Tobacco Documents Online

Tobacco Use. An American Crisis Final Report of the Conference January 9-T2;,19'93 Washington„DC Conference Sponsors American Medicxl Assoeiatlon City of Hope National Medical Center The Centers for Disease Control and Prevention Coaii6onon Smo{dng OR Health American Cancer Society American HeartlAssociation! American Lung Associadoni Memorial~Sloan-Kettering Cancer Center University of TRxas M.D. An&rson Cancer Center Editor, Thomas P. Houston, MD American MedicallAssociation Tobacco Use: An rlmerican Crisis i

Tobacaco Use: An A:meri'canCrisis In only seven1 yeats, we,willlreach the date the US Department of. Health and Human Services has set for a series of national'health goals called".Healthy People 2000."'lhe US Surgeon Generalhas calledifor a"Smokefnee Society by, Year 2ID00:"'Looking ahead to thataltnost mystical dkte,,members of the tobaceo.control com- munity assembled in Washington, DC January 9-12,,1993 to discuss, plan, and issue a series of goals and objectives in twelve areas concerning tobacco and health. Co-sponsored by the American Medical Association, the Centers for Disease Control and Pievention; the City of'Hope National Medical Center, the Coalition on Smoking OR Health (the Atneri- can Cancer Society, the American Hearrt Association;, and the American Lung Association), the Memorial Sloan-Kettering Cancer Center,,and the Univetsity, of Texas KD: Anderson Cancer Center, this conference represented a unique gathering of organirations and individuals concerned abourtobacco use and its impact on health. Putting aside "turf' issues,and differences in policy and priorities;,over 200 participants were educated, stimulated, and challenged by plenary, speakers and workshop activities. This document includes several of the plenarv, addresses,as well I as reports frotn each of the work areas. Each workshop report contains background information relevant to the issue, and ends with a series of recommendations for the future for each area. The recommendations are also summatnted at the end'of this report. The conference sponsors,hope that the proceedings will be a useful blueprint for the groups and!individuals represented arthe conference; local; state; and federal agencies andL^twmak-, ers; andlothers interested in preventive medicine and public health. Since the early 1950's; medical research has brought our knowl- edge about tobacco and health from an observation made by a few physicians that related smoking with lung cancer to our current realization that tobacco use is the single most important preventable cause of illness and premature death in this country. More than 60,000 studies about tobacco use have made this the most thoroughly studied subject in medical science. A stnall sample of tobacco's impact on American society reminds us of the importance of tobacco control in public health. Foreword • The annualltotal of premature deaths inAmerica from tobaccoo use is about 434,000 persons. Smoking is the major cause of lung cancer, of deaths from emphysemaland chronic bronchitis, and is a principal cause ofheart'disease and stroke. ..~bout'one-third off smokers will die from a tobacco- related illness or condition- almost 25% of the total deaths in the US. • Exposure to environmental tobacco smoke when nonsmokers inhale thousands of chemicals during "passive' smoking may kill as tttanyas 53,000 Americans yearfy. One analysis estimates that about 35,000 of these deaths are from heart disease: other stud- ies, including new conclusions released by the L5 Environmental ProtectionAgency, projectabout 3000 lung;cancer deaths from environmental tobaceo smoke exposure each year. In addition. environmental lstnoke imposed upon children causes I50',Ot>D to 3t)0,000 cases of bronchitis and!pneumonia each year. and Iwors= ens asthma in up to I million children annually. • Smoking among adults has fallen to the lowestilevel in over 5U yrars;,about 25%, but teert,smoking has not changed significantly since 1980. Eighty-five to ninety percent of new smokers begin before age 20. About 3.t>D0 childrert begin smoking each day in the United States. The tobacco industry spends about $4 billion each year for advertising and promotion of its products: activities that recruit new smokers and!attempt to convince current smok- ers not to quiC • Inereased'health care costs, lost productivity and misaed work. higher insurattce costs, and higher maintenance costs in busi- nesses in which employees may smoke are at least $68 billion annually. Conclusions of the conference Across different work groups, conference participants came to several points of concurrence that transcended their issue-spe- cific areas: ~. ~ Increase the Federal excise tax on cigarettes by 0) . two dollars per pack to The present Federal tax on cigarettes;,24 cents per pack, put.s the 0 United'States near the bottom of'the list among the indu.ctri.dized Ul nations, which tax tobacco atamuch higher rate. Conference Tobacco Use: An Antericart Criais iii

participants suggest $2 per pack as more in keeping with the health costs due to tobacco use. EWen more important, it was estimated that a $2 tax increaxe will save 2 million lives over time. The tax would deter.youth fiom~starting to smoke, perhaps more effectively than any other single health promotion tactic. Adults would also have an increased incentive to quitsmoking. Indepen- dentpublic opinion polls show broadbased support for a ciga- rette excise tax by over '0% of~ respondents. While not tying use of tax revenues to specific projects, participants agreed that the t7uc shouldibe indexed1 to the consumer price index or another suit- able marker that would keep ~the tax from being absorbed by inflatiom State governments should also raise the excise tax on tobacco products appriopriately: The Galifornia and Massachtsssetts expe- rience shows that voters ulll pass a tax increase if it gets on the ballot Enable regulatory agencies to assume jurisdiction over tobacco products. Cigarettes and other tobacco products are both the,most danger- ous and the least regulated consumerproduct;in the country, It;is the opinion ofimattyin the health community that the Food and Drttg Administration ~(FDA) currendy has the authority to regulate tobacco products as dmtgs when direct or implied health claims are made. The FDA should be given specific statutory, power by Congress to expand its authority to regulate the tnantdacxure, sale, labeling, advertising, and promotion of tobacco products. The Federal Trade Commission should use its authority, to regulate "vnfair and!deceptive" advertising, and the Departrrtentof Justice should enforce the ban on televised cigarette advertising,currently being broken by tobacco industry sports promotions:. Protect the public, especially children; from environmental tobacco smoke (ETS)exposure. As health professionals, we must educate our patients about the risks and dangers of ETS, and advocate for clean indoor air ordinances that protect the public from its harmful effects. This could cut costs related to acute illness among smoke-exposed chi9dren; and in the workplace, smoking bans would have thee dual effect of'health protection from ETS and help increase the number of adults that stop smoking: Restrict the tobacco industry's advertising and promotional campaigns. The tobacco industry currently spends about $4 billion each year on advertising and promotions, Banning sports sponsorships and other promotions and the tobaeco;industrys use of'healthy;,sexy, athletic models and cartoon figures in advertising should resultin a decrease in tobacco use, especially amongyouth, At the local level, the health community should be vocal in opposing the tobacco industry's use of sports sponsorships and other prorrto- tionallenticements, distributionof samples, and targeting of' minoritygroups for high concentrations of advertising.. Foreword sdapted!ftom Mouston4 TP: Tobacco Control: Toward the Year 2tNN1:7befounnal'ofPamityPractice 1993; 3G:60t-6o2i Reptinted'with permission. Ack11owl*CIrierits As chair of'~the conference planning cotnmittee, I would'like to thank its members for their hard work;,and the support from their institutions to the conference: City of Hope Yational Medical Center Karen;Warren; Executive Vice President Tite Centers for Disease Control and Prevention Michael Eniksen, ScD, Director, Office on Smoking and Health Coalition on Smoking OR Health~ Alan Davis, American Cancer Society Scott Ballin; Atnerican Heart Association Fran DuMelle, American Lung Association Memorial iSloanlKetteting Memorial Cancer Center James Quirk, Senior, Vice President University of Texas M. D: Anderson Cancer Center Harry Holmes, Associate Vice Presidentfor GoverrtmentRelations The eommittee sends special thanks to Jackie Craig, Margaret Garikes, Leslie lutdwick, and Michiko Sidney, of the AMA; Joy Epstein of'the Coalition, Karen Deasy and Gailya Walter of OSHI and also gcatefull}+ acknowledges financial support from the Roswell Park Cancer (nstitute and~GIBA-GE1GY: Ralph Reed,,MD, of the AMA Washington stalE,'shotild also be remembered for his thoughtful assistance in planning the confer- ence. Doctor Reedlwas forced to interrupt his participation with the committee midway through its work because of his fight against lympharic cancer. His death reminds us of life's fragiGty;o andlof the importance of our task in preventing tobacco s contri- bution to:its premature end. Thomas P: Houston„MD Director, Department of Preventive Medicine and Public He:dth American Medical Association, This conference was supported in Part'by G'rant ,Vumber RP,Y CCR5D7945-41 from the l1S Department of fdealtb andldrnnan Services; Centers for Disease Contnol and Prievention (CDC)': !ts contents are solely the responsiliility of the aut,bors arrd do not neces',sarrfy represent the qffwial views of the CDC iv

Table! of Clantents Foreword Arknowledgements; 27 Workshops Women's Issues Plenary Presentations 32 Childten and Youth Issues 1 Charies LeMaistre, MD 43' Minority Issues. President 48 Ehvironmental Tobacco Smoke (ETS) University of Texas A1.D. .Anrlerson Cancer Center 52 Regulation of'Toba,cco Products 3 Michael Eriksen, ScD Director, office of, Smoking and :Wealth 59 Excise Tax Centers forlJiserrse Control and Prevention 63 Tobacco Marketing and!Promotion 7 Michael Pertschuk 72 International Health and Tobacco Use Co-Director Adrlocac7+ Institute 75' State and Local Tobacco Control Battles 11 Alexander B_ Grannis 80 Gegal Issues iniTobacco Control Xew York State Assemh'lyrrran : 84 Agricultural Policy 12 Dianne Waison 89' Nicotine Dependence California State Senator 93' Workshop Recommendations 14 Antonia Novello, MD 21 U.S: Surgeon General Anne Northup 109 Appendlit 11I0~ Conferenoe Participants. 23 Kentucky Stlite Repnesentuta7,!e Honorable Henry A, Waxman Congressional Speaker

Introd'u~cti~on I would like to welcome you all to this meeting. t'.m Joe Painters from Houston, Texas, President-Flect of the httterican Medical Associationi (AMA) andihave the privilege, on betialf.of the orgatti- tations sponsorirtg,this meeting, to welcome you alL Almost a year ago;,during my tenure as chairman of the Board of Trustees of the AhL1,,I asked our staff to explore the possibility otconvening a, conference that would be a sequel to the 1'989 meeting,held in Houston„"[obacco Use inAnerica" Many of:the same groups co-sponsored that meeting and'have come together again to organize this weekend's conference. t would like to recognize those groups who have worked together so well!the last few months andlbave put together wktat l believe will an outstanding meeting.Representing;ttie Centers for Disease Control. Dr. Michael Ericsen,,who heads ttie OfBce of Smoking Health. l've Rnown Micliael Ifor a number of years, when he was at vl.D Anderson, before going,to his present post. He was a mem- ber of'the conference planning committee. Representing the City of Hope NationallWedicafCenter, Karen Warren, its Executive Vice President and Chief Executive Officer. She also served on the conference planning committee. Representing the Coalition on Smoking OR Health are Dr. John Seffritt, EVP of the American. Cancer Society, Dr. Alfred Munson, Pi•esident=elect'of the Atteri- can Lung Association and fiiially, Mr. Dudley Hafner, EVP of the American Heart Association. Representing the Memorial Sloan Kettering Cancer Center, Jim Quirk the Executive Vice President for admi.nistration, who also served on the,eonference planning committee. Josepb T: Painter, MD President-elect of the American MedicalA.ssociation, The other members of the planning eonference committee should also receive thanks for their work. Dr. Tom Houston from.the Atnerican Medical Associati.on; the Coalition on Smoking OR Health~has been represented!by tdeir steering committee: Alan Davis of'the American Cancer Society, Scott Ballin of the American Heart Association, and Fran DuMelle of the American Lung iLcso- ciaationi The MD Anderson Cancer Cznter was also represented by Dr. Harry Holmes. He's the executive assistant to Dn LeMaisure; who will Ibe our first speaker. like the 1989'meeting, this gathering of the tobacco control community is designed to consider a variety of!elements inithe tobacco control poli.cy. The AMA is not only, proud to be one of the sponsors andipartners in this conference, but is committed to: helping to forge ainew dimension in unut, cooperationiand joint effort as we fight to protect the healtli of the Anerican public in the war against tobacco. Tobacco use is really an American crisis, This meeting can setithe stage for the work thaf!must!be done to continue our'progress since the previous meeting two years aGo:. Again, Iiwekome youito this task as we set about developing.a program that will continue the fight against tobacco and the conmollof its use.

T'obacw Use: An American Crisis Our conference title'7obacco Use: An American Cilsis'"is most fitting. The awareness of crisis crystallized 29 years ago on a coldd and bleak Saturday morning here inWashington. The setting was the State Department auditorium. The participants were carefully screened: The committee making the report had surprisingly passed muster with the voluntary health agencies-and the tobacco interests. As it is today, the topic then was tobacco. And the message was the same as today-that cigarettes constitute a grave medical,, economic and moral issue. The occasion, however, was very different-a news conference, called by Dr. Luther Terry. He had summoned the media to re, lease the findings of the first report of the Surgeon General's Advisory Committee on Smoking and!Health. The atmosphere that moming was tense; the security was tight- word had already leaked out-to the media and to the tobacco indttstry that the findings were "explosive:" Saturday was chosen to minimize the impact of'the report on the stock market, if you can believe that! The media were escorted into the room; issued a copy of the report and, as incredible as it may seem today;,the doors were locked behind them, just to make sure no copies disappeared prematureiy. )ust how explosive was this evidence?'Franldy, pretty tame. by today's standards, Listen to jusra few of'our finding;, as they appeared in that first volume: •"Cigarette smoking,is causally related to lung cancer in men... The data for women, though less extensive, point in the same direction." • Here's another. "The evidence on the tobacco-esophageal~ cancer relationship supports the belief that an association exists:" • And: "Women who smoke cigarettes during pregnancytend!to have babies of lower birth weight. lt is not known whether, this decrease in birth weightihas any influence on the biological; fitness of the newborn," • And another. "Smoking is associated with accidental!deaths from fires in ttie home." Opening Remarks Charles A LeMaistre, M.D. President University of TeaaS. M.D. Anderson Cancer Center And, in the spirit of assuaging those who might be offended, aa chapter was devoted to the "beneficiall"aspects of tobacco, and on the report cover were tobacco leaves. And so itgoes,,as Linda Ellerbee would'say, A document couched inthe most conservative of'scientificterms, yet a document that was to begin a revolution in American behaw'ior„culture and health policy,.. A ret,olution that began qttite slowly and tentatively-dtte that would languish until the 1980's when for the firsttime anti- tobaccodegislation passed Congress withoutcompromse-and yet one that ha5 been gathering increasing momentum in the yearss since. But a revolution that is far from over-far too farfbom over,, considering the weight;of the preliminary scientific evidence that was already available in 11964, and the overwhelming;evidence that has been amassed since. On that preamble of reminiscences, I welcome you~to this impor- tant conference on An American Crisis: AnAmerican Crisis that has been without a final solution for diree decades and likely will continue for decades more at the rate progress is being made in bringing it under control.. Whavis the setti:ng,in which we meet to map strategy? First, the problem is no donger a medical or scientific controversv. The problem is now societal-it is political--it is economic cmd& it is moral. Second, we must accept the embarrassment thavit trulv is an American Crisis--made in America--marketed!and promoted in America and imposed largQlybyAmerica upon the rest of the world through marketing---driven by, disregard for human life and high regard for profiting, even if it involves the suffering of others. Third„we consider this crisis at a time when America is prx?occu- pied witti another erisis--the unrelenting spiral in the costr of tteating disease. Surprisingly few who talk about the cost crisis seem to understand the role of tobacco in the production of disease. Tobacco is by far the most sigtuficant cause of cata• strophic illness, a prunary driver of the rise in health care cost.: Consider for a moment health care costs--less one-third of~ all cancer, less one-half of cardiovascular disease and less nearly all' chronic bronchitis and!emphysema: Tobacco Use: An Ameri'can Crisrs 1

