 14.4 25.1 29.8 33.1 32.4 33.1 17.0 29.5 39,4 39.6 40.6 39.6 36.0 28,303 1976 12,7 20.9 25.6 28.4 31.2 30.0 13.9 31.1 38.7 43.5 42.5 40.8 35.1 20,848 1977 10.6 19.6 24.1 25.9 30:1 30.9 13.0 25.6 34.9 39.3 43.3 41.4 33:7 20,077 Reporting use of tobacco on fifty or oare occasions during preceding year. 1968 NA NA NA NA NA NA NA NA NA NA NA NA NA 18,774 1969 NA NA NA NA NA NA NA NA NA NA NA NA NA 25,883 1970 NA NA 22.8 27.2 28.9 30.8 NA NA 20.2 28.1 27.6 30.8 27.0 35,148 1971 NA NA 24.7 26.g 31.6 31.0 NA NA 23.6 30.1 31.9 30.4 28.8 35,701 1972 NA NA 22.9 27.8 28.3 31.2 NA NA 24.6 30.4 32.1 31.8 28.6 31,251 1973 10.3 17.3 24.3 26.3 28.6 30.1 9.6 19.7 27.0 27.9 31.1 32.0 28.4 27,388 1974 9.2 17.8 19.8 23.9 25.2 28.1 10.0 19.5 29.6 29:8 31.1 13,4 27.6 28,232 1975 7.5 16.0 20.6 23.2 24.4 24.7 8.3 18.9 27.3 30:0 32.4 31.8 26.9 28,303 1976 7.3 12.7 I8.1 21.1 23.0 23.3 6.7 18.4 27.1 35:0 34.1 33.1 26.6 20,848 1977 5.2 11.3 15.8 18;2 21.9 22.5 6.2 15.4 24.3 30.6 34.4 34.2 25.2 22,077 ssgeoseo Standar ize rates o use or senror- ig sc.ools are compute usrng equal popu -r0ns_ for eac t e etR t class/sex groups. This e1iminates distortioo bewuse- proportions af classes or se:es have changed between years. '•.Total nunber of respon}es used in tehulations for the year specified. 3/2/77 SA°! MATEO COUNTY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE "THE NON-USERS" LEVELS OF "N0 USE" AND "NO SIGNIFICANT USE"••' OF ANY OR ALL OF TIIF. FOLLOWING SIIBSTANCES: ALCOIIOL, ANPIIETANINF;S, LSU, /NRI./IIANA, AND TUBACCO REPORTED BY JUNIOR AND SENIOR NIf.li SCHOOL STUDENTS, 1968-1977 BY SC7100L GRADE ANU SE% OF IIESPONUENT, SPECIFIC RATES PER NUNURED RESPONSES. 7th 8th 9tk- -l0t lat 12t Grade Grade Grada Orade Grade Grade

311 _1 be completely less per pack number of national incer Advisory :an Lung Association _nnovative change initiatives .e the current iing in his '_ng on the =ort aimed at loking, thereby. aoking among ition is vitally :) start smoking ing cancer than ig a child's is most important. Ldren, there :heir control -- !s from friends, and to be borne by the iildremto the by the family, the schools, as well as the government. As written, S. 3118 would facilitate this shared responsibility by promoting school and community-based education programs. As importantly, the Legislation pending before this Subcommittee revises the current cigarette warning label. Warning statements have been required on all domestically distributed cigarettes since 1970, and represent an attempt to educate the public about the health ri~sks involvediin cigarette smoking. For the past seven years the Federali Trade Commission has been urging that this warning,label be made more explicit. While the FTC has petitioned Congress to consider altering the label so that the various smoking related:diseases would be liisted, the variation offered by S. 3118, that of a"revolving" label, is an adaptation of a practice currently used in some European countries. It is based omthe rationale that smokers will pay more attention to the warning if it varies. In,sum, I am in strong support of S. 3118, as it represents a major step toward a:national preventive health care policy. I am not, nor is to the best of my knowledge any member of this Committee, a scientist. Therefore, we must rely on those individuals with the necessary expertise and those who have been mandated by Congress to protect the health of the American people. Testimony will be presented by the Department of HEW, as well, as by several Nobel Laureates and other highly respected scientists and researchers. It is essential to engage the talents of such individuals in order to deal

4e find that a itering the environment. in cancer research, it ss spend'hundreds of 3nd cure human cancer. r, namely, stop ient this cancer. izes the growing of i Stockholm, I am !vent much human s not more widely -ge increase inifunding ,t present the U'. S. ults of this biomedicali ,ust be careful before dical research, and ty is stressed iniall s quality Is the rmore, although at lar problem, iin blems, if techniques supply a proper to~approach such y when a proper I wonder abouti the 5 advisability of trying to spend rapidly much larger sums of money in,this area. I suggest that a large and rapid increase in money iis not warranted. More important is a mechanism, for assurance of continuing support of good basic biomedical research and a good'peer review system,. Iniconc1'usion, I feel that the support previously extendedito cancer research by the U. S. people throughithe Congress indicates a concern wlith . preventing this disease. Research indicates that the best'present method available to prevent much cancer is to decrease smoking. I, therefore, support Congressional action to decrease smoking.

E6SE09E0 SAYiY MATEO COUNTY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE CUMULATIVE LEVELS OF USE REPORTED BY JUNIOR ANU SENIOR HIGH SCNOOL STUDENTS. 1968-1977 BY SCIIOOL GRADE AND SEII OF RESPONOENT, SPECIFIG RATES PER HUNDRED RESPONSES. NALES --YEAR OF 7th 8th 9t l0t - - SURVEY Grade Grade Grade Grade Grade Grade Reporting any use of LSO during preceding year. 1968 NA NA 8.1 11.1 14.6 16.6 NA NA 6.9 8.3 9.2 9.4 1969 2.8 8.7 11.0 16.9 19.2 23.0 2.1 6.0 11.2 12.8 13.0 11.2 1970 1.4 S.0 1D.8 17.0 18.5 17,4 0.9 4.1 9.2 15.0 12.4 11.9 1971 2.7 6.3 12.5 16.1 21.2 20.9 2.3 6.2 11.7 13.6 15.0 12.2 1972 2.7 7.1 12.2 17.6 17.6 21.2 2.5 6.3 11.9 14.5 1S.9 13.7 1973 4.0 7.6 14.6 18.8 21.3 20.0 2.8 7.1 13.8 15.7 16.4 13.4 1974 4.2 8.9 12.9 18.5 20.3 20.1 3.7 7.9 14.9 11.8 17.2 16,1 197S 2.9 6.6 12.4 15.2 19.0 19.6 3.3 ~ 6.7 12.0 16.1 . 16.5 16.1 1976 3.5 6.3 9.8 14.1 18.7 17.8 2.1 5.6 9.5 13.9 17.6 13.5 1977 2.6 5.0 8.1 12.7 17:6 18-.3 1.7 4.3 7.0 1 0.8 14.8 1S:1 Reporting us of LSD on ten or more occasions during prec eding year. F€NALES 7t 8t O[ 1ot Ilt 12t Grade Grade Grade Grade Grede Grade 1968 NA NA 2.6 4.2 5.7 6.6 NA NA 1.9 2.5 3.6 3.3 1969 0.2 2.4 4.5 7.2 8.5 10.5 0.4 1.3 3.5 4.4 4.6 4.1 1970 0.2 0.9 4.3 6.5 7.3 7.0 0.1 0.8 2.2 4.8 3.2 3.4 1971 0.9 2.0 4.4 5.9 8.7 7.3 0.2 1.3 3.0 4.1 3.9 3.0 1972 0.8 2.0 3.7 6.0 5.0 7.2 0.5 1.6 2.8 4.3 4.1 3.5 1973 1.0 1.9 4.8 5.6 6.9 6.2 0.6 1.2 3.0 3.0 4.0 3.5 1974 1.2 2.2 3.7 5.6 5.6 5.3 0.6 1.3 3.3 3.4 4.4 3.2 1975 0.7 1.4 3.1 4.5 5.4 5.2 0,8 1.0 2.6 3.6 2.6 4.4 1976 1.0 1.7 2.2 2.g 5.2 4.6 0.4 1.6 1.5 3.3 3.8 3.5 1977 0.4 1.5 1.6 3:0 4.2 5.2 0.4 0.9 1.5 2.4 2:4 3.0 Rep ti g use of LSD f-ifty or more o esions during preceding year. 1968 NA NA NA 1969 NA NA NA 1970 NA NA 2.0 1971 NA NA 2.U 1972 NA NA 1.3 1973 0.6 0.9 2.2 1974 0.8 0.9 1.8 1975 0.2 1.0 1.4 1976 0.6 1.1 0.9 1977 0.3 0.8 0.8 NA NA NA NA NA NA 2.3 2.6 2.6 2.7 3.9 3.4 2.3 2.2 2.8 2.2 2.9 2.6 2.1 1.7 1.8 1.8 1.7 2.4 1.0 1.9 1.9 1.1 1.7 2.3 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.7 1.4 0.8 1.0 NA NA 1.0 1.4 1.4 1.1 NA NA 1.0 1.4 1.3 1.2 0.4 0.4 L 4 0.5 1.l 1.0 0.2 0.6 1.1 1. 0 1.2 1 .1 0.5 0.4 0.9 1.0 0.5 1.3 0.2 '1.1 0.2 U.9 1.2 1.5 0.2 0.7 0.7 0.9 0.7 1.1 Standar-liized Rate` total Grades 9-12 10.5 14.8 14.0 15.4 15.6 16.8 16.9 15.9 14.4 13.1 3.8 5.9 4.B 5.0 4.7 4.6 4.3 3.9 3.4 2.9 NA NA 1.7 2.1 1.7 1.7 L. 5 1.4 1.2 1.2 •Standardized-rates of use or senior Ig sc oois-are cnnputed ustng equal populattons or earh o the eight c1ass/sex groups. This eliminates distortion because proportinns of class_s n. _exes huve changed-between years. ••TOta1 uumber of responses used in tabulations fur the yeer-specified. 3/2/71 SAN MATEO COUNfiY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE CUMULATIVE LEVELS OF USE REPORTED 8Y JUNIOR AND SENIOR IIIGIi SCIIOOL STUDENTS, 1968-1977 BY SCIIOOL GRADE AND SEX OF RESPOND[NT, SPECIFIC RATES PER NUNURED RESPONSES. .- MALES __- YEAIi OF 7t 8t 9t l0i 11t 12,h SURVEY Grade Grade Grade Grade Grade Grade Reporting any use of marijuana during preceding year. 1968 NA NA 26.8 1969 10.9 23,9 34.9 1970 9.8 22.8 34.0 1971 17.6 29.1 44.S 1972 17.1 33.2 43.9 32.3 36.9 44.6 41.7 45.5 50.1 44.9 48.9 50.9 49.7 57,9 58.6 51.8 59.5 60.7 pENALES -~- -7 . --9t 1 t 11t 12[ Grade Grade Grade Grade Grade Grade NA NA 22.9 28.1 31.7 31.9 10.7 21.8 31.9 35.5 38.3 38.1 7.2 16.7 31.9 42.1 42.6 44.4 12.6 26.4 40.5 48.1 50.2 48.3 13.2 29.3 39.0 49:2 50.8 52.9 MARIJUANA Stan erdize Rate• Total Grades 9-12 LSD Tatal•• Responses 18,774 25,883 35,I48 35,701 3I,251 27,388 29,232 28,303 20,848 22,077 18,774 25,883 3S,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 18 , 774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 Total•• Responses 31.9 39.5 42,5 49.7 51.0 18,774 25,883 35,148 35,701 31.251 I

ulrx Arn 9rx 10rx llrx 12. -7rx 6AAOF/QASS PIEFAREG AY~ F1StAA(N t SI~IISTICS YRION pEPT. fi NEALTN 1 IEiFAIIE SNI MilO [OUAIY. LUIFORIIA An 9m 10rx GM/CLAS IlrH 12Tx Or ` 7rx ATn LEVELS OF MARIJUANA USAGE SELECTED SURVEYS SAN MATEO COUNTY, CALIFORNIA, STUDENTS 12 968E09E0 LEVELS OF MARIJUANA USAGE 1968 - 1977 SAN MATEO COUNTY, CALIFORNIA. STUDENTS 11 9Tx 10rx C1AS5 i llrx 12. PunOEO AY: AATIOUL ItlSTITUTE a OpF AlOSE GAANT AoIRAOp095 - LILIMI ST, CUTA ALJLYFOND, PAIMCIPIL IAYF5116U0R N/IAEA AY, MAr101N INStIIUr€ 0A OAW AAILi[ 4uw1 Rll oAOm9M - LILIAf SI. 4AIA LLXXFOAD, VAII/CIPAL 1111ES11Wr011

1968 NA NA NA NA NA NA NA NA NA NA NA NA NA ]8,774 1969 NA NA NA NA NA NA NA NA NA NA NA NA NA 25,883 1970 NA NA 22.8 27.2 28.9 30.8 NA NA 20.2 28.1 27.6 30.8 27.0 35,148 1971 NA NA 24.7 26.8 31.6 31.0 NA NA 23.6 30.1 31.9 30.4 28.8 35,701 1972 NA NA 22:9 27.8 28.3 31.2 NA NA 24.6 30.4 32.1 31.8 28.6 31,251 1973 10.3 17.3 24,3 26.3 28:6 30.1 9.6 19.7 27.0 27.9 31.1 32.0 28.4 27,388 1974 9.2 17.8 19.8 23.9 25.2 28.1 10.0 19.5 29.6 29.8 31.1 33.4 27.6 28,232 1975 7.5 16.0 20.6 23.2 24.4 24.7 8.3 18.9 27.3 30.0 32.4 31.8 26.8 28,303 1976 7.3 12.7 18.1 21.1 23.0 23.3 6.7 18.4 27.1 33.0 34.1 33.1 26.6 20,848 1977 5.2 11.3 15.8 18.2 21.9 22.5 6.2 15.4 24.3 30.6 34.4 34.2 25.2 22,077 Standar tze rates o use or sentor tg sc aots- ar -- -- cless/sex groups. This eliminates distortion because proportions of classes or sexes have changed between years. ••Total nuinber of responses used in tabulatiuns for the year specified. 3/2/77 SAN MATEO COUNTY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE "THE NON-USERS" LEVELS OF "NO USE" AND "NO SIGNIFICANT USF.!'••• OF ANY OR ALL OF THE FOLLOWING Sl1BSTANCES: ALCOIIOL, AMPHETAMINES, LSD, NAR1Jl1ANA, AND TOBACCO REPORTED BY JUNIOR AND SENIOR HIGH SCHOOL STUDENTS, 1968-1977 BY SCHOOL GRADE AND SEx OF RESPUNDfNT, SPECIFIC RAT€S PER HIINDRED RESPONSES. MALES YEAR OF ---9tl-8th-`- 9th 10th llt 12th SURVEY Grade Grade Grade Grade Grade Grade FEMALES - - 7t gt 9t 10t 1/t 12t Crsde Crade Grade Grade Grade Grade Reporting that they had experienced no use I of an of the s ecified substances durin the ear recedin the surve : 1968 NA NA 24.4 24.1 19.7 15.7 NA NA 33.4 26.4 22.1 20.2 1969 36.6 29.1 26.4 19.1 15.4 12.4 47.8 36.2 30:4 24:6 20.9 17.9 1970 39.9 27.8 25.6 18.0 15.3 14.4 47:9 35:6 28.7 19.1 18.1 16.1 1971 35.1 24.7 19.0 17.8 12.8 12.3 46.7 30.2 23.6 19.2 16~.6 15.7 1972 32.8 21.7 18.2 14.1 11.5 --9:4 42.3 25.7 20.1 15.9 15.2 12.4 1973 21.0 16.5 13.3 11,2 10.9 10.7 27.3 16.0 15.4 12.7 1I.3 10.3 1974 21.2 13.7 12.1 12.7 -9:8 8.5 24.1 16.7 13.6 12.5 10.2 9.3 1975 23.4 17.0 13.1 10.5 10~.0 8.6 29.5 16.8 14.7 11.2 10.1 9.7 1976 25.5 18.1 14.6 11.1 8.4 ID.7 32.4 19.5 15.7 12.0 9.2 8.8 1977 24.0 16.2 12.3 10.3 8.5 7.4 30.2 20.9 14.3 1t.1 8.3 7.3 Reporting that theZ had eaperienced no "slgnificant usd'••• Df eny of tha sDectTied substances Jur ng t e year preceding the survey: 1969 NA NA 56.9 48.5 40.5 32.8 1970 80.9 65.1 57.5 46.4 39.2 36.7 1971 74.2 58.6 50.5 43.3 34.2 30.7 1972 71.4 55.3 48.6 39.6 34.4 27.2 1973 68.0 52.6 42.1 36.3 32.4 29.8 1974 68.7 50.7 45.3 35.1 11.3 27.3 1975 71.7 57.0 46.0 37.8 31.8 26.2 1976 74.7 59.4 51.6 41.3 31.4 29.8 1977 73.5 59.7 49.1 39.4 30.3 25.1 NA NA 603 56.9 49.2 45.5 84.8 71.2 61..0 49.4 43.4 44.2 80.5 64.6 52.4 45:9 43:1 42:3 77.2 59.7 51.6 42.6 38.9 36.5 73.6 55.6 46.7 42.3 37.7 35.5 71.2 56.1 44.4 39.9 36.4 31.7 75.9 60.0 46.6 40.1 35.9 32.5 79.1 59.5 49.0 38.0 34.8 34.6 79.4 63.3 49.3 40.3 33.4 30.S Standardzed Rate• Total Total•• Lrades 9-12 Res ouses 23.2 20.9 19.4 17.1 14.6 12.1 11.1 11.11 11.3 9.9 1g,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 48.8 47:2 42:9 39.9 37.8 36.4 37.1 38.8 37.2 +Stan ar rse rates o use or senror tg sc ools are compute using eque popu at;ons - r t e etg t class/sex groups. 7Tis elininates distortion because proportions of-classes or sexes hevechanged betweenyears. •aTotal number of respunses used in tabulations for thee year specified. •••Significant use: Alcohol - ten o more occasions; Tobacco - ten or more otcasions; Marijuana - ten or more occasions; LSD - three or more occasions; Anryhetumines - three or nore occasibns: -- 3/2/77 25,893 35,148 35,701 31,251 27,388 28,232 28,303 20,8 49 22,077 968E09f;0

Sai MATEO COUNTY, CAL(FORN[A, SURVEYS OF STUDENT DRUG USE Cl1MULATIVE LEVELS OF USE REPORTBU gY JUNIOR ANU SENIOR 111t:1/ SCIIOOL STUDENTS, 1968-1977 BY SCIIWL GRADE AND SEX OF RESPONUENT, SPECIFIC RATES PER NUNDREU RESPONSES. MALES FEMALES - YEAR OF 711 eth 9th 1Uth 11th 12th 7th 8th 9th 10th 11th 12t SURVEY Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Reporting any u of alcoholic beverages during preceding year. 1968 NA NA 61.0 64.5 70.7 76.5 NA NA 52.0 60.1 67.4 71.1 1969 52.3 60.2 66.3 75.2 78.9 82.0 38.4 S0.6 63.2 67.4 71.8 75.7 1970 49.0 61.4 66.1 76.8 79.2 80.6 42.0 53.8 62.6 73.3 76.0 77.0 1971 55.1 68.0 74.0 76.5 82.4 83.3 43.0 63.6 68.3 74.1 77.6 79.0 1972 58.5 70.5 75.8 81.7 84.5 87.5 48.6 67.2 73.7 79.5 eU.9 83.2 1973 72.8 79.6 82.4 85.6 86.6 86.4 67.2 78.3 80.3 84.5 84.0 86.8 1974 73.0 81.6 84.4 84.9 87.8 89.5 70.7 77.4 82.2 84.8 87.1 88.3 1975 70.0 79.2 82.7 87.0 87.9 89.3 63.7 77.3 82.2 86.2 87.7 87.6 1976 67.9 76.8 81.9 85.9 89.9 87.1 60.4 74.9 80.3 84,6 88.3 88.4 1977 71.8 78.7 84.4 86.9_ 90.2 91.4 63.5 73.0 82.5 87.3 89_.5 91.S Reporting use of alcoholic beverages on ten or more occasions during preceding year. 1968 NA NA 21.4 24.7 35.6 41.6 NA NA 13.4 15.1 24.0 27.0 1969 10.9 18.3 26.8 36.8 43.6 52.8 8.2 16.2 21.0 25.0 30.5 34.3 1970 11.7 22.6 26.5 38.8 45.8 49.8 6.7 15.0 20.9 31.2 35.0 36,7 1971 16.4 30.6 36.2 45.0 54.7 Stl.9 10.7 22.6 30.8 39.1 41.2 42.5 1972 19.8 33.4 39.1 50.0 56.5 66.0 14.0 27.7 35.4 44.0 49.4 52.4 1973 25.3 39.2 47.6 54.5 60.2 63.0 18.3 32.9 40.4 46.8 50.4 58.1 1974 24.9 39.5 45.9 56.1 61.7 67.4 19.7 32.0 42.2 50.0 54.7 59.0 1975 21.0 33.2 44.5 54.7 62,4 68.8 14.8 2B.S 411.8 49.0 54.5 59.5 1976 18.2 30.2 39.0 49.8 61.0 64.1 12.8 26.3 36.6 49.3 56.0 56.4 1977 19.1 30.4 41.1 53.8 63.4 68.9 13.3 25.2 38.0 50.9 58.8 62.7 Reporting use of alcohoilc beverages on fifty or more occasions during preceding year. 1968 NA NA NA NA NA NA 1969 NA NA NA NA NA NA 1970 NA NA 11.3 17.9 23.4 27.0 1971 NA NA 17.6 24.4 32.3 36.6 1972 NA NA 17.6 28.3 32.5 39.7 1973 10.5 18.7 23.4 31.2 37.D 39.9 1974 10.4 16.6 23.3 29.4 35.5 44.8 1975 8.0 15.2 20. 8 27.2 35.6 41.e 1976 6.7 13.1 17.7 25.2 33.3 37.6 1977 7.9 13.1 20.3 25.7 34.5 39.5 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 6.6 12.3 12.9 13.5 NA NA 12.8 17.6 19.2 18.5 NA NA 14.4 19.3 23.7 25.0 8.0 14.7 17.8 21.2 25.0 28.8 B.1 13.4 211.2 22.9 27.2 30.6 5.2 13.u 17.1 [1.0 26.6 30.0 4.8 10.6 14.5 23.6 76.6 26.2 4.7 10.7 15.3 23.8 29.8 32.1 ALCOHOLIC BEVERAGES Standardized Rate• total Grades 9-12 65.4 72.6 74.0 76.9 80.8 84.6 86.1 86.3 85.8 88.0 Tatal•' Responses 18774 25,,883 35,148 35,701 31,251 27,388 28,232 28;303 20;H4B 22,077 25.4 33.8 35.6 43.6 49.1 52.6 54.5 54.3 51.6 54.7 NA NA 15.6 22:4 25.1 28.0 29.2 21.5 25.6 27.6 18,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 18,774 25,883 35,148 35,701 31,251 27,388 28.232 28,303 20,848 22,077 •Standardited rates of u for senior igi schools are compute ustng equal populations or eac o T e etg [ - class/sex groups. lhiseliminates distoi-tion because pruportions u€ classesor sezes have changed between years. ••Totel number of cesponses used in tabulations for the year specified. -. 3/2/77 SAN MATEO CUUATY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE la1MULATIVI: LEVELS OF USE REPORTED BY JUNIOR ANU SENIOR 111G11 SCIIOUL ST1118ENTS, 1968-1977 BY Sf]IOOL GRADE ANU SEA OF RBSI'ONUFNT, SPECIFIC RA7tiS PER IIUNUREU RESPONSES. MAL€S YEAR OF 7th 8tl 9tl 1ot 11t 12t SURVEY Grade Grade f.rade Crado Grade Grade Reporting any use of amphetemines during preceding year. - - ~ - PEMALES - 7t _gt. Grade Grade Grade Grade Grade Grade ~ AMPHETAMINES 91andardized Rate•Total Grades 9-12 Total•• Responses 18,774 1968 NA NA 12,0 IS 8 17.9 20.5 I NA NA 12.9 16.1 17.1 16.1 I 16.0 25,883 1969 5.1 11.8 15.0 19.1 22.1 25.6 5.9 10.4 19.5 20.1 21.5 19.9 20.4 35,148 1970 3.7 9.5 13.8 18.5 20.7 18.8 2.8 8.2 17.4 24.4 22.3 20.2 19.5 1,. 7 S 0 11 1 ? S 76 8 75,6 72.9 23.3 35,701

