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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

-5- studies in which death rates were compared is that of Dr. E. Cuyler Hammond, conducted on over 35,000 "matched pair" subjects. These were persons physio-' logically and psychologically similar in many ways but different in their smoking practice. Hammond's latest findings reinforce the conclusion of a causative relationship between cigarette smoking and disease and death. The facts concerning the ill effects af cigarette smoking are just as conclusive, and just as depressing as those concerning poor sanitation or poor food. Reducing the use of the cigarette is clearly in the tradition of preserving the public's health. Legal Facts: Statutes Relating to the Use or Sale of Tobacco Tc;:ucco's role in affecting history can also be seen in the laws govern- ing its sale and use. In California, the Legislature has adopted statutes relating to tobacco to protect minors, to protect the general health, safety or welfare of California citizens, and to produce revenue. Under present California law, Penal Code section 308 makes it a misde- :~:c:acr to furnish ami.nor under age 18 with "any tobacco, cigarette or ciga- rette papers...." Violators, those supplying minors, are subject to fine V or imprisonment. Education Code section 1C6C2, by contrast, is directed at ninors themselves, prohibiting minors from having or using tobacco products on school premises. The teaching about tobacco is also written into•law, Education Code section 9309. Statutes mentioning tobacco and designed to protect the general health, safety or welfare of citizens are primarily concerned with insuring cleanli- ness and permitting the blind to sell cigarettes in licensed vending stands on State-owned premises. Since 1959, a tax of 30 per package has been levied on cigarettes in California, although the State was among the last to establish such a tax.

-6- It yields substantial revenues to the State General Fund but is still less than the tax in many other states. In the past decade, a number of bills have been proposed to alter the existing framework surrounding tobacco products. None has been passed. In the field of private law, of the five well-known cases in which a lung cancer plaintiff or his heirs sued a~tobacco company, not one has yet recovered damages. Plaintiffs have found it difficult to prove in court that cigarettes caused their particular cancers, among other reasons be- cause cigarette smoking is not the only cause of cancer. In the future, plaintiffs may fare better, since the Florida Supreme Court in the case of Green vs. the American Tobacco Company declared that recovery on the theory of implied warranty is possible, even though at the time the ciga- rettes were sold the manufacturer could not have known that users would be endangered by inhaling smoke from his cigarettes. Private law in this direction is bound to expand. Fiscal Facts: Taxation and Revenue from Sale of Tobacco Historically, tobacco products have been a major source of revenue in Western countries. At present, only six states have not levied taxes on cigarettes in addition to the Federal tax. Since California levied the 30 tax in 1959, revenue has risen from $64 million to over $70 million.per year. The existence of the tax has obviously not influenced cigarette sales to decline. In fact, until the subject of cigarettes being harmful to health reached its present momentum, sales of cigarettes in California were on the upswing. Though the practice of placing cigarette tax revenues into the General Fund is followed in California, the Legislature may earmark funds for special

-7- L purposes: e.g., automobile registration fees go to the Department of Motor Vehicles for highway improvement. The Advisory Committee considered the fiscal aspect of the problem only as it related to providing a state action program. As Governor Brown stated: health comes first; revenue second. Federal and state taxes in the United4States.on tobacco yield over $3 billion annually; export sales of tobacco and cigarettes bring in another half-billion dollars in sales which are taxable. The tobacco industry is severely troubled by the threat of sales depletion or more stringent methods of limiting sales; several states base-their education budgets on tobacco production taxes. The industry has been criticized because of the dispro- portionate sums expended on research and product promotion. The annual promotional expenditure of the tobacco companies exceeds $200 million, but until the recent grant to the American Medical Association, only $6.25 mi1- lion had been allocated to research outside the industry. How Mich of the private, undisclosed research within the industry has been to make the con- sumed product safer is unknown. It appears,that much of the industry re- search has been aimed at developing filters or new brands containing essentially the same tobacco. Educational Facts The teaching of health in California's public schools is constantly being modernized. However, one somewhat archaic statute does exist re- quiring that instruction be given in the "evil effects of•alcohol, tobacco and other narcotics on the human system." Education specifically on the health effects of these products has been limited. Informal polls conducted in California indicate that about half of the students in high schools smoke cigarettes by the time they graduate. The 1

-8- fact that section 308 of the Penal Code has not been enforced (no prose- cutions have ever been recorded) has permitted youngsters to purchase cigarettes quite easily with no apparent penalty to themselves or the persons dispensing them. Educators, physicians and now the government are concerned about the apathy of young people in not observing the law, and the apathy of adults, parents and vendors alike, who do not discourage its abuse. A number of studies have been conducted to try to determine why youngsters begin to smoke, the prime motivations for their continuing, and whether some char- acteristics of temperament distinguish the smoker from the nonsmoker. Youngsters tend to reflect the smoking practices of their parents and siblings as well as their peers; intelligence and achievement tests indi- cate that nonsmokers tend to perform better; nonsmokers are more inclined to participate in sports and other activities. Additional investigations of youth behavior are needed, including the development of means to discourage young people from adopting the habit in the first place. Behavioral Considerations The behavioral science disciplines may assist in ascertaining how health habits persist and how new health practices become established. Studies, demonstration projects and evaluation are needed to determine how prevailing ideas and customs related to cigarette smoking may be changed effectively. These would include longitudinal studies'of the natural his- tory of smoking to reveal those psychological, social and cultural determi- nants favoring the adoption of the practice as a normal activity; studies of personality traits displayed by smokers and nonsmokers; analyses of factors influencing cigarette smoking and of means designed to change the practice; and evaluation of curative and other action programs.

-9- Consumer Considerations Among the important behavioral considerations are those relating to the responsiveness of individuals as consumers. One question to be answered is: to what extent does the protection of the public's health require gov- ernmental participation in controlling the use of cigarettes? In meeting other health problems created by changing ~-z- often improving -- conditions of life, the government has played a central role in reducing health threats produced by environmental hazards, such as air pollution and food contami- nation. Our present way of life has produced a remarkable change in health: instead of succumbing to diseases due to unhealthful conditions of the past, such as fatigue and poor sanitation, Americans now become ill and die of "modern" conditions -- overindulgence in food and drink and insufficient exercise, for example. Consumer behavf or in the quest of life's "better things" largely influences patterns of disease and death. With respect to cigarette smoking, the cause of improving the public's health has been thwarted by promotion on many sides, bombarded by messages to buy, buy, buy cigarettes. About five percent of what the consumer spends on cigarettes comes back to him in advertising and promotion -- to keep on smoking. Research is badly needed to determine how to reach the consumer before the act of purchase. The role of the government in protecting our health has been distinguished. In this matter, also, it is needed. PROGRANiS OF AC'IION Health Plannina and Withdrawal Clinics Preserving and'improving the health of people has been the motivation for phenomenal changes in the conditions under which men live. In present

-10- times, as in the past, it is the conditions of life which determine the disease patterns of men and which suggest directions for improvement. Cigarette smoking is clearly one of the conditions of the "more abundant life" of modern times which has resulted in needless disability and pre- mature death from a number of chronic diseases. Prevention of this particular condition can be accomplished most readily through.intensive education of those who have not yet begun to smoke, especially young people. Further preventive strength can be generated by education of adults, particularly physicians and other health personnel and teachers. - At present, there are few cures for the conditions which cigarette smoking produces. Persons with lung cancer seldom live more than a year or two; coronary artery disease takes a great toll; and the progress of emphysema and chronic bronchitis cannot easily be arrested. However, some success has already been achieved in combating cigarette smoking. Tested and relatively effective are the withdrawal clinics for those individuals who want to give up the habit but seem unable by themselves to do so. Initiation and evaluation of such clinics sliould be encouraged as part of any statewide program against cigarette smoking. Withdrawal clinics would be but one of several activities which-the Committee recommends be consolidated into community Service Centers. In addition, professional education, community education and consultation to industry and agencies would originate here. Existing facilities, such as. hospitals, voluntary health agencies or-health departments, could accomo- date Service Centers. Lep,al Implicutions Governriental activity with respect to tobacco consumption and health is a subject presently well-publicized and fraught with emotion. In.

-11 addition, the subject has only recently developed, and legislative guide- lines are therefore few. With these observations in mind, the legislative recommendations of the Committee may be summarized as follows. In order to prevent uncontrolled access to cigarettes by minors, exist- ing legislation should be fully enforced and new legislation proposed to strengthen it. Penal Code section 308 might be held to apply to vending machine sales to minors, but ambiguities in the present statute make it unclear as to which person is actually responsible for infractions result- i ing from vending machine sales. The Committee therefore proposes amending section 308 to specifically include vending machine sales, designating pa no to 1 ~ i rties responsible for infractions. The suggested language should be broader in scope than necessary to prohibit the minor's present access vending machines. Statutory changes could be enacted to give cigarette-lung cancer plain- tiffs a better chance of recovery from cigarette manufacturers. Abolition of the defenses of contributory negligence and assumption of the risk, as well as an imposition on the manufacturers of a duty to warn, would make a negligence theory more actionable. Also, d new and more specific implied warranty, independent of and in addition to existing implied warranty, could make the implied warranty theory more helpful to the lung cancer plaintiff. There are few areas of human conduct which can or should be regulated I by the Federal government. None of the conduct which would be governed by the proposals made so far, with the possible exception of•the labeling statute, falls within exclusive Federal authority. However, several Federal agencies are contemplating the adoption of policies which would have an impact on the areas under discussion. The proposals for California action should complement contemplated Federal government action and delineate the role that California should adopt as a state in action against,cigarette smoking.

