Governor's Citizens'panel on Smoking & Health

Lorillard

Governor's Citizens'panel on Smoking & Health

Date: 18 Nov 1980
Length: 314 pages
85645818-85646131
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85645815 /85646194 /State Legislation Re: Michigan State Legislation

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r r r I I REPORT TO THE GOVERNOR BY THE GOVERNOR'S CITIZENS' PANEL ON SMOKING & HEALTH i C L L CONFICENTfAL 1 r.V~~'I:VLJv` L COAY. ~ _pF, !S __GOPIE.3 I / /

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Michigan Tobacco & Candy Distributors and Vendors Association 1nc. Affiliated Organization-Music Operators of Michigan 523 WEST IONIA STREET LANSING, MICHIGAN 48933 TELEPHONE (517) 3722323 MICHAEL R. SPANIOLO LEGISLATIVE AND GENERAL COUNSEL October 30, 1980 Mr. Sunny Sun Nai Fong Chief{ Office of Health Education Michigan Depaxtment of Puhlic Health P,O. Box 30035 Lansi.ng, MI 48909 WALTER P. MANER I11 EXECUTIVE SECRETARY Dear Mr. Fong: There'is enclosed the-mi.nority report of the Citizen's Panel on Smoking and fiealth. Professor Warner has assured me that the minority report will be submitted to the Governor, along with the~majority report, on November 15, 1980. As you will see, th:e-minority report exceeds the two page limitation tentatively imposed by the Panel maj ority. The reason for this is- that the issues before the Panel are far too complex to be'discussed intelligently and responsibly in two pages. While'I have attempted to make the minority report as brief as possible, to submit anything less than the enclosed report would deprive the Governor and the citizens of Michigan of important information to which they are entitled. Accordingly, I respectfully request that the enclosed minority report be'submitted in its entirety to the Governor on November 15, 1980. Sincerely, P Walter P. Maner III Executive Secretary ericl; bt cONFlDENT1AL ~~`~~[[~~'\) ~ \I T R1._P \ODU{~ ~.~I COPY...~L~d ._.OF....(~.1...._.c~oIPi E8

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October 31, 1980 MINORITY ?,EPORT The majority report recommends a series of costly and wide-ranging measures designed to curtail the use of tobacco products in the State of Michigan. In view of the drastic -- indeed, sometimes punitive -- nature of the recommendations, the Governor and the citizens of Michigan were entitled to a searching analysis by the panel of the majority's factual assumptions and a careful weighing of the probable costs and benefits of the measures being considered. Regrettably, this did not occur. The result is a series of hastily conceived recommendations that would disserve the citizens of the State of Michigan. The majority report contains several statements as to the health consequences of smoking on smokers as well as nonsmokers. As demonstrated in Part II of this Report, these statements are not warranted by the available medical and scientific evidence. Indeed, the theory of "excess" deaths or disease relied upon by the majority has been criticized repeatedly. The majority's assessment of the "costs" of smoking stands on no firmer footing, as explained in Part III below. Finally, Part IV of this Report sum- marizes some of the more glaring problems and objections associated with the majority's major policy recommendations. I. The Majority Report Is the Product of Hasty and Uncritical Deliberations by the Panel The idea of creating a citizens' panel to consider a particular public policy issue has much to recommend it. Such a panel can be composed of people having diverse exper- tise and interests, and can take advantage of its members' sense of community service. But these benefits cannot be realized if the panel is unduly limited in focus, is denied sufficient time or resources to complete its work or is controlled by some preordained notion of what would be an "acceptable" result. In the latter circumstances, the citizens' panel is little more than a charade -- with the attendant danger that the panel's recommendations will be given more attention than they deserve. That is precisely the danger presented here. I

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2 The ability of the present panel to contribute to the dialogue on smoking and health depended upon the panel's willingness to investigate, as comprehensively and objec- tively as possible, the available scientific evidence and then to recommend to the Governor any policy initiatives that seemed warranted by that evidence. But instead of proceeding in that manner, the panel engaged in a headlong rush to judgment. Prior to the first meeting of the panel, which took place on June 19, 1980, the Project Director, Dr. Kenneth E. Warner, sent to all panel members a memorandum that addressed in summary fashion a variety of smoking and health issues. The note that accompanied the memorandum pointed out that the memorandum was "a first draft" that had been prepared during the preceding "week and a half." The memorandum was entitled a "discussion paper," suggesting that the issues covered by Dr. Warner would be the subject of investigation and discussion by panel members. This suggestion was strengthened by the statement in Dr. Warner's covering note that "[t]he attached paper is intended to provide [panel members) with background information as a common starting point for the Panel's deliberations." Rather than providing a "starting point," the panel majority uncritically, and without the necessary examination, accepted the factual assertions in the Warner memorandum. In announcing the first meeting of the panel, Dr. Maurice S. Reizen, Director of the Department of Public Health, referred to the Warner memorandum and then informed panel members that "[d]ue to the limited amount of time to make recommendations to the Governor on a Statewide plan, we will begin with a discussion of policy options during the June 19th meeting." In fact, beginning with the June 19 meeting of the panel, and at all succeeding meetings, the panel majority simply ignored the acknowledged limitations of the Warner paper and, at the same time, refused to consider any opposing views. The panel majority seemed to view its responsibility solely in terms of identifying all conceivable means of curtailing the use of tobacco products in Michigan or pun- ishing the users of such products. At no time did the panel consider whether such goals were appropriate or feasible. After having challenged this restricted and mis- guided view of the panel's responsibility at the panel's July 17 and August 18 meetings, the minority summarized its

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3 concerns in a letter to Dr. Warner dated August 26, 1980. That letter pointed out, among other things, that -- °Many of the statements in the Warner memorandum concerning smoking and health are highly question- able,*and are based upon unproven medical assump- tions, dubious social accounting techniques, and unbalanced economic rationales. °The panel's decision to restrict public comment to a total of 1-1/2 hours effectively prevented any constructive public dialogue on the funda- mental issues that should have been of concern to the panel. °The delegation of much of the panel's work to a small subcommittee, which was not representative .of the entire panel, and the failure of many panel members to attend scheduled meetings, robbed the panel of its proper deliberative character, making the panel little more than a rubber stamp for staff and subcommittee decisions. The letter ended by noting that "unless the nature and scope of the Panel's deliberations are altered significantly to include a comple'te airing of the smoking and health issue, the Panel's ultimate recommendations to the Governor will represent a disservice to the citizens of the State of Michigan." On September 2, 1980, Dr. Warner wrote to the minority to make clear that no questioning of the factual assumptions being relied upon by the staff and the panel majority would be permitted. According to Dr. Warner, "[w)ith a lot more time and a commitment of significant fiscal resources, I am sure that we could refine our under- standing of policy needs and alternatives, but not, I suggest, of the basic smoking and health facts." In the same letter, written almost a month before panel proceedings had concluded, Dr. Warner suggested that the minority consider f iling a "minority report" -- thus leaving no doubt that the panel would pursue but one course, the course charted by Dr. Warner. In keeping with this attitude, the panel discour- aged participation by representatives of the business cor,ununity in favor of participation by groups with views

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4 identical to those of most panel members. Few business groups or emoloyer-related organizations even were apprised of the panel's meetings. Indeed, of a group of 28'organiza- tions that were notified of panel meetings, only four were business related; the rest were almost entirely health or health education groups.l/ The panel also refused to consider evidence, sub- mitted by the minority, that disputed the principal medical and economic assumptions contained in Dr. Warner's original "discussion paper."2/ The minority's complaints concerning the panel's failure to consider this evidence went largely unheeded, as did the frustration voiced by the minority over the panel's failure to consider fully the ramifications of the policy proposals advanced in the majority report. In sum, in their zeal to immose their views regarding smoking on all the people of Michigan, the major- ity failed to consider the propriety or wisdom of doing so. Because of the panel's failure to analyze the factual assump- tions underlying the majority recommendations, or to engage in a meaningful cost-benefit analysis of the proposals, the recommendations can only be viewed with substantial skepticism. II. The Medical Assumptions Relied Upon To Justify the blajority Recommendations Reauire Critical Evaluation The primary justification for the restrictive measures advanced by Dr. Warner in his original memorandum (and repeated without substantial change in the majority report) is the theory of "excess" deaths or disease due to 1/ The minority's request that business groups be notified of the panel's meetings or involved in the panel's delibera- tions was rebuffed by concerns about "time constraints," fears of "disrupting" the panel's schedule, and the sugges- tion that any response by the business community could be put off until the panel's reco:nmendations were submitted for legislative action. . 2/ Dr. George E. Schafer, "The Smoking and Health Contro- versy: Another Side," August 1980; Letter to Dr. Warner from Walter P. Maner III, dated October 1, 1980.

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cigarette smoking.l/ The paper of Dr. George L. Schafer, submitted by the minority, amply demonstrated the highly questionable nature of that theory. . Although the majority report assumes a causal connection between cigarette smoking and death or disease, no such causal relationship ever has been established. Moreover, the Advisory Committee that prepared the 1964 United States Surgeon General's Report expressly rejected the theory of "excess" deaths or disease upon which the panel majority has relied.2/ The questionable validity of assuming that "excess" deaths or disease are caused by cigarette smoking is demon- strated by a few simple facts. For instance, if smoking causes lung cancer, it would be reasonable to expect higher rates of the disease in countries where more cigarettes are smoked per capita. But that is not always the case. Lung cancer mortality rates vary from country to country, and many countries with low tobacco consumption patterns have high lung cancer mortality rates. Moreover, the age of onset of lung cancer is independent of the age of initiation of smoking: In fact, on the average, smokers and nonsmokers get lung cancer at approximately the same age -- a fact that is curious if smoking indeed causes lung cancer. There are 1/ Warner, "Smoking and Health in Michigan," p. 1; Majority Report, p. 1. 2/ The Advisory Committee stated: "The total number of excess deaths causally related to cigarette smoking in the U.S. population cannot be accurately estimated." United States Public Health Service, Smoking and Health: Report of-the Advisory Committee to the Surgeon General of the Public Health Service, Dep't of Health, Educ. and Welfare, PHS Pub. No. 1103 (1964). In explaining the reason for its refusal to claim "excess deaths," the Advisory Committee stated: "The Commit~ee considered the possibility of trying to make suc'rh calculations, but it involves so many assumptions that the Committee felt that it should not attempt this ***." Hundly, J., Transcript, News Conference, Released by United States Public tieal:.h Service (January 11, 1964). i

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6 many other factors linked with lung cancer such as occupa- tional exposures, viruses, diet, food additives, pollution, stress, aging, and impaired effectiveness of body defense' mechanisms.l/ Undue preoccupation with cigarette smoking can be counterproductive in searching for the causes of and cures for lung.cancer.2/ Likewise, it has not been established that ciga- rette smoking is Causally related to coronary heart disease. In addition, there is persuasive evidence, as reported by Dr. Carl Seltzer in "Smoking and Coronary Heart Disease:r What Are We To Believe?", American Heart Journal (September 1980), demonstrating the unreliability of the conventional view that cessation of smoking reduces the risk of death from heart disease. Dr. Seltzer also has pointed out that, despite many years of research and experimentation, a causal connection between smoking and coronary heart disease has not been established. In reality, cardiovascular disease is multifac- torial in origin. There are many suspects: high cholesterol, high blood pressure, diabetes, aging, being male, obesity, personality type, physical inactivity and stress. Dr. Ancel Keys, a noted scientist, emphasized in his recent book, Seven Countries Studv, that the relationship between smoking and heart disease is not as simple as first supposed. Others have found that the mortality rates for cardiovascular disease have declined markedly in the past decade. These declines are even more marked in women,than in men. Yet, during this same period, tobacco consumption by women was reportedly on the rise. These reports are difficult to reconcile with the causal hypothesis. Several national com- mittees have considered the decline in cardiovascular disease and have not been able to attribute the decline to any known factor or group of factors.3/ 1/ For example, the incidence of lung cancer at General riotors Corporation's Coldwater Road plant in Flint is more than double the national average. A signif icant number of lung cancer deaths at that plant occurred among people who worked in areas where chrome, nickel and,cadmium were used. The Tr:ashington Post, Sept. 23, 1980. 2/ Schafer paper, pp. 7-9. 3/ Schafer paper, pp. 10-13.

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7 The second major flaw in the "excess" deaths and disease theory is the unreliability of the "extrapolations from national data" used by Dr. Warner to arrive at smoking and health statistics purportedly meaningful to the State of Michigan.l/ Many of the national figures themselves are questionacle because they are out of date2/ or were the result of studies that -- - "tended to investigate the rate of smoking independently of other behavioral variables, such as alcohol consumption and other lifestyle factors, occupational and environmental hazards, and certain psychological factors."3/ In view of the questionable nature of the national data, "extrapolations" from that data must be examined with particular care -- all the more so when such extrapolations fail to take into account factors unique to the State of Michigan. The majority did not examine Dr. Warner's tech- nique of extrapolation or data base with regard to smokers at all. The factual assumptions underlying the*majority's recommendations to "protect" nonsmokers from tobacco smoke suffer from a similar lack of critical examination. For years, evidence on the possible health effects of tobacco smoke on nonsmokers has been limited and mixed. In fact, the 1979 Surgeon General's Report concluded: "Healthy nonsmokers exposed to cigarette smoke have little or no physiologic response to the smoke, and what response does occur may be due to psychological factors."4/ Many inde- pendent scientists have reached similar conclusions.5/ 1/ Warner, "Smoking and Health in Michigan," pp. 17, 20; Majority Report, p. 1. 2/ Schafer paper, p. 4. 3/ Schafer paper, p. 5; quoting from United States Public Health Service, Smoking and Health: A Report of the Sur eon General, Dep't of Health, Educ. and Welfare, DHEW Pub. No.. 79-50066 (1979). 4/ United States Public Health Service, Smoking and Health: A Report of the Surgeon General, Dep't of riealth- auc. and Welfare, DHEW Pub. No. 79-50066 (1979), at p. 11-28. 5/ Schafer paper, pp. 14-16.

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8 The panel majority, following Dr. Warner's lead, choose to ignore this.evidence 4nd to rely instead on a single, widely-criticized study by White and Froeb reported in the New Enaland Journal of Medicine.l/ Although the report of the stuay asserz.ed that ciiror.ic exposure to tobacco smoke affects the small airways of nonsmokers' lungs, many scientists have criticized the study for flaws in design, methodology and techniques -- and also for the conclusions drawn. Dr. Claude Le_zfant and Ms. Barbara Liu of the Heart, Lung and Blood Institute of the National Institutes of Health cautioned in an editorial in the same issue of the New England Journal of Medicine that contained the White-Froeb report: "The question must be asked whether White and Froeb's new evidence is sufficient to initiate new legislative actions that would further restrict smoking in public places. This is, of course, a difficult and delicate question. * * * [T]here is no proof as yet that the reported reduction in airways function has any physiological or clinical consecuences. The study is confined to only one aspect of an issue too complex to be resolved on such a limited basis."2/ In sum, there is substantial reason to doubt the factual assumptions underlying the recommendations in the majorityreport as to both smokers and nonsmokers. In recent years, smoking has become an easy target for people anxious to solve our nation's health problems. But these problems will not be solved by ignoring the scientific complexities surrounding the smoking and health issue. But that is precisely what the panel majority has done. 1/ White and Froeb, "Snall-Airc;ays Dysfunction in Non- smokers Chronically Exposed To Tobacco Smoke," New England , Journal of Medicine 720-723 (March 27, 1980). 2/ New England Journal of Medicine, pp. 742-743. For a representative listing of other critical discussion of the White-Froeb study, see Schafer paper, pp. 17-18.

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9 III. The Asserted Economic Justifications for the Majority's Recommendations Also Are Flawed The panel majority also accepted without critical scrutiny the assertions contained in Dr. Warner's original "discussion paper" as to the social "costs" of smoking. These assertions are made suspect,-of course, by the unreli- ability of the medical assumptions upon which they are based. But even if the problems with Dr. Warner's medical data and conclusions are put to one side, Dr. Warner's economic assessments cannot withstand analysis. Dr. Warner failed consistently in his discussion paper to distinguish between private costs, which accrue to individuals as a result of their own personal choices, and external or social costs, which fall upon others. As a result, there is extensive double-counting of costs through- out Dr. Warner's discussion paper. Absenteeism and medical costs, to take an example, are fundamentally private, rather than social costs. That some part of certain medical bills often are paid out of common funds does not change the aggregate wealth of society. These transfers are merely from one sector of society to another. Furthermore, it is clearly inappropriate to speak of "the net cost of smoking" because cost, in economics, is an opportunity concept. It requires that we compare one state of affairs with another. When it is said that the cost of smoking is x dollars per year, what is the alter- native against which this cost is measured? If the answer is "no smoking," it must be recognized that we know little about the costs that would then arise. The only natural use of such comparative costs is to evaluate a proposed policy: Will the policy's benefits exceed its-costs? That is the ~ central question to which the Governor and the people of Michigan need a realistic answer. But the majority did not even conside!r the question. Indeed, the panel proceeded no further in its analysis than Dr. Ularner's initial discussion paper. And even Dr. Warner conceded in that paper (p. 50) the need to study the cost-effectiveness of any proposals that might be made. On the other side of the cost-benefit equation, ~ ~ Dr. Warner's discussion paper unduly minimized the tobacco 9 C rA ~ ~ m

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industry's economic contribution to Michiga.n.l/ On Septem- ber 15, 1980, the Wharton Applied Research Center of the University of Pennsylvania released a study of the United States tobacco industry's economic contribution to the nation in 1979.2/ This study shows that in Michigan, in 1979, the direct and indirect contributions of the tobacco industry accounted for 76,410 full-time equivalent employees who earned over 1.2 billion dollars. Just under 10,000 of these employees were at work in 1979 because of the direct contributions of the core sectors of the tobacco industry in Michigan. These core sectors included intermediate dis- tribution, retailing and vending, and support industries such as media and promotion. Personal compensation in the support industries alone amounted to 11.5 million dollars. Gross sales exceeded 925 million dollars in the retailing and vending sectors, and approached 666 million dollars for the intermediate distribution sector. The direct contribu- tion to state taxes in Michigan in 1979 totaled 164.7 million dollars. Additionally, within the state, the tobacco industry's contribution to federal taxes totaled 171 million dollars (excise, FICA, personal income and corporate income). Thus, the policy recommendations of the panel majority, in addition to resting on highly questionable medical assumptions, arq the product of an economic analysis designed to inflate significantly the so-called "social" costs of smoking. This problem is compounded significantly by the fact that the panel majority chose to ignore entirely the substantial economic contributions of the tobacco industry to the State of Michigan and its citizens. 1/ Warner paper, pp. 27, 30. 2/ Wharton Applied Research Center and Wharton Econometric forecasting Associates, Inc., Report Summary, A Study of the U.S. Tobacco Industry's Economic Contribution to the Nation, Its Fifty States and The District of Columbia, (August 1980).

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IV. The Policy Recormendations in -.he Majority Report Are I11-Advised and Unwarranted Given the limited scope and nature of the panel's deliberations, the policy recom.mendations contained in the majority report are entitled to little weight in any respon- sible dialogue on smoking and health. Indeed, even a cursory examination of the majority recommendations is sufficient to-illustrate the types of problems that would ensue were the recommendations to be adopted. A. Recommendation Nos. 1 and 2. The centerpiece of the majority's recommendations is a proposal to increase by five cents per pack the state excise tax on cigarettes. The majority report suggests that this measure would yield sufficient additional revenue to f inance the remaining recommendations. The majority report also recommends that the Governor and the Michigan congressional delegation lobby the federal government for a "substantial" increase in the federal cigarette excise tax. Unfortunately, the panel majority did not consider the discriminatory features of the proposed excise tax increases. Without the proposed increases, the tax burden on cigarette smokers in Michigan already is great: of the average retail price of 57.2 cents for a pack of cigarettes, 19 cents or 33.2 percent of the price is made up of excise taxes, federal and state. The state's portion is 11 cents per pack. This tax burden means that cigarette smokers in Michigan are responsible for a disproportionately large contribution to state revenues. Total 1979 Michigan tax revenues attributable to the cigarette tax were $141 million, or 2.3 percent of the total state revenues.l/ While all state residents benefitted from these revenues, they were contributed by only 38 percent of the adult population in Michigan.2/ Moreover, any increase in the cigarette excise 1/ Dr. Warner's estimate.of smokers' contribution to state revenues is even higher, "close to 3 percent of the State's General Funds revenue." Warner paper, p. 28. 2/ Approximately 2.4 million people in A:ichigan smoke cigarettes. Figure derived frcm data compiled by Tobacco Tax Council. I 1

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tax would be clearly regressive in nature. The estimated $153.00 annual tax burden carried by a family with two smokers (prior to any tax increase as proposed by the majority) is felt more acutely by the lower income family least able to pay.i/ The suggestion in the majority report (p. 6) that the recommended tax increase will not contribute signif- icantly to cigarette bootlegging defies logic and ignores substantial evidence to the contrary. As support for this suggestion, Dr. Warner noted that Michigan's current 11-cent excise tax is close to the 12-cent average of all states.2/ Obviously, this does not support the assertion that a five- cent boost in the 11-cent rate will not provide a signif- icant incentive for bootlegging. In addition, Dr. Warner's original memorandum pro- claims that Michigan's location is "far enough away from the major cigarette 'exporting' states (Kentucky, New Hampshire and North Carolina) that transportation costs would dis- courage major smuggling operations."3/ However, the evidence Dr. Warner offers, far from supporting his conclusion, actually indicates that bootlegging may pose a very real problem. He asserts that "[m]ost of the states victimized by bootlegging are situated on the Atlantic coast," foot- noting the "je]xceptions" located distant from the states that he defines as the cigarette-exporting states: Arkansas, Washington, Texas, and Michigan's neighbor, Minnesota.4/ In fact, Kentucky, with only a three-cent tax, is closer to 1/ While the $153.00 annual tax represents only about .7 percent of the effective buying income of households within the Michigan average income bracket of $20,800, it represents 1.9 percent of the effective buying income of a family earning less than $8,000. See "The Survey of Buying Power -- Data Service 1979," Sales and Marketina Manacement Magazine, p. 7-32. 2/ Warner paper, 3/ Warner paper, 4/ Warner paper, P P P 28. 28. 28.

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Michigan than to Minnesota, only a few hours away by i:.ter- state expressway. If raised by five cents to 16 cents per pack, Michigan's tax will be over 500 percent higher than the Kentucky tax. The involvement of organized crime in cigarette bootlegging is well known. Every tax increase creates more incentive for organized crime to bootleg by making boot- legging operations more profitable. in New York, for example, an estimated 480 million packs of cigarettes move through illegal channels in the course of a year. To put this into perspective, these are more cigarettes than the combined annual sales during the past year in Alaska, Montana, Utah, Vermont and Wyoming. Organized crime infiltrates distribution channels in population centers where the biggest market for contra- band cigarettes exists. For example, approximately one- third of the adults in Pennsylvania live in the Philadelphia area, where a number of arrests involving organized crime and cigarette smuggling have been made. Likewise, Detroit also would be a likely target area for organized crime. The otherwise law-abiding citizen may feel that he is only voicing his frustrations at the exorbitant taxes on cigarettes when he buys smuggled cigarettes. But what he is really doing is financing a variety of other underworld activities such as drugs, prostitution and loan sharking. Although the majority report seeks to convey the impression that the "economic efficiency" of the majority's policy recommendations was carefully analyzed (p. 2), this impression is mistaken, as is demonstrated in Part III above. Aside from the social undesirability of inviting bootlegging and criminal elements into the State, the effect of bootlegging on the "economic efficiency" of the proposed Michigan excise tax increase was not studied at all, much less studied carefully. The revenue loss to state and local governments in high-tax states is the most visible and direct consequence of cigarette bootlegging. The Advisory Commission on Inter- governmental Relations stated in a 1977 report that about $337 million in revenue is lost each year because of the smuggling of cigarettes into high tax states. In Michigan, the Commission estim,ated an annual loss of $6.9 million.

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The problem of bootlegging also affects indirectly the "cost efficiency" of the majority's excise tax proposal. The Advisory Commission noted that cicarette bootlegging already has dealt a damaging blow to the legitimate tobacco industry. Many jobs have been lost at the wholesale and retail level. The-panel majority also failed to recognize or consider the disadvantage of earmarking revenues. Part of the proposed five-cent cigarette tax increase is recommended to be earmarked to create a fund to finance anti-smoking. projects.l/ This recommendation would eliminate legislative control over future appropriations for the designated projects, since it guarantees future funding regardless of whether the project has continuing merit. This is plainly contrary to the growing recognition of the beneficial purposes served by annual review of govera.~nent programs during the appropriations process. Understandably, there- fore, the growing trend in state governments is away from the kind of earmarking of funds that the majority recommends and towards placing all revenue in a general fund from which the legislature can make annual appropriations. This trend has led some states to adopt zero based budgeting and/or sunset provisions. These tools permit the state legislature to scrutinize all state programs and projects and determine their validity, continuing usefulness, and relative importance. B. Most of the remaining recommendations of the panel majority are designed to control or penalize the smoking of tobacco products in public places (e.q., Recom- mendation Nos. 5, 6, 7 and 8) and to encourage the cessation of smoking by adults through either public education pro- grams (Recommendation Nos. 10, 11, 12, 13, 14, 15, 16, 17 and 18) or monetary incentives (Recommendation Nos. 3 and 4). In addition to a lack of demonstrated need for any of these measures, the recommendations would deeply involve the state government in mat-ters of personal choice. During hearings in other states on bills to re- strict smoking in public places, the problems inherent in such legislation have been made clear. Chiefs of police have described the difficulty of en=orcement; owners of res- taurants have pointed to the costs of compliance, including 1/ Majority Report, p. 6.

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the loss of income due to customer dissatisfaction; and office managers have spoken of the threat to harmony in the workplace because of unpleasant confrontations between smoking and nonsmoking employees. And then there are the growing number of persons -- smokers and nonsmokers alike -- who fundamentally disagree with the increasing encroachment of government into matters of personal choice. As Dr. Warner stated with disquieting eauanimity in his original memorandum, "police monitoring [of) smoking behavior has a distinctive Orwellian flavor."1/ In fact, government regulation of smoking behavior raises particularly disturbing questions because of its regressive character and potential for abuse. The poor will be the people who most will feel the impact, socially and economically, of many of the majority's proposals -- including the proposed "establishment of stiff fines for violating smoking laws" and "we ll-publicized instances of enforcement."2/ Moreover, laws to restrict smoking_in public have a hidden potential for abuse. An analysis of one month's operation of the now-defunct Chicago smokers' court revealed that out of 279 people summoned, 248 were black. A columnist who is himself an anti-smoker observed: "The suspicion is strong that Chicago's smokers' court has absolutely nothing to do with promoting clean public air."3/ The abuse to which public smoking laws are subject has been a major factor in the refusal of other governmental entities to adopt recommendations like many of those contained in the majority report. 1/ Warner paper, p. 58. 2/ Majority Report, p. 11. 3/ Schafer paper, p. 19; quoting from Jones, W., "Chicago's Smokers Court Puffs Up Some Haze," Minneapolis Tribune, July 1976.

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f CONCLUSION The superficial character of the majority report, and of the underlying panel deliberations, must be taken into account in any consideration of the panel's recommenda- tions. The majority recommendations are not supported by the evidence before the panel. Examination of the evidence the majority chose to ignore simply confirms the vulner- ability of the recommendations. Walter P. Maner III Executive Secretary Michigan Tobacco and Candy Distributors and Vendors Association, Inc.

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I I F I I ~ I I i L nF urc~rr+ r~w ~ ~t>~.~ j~r= -~t, GOVSRNOP's CITIaENS' PANEL ON SMOKING & HEALTH Nf:.MHF:R.S Ren I). Itarkrr, 11.11.S., ( h.rtrper+on PrUaG1T I)rnr i..r -n Ilculrn 7.K. KellnKk IFown.i.ut.rn Scott K. \imun.l. 1)r. P.II., Vict-C:hurrper.on Protea..ur ~,f Ile.rith IiJuc..erun Unt.er.rty o/ ~lrr htn..n Flrvnor H.uhar, I)vtcrur Genr.ce Indr.in I cntor Donald Itrccki.n. Ph. 1). Prote..ur of Ilealrh Education Central Vrchis.n (:ntverstry Honorable Raymond W. Hood Mrchrctn Hou.e oi Representattves Jame% p. Ilovard, Asst. Dean C.olleRe of Osteopathtc .Wedictne Mtchraan Snte I:ntverstry Thomaa A. Hunter Vice-President National 8aok of dettott Vtrrtrnta L. Kiolhede, Preatdent \1t, Plea.ant School System Margaret Lee Drpa rrment oi Physint Education and Hnlth, DlVOIt Public Schools 7talter P. ,Nanet 111, Executive Secrerary 4icht,atn Tobacco.nd Candy Dtstrrtwtors and Vendura Asaocuuon ( /.+nrrt ueadovcro(t, President Bo~td ri fTrectors (:and Valley Reston of the Amencan s Association oi Nichipn I-t..arles FI..Nitchner, President Gttrarer LanxnR Urban League Mtchael A. 4ornmore Heaitn Education Drrecror Berrten County Health Department Robert T. Orrvnn Coordinator Subsrance Abuse Jfervtces 4rd-+Mtcnrttan District Health Dep.rtment Vorherr Retnntetn Publrc Ile-.tlth Consulrant Ilonur.rhie 7illiam A. Sederburlt Uichtnin State ~anutc Jamc. C. Ternun. MLI)., Ile,4lth Officer I.uceal.tcktnacAl,cer-Scho.dcra(t District IIrJItn Uepurrmcnt DouKlas Vilotu.. Coordinator Hr.t, th Education and Pre.enrton Blue C:ossi I11ue Shield of ,uichrtpn ('ieorite I). Ti.lrts. Secretary-Treaaurer Ntcht"n .{Fl.daO Arrhur 3'eaver, kI.D., Protessor of $ureery 7avne So.+te l:ntver.ay Scnool of Nedicrne iTA F h' Kenneth E. Tamer, Ph.ll., Prutect Utrector Sunnv Sun Var Futrt, Chief. Office of He-ilrh Elucanon Rhonda Ru.n Runner, Student A...atst~nrr Ofuee of ileaeh Fdunrton November 18, 1980 The Honorable William G. Nlilliken Governor of the State of Michigan State Capitol Lansing, Michigan Dear Governor Milliken: Ph. (517) 373-9.t37 On behalf of the Citizens' Panel on Smoking and Health, I am pleased to transmit to you the Panel's report on recom.rnended actions to reduce tobacco-related illness and death. We believe that our recortunendations repre- sent a framework for the development of a ccmprehensive Statewide smoking and health program. It is cur hope that you will comnit your office to impilement these and related actions. The Panel will be pleased to meet with you to clarify any questions you may have concerning the report and to discuss the implementation of a State smoking and health program. Working with this Panel has been a grati-lying experience. Panel members have displayed an unusually high level of conanitnent and cooperation; the project staff has been exceptionally able and supportive. We have benefited from the assistance of representatives of several bureaus within the Uepartment of Public Health as well as indivi- duals from other state departTrents and agencies. Our deliberations have been aided by the testimony, written and oral, of numerous citizens representing a variety of voluntary and private sector agencies. In short, this has been an enterprise marked by concern and coirnit:rent. As you observed in your 1980 State of the State message, 't...smoking is cited as the greatest single preventable cause of death in America todayr'. The Panel has accepted this fact, well docLmnented in Surgecn General's reports dating frcm 1964, as its point of departu7e. The limits of time and other resources available to us occasionally restricted our ability to study recomznendaticns to the extent we would have desired;censequently, a few of the reccirIInended actions reauire further stecification before translation into policy. In each of Lhese cases, we OFFICE OF HEALTH EDUCATION MicSigon Department of Public Heolfl 3500 Nortr Logan, Lansing, Mi. 48909

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Honorable William G. Milliken Page Two concur on the principle involved but feel that refi.ner.:ent of details shculd precede irmlem.entation. Several of our recorr.endaticns call for further investigation. Sti'hile we have attermted to be as ccrmrehensive as possible in considering alternatives, we aclmowZedge that we may have overlooked potentially useful actions. The Panel achieved a high degree of consensus on each action reconzr.ended in this report. We present these recommnendations with the conviction that the severity of the smoking and health problem in Michigan warrants isnnediate attention. We believe that the reconanendations are an irportant step in this direction and, if fully implemented, can contribute to reducing the social burden of smoking. The Panel expresses its gratitude to you and conmends you for the unique public health opportunity you have created within the State. Respectfully submitted, Ben D. Barker, D.D.S. Chairperson LI I p L I

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I T.kRLE CF CC:vTENTS P.aC-.-- I I I I CTIT11:ZENS' P.k\FL NIEMBERSriIP ................................................ iii PROJECT kND RESCURCE STAF"r ................................................ iv I. PROLCGJE ........................................................... 1 II. REC3tIEZID aCTICNS ................................................ 2 A. Listing of RecorrQnended Actions .................................. 2 B. Explanation of Recommended Actions .............................. 3 MINORI'I'`f REPORT ........................................................... 12 BIBLIGGRAPHY .............................................................. APPEQICES ................................................................ A. Origin of Project .................................................. 1. 1980 State of the State Message ................................ 16 2. Project Proposal: Michigan Smoking and Health ................. 17 Intervention Strategies in the 30's . 3. Nfe.morandum of Understanding Between the University ............. 26 1J 16 16 of tiichigan-School of Public Health and the Michigan Department of Public Health B. 4. Opening Remarks: bfaurice S. Reizen, Director .................. 23 Michigan Department of Public Health Prccedures ......................................................... 30 1. Descripticn of Procedure ....................................... 30 2. Minutes of 'Meetings ............................................ 31 3. Subcomaittees .................................................. 63 C. ~rticles and Draft Papers Distributed to the Citizens' ............. 6.1 Panel and Subcomnittees 1. Background Discussicn Paper: SmokinQ and Health ............... 66 in MiGtli gan Tobacco Institute Response: The Smoking and Health ............ 113 Controversv: another Side

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TABLE CF CC`TE<TS (C:.V'-'D1 I PACE I D. Public Ccrrments and Testimony ........................................ :-9 E. Corresrondence ....................................................... 2a0 F. Evaluation Fonn ...................................................... 232 I I I I L

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I CITIE: NS' P.k\cL >E~3ER..,~HIP , , i Eleanor Bar~_-er Director Genesee Indian Center Ben D. Barker, D.D.S., Cnairperson Program Director in Health W. K. Kellogg Foundation Donald Breckcn, Ph.D. Professor of Health Education Central Kichigan University Honorable Raymond W. Hcod Michigan House of Representatives James P. Howard Assistant Dean College of Osteopathic Medicine Michigan State University Thomas A. Hunter Vice-President National Bank of Detroit Virginia L. Kjolhede President Mt. Pleasant Schcol System Margaret Lee Depart.-ent of Physical Education and Health Detroit Public Schools Walter P. Maner III Executive Secretary .NLichigan Tobacco and Candy Distributors and Vendors Association Janice ,L-adcwcroft President Board of Directors Grand Valley Regicn of the American Lung Association of Michigan Michael A. ~:ort ^cre Health Educaticn Directcr Berrien Couztv Health Department Robert T. Cr~^.ein Coordinator Substance Abuse Services ~Lid-Michigan District Health Depart:-;ent \'orbert Reinstein Public Health Ccnsultant Honorable William A. Sederburg Michigan State Senate Scott K. Simonds, Dr. P.H., Vice-Chairperson Professor of Health Educaticn University of Niichigan *Greggory Smith Publisher Upnorth Publication, Inc. James C. Terrian, M.D. Health Officer Luce-Nlackinac-Alger-Schoolcraft District Health Department Douglas Vilnius Coordinator Health Education and Prevention Blue Cross/Blue Shield of tiiichigan George B. Watts Secr etary-Treasurer Michigan AFL-CIO arthur Weaver, .I.1.D. Professor of Surgery .Yavne State Universitv Scheol of Medicine Charles H. NLitchner President Greater Lansing Urban League *Res i gied -i~i-

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I PROJECT Si AFr Kenneth E. Warner, Ph.D., Project Director, Citizens' Panel, and As'seciate Professcr, University of Nlichioan, Schcol of Public E-iealth Sunnv Sun Nai rong, Chief, Office of Health Education, :Lichig.an Depart:^ent of Public Health Rhonda Rush R~=er, Student Assistant, Office of Health Education, Ntichigan Department of Public Health Lynne~A. Lee, Secretary, Office of Health Education, 'lic:zi5an Depart^:ent of Public Health RESOURCE SI'AFr Maurice S. Reizen, M.D., Director, !fic:2iclan Department of Public Health William Clexton, Associate Director, Michigan Depar-nrent of Public Health !~1a.~awe11 Alderson, Bureau of Perscnal Health Services, Ntichigan Department of Public Health Russell Holmes, LI-i.D., Bureau of Disease Centrol and Laboratory Services, Michigan Department of Public Health ~Vanda~ Jubb, Ntichigan Department of Education John Insel, Bureau of Environmental and Occupatienal Health, ~Iichigan Department of Public Health George Laffcas, Office of Substance :abuse Services, Michigan Depart-nent of Public Health Marion Vaughan, Office of Comuamication Services, Michigan Department of Public Health Walter hheeler, Assistant to the Director for Program Develcpment, Michigan Depart:rent of Public Health I I L L L L

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I. Prcloi~.:e* I I f .. Cigarette smoking is the nt.mber one cause of preventable illness and death in the State of Michigan. Each year, smoking claims the lives of over 14,000 of our citizens, including 9500 dying from cardiovascular diseases and 3500 from lung cancer. Smoking-induced chrcnic illnesses disable thousands of other citizens: Michigan smokers lose 4 million excess days of work, well over a third more work days than non-smokers, and e:cperience 15 percent r,tore days of bed disability. Few long-term heavy smokers escace the ravages of chronic bronchitis or emphysema. The physical and emotional suffering resulting from smoking-induced illness is its most significant cost, but smoking also imposes a formidable economic burden on our State. annual medical costs attributable to smoking exceed $500 million. Thus, through insurance premiums, taxes, and direct pay:rents, a family of four pays some $200 a year in smoking-related medical bills. Productivity losses due to excess mortality and disability total over $1 billion. The State's 2.5 million smokers, two-thirds of whom wish they could quit, annually spend $750 million on over 25 billion cigarettes. In recognition of the toll of smoking, in his 1980 State of the State Message Governor Milliken said, "It is time to develop a plan to confront the health effects of cigarette smoking, particularly among children and youth." K.e announced that he would "appoint a citizens' panel on smoking and health to reconnnend actions to reduce and prevent tobacco-related illnesses and death." The Governor asked that the reccnmendations of the panel, presented in this Report, be transmitted to him by November 15, 1980. The Citizens' Panel was appointed by the Governor on May 7, 1980. As indicated in the membership list, participants represented a broad spectnmi of State groups in- terested in smoking and health and each participant brought considerable expertise to the deliberations of the Panel. The Panel convened for the first time on June 19, 1980 and met monthly thereafter, with project staff and Panel subcoamittees working intensively between meetings. The PaneT's deliberations covered initially scores of possible actions addressing the Governor's mandate. Of these, the Panel selected the actions presented in the next section of this Report as worthy of being reccm- mended to the Governor. Throughout its deliberations, the Panel attempted to assure that selected alternatives would meet criteria such as economic efficiency and po- litical feasibility. Variety and innovativeness were sought, reflecting the diversity of smoking and health probleuLs in the State. However, the overriding concern was that each action recomanended directly address at least one of the follcwing proposed major goals of a State of Michigan smoking and health program: -Preventing initiation of smoking habits, particularly by children and youth. Assisting current smokers to cease smoking. Encouraging less hazardous smoking behaviors for or will not quit. -Protecting nonsmokers' health and their right to confirmed smokers clean air. who cannot *Statements of fact and conclusions presented in this prologue derive from the Panel's investigation of the scientific literature and State of Michigan data. References to the relevant literature are included in the Bac.kground Dis cassion parer and the Bibliography in the Appendix. -1-

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I I. Re c cm.men d ed .ac t i cn s The acticns rec ra nded by the Panel are presented belcw in two sections. In the first section, the actions are listed in abbreviated form so that the reader might get a good overview of the "package" of reccmmendations. In the second secticn, each individual recc,endaticn is expanded and elaborated upon, includ- ing consideration of the factors which motivated its acceptance by the Panel. A. Listing of Recormended Actions 1. We recommend that the State excise tax on cigarettes be increased 5 cents per package. We urge that 1 cent of this tax increase be earnarked for State smoking and health activities. 2. 1ti'e recommend that the Governor and the State's congressional delegation urge the federal government to adopt a substantial increase in the fed- eral cigarette excise tax. 3. We recommend that the State Insurance Ccr.~issicner, in cooperation with the Director of the Departmcnt of Public Health be charged with research- ing the feasibility of requiring insurance premitan differentials on the basis of smking status for life, health, homeowners, and automobile in- surance. The same officials should also be charged with studying whether insurors should be required to offer reimbursement of smoking cessation program expenses as a health insurance policy option. 4. We recor,u:end that the Governor and the State's congressional delegation seek inclusion of smoking cessation costs as a tax credit or allowable itemized deductions in the federal perscnal income tax. S. We reconmend that the State adopt new legislation assuring a more com- prehensive protection of the rights of nonsmokers to clean air in public places and work sites. 6. We reconsnend that the Governor i-®ediately direct all State agencies and 7. enrorcernent activities. departments to implement a "clean indoor air" smoking policy. We recommend that the Governor encourage ccapliance with existing smoking and health statutes by increasing the enforcement efforts and capabilities of appropriate agencies. Further, we recommend that the Governor encousage relevant agencies to inplement alternative enforcement mechanisms, such as monetary civil fines. The Governor shculd explore mechanisms by which individuals could pursue a private cause of action related to violation of smoking statutes. We urge that public education be a ccopcnent of all 8. We reccmrend that the Public Health Code be :aent of penalty points for violation of the smoking law. m amended to include the assess- CP frM cPnri ra Pctahl i chnwnt ~1 9. We reccr,mend that the State suDport a stz:dv of the cigarette purchasing p,atterms of Michigan children and teenagers. I I I I ~ L

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I I 10. We recomrr.end that program plans of ? ocal healt:: depart* ents incl::de a wide variety of s;r:oking and health activities. 11. We recommend that the Department of Public Health provide skills training for local public health educators in the planning, irmlementaticn, evalua- tion and promotion of smoking education programs. 12. We recommend full support of the efforts of the Depart.rent of Education in developing a comprehensive K-12 school health education program and urge adequate funding for its i,mplementation. 13. We recommend that funds be made available to the Deoar-_:Ient of Education for comarative evaluations of the effectiveness of Drcminent co rehensive school health education models. I 1 i I I- 14. We recommend that state colleges and universities aid their students in avoiding smoking, instruct prospective teachers in effective smoking and health education techniques, and undertake research directed toward the generation of new lmowledge relevant to increasing the nonsmoking por- tion of the population. 15. We recommend that the Department of Public Health be provided the authority and fumding to develop a program to fur.d research and demonstration pro- jects concerned with smoking prevention, cessation, and cessation rein- forcement. 16. We recommend that the Dena:tment of Public Health promote the use of pro- fessionally prepared smoking and health media packages. Further, we recomxr.end formation of a groun of prominent State citizens to advocate nonsmoking behavior through the use of the media and other public fonmLS. 17. We recommend that systematic evaluations of the effectiveness of smoking cessation programs be carried out and monitored, with consideration of the possible future certification of the effectiveness of such programs. 18. We recommend that the Governor appoint and provide resources for an ongoing citizens' committee to advise him an the irrplementation of a State smoking and health program, to monitor smoking and health activities and develop- ments in the State, and to recommend new directions on an annual basis. 19. We recon3nend that the Department of Public Health be assigned responsi- bility and resources for the overall coordination of the State's smoking and health program. The Department should seek guidance from and cooper- ate with the State's voluntary health agencies which have an active interest in smoking and health. B. E.-m lanaticn of Recomnended Acticns 1. We recen~end that the State excise tax on ci arettes be increased 5 cents pe r pac v~e, raising t, e tax from 11 cents to 1 cents. We urze that 1 cent or tnis tax increase be ear:nard e for State smoking and neaizn activities. -3-

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Ntic.':igan's cigarette excise tax ,,ias last raised ;n 1970. ss ^r:ces in general have doubled during the decade, the failure ci the tax to have kept up with in- flation means that, relative to other gccds, cigarettes are ncw less expensive than they were in 1970. A considerable body of research ind;cates that this lower real price has encouraged greater cigarette smoking. A S-cent increase in the tax would serve to discourage smcking. Recent research indicates that the principal mechanism for this effect would be the disincentive to begin Smoking. Furtne:-^ore, it is ccnnenly believed that your.g pecple are :rost price sensitive, so A tax increase could have its greatest i-7pact cn this i.-nportant target grcup. A 5-cent tax increase would generate additienal State revenues of up to $60 million. The final total would depend on the decrease in smoking induced by the tax and the possibility of losses due to cigarette bootlegging. C.-M.T.Mications with the State Police indicate that they do not fcrsee significant bootlegging problems arising due to the tax increase. A recent federal law and decreased cigarette slmuggling activity nationally support the State Police assessment. The revenues generated by the new tax would represent a welcome addition to the State treasury. We urge the earmarking of 1 cent of the new tax :or smoking and health activities as an essential corrponent of any serious attermt to develop a State smoking and health program. The revenue generated, up to S1Z million, would represent a reasonable arnount to fund such a progra,^a. Without this earmarked source or equivalent funding from another scurce, many of u e remaining recommer.ded actions would beccme impossible to i,mplement. 2. We recommend that the Governor and the State's conZessienal delegation urqe tr.e federal goverrTent to acont a substantial increase in t: e reaer~ cigarette excise tax. Smoking contributes significantly to the high cost of medical care as well as other social costs. The total social cost of smoking has been esti.-nated to be approximately 51.50 per pack of cigarettes. We feel it is apprcpriate for smokers to contribute at least a significant fraction of the revenues needed to address this social burden. The federal excise tax has remained at 8 cents per pack since 1952, a period in which other prices have tripled. Thus the federal excise tax has dropped from over 35 percent of the price of a pack of cigarettes in the early 1950s to 13 per- cent of teday's pack. The depressing effect on the real price of cigarettes has contributed to an increase in s7r:oking over the years. A substantial increase in the federal excise tax (say, 1S to 25 cents) would have an i.~tare~'..iat eiate and persisti.-ig effect of disccuragir.g s:mcking. In particslar, it might have its greatest L=act on decreasing the rate of initiation of _.ki_ng by children and teenagers. 3. We reccrrr.:end that the State Ias;=r:ce Ccmnissicner, in cecoeration with tr.e Director of the eoartment or o ic r.ealtn, be c,zarzea witH re- searcn~.zg the reasioi itv or reau?rinZ insurance oremiun airterentials on the oasis or snQKinq status roz L =e. nea ~tn. .cmeowners. ana auto- mooiie insurance e same orricials :neul also be c-harz i s,:.:nving wnetr:er insurors sncuse one recuirec to cr,er wZV re,--rourse:r.ent of smoking cessaticn nrograrn expenses as a::ealtn L.surance coiic, cotien. I I I r L L L I

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I I i i ! t , A plet`:era of evidence demonstrates the higher death rates, health care costs, and fire damage rates experienced by smokers. titihile a few insurance companies curTently offer nonsmoker pre.mium discounts for several t; 7,es ot insurance, many cemnanies do not. The effect of their failure to differentiate is that nonsmokers are forced to subsidize smokers' insurance policies. The inequity of this is clear. Furthermore, the efficiencv of the system can be called into questicn. If smokers had to pay the actuarial value of their policies, the increased pre.^tiu7Ls they would face would serve as a disincentive to smoke. The Panel urges the Governor to initiate a study of all of the pertinent issues connected with differential insurance premiums. The study should draw on the best actuarial data available and consideration of experiences throughout the United States. Imaginative approaches to technical problems should be actively sought (e.g.,methods of imalementing effective premium differentials in group policies). If feasible and desirable, premium differentials might serve the dual purposes of increasing equity and decreasing smoking. The offering of an insurance option to reiir.burse for smoking cessation program costs would serve as a positive incentive for smokers to seek assistance in quitting. 4. We recommend that the Governor and the State's congressional deleQation seek inclusicn or smxinQ cessation costs as a tax credit or allowable itemiz deducticns in t e t era personal income tax, ei er as meoical ucationa , or miscellaneous uctions. The attemDt to quit smoking represents a clear commitment to improve health, and with it to decrease future health care costs. Inclusion of the costs of smoking cessation in federal income tax deductions seems consistent with the intent of deductions and would serve as an additional economic incentive for smokers who wish to quit. 5. We recommend that the State adoot new legislation assurin a more com- pre ensive protection of .e ri ts or nonsmo ers to clean air in puo ic p aces ana work sites. The right to s=ke in public and the right to breathe unpolluted air often come into conflict. In recent years, the pendulum of popular opinion, legislative action, and ceurt decisions have swt.umg in the direction of protecting the right to breathe clean air. The majority of the states offer some protection in this regard; chronologically, Michigan was among the leaders in the legislative arena. While portions of Michigan law represent high standards of protection of nonsmokers (e.g., the restaurant law), legal coverage in our State lags well behind that of other states. In particular, Minnesota has a comprehensive law frequently cited as the model of protection of nonsmokers' rights. According to a respected Minnesota poll, this law, which includes coverage of public places and work sites, is highly accepted by smokers and nonsmokers alike. Development of a desirable law requires careful attention to the need to make the protection of clean air comDatible with a reasonable economic impact. That is, a clean indoor air law must be effective, but it must also be efficient. Com- pliance should not impose unreasonable burdens on businesses. Thus, while we feel that such legislation should represent a top priority in any State smoking and health program, we believe that it must be developed rrith the assistance of input from the business ccrmnmity. -~-

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6. We recoranend that the Gover^or Lrr:ediatelv direc~. all State aQencies and aeyar^ents to i:;wlement a"clean ^ccor a:r" s-ohinQ Jolicv. Passage of a general "clean indoor air" 1a:J will require time. In the interests of imr,ediately protecting thousands of State citi=ens and having State govern.^ient serve as exe.^tplar, we urge the Governor to adopt a clean indoor air polic,, for all State agencies and depart:.%ents. We note that e:rplovees in nu.:erous State governmental units have reauested of the Denartment of Public Health and the Denart:r.ent of Social Services the development of a smoking policy where t:,iey work. The role of the State as exemplar has been cited in the State Health Plan. 7. We reccnnend that the Governor encourage ccn: liance with existin smokin an ealt_ statutes by increasin t e enrorcer:ent errorts and caDaDl ltles of appropriate agencies, incluaing State and local oo ice an the pro- secutor's orrice. rurt er, we recemnen t,zat tne overnor encouraQe re- levent agencies to urrolement a ternative enforcement r,becnanis:rs, such as monetarv civil fines as roviaed ror in t:e ?L:)lic riea t z Code, Section £Z3'Z. T e Governor s ou a exn ore mecnanisms by whicn u:aiviaua-Is could urp sue a orivate cause or action re atea to vioiatuen or smoking statutes. we urge that public eQucatlon De a cormonent of all en2orceIilent activities. Voluntary compliance with srroking laws, and indeed custcm, is by far the most de- sirable way to achieve legislative and social objectives. Vevertheless, legal enforcement often becomes needed when voluntary efforts are inadequate. We suggest that where violations of law appear to be ccrrn:cn, as in the sale of cigarettes to minors, enforcement should be pursued. Specifically, we recoranend a strategy not unlike that recently applied to the sale of alceholic beverages to minors. We advocate the establishment of stiff fines for violating smoking laws, followed by a warning of enforcement, and then several well-publicized instances of enforce- ment of the law. If undertaken periodically, this strategy need not corrmand significant State resources, yet it could help to convey the seriousness with which the State views its smoking legislation. The possibility of private actions similarly would de:nenstrate the seriousness with which many private citizens view their right to clean air. 8. We reconnend that the Public Health Code be amended to include the assess- ment or penalty ooints for violation or tr.e rooa service establishment sHo g law. Currently, restaurant inspection forms require investigators to note whether or not extablishments are co=lying with the restaurant law, but noncempliance does not result in assessment of penalty points. Many restaurants throughout the State have done exe:rrolary jobs in coarolying with the law. They have accepted the burden of coIIroliance voluntarily. In fairness to them and to nonsmoking patrons of non- conmlying restaurants, we believe the State should use the pe.*ialty point system to increase ccmpliance State-wide. 9. We recomsnend that the State suDnort a st::dv of the ci arette ourcnasin patterns of Aicnigan children an teenagers, .~zt+ oartic ar attention to sources of acauisituon or ciQarettes Le.7., venain :nacriines, grocery stores, over-t_7e-ccunter sales, gas staticns, :,eers, parents GD C17 I I p I- L -o-

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I I I Deter:r.inat;cn of effective strategies to di_courage sToking bv minors ^^.:st include consideration of making access to cigarettes more di=fiel? t. Cur:-e.^.t :..cwledge of where voungsters acquire cigarettes is Iir^Lited and dated. ',tie believe t::at a small inves,.ent in '.alowledge :night have a high pa;rofy in deveicping preventicr, initiat:ves. ~ 10. We recomnend that orogram ola,-is of iocal health de^art:-,.ents include a 3 wide variety of smo king and nealtn acti~nties, =nc_ua_1zu tr.e :e._ew:ng: ~ -stimulatin and initiatir.g smoking and health activities ~rithin ~ t~ieir ur: iction, ar.a using t~.~ie availao_maeria-Is ar:d orograms ot vo untaiv and government age.^.cies ; I L" -develcoin and providin continuing educatien, inservice traininr, ana consultative services tor eroiessionals, aaraororessiona s, and commnuiity members; -encouraging and/or assisting the develoer.:ent of a smokin4 education comroonent as part or patient eaucaticn in aospitais, clinics, and ea tn maintenance organi_atlons; -encouraging and assisting the develocment of smoking education as part ot pre-nata an parenting educat:en nro;: ar.J ; and, -evaluating the effectiveness of smoking education programs. The Public Health Code, Act 368 as amended, requires local public health depart- ments to plan, i.-nplement, and evaluate health education. With their broad range of preventive programs and contacts with comlmmity members, organizations, and professionals, local public health depart,rents are in aLmique positicn to facilitate and coordinate activities addressing the effects of smoking on health. In addition, local health departments constitute a netl,~ork throughout the State which can provide extremely useful for comn.nlicating experiences and innovative ideas. We believe that private sector health professionals and institutions have a unirue opporttm.ity and obligation to combat smoking-induced illness. We note with pleasure the involvement of many hospitals in patient education regarding smoking and health and hope that there will be increasing imro lvement in the future. T}:e expertise and resources of local health departments should be available to facilitate such activity. 11. We recommend that the Denar-=,ent of Public Health nrovzde trainin for loca oublic nealt educators in the olanning, i:rmieme-entatien, evalua- tion, an orcmotion or smoking eaucaticn programs. Knowledge of effective smoking prevention and cessation technieues is limited; furthermore, that which is'known has not been widely disse:ninated. Our reconmenda- tions will achieve maximum imDact only if all efforts are handled skillfully and evaluated carefully so that futl.re efforts can build =an them. The Department of Public Health is resoonsible for providing leadership for health education in the State. Although the Depart:aent currently lacks adequate resources to perform this function fully, it remains the logical lecss of training and ccn- sultat4cn in this area. -7-

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12. it'e reccnlr:end full suecort of the efforts cf the Deoar r^:e::t of Sd ucation in eveioninQ a ccrrcrenensive K-1Z scncol :^eaith educatien oroe-::m and urge aaeauate n..^iai.*:o for its =ieT:entaticn. _Soecir'ical.v, .~e recerr.r:e^d: -integratin~ education about the health effects of sTCkinQ into a corrroreaensive health education cu::icu:w^a; -providing a series of traiaing proQrams for educators and ad.^tini- strators, to be iointly oevelopea ov ti:e Lecar-:rents of uolic Health ana raucaticn; and I -developing a refere~nce~_guide for teachers, in cocoeration i,,-it5 the ~art; ent or ~wl.c .ea1~~n Office oz _uDstance Abuse Ser.:ces, eoartinent or haucation, an voluntar~r agencies. School instruction in the area of substance abuse, which includes alcohol, tobacco, and drugs, is mandated by State law. However, this law is not being enforced. Local Boards of Education have the option to decide the method to be used. Health education curricula, where they exist, have traditionally included the topics of tobacco and its effects on human health. By the directive of the Governor, the Office of Health and Nledical Affairs is co- ordinating a task force to develop a plan to help public schools in establishing com,prehensive health education programs. The Departr::ent of Education, through the Aichigan Education Assessment Program ('NIEAP), conducts a State-wide sarmling of the health education lmowledge of 4th, 7th, and 10th grade students every three years. Health education support materials have been developed and workshops for the training of trainers will be conducted. The Departmient of Education has also developed guidelines for a comprehensive school health education program. Given the cemplex psyc.hosocial determinants of smoking and other substance abuse, we perceive considerable value in a com:prehensive, integrated approach to health education in this area. The mechanism to develop such an approach is in place. We support it and would not wish to ccrTete with it. 13. We recorr.mend that funds bv made available to the Deoart7ent of Educatien sor comnarative evaluations of the ertectiveness or rominent comr)re- ensive sc.noo ea tn education mo e s. For is u ose, the uovernor might seek r eral rtmd.ing to be allocated tnrouQn the oart;nent oi Lducation. The subconnittee recogii=es that school health educatien models are often inade- quately evaluated or not evaluated at all. Reasons for this include a lack of money and evaluative expertise. The State of 4lichigan has two educational models operating under Title IVC: CoIImrehensive Health Education for Kids (Project =<) and the K-6 Manistee School Health Project. 4lichigan should seek to become a;nodel site for the evaluation of these innovative projects, wfiich might serve the Nation as well as our own citizens. 14. We recorranend that State colleges and universit:es aid their students in avoiding SP.oKLTlg t~l. oUgn orevention and cessation activities, instruct prosoective teacners in errective smoKing ana nealth education tecnniaues, and unaert e researcn directea tewar the Qeneration or new cioaieaQe I I I L I L -a-

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relevant to 1nCr°3S1I1a the '1CILST:OiCi:1Q 7CrtiCn o= t^e -, OCU:at_CP.c in aaditicn, t7ev snoule ident_r: resource ^ecoie to censuit cn ..:e evalua- tlCn or t2st'_niz Taterlais ana ZCi:c3t2CP.a1 ":etn cas. f ; 1 I This reccr.r,:er.dation directs t.be colleges and universiti es to utili_e t: eir par- ticular e:ctertise in developing and ccr.r~iicatir*lg '^Zcwle^ge to addr ess :: e s~:oki::g and health problems of three constituencies: a. their students who smoke or are at risk of beccr.r2ing sr:oriers; b. ele:r.entary and secondary schcol students who will ce,.e t.z:der the educatier.al guidance of their graduates; and, c. society at large. Traditionally, college-aged students are enterL-ig a high cigarette const=tion phase of life, yet many are less habituated than uhey will be a few years later. Thus, college represents a desirable time and location for smoking prevention and cessation activities. Regarding their responsibility to prepare ele:r:entarv and secondary school teachers, state colleges and universities currently offer verv, llimited if any'training in effective health education techniques. The research mandate reflects the need, and the colleges' and universities' C3D- ability, to develop an understanding of smoking phenomena which will irprove the effectiveness of activities such as these first two. 15. We recor*7r.end that the DeDart:nent of Public Health be provided the authoritv and --uu:aing to evelop a Drogram to runa research an cemonstraticn pro- ecu concerned with smonkin prevention, cessation, and cessation rein- orcement. roums e i io e ror sucn grants should inc uae businesses, a or unions, non- rotit organizations, schoo s, osoita s, ar oca nea tn eoarunents. 1 1-iziea ro ects snou a inc_uce we -sreciried evaluation D ans, inc in provision for errective follow-up, and I s oui Drovide tor consultative serrices :vnen in-nouse evaiuat,cn ex- pertise is not avai aE e. As a relatively new area, program options for smoking prevention and cessation are far from exhausted. A grants program would encourage innovative thinking; demon- stration projects would set up highly visible models; and the evaluaticn cemponent of all projects would add a dimension to the smoking and health field which has been seriously lacking to date. We would not discourage old approaches with new twists, but we would be particularly supportive of truly innovative efforts, such as secondar,v school smoking cessaticn programs, uGnagement-labor cessation program.s witth salary incer.tives built into them, a"hotline" aoproach to cessation reinforcement (e. g,, "Snaokers Anenymous") and follow-up tied to other activities (e.g., hypertensicn control). 16. We rec=end that the DeDartlment of Public Health nrcmote the use of proressior.ailv-oreoa smoxing and h ealt. media Dacxages. r.L-t.:er, we reccrznena rorrnaticn of a aroua of Dromi.^,ent state citi_ens to advocate nons,-nox~.*?Q benavior t.nrougn tne use or t:e r~ea~a ar:a ot7er ouo ic :orsns. -9-

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T::e federal Office of Health Information, Health P:-cr:oticn, Physical F itness, and Soorts Medicine (CHIP) will be laur.ching a r:eria car,roaign in 1931 ;,~hich will focus on risk education. Smoking is one of t:^.e behaviors that will be addressed. CHIP is encouraging 1eca1 agencies to soenser their prepared and pre-tested media messages. Similarly, the federal ~ffice on Smokir.g and Health (OSH) has contracted with a professional advertising agency to develoo broadcast anti-sr.:oking messages. This appears to be an opportunity to take protessicnally- prepared health "advertisements" to our citizens at little cost and is consistent with the State Health Plan's call for a health prcmotion media campaign. The evidence on the effectiveness of media health education campaigns is limited but generally positive. Research indicates that the Fairness Doctrine anti- smoking messages, broadcast on 'N and radio from 1968 through 1970, decreased smoking about 4 percent each year. More recently, the Stanford Three-Ccrr~rrunity study found personalized instruction, supported by the mass media, to be an effective means of reducing the risk of heart disease. Given the ability of the mass media to access the population, this is an area in which evaluation should play a significant role. - The opportunity afforded by the CHIP, OSH, and other professional media packages should'be supplemented with media "testimonials" by prominent Michigan citizens, including athletes, politicians, and representatives of business and labor. Popular children's characters might be enlisted to support the prevention message (e . g. , Ronald ' McDonald) . All media efforts should be utilized in coordination with ongoing prevention and cessation activities. 17. We recorrmend that systematic evaluations of the effectiveness of smokin cessation pro ams e carri out an monitor , with consideration of t e oossio e ruture certificiation of t~le e=iectiveness or suc oro¢rams. The airrent paucity of understanding of which techniques are effective and which are not in smoking prevention and cessation precludes current attempts to rate or certify the quality of programs. However, should such knowledge evolve and should public monies be used to finance programs, certification might becczne possible and desirable in the future. Of at least equal importance, developing understanding of the characteristics of effective smoking cessation programs can guide the de- veloement of new efforts in this area and can serve to inform the public. 18. We recommend that the Governor avtoint and provide resources for an on- oing citizens' conmu ttee to a vise im on the imnle:nentaticn of a tate smo g and zeal oro am to monitor _moxin and health activities and aeve orments in une tate an to recor.mena new directions on an annua basis. This reccmnendation derives from three concerns: ~ C!` a. This panel has labored hard but over a relatively short time. We ~ believe that an ongoing comnittee might usefully build on the work tl~ we have begi.m. OD V1 b. :an ongoing ccamnittee could assist the Governor in identifying the ~ resources needed to imple:nent a smcking and health prcgran effectively. c. Issues ccncerning smoking and health are evolving ccnti.^.ueusly. I i I t I L L L -? 0-

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I I I i I I J Some truly profound changes ccc-ur over the srace of cnlv a few years; witness, for exa~le, the relative grcwth of smoking amcng wcrren and the rapidly i:-:creasi.zg popularity of low tar and nicotine cigarettes. Consequently, needs in the area cf smoking and health policies can be expected to change continucuslv teo. An on- going ccnmittee, reporting annually, could keep abreast of new develecr*ents and therebv assist the Governor in keeping the State's smoking and health pregram up to date. 19. We recemmend that the Deoartment of Public Health be assioned resnonsi- i itv and resources for t e overall coordination of t e Jtate's smex_IrR and nealtn orogram. Staff should be allocated sneciticallv for this urcose. one or its functions, the staff snou a assist the aoove- raention advisory citizens coTrunitteec ne epartment snou a seek i ce rrem and cooperate wi e tate's voluntarv health aqencies w icn have an active interest in smo ing and ea tn. As our recomnendations suggest, a State of Michigan smoking and health program will involve a wide variety of State and local agencies, including those concerned with health, education, and safety and criminal justice. Nevertheless, a successful program requires a central locus of coordination. Given the motivation for a smoking and health program--promoting health--and given the variety of recemmended activities involving heal th agencies, we believe that the Depart-nent of Public Health is the logical and desirable home for the State's program. In recognition of the demon- strated cormnit-rent of several voluntary health agencies to reducing smoking, we urge that the Department consult with these agencies to benefit from their exper- ience and cocperate with them to further the cause of smoking prevention and cessation. We wish to earohasize our firm conviction that a serious irtpact on our State's smoking problem requires a serious commitment of resources. A for.ialized base for a smoking and health program within the Department of Public Health would lend it visibility and credibility. Permanent staff would be essential to monitor the program, keep abreast of developments within and outside of Michigan, and other- wise promote the vibrant activity suggested by the Governor in his State of the State message. Obviously, finding the fiscal resources for any new program in the current austerity appears difficult. But here, at the end of cur discussion of recomnendations, we return to the first recommendation for a solution: im- plementaticn of an additional 5-cent excise tax, with 1-cent earmarked for the smoking and health program, would provide the needed resources for the program and sinultaneously=generate additional millions for the State treasury. Gb ~ i ~ I C!1 . 1/ m C!1 I f _ N -ll-

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I I I I I 1 ~ a i I i I L f ~ 1 1,tinor;tv Recort At its :r:eeti.^g on October 3, the Panel approved the for-~iat of its _`inal reoort, including provision for inclusion of minority reports not to exceed rn,o single- spaced pages in length. This limitation was considered appropriate given the anticipated 10-page length of the minority report. Walter Maner submitted a 16-page minority report, dated October 30. Many of the substantive concerns expressed in this minority report are included in a 10 page report and several letters previously submitted by Mr. Maner. These doa..^r.ents are included below in appendices C and E, as tthe Panel had agreed at the October 8 meeting. At the November 6 meeting, the Panel reaffirmed its decision regarding the length of minority reports; hence, Mr. Maner's minority report is not included in this report. However, the Panel does not wish to deprive the Governor or the citizens of Michigan of any input into the work of the Panel. Therefore, a copy of Mr. Maner' s report is on file at the Michigan Department of Public Health and may be obtained by anyone on request. -12-

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I I I I 3 F I- I BI3LICGR-~-E-' abramson J. , Hopp C. , Gofin J. , Gofin R. ,!takler A. , Habib J. , and Rcr.en I., "A Cc-m;auiit,v Program for the Control of Cardiovascular Risk Factors: A Preliminary Evaluation of the Effectiveness of the Crad Prog=n in Jerusalem", Journal of Cc .ru~itv f?ealth, S(1) : 3-21, Fall, 1979. Advisory Conanission on Intergoverrunental Relations, Cizarette Bootle2-inQ: A State and Federal Resronsibilitv, Washington, D..,: ay, 1977 Baric L., "Non-Smokers, Smokers, Ex-Smokers: Three Separate Problems for Health Education", International Journal of Health Educaticn, Supplement, XQCII (1 : 2-20, 197. Bennett D. and Levy B., "Smoking Policies and Smoking Cessation Programs of Large Emroloyers in Massachusetts", American Journal of Public Health, 70 (6): 629-630, June, 1980. - Botvin G. and Eng A., "A CoTmrehensive School-Based Smoking Prevention Pro- ' gram", Journal of School Health, pp. 209-213, April, 1980. Preventive Medicine, 7, 449-458, 1978. Breslow L., "Prospects for Improving Health Through Reducing Risk Factors", Califano J. A. , Address by the Secretary of Health, Education and Welfare to the National Interagency Council on Smoking and Health, Washingtcn, D. C., January, 1978. Danaher B., "Smoking Cessation Programs in Occupational Settings", Public Health Reports, 95 (2): 149-157, 1980. Evans D. and Lane D., "Long-Term Outcome of Smoking Cessation Workshops", American Journal of Public Health, 70 (7): 725-727, 1980. Fisher E., "Progress in Reducing Adolescent Smoking", editorial, American Journal of Public Health, 70 (7): 678-679, 1980. Food and Drug Administration, "Clinical Implications of Surgeon General's Report on Smoking and Health", FDA Drug Bulletin, pp. 4-6, February- March, 1979. Greene G., "Vonsmokers' Rights", Journal of the American Medical Associa- tion, 239 (20): 2125 - 2127, 1918. Kctin P. and Gaul L. A., "Smoking in the Workplace: A Hazard Ignored", .Ar:erican Journal of Public Health, 70 (6): 575-576, June, 1980. Lau R., Kane R., Beery S., Ware J., and Roy D., "Channeling Health: A Review of the Evaluation of Televised Health'Campaigns", Health Education Ctiarterlv, 7 (1): 56-89, 1930. Nic4lister A. , Perr,v C. ,?Cillen J. , Slinkard, L. and Maccoby N. "Pilot Study of Smoking, Alcohol and Drug Abuse Prevention: :american Journal of Public Health, 70 (7) : 719-721, 1980. -13-

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I Macoby V. , Farquhar J. W., Wood P.O. and :1.Iexander. J. ,"Reduc:ng t`:e Risk c: Cardiovascular Disease: Effects of a Ccnamnity-Eased Ca,-mai7,, cn Knowledge and Behavior", Journal of Cc,n^:ur.ity Health, 3: 100-114, 1977. !Moerloose J. De, "Legislative Action to Combat Smoki.-ig Arou7:d the l;'orld", IM-i0 Cnronicle, 31: 362-372, 1977. National Autcrratic Merchandising Associaticn, Gilbert Ycut!: Research Study, Chicago, 1963. Vaticnal Conunission on Smoking and Public Policy, A\atioral Di1e^IIra: CiQarette Smoking or The Health of Americans, Board of liirectors, erican Cancer ~,Zociery, nc., January, =i . National Institute of Education, Teenage Smoking: Ir,mediate and Lonsz Tern Patterns U. S. Department o Health ana m=an Services,'.tiasrungton, . C. , tiov er, 1979. ,National Interagency Council on Smoking and Health, "Smoking and the Work- place: A National Survey:, Ocaunational Health and Safety, pp. 31-32, May, 1980. Nation's Health, "15% of Companies Report Cessation Projects", 10 (5): 4, . y, . Perry C., Killen J., Telch M., Slinkard L., and Danaher B., "Modifying Smoking Behavior of Teenagers: A School-Based Intervention", American Journal of Public Health, 70 (7): 722-724, 1980. Puska, P., Koskela K., McAlister A., Pallonen V., Vartiainen E. and Homan K., "A Comprehensive Television Smoking Cessation Programme in Finland", International Journal of Health Education, Supplement, Vol. XXII, issue N.4, toder- emner, i_. Romas J. A., A Stud of Health Instructional Practices in ~Ntichi¢an Public Sch ls, unpulis e dissertation, University otTlicugan, ann Ar or, Simonds S., Ci arette Smokin -N+.odifyin Individual Behaviors, paper pre- sented at the A1 ie Hea Cancer Symposiuzn, 'folepp. 6-9, March 21, 1978. Surgeon General, Healthy Peoole, U.S. Lepart^:ent of Health and Hi..^ran Se=-ces,(,r Public Health ervice, , 9. CIT Surgeon General, Smokin and Healtt'1, U.S. Department of Health and E'.tunan CA Services, zice oz e rkssistant Secretary for Health, Office on QD Smoking and Health, 1979. ~ Surgeon General, The Health Ccnsequences of Smokinz for ,ti'o,nen, U.S. Depart- ment of Healt an Human Services, n ic .ea t.7 Service, Office of the Assistant Secretary for Health, Office on Smoking and Health, 19779. Thcmpscn E. L. ,"Smoking Education Programs 1960-1976", American Journal of Public Health, 68 (3) : 250-25 7,}farch, 1978. i I I F L L L -14-

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I I I I f I I i I I I I Tuomilaeto J.,-i<oskela K., Puska P. , Bjorkqvist S., and Salcnen J., "A Comrrnmitv .-Viti-Smoking PrograrrJne: Interim E:-aluation of the North Karelia Project", International Journal of 'r.ealth Education, )C(I (a) : 3-15, Gctooer- eceir,oer, 1978. U. S. Depart:nent of Health and Hunan Services, Smoking and Health: An :annotated Biblio a*ohy of Public and Professicnai aucation . terials, olic Healt Service, National Institutes of f'ea1 , April, 1980. U. S. Department of Health and Human Services, Smoking and Health Bulletin, Public Health Service, Office ofSmoKing an Health, 1973. i"bid., 1979 bi ., 1980 U. S. Department of Health and Human Services, State Le islation on Smoking and Health 1975, Public Health Service, Center tor Disease Control, reau ot Heal Education, Atlanta. Ibid., 1976 1977 Ibid., 1978 1979 U. S. Department of Health and Hman Services, The School Health Curriculun Proj~ect, Public Health Service, Center for Disease ontro , ureau or .eF aTff_Education, Atlanta, HEW Pub. No. (CDC) 78-8359, December, 1977. U. S. Department of Health and Human Services, The Prima Grades Health Curriculum Project, Public Health Service, Center for Disease entrol, Bureau ot ea Education, DHEW Pub. No. (CDC) 80-8382. U. S. Department of Health and Human Services, The Smokin Di est, Public Health Service, National Institutes of Hea t, October, 1979. Wallack L. M., "Mass Media Campaigns: The Odds Against Finding Behavior Change", preliminary copy of a chapter for a NIDA monograph on prevention, Socia1 Research Group, School of Public Health, University of California, Berkeley, February, 1980. Warner K., Smokin and Health, discussion paper prepared for the Governor's Citizens ane on o ang and Health, School of Public Health, University of Michigan, June, 1980. Warner K., "The Effects of the Anti-Smoking Campaign on Cigarette Consumption", american Journal of Public Health, 67 (7): July, 1977. White J. R. and Froeb H. F. ,"Small-Airwa,vs Dysfinction in Nonsmokers Chronically Exposed to Tobacco Smoke" The New En land Journal of NSedicine, 302: pp. 720-723, March 27, 1 . Norld Health Organization, World Health, Februar,v- March, 1980. ,Vynder E. L. and Hof£mann D., "Tobacco and Health: A Societal Cha.llenge" The New England Journal of Medicine pp. 894-903, April 19, 1979.