308 - 4 - In 1~976, this Subcommittee held a number of hearings on the subject of cigarette smoking and disease which resulted in an excellent accumulation of up-to-date scientific materiall and data. During those hearings, the Subcommittee received testimony from two Nobel Laureates -- Dr. Renato Dulbecco and Dr. Howard Temin -- reinforcing the 1975 Department of Health, Education and Welfore Report on the Health Consequences of Smoking. The concliusions of this Report and those of Drs. Dulbecco and Temin are extremely important an&are vital to this hearing. For this reason, I have appended parts of the HEW Report dealing with the causationlof disease and the 1976 statements presented by the Nobel Laureates to my remarks. More recently,, the National' Commission on Smoking and Public Policy made a major contribution in the area of smoking and health. Created by the American Cancer Society, the Commission undertook a review of existing scientific material on smoking and investigated the effectiveness of current anti-smoking activities. The Commission's report, published:in January 1978', incliudes a number of statistics which clearly delineate the dimensions of the problem facing, us. The report states that: o Cigarette production and consumption in the United States are at an all-time high. In June 1977, 48 million adults and 6 million children and teenagers were buying 626 billiion cigarettes annually. This is an average of 111,592 cigarettes, or 579 packs, per year for each smoker o More cigarettes are being consumed by those who smoke, and teenagers, especially young women, consti- tute a relatively higher percentage of smokers than ever before o The cost of relate&illn Clearinghous Medical Asso $11.4 billio billion. Ev to constitut $122 billion o The loss of related illn (as calculat the average U~S. Bureau The Commissi of recommendation to educate young existing cigarett tax based on tar packages be alter S. 3118 responds As many memY distinguished ChE and again in 197" rate tax on cigai on tar and nicot: incorporated intc less hazardous c: nicotine content• the measure estal over a four-year would actually r, cigarettes by 8t most toxic °'high

326 Senator KExxFnr. The subcommittee stands in recess. [The subcommittee recessed' at 1:10 p.m.] DISEASE _ Svsec The subcc riuin, Depa~ ence Avenu (chairman ~ Present : Senator I Committc member, R, member. The Subc day its he~ Health Pro On May tained in ti sions of tl emphasis o project gra This is a delivery ini making esc of disease extraordin We will who demoi the risk of Finland, a percent in men who e, heart atta( shown tha from 7 to Is is bec( cans live 1 help us li-, plab e so

,u t./ S.v 1972 NA NA 1.3 2.3 2.2 1975 0.6 0.9 2.2 2.2 2.9 1974 0.8 0.9 1.8 2.1 1.7 1975 U.2 1.0 1.4 1.8 1.7 1976 0.6 1.1 0.9 1.0 1.9 1977 0.3 0.8 0.8 1.1 1.7 3.4 2,e 2,6 1.8 1.9 2.3 NA NA 1.U 1.4 1.4 1.0 NA NA 1.0 1.4 1.3 1.2 0.4 0.4 1 .4 0.5 1.l 1.0 0.2 0.6 1.1 1.0 1.2 1.1 0.5 0.4 0.9 1.0 11.1 1.3 0.2 1.1 0.2 0.9 1.2 1.5 0,2 0.7 0.7 0.9 0.7 1.1 2.1 1.7 1.7 1.5 1.4 L: 2 1.2 35,701 31,251 27,388 28,232 28,303 20,848 22,077 •Standerdized rutes of use for seniu -g. sc.ools are coupute ustng equal populattqns eac o the etght-- ~-- class/sex groups. This eiiminates--distortion bncause proportiuns of clssses or sexes haverehanged between years. ••TOtal number of responsesused in tabulatians Far the yeer specified, 3/ 2/ 77 SAN MATEO COUNTY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE CUMULATIVE LEVELS OF USE REPORTED BY JUNIOR AND SENIOR I/1G11 SCIIOOL_ STUDENTS, 1968-1977 BY SCUIIOL GRADE ANU SEX OF RESPONDENT, SPECIFIC RATES FER NUNDRED RESPONSES. MALES YEAR OF 7th Bt 9th I [ 1 t SURVEY Grade Grade Grade frade Grade Grade Reporting any use of marijuana during preceding year. FENALE 7t 8t 9t 10z 1lt 12t Grade Grade Gtade Grade Grade Grade 1968 NA NA 26.8 32.3 36.9 44.6 NA NA 22.9 28.1 31.7 31.9 1969 10.9 23.9 34.9 41.7 45.5 50.1 10.7 21.8 31.9 35.5 38.3 38.1 1970 9.8 22.8 34,0 44.9 48.9 50.9 -7.2 16.7 31.9 42.1 42.6 44.4 1971 17.6 29.1 44.5 49.7 57,9 58.6 12.6 26.4 40.5 48.1 50.2 48.3 1972 17.1 33.2 43.9 51.8 59.5 60.7 13.2 29.3 39,0 49.2 S0.8 52.9 1973 20.0 34.3 51.2 56.1 58.5 61.0 15,0 31.5 47,0 51.9 55.3 57.3 1974 22,7 37.7 48.6 57.3 59.4 61,9 18.0 33.3 47.8 $4.6 56.7 58.2 1975 21.1 37.1 49.2 56.5 61.5 63.6 16.8 29.9 44.4 51.9 57.3 55.5 1976 21.7 36.5 47.8 57.5 61.8 61.1 15.6 32.4 46.1 54.4 57.9 56.0 1977 22.8 39.2 48.1 59;3 65.2 64.S 15.3 30.9 43,3 55_.3 62.8 61.4 Reporting u e of marijua on ten or mo ccesions during rreceding yeaa 1968 NA NA 14.3 18.1 22.5 25.6 NA NA 10.6 14.9 16.7 17.4 1969 4.1 11.6 20.2 25.6 30.2 34.0 1.7 7.4 18.1 21.2 23.2 22.4 1970 2,7 10,2 19.6 28.8 34.1 34.2 1.4 6,9 16.2 26.3 26.2 28.2 1971 S.3 14.6 26.2 33.3 42.3 43.3 4.1 12.3 23.3 31.0 32.9 30.5 1972 5.8 17.2 26.8 36.8 41.3 44.9 4.6 14.1 23.0 32.2 35.7 35.J 1973 6.7 16.3 31.9 39.6 43.4 45.4 5.2 14.8 27.0 32.9 36.6 37.8 1974 8,4 20.1 29.9 39.1 42.9 47.0 5.6 14.5 29.3 35.6 38.9 38.8 1975 6.9 17.9 29.5 36.9 43.8 45.4 5.0 13.3 25.2 33.6 38.6 37,2 1976 7.2 17.7 27.0 36.7 43.1 41.0 4.5 14.8 24.5 34.6 39.8 36.0 I977 7.8 18.2 27.0 38:0 46.7 47.7 4.2 12,7 21.8 33.4 41,9_ 40.3 Reporting use of narijuana on fifty or more occasions during preceding year. 1968 NA NA NA NA NA NA 1969 NA NA NA NA NA NA 1970 NA NA 11.4 19.2 23.5 22,0 1971 NA NA 17.2 23.2 30.3 31.9 1972 NA NA 15.9 25.5 27.8 31.6 1973 3.3 9.8 20.3 27.9 31.3 32.4 1974 4.0 11.4 19.6 26.3 31.4 34.2 1975 3.3 9.6 19.9 24.0 29:6 30.7 1976 3.9 9.8 17.0 24.3 29.8 30,0 1977 4.0 11.1 16.3 24.6 31.2 34.3 NA NA NA NA NA NA NA NA NA NA NA NA NA NA 7.2 14.0 14.4 15.3 NA NA 11.6 17.0 19.4 18.5 NA NA 12.4 19.1 21.1 20.2 2.3 7.5 14.2 18.8 21.5 20.4 2.3 7.8 17.4 22.0 22.4 22.8 2.4 7.0 13.7 18:9 23.0 20.9 2.2 7.6 13.5 19.2 24.6 21.3 2.0 6.8 11.6 19.4 24.6 24.2 MARIJUANA tan ar tzed Rate' TotalTotal•• Grades 9-12 Res onses 31.9 39.5 42.5 49.7 51.0 54.8 55,5 55.0 55.3 57.5 18,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 17.5 24,4 26.7 32.8 34.5 36.8 37,7 36.3 35.4 37.1 NA NA 15.9 21.1 21.7 23.4 24.5 22,6 22.5 23.3 18,774 ~ 25,883 ~ 35,148 1--• 35,701 31,251 27,38g 28,232 28,303 20,848 22,077 18,774 25,883 35,148 35,701 31,251 27 , 388 28,232 28,303 20,848 22,077 •Standiurd'rzed rates o useniur ig uls are compute us ng equal pupulattons or eac o- t e n g t ---- class/ser groups. 3Lis elininatns distortion because proportions of tlasses or se:es have changed Aetween-years. •• Total number of responses used in tabulations for the year specified. - -~ 3/2/77

310 12C per pack. By the fourth year, the tax will be completely phased in and the tax will then range from 8fi less per pack to 42G more. This proposal has the support of a large number of national health organi~zations including!the National Cancer Aduisory. Board, the American Cancer Society, the American Lung Association and the American Heart Association. Such an innovative change iin tax structure, when coupled with the other initiatives outlined in the bill, will significantly reduce the current health hazard posed by cigarettes. I want to commend the Chairman for including in his proposal a major and innovative program focusing,on the prevention of smoking among,children -- an effort aimed at educating children regarding the hazards of smoking, thereby attempting to stem the alarming increase in smoking among, individuals under 21 years of age. Such education is vitally important in light of the fact that people who start smoking at age 15 are 5 times more likely to die of lung cancer than those who start at age 25. Certainly, of all the influences affecting a child's decision to smoke, the example of his parents is most important. But even if parents try to dissuade their children, there are many other influences that remain beyond their control -- romantic creations of advertisements, pressures from friends, andi so forth. This enormous task then is not one to be borne by the family alone. Efforts to educate and alert children to the dangers of cigarette smoking shouli&be shared by the family, the schools, as would facilitate school and commu As importan Subcommittee rev. Warning statemen distributed ciga to educate the F cigarette smokir Trade Commissiorr made more explic to consider altf relate&disease: S. 3118, that o- practice curren based on the ra to the warning In sum, I a major step to D am not, nor i this Committee, those individua have been mande American people of HEW,, as weL: respected;sciei engage the talc:

oseEosco nepurttng u ut alcohulic Levarages on fiFty or mu occastuis during pre d'Jg yearJV SJ,/ 22,U17 1968 NA NA NA NA NA NA NA NA NA NA NA NA NA 18,774 1969 NA NA NA NA NA NA NA NA NA NA NA NA NA 25 883 1970 NA NA 11.3 17,9 23.4 27.0 NA NA 6.6 12,3 12.9 13,5 15.6 , 35,148 1971 NA NA 17.6 24.4 32.3 36.6 NA NA 12.8 17.6 19.2 18,5 22.4 35,701 1972 NA NA 17.6 28.3 32.5 39.7 NA NA 14.4 19.3 23,7 25.0 25.1 31 251 1973 10.5 18.7 23.4 31.2 37.0 39.9 8.0 14.7 17.8 21.2 25.0 28.8 28.0 , 27 388 1974 10.4 16.6 23.3 29.4 35.5 44.8 8.1 13.4 211.2 22.9 27.2 30.6 29.2 , 28 232 1975 8.0 15.2 2D.8 27.2 35.6 41.8 5.2 13.u 17.1 21.0 26.6 30.0 27.5 . 28 303 1976 6.7 13.1 17.7 25.2 33.3 37.6 4.8 10.6 14.5 23.6 26.6 26.2 25.6 20;848 1977 7.9 13.1 20.3 25.7 34.5 39.5 4.7 10.7 15.3 23.8 29.8 32.1 27.6 22,077 -- ' •Stamlardize& rates of use on tor igh--schvsls are cumpute ustng equal popu-]xtions or eac o- t e eight class/sex groups. This eliminates distortion because proportions ofclasses or sexes have Jianged between years. ~•Total numberuf responses used in tabulations for the year specified. 3/2/77 SAN MATEO COUATY, CALIFORNIA. SURVEYS OF STUDENT DRUC USE CUMULATIVE LEVELS OF U5E REPORTED BY JUNIOR ANU SENIOR HIGII SCHOOL STIIIIENTS, 1968-1977 BY S/'JIAOL GNAUI: ANU SEX OF RESPONDENT, SPECIFIC RA'1'ES PER I{UNUREU Itf.$pON5E5. AMPHETAMINES - -- -"- MAI.ES ---- - TEMALLS - tandar ited YEAR OF 7th 80, 9t 10th llt'h-- --12t 7th Rt 9th 10t Ilt l2 Rate• Total Total•• SUIiVEY Grade Gra,le Grade Grade Grade Grade Grade Grade Grade Grade Grade Grade Grades 9-12 Responses Re ortin use of mn hetam ines du rin recedin 1966 NA NA 12.0 15.8 17.9 20.5 NA NA 12.9 16.1 17.1 16.1 16.0 18,774 1969 5.1 11.8 15.0 19.1 22.1 25.6 5.9 10.4 19.5 20.1 21.5 19.9 20.4 25,883 1970 3.7 9.5 13.8 18,5 20.7 18.8 2.8 8.2 17.4 24.4 22.3 20.2 19.5 35,148 1971 5.3 10.9 18.0 19.5 24.6 26.7 5.9 13.1 22.5 26.8 25.6 22.8 23.3 35,701 1972 5.2 12.0 16.9 22.8 21.8 2S.8 6.1 14.6 21.7 27.4 28.1 24.4 23.6 31,251 1973 3.6 7.5 14.6 20.3 21.5 21.1 2.7 7.8 16.6 21.4 23.0 20.8 19.9 27,388 1974 3.4 7.5 11.1 17.7 20.7 22.2 3.4 7.4 15.3 20.1 22:8 23.8 19.2 28,232 1975 2.7 5.5 11.0 14.1 19.3 21.2 2.8 6.6 12.6 18.8 22.9 22.3 17.8 28,303 1976 2.6 5.0 8.8 13.6 16.3 18.4 2.0 5.5 9,8 15.4 21.7 18.6 15.3 20,848 1977 2.7 4.6 7.1 12.3 ]8.5 20.6 2.2 5.3 7.2 14.0 20.5 20.9 15.1 22,077 Re ortin use of am h etamines on ten or more o asions d urin recedin year. 1968 NA NA 4.0 S.8 7.0 9.5 NA NA 3.7 6.1 6.4 6.7 6.0 18,774 1y69 1.7 3.4 5.1 7,2 9.5 11.4 1.1 1.5 6.4 8.2 8.0 8.3 8.0 25,883 1970 0.6 2.8 4.2 5:8 8.2 7.8 0.4 2.1 5.4 9.3 8.3 7.8 7.1 35,148 1971 1.3 3.5 6.3 7.0 10.6 10,7 1.3 3.0 7.6 11.0 11.2 10.4 9.4 35,701 1972 1.4 3.4 5.3 8.5 9.2 10.9 1.4 4.7 8.5 11.1 12.S 11.4 9.7 31,251 1973 1.1 2,4 5.3 7.1 7.8 7.8 0.6 1.9 5.6 8.5 9.7 9.9 7.7 2I,388 1974 0.7 2.0 3.6 ti.l 7.4 8.0 0.9 1.7 5.2 7.4 10.6 10.2 7.3 28,232 1975 0.6 1:3 3.8 4.8 7.5 8.7 0.7 1.7 4.0 6,8 9.1 10.4 6.9 3 28303 1976 00.7 1:2 2.5 4.0 6.1 6.8 U.2 1.7 2.8 6.4 9.4 9.0 5.8 20,S4R 1977 0.6 1.5 1.3 3.3 6.1 7.8 0.4 1.4 1.7 5:1 9,3 8.1 5.3 22,077 Neponin use uf amph etamines on-fift more occasions during precedi ng }'ea r. 1968 NA NA NA NA NA NA NA NA NA NA NA NA NA 18,774 1969 NA NA NA NA NA NA NA NA NA NA NA NA NA 25,883 ] 970 NA NA 1.9 2.6 3.9 3.4 NA NA 1.6 3,8 2,9 2.7 2.8 35,148 1971 NA NA 2.9 3.0 4.8 5.6 NA NA 2.5 4.0 4.6 4.3 4.0 35,701 1972 NA NA 2.3 3.6 3.6 5.4 NA NA 3.1 4.5 5.3 4.9 4.1 31,251 1973 0.8 1.2 2.7 3.1 3.6 4.4 0 .4 0.6 2.3 3.5 4.4 4.1 3.5 27,388 1 974 0.5 l-,l 1.8 2.4 2.6 3.5 0.4 0.7 2.0 3.0 4.3 5.0 3.1 28,232 1975 U.4 0.9 1.7 2.1 3.1 3.8 0.5 0.6 1.9 t:5 3.7 4.4 2.9 28,303 1976 0.5 1.0 1.2 1.9 2.5 3.3 0.2 1.0 0.9 2.1 3.2 3.9 2.4 20,848 1977 -' 0.3 0.8_ 0.8 1.5 2.6 2.7 0.2 0.8 0.7 2,1 3.4 3.3 2.1 22,077 - Standardized rates of use for senior igh-schools are computed using equal popui-atiuus or ea o tie eig,t class/sex groups. This eliminates-distortion because proportions ofclasses-or sexes have changed betqeen years. `•Total number of responses used in tabulations for the year specified. - 3/2/77 I

- 2' - 306 Although an outright ban on the sale of cigarettes is not acceptable, it is interesting to note that the FDA recently removed the antidiabetic Phenforami'n from the marketplace because of its unacceptably high risk lievel -- the risk of death from cigarettes i~s five times greater. In 1977, it is estimated that well over a quarter million Americans died of smoking-related diseases -- more than five times our annual, toll for fatal car accidents. Over the past 50 years, improvements in public healith and technological advances have contributed significantly to life expectancy of Americans and for the most part have confined death to old age. Two of the most prevalent conditions which arise in o1d age and which often prove fatal:are arterial disease and cancer. Arterial disease now accounts for about 50% of alli deaths in the United States; cancers are responsible for almost 20%. In examining public reaction to these two diseases, it is apparent that many individuals have developed very distinct attitudes towards each. Heart attacks and strokes tend to be thought of as natural hazards of age. They are considered to be a normal end to a long~life, or, when they occur in younger individuals, the wages of overeating and lack of exercise. Cancer, on the other hand, is most often viewed as an unpredictable disease that strikes indiscriminately among alil people. Both of these perceptions are significantly in error: arterial disease is not necessarily a natural hazard of olid;age, and can uncontrollable caus estimate that 70% t environmental facto Hundreds of bi chemicals are now p Many of these chemi are finding others carcinogenic agent: and unavoidable -- workplaces. The ic are dangerous and placing us in the between endangerin our population or while a large numb market without ful carcinogenic agent existence for many exposure. But this is r. Although cigarette research has been healith eonsequencc and they are seri( preliminary data lung cancer. Ove report clearly li 0 ~ d ~ ~ ~

.ty years, since the. ', many more still ucation, suitable ossibly compensation r people will still smoke, of less harmful 3 determination of on the basis_of the- ' :ure of the cancer owever, reduction :e that the mutation- ' -inducing activity t if backed by the the cancer hazard liing like 30 mg as iy the hazard value rds of the smoke, which derive from a evaluated. i on the market for r have suffered than non smokers, inducing activity -d in order to t harmful cigarette, 325 -6- for instance by imposing a new heavy tax on cigarettes, proportional to the hazard 'value, The usefulness of this approach is indicated by several studies showing that increasing the cost of cigarettes decreases for a while their consumption. In order to sustain this reduction the tax should be increased gradually by a certain amount every year. Moreover once cigarettes of low hazard values have been successfully marketed, those of higher hazard may be banned altogether. The new tax would yield new revenue, very large at first, but subsequently declining, which could be used to support the proposed program and the necessary research, and if- necessary, to subsidise the necessary changes in agriculture and industry. The program I have outlined would require the formation of a special agency to implement it, to determine standards and to monitor its effects on the basis of the results of epidemiological studies. .

