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DEPARTMENTS OF LABOR AND HEALTH, EDUCATION. AND WELFARE APPROPRIATIONS FOR FISCAL YEAR 1977 IPRm.~Y~ FF.BRUARY 20~ 1976. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE WITNESSES DR. THEODORE COOPER, ASSISTANT SECRETARY FOR DR. DA~ ~. SENC~R, DIRECTOR, CENTER ~0R DISEASE CONTR0~ DR. J0~ ~. FINK~ DIR~CTOR, NATION~ INSTI~U~ 0~ 0CC~- PATIO~AL S~ETY ~ HEATH DR. D0~ALD S. ~REDRIKSON, DIRECTOR, NA~0N~ INSTITUTES DR. ROBERT VAN ~OEK, ~CT~G ~NIST~TOR, H~TH SBV- ICES ~M~ST~TION 3AMES D. ISBISTER, AD~STRATOB~ ~COHOL, DRUG ABUSE, MENTAL ~ALTH AD~STRATION D~. KENNETH M. ~NDICOTT~ ADMINISTRATOR, H~LTH RESOURCES ~INISTRAT~ON C~RL~S MILLER, DEPUTY ~SISTANT SECRETARY, CO~PTROLLER PETR~ J. BERSAN0, DIRECTOR, OF~I~ 0~ R~0~RC~ MENT, PUBLIC ~TH SERVICE A~r. FL0OV. The subcommit~e will come to order. %Ve have the Depa~ment o~ Health~ Education, and ~Vel~are. are pleased ~ hay6 I)r. Theodore Ceoper, the Assistant Secre~ry for Health. ~o do you haw~ w~th you that you want us to know ~ Dr. C~P~,. We have a very dis}in,fished panel~ Mr. Chairman, and mem~rs of the committee, and I would ]ike to go around from left right. Dr. Donald Frcdr~ckson, the D~rcctor of the National Institute~ Health; Dr. Kenneth Endicott, th~ Administrator o~ the Health sources Administration ; Mr. James lsblster~ the Administrator of the Alcohol Drug Abuse~ and A[entai ~Tealth Administration? Dr. Rob6rt van Hock, tim Ac~h~g Administrator of the Health Administration. Then to my right, Mr. Peter ~¢,rsano, the Direclor of our 0~ Resource Management in the Public Health Service, and t~ his right Dr. David J. Renter, Director of the Center for Disea~ Contxol ~nd at the far right, our distinguished colleague from tim Sec~etaryt~ 0ffice, Mr. Charles Miller. Mr. F~ou. Well, we have your biographlc~l sketch of Cooer, and, of court, we will place that in the ~cord ~t t~is point. [The information follows:] (1) TI06652355

I)EPARTMEI~TS OF LABOR ANI) HEALI~I, EDUCATIOH, AlqD WEI£ARE APPROPRIATIONS FOR 1977 HEARINGS III~I,'ORE A SUI~COMMITTEE 0F TilE C0~IMI'I:TEE 0R h~£R0PRIATIONS ROUSE 0F REPRESENTATIVES NINETY-FOURTtf CONGRESS SUBCOM.MI'~['EE ON TII~] DEPAItTMP~NT8 OF LABOR AND HEALTH, EDUCATION, A~D WELFARE DANIEL J. FLOOD, Pennsylvania, Ch~rm~ I,;I)WARD a. PaL'ffI'I,]N. New Jersey 81LVIO O. CONTE, Massachu~ett3 DAVID R. OBEY. Wisconsin El)WARD R. ROYIIAL, California JO~BPI[ D. EARLY, Massachusetts PART 3 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE: HEALTF[ ACTIVITIES (Excluding National Institutes of Health) Printed for the use nf the Committee on Appvopritttions U.S. G4~VERN~,lt~NT PRINTINR OFFICE WASIIINGTO14 : 1976 T106652356

1 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 2O 21 72 next year's funding. These have to do with setting up smoking education and smo}:ing cessation clinics, and to assist Dr. Callan on community programs. This is the end of the second year of the program. Last year, we had a report on the activities that were funded, what happened and so on, and this year we have asked for an annual report again, to review perhaps the entire 2 years, and describe for us what has happened. Are there any questions on this? If not, then we can go ahead with Mr. Horace Ogden, who is here as Director of the Mr. Ogden is ~e Director of it, and he will lead off and will introduce ~e other ~ree m~m~ers of the staff, ~.;ho will also present some short reports. ~. Ogden. 5~. OGDEN: Tha~ you very much, Bob. i am going to try to do a very brief sort of stage=setting, and then let the people who are really involved in the progr~s that you are closely associated with talk about their a~eas of activity. The B~reau of Health Education was formally est~!ished just this past Septe~er, so we are about 8 months old, and the Clearinghouse was organizationi-lly &ncorpornted into i~ and moved geographically in October. The move was completed by the T[06652357

