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i 102 AMERICAN LUNG ASSOCIATION ~The'Chnstmas Seaf People a ® 1740 Broadway • New York, N.Y. 10019 • (212)245-8000 THE IMPORTANCE OF THE FEDERAL GOVERNMENT IN THE PREVENTION OF SMOKING-RELATED DISEASES Testimony in Support of H.R. 5653 a revised version of H.R. 4957 the Comprehensive Smoking Prevention Education Act by The American Lung Association 103 y;arti~ular behavior is iar.nful even thou- .,cz ='-is knowledge into appropriate action. The:. _-:ieve. Health education is pitifully primit: ..,c_s. hea'a 4 educational spots have markedly decli _ c-gramming, and the miniature "warning" on ciga .a:ertisiag is ineffective. At,one time, when a ,_ -,o: Seen appointed to office, the tobacco indus ._~ :arning by pointing to the non-existence of the xp?eared on the cigarette package. .ation of warning labels that would constantly r ..,- ~noicers of specific diseases produced by cigarett _-e :hev reached for a smoke and would have an impor: _r•c:ng fact into belief. While cleariy less effect: -__.n dollar advertising blitz launched annually by t ..,cca rotating labels would be an important first ..-ce_tio^ of advertising material convinces most ob --_ssion is to encourage non-smokers co smoke and t .-..R:ag. Rotation of labels should be followed by ...:_ac.onal techniques such as the publication of ar. _ rrssage if identical size next to each smoking adve ._.:e :n a free society is only possible when each ir r-aa. Crying "fire" in a crowded theatre is not dis ..r3g:ng one's neighbor to regularly inhale smoke: Edmund C. Ca.cey, M.D, penl~'"Conrad N. FowIer, Prrlidnrr.(*pj- ` Richard Sinsheimer. Paa-prryy~ ..~ Walier 1. Hatcher. Virr-Prry/~r~. 0.1 Edward M. 5ewe11. N.D.. V~rr-Pre~~~= Roslrn Bilford, Bernard G. Kuplow. Tm, Jarnes A. Swo.mley- ManaViny D SMOKING DOES CAUSE HUMAN DISEASE Prepared by Stephen M. Avres M.D. Chairman, Smoking or Health Committee February 1982 FeuWN u 19W Ur Americ.n Wne Auocu,inn ixNEe. alllia,M aareciawu NrouaMU, n,e U.S...nd a meCiral recuw, We wmaic.n TLm.ck Sociep .-_aough the tobacco industry characterizes the 14 ._ scoKing and human illness as the "Smoking and Hes --s.+,' the only controversy is the unwillingness of •-_.. :oiuntarily phase out cigarette production and -.•aividuals to stop smoking. The evidence estab: .--re of cigarette smoke has been accumulating since •-l-c~o Df the first report of the Surgeon General in : •- .:sancs o: articles documenting the harmful effects -t -,ave been published and the United States Public He

a 103 a:articulac beh.avior is 'aar^iful even t'nough they do ais Knowleege into appropriate action. They know buc ~-,-~ -e:ieve• Health education is pitifully primitive in che 'ieaith educational spocs have markedly declined from ^rogra:eming, and the miniature "warning" on cigarettes and;;ji:e-•2 ,,.:ercising is ineffective. P.t_one time, when a surgeon ~...;.~_ .ac aot Seen anpointed to office, the tobacco industry ridiculed ,•.. .....ced varning by pointing to the non-existence of the individual ,R.:u a.~a appeared on the cigarette package. 3:;tation of warning labels that would constantly remind aaosers of specific diseases produced by cigarette smoking s.cc ::ce _hey reached for a smoke and would have an important effect iact into belief. While clearly less effective than dollar advertising blitz launched annually by the tobacco suca rotating labels would be an important first step. A cu._•. _nepectio^, of advertising material convinces most observers t14t '._i iission is to encourage non-smokers to smoke and to keep .~a.r. ,muking. Rotation of labels should be followed by other ecucational techniques such as the publication of an anti- sw<:~; ~essage of identical size next to each smoking advertisement. R.a <noice in a free society is only possible when each individual 1s :ncormed. Crying "fire" in a crowded theatre is not dissimilar to encouraging one's neighbor to regularly inhale smokel SMOKING DOES CAUSE HUMAN DISEASE athough the tobacco industry characterizes the linkage of ::g4rette smoking and human illness as the "Smoking and Health :antroversy," the only controversy is the unwillingness of that L^.o-astrr, to voluntarily phase out cigarette production and to •acourage individuals co stop smoking. The evidence establishing the cox:: nature of cigarette smoke has been accumulating since the Pub:ication of the first report of the Surgeon General in 1964. Since than,thousands o: articles documenting the harmful effects of cigarette taoking have been published and the United States Public Health Service r 0