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I I I I t I I I I i I I L I I f 1 ~ t L January 1980 Mich? ~~~ ~~a E~ c~1 ~.~~ ~ ~.~~Q MessageGovernoi L7Jiiliam G. Milliken Smoking and Health As part of our effort to shift the er^..phasis of hlichigan's health programs toward prevention, we have taken steps to ad--4ress the threat of tobacco-related t7lness and death. In 1979, the ditaensions of this problem were again outlined in the United States Surgeon Generzl's report on health promotion and dise3ss prevention. In that report, smoking is cited as the geatest single preventable cause of death in Amerira today. Michigan health statistics cite smoking as a factor in heart disease, cancer, strokes and even inIIuenta and pneurnonia, causing premature disabilities and death. It is time to develop a plan to confront the health effects of cigarette smoking, particularly among children and youth. I will soon appoint a citizens' panel on smoking and heah5 to recommend actions to reduce and prevent tobacco-related illnesses and death. This report should be submitted to me by November 15. -I6-

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I I U I i I I I I I I I- I I MIC-iIGaN SMOKING A:W FEAL'IH IvfERVLVTIGN ST:2ATTEGIES IN THE 80's april, 1980

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cUMMARy Cigarette smokers have a 70 percent greater rate of death from all causes than nonsmokers, and tobacco is asscciated with an esti:nated 320,000 premature deaths a year. The cost of cigarette smoking is borne not cnly by the individuals who smoke but by society at large. Of the ten (10) leading causes of death in Michigan, cigarette smoking has been identified as one of seven major risk factors. Cigarette smoking is the single most important preventable cause of death and disability. The Michigan Public Health Code provides that the Micchigan Depart-rent o= Public Health shall establish public health programs that address chronic disease pre- vention and health education. The Ccde also requires the 48 local health de- part-nents to provide health education services to Michigan residents. A one-year project is being proposed which will initiate the first step tcnvard a cocr.preheasive statewide intervention strategy in the reduction of risk factors associated with sr.oking, especially among children and adolescents. The first step is to establish a Governor's Citizens' Panel to study and recor,snend action on-these issues to the Governor. A cemprehensive statewide acticn plan will be the sequential effort to achieve this goal. I I t I L L -13-

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I F I i I I S11CKI\`G PRCPCSAI. Problem State:^ent Cigarette smoking has been identified by the Surgeon General's Report on E'.ealth Promotion and Disease Prevention (1979) as the "single most impor- tant preventable cause of death... cigarette smokers have a 70 percent greater rate of death from all causes than nonsmokers, and tobacco is associated u-ith an estimated 320,000 premature deaths a year. Another 10 million Americans currently suffer from debilitating chronic diseases caused by smoking". Cigarette smoking is a personal choice behavior. '+Vhile those who smoke increase their risk factors of premature death and disability, those people who stop smoking effectively decrease these risk factors. There is a de- clining mortality ratio for people who stop smoking: "After fifteen (15) years of smoking cessation, mortalit, y ratios for former cigarette smokers are similar to those who never smoked". Of the ten (10) leading causes of death in Michigan, cigarette smoking has been identified as one of seven major risk factors: heart dis.ease, cancer stroke, chronic obstructive lung disease, pneumonia and influenza, diabetes, and atherosclerosis. Furthermore, causal relationship has been established between cigarette smoking and the following: coronary heart disease, cancer and bronchitis. It should be noted that the risk associated with cigarette smoking increases proportionally with the ntrnber of cigarettes smoked and the amount of smoke inhaled. The cost of cigarette smoking is borne not only by the individuals who smoke but by society at large. The cost is manifested not only in increased mor- bidity and mortality but financially and emotionally. Financial costs arise from: the high rate of hospitalizations incurred by smokers; increased number of sick days frcm work; and the cost of supporting smokers permanently disabled by chronic disease. &notional costs include family disruption due to death and/or disability. Certain populations have decreased their consumption of cigarettes.* "... more than 30 million smokers have quit since the first Surgeon General's Report, and the proportion of adult smokers has declined from 42 percent in 1965 to a little more than one-third today". A major proportion of this decline results from men who have stopped smoking. Unfortunately there is evidence that smoking is on the increase among wcmen and adolescent women (12 to 18 years of age). Indeed, the proportion of adolescent women smokers has doubled. During the reproductive years women smokers not only place themselves at in- creased risk of developing lung cancer, they increase the risk factors of the unborn fetus. "Babies born to women who smoke during pregnancy are, on the average 200 grams lighter than babies born to comDarable women who do not s-moke". The risk of fetal death is also higher in wcrr:en who smoke. This is related to maternal comnlications including: "abruptio placenta, placenta previa, anteparttrn he:norrhage, and prolonged rupture of inembranes" Thus the iicr ease of s-moking amongst women j eopardizes the health of future generations. -19- ! ~

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Wcmen have been considered by some researc: ers to be the medel for health values within the famil,v structure. Smoking behavior c: :cmen affects these values negatively. If we are to prevent adolescents and adult wcmen frcm beceming :uture statistics of smoking-related chronic disease, health educa- tior. must be focused on their widely differing perspectives and needs. Health promotion and health prevention activities need to be introduced to children at an-early age. They should be maintained throughout the adoles- cent years when peer pressure has such a significant influence. Parents who smoke :nust_be made aware of, and encouraged to adopt more healthful life- styles, not only to reduce their cwn risk, but to provide positive role models for their children. I s "Smoking is the enemy and it has to be fought." Estelle R.a,Tey, chair of the health subccrrni.ittee of the President's Advisory Conanittee on 1.9cmen, advised her fellow members at the January 29, 1980 meeting that it "recog nizes that smoking is a political issue" but still to "take a strong, visible position". Legal Base The 1978 Michigan Public Health Code provides that "the deparz^Zent (Michigan Depart-r.ent of Public Health) shall establish a chronic disease preventien and control program which shall include arthritis, cancer, dental disease, diabetes, genetic disease, heart disease, hypertension, renal disease, and any other disease the departn:ent designates as chronic pursuant to Section 5439". Section 5439 may promulgate rules "to implement... rules designating addi- tional chronic diseases...". Cigarette smoking is a major contributing cause to several of these leading cripplers and killers: coronary heart disease, cancer, bror.chitis and increased risk factors of the unborn fetus. Healthy Peole, the Surgeon General's Report on Health Promotion and Disease r~e= ~ ventior; cites smoking as the single greatest cause of preventable disabilities and deaths in the L`nited States today. Section 2237 of the Code, as it defines "health education", directs "attention of individuals to their behavior with the goal of enabling the individuals to make reasoned decisions about their own health practice... efficacy or early prevention, disease detection and control... alternative health practices... and the effective assessment of an individual's own beliefs on health cutcomes". Public Policv As part of the Ntichigan effort to shift the emnhasize on .ealth promotien prevention and protection, Michigan must effectively address the threat of cigarette smoking-related disabilities and deaths. In his 1980 State of the State Message, Governor William G. ;lilliken will "soon aoooint a citi:ens' panel on smoking and health to recommend actions to reduce and prevent tobacco related illness and death". He wants this report to be submitted to hin by November 15, 1980. Progran Design - Methods ',Vhereas a large ni.mber of agencies and groups are cencerned and willing to help with a progr am to contain and reduce cigarette s;r.eking to the reducible :nini.^2..zn, the efforts so far have been mostly ad hcc, uncoordinated, frag.*nented, I E L L L -20-

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I f I I I ~ i f t I and pcorl~: funded. A major effort is needed now to develop and initiate a ^ulti-raceted and long-run program which can have maY:LT ...m i.mnact cn the prevention of premature disabilities and deaths resulting from cigarette s;tcking-related chronic diseases and the unborn fetus. The department must launch a vigorous new program- -a program o; public educatien and coordination--backed by: m,.ore energetic efforts; a cecJnitment frcm other members of the state goverr.ment, volumtar,r agencies, ot^er health providers and ccnsuners; and a_~t,.,iding base. 1. Informaticn, Education and Prc:roticn The first and most important element of this new program on sm.oking and health will be a major public information, education and promotion effort at the comn.mity level against cigarette smoking, particularly among adolescents and young children. There exists the most ccmpre- hensive research and convincing body of fact on smoking and health, these are useless if not comr.n.rnicated effectively. In recent years, vigorous public information efforts have done the most to encourage people in America to stop smoking or not to start. The departr:ent intends to step up existing efforts to inform, educate, promote and launch new initiatives through coordinated efforts with all those who are concerned. 2. Coordinated Program Development A program must be developed and launched involving those related health programs within the denart^.ent, other state departnents, 48 local health depart;nents, schools, including but not limited to the following in- terests and issues: a. Voluntary agencies: American Lung Association of Nlichigan, tilichi- gan Heart Associatien, American Cancer Society of ~lichigan, and the children's agencies. b. Professional associations: Kichigan State Medical Society, Michigan State Dental Association, Michigan Hospital Association, and other health associations. c. Business and labor: Industrial firms and unions. d. Local, state and federal: 48 local health departments, state de- partments of those bureaus/centers within DH-i.S such as the Office on Smoking and Health and Bureau of Health Education. The following must be given priority within a new program: prevention-- promotion--protection, smoking reduction intervention strategies, and development of a funding base. a. The 1979 federal initiative cn health education-risk reduction has established the Office of Health Education (CF-E) in the denart:nent as the state-level focal point to develop and implement smoking and alcohol intervention strategies. In 1980, new programs will be funded to implement an organited approach in the ccmirnmities through CHE. -Z-

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b. The Office of Health Educstion titias established in 1979 in the deparr:ent in respcnse to t:~e Pt:blic Health Code. Its responsi- bilities encomoass ccTniia:.ce of health education services tmcer the Code in 48 local health deparrnents, a state-wide fitness and health progra.~n, and health prc~:oticn efforts through coordinat:cn and cccperation with local, state and national pregrams. Objectives As the Michigan Departnent of Public Health is the state's ch.ief public health official, it is deter^.Lined to fulfill the responsibilities: 1. To provide information on cigarette smoking to encourage NLichigan re- sidents to make reasoned decisions about smoking and health; and 2. To develop and 'unplerr,ent rnulti-faceted and long-run programs to ^:odify personal choice behaviors with the goal of reducing risk factors re- lated to cigarette smoking, especially among children and yot..^ig pecple. 3. To implernent a one-year developmental project to be carried cut by a major research/development agency. Specific outcemes will include: a. A Citizens' Panel has organized, met and presented its recemmended actions on smoking and health to the Governor by November 15, 1980. b. Based upon the Citizens' Panel recocmended actions: Departnental plan of action will be developed; by February 15, 1981. c. A detailed 1980 Project Workplan is developed as a management tool to assure progress and outcomes (addendum 1). Staff I. An experienced person as the project director, who can provide both admin- istrative and technical support to assure the effective operation of the Citizens' Panel. The key responsibilities of this.individual include: 1. The preparation and presentation of a "starting point" for the Panel, which provides a basis from which a planned project can be accerplished; 2. Participate in direction of the search and review of relevant literature such as legislation, public policies, guidelines and currieslun, dccu- ments and scientific papers; 3. Participate in the organization of a specific work-plan for Panel activities; and contribute development of a final report by the Panel to the Governor by November 1980; ~ 4. The'coordination, collaboration, and directions with the Office of Heal th C1T Educaticn in bmPH to meet Panel goals and objectives. It is essential ~ that this individual cooperate closely with the MIDPH Office of Health ~ ~ Education and ccntribute a good understanding of preventive health and Oj health promotion pri.-iciples; kncwledge of health literature on smoking ~ I I { I I E I ~ L L L -22-

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i U i I I behavior and prevention modalit,,,; excerience in -.cup dynamics; ab:lit-. to ccrr.rninicate effec;.ivelv; and professienal maturity to exercise in- dependent judgement.when needed. II. ~EFH Staff _17urooort a. The Chief of the Office of Health Education provides the coordi.^.at:en, direction and suoervision necessary to accomplish the Citizens' Panel objectives. b. A graduate student in health education shall assist to discharge duties under supervision. c. Clerical support will be provided as needed. d. Other bIDPH expertise will be utilized thrcugh consultation. III. Budget While no funds are currently available for support, it is feasible that "in kind" contributions by all involved can overcome this obstacle to the success of the project. bDPH will provide rei_mbursement for panel members and the project director to the Citizens' Panel for meetings to be held in the Baker-Olin Complex at least monthly. ! 1 a I ( I ot C!f - ?! C!1 m -23-

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Addendiun - I ()NC YI:Aa WORKPLAN (1980) UI)jcct.ive a. Identify 15-20 candidates for the Ci t i zeii's Panel by Wrch, 1980. h. Governor makes Citizen's Panel appointments by ~tiy 1, 1980. c. Rijor research/development agency identified and contracted to carry out functions of the Ci t i zens' Panel by May 1, 1980. d. Citizens' Panel conducts meetings i N ~ i in first and third week monthly from .June through tktober, 1980 e. Final recouunended action to the Governor, November 19, 1980. f. Project agreement sign-off between h1I11'll and contractee by Ik;cemher 15, 1980. M C+'' IM b First draft of a state smoking and health intervention strategy is ready for internal collYnents and review by .January 15, 1981. ,p h. Ident i fy funcls to support a statewide ~ effort by February 1, 1980. ~i. Submit a statewide plan of action to the ININ'll Director for approval and and i ml>> -mentat i on. Activities Discuss and search out most qualified i candidates representing broad backbrouncl,l and interest. I All candidates considered by the Governor's office. Negotiation completed and contract awarded by the department. Staff identified to supportCitizens' Panel. Panel members and staff review all relevant materials on smoking and health and develops an agenda for action. Staff produce meeting minutes, reports, draft of reconnended actions and final report to f,Il)I'II as per agreement. All discussions and essential public hearings on the subject are completed and a final report is made to M1'll. All necessary doctunents and administra- tive matter are concluded and submitted to i`il)I'll as per agreement. lixplore all facets for a comprehensive statewide strategy to prevent premature disahility and death resulting from cigarette smokinb. Prepare budgetary statement and explore funding sources. Incorporate all connents received into final plan for action. r- rT1T' r Products List prepared and suI)mltted by 1,hrch. Appointments made. Schedule first Citizens' Panel mcetinb. An agenda is developed. A final report with recoimmndcd actions suhm i t t ed t o(`tDl'I I. Governor receives the reconunendation as scheclul ed. Agreement completed. flraft for review and conunent. Continue exploration. Plan accepted by the 1)irector.

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F I I I i I I I- I L BIBLIC I` HY Califano, Jr., Joseph A. Address to National Interagency Council on Smoking and Health, 1~lasnington, D. C., January 11, 1978. :Celly, Frank J. ,Mlichigan Attorney General, Michi;an, State Law Library, July, 1977. Health Education Report. 2 (3): 1-12. February 12, 1930. Health Educatien-Risk Reduction Grant Guidelines, March, 1930. NLich.igan Department of Public Health: 1978 Program Budget State^:ent. October, 1973. ,%iichigan Public Health Code, Public Act 368 of 1978, September, 1978. The National Institute of Education. Teena e Smoking: Irn;nediate and Lenq-Term Patterns. U. S. Department of .ea tn, Education an Welrare. DE-IE1+f, 1 79, 259 pp. U. S. Public Health Service. Healthy Peonle. The Surzeon General's Renort on Health Promotion and isease evention: 1979. U. S. Department or Heal Education, an SVel are. Lf- .V (PHS) Publication No. 79-55071, 1979, 177 pp. U. S. Public Health Service. Smokin and Health. A Report of the Sur?eon General. U. S. Department or Heait , ucat~on, and Weltare. sJ (PHS) Publication No. 79-50066. W. K. Kellogg Foundation: Toward a Healthier America, January, 1930. -25- ~

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STATE CF ,titICyIG:.'v .~ W1LL.AM G. MILLIKEN. Gcver^or DEPARTMENT OF PUBLIC HEALTH 3500 N LCGAN P.O. BOX 30035. LANSING. uiCriGAN 48909 MAURICE S. REIZEN. M.D. Cvecror MEMORA;dDUM OF UNDERSTANDING BET'WEEN UNIVERSITY OF MICHIGAN-SCHCOL OF PUBLIC HEALTH AND MICHIGAN CEPARTME;JT OF PUBLIC HEr'+LTH I. Puroose The purpose of this memorandum is to describe the objectives and respon- sibilities of these two organizations in a collaborative effort related to the goals and objectives of the Governor's Citizens' Panel on Smoking and Health. II. Objectives 1. To provide professional direction, administrative support and staff work necessary to achieve the goals of the Citizens' Panel as described in the Governor's 1980 State of the State Message by November 1980. 2. To organize and conduct a series of Citizens' Panel meetings during this time which will identify specific objectives in the development of a work plan, and provide the support needed to complete the"plan. 3. To produce a Citizens' Panel report to the Governor on Smoking and Health during November 1980. III. Roles and Resoonsibilities University of Michigan-School of Public Health The project director is Professor Ken Warner who will write a"starting point paper" for the Panel to use as backcround information and provide some alternative directions for the Panels' discussion and deliberation of its responsibility. The key issues to be addressed in this paper will include: historical perspective on changes, and behavior as related to smoking and health during the last 20 years;,some past and current state and national policies and/or legislation; moroidity and mortality related to smoking and health; economic loss due to disability and early death; and options (challenges) for consideraticn and action. I I I p L L L -26-

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I- I Ii r r I r I Memorandum of Understanding Pa ge Two A draft of his paper will be available for review and comment early June 1980. When finalized the paper will be sent to all panel members before the first panel meeting on June 19, 1980. Professor Warner, to be titled the Project Director, will contribute his expertise to the Panel, work with OHE staff (Fong and a graduate student) in the planning, development and coordination of activities related to the achievements of Panel goals and objectives, and par- ticipate by reviewing the development of the Panel report to the Governor's office. Michigan Department of Public Health The Chief of the Office of Health Education (OHE) will provide admini- strative direction and supervision and the OHE will provide clerical support to work with Professor Warner and the Panel to successfully complete the project. Dr. William Clexton will provide MDPH policy and direction as part of his departmental responsibilities. MDPH will provide reimbursement for travel to panel meetings for members and Professor Warner. Tasks such as literature research, organization of meetings, minutes, and reports will be carried out by the graduate student under the supervision of Mr. Fong. E [ G L I L L t IV. Timetable A schedule for panel meetings will be established at the Panels' first meeting. This wiTl include at least monthly meetings at the Baker-Olin Complex, usually from 1:00p.m. - 4:00 p.m. ~~;~ ~ ~y~"~ Maurice S. Reizen, M.D., Director Michigan Department of Public Health Richard R. Remington, Ph.D., Dean University of Michigan-School of Public Health Date -27-

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I Gave_^.cr's A,,-i^.te: Citizens' ?ar:el on Smaki.c azy-l :ealtz \.%C Ei1lLVV RZMa'SC<.1.7 Maurice S. Reizen, M.D., Director :Kichigan Departnent of Pl:blic Health June 19, 1980 The michigan Public Health Code was passed tao years ago and took effect CL;t :ber 1. It re.xarked the cne-hurxlred year history of assorted laws that the Public Health Decartnent had accL=ulated. Qze directive of the Public Health Code is t'^.at the Michigan Depa=.e.nt of Public Health sha11 establish a chronic disease prevention and control pro- gram which sha11l include arthritis, cancer, dental, diabetes, genetic disease heart disease, hyper},.ension, renal disease and any other disease that the Den3rtent designates as chronic pursuant to Section 5439. The Depart:-ent may prrmuigate rules to irrplenent the section including such rules desingating addi'.tional chronic diseases. Cigarette srmking is a major oontributing cause of chronic disease, including cancer, heart disease and hypertension. There is no doubt in the r,sids of most of us that the evidence is oveiwhe.Lmir:g that cigarette stnking is a major cause of disease and disability. u.icnigan has just begun to emphasize health p~ntion and health prevention activities. Part of this thrust is to recoc,-nize that smJcing is one of the causes of preventable disability and death in the State. Cigarette smoking is one of the major risk factors that is causally linked to many of the ten lead; ng causes of death in Michigan. Cove.rnflr William Milliken has specifi- cally ac3dressed this health problem in his 1980 State of the State Message. The State of the State Message was delivered in January of 1980. It states, "As part of our effort to shift the empi-~asis of Michigan's health prcgrans tcward preventicn, we have taken steps to address the tl,xeat of tobacco-related illness and death. In 1979, the dimen- sicns of this proble*n were again outlined in the United States Surgeon Ce-ne_~-al's report on health pza; oticn and disease preventicn. Lz that report, smaki.ng is cited as the greatest single preventable cause of death in Pmerica today. Mic'zigan health statistics cite sineking as a factor in heart disease, cancer, st--c}ce and even in- fluenza and gieL=aia, causing prenature disabilities and death. It is time to develop a plan to ccnfrcnt the health effects of cigarette smoring, annng chi].drez and youth. I wi11 socn agcoint a citizens' ranell on szrc,3cir:g and health to recaam_-4 act+cns to redl:ce and prevent toba~.-c_-,-related illr.ess and death. Mis reocrt shculd be sutrsit+..ed to me by Vovm-b-_- 15.11 I (

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r I I i I I I c t I Gpe-^.i:.g PE_-ar'l.s jL:.e 19, 1980 Pace ^~ This report is to be sz:Lznitted to the Co-,er.:or :y ~:o~~: ber 15, 1960. ;,,Iie ~ e task vcu urde_-ta~Ke to a.ccc=1ish this c,-eal, will be fcr.-~~bie i-i the short a.rcunt of ti.-ne you have been gi~,en, there is no cuest;cn that ..-cu wi].y be per:o .r ;tir.g a great service to t' :e people of th.is S t,.:te . I;:e Office of Health Educaticn was established in 1979 in the ~Lic.h.ican PeDar=rant of PubLc Health in resnense to the Public Health Code. The resaonsibil: ties of this unit to the Par.el are twofold. :he first is to provide professional direction, a'cmi.nistrative support and s`.aff work necessary to achieve the goal of the Citizens' Panel by Niove::re_Y, 1980. TZ:e second is to organize and ccnduct a series of Citizens' Panel meetLngs during this ti-re which will identify specific objectives in the develorrent of a work plan and provide the supoort needed to camlete the plan. Dcctor Willi.am Clextcn will represent me and will provide MDPH pelic_y a.^.d direc*,icn as needed and as recuested by you. Llhe University of :vlic:h.igan, Scct:ool of Public Health is cooperatina with the De^z.artmnt to prov~..de the r.ecessary staff to achieve the goals and ebjecj-aves of the Citizens' Panel. Professor Warr.er will contribute his expertise to the Panel, to work with the Cffice of Health Education staff in tr.e planninc, develcpment and caorrdi.ation of the Panel ac~~i.vities and participate by reviewing the develcpr.rnnt of the Panel Report to the Governor's office. It is our suggestion that this first meeting be devoted entirely to sur- veying possible policy alternatives and selecting these policy areas that will be discussed in subsequent meetings. We appreciate the fact that you have rrade time in your schedules to wvtc with us in reaching these ebj ectives . The tim allotted to ca=lete the report is short; therefore, it is essential to be as prcduc}..ive as possible in the next few mcntzs. Cn be?a1f of the Department and staff, we welcune you as mebers of the Citizens' Panel on i'mckir.g and Health. We welcome your i-ivwlcnmTP_nt and hard work in assisting the Department in carrying out its r.adate by the Governor. C?ie other ite:n I wauld like to share with you is the cor.cept of the a=Doint- ment of a chairperson of the Panel. Llie Governor has delegated the re- spons'zbility of appointing a chairperson to me. yIy met^cd of cpe~rati.^.g is to see how the grrnra wc~~cs and not to randc~nly appoint a cha.i_-person. So with your indulgas.ce, I cxnild like to ask Dr. Clexton to be C~ai~.--rsan ?_o Ten. After a neeting or t~%;o, the Panel may want to call for an elec+-icn. I trust that this wculd be acceptable to you. Cne final caveat, when you sit at any one of t~.e many bcar-~...s, ca:missicns, and cam.Littees that advise me, you are representing the e.^.t=re state of Michican and its people. I ask of you when you make decisions that _vcu ask ycu."selves, uinat is in the best interests of the nine plus milLcn people in the state. This is a difficult task to u7r:e_rtake and a challen,e that ;tust be treated with m:c:n resoect. -29-

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85645873 ai . .r..~. . ,_ . .....,. ~ ...~ ,».,,,...

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I I r I i I i L DESGRIPTIC,v CF rRC~C('~~ The Citizens' Panel formed four subcommittees: 1) Eccnomic Issues; 2) Legal Issues; 3) Education/~(edia/Publicity; and, 4) Recort Review. The first three subccrT~nittees were responsible for the development of the reccrrr:ended actions, whi ch were proposed in the full Panel meetings, and the fourth subccrr.nittee was responsible for the editing of the final report. The Panel ;ret monthly: June 19, July 17, August 13, September 11, October 8, and November 6.* The Subcommittee meetings were held bet.ieen the regularly scheduled Panel meetings. The Economic Issues Subcor,mittee met on July 9; The Legal Issues Subcommittee met on July 9, July 22, August 18, and August 29; The Education/.%tedia/Publicity Subcommittee met on July 23 and August 25; and the Report Review Subcommittee met on September 22. Agree.^tent or disagreement with the Panel's recc: -.r.endaticns of the draft report was solicited by staff from each member. The sta:f developed a cooperative working relationship with the Panel and Sub- ccrmnittee members. :an evaluation of the Panel and staff performance was conducted at the final meeting on November 6.* Of those twelve at the meeting who completed the form, the majority agreed that the staff had met the expectations csf the Panel members. Consensus was the modality in the discussicn of prcoosed rec=,er.daticns, with a vote taken on their formal adoption. The entire report was adopted by formal vote at the final Panel meeting. *Included in the appendix -30-

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I I I I I ~~XT MEETI`G D"kL: Thursday, Jui;r 1", 1980 1:00 - 4:00 p.M. Vorthend Modular L'nit 3300 N. Lcgan Lansing, MI CITIZENS' PANEL ON SM0KING aND fE_UT'r? M I'Y U T E S Conference Room 1-k and 2B Baker-Olin West Building Michigan Departnent of Public Health Jtme 19, 1980 1:00 - 4:00 p.m. I I %,0iBERS PRESE`T: Margaret Lee Arthur tir'eaver, , '1. D . Douglas Vilnius James Howard Greggory Smith .Michael 'Mortimo_re Charles Mitchner Robert Ortwein `0tBERS ABSENT : Representative Raymond Hood Senator William Sederburg Norbert Reinstein George Watts Scott Simonds, Dr.P.H. Janice L\,eadowcroft Virginia Kjolhede Eleanor Barber Donald Breckon, Ph.D. James Terrian, M.D. Ben Barker, D.D.S Walter Maner III STAFF PRESENT: :4aurice S. ReiZen, M.D., Director, Michigan Department of Public Health William Clexton, Associate Director, Office of Local Health Services Kenneth Warner, Ph.D., Project Director Si:nny Sun Nai Fong, Chief, Office of Health Education Rhonda Famner, Student Assistant, Office of Health Education Russell Holmes, M.D., Division of Chronic Disease GUESTS Michael Spaniolo, Michigan Tobacco & Candy Vendors Association -31-

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I. The meeting was called to crder by Maurice Rei_en, ',t.D. , 2irector of Public Health. After a round of intrcducticns '0Y Panel Te^~_,ers, Dr. Rei:en reviewed the histor: and respensibilities or t' e C'_ti:ens' Panel. The Citizens' Panel on Smoking and Fea;th was appointed by the Governor. A report of the Panel's reccrrmendaticns are to be cresented to the Governor by November 15, 1930. Dr. Reicen shared an excerpt from the Governor's State of the State message with Panel members. Dr. Rei_en appointed Dr. Clexton as Chai .rnan Pro Te:n until such time as the Panel shall elect a Chairman. I i I II. The packet materials were reviewed that each member received at the meeting which included an incor.plete address/phone list of Panel members, travel voucher, and a proposed schedule and agenda of meetings. III. Review of Background Paper - Professor Warner updated and reviewed the background paper that was sent to all Panel members. It was discussed that little data exists in the State of those who have cardiovascular disease who are also 7mokers. The recording of mortality data does not include the risk factor of smoking. Hospitals were suggested as a source of mortality data where information can be obtained on smoking. It was noted that nonsrokers exposed to secondhand smke suffer from adverse effects sir,tilar to that of smokers. r IV. Discussion of Policy Issues - It was emphasized that the Panel would recogni=e the differences that exist between adults and children and between preventing the initiation of smoking and encouraging the cessation of smoking. A Panel member noted that the school health education laws were vague. A law of 1886 mandated that the harmful effects of alcohol and tobacco be taught in the school. The Critical Health Problems Act does not mandate the teaching of health education. it was agreed that more information is needed on school heal th education such as require:r:ents by the state and local school health activities. A Panel member suggested an option within the area of economic strategies would be incentives given by insurance companies whereby nonsmokers would have lower insurance rates. Another member pointed out that this may not discourage much smoking and puts a burden on the smoker. It was also noted that verification of smoking is a problem here. It was suggested that one policy area might target the State ~fed.ical Association, hospitals and physicians. Providing training programs for physicians and smoking cessation as part of hospital patient ea:cation programs are alternatives. A ban was suggested on all advertising of tobacco predLcts. !bre info .rma- tion is needed on the extent of the State's legal powers. It was noted that there is a problem of youths smoking i-i the schcols. Non_mking is sometimes not enforced in schools and ce=liance varies within 1eca1 areas. A question was raised as to why ce,rmliance varies. It was indi- cated that there is "no smoking" allowed in the public schools in Detroit I h l -32- I- L

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I I I I i i I I i I I ~ ~ L although this does not apply to private schools. Youths will smoke in the public school lavatory unless it is monitored by an adult. It was also indicated that "no smoking" is enforced in the Mt. Pleasant hool System while the student is on school grounds ; ho,,,;ever, this S~ restriction cannot be enforced cnce t::e youth crosses the street. A Panel member noted that enforcement was an administrative problem. A point was made that compliance with the "no smoking" restriction in restaurants varies in local areas. A suggestion was made that compli- ance could be monitored as part of the yearly licensing review of restaurants. A suggested policy alternative is to remove cigarette vending machines from all public buildings and hospitals. Another suggestion was that mass media be utilized to a greater extent. A question was raised as to whether or not an employee has a right to ask a fellow employee not to smoke in the office. A legal precedent was set in New Jersey which granted an employee a right to work in a smoke free environment. It was indicated that smoking can be a negoti- ated item per union. OSHA sets safety standards and smoking restric- tions in some occupational settings. Restrictions take the form of a "no smoking" sign. Some work places use consensus of the group as the standard. A policy alternative that was suggested was the use of tax deductions for people who are trying to quit smoking. It was noted that the federal government already gives a tax deduction to those people who are engaged in smoking cessation activities prescribed by a physician. A Panel member noted that nonsmokers have a public health base for their interest in the cessation of smoking. It was brought out that anti-smoking ads are infrequently used as they ccmpete with other public service announcements. Ari inquiry was made as to whether or not Michigan has the authority to grant an excise tax. It was stated that an evaluation component must be a part of any recorrnnenda- tions made by the Panel. A suggestion was made that there may be a relationship between stress and smoking. Utilizing methods of reducing stress and conflict may be necessary. A Panel member noted that within the economic policy arena the most feasible recommendations are those that will have the support of the tobacco companies. It was further emphasized that the support of all industries is needed. Teacher training requirements in heal th education was discussed. There are no uniform requirements as the curriculum of universities vary. It was suggested that in-service training may be an option. It was noted -33-

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i that a model exists :or teacher training .,;orkshcos y-i substance abuse. Cemprehensive school health education is another suggested optien. Pre- sentlv local school districts decide the cur:=c.ilw"n and :r:ethedology. A comprehensive corrmumity health educaticn program was also suggested. Stress was discussed as an i,rportant factor in the continuation of smoking. Children learn how to handle stress using their_parents as models. It was decided that the policy option categories in the background paper should remain. Media and other publicity are to be merged as one category; therefore, leaving five policy areas: 1) ecenomic, 2) media and other publicity, 3) legal, 4) health education (media may be included); and, 5) other policy options. V. Proposed Future Meetings and Agendas - It was pointed out that the Executive Ccr:znittee will work in between Panel meetings with the staff. The Executive Committee and staff will abstract infor.mation to bring to Panel meetings. Individuals-can make contribu- tions through the Executive Cetrmittee or directly to the Panel. The Executive Com.mittee will meet one week after the Panel meeting. It was decided that subcemni.ttees may be a feasible organizational structure providing a work group for each policy option. The July meeting will address the policy categories of economic and legal strategies. The :august meeting will focus on media, other publicity, and health education. T}.e September meeting will include only other policy ar eas . It was agreed that the next meeting should be on Thursday, July 17th, 1:00 - 4:00 p.m. The August meeting date will need to be changed at the July meeting due to the fact that a nunber of people cannot attend on the proposed date. At subsequent meetings, the proposed meeting date for the following month will be confirmed. Any papers relating to the Panel's activities should be submitted to Sunny Fong, Office of Health Education. Infor.ration regarding the Panel and its activities should be directed to Sunny Fong, (517) 373-9437 and Rhonda Ihmner, (517) 373-9680 in the Michigan Departnent of Public Health and Ken Warner, (313) 764-2132 in the S&zol of Public Fealth, University of Michigan. -34- I I 1 I ~ I _, I t I L I L L

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NEXT MEET i `iG CATE : Monday, auaust 18, 1980 1:00 - 4:00 p.M. Baker-01in West Ccmplex Rcom 1C Michigan Department of Public Health 3500 North Logan Street Lansing, MI 48909 I CITIZENS' PANEL ON SMOKING AND HEALTH MINUTES Northend Modular Unit Michigan Department of Public Health July 17, 1980 1:00-4:00 p.m. I I i i I I MEMBERS PRESENT: Ben Barker, O.D.S. Walter Manner III Donald Breckon, Ph.D. Norbert Reinstein Terry Gerald (representing Rep. Raymond Hood) Senator William Sederburg Virginia Kjolhede Douglas Vilnius Margaret Lee MEMBERS ABSENT: Eleanor Barber Scott Simonds, Dr. P.H. James Howard Gregory Smith Janice Meadowcroft James Terrian, M.D. Charles Mitchner George Watts Michael Mortimore Arthur Weaver, M.D. STAFF PRESENT: Theodore Ervin, Deputy Director, Michigan Department of Public Health Kenneth Warner, Ph.D., Project Director, Univ. of Mich., School of Public Health Sunny Sun Nai Fong, Chief, Office of Health Education Rhonda Runner, Student Assistant, Office of Health Education John Insel, Bureau of Environmental & Occupational Health Russell Holmes, M.D., Bureau of Disease Control & Laboratory Services Maxwell Alderson, Bureau of Personal Health Services GUESTS: Dennis Schornack, Legislative Aide Michael Spaniolo, Legislative Counsel, Michigan Tobacco & Candy Vendors Assoc. Rick Davenport, American Lung Association Wanda Jubb, Department of Education Abdullah Al Ruwais, Student, Central Michigan University Betil Abri, Student, Central Michigan University -35- ~

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! ~ I. Call to Order , The meeting was called to order at 1:15 p.m. by Ted Ervin, Deputy Director of the Michigan Department of Public Health. Xr. Ervin chaired _r,e meeting 4 in the absence of William Clexton, Chairman Pro Tern. A round of introcuctions was conducted. II. Aooroval of Minutes The minutes of the June 19 meeting were unanimously approved III. Statement of Panel's Overall Objectives ~ The proposed objectives of the Panel were outlined and distributed to Panel members for discussion. The objectives were not outlined according to priority but reflected the fact that the Governor, in his mandate to the Panel, emphasized preventing initiation of a smoking habit, especially in teenagers and younger children. A panel member noted that the stated objectives were not measurable. Possibly in future subcommittee meetings, measurable objectives can be identified. Another member pointed out the difficulty of designing measurable objectives with the scarce resources of the Panel. Evaluation mechanisms and methodo- logies might be established by the Panel whereas operational agencies can quantify objectives from the stated goals. A question pertaining to clarification of the Panel's charge was raised. It was indicated by Michigan Department of Public Health staff that the Panel is to make recomrnendations to the Governor. If adopted, the recommendations will then be used as a base for program planning. An agency responsible for developing the program plan could'define measurable objectives. The Panel accepted the proposed objectives as a working statement of ooals. IV. Economic and Leoal Subcommittee Reoort The Project Director reported the Economic,and Legal Subcommittee's proposed recomnendatrons to the Panel. He indicated that, due to time ccnstraints, the subcommittee dealt with the legal alternatives in a general manner while the economic alternatives were discussed in greater depth. V. Discussion on Economic Approaches 1. There was a discussion on the proposed five-cent per pack excise tax increase which is also being recommended by the Public Health Advisory Council (PHAC). Concerning the bootlegging issue, a question was raised as to whether or not consideration was given to relative excise taxes of the various states. A point was made that there have been few tax increases and bootlegging has decreased nationwide. It was suggested that the Michigan Treasury Department be contacted for their impressions of the cigarette tax and its impact on bootlegging. Even with an increase in bootlegging and a subsequent loss in revenue, there will be clear tax revenue increase to QD the State. ~ ~ Cil m -3s- O I I . i I I ~ I L L L

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I I i p ~ ~ i With a 5c tax, there should be approximately a two-percent reduction in ciaarette consumption, considering the price elasticity of demand. A point was made that the data base does not separately take into account different population groups which include the relatively price- sensitive younger groups. A Panel member asked for clarification of the PHAC's intent in recommending a tax increase. The PHAC is trying to create an alternative source of funding for public health programs. A discussion about earmarking the revenues of the cigarette excise tax ensued. The Economic and Legal Subcommittee proposed to earmark one-half to one-cent of a five-cent excise tax for smoking and health activities. It was noted that without resources, programs cannot be c-reated or expanded. An earmarked five-cent excise tax is not inconsistent with alcohol and other tax programs where the revenue is used to benefit health programs. A suggestion was made for all revenue to be earmarked for substance abuse programs with a percentage for smoking and health activities. The rationale for this is that a strong lobby for substance abuse exists. Therefore, such a tax may be more saleable. A point was made that the General Fund is a form of earmarking since it is used for all public health programs. It was felt by a Panel member that earmarking revenue for a specific program made it easier to obtain public support as the public than under- stands how their tax dollars are being spent. A point was made that even though the revenue might be going into the General Fund, it would be possible to define for public information which programs will use the revenue. It was felt by another Panel member that specifically earmarking revenue for a single purpose would decrease its chances for passage in the legislative system as revenue in the General Fund is needed. A Panel member stated that to support the PHAC's recommendation is exceeding the charge of the Panel. The Panel decided to separate its prooosed five-cent excise tax increase rather than suo ort the tax increase as reccmrnended by the PHAC. The inten ed purpose of t e tax is to decrease consumption with increased revenue being a side issue. Further the Panel recommends that one-half to one-percent be earmarked for smoking and ea th activities. A question was raised as to how it is that we know enough revenue will be generated to support smoking and health activities. The response was that in order to more appropriately earmark for such activities a work group could be convened to decide on a more realistic percentage or to develop an incremental percentage. A point was made that the wording of the recommendations will come back before the Panel for further discussion and decision. Also, that the consensus of the Panel to accept a proposal at this time is not to be mistaken for adoption. Adoption of recommendations will occur when the Panel reviews and accepts the final report. -37- %

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i 2. The next proposed alternative was discussed. This requests the Governor and Michigan's congressional delegation to lobby the federal eovernment for a substantial increase in the federal cicarette excise tax. The subcemmittee felt the state, by itself, could not achieve this goal. Possibly the Governor could recommend or advocate a uniform tax on cigarettes by all states. A Panel member pointed out that in order to achieve uniformity, Michigan would have to lower its tax. If there is a federal tax increase then =1 proposal could be reduced to an excise tax of 1t. The Panel decided to seoarate both orooosal as a substantial federal tax increase seems remote at tnis time. A suggestion was made to earmark tax revenue nationally. The Panel aareed to amend this recommendation with an additional statement or earmarxinq fo r smokina and health activities. 3. There was general approval of the Governor and congressional deleoation working for inclusion of costs of smoking cessation as allowable itemized deduction in the federal personal income tax, either as medical deductions or miscellaneous. A Panel member noted that the Internal Revenue Service presently gives tax deductions for participation in smoking cessation programs if requested by a physician's prescription. A member asked why this recommendation is not proposed on a state level. It was reported that the subcommittee felt that the present state fiscal situation precluded this alternative for the State. The federal govern- ment would be better equipped to adopt the recom-,rendation. A Panel member sueaested that educational deductions be listed with medical and miscellaneous. The consensus of the Panel is to amen the proposa as such. The Panel agreed to consider this particular proposal at a later date. A point was made that people need additional financial incentives to quit smoking. The Panel agreed to table discussion or adootion on the orooosal. 4. A discussion followed on the next proposal that the Insurance Commissioner and Director of Public Health convene a meeting of representatives of in- surance companies in the State. There was general agreement that this is an important recommendation. A Panel member pointed out that Blue Cross/ Blue Shield is presently proposing a bill that will require differential insurance rates. It was suggested that the legal ramifications of the proposal be explored. A Panel member pointed out that it is difficult to implement differential premiums on an actuarial basis. The suggestion was made to combine recomrrendation #1 and T4 to use the tax as an off-set to the premiums. Further, it was recommended to include a provision that indepth research begin in the area. m The suggestion was made to include smoking cessation programs as insurance ~ reimbursable items. It was noted that insurance companies reimburse an ~ insurer for medical smoking cessation programs which may be the least ~ effective programs. CID N -38- I I , j I ( j I I t I i L

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I A panel member stated that nonsmokers shculd not have to pay for someone else's lung cancer caused by smoking through a higher insurance premium. A suggestion was made to separate smoking-related cases from all others to be reimbursed through a separate funding source. It was noted that it is difficult to ascertain if the cause of an illness is due to smoking. There was general agreement that the Insurance Commissioner and Director of Public Health should do more than convene a meeting. Exploration into the feasibility and possibility of developing differentials should be undertaken. The Michigan Department of Public Health offered its services to obtain information from the Insurance Commissioner by the September Panel meeting for preliminary review by the Panel. It was recognized that if informa- tion is obtained, the Panel may be able to make a more significant recommendation. I I i I i i 5. The proposal concerning grants to organized groups for demonstration projects on smoking prevention or cessation was discussed. A panel member questioned whether or not the Panel should propose a recommenda- tion having fiscal implications at this time of constrained resources. Another member responded that this recommendation could be one that will be implemented in two or three years. A panel member suggested the addition of demonstration projects or programs to the statement. Another suggestion was to add the term "well-evaluated" demonstration project or program. Program effectiveness should be proven in order to receive grant funds. It was noted that the statistics of evaluated programs are not reliable. It is not known how many people complete two or t~hree programs before they quit smoking. A Panel member stated smoking cessation programs are cost-effective; studies show for every program dollar spent, two dollars are saved. The suggestion was made that grants should be given to educational institutions which will evaluate program results. However, this may eliminate small organizations which cannot evaluate because of limited resources. The Panel a reed that the Education/ Media Subcommittee should explore this recommendation urt er. VI. Discussion on Legal Approaches 1. In discussion of more comprehensive protection of the rights of nonsmokers, panel members requested a copy of the Minnesota Clean Indoor Act from the staff. Also, they will receive a copy of the article on the effects of side stream smoke on nonsmokers from the New Enoland Journal of Medicine. A panel member further requested that the s-taff ana yze the laws so t ere is an understanding of how a more comprehensive protection of the rights of nonsmokers can be achieved. This orooosal will be discussed at a later date when the legal subcommittee can be more soecific about its recommendation. 2. The prohibition of vending machine cigarettes sold in State buildings was discussed. It was noted that employees will go elsewhere to buy cigarettes; therefore, this is not an effective strategy to decrease consumption. A Panel member stated that by allowing cigarette vendors in State buildings, we are endorsing smoking. It is inconsistent policy to fund activities that will decrease smoking and then sell cigarettes. The state should X conduct itself as a role model. C11 Cn ~ W ~ -39- ~ W L.

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A panel member stated that there have been orevious attempts to ban the selling of cigarettes from hospitals; however, they have been un- successful. There is some support to ban the selling of vending machine cigarettes because this is where teenaeers obtain them. There is strong opposition from the Teamsters who service the vending machines. A panel member noted that the Michigan Services for the Blind supply employees for State government snack bars. A portion of their volume of business stems from the sale of vending machine cigarette sales. There was consensus of the oanel to retain this recommendation for further discussion. 3. Compliance of the no-smoking restriction in restaurants was discussed. An MDPH representative from the Division of Food Service explained that the Public Health Code does not state the percentage of seating area that must be reserved for nonsmokers. There is no legal recourse for non- compliance, as the court system will not revoke a restaurant's license for breaking the nonsmoking law. The representative noted that com- pliance with the no smoking restriction is included on the inspection report form but no penalty points are given because of the national standardization of points. Employees, while in training, are instructed to check compliance with the law. A suggestion was made to have a toll free number where complaints about noncompliance in stores, restaurants, and State offices could be directed. The complaints would then be funneled to the appropriate State agency responsible for enforcing that law. It was a reed that the recommendation of assessing penalty points for noncemo lance shou d be taken to the Division of Food Service in the Michigan Department of Pu ic Hea th and the Environmenta Hea th Advisory Committee. It was noted that this is only one strategy out of many to improve compliance with the Public Health Code. 4. With respect to the fourth proposal of opposition to legislation which places reliance on criminal sanctions to achieve smoking and health objectives and opposition to earmarking legislative revenues for cate- gorical purposes, it was agreed that this may be used as a preamble in the final reoort. VII. Public Comments There were none who wished to speak to the Panel at this time. VIII. New Business The next Citizens' Panel meeting will be Monday, August 18. The Noverrber 6 meeting will be held at the Capitol Building since there are no available rooms in MDP4. Staff will contact members of the Education/Media Subcorrmittee -40- I I , I I I E I I L

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I I I to arrange a meetina. The Leaal Subccrrmitt2e will -ee= Tuesday, July 22 at 1:00 - 3:30 in Ann Arbor. _ IX. "'.djournment The meeting adjourned at 4:00 p.m. I I I I L -41- 1-_

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~=- =?.tiG ~-'.:.''E': CITIZE.`IS' P.k%-rM CN S-'_C:{i JG ?ND cT-.ALTF-i 'I'::urs:ay, Septerber 11, 1°80 1:00 - 4:00 p.:a. Baker-Ol' z ;+est Ca-,nleY - ?rm 3500 N. Locan Slzreet IdZLS l.^.C , :,LJG 1C3I1 13 I 'IML'TF..S Ccnference F3Dan 1C Baker-olin West ~?ui.ldir.g Michigan Depart;ent of Public Health Mcn'ay, Axgust 18, 1980 1:00-4:00 p.m. M,enbers Present: Margaret Lee Arthur Weaver, M.D. Douglas Vilnius Terry Gerald (representing Rep. Raynrnxi Hocd) Senatar WiLlian Sederhurg h3or:ert Reir.stein MsnbPSs Pbsent: Dcrald 3reckcn, Ph.D. Michael : Ycrt'_..-ncre Walter Mar:er III Scott Simcnfs, Dr. P.H., Vice-C-air Rcbex`t C-.1e.i_n Janice Mle~~f t James Howard Ben Barker, D.D.S., C-z..i: Eleanor Barber Charles MitGhr.er Virginia Rjoll^.ede George Watts James Terrian, M.D. 'IIzanas Hunter Staff Present: W'iL?iam Clextan, Associate Director af Irxa1 Health Services Sunny Sun Nai Fang, Chief, Office of Health Fsaucatic:n Renr.eth Warner, Ph.D., Project Directcr Rhcrda Runu:er, Student Assistant, Office of Health F~ucaticn Walter 'wheeler, Assistant to the Di.:ec+-..cr for Prcgran Develcpme-:t DouR-y las Park, Bureau of Erwr -crs*x--ntal ar:d 0--.inat i.cnal Health F3isse1l Holme.s, K.D., Division of Ghronic Disease Wanda Jubb, bii.c.h.igan Der.art-nent of rtucztion m Glests : ~ Jis^.e Asselin, !Zic..~igan Dental Associ.aticn Brick Lancaste--, Deputy Chief, Off:.ce of Health Fx3ucaticn aic'zael Scaniola, ; Sicc2ican Tcbacco and Car.dy Vendors Associ.at?.cn Bill Thar, Mid-Mic.w.gan Dist`ict Eealth Depaz-tnent R1C.tC Davenccrt, AniE'Sican IiTslg ASSOc13tiCn Te3 Beideraieden, knerican h=. Associat,.cr. I I I r I il I L -42-

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I 1 i i t ~ I- I. Call To Crder 'I,"~ meeting was called to order at 1:00 p.m. Ben Barker and Scott S:.-crrs wer~e acpointeci by Doc..or Reizen to serre as G'iairpesscn and Vice-G-La-i.-pex-scn respec-tively. Me Vice-Chair--erson c:.aired the meeti^.g because t^.e C-.air- Ferson was unable to attend. II. Pgenda Revieea The agenda was reviewed and no additions were made. 111. Arrorrrral of '.Kinutes Robert Crtwein's name was missing fran the list of ",viambe_rs Absent" on the July 17 minutes.Thz minutes were then unarListnusly aFnrovefl . IV. IntrcdLrticm of Visitors V. Legal Subcamittm Report The Lecal Subcortmittee's wxrk to date was reviewed. A wnrking draft of a ":Zichigan Clean Air Act" was presented in sLmmazy. This represents increased protection of nons.-inkers' rights over previous legislation. Me bill is de- signed to amend the Public Health Code, Environmental Health Section. It establishes environmental standards and prohibits sinking in publ.ic places and worksites ezceot in desigr.ated areas. The bill was presented arimarily for the r?npl's infoanaticn. The :Kichigan Clean Air Act' will be on the next meeti^r,'s a en:a, at which time it will be voted on for adoption. Cosnrer.ts on the bill are to be sutinitt.ed in writing to Scott Simends or Rhcrida Rurr.er witZin ten days. A suggestion was made to solicit carirents fran groups that may be affected by such legislation. It was suggested that the Gove.rnor's office be contacted to dete` if the Citizens' Panel has the authority to hold a public hearing. Either a public hearing could be held by the panel before the report is sub- mitted to the Governor, or a hearing could be held by the Governor's office after the subnission of the report. Prcpesed legislation was discussed. Senate Bill DTo. 388 prohibits sc'^.ool officials, emplcyees, pupils, and teachers fran smking on the pzcoert<y of a sci=l district. House Bill No. 5542 raises the szmo}eing age fran 18 to 19 years.Me Legal Subecnmittee reamrerrLs supporting proposed legislation relating to the prahibition of sraking, consistent with the panel's efforts to reduce the consumption of cigarettes. It uas noted that some sc3zools provide sunking areas for students who are 18 years of age or older, and that smeking behavior of minors is difficult to monitcr. -43-

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The Faz:el uas ur.ce_~--.sin abcut t:.eir si.,.~crt for Hcuse Bill ~;o. 5J-12, as it ~..culd be a law diffic.lt to enforce. Cn the other :.and, Senate Si" Nc. 388 wauld carale*.nent the pri:.ciple sciples of the drafted "~Li&_ican Clean r.ct" . Proposed Senate Bills Nos. 263 and 236 wi-Lc:z would orchibit snoki.c :.z =ub1ic olaces a_re i.^cltr?e3 wit'zin the frameaork of the drafted "Mic:^scan Clean At.r Actle_ - The sale of cigarettes in verdir.g machir.es was discussed. The Le~..-al (Sub- caamittee presented tao possible alterr.atives: 1) to crohibit all cigarette sales thrcuqh verrding machines; or 2) to raise the license fee cn vending rrach3nes. It was felt that r.:i..^.ors rrsay easily obt3in their cigarettes f=n unattended vending machih.es. E.ither strategy ~%culd r,axe ve-~,n.g :rzc:^.i:e cigarettes mare inaccessible to minors. It was noted that the subccr.mittee did not possess aciecw,ate data on the purcnasinq patterns and behavicrs ef teenage smrkers. Aceording to apanPl r,xrber, a survey of ..unors de*...e=nined t.~.at cny y a+rall percentage of cigarettes were bcught t'zrcugh vp-ndi*-, machines. 'LTM:e r.Tajority of cigarettes were obtained through friends, carents, and retail steres. Tf:e Far.el requested a copy of the survey. It was noted that bt. Banzhaf III, an attorney for ?,cticn on Snnki.^.g and Health, has suggested that the State take prciiibiti~,e actions acai^.st cigarette vending machine sales to prevent numrs f=nn smkir:g on a regul~r basis. Fhforceramnt issues were raised. It is =lear what a&ninistrative body is re- sponsible for enforcing the res7ttriction of cigarette sales to minors. A panel me<nber suggested that the panel address carwii.ance issues regarding utiat laws should be enforced, procedures to be used, and cost of enforcenent. More infcanatien is needed on effective carpliance :nec:n-anis+^s. It was sucr,ested that enforce:nent procedures with severe per.alties may be effective. This suggestion was tabled to the Legal Subcormittee. Furt~trer discussion of the cigarette vending machine and e_zfo.rcement issues wi11 be resi=ned at the next panel meAting. VI. Educaticn/-Media/Publi.city Subca;anittee Reoart 11'.e cropesed educaticn/media/Publicity alter.^.a~,..ives were reviewed. Regarding in-serv~e ce t~3q n irf-~ and ccnt=mang er-i-cation, a r_ar.el merber sLrgesy- that fure.ir.g may be a crcble:a. nie respc:nse was that some~ voluntary agencies presetly are providing smkis=g educaticai prtx;rams. The appzoach wculd be to tan into alrezriy existing snaki_ng arxi health ectivities.F=xding is available for a"tr a i n i ng of trair.ers " c.arksh,oo to be c=x!ucted by t'r.e Derz,r _ ~ent of ELz:caticn. 2'le svbarrmittee has not develcped speciiic recrimere-aticns fer c:n=re'r.e_n.sive school health educaticn, as this is alreacy bei.^-g handled by the Office of Health and `-Sedical Affairs (CHM) . The Gcve_TM,cr recuested that MIA cocra...i.n.ate I i I I ( I 1 i. I E i L I L

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I I I- I s a task Sorce to develoo a sc^.col health eaucati:.n =L3n «izich speci_`ica11 f deals with L-:-service and -=e-se_n,7ice trai.^.:_.~:g, and buccet c.^.nsideraticrss n-Lis plan is being desigr.ed to help scY,=ls in develcci.^g, i.^:plement' ng, and evaluati:.c d=rene*zsi:.,e sc.~=l health educatica r ogrm-s . A r.ar.el r,~:rbe* suggested that smoking cessaticn rrocrars be directed at the smoking population in secendazy sc.'~.ools. Z'he subc=rnitt--e was asked to =Lsider smking cessation programs for the sc.'=l-aced population as a specific proposal. n^..e suggestion was rmade that if oormliance mc^.ani~.-Rs are :rade more effective, t'ien mir.Qrs who are fosnd buying or smoking cigarettes cculd be referred to i s i ~ : smoki.^g cessation programs. Tl:e panel agreed that local health departrents should coccP.rate with hosbitais, clinics, and I?ealth Mainte.nance Organizations to provide a sroking education cer.~cr.e-nt in established pre-natal, parent, and patient education Frogram. Smkir.g preventicn and education prnerairs should provide evaluation data to s1zppcrt their effectiveness. Any request for proposals can stipulate that well done evaluation studies be a part of any proposed smoking prevention and edt=ation program. A panel marber suggested that ongoing consultation for smoking and health activities be provided to educators. The subc,-czrmit},.ee encourages locall health denartments to facilitate and co- ordinate sm.king prevention and education activities wit`zin their juris- dicti.ons. It was suggested that the suhczrnnit}..ee clearly delineate the fcr:n this leadership role should take. I I Several pan,el merbers expressed their interest in the fcz.-aticn of a pranir.ent citizens' group to publicly advocate mnssmking beP^avicr. . The subcatmi ttee was asked to identify additional resporLsibilities of a citizens' group. Qr.e task might be for the group to encourage national f irns ( e. g. McDonalds ) to adopt a no-smking theme. A survey of teenagers conducted in 1979, Teenage stnkina: Inme3iate and Lcng Ter.n Patterns, shews a decrease in sinkii:g in all sex and age categories, except 17- year old girls. Infozmaticn shculd be obtained ccncexning the reasons for this decline so that these nensncking behaviors can be encouraged. VII. Public Catr.tients Tt-x:)se wh.o direc+r,.ed craiments to the Citizens' Panel were the following: 1. Jime Asselin, Educaticn C,oordir.ator, Mic'^.igan Dental Association 2. Fti.r-k L`avPS=rt, Amasican Zaung Assoc.:.ation: ar.d, 3. Bill Thar, '-`ed;cal Director, :Zid -Mic'zigan District Healt.z Departnent. A-Ll --:bL.c ccrments wese included in the record. -45- ~

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1 VIII. Vew Busir.ess Greccory Srni.th resigre3 as a r=-ber of the Ci*~c`^s' ?ar.el. 'I'::=-z.s ~ Vi ce-President of the Naticnal Baruc of Cetroit, :as apccizted to z':e ?a.^el. Receiat of correspcnce.xe frGm Jchn 3ar.zhaf IyI, Dire=},.;r cf ?r-..'_cn cai S;nokizg and Health, was ackr.cwled5ed. A letter was also sent te Soctor Reizen frcm the Direci= of the Ceoar--ent of State Police. He stated that his staff, as well as the U.S. Dexrt-nent of --easux-y, Bureau of ALccrzl, Tobacco and Firear,^is, believe there vculd be :rn suhstsnti3l i^~xct ut_ cn stn :c,r, li.^g shzuld the excise tax on ci--arettes be ra.ise3. Albert Zack, Principal of Franklin iiicn School, subn.itteid a pcsiticn xpe: to the Citizens' Panel. The agenda for the Septerber 11 meetir.g will include four :m.i_-i itz.:s: 1) specif ic proposals fraa the Education/M~PubL' city 5ubca;ir.it}tee , 2) ex: cr-..ic recanren3aticns that have been either accepted or tabled, 3) propcsals fr cr,i the Iegal 5libca:mittee; and 4) alternative prcrosals as yet tu~is:..:sser?, such as an ongoing panel to :~nitor simkis:g and health activities. During the Octcbes meeting, a prelimisary draft of the final repcrt wiL be reviewe3, discussed and amerde3. A firal revisicn arx-I adctticn of the reoort will be made at the November panel n~ting. _ . The tent3tive foarat of the final report was cistr:buteci to each panel :re-bo-- for their review. I I i i The meeting adjourned at 4:00 p.m. I -46- I ~ I ~ L

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I I f I I I I I ! 3 I I N~.Yi N=-TING DATE: Wednesday, Cctcber 8, 1QS0 1:00 - -1:00 0.,. Nlichigan L`epartment of ~l:clic fealth Baker-Olin ~%'est Complex, Rocm iC 3500 N. Logan Street Lansing, titI 48909 CITI7E.VS' PANTEL ON SMDKING :kti'D HT-aL.TH - MItiL''I"°S Conference Room 1B Baker-Olin West Complex Michigan Department of Public Health September 11, 1930 1:00-4:00 p.m. N I DBER.S PRESEN-T : Eleanor Barber Ben Barker, D.D.S., Chairperson Donald Breckon, Ph.D. Terry Gerald (representing Rep. Raymond Thomas Hunter Walter P. Maner III Charles Mitchner Michael Sbrti:more Robert Ortwein Hood) Senator William Sederburg Scott Simonds, Dr. P.H., Vice-Chairperson Douglas ViLzius %D1BEZS ABSENT: James Howard Norbert Reinstein Virginia Kjolhede James Terrian, N1.D. Margaret Lee George Watts Janice %Seadewcroft Arthur Weaver, ~1. D. STAFF PRESENT: Kenneth Warner, Ph.D., Project Director Sur.ny Sun Nai Fong, Chief, Office of Health Education Rhonda Runner, Student Assistant, Office of Health Education Nta..~cwell Alderson, Bureau of Personal Health Services Russell Holmes, M.D., Bureau of Disease Control and Laboratory Services John Insel, Bureau of Environmental and Occupational Health George Lafkas, Office of Substance Abuse Services Walter Wheeler, Assistant to the Director for Program Develcpment Marion Vaughan, Office of Cormrnmication Services Wanda Jubb, Department of Education GUESTS : John Dernback, american Li.mg Association Brick Lancaster, Michigan Depart:nent of Public Health Bob Popp, Michigan License and Beverage Association Bob Smith, arnericsn Lung Association NSic.`zael Spaniolo, 1%Lic.higan Tobacco and Candy Distributors u`:endors Association Dcn Sweeney, Michigan Schcol Health Association -47-

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I I. Call to G}ruer The meeting :,;as called to order at 1:G0 a.~. II. Aooroval of %Linutes The minutes of the August 18 meeting ,iere ,.Tani-.ously approved. III. Introduction of Visitors IV. Legal Reconmendations It was stated that Panel members would vote on the reccr^Jr.ended actions proposed by the subccrmnittees, with the full report being fornally adopted on November 9. 1. We reccrrnend that the State adopt new legislation assuring a more compre- hensive protection of the rights of nonsmokers to clear air in public places and work sites. The =de1 of a"7,Lichigan Clean Air Act" will be included in the appendix of the report as being illustrative of the reco=r.endation's intent. A point was made that OSNA may already address the clean indcor air issue. The majority were in favor of the rece=endation; with cne ocposed and one abstaining. 2. We recoTrnend that the Governor adopt auniform policy on s;,ioxing, consistent wi th proposed legislation to protect the rights of nonsnokers, to be adopted by State agencies and depar,ents. The majority were in favor with one abstaining. 3. We recornend that further study be conducted on the purchasing patterns of children and teenagers to be funded by revenue that is generated from an increase in the sales tax on cigarettes, or from an increase in the vending machine license fee. It was stated that a paper distributed to the Panel by the Tcbacco Institute indicated that vending machines were not an'umportant point of purchase for teenagers. However, the Gilbert Ycuth Researc'1 Stud,v (now outdated) shows results which differ. Current infor~nation is needed on the cigarette purchasing patterns of children and teens. The reccrmiendaticn will be reworded to include a broad survev of the cigarette purchasing patterns of children and teenagers. It was decided to delete references to funding as that issue has already been addressed in a separate reccrrsnendaticn. :Lil were in favor of the recommendation as reworded. -48- I i I I ( I j 1.. I ~ I ~ I

