Tobacco Documents Online

~ American Heart Association + ~ swe," C A4n C. D.vn CArnwi Amernan Caar Sunny Scem D. BaRw. A~c111 Fltill AsWCYIqn Fnn D. Mtlk Ammnn L..n( Assnn.uan AMrirrMr • F.M..1 liu loy SO~ Fyske AIn.iMrH.r • Sfae Isro ieser FMn C.rw/ Mrtnc. l. Mvm Asbil. Jw*w lMym 1Rp.6d.e AM.imrv C Amencan AcaOnny o! Fa/mlr Rrvacum A1AH1G11 A[aOCw/y Cf Pft%fOK] Amenun Assocmmn fa Rnpnnry Cx Amencaa Cakqt nf CrAdoFy Amencan VYMK HbN11 Asfocuiqn A-can Suc~ d Imema Med- Avoculqn d Suk yW Tertttarul NeaMk Offcub Mrce d Umn Bmtt De(ecros FuwiEamn AMERICAN $ LUNG ASSOCIATION' ' n,e crmlmasSeai aeopr• . Coalition on Smoking OR Health TESTIMONY OF DILEEP G. BAL, M. D. ON BEHALF OF THE COALITION ON SMOKING OR HEALTH to the Special Committee on Aging U.S. Senate on Preventive Health Care May 6, 1993 1150 Connecticut Avenue. NW. Suite 820. Washington. DC 20036 Telephone: (202) 452-1184 FAX: (202) 452-1417

Mr. Chairman and members of the Senate Special Committee on Aging, I am Dr. Dileep G. Bal, President of the California Division of the American Cancer Society. I am also Chief of Chronic Diseases Control, with the State of California, Department of Health Services, although I am not here in that capacity today. I appreciate the opportunity to appear before you at today's hearing on behalf of the American Cancer Society, the American Heart Association, and the American Lung Association, united as the Coalition on Smoking OR Health. Formed in 1982, the coalition has worked to heighten public awareness about the impact of tobacco consumption upon public health. It believes strong measures should be imposed to discourage tobacco use in all segments of the population, including young and old people, women, and minorities. As the manager for over a decade of an innovative program in California, called the Preventive Health Care for the Aging Program, which provides comprehensive prevention health services to community-dwelling, non-frail, low-income, and ethnic minority persons, aged 60 years and older, I am convinced of the need to keep the well-elderly well, mobile, and adequately nourished. In this regard, I have seen clear evidence of how smoking robs our senior citizens of the enjoyment of their hard-earned retirement. On a more positive note, the 1990 Surgeon Genral's report on the health consequences of smoking highlighted the finding that even men and women who quit smoking at ages 65 to 69 increase their life expectancy significantly. Thus smoking cessation has clear benefits for the elderly. As a physician active in public health for over two decades, I bring to this committee experience from a state, and a health department, that has taken vigorous action to curtail tobacco use and tobacco related health costs, by raising the tobacco excise tax and using 20 percent of the attendant revenue increase for tobacco use prevention and cessation programs. The encouragement and leadership provided by the people, and the government of California, could very well be duplicated nationally. I am here to discuss the problem of tobacco use as it impacts on the cost of delivering medical care and treatment in this country. I want to also point out some of the benefits that would result from a substantial increase of the federal excise tax on tobacco. Before I present the specific recommendations of our coalition to this committee, I would like to briefly discuss two points particularly relevant to this Committee's deliberations regarding current legislative proposals. Firstlv. I will present you with a general and, I believe, inescapably alarming picture of the magnitude of the impact tobacco use is having on our health care system. ondl , I want to share with you a little of what we in California have learned from our experience with a tobacco tax increase linked with an ambitious tobacco use prevention education proEram. I am happy to report that, using this powerful combination, we have enjoyed considerable success in reducing tobacco use in our State. 1

