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STATEMENT . BY JOSEPH A. CALIFANO, JR. SECRETARY OF HEALTH, EDUCATION, AND WELFARE BEFORE THE SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT OF THE HOUSE INTERSTATE AND FOREIGN COMMERCE COMMITTEE February 15, 1978' .

I Mr. Chairman, and Members of the Subcommittee: I appreciate this opportunity to appear before you this morning to discuss the extremely important subject of smoking and the public health. You have long been leaders in the health field and so it is appropriate that you should hold this hearing on a subject of great concern to our nation. Last month, on the fourteenth anniversary of the Surgeon General's Report, I renewed the commitment of the Department of Health, Education, and Welfare to inform the American people about the dangers of smoking in a speech to the National Interagency Council on Smoking and Health. That speech -- and subsequent commentary and debate -- has focused attention again on the health and economic problems posed by cigarette use. I welcome that discussion; only with robust debate can we develop a new public consciousness and an appropriate public policy about smoking --the single greatest cause of disease and premature death in this country today. , I also welcome the opportunity to report to you today _on HEW''s anti-smoking effort -- its goals, its main components, and its limitations. I also hope to persuade some of the program's more intemperate critics that their concern --like their rhetoric -- is greatly exaggerated.

-z- At the heart of HEW,"s anti-smoking program is a deep 'commitment to informed personal choice. I would emphasize the word personal because ours is not primarily a regulatory effort that seeks by rules to change behavior. Nor, even less, is it a prohibitionist campaign designed'to outlaw cigarette consumption. Rather our anti-smoking initiatives are primarily in education and research. Education to better inform Americans especially young Americans -- about the hazards of smoking so that a decision to start or to~continue smoking is based, as fully as possible, on a sound foundation of fact. Research to understand better unanswered questions about why people smoke and how they can effectively stop if they wish to do so. Make no mistake, our efforts are to reduce smoking. But they are efforts grounded in persuasion and information that appeal to:the common sense of our citizens. They are not efforts based on coercion and scare tactics. I have the greatest empathy for the millions of Americans who want to stop smoking, but who find it very, very difficult to do so~. Quitting smoking was have ever done. one of the hardest things I

- 3 - Thus, contrary to those who charge that our efforts are somehow an intrusion on individual liberties, I must underscore that~our primary goal is to provide information and conduct research that will enhance, not reduce, personal choice. 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 still do not wish to give up a personal habit, however hazardous, then, except for protecting,the rights of non-smokers, I think government can properly do no more. The Problem~ I must also emphasize that the anti-smoking effort is premised on a bedrock fact -- cigarette smoking is harmful to individuals and is a multi-billion dollar public health problem for the nation. It is also a major problem for the federal government which in fiscal 1976 paid approximately $40: billion of the nation's $139 billion health bill. Smoking is preventable Public Health Enemy Number One. Those who smoke are committing slow mition sucide. Scientists and physicians -- professionals who are generally cautious in their use of language -- agree that smoking is a major cause of heart disease, respiratory disease, and cancer of the lung and other sites. These are not abstract dangers to our health, but very real diseases. And imthe view of scores of scientists who have studied the problem for decades, both~in this nation and around the world,

4 the link between these diseases an&smoking is "overwhelming." Representatives of the tobacco industry who q!uestion the overwhelming evidence do a disservice to science and to the public. They insist, for example, that not every smoker has been shown to develop lung cancer, but they fail to . acknowledge that smokers are approximately ten times more susceptible to lung cancer than non-smokers. In~fact, the evidence of the serious consequences of smoking has been most dramatically acknowledged by health professionals themselves. Physicians, dentists and pharmacists are the leaders among those who have quit smoking. In 19501about 65 percent of America's physicians smoked. By 1975, 10 years after the Surgeon General's Report, only 21 percent were smokers. Last year, it has been estimated that more than 320,000 people in this country died prematurely from diseases attributable to smoking. Smoking was a major contributor to 175,000 deaths from heart disease, 100,000 deaths from cancer, and 15,000 deaths from chronic bronchitis and emphysema. Over 37 million people --one out of every six American alive today -- will die years before they otherwise would, because of smoking.