315 ievelopment' of cancer ln tbe major cause of lung udfea. The risk of devei ~ cigarette smokers than ,reases with the number tte smokers who report ive smoked for a greater : shown to have a lower -, cigarettes, but' the rlsk , oial cavlty„esophagus, ;ber in cigarette smokers d to have elevated risks r, larynx, and esophagus report that they lnhale their lungs receive much to be the reason for the ir smokers compared to an men. This has been .s per day, the fact that smokers generally select ie.percentage of women In the last 90 years. snd ve increased proportlon- ; tncreased proportion of -e malignant changesInind a number of specltic e established as potent :ding carcinoma in sitr ytology of ezperlmentaloking-Induced morbidity .ve more frequent minor respiratory illness, and x frequently than non- i )ng-term followup have 'ehronic bronchitis and : e also been found to be 'unction tests and have kers. Data from autopsy I kely tobave the macro- :e closely related to the !rplasia haa been found iibits the clllary mottlon.. Statement for Hearing on the subject of "Ciigarette Smoking and' Diisease"', February 19, 1976, of the Subcommittee on Health of the U. S. Senate Committee on Labor and Publi:c Welfare. Howard. M. Temin Ameriican Cancer Society Professor of Viral Oncology and'Dell Biology McArdle Laboratory for Cancer Research The Medical School University of Wisconsiin - tladison Thank you, for givi:nq me the oppo.rtunityto speak with you on this topic. My,point of view is that of a cancer researcher who has been working for the last 20 years with RHA viruses that cause cancer in chickens. Since the early years of this century, it has been known that viruses cause cancer in chickens. In more recent years viruses have been, shown to cause cancer not only in chickens, but also in mice„ cats, and even in some primates. Therefore, iit was a reasonable hypothesis that viruses might cause cancer in humans an&that,,if a human cancer virus existed, it could be prevented by a vaccine as so many other virus diseases have been:prevented. Experiments performed in recent years have ledi to an understanding of much of the genetic basis of how viruses cause cancer in animals, namely, by adding their qenetiic information to the DNA, that iis, the genetic material, of the cel'll. WiYhithis understanding and the tools of molecular biology,, it has been possible to look for viruses potentially

322 -3- induce increases markedly as the period of exposure to a chemical' gets longer., Cigarette smoke acts in exactly the same way. It contains mutation-inducing chemicals, and can be shown to cause cancer in experimental animals; in man the lag between beginning of smoking and the appearance of cancer can be thirty, forty years. The action of smoking is cumulative: doubling the number of years one smokes increases about sixteen fold the risk of lung cancer. The evidence unambiguously shows that lung cancer is a prime example of a preventable cancer, caused by a clear!y identified and unessential agent, cigarette smoke. Why is it then that US governments have done so little to discourage smoking although they have very actively fought other dangerous drugs? Is it because key people in government have doubts about the evidence on the hazards of cigarettes? Certainly interested parties make every possible effort to create such doubts. But surely the government has means for getting to the truth, thus eliminating the artificially created doubts. Or is it because tobacco brings in revenue? But it is a gruesome revenue, based on the disease, death and great suffering of many people, and; anyway, probably outweighed by the costs of lost productivity and medical care. Or is it because powerful interests have their way, irrespective of the consequences? No matter what the cause is, it' is a great failing of our society that so little has been done to control tobacco smoking. Considex hing cancer, onf cumulative effec lag between beg~, cancer gives a f a second consec; those who give i that of non-srno consequenceis a dramatic effe, instance, those than those begir down the numbe at all, the most In, Tny v. dangers of toba concepts;- 1) The r not to- begin to directed at bre: value to cigare a complete ban promotion, oth by the clever p the eyes of the

309 -5- r of hearings on which resulted cientific material mittee received iato Dulbecco Department of 3ealth Consequences 3nd those of Drs. ld are vital to led parts of the :ase and the ites to my )n Smoking and ie area of Cancer Society, i scientific !ctiveness of ;ion's report, of statistics probliem facing the United 1977, 48 d teenagers lly. This 79 packs, ose who omen, consti- mokers than o The cost of medical and hospital bills due to cigarette related illness in 1975 was estimated by the National Clearinghouse on Smoking and Healith andithe American Medical Association to be between $11.1 billion and $11.4 billion. Other estimates are as high as $14 billion. Even the low estimate, however, came close to constituting 10% of the total U.S. health billi of $122 billion that year. The 1977 estimate is $15 billion o The loss of income from lost workdays due to cigarette- related illness amounts to about $3 billion each year (as calculated by multiplying,weeks of work lost times the average weekly wage of $190.90 reported by the U.S. Bureau of Labor Statistics for July 1977) The Commission concluded its report by making,a number of recommendations incliuding, that concerted efforts be made to educate young children on the dangers of smoking; the existing cigarette tax structure be changed to a graduated tax based on tar and nicotine; and warning label's on cigarette packages be altered to list specific smoking-reLated diseases. S. 3118 responds to a1~1 of these recommendations. As many members of this Subcommittee are aware, the distinguished Chairman and I introduced legislation in 1976 and again in 1977, proposing that the existing,Federal flat rate tax on cigarettes be replaced by a graduated tax based on tar and nicotine content. This proposal, which has been incorporated into S. 3118, will encourage smokers to purchase less hazardous cigarettes -- cigarettes with a low tar and nicotine content. Without going into detail, the measure establishes a five-bracket tax to be phased in over a four-year period. In the first year, our proposal woul&aetually reduce the price of low tar and nicotine cigarettes by 8t per pack while increasing the price of the most toxic "high" tar and nicotine cigarettes by as much as

324 Americans who have done so in the last twenty years, since the dAngers of smoking became known. However, many more still smoke. Further progress requires more education, suitable facilities, . such as specialised clinics, and possibly compensation for lost income during the treatment. 3~ Since, in spite of all efforts, many people will still smoke, it will be imperative to promote the adoption of less harmful eigaretfes; 'This requires in the first place a determination of the hazard value of a given type of cigarette, on the basis.of the' properties of the smoke. A recognised measure of the cancer hazard is the amount of tar in the smoke. However, reduction of tar must be accotnpanied by direct evidence- that the mutation- inducing activity of the smoke andits cancer-inducing activity in animals are also reduced. The tar content if backed by the biological tests, could be used to determine the cancer hazard value of each type of cigarette, taking something like 30 mg as 100°Je. It may be useful to prominently display the hazard value on cigarette.packets. Of course, other hazards of the smoke, such as chronic• bronchitis or heart disease, which derive from other constituents of the smoke, must be also evaluated. Cigarettes with reduced tar have been on the market for almost 20 years. Smokers who adopted them have suffered fewer lung cancers but stillfour times more than non smokers. Therefore a further reduction of the cancer-inducing activity of cigarettes must be attained. Considerable pressure must be exerted in order to • promote the development and: sale of the least harmful cigarette, for instance by impo to the hazard value. by several studies s decreases for a whi' reduction the tax sh every year. Moreo been successfully rrr altogether. The ne• first, but subsequer the proposed progr; necessary, to subsi industry. The prograr of a special agency and to monitor its ~ epidemiological sh

305 ~ "irnlrlitir,Itnna rrf I)i '...lrilnui;,rr„ lt,ir. l: Ill tllr 7'rr•nt7nr•nt r.f :\r•nte Iti'rin, srtrii,r :rntlhr~r). ;rnlatirrll .r \irn-t'r n~'r r° nt onf: rrn LnNrr .lr•qtrixiiihtt ntrrl 1!II lh-r:,aunln l'rosw• lrl,; rf: ntt 1)n!rt Ar•ryuixifintl nord 1111i_'Por•rntunu 1't•r•ss, I'p. ulg, arrlr. liur'irnru 11rrtIth, p,. t'nnllx'titr, ltisk. and i- 1!lhi;. Ccc,r t tnrn t I'l:r nn in„ l: ri t. .1. tirrn. An•r•h. krrrirnn! Ilrn7thi tprim; IWlrnrt. 1!1r;1. tod It:tt-;. 1 :S: Arniv Jfediral' 'rt #ri0.): 1d1(;l). (G. 1~l'riakrs. tieii•nt• :1 trrrv. .1. l'ub; llr nlllr, 'l)nthevisP, 1'.•Iccljn!, Rnpnrta, iii.,n Cnurlitions in ('ltiltilYnrnl,. antlinrl,i r.71' Ihilrrr•n-¢. 1)r•!%t•pfrrilrli l..lxsrnr... i~':41 .:I. a :111::rI-I :r3a, 1ll:r.l. ( L.,itt•ru_ ('hiirlrnn t; 111, I:rr•,rr r. seni6r :rrn fruri) .. i;•r• tinll'nlr utcrn, l nrrrli:rk .~rnl t•urr~, .1: 1:.: !r. I'~Ilrlr'ir!_, •trnrt ~i.. 1957. •i, 1':ultl I. 1:1~ 1'rrj. `,lic•ili;:an "j. MiuLi„in '/,!ti :1: :'rri~rr~it~ STATEMENT BY SENATOR GARY HART BEFORE THE SENATE HUMAN RESOURCES SUBCOMMITTEE:ON HEALTH AND SCIENCE ON S. 3118, THE SMOKING DETERENCE ACT OF 1978' Mr. Chairman and members of the Subcommittee, I want to begin by expressing my appreciation for the opportunity to offer testimony at the initiali hearing,on the National Disease Prevention and Health Promotion Act of 1978. While my remarks today wilil be confined to the area of cigarette smoking and disease, I would like to say that the legislative package recently'introduced by the distinguished Chairman and cosponsored by several;of his colleagues on this Subcommittee, represents a landmark in this country's efforts to deveLop a national strategy for the prevention of disease and disability. To date, only a miniscule portion of our health care dollars is focused;on avoiding illness and maintaining good health. As a result, many millions of Americans must suffer the burden of illness that coulidihave been prevented. Dt is only logical that such a comprehensive preventive health care strategy include efforts to reduce the hazard of cigarette smoking. Ei'.ghty percent of all lung cancers are caused by cigarette smoking. Cigarette smokers have 70% more heart attacks than nonsmokers and are 6 to 15 times more likely to~die from chronic bronchitis and emphysema. One of every three heavy smokers will die prematurely of a smoking-related disease.

323 -4- sure to a chemical way. It contains :o cause cancer beginning of rty, forty years. s number of years of lung cancer. ing cancer is a 3y a clear!y . Why is it then :rage smoking gerous drugs? Is about the r interested i doubts. But he truth,-thus ; it because . revenue, based r people, and, )roductivity and _s have their .tter what the ao little has Considering what the government might do to alleviate lung cancer, one must keep in mind the consequences of the cumulative effect of smoking. One consequence is that the long lag between beginning of smoking and the appearance of lung cancer gives a false sense of safety to those who begin smoking; a second consequence is that the reduction.of cancer incidence in those who give up smoking is slow, producing values close to that'of non-smokers in not less than ten years. Another consequence is that the age at which people begin to smoke has a dramatic effect on the later incidence of lung cancer. For instance, those beginning at 15 have a five fold higher incidence than those beginning at 25. -All these facts show that cutting down the number of years one smokes is, next to not smoking at all, the most effective way to alleviate lung cancer. Iri,tny view legislation is needed to alleviate the health dangers of tobacco smoke, and should be based on the following concepts;- 1) The main thrust should be to convince young people not to- begin to smoke, through a suitable program *of education directed at breaking the chain of events which give a status value to cigarette smoking. At the same time there should be a complete ban on any kind of cigarette advertisement or promotion, otherwise the truth about smoking would be submerged by the clever propaganda glamorising this dangerous habit in the eyes of the youth. 2) Since any shortening of the time one smokes will be very beneficial, efforts should be made at inducing people to quit smoking, even though they have already smoked for a long time. That quitting is possible has been shown by 30 million

307 - 3 - igarettes is not 2 FDA recently marketplace - the risk of In 1977, it is :ricans died of nes our annual :>ublic health ilgnificantly to part have cevalent conditions Fatal are arterial :1unts for about rs are responsible c diseases, it ped very distinct rokes tend to y are considered hey occur in and lack of viewed as an nately among gnificantly in naturaL hazard of old age, and cancer is not necessarily the resulit of uncontrollable causes. To the contrary, scientists now estimate that 70% to 90% of all cancers are the result of environmental factors. Hundreds of billions of pounds of synthetic organic chemicals are now produced annually in the United States. Many of these chemicals are harmless. But more and more we are finding others that are deadly. Human exposure too carcinogenic agents in the environment is frequently involuntary and unavoidable -- they are in our diets as well as our workplaces. The inability to distinguish between those which are dangerous and those which are not, is increasingly placing us in the impossible position of having to choose between endangering the healith of a substantial portion of our population or severe economic dislocation. Alternatively while a large number of chemicals are being put on the market without full scale testing to determine ilf they are carcinogenic agents, there are no simple predictive tests in existence for many of the health problems caused by chemical exposure. But this is not the case with tobacco and cigarettes. Although cigarettes are not subject to premarket testing, research has been done, conclusions have been drawn and the health consequences of smoking,have been clearly defined -- and they are serious. One quarter century ago, we had the preliminary data suggesting,that cigarette smoking caused lung cancer. Over a decade ago, the Surgeon General's report cleariy liinked cigarette smoking to lung cancer.

l.[ l.a I.6 1.4 U.L 1977 0.5 1.2 0.9 1.4 1.7 2.1 0.5 Reporting use of heroin fifty or more occasions during preceding 1968 NA NA NA NA NA NA 1969 NA NA NA NA NA NA 1970 NA NA NA NA NA NA 1971 NA NA 1.4 1.4 1.8 2.0 1972 NA NA D.7 1.2 1.2 1.2 1973 NA NA 1.3 1.2 1.7 1.7 1974 NA NA 1.7 1.4 1.1 1.4 1975 NA NA 1.0 1.2 1.4 1.4 1976 0.6 1.1 0.8 1.0 1.3 1.1 1977 0.4 1.1 0.5 0.9 1.4 1.8 NA NA NA 1.1 0.8 1.0 1.0 0.9 0.7 0.8 20,848 22,077 10,774 25,883 35,148 35 , 701 31,251 27,388 28,323 28,303 20,848 22,077 'Standa tte rates o use for sentnr tgi sciools are compute ustng equal popu atlons or eac o t e eig t class/sex groups. This eliminates distortion because proportions of classesor sexes have changed betweenyeers. •'Tota1 number of responses used in tabulations for the year specified. 3/2/77 SAN MATEO COUNTY, CALIFORNI,A, SURVEYS OF STUDEiVT DRUG USE CUINULATIVE LEVELS OF USE REPORTED BY JUNIOR AND SF.N10R HIGH Sf.HOOL STIIDFNTS, 1968-1977 BY SGIfOOL GRADE AND SEX OF RF.SPONI]ENT, SPECIFIC RATES PER 11UNDRED RESPONSES. - - NALES YEAR OF 7t Bth 9th IOt llt 12t SURVEY Grade Grade Grade 6rade Grade (;rade 1.3 U.4 0.4 U.9 0.9 1:1 0:5 0:8 0:1 0,8 year. NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.5 0.5 0.7 0.6 NA NA 0.6 0.6 0.7 0.6 NA NA 0.7 0.4 0.6 0.7 NA NA 0.4 0.7 0.5 1.0 NA NA 0.8 0.6 0.5 0.6 0.2 1.2 0.2 0.2 0.5 0.B 0.2 0.8 0.3 0.6 0.2 0.7 FLHALES }th ---9t 10t Ilt 12th Grade Grade Grade Grade Grade Grade. Reporting any use of barbiturates during preceding year. 1968 NA NA NA NA NA NA NA NA NA NA NA NA 1969 NA NA NA NA NA NA NA NA NA NA NA NA 1970 3.3 9.6 12.S 16.6 17.3 14.4 3.1 7.7 14.5 20.4 15.0 13.9 1971 5.8 1I.0 16.8 16.8 19.8 IB.S 5.4 12.2 18.0 19.1 17.9 15.0 1972 5.1 1 0.7 11.9 16.0 I4.3 15.4 4.8 11.1 13.6 17.2 16.0 14.1 1973 5.2 9.0 13.1 14.7 15.! 14.0 4.7 10.4 13.4 14.8 15.0 11.4 1974 5.0 9.0 1I.5 14.6 14.5 14.7 4.7 8.8 15.8 1.T.9 15.1 14.7 1975 3.8 6.8 10.5 11.1 13 A 13.1 3.4 7.9 12.5 14.4 14.7 14.1 1976 3.3 7.2 10.0 12.1 12.4 12.2 i.7 6.9 10.0 15.1 15.3 11.8 1977 3.5 5.8 6.6 9.4 11.6 12.8 1.7 6.7 9.9 12.2 12.9 12.9 Re ortin use of barbiturates on ten or more occasions durin recedin year. 1968 NA NA NA NA NA NA 1969 NA NA NA NA NA NA 1970 0.S 2.3 3.9 4.8 6.6 5.0 1971 1.2 3.7 5.5 5.7 7.7 7.2 1972 1.2 3.0 3.2 5.5 4.8 5.8 1973 1.3 2.5 3.7 4.3 4.5 4.8 1974 1.2 2.6 2.6 4.5 4.4 3.8 1975 0.6 1.5 2.8 2.7 4.3 3.9 1976 1:0 1.8 2.3 2.7 3.3 3.2 1977 0:6 1.7 1.5 2.2 3.9 3.5 Reporting use of barbiturates on fifty or more occasions 1968 NA NA NA NA NA NA 1969 NA NA NA NA NA NA 1970 NA NA 1.8 2.3 3.6 2.4 1971 NA NA 2.6 2.5 3.8 3.7 1972 NA NA 1.4 2.8 2.1 2.8 1973 0.8 1.2 1.9 2.3 2.1 2.7 1974 0.7 1.4 1.4 1.9 1.6 1.3 1975 0.3 1.0 1.1 1.6 1 .7 1.8 1976 0.5 1.0 1.1 1.2 1.5 2.2 1977 0.3 0.9 0.7 1.2 1.7 1.7 NA NA NA NA NA NA NA NA NA NA NA NA 0.4 2.1 4.6 7.7 4.5 4.6 1.0 3.5 5.3 6.2 6.8 5.3 0.8 2.7 3.4 5.3 4.4 4.0 0.6 2.2 3.1 3.8 4.2 5.4 0.9 1.9 3.4 3.3 4.1 3.4 0.9 1.3 3.3 3.4 3.4 3.5 0.5 1.8 2.3 4,4 4.5 4.3 0.4 1.7 1.8 4.0 3.4 3.2 uring preceding year. NA NA NA NA NA NA NA NA NA NA NA NA NA NA L.S 3.0 1.7 1.5 NA NA 1.6 2.3 2.7 2.2 NA NA 1.2 1.9 1.9 1.4 0 .3 0.9 1.4 1.3 1.9 1.2 0.5 0.7 1.3 1.4 1.4 L.3 0.5 0.5 1.3 1.1 1.4 1.3 0.1 1.1 0.8 1.4 1.3 1.0 0.2 1.1 0.7 1.2 1.0 1.0 BARBITURATES Stan a_rdized Rate• Tota1 Total•• Grades 9-12 _ Responses NA NA 15.6 17.7 148 13..9 14.4 13.0 12.4 11.0 NA NA 5.2 6.2 4.6 4.2 3.7 3.4 3.4 2.9 NA NA 2.2 2.7 1.9 1.9 1.4 l.4 1 .3 1.2 18,774 25,883 35,148 35,701 31,251 27,388 2g,232 28,303 20,848 22,077 18,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 18,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 • 0tandard ted rates o use- or~en or tg s[ ools aire compute using equal popuiat ons for eac o t e etg t class/sex groups. This eliminates distdrtion because proportions of-clesses or pexes have changed between years. ••Total nunber of responses used in tabulationn for theyear specifled. MEO9Fo