r has issued 13 subsequent reports on smoking and health. In 1976, the 11ational 8eart, Lune and 31cod Institute. a component of the prestiaious National :nscitutes of 5ea.th. concluded its 7ask Force Report on ?reventCon. Control and Education in Respiratory Diseases with the followine recommendation: "Cigarette smoking is the single most important risk factor for diseases of the lung. It is known to cause or exacerbate not only the respiratory diseases discussed in this report, but lung cancer, cardio- vascular disease and stroke, as well. Reduction, or ideally, elimination of cigarette smoking would have a major impact on national health and on the social and economic costs that are a consequence of smoking- related diseases. The problem of smoking warrancs the highest priority in all programs concerned with diseases of the lung. The most important target groups for antismoking programs are preadolescents and adolescents who have not yet started to smoke or invhom the smoking habit is not entrenched." In a free society, government cannot directly order abolition of destructive behavior but must constantly warn of the consequences of such behavior so that individual citizens can make informed choices. Such destructive behavior accounts for a large component of the annual mortality experience. In 1980, for example, approximately 700,000 died from c,ronary artery disease, 180,000 from stroke, 105,000 from lung cancer, 30,000 from bladder cancer, 7,500 from esophageal cancer and 60,000 from emphysema and other chronic obstructive pulmonary diseases. The common factor linking these one million deaths, more than half of the total deaths each year, is a demonstrated relationship to cigarette smoking. Many of these deaths are related to multiple factors includingheredity, exposure to environmental agents and excessive dietary cholesterol as well as to cigarette smoking. Cigarette smoking, however, is the single most important factor--nanv times more important than any other riskfactor. Detailed epidemiologic data allow separation of the mortality directly related to smnking. The Geller-Gesner Tables, published by Robbins and Hall in 1970, have been used by many physicians who practice "prospective medicine" to analyze the life expectancv of individual natients. The .e:=a snoes jeath rates for two hypothetical populati ;.:.:m 170,000 smokers and another group of 100,000 no: .':-~.a nur,.ber ot deaths expected in the subsequent ten years f;cDups of men between the ages of 55 and 59 are shovn. Onl: -..._t cen-.ocn causes of death aseociated with smoking are sho~ :1__1lation. Non-Smokers Smc ;_ronary Artery Disease 6,168 11, ._ 3 Cancer 257 3, coke =.-p'nvsema 1,066 69 -1, -zca_ Deaths Expected 7,560 17,: ''his analysis shows that for each 100,000 populatior _.. ";.e age group 55-59 years, the smoking population will he, -cre deaths than the non-smoking population. If one assumes hospital and professional cost of each individual prior ::eraged $10,000, the total excess health cost of the smoking s_lose to 100 million dollars. Since there are about five men in the United States between the ages of 55 and 59,the t 1xcess health cost in that age bracket is five billion dollar NEW AND CO*IFZRHINC EVIDENCE IS CONTINUALLY PUBLISHED Each year a large number of publications from laborac •~-'ucd the world confirm the relationship between cigarette sr -d 'auman disease. Hany different types of studies have been •-o:deoiologic study of death rates, results of stopping smokir. ='»g `unction, and examination of tissues at autopsy in smc ~•c 'on-smokers. A brief selection of several recent papers f -ch of these has been published in a highly respected, peer-r -e-aca! ;ournal. Two recent studies have shown increased life expectan :::cividuals who discontinued smoking compared to those who con