-12- It is desirable that the State work expeditiously along lines proposed by the Federal agencies directly concerned with the cigarette smoking-health issue. These agencies include: the Federal Trade Commission, the Federal Communications Commission, the Federal Food and Drug Administration, the Department of Health, Education and Welfare, the Department of Agriculture and the Department of Commerce. The first-..four mentioned began working on programs or reevaluations directly after the Report of the Advisory Committee to the Surgeon General was issued January 11, 1964. The other two have not yet indicated any plans to seek other uses or other markets for tobacco, to assist in improving the quality of the product now being manufactured, or to impose any new restrictions upon tobacco. Fiscal Considerations As cigarettes have been historically subject to taxation, fiscal con- siderations are inroortant. Unlike most countries which operate tobacco monopolies or which depend heavily upon the revenue accrued from taxes, in the United States tobacco production and distribution are conducted by free enterprise with relatively low taxes levied.by Federal and state governments. ~ The Federal tax is presently eight cents or roughly 31 percent of the cost of a package of cigarettes. The present State tax on cigarettes in California is among the lowest in the nation: three cents (about 13 percent). The State tax is so rela- tively low that it would be feasible to initiate and maintain a State program for protection of health against cigarettes by raising the present tax. Earmarking these funds, or part of them, for a cigarette smoking control program would place the cost upon those involved in the problem. This is not without precedent in California fiscal practice. For example, a por- tion of the alcoholic beverage tax is used for alcoholic rehabilitation,

-13- and funds appropriated from motor vehicle*registrations support highway improvements. One cent per package out of an increased cigarette tax would yield 25 million dollars. While this a sizable amount, it should be noted that it is not disproportionate with California's share of the cigarette in- dustry's annual, national, promotional cost of 200 million dollars. It is also not large in relation to the amount of'money lost each year in California by the expenses (medical care, work loss, public assistance, etc.) resulting from cigarette smoking. Selective taxation, for example, according to tar and nicotine content, has been suggested by some. However, it seems to offer little promise of being effective either from a health or fiscal point of view. Licensing vendors or vending machines is similarly not considered feasible; the tre- mendous cost of enforcement and administrGtion could not be balanced by expected reduction in consumption. Licensing could only apply, at present, to prohibiting minors from purchasing cigarettes illegally. ~ Therefore, the Governor's Advisory Committee proposes an increased f/ State tax on cigarettes, a portion of which should be used to support a I comprehensive program to combat the adverse health effects of cigarette moking. Education Needs Education is one of the most important means of changing the present attitudes and practices of people with respect to cigarette smoking. Just as cigarette smoking gained ascendance in the last decades, the evidence now suggests it should recede in the coming years. Through education, both youth and adults can be conditioned to think and act differently about smok- ing cigarettes.

Education in California cocicerning cigarette smoking has been lai•gely limited to modest teaching in public schools under an outmoded section of the Education Code which calls for instruction in the "evils" of smoking, alcohol and narcotics. The current state of knowledge about the health hazards of cigarette smoking is sufficien+t to warrant great:.= i,.".c;nsified instruction with a more factual orientatior}. Thc.Interagency Council on Cigarette Smoking and Health, of which the Department of Education is a member, has supported preparation of teacher's resource kits containing guides for elementary and secondary school teachers and a variety of cur- rent reference materials on the r:eaith he.zards of smoking. The school program alone, however, cannot be expected to be the sole, source of information and guidance on the subject of smoking. Supplemental activities will strengthen the content provided in the classroom and affect the social milieu. One'tecrnique is to conduct conferences -- a form of inservice training - for yout'rh leaders. ,- , h;ore dlrectly, the health education program in schools needs to be strengthened so that materials on smoking will be based on scientific evi- dence and health interes;.. T::a Ccr=dttee eavors devel opment of a Framework for i:4alth Instruction, providing continuity and guidance, to be tested and then introduced fully throughout the school system. Amendments to the Edu- cation and Administrative Ca3.es,,to enlarge the scope of teaching health education, are also recommer.ded. Related to improved health instruction is development of an improved recreational program. ihe latter should extend the structured day during which classroom content is integrated to the actual application of health principles. Not only will a sound recreat;ior,al program enhance •the well- being of youngsters, especially those from deprived backgrounds, but it

-15- will also reinforce the total educational experience so important during Lthe formative period. The Committee recommends development of seven pilot recreatfonal programs in California. Adults must also have the benefit of special educational techniques, sapplemented by clinical programs for those vho have medical or other rea- sons to stop smoking. Adults should be made aware of their role in setting an example for young people. Industries offer a fertile field of approach to the adult employee in curtailing cigarette smoking. Specialized education for physicians should be developed, for physi- cians have many roles to.perform 3n advancing this program. "A Committee of One '+'housan3" is being mobilized to recruit a staunch group of physicians ready to assurr,e active participation in many phases of program development. Re -~::arch Altering the present practice of cigarette smoking clearly depends on a thorough understanding of how cigarettes affect the human system and of the behavioral and social phenomena which condition acceptance -- and change. Scientific research must, therefore, be one component in a comprehensive rr:,gram of action. Research will also enrich man's understanding of other health-predicated behavior patterns. Committee proposes a plan of research embracing two types of ctivity: (i) basic research in both the medical and behavioral sciences; and (2) applied research -- evaluation, demonstration and training -- to test techniques in cigarette smoking control. The latter' activity would also serve to train personnel essential to staff educational, counseling The extent of investigation yet needed in the basic sciences remains formidable, despite the numerous studies which have been conducted to date. ,

-.:U- BLaic studics in cpidcm.iology, c,Y:c•nzstry, physi.olosy, and patho:%fy will refine the current state of knovief:ge regFrding the effects of cigarette smoking on the system. Ansk•ers might be found to some of the more baffling questions: What produces harm to the system? Could harm be averted by other than abstinence from smoking? Is smoking addictive? Bea:£ivior8,'l and social research on th~s form of habituation is very modest. Here, cor:sidera.bi.e scientific activity should be generated to unders tyr.d how ir.divi.ouul Pnd gr^ ;p beha.vior influences the practice of cigarette smoking. Basic research, opsr`stional research and evaluation of prodrams designed to c?-.u:.:xe smosang habi.ts are all essential. To fuiii.li tY.f .•ezssx^h -:;:.;,er,tia.l necessary to support a broad program of action, of a coordinated Research °rogrsm in ?'ch:.G.:.co S;,ud-' e.s. Tr_e pr: ncips', flznction, by the activity of a research adv-sor y conLTrdt -Let, -vould be to :,tir.-Lt ste research through awarding of graYits. Tr:e t?::... : ,asponNib:1'• ty for this function be delegated to the atr;.e Dz,,•~Yrt•rr.e:' o. rt~b_'-_:. aeait:n. The coordination of relevL-nt resesrc}: evuluat.ion, f,ublicstion and &.-pl.icatior, of findings woulc s=s:; te Pdm:.r_s-Lr•r::d tt:~ R:.;`_arch ?rcg:am. :s~:y a.~~~czs oi - - r~= ::°r~k~ ~=or, ncmo::str a.t_on and tra:nirk3 can be handled :.:ost ef fectl've_y ia a university seT.Y•:irig. 1.^.e t+o2''.:.'71iLY+ee reeommerd':i th&'t uTs:ts be estc-ODii s}:ed unC'Ler university 4LaSYices, from kriic:: consui.tat, .io:: to a;.l ot~:er p2a.ses of action can be ger.erated a.nd train::Z of qu~",i_ied staff undertaken. Consumer +.CitUd..C s Z`Ze role ;,f the coT:sux:f:r _:, .. -r?purt.'=.ra, one in ths ciga'rett•e smoking- health ~:Vcc dec.sion to or r.ot pur:;hcse cit,t:rcttcs be- corr:es an !:,diviau~_-_ exercise ,:: personx"i he:::th.

-17- Taking heed of the sales produced by effective advertising, the Governor's Adv;sory Committee recommends thAt consumer practice studies be initiated to indicate specifically how consumers come to spend their money on cigarettes or alternative items and What types of media presen- tations influence their purchases. Consumer practice studies could be conducted by independent market researchers, receiving grants from the Research Program in Tobacco Studies. ; ~Tr.e immense market potential of California means that the tobacco / ~ industry will be alerted by any consumer behavior which adversely affects I ; sales. This wil.l help activate company research toward producing a safer ; ; product from tobacco. 'Tae industry has ay rEady shown signs of moving in i the direction of consumer protection, and consumer behavior may well sccelerate this trend. .

