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DIEPARTMENT OF }9EALTH:l' HU.r't'AN SER~'fCESI Public Health Service Office: of the Assistant Secretaryfor Health: - W.asningtonOC'. 20201 FORRELEASE' ONLY UPON DELIVERY STATEMENT BY EDWARD N: BRANDT, JR., Mi.D. A55ISTANT SECRETARY FOR HEALTH'. PUBLIC HEALTH, SERVICE' DEPARTMENT OF HEALTH AND HUMAN SERVICES BEFORE THE SEN'ATE LABOR AND HUNtAN RESOURCES COMiV1ITTEE iNARCH' 16,, 1982

Cigarette smoking, acts synergistically with oral contraceptives to enhance the probability of coronary and some cerebrovascular disease;, with. alcohol to increase the risk of cancer of the larynx, oral cavity,and esophagus; with asbestos and some other occupationally encountered substances to increase the likelihood of cancer of the lung; and' with other risk factors to enhance cardiovascular risk. Involuntary or passive inhalation of cigarette smoke can precipitate or exacerbate symptoms of existing disease states, such as asthma and cardiovascular and resp'cratory diseases and may be, carcinogenic for nonsmokers. Smoking, is also the, major identifiable cause of deaths and injuries from residentiallfires. Mr. Chairman, cancer was the first disease to be associated with cigarette smoking. As Dr. Koop pointed out in introducing, our 1982 report on smoking and healthh a few weeks ago; reports linking smoking and lung cancer began appearing in the scientific literature as long as 5& years ago. In 1964, when the Surgeon. General's Advisory Com.mittee's report wasissued, l'ung cancer in men, and chronic bronchitis in both men~ and women, were the two diseases which, the Committee identified as being caused' by cigarette smoking. The evidence which links cigarette smoking with.l'ung, and other cancers was reviewed in the most careful detail in the 1982 report just issued. Today, 18 years after the 1964 report, additional' human, experience and, enormous amounts of new research, make it possible for science to conclude that cigarette smoking is a major cause of cancers of the lung, larynx,, oral caMity, and esophagus, and that it is a contribut- ory factor in the development of cancers of the bladder, pancreas;, and kidney. Lung cancer accounts for one out. of every four cancer deaths, and 85' percent of these are due to smoking, Overalll, approximately 30 percent of all cancer deaths are attributable to tobacco use. O W. OS 2'. - M+r ~ ~!1 ~i1

Mr. Chairman and Members of the Committee: I am pleased to submit to you. today this statement of the Departmen:: of Health and Human; Services. on. the health effectss of cigarette smoking. Thes- health effects and their significance to the American peopde must necessarL;: provide the rationale, and justification for whatever action your Committee nray take in regard to the bill before you. With. me today are Dr. C. Everett Kooo, Surgeon General, and, Dr. Joanne Luoto,. Acting Director, Office on Sm,oking and H'ealth.. I'will begin by presenting a capsule description of the health effects ef cigarette smoking and', then a more detailed description of smoking and cancer and cardiopulmonary diseases. I will also address research efforts by the National Institute on Drug Abuse on the addictive characteristics of'cigarette smoking. In summary, cigarette smoking,is clearly the single most important preventable cause. of premature illness and' death in the United States. Estimates of the. numt _•r of deaths related to smoking exceed 300,000' annually. One may compare this. figure with the I05;000 deaths that occur each year as a result of all injuries, 20,000 deaths fcomm homicides, or the 40,000 infant deaths:, Cigarette smoking is one of the three major independent riskk factors for coronary heart disease and arteriosclerotic peripheral vascular dfsease; a major cause of cancer of' the lung, larynx, oral cavity and esaphagur; and a major cause of chronic bronchitis and emphysema.. Cigarette smoking is a contributory factor in cancer ofthe urinary bladder, kidney,. and pancreas. It is also associated' with peptic ulcer disease. Maternall cigarette srnoking, is associated with retarded fetall growth,. an increasedrisk for spontaneous abortion andi prenatal death, and slight impairment of growth andi development during early childhoodL

The Watiunal. Cancer Insti;tute is interested in pursuing some new leads. There is a growing body of evidence that people who smoke low tar and, nicotine cigarettes adjust their smoking behavior-inhaling more deeply or covering the ventilation holes in the cigarette filters. This is thought to be an attempt to compensate for the decreased nicotine yield., We plan to take a look at this question. If these preliminary studses are confirrned; it would imply that smokers of tod'ays''cigarettes are not decreasing, their exposure to nicotine and in fact may actually be increasina their exposure to harmful combustion products such, as hydocarbons and carbon monoxide. Smoking and Cardio-pulmonary Disease Chronic, obstructive pulmonary diseases (COPD)' today represents the fastest growing,of the major causes of death, now ranking fifth. in. 1980, 55,000 Americans died of pulmonary diseases. Almost three million Americans now suffer from emphysema, a terribly debilitating disease. More than seven million have chronic bronchitis. Chronic respiratory diseases account for approximately ten percent of disability benefits for lost work. hours. And, the evidence is. substantial and unequivocaD that cigarette smoking is the chief culprit in the onset or exacerbation of these diseases. Research, has for some time provided us with data demonstrating that smokers have higher mortality rates from. chronic bronchitis and emphysema and that smokers. have far less pulmonary function than nonsmokers. During, the past ten. years, we have also obtained a far better understanding,of the mechanisms of lung,damage, including the destruction of elastin, a major structural protein of the lung which is adversel'y affected by cigarette smoking.. And, within recent years, evidence hasbeen reported~ which suggests that the small airways function of the lung may be adversely affected in healthy nonsmokers if'they are exposed, to cigarette smoke from others.