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r I- I I I I 4. We recor,nr.er.d that the Gcvernor encourage State and local police agencies and the prosecutor's office to comply with existing legisla- ticn. Pie urge that public education be a component cf enforcement activities. Further, that the Governor encourage State agencies and deoarunents to explore alternative enforcement mechanisms. All were in favor of the recornendation. A legal recorrr endation is needed to encourage compliance with smoking legislation in restaurants. Penalty points should be assigned to restaurants for noncompliance during the inspection of the facility. All were in favor of proposing that the Public Health Code be modified to permit the adjustment of the restaurant inspection form to include the assignment of penalty points for the violation of the smoking laws. V. Ecenemic Recorrmendations Two reccrIInendations have been previously approved. They are: I I I I I i i ~ 3. 4. 1. raising the State excise tax on cigarettes 5~ per pack, earmarking 1; for smoking and health activities; and, 2. lobbying the federal government for a substantial increase in the federal cigarette excise tax, earmarking a portion of the tax for smoking and health activities. Presently there are adequate resources to support federal smoking and health activities.. It was decided to delete the earmarking portion of recomanendation #2. A Panel member felt that an increase in the excise tax would result in more bootlegging activity. Correspondence frcm the Departaent of Treasury and the State Police indicate that a S¢ excise tax increase would not be a problem. It has been shown that a tax increase deters initiation of the cigarette habit, especially among young adult males. A vote was taken on each recommendation; both passed with one opposing vote. We recomsnend that the Governor and congressional delegation work for inclusion of smoking cessation costs as allowable itemized deductions in the federal personal income tax. The majority were in favor of this reconmiendation, with one abstention. ~ We recommend that the feasibility of requiring pre:nium differentials C l1 for life, health, homeowners, and automobile insurance for snokers and ~ nonsmokers be explored by the Insurance Cartanissioner. CA Correspondence from E. C. '.fackey, Acting Commissioner, indicated that tCD p many insurers offer a non-smoker's discount for home and life insurance. W He was unaware of any major healt.'i insurer which charges different rates for smokers. -49- ~ 4 L-

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I Bev Niener, Director of the E'.ealth I^sL'rance CJm. l:a.^.ce nl'.;s:Cn, a letter to staff stating that she is unaware o: any studies Nhich -cuis conclusively demonstrate the extent of the relationship bet.eeri smm:e.l-ing and the risk assumed by the insurance ccrmpany. It was noted that actuarial data does eYist cn which insurers base differential rates for smokers and nonsmokers. - The recocrnnendation will be reworded to state that the Insur:nce Corrmissioner in cooperation with the Ntichigan Depart,.ent of ?ublic ~:ealth research the feasibility of requiring prer.iium differentials. The recommendation passed, with one opposing vote. S. We recommend that smoking cessation programs be included as an insurance reimbursable item. Bev Wiener, in her correspondence with staf:,made three points con- cerning this recommendation: 1) mandating additional coverages would result in additional premium costs, 2) low costs of smoking Writh- drawal-programs may not be of benefit to the insured who , t pay a deductible; and, 3) the cost for an irsurance company to handle small claims is high, and-it is generally considered more important for health insurance policies to cover the expensive medical services. The Panel agreed that including smoking cessation programLs as an insurance reimbursable item could result in decreased premiuuns in the future. The principle of the recomnendation is to provide an incentive for smokers to quit smoking. The smoking cessation program, as an insurance reimbursable item, can be offered as an optional coverage by insurance ccr.panies or :r,andated by the State. - A Panel member noted that requiring insurance companies to cover the cost of smoking cessation programs would add a considerable cost to the price of health insurance. It was decided to research the feasibility of including smoking cessation programs as an insurance reimbursable item. All were in favor of adopting the recommendation, to be included as part of #4. VI. Educaticn/Nedia/Publicitv Recerr~r.endaticns 1. a. We reccnunend that local health deYarr:ezts accept as their respcnsi- bility the facilitation and coordination of sm,oking and health activities. m G'1 b. We reccrmnend that the Aic.'ligan Depar*:.^ent of Public Heal th provide M skills training in the planning, i.*rmlet:enting, and evaluating ~ smoking education programs for local public health educators. M CO The local health departments can submit as part of their healt-h O;b education plan, called for cmder the cost-sharing program, their Lmplementaticn activities related to _.:cki.^.g. The NlicHigan Eepar^:ent I I l1 f I ( I I I t h t ~ I L -50-

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I I I I I I ~ I of Public Health will take a leadership role in helping to direct t::cse activities. It was suggested that smoking cessation programs could become a basic (required) health service thrcugh cost-sharing. RecorrJnendation 1. a. will be reworded to state that local health departments should be encouraged to facilitate and coordinate health education activities in smoking. :U1 were in favor of both reccmr.endations 1. a. and 1. b. 2. The subcommittee supports the efforts of the Department of Education in its development of a comprehensive K-12 school health education pro- gram. . - All were in favor of adopting the recommendation. 3. We reccmmend that selected secondary schools include smoking cessation activities in their overall health program. - It was decided to merge this with recommendation #6, which provides for a grants program for demonstration projects directed toward smoking prevention or cessation. I I I t 4. We recommend that Michigan offer itself as a location for the evalua- tion of the impact of comprehensive school health education models on smoking. The me,^ibers agreed that the evaluation study should be a comparative one. :U1 were in favor of adopting the recommendaticn as reworded. S. Universities and colleges should conduct smoking education activities. The recort¢nendation should state that universities and colleges be encouraged to conduct smoking education activities. All were in favor of adopting the recomznendation as reworded. 6. We recommend that the Michigan DepartTent of Public Health be authori:ed to develop a program to fund research and demonstration projects con- cerned with smoking prevention and cessation. It was agreed that limiting program grants to serve only the high-risk populations would be too restrictive. All were in favor of adopting the recorrnnendaticn. We recommend that smoking cessation programs develop effective methccs to reinforce nonsmoking behavior. Follow-up activities should be a requirement of the grants program. The grants program should include three categories: 1) smoking pre- vention, 2) smoking cessation; and, 3) reinforcement of nonsmoking behavior. -51- ~ ~ t- - ------- -- ---- -- - -

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A11 were i.-t favor of including this reccr=endation with 46. S. 1:'e reccmr,end that the Michigan Department of A,iblic Lealth '--e authorized to pror^ote available professionally prepared med:s packages, a mechanism for their use, and an evaluaticn of their i:r,pact on target groups. The Panel felt that the Michigan Deparment of Public Health shculd not rely on available media packages, since that would prohibit the develoo- ment of their own materials. The word, "available", will be taken out of the reconnendation. All were in favor of adopting the reccrrmendation. 9. a. jle recommend that the Governor's office widely publicize the Panel's receTmendations and provide a public education component to promote support for the support of legislation relevant to smoking issues. It was agreed that this would be included in the process of submitting the recomr:endations to the Governor. b. We recommend the Governor's office form a prominent citizen's group to publicly advocate nonsmoking behavior. a11 were in favor of adopting the recerunendation. VII. Additional Recerrendations 1. We recorrmend that a well-designed evaluation protocol be a ce-,^ponent of all smoking and health activities. This is a duplicative recorrunendation; therefore, it was omitted. 2. We rec _ommend that the Governor appoint a citizens' group to advise him on a plan to implement the Panel's recomnendaticns and to monitor smking and health activities in the State. The Panel agreed that the Nlichigan Department of Public Health should be responsible for providing staff support to t;e citizens' ce=ttee. Further, the citizens' committee should recommend new directions on an annual basis to the Governor. All were in favor of adcpting this reccn~;.endatien. 3. There should be quality assurance of smoking cessation programs and possible certification requirements. A Panel member stated that we should move toward developing a quality model of smoking cessation programs..another member felt that we have no basis for certification since it is im.known what the ccrocnents of a"a,uality" program would be. Certifying programs may be a deterrent to innovation. It was pointed out that there are public policy needs that may recuire the certification of programs. For exarole, criteria should be developed for smoking cessation programs that would be -52- I I i I i I I I i I t t L

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I I eligible for inclusion as insurance reir;.burseable items. I f I .A11 but one Panel member was in favor of reccrrmendinQ that the issue of certification be addressed in the final report. 4. Smoking cessation programs should be a~,aT~dated'oasic service in local public health departments. It was felt that this is redtmdant since health education is already a basic health service in local health departments. The Education/Media/Publicity Subcommittee has already addressed this issue by recomnending that the local health departments be a focal point for smoking and health activities. The reccrrmendation was not accepted, with only two members in favor of it. S. The Michigan Department of Public Health should be given overall coordination and responsibility for smoking activities. It was agreed that the Michigan Department of Public Health is the logical unit to take a leadership role in coordinating smoking and health activities. . u I All were in favor of adopting this recommendation. The Panel asked the staff to review the reccmmendations and identify substantive areas that may have been ignored. VIII. Public CorrJnent Those who directed corrmients to the Citizens' Panel were the following: 1. Don Sweeney, President, Michigan School Health Association; and, 2. Bob Smith, Director, American Lung Association. A position paper was received from the Tobacco Institute. Walter Maner X. stated the Tobacco Institute would be sending another paper to the Panel members. The Society for Public Health Educators, Great Lakes Cl^.apter, and the 4-H Youth Programs sent position papers and these were distributed to Panel members. New Business Go ~ Receipt of correspondence was acknowledged from the following: ~ 1. E. C. Mackey, Acting Ccmmissioner, Insurance Bureau m CD 2. Bev Wiener, Director, Health Insurance Ccrrmliance Division ~ f ~ ~ 3. John Insel, Secticn Chief, Fcod Service Sanitation Division 4. Don Shopland, Technical Officer, Office on Smoking and Health S. Aic.hael Spaniolo, Chairman, Michid-,,an Tobacco Industry Advisory Council 6. Walter Maner III, Citizens' Panel member 7. Kenneth Warner, Project Director, Citizens' Panel -53- i

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I :he timetable of the Citi :ens ` Panel activities .,~ill be as fo1-ci:s : September 13-16 Seute:nber 22 Sevte.nber 70 October 8 November 6 staff .:ill draft the final recort subcer.,ittee review of the draft I redraft and :^ail to Panel me,:oers { amending of final draf tt minority reports received; formal adcpticn of report A Report Review Subcorrmittee has been for-med and will meet in Ann Arbor on September 22. - The executive sumTnary, which is the substance of the final report, will include the prologue and recer,ar.ended actions. The supporting materials will be in the appendix of the report. Dissenting opinicns, ccrynents, and reservations will also be included. Setting aside thirty minutes on the agenda every meeting for public cc~Tnr,:ent satisfies the requirements of the law. However, Panel members would like to provide another opportunity for the public to cc=..ent and add to the deliberation process. The Panel will hold a public hearing on October 8 from 10:00 a.m. - 12 noon. The full Panel meeting will be held from 1:00 - 4:00 p.m. on that date. Those who present oral testimeny should also submit a written statement to be included in the record. For those who cannot attend, a written position paper can be submitted to the Office of Health Education. The meeting was adjourned at 4:30 p.m. -:4- I i I I I t L 1

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I I I I I I i I I I I- I- 1 ~ t ~ ~ NEXT NtEEI'I\G L.aTy : Thursdav, November 6, 1930 1:00 - 4:00 p.M. Baker-01iz ~tiest Ccmplex, Rccm 30-'-C 3500 North Logan Street Lansing, MI a8909 CITIZENS' PANEL ON S~fOKING AND h'F_-%Li~i tifI L'UI'E,S Conference Room 1C Baker-Ol in tiv'e s t Bui lding Michigan Department of Public Health Wednesday, October 8, 1930 1:00 - 4:00 p.m. N01BERS PRESENT: Ben D. Barker, D.D.S., Chairperson Terry Gerald (representing Rep. Raymond Hood) Virginia Kjolhede Margaret Lee Walter P. Maner III :iichael A. Mortimore Robert T. Ort-,;ein Norbert Reinstein Scott Simonds, Dr. P.H., Vice-Chair- person James Terrian, ;t. D. Douglas Vilnius ~0- 03ERS aBSEM': Eleanor Barber Honorable William Sederburg Donald Breckon, Ph.D. Thomas Hunter James Howard George Watts Janice ',*,feadowcroft Arthur Weaver Charles NLitchner STAFF PRESEVT : Kenneth Warner, Ph.D., Project Director Sunny Sun Nai Fong, Chief, Office of Health Education Rhonda Rush Runner, Student Assistant, Office of Health Education INthxwell Alderson, Bureau of Personal Health Services Russell Holmes, M.D., Bureau of Disease Control & Laboratory Services John Insel, Bureau of Environmental F, Occuoational Health George Lafkas, Office of Substance Abuse Services Marion Vaughan, Office of Coriurnmication Services Wanda Jubb, Department of Education G(JESTS : Theodore Beiderwieden, American Lung Association Brick Lancaster, Office of Health Education Michael Spaniolo, Michigan Tobacco and Candy Distributors Assoc. Carol Vick, American Lung Association of Southeastern Michigan -~~- t t ~

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I. Call to Crder The meeting was called to order at 1:C0 p.m. II. Approval of Ainutes The minutes of the September 11 meeting were L.^ianu^ously approved. III. Introduction of Visitors IV. Review of Final Reoort The final report was drafted by staff, using the Panel's reccm^.endations and subsequently revised according to the Report Review Subcc=*ttee's comznents. To determine individual Panel members degree of support for the recommenda- tions, it was decided that the staff would solicit comments from each person within the next week. The opportunity to file a minority report wiii be extended at that time. The format of the minority reports as agreed on by the Panel is as follows: a) the report should not be more than two single-spaced pages, b) the report can refer to background materials contained in the appendi.x, c) staff will provide secretarial support for the typing of the minority report, consistent with the format of the majority report; and, d) minority reports will be listed in the table of contents. The following decisions were made concerning the draft of the report: The table of contents, under II "Reconanended Actions" the following will be listed: A. SimIInary and B. Conclusions. Appendix C will be re:noved as there wa.s ccnsiderable ccnfusion abcut the inclusion of a State "Clean Indoor Air Act". All references to the .act will be deleted in the body of the report. Cnly the minutes of the full Panel meeti.-ig will be included in the appendiY. Two backgroiuid papers will be included in the appendix of the report :Lrl a) Smokino and F?ealth in Mic:ziQan by Xenneth E. warner, Ph.D; and, M b) e _,~,mo Lnana :ea t. cntroversv: Another Side by George E. ~ Sc'~azer, . . . W O -56- i I ~ t I I t I- L L L L i `

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I I r I r I i ~ ~ I I I I The list of those who have submitted public corur,ents will ~e ca:egcri_ed by source (e.g. public health depar^:ents, private citizens). Correspondence will be listed, including the na;re and date. .an asterisk will indicate those letters that appear in the appendix. ConcerZing the Prologue, page 2, lines 21-23 will be deleted. The rationale for recomendation #2 should state the percentage of the drop in federal excise tax. Taking into'accotnt the public's conanents, reconanendaticn #4 will include the option of a federal tax credit for smoking cessation costs. Reconanendation #8 should state "food service establishment smoking law". The rationale for recommendation #10, line 21, should state the Public Health Code requires rather than rrandates local public health depart- ments to plan, implement, and evaluate health education. Recemnendation #12, line 17, should state "health education curricultrn". The rationale for recommendation #15 should state " . . . . progrmn options for smoking prevention and cessation are far from exhausted." Reconanendation #16 and #17 will be merged. The rationale for reccmmenda- tion #16 will be reworded to incorporate #17. Tr.e rationale, page 17, - line 3, will be amended to state ".... an effective means of reduc- ing the risk of heart disease." The phase, "given the critical importance of smoking to the health of Michigan's citizens" will be deleted from recommendation #19. During the public hearing, it was noted that the roles of the voluntary health agencies were omitted in the report. The Panel agreed that these agencies have been important in providing programs and activities aimed toward the reduction of smoking. Recorrmendation #20 will be modified to state that the responsibility of Michigan Department of Public Health will be to seek guidance and cooperation with voluntary health agencies. "Cur State" shculd be revised to "the State". V. Logistical Considerations The staff will contact the Governor's office to receive the following information: 1) how those members who have never attended a meeting at should be represented in the final report; and, 2) procedures for the ~ discharge of Panel member's duties. 04 It was reported that the Governor's Administrative Assistant will arrange ~ a meeting with the staff and CY~.airperson to discuss: 1) ranking the MO -57-

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I recc=er.dations in ter.ns of prioritv; and, 2) actions t::at t::e Governor' s orfice should take regarding the reccrr.r.er.dat:cns. The Panel agreed that a copy of the final report should be sent to everyone who has presented testimony or subr,iitted a~osition paper. Possibly an edited version with the exclusion of the apper.dices or the report can be available for general distribution. VI. Correspondence Receipt of correspondence betNeen Walter Maner III and Kenneth '.'.arner was aclmowledged. The Office of Fealth Education has received fifteen position papers since the last meeting. VII. .adjournment The meeting adjourned at 3:30 p.m. I ~ I t I I I I.. ~ L -58-

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I I I f ( i I I i I CITI:EENS' P.-V\EL CN S:,:GKI`;G .k\'D f-:EU;H M I\UTES* Conference Room 3A Baker-Olin West Building Michigan Lepart^.ent of Public f:ealth Thursday, November 6, 1980 1:00 - 4:00 p.m. MEMBERS PRE=: Ben D. Barker, D.D.S. Chairperson Donald Breckon, Ph.D. Terry Gerald (representing Rep. Raymond Hood) James P. Howard Virginia Kjolhede Walter P. Maner III Michael A. Mortir;ore Robert T. Ortwein 'orbert Reinstein Honorable William A. Sederburg James C. Terrian, M.D. Douglas Vilnius lENBERS AB.,,T: Eleanor Barber Scott Simonds, Ph.D., Vice-Chairperson Margaret Lee Thomas Hunter Janice ~,ieadowcroft George B. Watts Charles H. Ntitchner . :krthur Weaver, M.D. STAFF PRES~T: Kenneth E. Warner, Ph.D., Project Director Sunny Sun Nai Fcng, Chief, Office of Health Education Rhonda Rush Runner, Student Assistant, Office of Health Education Maxwell Alderson, Buseau of Personal Health Services Russell Holmes, M.D., Bureau of Disease Control and Laboratory Services Marion Vaughan, Office of Corrammication Serrices GiJESTS : Theodore Beiderwieden, .american Lung Association Nancy Dingman, Veterans Administration Hospital Mary Ci^rein Michael Spaniola, Michigan Tobacco and Candy Distributors Association *Since this was the last meeting of the Panel, the :ainutes were not for:r.ally reviewed and adopted. -59- ~ ~

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I I. Call to Order ihe ,meeting was called to order at 1:13 p.m. I I . Aooroval of ~tinutes The minutes of the October 8 meeting ~ere unani.meusly adcpted. III. Introduction of Visitors IV. Review of Final Renort The letter of transmittal will include: 1) a statement asking the Governor to meet with the Panel to discuss the irtpleTentation of the State's mnoicing and health program; and, 2) a statement that the Panel has accepted the tenet that smoking is the greatest single preventable cause of death in America today, docwrented by evidence that has . acctum.ilated since the 1964 Surgeon General's report. Recommendation #7 should state " . . . enforcement efforts, and capabilities". Recorr,rnendation #10 will be mcdified to state "... that the program plans of local health departments include a wide variety of ,+,oking and health activities". It was agreed that the rationale for recon~nendation 410 shculd recognize the i.^portance of the hospital's role in smoking and health education activities. Reccmmendations nos. 15, 18, and 19 should indicate afLmding m.echanism. Therefore, recommendation 415 will state ". . . that Lhe Department of Public Health be provided the authority and funding to develop a program to fund research and demonstration projects . . . ". Recemanendation 418 will state ". . that the Governor appoint and provide resources for an ongoing citizens' comnittee ...". Reconmiendation #19 will in- clude " . . . that the Department of Public Health be assigned responsi- bility and resources for the overall coordinatiern of the State's smoking and health program". The Panel's report should list the various subcortmtittees and their members. Norbert Reinstein's title will be corrected to "Public Health Ccnsultant". It was discussed that the minority report which was submitted to the Office of Health Education on October 30 was much renger than the 2-page limit that was set by the Panel in its October 3 meeting. :kfter receiv- ing the report, the staff and chairperson cerrJmuiicated to the :ninority on October 31 that the report's for.rat was inacceptable. At that time, several options were presented: 1) a two-page minority report could be submitted by the November 6 meeting to replace the present one; or, 2) a notation could be made in the full reoort'that the ;ninoritv report was not included because of its length, but that the report wculd be cn file at the Office of Health Education for anyone who wishes to obtain it. It was also stated that other options could be explored at the .November 6 meeting. i I I I i S I i I I I ~ -60-

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I I A discassien ensued on whether or not to include the ~inorit,~ report as submitted. A Panel member felt that since cnly one :nir.orit;: report ~as been submitted, it should be i.^cluded without regard to length. It ::as believed the minority should not be deprived of the right te e.raress his opinions. There was concern among several Panel members that .he minority report which is 16 pages in length would be gi-en undue weight as the majority report is only 10 pages long. Background materials sub- rnitted by the minority in the course of the Panel's deliberations will be included in the appendices. A motion was raised to include the entire minority report as submitted on October 30 to the Office of Health Education. Three members voted affirmatively; the rest were opposed. The motion did not carry, thus reaffirming the decision of a 2-page limitation on minority reports. The minority stated he would not be willing to submit a 2-page report if the deadline for the submission of minority reports were to be extended. The staff will make a notation in the full report that the minority report will be on file at the Office of Health Education. Adootion of the Final Reoort A formal vote was taken on the adoption of the final report. Of those present, one Panel member voted against the report's adopticn; all others voted to adopt the final report as reviewed and modified. VI. New Busi.ness I I r } ~ A. . Meeting with the Governor's office. The final report will be transmitted to the Governor with.in two weeks. The staff has arranged a meeting with Jan Bocskay, the Governor's Special Assistant, on November 25 at 9:30 a.m. The Chairperson will attend the meeting to represent the vzeti:s of the Panel. The primary task of the meeting will be to brief the Governor's Assistant on the report's development. All Panel members are invited to attend the meeting. The Panel asked that the staff further clarify the purpose of the meeting. Correspondence There were twelve Panel members who submitted formal reactions to the final draft of the report. These responses were solicited by the staff. Of the twelve responses, no one indicated a desire to i submit a minority report. ihe receipt of eight position papers were ac}ozowledged. Tl:ey are: t ~ 1. Theodore Beiderwieden, kmerican Lung Association 2. John C. Howell, Ph.D., President, Arriericaz Lung Association 3. Dick and Louanne Soczek, St. Ignace. 4. Thomas Logan, Director of Planning, West Mic.h_igan HS-\ 5. Dr. J. Byron Walthall, Michigan Academy of Family Physicians 6. Mark SciclLma, President, Red:ord Township Chamber or Comne:-ce ~ 7. Dr. Rasmu.ssen, Grand Rapids 8. Susan Hansen, Kalamazoo -61- `

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It was ac?ciowlec'ged that Walter Nfaner III wrote a letter tc the Project Director. There was a motion that the G".airYerson apprcoriately reccgnice the staff's contribution to the Citizen's Panel and that this 1,e conveyed to the relevant supervisors. All were in :avor of adcDt:ng this motion. C. Evaluation The Panel members were asked to complete an evaluation fcrm on the performance of the Panel and staff. VII. Adjournment The meeting was adjourned at 2:30 p.m. t i 1 i I I I I I I r 1 6 `

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I I I I U I F I I ~ ~ I i t r} l t ~ SUBCOM~fITT"~:.S Economic Subca.:r-.uttee Ben D. Barker, D.D.S. Charles H. LKlitc'rlner Kenne th E. ltiarner, Ph. D. Education/Media/Publicity Subcomnittee Donald Breckon, Ph.D. Janice Meadoucroft Norbert Reinstein Legal Subcormittee Terry Gerald (representing Honorable Ray,,.or.d W. Hood) Scott K. Simonds, Dr. P.H. Douglas Vilnius ReDort Review Subco.-mttee Ben D. Barker, D.D.S. Scott K. Simonds, Dr. P.H. Douglas Vilnius -63-

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I I I I I ( I I I C. ARTICLES AND DRAFT PAPERS DISTRIBUTED TO THE CITIZE'VS' PANEL AND SUBCCNMITTF_FS i- I

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I I I U I I I I IL I I i 3 ; ~ ~ t ~ } Articles and Draft Parers Distributed to the Citizens' Panel and 6ucccr,fiut.ee Baric, L., "Non-Smokers, Smokers, Ex-Smokers: Three Separate Problems for Health Education", International Journal of Health Education, supplement to vol. ?CCII, No. 1, Jan. -Marcn, 1979, pp. 2-20. Nfichigan Departnent of Public Health, "Health Educaticn Alternatives", draft prepared for the Education/.%;edia/Publicity Subccminittee, Office of Health Educa- ticn, August, 1980. Michigan DepartTnent of Public Health; ",NIichigan Smoking and Health Policy: Legal Strategies", draft prepared for the Legal and Economic Subcoranittee, Office of Health Education, July, 1980. Mir.neapolis Tribi,ume, '"Kinnesota Poll", 1980. National Autcmatic Merchandising Association, "A Review of Studies and Research Regarding Teen-Age Cigarette Smoking Habits and Purchases", Chicago, 1977. *Schafer, G.E., The Smokin and Health Controversv: Another Side, the Tobacco Institute, SeptemDer, 1980. Wallack, L.M.,':'Nass Nledia Camnaigns: The Odds Against Finding Behavior Change", preliminary copy of a chapter for a NIDA monograph on prevention, Social Research Group, School of Public Health, University of California, Berkeley, February, 1980. Warner, K., "Michigan Smoking and Health Policy: Economic Approaches", draft for the Legal and Economic Subcommittee, School of Public Health, University of Michigan, Ann Arbor, June, 1980. *Warner, K., "Smoking and Health in Michigan", draft of a discussion paper prepared for the Governor's Citicens' Panel on Smoking and Health, School of Public Health, University of Michigan, Ann Arbor, Ji,ne, 1980. White, J.R. and Froeb, H.F., "Small-Airways Dysfunction in Nonsmokers Chronically Exposed to Tobacco Smoke", New England Journal of Medicine, %Sarch 27, 1930, pp. 720-723. *Included in the appendix

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( i Existing and P:ocosed Leeisla;,icn Dist:-ibuted to the Citi:ens' ?snei and SL::^cc^aittee :knalysis of Senate Bill No. 388, Department of Educaticn House Bill No. 5542 House Bill No. 5830 ktichigan Eepart:rent of Public Health, Public Health Advisorr Council, Resolution, :Llternative Funding Sources for Local Health Departments, March, 1980. Niinnesota Statutes 144.411 - 144.417, Ntinnesota Clean Indoor Air Act, Laws of 1975, ch. 211, Jtme 2, 1975. Senate Bill No. 236 Senate Bill No. 263 Senate Bill No. 388 -o r I I I I I i I I r I L } L

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I Please do not cite cr quote withcut -:er-ussicn I I I I I i ~ I t I I I S`IOKING AND HFIILTH LN MIGt iIGAIN Discussion paper prepared for the Governor's Citizens' Panel on Smoking and Health Kenneth E. Warner, Ph.D. Associate Professor Departn:ent of Health Plar.r.ing and Administration Sc.}:ool of Public Health Ltnive rs i ty o f Mi rhi g an Ann Arbor, Mich. 48109 June 1980 - Draft I Research for this paper was supported in part by Grant Number HS 036-74 :rom the National Center for Hea].th Services Research, CASH.

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I Introducticn Cigarette smoking has been identified as Public 'r'.ealth Ene^tv M,.ber One, the most significant source of preventable .morbidit-r and mortality in the L'nited States today.* Each year, cigarette smoking is responsible for 350,000 prerature deaths and in excess of 80 million morbidity-days lost frem work (Surgeon General, 1979). The armual economic toll of smoking amcunts to $40 millicn, including $28 billion in avoidable productivity losses and roughly 8 percent of the Nation's direct health-care costs.** If Michigan's share of these burdens is proportienal to population, our State loses over 15,000 men and women eac, year to the ravages of smoking. Furtheznore, through taYes, insurance premiums, and direct pay^nents, Michigan citizens contribute over $500 million--or more than $50 per iran, woman, and child--to provide medical care for those made ill by smoking. Of course, these are only quantifiable costs of smoking. They ignore the inmeasurable suffering of the dying and disabled and their loved ones. In recognition of the severity of the smoking problem in Niichigan, Governor William Iiilliken has appointed a Citizens' Panel on Smoking and Health to study the problem and make recomtnendations for strategies to combat the initiation and continuation of smoking by Michigan residents. The purposes of this discussion paper are two: to provide Panel members with bac'.<grcund information and per- spective on the magnitude and nature of the smoking problem; and to suggest a wide variety of policy options to stimulate productive deliberations on desirable courses of action. The first section of the paper examines trends in smoking, including changes in the size and composition of the smoking population and changes in smokers' con- sumDtion habits (e.g., per capita consumption and tar and nicotine ingestion). The second section discusses the current health consequences of smoking and con- te=lates near-future shifts in the mix of health problems suggested by changing smoking patterns. The third section briefly examines the economics of smoking. The fourth section explores a variety of policy options to reduce the initiation of smoking habits and encourage cessation among existing smokers. This section opens with some historical backgTound on state and federal smoking policies and then focuses on areas of policy options in Michigan for the Panel's consideration. * This paper will focus exclusively on cigarette srrokizg. G't::er forms of tobacco use--cigars, pipes, snuff, and chewing tobacco--are less prevalent and, assumizg the absence of ccmplete ingestion (inhalation or swallowing), presum- ably less hazardous to health. About 20 percent of adult males smoke cigars and 12 percent pipes; 5 percent chew tobacco and 2.5 percent use snuff. Among women, all four alternative uses show very low prevalence. These habits are discsssed in the 1979 Surgeon General's Report. Should the Panel wish written materials on these habits, t.hese can be fort.'zccming. ** These economic estimates are derived from Luce and Schweitzer (1978), with direct and indirect costs inflated to 1980 dollars. I I I I I I I I I I ~ L -67-

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i I ( I I I I ~ ~ I I I I i I. Trends in Smoking Use of tobacco dates back at least to the mid-1500s. Substantial cigarette ccnsumption, however, is a phenomenon of the present century, with cigarette smoking having grokn from an infrequently indulged lu:rury at the turn of the century to a habit of a majority of adult males by the end of World War II. Consistent with the slogan of a cigarette marketed to females, women have "come a long way." As recently as the mid-1950s, surveys found cnly a quarter of adult women identifying themselves as smokers, a rate less than half that of men. A decade later, the female self-reported participation rate had risen to a third. By the mid-1970s, the gap between male and female participation rates had dropped to roughly 10 percentage points. (See Table 1.) Twn important phenomena are discernible in such data: (1) the rate of self- reported smoking has been declining significantly and (2) the predominance of males in the smoking population has been receding. Indeed, among the youngest age groups, females now report higher participation rates than males. A recent survey of teenage smoking behavior found girls smoking more than boys in two age classes, 12-14 years and 17-18 years. A decade ago, boys' smoking rates significantly dom.inated girls' rates in all age classes. (See Table 2.)* * Survey data must be interpreted with considerable care. Comparison of differ- ent national surveys shows aggregate participation rates often varying by 5 or more percentage points in a given year (Surgeon General, 1979; Appendix Table 1). Niore dramatically, an analysis corrparing survey results with objective production-and sales-based consumption data found underreporting on surveys of more than a third of actual total consumption in 1975, up from a quarter in 1964 ('Varner, 1978). Data on teenage smoking are particularly suspect. In an experi- mental setting, researchers at the University of Minnesota found that teens told that their smoking behavior would be assessed by means of a che:nical analysis reported 50 percent more smoking than those who were not subjected to the "threat" of objective confirmation. In some circunstances, teens who view smoking as "adult" may overreport their consumption. -68-

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i Table 1: Percentages of Acult Males s.nd Fe:.ales ReForting I Themselves to be Smokers, U.S., by Year Year ~Males % Fe:nales ~ Total I Ratio Male to Fema1e Rates 1955 52.6 24.5 37.6 I 2.15 1964 1966 52.9 51.9 31.5 33.7 40.3 42.2 1.68 i 1.54 1970 42.3 30.5 36.2 1.39 I 1975 39.3 28.9 33.8 1.36 1 Source: Surgeon General, 1979, appendix Table 1. Table 2: Percentages of Teenagers Reporting Themselves to be Regular Smokers, U.S., by Age, Sex. and Year % Males - % Fernales 1 I I Year: 1968 1970 1972 1974 1979 1968 1970 1972 1974 1979 Age ~ 12-14 2.9 5.7 4.6 4.2 3.2 0.6 3.0 2.3 4.9 4.3 ~ 15-16 17.0 19.5 17.8 18.1 13.5 9.6 14.4 16.3 20.2 11.3 17-18 30.2 37.3 30.2 31.0 19.3 13.6 22.3 25.3 25.9 26.2 ( Source: National Institute of Education 1979 Exhibit 1 , , . C11 L .D ~1! CD h+ -69-

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I I I I I I I I t I I I I- *,Nhile Tables 1 and : clearly indicate the decreasing rate of smoking since the mid-1960s, they fail to convey the raoid grcwth in smoking in the decades preced- ing the :r,iddle of the century. This reflects the unavailability of use:ul surrey data prior to the 1950s. Fortunately, objective data on aggregate cigarette con- su7mtiont :nirror the recent survey trends and add historical perspective. Figure 1 shows the growth in adult per capita cigarette censumptiont* since 1930 (the solid line). ihe data indicate steady and rapid growth in smoking to the early 19S0s, with renewed growth for a decade following a two-year decline in 1953 and 1954. Since 1964, the trend has been generally downward, with the excep- tion of upward "bi=ps" in uhe mid-1960s and early 1970s. Deviations from the predominant trend are not random. I will disc-,iss these in greater detail in Section IV of the paper; here, note the following: - the sharp increase in per capita consti°nption in the mid-1940s likely represents an artifact of cheap cigarettes being available to Arnerican soldiers and valued by them as a form of currency - the decreases in 1953 and 1954 occurred during the first discussion in the popular press of the health hazards of cigarette smoking (Norr, 1952; Lieb, 1953; Stiller and Mbnahan, 1954) - the decline in 1964 followed the highly publicized release in January of the first Surgeon General's Report on smoking and health (Surgeon General, 1964) - the consecutive decreases in 1968, 1969, and 1970 accompanied the broad- cast media anti-smoking campaign required by the Federal Cemmumication Commissior.'s Fairness Doctrine (Warner, 1979a) - the increases in the early 1970s followed the banning of pro-smoking advertising on the broadcast media on January 2, 1971 and the consequent elimination of the Fairness Doctrine requirement of donated air time for anti-smoking messages; a considerable body of analytical opinion holds that the anti-smoking messages deterred smoking more than pro-smoking ads encouraged it Cilarner, 1979a). * These data are frem the Economics, Statistics, and Cooperatives Service of the U.S. Department of Agriculture. They are derived from data on production and sales, excise taxes, i^rcorts and exports, and loose tobacco production (for hand- rolled cigarettes). They appear to be valid, reliable indicators of aggregate cigarette consumptien. Adult per capita cigarette consumption is defined as total annual cigarette consumption divided by .he population over 17 years of age. A corrar.on indicator OD of aggregate smoh.ing behavior, this measure masks c.'langes in the composition and ~ individual behavior of t_he smoking population. It offers no insight into varia- ~ tions in the sex, age, income, or education distribution of smokers; it fails to Cn distinguish a change in the number of snckers from a'change in the ntzr,ber of CD cigarettes the average smoker consumes; and it ignores several other potentially 6"~ important reported c'rzanges in smoking behavior, such as reductions in the amount CA of each cigarette smoked and shifts from one brand to a lower "tar" and nicotine brand. Nevertheless, subject to these caveats, this measure serves as a reascn- able index of the aggregate level of srrboking activi ty CYarn.er, 1977). -70-

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:,y,U r cz~ uu S u ~j i U 6000 5500 5000 4500 tti 4000 ~ 3500 .~ u' a u b 00 ~ 3000 2500 2 000- , 30 Actual and Predicted in Absence of Anti-Smoking Campaign 35 T 40 `,;Vurcc: Nirner, 1900 a. --- Actua l -------- Predicted, assuming actual price pattern ------------- Predicted, assuming steady prlce pat tern 4 5 .50 55 Ycar (19 ) 9T6S~9St~ 60 T 65 70 75 1 80

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I I I I ( I I I I t I I I "he annual decreases in per capita smoking since 1973, averaging over 1 percent per year ( and growing), cannot be associated with similar specific "events". Cne can hypothesize that this unprecedented downward trend si..~;oly reflects a delayed behavioral response to c.`ianged attitudes and ;.-zowledge. Uterzatively, it is possible that cohort effects account for the trend, e.g., lower smoking participaticn rates among the "baby boom" population which has ncw reached the prime s^oking age. Conveivably, smoking behavior is "riding the coattails" of a general sccial concern with physical fit-iess. SVhatever the exalanaticn, the six year-old decline in per capita consumption represents an ecnouraging development. The data on adult per capita ccnsurotion show a decline from 4443 cigarettes in 1963, the year prior to the original Surgeon General's Report (1964) and the peak year for per capita consumption, to 3989 cigarettes in 1978, a drop of 10 percent. :as the pre-1964 trend suggests, however, per capita ccnsumption might have been expected to have increased considerably had there been no adverse publicity on the effects of smoking. In particular, diffusion of the habit among women was lagging that of men by 20 or more years. Rapid growth in the percentage of female smokers in the 1950s and 1960s augured more of the same in the 1970s. Thus the decline in per capita constnmption in the antismoking era is more impressive than that indicated by the simple calculaticn of 10 percent. I have estimated that, in the absence of all anti-smoking activities and publicity, by 1978 adult per capita consumption wnuld have been roughly 40 percent greater than it actually was (warner, 1980a). Thus, relative to the expected trend, smoking has declined significantly. Decreasing per capita consurrption is particularly impressive in light of the continuing declines in average tar and nicotine per cigarette. Table 3 presents the average tar and nicotine per cigarette sold in the U.S. since 1954. According to the data, today's average cigarette contains less than half the tar of the typical mid-1950s cigarette, while nicotine has dropped by over 60 percent. One obvious implication-is that smokers today would have to be smoking more than twice as many cigarettes as they did in the 1950s to ingest a comparable amount of tar and nicotine (hereafter, t/n). Clearly, they are not doing this. Figure 2 shows the pattern of adult per capita ingestion of tar per year. The drop since the mid-1950s indicates the profindity of the change in smoking behavior.* The trend in recent years toward low t/n smoking shows no signs of abating. The tobacco industry invests over 50 percent of its cigarette advertising and virtually all of its new-product research and development in this highly competitive * Figure 2 should be interpreted with several caveats in mind: (1) Full "ingestion" asstunes inhalation, which does not characterize all smoking. Indeed, if low tar and nicotine (t/n) content makes inhalation easier, it is possible that more smokers are inhaling more of the time, and hence that Figure 2 overstates the magnitude of the ingestion reduction. (2) The 1954 levels of t/n have been assuned for earlier years, for which I have no data. Stronger tobaccos in earlier ~ years might mean that this understates the true t/n ingestion of those years. ~ However, more reliance in earlier years on hand-rolled cigarettes, often packed M more loosely than manufactured cigarettes, could have produced lower t/n per 4 cigarette. (3) The per capita consumption base does not allow assessment of per ~ smoker consumption. Thus, if relatively light smokers have been the ones quitting 6,A or reducing smoking, continuing smokers iray be ingesting t/n quantities not too ~ dissimilar to those of the 1950s. That is, a smaller proportion of adults may be smoking, implying more cigarettes per smoker relative to the per capita measure. -72-

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Table 3: Average Tar and ;licotine Per Cigarette 3old, by Y ear Year Tar (=Q) Nicotine (=Q) 1954 36.5 2.61 55 ' 37.0 2.69 56 35.4 2.56 57 37.0 2.55 58 33.5 2.20 59 28.9 1.84 60 27.0 1.60 61 26.6 1.57 62 26.3 1.52 63 25.1 1.44 64 23.0 1.30 65 22.8 1.39 66 23.5 1.47 67 22.4 1.43 68 21.6 1.40 69 21.0 1.39 70 19.9 1.40 71 19.6 1.38 72 19.3 1.35 73 18.5 1.26 74 18.3 1.26 75 18.0 1.1£ 76 17.3 1.15 7 / 16.7 1.14 Source: thipublished data from Phil:p L-ic. -73- I I t i ~ I L L

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I r__..- r ...,r.. C .~...., rr,.... r...... .r.a.~ ..rr... ...rr+., ~~..+. .r~r... w..rrti .....y .~.+Wti ----~ A.""

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I component of the smoking market.* ;Vhile the smcking-illness message clearly accounts for the current growth in low t/n smoking, credit must 'Ce acccrded the cigarette filter for producing the most dra.^utic decreases in average tar and nicotine. By 1964, the year of the Surgeon General's Report, tao-thi:-ds of the post-1954 tar reduction and over four-firths of the nicotine reduction had already been realized. Filter-tipped cigarettes constituted enlv 1.3 percent of all cigarettes smoked in 1952, but following two years of health scares, in 1955 fully 13.7 percent of cigarettes sold were filtered. Filters became the majority type of cigarette in 1960, captured four-fifths of the market by 1970, and currently account for over 90 percent of all cigarettes sold in the U.S. Other changes in smoking behavior have been explored in surreys (U.S. CE-ZV, 1969, 1973, 1976). These include proportion of cigarette smoked, freouency and depth of inhalation, and so on. While the surveys report many desirable changes, it is difficult to disentangle true behavioral changes from "guilt-induced" reporting errors. Suffice it to note that substantial behavioral changes in these areas do not seem probable to this observer. While the proportions of Americans smoking have dropped, population growth has kept the number of smokers from decreasing. On the debit side of the ledger, some 54 million American men and women are consuning over_600 billion cigarettes each year. In Michigan, 2.5 million smokers consumed close to 28 billion cigarettes in 1979. On the credit side of the ledger, nationally more than 30 million Americans have joined the ranks of the ex-smokers, well over a million of them citizens of our State. Furthermore, survey data suggest that fewer teenagers are initiating smoking habits (National Institute of Education, 1979). Continuation and intensification of this trend would assure decreases in the future smoking population, by a combination of attrition of current smokers and nonreplacement by the younger generation. The prevalence of smoking varies significantly within several socioeconomic, demographic categories, as sumtnarized in Table 4. The prime smoking age for both males and females--the years in which the highest percent of individuals are smokers--is from the mid-20s to the mid-40s. The participation rate drops precipitously following the mid-50s, in part due to the fact that cigarette- related deaths are concentrated in the older population. Mbre blacks smoke than whites, again for both men and women. Smoking rates differ dramatically by level of educational attainment, with close to half of males with some high school classified as smokers and fewer than 30 percent of college graduates. The comparable figures for women are a third and a fifth. The income distribution of smokers is surprisingly flat; while fewer high-inccme males smoke than do less affluent males, the highest smoking participation rate among women is in the highest income class. Among working groups, excepting the unemployed whose smoking rates exceed all others, blue collar workers are the heaviest smoking group in our society. Professional and technical workers are the lowest. Thus, though smoking is not confined to any single group in our population, it seems fair to observe that problems of smoking-induced illness have a class-based * The low-tar share of the market, defined as 15 or fewer mg tar per cigarette, exceeds 30 percent. As recently as 1974, it was under 10 percent; and in 1967, it totaled only 2 percent (Surgeon General, 1979). -75- I I I I I ~ °L

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I I I I I I I . I I I :able 4: Percentage of Begular Adult Smokers, by Sex and Socioeconoaic- Demographic Characteristics, 1975-76 2 Males " Females Age: 21-24 - 41.3 34.0 25-34 43.9 35.4 35-44 47.1 36,4 45-54 41.1 32.8 55-64 33.7 25.9 65+ 24.2 10.2 Race: White 41.2 31.8 Black 50.5 35.1 Education: Grade school or less 37.4 18.2 Some high school 47.8 33.2 High school graduate 45.6 31.9 Some callege 36.1 32.2 College graduate 28.1 21.1 Income: $0 - 4,999 42.5 28.3 $5,000 - 9,999 45.5 33.5 $10,000 - 14,999 45.5 32.5 515,000 - 24,999 40.4 33.0 $25,000 or more 34.7 35.1 Occupation: `Jhite collar 36.6 34.3 (Professional and technical) (30.0) (29.1) Blue collar 50.4 39.0 Farm 36.9 31.3 Unemployed 56.8 40.0 Vot in labor force 32.9 28.2 Source: Surgeon General, 1979, Appendix Tables 2, 5, 6, 7. I %-- -76-

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I distribution, with the greatest concentration of siokers fc=d in t~:e blue collar and une:rplo,ved low-education blac:< populaticn. * Finally, in light of recent evidence (jv'hite and Froeb, 1980) on the deletericus ~ "involuntary" or "passive" or "seccnd- ~~ smoking--non..~.~..oxers~ ef~ects of hd inhalation of smoke from others' cigarettes--it is interesting to contemplate trends in this form of smoke ingestion. hhile there is little concrete evidence on the extent of this phenomenon, recent changes in social mores, regarding smoking as the exception rather than the rule, suggest that nonsmokers are less likely to be exposed involuntarily to second-hand smoke. The non-smokers' rights movement (discussed in section N) is both a contributor to and a reflection of newly prevailing attitudes. In some instances, including Michigan's public smoking-restriction law, nonsmoking environments have been legislated into existence. As the above paragraphs suggest, the status of cigarette smoking in Atichigan and throughout the country represents a classic exarr,ple of the proverbial glass being half empty or half full. Over the past quarter of a century, and particularly within the last decade, significant progress has been made toward weaning Americans off of cigarettes. Nevertheless, millions of Americans persist in smoking, despite the widespread awareness of the health effects of sr.;ok.ing (discussed in the next section) and the fact that a majority of s:nokers desire to quit (U.S. DHEIV, 1976). z '~ The class differentials in future illness patterns will be exacerbated if, as C'T I suspect, the higher-participation groups smoke higher t/n cigarettes (and/or ~ more cigarettes per smoker). ~, These class distinctions are not new. Most of the high-participation groups N have held that status over at least the past couple of decades. For example, N while Table 4 shows almost a 20-percentage point difference between participation rates for males with some high school and college graduates, the same difference was evident in 1964 in higher participation rates for both groups (62.0 and 42.5 percent, respectively). Among women, however, the education-based difference is new. In 1964, the difference was only 1.5 percentage points (36.5 and 35.0 percent, respectively). -77- i I I I I I I E I L L L l

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L I I f I I I I I J I I I I- I ~ 1 L II. Health Effects of S;..ckinq* Maj or health effects of cigarette smoking are familiar to almost all kr:ericans : smoking is the principal cause of lung cancer, responsible for roughly 90 percent of all lung cancers and accounting for 80,000 lung cancer deaths per year; smoking annually claims over 200,000 victims-frcm cardiovascular disease; smoking is the major cause of chronic bronchitis and emphesema, debilitating chronic diseases whose toll includes close to 20,000 deaths per year. Michigan's share of this burden includes almost 10,000 cardiovascular deaths and over 3,500 lung cancer deaths. As the above data indicate, cardiovascular disease is by far the number one snroking=related killer. Nevertheless, the public's major smoking fear is lung cancer. The explanation for this likely reflects a combination of the general fear of cancer deaths and the heavy publicity emphasis on the link between cigarette smoking and lung cancer. The latter resulted in part from the clear attribution of causality, derived from overwhelming evidence, in the original Surgeon General's Report (Surgeon General, 1964). And while smoking-related cardiovascular disease may kill over two and a half times as many smokers as does lung cancer, the psychological linking of smoking with a disease which also kills hundreds of thousands of nonsmokers is i:uiderstandably somewhat tenuous. Comnon knowledge on smoking-related mortality can be supplemented with additional specific data. Overall, male smokers have a;nortality ratio of 1.7 compared to nonsmokers (i.e., a 70 percent excess for the former). The ratio rises to 2.0., or 100 percent excess, for two pack-a-day smokers. Another way to observe the mortality impact of smoking is to note that a 30- to 35-year old two pack-a-day smoker has a life expectancy 8 to 9 years shorter than that of a comparably aged nonsmoker. The mortality ratios of female smokers are less dramatic than those for males. Recent evidence suggests that this is explained by differences in exposure (e.g., later age of initiation of smoking, fewer cigarettes per day, lcwer average t/n per cigarette). Indeed, when analysts control for exposure character- istics, they find female mortality ratios comparable to those of males (Surgeon General, 1980). Smoking's contribution to cardiovascular disease is multifaceted, affecting numerous diseases in a variety of ways. In many instances, smoking appears to act synergistically with other risk factors, including hypertensicn and use of oral contraceptives. In addition to its role in lung cancer, smoking is implicated in over 20,000 deaths per year from other cancers, including oral cancer and cancers of the larynx, esophagus, bladder, kidney, and pancreas. Perhaps the most striking recent smoking-cancer news is identification of an epidemic of lung cancer among women, whom rrnich of the public thought to be "inamune" to this impact of smoking. The lung cancer mortality rate for women is three ti.-aes as high as it was in 1964, the year of the first Surgeon General's Report. Lfost dramatically, the nianber of deaths from lung cancer in wcmen will soon exceed the ntanber from * Unless otherwise indicated, the principal source of information for this section is the 1979 Surgeon General's Report. -78-

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I breast cancer, for years the leading cancer cause of death in women (Surgeen General, 1980). As grim as the smoking mortality picture is, epidemiological data provide encour- quitting. For non-ill quit*_ers,* agement for the current smoker contemplating mortality ratios decline monotonically over time. Fifteen years follewing cessa- tion, former smokers' mortality risks approach those of individuals who have never smoked. The decline in risk is a function of length of smoking history, age of initiation, extent of habit (cigarettes per day), average t/n, and similar vari- ables. It is also noteworthy that the nature of mortality risks changes follow- ing cessation, as some smoking-related diseases reflect cumulative consuznption (e.g., lung cancer), while others are more sensitive to the irrmediacy of smoking. For e:car,ple, some sudden cardiovascular deaths may be caused by the greatly heightened carbon monoxide concentration during and immediately following the smoking of a cigarette. CO concentrations recede fairly quickly after a cigarette is entinquished. The mortality toll of smoking is obviously its most dramatic impact, but the morbidity and disability consequences impose an inIInense burden on smokers, their families, and society in general. Relatively few smokers contract lt.mg cancer, but the vast majority of long-term heavy smokers eventually experience scme degree of chronic bronchitis and/or emphesema.** For those who are fortunate, their disease may simply restrict their "wind", their ability to exercise, climb stairs and the like. For the less fortunate, chronic bronchitis and emphesema are severe- ly debilitating illnesses, seriously restricting activity and often chaining the victim to mechanical breathing apparatus. Many victims of smoking-related heart disease also-find their activity levels restricted. The qualify-of-life implica- tions are profound. Disabling chronic diseases obviously remove many individuals from the labor force. Less corrmonly known are the short-term morbidity consequences of smoking. Male smokers lose 33 percent more work days than nonsmokers; female smokers lose 45 percent more work days than nonsmoking women. All told, this adds to more than 80 million excess person-days of work lost in the U.S. in a single year. In our own State, the figure is close to 4 million person-days of work lost. (See the ne.xt section.) Both male and female smokers experience roughly 15 percent more days of bed disability than non-smokers, or close to 150 million excess days of bed disability throughout the country. This is not far from one excess day each year per man, woman, and child in the State of Michigan. The morbidity and even mortality consequences of smoking are not restricted to smokers. A tenet of the nonsmokers' rights movement (discussed in Section N) long has been that a smoke-polluted environment is hazardous to the health of nonsmokers. For years, the evidence on this question has been limited and mixed, with consensus only that certain high-risk populations (e.g., those wi th heart or lung disease) exposed to concentrated smoke could suffer significant adverse consequences. Recently, however, a study published in the New England Journal of Medicine demonstrated that nonsmokers regularly working in settings have gn * The highest mortality ratios are for individuals who have quit within one year. Analysis suggests that many such individuals have quit because they were suffering smoking-related illnesses. When the motivation to quit is other than present illness, mortality ratios fall. ** :Iknong male smokers of two or more packs a day, the prevalence of these diseases is 4 times that of nonsmokers. arnong high-use female smokers, pre- valence is 10 times that of nonsmoking women. -79- I I I i I I I I I p I ~ L

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I F I I I I I I I I I concentrations of smoke experience health ir.macts si::ilar to those of light smokers te and Froeb, 1930) . T7,.us, the evidence on second-hand smoking is that it can be hazardous to health, though one must take care not to exaggerate the probable effects. The most recent Surgeon General's Report (1980), fccusing on smoking and health in women, has drawn considerable attention to another nonsmoking victi.^l of smoking: the fetus. Abundant evidence demonstrates that smoking during pregnancy is a cause of low birth weight. As smoking does not reduce the dura- tion of gestation, the lower birth weight of smokers' babies is attributable to retardation of fetal growth. Svhile the evidence is not conclusive, studies suggest that smoking during pregnancy may affect children's physical growth, mental development, and behavioral characteristics at least up to 11 years of- age. Finally, controlling for all other known factors, studies have found a highly significant risk of perinatal mortality attributable to smoking. The babies of women who smoke during pregnancy have increased risk of sudden infant death syndrome. Children's health can also be harmed by living with parents who smoke. One of the few definitive findings of the studies on second-hand smoking is that children of parents who smoke experience more bronchitis and pneunonia during the first year of life than do children of nonsmoking parents. Smoking and health in women and their children represents one of a few specific areas which are receiving focused attention within the smoking and health con¢mmity. Another area of considerable concern is the interaction of smoking with certain occupational hazards. It has been demonstrated, for exarple, that asbestos workers who smoke have a nich higher rate of lung cancer than would be suggested by the contributions to cancer of smoking and asbestos acting alone. That is, the effects appear to be synergistic rather than additive. Similar relationships between smoking and several chemicals have been suggested, but the epidemiological research needed to establish effects has not yet received adequate attention. While the list of health consequences of smoking is well defined, reflection on the implications of changing smoking behaviors gives pause in assessing the future health consequences of today's and tomorrow's smoking patterns. The illness patterns witnessed in 1980 reflect smoking behaviors initiated as long ago as the 1920s and 1930s. Today's lung cancers clearly represent the result in part of consumption of 1950s' cigarettes, a very different product from that consuned today. Intellectually, the shift toward lower t/n smoking suggests a decrease in at least some of the hazards associated with smoking, asstuning that smokers do not fully compensate for the lower unit dosage of t/n by smoking more cigarettes.* Recently, scientific evidence has emerged to support this logic. In general, low t/n smokers experience mortality ratios about 50 percent higher than those of nonsmokers, but 15 to 20 percent lower than those for all smokers. * The amotmt of nicotine compensation smokers do when shifting to a lower t/n cigarette has been the subject of much speculation and study. An articulate scientific proponent of the nicotine regulation hypothesis--that smokers do comnensate for the lower unit dose by smoking more cigarettes-- is Stanley Schicter (1978). Recent evidence, however, suggests that compensation is minimal, clearly less than that which would fully replace t/n ingestion before the switch (Garfinkel, 1979). -80-

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In an interesting new study, Auerback et al. (1979) reported that histologic changes in the bronchial eDithelium of .ecent heavy smokers (two-plus packs a day) showed a frequency similar to that of light smokers (under one pack a day) who died 20 to 25 years ago. They attributed the drar,iatic decrease in frequency in the heavy-use class (from 22.5 percent in the earlier grcup to 2.2 percent in the recent group) to the reduction in t/n per cigarette. They labeled their findings consistent with evidence from epide:niologic studies and interpreted the findings as "presag(ing) a decline in the death rates of cigarette smokers from lung cancer"at some future date." Other researchers have interpreted modern low t/n smoking habits in terms of their equivalency with smoking patterns in the 1950s, where numbers of low t/n cigarettes cr.ultiplied by t/n content were translated into the equivalent number of high (1950s) t/n cigarettes. Possible health outcomes of low t/n smokers were interpreted_in light of the health experience of the earlier generation of "equivalent'smokers. The bottom line of the study was that many of today's low t/n smokers may not be subjecting themselves to statistically significantly higher risks than nonsmokers (Gori and Lynch, 1978). The study can be faulted on numerous technical groiumds (Warner, 1979b), but it adds qualitative evidence to the hypothesis that modern smoking habits may be less deleterious to health. Final determination of the health effects of current smoking patterns must await the passage of a generation. Nevertheless, e:cisting evidence does permit some speculation on future trends. The declining percentages of smokers should reduce the illness toll of smoking, hopefully across the board. Decreased ingestion of tar may lead to a reversal of the lung cancer epidemic; indeed, I expect to see signs of this within a decade or so. However, an apparent increase in the daily number of cigarettes consumed by confirmed smokers* increases their exposure to carbon monoxide which, in turn, might increase their risk of cardiovascular pro- blems. Finally, trace amounts of 4000 additives in modern cigarettes could conceivably exacerbate existing health problems or introduce new ones. All such considerations suggest, at miniimun, a change in the mix of smoking-induced health outcomes (Wynder and HofLnann, 1979). The narrowed gap between male and female participation rates suggests a relative redistribution of the illness burden toward women. * Surveys indicate that average daily consumption has not changed much over the past decade and a half (U.S. DHEW, 1969, 1973, 1976). However, as aggregate underreporting appears to have increased (ZVarner, 1978), it seems plausible that smokers are i,mderreporting their daily consurrmtion by greater amounts. Simply looking at aggregate objective data, it is impossible to disentangle increases in daily consumntion by heavy smokers from decreased participation by light smokers. M, conjecture that regular smokers constnne more cigarettes on a daily basis rests on the assumption of some, though not complete, nicotine compensatien. I I I I I I J I I p L L L

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I I I I I I I I I 11! 11 I I- I ~ L L III. cconcmics of Smoking ;ebacco is big business. In 1973, Arericar.s eroended some S13 billion cn tobacco products, over 90 percent (516.6 billion) for cigarettes (Tobacco Institute, 1979). In Kic.iligan, smokers spent $780 million for their cigarettes.* To put these figures-into perspective in the autcmcbile State, national tobacco expenditures are-close to 40 percent of the amount Americans spend on new cars. annual expenditures on tobacco are comparable to the total spent on television sets, radios, records, and r,nisical instr^nents combined. Tobacco expenditures constitute roughly 1.3 percent of all retail expenditures (INli ller, 19"'8). Tobacco is big business, but it is also concentrated business. Despite the existence of dozens of brands of dcmestically-produced cigarettes, there are only six major U.S. tobacco firms. Rivalry among these companies is character- istic of that found in oligopolies (high.ly ccncentrated industries): cempeti- tion focuses on atterrIDts to differentiate and promote brands, as evidenced by close to a billion dollars in promotional spending; there is little price competi- tion. At the manufacturing level, in 1978, 147 establishments produced tobacco products in 20 states; but cigarette manufacturing, accounting for over 90 percent of tobacco retail sales, occurred in only 12 highly mechanized plants, 11 of which are located in three states (North Carolina, Virginia and Kentucky) (Tobacco Institute, 1979; Miller, 1978).** The cigarette business is least concentrated at both ends of the production- distribution spectrum. Final distribution to consumers occurs through some 1.4 million retail outlets, supulied by over 1500 primary tobacco wholesalers and another 1000 miscellaneous kholesalers which also distribute tobacco products (Tobacco Institute, 1979). At the other end of the spectrum, over a quarter of a million farms produced tobacco in 1977. Including farm operators, allottnent holders, and hired hands, an estimated one million people derive income from tobacco farming. However, most of the hired labor, over half of this total, is employed for less than 25 days a year (INtiller, 1978). Svhile tobacco is grown in 23 states, only half a dozen count tobacco as a major cash crop. Table 5 identifies these states and their estimated cash receipts for 1978. The total receipts for these six states is 93 percent of the value of the Nation's entire tobacco crop. That value--$2.55 billion--ranks tobacco as the country's sixth largest cash crop, accounting for 2.3 percent of the total for all cash crops and farm cornmodities (Tobacco Institute, 1979). * This is based on State tax-paid sales (Tobacco Tax Council, 1979). A study of cigarette bcotlegging (discussed below) estimated that 4 percent of Mli chigan cigarette censimmticn was non-State-tax-paid, i.e., bootlegged cigarettes (advisory Commission on Intergovernmental Relations, 1977). This suggests that actual Michigan expenditures were in excess of $800 million. ** The total number of tobacco products factories has dropped considerably in the past half dozen years. In 1972, there were 131 such establishments located in 29 states ClAiller, 1978). -a-

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I Table 5: State Cash Receipts :rcn Tobacco, 1978 I I I State Cash Receiots (millions) I North Carolina Kentucky South Carolina Virginia Georg ia Tennessee $ 1106 542 205 I All other states Source: Tobacco Institute, 1979. 174 174 165 184 TOTAL $ 2550 I I I IL L

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I I I I u ~ i ~ Tt.e significance of the size and geographical concentration of the industry is substantial. Fere, suffice it to note that the imortance of the crop and derived consumer products in the six tcbacco states has created a powerful tobacco interest in Congress. By contrast, outside of the tobacco states, for example in Michigan, the economic contribution-of tobacco growing and manufactur- ing is negligible. Indeed, aside from generating tax revenues (discussed i.-runediately below)., tobacco use produces significant econcmic costs in nontobacco states (discussed later in this section). - - The one direct benefit of smoking shared by all states and the federal govern- ment is the generation of revenue. Since 1968, when North Carolina adopted a 2 cents per pack excise tax, all states have taxed cigarettes. As of 1979, state excise tax rates range from a low of North Carolina's 2 cents to a high of 21 cents per pack in each of Connecticut, Florida, and Massachusetts. The federal government taxes cigarettes at 8 cents per pack, a rate unchanged since 1952.* The federal tax grossed $2.4 billion in fiscal 1979, while the states, collectively, grossed 33.7 billicn. In the 365 cities and counties imposing their own local taxes, revenues totaled $130 million.** Net state tax collections ranged from a low of $4.4 million in Alaska to a high of $326.6 million in New York. Michigan netted $141 million from its tax of 11 cents per pack, the tenth highest net revenue in the country (Tobacco Tax Council, 1979). The gap between high- and low-tax states' excise taxation rates explains almost all the roughly 20-cent differential between the average price of a pack of cigarettes in North Carolina (47.3 cents in 1979) and in several high-tax states. (Each of Connecticut, the District of Columbia, Florida, Massachusetts, New Jersey, and New York has average 1979 prices in excess of 65 cents). This price differential has created a lucrative market in cigarette bootlegging in which a single truckload of contraband cigarettes purportedly can yield $20,000 or more in smuggling profits ('Bootleg Cigarettes," 1978). Cverall, high-tax states are estimated to lose from $400 to $500 million in tax revenues each year due to bootlegging ("Cigarette Contraband," 1978; Advisory Ccmmission on Inter- governmental Relations, 1977). The one ter.hnical analysis of bootlegging which attempted to estimate individual states' net gains or losses found that Michigan loses about 4 percent of its excise tax revenue potential (Advisory CortQnission on Intergovermental Relations, 1977). Compared with other states, this does not represent much bootlegging. The incentives for smuggling cigarettes into Michigan are relatively small, since Michigan's 11-cent excise tax is close to the states' average (12 cents) and consequently the average retail price in the State (60.3 cents is close to the national average (60.0 cents). In addition, Michigan's location places it far enough away from the major cigarette "exporting" states (Kentuc'.<y, New Hampshire, and North Carolina) that transportation costs * Since the nominal federal tax rate has not changed during three decades in which virtnsally all other prices have risen, the federal tax has fallen from 35 percent of retail price in the mid-19S0s to 13 percent today. ** Close to half of this total was accounted for by New York City's municipal tax on cigarettes, which yielded $63 million in 1979. -34-

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would discourage major smuggling operaticns.* !bst of the states victiru_ed by bootlegging are situated on the Atlantic coast.** Cigarette excise taxes constitute a significant source of state revenue. In Michigan, the excise tax produces close to 3 percent- of t:^.e State's General Fur.ds revenue. One "pragmatic" argument against anti-smoking activities rests on the State's perceived dependence of excise tax revenues: successful anti-smoking efforts,night inflict damage on the State treasury. This argument suffers frcm two major flaws. The first is that even a highly successful anti-smoking effort would not reduce smoking sufficiently to drastically reduce cigarette tax revenues, and any revenue loss could be compensated for by raising the tax rate a modest amount.*** The second flaw in the argument is by far the more i:r~ortant; it is also a central feature of the economics of smoking: by causing illness, smoking imposes signifi- cant costs on the State and the Nation as a whole. Seme of these costs are direct-- the medical expenditures necessitated by smoking-induced illness--but the more substantial costs are indirect--namely, the productivity losses attributable to smokers' missing work due to smoking-related illness. As noted at the outset of this paper, estimates place the national costs of smoking in the vicinity of $40 billion per year. This includes some $12 billion in medical care costs and $28 billion in productivity losses. Together, the direct and indirect costs of smoking equal roughly 10 percent of the total social costs of illness in the U.S. (Cooper and-Rice, 1976, updated to 1980 prices); the direct costs alone account for approximately 8 percent of the Nation's medical care expenses. Michigan's share of these burdens exceeds $S00 million in medical care costs and over a billion dollars a year in productivity losses. This means that, thrcugh insurance premiums, taxes, and direct payments, a typical family of four pays some $200 per year in medical bills attributable to smoking. And the productivity losses due to smoking-related morbidity and disability total more than twice that sum. Both in terms of the public's general economic welfare and the State's budgetary expenditure requirements (e.g., Medicaid and welfare payments), smoking * While there is no published evidence to date, I would expect rising gasoline prices to have deterred stnugglers in general. This would reinforce the decreas- ing real value of the cigarette price differential among states which has been brought about by general inflation and the absence of any significant new state excise activity over the past several years. That is, the differential between high- and low-tax states has not changed, but its real value is dropping as the general price level rises. ** Exceptions are Arkansas, 4tinnesota, Texa.s, and Washingtcn. *** Virtually all studies of the price responsiveness of cigarette consumptien find that cigarette demand is price inelastic. This means that a given percent- age increase in price will produce a smaller percentage decrease in quantity demand. Consequently, a price rise increases total expenditures on cigarettes. This translates into increased tax revenue. 0 -a5- i I I I I I I L

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I I I i I I I i I I I 1 exacts a high price. Note again that few of the benefits of cigarette production are captured within Michigan to offset these costs.* * According to a recent study at the University of Pennsylvania, ffiumded by the Tobacco Institute, the core sectors of the tobacco industry (farming, auction warehouses, manufacturing, wholesaling, and vending), combined with support industries, contribute 3,800 jobs within Michigan and a payroll_of $52.3 million. The study estimates the total national economic contribution of tobacco to be close to $50 billion, but 60 percent of this total is the indirect contribution generated by the spending of tobacco-prcduced income Rlharton ARC, 1979). -86-

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i IV. Policy Gb tions Efforts to disccurage smoking are numerous and re^iarkably diverse, including such odd bedfellows as smoking cessation clinics and televised anti-smoking cartoons. Many efforts emanate from the public sector, the focus of the following discussion, but credit must be accorded private voluntary agencies for their long-standing active involvement (e.g., the American Cancer Society, American Heart Association, and American Lung Association). Even the for-profit private sector plays a significant role, marketing smoking cessation programs and paraphernalia (e.g., special filters and pills). One reason for the wide variety of anti-smoking activities is the multi- dilc:ensionality of the smoking problem. Helping people to quit smoking repre- sents something quite different than discouraging initiation of the habit. Cciram.micating about smoking effectively with teenagers, many of whom view themselves as imnortal, implies a different message than that which one might transmit to a more illness-conscious adult population. There are significant differences in smoking behaviors, even including specific brand preferer.ces, across age, sex, race, and socioeconomic groups. Though I will not always refer to the relevant sub-problem in the following discussion, these distinc- tions are highly germane to consideration of smoking and health policies. In particular, the two crucial distinctions are those of preventing initiation of smoking vs. assisting cessation and working with adults vs. dealing with children and teenagers. - This section of the paper opens with a brief historical examination of smoking and health policies in the federal government and in state and local govern- ments, with separate attention to Michigan. Following that presentation, I suggest a variety of possible policy initiatives within Michigan. My objective is not to provide a menu from which policies can be selected, but rather to offer a sampling of diverse alternatives to illustrate the range of options and to serve as food for thought. History of Smoking and Health Policies Federal Government Policies* Federal policy irn the area of smoking and health has concentrated on two not-unrelated principal tactics: (1) developing knowledge and providing infor- mation in order to educate and persuade the public not to smoke and (2) estab- lishing marketing rules of the game. The knowledge and information strategy dates from publication in January, 1964 of the first Surgeon General's Report, the Report of the Advisory Corrmittee to the Surgeon General of the Public Health Service on Smoking and Health (Surgeon General, 1964). Reflecting over a year's worth of-work by the 10- member Comnittee, the Report received widespread attention with its doctanenta- tion of the serious illness consequences of cigarette smoking. Perhaps most noted by the public was the Report's clearly defining the link between smoking * This discussion will focus exclusively on policies explicitly intended to discourage smoking. Thus, for example, federal tobacco price supports--an agricultural policy-will not be ccnsidered. C1~1 I I I i I I I I I L L L

