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TESTIMONY OF JOHN A. OATES, M'.D. CHAIRMAN SUBCOMMITTEE ON SMOKING AMERICAN HEART ASSOCIATION Before the SUBCOMMITTEE ON HEALTH AND.ENVIRONMENT COMMITTEE'ON ENERGY AND.COM'MERCE U.S. HOUSE OF REPRESENTATIVES MARCH 5, 1982'

-4- if the clearly deceptive i.ntention of cigarette advertising, is attenuated by including an effective: warning. The warning is yet another way, at no cost, ini which the'federall government can effectively assist the private sector in educating the public about the hazard of cigarette smokiing.. Therefore, the Americani Heart Association strongly supports the adoption of the six specific warni.ngs proposed in H.R'_4457. We further propose the incorporation of the "circle and' arrow" format, recommended by the FTCL', to displlay the warning on ad4ertisements. This format would! significantly enhance noticeabil'ity of the warning. Finally, requiring that the warning letters measure at least 25°'' of the maximum brand name letters and' be,of the same proportion,ate detail would much improve its visibility. "' These simple measures,'at no cost„ would'' contribute greatly to~tne education efforts of'the private sector.

-6- 12'. Office on Smoking, and Health, "'Highl'ights From the 1980 Supplement to the National Health Interview Survey," May 1981 13'.. The Roper Organization, A Study of Public Attitudes Toward. Cigarette Smoking,and the Tbbacco~Industry in 1978, Volume 1, May 1978'. 14. Public Health Service, The Health Consequences of' Smoking - The Changin.g Cigarettec A Reportof the Surgeon General, U.S. Department of Health and Human, Serviices,, 1980 15. Maxwell, J.C. ;"Cigarette Sales Up iin 1981"„ Adyertising Age, p. 77, December 7, 1981. 16. Castelli, W',.P'.-; Dawber, T.R..; Feiniief„ M.; Garrison,, R'.J.,; McNamara, P'.M. and Kannel„ W.B. "The Filter Ci'garette. and Coronary Heart Disease: The Framnngham Study,." Lancet 2' (8238): 109-113, July 18',, 1981. 17. Myers„ M.D.: Iscoe, C..; J'ennings, CaroT;, Lenox, W;. Minsky, E. and Sacks, A. Staff Report on the Cigarette Advertising Investigation , Federal'Trade Commission May, 1981 18'. Kaufman, "Memory Without Recall , Exposure Without Perception," ~ JournallAd'vertising Research„ August, 1978 19'.. Craig, et al "Advertising Wearout: An Experimental Analysis" Journal of'M'arketiing Research, November, 1976 20. Brodsky, L.P. andl Myrowitz, Ellilott, "Visibility o.f Smoking Warning on, Cigarette Billboards, American Journal of Optometry and Psysi'oiogi'call Optics. 58 (2): 117-1i24, February,, 1981. 21. The Tobacco Institute. Comments of the Tobacco Institute on the FTC Staff Report on Cigarette Advertising Investigation Washington, D_C. , 1!981 22. Smilth„ R.C."'The Magazines' Smoking Habit" Columbia Journalism Review 16 (,5): 29-31 January-February, 1978 23.Whelan, E; Sheridan, M; Meister, K. and Mosher, BI. "Analysis. of Coverage of 'Tabacco Hazards in Women's Magazines." Journal of Public Health Policy, 24. The,Roper Organization Ommilus Study #726 for the Federal Trade Commission,. 1980 yj'/thd7 3/1/82