I 2 3 4 5 6 7 8 9 10 11 12 14 15 16 17 18 '19 20 21 73 end of October. • he Bureau os sort of a strange fledgling, creature which is just beginning to, I thinh, find some of its ways of doing business. We have about three different functions, and I thought I would try to spell those out rather quickly, and then get on to the substance of the cancer education, with which you are most concerned. We were created as an offshoot, first of all, of the President's Committee on Health Education, and secondly, of a task force within the Department which proposed to Secretary Weinberger a three-part program to respond to what seemed to be identified needs in health 4ducation of the public across the country. One piece of the recommendations was to encoura e~.and explore the real feasibility of creating a private-sector-based national center for health education. We have contracted With the National Health Council, and they are in the late stages now of developing their recommendations for the creation of such an entity, which would be primarily privately initiated and financed on a basis of ongoing private support plus federal contract involvement. I have. been very pleased with the way the Council has gone at this assignment, and I think that in the meeting we are ~aving at the end of this week in Atlanta we will have quite an affirmative report to deal with. I was very skeptical about the concept at the beginning. I bel'ieve now, after they have been at it a year and have developed a lot of TI06652358

1 2 4 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 74 interest and a lot of support, I thir~ it may be for real. The second piece of the recom~mendation was to create a high-level advisory board within HEW to serve as an inter- departmental panel on health education, chaired by the Assistant Secretary and with membership from the directors, the actual decision-making directors, of the various components of HEW, the six health agencies, the Office of Education, the Director of the Medical Services Administration, the Director of the Medicare program, and several de@endencies within the Office of ~the Secretary. This panel has thus far only met once, owing to the fact that we had a change of horses at the Assistant SEcretary level just at the time we were about to have our second meeting. We are meeting later this month. The concept here is that there should be some high level and decision-capable group lqoking at overall problems of health education in the Department, becaus there are "at least 50 or 60 programs which have a clear-cut. education mission in health. Some of them are doing perhaps too much. Some of them are clearly doing not enough. In any case, they are fragmented and diffused. The third piece of the action was to create a Bureau of Health Education someplace, and it was established at the Center for Disease Control in Spetember, as I said. Our mission is kind of in three pieces. We are, first of all, a liaison operation for trying to begin to make some sense out of and to TI06652359

I 4 5 6 7 8 9 10 11 i:2 13 14 15 16 17 18 19 20 21 make some interagency combinations that will do a ~ore effective job of health education of the public than the strictly every- man-for-himself, disease-of-the-week-clubkind of thing that has characterized health education activities in the past in the Department. Our first job, which we are about nine-tenths through with, is to really take a look at where the action is around HEW, and w~ have been startled to find the number of different programs and the number of different projects within programs, all of which have some sort of at least educational intent with respect to health', some of w~ich seem to be making a lot of noise and doing very little, some-of which seem to be working • very quietly and doing some quite exciting things. " So our first job is a survey, really, of these things, and we are in the process of getting that together, working very closely with liaison people that have been designated to us by their bosses, who are the administrators of the various agencies. In NIH, Storm Whaley in the Director's. Office is our designated liaison, but because of the close working relationships with both Cancer and Heart and Lung Ins-titutes we have also had the benefit of a great deal of help and support from individuals in this room, in this group, and also their counterparts on the Heart and Lung side. So our first job, really, is to find out where the action is in HEW, and begin to recommend how programs can be TI08652360

1 2 3 5 6 7 8 9 10 11 12 15 17 put together logically to reinforce each other rather th~n compete with each other for school curriculum time, for media time, for the attention of people who are being bombarded a million times a day with different kinds of random health messages and stimuli. The second part of the action has been to incorporate and continue as best we can the ongoing activities of the Nationa Clearinghouse on Smoking and Health. As with any bureaucratic upheaval which also involves a geographic transplantation, and we had both of these simultaneously in this case, there are bound to be problems of individuals' preferences in ter~.s of working situations, and we have had, I think, a reasonably typical experience in having some problems with .that. I think we are now over the worst of those. We still have some very definite gaps, and some very serious gaps, in our armamentarium that have been created by people who chose not to come to Atlant~ with us, but I think thatthe team we do have down there is digging in and doing a very ~ood job. The Clearinghou~ in effect, the old Clearinghouse, constitutes two of the three.divisions of the new Bureau. One division is still called the National Clearinghouse on Smoking and Health, and it is carrying on the scientific and technical information and also public response services that the Clearing- house initiated. This group is responsible for thi production of the annual report to the Congress on the health consequences Ti0865236t