-18- PROPOSrD Rr^.GOA5'tE.'NDATIONS GOV'ERNOR'S ADVISORY COMMITTEE ON CIGARETTE SMOKING AND HEALTH In consideration of the foregoing, the Governor's Advisory Committee on Cigarette Smoking and Health therefore recommends that: 1. THE STATE DEVELOP A COORDINATED PROIRAM OF ACTION TO INFORM CALIFORNIAN`s ~ OF THE HEALTE HP.ZARDS OF CIGARETTE SMOKING AND TO CONTROL THE USE OF CIGARETTES. THE PRO3RAM SHOULD INCLUDE EXTENSIVE EDUCATIONAL ACTIVITIES FOR BOTH YOUTH AND ADULTS; BASIC AND APPLIED RESEARCH; EVALUATION, DEMON- STRATION AhrD TRAINING ACTIVITIES; ESTABLISHNZ-NT OF WITHDRAWAL CLINICS; AND STATUTOR!? CHANGES TO STRE!w'1'HEN EXi.STING CODES AND LEGAL INTERPRETA- TI ON RELATED TO CIGARETTE SHiOKI I:G . 2. FUNDS FOR Ti-PJ' PROGRAM BE OBTAINLD BY AN INCREASE IN THE STATE CIGARETTE TAX, WIri DESIGNATION OF A SPECIAL. FUND SUFFICIENT TO FINANCE THE ACTIVI- TIES PROPOSED. 3. EDUCATIONAL EFFORTS BE CONCENTRA'TED PRIt~`:ARILY ON YOUNGSTERS WHO HAVE NOT YET STARTED TO SMOKE CIGARETTES. IN PFRTICULAR, a. The State should develop an Fxtens~ve educational program, with suitable inaterials and specially trained teaching personnel, focussed primarily on young people. The program should also include those er:gaged in or training for the health and teaching professions, and adults general3y. b. The entire State health education program should be strengthened to enhance the effectiveness of specific efforts on cigarette smoking and health. A Framework in Health Instruct~on, providing continuity for all health instruction, would enabl.e thee teaching of health principles to be improved generally.

c. Action should be taken to strengthen the teaching of health in- struction in California scY:ools, and to 'enlarge the scope of persons to Vnom it should be taught. In particular, existing sections of the Education and Administrative Codes should be amended,as follows; 1. Education Code section 9309 should be amended to substitute the words "health hazards" for "eu~ls" with reference to alcohol, drugs and tobacco. 2. Education Code section 7852 should be.arrnded to include in- struction about the effects of smo:iing. 3. Education Code sectior: 7604 should be amended to require health instruction in a} i eler:: n;,ary gr ades as vas required until 1961. 4. Education Code 7700 shou:d be aminded to require health instrue- 5• tion in secondary grades. .A.dministrative Code, T~t"_e 5, section 6:30 should be amended to :eq~airE all teacr:ers qualify,ng for a tza.chir.g credential with speciaiization in elerr:entaxy educe.z,on to be prepared to teach stat-.+.o:y subjects, whicn include hea:.th, alcohol, narcotics and saf Lty. N d. The State should stirr.uip-tc: s.nd financial3.y support organized, recrea- tional activity in the after-school hours when youngsters are n,ost apt to be idle. The recrca-tC.:onal program. should be closely inte- brated with classroom content in health instruction. e. The State should sponsor Eva.:.ua.tion, Demonstration and Training units to develop and evaluate specific education e.i materials and methods for teaching the, adverse eff rcts of cigs.re tte sm-oking and to train personnel skilied in teuchirk;, counseling ar,d recreational activities. These units would function most effectively under university auspices.'

-20 - f. The Governor should establish pcriadfc California Youth Congresses on Smoking and Health, followed by regional or community youth conferences on the subjec: in State colleges, universities and secondary schools. 4. THE STATE ESTABLISH AND FINANCIALLY SUPPCRT A COORDINATED RESEARCH PROGRAM IN TOBACCO AND HEALTH, INCLUDIN.G INVESTIGATIONS IN MEDICINE, EPID:'~iIOLOGY, CHIZIS•TRY, PHYSIOLOGY, BEHAVIORAL SCIENCE AND CONSUMER PRArTICES. r.DMINISIkP2IVE RESPONSIBILIW SHCULD BE PLACED IN THE STATE DEPARTINE'NT OF PUbLIC NFALT:-i, WITH A AErI;S TO AWARD GRANTS TO INVF,STI- GATORS IN PRIVATE AND -PUBLIC AIENCIES TO COND'JCT hTEDED RESEARCH. THE FROsRAM SHOULD SERVE AS A TRAINING RESGJ'c.CE FOR EDUCATCRS, PHYSICIANS, HEALTH PERSONNEL AND OTPERS WCRKING ON THE PR03LEM; AND IT SHCIJLD FACILI- TATE APPLICATION OF FINDINGS TO ALL PHASES OF THE STATE PROGRA14 ON CIGA- RE`1'TE SMOKING. 5. THE ST!-_TE ESTABLISH AND FINANCIALLY SUP PC:RI• CO:%F~!LsNIT+ SERVICE CENTERS, IN WHICH CIGpR.:'i~E WII'HI)RAWAL CLINICS, P?OF FFSSIONAL AND COhg&JNITY ED'J- CATIC%.R, AND Cv^NSULTxTI01 SERVICES TO ITdD'.7Si'it`! FTTTJ A:JENCIES COULD BE C^vCitDIN!-~'LD. FJVAi:UATI0II OF CLINICS SHC".TLD BE INCORPORATED II3I'0 T'^:EIR Dr;VELCPi~ENN'I'. HOSPITALS, DEFrR`l~t>TvT:, OR VOLUNTARY hZE ALTH fsGENCIES MIGHT BE USED AS THE BAZE FOR SUCH SERVICE CENTERS. 6. ST:ICT Ei?FCRCEI-::..'IvT OF PENAL COD:: SECTION "zOS BE UIv'DER'!'AIC1I'I, PROHIBITZNv ACCESS OF T:INCRS TO CIGARETTr,S. UiE SECTION SHOJLD BE A.MENDED TO SPECIFICP.LI.,Y INCLUDF, VENDING MPL:iINES AS A SO'~RCE OF SALES TO MInORS, AND RESPONSIBILITY FOR INFRACTIOPdS BE S'IZFJLP-TED. 7. LEGISLATIGN SHOULD BE ENACTED: a. To ubulish the two defenses of contributory negligence and assump- tion of the risk, and impose on c:ga.rette manufacturers a duty to

-21- warn of the health risks, in order to make civil suit s against tobacco companies by lung cancer plaintiffs more actionable. b. To extend the implied warranty prevailing between the cigarette manufacturer and the consumer, as a tr,eans of stimulating research toward producing a safe cigarette. 8. "NO SMOKING" REGtTLATIONS, WHE-:ZE ESTABLISHED, . BE ENFORCED. 9. INDUSTRY ENCOURAGE EDUCATIONAL ACTIVITIES IiND WITHIDRAk'AL CLINICS FOR EMPLOYEES IN ORDER TO COrf3AT THE ADV"r.RSE EFFECTS OF SMOKINv ON THEIR HEALTH. 10. HE1,LT'ri AND EDUCATION INSTITUTIONS -- SOSPITALS, MEDICAL SCHOOLS, HEALTH DEi'ARTVCENTS, PRIVATE AND PUBLIC EDUCATIONAL INSTITUTIONS -- BE ENCaJRAGED TO RE:dOVE CIGARETTE VENDING MACHINES AND OTiirR SOURCES OF CIGARETTE Sh.'r^ FROM THEIR PREMISES. .

-22- CI:AI'TI:R 2 'TRODUCTION Much of the course of history, it is said, has been written in the quest and use of tobacco. Since its first traceable use by American Indians in the 15th century, tobacco has been a focal point of piracy, wars, costly trades and comMercial ventures, financial coups and taxation. Tobacco has won a colorful place in the history of Western man, just as betel nuts have assumed tremendous importance in Eastern cultures.- In 1921, a curious discovery was made by a young pathologist at the University of I•iinnesota. There Dr. I•ioses Barron observed that the inci- dence of lung cancer appeared to have increased amazingly. He cited this finding as an "epidemic of lung cancer." Since that first awareness, the evidence has been mounting. Lung cancer has certainly reached "epidemic proportions," being the principal cause of death in 1963 of more than 41,000 Anericans. This particular fo:rm of car.cer now exceeds all other types, and is becoming one of the most co:=,on killers of American men. T'i:e "epidemic" was long submerged both in its strength and the public's N awareness of it. lne country recovered from a depression, embarked on a war, and after the intensity of global strife, settled back to domestic mat- ters. 1'he "epidenic" of lung cancer thrust forward insidiously; by the late 19I:0's it could not fail to be noticed. Epidemiologists, reminded of Raymond Pearl's findings in 19381 and spurred by the interest of thoracic surgeons, began seeking the reason why lung cancer should have increased so remarkably. Whatever the factor might be, it was fairly recent in human experi- ence -- widespread perhaps no more than a few decades. Moreover, from studicc of carcinogenesis it appeared that exposure took place over long periods of time, rather than incnediately prior to onset of the disease. The

-23- epidc.~tic was not localized to one city or region; it was increasing in coun- tries other than the United States. And the carcinogenic agent did seem to have affected more men than women. Among the agents under scrutiny were: atmospheric pollutants, industrial and other environmental irritants, and tobacco -- or several of these in combination. E'pidemiologists and other investigators studied many types of exposure which might adversely affect the lungs. Research yielded steadily increas- ing knowledge of the effects which cigarette smoking has upon the human body. Time after time, in study after study, one fact recurred. Those persons who smoked cigarettes sustained not only more lung cancer but more other ill effects than those who did not smoke. During the 1950's and early 1960's, studies -- conducted both retrospec- tively on the experience of individuals already sick, and prospectively on changes in the health of persons followed over a period of time -- kept pro- ducing the same result. The health of those persons who smoked cigarettes compared unfavorably with those w'no did not. Each study was greeted by a wave of skepticism and "controversy." To accuse a familiar, comfortable habit of having deleterious health effects sounded almost "un-American." . People would listen, read, discuss _ir.dings and go riUht on smoking. Support was rallied by voluntary health wgencies, and statements admonish- ing the public to reevaluate the practice of cigarette smoking punctuated the scene. But more teen-agers every day, living in a culture that defi- nitely encouraged cigarette smoking, began testing a habit which would soon become so difficult to break that they would not even try. Surely if ciga- rettes were really harmful, the government that protected food, water and other things we take into our bodies would initiate appropriate action. '!'o a number of Covernments outside of the United States, which is the principal Crc•.rer and processor of cigarettes, the knowledge of adverse effects

-21E._ led to more than "controversy." By 1962, when the Royal College of Physicians of London addressed its report to the British Ministry of Health and the citi- zens of Great Britain, a number of other nations had already taken some action: scientific investigations flourished from Denmark to Ceylon (10 countries); information on the harmful effects had been disseminated by governmental and lay groups in 21 countries; Australia and West Germany had levied increased tobacco taxes; tobacco product advertising had been outlawed in Sweden, the Soviet Union and Italy; restrictions as to where cigarettes could be smoked or who could purchase them had been imposed in 5 nations. What had begun as a"controversy" now became a universally recognized health problem -- and it, was being attacked by a number of methods. In Iceland, for example, the Parliament passed an increased tax of ~ cent on each pack of cigarettes to be given to the Iceland Cancer Society "to be used to urge people, and espe- cially teen-a;ers, not to smoke..." In the United States, the government and citizens watched. Voluntary health agencjes initiated educational campaigns, especially directed at teen-agers vfno might forego cigarette smoking. Finally, in June 1961, the voluntary health agencies which had started the campaign alone urged then . President Kennedy to form an official commission to study the "widespread implications of the tobacco problem." In the ensuing months, m.any voices indicated that the situation had become a serious public health problem. On April 16, 1962, Surgeon General Terry sent a detailed proposal to the Secretaa-y of Health, Education and Welfare, calli ng for formation of an advisory group and for a reevalua;,ion of the position,taken in 1959 by Surgeon General Burney in the Journal of the rxlericar. Medical Association. Particularly, he noted a number of significar.t developments: 1. I~cw studicc indicating that smol-;inS has r..::;;or adverse health effecEs. 2. Representation from national voluntary health agencies for action on the part of the U.S. Public Health Service.