HEALTH CARE COSTS AND TOBACCO USE It has become almost a clich6 to say that smoking cigarettes is the gTeatest single cause of preventable disease and death_ in this country. Yet, it still remains difficult to grasp fully the magnitude of what that means in terms of unnecessary human suffering, lost years of life, lost productivity, and direct medical care and treatment costs. Smoking causes more disease and death in the United States than alcohol, drugs, fire, automobile accidents, homicides (including all street crime and drive-by shootings), suicides, and AIDS combined. It kills more than 435,000 smokers in this country each year. Of these, about 148,000 (34%) were caused by coronary heart disease, 139,000 (32%) by lung cancer, 74,000 (17%) by chronic obstructive pulmonary disease, 39,000 (9%) by cancer in other organs than the lung, and 35,000 (8%) by stroke (CDC, 1991). In everyday terms there are 50 smoking related deaths in the United States every hour of every day. Incredible though it sounds, that is nearly one death a minute. On average, life expectancy for smokers is 16 years less than it is for nonsmokers (Rice, 1992). So much for suicide and self-abuse. The irony is that it kills non-smokers as well. gn additiona153 000 deaths occur among nonsmokers as a result of cardiovascular and respiratory diseases and various cancers caused by exposure to secondhand smoke (Glantz et al., 1991). Furthermore, besides those who die from smoking-related illnesses each year, there are over 12 million Americans each year who suffer significant periods of debilitation from smoking-related chronic bronchitis and emphysema. The annual = of caring for all these people is astronomical. Smokers suffer 18 percent more disease over their lifetime than do nonsmokers (Hodgson, 1992). The total economic cost of smoking in the United States in 1990-including medical care costs and lost productivity and wages-was $72 billion per year according to one set of estimates (Rice, 1993), or $68 billion according to another (OTA, 1993). The cost of smoking in California alone amounts to over $7 6 billion pgr_year in medical care costs and lost productivity and wages (Rice, 1992). This includes $2.4 billion in direct medical care costs and $5.2 billion in lost productivity and wages due to excess illness and premature death. In our State, seventy-five percent of these direct medical care costs--or about $1.8 illi n-arp currently paid for by tax dollars. Thus the relationship to current health care costs is very, very real. WHAT WE LEARNED IN CALIFORNIA Proposition 99, the California Tobacco Tax and Health Promotion Act of 1988, raised the state tobacco excise tax by 25 cents to 35 cents. In addition it earmarked 20 percent of the annual revenues "for school and community health education programs for the prevention and reduction of tobacco use". Enabling legislation passed in 1989 provided a program funding base of about $115 million per year. The initial authorization had a two-year sunset clause regrettably inserted at the behest of the tobacco industry. Legislation extending the program for an additional three years, through June 30, 1994, reduced the annual appropriation to about $80 million per year. 2

Before I tell you more about our program in California, I would like to point out what I consider a key feature of Proposition 99 and other such past, present, or future initiatives. That is, the importance of an inherent linkage between the tobacco tax revenues and the success of the anti- tobacco education services. The tax then acts as both a price disincentive to smoking (in California it produced an immediate 7 percent drop in cigarette consumption) and a funding source for statewide tobacco-use prevention and cessation efforts. In California we designated a portion of the tobacco tax increase specifically for tobacco use prevention and cessation programs. The Office on Smoking and Health in the federal Centers for Disease Control and Prevention could use additional resources to increase their efforts with all the states to a level smilar to what we are doing in California. In California from 1990 to 1992 our adult smoking prevalence rate went down 22 percent to 20 percent. In the country as a whole, the adult prevalence rate was virtually flat from 1990 to 1991. More needs to be done nationally to reduce the smoking rates. California's Tobacco Control Program, administered by the California Department of Health Services (CDHS) and the California Department of Education (CDE), is a comprehensive, statewide health education program with multiple interventions delivered through community, school, workplace and health care channels. It is comprised of five basic components: 1) an aggressive paid advertising and public relations campaign, 2) community education through local health departments, 3) a competitive grants Drogram implemented through community-based organizations targeting populations at greatest risk for tobacco related health problems, 4) classroom education in the schools, augmented by an innovative projects grant program, and 5) a multifaceted, comprehensive program evaluation. The first piece of our program to be implemented was the paid advertisine. Right away we decided to not look like a public health campaign. Instead, we took a close look at the tobacco industry's various advertising and marketing strategies and tactics. Nothing expresses our resulting strategy better than the full-page newspaper ad that launched the campaign by throwing down the gauntlet to the tobacco industry in April of 1990. In pan, the ad reads: 3