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 '19 20 21 of smoking. It is responsible for running the Technical Info~ation Center and bibliographic and library services to the world at large, both to profassiQnal and to private citizen kinds of audiences. The second_piece is called the Community Program Development Division, which indeed is what it was called when it was within ~he Clearinghouse framework. Roy Davis, who is "here with me today and is going to take over when i stop, is the many who is now broadening out his interests, which have always been pretty broad, to spearhead the contracting we are able to do with anybody who has some innovative and kind of exciting ideas about health education. Roy will describe briefl~ the kinds of contracts that we are"involved in this year. Many of them are continuations, and somewhat broadened, of previous initiatives of the Clearinghouse. Others are some new things which we find kind of exciting, where we think some good health education may come about. The third piece of our bureau is a Division of Pro- fessional Services and Consultation, which is just what it says. People are writing us. by the thousands, many of them writing us saying, "Send money. ~henomenon to us a11. Project will follow", which is a familiar But many of them are actually asking for some help, some guidance, in designing more effective health education activities than they have had. And we do now have a small staff that is able to travel around the country or bring TI08652362

1 2 3 4 6 7 8 9 10 11 12 14 1,5 16 17 18 19 2O 21 78 people into the Center to ta~: about and try to.design better health education activities, combining different kinds of subject matter and different kinds of techniques and methodology. So we are partly, I hope, a contractor for innovation, partly a scientific resource in smoking, and partly a consul- tative source for people who feel that their.health education efforts can be better directed. In addition to that, we do have the overall kind of departmental liaison function. I resist calling it a coordinativ function, because I think "coordination" implies a degree of control and heavy-handedness. There are very few voluntary coordinatees in the world, and we think we can accomplish more by working with people and beginning to show that we can be helpful to them in developing their programs than we can if we come down with a heavy hand from the top.. I am going to quit there, while X am ahead, and ask Roy and then two of our other people, Dr. Green and Dr. Burns, to talk to you about specific portions of our activities. And then, perhaps, we should entertain questions collectively at the end, if that is satisfactory to all of you. Roy, are you indicating a different suggestion? DR. DAVIS: I think the Committee is interested in specific kinds of results, and I think the other two would be a bit more specific than I can be. DR. OGDEN: Okay. Dorothy, would you start? Dorothy T106652363

1 2 3 4. 5 6 7 8 9 10 11 12 13 14 1,5 16 17 18 19 20 21 79 Green, as you }now, is a member of the Clearinghouse staff, and is now working here with you in the Cancer Institute. We are delighted that she is also wor}~ing with us on our behalf with you. Dorothy? DR. GREEN: I am going to report very briefly on a very specific aspect of some of the work that has been done under this Inter-Agency Agreement that Dr. Woolridge has been talking about. Since 1968, there have been four surveys of teenagers. The last of these surveys, the 1974 survey, was financed and funded by the National Cancer Institute, ~at I would like to tell you tod~y is just a little smattering. You have the full report, and I would like to just tell you a little smattering of what has been happening with teenagers since our first survey, which was completed in January of 1968. These surveys were national probability samples of teenagers 12 to 18 years old, inclusive. They were conducted in the latter part of December and the first part of January in each case. These were not school surveys. These were really samples of teenagers, whether they were in school or not. We did not include any institutionalized teenagers~ During the latter part of December, most children are home. They are home from coliege, they are home from school, a~d therefore we had very few t hatwe could not reach. If you are at all interested in methodology, we used TI06652364

2 3 4 6 "7 8 9 10 12 13 14 16 17 20 21 ~. 22 ~ 23 80 telephone interviews. In the first survey, we used face to face interviews in households %;here there are no telephones, and we found that it did not make any difference, so we did not go to that trouble again. And anyway, the number of househoids with telephones is rapidly increasing. There was a lette~ to the editor of the ~ashington Post just the other day from the Vice President of C&P Telephone Company, and he said that in the Washington 9tea 95.3 percent of the households have telephones. That is just to tell you a little bit of the methodology. It really works very well, because you can collect the data so quickly. Sihce the first survey, in 1968, up to the present, 1974, what has happeneh. I do not think is discouraging. Some people think it is. Smoking among teenage boys has remained almost constant. Smoking among teenage girls has risen every time. However, up until 1968 the increasein cigarette smoking among teenagers was accelerating ~t a very rapid rate. So if you can slow it down just a little bit, it is something to be ve~l much encouraged about, I think. Now, I brought a few slides along. Bob, maybe you better go back there and punch them up. As I say, there are a lot of findings that I am not even going to talk about, because you have th rep~But I think this might give you some insights. First.slide, please. T[06652365