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I I i it I I I I I i q I I I and ltmg cancer in men as casual. Inresponse to the Report, adult per capita cigarette consurption dropped for only the second time since the smoking-health scares of 1955-54.* Following the Surgeon General's Report-, the "pure" knowledge and infor:nation strategy entered a lengthy "quiet" period.** The Federal Cigarette Labeling and Advertising Act of 1965 (P.L. 89-92) required the Secretary of the Depart- ment of Health, Education, and Welfare to prepare regular reports monitoring the scientific literature on smoking and health and offering legislative recom- mendations. Beginning in 1967, reports were published every year except 1970 and 1977. The reports, none of which received much public attention, were pre- pared by the National"Clearinghouse for Smoking and Health, the predecessor to the current Office on Smoking and Health. A small operation, NCSH labored with a budget of only $900,00 in its final year. As its name suggests, NCSH was an information clearinghouse primarily serving scientists and educators. NCSH attempted to keep on top of the burgeoning research in the area, much of it funded by the National Institute of Health, and to assist ccmn,mities in developing anti-smoking programs. The "quiet" information strategy ceased rather abruptly, if temporarily, in 1978 when HE.Y Secretary Joseph Califano labeled cigarette smoking "Public Health Enemy Number One" and announced a reinvigorated federal anti-smoking effort (Califano, 1978). Califano replaced the NCHS with the new Office on Smoking and Health and proposed a near-trebling of the government's smoking and health budget. While the publicity surrounding the initiative was spectac- lar, the guts of the federal comnitment looked suspiciously like those of earlier years, only more plentiful: most of the dollars were devoted to research and education, the least objectionable uses 'from the perspective of * Attribution of causality to the Report and associated publicity reflects my interpretation of the data (Warner, 1977). All that one can say scientifically is that per capita conswmption dropped that year following eight consecutive years of growth interrupted only by a slight decline in 1962. Note, however, that the single pre-1964 decline occurred the year of publication of England's "equivalent" of the Surgeon General's Report (Royal College of Physicians, 1962). Throughout this discussion I will discuss "events" (e.g., the Surgeon General's Report) as "causing" decreases in smoking rates. The reader is urged to keep the above caveat in mind. In addition, I am interpreting an "event" as includ- ing all of the publicity related to it, as well as derivative less-well-known activities which occurred the same year. ** By "pure", I mean activities intended solely to influence censimier behavior through development of knowledge and provision of information, but with no intervention into the marketing of cigarettes. As we shall see irmediately below, much of the gover.vnent's policy has used marketing interven- tions in order to persuade consumers. Such "impure" .rnowledge and information provision was hardly "quiet". -88-

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the pcwerful tobacco lobby-in Congress.* Follcwing months of heated exchanges in the press between Califano, the tobacco industry, and southern politicians, the "pure" information strategy regained its "quiet" status. The federal government's other strategy has involved several interventions into the marketing of cigarettes. The first, accomplished through the afore- mentioned Cigarette Labeling and Advertising Act of 1965, was to require inclu- sion of a health warning label on all cigarette packs. The warning was " strengthened in the Public Health Cigarette Smoking Act of 1969 (P.L. 91-299), which also required manufacturers to print per-cigarette tar and nicotine content on all cigarette packs and advertisements.** In addition to its labeling requirements, the 1969 Act wrote part of the text for one of the most interesting chapters in the smoking and health policy story: the Act banned broadcast advertising of cigarettes after January 1, 1971. While this might appear to have been a significant victory for the anti-smoking forces, considerable evidence suggests quite the opposite (Warner, 1979a). This is because, beginning in 1968, broadcasters were required to donate air time for anti-smoking messages to "counter" pro-smoking advertising. The Federal CocrIImmication Commission's Fairness Doctrine required broadcasters to balance time devoted to both sides of a controversial issue; and smoking, the Comnission declared, was a controversial issue. While donated time never approached pro- smoking ad time, the ruling amounted to a $75 million subsidy (in 1970 dollars) to anti-smoking groups. Several analyses have concluded that the anti-smoking messages were considerably more effective in deterring smoking than pro-smoking ads were in encouraging it (Hamilton, 1972; Warner, 1977). Thus the net effect of prohibiting broadcast advertising of cigarettes, and hence ending the obliga- tion of donated time, would be favorable to the tobacco interests. And it is an empirical fact that following consecutive declines in 1968, 1969, and 1970, per capita consumption rose in 1971. It should be noted that prior to passage of the Act, the tobacco industry had made efforts of its own to voluntarily withdraw from broadcast advertising (Friedman, 1975). * For fiscal year 1979 Califano proposed a total of roughly $30 million for all federal smoking and health activities. Of this, some $6 million was earmarked for the new Office on Smoking and Health. Immediately preceding the new initiative, federal smoking and health dollars summed to $10 to 12 million. Though the increase was substantial, the new total was not large by federal enterprise standards. A commonly-noted coccparison was the three-quarters of a billion dollars being spent by the tobacco industry on cigarette promotion. It should be noted, though, that the industry itself devotes funds to _cnoking and health research. As of June 1, 1979, the combined commitment of the indus- try equalled $82 million (Tobacco Institute, 1979). ** Many knowledgeable observers consider the Acts to have been tobacco indus- try victories. The Congressional-compromise process resulted in the 1965 Act's prohibiting for three years any governmental unit's requiring health warnings on cigarette advertisements. The industry also won its battle to prevent non- uniform state and local regulation, which would.have been costly. Even the health warning on cigarette packs could be viewed as a victory of sorts: some considered it to provide a legal defense for the industry in instances of personal injury suits (Friedman, 1975). I I I I I I I I ; I I L L L -89-- L

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I I I I I I I I I- I L L Ironically, an obvious potential federal policy lever has remained umtouched. .-Ls noted in section III, the federal cigarette excise tax has not been changed since 1952. The failure of this component of cigarette price to keep pace with inflation means that the federal government has been contributing to decreasing the real price of cigarettes, an influence which, other things being equal, translates into increased cigarette consumpticn.* While raising taxes is not in general, a popular governmental activity these days, the federal-goverrur,ent did_give consideration to taxation strategies in defining the new anti-smoking initiative. Of particular interest was the proposal for an excise tax graduated according to t/n content. At the same time that Administration analysts were examining the issue, Senator Edward Kennedy developed a bill which would have imposed taxes ranging from 5 cents per pack for the lowest t/n cigarettes to 50 cents for the highest. The logic behind the graduated tax is that it would induce high t/n smokers to switch to low t/n cigarettes. While there is some merit to the argument, ironically the tax could have the opposite impact for some individuals (Harris, forthcoming). The question is necessarily theoretical, since there is very limited experience with graduated taxes and no experience at the federal level, where presumably the system could work best.** State Policies While federal policies have focused on the marketing of cigarettes, state policies have concentrated on direct consurnption influences. In part, of course, this could reflect the prohibition of nonfederal advertising regulation included in the Federal Cigarette Labeling and Advertising Act of 1965. But both earlier and recent history suggest that the consumption orientation of state policies might have prevailed even in the absence of the Act's language. 'IWo types of policies have dominated states' activity in the smoking and health arena: excise taxation and restriction of smoking in public places. While three-quarters of the states have both in effect, the histories, motivations, and effects of the two policies have been radically different. Indeed, excise taxation cannot in fairness be labeled an "anti-smoking policy" at least as regards its origins. By contrast, the smoking restrictions laws are a direct development of the nonsmokers' rights movement, the 1970s' anti-smoking theme. *'Ihe consensus estimate of cigarette price elasticity of demand--a measure of the responsiveness of demand to price changes--is from -0.4 to -O.S. This means that a 10 percent price decrease (increase) would increase (decrease) demand by a 4 to 5 percent. While the federal government's excise tax did not keep pace with inflation, state excise taxes have, though not uniformly over time. As is discussed below, state excise taxes rose dramatically from 1964 to 1972, causing cigarette prices, to rise faster than general inflation, but since then there have been few excise tax increases; consequently, real cigarette prices (i.e., adjusted for infla- tion) have been dropping rapidly. ** New York has tried such a tax, but the potential for interstate bootlegging, the ease of state border crossing, makes it impossible for a state to administer successfully a significantly graduated tax. That could only occur at the federal level where the difficulties and costs of smuggling operations would be considerable. -90-

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I That excise taxation was not originally intended to discourage s~noking--rather it was viewed as a revenue-raising device--is illustrated by the early entry into taxation of the tobacco states. The average year of_first enac u;ent of a cigarette excise tax for those states was 1939, compared with an average of 1940 for the other states. If North Carolina, the last state to adopt an excise tax (1969), is dropped from the calculation, the five remaining tobacco states' aver- age entry occurred in 1933, considerably earlier than the non-tobacco states. Initiation of excise taxation cannot be considered an anti-smoking policy-- indeed, only three states did not tax cigarettes by 1964, the year of the first Surgeon General's Report--but evidence presented in Table 6 suggests that excise taxation gained an anti-smoking "flavor" in the early years of the anti-smoking campaign. Prior to the first widespread publicity linking snoking to illness in the early 1950s, both the tobacco and other states imposed or increased taxes . with an identical frequency; resultant tax rates were quite close. However, from the time of the first publicity to the year prior to the Surgeon General's Report, the non-tobacco states increased taxes 60 percent more often than the tobacco states; at the end of the period,per-pack tax rates in the former ex- ceeded rates in the latter by 40 percent. From 1964 through 19i9--the "modern era" of the anti-smoking campaign--non-tobacco states increased their taxes twice as often as did the tobacco states, and average tax rates at the close of the 1970s were twice as large.* The growth in excise taxation has not been uniform throughout the years of the anti-smoking era. The nine years following issuance of the Surgeon General's Report saw an unprecedented flurry of excise tax activity, with states averaging close to a dozen tax increases per year. Beginning in 1973, however, new tax legislation slowed to a virtual standstill. From that year through the end of the decade, states averaged under 3 increases per year. (See Table 7.) A gen- eral opposition to new taxation may account for some of the slowdown. The principal explanation, however, seems to be recognition that years of rapidly- growing tax rates in the non-tobacco states had produced cigarette price differentials large enough to encourage interstate bootlegging. In addition to the social undesirability of such crime, bootlegging was draining potential tax revenue from the high-price states. According to one study, New York State, the most significant victim of bootlegging, lost $72.3 million in excise tax revenue in 1975. Michigan--an average tax, average price state--lost about $6.9 million (Advisory Comnission on Intergovernmental Relations, 1977). The general taxation climate combined with the bootlegging concern suggests that state tax increases may remain infrequent in the next few years. If this proves to be true, and assuming that the federal gover-iment does not increase its rate, the real price of cigarettes (i.e., cigarette price relative to the general price level) will continue to fall. An index of real relative cigarette price (set at 100 in 1967) has already fallen from 107.98 in 1972 to 92.02 in 1978. Such decreases in the real price of cigarettes contribute to increased consumption. Perhaps of greatest concern, the most price-sensitive (Z consurr.ers--teenagers--are finding it continually easier to afford cigarettes. U1 * Due to the relatively small number of cases involved, these differences are to not statistically significant. Nevertheless, they are strcngly suggestive. w 0! i I I I I I- p L -91-

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I i I I Table 6: Excise Taxation by the States r i Average Number of Tax Average Rate of Per-?ack Increases Per State a Taxation (end of period) i 6 Tobacco States Other Statesb 6 Tobacco States Other Statesb ~ i 1921-1952 1.0 1.0 2.50C 2.88c I I 1953-1963 1.0 1.6 1964-1979 1.3 2.6 3.75 6.75 5.28 13.58 I I I Notes: a Includes first enactments b Includes District of Columbia - I Sources: Tobacco Tax Council, 1979, and Warner, 1980b. L L L -92-

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Table 5z: Number of States with Tax Increases (Decreases), By Year No. of States with No. of States with Year Increases (Decreases) Year increases (Decreases) 1 1951 4 1966 18 1952. 4 (2) 1967 4 (1) 1953 0 1968 14 1954 3 1969 8 1955 5 1970 17 1956 12 1971 13 1957 3 (1) 1972 13 1958 8 1973 2 1959 8 1974 2 1960 13 1975 5 1961 6 1976 2 1962 12 (1) 1977 2 1963 9 1978 6 1964 11 1979 1 (1) 1965 8 ~ Source: Tobacco Tax Council, 1979, Table 7. -93- I I u I I I I I I ~ L L L

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I I I I I I i i I I I I In contrast to excise taxaticn, state laws restricti.^.g srr.oking in public places are a pnencmencn of the 1970s, clearly a product of :.h:e anti-smoking csrmaigng nhile the :irst such law went on the books in 1392 (Ver;^ont prohibited smoking in any place in wnich the cwner or occupant posted no-smoking signs) , by the beginning of the 1970s only five states had relevant laws on the books. As Figure 3 shows, however, the growth rate from 1972 on aas explosive. By the end 1978, 36 states had relevant laws in effect. "Non-smokers' rights" has been -translated from a slogan into a reality. In addition to the simple diffusion of legislation a,^:ong the states, the re- strictiveness of laws has grown over time.* All of the five pre-1970s laws were only minimally restrictive. Of 13 laws passed frcm 1972 through 1974, eight were minimally restrictive, five moderately restrictive, and none highly restrictive. By contrast, of 37 new laws dating frcm 1975 through 1978, 10 were minimally restrictive, 17 moderately restrictive, and 10 highly restrictive. Table 8 presents data on the diffusion of new laws over time and the average restrictiveness weight per law per year.** Further evidence of the direct link between the nonsmokers' rights movement and smoking restricticn laws is fotmd in the distribution of laws among the states. By the end of 1978 only two of the six tobacco states (33 percent) had passed any smoking-restriction legislation, while 34 of the 45 other states (75 percent) '* Determination of the restrictiveness of a law required subjective judgments. In general, I rated laws as minimally restrictive if they refer to only a limited number of sites in which people spend relatively little time (e.g., elevators or public transportation). By contrast, a highly restrictive law is one with broad coverage and/or inclusion of sites populated by large rnmioers of people for significant periods of time (e.g., work places, public buildings, stores). While the classification of individual laws is subjective, I attempted a classification by myself and then compared my results with those prepared by the Tobacco Nferchants Association (Bloom, 1979). In the few instances in which discrepancies existed, I discussed them with an analyst at the Associa- tion and, when appropriate, adjusted my classification. Despite the subject- ivity of the process, our classifications were remarkably consistent. It should be eamhasized that "restrictiveness" is assessed independent of enforcement. Few of the laws are vigorously enforced. Most states rely on voluntary compliance resulting from social pressure and general "good citizen- ship." ** The restrictiveness weights were set arbitrarily as follows: minimally restrictive = 0.33, moderately restrictive = 0.67, and highly restrictive = 1.00. -94- 1

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Figure 3: Diffusion Among the States of Legislated Restricticns on Smoking in Public P(cces 40, 35 -~ ~ 4 49 5 67 68 69 70 71 72 73 74 75 76 77 78 Year (!9_) Source: Unpublished data supplied by the Tobaccc Merchants Association and the Tobacco Institute. -95- I I I I ~ I I I p L L L

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I I I I I Table 8: New Annual State Smoking-Restriction Legislation- Number and Average Restrictiveness I Year(s) -No. of new laws Average Restrictiveness* 7 5 1892-19 1 i 1972 3 .33 .33 1973 3 44 I 1974 7 . .52 1975 17 .65 1976 5 .60 1977 11 .76 1978 4 67 I . - 'See text footnotes for meaning of "restrictiveness" and restrictiveness weights. I Sources: Same as Figure 3, plus Warner, 1980b. L L -96-

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I had such legislation on the books. If one separates cut t:e six other states which account for almost all tobacco production not attributable to the "big six" states, the percentage rises to 32 percent. Indiana and Wisccnsil, t:,;o of the "little six" (the others being Florida, Maryland, Chio, and Connecticut), had no relevant laws on the books as of the end of 19;5. ,Ainnesota is commonly acknowledged as having the Nation's most comprehensive smoking-restriction law. Passed in 1975, H 79 (the nli,-wer of the bill) restricts smoking in work places, restaurants, food stores, retail stores, public build- ings and meetings, health facilities, cultural facilities, public transporta- tion, and elevators. A recent survey found the public generally quite supportive of the law, including the smoking population.* It should be emphasized that the motivation underlying smoking-restriction laws is not to reduce the amount of smoking pe~r se, but rather to protect nonsmokers from the irritation and potential hazar E7o7involuntary exposure to smoke. Nevertheless, one might expect that smoking-restriction laws, particularly the highly restrictive ones, would force a reduction in total cigarette consumption, simply because smokers would be prohibited from smoking in unavoidable designat- ed places. Unfortunately, analysis of this phenomenon has been extremely limited to date. One study comparing states' consumption rates did not identify an impact (Bloom, 1979) and my own aggregate time series study proved inadequate to the analytical task ('nlarner, 1980a). The question may never be resolved, though other state cross-sectional analyses or disaggregated microeconomic constmiption survey studies might identify such an effect. Growth of the laws correlates highly with the recent decline in per capita consumption, but this does not appear to reflect causation. Rather, it seems probable that the former serves simply as a good gauge of a growing public nonsmoking sentiment, while the consiumption declines reflect a delayed behavioral response to the entirety of the anti-smoking campaign. Taxes and smoking-restriction laws are not the only smoking-health activities engaged in by the states. Many states require education on smoking and health as part of-their schools' health education curricula.** Revie,s of school smoking education programs emphasize the nonscientific development of most such programs and the lack of evaluation mechanisms to assess the programs' effective- ness (Surgeon General, 1979; Thompson, 1978; Wynder and Hoffman, 1979). The * Personal cocrmamication with Steven Coombs, Director of the Minnesota Poll. ** It is virtually impossible to determine from readily available data how many states require such education. The most authoritative source, a survey by the American School Health Association, found 35 states mandating health educa- tion including material on alcohol, drugs, and tobacco. (Tobacco was not treated separately.) Another 12 states had legislation encouraging such educa- tion. However, many of the pieces of legislation are extremely ambiguous as to specific content, amount, and timing of the education. It appears that few if any states have specific requirements enbodied in legislation focusing exclusively on smoking. (Person cortmamication with ASHA.) -97- i I I I I ! I I I I ~ L

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I I I r I I u I ! I L reviewers' frustration at the inability to evaluate progrars is palpable. nere are a couple of prominent exceptions to the non-evaluation rule, including the School Health Curriculum Project and the University of Illinois .antisnoking Education study. Smoking education techniques have been categori:ed, with cne approach (with many variations) receiving a great deal of attention and experi- mentation: the youth-to-youth approach, use of respected peers in counseling and educational efforts. Unfortunately, the limited evidence on youth-to-youth programs and more traditional approaches is not enceuraging. In general, health education programs have not evidenced much ability to reduce the initiation or continuation of smoking among children. The children's knowledge level rises-- over 90 percent of surveyed students demonstrate an intellectual appreciation of the basic health consequences of smoking--but the link between their lciowledge and behavior is tenuous at best. This supports the notion that the conventional education message, effective with many adults, may not be an effective strategy in dealing with pre-adult smoking. . Other state-legislated activities, such as restrictions on vending, seem to be of minor importance. Local Government Policies Local government smoking and health policies are a microcosm of state policies, though at a much lower level of activity and with differences in emphasis. ttany, perhaps most local units have either no smoking-and-health policies or relatively insignificant rules, such as those relating to vending. Several towns, cities, and counties restrict smoking in public meetings and elsewhere. btany local school systems require smoking education components in their curricula, either in satisfaction of or in addition to those mandated by state policy. Relatively few local governments levy their own cigarette excise taxes, in part due to the ease of border crossing when the jurisdictional botmdaries are only a matter of a few miles at most. Furthermore, when local taxes are levied they tend to be small. A notable exception is New York City's tax which in 1979 generated $63 million, or close to 60 percent of the total revenue produced by - the 343 cities tadng cigarettes. Table 9 indicates the number of local tmits taxing cigarettes per year since 1963. Note that all such taxation is currently concentrated in seven states and only three of these have more than two local units taxing cigarettes (Alabama, biissouri, and Virginia). Michigan Policies In many respects, Michigan appears to be an average state in terms of its smoking and health policies. Its excise taxation pattern and amount are fairly typical; its smoking-restriction legislation, though progressive in certain dimensions, is rated moderately restrictive, the most corranon classification for those states which have laws in effect; the State has a broad school health education requirement which includes smoking along with numerous other health topics. -98-

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I I Table 9: Cigarette Excise Taxation by Local Units of Government iscal No. of_states with local units of government imposing own tax No. of cities with own tax* No. of counties with own tax Total local units with own tax Year (1) (2) (3) (4)-(2)+(3) 1963 10 219 6 225 1964 10 220 6 226 1965 11 254 7 261 . 1966 11 269 10 279 1967 11 303 10 313 1968 11 308 10 318 1969 10 251 11 262 1970 10 263 12 275 1971 10 272 14 286 1972 10 363 15 378 1973 10 355 15 370 1974 8 285 15 300 1975 7 . 349 16 365 1976 7 348 17 365 1977 7 347 17 364 1978 7 348 17 365 1979 7 348 17 365 *For 1963-1971, excludes Florida cities, since muni.cipal taxes were in effect in lieu of the state-imposed tax. Source: Tobacco Tax Couacil, 1979, Table 16. ~ C1T I I i I I L 6 L L -99- L

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i I I f I i'. I I I I i I t L Michigan enacted its first excise tax on cigarettas in 1947, beccraing the .i2r.d state to adcpt an excise tax.* The original 3-cent per pack tax was increased four times (legislation in 1957, 1960, 1962, and 1970) and decreased once (1961). The current tax of 11 cents per pack is close to the states' average (12 cents) and produces a retail price (60.3 cents) virtually identical to the national average (60 cents). The tax generated some S141 million in 19"9 on sales of close to 1.3 billion packs of cigarettes. There are no local umits of government within Michigan imposing their own cigarette excise tax. At one level, Michigan can be classified as an innovator in the area of smoking- restriction laws: in 1967 Michigan became only the ;ourth state, and the first outside of New England, to enact a public smoking restriction. The law, Act 227, prohibited smoking on elevators. In 1976 and 1977, the State legislature passed a series of smoking-restriction laws pertaining to health facilities, food stores, and restaurants. While health facilities are covered by most states' laws, only about 10 states restrict smoking in either food stores or restaurants. I have no concrete evidence on compliance, but my impression is that compliance is good, and based primarily on social pressure, the principal "enforcer" of virtually all smok- ing-restriction laws. In 1969 the State legislature passed the Critical Health Problems Act which re- quired health education on a wide variety of topics, including smoking, in both elementary and secondary schools. The Act is clear in its intent but (perhaps desirably) vague concerning implementation. Individual school districts throughout the State define their own health education curricula, and one suspects that those districts which provide significant smoking-and-health education do so out of their own conviction as to its importance; compliance with State law does not demand a significant effort.** Policy Options in Michigan In the remainder of this section, I describe a range of policy options for our State. As noted above, my purpose is simply to indicate the breadt.'i or diver- sity of options to stimulate productive deliberations by the Panel. Options missing here reflect the limits of my lanowledge and imagination, not intentional exclusions. Before listing policy options, I will identify seme guidelines which I personally believe important in approaching the smoking problem in Michigan: - A wide range of options should be examined with consideration given to recoeQnending many,if many appear likely to be cost- effective. *.actually, 31 states taxed cigarettes in 1947. In 1948, when Mic,'Ligan' s tax went into effect, seven states joined the rolls of cigarette-taxing states. ** Smoking education efforts probably vary widely across school districts. I have little knowledge of the variations and feel t.',.at this is a subject worthy of exploration. -1a0- L

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Policy recorrQnendations should concentrate separately cn each of preventing initiation and assisting cessaticn of smoking. The problem of smoking by teenagers should be viewed and treated separately from that of smoking by adults. Given the State's near-term economic climate, reccrsnended policies should not require substantial expenditures; revenue-raising proposals should not envision significant new taxation. No policy recornnended should be prohibitory, except for smoking prohibitions designed to protect the health or rights of others (e.g., nonsmokers) and prohibitions relating to the behavior of minors. RecorQnended policies should be flexible, i.e., readily capable of being modified or ceased; thus, for example, intractable bureaucratic approaches should be discouraged. Evaluation mechanisms should be built into any policy recommendations; the evaluation function should be taken seriously in designing, implementing, and running.recom- mended activities. - Innovative approaches to the smoking problem should be sought and should receive serious consideration. The snoking-and-health field suffers from a notable lack of imaginative approaches. There is no obvious categorization of "types" of policies in the area of smoking and health, but for convenience I have structured this presentation by grouping policy options under the following headings: economic approaches; media campaigns; other publicity; legal strategies; education; other. Please note that these are not mutually exclusive categories and that several policy options properly belong -in more than one category. Economic Anaroaches As section III and muc'a of the section have emphasized, excise taxation lies at the heart of economic policy regarding smoking. The most obvious economic policy option would be to significantly raise the State's excise tax. Given the inelasticity of demand for cigarettes--the relatively small response of quantity demanded to a change in price--an excise tax increase would be expected to reduce conszmmtion by a relatively small amount and increase tax revenues. Of course, the latter depends on the absence of significant new bootlegging. The threat of bootlegging serves as a constraint on the size of a tax increase. A significant increase in the excise tax does not seem to be a desirable policy for a number of reasons, including the threat of bootlegging, the current general antipathy toward additional taxation, and the sense that a new large cigarette tax might be viewed as punitive. However, variations on, or using, _101- ( I I l I i L L

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I u I I I I I ~ I I i I I I L L conventional excise taxation can be considered. Here I will discuss two, a graduated t/n tax and a small additional excise tax ea:marked for smoking-and- health program pureoses. The idea behind a graduated t/n tax is that while demand for cigarettes in general :ray be price inelastic, demand for different types of cigarettes may be quite price sensitive. That is, a general cigarette tax increase rr,a,v not discourage much smoking, but a tax rising significantly with t/n content r.tignt induce a lot of high t/n smokers to switch to low t/n cigarettes. For the con- firmed smoker, a long-term shift toward low t/n might substantially reduce health risk (Auerback et al., 1979; Gori and Lynch, 1978; 'Hymder and Hoffran, 1979). As noted above, the federal government investigated imposition of a federal graduated t/n excise tax, but neither HEW's investigation nor Senator Kennedy's bill resulted in adoption. Successful implementation of a significant State t/n would be exceedingly difficult due to the bootlegging incentives it would create. Adoption of a small differential tax would reduce the bootlegging danger, make the point such a tax is intended to convey, and establish Michigan as a"laboratory"-testing consumer response to a graduated t/n tax. We should keep in mind, however, that such a tax is not costless. In addition to the political response it would engender, it would add to distribution and collec- tion costs. Perhaps a more appealing tax strategy is a small "health tax." Revenues frcm the tax could be earmarked for one or more State smoking-and-health activities. For example, beginning in 1963 the government of Iceland imposed a tax on cigarettes which was devoted to supporting the entire program of the Icelandic Cancer Society. In 1971, the Australian Cancer Society proposed addition of a one-cent per pack educational tax. (The proposal was not accepted.) 1%7iile the idea of earmarking a cigarette tax might seem "radical", we should keep in mind that the U.S. national highway system has been financed by an earmarked gasoline excise tax (Green, 1977). As an example of a biichigan "health" tax, consider an increase in the current excise tax from 11 to 12 cents, or one cent per pack. Such a tax would be minimally burdensome--even a two-pack-a-day smoker would incur an additional annual tax liability of only $7.30 ($3.65 for the pack-a-day smoker)--yet it would generate revenues of roughly $13 million, a dramatic sum for State smoking- and-health spending. The tax has the additional attractive feature that it "self- destructs" as need for it recedes. That is, if the anti-snoking activities it funds are successful, revenues from the tax would drop as cigarette consimtption decreased. The excise tax is intended as a negative influence on smoking, a deterrent. Taxes can also be used as positive incentives. In particular, the State's individual income tax can be used to encourage individuals to quit smoking, while corporate taxes provide a vehicle for inducing business involvement in the anti-smoking effort. In both cases, some portion of expenditures on efforts to reduce or cease smoking can be allowed as tax credits. Thus, the individual who spends $150 on a c^mQnercial smoking cessation program mightbe entitled to a $75 credit on his or her income tax, similar to treatment of contributions to Nlichigan -102-

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I universities and libraries. Corporate tax credits could reward businesses for developing smoking cessation programs for their employees.* The major problem with this proposal, other than the loss of tax revenues and potential for abuse, is that it would be difficult, and possibly inappropriate, to provide such tax assistance for efforts to combat only one deleterious habit. Adoption of such tax credits would lead rapidly to demands for credits for e:cpenditures related to combatting alcoholism; excess weight, lack of exercise, etc. This would not necessarily be undesirable, but anyone consider- ing this strategy must recognize the substantial short-r,ui impact it would have on State revenues.** Nledia Camnaigns The saga of federal policy on broadcast advertising of smoking--and anti- smoking--serves as a potent reminder of the power of the media, as well as of the subtle, often counterintuitive outcomes of policy. When federal law re- moved pro-smoking advertising from the airwaves in 1971, anti-smoking forces hailed the move as a victory. So did the tobacco industry, albeit much more quietly. The industry recognized that the "equal-time" anti-smoking rr.essages, required to balance their ads, were deterring more smoking than their ads induced. Removal of both sets of ads, they reasoned (apparently correctly), would produce a net addition to cigarette consumpticn (Warner, 1979a). Elimination of the need for broadcasters to donate air time to the anti-smoking cause forced anti-smoking_messages to compete with munerous other worthy causes for scarce public-service air time. Consequently, the anti-smoking presence virtually disappeared from television and radio; it has been minimal for almost a decade. In foranil.ating the new anti-smoking campaign in 1977, HEW's Task Force examined strategies to regain some of the broadcast prominence of the anti-smoking message, but to date little has been accomplished in this area. Broadcast anti-smoking messages will never constitute a cure for smoking, but analysis suggests that the 1968-1970 messages decreased cigarette cons~tion 3 to 4 percent each year (~/arner, 1977). Long-run influences, particularly in keeping media-susceptible children off of cigarettes, are unknown. Nevertheless, use of media campaigns, particularly in the broadcast media, is a strategy which warrants serious attention. 17ie benefits of even small reductions in * Business involvement in promoting the health of employees is growing. RQughly 15 percent of businesses have smoking educaticn programs and another third have indicated interest in developing programs. Smoking ranks third behind hypertension and weight-control as the subject of business health education programs (National Interagency Council on Smoking and Health, 1979). ** I refer to the short-run impact because after a few years, it is possible that savings in Medicaid expenditures, worhan's compensation, etc., would outweigh the revenue loss, translating into a net suYplus. -103- II i I i IL 1 I L I- L

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i i I I I I I I I I I I L L I L smoking well may outweigh the costs of producing the campaigns.* `dchi:an cculd devote e:t-ort to getting anti-smoking messages on TV and radio within the State. The conventional "moral suasion" approach could be employed, but success in getting broadcasters to donate public service time to smoking would translate into reduced time for other worthy causes. Alternatively, the State could apply some or all of the one-cent health tax to purchasing cer.ercial air tir,:e. The $13 million generated by a one-cent health tax could buy a lot of local air time. Use of the media to sell health messages is in its infancy. Five years ago at the Third World Conference on Smoking and Health, an advertising executive urged policy makers to contract with professional advertising agencies to develop a complete broadcast media anti-smoking campaign. The executive noted the apparent success of the 1968-70 "equal-time" messages and wondered how much more effective they might have been had they benefited from professicnal manage- ment (Green, 1977). Her question remains; the State could begin to provide an answer. Indeed, the State might be able to take advantage of professionally- developed broadcast messages recently produced under contract with the federal Office on Smoking and Health. A variety of other media strategies seem open to exploration. Imitating the Anerican Cancer Society's "IQ" (for "I Quit")-campaign of several years ago, the State could use prominent local personalities--sports figures, news conmentators, etc.--to plug the anti-smoking message. The nonbroadcast media could be used too. Other Publicity At various times over the past sixteen years, the federal government has "bought" air time for its anti-smoking message by making smoking a newsworthy event, semething the TV and radio news networks felt compelled to cover. The principal occasions have been release of major docuznents, such as the first and two most recent Surgeon General's Reports (1964, 1979, 1980), and delivery of strongly-worded speeches by prominent individuals (Califano, 1978). The final outcomes of the deliberations of this Panel and Governor Milliken's aruiouncement of new State smoking-and-health initiatives could provide grist for this mill. Other opportunities to acquire publicity for the anti-smoking cause should be sought out and exploited. Possibly the State could sponsor a nonsmoking day or week or cooperate with the American Cancer Society in its annual "Great American Smoke-Out." Legal Strategies There are a variety of legal strategies with which to attack the State's smoking problems. With smoking-restrictiorn laws ever more conmonplace, and with social mores moving clearly in the direction of the rights of nonsmokers, new, more comprehensive public smoking-restriction legislation might receive a favorable * To date, no one has estimated the economic benefits attributable to reductions in smoking; they are not simply a proportionate decrease in the costs of smok- ing (Luce and Schweitzer, 1978). I am currently working on methods to estimate such benefits; but the benefit-cost balance will remain a mystery for at least several ;nonths. -104- L

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I t hearing. As noted before, Minnesota's law is generally regarded as the \aticn's most restrictive. Particularly given the acparently favorable assessmezt of the law, * it might serve as a model for new Nlichigan legislaticn. Areas covered by the liinnesota law not covered in Michigan include work places, retail stores, public buildings and meetings, cultural facilities, and public transportation. The last three of these are dealt with in the laws of a:najority of the states having smoking-restriction laws. For understandable reasons, the least-covered area across the states is the work place, with only five states i,rposing any relevant restrictions. However, the recent scientific evidence on the adverse effects of concentrated second-hand smoke in work settings (Stihite and Froeb, 1980) should increase interest in, as well as the logic of, work place restricucns. Needless to say, such restrictions must apply corrJnon sense, avoiding significant disturbance of production processes. Smoking restriction laws rely heavily on social pressure and voluntary compliance; police enforcement is a rarity. Legal enforcement of compliance represents an option open to the State. Compliance with existing law can be monitored, and appropriate penalties assessed, on a sporadic basis in most locations covered by law. Attention most likely should be focused on retailers' and managers' compli- ance, rather than on their customers'. Are vendors dispensing cigarettes to underage children? Do restaurants provide adequate nonsmoking areas? Do managers of grocery stores request smoking patrons to extinquish their cigarettes? While legal enforcement will remain an option, its drawbacks may be overwhelming ccmpared with its advantages. The dollar cost of a serious enforcement effort could be substantial; it is a labor-intensive activity, implying a high labor cost. Greater still could be the opportunity cost of using police officers, an increasingly scarce public resource, for such a relatively minor police problem. In addition, police monitoring smoking behavior has a distinctive Orwellian flavor. And in general voluntary compliance seems to work reasonably well. Direct legal-action strategies have attracted several organizations concerned with smoking and health. An often-mentioned tactic is to encourage suits by, for example, lung cancer victims against the tobacco companies for criminal negligence, wrongful death, etc. One lawyer-run national organization, Action an Smoking and Health (ASH), has focused much of its attention on such legal actions. Other organizations, including the American Cancer Society, have urged states to facilitate successful prosecution of the tobacco companies (National Commission on Smoking and Public Policy, 1978). 1 have no idea of the possibilities open to our State, but it seems obvious that successful multi- figure suits would severely, perhaps fatally, damage the industry.** *:as mentioned above, a recent poll found both smokers and nensmokers re- gistering approval- of the law (personal comlm.micatien with Steven Coombs, Director of the Minnesota Poll). ** Well-:rnown attorney Melvin Belli recently filed suit in U.S. District Court in California in behalf of a client who lost a lung to lung cancer a year ago (National Interagency Council on Smoking and Health, 1980). A ccmnon de- fense against such suits, I understand, is "contributory negligence" on the part of the smoker. In addition, of course, the plaintiff must establish a connection between smoking and lung cancer. _105- I I I I I I L ~ ,

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i I I I I i I I II I u L Health Education Traditional health education, in schools or other ccmrrunitv organizations, is the cornerstone of most efforts to inform people of hazards to their health and encourage them to avoid those hazards. -Unfortunately, the evidence on the effectiveness of traditional health education in the smoking area is relatively negative, particularly for school children (Surgeon General, 1979; Thompson, 1978; 1"der and Hoffrnann, 1979). Children seem to absorb the basic informa- tion on the disease consequences of smoking, but they do not personalize it.; it does not significantly alter smoking behavior. This has resulted in a variety of experiments with innovative educational approaches, including the afore- mentioned youth-to-youth programs. Further innovative experimentation seems desirable. For example, a current popular theme--teaching teenagers how to deal with peer pressure--will be applied next year to junior high school students in Ann Arbor as the vehicle for providing education on substance abuse (including tobacco). Conceivably, this could be mixed iAth the more traditional health information being pro- vided in the elementary and/or senior high grades. Teenagers may prove quite responsive to certain smoking-related themes. Perhaps classes could develop survey instrtanents to query their schoolmates on attitudes toward the attractiveness of smoking. In high school, for example, if it turned out that the vast majority of the members of one sex did not like kissing smokers, the other sex might be far more responsive to this input than to learning that their risk of lung cancer would increase ten-fold if they smoked two packs of cigarettes a day for 30 years. Similarly, clear evidence that smoking reduces one's present athletic potential could affPct the thinking of many teens. - The review literature on school smoking education programs is ccnsistent on one theme: few programs are structured in accordance with scientific principles of behavior and few are monitored through formal evaluation mechanisms. Our State could make a contribution to the Nation, as well as its own citizenry, if we could deviate from the norm in this regard. We need to search for innovative prograaIInatic approaches to smoking-and-health education, but we must be able to assess the worth of the new approaches. This is easier said than done. Probably few teachers are interested in formal evaluation; still fewer come equipped with knowledge of formal evaluation tech- niques. More basic is the problem that only a handful of teachers possess significant substantive knowledge on smoking and health, much less understanding of how to convey it effectively to children. To alleviate these problems, formal instruction on the substance and commtuiication of health material, and possibly on evaluation methods, could be required as a condition of teacher certification or employment within Hichigan. Alternatively, health education specialists could receive additional relevant training, possibly commumicating some of it to other teachers through in-service training. Again, of course, the principal burden of adding such responsibilities is the opportunity cost of what they displace.* * I am not familiar with either State certification requirements in this area or the relevant content in the programs of schools of education. rlssuming that Nlichigan is fairly typical, however, one can guess that teachers acquire only the most rudimentary knowledge and skills in this area. -106- i L

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Educational efforts can be carried on i.z zw ercus se*.tings outsiCe of schools. Niichigan's Public Health Code required local health departments to engage in ' health education activities in order to receive State funds; already, many departments have responded with ongoing or planned activities. Clearly this is a ready-made vehicle for experimentation and evaluation. In particular, local health departments might be encouraged to concentrate their efforts on high- motivaticn groups. For example, pregnant women have an importar.t and immediate reason to forswear smoking and hence may be auite susceptible to behavior-change education. Convincing the same group of the risks to infants and children of living in a smoked-filled environment may induce many women to maintain their cigarette abstinence beyong pregnancy (Surgeon General, 1980). In developing smoking education efforts, it is imperative to remember that the health information base has been transmitted reasonably successfully to most Americans (U.S. DHEW, 1976).* The factors which cause many people to continue to smoke and others to begin (apparently a declining fraction) are far more subtle and incidious than a "lack of information." It is possible that our knowledge of these factors - what they are, how they work, how they can be combated - is the major deficiency in smoking-and-health education. Other Policy Options Despite the wealth of knowledge of smoking and health, our knowledge is far from complete as -the preceding point illustrates. An obvious policy option is to'seek to fill gaps in knowledge through research. While I am not aware of any states which fund significant smoking-and-health research, thds has been a principal strategy adopted by the federal government. Indeed, a majority of the federal smoking-and-health dollars are devoted to research.** Basic research has classic characteristics of a "pure public good." That is, the results of such research enter the public domain and beceme useful to and usable by anyone, generally free of charge. For this reason, nationally- relevant research is commonly viewed as a federal government responsibility.*** With the exception of certain applied State-relevant research, such as evalua- tion of health education programs or estimation of the bootlegging effects of a State excise tax increase, the State's embarking on a serious research program * We know that the vast majority of Americans are aware that smoking causes lung cancer and emphesema, is a major contributing factor in heart disease, etc. fowever, the level of such lmowledge may be quite shallow. I have heard of (but cannot reference) one survey which found that 95 percent of the respondents kmow that smoking causes lung cancer, but a significant percentage did not know that lung cancer causes death. ** The motivation for this concentration is not wholly scientific. Research is viewed by the tobacco lobby as one of the more innocuous threats to the industry's economic health. -Indeed, same such research, such as work on "less hazardous" cigarettes, ultimately might contribute to the industry's survival and vitality. Recently, research published by a National Cancer Institute official created quite a furor within the anti-smoking establishment because lay interpretation of the research translated it into the conclusion that some very low t/n cigarettes were "safe" (Gori and Lynch, 1978). *** Put somewhat ,more prosaically, why should Michigan citizens pay the full cost of something which will be of benefit to the entire Nation? -10-1- i I J I I I ~ L

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I I I F I I i I i I I i ~ ~ ~ , ` L seems neither likely nor appropriate. Fowever, the State could use its presence in Washingtcn to lobby for more research or for specific types of research. The lobbying strategy--one the tobacco industry has used so.effectively for years-- lends itself to several smoking-and-health initiatives. For example, if a graduated t/n tax were deemed desirable by the Panel but infeasible for implemen- tation within a single State (due to border-crossing problems), the Michigan congressional delegation could be urged to work toward a national t/n tax. An indirect method of increasing our State's lobbying pressure would be to work with the local chapters of the prominent national voluntary organizations, encouraging them to urge their national offices to support the State's lobbying objective. The voluntary agencies--the American Cancer Society, American Heart Association, and :american Li.mg Association--represent a major source of interest, effort, and influence in the area of smoking and health. jyh.ile their fiscal resources have never matched those of government, their energy and visibility on the smoking issue make them desirable allies in any State smoking-and-health initiatives. I am not certain of the propriety, legality, or desirability of encouraging ccopera- tion among the voluntaries and between them and the State, but simple efficiency argunents favor exploration of the possibilities. The same thinking applies to the State's interactions with labor, industry, and in particular the health pro- fessions. Each of these influential groups should be included in State policy making. It is highly plausible that cooperation with these groups would pro- vide a lever to impact smoking in Michigan far more effective than anything the State could do relying solely on its own resources. In addition to the major national voluntary organizations, our State might explore establishing relationships with other national groups interested in smoking and health. A prominent organization is the National Interagency Coimcil on Smoking and Health which includes in its roster the Michigan Health Council.* The National Council is willing to assist states and regional groups in establishing their own interagency councils. Several states have developed such counci ls . * P.O. Box 1010, East Lansing 48823, C. Allen Payne, M.D. -108-

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I V. C:,nc'_usion The problem of smoking-induced illness -..=1; be with us for ;.any years to ccre. The start of the 1930s, however, represents a propitious time for the State of Michigan to launch smoking-controi ef;orts of our own. Cne can bemcan the horrendous magnitude of the problem--tz:o and one half million Michigan smcicers, ' over 15,000 deaths per year, half a billion dollars in unnecessary medical bills-- but one can also point with optimism to the recent trends in s-moking: six years of continuous decline in per capita consuir.ption; decreases in the per- centages of men, women, and teenagers who smoke; continuing decreases in the tar and nicotine content of cigarettes smoked. Both surveys and political develop- ments indicate popular acceptance of a ncnsnoking social ethic. The ccncept of nonsmokers' rights has become embodied in law in the vast ajority of L~e states. Two decades ago,_ the problem of smoking-induced illness derived in large part from ignorance. Many millions of continuing smokers, a majority of whcm have indicated they w+ould quit if there were "an easy way," are victims of that ignorance. Today, however, the public is well-informed and Imcwledgeable about the hazards of smoking. Thus the challenge is not to inform but rather to transform, to convert knowledge into consistent behavior. Clearly this challenge is intellectually vastly more taxing than that of disseminating inforrration. The problem of smoking must be attacked frcro several different directions. We must assist smokers who wish to quit; we must help children decide not to start. A comprehensive approach to smoking in our State must recognize, and address, the widely divergent influences on smoking across age, sex, and socioeconomic groups. The successes of a decade and a half of anti-smoking efforts leave a residual, perhaps more intractable smoking population. This fact alone recommnds a search for innovative approaches to smoking control. The difficulty of the task is multiplied by the severe resource constraints which will define and limit Michigan smoking-and-health initiatives at least through 1931. Thus, as the Citizens' Panel contemplates policy reccr,r:endations, it nust blend realism with creativity. The task is iirmense, but so are the problem and the potential reward. i I I I i i t r I- -109-

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i I I I I I I I I I L References advisory Ccrmissicn on Intergovernmental Relations (1977). CiQarette Bootleggina: A State and Federal Resoonsi'cilitv. LVashingtcn: ACIR. .auerbach, 0., E. Haranond, and L. Gartinkel (1979). "Changes in Brcn&.ial Epithelitzn in Relaticn to Cigarette Smoking, 1955-1960 vs. 19,0-197'." New Engl. J. Med. 300 (February 22) : ;81-356. Bloom, M. '(1979). "Restrictions on Srr.oking : Observations on Their I:rVact." Presented at the 28th Tobacco Workers' Conference, Orlando, Fla., Januar,v 18. "Bootleg Cigarettes" (1978). The lVashinQtcn Post, October 17 Califano, J. (1978). Address delivered to the National Interagency Council on Smoking and Health, January 11. "Cigarette Contraband" (1978). The Economist, March 11. Cooper, N., and D. Rice (1978). "Me Economic Cost of Illness Revisited." Soc. Secur. Bull., February, pp 21-36. Fried:nan, K. (1975). Public Policy and the Smoking-Health Controversy. - - Lexington, Mass.: re x ington o s. Garkinkel, L. (1979). "Changes in the Cigarette Consumption of Smokers in Relation to Changes in Tar-Nicotine Content of Cigarettes Smoked." Am. J. Pub. Health 69 (December): 1274-1278. Gori, G., and C. Lynch (1978). "Toward Less Hazardous Cigarettes - Current advances." J. Am. Med. Assoc. 240 (September 15 ): 1255-1259. Green, P. (1977). "The IMass Media Anti-Smoking Campaign Around the ti'r'orld." In J. Steinfeld et al., Proceedin s of the Third World Conference on Smoking and Healt, Vol. 11. Z..o. (: i,- 3, pp. 245-253. Hamilton, J. (1972). "The Demand for Cigarettes: Advertising, the f?ealth Scare, and the Cigarette Advertising Ban." Rev. Econ. Stat. 54 (.Wvember) : 401-411. - Harris. J. (forthcoming). "Taxing Tar and Nicotine." Am. Econ. Rev. Lieb, C. (1953). "Can the Poisons in Cigarettes Be Avoided?" Reader's Digest 63 (December): 45-47. Luce, B., and S. Schweitzer (1978). "Smoking and Alcohol Abuse: A Comparison of Their Economic Consequences." New Engl. J. 'Aed. 298 (,\farch 9) : 569-571. * - Miller, L., and J. Monahan (1954). "The Facts Behind the Cigarette Controversy." Reader's Digest 65 (July): 1-6. -110-

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I Miller, R. (1973). "The Economic Importance of the U. S. Tobacco Ir.d;.:s:^,." U.S. Departnn:ent of Agriculture, Fconcmics, Statistics, and Coeperatives Service (Z1ay) . ,N'ational Commis-sion on Smoking and Public Po?icy (1978). A Naticnal Di1e=a: Cigarette Smoking or the Health of Americans. Report to the k,.ericsn Cancer Seciety (January 31). National Institute of Education (1979). TeenaQe Smoking: I,=r.ediate and Long-Term Patterns. Washington: U.S. Government rinting oL_ice. National Interagency Council on Smoking and Health (1979). Smoking and the Workplace, Business Survey. New York. (1980. "^yelvinBelli vs. Tobacco Companies." Smoking and .ea :ewsletter 15:1, P. 7. Norr, R. (1952). "Cancer by the Carton." Reader's Digest 61 (Dece:r.ber): 7-8 Royal College of Physicians (1962). SmokinQ and Health. Sutrrnary ar.d Report of the Royal College of Physicians or naon on mo ing in Relation to Cancer of the Lung and Other Diseases. New York: PitTan Publishing Co. Schacter, S. (1978). "Pharmacological and Psychological Determinants of Smoking." Annals of Internal Med. 88 (January-) : 104-114. Surgeon General of the United States (1964). Smoking and Health. Report of the Advisory Corrmittee to the Surgeon Genera oz the ic Health Service, U. S. DHESV. PHS Pub. 1Vo. 1103. (1979). Smoking and Health. DHFiV Pub. No. (PHS) 79-50066. (1980). The Health Consequences of Smoking for 'N'onen. Thompson, E. (1978). "Smoking Education Programs 1960-1976." Am. J. Pub. Health 68 (March): 250:257. Tobacco Institute (1979). Tobacco Industry Profile 1979. Washington. Tobacco Tax Council (1979). The Tax Burden on Tobacco. Richinond. U. S. Deparrinent of Health, Education, and Welfare (1969). Use of Tobacco: Practices,Attitudes, Knowledge, and Beliefs, United States - Fall 1964 and Spring 1966. Washington: U.S. Governmnt Printing Office. (1973). Adult Use of Tobacco - 1970. Atlanta: isease ontrol (June). (1976). Adult Use of Tobacco - 1975. Atlanta: Disease ontrol (June). Center for Center for Warner, K. (1977). "The Effects of the Anti-Smoking Campaion on Cigarette Constmmtion. Am J. Pub. Health 67 (July): 645-650. I I I I I I I L -1:1- `-

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i I i I I I u i I I L I (1978). "Possible Increases in the Ltnderreporting of Cigarette 7cnsL.^;mtion." J. Am. Stat. Assoc. 73 (Jtu:e) : 3;13-315. (1979a). "Clearing the Aintiaves : T'-:e Cigarette Ad Ban Revisited." Pc1. Analvsis 5 (Fall) : 435-450. (1979b). "Toward Less Hazardous Cigarettes." J. Am. Med. -soc. :-i1 L~1ay 18) : 2143. (1980a). "Cigarette Smoking in the 'Seventies: Consumption act o= t..e Anti-Smoking Campaign." Revision of paper presented at the Fourth World Conference on Smoking and Health, Stockholm, June 18-21, 1979.. (1980b). "State Legislative Responses to the Anti-Smoking t.anqpaign: A Diffusion Study." Presented at the annual meeting of the Western Political Science Assoc., San Francisco, March 28. Wharton Applied Research Center (1979). A Study of the Tobacco Industry's Economic Contribution to the Nation, Its Fifty States, and the District of Columbia. Philadelphia, Univ. of Pennsylvania (April). White, J., and H. Froeb (1980). "Small-Airways D,vsfunction in Nonsmokers Chronically Exposed to Tobacco Smoke." New Engl. J. Med. 302 (March 27): 720-723. - Wynder, E., and D. Hoffman (1979). "Tobacco and Health - A Societal Challenge." New Engl. J. Med. 300 (April 19) : 894-903. -112-

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II i~. I I I i I U I I I L L Michigan Tobacco & Candy Distributors and Vendors Association Inc. Affiliated Organization-Ntusic Operators or Michigan 523 WEST IONIA STREET LANSING, ti11CHIGAN 18933 TELEPHONE 1517) 372 2323 MICHAEL R. SPANIOLO WALTER P. MANER III LEGISLATIVE AND EXECJTlVE SECRETARY GENERALCOUNSEL Septe:mer 11, 1980 Ki_-32et,t1 E. Warner, Ph.D Sc^.ool of Pti:blic u.ealth Lniversity of ; fic.bigan 109 Observatory Am Arbor, ;-11 48109 Dear Professor Warner: T.,,.ank yos for yotr letter of September 2 whe..-ein you acknzwledged &.,e time ccnstra:..->.ts facing the Panel and their ill effects on an accsate and adequate im-estigaticn. I appreciate your sincerity in vrging =y partic=aaticn ar.d the opporttnity of pointing out errors of fact in yois discussion paper. I too am sertsitrve to the need for object- ivity and have attached for yot=_and the Panel's review a paper entitledTY~.e Snolc-ne & Health Ccntrove-_sy: Anzther'-Side. I believe in discharging my responsibilit3es as a Panel rerber. I t.~+.erefore find it necessary to offer another side to svme of the issues addressed by the Pan.el. It is my belief the Panel will be better served by d-lis paper written by Dr. George Schafer, an objective sci~tsfic observer w~ questions scme of yois facts ccnce_''ning s='xi.n,g and health. Dr. S.afer is currentZy Medical Director of Preventive Health Progzam, Inc, and serves as a consultant to The Tobacco Institute. He is a graduate of the College of :-%dicane of the University of C3ncssrati and served 31 yea= in the United States Air Force. Dr. Schafer becane Cammander of the U-ited States Air Force Sc1oo1 of Aerospace 215edicir.e as well as Cc»ander of the Aerosaace Medical Division and cul.*mrated his Air Force career as S~sgeon General, 1975-1978.~ As is clear by Dr. Schafer's acca=1isF>ments, he is well rna1i fied to speak to the issues contained in this paper. I hope in rezr_ewing his paper the Panel will gai-i a greater trlde`starx1ing of the smoking and health contraversy. I tn:st in the Panel's c'.,el~?~erat--cn of these matters that Dr. Schafer's paner be given fair censie-E--ation. Given the brief period of time tmtii. the Panel nect meets, we have offered our ini yal response to your recent letter. In the vezy near :5ature we will talce the (=aortLaiI:- y of specify:lng other errors of fact (."dubious social account:.r.g tec-1;ni.rn:es ar.d inbalar.ced ecauuric rationales") raised in the ecrncmic/socr..al cost section of yocs discLssicn paper. Sincerely, ~ V. WaLte= P. Uar.er IIS ~ r.~oecutive Secretary Ln cc: Pane.l t>embers (with enc) os>--es) bt -113-

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I I I I I I I II I I I I I t IL IL I LTT!'RCC{~'ICN It Aculd be easy to accect t^.e widely held asstm:~ticrs regardi.-ig snck --Lng and health. ?dverse cc,=ents about s-neki.zg have been caiTcr_place for many years. Fiowe<~s, these asst..=tions icrrzre many rnuest:.cns that remain regarding clairrs t'zat smok:ng is the estaDlished cause of varicus r=an diseases. For ec=-~ple, if s;~cking has been proven to cause heart disease, hnw do we explain why a superbly corriiticr.ed athlete who has never sncked, has followed a strict diet, and seens to have avoided all of the htmtian "vi ces" requires open heart surcery in his early thirties? Further, if smoking causes lung cancer, how do we explain that the rate of lung cancer am=q nflnsmkers appears to be i.-Yxeasing?' 14bre- over, if these diseases have been proven to be caused by smoking, why do federal health agencies continue to plead for millions of dollars every year for research on their causes? Perr.aps because the scientific answers have not been fct.*nd after all. Perhaps because there is another side to the smoking and health ccntroversy which is frequently ignored in discussions of this issue. It is a side that eoncerns scientists and researchers who ;Q:aa that easy answers are not always the cnly answers or even necessarily the right answers. it is a side which mist be ccazsidered in discussing legislation that may aFfect raillions of people such as the proposals made by Dr. Kenneth E. Warner in the paper he prepared for this panel. In his paper, Warner urges that "the =r.ble:n" of smoking in Michigan "be at}acked". Zb justify making his rec=merzdations, he has presented only one side of the smoking and health controversy, that side uti.ch appears to support his own personal beliefs. in ccnsizlering legislation, however, especially in suh a centraversial area as smoking and health, both sides of the issue should be heard. Sir.,ce Wa.rner has discussed only one side of the ccntzoversy, this paper is in- tended to present the other side. Consequently, it should not be viewed as a camprehessive analysis, but as an effort to highlight often overlooked info=na- tion and to demanstrate that the convenient terdwcy to blane s:mking for disease and death needs to be carefully evaluated. To acazmplish that, this FaDer will address the major health claims made by Warnes: those relating to "excess deaths" and "excess costs," cardiovascular disease, lung cancer, and public sncksr.g. A brief description of the tobaccb industry's ccnmit:nent to scientific research in the smoking and health area will also be given. "Ea--ess Deaths" and "Excess Costs" Pmong Warner's major asser..icns is the ccatenticn that each year in the Cnited States, "cigaratte smmking is responsible for 350,000 premature deaths and in excess of 80 mi 11 i r,n L iditays lost frcaa wcrk. " Apparently by r.akir.g "extrapolations frcm nar ic*+a 1 data, " Warner further crntends that each year the state of Michigan loses "over 15,000 men and wanen" to smking-related diseases and many mi 11 icr,c of dollars in medical care arx2 cu-oductivity costs. Not crily is .er's source for these stataments sameahat vague, his discL:ssion of these claims does not even allude to the problem wh.ich have arisen regarding the use of st:ch figures. I ~

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I A brief revie~a of the historical develap)e^.t of c'_a:-.:s recard.ing "excess ceat'zs" is i.-~ortant in detey-r.i-iir.g ,,i:et':er t.ese sra~_-,v_^.s have e.ny scientidic vali.cit'r. Claims such as Warner's have b-ee.*: made in ccnrec-._icn with ~:.e =ricir:g and health controversy for more than 15 years. A1:noLct th e nu-bers tend to vary depe.-r:ir:g on who is giving them and when, they have been `roclaimed, cuoted, and r°peateu so often that many people accept then as fact. _--ven t^.cug'r, it is almost iir,pes- sible to dete=nir.e accurately where or how these figures origirated, esti.nates of 300,000 deaths, mcre or less, were already being made in 1964. F?owever, it is iirpor}..ant to note that even the Advisory C=mittee which prepared the 1964 U.S. Surgeon General's Report rejected the theory of "excess deaths" : "Zi^.e total ntart)er of excess deaths czusally related to cigaret}..e s:nokir.g in the U.S. popula- ticn cannot be accurately estiaated". 2 An explanation of why the r'dvisory Caamittee took this position is relerant to this discussicn: "The Carmittee considered the possibility of trying to make such calculaticns, but it involves making so many ass=ptions that the Cammittee felt that it should not attarwt this..."3 And-five years later, a distinguished physician bluntly dis;~issed such claims as "fanciful extrapolations and nat factual data."4 Over the years, hcwever, those cautionary state:rents were ig:.creL and clair,s about "excess deaths" continued to be made, very recently by former Secretary of Health, Fi:ucatian and welfare Joseph Califano in announcizg the release of the 1979 U.S. Surcrt.~cn General's Report. However, even this repoz t recognized the uncertainty that exists regarding atte=ts to establish a causal relationship between =nJsir.g. and disease: It has been only recently that data have aZso become avaiZabZe that indicate a relationship, aZthouah a s*atisticct reZationship and not an established causal relationship, be~een cigarette srr.oking and disability and_ other health indicators. 5 (Flmphasis ac:ded] Moreover, an examination of the report reveals a lack of data dealing with the relationship bet-aeen morbidity and those diseases which have been associated with snnkirg. For example, a review of the tables contained in the chaptFr on morbid- ity shcws that no data relating to such diseases were collected after June, 1965. Even when data are available, rnmxrous questicns about their reli.ability are noted. Chne such example is ill.aninating: Most Zarge scale studies on smoking and health have tended to investigate the rote of smoking independently of other behaviorat variables, such as alcohol consumpti.on and other lifestyle factors, occupa-ionat and environ- mental hazards, and certain osychoZoarcaZ factors. These vcrtiabZes are 'a~ to be related to health status ar:d mcnu are related to smoking habits. Thus it may well -!-,e .hat the eLi:rrna-cion of smoking without any crran.ges in the other factors will have only a ra_Tt iaZ -_~=ac-. on health stct-.cs3 6 F3ence, the authors point cut that impor'rant data have not been collected and suggest that the sole eiphasis on the Pl;ndnaticn of s:mking as a panacea to the prevention of illness might not provide the desired results. Perhags the most thCUght-crovGkir.g statF_-~ent on this issue was made by a researc:er in his review of clai.~ns that excess m.rbicity and disability can be ascribed to stnkir.g : -116- I I I I I I I I I I I p I ~

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i I I I I I I I ?erha:,s ar:y Zesson is to be Zearr.ed =rem this issue, . ~ -_~s nct smoKir~.c causes unroZd diseases and disa.,iZi:ias and Zoss ;'rcm :.;ork, -;-at ti^.a~ ci :ims ac,ou:: such controversiaZ tcpics need to be ca_re;'aZZu cnd inta Z Ziaent;,y rev iewed, even i f they are made :,y rubZic cgenc'_ as or _;-u orner yeneraZZy reZiaz Ze scurces.7 - Ccnseq,:ently, it is ap_r.arent that if clai~ of excess deat'^s and mCrbiditv based cn nati.cnal data are cuesticnable, "extracolations" mace on a state-wz.de ~asis are Li rcely only to caa=c=d such prcb1ems and - raise even .:rre rn:esticns. Given this unreliability, it seeris illogical that such evidence shzuid be used to justify restrictive legislation. lung cancer. Iimg Cancer warr.er's discussion of this subject is brief, but he does state that "the Fublic's major smoking fear is lung cancer." Instead of providing the cbjective discassicn which would seen to be requi red, tJarz:er sinply asserts that ever 3,500 lung czs.ce: deaths in 2tichigan are due to cigarette s-mr.king, without citing a source other than making a vague reference to the 1979 Surgeon General's Report. Perhaps he assLSred it was unneoessary. After all, almost eve.rvor.e has been told t~at S=kir.g causes Eut what do we really lmow about the nature of the association betwem smoking and lung cancer? Marny people do not realize that most of the data used to sugport clauns abcut cigarette smoking and lung cancer canes fram epidemiological (pocula- tion) studies. Such statistical studies can provide a great deal of infornaticn, but it is iVortant to renanbes that, accord3ng to one statistician, "cancer is a biologic, not a statistical, pLnblem."8 Although peogle have probably becane accustaned to saying that "statistics prove" sanething, it is a well-recognized principle that statistics can never prove causation. Even the 1964 Surgeon General's Report recognized that "statistical methods cannot establish proof of a causal relations.liip in an associaticai. "9 - Scientists have expressed concern about this tendency to equate statistical associ.atian and causal relationship. As early as 1969, aCanar3; an pathologist asserted that "in the a;ntext of smoking and disease, association has been con- fused with causation."10 bbre recently, a physician addxessed this same point, observing that a statisti.cal association "can lead to hypct'^.esis foanaticn" but it cannot "prove the truth of the hypothesis."11 rur'ther, , the population studies fran which these data have been taken are not tnassailable. Irr-egularities have been fcu-~d and publicized, utLic.h show that the case against smoking is not as sinple as many people wCuld 1ik.e to believe. For examle, if smoking causes lung cancer, it wail d be reasonable to ex_r~t hi~er rates of the disease in countries where mcre cigarettes are sirk,ed per canita. But that does not always happen. Cne scientist Ad-o found that lung cancer mortality rates vary significantly fran oo<mtry to camtry detP~r.iined that "t'vese large differences in mortalities cannot be explained by differences in cigarette _ , typps of tobacco used or the variation of smoking habits in these coimtries. 12_" If cigarettes do cause lung cancer, it also would seem logical that the earlier a person starts to smake and the mcre he sm.kas, the socner he would develop the disease. Yet nonsncicers and smokers (whether they smcke a lot cr a little) all -117-

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acoear to Ce`-eloo the disease at acorc.~csatelv the sare age. ~=,ccordi.c to cr.e e~e..-t: at hath the ace of st,~s-ti.^g to smck.e, and t':e~rate cf &-,cki±.c, s'r.culd have no ap: reciable influez-ze cn the ave..Yace ace of cnset of lung cancer creat.ly taxes, if it does r.ot destroy, any causal 'r.wctzesis."14 As a conseq;.ence of similar irregularities in his cwn analysis of male and ferale iung cancer mnr}ality patterns in anglan3 and Wales, a British .*nedical physicist argues that "no definitive cor.clusions can be reacized, as yet, about the e_xtent of any causal link bet~A---n smoking and lung cancer."15 By assmir.g that smking causes lung cancer and by ccaiparing erpected lung cancer r,icrtality trends against cbserved trends, Professor Philip Burch atte*r~ to deteatune whether the associa- tion betae°.z sncl:ing and lung cancer could be causal. But in his wor-~.s, "cbserved and expec~.~c3 trends cor.fli.ct with the causal hypot'^.esis.16 In another analysis of similar data, Burch reiterated his beliefs regarding the scientific basis for claims about smoking and health. In the absence of "suitably critical eviderxe" fran other sources, he concluded that "the contention that ahmst a11 cases of luaig cancer are caused by cigarette s-rnking seems to be un- Froven and prematwre."17 In light of Warner's assertions, BLSch's ccncluding re:narjcs regarding the general axeptance of the causal hypothesis should be carefully considered: As we are all well aware, rr=y emmnent persons,.ccr.m*ttees and cc~rissions have unanimously concZuded that Zwig cancer "is aZmost entirely due to cigarette smokir.g. " I once shared that view, but having now stuciied the evidence in more detail and from-new angles I feel unable to reach a definitive conclusion, apsrt from re,7ecting the "pure" causal theory. Zs In acditicn to epideaniologicall st-uiies, clinical and laboratory data are used to sup_oart the assertieai that smoking causes lung c3ncer. However, the validity of such data also has been challenged and inconsistencies noted which do not "fit" the causal hypothesis. A Yale physician and epide:niologist, with an extensive background in the smking and health controversy, summarized several of these "loose stratY3s" : 1. The supporting evidence in hwr.mzs rests entirely on statistical analyses af observational data, and has not been (because it can- not be) confirmed by randomized experimentaZ trials. 2. No we Z Z-designed and we Z Z-conducted ew;,eriments have shown that q cancer in animaZs.19 cigarette smoking causes Zun 1vxreover, it mist be considered that the same type of evislenoe which has been used to lirik cigarette smoking and ltmg cancer also suggests that many other fectors aay be involved in the develc~.znent of lung cancer. These inclivde occapa- tiar.al exFosures, viruses, diet, food additives, pollution, stress, aging and II~'.37.z2d bory defense mec'_han i cms, In s=.ation, the simnle assertion that sm.3cing causes lung cancer does not take all of these points into consideration. Therefore, itseems premature to ccnclude that smoking causes lung cancer. The type of one-sided attack on cigarette smoking made in Warner' s discussion does nothing to advance the search for causes and cure of lung cancer. -118- I ( I I I I I I I p I

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I I I I I I I II II Cardiovascular Disease War:.er's dis.:.:ssicn of cardiovascular disease, whic'i he ccnte--r-Is is "by far. the ntmicnz cr.e s-roki^.g-relate3 lciller, " is oversiz=lified and larcely ur.sz:=pcr-e.'. Basically, he asserts that each year, sr,ioking causes a large of deaths f-cm caxr?icvasc.:lar disease, apparently on the assum: ticn that no one wculA disacTee with that state:nent. F.x7wever, t~ scientific picture surrcurxiir.g t".e etiology of hear` disease is sinmly not as clear as Warner's paper suggests. In fact, many scientists and researchers oft.en nn refer to the "naltifactorial" origin of ca~iovascuLar disease, rneaning tiat mare than cne factor sast be included in discussicr.s of its develcp- ment. In this ccntext, the tean "risk factor" has been used to describe those characteristics (either bi.ological cr behavioral) that have been statisrically associated with the develogment of heart disease. Cigarette smk:.ng has been reportsi to be a risk factor, but so have aging, sex (i.e., being male rather than female), elevated levels of cholesterol aryd of relate3 fats in the blood, hypertension, diabetes, parental history of heart disease, obesity, perscnality type, and physical inactivity. To Michigan researchers have suggested another possible risk factor - "job dissatisfacticn."20 wr.at is inpartant to remenber, however, is that "risk factor" does not me-an "cause". This was illustrated by Dr. Theodore Cooper's testi:mcny before Congress when he served as the Assistant Secretary for Health of the Departrent of health, Education arri Welfare. Dr. Cooper was given the cr_-portunity to identify cigarette smoking as a cause of heart disease, but he declir.ed : Senator 3art: "I would merely ask if ctiaarette smoking causes heart disease?" Dr. Coover: "Yo. " Senator Hart: "It does not?" I I i I L Dr. Cooper: "No. I think to be absolutely candid with you, the risk factor does not mean cc:cae ...... 21 [Empi, .asis added] A ffiitish Medical Jour.+al editorial differentiated even more strongly between cause anT risk fictareq:~hasizing that the presence of risk factrxs may have little significance in identifying future heart disease: "We mist therefore realiae that risk factors cannot be causal and that they have very pocr pre- dictive value.^22 This point was clearly illustrated by the results of Keys' recent tax'.ate of the Seven Countries Study. Zn his on-going study of over 12,000 men, Keys found that "the differences among the cohorts in the incidence rates of carcnaiy heart disease and of death fran all causes are not explained by, or related to, the differences anong the cohorts in their src.lun hanits. "2-3 [IIqiiasis added] In the context of Warner's statements about smoking and caxdiovasclar disease, Zeys' observations regarding smking as a risk factor are rbot.ewcrthy: "The fizdircs about cigarette sanakiuzg as a risk factor irdicate that here, too, relaticnships are not as ssmle as first supocsed. ^24 (IImpt^asis aV;,;ed] M ~ In acd.ition, an editorial by The Iancet foaLsed on reZ t data di_~icslt to re- . A V ~ _ cor.cile with the causal hypot~esis. In its cccrnx--:ts on the renrr~-~ decline in caronary heart disease irr,rt~ality atmng pmericans , the ed:.terial noted that: ~ -119- L