Mr.. Chairman and members of the Subcommittee on Health and Environment, my name is John A. Oates„ M.D. I am Professor of Medlicine and Pharmacology at Vanderbilt University and Chairman ofthe Subcommittee on Smoking of the AmericaniHeart Association. I appreciate the: oppartuniity to appear before this Subcommittee on behadf of the American Heart Associati'on to testify in support of the "Comprehensive Smoking Act, o.f 1981_" As you may know, the American Heart Association is a nonprofit voluntary health organization with over 119,000 members and almost 2 millilon other volunteers who are dedicated to the reduction of premature death and disabillity from cardiovascular diseases.' Cardiovascular diseases kill nearly one million Americans each year. This iis more: than all other causes combined. Heart attacks, the nation's number one killer, claims most of these liives. This year, as many as 1.5 million Ameriicans cani be expected to. have a heart attack and about 550,000 of them will die. The survivors will joiln over 4 million Americans,who have a history of coronary di'sease.2 These, figures have spe€iall significance because cigarette smoking, has been firmly i'mpiicatedi as a major contributor to the occurrence of heart attacks, sudden death, peripheral vascular disease and itt greatly aggravates other forms of cardiovascular d'iseases.. Cigarette smokers are, more, likely, than non-smokers„ to suffer a heart attack,, more likely to die from these attacks and more likely to die suddenly. Thi!ss effect is directly related to the amount smoked withiheavy smokers being at three times the risk of non-smokers. Fortunately„ ceasi'ng,to smoke reduces the risk toward that of nonsmokers.' Based on data from~ the Framingham Heart Study", we estimate that over 174,000 Americans will develop peripheral'vascular disease this year. While, twenty percent of' these people will be diabetics, 70% of the remainder willY be cigarette smokers:.s Moreover,, diabetics who also smoke are at even greater risk..' The link of cigarette smoking to peripherali vascular disease' iis consistent and independent of diabetes andi other risk factors and related directly to~the number of cigarettes smoked..' Perhap.s most significant is the fact.that whenipeople stop smoki'ng,, their risk of these cardiovascular diseases. graftall~ returns to: normal. The risk of fatal and non fatal heart attacks among ex-smokers is similar to non-smokers in about 1'DI years.''' The risk ofperipheral vascular disease is similarly reduced to that of a non-smoker in, about 5 years.l" The evidence incriminating cigarette smoking as a major risk factor for heart attack and periipheral vascular disease wasjudged by an expert panel of the American Heart Associlation to be conclusive.," They further concluded that p "Theoretilcal'ly, cigarette smokiing is the most preventable cause ofthese w cardiovascular diseases and'mortal':ity therefrom".' ~ ~ In spite of the overwhelming evidence linking cigarette smoking to GJ ' cardiovascuilar and other diseases, over 52 million Americans are sti11 ~ smoking.'1 However, two thirds of these smokers would like to quit and most

-5- 1!. American Heart Associ'ation„ 1981 N'ational Annual Reporb National Center: Dallais, Texas 1981 2. American Heart Associato , Heart Facts: 1982', National Center: Dallas, Texas.1982 3'. Kanne7, W'..B'_,; Doylle, J.T.; Fredrickson,, D..T. and Harlan, W.R. Report of the AD Hoc Committee. on Cigarette Smoking and Cardiovascular Diseases: For Health Profess.ionalis; No: 71-001-B American Heart Association; Dallas„ Texas'1977 4'. Shurtleff; Dewey;, Some, Characteristics Related' to the Incidence of Cardiovascular Disease and Death: FramingPoam Study' 18 year Foll'ow-uo. -Framingham Study; Section 30; DHEW PubTicatio.n No. (NIH) 74-599, February, 1974 5. Weiss,, N..S. 10Cigarette Smoking and Arteriosclerosis Obliterans: An Epidemiologic Approach"''. American Journal of Epiidemiology 95(1).: 17-25, 1972 6'.. We#nroth, L.A. and Herzstein, J. "Relationship of Tobacco and Smoking to Arterioscllerosis. Obliterans in Diabetes Mellitus." Journal of the American Medical Association 13'1(3): 20Fr209, May, 19'46. 7'. Kannel:,. W.B. "Epidemiologic Stud'ies.on Smoking in Cerebral and Peripheral Vascular Di!sease" in Wynder, E.L..; Hoffman, 0; Gori, G.G. (Editors),. P'roceadiiings of the Third' World; Conference on. Smoking and Health. DHEW'Publicatilon No.. (NIH) 76-1221. 1:257-274, 1976 8',. Doll, R. and Peto,, R',.. "Mortality in Relations to Smokiing: 20 Years' Observation.s on Male British Doctors." British Medical' Journal 2 (6051): 1525-1536,, December 25„ 1976 9. Gordon, T..; Kannel, W.$'_;, M€Gee; Dawher„ T.R.; "Death, and Coronary Attacks in Men After Giving U'p Cigiarettes: A Report from the Framingham Study,° Lancet 2':1345-1348', December 7'„ 1974 10:. Koch, A. "Smokiing, and Peripheral Arterial Disease," In: Wynder, E.L.; Hoffman„ D; Gori, G.B'_ (Ed'i'tars) Proceeding of the Third World Co.nference on Smoking and Health... DHEW Publication No:. (NIH) 76-122I 1: 281'-283 T976. 11. Kannel, W.B.; Doyle,,, J.T.; Frederickson, D.,T. andi Harlan, W~.R.; Report of the Ad Hoc Committee on Smoking and Card'iovascullar Diseases No. 51-028-A„ American Heart Association: Daillas, Texas 1974