"The evidence unambiguously shows that lung cancer is,a prime example of a preventable cancer, caused by a clearly identified and unessential agent, cigarette smoke. Why is it then that the U.S. governments have done so little to discourage smoking,although they have very actively fought other dangerous drugs? Is it because key people in government have doubts about the evidence on the hazards of cigarettes? Certainly interested parties make every possible effort to create such doubts. But surely the government has means of getting,to the truth, thus eliminating the artificially created doubts. Or is it because tobacco brings in revenue? But it is a gruesome revenue, based on the disease, death and;great suffering,of many people, and, anyway, probably outweighed by the costs of lost productivity and medical care. Or is it because powerfuli interests have their way, irrespective of the consequences? No matter what the cause is, it is a great failing of our society that so little has been done to control tobacco smoking." OvF:R\, The statement. "W rette. Smoking Is Dat rette packaging since of 1969. This Act was on the bealth conset available (the Surge, nd 1889 PHS Healtt a serles of important, answered. Tbe following dlscu to determine the lnsw The Inltial questlo smoking was "Are th answer to this quest that some diseases oc ond, a causal relatio: A reasonable plact smoking was In the a substantially to the c a higher overall dea clearly shown that c smokers of the same s Demonstrating tbl causal nature.of the decision whether or statistical probabilltezcessdeath rates.ts. criterla had been me ment. These criteria a. The consistency b. The strength of, r- The speci8city o d. The temporal re e. The cobereace o The association t sistently been demo last 80 years. The Y tn their design or a The strength of tt ing that cigarette at death rates of nonsnThe speclEcity of stantlal ezoessove age, sez,..race, socfi other variables. The temporal rel overall death rates rates that occurs afL The coherence o response relatlonsh rettes smoked per ~, of inhalation, or pa In prospective aswC Thus, theeztens . 6atbered byy maop~ temporal relatlonsb the cause of the erm The estab118hmeu additionalquestioo Individual disease The most import: of the number of p' disease (CHD). It greater risk ofdef nonsmokers. Prosp death rates from C than nonsmokers. a cigarette smoker CHD than a nonsa IndependentCHD alterable CHD rls' Autopsy studies 1'; severe coronary at The Health Consequen U.S. Department of H Public Health Servic Center for Disease C -a- 312 effectively with the problem before us. We have been confronted time and again with the fact that "'cigarette smoking is the largest single unnq~cessary and preventable cause of i~llness and early death"' in the Unite&States, yet we continue to a1Low smoking to exact intolerable costs -- both in human and economic terms -- from the American public. We must commit ourselves to make the kind of public policy decisions which will reverse this situation and offer some protection to our most precious nationali resource. While I have already requested that Dr. Dulbecco's statement be printed in the hearing record, one paragraph of that statement is particularly worth repeating:

only three years longer than his counterpart living in 1900. The science and technology of modern medicine has evidently added little to adult life expectancy. We have become increasingly aware that the road to better health is not necessariliy paved with better medicine. t. A child ld born of about a n infant f improved pasteuri- a crowding. On the t to live Factors other than med+ical~ therapies must clearly be given principal credit for the significant declines in deaths relate&to infectious diseases which predated introducti('n of medical interventions. These factors include better nutrition, improved hygienic measures such as effective sewage disposal, water purification, and pasteurization of Mwn milk. A Sritish authority, Dr. Thomas , credits hygiene for at least 20 percent of the total reduction of mortality which has occurred in the last century. In singling,out nutrition as particularly important, he further notes that the decline in mortality caused by infections began even before the introduction of sanitary measures. Improvements in nutrition during the course of the nineteenth century are the likely explanation for increased resistance to infectious diseases.

action. However, when, as in the case of smoking, we find that a carcinogen'exiists, we must act to prevent it from entering the environment. From the point of view of a scientist engaged in cancer research, it is paradoxical that the U.S. people, through Congress spend hundreds of millions of dollars a year for research to prevent and cure human cancer. But when we can say how to prevent much humanicancer, namely, stop cigarette smoking, liiittle or nothing is done to prevent this cancer. In fact, I believe the U. S. government even, subsidizes the growiing of tobacco. As I said at the NobeliFestival banquet in Stockholm, I am outrage&that this one major method available to prevent much human cancer, namely the cessation ofcigarette smoking, is not more widhly adopted. I should also like to comment onia possiible large increase in funding for biomedicallandotfier health-related research. At present the U. S. system of support of biomedical research and the results of this biomediical research are the best in the world. Therefore, we must be careful before undertaking drastic changes inithe way we fund biomedical research, and we shoulid especially be careful to ensure that quality, is stressed in all biomedical research. An excellent way to insure this qualityls the system of peer review of grants used at NIH. Furthermore, although at a particular time we.might wish to work onia partiicular problem in biomedical research or solve some healthrrelated problems, if techniques and theoretical knowledge are not advaneed enough to supply a proper foundStion for the research, i3~ may not bepossibleto approach such problems. Nature yields her secrets slowly, an&only when a proper foundation of previous knowledge exists. Therefore, I wonder about the aduisability of ti area. I suggest ' More important is basiic biomedical i Iniconcliusio research by the U preventing this d available to prev support Congressi,

317 2 ,ncer. Uhfortunately, :r is not caused by such , for science progresses ntiive medicine, I believe would prevent cancer ng cancer7 t chemicals and radiation ome has been strongly, has shown that the parts of the world -iee of human cancer andlpopulation group environment. Therefore,. Jetermining role in the ly, established of these irette smoking. )babiility of developing but the smokers have :her diseases. Therefore, )t appear to lie in a ng the levels of cinogens an&tHe one probablly especially 3 the tars f,rom tobacco. The American Cancer Society estimates that the life expectancy of a man of 25 who continually smokes 2 packs of cigarettes a day is 8'years less than that of a 25-year-ol!d nonsmoker. Stopping, cigarette smoking would have the greatest effect on increasing life expectancy, but, if that is not possible, reducing the level of tar fromitobaeco would at least serve to reduce the cancer risk of smokers. Therefore, if a tax based on the level of tar and nicotine in cigarettes decreased the amount of exposure to tar, it would help:to prevent some of the cancers which otherwise would be caused by, smoking. However, further research is still needed on cancer and other diseases both to help prevent those diseases that are not' caused by smoking and to help cure those diseases that cannot be preventedL For example, we need to develop better therapies for cancer based upon an understanding of' the differences in,biochemistry and:controllofi cell multipl!i'cation, between cancer cells and normall cells. Compariison of virus-transformed cells andinormal cells is one of the best systems to find such differences. However, we must try even harder to prevent cancer before it starts, since so far iit has been difficult to find many biochemical differences between cancer cells and normal cells that can be exploited in therapy. For prevention, we must devise better methods of testing for factors in the environment, including chemicals from industrial processes and' possibly'food additives „ that can cause cancer, and after we find'these fiactors we must try to remove them. In addiitiion, we must try to understand more of the mechaniisms by which chemicals and radiationicause cancer in the hope that such knowledge willll make it easier for us to recogqize these carcinogens and perhaps to devise means to prevent thelr

Ly on :) like S to rvices. ue to attention health care s the same achieved rvices. S. 3115, a compre- analyzed by thermore, 351 the budgetary provisions contained in S. 3115 have substantial implications for FY 1980 and beyond, and the Department has just begun to formulate its budget recommendations for FY 1980. Certain general comments can, however, be made today. Title I Title I of S. 3115 establishes formula and project grants for preventive health services. The health promotion and disease prevention activities proposed in Title L incorporate many of the activities currently underway in HEw and proposed for consoliidation in S. 3099~. As you know, Mr. Chairman, you have recently introduced the Administration's services proposal, S. 3099, whi~ch, consolidates a number of the authorities, covered in Title I of S. 3115, into a comprehensive grant which would provide States with sufficient flexibility to determine their own priorities for using Federal funds. We appreciate your introduction of this measure and would urge your considerati~on of the approach embodied in the Administration bill.

M. WgAil IW0 MTY,NWIFWA, lMVERW S"RNT W URM M = M M ONNERM M CUMULATIVE LEVELS OF USE REPORTED BY JUNIOR AND SENIOR BIGH SCIIOOL STUDENTS, 1968-1977 BY SCHOOL GRADE AND SEX OF RESPONDENT, SPECIFIC RATES PER HUNDRED RESPONSES. MALES YEAR OF 7th- -- 8th 9t lOth ltth 12tt SURVEY Grade Grade Grade Grade Grade Grade Reporting any use of heroin during preceding year. fEMLES 7t 8t -9t 10t 11t k.. Grade Grade Grade Grade Grade Grade 1968 NA NA NA NA NA NA NA NA NA NA NA NA 1969 NA NA NA NA NA NA NA NA NA NA NA NA 1970 NA NA NA NA NA NA NA NA NA NA NA NA 1971 NA NA 3.7 3.9 4.9 5.9 NA . NA 1.9 2.0 3.3 2,6 1972 NA NA 2.7 4.0 3.7 4.6 NA NA 2.3 2.6 3,0 2,7 1973 NA NA 3.1 4.1 3.7 4.3 NA NA 2.3 2.1 2.6 2.8 1974 NA NA 3.3 3.9 3.5 4.2 NA NA 2.3 2.0 2.5 2.7 1975 NA NA 2.7 3.2 4.0 4.3 NA NA 2.5 2.7 1.8 2.9 1976 2.2 3.3 4,0 2.8 3.4 3.8 1.0 2,4 2.2 1.6 2.2 2:I 1977 2.4 2.8 2.4 2.7 4.0 4.1 1.4 2.5 2.0 2,4 2.4 2.9 Reporting use of heroin ten or more occasions during preceding year. 1968 NA NA NA NA NA NA NA NA 1969 NA NA NA NA NA NA NA NA 1970 NA NA NA NA NA NA NA NA 1971 NA NA 1.8 1.1 2.4 3.0 NA NA 1972 NA NA 1.1 1.7 1.6 1.6 NA NA 1973 NA NA 1.5 1.8 1.9 2.D NA NA 1974 NA NA 1.9 1.8 1.5 1.7 NA NA 1975 NA NA l-4 1.7 1.6 1,6 NA NA 1976 0.8 1.4 1.2 1.3 1.8 1.4 0,2 1.3 1977 0.5 1:2 0.9 1.4 1:7 2.1 0,5 1.1 Neporting use of heroin fifty or more occasions during preceding year. 1968 NA NA NA NA NA NA 1969 NA NA NA NA NA NA 1970 NA NA NA NA NA NA 1971 NA NA 1.4 1.4 1.8 2.0 1972 NA NA 0.7 1.2 1,2 1,2 1973 NA NA 1.3 1.1 1.7 1.7 1974 NA NA 1.7 f.4 1.1 1.4 1975 NA NA 1.0 1.2 1.4 1.4 1976 0.6 1.1 0.8 1.0 1.3 1.1 1977 0.4 1.1 0.5 0.9 1.4 1.8 NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA 0.2 1.2 0.2 0.8 NA NA NA NA NA NA NA NA NA NA NA NA 0.7 0.8 l.l 1.1 0.8 O.B 1.2 1.0 0 .9 0.6 0.8 0.9 0.6 1.0 0.8 1.2 1.2 0.8 0.6 1.0 0.4 0.4 0.9 0.9 0.5 0.8 0.3 0.8 NA NA NA NA NA NA NA NA NA NA NA NA 0.5 0.5 0.7 0.6 0.6 0.6 0.7 0.6 0.7 0.4 0,6 0.7 0.4 0.7 0.5 1.0 0.8 0.6 0.5 0.6 0.2 0.2 0.5 0.8 0.3 0.6 0.2 0.7 t~~r ize Rate• Total Total•• GradeS 9-12 Res onses NA NA NA 3. 5 3.2 3. 1 3. 4 3.0 2.8 2.9 1g,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,D7I NA NA NA 1.6 1.2 1.3 1.3 1.3 1.0 1.1 NA NA NA 1.1 0.8 1.0 1.0 0.9 0,7 0.8 18,774 25,883 35,148 35,701 31,251 27,388 28,232 28,303 20,848 22,077 18,774 25,983 35,148 35, 701 31,251 27,388 28,323 28,303 20,848 22,077 'Standardizedzates_ a use for srntor 19, schools-are_ compute usrng-zqoa populatrons or eac of t e e R t- class/sex groups.- This eliminates-distortlon because proportions of classes or sexes havechanged between years. E`Total number of responses used in tabulatione for the year specified. 3/2177 isSeoSco 5NV MATEO COUNTY, CALIFORNIA, SURVEYS OF STUDENT DRUG USE CUHULATIV€ LEVELS OF USE REPORTED BY JUNIOR AND SENIOR HIGH SCHOOL STUDENTS, 1968-_1977 BY SCHOOL GRADE AND SEX OF RESPONUENT, SPECIFIC RATES PER IIUNDR€D RESPONSES. BARBITURATES .tan ar ~te~ T'•_ '•

products, as well as increasing the number of persons under hypertensive medication. Most importantly, reduction in the incidence of stroke and myocardial infarction for the middle-aged population has been reported. elp been limited are yielding 1 Heart, unity inter- ase Program unity health behavior o hyper- ave shown or of those ion programs .ny spccial , also o reduce ;h study, Aucing fat dairy Another systematic effort which may be bearing fruit on a national scale is the National High Bliood Pressure Education Program which the Department has been sponsoringg since 1972. This program has promoted appropriate therapies for a high proportion of the 35 million Americans with high blood pressure. At l~east partially as a result of this program, 50 percent more patients visit the doctor to have their high blood pressure treated and the proportion of people with untreated high blood pressure has dropped f rom 49 percent, estimated in 1972;to 30 percent in 1974:, based on a study of fourteen communities. More importantly, since 11972, the death rate from stroke has fallen by over 20 percent and from heart attack by over 15 percen... Life expectancy in the Black population has increased almost three years in the last five years. Part of this gain can be attributed to improved hypertension control. The Administration concurs in your identification of the importance of these activities an&has requested $11 million to support its hypertension activities in 1979~.

354 In addition, Mr. Chairman, we also have a number of specific suggestions regarding provisions of Title I which we would be happy to share with your staff. For example, Mr. Chairman, we have reservations regarding the requirement that States use their formula grant funds for programs aimed at one or more of the five leading causes of death within their States. Pri~orities set by either mortality or morbidity would vary with different age and ethnic groups and with different classification schemes. Other factors also complicate the use of simple mortality l~evels as program determinants and we believe States should have greater flexibility in determining program priorities. The wording for the medical record confidentiality requirements set out in sections 315(h) and 3117(g) of your proposal appears to have been taken from the confidentiality provision found in the venereal disease provisions of the PHS Act. However, venereal disease programs have significantly different confidentiality requirements than the rest of the PHS Act. Yet this language in S. 3115 would be applied far broader range of activities and programs. to a As I are into tY7 this pz the ReF result prepar: propos: of the: been s• Title : resour( includh health demons formul, profiL, of the preven commun of the surrou There throug Health

346. o Nutrition has played a role in enhancing resistance to infectious diseases, but has more recently been found to be a major contributor to the chronic diseases that plague our population. Studies, such as the Framingham Study conducted in your home State, Mr. Chairman, point to the importance of elievated cholesterol levels as a contributor to heart disease and:stroke. Other studies linking serum levels with dietary intake point to the need to strengthen our nutrition efforts in the control of heart disease and in the search for the cause of a number of other diseases. o AlcohoLism afflicts almost 101million problem drinkers in the adult population of the United States today and, most alarmingly, one in four teenagers are moderate to heavy drinkers. Despite some leveling off, cirrhosis remains the sixth most common cause of death in ta,e United States, with up to 95 percent of the cases estimated to be alcoholi-related. Alcohol use has been implicated in over 50 percent of allifatal highway accidents, and its toll in death and disease, lost productivity, and property damage, in recent years is,estimated to cost the United States more than $45 IsELlion annually. Mr. Chairman, not o standing of the imp as importantly, we that effective prog lifestyle change. 1964 the percent of dropped dramaticall significant decreas of the cigarettes c adults who smoke wc the adult smokers c once to stop smokirr in stopping in impi 65 percent of U.S. over 20 percent smc The growing awarene is apparent on the Estimates indicate 15 million swimmer: 14 million regular number of adults wY since 1960, and 50 claims to engage ir

350 Mr. Chairman, thus far I have focused primarily on the importance of lifestyle factors in disease prevention~and health promotion. I would also like to note the importance the Department ascribes to environmental efforts and other preventive services. With your support, the Department will continue to strengthen its efforts to protect the Nation's children against the immunizable diseases, to promote expansion of fluoridation of the Nation's water supplies, to reduce the threat of lead-based painc as a poison to the physical and mental health of children, to eliminate rat infestation and to reduce the broad range of occupational and environmental hazards which imperil our health. Administration Views on S. 3115 Clearly we share a similar objective--to focus attention on preventive measures as a key element in our heaLth care strategy. We read the same statistics and share the same disappointment in the health status improvement achieved through unprecedented expenditures on health services. Yet, while we support many of the objectives of S. 3115, analysis of alternative approaches to design of a compre- hensive prevention program are currently being analyzed by the Departmental Task Force on~Prevention. Furthermore, the budgetary provi substantial implica the Department has recommendations for can, however, be ma Title I Title I of S. 3115 for preventive hea: disease preven*_ion many of the activi! for consolidation - As you know, Mr. C: the Administration consolidates a num: Title I of S. 3115 would provide Stat determine their ow We appreciate your urge your consider Administration bil

320 Statement on the health hazard of cigarette smoking to the US Senate Health Subcommittee R. Dulbecco I am glad to have the opportunity to appear in front of this subcommittee to discuss the health hazards of cigarette smoking, because this is an issue requiring both scientific knowledge and governmental action. I think that in the past there has been too little cooperaHon'between scientists and government on issues which, like this one, can improve the welfare of society; but I hope thaL this attitude is changing on both sides, and that my presence here reflects such a change. Among the health hazards of cigarette smoke, I will concentrate on lung cancer, which is within my field of competence. The disease is essentially incurable and can only be alleviated through prevention. Prevention has great value in most cancers, because it is now clear that 80% of all human cancers are due to environmental causes, such as what we eat, what we drink, and the air we breathe. The case for prevention rests on the public health experience with infectious diseases during the last century. ' In fact these diseases have been controlled mostly by preventive measures, such as hygiene and vaccination, an& very little by therapy. Preventive measures are applicable to all environmental cancers, but will be most effective for those cancers whose agents are known and are not essential. The cancer of the lung is by far the most common cancer of the latter type; the agent, cigarette smoking, is known and is not essential to life. Hence this cancer should be completely preventable. The fact that it has not been prevented, and that I sixty thousan squarely attr and its failur scientists, 0 and as a med question the However, I I implernentin; and other dif to this count measure s. Inor mounted, it of the heredi', determines ; chemicals c; mutations, % to cancer re cell; therefo chemical, rr no rmal. In exposure to lag can be t• cells and ca inducing chc of mutationt cancer-indu 0 ~ ~ ~ W ~ ~ ~

344 These lessons highlight the importance of lifestyle factors in preventing the infectious disease killers of the past. The impact of infectious disease has diminished to the point that these killers of the past now account for only about two percent of the mortality among persons over one year of age. Of infectious diseases, only influenza, when associated with pneumonia, persists among the ten leading causes of death in the country. Presently over three-quarters of alil deaths in the country are attributable to chronic diseases. Cardio- vascular disease, including,both heart disease and stroke,, account for over 50:percent of the deaths. Cancer accounts for another 20 percent and diabetes and cirrhosis together account for almost four percent more. Many of the deaths due to these chronic diseases are also preventable with changes in liifestyle. However, the focus of productive 3nterventions has shifted from, the community to the individual. There are indications that the develop.uent of effective measures to improve people's behavior with respect to smoking, exercise, nutriti~on, and alcohol abuse, in addition to improving control over hypertension, could result in significant decreases in morbidity and mortality due to these chronic diseases.

352' Our proposal would consolidate a number of current preventive health authorities into a single program of State formula grants for preventive health activities,, with funds earmarked foF immunization activities. Programs consolidated by the Administration proposal would include currently authorized immunization, disease control, venereal disease, rat control, and lead-based paint authorities. The consolidation would also incorporate public health grants to States, with the exception of hypertensioniand mental health programs. Formula grant funds would be distributed so that each State would be allocated at least the amount it had received from funds appropriated under these authorities in FY 1978. In ad for t of S. this : grant essen which drama disea sewag assur campa partn We are well aware, Mr. Chairman, that this proposal does not comprise a comprehensive prevention program. For the immediate future--that is, for FY 1979--however, we have determined that the combination of current budget priorities skyrocketing hospital costs, and the imminent prospect of developing a national health program prevent us from entertaining,significantly larger appropriations at this time. The mandate of our Task Force on Prevention, however, is to fully analyze all present and future preventive health needs, in order to make legislative, administrative and budgetary proposals for the future. Howev and c: cause healt gover towar preve facto exhib ment

321 smoking ce ear in front of this cigarette smoking, ic knowledge and ,ere has been too unent on issues A society; but -s, and that my moke, I will concentrate ipetence. The disease ted through prevention, :causc it is now clear )nmental causes, r we breathe. The xperience with i fact these diseases sures, such as apy. Preventive ancers, but will be ire known and are the most common moking, is known shoul& be completely ented, and that r -Z- sixtythousand Americans are killed by it every year must be squarely attributed to lack of adequate action by the government, and its failure to heed the many calls made by responsible scientists, over the last two decades. As a cancer researcher and as a medical man I am shocked by this lack of action, and I questicn the credibility of the government as a promoter of health. However, I hope that the government will now take a firm stand, implementing measures suitable for stamping out lung cancer and other diseases caused by cigarettes. The world is looking to this country to lead the way by adopting strong and effective measures. In order to understana how cancer prevention can be mounted, it is important to understand that cancer is a disease of the hereditary material of the cells of our body, which determines all the properties of the cells. Cancer-inducing chemicals cause damages of the hereditary material, called mutations, which in turn change the cells. However the change to cancer requires several mutations and other events in the same cell; therefore in the early period of exposure to a.cancer-inducing chemical, mutations occur but remain silent, i. e. the ce1Ls stay normal. In experimental animals cancers begin to arise long after exposure to a chemical has begun; in industrial cancers in man the lag can be twenty to forty years. Silent mutations persist in the cells and can cause cancer at a later time, even after the cancer- inducing chemical is withdrawn frorn the environment. Accumulation of mutations in cells of the body explains the cumulative action of cancer_inducing chemicals, i. e. that the number of cancers they

355 i number of 3 of Title I ar staff. zations a their formula more of the States. 'bidity would a and with factors also ?vels as program Lhave greater -ties. .entiality ind 317 (g)~ of your the confidentiality )rovisions of the PHS have significantly ian the rest of the )uld be applied' to a -ams. As I, am sure you are aware, considerable thought has gone into the issue of medical record confidentiality since this provision was first drafted--much of it reflected in the Report of the President's Commission on Privacy. As a result of that attention, we are now in the process of preparing comprehensive medical record confidentiality proposals, and would urge you to postpone consideration of these particular provisions until that legislation has been submitted. y Title II, of S. 3115 calls for the provision of resources for disease prevention and health promotion, including the development of five regional centers for health promotion, the development of community-based demonstrations of preventive health services, and the formulation of periodic national disease prevention data profile. Mr. Chairman, the Administration is acutely aware of the needs addressediby these provisions. Disease prevention, health promotion and health education are essentially community affairs. They are, to a great extent, the product of the lifestyles of individuals and families - the environment surrounding them and the services available to them. There are a growing number of community activities develioping throughout the country. For example, at the locaL level, a Health Education Center has been developed in Pittsburgh.