1 2 3 4 5 6 7 8 9 10 11 15 81 That just gives you an example of the kind of art work that DCCI can do. ~ext slide. There you are, with boys. You can see that among boys there was very little change in the percentage of cigarette smokers over the four surveys. You can see that it is almost flat across the four surveys, 1968, 1970, 1972, and 1974. That funny thing among 17 and 18-year-old boys in 1970 -- Statistical] it says it is significant. M~ guess is that it is some sort of aberration, because it went right back to where it was, and stayed there. So I think that i~ is safe to say that among boys, smoking has not continued to accelerate over this period, and it looks like it has leveled off. The next slide shows the girls. I think you can see that the acceleration has stopped. Among 17- and 18-year-old girls,-it iooks like a trend towards slowing down in the rate of taking up smoking, when the girls get to be 17 and 18. ' Now, what'this has-done, by the increase in smoking among girls and the decrease in smoking among-boys, is that there is no longer any difference between boys and girls. They are both smoking at the same rate. A few years ago, twice as many boys as girls were smoking. At the Third World Conference on Smoking and Health, I think the question I was asked =nst Tl08652366

1 2 3 4 5 6 7 8 9 .10 11 12. 13 14 15 16 17 18 19 20 21 82 often is, "~, are girls caught up with boys? h~y are girls ~ore like bo~,s?" I do not ~now. ~hy are girls and boys alike in so many ways now. I think it ~would be funny if they were not getting to be alike. I think we need to be concerned, though The next slide gives us a little indication of what effect the p~rents have on the children. The first bar shows what happens if both parents smoke, by age. You can see that that is the highest, just about, all the way through. The yello~ line is if only the father smokes. The next line is~ if only the mother smokes. You see, the mother tends to have a little bit more influence on the smoking of the child than does the father. And the blue line, which is the lowest in all cases, is where neither parent smokes. You can see, too, that this influence is more pro- nounced at the younger age groups, 15- and 16-year-olds, than it is as they get older. Incidentally, older siblings have the same sort of influence as parent~. Next slide. selves. So we looked at some things about the teenagers them- One was if they worked outside the home~ Now, "worked outside the home" could mean part time, full time, part of the year, all of the year. And w~ found that most boys do work, and really, most girls do work at some time. The ones that do not work are very few, and the ones that did n~t work at TI06652367

1 2 3 ,4 6 7 8 9 10 11 13 1.5 16 17 18 1.9 20 21 23, 83 all are not very likely to be smokers. They are much less l~ely than those who worked. There are a number of possible explanations, one of which could be that they have no money, and the other of which could be that that green line of children are really pretty protected. They have not even worked outside the home. But we do not really know. The next slide shows us a little bit about aspirations their educational aspirations. This is based on just those who are in high school. We asked them, "If you are in high school, what kind of course are you taking?" If you are taking a colleg~ preparatory course, you are less likely to be a smoker than if you .are taking any other course besides college preparatory. This we also found gets borne out in our 18-year-olds. The 18-year-olds are divided pretty much into three equal groups, those who are still in high school, those who are in college, and those who have dropped out. Those in college have the lowest smoking rate. Those who are out of school hive the highest, and the high school students in between. So it is becoming a socioeconomic thing, insofar as we can measure that by education. The next slide shows us the education of the parents, and again, this bears out the fact that'the better educated the parents, the less likely the child is to smoke. I think that. this is not just a matter of education. X think what we are talking about is a socioeconomic phenomenon where ~moking is- Tl06652368