This amply supports the need for varied warning statements in a format that is visi!ble. However, the Tobacco. Instiltute=x in response to the: FTC Staff Report, argued' that the effectiveness of' the ci~garette advertilsement and warning statement must be judged' by different criteria. The rati'onale is that "the former (advertiisement) must achieve consumer recall for a particular brand among numerous other brands, all of which present competing and conflicting: messages while the latter (warning)appears consistently to the consumer in every advertisement and' on every pack of cigarettes."' TMis'dual criteria is not only unsupported but unsupportable. If the warning statement has been "bemarkably effective" by being presented consistently the same way then it would seem that brandlrecall would be enhancedi if the, portrayed image was maintained unchanged ove.r the years. For exampl'e, the Marlboro advertisement should! be most effective i~f the original adi copy was continued. Yet,, the copy is changed andl changed frequently. Different cowboys are used in different settings., Add'iltionally„ Brown and Willi~amson made several changes in its very successful' Barclay campaign last year. The Tobacco Institute also notedl that ciga~rette advertising uses a multiltude of images to appeal to different markets. This tis indeed consilstent with the concept of market, segmentation. The logicali extension of this is that the warni'ng,must allso be tailored to, appeal to di:ffering consumers. For example; smokers with a history of heart disease iin theiir fami:lies may find a warning on smoking and Meart attack much more personally relevant than a general message. Moreover, the argument that cigarette adverti'ising is limited to the print media while consumers are exposed i'nn all media to informatilon on the hazards of' smoking~ is mi'sl~eading. The number of anti-smoking PSA aired on televilsi'on since the ban on cigarette commercials has been drastical,ly reduced wi'th hardly any being shown during prime time. Additionally, information on smoking, and health in the print media has been equally scarce. It fias even been suggested by some22-=' that the tobacco industry may be using its advertising, as a l:everage to diiscourage coverage on the hazards of smoking in the pri'nt media. For whatever reason, the: broadcast and print media is largely ilnaccessilble for informing the public of the dangers of smoking. Meanwhile, the so called brand advertising goes on at the tune of one billion do:lla~rs per year.l' Regardless of ttie iintent, non-smokers and chilid'ren are heavily exposed to this advertising. It would be, very difficult to argue convincingly that some non-smokers, especi'ally children and teenagers, are not affected'by this constant portrayal of smokers as being young, attractive, healthy and enjoying an adventorous'and pleasurable lifestyle. WitM this~kilnd of bombardment with no effective counter, it is not hard to understand why 53% of smokers do; not know or believe that smoking! causes many cases of heart attack.=` For the above: reasons, the warning label becomes a, very important medium to get more information to the pvbdic. The American Heart Assoctaton has made and willl continue to,make efforts to better inform the publlic about hazards of smoking. However, we do not believe that we have adequate access to the mediia to: fully inform the public. Our efforts will have a greater chance of success

-2- Mave tried to d'o, so_1O Fol'llowing an unsuccessful attempt. to quit, many of' these smokers. tend to switch to low tar and nicotine cigareettes.,l"-" Thils is evidenced by the continuing riise i~n the market. share, of these cigarettes to 60.9% of all sales in 1981,.15 This development is alarmi~ng because the evid'ence " suggests that many people switch to low tar and nicotine in an effort to lower their risk of adverse heallth effect. Whi'le switching to. these cigarettes may lower the risk for some diseases, there: is no evidence of a reduction in!risk for cardiovascular d'i'seases.'°' In fact, recent evidence from the Framingham Heart Study"°, suggests that low tar and' nicotine cigarettes may even increase the risk of cardiovascular disease:. This could be a very dangerous development' since most cigarette-related deaths are from heart attacks.'Tiie American Heart Association is committed' to helping smokers who, want to quit and preventing children from starting to smoke. Accordingly, we wholeheartedly support the passage of HI.R. 4957, the "'Comprehensi~ve Smoking Preventi'oni Education Act of 1981"'. The provision of statutory standing to the Office on Smoking and Health ils very important. The proposed role of the and Office on Smoking and Health wi111 be instrumental in combinirgd coordinating the efforts of the public and private sectors to address the probl'em,of cigarette smoking. This is a clear case where a relatively small federall effort can be used to mobilize enormous private sector resources to address a major health problem. The provisibn requiring the rotation of six, new warning statements on cigarette packages and advertisements i;s needed to better inform the public of the specific dangers of cilgarette smokiing, , The rationale for the requirement of a warning statement in the first place,, was to inform consumers. of the health hazard. However, the FTC''T has recently concluded that the current warning statement, which has been used on packages and advertisement since 1972, is overexposed and worn out. This. conclusion was. supported in part.by a study by Starch Message Report Service which found that only 2.4% of' adults exposed to~ cigarette ads reads the Surgeon General's warnings. This showld come as no surprise since any message presented exactly the same way wiill soon become so familli'ar that It will llose its effecti.veness.3Q` ' Furthermore, since cigarette companies. vary the copy of their advertisements to avoi'd the "lvear out"'effect, it seems reasonable to conclude that the warning, statement requries no less. Brodsky andl Myrowitz,2d' in a study of cigarette billboards, found the warning statement to be' written uniformly on all billlboards and.in a.manner similar to that used in newspaper and'. magazines:. Individual letters in the warning consistentl',y appeared the same, i.e., reduced detail. When compared with the detai'l and size of the letters in the brand' name, the two largest observed warning statements were 38 and 17 times smaller.. These two optometrists conclluded from their test that while the brand name was visible, the.warning was not., O C5 Ir+ 9