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I :rends in smcking it tne icec.r±-cisease rer.cs -7ess .;ell. :i:e orocor.:icn of Ar,:er'_ecr: men .;i:o smoke r.as Cec:'easec zuo :'r.2 pro^^r~icn o; ~;cmen ~::o smoke has inereased; ye ~^or-a? i - has ~ec 7 ir.ec morev ::n L;cmen z-r.cn tin men. 25 Tvo recent reperts by the National F?eart, Lur.g ar3 Blood _Tnstitute (NHI.EI) dis- cuss the scie.^tific ~ncerta.inty abcut the reasons for the rexry.ed decline in coronary heart disease mcrtality. For e:canple, in 1979, an tiF~...3I wo.rkisx3 group concluded that "the reasons for the real decline in cardiovascular morta.lity rgnain tmr3etermined, and Friirarily because of inadect:,ate data, it is uncertain whether chax;es in any of these risk factors (inclLrl.ing cigarette smking) can accouit for the decrease. "26 The szuimar7 report of a 1978 ccnferer.ce held by the i+=I similarly ccncltded that "alt'^.ouc,-h t.ere was general agreeT~ent t'aat the decline in ccrcnary heart d.isease is real, the probable cause or causes cou1d not be precisely identified."27 R,eparts and caaments by irriividual scientists atterdirxg that conference fur~t!^.er highlight the lack-of tnderstanding about the decline in ccronary heart disease martality. (ne scientist who has argued in the past that smokirig plays a role in oorcne.r-y heart disease develo_rsrnnt stated that "the reality is that we wi11 have to wait scane years before hard data are available ec`.ce_r.^:.rig the reascns for the mcr*a1 ; ty dawntrerri. "28 Another researcher who has also exaresse3 anti- sroking sentiments obsezved that "the re3scn or reasons Fcr the decline in c~ID marta].ity have not yet been establisi~. "29 And perha_,s-rmst relevant to this discussion are oatments made by researcizers who noted that the reparted decli-ue could not be em-alair.ed by charges in smkinc- consuTption trends. For ex-mple, the director of a maj or research and develcrsr.ent center stated that "coe don' t 3mow enaugh about what is happeni ng with srLking. When we lock at sroking changes by race and sex, we den't see the consistent patterns one would have expected with the observed mortality trends. A great deal mcre wzzrk is necessary".30 What can one conclude f±-an such observations? It is obvious that because of the extreme ccnplexities they den=mstrate, heart disease contimes to pose a irultitude of unanswered questions. Consequently, Warner's oversirrplificaticns of this pro- blen do not provide an objective evaluation of the situation. Public 97noking Warr.er's discussicn of the possible health effects of tobacco snnke on n=snokPSs in public places is extrenely short and ignores significant research findirqs on this issue. Howmver, Warner sesas aware of these other studies when he admits that "for years, the evidence on this question has been limited and mixe3..." This is, of course,= consistent with a ccr:clusicn ccntained in the 1979 Surgeon C'eneral' s R+epcrt: "Healthy ncnsmcker s exposed to cigarette smcice have little or no physi.ologic response to the smake, and what resacnse does occi.r may be due to psyc.'lological factors."31 Many irde aent scientists have made similar deteaninati.ons based on their review of the existirig literatsre. For exa=le, Dr. Siraa T. Ianqstcn, a former president of the American Pssociation for ;~h=acic Surgery and prese.Ztly Cli.-iical Professor of Surgery at the Nar~~1:Aestern University Medical School, e='rasized, in testi.*ricny before the Ciicago City Council's Catr mit}..ee cn Erriroririeztal Control, his conclusion that: I i I I I I I I I I L L , ~

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I I f I I ~in assertion that coCacco smoke is a ;~.ec'_'ill t2aza_^.^. ';a ,the ncr'^aZ nons,^'CKZr is unrer,ao Ze. The wei5izt o:' ev i,;:ence as i o e=s ~s in :%e ~;cr?c ? ~arct ~^e cces noc supror: a claim o,' adverse ;4eaZtn e;'.'ec:s ; or :'r:ose exscsea :o "-assiue smokting."32 Tharr:er f~ ~':er asse.r-s "that certain 'riich-r=sk prpilatic.-is (e, g. , those with heart or lung disease) expcsed to concent`ated mr.ke ccad suffer sianific ant adverse corseGue.-ces." This assertircn, as it relates to pecple with heart di- sease, relies heavily on articles publishe3 by or. Wil!hkeart r'1rencw. In his mest publicized st~y, P.roncw exanined 10 patients with ancir.a pectoris and reporte: that they Ceveloce.d. heart pain sooner after exercise when they had been expose3 to tobacco smake.33 f~.cxaf.'ver, Aronow's study design and results have been pub- licly criticized. The sa=le was extre:nely smail, no allowance was made for the possible effects of psychological stress, and alt'^.oucn Arorow attributed some of the results to nicotine, no measvrements of nicotine absorgtion were publisi^.e3. After revieTwing these objections, one professor of nathnlogy called the experi- mental design of Aror.caa's work "exceedingly poor,"34 arr3 a Ires Angeles chest physician concluded that the study is quest:.or.able. "35 Dr. Suzanne B. Xnoebel, Prrof essor of MecLcine at the T*dia*+a UnivQrsity School of Medicine, stated: There are no indications that tobacco smoke in the at:nosp'nere either causes or acceZerates c=diovascutar disease in the heaZthy ronsmoker. Nor do avaiZabZe stuciies estabtish that atmospheric tobacco smoke under reaZistic conditions adversety affects nonsmokers with preexistent cardiovascuZa.r disease.3o I r I I I I L With respect to patients with lung problem, Canad; a*+ researchers studied the reactions of asthmatics to levels of tobacco smake typically foand in public placeas.37 After two hours of exposure, no systenatic lung changes could be observed. These and other findings prampted a w+e.ll-known pulmcT3a=y expert to say: "I must ccrLClude that there is no proof that smoking in public places adversely affects patients with lemg-disease either acutely or chrcalically."38 Warner also alludes to one study which reportedly f=-d that "G~ildren's health can also be harned by living with parents who smoke." Again he seens to ignore the results of studies with reported conflicting findings. Zeboaritz and Btsrozas, for example, found that %tvPn the presence of sy=t--ns in adults was takm into account ... no statistically significant difference renai.ned in children's syrrvtans related to the hcusehold stnking habits."39 Dutch researchers, after a five-year study of respiratory ailrcents in 428 children, concluced :"3rr.king and zonsmking parents have abcut - t'ze same proportion of children with respiratory syrrptas. The zunber of cigarettes smked by the parents has no influence on respiratory srTtcms in their children."40 In one of the largest studies on the subject, Sc. 'h~ng, et al.,ccrbclude3 that "ex_r_ost=e to low levels of saoke p:rocuced by cigarette sar.kers does not result in chronic resniratory sysrptuns or loss of lung ftmctir.~n amcr.g children rxsr among adults. "41 cansideri.*x3 these and several other stUCbies with si m; 1 ar f1SdlI1gS, Warner hardly seSils jLlstif ied in te3miTKJ the associaticn between parental snaking and childhood respiratery disease as "definitive." Thus, Warner's recatnrzidaticais of legislation restricting s;ne.king in public places is based aimost entirely on the findings regarding the "l=*+ary functions of office ow=kars rer.:orted earlier this year by i~ite and ~oeb. `~2 By ~paring t~.e test results of ncnsmke.rs who said they worked for mrare than 20 years in of fices where there was no srnking with the measzranents of rcrmrakess who had rerar}.edLy worked the sane lerl3th of time in offices where s-tricing diL occur, White and Froeb asserted that "chrcnic exacsure to t.^;: acco smoke in the work e:Tvircx=e_nt ... sicnisicantly reduced sma11-airways _`uncrrcn. "43 _121- 1

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I Cespite the widespre...ad ~;edia att-enticn the xce_ :ece_.-ed, many rredical e.rnerts have cuestioned whel:':er the reported firdi^-s pzoof of any real harm to ncnsoeke.rs. For ~.le, Dr. Michael J. L:a?~-st~,-st~, a weL-;mcwn rredlical co1;-siist, said, ",vize*..her or r.ot this study will be ccnf^-'.ed cy other irnvesticaticns, ard whether cr not actual diseases accear in ncns,-,ckir.g -,,~-ple wt.o wcrk in a s:,iexir:g envir=nent has yet to be resolved ."44 Dr. Claude Lenfant and :2s. Barbara Liu of the Naticnal L-istitues of F:ealth noted in an editotial ecc.arcanying the 4vhite/FYceb article that "G2zerally speaking, the evider.ce that passive s.-roking in a general envi-rcrr,ent has health effects remairs sparse, inc=lete ard sanetimes unccnvi.cir.g ... there is no Frocf as yet that the re_ e3 reduction in airways furzticn has any physiological or - c1.irLi,cal, conscqi.ie.^.,..^es. "45 Fecently, several cther experts have criticized the Svhite/FYoeb study. In a letter to the editor of the journal which published their study, one doc},,.cr questioned their e.raerimental premi.se: "It is difficult to believe that the researchers have been able to identify a truly representative group of subjects who have uork histories of 20 years or more but have never been expose.ad to tobacco s;:nke. "46 Another researcher asserted that Gdzite ar,d Ftiroeb did not have reliable estimates of anomt of smake to which t' :e nonsnekers were e.~csed because "carbon ~ide is not an ' actvrate' irr3ex of sRrke exposure ..."47 Ansthes doct.ar stated tY.at their study was "flawed" because they used a lung fu^.cticn analyzer wh.i.ch "fails to meet the technical reccrarer-dations of the Arrr--ican Tttoracic Society."48 So it wou.ld seem that, based on a review of the existing scientific literature, Dr. Iangston's evaluation of the legislative aspects of the ncrosncker issue is sti11 valid: "The -regulaticn of public smking, ureer the guise of a mandate to protect the public health, is without scientific justificatica:. "49 Lenfant_ and Liu a'cc.ressed the same issue in their editorial. They asked &.etcrically whether this ne,q evidence was "sufficient to initiate new legislative ac..ions that wvuld further restrict snokirsg in public plac~.s ." They responded with the obsezvatlcn that this is a "difficult and delicate question" and ccrcluded that the Stihite/7toeb study "is ccnfined to onl ene aspect of an issue too oaplex to be resolved on such a limite3 basis."5~ Once the alleged danger of these "potential hazards" has been put into perspective, the difficulties urderlying such legislaticn beccme nuch clearer. At h,earings on bills proposed to restrict smaking.in public places in other states, experts have repeatedly underscared the prcblew surrounding such prohibiticns. Clziefs of police have discussed their concerns over the diffic.alty in enforci-ig such laws; cwners of restaurants have predicted their loss of ir.come when esstariers becane dissatisfied; office ma nage-s have anticipated urmleasant canfrcntaticns between smoking and ncri.-tckir.g employees and the dest_^action of harmony in the wczrkplace. Warner hinself int_*cduces one of the mcst discuietir.g points involved in this issue: the increas=,g t of gcve=.w.--nt into inatters of personal choice. As he puts it, "police monitaring smksg behavior has a distinctive vl wC.L.l.la11 fl3v0'r. . " - A danger posed by possible gove`nanent excess is made clear by the results of cne such law regulating s:mki.*x3 in public places. An analysis of one month's ocera- tion of the CZicago ssckers' court reveals that cut of 279 peoQle s-umm,rr.ed 248 were 31eck. A colunist uho is h mset f an anti-stcke* has ohsE.Ywed : "The suspicicn is strcng that Czicaco's s=kers' ccurt has absolutely nothing to do with ;ranctir.g clean aublic air. "51 -122- f I I I I I I I p IL

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i I I I I I I s I u I I t L L Cne :;a:st ask, then, whe*.her the real issue here is the crese_^zaticn of the :.ea1Lh, or the atte~--.t of single issue activists to "save smckers -,~-'an t.e:rselves." wari:er hints at this hidden iaativaticn. L7rediately after asser-._i:.g t'^at t-.ese bills sippcserlv will "rrotec t" ncns;nicers,he ac?cs : "Nere--tneless, cne :nich t expect that sr7c}c::.c-restsic...icn laws, par-..icalarly the iLiq~ly res'csic},e ive cr.es, wnuld force a re~ti:c-._.icn in total cigarette ccnszu=ticn, sirr--ly because r-nc:cz-s - wculd be cr^..nibited fran --,rickir:g in unavoidable designated places." The cov:ous cLestion is wt.,ethe.r laws should be used to control or p:nish --mkers. Another we?1 recognized facet of this issue is that certain peoole -simply do not like cigarettes or cigarette smake. Scrm seek to justify their anncyance by claisning that they are allergic to it. Yet the fact is that no scientific re- serach has proved that people are allergic to cigarette s:neke.S2 Certainly t'^.exe are "c'.Qezniented" cases of annoyance and di.scartfort, but how etensive are these camplaints amang the general public? According to one naticnal sutvey, adr.ini- stere3 by Respcnse Analysis of Princeton, New Jersey, only three percent of the annoyances Listed by ronsnakcss were related to cigarette snc'rs.5~ Those results should prrnp t a ntIInber of questicn.s. Mbst importantly, it can be asked whether the high visibility of t`Lis issue is the result of certain "anti- smcking" group tactics. If so, should laws be passed to satisfy the preferer.ces of a sma11 minority? Single-interest factions can be blind to the larger concerrs of society. But policy makers cannot afford to be. Irdust..,-v-Spcnsore3 Fesearch As previously mentioned, this discussion was intended to raise questions about srroking and health issues. But the tobacco industry is not satisfied wit.1i sL=ly raising cuestiarns; it is also concerr:ed about furthering scientific understanding of disease causation and developnent. To that end, the industry has cumLitted over $85 million to researdh designed to expand our }mowledge in these areas. In many years, tobacco industry sncking and health researc'z spending has exceeded that of any governmental department as well as the ccn~bir.e3 grants of the major voluntary health agencies. - Brtad research grograms have been supported by industry funds. For eximple, with the help of $2.75 million, the UCIA School of Med.icine is exploring lir:g defense mecisanisns and early detection and treatment of cancer. nie research teatn is also studying novel concepts of treatmezt (inclur'' ng recarbinant L'NA) of other diseases such as sickle ce11 anesnia. Anot'-~er grant for $5.4 million to Washinctcn L'nivPSsity in St. Lcuis is underariting a study of possible inn~ logic factors in cancer. And a $4.7 million commitment to F.arrar: :2edical ScI=l has nurxied wor-c on pulmcnazy and cardiovascular diseases. Other projects have been funded through The Council for Tobacco Rese~~h - U.S.A., Inc. (CIR). Although its financial su_oport is provir3ed by the tobacco industry, CTR is autcr.amus in awasd; ng grants to scientists for the stuc.'y of sm.,king and health euestions. As an actmnistrative agency, CTR evaluates research _rscoosals through an advisory board of independent scientists; it does not operate a re- seach facility. As- of Nlarch 1980, n~e than 390 scientists in 250 medica'_ schools, hcsaitals and ir.stituti.cns in the U. S. and 10 foreian calntries have been funded. They have ca.mlete scientific freedan to conc:uct their st-.:dies, and they alcr.e are respcnsible for report-ing or r.ublishing their findings. In total, these re- searchers have pubLished 1,772 scienti-fic papers. -123- I L

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Through these research proc-ams, ccnce_-~-...ei atte*pts are beir.c 7sce to zr~..an3 our }a:owlecge of smcki.ng and nealth-related cuesticns. ':".-:e xsit.icn of the tobacco ir)cust.v is that the answers w-i'? : e found cnl,,r t.rct:ch scL:nd, cbjec- tive scientific inqu; .*y. To this enc, its =tiit--i---:t to researr..h is s.:,bstanti.al. Ccr.c'_usicn In recent years, ssroking has beccme an ea,-,, target for pecole anxicus to solve our nation' s health prcblem. But these probler.is ~ai? 1 not be solved by icr.ori.^.g the scientific cazple.cities si=LTdi^g smekir.g and health issues. Nor will they be resolved by legislation that interferes with the perscr.al choices of a large section of the populaticn, and has the cotential for unfavorabie social and political ircpacts. onl.y an ebjec-,ive analysis of the evide-rice aryd the contint,ed pursuit of scientific ]Qiowler:ge can help resolve t'^.cse prcble::s. It is to be hoped that the Panel, with the assistance of its Project Director, will present, after full consideraticn ef the issues, a balz.r.cer3 analysis. I I I I I I j I I- I -124-

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i R=,E::C.:S I I I I I I I i I i j 1 ~ ! i 1. G~15tr=, J. , "Rising Lung- C3ncer MOi-`'~.~...~il`' NC^.3iY;}Ce_''s, " J_ ::c:::l Cancer L^5t 62 (4) . 7s;-760, h.a'il, 1979. 2, U.S. ?t:b~~ cc i?eatth S,,_-r_ce, _1-'nokir.(z ar.d ::ea1tZ. of the ?cvisorv Catr,uttee to the Surce^..n Ger.eral or t.e ?:blzz Heer=n Sz...^rice, Depzr-_ie*:t oz ~ 1, r: ;:cat~n dWelfare, PNS P.:biiat+cn No. 1103, 1964. 3. Hku)cley, J., Trans=iat, .ti'ews CG:nfere.^.ce Pe.d eased by U. S. Public F.eal th Service, JanLar_r 11, 1964. 4. Rosenblatt, ,K. , Statement, U.S., Ccngress, House, Catmittee cn Interstate and Foreign Corcirprce, Ci ett~e Labe.li:.Q and Advertisir.g - 1969, Hearing, 91st Ccng. , 1st Sess. , april 15-30 and MayT, 1969 (Washingtcn: G~e_Y:rne.zt Printing Office, 1969), pp. 1255-1271. 5. U.S. Public Health Service, Smokir.a and Health. A Re=_ ort of the Stscecn General, Depax-.,ent of Y-:ealtn, £ucaticn arri welfare, DhffW__Publ caucn No. TTZ-37T66, 1979. 6. Ibid. 7. Sterling, T., "A Review of the Claim that Eccess Morbidity and Disability Can be Ascribed to Smkir.g," J Am Stat Assoc 66(334): 251-257, June, 1971. 8. Berkson, J. ,"Sankinr and Lmg Cancer: Sane Cbsesvaticns on Tsao Recent Reports," JAn Stat Assoc 53 (281) : 23-38, 1958. 9. U.S. Public Health Service, Siing and Health, 1964. 10. Lees, T., Statement, Carada, House of Ca:mons, Standing Coin.uttee on Health, Welfare and Social Affairs, Hearing, 28th Parl=-ent, 1st Sess., May 13, 1969 (Ottawa: The Queen's Printer, 1969), pp. 1058-1078, 1087-1113. 11. Dijkstra, B., "Cn Srmxing and IArq Cancer," Suid-Afr' aa*+se Kanker'_N~eti*: 23(3): 87-109, July-Segtenber, 1979. 12. Sc.'zrauzer, G., Statemient, U.S., Coi-igress, Fzuse, Car,mittee on Agri.culture, Suboarmittee on Tolacxo, Effect of Slmkir.Q on N.4_-T~kers, Hearing, 95th Ccng., 2nd Sess., September 7, 197$(Wasning=: G6,-e_^ane*:t Printing Office, 1978) pp. 139-157. 1 13. Buhler, V., State:rent, U.S., Congress, House Catmit*..ee on Interstate and Foreign Caamesce, Cigarette Laheli~ and AiivQrt:sirq-1969, Hearing, 91st Ccaq., 1st Sess., AgrIr30,ar May~I, 1369 ( a, . Gcvezrrrnt Print- ing Office, 1969), pp. 769-787. Burch, P.,"Sanking and Czsicer, " Lancet I: 1315-1316, June 9, 1973. 14. Burch, "Srmking and Car:cer. " 15. Burch, P. ,"Smaking and Iung Cancer: '2^.e P'roblem of Inferring C2arse, " J R Stat Soc A 141 (Part 4): 437-458, 1978. -- -125-

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16. lb i d . 17. Bur:»z, P. ,"Strok:.::g and Lur:g Cancer. Tests of aCsl:sa? ::yoct:.esis, °.; C,.^n Dis 33: 221-238, 1980. 18. Burch, P. ,q and Lung Cance_*-: T".:e P=ble=n of L-iFzrri.g Cause." 19. Fei ei,A,. , Ccznp-zts on "Discussion" of presentat'_cn by P. Burch, and Lung Ca.^.cer: The Prcblem of Inferring Cause (Wit'i Discussion," J R Stat Scc A 141 (Part 4): 437-477, 1978. 20. Sales, S. ar~d J: House, "Job Dissatisfaction As a Possible Risk :'actcr in Corcnar_r Heart Disease," J G`ircn Dis 23: 861-873, 1971. 21. Coopes, T., Statenent, U.S., Cangress, Senate, Ccnmit}.ee on Labor and Public Welfare, bubc.inittee on Health, Cicarette &mkina and Disease, 1976, I:earing, 94th Cczig., 2nd Sess., Febnuary 1,Marc.'n 24, and :7ay 2~7~ (w szirg'-,^n: Goverranent Printing Office, 1976), pp. 175-208. 22. Fr:itorial., "Very Early Recognition of Coronary 'r.'eart Disease," Br J_ Med I: 1302, May 21, 1977. 23. Reys, A., Seven Counties: A:hiltivariate Analvsis of Death and Corcra~-v Heart Disease (Cazmridge: fiaxvand L'niversity Press0) . 24. Ibid. 25. Editorial, "'ehy the American Decline in Coro^.azy Heart Disease?," Lancet I: 183-184, Jarnsary 26, 1980. 26. National Heart, Iung and Blood Institute, National Institutes of Health, Report: Working Group on Heart Disease Epidemiology, Depart;ient of Health, Ed-acaticn, and Yr'e *a` ,e ,14M Publicaticn No. i - 7, 1979 . 27. Naticnal F~:eart, Limc- and Blood Institute, Naticxal Institutes of Health, "S1mm~.~ry of the Ccnference on the Decline in Ccrcnary Heart Disease Mortality," Procee3incs of the Ccnference on the Decline in Coronary Heart Disease Mortalitv, Decartrent oi N.31t:j Du-cat~aiZ-W=ra-re, Nrr1 P Ticat.icn .No .=,~ pp x~ciii-=vii, 1979. 28. Stz snler, J., "Sessics: IV: Stsategies for Quantifying and StLc.'ying CED C7mge," Pzoces°_ir:cs of the C,onference on the Decline in Corenary Heart Disease Mortality, DeparEe*Roi F.Ea-rt7, on rweEare~, Km P=,=ticn LNo. 79-I'oY ,- 3810399, 1979._ 29. F---ie3man, G. ,"Decline in Hospit?lizaticns for Coronary Heart Disease and Stroke: The Kaise=-Pe=nanente Dxpesiece in Northe`n Califernia, 1971-1977,: Proceedings of the Ccnfere.-ce cn the Decline in Corcr.ary Heart Disease 1%brtality, Dep3rt:nent oi Heal` ,c:cati39 ax 'tiveliare, NI'rI-cation No.~i5-76Sd pQ Ib9-114, 1979. 30. Shapiro, S., "Session IV: Strategies for Quantif_virg and Studying GHD Qzange," Proces': ncs of t':e Cbrference on the Decli^.e in Corenarv Heart Disease Mortality, Derzr=ezt ci i?e. , i;cauoa ana'W=are :1rdPtA~auon .1o. 79-161 , pp. 381-399, 1979. (z C!' ~ G'1 -126- ~ i i I I I I I I I I N t t

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I I I I I I I i I I I I 31. U.S. P~;blic Health Se`~rice, -`ncki^.c and Health, 1979. 32. Iar.gstcn, H., Statenent, U.S., Cor.gress, 'rioi:se, Ccmtit},.ee cn St:.,'~ Ca:mit}m on 7-tbacco, Zfrect of S;rokinc cn %1cns:xke_-s, 'r_eari^.g, 95en C:,r.g., 2.-Y-J Sess., Segte.*rhZ 7, 1978 (6ras-y~;n: Gc-,F---: e.rt Printing Office, 1978), -m. 158-184. 33. A`-cnew, W. , "Effect of Passive Smoking on Ar:gi.^.a ?ec~cr=s ," New E:cl JML-_,? 299(1): 21-24, 1978. - - - 34. Fisher, E., Sta*..e.me-*it, U.S. Congress, House, Cc.a;mity..ee on Ac;ricaLt.:~re, Sub- ca;mittes on Tobacco, Effect of Smokir.G on ,:on...~~nck.ers, Hearing, 95th Cong., 2.-ri Sess. , September 7, 1978 (ashingtCn( Gcwe,_-,e.-it Pr:rzting Office, 1978), pp. 2-20. 35. Niden, A. ,"No: Fhvirormental Srncke Can Ir_itate Not Injise pthers," Lcs Angeles Times, Cctober 29, 1978. _ - 36. Knoebel, S., Statement, U.S., Congress, House, Cor,mitt..ee on Agriculture, Sutr- carnittee on Tcbacco, Effect of STmki1^g on Nons-zek.ers, Hearing, 95th Ccng., 2nd Sess., Sept,erbes 7, 197$ (Washing}..c.n: Govern--nent Printing Office, 1978), pp. 49-55. 37. Piam, P., et al., "Physiological Effects of Acute Passive E~=osure to Cigarette Smoke in Asthnatics," Fed Proc 36 (3 ): 606, 1977. 38. .47cser, K., Statement, U.S. Congress, House, Comnit+,.ee on Agriculture, SUb- Coianittee on Tabacco, Effect of Snn~king on Nansmckers, Hearing, 95th Cong., 2nd Sess., Septenbes 7, 19 7 8(~~:~ton: Gez,er; mernt Printi^.g Office, 1978), pp. 35-40. 39. LzbC.wi}.z, M. and B. Burrows, "Respiratory Sym=tzm ReLated to Srm.king Habits of Family Adults, " Cr.est 69 (1) : 48-50, January, 1976. 40. Kerrebijn, K. ,' et al., "Qzronic Nonspecific Respira}..ary Disease in Czi.ldren A Five Year Fo11ow-up Stu~.y," Acta Paediatr Scsnd Supol 261: 1-72, 1977. 41. Sc-h? il; n g, R., et al.,"Ltu:g Function, Respiratcry Disease and gnokir:g in Families," Am J Ebidemiol 106(4): 274-283, 1977. 42. '+vhite, J. and H. Proeb, "Small-Airdays Dysfunc+ ..i.cn in Ncnsrckers G'z.--onically E:qosed to Tobacco Smcke," N Fhcrl JMed 302 (13) : 720-723, March 27, 1980. 43. IUi.d. 44. Halbe.rst3n, M., "SL-,jdy on Second-harri Smoke EValuated," The (LouisviLle, KY) Ccuri.estiour+.al, Arril 27, 1980. - 45. Iznfant, C. and B. Liu, "(Passi,e) Sankers Versus (Voluntary) Snnkers, " N Ehcl JMed 302(13) : 742-743,_ Harc'i 27, 1980. - 46. Aviado, D. ,"Sma11-ki.^days Dysfunction in Passive Sir~rs, "N IIzc1 JMes3 303 (7) : 393, August 14, 1980. - - - -127-

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I 392, auc,ust 14, 1980. 47. Huber, G. ,"Sma11-.ki-naays L`vsfiaIcticn izPassi~-e 2:,,cice_-s," N L c1 J:ed 303 (7) : ~--- 48. 'rYeed:man, A., "Small-Airwavs Dvs---unc'.icn in Passive --m.kers," V H;c1 JMe3 303 (7) : 393, at:cust 14, 1980. 49. Langstcn, State:ne.zt. 50. Lenfant, C. a.zY: B. Liu, "(Passive) Snoke:s Versus (Voluntary) Sinckers." 51. Jones, W. ,"Caic: co's Sncke_rs Court Puffs Up Scme Haze, " Minr.eaoolis 'IYibc:r.e, July 1976. 52. Salvaggio, J., Statement, U.S., Congress, Fcuse, CUtmit,..ee on Agriculture, Sub- oannittee on Tc.bacoo, Effect of Smckiria cn Ncnsnokers, N.earing, 95th Ccng., 2nc.' Sess., Segte:rber 7, = (was ur.gtcn: Govazzarent Printing Office, 1978) , pp. 46-49. 53. Cohesi, R. , Statement, U. S. , Congress, Fouse, Ccnmittee cn Ar.;ricult-.e, St:b- caTanittee on Tcbacco, Effect of ~Smcki_~n on I3onstmkers, Hearing, 95t'~ Cong., 2nd Sess., Septerher 7, IS'i $~waun-qtorr: Govpsrlne.~t Pr izting Of fice 1978) FP 69-75. I I I I I I- p L 6 L I -128- ~ ~ `

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95645974 6

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I I i I I I I I i F I I L L 1 L L PQSITICV STai7a=IS SUB`tITTED TO TrE CI T I:E.\S' P?.N[Ei. Public F?ealth Organizaticns Maurice S. Reioen, ti1.D., Director Michigan Department of Public Health Lansing Beverly Chethik, Health Educator Washtenaw County Health Departinent Ann Arbor %villiam E. Thar, M.D., M.P.i?. `Iedical Director Mlid-Mic.higan District Health Depart7rent Stanton Thomas H. Logan, Director of Planning West Michigan Health Systems Agency Grand Rapids Voluntary Organi:aticns and Agencies Arerican Lung Associaticn of INlichigan Lans ing The Metrovolitan Detroit Coalition for High Blood Pressure Control Detroit United CoIIaamity Services of N4etropolitan Detroit Detroit Ann Quigley, Health Educator St. Joseph Mercy Hospital Ann Arbor Dr. Murrav Jackson American Lung Assoication of Southeastern Michigan Detroit Joy Harsen, Chief Cancer Prevention Sec:icn %lichigan Cancer Foundation Detroit Don E. Coleman, Ph.D., President Elect Herbert A. Auer, Executive Vice-President Michigan Health Co,,mcil East Lansing Judy Goth-Owens, Graduate Assistant Michigan 4-H Programs _ Michigan State University and U. S. Departr:ent of Agriculture Cooperating Lansing Willam A. Saville, Ph.D., Project Director Detroit Hypertension Control Program Detroit Merrill Fleming I Michigan Conference of Seventh Day Adventists Lans ing Academic Richard D. Remington, Ph.D., Dean School of Public Health tTnivers i ty o f Michi gan Ann Arbor Institutions Richard G. Cornell, Ph.D., Professor and University of Michigan Ann Arbor Deoartnent of Biostatistics %I School of Public Health CA Chair:nan Jairus D. Flora, Jr., Ph.D., Associate Professor William J. Butler, Ph.D., Assistant Professor -129-

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II Business and Industry R.L. Rcd Brown, E_xecutive Director Aichigan Licensed Beverage Association Lans ing Henr,v A. Montague, President Michigan Restaurant Association Southfield W.A. Wickham, General and Legislative Council - Michigan State Charnber of CoAanerce Lansing William E. Blevings, Senior Vice-President National Bank of Detroit Lansing Richard E. Augenstein, Director of Government Affairs Michigan Manufacturers Association Lansing - Professional Don Sweeney, President Michigan School Health Association June Asselin, Edtcation Coordinator Michigan Dental Association J. Byron Walthall, M.D., Chairman Resident's CoBanittee Michigan Academy of Family Physicians Lansing Michael Cardin, J.D., Dr. P.H. President Michigan Public Health Association, Inc. Professionals Not Renresenting Organizations Stephen J. Galetti, Associate Professor of Physical Education University of Michigan Chairperson, Michigan Coimcil on Physical Fitness and Health George F. Sedlacek, Jr. Health Education -Coordinator District Health Department #4 Alpena Joseph Arends, M.D. Troy Theodore W. Beiderdieden III, Director of Regional Operations American Lung Association of Michigan Lansing Richard C. Bates, M.D. Lansing Richard A. Rasmussen, M.D. Grand Rapids John H. Rcmani, Ph.D. Ann Arbor I 1 I I I I I I F I L L L Michael R. Spaniolo, General Council Michigan Tobacco Industry Advisory Ccuncil Tobacco Institute Tobacco Tax Council George L. Voorhis, EYecutive Assistant Michigan Bell Telephcne Lans ing Raymond G. Gonczy,-Governmental Affairs yanager General Telephcne Company of Michigan ;tiius kegon Mark Sciculuna, President Redford Township Chamber of Coiranerce Organizations The Society of Public Health Education Great Lakes Chapter -130-

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i I d I I I Private Citi_ens .Ubert :ack Far;rwzgton Hills Mrs. Steve Kish, Sr. Caro Laurel L. Bocne idland M A Ncn-Smcker Sault Ste. Nfarie Sharon Moore Beaverton Dick and Louanne Soczek St. Ignace Mrs. Arthur Ketelhut Garden City Sharon S. Wonn Sault Ste. Marie Susan Hansen Kalamazoo Those Who Have Testified But Have Not Submitted a written Statement I I i I I I Honorable George Cushingberry, Jr. Michigan State Representative Lansing Herbert E. Kipke Lansing Honorable Harry A. DeMaso Michigan State Senator Lansing R. J. Ritzenthaler, Chief Cardiological/Respiratory Department Sturgis Hospital Sturgis -131-

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I I I i I I I I F 25291 Wykeshire Road Farmington, Hills 48013 August 8, 1980 Mr. Sunny Sun Nai Fong Michigan Department of Public Health Office of Health Education 3500 N. Logan Street Box 30035 Lansing, Michigan 48909 Dear Mr. Fong: I am submitting the following statement which I hope you will share with the Citizens' Panel on Smoking and Health which was appointed by Governor Milliken for the purpose of soliciting recommendations on how to reduce tobacco related disabilities. I am a high school principal with some 15 years in this position in the school districts of Detroit and Livonia. I am a member of the Board of Directors of the Wayne County Chapter of the American Cancer Society and I served for many years as a member of the Wayne County Council on Smoking and Health. I strongly urge the members of the committee to support the recommendations made in Senate Bill #388 as originally introduced by Senator Robert Geake. This bill would have banned smoking in all public schools and on public school property by all persons - board of education members, parents, superintendents, principals, teachers, support staff and students. Both the office of the United States Department of Health, Education and Welfare as well as the Surgeon General of the United States have recognized that preventive education is the most valuable way to protect our young from the pernicious effects of smoking and the seductive and beguiling influence of tobacco advertising. As long as smoking is permitted in the school setting, any preventive education program regarding the adverse effect of smoking will be largely unsuccessful and well meaning efforts to teach the full meaning of the warning which is written on every package of cigarettes will be undermined. When we permit smoking by anyone in the school setting, we mortgage our credibility because we are telling children "Do as I say and not as I do". Navy Surgeon General Willard P. Arentzen has stated what is perhaps the most cogent reason to justify such legislation. "We must not only recognize that tobacco smoking is harmful, but must behave in a manner consistent with the knowledge that smoking is a health hazard." Senate Bill #388, as oriainally introduced, would make it easier for school personnel to enforce smoking prohibitions in the school setting where peer influence is so comoelling. The message to students is that "No one smokes here - neither principal, secreta ry, custodian, parent nor student." -132- 1 ~

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I Those adults who elect to work in the school setting with children have a unique obligation to set a personal example by not smoking on school premises. Legis-. lation which prohibits smoking in schools is no more a denial of civil liberties or work rights than comparable existing legislation which prohibits the drinking of alcohol on school property or which bans smoking in supermarkets. Neither is it an attack upon free choice or the free enterprise system. It is, instead,an effort to save lives and to counter in our schools the influence of cigarette promotion which portrays smoking as a glamorous activity. I understand that Senate Bill #388 was amended to allow approved smoking areas for staff because of the intervention of the Michigan Education Association. it is regretm ble that the media failed to appropriately publicize this action which in effect emasculated the intent of the bill. The public has a right to know when legislation to protect the health of children is compromised by a special interest lobby. I am bothered also by the absence of concern on the part of local, state and national leadership of PTA with regard to the influence of smoking on the health of children. I was heartened by their commendable concern about excessive vio- lence on TV and its effect upon children. The violence to children who fall victim to the seductive advertising of the tobacco industry, however, is an even more ominous threat to the safety of'children and is equally deserving of protest and calls for corrective action by the PTA. Without an overall cortmitment to prohibit all smoking in the school setting, the preventive education efforts of school programs to teach about the dangers of smoking will be compromised. Research tells us that young people are more afraid of being rejected by their friends than of losing years of their lives. Approved smoking areas for students stimulate peer pressure to smoke and foster the sale and use of Illegal drugs. Staff members who smoke in the school setting separate themselves from the problem and their absence of commitment mocks the integrity of the school's health education Instruction. This anomaly Is perceived by even. little children. The State of Arizona has already acted with courageous responsibility on behalf of the safety of its children by banning smoking on public school property. Can we do less for our own children? Approved smoking areas for staff and students, like the ever present ash tray, give license to the practice and conceal the i ns id i ous dangers 4rh i ch attend. Very truly yours, ~. _ _ . Albert Zack AZ/mb cc: Senator Robert Geake I I I I I E I L L -133-

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I I P I I I L L L Adolescence is a time when individuals first begin to make decisions that have lifelong consequences. One of these decisions for many young people is whether or not to smoke cigarettes. Those of us who are deeply concerned and involved with youths need to be aware that we can have an impact on that decision--through the programs we provide, the policies we institute and the interpersonal relationships we cultivate with young people. Preventing adolescents from smoking before they begin involves a more comprehensive effort than the traditional "scare tactic" approach. Adolescence is a time for trying on new behaviors and taking new risks. "Scare tactics" may serve to challenge and tempt the very young people we aim to convince. Richard I. Evens of the University of Houston talked about the inaopropriateness of traditional approaches for young people: "Anti-smoking messages focus too much on the futu:-e dangers. Children are more likely to focus on the present."1 Evens, citing two other studies aimed at finding out what works and what doesn't work in anti- sinokino campaigns, concluded that no-smoking messages were more effective when they included students themselves showing how to say no to peer pressures to smoke than when they employed the use of authority figure adults presenting high fear arousal messages. Smoking prevention can be appropriately placed within the larger realm of substance abuse prevention. This view define$ a substance as any chemical th3t brings about physical, emotional or mental changes in a Statement sucmit'r.ed by Judy Ann Got':-CtaL-_ns, 4-H Ycuth Prograr,ts, August, 1980. -134-

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I A person. Abuse is the use of a chemical substance in such a way that it causes physical, mental or social harm to a person or to people close to him or her. Thus, smoking tobacco can be seen as substance abuse. The current prevention approaches to substance abuse which emphasize the development of life skills are appropriate as ap approach to smoking prevention, as well as being consistent with the goals and philosophy of the %iichigan 4-H - Youth Programs. The major goal of the Michigan 4-H - Youth Programs is to help young people become self-directing, productive, and contributing members of society. In order to achieve this goal, 4-H strives to assist both youths and volunteers in the acquisition of the following life skills: - learning how to learn, F f I I I I I I - relating to change, - using knowledge, and - developing self.2 The Michigan 4-H - Youth Programs'believes that a basic need of all human beings is to develop and enjoy caring relationships with others. There is a commitment to helping these relationships evolve into quality human interactions. This is accomplished by making it possible for volunteers to interact with youths on a continuing basis in a group setting. Primary prevention strategies are largely psycho-social, people- oriented approaches concerned with reducing the demand for the substance, in this case tobacco. The goals are to nurture and help a person grow and mature without reliance on chemical substancps. ] I I E ~ L ~ L .~

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i I I I i I I I L L L L The National Institute on Drug Abuse (NIDA) has developed a matrix for prevention that encompasses ~our catecories of activities: information, education, alternatives and early interrention. According to Lura Street Jackson, program advisor at the NIDA, a good comprehensive program includes all four types of activities.3 An elaboration of this matrix and an investigation of the current ?iichigan 4-H projects and programs serve to emphasize the consistency between the 4-H philosophy and the primary prevention model. Information--The first component described involves providing accurate and honest information. Information should be seen as an important adjunct to a good prevention program, but that information should not stand alone. Research studies have shown that factual data, widely used as the sole prevention tool in earlier years, frequently generated more curiosity in young people than wisdom."4 Yet, information appropriately targeted at specific audiences can be an important tool in smoking prevention. The dissemination of information is a basic component of 4-H in its linkage to the land-grant universities. 4-H continues to serve as an important means for extending the findings of the land-grant institution to the people, whether the research deals with improving interpersonal communication skills or the latest findings about smoking and health. The linkage with subject-matter expertise at the land-grant universities ensures that the 4-H agents and the people with whom they work will be kept up to date on the latest research. The university extends information into the home in the form of home visits, bulletins and radio or television programs.s _136-

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I Two current Michigan 4-H orojects are concerned d?:ectly with providing health information to 4-H members and to the public in general. Through Health Fairs and Health Awareness Teams, II-H members become personally involved in a variety of health topics, including smoking. Education--Education is seen by preventors today as a process that helps individuals develop the skills they need to help themselves. This education includes not only the development of the intellect, but attention to emotional development and opportunities for growth. The activities may include development of decision-making skills, values awareness, problem-solving, development of communication and inte:-personal skills, and career education and the development of knoKledge, skills and attitudes useful in the work place. An ii-inportant part of this component is the training of teachers and leaders in these skills. Through this system of trained volunteer leaders and small group settings, 4-H has many programs focused on just this aspect of education. For example, High On Myself is a program of self-inquiry and intergroup sharing and includes exercises in communication skills, values clarification, problem-solving skills, decision-making skills and stress reduction. Other examples include the Peer-Plus, Group Dynamite, Stress Connection and Starship Self programs. Informal evaluations have shown that 4-H is effective in improving difficult to measure hunan resource attributes of self-esteem, confidence and the ability to cope with stress.6 I I I I I I I I t L L -137-

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I I I I I I Alternatives--The strategy of this component is to provide experiences where young people can develop the positive skills and feelings t'.:ey need to become mature people. These programs should furnish ooportsnities that provide adventure, involvement, open and direct communications with others, creativity, or the sense of accomplishment and personal potency that comes from being able to control or change one's environment. Michigan 4-H - Youth Programs is a perfect example of a community program that can provide these kinds of challenges. 4-H provides opportunities for youths to experience success. Khether through completing a tie-dye project in African Cultural Heritage, growing vegetables, nego- tiating a bicycle safety course, or chairing a meeting, 4-H can help counteract the feelings of hopelessness and disappointment often prevalent among some of today's youths. Early Intervention--Early intervention involves giving support to young people during the crises of growing up. Adolescence is the time for growing up, and the target audience for 4-H is youths aged 9 to 18. Reaching out toward special groups, including multicultural groups, ethnic minorities, handicapper youths and rural and urban groups, 4-H recognizes the diversity of the youth population and the multitude of crises that growing up can present. The National Institute of Drug Abuse has found that the most significant aspect of any program attempting to prevent substance abuse is that the program involve both.youths and adults, with adults doing things with kids, not for or to them.

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I Thus it see:is that the Michigrn -':outh Programs u;.d the primary prevention model of smoking prevention share a common outlook toward youths. In particular, 4-H and the ;lIDAsupport the following objectives: - Improving decision-making skills - Improving co,:,.munication and interrersonal relationships - Improving health habits and health education - Providing appropriate role models for youths - Encouraging the young to respect themselves - Releasing the imagination, curiosity, creativity, and compassion that are natural expressions of young people Identifying the resources of our cocrnunities--knowledge, skills, generations, heritages, and cultures--to create a strong and cohesive environnent.I Young people who have developed effective communication and decision- making skills are those who will be most likely to seek out information and use that information to make wise decisions regarding smoking and health. Giving young people the kinds of attention and experiences can help them to grow up will have positive lifelong consequences. that I I I I I J I I L L L L -139-

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I I I I I I I I 1Richard I. Evens, "Tobacco," D rsg Uodate. Vol. 1, No. 2, September 1973. 2From the Michigan 4-H - Youth Programs Mission Statement. 'Lura Street Jackson, "Some Promising Strategies and Models in Prevention Programming," a paper presented at the Seventh International Congress on the Prevention and Treatment of Drug Dependence, Lisbon, Portugal, October 18, 1977. 4Ibid. SAbigail Sanborn, "4-H: A SVise Investment of Our Tax Dollars," %,tichigan 4-H - Youth Programs, 1979. 6Ibid. 7Drug Abuse Prevention, National Institue on Drug Abuse, 1973, DHEW Publication `o. (ADM) 78-586. -140-

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Au-,:st _ +, My name is June Asselin and I am the Education Coord:nator with the Michigan Dental Association. The ".;chigan Dental Association is the professional representat_ve bedy for dent_str,/ ir. Michigan. As dental care is essential to teta'_ bcdy :,rell-beinh, the MDA has worked diligently to provide health education for the public and has a compelling interest in oral health. Consecuently, I am here today to testify in support of anti-smoking legislation, anti-smoking education, and any other measures to recuce or elimi- nate tobacco use. The relationship between tobacco use and cancer has ieen amply documnented. The use of tobacco, both in s^io;ci::^ and chewinh, is attended by an increased risk of ccntracting cancer in the oral cavity and surrounding tissues. The various forms of carcinoma associated with the smoking and/or chewing o.` tobacco present a disease state which has a disappointingly low cure rate, given the fact that oral cancer often grows insidiouslv until gross defor^:- ities demand a late recognition. Once oral cancer is diagnosed, sur,aica: procedures are often necessary. These procedures can result in severe disfigurement of the head and neck area. Such patients can be unable to resume prior eccupational and social activity. The resultant cost to society and to the individual is crippling, though difficult to measure. Concerned with the prevention of oral cancer, the uDA Board of Trustees recommended a rigorous educational program for both the public and the dental profession by passing resolutions for its members to: 1. Set an example by not smoking; 2. Encourage patients not to smoke; 3. Discourage the sale of smoking tobacco in public b ildi 4. u ngs ; Encour age the establishment cf .^.cn-smeki.^.g areas 5. in public; Encourage and all members of the health team, as well as the public, not to smoke. Further, the use of smoking tobacco has been prohibited at all of ficial meetings of the Xichigan Denta'_ Asseciation. Most recently, the MDA Committee on Cancer Control, Vcspital and InstitLa_Cnal Dental Services sDOnsoreC, :n cooDeratlon with the A-mer_can Cancer Society, an oral cancer symposium for metical and dental professionals. The 250 partici^a::-s were alerted to diag:,ostic indicators of oral cancer as we_; as current treatmen~ -:odalities. I I I I I I p I ~ L ..,-)1, , . -_ ~ i, MICHIGAN DENTAL ASSOCIATION -141- L

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I I I I I I I I L L L L ^ee oral cancer screenings _c-r _ne oub~_c ^ave a_so --een o::ered by soc_et=es o_ 7^E ~^.~. S:att-(J_'Z?. e sCre?.^.iaos have _deni.i=ie'.j cases O: rai CaP.cEr a5 'r1L'-1'_ dc- Crovided Cn-the-57o-, ^d_innt Ed::cat_Cn to hundreds OC DeOC_°_ '"he `"ichir.an Der.tal Assoc:atior, reaf f:rms ~`s res,-:ve to educate `iichi'gan residents regarding the cancer-causin~,, potential of tobacco use. Fu-.ure hope for oral cancer control rests pri- mari'_y upon public and Drofessional awareness, early datec_icn and preveP.tion. IoreRiost in prevent_oZ is °_l:mi.^.atioa of the known hazard, tobacco use. The MDA urges the Citizens Panel on Sr.,or.;nE and Health to ;.^.form the public that smoking eliminates health. cmb -142- ~ `

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~r91t~-~i~~Fii~ tt,ri D1S; i;ia; s i-lcr;:.': i~ uc:' . t; r.7~ Gi c CLINTON GRATIOT MONTCAL:.1 MAIN OFFICE Cf .. . D~a~ _. D STAN-Ori, .. -..:5 . .- .. , ..-- . ~a.^_. . . . .:a17 ,...-oW, V.lcP+.:cG!a 22rIiv5 a75-S6a1 9J1s779 A. We support the cor.cept of an ear^_arked c;garette "health tax" to be used for anti-saoking pron-rams. B. The earmar:{ed funds should be used for scokirg deterrence and smoking cessaticn protrams. C. A specific state agency should be respor.sible for the management c: the revenues generated by the "health ta.:" D. We believe that the Office of Healta Education of the Michig^n Department of Pablie Hea lth should be specifically naxed as the body responsible for the management of "health tax" revenues. 1. MRndate of the Public Health Code, for health eciuca tion resporsiblity 2. Office of Health Education is already the cozrdinr*.:ng agency for Health Education 4:sk Reduction pr ogra m'_^.g for the state. Sincerely, Ni11iam E. -:'h-r, hID, Y2q bSedical Director, 14id-Michigan District Health Deperr.:.an t. -143- I F U I r1 I I r I- L I- 17

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michi~an health council SUITE 340. NISBET BUILDING. 1407 S. HARRISON ROAD EAST LANSiNG. MICHIGAN 48823 Telephane: Area Cdde 517, 337-1615 I I i u L I L L September 3, 1980 The Michigan Healt-h Council advocates NOT SMOKING as a good health practice. Since 1939, numerous scientific studies have been conducted to deteraine whether smoking is a health hazard. It has been well documented that cigarette smoking is a major cause of: emphysema, chronic bronchitis, lung cancer, and heart disease. According to the American Lung Association, each year an estimated 300,000 Americans die prematurely from the effects of smoking. As a result, cigarette smoking accounts for an estimated $5-8 billion in direct health care expense. Indirect costs incurred through lost productivity and absenteeism account for another $12-18 billion. Smoking just one cigarette can: increase heartbeat and blood pressure, upset blood and air flow in the lungs, and cause a drop in the skin tempera- ture of fingers and toes. Pregnant women who smoke are taking an even greater risk. They have more still-born births, spontaneous abortions, and low-weight babies than do non-smokir.g mothers. Indirect health hazards as a result of smoking include: fire, interference with safe driving, and second-hand smoke. Inhaling second-hand smoke increases the blood pressure and the level of carbon monoxide in the body. Research has documented that lung illness is twice as common in young children whose parents smoke at home, compared to those with non-smoking parents. Large doses of cadmium, which is present in smoke that drifts off the bu_^iinq end of a cigarette, has been linked to hypertension, chronic bronchitis, and emphysema. Finally, an estimated 2 million Americans are sensitive to tobacco smoke and suffer smoke-caused asthma attacks. The Michigan Health Council recognizes that cigarette smoking is a serious health risk and pledges to help educate the public and promote NOT SMOKING as a good health practice. -144-

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I AFFILIATED WITH AMERICAN SCHOOL HEALTH ASSOCIATION SMOKLNC A.VD tiL:.1L'.1! Testimony given SepteWber 11, 1900 by Don Sweeney, President Michigan School Health association "any of us who seek to inform, motivate and modify the behavior of the general public have looked for the point of least resistance with maximum impact and have consequently gone to school systems. For this reason, they are being inundated with very worthwhile and reievant health issues. Smoking, as a major health threat, is receiving increasing recognition by school health educators. I would encourage your group to avoid the searching-out of single issue solutions and look to a format of compre- hensive school health programming. This includes curriculum, services, and environment in a sequential planned learning process. It is essential to avoid scare tar,tics;_similar short-term motivators; and to instead, stress concepts dealing with individuals making informed decisions about their own health. Educational techniques dealing with attitudes and values need to be incorporated into program plans. By working togtther, looking for com- mon issues, and promoting comprehensive school health education, we can I I I ~ I I maximize our resources and long-term impact. If we compete for the limited ~ time, attention, and interest of school systems, the result can only be ~ chaos. By working together, we have a chance to improve health and promote healthy living. / The Michigan School Health Association is anxious to work with you on C11 all areas that affect the health of school-age children in our state. L t0 Thank you for the opportunity to present these issues for your consider- CD M+ ation. L L I-

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I I A POSITION PAPER PRESENTED TO THE CITIZENS PANEL O;r S:!0?:I:,G AND HEALTH FRO:! THE SOCIETY FOR PUBLIC HEALTH EDUCATION GREAT LAKES CHAPTER t I I- The Society for Public Health Education, Great Lakes Chapter, totally supports comprehensive smoking education programs in both the school and cocrosunity settings. We support a unified planned program of instruction with scope, sequence, progression and continuity. The program should include but not be limited to education regarding immediate and future effects of smoking, advertising techniques, consumer awareness, rights of non smokers, legal considerations and value clarification techniques. Initially, smoking cessation clinics may also be an appropriate and needed part of the curriculum. We urge comprehensive and unified evaluation so research concerning superior and appropriate teaching techniques and methodologies can be recognized. We also feel strongly that the rights of the non smoker be examined and discussed to bring smokers and non smokers to a better degree of understanding. The proper setting for a smoking education curriculum is within a total com- prehensive health curriculum which can be implemented in both school and community education programs. We urge that local public health departments be used as a focal point for coordination of these community education programs. The purpose of that curriculum is to promote positive health and wellness achieveable only through positive health behavior. Health Education promotes a lifestyle and the positive health choices which allows an individual to achieve maximum physical and mental well being. Smoking is in opposition to this philosophy. We therefore support smoking education programs within a comprehensive health L education program and urge the conmittee establish this as the top priority and cr Ul 0~ take the necessary action, united with public and voluntary health agencies, to in- ~ sure the existence of this program. ~ N -146-

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(313) 764-3473 Undergraduates (313) 764-1342 Craduates I I I MEMOFANDUM ,~ Oepartment of Physirrl Education 401 Washtenaw Avenue Ann Arbor, htichigan 48109 September 30, 1980 To: -Mr. Sunny Fong Office of Health Education Michigan Department of Public Health 3500 N-Logan P.O-. Box 30035 Lansing, Michigan 48909 From: Stephen T. Galetti - Associate Professor of Physical Education University of Michigan Chairperson, Michigan Council on Physical Fitness and Health Subject: A personal statement relative to the relationship of smoking to health for Michigan citizens I wish to begin my statement by commending Governor Milliken for the establishment of a Citizen's Panel on Smoking and Health. The leadership he is providing will enable many concerned citizens to vent their concern with a problem that not only affects the health and well-being of those who participate as smokers, but also prevents non-smokers from being exposed to a form of air pollution that hinders their right for a quality environment. Ever since the initial report provided by the Surgeon General's office concerning the potential effects of cigarette smoking, many groups have initiated action to both alert the public to these potential problems and to successfully promote legislation to protect the non-smokers right to a quality environment. In my opinion, the research is clear as to the potential harm all forms of smoking provide to its participants. I am also aware of the efforts of the tabacco industry and their supporters who challenge much of the research of the anti-smoking coalition. I do not wish to dwell on this issue, although I consider it of vital im portanc e , I I I i I I L -147-

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I I I I n I I I I I I L L September 30, 1980 Memo to: Fong Page -Ir 2 I wish to instead speak to the effect that smoking has on those who prefer not to take part. In my professional capacity I attend many meetings which require attendance of at least two consecutive hours. In most cases these meetings take place indoors in rooms that accommodate from 5 to 15 people. I am amazed at the number of people who still are inconsiderate of the rights and well-being of others by their use of cigars, pipes, or cigarettes . It further saddens me when a vote may be taken and that majority rule dictates the quality of the environment. &1; C,~. ;-z r The ei=64sn of individuals to threaten their own well-being by smoking frightens me, but the failure to recognize the rights of others angers me. I sincerely hope that the Citizen's Panel on Smoking and Health will recommend appropriate action to forbid smoking of any type in all public and private enclosures that service the citizens of Michigan. I further urge the panel to recommend appropriate punitive action to those who fail to comply. - Our society accepts the fact that over-parking by citizens be punishable by a monetary penalty levied to the offender, yet we pay little concern to individuals who impose on the health and well-being of others. The mission of the Citizen's Panel is clearly one of protecting the well-being of all Michigan citizens. I will eagerly be awaiting the recommendations of the panel and the actions taken on those recommendations. -148-

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I 1521 W. CHISHOLSA STREET WEST COUNTY ANNEX BUILDING ALPENA, MICHIGAN 49707 ALPENA, MICHIGAN 49707 PHONE: 15171 356-4507 October 2, 1980 Sunny Fong, Chief Office of Health Education Michigan Department of Public Health 3500 North Logan, P.O. Box 30035 Lansing, Michigan 48909 Dear Sunny: C.ntrai Office ALPENA 8rancn Offices Fiogerf CiN Atlanta Ch.poyqan I am writing- to express my written opinion in regards to the Smoking and Health Public Hearing. First of all, I feel that we as health professionals recognize the costs of tobacco-related illnesses and death to our society. We work with people who have contracted lung and heart disease because of smoking. We work with statistics which show the tremendous burden smoking causes our society today. With these thoughts in mind we need to greatly expand our roles to meet this problem. It is important, especially in today's world, that we carefully consider directions to take in reducing this problem. Hopefully this hearing will play a beginning role. In view of tabacco's addictive effects, both psychological and physical, regulatory controls such as expansion of current laws, strict control of vending machines are not going to be the answer. People who smoke will not take increased controls lightly. It is one thing to permit smoking and non- smoking sections, but is another to entirely ban smoking in public places. There is a feeling in this country today that we are being over-regulated. I fear that these actions would only fuel the argument and damage current laws. In my opinion, current regulations are satisfactory. I am also against increased cigarette taxes, such taxes;will not have a major impact on the reduction of cigarette smoking; will cause additional strains on our low-income population; will increase "racketeering" of cigar- ettes, thus reducing revenue from current taxes, etc. Americans have always rebelled against anything they felt as unjust. Increased taxes and increased regulations are not in my opinion worth the risk to implement for the small gain they may accomplish. Positive reinforcement efforts such as insurance advantages could have a major impact. Common psychological theory always states that positive reinforcement methods have a greater impact than.do negative reinforcement or punishment. These types of programs need to be identified, expanded and publicized. Based upon our economic system people will reduce or quit entirely if the incentives are great enough. -149- DISTRICT HEALTH DEPARTMENT NO. 4 I I I I I I I I I L L 1 -

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I F F I I I I I Page-2 October 2, 1980 Sunny Fong, Chief Office of. Health Education Education is definitely the most efficient way to reduce tobacco consumption. People smoke because of education efforts by the tobacco companies publiciz- ing the "rewards" of smoking. They are successful because of the money they can put into-their 'education" programs. Health agencies such as, local health department's, American Lung Association, and the American Cancer Society must consolidate and coordinate their efforts to combat this problem. Increased funding sources need to be identified. Public health should receive a major portion of the cigarette tax to be put directly in anti- smoking programs. . In summation, we have made gains in the past ten years in the reduction of the tobacco-consumption rate. In'every category (except teenage females) we have seen a significant reduction in smoking. There is still a long way to go. Additional programs have to be'carefully thought out. We must not jeopardize accomplishments gained. These opinions represent my own views and as such may not represent our departments policy. Sincerely, George F. Sedlacek, Jr. Health Education Coordinator I- I- 1 L L GFS:ca cc: Brian Youngs, M.D., Medical Director -150- :Ea+~'3f - . 7.- .

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Michigan Bell George L Voortvs 221 N. Wasnnc,ton Avrw,e Eyecurne Asuvartt Lansn9. titicn5an 48914 Phone 15171372-n70 Phone(313)223-~85 October 2, 1980 Mr. Sunny Fong Department of Public Health P.O. Box 30035 Lansing, MI 48909- Dear Mr. Fong: -We have followed, with great interest, the Governor's Panel on Smoking and Health, and the proposed language for a "Clean Air Act" as possible legislation. I would like to take the opportunity at this early date to ex- press some of our concerns and opposition to such a proposal. It's not too unlike the language of SB 263 introduced during the current legislative session, which we also opposed for basically the following reasons. As the fourth largest employer in Michigan, with approximately 30,000 employees, Michigan Bell is also the largest non-government real estate owner or operator in the state with over 800 individual buildings which would have to be altered or adapted to accommodate the demands of such an act. At a time when business and industry is already being stifled, it seems most inappropriate that such a proposal would be considered, in view of the confiscatory nature and the prohibitive costs to both business and government of implementing it. Over and above the obvious objection of cost to the public and private sector and the growth in bureaucracy, there are the more subtle and less obvious problems of employee morale, civil rights implications, and the fact that such drastic change in working conditions could not be affected by most employers without union negotiations. The air change and purity standards of this proposal could also be a set back to the energy conservation program of many employers who presently do more air recycling, rather than constantly heating or cooling outside air. I I I I I I I a L L L L L

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r I F I I We feel in these times of rising costs, this proposal would place another expensive burden on utility customers who would bear the cost of modi- fication and renovation of building space. It's also unlikely that the tax- payers of Michigan are able or even willing to pay the tab for alterations of government work locations and the costly enforcement needed. There is no doubt that the problem your panel has addressed is of real concern to many of us and your effort and intentions are most honorable. We would, however, join many others in opposing any effort at such restrictive legislation, which is well, intentioned, but ill conceived. We would hope that the panel would reevaluate the tentative recom- mendation and examine other and more practical means (possibly public education) of addressing this problem. Sincerely, I I L L G. ,L. Voorhis Exicu{ive Assistant -152-

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INTCRNAL M [DIC1N[ 1!O tA/T 7RAMO IV[ AV(NU[ LAN0IMQ. YICMIGAM 4.I1 October 3, 1980 Sunny Fong Office of Health Education Michigan Department of Public Health 3500 N. Logan P. 0. Box 30035 Lansing, Michigan 48909 .A.C.P. . 31) 403101 Re: Citizens Panel on Smoking and Health Dear Mr. FonQ: For the report of the Panel to the Governor, I hope you will consider recommendation of the following measures: 1. Significantly increase the State tax on tobacco. This will have to be done, of course, in cooper- ation with neighboring states in order to reduce boot legging. Studies have repeatedly shown that any rise in the cost of cigarettes results in a decline in the numbers of smokers. 2. Promote insurance premium reductions for non- smokers for accident, fire, life and health policies. 3.a.Abolish sales of cigarettes in vending machines: b.Enforce the law governing sale of tobacco to minors. 4. Prohibit smoking in hospitals and on R-12 school grounds. 5. Publicize the work records of non-smokers vs. smokers as an inducement to give preference in hiring to non- smokers. Since only a third of adults smoke, it seems politically feasible to legislate in favor of the majority. At present, economic sanctions against smoking appear to have the best chance of reducing the problem still further. It should be noted that smoking is no longer a significant problem among the educated upper class, so that your efforts should be directed toward the lower and lower middle classes, many of whom do not become in- formed through written materials. _153- . K . R I C H A R D C. S A T E S. M. D.. F I I I I I I I j j I I p L L L L

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I I Sincerely, \ Richard C. Bates, M.D. I I L L L Page 2 I do not favor the promotion of low-tar, low-nicotine cigarettes as a partial solution to the problem because it appears to provide many smokers with a false sense of security and hence to provide them a defense against smoking cessation. RCB:cs .J L

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I JOSEPH ARENDS, M. D. H1ORlSlONAL CO1IP-O/IATION 1331 W[sT BIG B£AV£R ROAD ROSCRTA MUILfN! TROY. MICHIGAN 48084 RUTH LIWIf (APrOlNrNCNTrr) STEPHANIE GOODRtCH = _ October 3, 1980 Sunny Fong Office of Health Education Michigan Department of Public Health 3500 N. Logan P.O. Box 30035 Lansing, 141 48909 Dear Governor: (313) 643.7770 The single greatest impact that can be brought to bear upon tobacco usage by the public is to socially ostracize smoking. As chewing tobacco and spitting were ostracized 75 years ago because of Tuberculosis, so too can smoking be ostracized as a socially unacceptable act. This can be accomplished by prohibiting smoking in all public buildings, all restuarants, sporting events, schools, hospitals and any means of public conveyance. I personally do not care if some other person wants to commit suicide through smoking, but I take a great deal of offense in inhaling the toxins and cancer of some other person. My rights as a nonsmoker are being obstructed and I vehemently oppose the economic interests of certain busi- nesses promoters who will not even enforce those regulations already on the books. Sitting in the Pontiac Silverdome is an exercise in futility. Although the regulation is to smoke only under the stands, the rule is not enforced and the atmosphere is absolutely intolerable. Not only do your eyes burn, your breathing become labored and pose a threat to cardiac patients and asthmatics but your clothes stink for three days. It is not fair that a minority of the population (25%) should inflict their self abuse and unpleasant behavior upon others. By making smoking socially unacceptable we will deliver the greatest blow to the tobacco industry. The tobacco industry is keenly aware of this problem and spends as many dollars as possible to counteract this effort. It must be recognized that we will hurt the tobacco industry if this campaign is carried forward, but these people will still survive and the overall benefit to our people is a higher priority. Sincerely, ,~.A) - Josepti Arends, M.D. JA/ck -155- I I I I I I I I I I I- p t I E L L .:r::-

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I I I I I I I I 1 i I " :. , ~ v tj ~`r ASHT~.NAV`! CCUNTY ..LTn ~` ?AR1'M cNT 4701 .Jasncenaw acaa P.C. 3oa 9E~5 .;rn ar~or. ... n qan s3t07 OIaEZ'2 a .O/'r '3. ?LNa:@r . D. ,;r. P M. cc'~...cber 3, 1980 Sunny Fong, Chief Office of Health Education tlichican DeT~nt of Public Eealth 350o horth Logan Street P.O. 30035 LansiZ g, Michigan 48909 FE: SmOking and Health - Attention Public hearing calling the Gove_-nor's Citizens Panel Dear Simny : Sr'r:lcing, acoordizg _ to the 1979 Surqeon General' s ReDort on Health Pramcticn and Disease Prevention, is the larcest single preventable cause of illness and premature death. C.igarette sm.kers have a 70% greater rate of death frcm all causes than non- smkers. g*nki.g is the leading cause of lung cancer; the chance of a sinker developing lung cancer is lox greater than that of a r.on-sroker. Smcking is an i-7portant factor in death frncn heart disease, is the chief cause of c.'~xnnic bzr;nchitis, cOntributes to merbidity fran egphysema and has been related to increased sic'a-ess and absenteeism. Besides the direct effects on the snnker's own personal health, smcking also affects others, incltxiing the unborn fetus. 9mking mothPxs have babies with a higher in- cidence of prematurity, small stature, lower I.4., greater inciCence of respiratory i.llr%--ss, and respiratory death in the first year of life. And 27% of girls betsreen t~e ages of 13 and 17 - of child bearing age - now snoke as carvared to 22% 10 years agv. 40 $ of tt^.ese f emales szrJke 1 pack per day, whe_*eas only 10 $ smcked this nnych 10 years ago. Izrpressicnab.le children see parents, older siblings, and other admi-red adults smeke, and i.-nita},.e tt,.e*n because "srcking makes me look gncrAn-up. " Or.e of 20 5th graders s:nkes , while by 7th grade, 1 of 5 snokes . The rate increases by high school to in- clude 1 of 3 teenacess. Non-smcke_-s are also adversely affected by sroking. Several hazardous c'ie:.nical can- actmds are found in tcbacco and released when tobacco bu...*s. Tobacco &Tcke enters the at:rms:a^.e.re_e f~n 2 sour~+s : the bu=uuig end of the cigarette/cigar/pipe and the s:,nke i*z~,-iled and t'^.en exnaled by the smak.er h:..~rself. St,:dies have shown that the s:mke -156- ~

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I Ccn't 2 frcm the burning end, sidestream ~cke, has Iiict:er ccnce.^tr3ticns of r.oxict:s ca-,xunc's than t~e mainstream smoke inhaled bv the s:noker! Because of the adverse effects of smcking on all rie-Ti~ers of the local pcoulaticn, s:nokers and non-sinokers, children and adults ali}:e, t' :e washtenaw Countv !:ea' th Depart-ent stTports the proposal to increase health educaticn efforts in schools and hospitaLs so that the decision to s:ricke or not smoke can be made intelligently with full uidezstar.ding of the hazards involved. Because educaticnal prograazs have enjc only 1im:ted success in the past, this N.ealth Department also str=.~ports the use of iinancia.l incentives to c:iseourage people fr= =Ici.r.g. Possible aw ..errr.^ts include increasing cigarette taxes and offering insurance advantages to non-ssnkers. Of ncte is the American Cancer Society' s"n^.e Great American Sneke-Out," a one-day program encouraging a day's respite :zom smcking. Our cepartment cxnsiders this a project wt>rthy of our own and the general public's support and participation. In sLammsy, c.e strongly sta.~port, in the interest of general heah th and crell-being, the control of public exposure to the pzcarotion, sale and smcJciu:g of cigarettes and other tabacoo products. I I I I J I I I L -157-

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I q Detroit Depar,ment oi Heeltn Soutneastern micniqan Heaitn Asscration Untted Community Serv ces of Ltetropoiitan Cetrcrt Herman Kiefer Healtfl Complex 1151 Taylor - 2nd F!oor, Pav. 6 Detroit, Micnigan »82G2 (313) 876-4713 DETROIT HYPERTENSION CONTROL PROGRAM I i I I I I I Citizens' Panel on Smoking and Health STATE= The reduction and prevention of tobacco-related illness and death can only happen from the reduction in the number of cigarettes smoked. The issue is one of supply and demand. I will defend the right of any mature adult, who is well-informed as to the effects of cigarette smoke, to choose to smoke. However, the costs to society in general that result from illnesses related to this behavior should be fully borne by this group. Additional medical costs, etc. should be reflected in a direct tax upon thiS commodity. Additional insurance costs, etc. should also be reflected in the tax on cigarettes. There shoul.d be an immediate withdrawal of any government subsidy to any aspects of tobacco growth and manufacture. The resultant increased costs would serve to limit demand by potential users. The supply of cigarettes should be severely regulated, much like alcohol, to the population deemed to be adult (18? 21?). Removal of cigarette vending machines, strong enforcement of existing restrictive laws, etc. should be vigorously pursued. Finally, the rights of the non-smoker should be clearly stated and defended. As the rights of the smoker are defined as personal liberty and freedom of choice, so too should the non-smoker be able to choose clean air at all times. This should apply to all public places, public events, and the work place. Recent medical evidence of the hazards to non-smokers from smoke contaminated air is such that the rights of non-smokers should be guaranteed. I William A. Saville, Ph.D. Project Director -L8-

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-159- .~Lt~L?ja+ :-aGC G, L c2i =e~C ~-L~ I I i I I I I I I I t ~ L L L

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I I i i I I I I I I I- I I I I -160- ~-~...~ .