357 ve program resources. ersity School ndustries and: 3e a wide ces. The adults in i, operates _he general education region, and I resource. th bliems in In your own Region, Mr. Chairman, the New Eng-TanFlealth Promotion Council, initiated three years ago with the help of a CDC contract, is providing a focus for inter- agency planning and activity in the six New England States. Among,the significant spin-offs of this very modest endeavor has been the effective involvement of the Cooperative Extension Service of New Hampshire in the State's childhood immunization program, which in turn has provided a model for other States. The three examples I have cited are not unique, nor are they illustrative of the full range of problems implicit in disease prevention and health promotion. They do, however, point to the potential for local, State and regionali collaboration in these fields. We need to work with, and through, the resources in our communities. We would oppose, however, the specific mandate to develop five centers, in order to provide the Secretary the flexibility to use the funds most appropriately. I am pleased to note, Mr. Chairman, that the Office :,f Health Information and Health Promotion, establishe&as a result of your leadership in enacti~ng,Public Law 94-317, is undertaking a number of activities to strengthemthe Federal support of locally-based health promoti!on efforts, as well as to strengthen the national data base for prevention. Specifically, a series

338 Dr. McGixNis. Let me just add one: comment t'o that. The Depart- ment considers the dissemination of information about fetal alcohol syndrome to be one of the central and most important programs related to any alcohol reduction ef£ort, and we'll be specifically identifying mechanisms to undertake a national information program related to the fetal alcohol syndrome. Senator Krs:cnnv. Myunderstanding, is that you are considering the consolidation of a number of different proposals within,the admin- istration-such as venereal disease, rat control, lead' paint poisoning, the immunization programs and the other formula grants. Cnn you tell us at this time whether you have any recommendations as to which of those programs ought to be expanded or where there willl be the transfer of resources from one to another?' Dr. McGiNxrs. I think the emphasis here, in discussin(r the philoso- phy behind our recommendation for consolidation of those programs, really ought to lay with our increased' understanding about the im- portance of health promotion programs, in addition to health protec- tion activities: We would like to provide the States with the flexibility to shift some of their emphases along the line of health promotiony if they deem, some of those activit'ies to be more important tham the cur- rently mandated health protection activities. I am struck, for etample, by the fact that of the 10 leading causes of death in the country, 8' of those 10 might be significantly impacted if effective health promotioni programscould be mounted a~ainst,just five behaviors-smoking, nutritiony exercise, alcohol abuse, and adher- ence to hypertensive regimens. This phenonmenon,, I think, compels us to provide the flexibility to the States to shift some of their resources into health promotional, activities-ifl they so desire. Senator KFVN-EnY. The relationship with the States~is a key element which: we will Ncork with you on. And also, how you get the degree of fleiibility for States that have been creative and imaginative; the degree of accountability, and also the degree of targeting ~inwhat are the generally agreed areas, as you testified and as has been testified before in this committee, the areas of principal! need. So we will look forward to workin~r with y ou on that. Dr. McGr.N-~Nis: Thank you, Senator. [The prepared statement ofi Dr. McGinnis follows:]

362 Section 302(b)(11) of Title III requires the Secretary to prescribe a symbol to signify the presence of an artificial flavor or color. A similar symbol has been suggested in other legislation to indicate the sence of artificial flavor or color. These contradictory approaches highl~ight the need for further study. In fact, this issue has been targeted for discussion in our regional hearings on food labeling. We would be happy to share the results of this analysis with your staff. Section 306(b) of Title III requires the Federal, Trade Commission (FTC) to report to Congress on how it has responded to Department of Health, Education, and Welfare recommendations for advertising regulations corresponding to nutritionalilabeling regulations. We defer to the FTC regarding the need for preparing a formal report to Congress. The Department is committed to making every effort to coordinate its regulations with those of the FTC in order to assure that product claims made in advertising are consistent with those made on the label. Tit'_ labe dif3 Adm: the undc in c In : are the to are bil rea nea bef eff pre

geographic access to care and the quality of health care delivered are all immediate and important problems for health policy. We must not lose sight, however, of the fact that the central objective of our health policy must be reduction of the burden of disease. Prevention - not expensive therapeutic techniques - clearly constitutes the most direcf and effective approach to that objective. An illustration may serve to underscore this point. A child born in 1900 could expect to live 47 years; a child born in 1976, on the other hand, had a life expectancy of about 73 years. This difference of nearly a quarter of a century is attributable to a remarkable decline in infant and child mortality--in large measure, a result of improved environmental sanitation, better nutrition, milk pasteuri- zationy infectious di~sease control, a reduction in crowding as well as increased and improved immunizations. On the other hand, a 45 year old man in 1974 could expect to live only + The sc added increc neces. Facto princ relat of me nutri sewag milk. for a whicl nutri the c the i nutr: the = disez

356 As Senator Schweiker is well aware, this innovative program has been developed almost entirely through local resources. Resources of the public health agencies, the University School of Public Health, the major voluntary agencies, industries andi private philanthropy, have been combined to provide a wide range of educational and health promotional services. The Center conducts classes for both young people and adults in many aspects of prevention and lifestyle education, operates one of the Nation's best dial-access systems for the generali public, provides technical consultation in health education and prevention to health planning agencies in the region, and has become in a very few years a widely recognized resource. At the State level, a less fully developed but highly promising activity is underway in New Mexico. The New Mexico Health Education Coalition was established several years ago through the Regional Medical Program and supported in part by contracts with the Bureau of Heal~th Education at the Center for Disease Control and more recently by the National Cancer Institute. This formal confederation of public and voluntary health agencies has directed particuLar attention to problems of health promotion an&disease prevention among Mexican-American and American Indian communities in New Mexico. In your owi Promotion ( help of a c agency pla: States. A: modest end the Cooper the State' turn has p The three illustrat. preventio the poten these fie in our co mandate t Secretary I am plea Informati your lead a number locally-t the natilc

316' 2 preventable by vaccines that might cause human cancer. Unfortunately, I think we can now conclude that most human cancer is not caused by such viruses. Scientifically, this conclusion is an advance, for science progresses by disproving hypotheses. But, in terms of preventive mediciine, I believe this conclusion ends the hope for a vaccine that would prevent cancer caused'by viruses. Must we, therefore, give up hope of prevenLing cancer7 No, For in recent years, the hypothesis that chemicals and radiation probably cause cancer by mutation of the celllgenome has been stirongly. supporGed'. Furthermore, epidemiological evidence has shown that the incidence of human cancer is not the same in all parts of the world and in all population groups, but that the incidence of human cancer varies from country to country, region to region, and population group to populationigroup depending on the nature of the environment. Therefore, there must be environmental features that play a determining role in the formation of human cancer. One of the most clearly,eseablished of these envi'ronmental features is smoking, especially cigarette smoking. Cigarette smokers nott only,Have a much greater prohahiilli'ty of developing lung cancer thanido otherwise similar nonsmokers, but the smokers have a greater probability of dying from a number of other diseases. Therefore, our best present hope of preventing cancer does not appear to lie in a vaccine against viruses, but in removiing or reducing the levels of chemical carcinogens firomithe environment. The.siingle most important source of these carcinogens and the one which should be most easily removable is tobacco, probably especialllyy the tars f,rom to life expectancy a day is 8'years cigarette smokin expectancy, but, from tobacco woul Therefore, if a decreased the an of the cancers w However, fu both to help pre to help cure thc need to develop of the differenc between,cancer c cells and normai However, wc since so far it between cancer For prevention.,, the environment possiibly food a factors we must understand more cancer in the h recognize these

363 atafff s d Ti~tle III would preempt all State laws concerning labeLing requirements which are in addition to or different from information required under this Act. Administration analysis regarding,this provision and the provision relating,to alcohol labeling is currently underway. We would be pleased to provide our suggestions in our report on this bill. In summary, Mr. Chairman, the issues addressed by S. 31'15 are among the most important health policy issues facing the country today. Your leadership in focusing attention to these issues is very much appreciated. We regret we are unable to offer detailed responses to many of the bill's provisions today, but hope to provide more specific reactions, as well as additional proposals, in the very near future. We appreciate the opportunity to appear before you and look forward to working with you in the effort to strengthen the nation's program in disease prevention and health promotion. 0

_s. ition 361 developing and changing at a rapid pace. We db not believe that specific listings should be locked in statutory language when such matters could be handled more appropriately by regulation. Therefore, we would strongly recommend that the specific listing of nutrition labeling requirements, as found in Title III, be deleted. Section 403(g)(2) would authorize the Secretary to prescribe by regulation a system of symbols, figures, or other devices that would enable consumers to readily comprehend the nutrition information on labels as required by the preceding section. We fully support the objective of establishing a system of symbols or figures to convey certain nutrition information to consumers. However, we would not wish to see this authority limited to only those items Listed in. section 403(g)(1) of the bill. There may be other nutrition information for which a symbol woul&be extremely useful. Nevertheless, the Secretary would be unable to require additional symbols if this authority is limited to those listed in the bill. We urge an amendlnent giving the Secretary the discretion to determine when the use of such symbols is appropriate and to require it for any nutritional information. .ii_Sau~.~i - :;, -zl 0 0

ar before .on's views on by the of 1978, .he witnesses x for Disease )ods, Food and 3 from the Bureau .enter for Health Lood Institute, •01 will be iave regarding ;lation is _ng to strengthen .sease ana the )r. Foege, who 'y Califano idership you yn. The issues i, like Title IV lesign of a 341 As you know, Mr. Chairman, the issues related to disease prevention and health promotion are of particular concern to the-Administration. In addition to the $30 million smoking and health initiative, discussed by Dr. Foege, special initiatives have already been launched to address problems related to childhood immunization and adolescent pregnancy. In addition, a Departmental Task Force on, Prevention is currently examining the renewal and strengthening of efforts in the broad range of issues encompassed by prevention. The Role of Prevention in our Health Strategy As you know, historically the most important gains in the reduction of morbidity and mortality have been achieved through efforts to prevent disease and promote health, rather than gains in medical treatment. Yet the focus of health care and health policy has shifted in recent years from preventive health activities to the delivery of acute care. The implications for our national budget have been astounding. The share of our economic resources going to payments for health care has increased drama- tieaLly. Yet there is little indication that those increases in expenditures are yiel~ding proportionate decreases in morbidity and mortality for our population. These costs, along with deficiencies in financial and

of regional health promotion conferences will be sponsored in order to provide a forum for community leaders and organizations to exchange experiences in community health promotion/risk reduction intervention programs. In addition, a technical assistance program is being developed which will aid selected communities in the planning of community health promotion/risk reduction programs. Furthermore, through the provision of funds to the National' Center for Health Stati~stics, the Office of Health Information and Health Promotion is supporting a national study to obtain a better understandingf of the impact of lifestyle factors on morbidity and mortality. We are also working with private industry to develop risk reductioniprograms appropriate for occupational settings. We are reviewing these activities to determine their adequacy in meeting the need for research and innovation on which to build a sound prevention program. The approach outlined in Title II will be closely evaluated in these efforts. We hope to have more detailed comments and additional suggestions to you in the near future. Title III Title ILI of S. 3115 would increase the Secretary's authority over food labeling. We are gratified by this specific focus on nutrition - an area in which the Department is moving aggressively to strengthen its activities. We support the ob: cor mer p1z re•, an of in:. Cu_ th: co: th Th cl ('U No De in bu pa fu th to be Ba

ient to that. The Depart'- ation about' fetal alcohol _portant programs related e specifically identifying ation program related to that you are considering )posals within the admin- ~ol, lead paint poisoning, ormula grants. ive any recommendations expanded or where there another? in discussina the philoso- lation of those programs, ~rstanding about' the im- ddition to health protec- ~tateswith the flexibility e, of health promotiony if , important thani the cur- of the 110 leading causess be significantly impacted be mounted against just. ilcohol abuse, and, adher- o provide the flexibility into health promotional ie States is a key elementt ow you get the degree of ~,e and imaginative; the of' targeting in what are ~lnd as has been testified )ali need. So we will look follows :] 339 FOR RELEASE ONLY UPON DELIVERY DEPARTMENT OF HEALTH! EDUCATION. AND WELFARE STATEMENT BY J. MICHAEL MCGINNIS, M.D. DEPUTY ASSISTANT SECRETARY FOR HEALTH (SPECIAL HEALTH'INITIATIVES) BEFORE THE SUBCOMMITTEE ON HEALTH AND SCIENTIFIC RESEARCH COMMITTEE ON HUMAN RESOURCES UNITED STATES SENATE' WEDNESDAY, JUNE 7, 1978

MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE: I am pleased to have the opportunity to appear before you this morning to discuss the Administration's views prevention and many of the issues addressed by the Disease Prevention andiHealth Promotion Act of 1978, on S. 3115. I would like to introduce to you the witnesses who accompany me, Donald Millar of the Center for Disease Control and Taylor Quinn of the Bureau of Foods, Food and Drug Administration. In addition, officials from the Bureau of Community Health Services, the National Center for Health Statistics, the National Heart, Lung, and'.Blood Institute, and others from the Center for Disease Control will be available to address any questions you may have regarding this broad area. Mr_ Chairman, the introduction of this legislation is evidence of your continued interest in working to strengthen the Nation!s efforts in the prevention of disease and the promotion of health. I join my colleague, Dr. Foege, who conveyed to you the appreciation of Secretary Califano and Assistant Secretary Richmond for the leadership you have shown in drawing attention to prevention. The issues ~ addresoed in Titles I through!III of S. 31~15, like Title IV discussed by Dr. Foege, are central to the design of a comprehensive prevention proQram. As you preven to the smokin specia proble pregna Preven streng encomp The Rc As yoc reduct throug rathez of hea years of acc have t going ticall increa decrea These

345 3f lifestyle factors Llers of the past. ninished to the point intt for only about two Dver one year of age. when associated with ig causes of death iarters of all deaths iic diseases. Cardio- lisease and stroke, is. Cancer accounts cirrhosis together Time will not permit a complete review of the growing body of evidence which implicates these habits as critical factors in the major chronic diseases. In brief, we know that: • o Smoking causes at least 80 percent of all lung deaths and ranks first as the leading cause of cancer among men. Smoking i~s also a primary risk factor for cardiovascular disease. The death toll from smoking-related heart disease eclipses the significant death toll from cancer caused by smoking. I need not elaborate on the additional misery which smoking inflicts through emphysema and chronic bronchitis. Reasons for our identification of smoking as public health diseases are also However, the focus of 1 the community to the the develop.«ent of )ehavior wi~thirespect ~ohol abuse, in addition could result in :ortality due to these enemy number one are evident. The Department appreciates your leadership, Mr. Chairman, in drawing attention to this issue. o Exercise has been shown by many studies to reduce the risk of fatal heart attack. Research is continuing to identify the specific mechanism of action, but the preventive impact is clear. Furthermore, anecdotal' evidence is now accumlating, to indicate that exercise may also be useful in rehabilitative programs for patients who have suffered heart attacks. .. .,su , ,.- 7 „ - -, a

347 :nhancing resistance more recently utor to the population. Study conducted , point to the 01 levels as a stroke. Other h dietary intake our nutrition disease and in nber of other Llion probl'em of the United f, one in four drinkers. osis remains eath in t;ie ::ent of the cases Alcohol use has Zt of all fatal ;.n death and 3roperty damage, ,ost the United ally. Mr. Chairman, not only do we now have a better under- standing of the impact of chronic disease, but, just as importantly, we are now beginning to see evidence that effective programs can be mounted to facilitate lifestyle change. We see, for example, that since 1964 the percent of males smoking cigarettes has dropped dramatically. In addition, we have seen a significant decrease in the tar and nicotine level of the cigarettes consumed. Eighty percent of the adults who smoke would like to quit, more than half the adult smokers of both sexes have tried at least once to stop smoking, and physicians have succeeded! in stopping inlimpressive numbers. In 1950 about 65 percent of U.S. physicians smoked by 1975 just over 20:percent smoked. The growing awareness of the importance of exercise is apparent on the streets of every American city. Estimates indicate that there are 11 million jogge_s, 15 million swimmers, 15 million bicyclists, and almost 14 million regular tennis pl~ayers in the U.S. today. The number of adults who exercise has more than doubled since 1960, and 50 percent of the Americanipopulation claims to engage in some form of exercise. The President's

353 of current glie program of th activities, tivities. ion proposal ization, disease and lead-based uld also incorporate exception of Formula grant State would be eived:from funds FY 1978. is proposal does program. For the however, we have nt budget priorities inent prospect of vent us from riations at this Prevention, however, re preventive healith inistrative and In addition, I would like to note the key role provided for the States as mediator in the preventive programs of S. 3115. We have also stressed the importance of this Federal/State relationship in the consolidated grant authorities proposed in our bill. We feel it is essential to revive the strong Federal/State alliance which was forged earlier this century in the face of a dramatic toll of death and disease from communicable diseases through environmental measures to improve sewage disposal~ and water purification, measures to assure a safe food and milk supply, and mass immunization campaigns. The record of this strong!Federal/State partnership was impressive. However, as the disease profile for the country changed: and chronic diseases and accidents became the leading cause of morbidity and mortality, the close public health relationship between the States and the Federal! government changedialso. Change in disease patterns toward chronic diseases does not preclude aggressive prevention programs aimed at lifestyle and environmentall factors. Some of the States have already begun to exhibit leadership in this effort and the Federal govern- ment shoul3 do what it can to promote their activities.

348' Council on Physical Fitness and Sports has played an important role in raising the level of consciousness of the American public on the importance of exercise. If efforts can be strengthened to enhance these trends, the health benefits may be significant. Controlled studies of community programs to help individuals change their risky behavior have been limited to date, but those which have been undertaken are yielding optimistic results. For example, the National Heart, Lung and Blood Institute has sponsored a community inter- vention study~ through the Stanford Heart Disease Program in California which has attempted to use community health education and counseling to improve people's behavior with regard to diet, smoking, and adherence to hyper- tensive medication regimens. Results there have shown more improvement imthe community-wide behavior of those communities which were subjected to intervention programs versus the communi~ty which was not provided any spccial efforts. Another study, conducted in Finland, also indicated success at communi!ty-wide efforts to reduce multiple cardiac risk factors. In the Finnish study, success has been reported in significantly reducing the incidence of smoking and the use of high fat dairy products, as well as under hypertensive me reduction in the inci infarction for the mi reported. Another systematic ef on a national scale i Education Program whi since 1972. This prc for a high proportior high blood pressure. thi~s program, 50 perc to have their high bl of people with~ untrez f rom 49 percent, est- based on a study of - since 1972, the deat: 20 percent and from . expectancy in the B1. three years in the 1- be attributed to imp: Administration concu importance of these to support its hyper

3fi0 We also support the requirement that colors be specifically identified on food labels. Indeed earlier this year FDA Commissioner Kennedy wrote to the presidents of the major food:companies and urge&that they voluntarily undertake to di'~scLose the use of colors in their products. In addition, we support the provision of discretionary authority to require declaration of individual spices and flavors on labels. The bill aLso provides explicit authority to require nutrition l~abeling. Under present authority FDA has issued regulations requiring nutritional labeling where nutrients are added or where nutritional, claims are made for the product in labeling,or advertising. The bill would extend FDA's authority and enable us to require nutritional labelling on all foods. We support this provision,although it shoulid be kept in mind that for some foods nutritional labeling would be unnecessary andiwe wouldinot intend to require it. However, we do not favor the requirement in the bill to list certain specific nutrition information. Nutrition labeling is currently a dynamic subject area which is

ds in recess. DISEASE PREVENTION AND HEALTH PROMOTION ACT OF 1978 WEDNESDAY, JUNE 7,,1978 U'.S. SENATE, SIIBCo11i3iITTEE ON HEALTH AND SCIENTIFIC RESEARCH OF THE CommITTEE oN HIIMAZV RESOURCES, 1?Vask2ngton, D.C. The subcommittee met, pursuant to notice, at 9 a.nn., in the audito- ri'um,D'epa2tment ofHea1t1l, Education, and Welfare, 330 Independ- ence Avenue S.W., Washington, D.C., Senator Echvard' M. Kennedy. (chairmanofthesubconamittee)presiding, Present : Senators Kennedy and Chafee. Senator KENNEDY. The hearing will come to ord'er. Committee staff present: Dr. David Blumenthal, professional staff member, Robert M. Wenger, counsel, Fran Paris, professionall staff' member. The Subcommittee on Health and Scientific Research continues to- day its hearings on S. 311'5, the National Disease Prevention and Health Promotion Act of 1978. On May 25 we heard testimony on, antismoking provisions con- tained, in title IV of the act. Today we shift our focus to begin discus- sions of t'he balance of the legislfttion. We willl place particular emphasis on title I of the legislation, which authorizes formula and project grants1or preventive health services: This is an historic time in the evolution of medicine and health care delivery in our country. Our medical scientists and epidemiologists are, making exciting new strides in developing methods for the prevention of disease and the promotion of good health, and their work holdss extraordinary promise for reducing the burden of illness in our society. We will hear today from~ a researcher from Stanford University who demonstrated that innovative prevention programs could reduce the risk of heart disease by 20 percent in a California community. In Finland, a pioneering prevention effort cut heart attack rates by 40' percent in one county. We have seen studies which demonstrate that men who exerciseregula2•lyand vigorouslyexperience 00~percent fewerheart attacks than their more sed'entary peers. And other research has shown that improved lifestyle can extend life expectancy by anywherefrom 7 to 11 years. Is is becoming clear, theny that disease prevention can help Ameri, cans live longer. But just as clear is that prevention programs can alsoo help us live better lives. By preventing the chronic diseases which now plague so many of our citizens-especially our older zlnsericans-we (327),

isored I .alth iddition, :ch will 1health )ugh the Statistics, I is standing iortal~ity. risk !ngs. adequacy rich to ned in We iggestions iuthority '_c focus !ing :t the 359 objectives of these provisions, Mr. Chairman. However, before commenting in detail on this title, I would like to briefly mention the Food and Drug Administration (FDA's) recent and plannediactivities in the food labelling area. FDA is currently reviewing its food labeling regulations in order to develop an overall approach to label'ing that responds to the needs of consumers. The Agency's review began with a series of informal meetings wi~thiconsumers in l~ate 1977 and early 1978. Currently, FDA is preparing for legislative-style hearings this summer and fall to eLicLt further ideas and concerns of consumers about a wide range of food labeling issues, including the use of ingredient, nutritional and other dietary information. This review of current food labeling regulations is being closely coordinated with the U.S. Department of Agriculture (USDA), and the Federal Trade Commission (FTC). Now let me turn to the specific provisions of Title III. The Department understands that many consumers have a strong interest in informative content labeling of the products they buy, and the Department agrees with this principle. In the past, FDA has attempted within the limits of the law to require full ingredient labeling on all, foods. We are pleased that the legislati:onirequires manufacturers of standardized foods to list their ingredients in the order of predominance. We believe that standardized foods should be placed under the aame labeling requirements as nonstandardized foods. 1