"First, the smoke. Now, the mirrors. In less than a generation, the bad news about cigarettes has become no news. Most Americans-even the very young--know the unavoidable connection between smoking and cancer, smoking and heart disease, smoking and emphysema and strokes. "So, we seemed to know about the smoke. But what about the really dangerous stuff-all those carefully polished, fatal illusions, the tobacco industry has crafted to mess with our minds so they can mess with our lives? 'Smoking is important. It makes you beautiful and fun and sexy. (Okay, it's dangerous. But lots of exciting things are dangerous.) Smoking makes you powerful. It says you're sensitive and grown up. ` The ad finishes with: "This is going to be a media campaign about a media campaign-as much about hype as hygiene. It's going to talk about a shared community opportunity and a shared community menace." The program's hard-hitting p&id advertising sounded the major themes of the overall, multinle comMnent education campaign. While the former was and is the most publicized, it is the tip of the iceberg which is the overall campaign. Counter-advertising on this scale ($16 million per year) had not been part of any health education campaign since the Fairness Doctrine anti- tobacco messages on television and radio in 1967-70. With paid advertising we were able to reach large youth and ethnic audiences. These provocative messages have resulted in uncommonly high ad recall rates for the campaign (87.5 % for teens; 78.796 for adult smokers). Interestingly, the recall rates were highest for African-Americans, a group we had very specifically targeted. Similarly, we have pushed in a major way for the development of tobacco control policies and ordinances in local communities and governments. These activities are being carried out or promoted by our local lead programs based in county and city health departments as well as by some of our competitive grant projects. Activities include establishing policies and local ordinances prohibiting smoking in public places and restricting access of minors to tobacco products. A"smoke free cities" program that provides mini-grants to promote such policy actions was established in collaboration with the League of California Cities. Local programs and community coalitions were trained in advocacy--how to build a base of support for the new policy or ordinance, select appropriate issues, phrase the new guidelines or laws, etc. We have a growing body of data showing that the program is having a positive effect on the opinions of community leaders across the state, as well as the general public. Evaluation survey results indicate that we have raised the public's general awareness of the public health importance of tightening the controls on tobacco use, sales, and advertising/promotion. 4

By the end of 1990, a majority of California adults were in favor of banning: 1) cigarette vending machines, 2) outdoor billboard cigarette ads, 3) tobacco company sponsorship of sporting and cultural events, and 4) the distribution of free tobacco product samples in public places. However, only about half of California adults favored ga further increase of the state excise tax on tobacco that year. By 1992, however, this had changed significantly. Over 90 percent of Californians indicated support for the current level of tobacco taxation in California, while about 82 percent were willing to increase it by another 25 cents Wr pack and 60 percent would increase it by 50 cents = RK • To overcome obstacles to health education activities posed by California's unique demo hic and e=Mhic diversity, the program has made a concerted effort to facilitate the growth of new alliances among the various ethnic populations and within regions of the state. With encouragement by the program, four te ethnic networks for tobacco control-African American, Asian/Pacific Islander, American Indian, and Lj~= networks-have emerged. Each serves to link the ethnically focused local projects to improve sharing of resources, the development of ethnically tailored program strategies, the fostering of leadership and other organizational skills, and the setting of statewide or regional agendas for each ethnic group. Similarly, regional networks have emerged to facilitate collaborative efforts requiring greater resources than a single community- or county-based organization can muster (such as regional media projects, large regional events, etc.). Thanks to our program evaluation, I am able to tell you with some confidence some of the things we know we have accomplished with the program. Our comprehensive evaluation component is comprised of 1) periodic random-sample te~hone survevs of knowledge, attitudes, and practices related to tobacco use; 2) a separate evaluation of the media camoaien; and 3) a process evaluation that systematically monitors progress of statewide, regional and local program activities over time. Although it is obviously too early to see declines in tobacco-related illnesses and deaths, we have seen important gains in all other measures of program impact. In the beginning, mere implementation of a program of this magnitude was an accomplishment of itself. We moved from start-up to full-scale implementation of all facets of this program-- including over 300 community-based programs--by the end of 1991. Over 100 new community ordinances were passed and more than 60 additional, currently pending ordinances have been initiated since the program began. These ordinances institute smoke free policies in public places and enclosed workplaces and restrict access of cigarettes to minors. More than 12 million 5