Even so today we are better prepared to addi ess this American Crisis than ever before. Thtartk goodness, the conservative rhetoric of the ficstiSurgeon. General's Report has been replaced by plain-spea{dng that is both strident andlunderstandable. Thank goodness, we have moved beyond;the individual, indepe.n- dent interests of agencies;,associations and centets and now focus on the synergism~that comes from working together. Tltank goodness, that we have rallied many, many more to the cause and that the collective impact of theireffort is the reason why our countrys mores changed so radically in the 1980's. And thank goodness, we have learned a thing or two about ctNm- munication and behavior change, about advocacy and market- ingo so that we can meet the merchants of death on almost-equal footing. ,artd!even now; three decades after the cau3e of [he A[nerican Crisis was crystal clear, there are those who seek to soften the truthrthat is so patently obvious. Today tobacco remains the single most-preventable cause of illness, of catasttrophic disease and of death. Today, tobacco is a highly profitable, legally tttanufactttredd and deadly product that neither our state nor federaligovernments have seriously, attempted''to regulate or control in the protection of the publids health. Today, inlaNatant disregard 6orthe rest of the world's health, our, government has fostered participationof tobacco in favored trade status, When inthe light of humanhistory; our American society i5 judged for its 20th century performance on soeial; moral and httmanvalues, we can indeed be proud that manyachievements will resound to.our credit Regrettably, the disgrace that is the Artterican tobacco crisis will not be one that we can take pride in. It likelq; will be said that we have placed greed ahead of our regard for human life and con= cetm for suffering;. We are but seven shortwears from the close of the books on the 2'0th~eentury.lfiere can be little doubt that we know the ultimale solution~to this American Crisis. The only real unltnownis whethervou and I have the will to achieve the solution. Now the time has come to do more, and who better to set the stage for our discussions than two great lea+ders in American health promotion. What a nice privilege it is to share,tlie platform this morning with these two friends, whose contributions to the goals we share I admire so much - My long-time M.D. Anderson colleague, Michael Eriksen, who hass recently gone on to become the Director of.tbe Office of~ Smoldng and Health at the Centers for Disease ContnolJ who will'speak first_ He will be followed by Michael Pertschuk; whose taughtus all soo much about the power of persuasion„who eo-iiirects the Advo- cacy Institute. I'am delighted to call Michael Eriksen to the podium now, and!he will be followed!by Michael Pertschttk~. 2

"Healthy People Zooo" and its Tobacco Control Objectives Introduction Today, my presentation is entitled "Healthy~People 2000" and it is my goal to attempt to link the Year 2000 tobacco objectives to the recommendations thatcame out of the Houston Conference andi to similar recommendations that might~emattate from our current meeting. Year 2000 framework National objectives provide useful planning perspective for to- bacco control in the 1990s. There are 16 major tobacco objec- tives which provide specific measurable targets for us to aim for. These objectives also cover most oPthe major contemporary tobacco control strategies (clean indoor air, advertising and youth access). There are specific gaps relktedto excise taxes and product regulation and hopefully during this meeting we can discuss ways of integrating conference recommendations into the Healthy People framework wherever possible. Year 2!()00 progress ,4ttal~sis ofour movement toward these objectives reveals a mix of good and bad news, Some of our key indicators: First, theGood News.... 0bfpctive 3.4: Reduce cigarette smoking to a prevalence of no more than 15percent among people aged 20 and olde>i. Last year we reported that U.S: adulrsmoking prevalence in~ 1990, the most current year ofidata available: was at its lowesrpoint since the government fustbegan national surveys-25,5 percent for the population overall. 0bjectiue 3.11: Increase to at least'75 percent tbe proportion of worksites with a fwrmal smokingpoticy that probibits or severely restricts smoking at the workplace. Eighty-five percent of workplaces have some form of smoking policies, up from 36 pereentin 1986. .utd 59 percent of compa, nies with 50 or more employees have policies that ban or severely restrict, smoking-up from 27 percent in 1985:. :Yow,, Some Bad' News.... 04fectirae3.5.' Reduce the initiation of cigarette smoking by children andyoutb so that no more than 15 percent bave become regular cigarette smokers by age 20; Hichael P. Eriksen;ScD Director, Office on Smoking and Health Centers for Disease Control and Prevention Overall