5 Some individuals are at especially high risk of smoking- related'disease and death. o Those who are more susceptible to heart disease, emphysema or lung cancer because of other risk factors, are compounding their risk dramatically if they smoke. o Those who work in certain industries and are expose&to occupational hazards such as asbestos, aluminum, coal, cotton and steel, will find those hazards much more harmful if they smoke than if they do not.. o Those women over 30 who use oral contraceptives are about 5 to 10 times more likely to die from heart disease than those who use birth control pills but do not smoke -- and smoking increases the heart disease death rate for women on birth control pills by 40 percent. The economic toll that these diseases impose on the country is also enormous. It has been estimated that in 1975 from $5 to $7 billion,were required'to treat smoking- related related illnesses. Another $12 to $18 billion T.rere lost in productivity in the work place due to absenteeism related to smoking. These costs do not reflect wages or productivity lost due to early death, nor do they reflect the costs of household fires -- about 13 percent of which are estimated to be related to smoking.

6 The most troublesome aspect of the problems related to smoking, in my view, is the fact that so many Americans start smoking at a very early age, as a result, in part, of expensive cigarette advertising campaigns. In fact, each day of the year approximately 4,000 children become cigarette smokers. - Seventy-five percent of American adults who smoke started before they were 21 years old. Ninety percent of today's smokers started smoking before age 25. These startling statistics indicate that to a very considerable degree, smoking in America is a problem of young people. Indeed, teen-age girls are now smoking more heavily than ever in the past. Since 1968, the percentage of teenage girls who smoke has more than doubled, so that the difference in smoking rates between teenage girls and boys has virtually disappeared. In 1969', 10 percent of all teenage girls who smoked used at least a pack a day. -Now, 39 percent of the teenage girls who use cigarettes smoke at least a pack a day. Thus, more teenage girls are smoking > now and they are heavier smokers than ever before._ ,

- 7- Moreover, the rate of teenage smoking is apparently on the rise -- and teenagers are starting to smoke at even younger ages. Teenagers and children who make the decision to smoke V i I a are often not doing so with the benefit of a fully informed perspective about the hazards of smoking. They are often responding to a half a billion dollar advertising campaign which portrays smoking as attractive and mature. When those young people become adults, they discover that smoking is neither adult nor sexy. It is extremely difficult to quit because smoking can often be addictive. Fully 80 percent of the adults who smoke would like to quit if they could find an easy way to do it, and over half have tried unsuccessfully to quit. Finally, health authorities have demonstrated that the increased mortality rate for smokers is significantly higher for those who start smoking as adolescents than for those who acquire the habit later in life. Let me underscore the great danger smoking poses to teenagers by describing four 16 year olds -- a boy and girl who start smoking at that age and a boy and girl who do not: cow ~ ~ Xb j `-

8 The two who smoke (assuming a pack a day)~ will have a 1 in 20 chance of developing lung cancer over their lifetime; the boy and girl who do not smoke will have only a 1 in 200~ chance of suffering from the same disease. o The two who smoke will have 6 chances in 10 of having a'heart attack; the two who don't smoke have only 3 chances in 10. The 16 year old smokers are doubling their lifetime risk of heart attacks by smoking. o The two who smoke have 1 chance in 20 of developing chronic bronchitis or emphysema; the two who don't smoke have only 1 chance in 200 of suffering from the same diseases. Thus, over their lifetime, the 16 year olds who smoke will have a 1 in 10 chance of developing a serious lungg disease such as lung cancer, emphysema, or chronic bronchitis, providing they manage not to have a heart attack. By contrast, the 16 year olds who do not smoke will have a 1 in 100 chance of contracting a serious lung disease over their lifetime.