-2>- 3. The f inc? ir.,,s and report of the Royal Co11eGe of Physicians of London. 4. Action of the Italian government forbidding cigarette tobacco advertising; curtailed television advertisement of cigarettes by British and Danish tobacco industries. 5. A proposal by Senator Maurine Neuberger (Oregon) that Congress create an investigatory conBnittee. 6. A request for technical guidance by the Public Health Service from the Federal Trade Commission`-on labeling and advertising of tobacco products. 7. Evidence2that medical opinion had shifted significantly against sMoking. On June 7, 1962, the Surgeon General announced he was establishing an expert cornittee to review all data on smoking and health. The President acknowledged and approved this decision. The Advisory Comnittee to the Surgeon General functioned for 18 months, and their findings, which will be d.iscussed later, were made public January 11, 1964. ,i ~_~.f or•:~' a Ta. 0-lw~ ~r.a - ,;u. .~,. ..~, , i9, 19' y .es A 03 C~. Interest ^r:ong health professionals and r.mr.y me:aoers of the public "was not confined to activity at the Federwl levei. Irdividue,l investigators, . physicians and educators continued to study ;,he problem; and they began ad- monishing quietly against cigarette s.:okin S as a health hazard. A number of state health departments and medical societies had been outspoken'through the 50's, but until July 19, 1g63, none of them had taken a definitive stand on the matter, calling for large-scale, deliberate action. In California, the State Department of Public Health had conducted a number of epideniological studies in the late 40's and 50's in which the harmful influence of cigarette smoking was found to be considerable. These were studies on large population groups, some on persons with common occu- pational experience and similarity of residence. Each successive study

-26- brou;;ht i2: further information on morbidity and mortality, corroborating the earlier findings: that cigarette smoking does have a serious adverse effect on health by increasing the likelihood of certain diseases and pre- mature death. Other research demonstrated the physiologic effect of smoke inhalation on the body, particularly the increase of carbon monoxide. In compilir.g the findings over a period of fifteen years, the State Department of Public Health noted in the document, "Cigarette Smoking and Health:" It is evident that the adverse effect of cigarette smoking on human health can be measured not only in terms of mortality and anatomical changes, but also in terms of morbidity and physiologic impairment. It has been well established that ci{;arette.smoking increases many times the risk of lung cancer -- the greater the amount of smoking the greater the risk. Cigarette smoking substantially increases the risk of dying from coronary heart disease and other diseases as weil. For excnple, one California study involving the follow-up of 68,154 nii:dle-aged men showed that cigarette smoking, all amounts combined, increased the risk of lung cancer death by 14 times. Two-pack-a-day smokin.-, increased the risk 26 times. The risk of death from coronary heart disease was about twice as high among cigarette smokers as among non -smo:cers, and the risk of death from all other causes increased by about one-third among cigarette smokers. In add.iti on, the California ciata...revealed that activity limitation and,days of disability occasioned by chronic conditions were substan- tially greater a.mong r:en aged 25-64' w::o s::ioke cigarettes than among non-smo._ers. Sir.iilarly, the frequency of such conditions as cough was nuc : hi Cher anong cigarette smokers, though the latter finding hardly reouired "study." ~ __ a;:.... nt hcs Z~ee:: sho,:^: to ba associcted with - . .. . --- -.-- , ... V r V a ...__ .. . . . . . ' air. Investigations of -cne lu~ cigarette smokers, and one-third of heavy smokers exceeded the level of carbon mono..i de in expired air which corrsspo::ds •to seven percent carboxyhe..•~o~,lobin,,lobin, within the range zrr.ere physiologic impairment appar- ently begins. Coupled with the fact that a higher propo rivion of Californians smoke cigarettes than persons in many other parts of the country, these data suggest that the State faces a serious problem in cigarette smoking, ::an-ely, a severe hazard to heal-th.3 Publication of these findinCc and the resolution of the California State Board of I:ealth t;;;re not taken quietly. Califcrnia had taken a stand -- to

initiate action. 11nd the nation noticed. Response to the report and the Resolution of the State Board of Health (See Appendix I) was inmediate -- and overwhelMinG. I t ranSed from enthusiastic approval and support to the familiar skepticism. But the vast majority of com¢nents, following national press and broadcast coverage, was laudatory. Officials and the public around the nation comnended the Department stand. The Governor inmediately pledged his support to an action program designed to control this increasing health problen. Teachers, students, physicians and others asked what they could do to help. 'Requests for copies of the report exhausted supplies. (Since July 1963, more than 80,000 copies of the report have been distrib- uted.) At about the sane time, the California Interagency Council on Cigarette' Smoking and Health -- composed of voluntary health groups, medical and State governmental representatives workir.C on the problem -- became active. The prime objective of the Council was to develop a coordinated program of aetion. The initial focus z-rws educatio:.al. Similar interagency councils spranG up throu- :~.out California with impetus _rom the State body. The Council is com-. .. . .,~ :c.~. the Cali:,orr:ia iieart Association; the Tuberculosis and Health Association of California; the California 'dedical Association; the State Department of Education and the State Department of Public Health. Local interagency coun- cils have a co:::parwble membership. Aroumd the State, "controversy" had been replaced by conviction. "Wait and see" had been replaced by acti o::. California was about to set another precedent: t:e first State to se. _ously combat the healtrh hazard of ciga- rette sr.io?:j.nUo

-?3- T::e Federal Gover:ment 11111:es a Sta.nd T'nroughout this same period, the Advisory Committee to the Surgeon General was conducting its own study. Ten scientists -- physicians, biostatisticians, medical school professors -- who had never committed themselves on the ciga- rette smoking issue reviewed all the evidence in publications and heard special reports on more recent studies. Their review took more than a year and was encyclopedic in scope: they surveyed more than 500 studies; requested reports and testimony from over 150 consultants; and sought assistance of.many gov- ernmental, professional and voluntary health agencies. Their report describes in deta_1 not only the demonstrated ef f ects of cigarette smoking on morbidity and mortality of human beings, but also the pharmacology and toxicology of cigarette smoke, and the psycho-social and morphological aspects of the ciga- rette habit. Publication of this report on January 11, 1964, led to headlines across the nation anr.ouncinG: "Smoking a Hazard." Surgeon General Terry confirmed ti-rhwt the public had been expectinZ, that the link between cigarette smoking and ill health was indisputwble. He further indicated that the Federal gover:-ment's position would not cr.d with *e Report. 1tow, the Federal Trade Commission, the Federal Co!~imunications Cor-mission, t:e Food and Drug Admin- istration, the Department of Co:;~~erce and the Department of Agriculture, as well as the Department of Health, +.'.ducat].on and Welfare would have work to do. The stan:p of Federal inquiry had confirmed the evidence as convincing. T:e findings of this Co::mittee received nationwide attention. j•li;; :in two weeks, every physician in the country had received a copy of the Report. The newspapers carried excerpts fro:m the Report for seti•eral wee'C:s; co3t:mnists and r.el.f- :tyled "quittcrs" related their experiences in givinL up cigarette smoking -- or not being able to. i'r.e s;,ock ~'iar:~tet reported only marginal

-2g- losses in tobacco stocks, although first quarter sales in 1964 were signifi- cantly lower. The tobacco companies announced a $10 million program of grants for more research to be conducted by the American Medical Association. The Federal Trade Commission embarked on a series of hearings regarding• placement of "warning" labels on cigarettes as they must be placed on other "hazardous substances." The Federal Communications Cos¢nission began hear- k ings on restricting misleading content in radio and television advertising of cigarettes. The tobacco industry itself announced its own "Code" of self-censorship. The nine firms that make 99 percent of all U.S. cigarettes announced that they had agreed on certain advertising curbs and hired a code administrator, former New Jersey Governor Meyner, who could fine any viola- tor as much as $100,000. They said they would: 1. Ban testimonials by athletic heroes, famous entertainers, or others who have a special attraction to persons.under 21. 2. Bar any appeal aimed directly at persons under 21. 3. Quit suggesting that cigarette smoking is essential to social prominence, business, success, or sex appeal. 4. Stop claiming that a filter makes a cigarette less harmful. . • 5. Forbid distribution of free cigardttes on college campuses. 6. Use models over 24 years of age. (None of these curbs does what FTC has suggested -- warn smokers that cigarettes are a health hazard.) The Public Health Service, aware than public interest in as volatile an issue could easily pass, announced a long-term educational and informa- tional campaign to "keep the knowledge.of cigarette smoking's hazards in the forefront of public concern." Senator Maurine Neuberger proposed legislation to place cigarettes under the authority of the Food and Drug Administration.

-30- Various responses occurred on many scenes: One'California radio station banned cigarette advertising. In Los AnQeles, the Alliance Cmbating Tobacco Infection of Non-Adults (ACTION), a militant citizen's group, appealed to City officials to seal unsupervised cigarette vending machines. Vending machines were removed from State-operated hospitals and offices in a number of states. The Air Force stopped free distribution of cigarettes. Dduca- ~ tional programs were intensified. Legislators•proposed bills to require "warning" labels and to raise cigarette taxes, earmarking funds for cancer research and education. Licensing of vending machines was considered in some locales; one vending machine operator in Ohio began restricting his equipment to supervised locations,.installing none in public places. The televisionbroadcasters announced plans to review their advertis- ing standards, "to put their own houses in order." (Ironically, on January 11, after the Surgeon General was interviewed on the contents of the Report, the item next shown was a cigarette conunercial.) The National Automatic Merchandising Association intensified its self-regulatory campaign, made "warning" labels available to its distributors. As one dissident, Baseball Commissioner Ford Frick declined to excludL cigarette companies from spon- soring major league games. To all the concern, the Tobacco Institute President, George V..Allen, was quoted as saying: "The tobacco industry, which is already supporting a considerable body of health research, stands ready to increase that support and also to cooperate with the Government and with other groups on any prgblems " which offer possibilities for filling the gaps in knowledge..... The evidence had already enabled the Surgeor• General's Advisory Com- mittee to apply the term "cause" to the cigarette smoking-health association. "Cause" had been a very sticky word until then, resisted by many scientists.'

'~i~ "CAl:£;C " b1a1S clcarly shown -- and said so. SomC of the h^E;r:li~',h'.•s of the Report Were these: Lur,O cancer deaths, less t. ur, 3,000 in 1930, increased to 18,000 in 1950. ;'ro::: 1955 to _962, l::•rL- cwr.cer deaths rose from less than 2;,000 to 41,000. T'nis extraordir,u.y rise has not been recorded for cancer of L'..'1y other site. ,r,E:: ths froi:i :3:^oYiarl' and degenera:.iYe 2'.eart disease r ose 273, Qv0 in 5,:'C).1vQO in 119062 ....REported ::E'a',.•:is f io:i c:.:ro:^.iC Dr oY:chi'L' i s ~:.,.`:~` c.;w7j~se.":a r ose from 2, 300 in 1945 T,o .~i5, V'J0 in 1962. 1'ior: _ ~=o _'CY' ...__C C ~.•.:Ce;.ze s:ioZ:c'_'s c0..'Jnr~ u_ ea with r:or:s :ci, " _._ ..wa:.e: of diza2:: :.u=:e :' :.s 1.63, -repre- .riG~.:,_. ., w zo;.a': aeat:: raz.e ne4r=y 70 percerat :i.-h.._ t'~a:: for non- CO:.~b`r--. ...c- ~~1.r :Ld ..:.:i..1•,.. Zs of ~ sct rer: pros pe;: ~~~ G ~= r^ n JL':zQ-E..a, ~ r the a..V..t . . w. o~. ...... of c:.~aret:evaret:e sr.~:::ers o~rer non-sz:o'r.er s'.ers -vas p"rticularly ~. re-r o.c:st4.cso cancer of the 10.8; .ronchitis =;~...: C?o1; i:a::CC'r of :'.":e 2.%•ry:aX, 5•4e.•coro:iGr;' artery dis- et=~'C:, .r".'.J a this is f.''CUiyaie::tl Tio saying Li i.._ .. .._ •:ti1'.rr~/ c. .~'. v:,_r~ C_.c:~r."I, T ..I:'• 'f,:u.. ~ v. , .v CC of QCL'•t'. ~. _ : :~..:.:.~'v in this ~Sit Gcr:•t: rate i' 70 :.~,rcC::•t ~,rcC::•t ::~ -:C:r:or CwK.c ciaarette s:nokers. •,io:: ea3ir.g r --To.r.".:.itis ^ and ti.. .vch+ ..vch'=ch &re a:g r••~, the leading of SG`+'Cr .° i 15c^ C? li :~r, ":~ CLe: ;,f: r c:.i.e for Ci~^',c^.rc?1::.e smokers is ^ "• : ~i li;.i, for For lua~ Cc,t nr J.•t^er, the most ivv :.~:4 of cancer iYa tt3L dec:.'G : rate is : Cc•'iriy l, 300 per- cCr z ,,.^.E' ?"aa:C;r OI c-13'aret'Ges smoked daily, death 1.S i~`/ -,-o l:i.::3 C.°.2'tcer ia T•:en j : E ~e s:ac7ri~ -._. ~t~tti•lc:ibhs a~ l Tne o_' df:Ve_opir:~ '-a.nL• cancer *L=reases vrith durai,ion of and ;.Y:e :i'.:n. :,E.r of ci E;E•:'c"•ti:ccs smokEk ~~E'r day, and is diIlin- _:.: C~ 1C of t}lt.. Ci:uSE 3 of broY:....=t.iC i r: 'tatCs, :rS:d ir:creae.f::3 the risk of dyingg frol:l chronic

- 32- fiae ::r.iokin,Y of cigarettes is associated with an increased risk of dyinr, from pulmonary emphysema. For the bu?~: of the population of the United States, the impor- tance of ci3arette $m-oking as a cause of chronic bronchopulmonary disease is much greater thar. that of atmospheric pollution or occu- pational ex_ osures. Male ciGar ette smokers have a higher death rate from eoronary artery disease than non-smoking nales, but it is not clear that the association has causal s:.Cnificance. 'i'he ovcrti:hclr•rind evidence points to the conclusion that smok- ing -- its beginning, habituation, and occasional discontinuation -- irs to a large extent_psychologically and socially determined. This does not rule out physiological factors, especially in respect to habituation, nor the existence of predisposing constitutional or he- redi;,ary factoro.5 In brief, the Corriittee summarized their overall conclusions by saying: CiCzr ette sn ol::.::r ca health hazard of sufficient importance in the Ur.ite :: tcte: -:r.rrant appronriate remedial action. Apathy, ind.i''fere::ce, iSno, ance, arr oG.:nce -- none of these feelings could carry r:uc?: weiC'r.t any more. The irfluence of cigarette smoking on Y tt.e health of of A::ericu•ns had now become a matter of state and national concern. :•l:utever the Federal dovernment does do in the next few years in the direction of controlling this health hazard, the'State should not rer•.ain idle. To change the pervasive acceptance of cigarette smokin3 is Soin~ to teA:e tremendous understanding and wisdom on the .part of all concer::ed. A progr; m on the State level, reaching to the ranks of individual citizens, should go hand in hand with any Federal activities -- and in fact r:a.te such activities more effectively received in California. Aotlor::: of the liverlcnn blcdical Association Z•lhilc resolut:o.^.s and sone public informatiorn activities had been adopted,by individual state r.°+edical societies during the last decade, not

-33- until 1.963 did the American Medical Association take a stand on the matter. At that time; the House of Delegates passed a resolution indica- ting that the American Medical Association "feels it is duty-bound 'to point out the effects on the young of the use of toxic materials, in- cluding tobacco,' and urges school programs to teach the facts about smoking and disease." A spokesman for the Association indicated on January 11, 1964, following the report of the Surgeon General's Advisory Cotrunittee that education was the key to changing the public's regard for cigarettes. However, in the ensuing months, impetus was generated to produce a more determined position within the medical profession. The resolution which was one of the contested items at the 1964 annual meeting of the AMA did, in fact, reflect a somewhat strengthened position. It states: "...that.the American Medical Association is on record and does recognize a significant relationship between cigarette smoking A.nO '-'bP incidence of lung cancer and certain other dis~ases, ancthat zigarette smoking is a serious health ha2ard." Just prior to adoption of this resolution, the news was widely circu- lated that the RV.A had accepted a $10 million grant from the tobacco ~ industry to further research on the smoking-health correlation. History of Anti-Smoking Campaigns The practice of smoking has seldom been without criticism. -Orig- inally, criticism was purely on moral grounds. Smoking was deprecated by the clergy and such early rulers as King James I of asgland. James cursed tobacco with one breath, but began the policy of taxing tobacco as a prime source of revenue when he raised the import duty.4,000 per- cent. The r.:cdical )pir.ian of James' tir:c, the 17th century, was divided: a number oi' physicians claimed smoking had curative effects, curing hoarsn- ness, headaches, and in months spelled with an "R" especially recoumtendable for "toothache, the falling sicknesse, the dropsie, and the gout."

-34- Medical f:nterest in the qualities of tobacco remained minimal until modern times. One American cigarette company did base a campaign in the late 30's on the possibility that cigarettes were healthful. "More Doctors Smoke X Brand Than Any Other Cigarette" was the slogan of one of the leading brand's advertising for some time. In the 1950's, P. I.orillard Co.'s claim that their brand of cigarettes would make the throat feel better was restrained by the Federal Trade Commission as being misleading. Testi- monials by opera singers attested that "I Protect My Precious Voice With X Brand;" another brand assured there was "Not a Cough in a Carload of...." World Wur I introduced cigarette smoking to thousands of young, rest- less soldiers almost overnig h t. Some of these former soldiers have un- doubtedly become recent statistics in mortality tables. Tobacco usage soared again during the Second World War. Free cigarettes were distributed to servicemen around the globe: cigarettes represented one of the most universal forms of barter in foreign lands, and the American cigarette was the most prized. Throughout the war years and thereafter, millions of per- sons took up cigarette smoking -- and stuck with it. Today, the largest potential group of new customers is theYteen-age population. Studies indi- cate that more than half of American teen-agers are smoking cigarettes regularly by the time they complete high school. It has been to these teen-agers that educational campaigns have been mainly directed since the cigarette smoking and health issue became so well recognized. The American Cancer Society has been running a campaign in schools across the nation since 1957, with emphasis on the,causes and pre- vention of lung cancer. One interesting outcome of the campaign has been the formation of TACS -- Teens l3ainst Cancer -- teen-age groups who assist local Society

-35- ch.:pters in performing various tasks and speak before fellow student groups. TACS groups also focus on other health problems and stimulate interest in entering health careers. Evaluation of pilot Youth Conferences on Cigarette Smoking con- d ducted by the Society indicates that students respond to objective, not moralistic, programs. The behavior of parents, teachers, athletic coaches and other teen-agers usually plays an important part in the de- cision to smoke or not. Presenting the facts and reasoning with youth before they are tempted to start are considered the soundest approach to diminish the numbers of smokers who begin in their youth -- and then find as adults, the habit is too difficult to break.7 The Danish Cancer Society also has aimed its anti-smoking campaign primarily at young people. In 1960, they staged a nationwide poster con- test. Approximately 6400 poster designs were submitted by school chil- dren dealing wit-h reasons not to smoke cigarettes. The best entries were ex:zibited at Copenhagen Town Hall with appropriate press coverage. A booklet "Young -- 1-Soney -- Tobacco" was distributed to every child above second grade -- 600,000 copies. After the'3udging of the posters, four full-color reproductions were sent to each school. 'Gummed stickers (com- parable to our Easter Seals) were made from the designs, to be glued on matchbooks. Bulletin boards of all railroad stations displayed a poster depicting a huge, baited,,hungry-looking rat trap bearing the legend "Lung Cancer." Evaluation of the Danish campaign indicates that it did influence a number of parents to stop smoking, to reduce consumption or switch to other forms.of tobacco. To what extent the campaign influenced youngsters not to initiate the habit will be determined in the coming years by follow- up evaluations.8

-36- Another widely discussed'anti-smoking campaign bas been that in Great Britain started by the Minis try of Health shortly after the Report of the Royal College of Physicians of London, March 1962. At that time, lung cancer was killing 500 Britons a week, one every twenty-five minutes. The imaediate impact of the Royal College Report dropped cigarette sales by 20 percent; but this was only temporary. The campaign took several forms: posters displayed by physicians, schools, youth clubs, and local poster sites; distribution of booklets in one quarter of London; spotty campiagns in other local coaQnunities. An exhibit, Smokarama, in which a giant model of a cigarette unpeels its outer paper to reveal animated cartoons of a cancerous lung, was purchased for 7,000 pounds by one Scottish town council. A film, "This is Your Lung," depicting the downward path of a pack-a-day smoker, xas made available. Survey research, however, has indicated that teen-age smoking is again on the increase in Britain. The campaign described above cost about $75,000; cigarette adver- tisers spent about $42,000,000 during t4e same period. In the 22 months of the campaign, a dozen new brands were introduced. Many observers of the campaign feel that not only the disproportion- ate sums of money, but lack of Imaginative and repeated exposures tended to dilute the campaign from the beginning. Cigarette sales certainly suggest that the campaign was far from succeseful: 109 billion pounds sterling in 1962; 115 billion in 1963. A number of other ideas have been advanced as to why the British campaign has been seemingly ignored: the dubious protection of filtersi an attitude of "shrug-off" fatalism, the mere fact that for most people

-37- who have started cigarette smoking is s3mp7y too difficult a habit to break. Psychologists suggest that in an affluent society people tend to develop a nagging fear that one day the bubble will burst, affkience will disappearj many smokers justify their position by saying, "after all, you have to get some pleasure out of life."9 The pleasure is apparently not dispelled by trying to arouse fear in ~ smokers,who are well, particularly young smokers, through the depiction of painful and wasteful illness, or anything as unpleasant as the sight of a disease-riddled lung. The "scare" approach alone, one might learn from this experience, is not remarkably successful. Efforts to control cigarette consumption are not being abandoned by the British government, although there has been no announcement that changes or expansion in the program are contemplated. A ban on cigarette advertising, like that in Italy, has been proposed by several members of Parliament; so far, the advertisers have made two concessions, to adver- tise only after 9 p.m. and to remove "romance" elements from advertising content. , As in any nation where tobacco has been a reliable and easy.source of tax revenue, Great Britain regards the loss of 20 percent of its cur- rent annual revenue somewhat warily. 'T'he Ministry of Health has not been instrumental in advising.the Exchequer where this 800 million'pounds could be found elsewhere. Other nations have-indicated their appreciation of the problem by re- stricting the advertisement of cigarettes, where cigarettes can be smoked, or by light propaganda. But none of these gestures originated from a deliberate, well-constructed.program to alter a pattern of behavior known to be harmful to health. In Sweden, a nation w?iich enjoys a standard of living comparable to our own, some activity has been generated by a govern- ment seriously troubled by the health effects of excesses both of alcohol

-38- and cigarettes. In 1959, a campaign to discourage youth from smoking was organized, supported by banke, parent groups, and the Swedish Tobacco Monopoly. A major advertising agency donated free,expert technical guid- ance. In Sweden also, Dr. Borje Ejrup instituted a remarkably enterprising clinical program in which smoking is treated as an addiction responsive to therapy. His six clinics have enabled more than 6,000 persons to give up ~ .-r the habit completely in a 10-day course of treatment. Dr. E,irup has re- ported that the treatment had ininediate, total impact on 76 percent of the subjects, and on 22.percent more who decreased their consumption to one- fourth or less of their earlier consumption. Ninety-eight percent success is a remarkably gratifying resu1t.10 The experience of other nations, states and.agencies in combatting cigarette smoking is invaluable, for it suggests the type of activity which' tends to succeed and that which fails, and the nature of funding and organi- zation necessary for an effective "counter-advertising" program. As re- straint of advertising is probably not•too likely in the near future, the use of a "counter-advertising" program may be of considerable importance. The Scope of the Governor's Advisory Committee The Governor's Advisory Committee on Cigarette Smoking and Health stemmed from Governor Brown's iaQnediate support of the Resolution passed by the State Board of Health, July 19, 1963, and particularly the'recom- mendation in the Report of the Department of Public Health that a Committee be created "to conduct investigations and to apprise the Governor of the implications of the situation and recommend action."11 Governor Brown himself attended several of the meetings. He en~pha- sized in his opening remarks th e. urgency of the Coaenittee's deliberations and his expectation that a program reflectitig insight and understanding of ~

•39- the problem would be proposed. The Committee was urged not to restrict its investigative activities solely to its own resources, but to seek knowl- I I a . edge and information outside its ranks. Accordingl,y, the members consulted other individuals and agencies whose experience might be useful. Federal agencies, for example, were consulted throughout the course of the Cosmittee's work to learn what measures they were taking or contemplating. ~ Generally, the Camcaittee meetings took on the quality of forwns, with members giving presentations of findings or proposals suitable for Committee consideration,. Staff work between the meetings by several of the depart- ments and agencies represented on the Committee pertnitted materials relevant to each aspect of the subject to be circulated. Tvo subcomxnittees, one on State Program Development and one on :ResePrcb, were formed to design a spe- cific program feasible for California implementation. The atmosphere of the meetings was always stimulating and resourceful. Publicity about the Cearanittee's activity was considerable. A great deal of mail was received after the Conmiittee's first meeting, conmaending the Governor's action, and encouraging the Committee in its endeavors. ' , .. Senator Neuberger, who is intensely interested in the cigarette smoking- health problem and the author of a book on the subject..•"S~noke Screen: Tobacco and the Public Welfare," commented: "The Governor has once again placed California in the vanguard of public health responsibility."

-40- References CHAPTER 2 ... 1. Tobacco Smoking and Longevit,Zr. Raymond Pearl, Science, 87:216-217, 1938. ~ 2. Smoking and Health. Report of the Advisory Camittee to the Surgeon 3. 4. . 5. 6. 7. 8. 9. 10. 11. General of the Public Health Service. U.S. Dept. of Health, Dducation , and Welfare, Public.Health Service Publication No. 1103. January, 1964, pp. 7-8. i Cigarette Smoking and Health. State of California, Department of Public Health. Berkeley, California. July, 1963, P• 19• Government to Act Cautiously on Smoki Re rt: Local Drives to'Center on Schools and Legislature: Jonat an Spivac . W St. Journa , Paci ic Coast Editior., .January , 1964, p. 3, 8. Smoking and Health. Report of the Advisory Comnittee to the Surgeon General of the Pu lic Health Service. U.S. Dept. of Health, Dducation, and Welfare,'Public Health Service Publication.No. 1103. January 1964, pp. 25-40. Resolution. Adopted by Reference Comcuittee on Public Health and Occupa- .tional Health. House of Delegates, American Medical Association. San Francisco. June, 1964. Evaluation of Cancer Dducation*Pro rammaes Directed to Yo Peo le. J. W. Leverenz. Union nternational s Contra Canorum cts, s -, 1963• Anti-Schoolchild-Smoki Cam i n in Denmark. T. Cramer. Union Inter- nationalis Contra Cancrum.Acta, 19:9 - , 1963. John Bull Keeps Right on Smokin,g. A..iCarthew. New York Times Magazine, January 19, l9b4, P. 17. Ecperiences in Smoki Withdrawal Clinics. Borje Ejrup. Science Writers Seminar, LaJol , Ca i ornia, Apr - 0, 1963. (Sponsored by the American Cancer Society). Hea th. Ber e ey, Ca iforn a. July, 1963, P• 36• Ci arette S,naoki and Health. State of Caiifornia. Department of Public