Californians have been affected by public and workplace policies enacted between September 1990 and January 1992. The program has produced a direct im=t on the rate of smoking in California. The current prevalence of cigarette smoking among Californians aged 20 or older is 20.4%. This represents a 23.6% drop in smoking prevalence from the 1988 pre-Tobacco Tax Initiative rate of 26.7%. The current prevalence rate is 14.6% lower than it would have been had the 1974-1988 smoking prevalence trend continued. Moreover, California cigarette consumption data confirm this decline. Average ver capita consumRtion in 1992 was 13.82 % lower than it would have been if consumption trends before the Tobacco Tax Initiative had continued through 1992. In fact, by 1992, there were approximately 950,000 fewer smokers in California than there would have been without the tax initiative and the new programs. We estimate that as much as half of these extra declines in the prevalence of smoking and cigarette consumption are attributable to the 25-cent per pack increase mandated by Proposition 99. The rest are attributable specifically to the tobacco use prevention education programs funded by Proposition 99. In dollars saved, 950,000 fewer California smokers translates to approximately $1.5 billion (assuming the Rice & Max [1992] cost per smoker of $1,543). (This reduction is the result of fewer p=le starting to smoke and smokers quitting.) The cost savings attributable to the program over the three years is approximately $1.5 billion. Weighed against the $300 million cost of the program during this period, this represents a savings of over $1.2 billion dollars--a remarkable cost benefit for any program, let alone a government program. m ~ ~ ~ ~ ~ 6 ~

RECOMMENDATIONS TO THE COlVMIT'I'EE The California example, I feel, is directly relevant to deliberations regarding the $2.00 Rar RKk federal excise t~r on cigarettes endorsed by the coalition. the AMA, former President Carter and QjhM. We of the Coalition on Smoking or Health wish to register OUR WHOLEHEARTED SUPPORT FOR SUCH A TAX INCREASE. • By itself, it would producp an immediate and significant decline in smoking prevalence across the countrv-perhaps as great as 30 percent. The recent Canadian tax effect shows this to be true. No single measure could do more to begin to reduce the $37.4 billion excess medical care costs caused by smoking in this country. • In addition, the tax would s.-rve as an important source of much-needed revenues for President Clinton's health reform program. The coalition estimates a $2 per pack increase would ra1~e aQproximatel,y $25 billion dollars the first year, even with a 25 percent drop in consumption as a result of the tax (assuming that there are about 46.3 million current smokers in the United States who smoke an average of one pack per day-- CDC, 1993). To conclude, the Coalition on Smoking or Health urges that the federal excise tax on tobacco be increased by $2.00 per pack of cigarettes. I would also like to note that the coalition believes that regulation of the manufacture, distribution, sale, labeling, advertising, and promotion of tobacco products must be an essential part of any program that is serious about preventive health care. In closing, I would add that after nearly 30 years of Surgeion General's reports on the health consequences of smoking, the tobacco industry still talks about the health controversy. What is the controversy? To paraphrase a distinguished former member of this body, the late Senator Sam Ervin, "What don't we know and when didn't we know it?" Thank you, Mr. Chairman. 7

SELECTED BIBLIOGRAPHY Burns, D and Pierce, JP. Tobacco Use in California, 1990-1991. Sacramento: California Department of Health Services, 1992. CDC. Cigarette smoking among adults - United States, 1991. MMWR 1993;42:230-233. CDC. Smoking-attributable mortality and years of potential life lost - United States, 1988. N04WR 1991;40:62-63,69-71. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS pub. no. (CDC)90-8416. CDC. Reducing the health consequences of smoking: 25 years of progress--a report of the Surgeon General, 1989. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS pub. no. (CDC)89-8411. Hodgson, TA. Cigarette smoking and lifetime medical expenditures. The Milbank Quarterly 1992;70,109-115. Pierce, JP et al. Tobacco use in California, 1992. A focus on preventing uptake in adolescents. Sacramento, California Department of Health Services, 1993. Rice, DP and Max W. The cost of smoking in California, 1989. Sacramento, CA: California State Department of Health Services, 1992. Rice, DP, Max W, et al. The cost of smoking revisited: preliminary estimates, 1990. Data presented at the American Public Health Association Annual Meeting, Washington, D.C., November 23, 1992. Public Health Service. Healthy people: National health Promotion and disease prevention objective. US Department of Health and Human Services, 1990; DHHS publication no. (PHS)91-50213. 8 ;~b N