1 2 3 4 6 7 9 10 "11 12 13 14 15 16 17 18 19 20 21 no longer accepted among the well-educated. You will find lots of other data in the report, but I thinh the main thing that I would like to say, finally, is that we do ~ow that these teenagers are aware that cigarette. smoking is a health threat. About 93 percent of them say that cigarette smoking is harmful to health. And this implies, to me, that we stop telling them that cigarette smoking is harmful • "Oh you mean you do not want to health Now, somebody says, , us to educate them any more?" Well, yelling at them about "harmful to health" when t~ey already know it is not educating them. I think we have to move away fro~ just saying, "Oh, you have to quit smoking", to "This is what smoking does to you." .... .... I.think that is probably all there is time for, unless you have some questions. DR. MURPHY: Perhaps we could defer the questions until all the speakers have spoken. Thank you very much. MR. OGDEN: Thanks, Dorothy. I would now iike to ask Dr. David Burns to talk a little bit about the 1975 report on Health Cons'equences of Smoking, and fn particular the chapter on involuntary smoking. Dave? DR. BURNS: I would like to start by simply running through some of'the high points of this year's report.. Carbon monoxide has continued to develop as a major factor in cardio- vascular disease, both in etiology and also in the pathophysioloc of cardiovascular disease, showing a marked tendency to aggravate T106652369

I 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 20 21 85 people with angina, shortening their exercise tolerance, and also has been shown to have a negative inotropic effect on the diseased heart. Cigarette smoking has been shown to be the major source ofcarbon monoxide absorption for most smokers in the country, and that is well ahead, running three to four times the level that is absorbed due to industrial exposure, even in people that are industrially exposed. In other wor~s, the magnitude of the increase in carbon monoxide absorption is three times as great in people smoking cigarettes as it is in people who are industrially exposed to carbon monoxide. For the new evidence in the cancer chapter, smokers who have switched to filter cigarettes for over lO years hay& been shown to have a lower risk of developing lung cancer than those who continue to smoke regular cigarettes. Cigarette smoking and exposure to radioactivity by uranium mining have bee~ related to the cytologic changes" in respiratory tract epithelium, but cigarette smoking again has a much stronger association than simply exposure to radioactive radon daughters by mining. In one very interesting rgport from the Soviet Union, chrysotile asbestos has been shown to contain traces of the carcinogen, benzoate pyrene, which may have implications for the reason why asbestos workers have a very marked increase in lung cancer incidence, but that. lung cancer incidence is almost entirely contained in the smoking asbestos workers. T106652370

1 2 3 4 5 6 7 8 9 10 1 I 17 86 Smohing after first primary oral cavity tub.or predisposes to a second respiratory tract or oral cavity tumor. The evidence on aryl hydrocarbon hydroxylase ha~ con- tinued to develop. This is an enzyme which metabolizes some of the compounds that are considered to be carcinogenic. In one study, a group of patients with lung cancer were examined for what was felt to be a measure of the genetic capacity to produce this enzyme~ and it was found that substantially more of the lung cancer patients had an ability to produce high levels of this enzyme than did either other tumor controls or the normal population. However, in the light of the we~l-established fact that l~ng cancer does not have a genetic predisposition, or at least a strong genetic predisposition, certainly more evidence in this area is going to be needed before we can really make sound judgments on that. In the pulmonary area, tests of small airway dysfunctio seemed to be abnormal in a large percentage of asymptomatic smoke~s, and autopsy studies have shown a very good, strong dose-response relationship between cigarette smoking and the microscopic changes of chronic bronchitis and emphysema. One study has shown that bronchiolitis is much more common in smokers who died at an early age due to accidents than in nonsmokers. Finally, there is a chapter on involuntary smoking, or what has been called passive smoking in the past. We have chosen to call it involuntary smoking, due to the fact that it Ti08652371

1 2 3 4 5 6 7 8 9 10 11 13 14 15 16 17 18 19 20 21 87 is s~o~:ing due to the e:~osure to many of the same constituents that are present in cigarette smohe, and it is involuntary, due to the fact that it occurs as a result of the necessary act of breathing in a smoke-filled room. A number of studies have determined levels of carbon monoxide in various situations, both experimental and environ- mental situations, and substantial levels of carbon monoxide have been d~termined due to cigarette smoke; levels anywhere from 3 to ll0 parts per million have been recorded in situations. The higher levels occur only in those situations where there is very heavy smoke pollution -- i.e., a large number of cigarettes smoked -- and very poor ventilation. But these situations occur; a room such as this does not really have adequate ventilation ~o remove the smoke. This is also of major concern at this point due to the fact that because of the energy costs of drawing in air from the outside, ventilation systems are now being designed to draw in less and less air from the outside, and use recirculated. air. And today, the technology does no~ exist -- and I repeat, it does not exist~-- to adequately remove the smoke contaminatior due to cigarette smoke. There are other forms of dust which can be removed. Certain forms of pollen can be removed. But neither carbon monoxide northe solid particulate matter due to cigarette s~oke can adequately be removed from the ~efiltered air. So therefore, in the buildings that are now being designed, TI06652372