•nling with com- c imi'~jF,rit}~of m~• ~retationof data. rateti specitical9v ,g environulentwil rial workers, t1ki, t apl,earance of lic,lth. :knd, i'2l, greneral public.. „a consult;u,t to ion and a11:Llvsls.. at lollail ac:l(lemv C'enters, as well •c on nn' own he- t I•ctrtlnr.i:,, not, in e re,tched hythe by it that ~.-~ill be ted and' by other hese inst:mces of he data and that 4 parties, rather mcrressional conl- oll~ "Ci(rarette Ronuld \Vilsoii; ; National Center National Healtli ,naUysis produced iee, as well as to ; study have been ' the information tics and on addi- lata on which the ristics" is based. -)ort's. All reports r of the National rwarded also to a ned with evaltlat- overs mat.erial of e some time ago.' te smoking eauses. M, as disabilities, : ere collected and Ice& for purposess number of' major %rious that clear- oking and Health of statistical and reeordot thlY bearing , 295 932 scientific procedures: I will endeavor to summarize briefly the sub- stance of t'he major shortcomin~;s which exist in that report. There are three major objections to the report and to the use of the data, on which it is based for e•stiniating the incidence of disability : 1. It is not. clear what the basis data actually represent. As an index of health or disability, the information collected by the National Health Siuvev is beset wi'th, errors. These errors areof such demon, strated magnitude that inferences drawn from such material about difference5 between population groups such as between smokers and nonsmokers; are prol,:rblyy invalid. Certainly estimates that a particu- lar mimberof disabilities-or that anycjisabilities=are ca'used: by sluolcin- are meaningless. ~~. Tlie dat~, olitained by, the. National Health Interview Surveyy are complexly affected by a variety of confounding vuria.bles. What dif- ferences may appear bctween disease and disability counts of smok- ers and nonsmokers depend on t.lle manner by which the d'aGa are dividhcU into catc1gories according to health, sex, age, employment, and other popnlation, characteristicsand bywhic4 ohserve& disease counts arN "corrected" according to differences in the distributions of! pos- siblv confoundinn factors between smokers and nonsmokers. The conl- parisrnr of "raw'rdisease counts does not really show any,thin7 about t9ic ell•ect of smoking, nor would this constitute a,roper comparlson: On the other hand, it is well known~ that the multivariate data may be mada to show almost anything, depending on how they are divided up for comparison and depending on what Eases are used to "adjust" observed numbers. The analyses performed on these complex dat'a fail to adjust for so many sources and factors of confounding that their conclusions lack conviction. This weak and unsatisfactory analysis of data, lacking already in validity and! reliability, does not demon- strate any health consequences due to smoking or associated with it. 3. Even if the caliculated disability rates are accepted on their face value, which they should not be, they do not, in fact, show that smok- ers suffer from more disabilities than do nonsmokers. In fact, female smokers for whom mucll more reliable data are available than for male smokers, have f'ewer disabilities than~ do nonsmokers. Also, the con- sist!vnt: pnttern, «-ith which former smokers appear to suffer from the highest disability rates is in contradiction not only to the conclusions of t'14is report but also to the insistence that one of the Inajpr pieces of evidence for the harmful effect of smokiulf;, is that stopping will be fol1m.•ed'by a reversal of ill efl•ects. 1. 'rl dE EXTF.NT OF F,P.ItOR$ IN TIIE SOURCI: D.\'I.1 «'llen two groups are compared on some measurement, the observed difference should he evaluated with due regard! for the accuracy of the tool which is used t~o measure. This is a verv' commonsense rule. Let iIs take an instaucs in which we are measuring tlle height of in- dividuals by asking cliildren under 5 years of age the height of '•(lud:ly~"Assiinlcthat if we compare the height of daddyas estimatetl by a .,~ yea.r-olcl to daddy's real height, a 5-year-old is wrong on thee average by as much as 3 feet. We would hardly pay much attention tlo a r,^portwhich cl:tims that tlhe,average heiglit of daddies who are firm (liscinlinarians, measured by this uncertain method, differs by 2

313 : been confronted ,king is the : of ililness mtinue to : in human We must cy decisions protection have al~ready ediin thee is particularly lung cancer caused by a igarette ments have .gli they have ' Is it s about Certainly ,rt to create means of artificially ~rings in ed on the people, and, lost productivity 1 interests ences? No .ling of our .troli tohacCo OST:'RYIEII'-Hl:wLTH'Co\sEQVEfcEa OFSfIOKI7iO The statement„"Waroing: The Surgeon General Has Determined That Ciga- rette Smoking Is Dangerous to Tour Health." has been required by law on ciga- rette packaging since 1ST0 as a part of the Public Health Cigarette Smoking Act of 1908. Th1t Act was a response by the U.S. Congress to the scientific Information on the health consequences of cigarette smoking summarized in reports then available (the Surgeon General's Report of 1964 and the subsequent 1907, 18t1$ and 19% PHS Health Consequences of Smoking). Thls Act was passed because a series of Important questions concerning cigarette smoking and health had been answered. The following discussion summarizes the basic questlons„the methodology used to determine the answers, and the answers themselves. The init.fal question to be answered concerning the health consequences of smoking was "Are there any harmful health effects of smoking cigarettes?" The answer to this question was provided in two ways. First, It was demonstrated that some diseases occurred more frequently In smokers than In nonsmokers. Seo ond, a causal relationshlp was established between smoking and these diseasea. A reasonable place to begin to look at the bealth consequences of cigarette smoking was In the area of overall death rates. If cigarette smoking contributed substantlally to the development of any major disease, this would be reflected !n  higher overall death rate for smokers. Several large prospective studies have clearly shown tbat cigarette smokers have higher overall'death rates than non- smokers of the same age and sex. Demonstrating this association, however, was not enough to establish the causal nature of therelattonshlp betkveen smoking and, excess death rates. The decision whether or not an association le causal ls not merely a statement of statistical probability. Determiningg that the association between smoking and excess death rates is causal was a judgment made by DHEW after a number of criteria bad been met; no one of which by ltself was sufficient to makethls judg- ment. These criteria Include: a. The consistency of the assoctatloa b. The strength of the association. c. The specificity of the association. - d. The temporal relationship of the association. e. The coherence of the association. Thee association between cigarettee smoking.and excess death rates has con- sistently been demonstrated In a large number of studies performed during the last 80 years. The few studles'not showingthis.relationship hadserions defects In ttieir design or analysis which limited the interpretation of their results. Thee strength of the association has been firmly established by repeatedly show- tng that cigarette smokers have one and a half to two and a half times the overall death rates of nonsmokers. The.speciIlcity of the assoclatlonwae demonstrated by establishing that sub- stantial excess overall rates occurred In populations of smokers grouped by age, sex, race, socioeconomic class, occupatSon, place or residence, and many other variab1es. The temporal relationship of the association between cigarette smoking and overall death rates was clearly shown by the marked decrease in excess death rates that occurs after stopping smoking. The coherence of the association was established by showing that a dose- response relatlonship persisted when dosagee was measured by number of clga- rettes smoked per day, duration ofsmoking„age oflnitlatlon of smoking, depth of Inhalatlon, or pack years of smoking. This relationship was also demonstrated in prospective as well as retrospective studles.: Thus, the extensive evidence concerning thehealth, consequences of smoking gathered by many researchers and analyzed for consistency„strength, speci9clty. temporal relatlonship„and coherence has clearly established cigarette smoking aa thee cause of the excess mortality smoking cigarette smokers. The establishment ofsmokingf as the: cause of excess mortality brought up the additional question: "Howare the health consequences.af smoking expressed as Individual dibeaseprocesseaY'The most important specific health consequence of cigarette smoking In terms Of the numberr of people affected ts the development of premature coronary heart disease (CHD): Retrospective studies established that cigarette smokers have a greater risk of death, due to CHD and have a higher prevalence of CHD than nonsmokers. Prospective studies confirmed that cigarette smokera have higher dea(h rates from CHD and established that they have a higher incidence of CHD than nonsmokers. Long-term followup of healthy populatfons has con9rmedthat a cigarette smoker is'more likely to have a myocardial lnfarctton and to4ie from CHDYhan a nonsmoker. Cigarette smoking has been shown to bee one of the major Independent CHD risk fect.ors.and to act, synergistically with the other major alterable CHD rlsk factora (high blood pressure and elevated serum cholesterol): Autopsy studies have shown that persons who smoked cigarettess have more severe coronary atherosclerosis than persons who did not emoke. The Health Consequences of Smoking,, 1975 U.S. Department of Health Education and'Welfare Public Health Service Center for Disease Control 3- 53(; 0 - , ., - 21

-e have. «'e can help citizens that would be a rare and valu- ties into realities. It embodies :ind the maintenance of good ind most humane approachto ntry: or will shortly develop them,. Americans. inescusablethat we spend less reventive health programs. ;ion programs must be firmly tnd that State and local gov- eadership and coordination in lotion prograins, ocal government in their pre- t must strike an appropri'ate _dl maintaiiting accountability. 'ention, and health promotion elat!est and most sophisticated ntry, including the electronic iis country to develop al truly disease and promoting health rs to the American people the to improve and lengthen their :eve. I am confident thab with >mademajor contributions to those before us today, we can rden of illness in the United li DTaGinnis, Deputy Assistant nitiatives; of HEAY. cGinnis. , M.D., DEPUTY ASSISTANT `IAL HEALTH INITIATIVES, CENTER FOR DISEASE CON- U OF FOODS, U,S: FOOD AND man. I am pleased! to have the nmingto dfiscus.s the adminis- yof the issues addressed by iotionAct of 1978, S. 3115. vitnesses who accompany me . e Control, and Taylor Quinny ~dministration. of Communitv Health Serv- [aitistics, t'lie \ational Heart, from the ('enterfor Disease 329 Control, n ill be available t'o address any questions you may have re- gardingthis,broad area. Mr. Chairma.n, the introduction of this llegisla-tionis evidence of' your continued interest in working to strengthen the Nation?s efforts in the prevention of disease and the promotion of healtlh, I join myy col- league, Dr. Foege, whoconveyed to you the appreciation ofSecretar,y Califano and Assistant Secretary ltichmond for the leadership you have shown in drawing attention to prevention. The issues addressed in titles I through III of~ S. 311>; like title IV discussed by Dr. Foege, are central to the design of a comprehensive prevention program. As you know, Mr. Chairman, the issues related to disease prevention and health promotion are of particular concern to the administration. In addition to the $30 million smoking and health initiative, discussed by IOir. Foege, special initiatives have already been launched to address problems related to childhood immunization and adolescent pregnancy. In addition, a departmentall task force on prevention is currently esaminingthe renewal and strengthening of eii'ortls in the broad range of issues encompassed by prevention. Senator KENNEDY. Well, we db want the input of the members of the administration who are generally familiar with the position which should be outlined in your presentation thismorning.. I suppose what we would like to do-you know, you mentioned! you'll have the bulk of it finished in the next few weeks. t hope maybe later in your testimony you will be able to begin to stress the particular priority items, without thedlegree of specificity that you'll eventually tr,yt'o develbp~during the course of your presentation here this morning. ' Dr. llcGiNwis. We certainly will make every effort to point out those Senator KENNEDY. And when you get to the basic recommendations, Iunderst'and the processt!hat has to be follonved, but we'd'liketo be able to find out the areas of priorities that the administration has,, which we obviously want to be sensitive to. Dr. McGir NIS: Certainly. Senator KENNEDY. All right. Why don't you continue. Dr. .11cGY:`rIs. As you know, historically the most important gains in the reduction of morbidity and mortality havebeen achieved through efforts to prevent disease: and! promote health, rather than gains in medical treatment. Yet the focus of health care and health policy has shifted in recent years from preventive healthiactivities to the deliver,y of acute care. The implications for our national budget have been astounding. The share of' our economic resources goingto payments for health care has increased dramatically. Yet there is litt'leindication that those increases in expenditures are yielding proportionated'ecreasesin morbidity and mortality for our population. We must notllose sight, however, of the fact that the central objective of our health policy must be reduction of the burden of disease. Preven- tion, not espensive therapeutic techniclues, clearly constitutes the most direct and ef£ectlive approach to that objective. An illustration mav serve to underscore this point. A child born in1!900 could expect to live 47 years; a child born in 1976, on t!heot'her hand, had a life expectancy of about 73 years. This difference over a

330 quarter of & century is attributable to a remarkable decline in infant and child mortality-im large measure, the result of improved environ- mental sanitation, better nutritiony milk pasteurization, infectious disease control, as well as increased and improved immunizations. On the other hand, a 45-year-old man in 1974 could expect to live only 3' years,longer than his counterpart living in 1900. The science and technology of modern medicine has evidently added little to adult life expectancy. We have become increasingly aware that the road to better health is not necessarily paved with better medicine. These lessons highlight the importance of lifestyle factors in pre- venting the infectious disease killers of the past. Tlie impact ofl infec- tious disease has, diminished to the point that these killers of the pastnow account for only about 2 percent of the mortality among persons overl year of age. Of infectious diseases, only influenza, when associated with pneu- monia, persists among the 10 leading causes of death in the country. Presently over three-fourths of alli deaths in the country are attribut- able to chronic diseases. 'Cardiovaseular disease, including both heart disease and stroke„ account for over 50 percent of the deat'hs. Cancer accounts for another 20 percent, and diabetes and cirrhosis~ together account for almost 4 percent more. Many of the deathsdue to these chronic diseases are also prev.entablee with changes~ in lifestyle. However, there are indications that the development of effective measures to improve people's behavior with respect to smoking, exercise, nutrition4 and alcohol abuse-all priority areas that we will be particularly focusing on in our task force work- in addition to improving control over hypertension, could result in significant deereases in morbidity and mortality due to these chronic diseases. Time will not permit a complete review of the growing body of evidence whiclt implicates these habits ascritical factors in the major chronic diseases. In brief, we know that smoking causes at least 80 per- cent of all lung deaths, and ranks first as the leading cause of cancer among men. Smoking is also a. primary risk factor for cardiovascular disease: The Department appreciates your leadership, Mr. Chairman, in drawing attention to this issue. Exercise has been shown by man,ystudies to reducet'~herisk of fatal heart attack. Research is needed to identify the specific mechanismsof action,,but the prevent-iveimpact is clear. Nutrition has played a role in enhancing resistance to infectious diseases, but has more recently been found to be a major contributor to the chronic diseases that plague our populiation. Alcoholism afflicts almost 10 million problem drinkers in the adult population of the United States t'od'€iv., and most alarmingly, one in four teenagers aremoderate to heavy ~drinkers. Despite some leveling, off, cirrhosis remains t'hesixt4 mostconunon cause of death, int'heUnited States, and the estimated economic impact,of alcoholism on the United States economy is $15 Inillion. Mr. Chairman, not only dowe nonw have a better understanding of theiQlipact'of chronic disease, but just'~as importantly, we are noavw be- ginning to see evidence that effective programs can be mounted to facilitate lifestyle change. We see, for esample, t'hatt since,19G-1 the percent of males smoking cigarettes has dropped dramatically. Eighty percent of the adults who smoke would like to quit impressive numbers. The growing awarenE on the streets of every : ercisehas more than doti can population claims to be strengthened to enhr significant!. Controlled studies of factors, for cardiovascul mentioned the two prir t'hose which have been • The results of those s•, cess in significantly red tion of smoking and thE creasing the number of importantly, reduction farction for the middle Another systematic e scale is the national hia Department has been sl tensive peoplewho are mated in 1972, to 30 per( More importantly, si_ by over 20 percent, anc Mr. Chairman, thus f of lifestylefact'orsin di also like to note the in mental efforts and facil With y our support', refforts to protect the ~ eases, to promote expai plies, to reducethe thrc cal. and mental health reduce the broad ranr which imperil our healt Clearly we share a s tive measures as a kev the same statistics anc status improvement ac, health services. Yet, wl analysis of alternative vent'ion programi are prevention, towhicliI ~ Furthermore, the b,, substantial implicatioil partment has just begi fiscal year 1980. Cert today. c Title I of', S'. 3115 ventive health service activities proposed in rcntly irncl'erwav in F' As, you, know, lir. C ministration's service~

334 Dr. McGrwr rs. OK. Senat'~orKFxN FnY. How many people do you have there? Dr. MicGzNNis. The legislation est'~ablishingt'heofl'ice allows, eight people. Thereare, in essence, five, professionals and three support staff. It's a very smalllstaff. The Office of'~ Health Information and Health Promotion has obvi- ously encountered a number of problems in developing its programy and it has a staff that is small-which I mentioned liefore Senator KENNEDY. Did we limit thenumbers?~ Dr. llcGi-, ~Nrs. The numbers are not limited, no. Senator hL,Ntir,oY. Where did youlgettlleeight? Dr. llcGr.N.xis. The appropri.ations liinguacye allows-requires eight individuals. It's not a limit'~ation, however. SenatorKENvFnv., Appropriatlions? Dr. b2cGz.N,.Nis: Yes; the funds available to that office R-erenot avail- able really until earlyy this year, in January of this year, for all practi- cal purposes. The Interim~ Director of the office, unfortunatlely,, was ill and had to assume about three months ago limited' responsibilities. I3iit there are eertaii<ispecitic mandates which the Office ha.sthat any coordinated office of this varietyy should have, and I think it has beb n in tlie.last few months to niove to fullfil those mandates. Specifically, I'm talking about the mandate to coordinate prevention activities across the Department, and in that regard it has prov ided significant support for the activities of the Smoking Task Forceand! the Preven- tion TaskForce. In addition, it serves as the principall staff arm for the Departiment's Nutrition CoorcLinatingCommittec. Second, OHIIIP has an obligation to facilitate information dis- semination, both insideand outside the Department. The activit'iesit is moving to incorporate into it's program in that regard are the estab- lishment of' ai National Health Information Clenringhouse, and an individtial has been identified who will be joining us within 3 weeks to begin that effort. We have d'eveloped a contract in order to anal~ ze. the resources of' the existing 12 clearinghouses, to most ap- propriately design the network to enhance the current activities of those clearinghouses. In addition, in the information, dissemination category; the Office is in the process of developing a Surgeon General's Report on Preven- tion. which will hopefully prov.ide a tone and a framework within which our departmential activities can beundertaken. OHIHP is also boing to be sponsoring a series of eight regional health, promotion fornms over the next 18' months, in order to bring community leaders intocontact'R-itheach other so that infornlat;ion- sha.ringcan take place and so they can learn the directionsof theFed- eral Government and they can learn from each other in termsofl thee pro-grams tliathave beeni undertaken. There is a third msndhte which I thinlk is important as~ well, and that is theproT-ision of stimulhis for new concepts in disease prevention and heal'th, promotion. There are a couple of activities related to tlheproviMion of new concept'.swhich the Ofilce isiuldertaking. Oi1e, itt is int'heprocess of identifi-in,-- specific exnertsw}ho can provide teclinical assisthnce to a small nnmber. approximately 20 com, mIui2ties. in the ectnrd dbsi'inn ofhcrilth, promotion proff rams. learnine from the two activities that you havejnst referenced-the Finnish, study and t' those comm design a sp some mome Second, ( ing for the for Health has not pre of preventi.( It's a sm,-~ Senator _ prevention and I thinl: particular : of t.ime, wl Dr. McG before the , is really gc umbrel!la oii to you-co: for new coi Whether point. Thi~ that kind : thatt would the resour prev.ention. There h~ Wearei Chairman. search and The appro efforts. ~~~'FC gestions to Title II= food labeli area in wh activities. I Howes-e; ciote thatl t it~ t"ood lal' labelinif tl paringfoi further id, labeling is `enAtor O Dr. _lIc( Gr ~ .Znd evtenci ~ This re'~ W coordinate ~ or,rl Tr.lcle ~ I tvnnhl ~ title III. '