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t'Yiichigan Manufacturers association 124 East Kalamama Street PRESIOEMT 1N.aTMMf nCf nRESTDElITJSFCRETARY tU.. rt. la..rl.e+r CwuawAX ~r~~ .reeloot VICE CUAIRMaN rwr L MMCMn Lem ~r u TREASURER Ala. o. IL.das.. Toudn Rlas & Co. Detroit DIRECTORS TMwn w. Cllu TM 'Mleta CorP. U9l+nwr a,.tr.C.re.Jr. Frwnw+ Cmv. o.ao+t bwt L oast! fooQYMr Tln a RuaOet ~ t Ift" A.Dip" Cl.ct Eaa~wnac co. wew.. 1M~ M. ev~R c~rana wow. CUM 0 1 WI prodWIS MWSMu tl [!pr L Mtyen soon. mc. U21111119 CMrts Q. NMNap Tnaowti Cor9oratlon Holhad Ala 0. U.. Tonaie Uma a CIL Detroit ni ClealGAfh I G~~ Kor S"up I= W. R L~ oo~w+ a tanusae Co. Detroit ....rt r. wsau C.n«a/ 1lofaa corv. Detroit TMQwfi~bs. t~ Kawsooo WHOsin L MeMbf GrO.r rtoaYOO Co. iruno.t ~orlaoou~ ~ ror ~~ ~ l'iti S~. Ira Me.aW IWMft % NRalre map.o" umavl.r, I= uUMMa ,w i Ihpl Rm. Ilolr. ino. Da7at w~bit P Mutua1I ~ [~ I. itla" fa1N Powv CaN. YoiR~os Ford MatDr COapary OqfOof% 1MA t. TMrb Mknipe Mfn.futahrf daoef+tla. Lamlet Lansing. Mfchigan 48933 Pfione: Area Code 517 372-5900 October 3, 1980 Mr. Sunny Fong Office of Health Education Michigan Department of Public Health 3500 N. Logan (P0 8ox-30035) Lansing, Michigan 48909 - Dear Mr. Fong: Michigan manufacturers are now doing business in a serio.usly flawed state business climate, face soaring costs, and are looking for markets in a depressed economy. Given these conditions, aside from any personal views on the issue of smoking in public places, our businesses simply cannot absorb any additional costs of doing business in this State; and, therefore, strongly oppose efforts of the Citizens Panel on Smoking and Health that support a program such as contained in the so-called-"Clean Air Act". It is my understanding that the Panel will include a copy of a "Clean Air Act" in its report--similar to those introduced in the past, which were opposed by MMA--as an "illustration" of the type of legislation supported by the Panel. Therefore, the Michigan Manufacturers Association would like to have this letter filed as a part of the public record at the October 8, 1980 hearing of the Panel. The MMA does not oppose voluntary and state-assisted efforts to educate employees on any possible health hazards resulting from smoking. However, provisions of the proposed "Clean Air Act" which force major shifts of a work force or renovations of physical facilities to accommodate non-smokers are an impractical and costly burden to place on Michigan employers. Richard E. Augenste'in Director of Government Affairs F I I I I I I t ~ -161-

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r F I r i I I I I I I I- L LAUREL L. BOONE 213 EAST MEADOwBROCK DRIVE MIDLAND. MICHIGAN 48640 October 4, 1980 Sunny Fong, Chief Office of Health Education MichiQan Department of Public Health 3500 North Logan Street P.O. Box 30035 Lansing, Michigan 48909 Dear Sir/Madam: Please see that this statement is included in the record of the hearing held by the Governor's Citizens Panel on Smoking set for October 8, 1980, as I will be unable to attend the hearing. Tobacco smoke is a known carcinoFen and as such, very hazardous to the health of those who breathe smoke-filled air. There are state and federal regulations on various hazardous substances and tobacco smoke should be no ex- ception. There iss great need for regulation of tobacco smoke in the work place. Employers should be required to rovide smoke-free air for those employees and customers/clients who do not wish to breathe second hand smoke. It is in society's interest that persons become gain- fully employed. However it is intolerable that acceptance of employment often carries with it exposure to poisonous tobacco smoke. Employers could be given four alternatives : 1. No smoking whatsoever in the work place. 2. A separate area, away from common work areas (and with no air flow into work areas) in which employees would be required to do their smcking. 3. Strict segregation with physical barriers between smokers and non-smokers. 4. Powerful (certain capacity depending on size of work place) exhaust systems to carry smoke away. It is indeed tragic that many in our society are commit- ting suicide, slowly, by smoking. But perhaps it is an individual's right to harm himself. However no one has the right to poison others. This is a very serious matter effecting workers almost everywhere. But unlike many problems, something can and must be done to regulate tobacco smoke. Immediate attention at state and federal levels is necessary. ' A most unwilling victim of tobacco smoke poisoning who has not yet given up -~-`~C~C ~ M"rs. Jeffrey S. (Laurie) Boone -162- ' .~ .: ....~

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. L .~r 7 v ~ I I I- e!A4, 4- 1 Ls-n-~- . c:,} c,c c. ~ r--f -ctL 1I /J -71v ~ /.~ - - .r 1 /I I L ~ Z:,~ '- 1/ -_'--c 4;A..-_U- " -1fi3- 1 I I I L I- I-

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I F I F I I I I I I E I I L i L I , A L Lt"Ylrr..- A!' , . -~ .~ ~ ~. (' /, ~ ~ . , ~ . r k.coL ?-L hL/T 1 ~ ~ t ,J ' / ' ~ ~ f7 . ,~ ,-fa . -164-

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\ V ' ~((( ~ ~l- . fJ. I v 1}/1\O`. r r x , ~ `rl( ~7 C- . 4: -:*,~, C1- ~~ r r (R, . N Q J LT09~9S9

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I I I Sharon S. ::orz 3341 Laiceshore Zr 4ve Sault Ste. ;'.ar ie, 97;;3 I October 5, .-%0 I i I I I I L L Sunny :ong Chief, Office of Health Education State Health Department 3500 North Logan Str eet Lansing, ;tichigan RE: Governor's Citizen's Panel on Smoking and Health - In respor.se to Dr. Terrian's request for opinions and thoughts on smoking from Chippewa County residents, I would like to submit the following: As a nonsmoker with an allergy to tobacco smoke, my primary concern is the effect of second-hand smoke on the nonsmoker. As I am sure you are aware, medical evidence has shown that second-hand smoke can cause many ill effects on the nonsmoker. I would like to see strict control on smoking in public places, shopping areas, government agencys, restaurants - any area where a nonsmoker's right to treathe reasonably clean air is being violated. I work in an office where the nonsmokers out number the smokers tdo to one.- Yet, the minority (smokers) are controlling the environment of the ma j ority ( nonsmoker s) . We have no air outtake in our ventilation system and there is a constant "cloud" in the office. I would like to see legislation to control this type of offense. I believe employees should have some legal recourse when an employer refuses to provide adequate ventilation and separation of smokers and nonsmokers. I have previously worked for the State of Oregon and they have a reasonably effective smoking control policy for state offices. It provides for separation by physical barriers and for a ventilation system that must be capable of removing all visible smoke within five minutes. It also stipulates no smoking in conference rooms and allows for the nonsmoker's right to clean air to supercede the smoker's right to smoke. Of course, I would like to see this policy extend to private businesses and restaurants. I am also concerned about the tax subsidy to the tobacco industry. Our govern- ment goes overboard in some instances to protect us from ourselves tnrough legislation and regulation - yet in the case of the tobacco industry, ooverna,ent encourages production of a harmful substance - one that is harmful not only to those who use it but also to the innocent bystanders.' I do not want my tax dollars to subsidize a product that is harmful to my health and to the health of millions. I realize that stopping the suosidy would not mean an immediate cutbac'sc in the number of smokers. However, it would cause the cost of a pack of cigarettes to be extremely high and would thus discourage young people from starting to smoke and would give the current smokers a monetary incentive to quit. T::is would be a slow enough process to allow the tobacco industry time to convert -166-

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Sharon S. ~-1onn October 5, 196-10 their tobacco growing and processing operations to something equally profitable but with the public good in mind. I feel regulating smoking in public places together with the cessation of government subsidy to the tobacco industry could cause a great reducation in tobacco related illnesses and death. As it is impossible for me to attend public meetings in Lansing, I would appreciate information on the outcome of these meetings. I am also very willing to become_involved in any capacity to assist with smoking control endeavors in Chippewa County. Thank you for your attention: to this problem in the State of biichigan. Sincerely, SHAROM S. WOIYN P.S. You may contact me by phone at home, 906-fi32-6467, or during the day at the EUP Employment and Training Consortium, 906-635-1752. F F I I I I I I F > I E I L I- L -167-

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f r I i r I I i i l i f L L L .t l ~ L < < . /. ~...t ~/ i '~ . ~ C .. C LCc a ~~cc / V . ~. ; . , cc.C< ; ~ ` c C c ~ .1 ..~ -~ ~ ~- . l: il~ !lZ. r~ ~ ~ . r /L C'~L .tGc~ s c~~c C. L << ~ . Zc' c'iiiS f . ier Zr ~ ./C~... K.lCi~f , ~ .. L . . ~. .t .;~/...r. -I68-

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I WIWAM G. MILLIKEN, Go..rnor MAURICE S. REIZEN, M.D., D'v.clor Ben D. Barker, D.D.S., Chairperson Citizens' Panel on Smoking and Health 3500 North Logan Street P. 0. Box 30035 Lansing, Michigan 48909 Dear Doctor Barker: STATE OF MICHIGAN DEPARTMENT OF PUBLIC HEALTH 3500 N. LOGAN. P.O. BOX 30035. LANSING. MICHIGAN 48909 October 7, 1980 Cigarette smoking is a public health problem of paramount importance in the United States. The major killers and cripplers of 1980 are chronic diseases. Among the major causative factors of the modern epidemic diseases that can be controlled is cigarette smoking. In fact, cigarette smoking is the most important preventable cause of avoidable mortality and morbidity in the American population today. Evidence to this effect is contained in the attached summary of major research reports on the health effects of cigarette smoking. Viewed as a public health problem posing significant hazards and expense to both smokers and non-smokers, it is entirely appropriate for measures to be taken to reduce and control cigarette smoking in order to protect the health and safety of the public. The full range of possible remedies to the smoking problem in Michigan has been examined by the select Citizens' Panel on Smoking and Health appointed by Governor Milliken in 1980. The Panel has, after several months of exhaustive research and public testimony from interested organizations in Michigan, produced a set of recommendations constituting a practical and feasible action plan for consideration by the citizens of the state and their elected officials. The Michigan Department of Public Health strongly endorses the statements of findings and recommendations set forth in the proceedings and draft Report of the Citizens' Panel on Smoking and Health. These recommended actions to contain and reduce cigarette smoking to protect the public warrant the full cooperation and support of the legislative and executive branches of state government. This is a problem of first order that we can afford to control without delay, in the interest of present and future generations of Michigan citizens. Sincerely, Maurice S. Rbizen, M.D. Di rector F f I. i ~ I i r i i 'Eqva! Health Opportueihj for AIt' -is9- L

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I I I u i U I L L SliP"MARY OF RESEARCH FINDINGS ON HEALTH EFFECTS OF CiGARE:E SiMOK:,';G* CIGARE7E SMOKING IS THE SINGLE MOST IMPORTANT PREVENTABLE CAUSE OF DEr,TH IN THE UNITED STATES, according to the Surgeon General. Beginning with the 1964 reUort of the Surgeon General's Advisory Committee on Smoking and Health, the scientific evidence on the health hazards of cigarette smoking from thousands of studies has been o_verNhelming. Cigarette smoking is responsible for more cancer cases and more cancer deaths than any other known agent. The incidence of cancer of the lung, oral cavity, larynx and urinary bladder are elevated several fold in cigarette smokers versus non-smokers. Cancer of the lung since 1945 has more than tripled in U.S. females, paralleling the postwar increase in smoking among U.S. women. Cigarette smoking continues to increase among young women age 17-18. This is the same grouo in the population that'is already at increased risk of venous thromboembolism and stroke due to the use of oral contraceotives among women of childbearing age. Cigarette smoking compounds these risks among young female smokers. Research since the late 1940's has.consistently shown that cigarette smokers have nearly twice the heart disease death rate of non-smokers. The difference in mortality is particularly great in individuals under age 65. Estimates derived from five major population studies of U.S. men aged 40-54 suggest that coronary heart disease death rates could be reduced by as much as 35 percent for whites and 32 percent for blacks by elimination of cigarette smoking. The excess coronary heart disease mortality in men attributable to cigarette smoking exceeds that due to the next two most important risk factors, hypertension and high blood cholesterol levels, put together. A seven year study by the Center for Disease Control of over 15,000 women published in the Journal of the American Medical Association in 1979 compared the risk of vascular disease in women from several causes. The study found that "cigarette smoking was overwhelmingly the most important risk factor for vascular disease in women." A 15-year study by a major life insurance company reported in 1979 that cigarette smokers have more than twice the death rate of non-smokers. Striking elevations in death rates among smokers were noted for respiratory cancer (15 times)~ other respiratory disease (3.7 times), heart disease (2.9 times), and motor vehicle accidents (2.6 times). The incidence of death by all causes was increased 2.2 times among smokers. Cigarette smoking has been shown to be hazardous to "passive" smokers as well as to smokers themselves. Studies recently reported in The New England Journal of Medicine demonstrated "that chronic exposure to tobacco smoke in the work environment is deleterious to the non-smoker and significantly T reduces small-airways function." The researchers found that "there was no Ul significant difference in the (lung damage) scores bf the passive (non-smokers), ~ the smokers who did not inhale and the light smokers." Thus, persons who ~ work around smokers for a sufficient period of time can be shown to experience ~ quantitatively measurable lung damage, which may precede associated lung ~ disease such as emphysema and lung cancer. p~ *Sua,m~ity..e3 by uaur~,ce S. Reizen, H.D., Di.-ec*wr, .Lichigan Derarrnent of Pt:blic l.~Va -170-

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Cigarette smoking is causally implicated as a major contributory Factor in the leading causes of death and disability: heart disease, cancer and stroke. These diseases are not only killers, but constitute major drains on the nation's and state's health care resources. The costs attributable to such diseases, including direct medical care expenses plus disability and lost productivity costs, run into billions of dollars annually in the U.S. The human costs to individuals and survivors, of course, are beyond measure. I I I I I I I I .i I I I -171-

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I U I I I I I I , I I L L L L Michigan Public Health Association. Inc. Affiliated with American Public Health Association mgxxTvvx )mxttsexX-x)a x=kX xxxlmx x xxit xx xxKX XIic xkX I Suite 340, Nisbet Building, 1407 S. Harrison, East Lansing, MI 48823 (517) 332-7271 October 7, 1980 Citizens' Panel on Smoking and Health Lansing, Michigan Members of the Panel: I am privileged to present the views of the Michigan Public Health Association for your consideration. The Association represents the professional heart of public health in Michigan across a wide array of disciplines and programs. As public health workers, our members see in daily work the tremendous costs of smoking. Thus, our view that smoking is a severe public health hazard deserves great weight as an expression of professional opinion based on experience as well as data. Smoking is without a doubt public health enemy number one. 375,000 excess deaths per year nation-wide are ascribed to this habit, and Michigan shares proportionately in this grim statistic. Also without a doubt, however, meaningful reductions in smoking are not readily susceptible to direct governmental intervention. But a broad attack on many fronts, including the symbolic, will gradually reduce the social support currently provided to smoking. The Michigan Public Health Association, therefore, strongly endorses your work to date as consistent with the letter and the spirit of_our resolutions on the subject of smoking and health. These resolutions are attached for your review. Thank you for the opportunity to present MPHA's views for the record. I regret I am unable to attend your October 8 hearing to present them personally. I stand prepared as President of i4PHA and as a public health professional to help'implement the Panel's final report. Michael Cardin, J.D., Dr.P.H. President Attachments

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I Michigan Public Health Association, Inc. Affiliated with American Public Health Association )fl22x)NXAV(X=XxxX ,z,x=x)zXxxxx,XxXxx)Gxxx?cxxx"x)9~xxx)E)~4x Suite 340, Nisbet Building, 1407 S. Harrison, East Lansing, MI 48823 (517) 332-7271 POSITION PAPER ON SMOKING AND HEALTH The Michigan Public Health Association supports a comprehensive approach to smoking and health in Michigan. The Michigan Public Health Association encourages implementation of programs across a broad front of legal, economic, and health education strategies for smoking and health. A. Legal: The Michigan Public Health Association supports non-smokers' rights in the work place and in public areas. The Michigan Public Health Association has held a strong position on non-smokers' rights since 1972 (resolution No. 1, 1972). B. Economics: The Michigan Public Health Association supports an in- crease in the cigarette tax from 11t to 16t per pack. The Michigan Public Health Association also encourages: 1. The development of insurance guidelines providing reduced rates to non-smokers where a risk differential exists between smokers and non-smokers. 2. State tax credits for smoking cessation programs and a state lobby effort to encourage federal tax credi ts fo r smoki ng cessati on programs. 3. Coverage of smoking cessation costs by health insurance providers. - C. Health Education: The Public Health Code (P.A. 368 of 1978) requires local health departments to "Plan, implement, and evaluate health education ...." The Michigan Public Health Association supports a central role for local health departments in the coordination of community smoking programs. The Michigan Public Health Association also encourages: 1. The Michigan Department of Public Health to provide skill training to local health departments and other agencies active in smoking programs. 2. The adoption of a comprehensive K-12 school health education program. 3. Coordination of state programs with national smoking campaigns. Adopted by the Board of Directors, September 18, 1480 -173- I I I I I I I E I L

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I I I I I I I L L ~ L RESOLUTION MICHIGAN PUBLIC HEALTH ASSOCIATION, INC. SMOKING WHEREAS, Smoking has proved beyond all reasonable doubt to be injurious to the smoker's health, and WHEREAS, Smoking is now known to have harmful effects on the non-smoker as well, and these harmful effects have been documented in the U. S. Surgeon General's 1972 Report on "Smoking and Health to Congress," and WHEREAS, It is recognized that social attitudes toward smoking constitute a powerful force influencing the individual's decision to begin smoking or continue smoking -- or not to do so -- and WHEREAS, The membership which comprises the Michigan Public Health Association, because of its important role in health care and in striving for the prevention of illness, and which along with other members of the health profession is in constant contact with patients and the public, THEREFORE BE IT RESOLVED: That we as members of the Michigan Public Health Association shall: Michigan Public Health Association, Inc. Affiliated with American Public Health Association x~ x x~x x~x x x x X x xx~~xxyc ~cx:x xx x~cx x:~ x~c xx x x~x x x:~ xxxxz Suite 340, Nisbet Building, 1407 S. Harrison, East Lansing, MI 48823 (517) 332-7271 1. Voluntarily eliminate smoking at all board, House of Delegates, committee and general session meetings of the Association and direct that this policy be announced by the presiding officer at the beginning of each function. 2. Encourage, by an exemplar role, other members of MPHA and the health team not to smoke. 3. Discourage the sale of cigarettes in health agencies -- including hospitals, clinics, health departments, voluntary agencies- and others. 4. Make an official commitment to the concept of non- smokers' rights to unpollute air. 5. Encourage visitors and guests not to smoke. -174- (over)

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AND 6E IT FURTHER RESOLVED: That the MPHA encourage adoption of this resolution by the APHA to provide for a united effort against tho health hazard of srnoking. Adopted by the House of Delegates May 17, 1973 Subnitted by Health Education Division, MPHA I I I I r I L -175-

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I- I r I I I I I i I I I ~ I ~ ~ L L L OFFICERS Y.u. A. "w Cwr,ww A ,w. @.«. M 0 VK- I_/,N.. Mt M...-p.M p.wr. 0- v.c. C~ .9 wa._* r.«+. Mqp R_ u.c. rw..qs....r ~...~ .,...r.. O.- _.,r n.a.. n. ~aw M~ 4 1M.us.. hMM. BOARD OF DIRECTORS t.... C Maw fr+ S..e.w w.ur Ow. M J G" C.A. vu. C.w.rr J..r T. C.r.~ O.ew J... G..p .r.... o,.,. w.... CA V ..N S.w,Kr. ~.s. 9.16- C." A- Apft~ Ca,.M. w /Ww F.yw b... /4.r. ..,,.. . .~,..,,. . i.~.. b. GwM Js..r Iew, I.., .U..w, J W..... 6,. M.. «.u ..-- w. - Jw.r 0 Mww D.~.n J L ws.e. C. ar a J....+~ o..a. Lw. . JMti T.ww. GwV m«... ,... . J.ww.w ow~ In~r. Irwa,. C..,. ....... 1.. o.. U U... ~ 'w,w 6.1 M_ a A.. ...... F,. 4.K.w Gr C. R.Y.. 0._Mw u~~ C Y_M. 1w.7 ~ R~ aa~ M...vs.ue Faea t.w.c. Co n,.,... ..r.o o..w C~.. Can.. C. Crwrrr TM Asr- a«,..«,«.,«.,. Y ~..... M.. h.. ~~o. ...ur.ws ....,. a~ o...n oF..r,....C«..... OM.w. Y T..0.w b.M." .04K.I . r... ..,.., r a.. ,p... CG«..., iK PAST CHAIRPERSONS OF THE BOARD ,-e L ..... w.~.r ~... M.ft.- C ...«~. ~.,....., ...«.« . ..K. .«« J.a..u J M..w.w .rw.yo.. .««.a . ~.,.,,... J.wn l FrO... q.w,M.. NC Mw.M /,LCO~.M ~KMSM ~wq 11~... * G«I Ow~. CAa... A-. rp.,N, IwC Yw A MYN p,r....w rn. 0- w Y w.MrA 1.rMr4 ~M..HMMIM. ~K 9«,r Q... N CY. a...y.~ r«. o.~.. 0 ..., r. a....,. [vl 4, ,1«MIO.,`. Mt AMM. t l&/F. M..,. o. ,.«ti. ....,..Nn. MMA O W<ti. IMVplM IK Mft~ A 1Yn.yu. 1~en.,.w 4.,wr..w YwC~w.w , M.w Caw.new II.U.. ....n. .«M. / JY. SIwKM /lall_. G StM.M DM.M/1 c..,_ C- M_ft_. M h/w. W.nY nY St-O MMi Nl~ J 7e/,.r M_M.rl 'H`A SC.w« t ~K Yw J f.-.rrw_ MM. G... La. C. twsft. Jr M~. J...., r w.._ ~_I w....«., s o.... 00 Suite 300 313/645-9770 30161 Southfield Road Southfield, Michigan 48076 Promoting Excellence in Food Service since 1921 October 7, 1980 Mr. Sunny Fong Office of Health Education Michigan Department of Public Health 3500 N. Logan, P.O. Box 30035 Lansing,. MI Dear Mr. Fong: The Michigan Restaurant Association, as you may know, was involved with the Michigan Department of Health and the American Lung Association in writing the present no smoling laws currently enforced in our restaurants. ^ We have continued our cooperation with the Health Depart- ments by continually reminding our members of their obligation to serve all of the public, both non smoker and smoker and serve them in such a way that the result is an enjoyable ex- perience. We print and supply at cost the necessary signs for our membership and attempt continually to monitor our restaurants to see that they are in compliance. It is our purpose to continue to cooperate in all ac- tions which will permit us to better serve the eating out pub- lic for we all realize that a dissatisfied customer never be- comes a regular customer. We ttiank you for the opportunity of placing our feelings before the Citizen's Panel on Smoking and Health. HAM: dk cc: Mr. Jerry Hill Chairman - Government Affairs Committee President - Bill Knapp's/Battle Creek -176-

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I F r I I I r I f i I L ~ L National Bank of Detroit wnaam e. eaY+ns October 7, 1980 $.nsor Vke Preaident and oirector of Peraonnel _ Mr. Sunny Fong Department of Public Health P. 0. Box 30035 Lansing, Michigan 48909 ATTN: Citizens Panel on Smoking and Health Dear Mr. Fong: We are following with interest the discussions and proposals of the Governor's panel on smoking and health. We share the desire to provide a pleasant and healthy working environment for employees. We are concerned, however, that certain provisions of your panel's proposed bill would create a real hardship for employers in Michigan. Specifically, the required separation of smokers and non-smokers would be incompatible with the natural flow of work in office operations and would require the addition of considerably more space to handle the same volume of work. The 50% limitation on smoking area would in may cases-not correspond to the actual percentage of smokers in the work force and would similarly require additional space. The provision for criminal penalties and civil damages would have an intimidating effect on anyone's considering hiring employees in Michigan. Taken together, these restrictions would add additional costs to companies doing business 1n Michigan and we feel they would be a negative factor in any decision to locate a business operation in the state. This is the time when maximum effort should be devoted to increasing employment and prosperity of business in our state. We feel that education and other efforts to limit smoking can have the same desirable affect of reducing this habit without adding undue additional costs and restrictions in the employment of Michigan workers. Sincerely yours, 'n9* V--, L -177- o.troit Mkniqan 48232 ra.onon. (313) 22S-22e2

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/~ZPi ~1Z108t~L~ SCHOOL OF PUBLIC HEALTH DEPARTMENT OF BIOSTAT{ST1CS 109 SOUTH OBSERVATORY ANN ARBOR, MICHIGAN 48109 (313) 764-5450 The effects of smoking on health has been a subject of debate since long before the original Surgeon General's report in 1964. The debate has - intensified since that report, with increased attention being given to the methods of study, statistical procedures, and to scientific reasoning in general. "Ihe interpretation of statistical association in terms of cause- effect relationships has been at the center of this discussion. Statistical a$sociations, like the one between smoking and health, can reflect causal relationships, but it is not true that such an association proves causality. A statistical association, no matter how strong, can still result from confounding with other factors. This is particularly true in the case of association with chronic diseases or diseases with a long latent period. However, if association still persists after all non-causal alternative theories have been exhausted, one has little alternative than to act as if the association is in fact causal. In recent years a great deal of research on the relationship of smok- ing and health has been carried out. This research has investigated the role of a large number of possible risk factors in explaining the observed association between smoking and disease. Studies include animal trials, retrospective studies, prospective studies, as well as investigations into the basic physiology of smoking. These studies have consistently found a strong association between smoking and disease, particularly between smoking and lung cancer and smoking and cardiovascular disease. The wide range of populations studied in the U.S. and other countries, as well as the wide range of study types and analytical techniques lend credence to the possiblity that smoking is a contributing cause of lung cancer and of cardiovascular disease. The observation of a dose-response relationship enhances this possibility. (incidence of lung cancer and cardiovascular disease is-lowest in non-smokers, and shows a nonotone increase with the amount smoked). Further, groups of persons who discontinued smoking have shown reduced risk compared to those who continued to smoke. The strength and consistency of the observed relation- ship, together with the fact that an alternative non-causal explanation requires some factor or factors to be very strongly associated with both smoking behavior and with the diseases, makes it unlikely that the associa- tion between smoking and disease is entirely non-causal. I I I I I I I I t I ~ L -178-

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( r I F I I I I F In sumnary the overwhelming evidence of association between smoking and disease, though not proving causality, does lead one to act as if the relation- ship is causal. However, it should be recognized that for public health, proof of causation, specification of the details of causation, or elucidation of the mechanism of causation is not the main concern. The weight of evidence strongly supports the conclusion that the risk of lung cancer and heart disease is lower for those who never smoked than for those who smoke, and the risk is lower for persons who-stop smoking than for persons who continue to smoke. Thus, programs to discourage people from starting to smoke, to encourage smokers to discontinue smoking, or to protect non-smokers from unwanted exposure to cigarette smoke is expected to result in fewer premature deaths from lung cancer and heart disease and better general health of the public. This is all that is needed to warrent the initiation of effective public health programs to reduce smoking, along with evaluation plans to ensure that these programs are, in fact, effective. Richard G. Cornell, Ph.D. Professor and Chairman J'rus D.- Flora, Jr., Ph. . Associate Professor William J. B er, Ph.D. Assistant Professor I- I- I- I- I L L Department of Biostatistics School of Public Health University of Michigan Ann Arbor, Michigan 48109 Testimony presented at the Public Hearing, Citizens' Panel on Smoking and Health, October 8, 1980. -179-

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i TESTIMONY TO CI T IZE'JS' PANEL ON St'OKING AND HEALTH As Dean of the University of Michigan School of Public Health, I appreciate the opportunity to provide written testimony to the Panel. The cigarette is the largest single preventable cause of premature death and major illness in I'lichigan. It adds literally millions of dollars of unnecessary medical expenses to the health budget of this State every year. It produces widows and orphans at an appalling rate. Its role as premier causal agent for the dread disease lung cancer is widely understood. However, fewer of our citizens are aware that it -causes even more unnecessary deaths_from heart -attacks and that it is a more important risk factor than cholesterol. Yet, the tobacco industry continues to advertise the cigarette, to deny its well established health effects, and to portray cigarette smokers as suave sophisticates practicing a socially attractive habit. This is the industry that is responsible for today's mass pro-smoking campaigns in third world countries, exporting illness and death in the name of American free enterprise. I urge the Panel to take all reasonable steps to restrict cigarette usage in Michigan. Efforts to make smoking-socially un- desirable should be increased. Smoking in public places, such as air- ports, should be eliminated. Smoking on commercial air carriers and other public transport should be prohibited in Michigan by law. Non- smoking areas in restaurants should be made more attractive and expanded in size, thereby making smokers wait longer for service. Cigarette advertising should be sharply curtailed. The excise tax on cigarettes should be increased, the proceeds being used to advance the public health. Ultimately, tobacco companies should pay the costs of the unnecessary health care resulting from sale of their pernicious product. No reasonable body of scientific opinion defends the safety of cigarette smoking. Epidemiologists and statisticians agree that a huge mass of evidence condemns cigarette smoking beyond any shadow of a doubt. I urge the Panel to take action on behalf of the public health and safety to reduce cigarette usage by all of Michigan citizens. Richard D. Remington, Ph.D. Dean, University of Michigan School of Public Health i i I I I I I E ~ ~ L

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I I f I I ~ Vil } ,! Searching for Cures L h_ Helping the Cancer Patient Michigan Cancer Foundation Mever L Prentu Gncer Center - 110 E. Werren Avenue Detroit.ylichigen TESTIMONY TO THE GOVERNOR'S PANEL ON SMOKING AND HEALTH (3131 833-0710 Mr. Chairperson and panel members: As a representative of the Michigan Cancer Foundation, an organization dedicated to research, prevention and service, may I say that we appreciate your invitation to address you regarding the very important issues relating to smoking and health. Cigarette smoking has been called this country's foremost preventable cause of death and disability and its greatest public health problem. In 1977, smoking played a major role in 220,000 deaths from heart disease, 78,000 lung cancer deaths and 22,000 deaths from other causes. Smoking has been estimated to be responsible for 20 percent of all cancer, 25 per- cent of all cardiovascular disease, and 40 percent of all respiratory disease. Michigan residents have shared in these statistics with a yearly death toll of over 14,000 of which 3,500 have been attributed to lung cancer and 9,500 to cardiovascular disease. National estimates of the number of working days lost annually because oF smoking range from 77 million in 1971 to 81 million in 1978. Michigan smokers hold their share in this area of disability loss of 4 million excess days of work per year. It has been suggested that smoking costs $3 per day per smoking employee based on insurance costs, sick days, absenteeism, down time, lost productivity and maintenance costs. According to the 1979 Surgeon General's Report on Smoking=and Health, current cigarette smokers have an approximately 70 percent greater chance of dying from cancer and other-diseases than nonsmokers. These diseases include lung cancer and cancers of the lip, tongue, mouth, larynx, pharynx, esophagus, and urinary bladder; coronary heart disease, stroke and aortic aneurysm; chronic bronchitis and emphysema; and other diseases including peptic ulcers. Death rates for lung cancer are directly proportional to the number of cigar- ettes smokedand to the years of cigarette smoking. Rates are higher for those who started smoking at younger ages and for those who inhale. ~ tn The best way to prevent lung cancer is not to smoke. After a person O~ stops smoking, the risk of lung cancer is greatly reduced. Although approxi- ~ mately 30-million Americans have stopped stsoking, about 50 million people in ~ the U.S. (2.5 million in Michigan) still smoke. Men develop lung cancer about ~ four times more often than do wor.:en, but the rate of lung cancer in women is .~ .increasing more rapidly than in men. The cancer registry data of the metro- politan Detroit area has revealed that there has been a marked increase of lung cancer of 34 percent for black wcmen between 1973 and 1977. The statistics for teenagers a s ovide little comfort. In 1977, 22 percent of youne people aged 12-17 were defined as smokers. From 1968 to 1974, there was a substantial in- crease in the percent of teenage girls reporting themselves to be regular ciaar- ette smokers. A Torrh Drive LnitcA 11'a~ .lccnn r -ia -

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, Page 2 Although the decision to smoke or not to smoke may be individual in nature, the impact of such action is not simply a matter of individual choice. The choice to smoke is made in the context of a society which uses mass media to emphasize the habit and which continues to support industries which depend on- unhealthy products. We strongly recommend that the State of Michigan should take action to affect the environment in Michigan by providing a clear message in support of disease prevention and health promotion. The choice to smoke or not to smoke is truly not a personal one--it effects all citizens and is legi- timately a fundamental public concern. In light of these critical issues, we would strongly support an increase in the cigarette tax, which may reduce smoking among adults, and because of price elasticity in lower age groups, may tend to reduce or prevent smoking by teenagers and-pre-teens. In 1970, the Michigan cigarette tax was established at llt per pack. This tax has not been raised in 9 years. A pack of cigarettes which cost 35t in 1970 now costs about 70t. Thus the tax which, as a percent- of cost was 32 percent in 1970, is now only 16 percent. In order to properly address the problems posed by cigarette smoking and public health concerns, we urge the committee to recommend an increase of 5t per pack to be enacted and that 1t of this increase be slated for State smoking and health activities. The research mandate of the Governor's Citizen Panel reflects the need to develop an understanding of smoking phenomena which will improve the effective- ness of anti-smoking activities. A research grant program supported by the pro-. posed tax revenue would encourage innovative thinking and the development of effective and visible demonstrations. We strongly recommend that the Department of Public Health be authorized to develop a program to fund research and demon- stration projects concerned with smoking prevention, cessation and cessation reinforcement. In the legislative realm, we recommend oew legislation to assure compre- hensive protection of the rights of non-smokers for clean air in public places and work sites, accompanied by appropriate executive action for compliance and enforcement mechanisms; State support for federal adoption of a substantial (10-200 increase.in the Federal excise tax on cigarettes as a further means of discouraging the smoking habit. Economic issues that deal with incentives through insurance for nonsmoking as well as reimbursement for smoking cessation program participation should be cDnsidered. In the educational arena.we urge the panel to consider the develooment of new mechanisms to impact and innovative programs to assist smokers to quit, to promote the non-smoking behavior of children so they don't start to smoke and to provide support mechanisms to help individuals maintain a non-smol:ing habit. We at the Michigan Cancer Foundation pledge our support in advocating NOT SMOKING as one of the best ways to impact on disease, death and disability for ~ the citizens of Michigan. e6-1/,Fx177C77 sEC r/ 471 Ch*{ (-Q - Fouxol 4-77c7i /72 -rem -182- ( ~ f I I I I I d L E ~ L L

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I I I I I r El I- I L Statemeat Governor's Cit:zens ?a.zel on Smoking and -e:~' tft submitted to the Cffice of Health Educaticn Michigan Lerartment of Public ciealt:: in behalf of United Ccm:m:nity Services of Metropolitan Detroit October 8, 1980 United Community Services is a cititen-based social planning organization which has dealt with problems and issues of human services in the Detroit metropolitan area for nearly sixty years. Health problems, and how to solre them, have been one of the major concerns of our agency in recent yea.^s. T:iese concerns have teer. expressed in the form of study recommendations and policy stateWents on maJor issues by our Board of Directors. The following concerns addressed in this statement relative to the use and abuse of tobacco_products are based upon approved policy statements that deal with health education, preventive health services, and school health services: I. Health insurance companies have begun to recognize the importance of health education as part of patient services. UCS fully supports the notion that Blue Cross-Blue Shield of Michigan and other co=ercial carriers_should consider i.zc lusion of health education costs in health insurance benefits. Such health education services would !zclude the use and abuse of tobacco products with the provision of intervent:ans to reduce the risk taking behavior. To further support such interventions, UCS encourages hospital based health education projects to demonstrate whether health education can cut the cost of health services or increase their efficiency; and urges the health systems agencies to encourage the inclusion of health education components ir. those programs whic:: they review or assist !.n planning. -183-

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I II. UCS, i.Z concert ,rith other organizations, has encouraged and supcorted proposed legislation requiring local school districts to lmpt ement a comprehensire health education c.:rriculum ccnsistent vr :.". the `"ichigar: DepartWent of Education's Minimal Performance Objectives ir. iealth Education for the State of Michigan. Such a curr'_cu1;:m would be an integra+l part of the total school health prog"am. Cor.c::rrently, this agency has advocated for the inclusion of a school health services component within the school health program, and feels that due to the sizable population in question, the state legislature Wust accept reasonable costs for the provision of such a program ar.d provide appropriate funding through tax dollars. Recognizing the health consequences of long-term tobacco abuse and the difficulty of quitting once the smoking habit has been acquired, it is essential that a concerted effort be make, orn behalf of our future adults, to provide interventions. Such interventions in the school setting should address the changing of risk taking behaviors and prcWote health and Frellness. Additionally, heal t`~ departments need to relate to such a school based effort so that they may fulfill their health education functions. Health department personnel can assist local school districts ~n ccr.ducting r.eeds I d i I F t assessment, curriculum planning, development, implementation and evaluation. ~ Co tl it b d + ase ncurrsn y, commun y agencies can provide ssular functiens. By working cooperatively, we can maximize cur resources and the potential for long-term impact. ~ W O L -184-

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=Z c'_os:ng, UCS srishes to thank the Citiceas ?ar.e? cn Smotci.^g and Health for prov{ding :^terested organizztions and concerned citicens with an ooFortunity to comcaent on this issue. I I I I- I ~ `

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I THE GOVERNOR'S CITIZENS PANEL ON SMOKING AND HEALTH THE METROPOLITAN DETROIT COALITION FOR HIGH BLOOD PRESSURE CONTROL PUBLIC HEARING COMMENT ON SMOKING AND HEALTH OCTOBER 8, 1980 The Metropolitan Detroit Coalition for High Blood Pressure Control is an organization of health care, community, education, business, and labor groups which takes action to reduce mortality and morbidity from cardiovascular disease through blood pressure control. Cardiovascular disease is the prominent cause of death in Michigan as well as the nation. Since we are dedicated to reduce the consequences of cardiovascular dis- ease, the Coalition is very concerned about all cardiovascular risk factors which lead to death and disability. Smoking, like high blood pressure, cholesterol, and Type A personality has been identified as a risk factor. There is substantial evidence that smoking increases heart rate, produces vasoconstriction, destroys cilliary tissue of the lung, and reduces oxygen concentrations in the blood as well as placing carbon monoxide into the circulatory system. It is important to work toward control or elimination of risk factors in order to reduce the consequences of cardiovascular disease (e.g. stroke, heart attack, and kidney failure). The Metropolitan Detroit Coalition-for High Blood Pressure Control will support action by the Governor's Citizens Panel on Smoking and Health that seeks to reduce the risk of cardiovascular disease as it relates to smoking. The Coalition thanks the Governor's Citizens Panel on Health and Smoking and the Michigan Department of Public Health for the,opportunity to bring forth our position on smoking control and good health. . I I I I r t 4 I -186-

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I Statement by John 3. .°.or.3ni, ?h..,. I L I am ~ohn H. Romani of Ann Arbor and appear today :n a dual c-a^acity. c'irst is as a private citizen concerned with the dangers to our health which arise frca cigarette smoking and the use of tobacco products. Second is as the :==ediate Past President of the lmerican r,:blic Health Association which is a professional organization composed of over 30,000 public health workers throu3hout the countrf. Since 1959 when it adotted its first official policy on the health problems related to cigarette smoking, the Association has been on record as having a deep concern with the threats to the public health posed by the use of tobacco products. This first statement of APy.a policy has been exranded and refined by subsequent resolutions, each one reflecting our in- creased scientif~c understanding of the risks to human health uhich come from smoking. The data on which ve have taken these actions are those with rhich I am certain you are most faailiar. `.lot only is cigarette smoking implicated as a significant factor in contributing to lung disease, it is also a^,a,+,or element in increasing risks for heart disease and associated circulato rf disorders. Moreover, as recent studies have suggested, it is not only the individual smoker who is at risk, but also the aany smokers exposed to tobacco smoke. As pointed out in the retort of the Surgeon General, Healthy People, issued last year: "Cigarette smoking is the single most preventable cause of death." This, if nothing else, should urge us to develop public policies which will lead to a reduction in smoking among all segments of our population. The issues raised by cigarette smoking and health are, in .:.any respects, comparable to those we have confronted in other areas where the health of the public is a major consideration. A basic principle of public health is to erect, by one means or another, barriers between the agent which causes illness, and the individuals who, in the absence of such barriers, would be exposed to such threats to their health. Further, such action is generally undertaken as a collective effort by the state or the community in the dis- charge of their responsibilities to protect the public health, safety and welfare of their citizens. This is the principle we use to support immuniza- tion against communicable diseases, purification of our water supplies, develop- ment of aaste disposal systems and other comparable public health measures. In each of these cases there was clear ard demonstrable scientific evidence that the actions undertaken would result in a reduction in morbidity and mortality from the disease agent involved. Such actions, by their nature, iWmosed restric- tions on individuals and groups - children vere required to be im=unized prior to entering school; householders could not dispose of waste as they saw fit; and lia;.tations were placed on sources of water. ~ ?re-,ared for mresentat;on to the Governor's Citizens' ?anel on Saoking and 3eaith, October 8, 1980. -187-

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I -2- +Then we attempt to applf these principles to the questiorn of ci3srette smoking, the objection is frequently raised that control of smo'r.ing is an unnecessary curtailaAnt of one's freedo:a. :t is argued that _ ndiv:duals have a right to be as healthy or unhealthy as they choose, particularly :.° their behavior does not affect others. Smoking, it is suggested, is such a behavior. This argument breaks down for at least three different reasons. First, as I have noted, exposure to tobacco smoke constitutes a hazard to the health of many of those exposed. Thus, curtailWent o.° smoking is an appropriate measure to take in protecting the tublic health. Second, those who become ill as a consequence of smoking constitute an economic burden which is not solely borne-by the person directly involved. The costs of treating the lung cancer patient, the heart disease patient, among other illnesses of smoking, are reflected in the higher premiums we pay for health ins-urance, both as individuals and as taxpayers when our taxes are used to subsidize coverage for certain people in need. Thirdly, -re have found it appropriate for government - either by taxation, prohibition, or some other measure - to restrict the use of drugs or other substances which have been demonstrated as being dangerous to individual health. The same logic, at least from my perspective, applies in the case of smoking. The other argument frequently raised is that additional restrictions on the use of cigarettes would unfairly impact on certain businesses and related enterprises. No doubt this would happen and it is not something we should dismiss out of hand. There is no question that the economic well-being of some firms may be adversely affected by additional regulation in this area. Again, however, the issue is one of balancing public interests against private interests. The question must always be what will be best for the state or community as a whole. The long term gains which would come from actions to restrict smoking are, at least in my judgment, greater than the shorter term problem of adjustment which speci.*ic enterprises might face. In summary, there are strong arguments in support of strengthening the existing laws regulating smokiz13 in public places and to provide for their enforcement. ~e most effecti`~s~trateKr in this area is to prevent people from starting to smoke in the first instance, and here, expanded efforts among young adults who are most susceptible to the idea of cigarette use are greatly needed. Also required are more vigorous endeavors to inform people about the adverse effects of smoking on health. Governor Milliken and the Panel are to be commended for focusing the attention of the citizens of Michigan on this critical public health issue. i 1 I I I I I d I I I ~ L -188-

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i I I S':ATE:IE.IT GIVEN BY DR. MURRAY JACKSON IN BEHALF OF THE AMERICA:i LUNG ASSOCIATION OF SOUTHEASTERN :dICI-IIGa:i 'IO THE PANEL ON S:lOKI;iG AND HEALTH - WEDNESDAY, OCTOBER 8, 1980. MY NAME IS MURRAY .?aCKSON AND I AM A PAST PRESIDENT OF THE AMERICAN LUNG ASSOCIATION OF SOUTHEASTERN MICHIGAN. CURRENTLY I SERVE AS CHAIRPERSON OF THE ASSOCIATION'S SMOKING AND HEALTH COMMITTEE. WE ARE DELIGHTED THAT THE GOVERNOR -- THROUGH THE FORMATION OF THIS DISTINGUISHED CITIZENS' PANEL -- HAS RECOGNIZED THAT TOBACCO SMOKING IS A SIGNIFICANT -(AND PREVENTIBLE) HEALTH HAZARD TO THE PEOPLE OF THE STATE OF MICHIGAN. THAT HE HAS CHOSEN TO NAME A GROUP OF SUCH CONCER:IED AND CONSCIENTSOUS INDIVIDUALS TO THE PANEL IS EVEN MORE ENCOURAGING. WE KNOW THAT TEE RECOMMENDATIONS OF THIS PANEL WILL BE WELCOME, WILL BE WELL-CONSIDERED AND WILL BE WELL-RECEIVED BY ALL OF OUR FELLOW CITIZENS. ~ I ~ L AS AN AGENCY THAT HAS TRADITIONALLY ENDEAVORED TO WARN SMOKERS ABOUT THE HAZARDS OF TOBACCO, THE AMERICAN LUNG ASSOCIATION NATION-WIDE IS VERY SUPPORTIVE OF YOUR DELIBERATIONS AND'WE EAGERLY LOOK FORWARD TO YOUR CONCLUSIONS. THE AMERICAN LUNG ASSOCIATION OF SOUTHEASTERN MICHIGAN SPECIFICALLY SERVES WAYNE, OAKLAND AND MACOMB COUNTIES WHERE NEARLY HALF OUR STATE'S PEOPLE LIVE, AND WE WISH TO GO ON RECORD AS CONCURRING IN THE LEGISLATIVE AND ECONOMIC RECOMMENDATIONS THAT HAVE BEEN MADF. TO THIS PANEL BY.OUR INDEPENDENT SISTER ORGANIZATION, THE AMERICAN LUNG ASSOCIATION OF MICHIGAN, HEADQUARTERED IN LANSING. .ob CrT -189-

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I STATEMENT BY MUQRAY JaCtSON CITIZENS' PANEL; LANSING PAGE TWO I HOWEVER, WE DO HAVE CERTAIN RESERVATIONS ABOUT THE PHILOSOPHY THAT SEEMS TO PERMEATE THE PANEL' S ED'JCaTION/KEDIA/PUBLICITY RECOMMENDATIONS AS IDENTIFIED IN YOUR MEETING MINUTES OF SEPTEMBER 11, 1980. I THROUGHOUT THIS SERIES OF RECOMMENDATIONS, VARIOUS GOVERNMENTAL AGENCIES AND TAX-SUPPORTED EDUCATIONAL INSTITUTIONS ARE IDENTIFIED AS HAVING ~ SOLE RESPONSIBILITY AND AUTHORITY FOR PLANNING, IMPLEMENTING AND EVALUATING SMOKING CESSATION PROGRAMS. YET THE AMERICAN LUNG ASSOCIATION OF SOUTHEASTERN MICHIGAN HAS MUCH . VALUABLE INSIGHT TO OFFER IN THIS AREA AND, IN FACT, WE HAVE BEEN INCLUDED AS AN IMPLEMENTING AGENCY IN BOTH THE CURRENT ANNUAL AND THE FIVE-YEAR PLANS OF THE COMPREHENSIVE HEALTH PLANNING COUNCIL OF SOUTHEASTERN MICHIGAN. WE ARE MYSTIFIED-AS TO WHY THE RICH RESOURCE OF-VOLUNTARY HEALTH AGENCIES HAS BEEN SO CONSPICUOUSLY IGNORED IN THIS PANEL'S RECOMMENDATIONS. GIVING SOLE AUTHORITY TO TAX-SUPPORTED AGENCIES IN SUCH AN IMPORTANT AREA OF PUBLIC HEALTH CAN ONLY REDUCE THE CONTRIBUTION OF SKILLS, MANPOWER AND EXPERIENCE AVAILABLE FROM VOLUNTARY, PUBLICLY-SUPPORTED AGENCIES SUCH AS THE AMERIC AN LUNG ASSOCIATION. INDEED, IT WAS ONLY BY CHANCE THAT THE AMERICAN LUNG ASSOCIATION OF SOUTHEASTERN MICHIGAN Ot EVEN LEARNED OF THIS CITIZENS' PANEL'S EXISTENCE AND DELIBERATIONS. ,p ~ WE PRESUME THIS WAS MERELY AN OVERSIGHT, SINCE THAT LETTERS ANNOUNCING THESE PROCEEDINGS WERE WE HAVE BEEN ADVISED SENT TO 125 INDIVIDUALS AND OTHER AGEaCIES. YET WE -- AND THE MORE THAN 300,000 FINANCIAL m i I ~ I AGENCY -- BELIEVE THAT WE HAVE UNIQUE CONTRIBUTIONS CONTRIBUTORS TO OUR -190- L

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I STATEMENT BY MURRAY JACKSON CITIZE:IS' PANEL, LANSING PAGE TT3RE E TO OFFER I:J SUPPORT OF ANY STATEWID E ANTI-SMOKING EFFORT. I I WE WOULD URGE, THEREFORE, THAT THE AMERICAN LUNG ASSOC,ATION OF SOUTHEASTERN MICaIGAN -- PERHAPS ALONG WITH OTHER NON-GOVERNMENTAL AGENCIES CONCERNED WITH SMOKING BEHAVIOR -- BE SPECIFICALLY DELINEATED IN YOUR RECOMMENDATIONS AND GIVEN A DEFINED AND DECISIVE ROLE. CONSIDERIaG THE TIGHT BUDGETS THAT NOW RESTRICT T'.iE ACTIVITIES AND PROGRAMS OF SO MANY GOVERNMENT AGENCIES, WE FEEL IT IS PARTICULARLY FOOLHARDY TO OVERLOOK ANY COMMUNITY RESOURCE -- ESPECIALLY ONE WITH I THE RECOGNIZED AND RESPECTED ROLE IN SMOKING CESSATION ACTIVITIES THAT HAS BEEN EARNED BY THE AMERICAN LUNG ASSOCIATION OF SOUTHEASTERN ~ MICHIGAN. LADIES AND GENTLEMEN, WE APPLAUD YOUR EFFORTS AND WE SHARE YOUR CONVICTION AS TO THEIR IMPORTANCE. WE PLAN TO CONTINUE OUR ANTI-SMOKING PROGRAMS TO EDUCATE, INFORM AND HELP REDUCE THE RAVAGES OF TOBACCO AISONG ALL SEGMENTS OF THE POPULATION -- INCLUDING ALL AGE GROUPS -- THROUGHOUT SOUTHEASTERN MICHIGAN. YET WE RECOGNIZE THAT WE CAN BE EVEN MORE EFFECTIVE I-^ WE ARE INCLUDED IN AN OVERALL GAME PLAN, SUCH AS YOU HAVE BEEN CHARGED WITH FORMULATING. WE DO NOT WISH TO COMPETE -- WE WISH TO COOPERATE. WE KNOW THAT THE CITIZENS OF WAYNE, OAKLAND AND MACOMB COUNTIES ENCOURAGE OUR EFFORTS AND WILL ENTHUSIASTICALLY SUPPORT OUR INCLUSION IN YOUR FINAL RECOMMENDATIONS. -191-

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I i STATEMENT BY KfJRRaY JACKSON CITIZENS' PANEL, LANSING PAGE FOUR I I YOUR B.i AND - * - 0 EC-^'ZV~S OURS COINCIDE - DO :IOT OVER..OOK US OR THE .. WIDo.. 5?READ SUPPORT WE CAN BRING TO THIS C:TIZE:dS' CRUSADE. THANK YOU FOR YOUR ATTENTION AND YOUR CONCERN ABOUT THE PROBLEM OF TOBkCCO SMOKING -- A FIGHT IN WHICH THE STAFF, VOLUNTEERS AND MANY MILLIONS OF SUPPORTERS OF THE AMERICAN LUNG ASSOCIATION HAVE BEEN, AND WILL CONTINUE TO BE, DEEPLY INVOLVED. I I I i I I d I I I L -1,92- 1 L_

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Dr. Isaac Asimav, the veil-known science and science-fiction writer, is a dedicated non-smoker. Here are some of his views: "I don't smoke. I have never smoked. The reason is simple - I don't like the smell. I took a puff once and didn't lika the taste or any part of the sensation. I per- fectly understand that is I try it enough I will learn to love it, but there are enough things I lave at once and a priori so that I don't have to go through unpleasantness.... tithen someone smokes in my presence.. his vice s is not private. His foul emanations find their way into my lungs and blood stream. Bis stench becomes my stench and clings to me. His effluvia make their mark on me. To be sure, he gets intense pleasure out of it but that is no excuse for victimizing me, and, of course, he raises my chance at heart disease and lung cancer for his pleasure. Let him or her smoke by all means, but only in private or in the company of those who do not ob- ject. I would not deprive him or her of lung cancer, if he or she wants it dreadfully, for anything. I just want a chance to avoid it myselt.... Let's put it this way, your freedom to smoke ends where my lungs begin." Cancer News, American Cancer Society, SpringlSummer, 1979, p.2 SMOKERS AWARE 0F LIING DAiiAGE I4..B40 A survey sponsored by the American Cancer Society reveals that a large majority of both smokers and nonsmokers believe that cigarette smoking is a major cause of cancer and chose smokiag as the culprit over 19 other possible causes. . The study, conducted by Liberman Research Inc., a major public opinion poZling organization, covered a nationwide sampling of 1,553 men and women I8 years and older. It shotired that cigarette smokers are aware they are endangering their health by smoking, and more than half smokers feel they are "very likely" or "fairly likaly" to develop lung cancer. Only 21Z of er-smokers and 14% of those who never smoked feel that they are going to develop lung cancer. But despite the "writing on the vall," smokers find it hard to quit. And smokers are optimistic that they can be saved from cancer if it is de- tected soon enough. Seventy-one per cent believe that if cancer is caught early enough by screening, there is a good chance of cuYe. The oPtlmisa esists despite the fact that lung cancer is one of the most uncurable forms of the disease, says the American Cancer Society. 'Phe U. S. Joursal of 'JraR and Alcohol Denendence, ?Siami, Fla., June 1980, p.5 -193-

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10/80 I I I SMOKZYG dPM E'.*4LT°S'r:.`SA B-348 One of the fastest-growing health problens in Aaerica today is a disease knavn as pulmonary emphyseasa. Enghysena now affects.over one million Ameri- cans, and fift7 to fift7-five thousand die each year because of it. The disease has mu.ch in cor.mon with lung cancer-both involve changes in the surface ce11.s of the lung's air passages, and both are related to saoking. Emphysema occurs when the surface cells, because of outside irritants, be- gin to grow abnornally. As the growth conti:ues, they begin to block the smatl air tubes inside the lungs, trapping carbon dioxide within. Because of this blockage the person with emphysema.finds it difficult to ezhale air. As the condition worsens, the small air-sac walls in the lungs swell and rupture under the stress, producing larger and larger balloonlike sacs or "blebe." The valls of these blebs lose their elasticity as a result of the chemicala in the gases and tars. Persons with emphysema experience shortness of breath, lack of energy, and decreased efficiency. Eventually they canaot perform the necessary duties of life. Quitting sm+oking enables the luags to function more effectively again, but the broken air-sac walls never heal. Warniast: The Sur eon General Has Dete-r--tined That Cigarette Smoking is Danste_rous to Your Health, Robert Haddoc3c, Editor, Southern Publishing Association, Nashville, Tennessee, 1973, pp. 18, 19 I I I i ~ 10/80 SWICLYG d.~ID :40BTALITY * 14-B 34 t A monumental, 20-year biological study sponsored by the American Cancer Soc- iety haa found evidence of the lethal hazards of cigarette smoking. Not only does smoking significantly increase the death rate from cancer of the lung, but from cancers of the lip, tongue, bladder and esophagus. Startlingly, its increase in the death rate from heart disease and stroke is even 10 times higher than the increase from mmalignancies. Compared with the non-smokers in the stpdy, the smoker, especially the heavy smokers using the type of cigar- attes smoked in 1959, on average lost 8.3 years of-life. Does a switch to lov-tar, low-nicotine brands reduce the chances of heart disease and cancer? It helps, but still the smoker has a higher death rate than the nonsmoker; the risk does not evaporate. Upon quitting entirely, an ax-smoker does have a much more favorable outlook-and the longer he or she has stopped, the bet- ter the outiook. Not surprisingly, the study revealed a great and grwing r+lsk of fatal lung cancer among women smokers. Lung cancer now is the second leading cause of caacer death in women, 25 million of whom smoke. Air pol- ' lution had been thought by maay to be a major factor in lung cancer. Withouts, exonerating pollution and its role in chronic bronchitis and effiphysema, the study found it to be no great culprit for lung malignancy. Smoking is the key factor. -z.aecstive Health, Santa re, California, August 1980 t L L L -194- . 85646040 ~

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I I I t ~ 10/80 SN.OKLYG HA3ITS LY 70tTtiG WON...~:1 WI:3 PSYCHOSC:SA~"'IC DISORDERS M-337 A disproportionately large nuaber of habitual smokers, particularly stress smokers, can be found among young women with psychosomatic disorders. In an exploratory enqulr7, 111 women staying at a health resort were asked ques- tions regarding smoking habits and personalit9 traits. Smok.er and nons=ker images were compared in nonsmokers, ea-smokers, stress smokers, an-d non- stress smokers. The female smokers,. especially stress smokers, showed more anomalies accord- ing to the Freiburg Personality Inventory than the nonsmokers (among other characteristics, a greater degree of nervousness and a larger amount of neurotic tendencies). Also seen were indications that atress smokers felt less responsible for having acquired and upheld the smoking habit. In both groups of smokers, social factors had a prominent habit-forming function. There were hardly any group-specilic differences between the smoker and nonsmoker stereo- types. However, the nonsmoker image usually showed more positive traits. Smokins and Health Bulletin, II.S. Department of Health and Human Services, Rockville, Haryland, Harch 1980, p. 97 10/80 COBONARY HF.aEI DISEASE AND SK.OKLiG M-339 Coronary heart disease now accounts for about one quarter of all deaths in England and Wales. Furthermore, cigarette smokers suffer a higher mor- tality from the disease than nonsmokers, although the relative risk con- nected-with smoking decreases with increasing age. The question, therefore, ar~'..ses: Does smoking actually cause coronary heart disease? Or does the association have a constitutional basis? Gen- etic factors predispose both to smoking and to coronary heart disease, and we need to determine whether these factors are associated. Iw.ertality atatistics for England and Wales over the period 1921 to 1973 have been studied in aa attempt to resolve these questions. These data bear critically on the issue of smoking and coronary heart dis- ease, and tsey show that littre or no causal action is involved; the assoc- i.ation of the habit with the disease has a genetic basis. Smokinq and Health Bulletin, U.S. Department of Health and Human Services, Roclcville, :*.ax9land, ;tarch 1980, p. 8Z -195-

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i El 10/80 SMOXIMNG AM LIS:TG C1.VC°...'~t B-340 L° you smoke, your chances of dying from lung cancer are 700z greater than those who have never smoked on a regular basis. 'w'hen the average sr..oker takes a long drag on his cigarette, he inhales deeply, forcing smoke into the remotest sectione of his lungs. The smoke contains tar and nicotine which invade thousands of the innuanrable air sacs in the lungs. As he con- tinues to smoke, the smoker's air passages become increasingly coated with the sticky tar, which includes several cancer-causing agents. Ordiaarl-1y "c.ilia," small hairlike structures, brush invading matter from the air pas- sages.. But the tar from tobacco paralyzes these structures and makes its way to the lungs. As the tar residues continue to build up in the air pas- sages over several years, they begin to change the surface cells of the passages. The cells begin to increase in number. Within a few years lung cancer often appears._ From the lungs, cancer cells enter the blood and lymphatic vessels and spread to all sections of the body. By the t'.e a di- agnosis finally confirms the presence of lung cancer, the disease has usu- ally spread beyond control. That's why, even today with all the spectacular advances in medical science, lung cancer still proves 95 percent fatal. Warning: The Sur eon General Has Dete=ined That CiQarette Smokin is Dangerous to Your Health, Robert Haddock, Editor, Southern Publishiag Association, Nashville, Tennessee, 1973, pp. 13, 14 I i I d OC 10/80 ~ ~ S2tORI:4G 3.*~ S20IriAGq 4LCE3 :4-333 ~ ~ Why do doctors forbid their storsach-ulcer patients to smoke? No one caa state with certainty the exact cause of ulceration in the stomach or duoden- um. All we can say is that there are many contributing factors. Apparently somethiag happens to the 1Sning of a sma.Il area of the stomach that dis- rupts its protective mecha+j = and allows it to be digested by its own ) uice. This conditlon may velS have to do with a spasm or stoppage in a tiny artery supplying that area with blood. rhatever the cause, here is an area that is unprotected from the irritating ef;e=t.of tobacco tar. The whole effort be- hind the treatment of stommach ulcer is to cut down on the secretion of stom- ach digestive juice and neutralize the hydrochloric acid normally present. Nicotine circulating in the blood stream can cause spasm or nar.owing of tiny arteries. This reaction is the opposite to wizat is being attempted by the doctor. When he is tiYing to treat a person with stomach ulcer, he has every reason to forbid the use of tobacco. The body undergoes changes to ccmaen- sate for its use, and.when the drug is no longer taken, there is great men- tal aas_4ety and tension during the withdrawal period. The ulcer patient who hopes for ultimate permanent rare must give up tobacco. Home and Health, Cape Town, South Africa, Sentinel Publishing Asan. I ~ I Qndated, pp. 13, 14 -196-

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I I I i i ~ ~ L 9/80 June 1, 1980, p. 4 LCW-TAR CIGaRETTES **.AY 9E u.ORE HAR.'l= K-364 Cigarette smokers may think they are doing theaselves a favor by svitching to low-tar brands, but a Canadian study shows other harmful agents in the smoke cay-actual].y be higher in some law-tar brands than in high-tar cigar- ettes. A Ritchener laboratory that has the federal governaent testing con- tract, Labstat, Inc., has produced an evaluation-of 102 Canadian cigarette brands based not only on tar and nicotine content, but also on 4 other poten- tially toxic elements in the smoke. In addition to those 3 elements, the Labstat study tested for hydrogen cyanide, aldehydes, and acrolein. Biologi- cal tests have linked these substances to respiratory and heart diseases, Dr. Rickert said. Carbon monoxide (CO) has been shown to-increase the risk of angina and heart attack and to contribute to a condition known as intermit- tent claudication which produces pain and weakness with movement. Hydrogen cyanide (ECN) has been shown to inhibit some respiratory enzymes and i_pede the function of cilia, tiny hairs which clean out the lungs and respiratory tract. That means tar and nicotine may be allowed to collect in the lungs for a longer period, perhaps enhancing their hazards, Dr. Rickert said. A list of "low hazard" and "high hazard" cigarette brands was compiled. 15 brands were ranked as "low hazard" and 9 brands were listed as "high." The Journal, Addiction Research Foundation, Toronto, Ontario, Canada, 9/80 ASd ?{EPQESZNTS NONS:~AMS ON RESTAIIBA.'~iT ISSUES :4-BS8 An increasing number of restaurants are making accommodations for nonsmoking patrons, either voluatarily or because of existing or threatened legislation. Food Service Marketing, the magazine of the restaurant business, reviewed this trend in the cover story of its March, 1980, issue; it relied principal- ly on lISFi (Action on Smoking aad Health) to present the nonsmokers' point of view. The following is an excerpt from the article: The number of nonsmokers (70x of U.S. adult women and 602 of adult men) is growing, along with their militancy. These statistics alone are enough to justify laws to protect the rights of nonsmokers, according to groups behind current no-smoking legislation. One such group, ASIA, headed by John Banzhaf, has been responsible for much of the effort to ban radio and television cig- arette commercials, provide separate no-smoking areas on all major airlines, trains and buses, plus win more than $200 million in free broadcast time for anti-smoking messages. One of their current goals is the protection of non- smokers in restaurants and all public places of assembly. "What we would like to see is a situation where people have a choice," said 3anzhaf. "A smoking and a no-smoking section should be available at all times...People are becom- ing-more accustomed to no-smoking areas on the airlines, and the same thing will happen with restaurants." ASH Newsletter, action on Smoking and Health, Washington, D. C., :Sarct~-April 1980, p. 5 -197-

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I I , ..:~:~ 8/a0 AIRLLYE 'DUEL' UNDERSCORES CONTZYIIZNG NO-SMOKZ:iG BATTLE CARD # 1 M-B58 A verbal duel that erupted between smokers and nonsmokers aboard an Gastern Airlines shuttle flight was only a dramatic etample of the non-smoking bat- tles smoldering every day across the United States. So says the National Ynteragency Council on Smoking and Health in New York. Sharp words betaeen smokers and nonsmokers aboard Eastern flight 1410 December 5,1979, caused the pilot to abort a flight from Washington and land in Baltimore instead of New York because of the "insurrection." But similar outbursts occur daily in lobbies, offices, restaurants and elevators, says Louis Cenci, director of the interagency council. Al- though they are not as theatrical or well publicized as the airline in- cident, cident, these battles go a long way toward shaping public compliance with no-smoking laws, Mr. Cenci says. The airline incident "heightens the awareness of a very definite nuisance problem," he adds. In the effort to clear the air for those who wish to work, eat, or -travel free from a smoky environment, observers are noting these milestones: Christian Science Monitor, Boston,Mass., December 7, 1979 I I I d I i 8/80 AIHLLlE ' DUEL' UNDERSCORES CONTLI;ULYG NO-S:SORIlYG BATTLE CARD ~2 M-B58 In the past few years more and more restaurants, from big chains to "mom and pop" family-run eateries, have provided nonsmoking areas. Preliminax-y findings of a survey by the interagency council of 3,000 Amer- ican busir~ess firms, including some of the nation's largest, show they are increasingly providing "smoking lounges" so that there will be a smoke- free atmosphere in working areas. . Passenger airlines have gone a long way toward accommodating nonsmokers. However, the couacil and other antismoking organizations have asked for some Mnd of "buffer zone" to be installed between smokers and nonsmokers. Spokesmen for the airlines, meanwhile, say the eahaust system is so good on most jets that smoke doesn't waft very much away from the smoker. Last year, the U.S. Civil Aeronautics Board (CAB) banned the smoking of cigars and pipes from the nation's air passenger fleets. antismoking groups have petitioned the CAB to ban cigarettes as well, but airline executives say there is little chance that the CAB will act on that matter in the near fucure........ Christian Science Monitor, Boston, u.ass., December 7, 1979 -198- I O ON .Oik 1 ~ ---- -..........,r,,,~ ~

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I I I I ,...~~ 9/80 rL"^JR.E OF TOBACCO INDUSTRY IS THRFIIT'=Nr.""J~ ;f-a27 A confidential poll taken every two years since 1968 has confir.aed the tobacco industry's worst fears about anti-smoking campaigns. The latest survey, by the Roper_Organization for the industry's Tobacco Institute, says the findings are "mostly foreboding as regards the ver7 future of the tobacco industry." The most signif icant new trend is an ever-increasing percentage of people who believe cigarette smoke is harm.iul to smokers and nonsmokers alike. "Nearly six out of ten believe_that smoking is hazardous to the nonsmok- er's health, up sharply over the last four years. More than tvo-chirds of nonsmokers believe it, and nearly half of all smokers believe it." Smoke Signals, Washington D.C., January 1980, p.t i I - - go 1;0- W. 0 C"M 9/80 0SIIRA,vCE STUDY SAYS CIG.1RETiES CUT LIFr SPAN M-B34 A new mortality study of life iitsurance customers-the first of its kind- has confirmed the death rate of cigarette smokers Is "significantly higher" than that for non-smokers. The report supports a move toward industry-wide recfl griition of this in the marketing of policies. The differences "are too large to be ignored," contended statistical experts for the State Mutual Life Assurance Co. of America. The firm pioneered discount rates for non-scokers after the U.S. surgeon general's original report on smoking and health in 1964. The follow-up study by State Mutual of some 100,000 insurance policy- holders since then found that death rates among smokers of all ages were more than twice as great as those of non-smokers and, for certain causes such as respirator7 cancer, ran as much as 15 times higher. The company also found that smoking habits could be as important in predicting a person's chances of dying prematurely as are commonly recogaized differences between the sex- es. A healthy woman of 32 is expected to live to the age of 79.2 years-5 years longer than the life expectancy of a man of 32. However, a healthy, non-smoking 32-year-old man can expect to live to 78.9 years of age, while the 11fe expectancy of the man of 32 who smokes is 71.6 years- a difference of 7.3 years. -199- 'Phe Washing-ton Star, Washington, D. C., October 22, 1979

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F 4 , , MlCHAEL R. SPANIOLO . ATTORNEY AND COUNSELOR AT LAW ]837 WAVCRLY HILLS ROAO LANSING. MICHIGAN 441217 HONt 717 372-2323 Open Letter And Statement To The Citizen's Panel On Smoking & Health October 8, 1980 - 10 A.M. Michigan Department of Health Lansing, Michigan FROM Michael R. Spaniolo I/VZ4`" .~' General Counsel: Michigan Tobacco Industry Advisory Council Tobacco Institute Tobacco Tax Council The Citizen's Panel on Smoking & Health, guided by the Michigan Department of Public Health, is recommending that the ci arette tax be raised by $60 million to discourage smoking and to earmark ~12 million for smoking-health activities. a I I- f I I Senator Edward Kennedy on the Floor of the Senate of the United States, ' November 3, 1978 stated: "Cigarette bootlegging, as it is comm only referred to, has become not only a serious problem for the many states which rely on cigarette taxes for needed revenue, but also has become a major revenue source for organized crime groups. It has been estimated that the states are losing over $400 million a year because of this activity, and that is a very conservative estimate. The only ones profiting from this activity are the major organized crime families which control between 40 to 50 percent of the activity. Cigarette bootlegging is now ranked as the sixth major revenue source for organized crime with a gross of $1.5 billion a year and profits estimated at $800 million. Even worse than the smuggling itself is the violence that accompanies the activity - - truck hi-jacking, armed robberies, serious assaults, extor- tion, murder, and corruption of public officials. - I L t L L The effects of this activity does not stop there. The indirect result of cigarette bootlegging is the loss of jobs and businesses of those lEgiti- L mate wholesalers, vendors, and sales people. In the past 10 years, 50 percent of the employees of wholesalers and vendors have lost their jobs, and 35 percent of the wholesalers have gone out of business because o& this. " ~ 0! . _ . _ . .. .- . . 0~3 -200- ?! .