smoking'ratesamong young people have remained virtu- ally unchanged over the pasrdecade. In fact; smoking among mafe high school seniors actually has been inching up since 1'987: Smoking among black youths continues a dramatic decline that began more than a decade ago---daily smoking among black high school seniors now has fallen to 5 percent--one glimmer of'hope we must endeavor to understand. Obj'ectke 3.4b: Reduce cigarette smoking to a preualence of no more than 15percent among blue-collar workers aged 20 and older. The rate of smoking among blue-collar workers did not decrease between 1987 and 1990 and is still nearly double the target level for the year 2000-37 percent vs. 20 percent. Objectii!e3:12; Enact in 3C3 States comprehensive laws on clean indoocair tbat'pr~obibit or strictly limit smoking in the workplace and enclosed public places. Aithough allstates but Montana have some form of laws restnct- ing,minors! access to tobacco, enforcement is virtually nonexist- ent in many states. We reported this year (from TAPS) that if 12- to 17-year-oki5 want to buy cigarettes, they, have little or no trouble doing so. Objectiae 3.15: Elirninate or sewenely restrict all forms of to- bacco product advertising and pramotion to which youtb younger than age 18 are likely to be exposed Tobacco-advertising andlpromotions that appeal to young people remain virtually unrestricted. There is a direct connection be- tween the amount of advertising ofspecific cigarette brands :,nd' young people's preference for those brands-witness the sricce.cs oflNarlboro, Camel, andiYewportin gaining the loyalty of new smokers: The national response I am pleased to report thatime've made some real progress in accelerating tobacco control at the national and'state levels, For example, just 2 days ago here in Washington, EPA relea.sed its finaf risk as5es.sment on ETS and respiratory disease. The desiGna- tion of ETS as a Group A carcino8en (known to cause eancer, in humans) by EPA along with NIOSH's classification of f.'7'S as a ..potential occupational carcinogen," provides its with powerful Tobacco Use: An American Crisis 3

new ammunition to mork harder to protect the he•alth of non- smokers. OSH is working ciosely with EPA to publicize the results of this report and to motivate the public to take action: The American Stop Smoking Intervention Stu&• for Cancer Pre- vention, or ASSIST, has entered its second year of planning and will begin full-scale implementation in 17 states this fall. At the same time, California enters a new year of acavity inlits statewide tobacco control effort with a redueed! but still remarkable, level' of funding: Now the challenge is to provide necessary, help to thee other 32 stgtes and DC so that they can take advantage of the training and technology developed for the A'SSLST'and California, initiatives. We at OSH are hoping to ~do so, both by beginning to provide,direetinancialiassistartee to States' tobacco control efforts via a competitive cooperative agreement program„but also identifying;,collectingand redistributing the best available tobacco control programs and materials among States and organizations. In addition, the Preventive Services Block Giant legislation has beeni rewritten providing for greater opportunity for use of these funds for chronic disease prevention, including,tobacco controL The SGIRCNET efectronic tobaceo control network, spearheaded' by Mike Pertschuk and his staff at the Advocacy Institute, eontin- ues to be an invaluable source of'news and intelligence for advo- cates across the nation. SGItCNEf has made our jobs easier tracking such tireaking,issues as the Cipollone Supreme Court decision; efforts to divert funds from tobacco control in Califor- nia; and the tobacco industry's unsuccessful attempt to derail the. Massachusetts excise tax initiative. The tecentlypassedlAlcohol;,IDrug Abuse, and Mental Health Administration ReorganirationAct now requires States to have minimttm age laws for the purchase of tobaixo: products, and to enfor+ce these latvs--otherwise the states will lose a considerable portion of their federal block grartt monies for substance abuse programs. We owe our thanks for this provision to the efforts of : Oklatioma Congressman Mike Svnan. who as it turns out was one of the congressional co-sponsors of the 1989 Houston meeting. NCI, A.titA; ACS, and a number of other professional organizations have continued a national initiative to train health~care providers in smoking cessation. AICI hopes that, 1tDB,000'professionais will be fully trained by the end of this year. The Coalition on Smoking or Health continues its