Research~ continues in this area to give us a better basis of knowledge in order to prevent or arrest the progress of pulmonary diseases. Stud'tesfiave demonstra2ed the benefits of smoking,cessation, including improvements in lung performance on stand'ard' spirometric (breathing) tests soon after one quits. However,. pulmonary diseases represent a progressive condition and once a certain point is reachedl we can only hope to retard its progression. Investigators are working towards deveYoping a simplified means of d'etecting the disease condition at an early enough stage too intervene and reverse the process. At the same time,, research continues to:•try to develop and evaluate programs designed to help individuals give up smoking, since. smoking prevention or cessation represents the only effective intervention: measure we now have. Despite a dramatic decline in: mortality during the past decade, coronary heart disease remains the number' one killer in this country, cPairning, three-quarters of a millicn lives in the Uni2ed~ States each year. For every: minute of the day, there are aboutthree Americans who suffer a heart attack. While the progress in reducing coronary heart disease and'other cardiovascular deaths during recent years is heartening, the scope of the probiemm remains enormous. Cigarette smokingg is one of the three major risk factors for coronary heart disease; the other two being high blood pressure and high, serum cholesterol. Epidemiological evidence clearly places the smoker at a higher risk of heart disease than, the. nonsmoker. The more one smokes, the greater the risk.. There is also evidence that smoking cessation can decrease the risk. After only one year free ofi'cigarettes, a former smoker may be able to reduce the risk of heart disease to close within that of the nonsmoker:, The exact mechaniisms of how cigarette smoking affects coronary heart disease are still unknown and are the subject of considerable research, now underway. Nevertheless, the evidence based on epidemiologic and autopsy studies clearly linking the amount of smoking with higher incidence of heart disease, is indeed impressive. 6,

o It is now clear from a large number of epidemlologie studies--both retro- spectiue and prospective--that smoking is causally related to,at least 30 percent of all cancer deaths.. This means that approximately 129,000 people a,vear die of cancers related to smoking. o The causal relationships are strong.If we. just look at lung cancer, the major cause of cancer death among, U.S, males, a. cigarette smoker is 60, times more likely to die of this disease than a nonsmoker'.. And this risk increases witlh the number of cigarett'.es'smoked--a direct dose- response relationship. o>ror the first time,, two preliminary epidemiologic studies are suggesting an increased risk of lung cancer in nonsmoking wives of smoking husbands, implicating sidestream smoke as a cancer ri=_k factor, o We are encouraged by the figures om people who have been able to quit smoking, most of them through their own efforts. Im 1965, 42' percent of adults inthe United' Statessmoked. In 1980, the proportion dropped' to 33 percent. I would like to mention one program of the Office of Cancer Communications because we are proud of itssuccess. Based on the well L-docum en ted evidence that counseling, by a physician can motivate smokers. to quit, the office developed a"Nelping Smokers. Quit Kit" for physicians to use with, patients. More than 135,000 of thesee kits-wMich include posters for the waiting room,. take-home materials for smokers, and information on counseling the smoking, patient--were distributed. In fact, the kit was so well recelved that a similar one was created for dentists. This project was endorsed by the American Dental Association, which,is cooperating with us to distribute the kit. Staff are now working with the American Pharmaceutical Association to develop a similar program for pharmacists. 4

A subject which was hardly touched upon in the 1964 report is the effect of smoking on. women, and in the case of maternal smoking, its effect on the fetus and infant. In 1980, this was the topic of the Department''s report to Congress.. Its, concl'usions were that women are not immune to the damaging effects of smoking,, and that the lesser occurrence of smoking-related diseases among women smokers is a result of' women having, lagged one-quartier century behind men in. their widespread use of cigarettes. The 1980. report established that cigarette smoking is a major threat to the outcome of pregnancy and the well-being of the baby. The risk of spontaneous abortion, fetal death, and'. neonatal death increases directly with. increasing levels of maternal, smoking during pregnancy. Smoking causes a markedly increased risk of heart attack, and subarachnoid hemorrhage:, Another public health question, now enormously important, relates~ m the use of the. new, low-yield cigarettes. This was the subject of. the Department's.19'$1 report. The Report's conclusions were that although~ there is no safe cigarette, smoking cigarettes with.lower yields of tar and nicotine poses a lower risk off lung cancer than smoking higher-yield cigarettes, provided' there is no. compensatory change in smoking patterns.. Increasingly, smokers have turned to these lower- yield products; there is evidence to suggest that in doing,so, at least some have increased' their smoking or changed the way they smoke. This may have negated any potentiai,benefit in,their having switched to these products. Smoking and Cancer The 1982 Report of the 5urgeon General on the Health Consequences of Smoking, focussed upon, cancer. The report noted that the more than 100 diseases we call cancer are the second leading, cause off death. in the Unitedl Sates. The report also made these importantpoints: