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HEALTH VS. CIGARETTE SMOKING REPORT OF THE aCVERNCA IS IwYISCRY CObWTTEE CN CIGARETTE SMOKING AND HEALTH . NovEreER, 1964 ` j J

GOVERNOR'S ADVISORY COMMITTEE ON CIGARETTE SMOKING AND HEALTH Malcolm H. Merrill, M.D.,, Chairman Director of Public Health Berkeley ' Sol R. Baker, M.D. President, 1962-1965 American Cancer Society California Division San Francisco Vincent P. Carroll, M.D. Laguna Beach Honorable Hale Champion Director Department of Finance Sacramento Henry R. Davidson President Automatic Merchandising Co. Beverly Hills H. Corwin Hinshav, M.D. San Francisco Benjamin D: Paul, Ph.D. Director, Prcgram in Medicine and the Behavioral Sciences Department of Anthropology Stanford University Stanford. Max Rafferty, Ed.D. Superintendent of Public Instruction Sacramento Victor Richards, M.D. Chief of Staff Presbyterian Medical Center San Francisco Guy,W. Steuart, Ph.D. 4lssoci ate Professor of Public Health University of California Los Angeles Honorable Stanley Mosk Attorney General (To August 31, 1964) Sacramento William H. Thomas, M.D. President, 1963-1964 California Heart Association San Francisco

i HEAIA'H VS. CIGARET'1'E SMOKING ~ A Report and A Program For California 0 Report and Recommendations of the Governor's Advisory Committee on Cigarette Smoking and Health November 1964 ,

ii November 1, 1964 The Honorable Edmund G. Brown Governor of California Sacramento, California Dear Governor Brown: In response to your charge ten months ago, your Committee on Cigarette Smoking and Health presents this report. It reflects the concerted efforts of the Committee to unders.tand the nature and scope of this problem and to recommend various lines of action which together may effect substantial improvement in the health of California citizens. The seriousness of this particular health threat, while often eclipsed by contrary promotional information, has been clearly stated both in reports issued in California and by the Federal government. The Committee is in full accord that, in addition to any activities proposed or undertaken by Federal agencies, the problem is great in California and the State must embark on a program to assist its own citizens. May I personally congratulate you on the appointments made to this Committee. Each member approached the task with insight and en- thusiasm and brought to the assignment spec,ial knowledge valuable in formulating recommendations which would be v forthright yet practical. The support provided by the staff enabled the Committee to review carefully all pertinent materials and to progress in our delib- erations. The Committee appreciates the strength of your charge and the importance you have given this matter. We respectfully hope that these recommendations may guide the needed action program. Malcolm H. Merrill', M.D. Chairman

FRONTISPIECE iii The Governor's Advisory Committee on Cigarette Smoking and Health On July 19, 1963, The California State Board of Health passed a reso- lution favoring a statewide campaign to control cigarette smoking as a severe hazard to health. The resolution derived from a series of presen- t~.•icas to the Board, culminating in the publication of "Cigarette Smoking and Health" by the State Department of Puk2ic Health. The scientific data and authoritative statements contained in this document were based on re- search findings, principally from Departmental'investigations over 15 years, which clearly associated cigarette smoking with severall forms of ill health. Bnth shortening of life and more illness were found among individuals who s%oked cigarettes compared with persons who did not. The response to the report and the resolution, both action-oriented statements, was instantaneous. Governor Edmund G. Brown was among the first to indicate his fuli commitment to a program of action. Shortly thereafter-, he appointed the Governor's Advisory Committee on Cigarette Smoking and Health to explore the directions which control measures should take. At the first meeting, December 11, J.963, Governor Brmvn charged the Committee to: Review all State policies pertaining to the issue of Cigarette Smoking and Health L including: 1. laws regarding sales of cigarettes to minors, and their enforcement; 2. other legislative measures; 3. educational policies for both youths and adults; 4. public health; 0 5. fiscal considerations. The aim of these deliberations, the Governor emphasized, was to shape a program of positive action. He urged members not to limit their thinking by any considerations other than those in the best interest of the public's health. The Committee met six times over a period of nine months. Each member of the Committee assumed a specia3l role, presenting segments of a comprehen- sive attack on the problem according to.his knowledge and experience. One subcommittee was formed to develop plans for a specific State action program, and a subcommittee on research was appointed. This report is a summation of the Committee's efforts to develop the means for wisely applying the knowledge that cigarette smoking is harmful to health. Recommendations of the Committee, including the design of the State Program, are contained in ChaptLr 1, pp. 18-21. They are compatible with activities being undertaken by the Federal government.

iv TABLE OF CONTENTS CHAPTER ~ PAGE 1 Summary and Recommendations 1 2 Introduction 22 3 Comprehensive Review of Facts kl 4 Programs of Action 69 APPENDIC ES I Resolution of the State Board of Health, July 19, 1963 152 II California Statutes Relating Directly or Indirectly to the Sale or Use of Tobacco Products 153 III Trade Regulation Rules Proposed by Federal Trade Commission, June, 1964 158 •