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I i I Other recommendations being considered are rest_ict'_ons on smoking irn all office and factory areas - with confiscatory expense for the business community as well as governmental agencies. This raises some serious questions about the paternalistic role of big gover^.r.ent. Liberals often try to portray those who question the validity of the welfare state as cold hearted monsters who enjoy turning of_` the heat in senior citizen homes who are deliquent in paying their energy bills. This is an emotional smokescreen obscuring the real issue which involves the extent to ~.qhicn federal and state governments should devote time and money to telling us what we should or should not do. It is not as if the government is dealing with an obscure issue. The American public has known since the 1960's the alleged effects of smoking and the warnings. Their choice to smoke may be a cause of concern to those individuals involved, but should it be the focus of governments job to tuck us in every night? Why should the taxpayers be forced to pay for a program that tells people how to behave? The question of smoking has long ceased to be a question of ignorance. It is a question of the smoker's will to quit. Spending state tax money to inspire will power is an obvious extension of the welfare state. In a broader sense, it is an intrusion into our freedom. We might as well be spending state_tax money to promote health foods, "because it's good for you". Certainly ;Iichigan and the Department of Health could find a more urgent use for tax money_- especially in view of the Governor's call for serious budgetcuts - in view of declining tax collections, unemployment, and business closings. Government doesn't seem to want to listen to what the voters are saying and continued ignoring will bring a tax revolt and the confrontation at the pass. Some of the Panel's recommendations envision the creation of a huge health department bureaucracy at local and state levels. We can forsee an ambitious program with a Smoking-Health unit in every local health department in Richigan with an overseer division of the State Department of Health, at the cost of millions of dollars. No one has estimated the cost in taxes. We can assure you that this is the sort of thing that is fueling the Tisch Amendment drive. The Panel's recommendations are being circulated state wide and are today being examined by the Tisch forces. This will undoubtedly make thousands of votes for Tisch. We hope that Governor-Milliken will consider carefully the recommendations made by the Panel and their impact on the business community, on all govern- ment agencies, and the unions which will be effected. The $60 million requested increase in the cigarette tax - the most regressive tax on the books - is an open invitation to organized crime to take over the cigarette business as has been done in other high tax states. We ask Governor Milliken to say "No" to the $60'million tax increase, to the proposed bureaucracy for Smoking & Health at state and local levels, and to the proposed Michigan Clean Air Act with its confiscatorv provision for the GO ~ business community as well as all government agencies state and local V , . M O -201- ~

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I COST-E: rECTIVE:VESS kYD BE:VEFITS OF S'M0KE SiCPPERS PRCGRAM AS CCMPARED TO 7VO OTHER POPULkR RtOKI:lG CESSATICN PROGRAMS* The attached analysis was done for St. Joseph Mercy Hospital in Ann Arbor, Michigan in order to document the benefits to that hospital of having 120 employees and 5 of their spouses participate in the Smoke Stoppers.smok- ing cessation program. The analysis comoares the outcomes and savings of the Smoke Stopoers-program with the other two programs in order to determine which of the three is the most cost-effective. The analysis highlights several important findings: 1. The efficacy of Smoke Stoppers (320) clearly exceeds that of two other popular area programs. A graduate student in Public Health Education did a follow-up study on the participants who had been out of the program for more than a year to determine this percen- tage. Most programs cited in the literature report 20-25% effi- cacy; frequently this is a vastly overestimated figure as they - do not include in their percentage those clients whom they could not reach. The 32% figure accounts for all clients who have been out of the program for a year. 2. The literat-sre states that of all those smokers who want to quit only about 2% attend a formal program such as Smoke Stoppers. The 4.6% effectiveness (impact divided by need) is high when we consider the former statistic. 3. Program costs have been kept to a minimum for three reasons: a. Smoke Stoppers' willingness to offer the program to the hos- pital at a reduced fee b. their cancellation of the hospital's contribution to the em- ployees' fee c. their willingness to assume costs for secretarial time, pub- licity, etc. As we can see, running Program A would have cost the hospital about three times as much. With Progr= B the costs would have been about 4h times as much. Smoke Stoppers is clearly the most efficient program. 4. Not only is Smoke Stoppers efficient, it is also cost-effective. This is surprising, because although group teaching methods are usually more efficient, they are not always more effective (1:1 counselling is usually more effective). It is remarkable to see that a similar outcome with Program B, a 1:1 counselling program, would have cost us about 7~ t:Cmes as much. , I a I I ~ d I I E 1.. L L *Subatit'.s3 by Am Quigley, Flealth Fducatar, St. Joserh Mercy Hos-Dit:al, Ann Arbor ~ C1T 0~ L -202- O

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I U Researi:h has doc,.mtented that non-smokers .ive seven years longer than smokers and r,ui a lesser risk of acquiring certain chronic conditions such as lung cancer or emphysema. Nonetheless, these benefits are not immediate, and we would need a long-term pro- spective study to measure them. However, there are two i.=ediately tangible benefits which we can calculate. a. savings to the hospital for not having to pay wages for sick time b. savings to the employees who no longer buy cigarettes 6. In calculating_just the two benefits described above, we can see that after one year, for each $1 invested in the Smoke Stoppers program, $3.60 has been recovered as a benefit. This is a very favorable cost-benefit ratio when compared to the other two pro- g='sms Over time and with further study it should be possible to document the savings from a. fires prevented (Smoking is the second most frequent cause of fires in homes.) b. deereased hospitalization (Smokers are hospitalized 1h times more than non-smokers.) Adding these cost savings to the savings mentioned in Sa and Sb, it will be possible to demonstrate an even more favorable cost-benefit ratio than 3.6/1. -203-

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*Cost-Effectiveness and Cost-Benefit Computations for Smoke Stoppers Program Compared to Two Othor Popular Smoking Cessation Programs Smoke Stoppers Prograw A Program 8 A. Need (estimated population eligible) 8751 8751 8751 B. Reached (attended)2 125 1253 1253 C. Coverage (R/A x 100) 14% 14% 14% D. Impact4 40 345 256 i @. Efficacy (D/8) 32% 27X 20% F. Effectiveness (D/A) 4.6X 7 3.9% 2.9% C. 1'rograiu CoatB $ 4,820.00 $13,603.50 $22,672.50 11. I. I:fficlency (C/g) Coat-effectiveness (G/D) $ 38.56/client $ 120.50/outcome $ 108.83/elient $ 400.10/outcome $ 181.38/cllent $ 906.90/outcome J. Uenefita 9 $ 943.20 savings in lost work days $16,352.00 savings from not buying cigarettes $ 801.72 savings in lost work days $13,899.20 savings from not buyiny cigarettes $ 589.50 savinEs in lost work daya $10,220.00 savJngs from tiot buyJng c1gilreLtcs K. Cost/benefit (J/C)t0 3.6/1 1.1/1 ,5/1 0509V9SA Computations done for St. Joseph Morcy Hospital, Ann Arbor, Michigan by Aiuno4 (hilgluy. August 28, 1980. ...._ ...... ..,OM r--- ~-- f.~... ...... ~-- ~--- L,~`--- r---- ~-- r--- rw

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1 Out of 2,624 SJMII employees, approximately 1/3 (875) are smokers, according to national utatistics. Total attendanca of St. Joseph 1lercy tiospital employees and spouses in Smoke Stoppers program from 1-1-79 to 12-31-79. 2 3 Ilypothetical attendance if program had been held at SJMI1. 4lmpact - outcome - client who has maintained non-amoking behavior for at 5 Uased on program success rate of 27%, as documented in the literature. 6 lfnsell on program success rate of 20%, as documented in the literature. 7'fhls ia a high least one year. effectiveness rate when one considers that only 2% of those programe such as this. who want to quit amoking attend fornal OCost - contributions paid by SJl4i for each employee and spouse who went through progrnm. Hospital paid 69X of fee for euch employee and 50% of fee for each spouse, until September 1979 at which time Smoke Stoppers waived the hospital's contribution. Therefore, the hospital paid a partial fee for 84 employees and 5 spouses. Had the hospital utilized Program A or Program B, the same percentage probably would have applied. However, their program costa would have been higher. For example: Smoke Stoppers $ 80/client Program A $225/client Program B $375/client (based on a minimum of 3 sessions at $125/session) Also, it is not known whether or not Program A and Program B would have cancelled the hospital's contribu- tion in September. These statistics are based on the conjecture that they might have done so, due to SJM1I support and number of progrum enrollees. However, cancellation of the hospital's contribution clearly wukes the Smoke Stoppers program all the aore cost effective for the hospital to run. 'i'Iiere are no otlier program cnacs. All costs for secretarial time, publicity, room rental, etc., are billed co Smoke Stoppers. 91(eduction in costs due to deaths and disabilities ia very speculative. These are long-terru benefit5 which can only be measured by a prospective study. Therefore, take tangible benefits which can be measured immediately, auch as a) Suvin6s in lost-work days (1 smoker quits smoking - 3 lost work days saved per year) (benefit to the hospital) (as docuunented by an I1.@.W. study) b) Savings from not buyinp, cigarettes (before the program clients smoked 14 packs cigarettes/day) Calculate on basis of 1 pack cigarettes - 75C- (benefit to tlie progrum participants) ' TS0969S9

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3 I For example, with Smoke Stoppers 40 employees stopped emoking x 3 120 work days saved x 7.86/hr (average hourly rate for employees) $943.20 saved by hospital 10 Cost benefit ratio for Smoke Stoppers,reade: For each $1 invested in the program, $3.60 are saved. Therefore, the higher the number in the numerator, the greater the coet-benefit. The cost benefit ratio should be at least 1/1 for a program to break even. With hypnosis this is not the case. For each $1 invested in the pro6ram, only 50C iy recovered as a benefit. 1 zsosPsse , _ r--- E::~r---- r-- ~-.- r--- ~- r-- Q.-

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H i I l ( STATEMENT OF W. A. WICKHAM, GENERAL & LEGISLATIVE COUNSEL MICHIGAN STATE CHAMBER OF COMMERCE TO GOVERNOR'S CITIZEN PANEL ON SMOKING & HEALTH WEDNESDAY, OCTOBER 8, 1980 MR. BARKER AND PANEL MEMBERS - YOUR LETTER, MR. BARKER, OF SEPTEMBER 26, 1980 WAS RECEIVED BY THE STATE CHAMBER ON FRIDAY, OCTOBER 3, (mailed on October 2) REQUESTING TESTIMONY "ON A VARIETY OF ECONOMIC, LEGAL AND EDUCATIONAL ISSUES RELATED TO "SMOKING", IN FIVEMINUTES OF ALLOTED TIME. YOUR NOTICE DID NOT SET OUT ANY AREAS OF RECOMMENDATIONS THAT THE PANEL HAS UNDER CONSIDERATION. FROM MY REVIEW OF PRELIMINARY MATERIALS PROVIDED BY MR. FONG, AND DISCUSSIONS WITH A PANEL MEMBER, THE STATE CHAMBER HAS A SERIOUS CONCERN WHICH I WILL OUTLINE WITHIN THE FIVE MINUTES ALLOCATED. THE MICHIGAN STATE CHAMBER OF COMMERCE UNDERSTANDS, AS PART OF YOUR RECOMMENDATIONS TO THE GOVERNOR, YOU ARE CONSIDERING PROPOSALS TO "PROTECT NON-SMOKERS FROM SMOKERS IN PUBLIC PLACES AND PLACES OF EMPLOYMENT". IT IS MY UNDERSTANDING THAT THE PANEL WILL CONSIDER THE INCLUSION OF A DRAFT OF A LEGISLATIVE BILL AS AN "ILLUSTRATION" OF THE TYPE OF LEGISLATION THE PANEL WOULD RECOMMEND BE ENACTED BY THE MICHIGAN LEGISLATURE. THE PURPOSE, AS PREVIOUSLY STATED, IS TO BE ACCOMPLISHED BY ADDING A NEWPART TO OUR NEW PUBLIC HEALTH CODE, RELATING TO "INDOOR AIR". THE STATE CHAMBER HAS TRADITIONALLY MAINTAINED THAT THERE IS AN IMPORTANT AND WIDE DIFFERENCE BETWEEN "PUBLIC AREAS AND PRIVATE AREAS," INCLUDING PRIVATE AREAS OF EMPLOYMENT NOT AVAILABLE TO OR USED BY THE PUBLIC IN CARRYING OUT THE EMPLOYERS BUSINESS PURPOSE. IN THESE FIRST OR "PUBLIC" AREAS WE HAVE CONCURRED IN THE ENACTED LEGISLATION, RELATING TO SMOKING CONTROL IN RESTAURANTS, HOSPITALS, NURSING HOMES, TRANSPORTATION, AND ELEVATORS, AS BEING REASONABLE. -207-

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I , , AT THE SAME TIME, WE HAVE STEADFASTLY ~1AINTAINED THAT OTHER PLACES OF PRIVATE EMPLOYMENT BE SUBJECT TO REASONABLE WORK SAFETY AND HEALTH RULES, AS PROVIDED UNDER THE MICHIGAN OCCUPATIONAL SAFETY AND HEALTH ACT. WE WILL STRONGLY RESIST ANY RECOMMENDATIONS FOR LEGISLATION THAT WOULD, IN ONE BROAD DEFINITION OF "PUBLIC" INCLUDE ALL PLACES OF WORK. PARTICULARLY, IF SUCH "PLACES OF WORK" ARE TO BE MADE THE SUBJECT OF SEPARATE RULES, AND REQUIREMENTS OUTSIDE OF THE ESTABLISHED APPLICABLE HEALTH AND SAFETY RULES, AND THEIR CURRENT ADMINISTRATIVE PROCESSES OF ENFORCEMENT. FURTHER, WE WILL STRONGLY OPPOSE LEGISLATIVE PROPOSALS THAT IMPOSE NEW AND UNNECESSARY COSTS ON EMPLOYERS TO MEET SEGREGATED REQUIREMENTS IN THE ABSENCE OF ANY RELIABLE DOCUMENTED PROOF OF EMPLOYEE HARM OR BENEFIT - OTHER THAN TO SATISFY THE APPARENT MOVEMENT TO BAN ALL SMOKING IN ANY PLACE. EMPLOYEES ARE CURRENTLY PROTECTED BY MIOSHA HEALTH AND SAFETY RULES, INCLUDING AIR STANDARDS. FURTHER, MANY BUSINESS PRACTICES AND POLICIES ARE ESTABLISHED, AND MANY TIMES, DICTATED, BY COLLECTIVE BARGAINING AGREEMENTS. THEREFORE, IF THE PANEL IS CONCERNED WITH ALLEGED EXPOSURES OF NON-SMOKERS IN THE WORK PLACE, THEN SUCH RECOMMENDATIONS SHOULD BE ADDRESSED TO THE DEPARTMENT OF PUBLIC HEALTH TO BE CONSIDERED UNDER MIOSHA RULES, AND NOT CREATE A WHOLE NEW SECTION OF BUREAUCRATS, TO ADMINISTER AND ENFORCE A SO-CALLED INDOOR AIR ACT. YOUR PANEL MUST CONSIDER THAT THE STATE OF MICHIGAN IS TRULY a I i I I i d I I E EXPERIENCING WHAT THE MAJORITY OF MICHIGAN EMPLOYERS HAVE KNOWN FOR A LONG L TIME REDUCTION OF REVENUES. . . SO THE STATE LIKE BUSINESS MUST NOT BE SADDLED WITH NEW, UNNECESSARY EXPENSES, NOTHWITHSTANDING A PRESUMED NOBLE ~ PURPOSE, WHEN A MECHANISM IS ALREADY IN PLACE. FURTHER, ALL SUCH LEGISLATIVE PROPOSALS SHOULD NOT ADD NEW CIVIL ACTIONS L SOLELY AGAINST EMPLOYERS, WITH COSTS AND ATTORNEY FEES PERMITTED TO BE C11 ~ AWARDED ONLY TO THE COMPLAINANTS. THERE IS TOO MUCH LITIGATION TODAY, BOTH "o' ~ BY AGENCIES AND"PRIVATE GROUPS. IT IS THIS SORT OF PROPOSED LEGISLATION THAT C~l1" ADDS FURTHER OBSTACLES TO THE ABILITY OF PRIVATE, JOB PROVIDING, TAX PAYING -208- 1 L

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I i BUSINESS TO ENTER, EXPAND OR REMAIN IN MICHIGAN. AND IF PRIVATE BUSINESS AND INDUSTRY CANNOT PAY TAXES, GOVERNMENT, INCLUDING THE DEPARTMENT OF HEALTH CAN'T FUNCTION, AS THE SOLE SUPPORT OF GOVERNMENT IS FROM "TAXES" GENERATED BY BUSINESS, INDUSTRY AND INVESTMENTS ...AND MICHIGAN CAN'T PRINT MONEY, AS YET, AS IS DONE IN WASHINGTON TO MEET THEIR BUDGET. THE MICHIGAN STATE CHAMBER OF COMMERCE IS NOT TAKING THE SIDE OF 1 NON-SMOKERS VERSUS THE SMOKER, BUT ADVOCATES FOR EITHER SIDE PROPOSE WE BECAME VITALLY CONCERNED WHEN THE LEGISLATION THAT ADDS NEW BURDENS AND ~ , ~ I COSTS ON OUR OVER 6,400 BUSINESS AND INDUSTRY MEMBERS, WHEN CURRENT LAWS AND RULES COVERING THE WORK PLACE ARE OR COULD BE UTILIZED TO MEET ANY ALLEGED CONDITIONS. , I HOWEVER, IF THE DRAFT OF THE PREPARED LEGISLATION TO BE USED FOR "SUCH ILLUSTRATION" IS THE SAME AS THE DRAFT OF A PROPOSED "CLEAN INDOOR AIR" ACT, THEN YOU CAN BE ASSURED OF THE STRONG OPPOSITION OF THE STATE CHAMBER OF COMMERCE, AS THIS PROPOSAL INCLUDES ALL OF THE OBJECTIONS I HAVE STATED, PLUS MANY MORE. I WOULD URGE YOU TO MAKE YOUR RECOMMENDATIONS AND LEAVE THE DRAFTING OF SUCH LEGISLATIVE PROPOSALS TO THE LEGISLATIVE SERVICE BUREAU. WE TRUST SUCH RECOMMENDATIONS WILL CONSIDER THE IMPORTANT POINTS AND OBJECTIONS I HAVE STATED TO YOU IN THIS BRIEF PRESENTATION. IN CLOSING I REMIND YOU AGAIN OF THE FINAL IMPORTANT CAVEAT BY MY GOOD FRIEND DR. REIZEN, IN HIS CONCLUDING REMARKS TO YOU AT THE CONVENING OF THIS PANEL ON JUNE 19th: "ONE FINAL CAVEAT, WHEN YOU SIT AT ANY ONE OF THE MANY BOARDS, COMMISSIONS, AND COMMITTEES THAT ADVISE ME, YOU ARE REPRESENTING THE ENTIRE STATE OF MICHIGAN AND ITS PEOPLE. I ASK OF YOU WHEN YOU MAKE DECISIONS THAT YOU ASK YOURSELVES, WHAT IS IN THE BEST INTEREST OF THE NINE PLUS MILLION PEOPLE IN THE STATE. THIS IS A- DIFFICULT TASK TO UNDERTAKE AND A CHALLENGE THAT MUST BE TREATED WITH MUCH RESPECT." -209-

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I IT IS THE POSITION OF THE MICHIGAN STATE CHAMBER OF COMMERCE THAT THE "HEALTH" OF THE MICHIGAN BUSINESS COMMUNITY IS, OF NECESSITY, ALSO IN THE BEST INTERESTS OF ALL THE PEOPLE IN THIS STATE. I I I I I I i I I L L -210-

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.~...,_ . :.~.. .,_.. _,.. ,_ .., t o . ~ Z . ~ T.^ w- . -. ~ . .. `. 0 ... _.. wGr11._ rr ~_.. . L . r -3 . ^ ... ~~. r-..,.~ A 1C.-- ~ . t.. _': J-,d.._, 4 ^_a-_a.... .._- _ a-., ...-- --; . n 2 1

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F U l October 14, 1980 Mr. Ben B. Barker and Panel Members Office of Health Education Michigan Department of Public Health 3500 N. Logan P.O. Box 30035 Lansing, MI 48909 Dear Mr. Barker and Panel Members: General Telephone Company of Michigan 155 E Ens Roaa Musxegon Liicnigan :9-4s3 (616)798-5a1 ' I received your letter of September 26 and attended your October 8 meeting at the Michigan Department of Public Health. Quite frankly, after sitting through your meeting and listening to the testimony, I am concerned about the direction the citizens panel seems to be taking. . In any event, I would ask you to carefully consider any recommendations by your panel that would add additional financial burdens to business and industry that must ultimately be borne by the public. Additional financial burdens to a company such as General Telephone, with over 300 buildings in Michigan, could be particularly onerous. Y will be looking forward to your report to the Governor and trust that if the measures recommended by your panel are stringent and expensive to implement that the medical data and expert testimony supporting them will be of unquestioned validity. n RAYMOND G. GONCZ Governmental AffWiX~s Manager. RGG kj :6 A part of General Te!eohore & Epccronics -212- I I I I I j F L L

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~ichigan Zicensed lgeverage 1'¢ssociAtion 531 SOUTH WALNt`t STREET TELEPHOyE (AC; S 1') 182L0803 LANSI%G. %1IC111(:A.S 1M933 Mailing Adltess P.O. Boc 10043 Lansing. NI 48901 Y - PRESIDE.% T DOtiALDE.CLARK h'.t TlON.tL LICEVSED BEVER.1GEASSOCId TlON D/RECTOR Ernest Swanton w..... AL TER.%'a TE DIRECTOR Yorman Smith L..,~. t'1CE PRESIDEN7S Uwrsnce Gregory r~ Ra1mond Jablonski .w w.s Betty Smith t#~ ExECGTl t E BOa RD .t/EWBERS Nae Benham v..., Vinct Catapano nxl~ Jim Dammann L..... Tom Dunieary a.~ ~d Elderida ~ J..~. - Jerry Long Ted `1etzYer P1.....N SaU> Morey L .- LYI Patty ylorrow L,.~ Ed Mosteiko n.... George Parlmer S.IW! \M 4 A.n/ Bob Popp L~ Luke Sanak L. H.L. Tom Smith A mw..-- Lois Warren 0'-w Bob Wieland M. G. Wanda Williams 4rwM C....+ Stan Wisiaski (ieV Rwyr BOa RD OF GOVERNORS `orman Smith. Chalrman (R.Md1 Ed Tril . ~,. ore. + LMI Lea S(ainer Gwen Cheek 6 ~ -2.L3- Aa Aft111ate o( tht Vationat Licensed Be.eraee .%uoeiatiun. Alec.edna. Y A" L PRESIDE.NT PROTEA! SECR£Ta R}" TRE.aSC RER E.1 £CC Tlt t hlRh.( 7l)R HERBERT C. TL'RLEY HAROLD PALA[A` ROD BRON% ~ SYWI SH. t/I/K CJU+Rf ) ,0..- T0: Ci.ti=ews Pane,e on Smofz.ing 5 Heae..th FROM: Xkch.i.gan L.i.eenaed Sevena.ge Aaaoc-i,at,iort Stl8.7ECT: Panee Repott S' IUuattation' Aa an asaoc,iu,tion nepaehenting beveJtage .P,icenaee-s actoaa .the s.tu,te o5 ,tkchigan, we wou.td tifze to Keg.i.a-ten ouA op,ooal.tZ.on to any Ktvtthe2 govetntmen.t n.egu.Q.a,Lf.ona which aK,Q,e .ut appLi.ca,tion add to the atAeady h,tgh coa.ta o5 do.tng bua-i.neao .i.n .th.i,a ata.te. Remembe2 these c.oats mua.t be paaaed on to the eonbumen. A nev.tew 06 ma.telr,La,ea to be aubmi.Lted to the Govennon 604 conai.deuLt,i.on, ou.t,t,i.nea aevenaPt aea,tun&s which .i.n oun op.un.r_on ane eompee.te,£y umeaaonabte and wou.Ld be .impoa-6i..b.2e to enaonee. Let ud- atYt won.k .tcwand a neaaonabte, nea.LLa.Lie pnogn.am whi.ch witt aCComp.e,Ga h what we a,tt ukLYbt - C,eean a.Clt. Thanfz you Son youn conaidena,tion, l ' ~ 1 , R.L.'Rod' BRown, Execu,t,Lve II.vicec,ton

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: :r..,..Gf. ~..,.r...~. Allegan iorna Kent Lake Mason Mecosta Montcaim Muskegon Newaygo Oceana Osceoia Ottawa , I I CC ~ Leslie V. Spriggs. 0.0.. President Donald 8. Birtwistle. Pirst Vice President Bemaoine J. Hednck. Second Vice Presfcent Jessie F. Dalman, Secretary William J. Downer. Jr.. rreasurer Philip E. VanMeest, E.cecutive Oirector VJ 0 -214- West Michigan Health Systems Agency /s,/, /./. -/ u~ii'6 "w..Gw./ - i~..+.~..~.. l.rY.. ~..d.! 300 Peoples Building, Grand Rapids, Michigan 49503 616-459-1323 October 16, 1980 Mr. Sunny Fong Office of Health Education Michigan Department of Public Health 3500 N. Logan P.O. Box 30035 - Lansing, Michigan 48909 Dear Mr. Fong: 115111111111111 This is in response to the invitation of Ben D. Barker in his letter of September 26, 1980, to submit testimony to the Citizen's Panel on Smoking and Health. The Health S stems Plan for West Central Michigan emphasizes the signl i.cant impact smoking has on heart disease, cancers, and chronic respiratory diseases in particular. The Plan calls for more attention to preventive-efforts to reduce smoking and other un- healthful behavior: health education in the schools, community, and both primary and specialized health care settings; health pro- motion programs in places of employment; and a stronger primary care system that emphasizes prevention. We believe there are two key problems with many educational and other prevention efforts: 1) there is too little evaluation to lead us to the most effective approaches; 2) the efforts are vitiated by not being coordinated with reinforcing programs, and they are often abandoned or replaced after only a short trial. The WMHSA has developed a Cardiovascular Disease Prevention Project Plan (Study No. 80-5) which sets zort t e design or a pi ot pro- ject for three communities with an areawide component. It would coordinate the range of prevention activities from general educa- tion through rehabilitation; it would continue this community-wide OFFICERS: I ~ I 1 I I di I I I L

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I t Mr. Sunny Fong October 16, 1980 Page Two effort over a long period; and it would include a significant evaluation component. It is built on research which has already validated the approach, but it applies to a larger area. It spe- cifically identifies smoking as one of the relevant life-style- related risk factors in heart disease. While it focuses on heart disease, the approach has-much broader applicability. We would recommend this kind of approach to the Panel: coordinated, long-term programs, subject to evaluation of both the short and long-range impacts. work of the panel, please feel free to call upon us. We appreciate the opportunity to comment. If we can support the Sincerely, Director of Planning Thomas H. Logan TFiL/hb cc: Ann Curtis Donald Wideman Attachment

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Michigan Academy of Family Physicians ,f I I I } 16 NORTH HOMER. SUITE 107 October 17, 1980 Rhonda Runner 3500 North Logan P.O. Box 30035 Lansing, MI 48909 Dear Ms. Runner: - LANSIIrG.M1CHIGAN .t912 PMO!4E (St7) 10HN M. 6ATTLE. yD. s![.. aa XU Il1OlM BERNARD 1. a'OODIEY. YD. v1Q 7KA[I TALYTUII ROlERT 1. TOTEFF. YD. TIIlANIil fAGi.`/AW JJ72061 DONALD E. D.rTTT. * %ID. P.ST r.ulot" uLAJ1At00 HAIOLD P Rf vDR1tZ. M.D. Si[Z1TAa T POMK !Q LDRfTTAJOYCE inn.Irvi D1 atc-oa 1Awsa.c This letter will describe the position of DOC regarding Smoking & Public Health/ Safety. DOC is "Doctors Ought to Care", a physician-organized national non-profit organization with a`iichigan chapter originating in the Family Practice Residency Programs and the Michigan Academy of Family Physicians. DOC believes that the most significant reduction in mortality and morbidity in the general population can be achieved by prevention and elimination of specific poor health habits. This "New Public Health" must involve a direct attack against the disease-carrying factors in our environment. Cigarette smoking is a prime example of a preventable poor health habit. A physical and psychological addiction that'is very hard to break; smoking usually begins in the late pre-teens and the early teens. Smoking habits have been found to result almost entirely from the "Three P's" - Parental smoking, Peer pressure and Popular opinion. All children are at risk for later tobacco-related illness. The Three P's are the vectors - the carriers and spreaders - of this illness. Just as eradication of malaria depends on control of the vector mosquito, reduction of tobacco-related cancer, emphysema and heart disease must occur by-helping parents stop, reducing peer pressure, and developing a negative public view of smoking. ~ C1T It is DOC's belief that the $800 million annual advertising expenditures of the tobacco industry is extremely effective in portraying smokers as strong, macho, rugged, outdoorsmen and svelte, sexy, liberated, active women. Advertising is the single most powerful vector of tobacco-related illnesses. The $1 million spent by the government against tobacco usage is not effective. This is not because of the amount spent, but rather because of the use to which it is put.' The U.S. Government material is primarily informational in character and generally must be requested. Advertising, O N asuros WHO!~6LWY.1f.11D_Cw.14NCNLIAYG./OMiR.YD. G~M,.aOUtLttM LOD1R'.11II.L.rr.1~1LST~'[1M[LYD_G7.rr.IlA/uY[.7C7MQTL1.IL1rD_w~AnrJ01d1 Q,LLTYD.AI.. ~ hR:'~!'MIS Y.:oY. YD. CJr/~: Y(.1!<A1 N. ]IXN791/. IID. F~:G LDwAlDCOTSQm. Y.D. l~.~t OOUG.wiA RA17i.J/ D. M M~a OOMA(D L Y.C9, f VII, W-.~1GW[PM T. LATDOV. V D. Gr gba oascAas ro w.P. uaRi..n ousur.a a.u~. p6"T L YRU. CiO0t A. D[AM. Y D. 3w.dY OWLn t. ID10fT. r D. Cw~ WiDON .. NLLOU011 n. P..dw -21G- I I I I i 1 I I ~ L t

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II i Rhonda Runner, Page 2 on the other hand, is primarily emotional in character and is exhibited to the public without the need of request. Tobacco advertising was withdrawn from television at the request of the tobacco industry - why? Because the sparse, brief, non-prime-time counter-advertising had caused intermediate loss of tobacco sales in the affected areas. - DOC very heartily agrees with the drafted recommendations of the Citizens' Panel on Smoking and Health entitled Economic Recommendations, Legal Recommendations, and Additional Recommendations. These are dated respectively 8/27/80; 9/2/80 and 9/30/80. In addition, DOC would propose that public bars be required to have no-smoking areas with adequate ventilation. DOC would advocate prohibition of sale or dispensation of any form of tobacco, except on physicians' orders, in any hospital receiving state funds. DOC would also advocate the prohibition of smoking in public stadia receiving state funds and the sale of tobacco on any state-owned ground. DOC would encourage . that smoking does not take place on school grounds. With such measures, we would hope to make smoking less dangerous to others and a less acceptable behavior in public opinion. The DOC organization also agrees in principle with most of the recommendations regarding health department involvement; roles of colleges and universities, etc., included in a draft report received. Sincerely, We do feel however, that the strongest stress should be on preventative measures, not changing present smoking behaviors. Although the latter is an admirable goal, (especially in helping parents quit) the -return per dollar spent will-be far less than with the use of the former method. We heartily advocate a massive and prolonged counter-advertising campaign whose primary aim is not informational, but attitudinal in nature. The most effective usage of such advertising centers on the use of satire, especially directed against existing tobacco industry advertising. Non-smokers should be portrayed as attractive and smokers as unattractive in a variety of ways. Proven examples in several states across the nation have used bus stations, radio, buses, billboards, and posters for distribution in medical offices and schoolrooms, etc. In sum, DOC is a group of physicians and non-physicians who strongly feel that health habits are influenced primarily by emotional lures from advertising, and therefore should be developed in appropriate ways by the effective use-of counter-advertising. We also support the drafted recommendations stated earlier. . ~ 1 OLlQ n n rv^r i ~ ~`'t~~ ~J~~'t~C.~ t 1 ( ~ld'1l1 \ J. Byron WaY, thall, M.D. Chairman, Resident's Committee, Michigan Academy of Family Physicians Chairman, Doctors Ought to Care - ~ JBW:gk ~ L -217-

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i AMERICAN t LUNG ASSOCIATION of Michigan The Christmas Seal Peop/e, 403 SEYMOUR AVENUE. LANSING. MICHIGAN 48914 John C. Howetl. PhD Hmdew. October 22, 1980 f. I I I , i ( Ben 0. Barker, D.O.S., Chairman Governor's Citizens' Panel on Smoking and Health c/o Office of Health Education Michigan Department of Public Health Box 30035 Lansing, MI 48909 Dear Dr. Barker: . Sf7/<d1 's4l Robert G. Smith E.w,... o..v.. Although I have previously offered testimony on behalf of the American Lung Association of Michigan's Task Force on Smoking and Health, I would like to take this opportunity, as a concerned citizen and, coincidentally,.a professional health worker, to offer some additional comments. Despite notable progress in curbing the ravages of contagious respiratory diseases, like influenza and pneumonia, three other diseases have become more and more prevalent throughout the United States: emphysema, chronic bronchitis and lung cancer. Indeed, emphysema, an insidious disease which literally robs its victims of breath, is now the second leading cause of disability in.the United States. Yet, it is a disease that is largely preventable because the national statistic is that 95% of emphysema victims_are or have been cigarette smokers. Lung cancer killed very few people a century ago. Even in 1914, only 371 deaths were attributed to it; but by 1930, the figure had risen to 2,357. Today, lung cancer claims more than 64,000 lives a year. Even allowing for the growth and aging of the population and for improved diagnosis, the statistical trends reveal a major new health hazard. In seeking to explain such a tragic increase amid generally improved standards of health, we are struck by two phenomena: the enormous increase in cigarette smoking and the increase in air pollution. Without getting into a dissertation on the kinds of damage that inhaled smoke can do to the breathing system, consider some of the massive accumulation of statistical data from a great number of sources. f th f t S s are: ome o e ac Cigarette smoking shortens life. Repeated studies show that cigarette smokers (Z are much more likely than nonsmokers-to die before their time. ~ The more cigarettes a person smokes, the more likely he is to die early. ~ .~ O It's a Matter of Life and Breath /pt.dd i. 17WW the At.ena. Lwy A,waanoe melWe IOp.ffiWteO a..caam t1ra.,Mld tea U.3.. aat a m.emi wW.k th.Aawon TAOr.ac Socxl. _218_ i i i I d, , I L L

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Ben 0. Barker, D.D.S. Page 2 October 22, 1980 L The earlier in life a person starts smoking, the more likely he is to die early. The more a person inhales, the more likely he is to die early. A person who stops smoking is much-safer than if he continues to smoke cigarettes. Cigarette smokers are much more likely than nonsmokers to die from emphysema. Cigarette smokers-are much more likely than nonsmokers to die from chronic bronchitis. Cigarette smokers are much more likely than nonsmokers to die from lung cancer. There can be no question of the validity of these statements. Thousands of careful scientific studies have documented the evidence. There is not a medical or scientific agency which questions them, yet cigarettes are still advertised, sold and used everywhere. If some casual action, like eating parsley, were even suspected as a possible cause of three such deva-stating diseases as lung cancer, chronic bronchitis and emphysema, it is easy to guess what action would be taken. The very day the danger was announced, everyone would stop eating parsley. Soon the ship- ment and sale of parsley would be prohibited under the food and drug laws. How does cigarette smoking differ from parsley eating? In three ways. They are ways that make cigarette smoking much more difficult to curb. First, there is widespread opposition to banning, by law, anything--like smoking-- that is generally-considered a simple pleasure. When the United States-tried to ban alcoholic beverages by law, the result not only failed-, but also produced a number of unfortunate side effects, like bootlegging, smuggling and gangsterism. Accordingly, few voices have been raised to urge that cigarette smoking be totally banned by law. Second, many, if not most, smokers find it very difficult to stop smoking. Many people continue, even when they are so poor that they have to cut down on eating and other pleasures. When the cigarette supply is cut in time of war, people pay enormous sums for one pack. Even very sick people who know that quitting may save their lives, often go right on smoking when they would stop eating parsley without a qualm. Third, the growing of tobacco and the manufacturing and distribution of cigarettes are prosperous parts of the Arnerican economy. Henqe, there is powerful economic opposition to any proposal like control of cigarette adver- tising that might discourage smoking. In the years since the Surgeon General told us that smoking may be hazardous to our health, an increasing proportion of Americans have chosen to call themselves nonsmokers. The United States Department of Agriculture reports that today 98 million people over the age of 18 do not smoke. In 1964, two years before the Surgeon General tacked his famous warning on cigarette packages, 70 million persons were nonsmokers. That indrease in nonsmokers is roughly equivalent to the population of 23 states. -219-

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I Ben D. Barker, D.D.S. Page 3 October 22, 1980 Unfortunately, public policy has been slow to'follow the scientific community. Although there has been progress in the control of outdoor and indoor air pollution, it has been delayed by the inevitable conflicts between the need for economic growth and the need for a healthy population. Nowhere is the gap between scientific knowledge and public policy more dismaying than in the case of the cigarette. We know that the smoker who takes up the cigarette habit before reaching the age of twenty is the one who goes on to smoke more cigarettes for more years and who inhales more deeply. And the smoker most likely to be disabled or killed by cigarettes is the same person who smokes more cigarettes for more years and who inhales more deeply. We know that many thousands of Americans will die from' chronic lung diseases, such as emphysema, bronchitis and lung cancer. The evidence is quite conclusive that many of these diseases are aggravated, if not actually produced, by cigarette smoking, yet cigarettes are still advertised and sold throughout the country. It is, perhaps, sad that the tobacco industry has simply chosen to ignore the overwhelming number of studies which show that smoking definitely has more than an incidental relationship to many lung diseases and health problems. The general climate of acceptability of smoking is probably one of the strongest influences that makes smoking attractive, but acceptability is a social phenomenon and can be changed. It has been altered in many social and business settings. Public smoking is becoming rarer and those who smoke are often made to feel uncomfortable pr embarrassed. There is a real groundswell toward the social acceptability of the nonsmoker and the social unacceptability of the smoker. It just seems as if everyone smokes. The fact is that most people do not smoke. The heart of the nonsmokers' rights movement is an effort to protect the basic civil rights of nonsmokers. Foremost of these, of course, is the right to breathe clean air. Moral persuasion has not worked. Most smokers are not considerate of the nonsmoker's well-being. This must now be protected by intensified education and legislative support. There are changing attitudes on smoking in public, but we have only seen the tip of the iceberg. Smoking is no longer a personal right. It is instead a selfish invasion of another person's well-being. It has been said that smoking in public is a tyranny so complete that the victims are required to apologize to those who have assaulted them. That's how badly the public has been brainwashed by the tobacco companies. Nonsmokers have unwittingly allowed themselves to be on the defensive, always trying to prove that tobacco smoke is harmful. I submit that the burden of proof should be reversed and the smoker should have to prove that tobacco smoke is not harmful. Nonsmokers often fall into another trap. That is, the tendency to get into debates about whether smokers or nonsmokers constitute a majority. Although it is important to point out that nonsmokers comprise two-thirds of the adult population and most of the non-adult population, this misses the main point which is that we are trying to protect a civil right that cannot be taken away no matter who is in the majority and who is in the minority. The right to breathe clean air should be thought of in the same terms as the right to I 1 I I I a. I p I L L -220-

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I I I Ben 0. Barker, D.D.S. Page 4 October 22, 1980 freedom of speech. In the United States, persons do not have that right or lose it according to a vote. It is a consititutional right that cannot be taken away from anybody._ The Citizens' Panel has considered some very serious issues. You are to be commended for your thoughtfulness and sincerity. Personally and professionally I pledge to you my continued support and cooperation. heodore W. Beiderwieden, III Director of Regional Operations /gk

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I October 23, 1980 I I 1".r . Sonny Fong ~ Health & Education Department ~ State of Michigan ; Lansing, Michigan Dear Mr. Fong: In re,-ard to the Governor's Citizen Panel on Smoking and Health, it appears that this panel will recocmaend serious and restrictive legislation regulating smoking in the work place. The Redford Township Chamber of Commerce is not taking the side of the nonsmoker vs. the smoker, but rather with concern to added bur- dens and costs on 1,200 businesses in our area. Let it be noted that the Redford Township Chamber of Com:aerce strongly opposes legislative proposals such as this that impose new and unnecessary costs on employers. Sincerely, REDFORD TOWNSiiI? C'dr12BER OF C01C~ERCE ~'~~ Mark Scicluna, President MS : j . cc: Representative John 3ennect Senator Robert Geake oltejn6ct aam&s of eommczcc o f t4c QLniEcd cSEaEca -222- Phone: KEnwood 5-0960 26050 Five Mile Rood Redford Township, MI 48229 I I I I I L L

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I I i October 30, 2900 245 Second Street S+. Ie-.ace, Michiean 447R1 Mr. Sunny For.? C1+ief of the Office of Health Education State Health Deuartment 3500 North Loean Street Lansin¢, Michigan Dp:ar Mr. FonF, My wife and I have some deep cencerns about smokin¢. We are opposed to the unpleasant odor ~. smoke leaves on our clothes and body. When I an exposed to smoke, I develope a chronic smokers coue;h. Because of these problems we are forced to avoid many gatherings, public meetings, ni¢ht clubs i and restaurants. . . r i ~ 1 l ~. l To help aleviate these problemQ-wP would like to make the following recommendations in regard to smoking in public r 1. The existing smoking laws be more rigidly enforced. ISmokin¢ prohibited in food stores, certain arsas in restaurants, hospitals, schools, and other public bu ild ings. ) 2. Smokina be prohibited at all public -meetings. 3. Smoking be prohibited in public buildings except for smoking rooms. 4. Have smokine areas completely closed off from non-smoking areas in restaurants and night clubs. Sincerely Yours, ~ ow..~.....:., ab .- ~ . L Dick & Louanne Soczek ~ -223-

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Ay1ERICAN t LUNG ASSOCIATION of Michigan The Christmas Seal Peoplo 403 SEYMOUR AVENUE. LANSING. 411CHIGAN 48914 . 317/.t84-1341 fo ~ i John C. HowcU. PhD Nv.en.r November 3, 1980 Dr. Ben Barker, Chairman Governor's Citizens' Panel on Smoking and Health c/o Office of Health Education Michigan Department of Public Health Box 30035 Lansing, MI 48909 Dear Dr. Barker: At the October 29-30, 1980 meeting, the Board of Trustees of the American Lung Association of Michigan formally endorsed the work of the Governor's Citizens' Panel on Smoking and Health. We enclose the adopted resolution for the final report of the panel. Implicit tn this resolution is the continued support and cooperation of the volunteer and staff structures of the American Lung Associatiorf of Michigan. , Sincerely, John C. Howell, Ph.D. President /gk Enclosure 4j lt's a Matter oj Lrje and Breath roa.aea u 1W.. [M Awu,o. L.n A..oaabon mdree 2o.rr".0.noaaooW tOrorpwt the U3.. aM 4 mea.o/ +eawM. OM Aen.raa Twnoe Soo". -'Z'2`,- I f r L h i ~, !...rrw~a ~.~'y Robert G. Smich Eauwn. Ow.a«

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i I I I I AINIERICAN =;: LUNG ASSOCIATION of Michigan The Christmas Seal Peop(e.9 403 SEYMOUR AVENUE. LANSING. .`11CHlGAN 48914 . 5 17. 484-+54 l lohn C. Howell, PhD Robert G. Smith R.:+e.wr Eawvtn. DPnaor Whereas, the recommendations of the Governor's Citizens' Panel on Smoking and Health have as their objective the promotion of respiratory health, and Whereas, the Panel's recommendations provide the Governor with a variety of commendable initiatives which would contribute to the health and well-being of the citizens of Michigan, rD Therefore, be it resolved that the Board of Trustees of the American Lung Association of Michigan endorses in principle the report of the Governor's Citizens' Panel on Smoking and Health and urges the Governor to study its recommendations with care and implement a State program of action. It's a Matter of Life and Breath FwnWa sn 190a. the Amenon Lun, As.oounw ~nduae :AfW a(filuua aaaociamw., iMOU,now the U.S.. ana a meaho/ xaan. tn.Amaoe TAmnc Socwry.

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DRS. RASMUSSEN. HARRISON. KiM, DELAVAN & ROBSON, PC LODG[TT rROrESS1ONAL O/riC[ BUILDING - SUITE 2!0 GRAND RAPIDS. MICHIGAN 49506 TaLZnHOw[ (416) 459-7278 - RICHARD A. RASMUSSEN. M. 0. ROt[RT W. HARRISON. M. 0. YOUN S. KIM. M. 0. JAMES W. D[LAVAN. M. 0. LARRY J. ROBfON, M. 0. November 4, 1980 TMORAGC BUwoOIIf G.wDloVSCUU.A uwa[w 9MDaiCOIt I f I STATEMENT : I am a Senior Thoracic Surgeon practicing in West Michigan since 1946. I have seen the adverse health effects of tobacco on our people, especially in the respiratory, and the cardiovascular system as well as ocher systems. A large part of the work of health care providers consists of caring for these persons- the 1/3 of our adults who smoke. Our health care resources are unduly strained. The disability and early death amongst the smokers, and the economic cost area disaster. The cigarette, amongst the various forms in which tobacco, a poisonous substance, is used is the prime cause of the total problem. It is so because of availability, ease of use, and the violation of the respiratory system. There is an incessent promotion.of the product in spite of the obvious and known hazard. This has a great impact, especially on the youth of our country. This drug and, a related smoking product - marijuana - are dangerous, addictive and, once the habit is established, tend to be perpetuated with the resultant gradual development of serious disease. As a concerned physician, it is indeed discouraging to see this trend continue. During the past 34 years, I have also given much time to society and public community work, and was for nearly 6 years a member of our Michigan Air Pollution Control Commission - 1969-1975. In 1973, I sponsored a resolution prohibiting smoking at Committee Meetings. It was passed and the indoor air cleared substantially there, and soon also in other public places. An effective Preventive program is urgently needed in order to improve the health of our citizens and reduction of preventable diseases such as lung cancer. (which alone is expected to account for 100,000 deaths in the U.S. in 1980),other cancers, Emphysema, and cardiovascular and other body diseases; GI intestinal and GU tract, accidents and even fire ("due to careless smoking"). This is in the public interest. The need for a broad program is justified. It demands action by every means possible. These lare the recommendations which I would like to present to the Committee for consideration, and, hopefully, to include in its final recommendatiou to the Governor. 1. EDUCATION - a positive responsible program to expose the hazard and to dis- courage tobacco smoking should be developed. The help of the medical profession is available and should be utilized. The program should include assistance to the profession. 2) A meaningful tax on tobacco products, sales places, and all tobacco vending devices should be imposed. This should be high enough to discourageuse, almost prohibitive. The sales of tobacco, including vending devices, should be outlawed in public places, especially hospitals and any other health care -226- u d I I 1 t L_

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STaTEiE.`1T (conc) 2) Cont facilities in this State. The proceeds should be used to finance the Education Program, but more especially directed somehow to care for the tobacco victim, perhaps to assist the Department of Social Services with its expenditure for cancer, emphysema, cardiovascular disease, and the disabled as related to tobacco. This would lessen the cost born by the public - the non-smoker who works longer and pays more. 3) A Restriction on the advertising of tobacco products. The advertising is misleading and anything but the truth, except a small obscure standard requirement - "The Surgeon General Has Determined that Cigarette SmoRing is Dangerous to your Health". There is no other suggestion of the dreadful effedts of prolonged tobacco use. The distractive, unsightly billboards adorning our often beautiful Michigan roadways should be outlawed. Since the advertising of tobacco products was eliminated on Television, the industry has diverted more millions to the news media in promotion of tobacco products. A few newspapers refuse to accept such advertising but most others use the revenue to print excessive paper which adds to our solid waste problem and serves little useful purpose. Outright elimination on Michigan publications should be considered as it was on television, .perhaps coordinated with a national program. -~ ,rL. .~.. ~ G\ Richard A. Rasmussen, M.D. 1900 WEalthy St., SE Grand Rapids, Mich. 49506 { -227- S(/ \-_

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. -'-~ . n t ~?^-~ a~ IdK C ccz~:cca-~ ~' U. ~z ~ ".3aa3s .4 f I I I I

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856460"15

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85646076 I

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I I I r i Corresyoirience to the Citizens' Par:el John F. Banzhaf III, Executive Director Action on Smoking and Health Washington, DC Collet Guerard, Deputy Director Advertising Practices Federal Trade Comnission Representative Raymond W. Hood Lansing Gerald Hough, Director Department of State Police East Lansing John Insel, Section Chief Division of Food Services Sanitation Michigan Depar4nent of Public Health Lansing E.C. Mackey, Acting Comaissioner of Insurance Department of Connerce Insurance Bureau Lansing Walter Maner III, Executive Secretary Michigan Tobacco and Candy Distributors and Vendors Association, Inc. Ians ing Richard Rasrmissen, M.D. Grand Rapids Greggory Smith, Publisher Upnorth Publications, Inc. Michael R. Spaniolo, Council Chairman Michigan Tobacco Industry Advisory Council Lansing R. Douglas Trezise, Deputy State Treasurer Department of Treasury Lansing Kenneth E. Warner, Proj ect Director Governor's Citizens' Panel on Smoking and Health University of Michigan, School of Public Health Ann Arbor Beverly Wiener, Director Department of Comnerce Health Insurance Compliance Division , ~ ~ i L - _ -230- ,._._.._.~~-- _- -

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I r.MCMarl OEPART;,tENT CF PUSL1C HEALTH hl, 5. Rvten, h9.0. O-rector TO: Kenneth L. Eaton, Admir.istrator Office of Substance Abuse Seivices FROW h`illiam Clex o,ssociate Director Office of Local E?ealt.z Services DATE: 6-16-301 I SU3IECT: Citizens' Panel on Smoki*:g and Health The Governor has recently appointed a Citizens' Panel on Smoking and Health. The Panel's task is to study various policy options and make - recommendations that will reduce the incidence of tobacco-related illness and death. The Panel's recorc:end,ations will be submitted in a report to the Governor by November 15, 1980. The Office of Health Education will act in the capacity of staff to the Panel. Ihe issues and tasks that ti.-ill be dealt with in the Citi zens' Panel may be directly related to the activities within your Bureau. I would appreciate it if you uvuld nominate a representative from your Bureau u.-ho will work closely with the staff from the Office of Health Education to ensure the development of coordinated input from hIDPH _to the Panel by providing valuable information and resources to the staff on Bureau objectives and activities in this area. This "in-house" group should enhance the quality of recomendatiens that uTill be proposed to the Governor in November. Please have your representative contact Sunny Fong at 3-9437. WC: cb I I r I I I i. I t L -231- k21 '

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f F I F I I I WP W ,~ ~.i PUBIICATI0N5. INC. 106 N. BrldOe 5?. 112 E. itat. St. 311 N. Cadar St. BMlalra. Mlchlpan s%15 Mancfldna. Mict+lQan 4" Kalkaska. Michigan AfA6 (614) 371il73 (616) Si7W1 (614) 2S5r600 iltn ces ,~_._...ar. : ,:, 'T e:-- ~~ :r. a1 :1zaie !iticer b=7 r(jJl f'Zbio.1, as C~ U; rCz.s t rar el cr. Jz.c,:f r..; arc :.aa=tQ aL ~IS :iit"n a G3°T' 90r99 C1' p°r9Cat1. :° ;reL t.:3t _ ~ 1.,,7,it _ . 1' ) .~ ':her + accepted t.:Q a- :ciTltrer* tc t;'e cG;: t_ L ~ ,.ar.s+ r ._~s r_c:., + r._~ dic. 't 3J3.^u 1_'.Ca it :.~cu1d inter£o:^e .:' t: ,~ 3C:~edl:le. . -~,er. c~: ~:c-- ._O::A'v3a, 3iT:ce t:i?t t~.^.Q 19 ~'':»72 .^.C~~aC `:._ `@@ ^L :iiC'~t~CY 3 tO a;- cut-ut. _;:nt :~cv , tAFled :.*ttc t~e ~-re , s.4 -=:er ,esc:: sc;scr , :~~s dast_ca1~~y 1:_1 t'' -F cf ar: a~:~a7s . :tec sr:er, }- e ; ubli3 :?r- bu s i:: Q sss itt 3=:7 : ir": J3li@f t:'C} t':e rec.^..er.c:it'_cris .T"ie:I'^ f.^.i''^L~ ated t'-- -1 - - ...tiz--rst -..ot.:r_ci1 w'_12 play a rafcr rcie ir Trcfictir.- 3o,.r.d , . :;^8 ci ti~' ` + ~ ... z::r.s c __ chi;ar in tha ?r=rs `c : cr-e . i y- c: l-* :e,~., t° a: 1 cc lc' 1 t t7: -, : "e .^..C-@ =i.'i1: ::_'j:: ::s tc --c:, Sr-_*he :cl.;::ci=. I tC "1:CHiGr' A ,: P!,?L!C HEA! i H JUL?-'_1 !°c"U Ur=iCt 'JF ::C1.1 HEAITH S=?YtC-ES ru.usNSRSO. ~ Afltr(1T1 GOYRty Nwwf lo~ & ThM Ka/kalk/afl rMMIy SfrttCtNr . WIflfK Up NOrftl SI/AI~ Up NOrfR -232- .....~..v~ . ..~.d~" 7L'.w:. . .

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STATE OF M1CHIGAN !:OVERP:OR DEPAR T ivlENT Ot= STATE POLICE 714 s. HARRISON RD.. EAST LANSING. MICHIGAN 48823 COL GCRALD L MOVGN, OIRtCTOR July 30, 1980 Maurice S. Reizen,' M.D. D irector Department of Public Health 3500 N. Logan Lansing, Michigan 48909 Dear Dr. Reizen: Upon receipt of your letter of Julv 23 regarding the recommended five-cent per pack increase in cigarettes, I asked the commander of our investigative services to check on any potential impact this would have upon cigarette smuggling. I have now been advised by both my staff and the U.S._ Department of Treasury, Bureau of Alcohol, Tobacco, and Firearms, that it is their combined belief there would be no substantial impact upon smuggling should the price be raised. They feel that cigarette smuggling in Michigan is at a minimum and that the increased cost of gasoline and the lucrative narcotic business is also causing further reduction in cigarette smuggling. - Thank you for allowing us to comment on this recommendation. lf we may be of any further help, please do not hesitate to call on us. -233- 0 F i r I I I I I I j i t I :

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i I I ACTION ON SMOKING AND HEALTH 2000 H Street, N. W. Washington, D.C. 20006 (202) 659-s.?10 August 12, 1980 Mr. Sunny Sun Nai Fong Chief, Office of Health Education State Department of Public Health 3500 N. Logan P.O. Box 30035 Lansing, Michigan 48909 Dear Mr. Fong: I am happy to respond to your letter of July 31, 1980 and to very briefly answer the questions you raised. As you may know, I was the attorney who applied the fairness doctrine to cigarette advertising, and our organization has been involved in and particularly interested in that matter ever since. 1. So far as I am aware, there is no general legal impediment to states' or state agencies' purchasing broadcast time. However, you may wish to get an opinion from your own Attorney General as to whether any one particular statute or judicial opinion prohibits it with regard to the State of Michigan. 2. I am not aware of any state or state subdivision which has attempted to purchase broadcast time for antismoking messages. 3. I do see some serious problems with the proposal that the State purchase broadcast time to present antismoking messages. First, unless very large sums of money are spent, the impact may not be significant. Although cigarette manufacturers are prohibited from advertising on the radio and television, they are currently spending at the rate of over $900 million a year in cigarette advertising which appears virtually every- where you look: billboards, newspapers, magazines, point-of-sale, etc. Second, if you begin purchasing time for such announcements it may be more difficult for the State of Michigan or other private organizations con- cerned with smoking to persuade broadcasters to make time for antismoking messages available free on a public service basis. Indeed, stations might cut back on the limited time they already provide for such messages. Third, if the State simply presents the same kind (generally low-key, inoffensive, nonadversarial, etc.) of antismoking messages as are now being distributed by major antismoking organizations, there will be little net gain. 4. Contrary to the statement in your letter, broadcast licensees of the Federal Commimications Commi.ssion do have an affirmative legal obliga- tion to present programming responsive to the needs of the community and dealing with issues of interest to the cvmmunity. One of the most popular ways of attempting to discharge this obligation is to broadcast public service announcements. In addition, broadcasters have an obligation to affirmatively seek out responsible citizens and spokesmen for various interests to determine the issues as to which they should address their programming. Legal Action and Education on the Hazards of Smoking Protecting the Rights ot the Nonsmoking Ma/ority -234-

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Mr. Sunny Sun Nai Fong August 12, 1980 , 5. Thus, an alternative means of getting effective broadcast time for antismoking messages other than a comnerciai purchase would be to take the following steps: A. The Office of the Governor, the Department of Public Health, all other State agencies concerned with health, environmental protection, fire safety, etc., and, insofar as possible, the individual counties, cities, etc., within the State should notify radio and television stations serving Michigan that smoking is the number one health problem and that programming in the form of public service messages,-among others, should be very sub- stantially increased. The letters should be sent by Certified Mail, Return Receipt Requested,-with a carbon-copy to the Federal Communications Commis- sion (1919 M Street, N.W., Washington, D.C. 20554] asking that the letters be placed in the stations' files. The letters should further state that if the station does not fulfill its responsibility in this area, additional action may be-taken. Although it need not be spelled out, this "additional action" would-be an objection to the renewal of the license of the station. B. A concerted effort should be made to get similar letters sent by all the major health organizations, religious organizations, environmental, safety, etc. organizations, and groups in Michigan to the stations. - - C. Some mechanism should be set up so that announcements appropriate to the audiences of the individual stations are available and to serve as a distribution point for such messages. D. If possible, stations should be monitored for running anti- smoking messages, and requests can be made for them to provide this infor- mation voluntarily. In addition, their program logs and records are, by law, available for public inspection. - IF-YOU TAKE THE STEPS SUGGESTED ABOVE, I WILL VIRTUALLY GUARANTEE TSAT YOU WILL RECEIVE FAR MORE BROADCAST TIl`SEE FOR ANTISMOKING MESSAGES THAN YOU COULD POSSIBLY PURCHASE FROM THE STATE'S LLiITED FUNDS. MOREOVER, YOUR EFFORT MIGHT WELL INSPIRE SIMILAR CAMPAIGYS IN OTHER STATES, AND COULD EASILY HAVE A S.10W-BALLL*1G EFFECT. 6. At the moment I do not believe it is politically feasible to attempt to get Congress to pass a bill providing taa incentives to encourage radio and television stations to broadcast antismoking messages. Indeed, until the major health organizations make a strong commitment to become involved in lobbying, no plan involving Congressional action has much political feasi- bility. 7. Contrary to the statement in your letter, stations were never C!1 required to provide equal time for antismoking messages. Under the provi- 09 sions of the fairness doctrine they were required to provide only a reason- ~ able period of time to respond. I do not think it would be possible for the State of Michigan to attempt to apply a fairness-doctrine approach to the 4 co print media. N I I II I I I j I I t L -235-

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i ar. Sunny Sun :Iai Fong August 12, 1980 While I am delighted to learn of your group's interest in this area, I would like to respectfully suggest that you seem to be exploring a strategy which might be one of the least effective. Trying to compete in the advertising arena with the immensely well-financed tobacco industry is almost certainly a losing proposition. Fortunately, there are, I believe, many other steps which can be taken which.would be far more effective in reducing the problem. The following are only a few suggestions: 1. Secret documents obtained by the Federal Trade Commission from the tobacco industry confirm the view long taken by ASfl, the FTC aad other organizations that the nonsmokers' rights movement is today the major force in persuading people to quit smoking or never to begin. Establishing and enforcing an effective program limiting smoking in places of public frequence would be the most effective step you could take in reducing smoking in the State of Michigan. In addition, it would have the strong support of most nonsmokers, and would help to protect the rights and health of the majority of the State's citizens who have wisely chosen not to smoke. 2. Most people begin smoking at a very early age: one out of five 12-year-olds is already a smoker, and most persons who will become smokers are well entrenched into the habit by age 16. One of the reasons is that, despite state laws restricting the sale of cigarettes to minors, cigarettes are, in fact, readily available to any child tall enough to put a coin in the slot of an unattended vending machine. We would suggest, therefore, that you take steps to prohibit the sale of cigarettes through vending machines either by adopting a statute to that effect or by initiating criminal pro- ceedings in situations where persons are selling cigarettes to minors through vending machines. Getting cigarettes out of vending machines and otherwise cracking down on the sale of cigarettes to minors would not prevent the problem of teen-age smoking any more than similar measures have prevented the problem of teen-age drinking, but such measures would make it far more difficult for teen-agers to smoke cigarettes on a regular basis as they now do, and would go a long way towards solving the problem. In considering 'this, you might, by the way; want to imagine what would happen if vodka, - scotch and-other hard liquors were sold in unattended vending machines; if teen-agers were frequently observed walking in shopping malls drinking alcoholic beverages; and if schools set aside separate rooms in which their - students could imbibeS - 3. It is now well established that smoking is the major preventable cause of our increased health care costs. Why not adopt a program under which persons receiving various health-care benefits from the State, or with State participation, would pay more if they deliberately engaged in this self-destructive behavior. Experience has dictated over and over again that an increased cost can be a powerful incentive in changing behavior and thus decreasing the incidence of smoking. For those who refuse to quit smoking, such a plan will at least make them pay.their fair share of the added health costs to which their conduct is directly contributing. -236- I

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Mr. Sunny Sun Nai Fong August 12, 1980 Thank you so very much for writing to ASH for our suggestions. We look forward to hearing from you, and hope that you will keep us advised of the steps you will be taking in this area. JFB:fdr / ha£.'I: t A m CA F I I I i I I I I I P I L i -237-

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f A-11SS WILUAM G. MII.UKEN, Governor t.OREN E. MONROE. Stau Trea.ur.r STATE OF MICHIGAN DEPARTMENT OF TREASURY TREASURV IUIIDING LANSJNG, MICHIGAN d922 August 15, 1980 Mr. Sunny Fong Chief of Health Education Department of Public Health 3500 N. Logan Lansing, Michigan 48909 Dea r Mr. Fong : , r , . State Treasurer Loren Monroe has asked me to respond to Dr. Reizen's letter of July 23, 1980 concerning the proposal of the Governor's Citizens' Panel on Smoking and Health. From the standpoint of this department the proposal to increase the cigarette tax by five cents presents no great problem. It is no more complicated to collect 16 cents per pack than 11 cents. There may be some trend toward an increase in bootlegging activity as the result of an increase. Our.present rate of tax is below the median for all states and naturally bootleggers want to sell their goods in the states where it commands the higher price. Recent federal legis- lation making it a federal offense to move a quantity of cigarettes from one taxing jurisdiction to another without proper authorization has re- duced our bootlegging problem to almost nothing. The potential gain is apparently not worth the risk. For your information I am enclosing some literature which you may not have had available for the panel during its deliberations. Included is a map which lists, among other data, the cigarette tax in effect in each of the 50 states as of July 1, 1980. There are also two issues of the Tax Administrators News containing articles relating to cigarette con- sumption and tax data. You may be able to find some correlation between the tax rates and usage in the various states. If I can help further let me know. R. Douglas Trezise Deputy State Treasurer ROT:c enc. cc: Dr. M. Reizen Loren Monroe -238-

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I I -239- STATE OF MICHIGAN _V1 A, . . "~' WILLIAM G. MILLIKEN, Govemor DEPARTMENT OF COMMERCE WILLIAM F. MtLAUGHLIN. Director August 26, 1980 Dr. Maurice S. Reizen, Director Department of Public Health 3500 N. Logan Lansing, Michigan 48909 Dear Dr. Reizen: INSURANCE BUREAU 1048 PIERPONT P O. BOX 30220 tJ\NSINQ. MICHIQAl/ sa90p This letter is to assure you that the Insurance Bureau will assist your department in whatever way it can to provide information regarding smoking and insurance premiums to the panel studying the problems of smoking and health. I have asked Beverly Wiener of my staff to contact Mr. Fong immediately to see what specific questions he may have. In general terms, I can give you some indication of how insurers treat smoking as an element in determining premiums. The factors which may be used for rate classifications in auto and home insurance, including renters insurance, are specifically listed in P.A. 145 of 1979. These classifications which take effect January 1, 1981, include the use of smoking materials within the structure as an allowable rating factor for home insurance. Although the presence of smokers is not a mandatory rating factor, many insurers already offer a non-smoker's discount for home insurance, and at least as many will continue to do so after January 1. You have probably seen advertising regarding these discounts, as the companies have run national television ad compaigns marketing this feature. The classifications allowed for auto insurance rating do not include use of smoking materials, and there are presently no insurers in Michigan who charge differential auto rates for smokers and non-smokers. Based on the lack of evidence linking smoking to an increased probability of loss, I would not support amending P.A. 145 of 1979 to mandate smoking as an auto rating factor at this time. A number of life insurers do offer differential premium structures for smokers and non-smokers. A list of insurers which offer non-smoker discounts could probably be compiled by surveying the life insurance market, or perhaps obtained from a trade association s~q6,a%~e r~tc~LTH Council of Life Insurers. RECEIVED AUG26t980 v1itECTOR'S OFFICE F f I I I I I I i I- t t t L L i