332 of the authorities, covered in title I of S. 3115, into a comprehensive grant which wouU provide States with sufficient flexibility to deter- mine their own priorities for using Federal funds. We appreciate your introduction of' this measure and would urge your consideration of the approach embodied'inthe Administration bill. VV'e are well aware, Mr. Chairman, that this proposal d'oes not com- prise a comprehensive prevention program. For the immediate future- that is, for fiscal year 1979-however, we have determined that the combination of current budget priorities, skyrocketing hospital costs,, and the imminent prospect of developing a national health program prevent us-compel us to delay the consideration of significantly larger appropriations at this time. The mand'ate of our task force on preven- tion, however is to analyze fullyy all present and future preventive health needs, in order to make legislative, administrative, and budg- et!ary proposals for the future. I would like to note the key role provided for the States as mediator in the preventive programs of S. 3115. We have also stressed the i.m- portance of this Federal/State relationship in the consolidated' grant authorit'ies proposed in our bilh We feel it is essential to revive the strong Federal/State alliance which has achieved impressive results in the:past. Change in disease patterns toward chronic diseases does not preclude aggressive prevention programs aimed at lifestyle and environmentall factors. Some of the States have already begun to exhibit leadership in this effort and-,you'1l hear from representatives of certain~ of those States today. And the Federal Government should do what it can to promote those activities. In addition, Mr. Chairman, we also have a number of Senator KENNEDY. We really haven't had~ much of an assessment about how they are specifically using the funds that they have at the present time, have we ? Dr. McGizvNZS. No, we- Senator KENNEDY. I mean, we really haven't assessed the various programs. I think, quite frankly, it has been kin& of a mixed bag. Dr. McGiNNis. To a certain extent we feeL that is the case. There is a need for greater assessment of the programs that have been efflected in the States. There is also a need for increased flexibility on the part of the Senator KENNEDY. Well, that's what I'm interested in finding out, whether you think that'the provisions of the bill are too flexible and if we're providing sufficient accountability. Do you have any opinion on t'hat ? Dr. McGrNN~is: In terms of the provisions of the bi11, with regards to their obligation to target on t'hetop five causes of morbidity and mortality in the States-specifically mortality, w,ith an option for mor- biditv-we think that you, might consider enhancing the flexibility of' the Sitatles in that regard. «'e certainly endorse some notion of rational and systematic targeting. There's no question that that's an effort which has to be improved. But the iarget!ing process is obviousln= a complex one. The different classification schemes for classifving mortality use different categories which affect tlieranking of those mortalityclassifications. Morbidity measures contain t'remendons~ measiu•ement problems; specifically, how can one quantify mental health problems ; how can one quantify problen acute respiratory Some measure ventability is in. employ. For exa into those top fi most important health promotio Some considei disease, both thc on a State by a c that sort of anal of mortality. We might loo top causes of mc from those whic before age 74, ai in more Product' We might wa., ethnic groups v, it's a very comp of rational and but.would hope Senator KEN: that wehaveam~that we get a s grounds are. Dr. McGrNNr:. Senator KEN ° legislation. OK. Why don Dr.lfcGrxai for disease pre,ment of five re: of commimit,y-b t'~heformulatior Mr. Cltairmal addressed bvt9l and health edu( I have descri mnni'ty health the country. Y develop five cel Secretarvto tls( I am pleased ination and He .'onr leadershiv l)er ofactivitiE liealth promoti( Senator KF-N me on the bill, (:f things that N .lLay,beyou ~ \%,ith the Office

391 Lt is an exercise in self-delusion to insist, as some do„ that the messages of the mass media -- particularly the electronic media -- do not dominate our thinking and attitudes or our awareness and acceptance of changing behavioraI values. We may engage in the practice of comparing the relative influence of the mass media, the school, the family and the church but this is largely a fruitless endeavor because these other institutions are no longer separate and independent. They have been invaded by radio and'television. The family -- the home -- is obviously an important educationali institution. But that institution has the television set on for some 7 hours a day and the family's teachings are greatly influence6 by what it is learning from television. Only the misguided direct their concern to the power of the electronic media. Concern is more properly directed to the ways in which that power is employed. The mass media are the market of America. But entertainment and marketing are not their only possibiliities. They should have been and! must become an extension of the schoolroom as well. We who work with ad{vertising are well aware of the formidable power of this social technology for reaching people en masse and persuading them to new products and ideas. 11

393 he for licy ct of he ues and dom sis The ost as old ern who the he ithy, 5hed radio aon This revelation has eluded the modern educator. The medium tends to be identified with the message and since the prevailing message is a commercial, some educators have disdained the medium as unworthy. Others„ more enlightened, have found the media inaccessible. This has cost us dearly in life-style degradation. Public service performance has been inadequate. For the truth of that experience is that the public service obligation of the station licensee is really licensee philanthropy and it has been dispensed parsimoniously -- too little, too late at night; too~little, too early in the morning. This may add up to a lot of spots but to us who know how to calculate our audiences, they add up to precious few rating points. There is much to criticize inithis situation. We are the most advanced country in the world with the most sophisti- cated communications media. Yet ours is the only country in the world'to have given its airwaves entirely away to commercial exploitation and mandated none for the public interest. M I ,

But the technique is not the exclusive property of the commercial marketer even though he has preempted'it for his purposes. A long time ago the communications policy of our country, as expressed in the Communications Act of 1934, might very well have mandated other uses for the public media and for the application of suchitechniques as advertising to the full range of social purposes and objectives. But that would have taken a greater wisd'om than was available to us at that time. We had no basis for anticipating the media's ultimate capabilities. The commercial marketer stumbled on to it and made the most of it. Station licensees were willing. The rest is history. The reach-and'-frequency technique of advertising is:as old as human communication. All the great ideas of Eastern and:of Western man were propagated by great thinkers who were also gifted communicators. Whether we live by the Ten Cotmnandments or the five tenets of Hinduism or the wisdom of the Koran, we receive our instruction in pithy„ memorable strictures of unvarying fo=. The effectiveness of this message design is undiminished to this day. Only the medium has changed. Given a radio station, Jiesus Christ would have used it for His Sermon, on the Mount. This re% medium t the pre-, nave di; enlighte cost us Public : truth! o-* obliigat= ahilant. too litr the mor: us who 1' to prec: There i most ad- cated c in the - coumlerc. iriteres

isioner tion of ~cutive )n; Dr. aicine ; -ion of ER OF S iame is lth for ) speak eitoriall ciation, ion and! of the public eld ap- i'lity of'-abuse, -us: ingness abilita- Ales for health \ or are nicable U elimi- U of us, ir roles aiies on ion and ry pre- whichl carries ; of' in- ')oth of ,al pro- cention ,-)pment ilr l ives: ,tall role 365 to play in the further development and implementation of prevention and~ promotion programs. As you you have remarked yourself, Mr. Chairman, in referring to the work of John Snow in removing the pump handle in London, prevention is the operating dictumi and first. principle around whichi public health efforts revolve. State and local health department's have a rich tradition of being at the forefront of new programs and new ideas. Titlles I and IV of this proposed! legislation, acknowledge this important role and provid'e the opportunity for our agencies to participate in new program develop- ment and implementation. The association wants to underline the importance of' both tlhe level of new funding requested and the proposed increases in the 314(d) appropriation. As you have pointed out, prevention~ get's less than 2 percent of the health care budget~. If the increases that y ou propose seeni large to some, they should considhr that.theannual'iQicreases pro- posed are less than $200:million, a small part of the $20 to $30 billion that the cost of curative medicine is increasing each year to pay for roughly the same services and programs. The increased appropriation proposed for 314(d) is essentiallbecause it provides the basic operatingsupport' funds for many healthi depart- ments. The appropriation levels under this authority have been fixed at $90, million since 1971, and thishas meant'shrinkaget in real dollar terms. This has led in some cases to health department's cutting back staffing levels and public health programs. The increase proposed in S. 3115 will have a major beneficial effect on stabilizing the infrastructure of State health departments and thus enhance our ability to develop and carry out the new program initiatives outlined int'his legislation. Inadditiony tlhe increased dbllars you propose could assure the continuity and funding of existing pro- grams aimed at maintenance of current levels of disease control. The idea of developing, ai health communications program is a par- ticularlv appealing one, given the plethora of drab, unimaginative pamphlets handed out in the name of health education. We believe that this goal of attracting marketing and advertising experts to address themselves to health issues is overdue and essential to effective use of tlhemassmedia, The suggested 10 cents, per capita allotment, while small con1pared'to the total'i advertising budget it needs t'o counter, is in our view suffic.ient to begin~to overcome the negative impact of the mass media on the behavior of individuals. Finally, the approach to smoking which attempts to integrate a range of strategies from taxing cigarettes by tar and nicotine content to prohibiting smoking on interstate carriers has to be seen as an im portant beginning to the dievelopment of a comprehensive program aimed at a problem that lamentably remains the leading cause of pre- mature death in thiscountry. As I havejust indicated, the association appltiuds and supports the basic outlines and concepts encompassed in the legislativ.e pacltage„but Q tlhere are a f'ew areas which we think need furtlier clarification and W 'pecifiicityare warranted. M Tlie~ planning process as outlined in title I provides an important W 1nduniqueopportunity to eomplernent the planning process heing, carried out under Public Law 93-g41'. Since the act, Public Law 93- - 00 GD Qf ~ 8

A second major health consequence of smoking is the development of cancer 1n smokers. Cigarette smoking was firmly established as the major cause of lung cancer by several large retrospective and prospective studies. The risk of devel- oping lung cancer was found to be 10 times greater for cigarette smokers than for nonsmokers. The risk of developing lung cancer Increases with the number , of cigarettes smoked per day and is greater in cigarette smokers who report inhaling, who started smoking at an early age, or who have smoked for a greater number of years. Smokers of filter cigarettes have been shown to bave a lower risk of developing lung cancer than smokers of nonGlter cigarettes, but the risk remalns well'above that for nonsmokers. The risk of developing cancer of the larynx, pharynz, oral cavity, esopbagus, and urinary bladder was also found to be significantly higher in cigarette smokers . than In nonsmokers. Pipe and cigar smokers were found to have elevated risks for the development of cancer of the oral cavity, pbaryn=, larynx, and esophagus when compared to nonsmokers. Pipe and cigar smokers report that they inhale much less4requently than cigarettesmokers. As a result their lungs reeeive much less smoke exposure than cigarette s~mokers'. This Is felt to be the reason for the lower, incidence of cancer of the lung for pipe and cigar smokers compared to cigarette smokers. • Women have bad far lower rates of lung cancer than men. This has been attributed to womenls tendency to smoke fewer cigarettes perday, the fact that fewer women than men smoke, sod the fact that women smokers genenlly select filter and low tar and nicotine cigarettes. However, the percentage of women ,mokers In the United States has Increased dramatically In the last 30 years, and sInce 1955 the death rates from lung cancer in women have Increased proportion- ately more rapidly than thee rates for men, reflecting this Increased proportion of women smokers. The tar from cigarette smoke has been found to Induce malignant: changes in the skin and respiratory tract of experimental anlmala, and a number of specific chemical compounds contained in cigarette smoke were established ae potent carcinogens oreo-carclnogensr Malignant changesIncluding. carcinoma tn. atta were found in the larynx and the sputum ezfoltative cytology of experimental animals ezpoeed to cigarette smoke. Nonmalignant reaplratory disease ls a third area of smoking-induced morbidity and mortality. Cigarette.smokers have been shown to have.more.frequent minor respiratory infections, miss more days from work due to respiratory Illness, and report symptoms of cough and sputum production more frequently than non- i amokers: Retrospectivee and prospective studies with long-term followup have found that cigarette smoking la the primary cause of chronir bronchitis and . emphysema in the United States. Cigarette smokers have also been found to be more likely to have abnormalities of their pulmonary function tests and have higher death rates from respiratory diseases than nonsmokers. Data from autopsy studies have shown that cigarette msokers were more likely to have the macro scoptc changes of emphysema, and that these changes are closely related to the number of cigarettes smoked per day. Mucous cell hyperplasia bae been found more often In cigarettesmokera Cigarette smoke also Inhibits the cSliary motion., responsible forr cleansing the respiratory tract. Statement fc Oisease"', Februar Senate Comoi ttee Hc Ar Mi T; U Thank you F topic. My point working for thee chickens. Since the e cause cancer in to cause cancer some primates. might cause canc it couldlbe pre• been prevented. Experiment• of much of the namely., by, addi genetic materia molecular biolo

367 riority areas, ome measure given to the ior modipica, t'itle I, at, a vention is a alth systems ~r" outlining iat these, in ~ in focusing , State plans e prevention i in terms of own on thatt in terms of ailed plan to and targeted I think that atitude that -ram~ dollars. of targeting lear R hether ffiajor causes 7hich almost ,e and dental only minor •tanti. Sports ts, might be Ality within How de we !wiouslvthe urse of our lot of hard ng with the States, as to )rts to begin longperiodinlg what we mable us to - on a broad scalle to date, to look at these intermediate objectives as valid proxies for even longer term impacts. I think the mechanisms ~ are there in most areas. We: are going to need community surveys: ini ways that have not been done as carefully as they might, but there are, for exampl'e,,t'he baselines to look at the impacts on cardiovascular mortality. That information is available. The impact on cancer; the impact on accidents. That data, in terms of niortality, is already available. The morbidity data is, I think, softer. We have to.vork at improving that. Senator h'E1 NEDT. The Finland! study, of course, we got the infor- mation quite quichly, in terms of t'heimpact of those efforts there. Dr. FIELDING. The North Karelia project f'ocused on 180,000 people, and had a national health system behind it, with one way of collecting data and one way of financing, making it much easier than currently in the United States, where we're dealing with over 200 million people and a fragmented system. I think ai lott more can be done, but I d'on't think the two areas are entirely comparable. In Massachusetts we are spending between $500,000 and $1 million a year in trying to develop demonstration projects and! building an eval- uation into each one. The important thing isthat all theprojects that'. .ire funded under grants to States and through~ States need to have evaluations built in so that it is very clear up front the kind of infor- mation R e need to look at effectiveness. I think also the money earmarked for the national reporting system is particularly import~aiit, and we have to look very hard' at how we can get- that reporting system in line with the objectivesAhat we all want to see and make them as concrete and as definite and irrefutable as possible: In conclusion, I would agree that there.is ample and growing evi- dlencethat prev ention and health promotion activities work; the de= clining incidence of death f'romcoronary heart disease, the decrease in ~imohing, the experience with immun.ization andlfluoridation of public water supplies, the decline of automobile deaths after the imposition~of the 55-mile-an-hour speed limit, t'he reduction in stroke attendant npon, the improved! detectioni and treatment of hypertension are just a few examples. It is clear, however, that if we are to help Americans~ achieve the level of health theyv both want and can, attain, a program for preven- tion and promotion must have national scope. S. 3115 be;ins to pro, vide that l.imd! of' scope, andASTI+IOcommends you and your com- mittee for both vour vision and your sense of priorities. Senator Kna aEDY. I gather from what you're saying, you agree on the stress on prevention, you agree ree on the establishment of the pr.ior- itics; so you will help us in terms of how we do that and how we relate to some of the points that you have raised. You agree on the impor- tance of'accountabilitvf in terms of the States. Do I understand you correctly in eachi of thoseareas?Dr, FiELDiN-:c: That's entirely correct'. We think alll those arever,yimportant. Senator KE` NEDY. OK. Dr. Steen ?

364 Senator KENNEDY. Our next witness is Dr. Fielding, commissioner of public health fromi Massachusetts, representing,the Association of State and Territorial Health, Ofl'icials. With him will be Dr. Lowell Steen, who is a member of the executive committee of! the board of trustees,,American DiedicallAssociation;,Dr. Arnold, who representis the American College of Preventive DZedicine; and Dr. J. Brett Lazar, who represents the National Association of Counties and! American Public Health Association. Dr. Fielding, we'll start with you. STATEMENT OF DR. JONATHAN E. FIELDING, COMMISSIONER OF PUBLIC HEALTH, COMMONWEALTH OF MASSACHUSETTS Dr. FIELDING. Thank you very muchy Senator Kennedy. i1ryy name is Jolinathan Fielding, and I am the commissioner of public health for the CommomvealtIt of 'Massachusetts. I come before you today to speak on behalf of bot4 ASTHO-Association of State and Territorial Health Ofl'icials-an.d' the Commonwealth of' Massachusetts: My purpose in~ being here today is to lend support of oturassociation to the bill that you have proposed, tllie \' ational Disease Prevention and Health Promotion Act of 1978. In its focus and conceptlualizationy this bill embodies many of the ideas andi principles which form sensible and! cost-effective public, health practice. As we approach the 1980's, wefinde ourselves in the health field ap- proaching several limitts:jVearereaching the limits of the ability of curative medicine to reverse and offset the multiple effects of self-abuse, genetic susceptibility, and environmental impact on health status. We have reached, and~ many n-oul'd~ say surpassed, t'hewillingness and ability of society to pay for corrective intervention and rehabilita- tion. Gone are thedays when changes in the dollar expenditures for personal health~ care were r.eflectedl ini comparable changes i4t healtlrh status as measured by indices such as morbidityy and mortality. \ or are we in public health immune from these changes. The days have ended when sanitary science and communicable disease epidemioliagyy alone held tlrepromiseof controlling and eli¢iai', natingt'hemajor causes of death and disability in this country. It is clear that we stand at an important juncture when all of us, whether at the Federal, State, or lbcal level must esaunineourroles and reorient our thinking tofocus-and concentrateou2• energies on prevention~of disease and promotion of health. I think it is important to distinguish between disease prevent~ion and' health promotion, since the two are freeluently confused. Primary pre= vention implies the removal or neutralization ofspe.cific factors which cause a single diseaseorgroupof' diseases. I~Iealth promotioni carries .vit!h it a Inore afiirmativecolulot'ation of enhancing the abilhtyy of in, dividitals to resist disease andito feel and behealt'hier. Tb ai great estent,, Senate311i:iincorporates and embodies both of' t'hese important eoncept!s which «•efeel are essentiah A national pro- l;ram «-lioseelnphasis was directed' entirel~-at primary prevention would faid to respond fullv to tlie,importtint nuandate for develbpmentoi1 progra~mswllich can help people enhance the quality of't'heir lives. It is clear that Stat'eand local health depart'ments ha%7e a pivotal role to aI pi ti P or m n c r

328 can improve the quality of the years we have. ZV, e can help citizens stay productive, active, and' liappy. And that would be a rare and valu- able accomplishment, indeed. S. 3115 aims at making these possibilities into realities. It embodies the following principles: First, that , the prevention of illness and the maintenance of goo& health is the wisest, most'cost-effect'ive and most humane approach to reducing the burden of illness in our country. Second', that we now have the means, or will shortly develop them, to prevent the diseases which afflict many Americans. Third, that in light of these facts, it is inexcusable that we spend less than 3' percent of our health dollar on preventive health: programs. Fourth, that to work,, disease prevention programs must be firmly based' in the communities of America, and thatState and local gov- ernments are ideally suited to provide leadership and coordination in nurturing community-based'i health promotion programs. Fifth, that, in supporting State and lbcal government in their pre- vention efforts, the Federal Government must strike an appropriatlee balancc between providing$exibility and maintaining accountability. Sixth, that programs of diseascprevention and health promotion must reach out to Americans by using the latest and most sophisticated methods of communications in this country, including the electronic media. And lastly, that'it is now time for this country to develop a trullycomprehenslve strategy forpreventlingdisease.and promoting heal'tIt a.mong our people, a strategy that brings to the American people the fruits of our new knowledge about howtoi'mproveand lengthen their lives through protecting their health. That is what S. 3115 attempts to achieve. I am confident that with the wise assistance of my colleagues, who made major contributions too this ~ legislatlion, and of witnesses such as those before us today, we can make major strides in reducing the burden of illness in the Uhited States. Our first witness today is~Dr. 147ichnel' McGinnis, Deputy Assistant' Secretary of Health for Special Health Initiatives, of HEW. We're pleased to have you here, Dr. McGinnis. STATEMENT OF MICHAEL McGINNIS, M.D., DEPUTY ASSISTANT SECRETARY FOR HEALTH FOR SPECIAL HEALTH INITIATIVES;. ACCOMPANIED BY DONALD MILLAR, CENTER FOR DISEASE CON- TROL, AND TAYLOR QUINN, BUREAU OF FOODS„ U.S. FOOD AND DRUG ADMINISTRATION Dr. 1TcGiN:~-rs. Thank you, Mr. Chairman. I am pleased to have the opportunity to appear before you this morning to discuss the adminis- tration'svIe«s on prevention and many of the issues addressed by the Di'sease Prevention and Health Promotion Act of 1i9'78, S. 3115. I R ould like to iuitrodncetlo you thewitnesses n-hoaccompany me : Donald 1>=illar, of theCenterf©r DiseaseControl, and Taylor (~uinn, of the Bureau of Foods, Food and DrugAdministration. In addition, oilicials, from the Bureau of Commnandtv Heal'thServ- ices, t'heNational' Center for Health Statistics, the21~ationali Heart, Lung and Blood Institute,, and others froiui the Center for Disease Control, v garding t'l Mr. Ch your conti the preve: league, D. Caiifano have sholA The issi discussed preventio: As you and healt In additi4 by Dr. Fc problems In add eaaminin.. of issues,c Senato administi should be I suppc have the, your testi ~ items, w] develop c Dr. M those- Senate: I unders able to I which w( Dr. lh Senatc Dr. 1L in the ithrough gains in policy h the deliv The in share of increasec( in espeni mortlalit We m of our h tion. not direct ar An i1 1900 coi. hand, Ir

used for other areas of disease prevention where desirable results are also sought and! R here such funds might have greater impact. If it is intended that formula grant funds be used to at~tiack such~ problems as automobile accident'sand homicide, it'may be wiseto~piacea percentage limitation on the use of funds for such purposes-at least until' the States gain more : experience in such preventive activities in these areas. We also note that each State receiving a grant would have to set up a special health communications unit'whose purpose would be to en- courage health promotion and education using all media.y especially electronic. We think this proposal has great merit. Often the informa- tion needed, by the public is not sufficiently disseminated, especially in the area of health. Health communications units could be one answer to this problem. However, we must again stress the need to fund these act-iv.itiesadequatelyso that themessage-willl be, delivered effectively. jVe would also urge that these be structured in such & way that they are readily understood. Senator KENNEDY. What are you talking about in terms of figures? Dr. STm.N. We do not have a figure at this time, Senator. We just ask you to lbok at it very carefully. I also wanted' t~o tell you that the AMA has recently embarked' upon a national advertising campaign, some of' which you have have already seen in national news magazines. Very shortly a second one of these ads will' be released, in which is said somethang, to the effect, "Your doctor wishes y ou w.oukl ***" and then list's such items as, "quit smoking," "drink with~ moderation," "eat sensibly," "exercise regu- larly" and~ so forth. This is also additive and supportive of' the entire educational effort toward disease prevention. To continue, this title also extends the funding for section 314(d), grants for comprehensive public health services. These funds, in essence a block grant to the States, have represented a~ major source of money for a variety of State and local public health activities. They could also be used to supplement themew initiativesdn health:prornotion~ and disease prevention under S. 3115. We have supported this block grant program since its inception~ and we support its, expansion. Tit'1e II proposes~ a Federal support system for the foregoing State programs, an& we will discuss this now. The Fed'eral, Government would establish~five centers for health!pro- motion. The pur ose of these centers would be to provide technical assistance to the ~tates in carying out their programs for "preventive health services" outlined in title I. The Secretary would' also set up community-based demonstration projects to test methods for organizing and delivering comprehensivee preventive health services to defined populations. We concur with the need to disseminate to the States additional in- formationi on disease prevention and health promotion. The proposed centers and demonstration grant's are one means of accomplishing this. However, before such activities are instituted, we would urge the sub~ committee to review carefu]ly existing Federal activities under the auspices of the National Institutes of IIealth, other arms of HEW, and other agencies~such as EPA, to determine if, in fact, resources are not already available to the Stat~e,init'hese areas, Si prof S( in tl Pro=c vari< D indi, S( of'~ y here SOAI" D T date fhe defii ing dict S( T Adr to ci app S, froil I; S F feta 1io1i tod: n-or as a S vou is a? inetIthat Me] whs r 11he alcr I : tha I' 1pe aro I