-41- CxnPfiER 3 COMPREHENSIVE REVIEW OF FACTS In reviewing the information concerning cigarette smoking's influence on the health of individuals, the Governor's Advisory Committee had to die- tinguish between supposition and fact. The subJect has aroused considerable controversy in the last decade or so. In the light of evidence that cigarettes are harmful to man's health, the tobacco industry has issued its own state= ments -- to keep selling more and more cigarettes. Statements from the indus- try have come chiefly in two forms: direct public pronouncements and adver- tising eampaigns,-more subtle in character and perhaps more effective as sales- producers. In 1954, Tobacco Leaf Magazine said, "...we are more than ever convinced that the medico-adman-stock tipster assault on cigarettes and the value of cigarette company securities is premediated and planned.propaganda."1 The same periodical identified Senator Maurine Neuberger as a "violent antibac," carrying on a"personal'vendetta against thp tobacco industry."2 The American Cancer Society, against whom the industry has levelled much of its fire, was accused of relying "upon health scare propaganda to raise millions of dollars from a gullible public."3 The Society reacted w1th frank- ness: "We think the industry's public relations response has been stupid. They ought to admit there is a connection between smoking and health and do something about it."4 The Society insistj it has not exploited the issue, that is anti-cancer, not anti-cigarette, and would be delighted with a safe cigarette. The ltmerican Cancer Society has continued to spend large sums of iaoney on research as well as on education to lessen the annual toll from all forms : 0

-42- of cancer. The tobacco industry has continued to spend larger sums of money on product advertising and some on research. Of the research undertaken by the Tobacco Industry Research Conpaittee, Dr. Paul Kotin, a member of its Scientific Advisory Board, has said: "If they'd come to me at the beginning I would have said to give the money to an impartial research organization... I'd still say it."5 The T.I.R.C. is one flulction of the Tobacco Institute, which is heavily supported by 12 tobacco product manufacturers. Zbe Institute has worked hard to establish the traditional place of tobacco in American culture and to publicize the significant economic character of tobacco. The Institute's stand on taxes, for example, implies that the government could barely function without tobacco taxes -- but that these same taxes are too high.6 Perhaps no one has expressed the dilemma of the tobacco industry as* effectively as Lord Hailsham in the Housee of Lords. "it is not that I condemn them. It is not that I criticise them in any way, save this one. On the'contrary, I realise that it must be a hard and bitter thing to persuade oneself that an honorable business, decently built up, is in fact purveying a substance capable of implanting morta`1 disease without any fault on the part of the purveyor. But thd facts of life are often hard things to face, and the impression the tobacco manufacturers now make on public opinion...will largely depend on the extent to which they prove themselves able to recognise as facts propo- sitions which are accepted by impartial scientists everywhere but which they find so unpalatable...I'm quite sure myself that it would in the end be more to their credit and less to their dis- advantage if they got together in their board rooms and frankly recognised that the merchandise they are now selling...is danger- ous and, taken to any degree of excess, potentially lethal..."7 The advertising industry, which depends so heavily on tobacco products, is beginning to have some doubts about the ethical nature of the situation. Cameron Day, managing editor of Printer's Ink, states, "The cigarette companies have pushed themselves into a bad position. We don't know what they can do

-43- but they must do something. They have been waiting for a miracle -- hoping that the problem wiil solve itself -- but it isn't likely to get better; in all probability, it will get worse."8 In January 1964 the situation did get "worse." Past statements by proponents and antagonists of cigarettes' merits became submerged-by the ` . announcement of the Advisory Committee to the Surgeon General that "Ciga- rette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action." One statement of George V. Allen, President of the Tobacco Institute, seems particularly relevant. It points the direction which the industry, as well as the public, s2iould take:. "We must learn to distinguish the real facts about tobacco from unjustified emotional campaigns..." Nir. Allen may have spoiled the fundamental strength of the statementby adding... "based on the 'health scare' technique -- a technique not successful today."9 If the "health alert" technique has done anything, it has shaken the eompla- cency of people around the world for whom cigarette smoking has been a plea- surable though dangerous pastime. "Health a].erts" are designed to remind, not necessarily to scare. In a period wben human life has been lengthened by improved conditions of living, the reminder that something may be interfering with health should hardly be interpreted as a "scare." In the nineteenth century, those who pressed for better housing and working conditions did not just correct a social ill. The prevalence of tuberculosis, a disease orig- inating in unhealthful conditions, had reached such proportions th.at the _ industrial revolution was being undermined at its core: manpower. History has not indicated that the "tuberculosis alert" was misunderstood. The near eradication of this disease in many countries is regarded as one of the out- standing achievements of disease control. Alerting the public to the necessity of providing healthier conditions of work and life bad a great deal•xo do with' , ,. 'its reduction.

Health Fa::ts lne health alert surrounding cigarette smoking rests on facts. It is a fact, for example, that among a large sample of working men in California, those who smoked cigarettes sustained twice as many chronic conditions which interfered with their normal routine as those men who did not smoke cigarettes. These same smok'~rs spent twice as many days being disabled by ill health as the men who did not smoke. Another fact is that in a study of 68,154 California men aged 35-64 who were observed for about three years, the risk of dying from lung cancer was 14 times g, eater among the men who smoked as among those who did not. Over 1700 deaths were recorded in this study group; not only was the rate of death from,1ung cancer higher among cigarette smoker& but the gradient rose with the amount of smoking, ranging from six times for the light smoker to 26.4 times greater for the man who smoked two or more packs a day.10 (See Table #l . ). Table 1 RGVATIVF: RISK OF N!ORTALIZ'Y9 SET;EC= CAUSES ACCOaDING TO CZGpReTTE S'.~JKING C'~ASS9 CAbIFORNiA,MEN IN CERTAIN OCLUPATION$* Non- All ~ Less About About About 2 or More Cigs,rette Smokers Cigarette Smokers Than 5 Per Day J- Pack Per Day ..._ 1 Pack Per Day 11 Packs Per Day Packs Per Day -..~..~..~ „r Lung Cbncer 1.0 14.4 5.6 6.0 15.6 20.0 26.4 Coranr~.x°y He z:~r±, Dises.:;; 1.0 1.9 1.2 1.7 2.0 2.2 1.5 All Other Causzs 1.0 1.3 1.3 1.2 1.4 1.3 1.5 NCT-:": b'fEN AuF": 35-6~ , gASEr ON 225,137 ~rZ.SO;i-Y".AFS OF OSSERVATION. *WELDEFE, PAIhTEfiS, CO'.,KS, ASBESTOS WORKERS, PRIN'"E:RS, MARINE ENGINEERS, ELECTRIC ISr~,TB3E CRANE OP'EF~ITORS, PY~J~+iBERS (NO ASRESTOS), SHEET METAL'WORKERS, ELECTR'ICIANS, AND 0Tf iER PUBLIC L'TI I:I TY EM..°IAYEES. SOURCE: Unpublishe3 Data, California State Department of Public Health , ,

-45- In this same study, an excessive risk of dying from coronary beart disease among cigarette smokers was also found. This disease ranks as the number one killer of American men. The risk of dying from this disease was almost twice as great among men who smoked as among those who did.not. It is also a fact that the risk of dying from all other causes was one-third higher among California male smokers in tUis same study.ll The California data mentioned above are but a portion of the vast in- formation which has been collected in the last 15 years on the effects which cigarette smoking produces on the health of Americans. The Advisory Committee to the Surgeon General compiled these findings. Seven prospective surveys, which included observations extending over several years among'10120,000 per- aonss disclosed the fact that the number of deaths from lung cancer among cigarette smokers was nearly 11 times greater than among non-cigarette smokers. Further, six times as many deaths from emphysema and chronic bronchitis were recorded among cigarette smokers as among nonsmokers. For more than fifteen other disease entities, the frequency of death among cigarette smokers was recognizably greater than among those who did not smoke. Among the most convincing evidence has been that recently reported by Dr. E. Cuyler Hammond12 who observed "matched pairs," individuals who re- sembled each other closely in various traits, but differed in one: smoking practice. The men selected as a pair had certain identical characteristics: race, height, nativity,.rpsidence; urban occupational exposures; religion, education, marital status; drinking practices, sleeping habits; quantity of exercise; nervous tension, whether or not they used tranquilizers; state of health, including any history of cancer, heart disease, stroke or high blood pressure. Thirty-six thousand, nine hundred and seventy five pairs of men were thus studied. The results of this analysis are quite striking: I

-46- of the original study group, only 662 nonsmokers (1.8%) died whereas 1,385 (3.7%) of the matched cigarette smokers died. In each 5-year age group fraa 40 through 79, the number of cigarette smokers who died significantly exceeded the number of nonsmokers. (See Table #2.) ~ Table 2. Matched Pair An sis. Number of Deaths From Various Causes Among 36,975 Men Who Never Smoked Regularly and 36,975 Men Who Were Currently Smoking 20 or More Cigarettes a Day at the time of Enrollment. Age R ange 40 to 79. Number of Deaths Underlying Cause of Death Never Smoked Regularly Cigarettes 20+ A Day, Cancer (Total) 96 261 Lung 110 8uceall PharM z 3 Larynx 0 3 Eso hagus 0 6 p Bladder 1 2 Pancreas 6 16 Liver & Biliary Passages 1 7 Stomach 9 10 Colon; Rectum . 20 25 Other Specified Sites 43 64 ~ Site Unknown 3 15 . Heart & Circulatory (Total) 401 Coronary 3a+ 65~ Other Heart 30 64 Aortic Aneurysm 8 30 Cerebral Vascular 44 84 Other Circulatory 15 22 Other Diseases 73 127 Emphysema 1 15 Gastric Ulcer 3 5 Cirrhosis of Liver 17 Other Specified Diseases 59 86 Ill-Defined Diseases 1 4 Accidents: Violence; Suicides 58 66 Total Death Certificates 628 1,308 No Death Certificates 34 77- Grand Total 662 , 1,385 SOURCE: Hammond 12