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I F f ~ II Dr. Maurice S. Reizen, Director Page 2 August 26, 1980 A comparable association for health insurers, the Health Insurance Association of America, may also have information regarding health insurance premiums and smoking. Though there may be some exceptions, I am not aware of any major health insurer which charges different rates for smokers. Since the majority of people are covered by employer- provided group health insurance or governmental health programs that do not surcharge for smokers, recommendations in this area will have to take into account the uneven impact that a smoker's rate for health insurance would have. These are just a few preliminary abservations regarding the treatment of smoking by insurers for various types of insurance. I am sure that Ms. Wiener will be able to provide more specific information. E. C. Mackey Acting Commissioner of Ins cc: Sunny Fong Beverly Wiener m . O~ ,.J m J -240- ,

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Michigan Tobacc-o & Candy ~ % Distributors and Vendors Associatian- Inc. ~ Affiliated Orgsnization-,~lusic Operators of ,titichigan 523 WEST IONIA STREET LANSING, MICHIGAN 48933 TELEPHONE (517) 372 2323 MICHAEL R. SPANIOLO WALTER P. MANER III LEGiSLATIVE AND EXECUTIVE SECRETARY GENERAL COUNSEL August 26, 1980 Governor's Citizen's Panel on Smoking and Health Department of Health Planning & Administration School of Public Health University of Michigan 109 Observatory Ann Arbor, MI 48109 Dr. Kenneth E .- Warner Project Director Dear Dr. Warner : Now that the Panel members have discussed the many proposals dealing with smoking in some detail, I feel it is time to raise some funda- mental mental questions concerning the nature and scope of the Panel's deliberation. I I I I I I In my letter to Governor Milliken - after he announced the formation of the Citizen's Panel in his State of the State message - I suggested he appoint a representative of the tobacco industry because I assumed that there would be a thorough investigation of the smoking and health ( question from the beginning of the discussion. If this type of care- ful investigation was not to be conducted, it would make it unnecessary, for a member of the tobacco industry to serve in the first place /`. But, before the Panel could undertake any such investigation, we received from you a memorandum in the form of a discussion paper, ~ addressing in s,.=ary fashion a variety of smoking and health issues. You yourself noted that "the limitations of the paper reflected the fact that it is a first draft". Moreover, your memorandum stated the paaer "will rev,uire further research". ! Unfortunately.because of sparse attendance, there has been no discussion of the memorandum by all members of the Panel at one time. Rather than~ providing a starting point for the Panel's deliberations, the factual assertions in the memorandum have been regarded as a given. Many of the statements in the memorandum concerning smoking and health are highly questionable and based upon unproven medical assumptions, dubious sociaL accounting techniques and unbalanced economic rationales. Others are simply inaccurate, yet members of the Panel have shown no inclination to undertake the kind of inquiry that is sorely needed. -241-

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i I i J The decision that has been made to restrict public comment to a total of 30 minutes per meeting, prevents any constructive dialogue on issues that should be of concern to Panel members. This problem.would not be solved by doubling or tripling of the time set aside for public presentations. In the Panel's haste to consider possible policy recommendations, it-has simply overlooked, or chosen to ignore, that recommendations should be grounded on an accurate and adequate investigation of relevant facts con- cerning smoking and health. The burden of studying or presenting the facts on all sides of an issue such as this should not be left entirely in the hands of the project director. The entire committee, if it is to live up to its charge, should be willing to accept the responsibility and in fact, encourage it. The recent drafting of a proposed Michigan Clean Air Act is but one example of the proposals which will bear heavily on the Michigan business community, unions, federal, state,and local governments, and all other public areas. I am convinced that, unless the nature and scope of the Panel's delibera- tions are altered significantly to include a complete airing of the smoking and health issue, the Panel's ultimate recommendations to the Governor will represent a disservice to the citizens of the State of Michigan. - To complete the investigation.that is needed may involve some delay in the Panel's reporting to the Governor. But the alternative is to present to the Governor, in order to meet an unrealistic time schedule, policy recommendations based upon inaccurate factual assumptions. As a member of the Panel, I trust you will consider these points and I look forward to hearing from you. t~ T' !-1 ~. ~. i -ti-~ Walter P. Maner III Executive Secretary cc: Members of the Panel jJPM/b t ~ .A O -242-

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U WNIa P. 4.n.r Gu'aI Sx+r.ary MoCr. TOOJ:CO-(anCy a!L a Y.nCarf Aftn. 4&".Aq. u rr,q.n cavneu.n 11:efta.« 0. fosnloy u cr Tr..cc,.Caner asc 1':fn:OIS AlSr7. ta.~m r,.cr,.q.n G.n. ren:an. rM.r.rs aw.s :war. .:4+.qaw O.e.a. !. No:an 3~~+` t Yla:~a.~+s0~ TOo. GOrO. :0..1vlY. <!naC~y Jaw.s r. WNr.. !nC :xar~ rx~Kan Oenab G Tss:a vKr.ga.s '4eMnancs Coueua LaRwj. 4.,.Cm ,,an Cbn N.les.y C ^_a. Co. &q AJsC%. :.;n.33n rms K. as.n ."e! Y"::% Int. C.-,% c.~, 4 ~ `»tCHIF.k% rCi1ACC01__1 ~1 INCLSrar , sOVISR%tY / \L 1 ~ / _ .I-- w.r t...... C..-.. 3833 Waverfy Hi:fa hoad LANSING, t.tICHtGAN :0917 h ltlc~.a n. SO.^NN LOrrGI CJ1YnMi1 TM.Ooo^. (5171 77?2]" August 27, 1980 I- I I Dear Panelist: The Michigan Tobacco Industry Advisory Council is a seven t. mem:Der group appointed by the Governor to advise him and the Co:amissioner of Revenue concerning the Michigan Cigarette Tax Act. A copy of the Act and the last MTIAC report is attached. TIe cal1 your attention to one of the recor+mendations made to I Governor Mi1liKen and Co=issioner of Revenue, Sydney Goodman, ~ on ::ay 30, 1979: - There should be no increase in the Michigan Cigarette Tax. The basis of the recomrtlc .~...ndat-'-ons are detailed in the MaY 30 ' s 1979 report. r I several states have inauired about it. The National Associa- ~ tion of Tobacco Distributors recently said, "The Michigan Tobacco Industry Council is the hallmark of industry and govern- :;e emphasize that the CoLnci1 is strictly a volunteer group whose importar.ce'has been recoo ized by the Legislature and Governor Milliken. We have devoted a great deal of time and expense to the Council in the interest of this industry. The Council is the only one of its kind in the nation and ment relations", The Council represents an industy which is of vital economic iapor*_ar-ce to Michigan in jobs and tax collections. No other ager_cy, private or governmental, can monitor the conditions - and the Council does this without cost to the State. No ex:)er_ses of any kind are allowed. Governor.Xz'.lliken once told me that business should be encour- aged to volunteer in the governmental process. It is our hope that you, as a panelist, will read the report and consider it in your deliberations. S; rcerel y ., , X-4-chael R. Spani o-lo Co=lcil Chairman =r :T IAC t I -243-

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I f I I I MiCHIGAN DEPARTMENT OF PUBLIC HEALTH M. $. Ru:en, M.D. D-r.ecor TO: Sonny Fong Office of Health Education FROM: John Insel Division of Food Service Sanitation SUBJECT: A Proposed Michigan Clean Air Act DATE: 8-29-80 After reviewing tentative wording in the proposed Act, we offer the following comments: ^ a) The term "restaurants" is but one type of food service establish- ~ ment. If the Act is to broadly address smoking in public eating A places, we suggest using the term "food service establishment." Z b) For over a decade, we have recognized the greatest number of ~ smokers and the greatest accumulation of smoke is found in taverns, ~ bars, and other food service establishments where liquor is served. On the other hand, smoking does not occur and, in fact, is not Q allowed in-high school cafeterias, hospital dining areas, and C other restricted areas. We suggest the Act contain more directed .~.~ verbage to clarify the intent of the Act. ~ c) Section 12605(1) contains a provision for allocating 50: of "any ~ room" in a public place as a nonsmoking area. It is unclear if this references-one-half of the square footage of the room or if the intent is to divide the seating area in half. d) The recommended air changes per hour would seem adequate for the size of most dining areas. For example, a 40' X 50' X 10' room would require a 2,000 CFM fan. Since the word "circulation" is used, we surmise the intent is to filter and circulate this air rather than exhaust it to the outside air. You should recognize an advantage and a disadvantage to this method. The advantage is total building exhaust does not increase and, therefore, total make-up air does not increase (a considerable savings in maintenance cost). The disadvantage is filtered air may not be as "clean" as outside air. e) The equipment required for monitoring carbon monoxide concentra- tions is not available in local health departments. Approximately ~ 100 units would have to be made available to these departments for ~ such testing. You may want to contact the Division of Occupational Health to determine the approximate cost. ~ ~ 1' f) Section 12609(1) provides for possible waiver from provisions of the Act. It is not clear which bureau, division, section, or local health department,etc., would represent the Department in granting such waivers. g) Our statute and rules contain two provisions which exempt food service establishments which were in operation prior to October, f th i ll i i i i h ons o new prov .s e a ng requ red to comply w t 1978, from be ~ C J law. If the proposed Clean Air Act is to apply to all food service establishments, it would be necessary to specifically address ~ these exemptions. ~ -244- L At1 1iO*

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-2- h) Section 12609(5)(b) contains the provision to deleqate the administration and enforce.T.ent of the Act to caoable local health departments. Which o-lflce/division of the '"ic~ican Department of Public Health is responsible for imolementation if the local health deoartment does not deTonstrate the ability or willingness to administer or enforce the statute? i) Section 12611(2) and Section 12613(2) contain the term "may." You may wish to fully consider the ramifications of these terms. We are enclosing a copy of a survey which aoparently indicates relatively low interest by the dining public in nonsmoking areas. The survey was taken in 1977 by the National Restaurant Association, Chicaqo, Illinois. We would suggest that the Michigan Restaurant Association be included in your deliberations as the oraanization represents many ot the 25,000 fixed food service establishments we license each year._ Finally, the need for enforcement, an issue addressed several times by the Task Force, will not be clarified by the proposed Act. As we have indicated by public comment and personal discussions, county prosecuting attorneys prioritize their participation in criminal litigation accordina to community needs, e.g. assaults, larceny, homicide, etc. As a result, we have often encountered prosecutors reluctant to even prosecute a food service establishment operator who failed to obtain a license or who had failed to comply with the most basic requirements. We believe the issue of food service establishment operators failing to meet the provisions of a Clean Air Act will ultimately become a matter presented to orosecutinq attorneys. Failing to address this issue, e.o. providing an alterna tive interim enforcement procedure, may result in the Act becoming another unenforceable statute. We trust this information will assist you in your deliberations. JRI:DPB I i I I I I I I I r I L -245-

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i t I I I THE UNIVERSITY OF NUCHIG.1N SCHOOL OF PUBLIC HEALTI-i DEP.IRTNSE.\T OF HEALTH PLA.^I`7I1(: AND ADMINISTRATION A:IN ARBOR, NIICHICAY 48109 September 2, 1980 Walter P. Maner III Executive Secretary Michigan Tobacco f, Candy Distributors and Vendors Association Inc. 523 West Ionia Street Lansing, Michigan 48933 Dear Walt: Thank you for your letter of August 26 concerning-the work of the Governor's Citizens' Panel on Smoking and Health. I am writing now to respond promptly, fully, and candidly. I share your concern about the serious time constraint confronting the Panel. Clearly, that factor restricts our ability, as a group, to investigate data and issues at a depth we would desire in a constraint-free world. As I have noted at Panel meetings,: I am taking the view that the work of the Panel must be considered in light of the restrictions on time and other resources. I hope that the Panel will recommend that the Governor charge an existing or new bureaucratic entity, or perhaps a new citizens' panel, to investigate the issues and monitor State smoking-and-health " activities on a dontinuing basis. I cannot agree, however, with a basic theme of your letter, namely, that "'Hany of the statements in [the discussion paper) concerning smoking and health are highly questionable and based upon unproven medical assumptions, dubious social accounting techniques and unbalanced economic rationales. Others are simply inaccurate..." As a scientist, I am particularly sensitive to the need for objectivity and proof. I believe that my published work on the subject of smoking and health demonstrates that; and_Mr. Spaniolo (and, I thought, you tDo) commented quite favorably on the balance in the paper after the first Panel meeting. The facts presented in that paper are just that: facts. The causal evidence linking cigarette smoking to a variety of debilitating and fatal illnesses is scientifically overwhelming. Even the recent, long-term, tobacco industry-financed study by the AMA drew that con- clusion. I do not know of any objective, scienti-fic observer who questions the basic facts of smoking and health. I am quite prepared to believe that the quantitative estimates -- of -246-

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I lralter P. Maner III September 2, 1980 Page Two - the prevalence of smoking-induced illness, its cost, etc. -- may be imprecise; but I am firmly convinced that the qualitative story those figures portray is wholly accurate. I cannot see that the Panel's work would have changed at all had we concluded that smoking annually cont:ibutes to the deaths of 200,000 Americans, instead of over 300,000, or that the economic costs of smoking induced illness are really $30 billion instead of $40 billion. And the estimates used are likely to be much closer to accuracy than deviations such as these. . - I might add, for clarification, that my caveat on the "limitations of the paper" referred to omissions, writing style, and the like. I did not mean to suggest that factual assertions might be in error. Facts are well documented in the cited references, as well as elsewhere. In short, I firmly believe that any recommendations which emerge from the Panel will be based "on an accurate and adequate investigation of relevant facts concerning smoking and health." I am surprised by your impression that '"Che burden of studying or presenting the facts on all sides of an issue such as this (has been] left entirely in the hands of the project director." Regarding smoking-and- health facts, I did indeed present the only document written by someone involved in this current activity, though many published documents are familiar to all Panel members. With reference to the Panel's work on recommendations, I have played a relatively minor role, chairing the first subcommittee meeting on economic and legal issues. The ensuing work of the legal issues subcommittee, as well as all of that of the education and media subcommittee, has been undertaken without involvement of the project director. Indeed, I have been delighted with the willingness of several Panel members to devote considerable time and energy outside of the monthly Panel meetings. Unlike most advisory panel activities with which I have been involved, this Panel is doing a lot of the.basic thinking and proposal formulation. This-is clearly a group effort. I regret that we must complete the immediate work of this Panel by mid- November, but that is our charge. With a lot more time and a commitment of significant fiscal resources, I am sure that we could refine our understanding of policy needs and alternatives, but not, I suggest, of the basic smoking- and-health facts. I do not know that such an additional effort would qualitatively alter the recommendations of the.Panel, but as I see the possibility, I hope that you will'join me in supporting a proposal for an ongoing State effort in this area. - I will conclude by suggesting some contributions you might make to further assist the Panel in its deliberations: (1) If you find errors of fact in my discussion paper or in other relevant documents, please share them with us. You have had that opportunity all along, yet your letter of August 26 is the first indication that you believe such errors exist and you have not been specific as regards any of them. -Again, the only previous reaction of your rob I I I I I i i I I I t t L L L L -247-

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r I (3) organization, conveyed the day of the first Panel akeeting, was that you found the written presentation much more balanced and objective than you had anticipated. (2) Contrary to your conclusion in the second paragraph of your letter, I find your participation on the Panel use- ful and essential. As a direct example of yoiir influence, I would point to the thus-far balanced consideration of the vending machine issue. I sincerely believe that your input and your very presence have been instrumental in shaping that discussion. I urge you to continue par- ticipating and contributing to Panel discussion. You are of course welcome to contribute written materials for the Panel's attention, as you have promised to do with regard to the question of teenagers' use of vending machines for access to cigarettes.. (4) You can encourage other representatives of the industry to share their thoughts with the Panel.. From the first meeting, I understood from you and Mr. Spaniolo that you intended to have a representative from the Tobacco Institute make a presentation to the Panel. The oppor- tunity for that remains. (S) As we discussed, I believe it would be appropriate for you to file a minority report for inclusion in the record, if you so desire. f Walter P. Maner III September 2, 1980 Page Three I hope that you find this an adequate response to your letter. I can appreciate your frustration, and I only hope that you appreciate the sincerity of my feeling that your continued participation represents an important input into the work of the Panel. Sincerely, /C_'P~ Xenneth E. Warner Project Director Governor's Citizens' Panel on Smoking and Health hEW:csb cc: Panel members and staff -248- ~

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~fati /ti~ied~nEalive Rd W ..J~fooc~ ~~. ~.------~-, ac~inon ~] C7p ~ 1*~iedi~fant rtlooP eCrucia f Ih JI N(M.(A 0/ COMNITTC(f aN: ~ ~enonnr[ O~ica~ 2-boit - 7fli 1Ji~fiict ora.uiny 517-3 73-1782 . SEP 9 1980 September 3, 1980 II --~ .,..~,e .s..n.. cN.~....w ~' lDUC.TIQW II ~NO aCA[aICN ,__-a `-1 I Mr. Ben Barker, Chairman Citizens Panel on Smoking and Health Michigan Department of Public Health Lansing, Michigan I:...r; aa=u ui ol1.r O::eese hcadle p Pt:a:o S.c.\:j ~ PorYanrl,:fc:~ztion p t'c: ~bu-C~a:aeata Dear Mr. Barker, I greatly appreciate having the opportunity to serve on the Citizens Panel on Smoking and Health. Although I have been unable to-attend personally, I have asked my aide, Terry Gerald, to attend the meetings for me and to keep me informed on the Panel's progress. I realize that the.Panel is under a very tight time constraint and I commend you and the panel members for the work you have done thus far. My purpose in writing is to make clear my position on various legislative proposals now under consideration by the Panel. In the past, it has been my position as chair of the House Public Health Committee to avoid taking posi- tions on specific bills until the full conmtittee has had an opportunity to hear testimony and debate on the bills. I believe that remaining neutral until all interested parties have an opportunity to express their views on the proposed legislation is appropriate, especially for a committee chairman. Therefore, even though I support the inclusion of recommendations on various legislative proposals in your report to the Governor, that support should not be interpreted as a personal endorsement of any specific bill. I believe that.this clarification is necessary so that there is no misunderstanding on the part of the panel members or the public. Once again, I commend you and the panel members for your diligent efforts and I look fordard to reviewing your final report. rwh:cbl -249- F F I I I I I F E ~

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Michigan Tobacco & Candy Dist: i-bu1ors and Ve3ador5 A53-ociaiion Imc. Affiliated Organization-Music Operators of Michigan 523 WEST IONIA STREET LANSING, MICHIGAN 43933 TELEPHONE (517) 372 2323 MICHAEL R. SPANIOLO WALTER P. MANER III LEGISLATIVE ANO EXECUTIVE SECRETARY GENERAL COUNSEL - September 5, 1980 TO: GOVERNCR'S CITIZENS' PANEL ON SMOKING & HEALTH FROM: WALT MA.NER~''\~ Enclosed is information regarding two proposed panel recommendations. that have been discussed previously: 1. the proposal to increase the cigarette tax from 11C to 16C per pack; 2. the proposal to ban cigarette vending machines in Michigan. We will appreciate your consideration of the material. -250- .Y~;:

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I The Gove=or's Citizens' Panel on Smoking & Heal--a is conslderi:,o a recoII:Clen- dation to increase the cigarette tax from 11(,, per pac'.c :o loC ter pack. I i Differences in state cigarette tax levies cause increased cigarette bootleggii and the encroachment of organized crime into legitiWate busiaess t. Any increase in the cigarette tax should be opposed. 1 HIGH TAX STATES' SUFFER REVENUE' LOSSc.S ~ According to the Advisory Cormission on IntergovernWental Relations (ACIR), I cigarette bootlegging has become a severe problem in states with high cigar- ' ette taxes. See Eshibit A I. New York, Pennsylvania, Florida, and ~Iassachusetts are examples of states that have raised their cigarette taxes to levels that have invited chaos in tax administration, bootlegging, and have involved organized crime. - ACIR estimates of tax evasion show that ttichigan is currently losing $6.9 million in cigarette tax revenue. (The report was spearheaded by a current Michigan Executive Office official who was on leave from his job here.) Neighboring states with higher tax rates are losing even more according to ACIR: - I1linoi s- losing $21 million annually (12C ta_Y). - Wisconsin - losing $13 million annually (16C tax). - Ohio - losing $16 million annually (15c, tax). - Indiana - losing $13 million annually (10.5C tax). A HIGHER ?1ICHIGAN CIGARETTE 'rzk:; T .1ILL LEAD TO AN INCREASE C!T ~ IN ILLEGAL CIGA'_RETTE SALES t, p CD -251- I I I E L L L L

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Sydney D. Goodman, Coc:.missioner of Revenue, Departr.:ent of Treasury, says, "By I I I I Keeping our tax rate down, we're able to avoid s3uggling problems. The stuff " we've got going on here is all small ope=ations". David Parker, administrator of the cigarette tax, Depa:tment of Treasury, comments, "We do have problems but not like they do in the East. We don't think they're coming in by the truckload". However, if Michigan were to increase its cigarette tax rate, that would likely change a minor bootlegging problem into a major one. A HIGHER MICHIGAN CIGARETTE TAX IS AN OPEN I~+'VITATION TO ORGANIZED CRIME In other states where high cigarette taxes exist, the criminal element has ~~uickly become involved. I The incentive to bootleg cigarettes from low tax states to high tax states also results in many areas in hi-jacking of trucks, personal violence against delivery drivers, and even deaths. Every citizen deserves to live in a society and community free of the threat of organized crime. ct Ul Here's what Senator Edward Kennedy said on the Floor of the Senate of the ~ United States on November 3, 1978: "Cigarette bootlegging, as it is cor.mmonly referred to, has become not only a serious problem for the many states which rely on cigarette taxes for needed revenue, but also has become a major revenue source for organized crime .groups. It has been estimated that the states are losing over $400 million a ~ Jyear because of this activity, and that is a very conservative estimate. The ~ ~ ~ -252-

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I only ones profiting from this activity are the major organiced crime familik. ~ which control between 40 to 50 percent of the activity. Cigarette bootlegging is now ranked as the sixth major revenue source for organized crime with a gross of $1.5 billion a year and profits estimated at $800 million. Even worse than the smuggling itself is the violence that acco:rro anies the i i activity - - truck hi-jacking, armed robberies, serious assaults, extortion, ( murder, and corruption of public officials. The effects of this activity do not stop there. The indirect result of cig- arette bootlegging is the loss of jobs and businesses of those legitimate wholesalers, vendors, and sales people. In the past 10 years the employees of wholesalers and vendors have lost their jobs of the wholesalers have gone out of business becaus.e of this." HIGHER CIGARETTE TAXES HURT bEGITIMATE BUSINESS j I An increase in the cigarette tax will result in loss of further business to 60,000 Michigan retailers, wholesalers, and vendors, from tax evasion. Cigal ettes are used as a leader to attract business to retail stores where custom -: bay other items. These together mean less revenue from other tax sources sudiz as sales tax, Single Business Tax, and individual income tax. Cr L ~ a ~ CONCLUSION ~ ~ O While an increase in the cigarette tax may be seen by some to painless solution to governmental revenue problems, or to discourage cigarette consumption, the experience of other states must be heeded. Michigan should not go the way the hard way. of other states who -253- have have learned their lesson L I 50 percent of and 35 percentl O be a quick and L L

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i I I I I I I 1. Higrh cigarette taxes increase illegal sales o;: cigarettes. 2. High cigarette taxes cause an overall revenue loss irn several tax sources. 3. High cigarette taxes are an open invitation to organized crime. 4. High cigarette taxes hurt legit Wate businessmen and their employees who depend on their jobs for a living. -254-

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~TNEICI a{ ORI)~LOW TAX~ST~CSU ~- ~ -- TO OSST~~NNTAX tRAIS~EDN ~J ~~ ~AIN DUES1`0-~ ~G'I1~6RII~G+~ IN 1977 IIIGH TAX STATI:S State Cigarette Tax Rat s* ,~ ancl Ci~arettc ~mug~ling E~evenue Gai~ s and Losses** 56~6102 ,_:,.~_,; ~, 12~ ~ ~ wro. _ 9.1 ~ 10~ 10~ a~ n~ a - 10~ 11 ~ ~'' `s. ~ _____.~~ 10 ~, . ~''+r.'-' 12~ ~' e :i :}-16 ~ 10. 11~ 9 OKIA. II ~lAAc IIK ~ `s 13~ 7.75~ tiy~~, ~ s~ ~,~i' . . 'fi '~ ~! p.~;,~',t~l~~~,~N, ~,~~ :~a ~,~i:~:~x. '~ ~- i S' : t'~'i ~ ~ ~r ~1a.5a~ ~~~~~,~~ 11Q~ ~~t ri~l;Kf. .1 kr~l,%~. . ,.N; ~ ;~.l . ,~X~t, If ": 13 ~ `,: ' ~si'" c~ ~11~ ~2 ~ ~ 12 S~ ' ,. a:: 12~ ~ 5~ ~~ 21~ n~ ~ .k.; , ~~.1n~ ;,~ ~ ~~o~~21Q i i . h,.19 ~ '.~. : ., _ : r~"~,~~'~~.: '~11.1 ~la :I I1" :: ~G13~ 17c ;~~ ~;:' WIIIU s2.5~~::;.., M~10~ :_,~lM~,, r~ G~ ' EXHIBIT A ~``.~ ~ ~ ~ r;?~'"~?~~~''~`~6~.~5?'~d '~', KEY - !~ ~(r ~~,~ 7 Mlnorrevenuaaoeses ~:~ ' L.~ ~ or smatl gains ~~` i `j;' ' (syo or se~s) ~,t~ ;~ ® Moderale revenue losses e ~ ~ ~e'Y. or less) ns of JulY 1, 1916 NOTE: Estimales of dollar revenue ~~ Lnrfle revenue lossee "Based on ACUI IUA'All ~~ ~"-"=(E96 or more) (/ains nnd lossos ere presonled in slall eslimtes- Q 0% ~ 1 1 Q~ (, >:.;::.; .; Lerge revcnuo'yelns Table l9. 1975 dal \\\/// ~ (596 or morc/ NOTE: Since 1977, ]-0 states have r~~ised cil;rarette tax levels while one has lowered its tax,

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S[Rokinztlealth and Ci -a=et:e TTe-:d? n!z I I Discussion regarding the access of teena~ers to unattended cigarette vendir.-. machines has intensified in the Gove=-r:or's Citizens' Panel on Smoking and Health during recent meetings. The feelino amono some Panel members is to limit availability to the machines as a method of discouraging teenagers from smoking. VENDING MACHINES FALSELY ACCUSED I Those who advacate legislative restrictions on cigarette vending machines argue that they are a major source of cigarettes for minors. The idea is that since the machine cannot distinguish between adults and teenagers, cigarette vending machines must be a major source of cigarettes for teenagers thus circumventing state laws which prohibit the sale of tobacco products to minors. This argument ignores the facts. If an understanding of vending as a method of retailing cigarettes exists, the facts become clear. FACTS ABOUT TEENAGE SMOKING AND SOURCE OF CIGARETTES The facts about actual teenage cigarette pruchases and smoking habits dis- prove the idea that vending_might be a source of cigarettes for minors. Current studies published by the U.S. Government show that: a. only a small number of teenagers smoke-- and that number is declining; b. only 1 out of 10 teenage smokers purchases cigarettes; and c. over 97e of teenage smokers-do not buy from vending machines -256-

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i I Twi2e~~:er Dare^.ts smoke is the I?lost iTnor:an: 4:::e::c°_ on teenagers s^CcCing, , ~ tolZoCJeQ by peer groL:p e::amDles and oress~res, and t::e desire to be adult. PRICE DETERS TEE11rsGE ?U? C:ASES I If it can be assumed that price differentials of cigarettes between over-the- counter and cigarette machines act as a deterrent to vending machine sales of cigarettes, it is further clear that cigarettes are not being purchased this way. Anyone can observe that the current difference between over-the-) counter and machine prices are anywhere from 25 cents to 35 cents per pack, with the machine being the more expensive method of sale. MIARKET_ S N4 VE CHANGED I I . I In the past few years, the self-serve gas stations that have proliferated J around the country have become a large retail cigarette market. ConsequentLi machine sales of cigarettes have dropped dramatically as have the nuwber of locations where machines are located. I Currently about 907e of all cigarette machines are located in "adult type" ~ locations such as bars, better restaurants, hotels/motels, and the like. These are locations unlikely to be frequented by teenagers on a massive basil. Gt u' S THE SIX STEP SELr -REGULATI0:1 PROGR.-_f c 0:2 VENDING "~ 01) The vending industry has long recognized its resocr.sibility to prevent minors' purchasing cioarettes from vending machines. The vending operator, aware ofL laws which prohibit sales to minors, has long conducted his business under _, an industry code of self-regulation designed to make sure cigarette vending -257- ( I

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machines are not a source of cigarettes to minors. Following is a brief statement of the six step program: 1. Survey the entire cigarette operation to determine the location of those machines to which minors are likely to have access. As part of this survey, maintain a permanent file record for each machine location. 2. Post "Minors Are Forbidden" decals conspicuously on all machines. 3. Post on each machine the name, address, and phone number of the operator. 4. Solicit the location owner's cooperation to prevent minors from purchasing from machines to which minors have access. Reposition machines where necessary, to assure adequate supervision. 5. Remove machines from locations where the sale of cigarettes to minors cannot be prevented. 6. Cooperate with competitors to achieve area-wide compliance of preventing the purchase of cigarettes by minors from vending machine: CONCLUSION Accusations against cigarette vending machines related to teenage smoking have no basis in fact. The vending industry continues to recognize its responsibilities through self-regulation (even though few teenagers actually purchase cigarettes from vending machines). It stands ready to cooperate with all groups to make sure that its record of responsible conduct and comp?iance with established laws is maintained in fact and in spirit. -258-

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STATE OF MICHIGAN ~ 1_~cS ~~~~ WILLIAM G. MILLIKEN, Governor DEPARTMENT OF COMMERCE WILLlAM F. MCLAUGHLIN. Oirector Septemoer 10, 1980 MEMORANDUM TO: - Rhonda Runner FROM: Beverly Wiener SUBJECT: Smoking and Insurance INSURANCE BUREAU 10A8 PIERPONT P O. BOX 70220 LAN$;NG. MICHIGAN A8909 I'm sorry I won't be able to attend the meeting on Thursday, September 11. Based on our phone conversation, I am sending the following general comments on the proposed recommendations that relate to insurance. - Please feel free to call me if you have any questions. Recommendation 1: The feasibility of requiring premium differentials be explored with the Commissioner of Insurance. As described in a letter from Commissioner Mackey to Dr. Reizen dated August 26, 1980, a copy of which is attached, the relevance of smoking as a factor in insurance rating varies with the type of insurance. I am not aware of any studies which would conclusively demonstrate the extent of the relationship between smoking and the extent of the risk assumed by the insurance company. Without reliable studies, it is not possible to actuarially determine those situations in wnich premium differentials would be appropriate and what should be the amount of such differentials. Recommendation 2: Smoking cessation programs be included in health insurance policies. To require health insurance policies to include coverage for smoking cessation programs would require legislation. Because of the increasing cost of health care in recent years, which has resulted in increased premiums for health insurance, some people would oppose mandating additional coverages which would result in additional premium costs. -259- I I ,I I I I i I { I I r. I 6 I L

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Page Two September 10, 1980 Rhonda Runner I I i I The costs you cited for smoking withdrawal programs are fairly low. Many health insurance policies contain deductibles of $50, $100 or more a year. Even if smoking withdrawal programs were covered, programs which cost less than the deductible would not be paid for unless the insured had other covered medical expenses during the year which were equal to or higher than the deductible. The cost for an insurance company to handle small claims is relatively high, and it is generally considered more important for health insurance policies to cover the expensive medical services which could put a person deeply in debt. BW:kab ~ ~_

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FEDERAL TRADE COMMISSION WASHINGTON. D. C. 20580 BUREAU OF CONSU.l1ER PROTECTION Sunny Sun Nai Fong, Chief Office of Health Education 3500 N. Logan P.O. Box 30035 Lansing, Michigan 48909 Dear Mr. Fong: S~? ~ 4 19Ea Your letter to Ms. Cheek has been referred to me for reply. I apologize for the delay in responding. I notice that you were to have held a meeting on August 18 and had hoped for answers by that date. Unfortunately, I was out of the office on business for most of the month of August. I caution you that the following represent my own personal opinion. These answers should not be taken as the view of the Commission. First, to the best of my knowledge, there are no federal restrictions prohibiting states from purchasing air time on television or radio stations to discuss various issues, including to advocate an anti-smcking position. To the best of my knowledge, there are no guidelines or rules issued by the Federal Communications Commission that prohibit a state from buying time. There may be state restrictions on the use of state funds to buy advertising time: I am not in a position to advise you whether Micbigan has any such restrictions. I personally do not know whether any states have bought time to advocate or discuss anti-smoking positions. You could consult with John Banzhaf, Director, Action for Smoking and Health, George Washington Law School, Washington, D.C. He may have an answer to this question. Of course, you should recognize that the stations do not have to sell you time to discuss the anti-smoking issue. Each individual station management is responsible for the programzning content and the decision on what to broad- cast is left primarily to the stations. I I I I I I I L -261-

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Mr. Fong F I Second, I- am unaware of any mechanisms that will ensurP the airiny of public service announcements during prime time. I cannot coaunent upon the political feasibility of offering tax incentives to radio and TV stations which broadcast PSAs during prime time. Third, under the FCC's fairness doctrine, broadcast stations were required to carry anti-smoking positions if they carried cigarette advertising. The FCC has since ruled that ordinary product advertisements, such as cigarette commercials, do not normally discuss controversial issues of public importance and thus do not give rise to fairness doctrine obligations to air contrastir,g views. It is my personal opinion that it would be difficult to adopt a fairness doctrine approach for magazines - distributed in Michigan. The fairness doctrine was upheld against first amendzaent attack because broadcasters are considered public trustees, with.certain obligations to the public. Magazines are wholly private concerns. They do not get a license from th.e government to operate. They are not required to ~-~ carry any proqramtning they do not want to. They are much less ~..J subject to regulation by the government than are broadcast stations, wh.ich receive their license to operate from the government. - I hope this information is of assistance to you. Again, I apologize for the delay. Sircerely, i Collot Guerard_, Deputy Director for -Advertising Practices -262-

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I I 6EN 0. BAaxE2. o.o.S. Aov-aT owtct« W. K.KELLOGG FOUNDATION September 26, 1980 r r I Dear Colleague, In the 1980 State of the State Message, Governor W.G. Milliken appointed a Citizens' Panel on Smoking and Health to reco»mend actions that will reduce and prevent tobacco-related illness and death. These recommenda- tions will be submitted to the Governor by November 15. I invite interested organizations, groups, or individuals to give testimony on a variety of economic, legal, and educational issues related to smoking. The Citizens' Panel will be conducting a public hearing on Wednesday, October 8, 10:00-12:00 a.m. at the Hichigan Department of Public Health, Baker-Olin West Complex, 3500 N. Logan, Lansing. Oral presentations will be limited to five minutes. A written statement should accompany the oral testimony so that it can be included in the record. Anyone who would like to co»ent but cannot attend on October 8 can submit a written statement to Mr. Sunny Fong, Office of Health Education, Michigan Department of Public Health, 3500 N. Logan, P.O. Box 30035, Lansing, 48909. The Office of Health Education is providing staff support to the Citizens' Panel. If you have questions or need additional information, please contact Sunny Fong at (517) 373-9437. Sincerely, - j!, ` ~~~ ~~`L`.%_ Ben D. Barker, Chairperson Citizens' Panel on Smoking and Health BDB/bl Ken Warner cc: Sunny Fong Members of the Citizens' Panel 100 NORTH AvENUE / SATiLE CREEK. MICNICAN 490161 PHONE 616 %5-1221 -263- r I L

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STATE OF MICHIGAN r I 1 r WILLIAM G. MILUKEN, Governor DEPARTMENT OF PUBLIC HEALTH 3500 N. LOGAN P.O. BOX 30035. LANSING. MICHlGAN 44909 MAURICE S. REIZEN. M.D.. Dir.ctor Septerher 29, 1980 TO: Ben Barker, Chaisperson CitizerLs' Panel ofi Srcking and Health i i FFat Sunny Sun Nai F~c* Chief Office of Fiealth~Fi?iication SUBT'c,Ci': Update on the Resource People Selected to Represent Various Bureaus in the Michigan Departtrent of Public Health In June, The Office of Health Education was asked to organize an in-house group. For your informaticn, attached is a oopy of a memo requesting that dePartnenta.l chiefs select a representative to bec.~ane part of an fn-house resource group. Zhe mam was sent to the following: R~p-nmth Eaton, Office of Substance P,bu.se Services; Lee Jager, Bureau of IIzvixarmental and Occupa- ti.onal Health; Kenneth Wilcox, Bureau of Disease Oontrol and Iaboratozy Services; Hexmann Ziel, Bureau of -Hea.lth Care Adrdnistraticn: and, R. G. Rice, Bureau of Personal Health Serrices. Selected representatives are: George Iafkas, Office of Substance Abuse Services; John Insel, Bureau of Fhvi=rnntal and Health; Fussell Holmes, M.D., Bureau of Disease Control and Labaratory Services; and, MaXaell Alderson, Bureau of Personal Health Services. Other resource staff; Walter Wheeler, Assistant to the Director for Progran DeveLognent; Marion Vaug.han, Office of Caummicaticn Services; and, Wanda Jubb, Michigan Departsnent of FAucaticn. SSW/rrl AttacYanents cc: Citizens' Panel Men+bers -264-

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MICHIGAN DEPARTMENT OF PUBLIC HEALTH TO: Sonny Fong Office of Health Education FROM: John R. Insel Division of Food Service Sanitation DATE: 10-1-80 M. S. Reizen, M.D. SUBJECT: Citizens' Panel on Smoking and Health Di.ecTor In our me.~no dated August 29, 1980, item d addressed the proposed number of air changes per hour and our interpretation of the word "circulation." Further discussion and research has revealed the following information: a) The Department of Labor, Construction Code Commission, has rules which specifically address ventilation requirements for five categories of food service establishments. b) The term "total air circulation" as proposed in Section 12605(2)(c) would not qualify for filtration and recirculation within the building. In accordance with the Mechanical Code Rules (M317.1.1.), this air would need to be exhausted to the outside and replaced with 100% outdoor air which is heated. I I I I c) With the exception of one category, all food service establishments ' will need to provide 30 CFM per occupant. The requirement of 30 C FM for food service establishments typically exceeds the CFM requirements for most other public places. Af ter reviewing the draft entitled "Report of the Governor's Citizens' Panel ~ on Smoking and Health," we offer the following comment: Proposal #8 recommends-amendment of the Public Health Code to allow ~ for the assessment of penalty points for violation of the food service establishment smoking law. It shoul-d be recognized that environmental health activities are predominantly oriented to request services. ~ Consequently, mandated/required services do not always receive the necessary attention. The Division of Food Service Sanitation has been evaluating the effectiveness of local health department food service sanitation programs since 1969. Between August, 1971 and ~ May, 1979, the Division has conducted 110 separate surveys. One of the administratjve considerations concerns the proper frequency of routine inspection as required in the Food Service Manual, which ` states: "An inspection of a-food service establishment shall b /llle performed at least once every 6 months. Additional inspections of the food service establishment shall be performed as often as at necessary for the enforcement of this ordinance." To receive ~~ credit for the inspection, local health departments had to- inspect the survey sample at the proper frequency of inspection. This - ~ is not to say that those establishments which were not visited at N an approved frequency were never inspected; but the inspections IPA ~ conducted were not within the time frame specified. During the aforementioned time frame, the state-wide average frequency (in 47 jurisdictions) of approved inspection was 32.45%. In other words, L less than one-third of the establishments surveyed had been inspected at the proper frequency. On four separate occasions, local health ~ departments had not inspected any of the selected establishments at the correct frequency, resulting in a 0o frequency of inspection. ~ -265- A21 11I L

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I I I i I I I I II I C ) Sonny Fong Page 2 October 1, 1980 Likewise, only 6 evaluations demonstrated a sufficiently high frequency of inspection to qualify for any administrative credit. The conclusion to be drawn should be clear. Presently, insufficient manpower is a primary factor for local health departments not meeting the minimum mandated inspections for sanitation purposes. Assignment of penalty points for violation of the smoking requirements alone will not, in itself, insure compliance with this specific section of the law. Regardless of the enforcement mechanism decided upon by this body, additional funding will be necessary if local health department sanitarians are to routinely-be able to inspect food service establishments to determine compliance with Part 129 of the Public Health Code. It is suggested that a portion of the proposed excise tax could be effectively used to support additional local health department enforcement. JRI:Ib -266-

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Michigan Tobacco & Candy Distributors and Vendors Association Inc. Affiliated Organization-Music Operators of Michigan 523 WEST IONIA STREET LANSING, MICHIGAN 48933 TELEPHONE (517) 372 2323 MICHAEL R. SPANIOLO - WALTER P. MANER III LEGISLATIVE AND - EXECUTIVE SECRETARY GENERAL COUNSEL - I F I ~ October 1, 1980 1 Dr. Kenneth E. Warner, Ph.D , School of Public Healt //h University of Michigan 109 Observatory Ann Arbor, MI 48109 Dear Professor Warner: , In my letter of September 11, 1980, I made mention of the fact thut I do not agree with the judgments you have made in the smoking and health area. Indeed, I had hoped Dr. Schafer's paper which I sub- mitted would elicit a more objective viewpoint on the part of the Citizen's Panel. However, in reviewing the draft majority report of the Panel, I feel that the other side of the smoking and health contro- versy has been ignored. In the same letter I stated I would supplement our viewpoint by specifying other errors of fact raised in the economic/social cost section of your discussion paper. Therefore, the following review is concerned solely with that part of the paper. However, my comments in no way acquiesce in other assertions made in your discussion paper. What follows is merely meant to be a succinct review of your erroneous analysis of the notion of claimed economic costs of smoking, based on views of other professional-economists. Your approach fails to distinguish between private costs, which accrue to individuals through their personal choices, and external, or social costs, which fall upon others. As a result, there is extensive double- counting of costs throughout the paper. In general without any reference to smoking, absenteeism and medical costs are fundamentally private, rather than social costs. That some part of the medical bills are paid out of common funds does not change the aggregate wealth of society. These transfers are merely from one sector of society to another. Your treatment of medical costs as so-called net costs of smoking is entirely unsupported by reliable scientific data. Although certain diseases are said to be associated with smoking, you have not provided evidence that smokers use more medical care over their lifetimes than nonsmokers. Further, it is clearly inappropriate to speak of the net cost of smoking, because cost, in economics, is an opportunity concept. It requires that we compare one state of affairs with another. Gt ~ .~ -267- IPA . ~ I I i I I F L ~ L L L

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When it is said that the cost of smoking is x dollars per year, what is the alternative against which this cost is measured? If the answer is "no smoking", we do not know anything about the costs which would then arise. The only natural use of these costs is to evaluate a pro- posed policy. Will the policy's benefits exceed its costs? Indirect costs, such as annoyance costs, are largely private costs, as long as there is a "market" for them. This market, which is the most eff icient arbiter of costs between people, depends on the existence of clear property rights. When such rights are limited, as when a proprie- tor may not resolve the smoking issue in his own establishment, it is the restriction which gives rise to social costs. Whether the law re- quires that people be allowed to smoke or that they be restrained from smoking, it is likely that the cost to smoker and,nonsmoker will be higher than in the case of a mutually agreed solution. In commenting on the claimed economic costs of smoking, you say "...that few of the benefits of cigarette production are captured by Michigan to offset these costs...". However, you minimize the economic contributions of the tobacco industry. 0 i I On September 15, 1980, the Wharton Applied Research Center of the University of Pennsylvania released a study of the U.S. tobacco industry's economic contribution to the nation in 1979. This study shows that in Michigan, in 1979, the direct and indirect contributions of the tobacco industry accounted for 76,410 full-time equivalent employees who earned over 1.2 billion dollars. Just under 10,000 of these employees were at work in 1979 because of the direct contributions of the core sectors of the tobacco industry in Michigan. These core sectors included intermediate distribution, retail- ing and vending, and support industries such as media and promotion. Personal compensation in the support industries' alone amounted to 11.5 million dollars. Gross sales exceeded 925 million dollars in the retailing and vending sectors, and approximated 666 million dollars for the intermediate distrib ution sector. ' The direct contribution to state taxes in 1.1lichigan totaled 164.7 million dollars. Additionally, within the state, the tobacco industry's contribution to federal taxes totaled 171 million dollars (excise, FICA, personal income and corporate income). -268-

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I , In closing, I feel I have fulfilled my commitment expressed in my letter of September 11. Although I have sincerely tried to discharge my responsibilities as a Panel member, I must state my frustration in impacting the apparently "approved version" of the Panel recommendations. A careful review of the prologue and recommendations of the Panel's majority report reveals virtually no change from the conclusions in your initial discussion paper. One can only conclude that the sparsely attended summer meetings, as well as your urging my participation, was merely intended to be "window dressing" for the pre-ordained recommen- dations. To say that I am disheartened by such an experience would be the height of understatement. I I I I I Sincerely, Gc"&: / Walter P. Maner III Executive Secretary cc: Members of the Panel bt I I L r I 6 L -269-

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THE UNIVERSITY OF MICHIGAN I I I i I I I SCHOOL OF PUBLIc HE.%LTH DEPART\[EVT OF HEALTH PLA\'NI\C A.1D ADMIaISTR.iTLON rj:v-4 AxsOR. MICHIC.vi 48109 October 6, 1980 Walter P. Maner III Executive Secretary Michigan Tobacco G Candy Distributors and Vendors Assoc. Inc. 523 West Ionia Street Lans ing, Michigan 48933 Dear Walt: Thank you for your letter of October 1. You did not request a response, but I feel that your comments warrant one. First, I want you to know that I read Dr. Schafer's paper with great care and interest. I_am familiar with some of the literature which questions the smoking-illness connection and since you hold Dr. Schafer in such esteem, I looked forward to his review and interpretation of that literature. After read- ing it I chose not to respond to it in writing because, frankly, I felt that it speaks for itself. Since you have mentioned his paper again, I will now convey to you my principal reactions. . Throughout his paper, Dr. Schafer emphasizes one point: that statistics cannot literally prove causality. I agree fully with the technical argument but find it substantively vacuous. For all practical intents and purposes -- including both individuals' decisions about how they want to live their own lives and governments' decisions on public policy -- the strength of the statistical association linking smoking to illness is so overwhelming that calling smoking a risk factor instead of a cause of illness reduces to a matter of semantics. To put it another way, I agree that causality cannot be proven in a literal sense by statistics -- such "proof' is tautologically impossible -- but I would regard as foolish anyone wfio failed to perceive the health hazard associated with smoking because the truly extraordinary correlation between smoking and a variety of illnesses "only" establishes smoking as a "major risk factor" in these diseases. Walt, would you hand the keys to your car to a man who was staggering after having consumed ten drinks? Should the police not try to get drunken drivers off the road? The link between driving while intoxicated and a much higher than normal accident rate represents a statistical association, like smoking and illness a strong one, though I would guess that it is statistically less well established than the smoking and illness case. Literally, drinking is a risk factor in motor vehicle accidents and fatalities. Dr. Schafer, you, or I could argue, correctly, that statistics cannot prove that driving while intoxicated causes accidents. It will be a dismal day when society awaits an impossible "proof" to take action to protect the public's health and welfare. I might add that I was astonished by the first page of Dr. Schafer's text. Does he believe -- or do you or does the Tobacco Institute -- that anyone with a moderate degree of health knowledge thinks smoking is the only cause of lung cancer and heart disease? I have never seen that seriously suggested. It is well establish- ed, with an unusual degree of sound statistical and epidemiological evidence, that -270-

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Nlalter ?. ~faner III October 6, 1980 cigarette smoking is the major risk factor in lun g cancer, but not the only one, and a major risk factor in a variety of heart diseases, but again certainly not the only one. Thus I can only interpret the straw man that Dr. Schafer attacks as being one of his own construction. In short, Walt, I found no meaningful evidence in Dr. Schafer's paper to challenge the basic understanding of smoking and illness with which the Panel has been proceeding;- neither have several Panel and staff inembers with whom i have spoken about the paper. I have suggested, and hope that the Panel will agree, that Dr. Schafer's paper be included in the appendices to the Panel's report alongside my original discussion paper. That way, others can read both papers and decide for themselves. Most of your October 1st letter was devoted to your review of -my analysis of the economic costs of smoking. In the remainder of this letter I will respond to your comments. I do so, however, in the hope that we are in agreement that the health effects of smoking are of paramount importance in the work of the Panel. A fundamental premise of your arguments-against my economic assessment is that I fail to distinguish between private costs and external or social costs. To the contrary, the problem is that we define social costs differently. I think of social costs as the sum of private costs and negative externalities. Social costs, in essence, are those-acc ruing to all members of society, including those which individuals incur willingly and those (external costs) which are imposed on others without their willful action.. . Given this definition, I will address your points seriatim, beginning with the third paragraph of your letter. If you accept my definition, there is no double counting of cos-ts. In fact, I fail to see how there would be double counting even if we adopted your definition. You have not offered any explanation to which I can respond. Secondly, avoidable absenteeism and medical costs represent a deadweight productivity loss. Your assertion that they result merely in transfers is simply wrong. Consistent with your idea that opportunity cost i-s the correct concept for assessing true costs.in economics, absenteeism and medical resource consumption both have high opportunity costs because they consume scarce resources at the same time that the individuals involved fail to return a productive contribution. Thirdly, I do not recall having said that "smokers use more medical care over their lifetimes than nonsmokers." The medical costs of smoking are those attributable to treatment of smoking-related illnesses. To the extent that such illnesses could be avoided, presumably by cessation or avoidance of initiation of smoking, the associated medical costs could be avoided. Again, they represent a deadweight loss. Regarding the total lifetime stream of medical expenditures, personally I would find preferable a higher total experienced over, say, a healthy 85 years of life than a lower total experienced, say,-over a less healthy 60 years of life terminated prematurely due to smoking-related illness. I might add that I have never calculated such lifetime expenditure streams, but when one realizes that in the former case significant expenses occur in later years, discounting -271- 2 Ci' ~ h+ IPA m I I p I I I I I f I I 4

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;alter ?. :faner iII October 6, 1980 i ~ I i I I r I i the costs to present value misht well -ake the SS year-old's present discounted ':al::e of costs lower. Of course, it is aertai nly : ossible that the total, without discoc..^zting, is lower, since diseases like lung cancer and heart disease can be cuite exDensive to treat. Fourthly, I agree with you that the way to evaluate a proposed smoking and health polic,v is to compare its costs and bene-'its. I disagree that we know nothing about the costs of "no smoking." To assert this is to deny the abundance of sound evidence an dif:erences between smokers and nonsmokers with which we are all _amiliar._ - - Fifthiy, I agree that many annoyance costs are private costs determined in private markets given defined property rights. I was surprised, however, by your use of this notion in the context of smoking restriction laks._ Bv definition, all deter:ninations of-property rights limit someone's freedoms. One of the most fundamental and conservative roles of the state is the definition and orotection of property rights. If the right to clean air is protected for nonsmokers, some smokers may feel their rights restricted. Conversely, if the right to air is protected for smokers, some nonsmokers will find their perception of their rights violated. I agree with you that the optimal state of affairs would be "a mutually agreed solution." (By this I assume you mean an unlegislated agreement. After all, legislation can be construed as a mechanism for defining agreement in a social context.) The perceived need for legislated solutions reflects an inability for mutual (unlegislated) agreement to satisfy all. I do want to emphasize that not all annoyance costs are simple one-on-one private costs. In congested public places, a few smokers can create a widespread annoyance. In effect, in the economic jargon, they are creating a "public bad." In theory and practice, this is a clear-cut case for collective or governmental intervention. Sixthly, I am aware of, but have not read, the new k'harton ARC study. I have read the previous study which, from what I have heard of the new one, is similar in substance. The one point I would make is that all significant industries generate large direct and indirect economic contributions. As I recall the previous study, the indirect contributions vastly outweighed the direct, as would be true of many industries. I find some of the numbers regarding these indirect contri- butions potentially conf,u ing and misleading. For example, take the 76,410 "full-time equivalent employees." Most of the indi,:iduals comprising this number wvsld, I 3sess, rely on tobacco for a livelihood in only a very minor way. I assume that this number includes thousands of people working in drug stores and the like in which -cigarette sales take place. Ztinat proportion (or number) of these people are dependent on tobacco for cont-:;.uation of their jobs? I would guess that it is relativel,v fe~:. I note, too, that the dollar-vol::,e measure of economic contribution is value- and content-free. ihe i:.:portant :oint, as you noted earlier in your letter, is the opportsni.}" cost: the value of opportunities . - :_re;oze ;..:e to use of resources in t::ts activ:_N In __osing my response to vour cor_ er.ts on - cost ana'-_sis, : reiterate that ac':noWled7e the poss~~2litv ttat V Cost-o:-smo:.1P.; ---L'res 2v be off -_:- "t= .:11" by a substantial amount. _h e s e ._;~.r°_s are o.^.1y est.'.-tes. r.nalysts, _ . - are .:or-kin; c::r.ant: to t:y :o est-rates, -272-

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I I Walter P. Maner III October 6, 1950 by the way, could as easily be much higher as lower than current ones. Frankly, however, the precise magnitude of these figures strikes me as being of little practical importance. It is the qualitative story that matters. What difference would it make if the costs of smoking were $20 billion or $60 billion instead of $40 billion? For the record I would like to reiterate several points which we have dis- cussed orally and in writing. One, and the most important, is that the staff have considered your input into the work of the Panel to be of great importance from the outset. It is visible in such outcomes as the Panel's decision not to recommend a ban on vending machine sales of cigarettes. I for one found your input on this matter educational and useful. Similarly, my feeling that our model of a clean indoor air act should be put into an appendix as purely illustrative reflected concerns expressed by you and one other Panel member about our lack of appreciation of specific economic consequences of the model bill. I will admit to being disappointed that you did not choose to participate more actively in the subcommittee work which produced the draft proposal recom- mendations. You were asked to participate and decided not to. Similarly, I regret that you waited so long to submit your written contributions (your letters Dr. Schafer's paper, and other documents). You knew the timetable for the work of the Panel arid surely were aware of the difficulties all of us would have in dealing with new documents late in the process. Despite that lateness, however, I want to assure you that the staff have examined your documents carefully and considered them seriously. , t r i I I I I F I will repeat, also, my lack of understanding why Mr. Spaniolo and, I thought, you too originally described my background paper as "surprisingly balanced," yet now you express frustration that it is "one-sided." Finally, I am_sorry that you feel disheartened by your experience with the Panel. I sincerely believe that we have solicited your input in good faith; that we have considered it seriously and utilized some of it in writing the Panel's report; and that we,are giving you ample opportunity to express your view of the "other side" of the story by writing a minority report and by including Dr. Schafer's paper in the appendix of the Panel's report. Sincerely, KEtti : ab Kenneth E. Warner Project Director Citizens' Panel on Smoking and Health GD C!1 ~. ~ . Mr -273- O S

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I J October 7, 1980 Mr. Ben Barker, Chairman Governor's Citizens Committee on - Smoking and Health Office of Health & Education Michigan Dept. of Public Health 3500 N. Logan Box 30035 Lansing, Mich. Dear Mr. Barker: MOR40C fYMOIt G.RD/ovaCVLAw .uwacR 61,1OO110C.OlT I learned only yesterday about the public hearing scheduled for 10-8-80 at the State Health Department, this'through one of my longtime colleagues at the Health Department. It is well known that I have long been concerned about the whole problem of tobacco and health and have obviously developed some realistic thoughts about how it could be improved. The health effect of tobacco is a disaster of he greatest proportion if we look at all the disease it causes and the cost to the persons and to the people of our State and the Nation. Tobacco is a deadly poison. Its effect has not yet been fully assessed. In 1973, while serving as the physician on the Michigan Air Pollution Control Commission, I did propose and obtain passage of a ban on smoking during commission sessions. Our Michigan law on smoking in public places and hospitals came soon afterward. As recently as this July, I did assist with the development of a smoking policy restriction at the Grand Rapids Commission sessions. It was approved. It is clear that we need additional measures to further encircle this as yet fairly unrestricted and distorted problem. I understand that you will be assembling information to be considered for a November deadline. If acceptable, I would like to present a statement with some policy and action recommendations by then. Yours sincerely, RAR/gdy CC: Governor's Office t...e~....~cL v~. Richard A. Rasmussen, M.D. -274- RICNARO A. RAfM01113EN. M. 0. ROS[RT W. NARRt6ON. M. 0. YOUN S. KIM. M. 0. JAMEf W. D[LAVAN. M. 0. LARRY J. ROBlON. M. 0. DRS. RASMUSSEN. HARRISON. KIM. OELAVAN & ROBSON. PC LODGETT FROFES',IIONAL OFFICL HUILDING - SV IT! 200 GRAND RAMD4. MICHIGAN 49504 TEL[FwOMt (616) 40Y.727

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STATE OF MICHIGAN WILLIAM G. MILLIKEN. Governor DEPARTMENT OF PU8L1C HEALTH ; ti 3500 N. LOGAN P.O. BOX 30035. LANSING. MICHIGAN 98909 MAURICE S. RE1ZEN. M.D.. Dir.ctor October 15, 1930 Honorable Harry DeMaso Michigan State-Senate State Capitol Building Lansing, NQ 48909 Dear Senator Destilaso: On behalf of the Panel members, I want to extend my appreciation for your interest and participation in the activities of the Citizens' Panel on Smoking and Health. Thank you for taking time out of your busy schedule to speak to the Citizen_s' Panel. Sincerely, ' SSINF: rrb -2'95- ._ducation ._._...~..,~......r ~ Nai ~, Chief r I i I E ~

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U WfLUAM G. MIWKEN, Govsrnor DEPARTMENT OF PUBLIC HEALTH 3500 N. LOGav = 1 P.O. BOX 7=1S. LANSw(3, MuCt+iGatv 441909 MAURICE S. REiZ_!V, M.O, Dir.ctor October 15, 1930 Mrs. Arthur Ketelhut 29594 1%faplewrood Garden City, MI 48135 Dear r1rs. ffetelhut: The letter you sent to the Citizens' Panel on Satoking and Health in which you expressed your views on smoking has been distributed to the Panel members. It will also be included in the final report. On behalf of the Citizens' Panel, I uvuld like to thank you for your interest and participation in the Panel's activities. SSNF:rrb Sincerely, ~ :7 : Scmny~--.. - ~ , mny Sc~Sai Fong,,¢Lief Office of Health Education -276- - r,...-..+- +-~.~..~.r..+...e. :Kl ~. , __ .+.....,...~.~...~.'~.._.,...~R~'

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Michigan Tobacco & Candy Distributors and Vendors Association Inc. Affiliated Organization-Music Operators of Michigan 523 WEST IONIA STREET LANSING, MICHIGAN a8933 TELEPHONE (517) 372 2323 MICHAEL R. SPANIOLO WALTER P. MANER III LEGISLATIVE AND EXECUTIVE SECRETARY GENERAL COUNSEL October 30, 1980 i I Mr, Sunny Sun Nai Fong Chief, Office of Health Education Michigan Department of Public Health P.O. Box 30035 Lansing, MI 48909 Dear Mr. Fong: There is enclosed the minority report of the Citizen's Panel on Smoking and Health. Professor Warner has assured me that the minority report will be submitted to the Governor, along with the majority report, on November 15, 1980. As you will see, the minority report exceeds the two page limitation tentatively imposed by the Panel majority. The reason for this is that the issues before the Panel are far too complex to be discussed intelligently and responsibly in two pages. While I have attempted to make the minority report as brief as possible, to submit anything less than the enclosed report would deprive the Governor and the citizens of Michigan of important information to which they are entitled. Accordingly, I respectfully request that the enclosed minority report be submitted in its entirety to the Governor on November 15, 1980. Sincerely, I Aa,~ Walter P. Maner III Executive Secretary encl: bt -278- F F I I i I ( I t ~

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STATE OF MICy1GAN I r F F 1N1LLlAM G. MILLIKEN. Governor DEPARTMENT OF PUBLIC HEALTH 3500 N. LOGAN - P.O. BOX 90075. V,NStNG. W1CHiGaN 48909 MAURICE S. REIZEN. M.D.. Director October 31, 1980 Walt Maner III, bcecutiv+e Secretary Michigan Toba+cco and Candy Distributors and Vendors Association, Inc. 523 West Zoni.a Street Lansing, MI 48933 Dear Walt; TM minarity report that you have submitte!i to the Citizens' Panel on 3roking arx3 Health was reoeived on October 31 at the Office of Health F13wcaticn. The length of minrarity reports, which was agree3 on by the Panel in its Ootoaber 8 meeting, was to be no longer than two pages. Please note in the OctIober 8 minutes, page 2, the foamat of mincrity reports is statExl. Also in a subsequent letter dated Octaber 17, a descripti.m of the format of minority reports was sent to you on your request. After a discussion with Doctor Ben Barker and urarbecs of the staff, it was their decision that your su}:aitted repart is unacceptable in its present fona as it exceeds the maximaa length. There are several ogtions open to yvu : 1. Aaottier mirority report can be st;}snitted before the Panel meetinq on Ncvsnter 6 which is two pages or fewer in length; or, 2. A notation can be made in the full repnrt that states yas IzL=ity report was not ;*+cluded because of its length. It will be nated that a ovpy of the reFClrt wi11 be kept on file at the Office of Health Il3ucatioci for anyone who wishes to obtain it. Other optirms can be exp3.ered at the Noveaber 6 maet' ng by the full Panel. 1hank you. Sincecely, 1 ' smn~-sun rukr Office of ~ealth SRiF'/ral CC: Ben D. Barker, D.D.S., Chai_rm.,n Re3'uleth E. Warnet, Ph.D., Project Direct= Panel Menbers -279- 9=

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I Michigan Tobacco & Candy Distributors and Vendors Association Inc. Affiliated Organization-Music Operators of Michigan 523 WEST ION!A STREET LANSING, MICHIGAN 48933 TELEPHONE 1517I 372 2323 MICHAEL R. SPANIOLO WALTER P. MANER III LEGISLATIVE ANO EXECUTIVE SECRETARY GENERAL COUNSEL November 6, 198u Dr. Kenneth E. Warner, Ph.D School of Public Health University of Michigan 109 Observatory Ann Arbor, MI 48109 Dear Professor Warner: \ Given my preoccupation with completion of the minority report, I_ have only now had the opportunity to respond to your tetter of October 6, 1980. Since your letter dealt first with Dr. Schafer's paper and second with the analysis of the economic costs of smoking, I will respond to you in the same order. Your letter reveals a basic misconception of the purpose and a misconstruction of the substance of Dr. Schafer's paper. The paper was written, as stated in the introduction, specificaliy to present the other "side to the smoking and health controversy", a side that "is frequently ignored in discussions of this issue" in presenting this paper to ttze Panel, I had hoped to make its members aware that there is a great deal of scientific information that is often over- looked in the "convenient tendency to blame smoking for disease and death" and consequently that careful attention to both sides of this issue is required for an objective evaluation. Your recognition that statistical association and causality are not synonymous is appreciated. However, that you find this "Technical argument...substantively vacuous" is unfortunate and at odds with many eminent scientists. In describing these statistical associations as "overwhelming", you conveniently ignore that tney have been reported in stuaies with recognized flaws in their designs, methodologies, and conclusions. Dr. Schafer took considerable care to point out such de- fects. It is simply not just a question of "semantics". Contrary to your-assertions, Dr. Schafer's paper neither states nor. implies that "Anyone with a moderate degree of health knowledge thinks that smoking is the only cause of lung cancer and heart disease". Dr. Schafer certainly did not construct a "straw man" and his many refer- ences to published scientific papers provide support for the position that smoking has not been scientifically proven to cause disease. (Z ~ ~ ~ _Z80_ N N ~ i I I I I I I I I t I 6 L L L

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Your letter does gpeak to-the difference between risk factor and causation agent. The-backgroumd paper you developed for the Panel's deliberations does not; "Smoking is the principal cause of Lung cancer...smoking annual- :,y claims over 100,00U victims from cardiovascular disease; smoking is the major cause of chronic bronchitis and emphysema...". This distinction is critical in a balanced discussion of the issue. Fa.na~~y, it was disappointing not to see anything in your letter that aa:;-:ssses the public smoking issue, for this occupied a major part of the Panel's attention. I am sorry that the analysis of the public smoking issue contained in Dr. Schafer's paper did not elicit a response. W'_;ci regard to economic costs of smoking, you offer your personal defini- tion of social costs. "1 think of social costs as the sum of private costs and negative externalities". Clearly, what follows from-hat point depends upon our acceptance of your personal definition. Indeed soon thereafter you offer several conditional clauses: "Given this definition" and "If you accept this definition". Neither I nor any professional in the economic community of whom I am aware defines social costs in this way. Medical insurance-and sick-leave*programs are areas in which double count- ing takes place. If you count the cost of the insurance or the sick-leave program, and then count the cost of using the insurance benefits or the sick-leave benefits, you are indeed double counting. All insurance pro- grams, including social security,. are designed to be self-supporting --- the benefits are derived from the costs (premiums), and the costs pay for ~ the benefits. Finally, I was dismayed by your apparent misunderstanding of the concept of "full-time equivalent" employees. The 7b,410 full-time equivalent jobs in Michigan are an aggregate of'possibly three to five times as many people who work full or part-time because of tobacco. Your remarks should relate to over a uarter of a mi11'ioii Michiganders who derive all or part of their earnings directly or -inndirect y rom to acco products. Your letter of October'b closes by assuring me again that submission of a minority report will provide "ample opportunity" to describe the other side of the smoking and health controversy. The good faith of this statement can be demonstrated now only if the minority report that I have prepared be submitted to the Governor as promised. S-!,aSere,1y, n Walter P."Maner III Executive Secretary WP?ri/b t cc: Panel Members -2s1- L

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I I I I I ~ ~ F. EVALUATION FCRM ~ I I I I i I_ ct Ul . ,~ ~ ~ L

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...... ...unn, rwunuti ..--, ~...... TAsZT CITIZENS' PANEL Q. SNYJKING AND HCALTII EVA.LUATIQN OF PANEL PF.RhOIMNCE 1N.;77rUC1'IONS: Cc:role the ntunber repreQenting your opinion about each dtatement. Strongly Disagree Disagree Tend to Disagree 7u Yi to Acjree Aj3ree Stxorv3ly Ac3rce 1. Tbe background materials were prepared and 1 2 3[1] 4 5 151 6 [61 distributed in enough time before each meeting. 2. 7be staff was responsive to the needs of the 1 2 3 4 5[51 6 [71 panel. 3. 7be content of the distributed materials were 1 2 3 4 5(8] 6 131 relevant to the tasks of the panel. 4. The quality of the final report is good, given 1 2 [1] 3 4 [1] 5[6] 6 (41 the time constraints. 5. The staff was able to follow through on tasks 1 2 3 4 (1] 5[31 6 161 related to panel activities: 6. '1be minutes of the panel meetings reflected the 1 2 3 4 (1) 5[31 6 (81 key issues and decisions of the panel. 7. 71ie staff was able to organize the panel's 1 2 3[1] 4 121 5 141 6 151 activities consistent with its purpose. 8. I had anple opportunity to express ny Ideas. 1 2 3 4 5[5] 6 (G) 9. 7be nimber of times the panel met between June 1(1] 2 [1) 3 111 4 121 5(3) 6 131 ajxl NovaiJ-xer was sufficient to meet its charge. 10. '11ie staff eaiminicated effectively with the full 1 2 [1) 3 4 5 151 6 161 Iaaitic:l zud individual paru:l mcni)ers. 11. I was able to make a contribution to the panel. 1(1] 2 3[1] ' 4 (1] 5(4) 6 [51 'Ilicre were twelve respondents. The numbers within the brackets represent the mmber of responses. szTSb9se

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Canments: Staff work was good and the Panel did a good job--on time--amazing. Good exherience. Excellent staff support. Very well conducted. It was a pleasure to be a part of this process. A very good (rewarding) experience. If you aerved on a aubconunittee, pleaee rate the folloiaing (1-poor; 2-mediocre; 3-good; 9-ea:cellent): 1. Relevance of background materials to key issues. [3] good; [2] excellent 2. Quality of distributed materials. [1] poor; [2] good; [2] excellent 3. Ability of staff to eonmunicate information. [4] excellent 4. Ability of suhca7mittee members to work together. [5] excellent 5. ¢iality of proposed re.ernmendations. [3] good; [2] excellent Canrents: 0^i9MA /25 80 F--- r---

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85646131 V.. 1. (~ L~ r~ i~ ~..~ ..... ~ ~ ~

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