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 ~. 22 88 we are faced with a situation ~ere the indoor environmental quality is being compromised due to the energy costs of drawing in outside air. In addition, there are two other areas where the effects of involuntary smoking have been studied. On &ircraft • and busses it has been shown that a substantial percentage of the nonsmokers are annoyed by cigarette smoking. It was also worth noting that segregation of the smokers was felt to be an adequate solution to this problem. And finally, in two studies, one that was not quite adequately controlled, from Israel, and one that was quite well contr611ed, from England, studied the incidence of bronchitis ~nd pneumonia in infants within the first year of life. The English study continued for the first 5 years of life, but was only able to show an increased incidence of bronchitis and pneumonia in infants of smoking parents during the first year. This increased incidence persisted when the birth weight of the baby was controlled for. It also persisted when socioeconomic class was controlled for. And very interestingly, it increased with increasing numbers of cigarettes smoked in the house. The one aspect of this area that needs to be further studied is that what was not controlled for was factors that may be related to cigarette smoking, such,as parenta~ neglect~ In the study from Israel, infants who were admitted for poisoninc also more frequently had parents who were s~kers. So that it TI06652373

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 ~ 25 89 is not Clear yet that the incidence is due to enviroruT.ental pollution, but it is clear that infants of smoking ~.others do have a higher risk of developing bronchitis and pneumonia in ~he first year of life. I thinh that about sums it up. ~R. OGDEN: Thank you, Dave. I would like Roy Davis now to talk briefly about some of our contract activities', and then we wi~ all collectively be available for some questions. Roy. DR. DAVIS: First, I will acknowledge that it is about 2 minutes past the time that it is all to have ended, and I know that you have to return at 1 o'clock, so I will be just extremely brief. First of all, this year's fiscal year budget in the Reimbursement Agreement is in the general vicinity of $900,000, and the first thing I want to report is that the Bureau of Health Education has allocated from its funds something in t~e vicinity of $1.5 million or perhaps $2 million for the conduct of the same kinds of activities. I think it is important that we recognize that fact. The second thing is that it has already been noted that the major thrust of the smoking control program has been contin- ued in this year's agreement, but it has been extended to in-. clude a little bit more of health education, but I would like to say not general health education but health education that T106652374

I 2 3 4 5 6 7 8 9 10 11 is highly specific to the prevention and control of cancer.~ This pervades all of our activities. The next thing I would like to simply observe is that we carry out this work, or we will be carrying out this work in the coming year, under about 25 or 30 contracts. I cannot possibly discuss 25 or 30 contracts here. I can only bake some very general observations about them. I would like at this point to simply r~gister very hearty approval with what I heard Mr. Fink saying, of finding some ways for us to communicate in more detail about some of these activities, and having help and guidance along the line, and sharing information• It is very difficult to do in written for~ in here. Also, I should observe that almost every one of the 25 contracts that I am referring to will be negotiated or have been negotiated in this month. So obviously, the activities do not get started until the last few days of this month or the beginning of the new.fiscal year." That is all+ primarily, shall we say, because of'the late arrival of the money last year, unde~ last year's agreement. We did not get started to get things under way until the tail end of that particular fiscal year. Okay,.the three general area~ in which ~e.are operat- ing -- and again, this has to be extremely ~s~--__ are that we continue to operate to do something about health professional~, which has already come up at t~is meeting -- nurses'and physician and other people whom we know have a different kind of cr~d TI06652375

1 2 3 4 5 6 7 8 9 10 11 12 14 15 17 " i 22 91 than just the average citizen walking on the street. Our older activities which you may be able to identify with are the activi- ties with the American Public Health Association, which is an attempt to reach public health workers and to educate them, tq train them, to sensitize them, to develop materials and to get model program activities going out in public health types of agencies. A different kind of activity continues with the American College of Radiology, which is much more hospital-based and attempts to get the physician in a hospital to do things with other physicians and other people who work in that hospital, including, of course, patients and their families. New activities in this area which we have not worked with before would be, for example, two new contracts which we have, one with the Student American Medical Association and another with the Student National Medical Association, the latter being the black organization. Obviously, these two contracts are to try to do something with physicians before they become physicians. The National Medical Association does a good deal of work with the other groups, like nurses and other groups that work with physicians, and so their particular contract will shoot off into that area. I will skip all the others. The second general area that you have had interest in since the beginning dealt with what we call community organi- zation or health education programs or smoking programs for T~06652376