105 IN .,_,_ ,___.. scews deacn races for cwo hypothetical population sampies; _,,C,J00 smoKers and another group of 100,000 non-smokers. -.-,.-.oer o: deatis expected in the subsequent ten years for the two ,.:.°s oi :en '~et~een the ages of 55 and 59 are shown. Only the four :_a:,cn .auses of death as;ociated with smoking are shown in this c,1_.-_at~0n. Non-Smokers Smokers Artery Disease 6.168 11,454 ancer 257 3,223 Scn<e 1,066 1,600 _ h:sama 69 860 '::a: Deaths Expected 7,560 . 17,137 This analysis shows that for each 100,000 population sample i-1:^e age group 55-59 years, the smoking population will have 9,577 aore deaths than the non-smoking population. If one assumes that the cota' iospital and professional cost of-each individual prior to death ave:aged 510,000, the total excess health cost of the smoking group is c:ose to 100 million dollars. Since there are about five million xn in the United States between the ages of 55 and 59, the total excess health cost in that age bracket is five billion dollars. 3E'd AND CONFIRtiINC EVID^ICE IS CONTINUALLY PUBLISHED Each year a large number of publications from laboratories • arjur.d che world confirm the relationship between cigarette smoking and Suman disease. `fany different types of studies have been performed-- .ptdemioiogic study of death rates, results of stopping smoking, studies of :ung Eunction, and examination of tissues at autopsy in smokers and non-smokers. A brief selection of several recent papers follows. Lach of these has been published in a highly respected, peer-reviewed Mdtcal journal. Two recent studies have shown increased life expectancy in iadividuals who discontinued smoking compared to those who continued

i 106 with the habit. Doll and Peto (British Medical Journal, 2: 1525-1536, :976) followed 34.000 phvsicians in Great Britain for 20 years; half of the phvsicians followed stopped smoking during that period. Deaths from chronic obstructive lung disease decreased bv 24% in the physician group while the decline was but +X in the general public. The death rate from lung cancer in physicians who continued to smoke was 16 times that observed in lifetime non-smokers; the deach rate for physicians who had refrained from smoking for from five to nine years was six times that of non-smokers and fell to twice the rate of non-smokers after fifteen years of abstinence. The study also demonstrated an important relationship between the duration and the amount of smoking and the occurrence of lung cancer, dose-response relationships that strongly support the concept of direct causality. Friedman and associates (New England Journal of Medicine 300, 213-217, 1979) followed 4004 men and women over an eleven year period after an initial evaluation. The mortality rate in smokers was 2.6 greater than that in non-smokers and the differences could not be explained by any of 48 baseline characteristics. In a later study, the same group (New England Journal of Medicine 304 1407-1410, 1981) studied the effects of stopping cigarette smoking on death rates. The overall death rate was 2.22 greater in those who did noc stop smoking compared to those who did. Of great importance was the observation that among chose individuals who had coronary artery disease at the tine of the initial observation, the death rate in those who continued to smoke was 3.92 times that in the group that stopped smoking. Evidence that cigarette smoking may produce an acute myocardial infarction (heart attack) was presented by Hartz et al (Journal of che American Medical Association 246 851-853, 1981). Heart attacks were 2.27 times more common in the heavy smokers aged 35-49 compared to non-smokers; they were 1.95 times more common in the heavy smokers aged 35-65. ' Both lung function studies and pathologic studies on human Lungs have shown the deleterious effects of cigarette smoking. White and Froeb (New England Journal of Medicine 302 720-723, 1980) observed that lung function was 31% lower in individuals smoking more than two packs of cigarettes each day compared to non-smokers. Of great interest,lung 'unction was 132 lower in non-smokers working in a smoke-filled environment compared to those in a fresh atmosphere. Cosio et al 107 'he environmental sanitation movement of the "aiti an emphasis on pure drinking water and s: ".