9 Most strikingly, the life expectancy of the 16 year old make smoker is 65 years (at one pack a day) or 62 years (at two packs a day); the life expectancy for the 16 year o1d male non-smoker is 71 years. Similarly, the life expectancy of a 16 year old female smoker is 72 years (at one pack a day) and 70 years (at two packs a day): the life-expectancy of a 16 year old female non-smoker is 78 years. Thus, at the heart of the anti-smoking effort is a deep concern about smoking health effects =young,people.

-10- The Program Let me now describe the principle components of the HEW program in smoking and health. Education In order to provide a central coordinating focus to Departmental and government smoking activities -- especially our educational initiatives -- and to give this effort the prominence it deserves, I am establishing an Office on Smoking and Health in the immediate office of the Surgeon General. Mr. Chairman, the legislation you sponsored -- the National Health Information and Health Promotion Act of 1976 -- makes it possible for this office to carry out important functions. This office will be responsible for providing leadership in the area of smoking and health by expediting the development of educational materials which can be used in the programs of states, municipalities, and voluntary organizations; by working to establish behavioral and biomedical research priorities; by serving as a clearinghouse for requests fcr public and technical information related to smoking; by serving as a liaison between the Department and'other government{ and non-governmental organizations; and by facilitating the cooperation of the Public Health Service and the Office of Education in identifying school health education curricula

I would~like to elaborate briefly on this last point. I am convinced that if we are to provide young people with the perspective they need to make a truly informed choice on smoking as well as other health problems, we have to improve the health education programs offered in our schools. _I have therefore asked the Office of Education and Public Health Service to help in-the identification and demonstratiom of improved health curricula. I have also asked the chief state school officers of each state and 16,000 school district superintendants to concentrate as well on these important issues. We must provide teens and sub-teens with information to balance against the advertisements which appear in newspapers, in magazines, at sporting events an&on billboards and which portray smoking as glamorous. .The Office on Smoking and Health will also serve as the principal focal point for the drafting of a new Surgeon General's Report on Smoking. This Report will provide a comprehensive review of the biomedical and'behavioral research ~ --which has been conducted since 1964. It will note opportunities --for future research, and will review efforts available to .assist in smoking cessation. A major emphasis will be placed on young people and smokers at special risk. O ="a C.) .. ~ ~ A rV MP+ ~=-_

. * t i -12- There are those who say that education will not work -- that the habit of smoking is too ingrained. But our experience in the years since the 1964 Surgeon General's Report indicates that education is a powerful tool in this area, even though .much remains to be done: o Health professionals, as I have noted, have stopped smoking at marked~rates. o..The percentage of American males who smoke has also dropped encouragingly, from 52 percent in 1964 to 39 percent in 1977. The National Cancer Institute estimates that those withicoLlege educations are less likely to smoke than those who are high school graduates. Our central thrust, as I have noted, will thus be on education to ensure that individuals -- and especially the young -- have the facts before them when they decide to start or to continue smoking. ) Research = Research into the biomedical and behavioral factors in smoking is a second major focus of the program on smoking and health. Indeed, fully two-thirds of the Administration's

r -13'- $30 million FY 1979'smoking and health budget will be devote6 to research. An important element in this research program will be $4 million identified'for use by the National Institute on Child Idealtih~ and Human Development to investigate the childhood developmental determinants of smoking behavior. This work should help us to understand better those factors responsible for a child's decision to start smoking, or to adopt other behaviors which may ultimately be detrimental to his or her health. Other behavioral research will be directed at studying the addictive properties of nicotine, as well as the efficacy .of various smoking cessation~methods. We will continue or accelerate biomedical and epidemiologic research into the health consequences of smoking, the redticed risk in smoking lower tar and nicotine cigarettes, and'the interaction of smoking with other drugs and with occupational and'physiologic risks. There will also be research into a much-debated and very important problem -- the effects of smoke on non- smokers. Additional Elements In addition, I have requested that all states examine their laws on smoking in~public places and in health facilities, with the aim of'ensuring, where possible, the rights of non- smokers to clean indoor air. Similarly, in order to protect I