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 "20 21 25 92 special population groups, groups that for one reason or another are more reachable or, on the ot her hand, may be at greater risk. The one contract in this area that you will identify with is the smoking research or the San Diego Community Laboratory.. That activity continues. We have had some very difficult times, for a number of reasons, primarily dealing with the end of one contract and a long period of time, and then the Medical Society in San Diego~wanted to have -- or needed, felt they had to have - ~a cash advance, and that got some bureaucratic things in the way, so that that particular contract has also been just signed. In the new areas that we will be moving into, we will have one contract with a group in New Mexico, and it will dealve much more into identifying the people who have credibility and sophistication -- perhaps not sophistication, but are in a better way to carry on education activities in the rural, barrio, Indian or rural disadvantaged types of situations, identifying these people and developing model ~rograms, with a very heavy emphasis on cancer prevention and control. A similar kind of activity will be going on in the Tuskeegee Health Education Center~ and also in the Southern Association of ~eighborhoodHealth Centers. These activities are in the vicinity of $50,000 a year. The third area you have always had interest in was the surveys. You have heard Dorothy Green talk about one result bf a survey. She did not say anything about the fact that the TI08652377

I 2 :3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 ~" i 22 93 adult surveys are continuing, and will be grinding out informa- tion. And further than this, a question came out on smoking amongst professional groups. The survey for the various pro- fessionals is also under way, and I am sure Dorothy Green or somebody else will be back to report on that closer to the end of this period.. Finally, the last area does deal with the prevention of smoking and good sound health education for boys and girls, or working with teachers or school curricula, that we continue that activity. I wiil simply observe again that the youngsters that we have been working with are just entering into the age group where they might become counted in Dorothy Green's survey, the basic idea here being that you have to carry on education over a long period of time, if kids are going to make the right kinds of decisions for themselves, and we are now getting to thal point. There will be 25 workshqps conducted this summer all over the United States. For those of you who know the Berkeley project, we have developed a new fourth grade unit which deals with the energy system in the environment and how that energy system is used by the body, what the digestive system is like, and this unit was developed for the specific purpose of bringing kids understanding about cancer. And that can be visited in about i0 places around the Uni£ed States, by anybody that wishes to visit it. T106652378

1 2 3 4 5 6 7 8 9 10 11 12 13" 14 15 16 17 18 19 20 21 94 In the evaluative area -- and this is my last point -- we are using the same instru~antation and approaches that Dorothy Green talked about. We are evaluating boys and girls who were exposed to our curriculum 5 and 6 years ago, who are right th~s summer graduating from high school. The preliminary information simply indicates that the more units that a boy or girl has had of this particular curriculum, the lower is the smoking. But that is extremely preliminary. Right now, the data is being gathered, and I feel very sure that in a number of months we can report something out. It has already been indicated that the money, the approximately $200,000 of 1976 funds, will be used primarily in the area of development of model community programs, at least in three communities, and also for much more intensive work in the situation in Tyler, Texas, which I assume you know more abou~ than I do. Thank you. DR. MURP}IY: Thank you very much. Are there any questions of this very rapid report, some of which was, of course 1~.your mrocnure~ .~/ Mrs. Monaco? MRS. MONACO: The question I have I do not know whether it would be better put to the B~Lreau of nealth Education person- nel that have been speaking to us, or to the DCCR staff. I noted on page 6 of ~h~Status of Program Activities ~e program T108652379

I 2 3 4 5 6 7 8 9 10 11 f2 13 1.4 15 16 17 18 19 20 21 .- ~ 95 that deals with co,unity organization cooperative efforts between the Bureau and DCCE. It appears to be an overlay on the existing comprehensive saturation community program. I am ested in knowing whether this program will -- is intended in any way to ---take over the educational component of the selected funded community programs, or whether it is merely going to assist in development of the educational component. And to either extent, I am interested in knowing how the cost of this program, the continuation of this type of educational component, can be accounted for by the planners for the community programs, so that they can try to envision a reimbursement source to con- tinue theseprograms after the planning period is terminated. DR. WOOLRIDGE: Dr. Callan, who is sitting right you, Mrs. Monaco, is the Associate Director for the community program segment. And when this part was worked into the inter- agency agreement, Dr. Callan was not aboard. He is. now, and is just getting his program started. And because the-Bureau of Health Education wanted to move into the co'unity program area to assist, we asked them if they would like to help Dr. Callan with the community program work, to get it moving. Because when he came in he was all alone, and I think he only has a secretary right now, and can use some support. So it was this idea, that this part was put in. Secondly, because of the time element and the lateness, this does not become effective in FY 75. It becomes effective T106652380