persistertt, focused advocacy to influence Federal tobacco control policy. Most recently, the day before the EPA "Group A'' announcement, the Coalition held its own press conference to call for greater Federal andState clean indoor air legislation, regulation of to- bacco:products by, the FDA, and a $2 incre3se in the : Federal excise tax on cigarettes. Our "activist" partners-DOC, ANR, STAT; GASP, and others-- continue theiraggressive;,creative efforts u both the national and community levels to upset the status quo in ~tobacco control!and bring,about faster change. I would give tttany more examples if;time permitted. I'll let Mike Pertschuk expand on mylist; which he will do from~his keen andd unique perspective, Butlit's my observation that there is more happening currently in tobaeco eontrol than at any time in our history. Our charge now, and l use the word'^our" in its most collective sense, is to orchestrate these efforts as strategically as possible: An unusual strength of the tobacco control movement! is that it is ertremely broad and'deeentralized-we never want to sap that strength with unnecessary bureaucracy or centralized!decision making. Butithere's a clear need for greater communication and coordination, both to enhance what is already happening and to unlock new opportunities. That also is a theme that Mike will underscore emphatically, Proposal!for a unifying f'ramework. Returrttittg to my initial comments;l propose that this conference consider sttucturing its conclusions and recommendations in 1993' around the Healthy People 2000 objectives. Except for the issue of'excise taxes, an imporrtant approach that I would supporr adding, the Healthy People objectives address all the critical components of a comprehensive tobacco control strategy. 7fiese objectives already have broad-based support from both within andioutside the public health community. They have beenn adopted'and adapted by,countless public and'iprivate organiza~ tions at the national, state, and local levels, and are actively being used to.plan programs and establish budgets. Though far, from perfecti the Healthy People 2000 objectives benefit from being,feasible, specific, and measurable-the three hallmarks of effective health promotion and disease prevention objectives. Lessons from Houston The Houston meeting 4'years ago made a valiant attempt to set aa common tobacco control agenda for the Mation;,but 1'think the impact of its recommendations has been tempered by, two basic shortcomings: oLwrambition.of purpose and underestimation of political reality:. First, the issue of 'overambi6on. The conference advanced 766 separate recommendations for controlling tobacco use, all of them.thoughtfulland insightful. But their sheer number and leveli of detail has, in my judgment„somewltat blurred the strategic vision of.the conference organizers---to develop a common national agenda to reduce the death andI disea.se caused'byto- bacco: I don't mean for a momentito discount the outcome of that meet- ing. A number of its recommendations have been realiied„and' with considerable impact • Smoking,was banned on all domestic flights, thanks largely to the efforts of Senator Frank Lautenberg and Representative fDick Durbin, who,was the other Congressional lco-sponsor of that conference: • As a requirement for continuing aeereditation, all hospitals soon wdll be smoke+fnee. 4

• And there have been other successes. But now let me move to my second point, the issue of political realism. The six major recommendations of the conference dealt squarely with topics under the primary, purview of the Federall Government 1) regulation of all tobacco products by the FDA, 2)) elimination of the Tobacco Price Support Program; 3) reversal of the government's international tobacco trade poliicies, 4) elimi+ nating the influence of tobacco advertising, 5) increased excise taxes,,and 6) action to protect nonsmokers. These all are politically charged issues, owing to a single prevail- ing,force: the economic enormity of the tobacco industry: We'ree getting smarter each day;,but I still think we underestimate our foe and fail to learn allme can from its high-powered marketing and publia relations machine. But I'd like to end today by reflecting on what I believe is even more fundamental to the success of our mission than the issue of organizational process and goodwilL It's the issue of citizen involvement I've spoken in recent months to a number of'state and community groups, from North Carolina to Arizona. I hear one consistent lament despite the commitment, gqod ideas, andlboundless energy, of individuals working