-14- t t the rights of non-smokers, I have issued tighter rules for smoking in HEW buildings and have asked the General Services Administration to consider such rules in all Federal buildings. This Department has also formed Task Forces with the Federal Trade Commission and the Department of the Treasury to examine questions of mutual interest related to smoking. With the FTC we will consider what constitutes unfair or deceptive advertising targeted at children or teen-agers. And with the Treasury we will study whether legislation is neede&which woul&increase the excise taxes on cigarettes, perhaps in a graduated fashion. Evidence from this country and abroad indicates that a 20 percent price increase -- an increase of about 10-15 cents a pack could lead to an overall smoking reduction of at least 5 to 10 percent. We are also exploring whether a higher tax would affect the choice of the young, beginning smoker. The Reaction As I indicated earlier, much attention has surrounded our identification of smoking as 1a significant public health problem. Most major newspapers have debated-the-subject.-- I have personally received well over 3,000 letters regarding this smoking effort. Thousands more have been addressed to key health officials throughout the Department. While nearly seventy percent of the correspondence received in HEW

-15- has been favorable, we have received a broa&range of ideas and constructive criticism. For example, a recent report commissioned by the American~ Cancer Society recommended, among other things, that the warning label on cigarette packages be revised and that an increased graduated Federal tax be imposed. This is a thoughtful report and,=although we are not yet prepared to advocate them, we are studying these recommend'ations. I woul&note, Mr. Chairman, that many European countries are far more stringent than the United States in~their anti- smoking efforts. . In Sweden, a new tobacco labelling act requires a declaration of content on each package that indicates tar, nicotine and carbon monoxide levels for the particular brand of cigarette. And to encourage comparison and drive down levels, the average amount of harmful substances contained in aLl brands in the country is also noted. • Sweden has also adopted a "fortune cookie" approach_ to warning notices on cigarette packages. There - are 16 different notices which are rotated among all packages. This decreases the likelihood that rs G

-16- the notice will simply be overlooke&and also provides the public with much more information than could be communicated in a single notice. In Norway, Finland and Italy, tobacco advertising is prohibited. In Finland, a certain percent of tobacco tax proceeds is earmarked annually for health education, research, and evaluation. In Finland, too, limits on tar, nicotine, and carbon monoxide are set by the government. 17i Nor are we prepared to advocate these measures at this time as a matter of Federal policy. In anti-smoking efforts, as in so many other areas, it is more appropriate for the States to experiment with more far-reaching measures before they are given in-depth consideratio as a federal policy for the whole nation. _ > _ . _. .. _ _. Thus, twenty-eight states have adopted "Clean Indoor Air Acts" and many more states and municipalities are considering such legislaaion. These bills govern smoking in public places and certain facilities such as hospitals and nursing

KI 44 -17- homes. We are encouraging other states, and'~ndeed government agencies, to consider the appropriateness of these provisions as they mount their own efforts to discourage smoking and protect the rights of non-smokers. As you know, most federal offices currently have no policy protecting non-smokers. In short, the program I set forth in my speech last month does not go nearly as far as programs some have urged and some jurisdictions have enacted. But our balanced program of education and'research is appropriate at this time. It is also appropriate that we take under further study more far-reaching,measures that would establish new regulations or incentives to discourage smoking or protect the rights of non-smokers. We believe our anti-smoking initiative will succeed. People are ready to quit. And the most significant drop smoking occurred during,another period of widespread public -~ debate and concern when the highly visible counter-advertisements appeared on television and radio from 1968 to 1970. Finally, our greatest concern is to reach children. I know of no responsible parent who would encourage a child to smoke, yet we have not been able to reverse the trend of smoking start-up in this vulnerable group. I am convinced that we can, but it will take a concerted effort not only by i

-18- this Department, but by pareints, teachers, employers, physicians, health agencies, voluntary associations, and state and local governments. It is clear that an important measure of the . success of the program will be a reduction in the number of teen-agers and pre-teens who reucr start smoking. The anti-smoking initiative is a sound'investment that can realize a priceless dividend -- a healthier future for the nation. Thank you very much. .~