-;a': orovided clear_ evidence that maintenance of - - ,-.a_or responsibility of government. More recen~ of cigarette smoking has led to a new epidem: .._.s _hat can only be eliminated b,v direct action o: . r__ies. Like the Black Death or Plague of 1348-= of the population, cigarette smoking leads c ._.. _' large numbers of a nation's population. Adc _, :he "Comprehensive Smoking Prevention Act"would _s government squarely in the role of defender of The Federal Government must attempt to elimir •-..,ndreds of thousands of deaths due to cigarette s .. rzd~ce the billions of dollars spent for the ca --oacco-related diseases. Every effort must be ¢ , xopie from starting smoking and to help confira -- 'he increase in cigarette smoking among idol " .... ~articularly alarming and there is reason to .... __ societal pressures are responsible for this -s at one time extremely rare in women; its dr :ast decade is a stark reminder of the risks of ..+recte smoking: KNOWLEDGE AND BELIEF ":nv do people smoke? The'Roper Report commis -"+ .- .adustry warned that most people knew that cig and that many smokers desired to scop. Th detailed a series of problems that threat the tobacco industry and emphasized parti s-owiedge among the public and the growing a ""•=.r:unately, the knowledge that cigarette s - rcessariiy translated into abstinence. Behavi -fed the "health belief" model to explain wh~

'.tie environmental sanitation movement of the early Twentieth ,;r^curlwith an emphasis on pure drinking water and sanitary waste ..=-csa1 provided clear_ evidence that maintenance of the public health vas a naJor responsibility of government. More recently, the widespread ac ^ci~n of cigarette smoking has led to a new epidemic of preventable iwr•.s that can only be eliminated by direct action of public health r,;~.-r-cies. Like the Black Death or plague of 1348-1350 which killed :ae --ird of the population, cigarette smoking leads to the premature :aach.s of large numbers of a nation's population. Adoption of H.H. ;,;3, the "Comprehensive Smoking Prevention Acc"would place the United Sca:es government squarely in the role of defender of the public health. The Federal Government must attempt to eliminate as many of the aundreds of thousands of deaths due to cigarette smoking as possible ana :a reduce the billions of dollars spent for the care of people• v'.tr. cobacco-related diseases. Every effort must be made to discourage vccng people from starting smoking and to help confirmed smokers stop sxoKing. The increase in cigarette smoking among ~dolescent girls rtas -.een parcicularly alarming and there is reason to believe that a gr-uo of societal pressures are responsible for this situation. Lung cancer was at one time extremely rare in women; its dramatic increase in che past decade is a stark reminder of the risks of adolescent cigarette smoking: IQ70WLEDGE AND BELIEF '.Riy do people smoke? The'Roper Report commissioned by the tzbacco industry warned that most people knew that cigarette smoking , we harmful and that many smokers desired to stop. This public opinion arganization detailed a series of problems that threatened the continued aabilicy of the tobacco industry and emphasized particularly the spread ot hea:th Knowiedge among the public and the growing activism of non- ~ters. Unfortunately, the knowledge that cigarette smoking is dangerous L not necessarilv translated into abstinence. Behavioral scientists Irse developed the "health belief" model to explain why individuals WyV,i 0_hz__d

108 smokers had aignificar.cly more evidence oi inflammation in the smallest areas of the airways and chat this inilammation was orobabiv reversible when smoking was discontinued. Hale et al in an article published in the same journal demonstraced for the first time that smokers dying without obvious heart disease had thickening of the pulmonary blood vessels. These daca suggest a response to reduced oxygen concentrations in the smaller airways related to cigarette smoking. - - The toxicity of cigarette smoke to innocent bystanders as well as to smokers was shown by a recent study of Dahms et al. (Chest 80 530- 534, 1981).Ten patients with bronchial asthma and ten normal indivi- duals were exposed to cigarette smoke in an environmental chamber. Pulmonary function tests (the FEV1.0 ) decreased 21% in the asthmatics but not in the normals. The asthmatic patients were not particularly sick and were ambulatory. A substantial percentage of the general population has the sort of reactive airways demonstrated by the asthmatic so that the study emphasizes a major public health concern. "I 109 TESTIMONY OF JOHN A. OATES, M.D. CHAIRMAN SUBCOMMITTEE ON SMOKING AMERICAN HEART ASSOCIATION Submitted to the COMMITTEE ON LABOR AND HUMAN RESOURCE U.S. SENATE MARCH 16, 1982