CHAPTER 1 SUMMARY AND RECODA2ENDATIONS INTRODUCTION For centuries, tobacco has played an important role in the historical development of western culture. Until recently, objections to tobacco's ~ use have been based on moral issues, but now the adverse influence of smoking cigarettes upon human health has become paramount. The.markedly increasing incidence of lung cancer, a condition which today ranks as the m ost common form of fatal cancer and which in 1963 caused the death of 1+1,000 Americans, may be justly described as "epidemic." Searching for the cause of this epidemic has occupied scientists in many disciplines. Hundreds of studies upon animals and men point to the same conclusions: cigarette smoking is a causative agent in lung cancer and contributes to greater illness and death from a number of other condi- tions. Each major study has encountered•a wave of skepticism and "contro- versy," but the overall conclusions meet wider and wider acceptance. In a number of other nations where scientific knpwledge on the subject has aroused health and government officials, action to discourage cigarette smoking has already been implemented. Health authorities in this nation succeeded in 1961. in bringing the situation to the'firm attention of the Federal govern- ment. To study the problem more intensively, an Advisory Committee to review the scientific evidence on the subject of smoking and health was appointed in 1962 by the Surgeon General. California'Takes a Stand Interest in the smoking and health problem had run high in California, where epidersiological studies iieveloped as early as 1949 indicated cigarette smoking's harmful effects on health. Many of these investigations had been

-2- conducted by or with the support of the California State Department of Public Health. The Department summarized the findings in a.report to the State Board of Health, "Cigarette Smoking and Health," in July, 1963. Publications of findings and the subsequent resolution of the State Board of Health (See Appendix I) to initiate action on the problem were enthusiastically received. California thug became the first state govern- ment to speak definitively on the subject, advocating a number of actions. Most of the response to these pronouncements was laudatory. Governor Brown pledged his support to an action program designed to control cigarette smoking. Further active support was generated by the California Interagency Council on Cigarette Smoking and Health, composed of voluntary health groups, medical and state governmental representatives who have sponsored a statewide educational campaign. In California, "controversy" was replaced by "conviction" as the State began to wrestle with this serious health problem. The Federal Government Takes a Stand Through this same period, the Advisoryy Committee to the Surgeon General was conducting its own study. The Committee report describes in detail not only the effects of cigarette smoking on morbidity and mortality of human beings, but also the pharmacology and toxicology of cigarette smoke, and the psycho-social aspects of the cigarette smoking habit. Publication of the report January 11, 1964 produced nationwide head- lines announcing: "Smoking a Hazard."- The stamp of Federal inquiry had confirmed the evidence as convincing. Reaction to the report was enormous: first quarter sales of cigarettes declined in 1964; the tobacco companies gave $10 million to the American

-3- Medical Association to conduct research; the Federal Trade Commission held hearings and announced that cigarette packages would have to bear a"warning" legend; the tobacco industry announced a self-regulating advertiFing code; locc,l groups all over the country indicated recognition of the health hazards. Again, controversy had been supplanted by conviction -- and action. History of Anti-Smoking Campaigns : Drives against smoking are as old as the habit itself. Since the medi- cal evidence has been mounting,-however, three campaigns have been developed to educate youth in particular on the health hazards of cigarette smoking. The American Cancer Society has been conducting a continuous educational cam- paign in many public schools in this country since 1957.. The Danish Cancer Society has also aimed its program primarily toward young people. But in Great Britain, the drive was aimed at both youngsters and adults. Despite an investment of $75,000 in materials, the British educational drive could . not compete against the volume of cigarette advertisements urging people to smoke. The campaign in Britain has not been regarded as successful, although efforts to improve and expand it will be made. Gther nations have initiated a wide vaaiety of activities, including withdrawal clinics, prohibiting smoking in public places, aind banning ciga- rette advertising. The experience of other nations, states and agencies in combating cigarette smoking is invaluable, for it suggests the type of activ- ity which tends to succeed and that which fails. The Scope of the Governor's Advisory Committee The Governor's Advisory Committee on Cigarette Smoking and Health stemmed from Governor Brown's immediate support of the Resolution passed by the State Board of Health on July 19, 1963, advocating a program of action. The Com- mittee was formed to conduct an investigation of the problem, to apprise the

-4- Governor of the implications of the situation and to recommend action. (This Committee, unlike that of the Surgeon General, was action-oriented.) Governor Brown emphasized to the Committee the urgency of their delib- erations and his expectation that a program reflecting understanding of the problem would be proposed. The Committee met several times during the year. Members gave presentations and made proposais for.Committee review. The Committee's formation was widely publicized as being the first of its kind in the nation. The Committee was also conscious that its.deeisions were being watched by people around the nation. COMPREHENSIVE REVIEW OF FACTS During the last decade or so, many spokesmen have voiced strong opinions on the subject of smoking and health. Representatives of the tobacco industry, in turn, have criticized physicians, scientists, voluntary health agencies, and senators. These parties have responded with counter-criticism.- Final analysis, however, must rest upon demonstrated facts, not unsupported opinions. Health Facts It is a fact, for example, that among a large sample of men in California, those who smoked cigarettes sustained twice-4as many chronic conditions inter- fering with their normal routine as those men who did not smoke cigarettes. Moreover, in a study of California men of working age, the risk of dying from lung cancer was 14 times greater among cigarette smokers than among those who did not smoke cigarettes. Mortality rates from other conditions, such as coronary heart disease, emphysema, chronic bronchitis and 'other respiratory diseases,were also distinctly higher among cigarette smokers. Studies conducted outside of California are just as definite in dis- closing higher morbidity and mortality rates among cigarette smokers. Dura- tion of smoking and quantity influence these rates. One of the more dramatic