1 2 3 4 .5 6 7 8 9 10 11 12 14 15 16 17 18 19 2O 21 25 96 on 1 July, which is FY 76. And they have been meeting with Dr. Callan to determine the type of support which they can give him. This is also within the guidelines of the Bureau of Health Education to -- I do not want to use the word "coordinate" but to assist and give support where it is needed in HEW. While I have the floor, let me make just one other point. Because the funding for this year was not available until the last quarter, these programs will run through FY 76 into April, May, and June before they are ended. So we can expect another review a year from now to report, really at that time, on the entire Intra-Agency Agreement. DR. MURPHY: There will, of course, be a presentation later this afternoon on the community acti@ities. Perhaps after a little more overview from that and ~pdating, we can get to that. • Mr. Fink? MR. FINK: I would like. to ask whether these folks are doing anything to take advantage of the rising tide within the communities that they are spending educational funds in on education on s~king, whether they are taking advantage of the rising-tide within those communities of people who are joining togethe~ and banding together in antismoking efforts and in nonsmokers' rights, whether they are exploiting that tremendous potential opportunity. And if not, what do they intend to do about it? TI06652381

1 2 3 4 6 7" 8 9 10 I1 14 1.5 16 17 18 19 20 21 "'-- i 22 97 DR. 5~URPHY: E~. Ogden? ~. OGDEt~: I think the point is very well t~:en. We are trying, I'think, to identify those movements which really seem to have some strength behind them, and also some efforts that could hopefully be replicated around in other places, Mr. Fink. I believe that we are going to find ourselves working much more closely with those groups. We also have maintained, as you know, I think, a relationship over the years with the Inter-Agency Council on Smoking and Health, which we are now attem~.in~ho-slt~en.gthe.~_.9_.~!t and_ ~--get on a new kind of a footin¢ where we can work with the private sector more ~losely. I agree with you that there is a real surge of interest at this point, and I think it would be.very foolish of us not to try to ride th~ tide as hard as we can, and help it grow and broaden. DR. DAVIS: I am going to use the same response to ~espond to Mrs. Monaco's question. I think the point I would make is that if there is one thing we have learned about the school business and changing what happens to boys and girls or teachers, or if there is one thing we have learned from San " Diego and these kinds of activities, is that there has to be a reinforcing mechanism." You have tO have as many organizations and credible p~ople and official agencies working together and coming up with some kind of a uniform method. Incidentally, tha~ is another reason why it has to be broader than just the narrow category called smoking. But anyway, without getting into that, TI08652382

1 2 3 4 5 6 7 9 10 11 12 14 15 16 17 18 19 2O 21 98 I would say that we have learned a great deal in the Clearing- house, and certainly we have learned a great deal in the last few years, and I think that will be a contribution that we can m~e to your community endeavors. We know a lot about getting all these groups working together in effective kinds of ways, and reinforcing each other. So we have been doing it, and obviously we have more to do along these lines. That is why the Students o~ganizations and other organizations I have mentioned are important. ~. FINK~ I would like to suggest that there are a vast number of ongoing model programs in that respect, and I would like to suggest that you people look at the total spectrum all the way from the vast organizations like GASP and ASH all the way down to the miniscule efforts of, say, a woman like Mrs. Plescow in New York State, who by herself gathered together 7,000 people in an antismoking drive. And between the two ends of the spectrum, you certainly should have a volume of opportuni% DR. MURPHY: As a point of information for the Clear- inghouse, since it is that, in Ontario, Canada, the Ontario Cancer Division, they have a whole package with a movie and an instructional course for the younger age student, younger than you have mentioned. It is entitled, "~.Celly", or the normal cancer cell, and it shows the youngsters what happens when it gets exposed to those noxious elements. We have adapted that for our ~ew Yo~: State Division, and it seems to be, at least T106652383

1 2 4 5 6 7 8 9 10 11 14 15 16 17 18 19 2O 2.1 99 initially, of interest. ~. OGDen: We have been working very closely with the Canadian people, who have been some leaps ahead of us. DR. MURPHY: Their TVprogrammlng certainly is very good. questions, we will accept this initial report. much for d~ing such. We will reconvene at i:15, in this room. (Thereupon, at 12:12 p.m., a recess was taken, to reconvene at 1:15 p.m., the same day.) Considering the hour, then, and I do not see any other Thank you very TI06652384