in tobacco controi; they often find that the doors to substantive change are closed because of pur- chased influence by the tobacco industry at all levels. The pervasive influence of tobacco interests on the entire politicall process has been demonstrated, in startling color, through recent reports leaked by industry lobbyists ... through secret corporate memos obtained by our advocate-sleuths...through reports of tobacco company campaign contributions:..through other indus- try documents subpoenaed'for court ca5es...and through the bitter anecdotal experiences of our allies working in the field. We now know, for eaatnple; that the industtywillfully launched a massive misinformation campaign to undermine the credibility of the 1964 Surgeon General's report:ltte industry poured the same energy into its unsuccessful attempts to scuttle the EPA risk as sessment and vilify the reputation of the agency itselE And ask our friends from California and Massachusetts about the behavior of the industry in those states. What does this influence mean? It means, quite simply, that decisionmakers both in government and in oqanizations, at the local, State and Federal levels; are being paid for their silence on the tobacco issue. Ibmean,s that these decisionmakers will choose not to bring a tobacco control issue out of committee ... choose to vote against a community smoke-fbee ordinance ... choose not to protect the health of children by continuing to allow teachers too smoke in school buildings ... choose not to include tobacco control in health promotion offerings to their memberships. It means that the best-pl.vuted tobacco control efforts maywither, and the from failing to see the light of'dA}+. Let me quote directly from Secretary Sullivan?s remarks at Ttiursday's EPA press conference: "Now it is time for our public officeholders of both parties to withstand'the pressure of the tobacco industry to water down,or defeat anti-smoking legislation--pressure fueled by millions of dollars in political contributions and additional fundS to support so-called 'smokers rights' campaigns." He continuedi "Quitesimply; if the concern expressediby our officeholders for the health and well-being of their constituents is to be considered genuine, then they cannot allow the tobacco industry to influence their decisions on issues of such vital impor- tance as the health and survival of our citizens-particularly our childten." None of us at this meeting, even with our collective budgets, can . fightitobacco influence with money, After all, how can we compete with an industry that reported afler-tax profits of $7.2 billion in, 1989-an industry that spends $4 billion just on advertising and promotion each year? The only weapon we have as Americans is ourselves. Yes, we have the truth and the statistics on our side. And yes, we have public opinion on our side. But we really donlt have the public on our side--not actftaely on our side. To do that-to get people to embrace tobacco as apersonalt concern-we have to move far beypnd the medical facts that smoking is harmful and addictive. We must instead educate people about the greed and influence of tobacco interests. We must stir'people so that they view tobacco with social andmoral outrage. We must publicly shame the tobacco industry for their actions. We must raise the issue of tobacco control on people's personal agendas so that they will talk to-their neigtibors abourit-tettify publicly about it-andieonsider it in their actions, including,thein voting decisions about political candidates. I believe decisionmakers will turn down tobacco money only when they perceive such contributions to be a political liability: For that to happen everyday Americans must voice their eon- cerns-loudly and consistently-abouthow the tobacco industrys self-interests are perverting our very system of democ- racy, and how they will translate that concern at thetiallot box. only then willitobacco money become worthless;,and!the tobacco industrv lose its influence. We must strive to create a national in,dignaldon. But how can we mobilize the citizenry? This same concern wa-,;expres3ad at this same meeting four years ago: "Qollectively„ the participating,orgartir,ttions can mobilize millions of citizens at the grassroots level!to create a strong coherent body able to more effectively influence and educate poliw-makers throughout goven:tment." But I say that it will take more, much more, than getting our health constituencies involved. Wemust get involved the very people who are not partlof the .'movement'.'We musrget aU of America involved! Tobacco Use: An AmeriCan Crises