296 933 - inches from the average height' of'~ daddies who are soft disciplinarians. We would insist that the di'tferencP of 2 inclhes in the average rellorted height of different types of daddies is trivial whelr camp:aretl' to the average error in the method bvy which the heil;ht is actually measured. ' We would be even more disinclined' to take this reported difference seriously if there is some suspicion that being a harsh disciplinarian - has some effect on~ the way a child perceives the heinht of his father. The method used by the househola~interview survey produced er- rors of such mae it'ude in counting the incidence ofdisabilit'iies that our analogy is not irnreasonahlh. To unclerstand~ better .rhy the dut:t are so unsuitable, we might begin by asking oursc~l~.~es a•llere esat~t l~• did they come from, whose illnesses do thev represent, and to Nt hst extent Ao they measure accurately the incidenee of disabilities in tile population ? a. Persons interviewed zvere not a representative populativm and inwst of the information on naale,e wyns oNained .4ceonxl hand. The report proceeds from the assumption that its f indings are based on a representative sample of the U.S. polnllation. In fact;,: t is stressed in "Cigarette Smoking and Health Characteristics," on page 6,• that: One of the advantages of this study is that the data on relationships between cigarette smoking and health are based on reGponses from a probabilit';v sawple whicL is represeatative of the civilion, nuuinaitntional 1Klpnlnl'iun of ttie iluited States, thus allowing the data to be presented in the fonn of mttiunaliestimatea The claim that the data are represetat;ltivee of the iT.S: population forms, in fact, the basis on which, the "Health Consequence of Smok- in *' m:lkes Its estimates on the number of disabilities due to smoking. 1Ve find' on pa ;e 23 : As the primary source of data In the L'nitedi States on disability, the survey relxlrt., being based on a national probaliility santitle, llrnvide.s a wtlid base for 2stimating the excess overall disability assuciated «•ith cil;;lrette Mnwking. Are these stat'ements,ustified?The method of sampling used by the National Health Sltrvey was a mristure of randomi and nonrandom sanlllling. Cost and convenience factors had' to prescribe so nlanv compromises with what are normal, random sampling procedures that the final result can lle called a nrababilit'y sam ple onlv bt• some stretch of the inlarinaticn. In fact die desipners of the.\''ational ilealtir Survey 11oi~ntetU ollt from the+ie~,%:nnin g:nning that the cdi~~i;icln of the land nlass of a colnlt'mv into areas f'tlr which samples are to be clr:llvnwas nn ..;lrt" rathiqr tll:l lt a-.-cience.2 ThesampliRlg procecinre resulted in the lbsti ofaddre=ses of house- ilolil-, whose members were~ to ho interviewed and nclt in :t sample of tlonin I -;titiutionali'zed civilians. 1;'utn•hois nsuallvfollnd in the ho~use- 11old clurin~ normal working hours? ''hcyare llrnlseN~~~i~•es, chilciren, unelnplbved persons, retire.'d, elderly, and temporarily or perma- nently disabled individuals. The large part of'~ the male and the cur- rentlh, employed female population could not lleespect.eci t'iobe present in most instances wlien the interviewer e:tlledy and thustlicl not f'hlrlli;h, informat'ion about themselwes. This particular shontcotni'ng hncli beeni ceco,-nized f'mom the beginning, We find in the Concepts :tncl 1)elini-tions in the Health Household-Interview tiut•vtry, page 3: From the standpoint of reliability of responses it would be ideal iu bous- hold interviews if every adult cuu1Qi be interv,inwf-l for him.,e18. The cost of, 2 The Statirtical DesfyR of the lleatth Hotteehoid4nterrieta Survey, seriee A-2, p. 10. I' such a proced required. The Is least expen most reliable, It is. imp ree p~ secol Smoking ar proxy respc from 40 pel adilition, it caute mostl unemployec in informatl as great as also known and psycho Thus, th- nals who a l ation. :11 s4. source dat:! error as d: Slltol:('t'ti 711 5111(1ke11~; :! attention, 1). F, ruot, drnee of f Nrth., et cc l)isease c.al esatrlin medicallr- allnut .vhe informed, toms. The tollttvesl. , iln:lt'inecl to indycat+ counts of of rrledica A nnlll forred fr records. ( in terms I In itu• r PlilrltL•adton mnles.and t ••ClClrrettr 'male smnkel~~ verifiPd luf: e ~A unneh . resPondents ePtinuate: F Ca(LRrette. C tilittee (nlnti 3 The reP, Serles :-N Cnfe" anri ill even larger pnblicttt; cc pyycluolagl . 39-535'(

?i©reover, in placing them in~and among programs pre- selected for their target audiences„ we will have the assurance of reaching large numbers of people who might not be motivated to seek out these instructions on their own. The reach-and'-frequency technique is ideal for such a task. More traditional educational systems have difficulties in reaching,the unmotivated. Preventive health education cannot do without its mass media component. Preventive health education cannot do without the intervention,of an informed populace acting onlits own behalf. Preventive healithieducation cannot work unless we make a beginning in training people to oecome custodians of their own health. This proposed' legislation makes an extraordinary beginning. ;li 4

is 395 We in advertising are the most faithful believers in the media's possibilities. The faith derives both fromm our commercial experience as well as from our experience in public service campaigns through the Ad Council. We have faith in the power of the fastidiously designed message -- once it is d'elivered through equally fastidiously designed'media plans:, adequately weighted and'properly directed to pre-selected target audiences. 'de have been less than totally satisfied with public service efforts in the past because of our inability to control both media weight and timing. Our commercial experience has instructed us in the difference such control makes. By enabling state programs to purchase media time in~ accordance with sound'message and'audience strategies, this legislation will historically advance health education and set a new standard for the public service performance of our media. Some of us have been privileged to work with health education programs in:which:the public media have played central roles. Manoff International has done so in Ecuador in behalf of such pressing concerns as the decl'.ine of i (i

394 • The U.S. Government has, in the meantime, become one of the nation's biggest advertisers, ranking somewhere among the top twenty for the past few years and among,the top ten in one or two of them. To pay for the air it owns and licenses must be one of the classic ironies of a1'1 time. Yet, the availiability of that time is more important than its cost when vital social concerns are at stake and the Government has an obligation to communi- cate with the people. To date, governmental use of radio and television and other media has been mainly in behalf of recruitment for our armed services and'the coast guard. The interests of national security are at stake. One of the great contri- butions of this proposed legislation is to broaden~our interpretation of national security to embrace the nation's health and the obligation of our Government to employ the most sophisticated means to provide the supporting education. The funding provide&by S. 3115 is a minimum for effective use of mass media. We must guard against frivolous use of these funds. We in advc the media: our comme= in public have fait' message -- designed - directed' We have b~ service e control b, experienc makes. E in accorc this legi and set a of our me Some of t educatior central i~ in behal`_

396 breast-feeding, the importance of iodize&salt in the Andean valley; in the Philippines to teach mothers to enrich the traditional weaning food so as to increase the caloric intake of Philippino children; in Nicaragua to teach village mothers by radio how to prepare a simple oral' rehydration beverage for children with diarrhea andidysentery so as to prevent d'eath from dehydration. And elsewhere. These efforts were accompanied1by study teams conducting evaluations of the impact on knowledge, attitude and practice. The results in these rigid traditional cultures have been dramatic. It is another irony that so much more has been done in the mass media in these developing countries than in our own. We have a long way to go to catch up with our bwn capability. The mass media are uniquely suited as delivery systems for education dealing with the major health risks of our nation. The latter are singularly clear and urgent. They can be dealt with in singularly clear messages, designed for repeated exposure over long periods of time. `".oreov select assura not be own. a task diffic: Prevent -:edia c :7ithout on its -.;ork ur. ~_ecome _egisla

l)ISE.

Senator CtLNFEn. A11 right, that completes our hearing. We will re- cess until Friday, at 4222 Dirksen Building. [Whereupon, at 12:20' p:m., the subcommittee was adjourned.]

Senator CHAFEE. I share your concern about-what I)r. Farquhar was sayingabout those coming to lectures. It is veryliard to getpeoplei o come to nutritioni lectures. Mr. '-'NiAroFF. The point is, Senator, such activities are going on any- way. Pamphlets arebeingprinted'y lectures are being,giv.eny newspaper coliimns arebeing,published, et cetera. Let us concentrate oni those activities that are not being done and that R ill make a qualitative difference in the effort we undertake. That's all I'm saying. Manoff International has done work in Ecuador. We know this communications technique works. We have worked on breast feeding in Ccuador and have sold iodized salt to Indians in the Andes~and made an almost total conversion and havetaughtmothers,in the Philippines liotivtoreformulate tlhetraditional weaning food for more calories; vitamins, minerals;andprot~ein-and w.ehave done this in all these countries byy the radio which thanks to the transistor, is now an almost universal medium. I want to end by saying I feel very strongly in favor of S. 3115. These (lays it is extraordinary for anadvertising man to come to Washington tobeiin favorof a piece of legislation. I want to~say.ftirther that I am very grateful to you and the committee. S. 31U will be good for the country, and what is good for the country is good for business. There aresomeof' us-and the number is growing-who believe there ought to be more balance in the m2terial on television. Thereis, a nced! for aald! there is room for healthedlicntion messages in that mixture. Ne commend'you for this legislation. Thank you. [The,preparedstatement of Mr. llanoi£ follohvs :] q I `

390 My name is Richard K. Manoff. I am the Chairman and!Chief Executive Officer of Richard K. Manoff Inc., an advertising agency with headquarters in New York City serving a roster of we11-known consumer goods companies in all parts of the country. I am also the Chairman of Manoff International Inc., an international communications consultancy which has for a period of some 12 years been engaged in designing, nutrition and heaLth edhcation programs imdeveloping countries for USAID, the Ford Foundation, the UnitediNations, the World Bank and directly with governments themselves. I have serve&as a Secretary-Treasurer for the American Association of Advertising Agencies and have been a Director of that organization. The 4 A"s have askedime to appear here. Ii want to address myself to the provisionn under Title I for a "separate health communications component in the program" and:to stress the role of television and radio. I have worked'alL my professional life with the mass media; an6have developed an awesome regard for their power too influence human behavior, whether for the consumption of products or the acceptance of new ideas and practices. It is an e:. that the me electronic n attitudes behavioral comparing - schooli, th fruitless no longer invaded by is obvious that insti hours a da by what it Only the c electronic ways : in wi the marke- not their must beco:l who work power of and persu

368 STATEMENT' OF LOWELL H. STEEN, M.D., REPRESENTING THE AMERICAN MEDICAL ASSOCIATION; ACCOMPANIED BY HARRY N. PETERSON, DIRECTOR, AMA DEPARTMENT OF LEGISLATION Dr. STEEN, Thank you, Senator. DIy name is Lowell H'. Steen, 1I.D. lam a practicing physician in Hammond. Incl.. and I ama member of the AMA's board of trustees. With me today is Harry,1T. Peterson, director of AAMA's department of 1c;isliltiom, We are pleased~to present our views on S. 3115. Since its foundinz in 1817, the American Medical Association has sought the betterment of public health. We have supported many ef- forts, both private and' ~;overnmental4 desioned to improve the health of each and every citizen. These efforts have been~ directed toward many, many measures. Mr. Chairmany itt is well recogIlized' that many of the greatest im~ provements in public health have come about through advancements in the methods of preventing disease. such as immttniPat.ions; improved sanitation, and better nutrition. These have been achieved through a cooperative effort among Federal, State, and local government's, the medical profession, and the public. To that end, the American Medical Associiltiomlias particularly sup- ported earlier Federal programs in disease prevention and we are pleased to see an extension and expansion of these activities. Your consideration of S. 31,15 at this time is propitious, since it can focus public attention on the heal6'h issues to be considered at the July conference entitled "Focus on Positive Health Strategies," jointly sponsored by you, Senator Kennedy, and the American lledical Asso- ciation. Hopefully, all these activities will encourage the public to be more aware of the benefits of disease prevention and the individual's important role in preservin-a his or her ownhealth. S'. 3115 is a wlde, ranging effort to reinforce programs of disease prevention, health promotiom and health: education, through long proven sllceessful cooperative Federal-State activities. At'this time, '.NTr. Chairman, wewould! . like to address, specific pro- visions of the legislation. jV, hile we support the overall goals of this bill, and the thrust of major provisions of it,certain provisions do raise some questions that we believe should' be answered early in the consideration of t'hebill. We believe cert'ainmodifications would en- hance the beneficial intent of the bill. Title I tvould! provid'e a ne.vpro_-ram~ ofFederall formula grants t'o States to assist them in meeting the cost~s of plannin;, and provid'- inm preventive health services. These Stat'eprograms would bedirected' at reducing the five lead- ing causes of mortality.wi'thin the State throu~gh systems of early detection, screenint, andl prevent~ion of thesee conditions. A State could also receiveformula (rrants~ for prorrams, desicrned to reduce the fivee leading causesofmorbidit' v within the State. Special project grant'swould also be available for thefollbwing health seln Ices-and we ennmerat'ealll of them in our statement-detec- tion of hypertension, immunization of children, community fluorida- tion pro~rams, et cetera. C tioni ~,ena ~IIp' rise of l: tion iliti to V h ~ert cal its _ ;;uri Iitn tho, 11 _ adv f,f : lies- rleifl :LVa Aho CC ple: pri( por uiut. I- Iid tlie¢. .l ho` Iili{~ ~lev ~}ua tI}~. for C ~'ar «°e 1,re O I1oi W oF' 1 Q pr ~ in ~ I~~~~

331 jlo declinein infant f improved environ, irization, infectious immunizations; could expect't'olive. .n 1900. The sciencee added little toad'ult, are that the road to iedicine. Ayle factors in pre- 'he impact of infec- e killers of the past ility among persons 4ociat!ed with pneu- mth in the country: ountry are attribut- lcluding both heart ' the deaths, Cancer _1! cirrhosis tog ether are also preventable _idications that theple's behavior with abuse-al2 priority r task force work- ion, could! result in !ue to these chronic e grow.ing body of 'itct'ors, ini the maj or uses at least 80 per- ing cause of cancer for cardiovascular iip, Mr. Chairman, ice the risk of fatal cific mechanisms of tance to infectious [ajor contributor to inkers in the adult alarmingly, one in ,piteromelevelinbse of death in the f alcoholism on the r understanding of -'lv, we are no«be- an be mountecd to of males smokingt of the adults who smoke would, like to quit, and physicians have succeeded in stopping in impressive numbers. The growing awareness of the importance of exercise is apparent on the streets of every American city. The, number of adults who ex- ercise has more thani doubled since 1960, and 50 percent of theAmeri- ean population claims to engage in same form of exercise. If efforts can be strengthened to enhance these trends, the health benefits may be significant'. Controlled studies of community programs directed at multiple risk factors for cardiovascular disease have been limited to date-and' you mentioned the two principal ones for which we have evidence. But those which have been undertaken are yielding optimistic results. The results of those studies from California and' Finland! show suc- cess in significantly reducing the incidence among an entire popula- tion of smoking, and the use of high-fat dairy prodhzcts, as well as in- creasing the number of persons under hypertensive medication. Most importantly, reduction in the incidence of stroke and myocardial in- farction for the middle-aged population has been reported. Another systematic effort which may be bearing fruit on a national scale is the national highl blood pressure education program which the Department has been sponsoring since 1972. The.proportion ofl hyper- tensive people who are untreated has dropped from 49 percent, esti- mated in 1972, to 30 percent in 1974 basedion a study of 14 communities. More importantly, since 1972, the death rate from stroke has fallen by over 20 percent, and from, heart attack by over 15 percent. Mr. Chairman, thus far I have focused primaril,y on the importance of lifestyle factors in disease prevention and health promotion. I would also like to note the importance the Department ascribes to environ- mental efE'orts and facilitatina,aecess to preventive services. With your support, the Department will continue to strengthen its efforts to protect the Nation's children against the immunizable dis- eases, to promote e:epansion, of fluoridation, of the Nation's water sup- plies, to redltce the.threat'of lead-based~ paint as a poison to the physi- caland mental health of children, to eliminate rat infestation and to reduce the broad range of occupational and environmental hazards which imperill our health. Clearly we share a similar objective, to focus attention on preven- tive measures, as a key element in our health care strategy. We read the same statistics and share the same disappointment in the health status improvement achieved through unprecedented expenditures on health services. Yet, while we support manyy of the objectives of S. 3115, analysis of alternative approaches to design of a comprehensive pre- vention, program: are current'ly being analyzed by the task force on prevention towhichiIalluded earlier. Furthermore, the budgetary provisions contained in S. 3115 have substantial implications for fiscal year1980and beyond, and theDe- partment has just begun to formulate its budget' recommendations for fiscal year 1980: Cert'aingenerall comments can, however, be made today. Title I of S. 3115 establishes formula and project grants for pre- ventive health services. The health promotion and disease prevention activities proposed in title I incorporate many of the activities cur- rcntly underway in HE«" and propose(I for consolidation in S. 3090. As you l.now, Mr. ChairmanL you have recently introduced the ad- minis6'ration's services proposal, S. 3099, which consolidates a number

~result's are, ~t. attack such "ise to place 'es-at least ictivities in, ' tosetupa. I be to en- , especially le informa- ipecially in one answer fund these effectively. y that they of figures? )r. We just Irked upon rve already rge of these 'ect, "Your s as, ~gquit rcise regni- ''the entire on 31=1(d), in essence, of money 'hey could iotion, and 3ption, and ,ling Stat'ee iealth pro- technical )reventive. )nstration zrehensive i'tional in-proposed hing this. e the sub- mder the )f HEW, )urces are 371 Similarly, concerning the proposed national disease prevention data hrofile- Senator KEVxEnY. You have indicated the AMA has been interested in this over a long period of t~ime, and you have develbped your own programy as you have identified here. In your own inquiry into these various agencies, have you found' they do have such information? Dr. STEEx: I do not have t'hose, f'~act's available at hand. I believe the individuals from the Administration, this morning alluded to- Senator KE-NxEDY. I was just wondering whether in the fashioning of your own program, the kind of nationali program that you mention, here, whether the AMA went to any of these agencies and found re- sources in these various agencies which would support this comment. Dr. STEEN-. No, sir; I don't believe we have. Title III would amend the Food. Drug and Cosmetics Act to man- clate that ingredient and health and nutrition information appear on the, labelind of all packaged foods. The bill would also amend the definition of food to include alcoholic beverages, thus specifically bring- ing the labelina requirements of alcoholic beverages under the juris- diction of the FDA. Senator KENNEDY. And you support that? Dr. STEFx. Yes. The U.S. Department of Agriculture and' the Food and' Drug _Wministration are to conduct joint public hearings in~ t'he near future to determine what types of information would be most beneficial to appear in food labeling- Senator Senator KENNEDY. Just elaborate for 30 seconds why it is important from~ a health, point of view, on the alcohol,-- Dr. STEEN. On the labeling? Se nator KEti NEDY. Yes. Dr. STF:EV. W'el1~ already one of the gentlemen earlier alluded tothe fetal alcohol, syndrome. There is no question about the fact that alco- holic~ beverages constitute one~ of the major problems in this country today in terms of morbidity and mortality, in terms of lost time from work, and in terms of other societal impacts, such as on families. And as a consequence Senator KE:. xEDY. I was interested in the label6ng aspects, because vou hear theargument~s1 rom the other side saying that any commodity is abused, that it'wiil have an adverse health impact. That's an argu, inent you'll hear. I'm interested specifically in terms of alcohol. It's my impression thatt'~hecalorie intake and the~ fetal alcohol syndrome, which! you've mentioned, are certainly two. But I would like to hear from the AMA what the health implications are of labeling. Dr. STEEN. Well, I think there are manv, health implications from the. excessive use of alcoholic beverages: AVe support the labeling of aleoholic beverages. Have I addressed4he question~you Senator KE:,wEDY. Well, the reason beyond the abuses of it. We hear that anything can be abused', so should anything be labeled. I understand that in terms of alcohol, like others; there are rather specific kinds, besides the abuse and the~issues ofalcoliolism, that'theret are other health implications. One isthe amount of calories. Dr. STEEV. That's true.

380. Our predietions~were that if we were lucky, given the numerous past failures in health edtication. we might obtain a few changes. Our re- sults were surprisina to us in the dearee of table change in smoking, cholesterol level and blood pressure: in the individuals receiving mass media only. The group that received mass media and supplemental face-to-face classroom instruction had somewhat greater change,, par- ticularly in smoking cessation. A fifty percent quit rate occurred and was sustained for three years in this group. The public policy implications of our findings must be carefully separated from the strict interpretation of the results of our reseach, Although our results were very encouraging, we believe that replica- tion of these studies and extension to different types of populations is needed before we can fully be confident that the.methods we develbped are generally applicable. Nevertheless, an optimistic page in the book of! health education has been: written. A few of our recommend'ations are as follows : One,, it does appear that many American citizens are greatly inter- ested in.i nutrition and disease prevention and that a relatively minor amount of informatlion from a credible source can outweigh the larger resources of groups that may wish to sell'y for their own material gain, unhealthy lifestyles. Theref