-47- Table #2 illustrates the causes of death. Of the 36,975 cigarette smokers, 110 died of lung cancer; among the canparable group of nonsmokers, only 12 died of lung cancer. Cancers of the pharynx, larynx, esophagus, and other sites took substantially more cigarette smokers than nonsmokers. Emphysema killed 15 cigarette smokers but only 1 nonsmoker. ~ . The principal cause of death was coronary artery disease, which killed more than twice as many of the cigarette smokers as it did the nonsmokers. Other studies indicate that symptoms which may be precursors to more illness, such as cough and other evidence of lung abnormality, occur more frequently among cigarette smokers. Experiments on animals corroborate the ill effects which continued exposure to cigarette smoke can produce. The facts concerning the ill effects of cigarette smoking are just as prominent, just as depressing as those concerning poor sanitation or poor food. Controlling the use of cigarette smoking is in the tradition of preserving the public's health. Facts, not attitudes, support this position. Legal Facts: Statutes Relating to th~ Use or Sale of Tobacco As suggested earlier, tobacco has occupied a special place in the shaping of history. Laws governing its use and sale have been integral parts of the governing codes of many nations and states. Because the future of tobacco products is under reconsideration, these laws are under serious scrutiny. For only through law can order be structured for the good of all people. There are a number of statutes which affect the use or sale of tobacco. These statutes can be placed in one of the three following classifications: a) statutes designed to protect minors; b) statutes designed to protect the general health, safety of welfare of persons subject to California law; and c) revenue producing statutes. (The full text of all present statutes pertaining to cigarettes is contained in Appendix IL )

.•r -48- a.) Statutes Designed to Protect Minors The most direct legislative attempt to protect minors against ciga- rette smoking is found in Penal Code section 308 (1891)* which makes it a misdemeanor to furnish a minor under the age of eighteen, except as pro- ~ vided in Penal Code section 308a, with "any tobacco# cigarette or cigarette ~ papers, or any preparation of tobacco..." A first violation of this section is punished by a fine of between twenty-five and one hundred dollars or by imprisonment for not more than sixty days. A second violation is punished by a fine of between fifty and two hundred dollars or by imprisonment for- not more than ninety days. Third and subsequent violations are punished ,. by a fine of between one hundred and three hundred dollars or by imprison- ment for not lees than ninety days nor more than six months, or botb fine, and imprisonment. Ztwo bills were introduced in the 1963 legislative session which would have altered the law applicable to minors' use of tobacco. Senate Bill 897 would have amended Penal Code section 308 by increasing the fines and imprison- ment to be imposed upon those who sold ~obacco products to minors: a first viola tLon would have been punished by a fine of between•one hundred and three hundred dollars or by 'imprisonment for not.more than ninety days; a second violation,'by a fine of not less than two hundred nor more than five hundred. dollars or by imprisonment for not more than one hundred twenty days. Fur- ther violations would have been punished by a fine of not less than two hundred nor more than five hundred dollars or by imprisonment for not less than one hundred twenty days nor more than six monthst or both fine and imprisonment. Senate Bill 897, howevert was not enacted into law. • *The dates following the sections mentioned hereafter are the dates on .which the section was originally enacted or first amended to deal directly with tobacco. . ~

-49- A second relevant bill, Senate Bill 1005, would have added section 308b to the Penal Code to make it a misdemeanor for any person to install, or for any person in control of any premises to allow to be installed,any automatic cigarette vending machine or any cigarette dispensing mechanical device in such a manner that persons under the age of eighteen years would have fr.ee. and uncontrolled access to such a machine or device. Senate Bill 1005 would also have made it a misdemeanor for any person in control of any premises to allow any minor under eighteen years of age to enter a portion of the premises from which such minor would have free and uncontrolled access to any such machine or device. Senate Bill 1005 also failed to,be- coane law. Section 308 of the Penal Code is obviously designed to punish'those who furnish minors with tobacco products. Education Code section 10602 (1915), in contrast, is designed to punish minors themselves. This section declares that smoking or having tobacco on school premises constitutes a good cause for the suspension or expulsion of a pupil from school, unless inter alia (among other things), such pupil is attending a junior college r which'does not share its campus with a high school. Education Code section 10602 is amplified by the regulations contained in Title 5, California Administrative*Code, which states that the use of tobacco on the part of pupils shall not be tolerated. A further statute designed-to protect minors is Education Code section 9309 (1909) which directs the State Board of Education to include in text- books and teachers' manuals and materials necessary and proper to teach "the evil effects of tobacco." Recent proposed legislation sought to implement this policy. Assembly Bill 1094 would have required the governing board of any school district and the trustees of any California state college to

-50- prohibit the advertising of tobacco products in any school newspaper'or publication. This bill also would have empowered the Regents of the University of California to adopt a similar resolution. Assembly Bill 1094, however, did not become law. These statutes have attempted to prevent minors under eighteen ~ years of age from using tobacco products.' The Labor Code, in sections 1294 (f) and 1303 (193?), declares it a misdemeanor for any person to employ a minor under sixteen years of age in any capacity in assorting, manufacturing, or packaging tobacco. A violation of chis prohibition is punishable by fine of between fifty and two hundred dollars or imprison- ment for not more than sixty days, or both fine and imprisonment. Forty-six other states -- including tobacco-producing states'-- also prohibit by statute the sale of cigarettes to children. These laws have been difficult to enforce elsewhere, as well as in California. I b.) Statutes Designed to Protect the General Health, Safety or*Welfare The statutes falling within this classification are, on the whole, concerned with matters other than the use or sale of tobacco-products, but they affect use or sale indirectly. Thus in order-to insure clean- liness in products consumed by the general public, Health and Safety Code section 28686 (1961) prohibits employees from using tobacco in any form while handling food served for public consumption. Also furthering the same policy is Labor Code 2651 (1939) which prohibits the manufacture of tobacco by industrial homework. Finally, statutes exist which provide that space in state buildings may be used by vendors of food, beverages,'reading materials and tobacco. Thus, in order to provide blind persons with remunerative employment, Government Code sections 6900, 6901, and 6907 (1945) aallow licensed blind t . (

.. -51- • persons to operate, in State buildings, vending stands which offer various items, including tobacco products, for sale to the general public. Also Welfare and Institutions Code section 6564 (1943) empowers the Director of Mental Hygiene to set aside otherwise unused space in State institutions for use as a store or canteen for the sale of cigarettes and other items. ~ These stores in State institutions are managed on a nonprofit basis, for the benefit of inmates, but any profits which may be realized are deposited in the institution's benefit fund. Three additional bills pertaining to cigarette smoking were introduced in the 1963 legislative session. Assembly Bill 1664 would have prohibited a cigarette advertisement from containing a picture of minors or family scones, Assembly Bill 1374 would have made changes in the Cigarette Tax Iraw, and Assembly Bill 2590 would have created an unfair cigarette sales act. All of these bills failed to gain passage. They do indicate, however, a lively interest in altering the present position of the State with respect to cigarette smoking.: c.) Revenue Producing Statutes r In 1959, the Legislature added part 13(sections 30001-30476) to the Revenue and Taxation Code, creating a cigarette tax of one and one-half mills ($0.0015) per_cigarette, or three cents per package. A number of other states tax cigarettes at c higher rate, soane as much as 10 cents per package. The California rate is nominal indeed compared with that levied in some nations, such as Sweden or Denmark, where 80 percent of the retail price of*a-package of cigarettes goes into tax reveniue: In addition to revenue produced under the three cents per package .rate, other revenue may be realized, though in much smaller amount, through r

-52- the imposition and collection of various fines provided for in the Cigarette and Tax Law (e.g. Revenue and Taxation Code, sections 30204, 30205, 302240 30281 and 30433). d.) Private Law As is evident from the foregoing discussion, California statutes re- lating to the use or sale of tobacco are designed to redress or prevent wrongs which are generally public in nature. Thus, the development of private law in this area has been dependent upon judicial decision. A search of California judicial decisions has yielded but one case! which dealt with the duty owed by a tobacco manufacturer to the consuirier. In Liggett & Meyers Tobacco Co, v. Delape,13 a cigarette smoker recovered from the Liggett & Meyers Tobacco Co. for injuries suffered when a ciga- rette exploded in the plaintiff's mouth. In upholding the verdict, the Federal Court of Appeals held that a cigarette manufacturer had a duty to use reasonable care in the manu2'acture of his cigarettes in order to keep them free of substances which would cause, in the anticipated use of cigarettes, harm as suffered by the plaintiff. v More in the forefront of current public awareness, however, is the question of whether a cigarette smoker, or his executor, may recover damages from a cigarette company for injury or death resulting from can- cer induced by using the cigarette company's cigarettes. In the five 14 well-known cases in this area, not one plaintiff has recovered. In these cigarette-cancer cases, plaintiffs have found it diffi- cult to prove that cigarettes in fact cause cancer; however, a recent case held that this question is for the jury to decide (Pritchard v. Liggett & Meyers Tobacco Co.,) 295 F:2d 292 (3d Cir. 1961). Furthermore, in these cigarette-cancer cases, defendant cigarette companies have used, .

-53- with some success, the defenses of assumption of the risk and contributory negligence. Plaintiffs may in the future fare somewhat better on a warranty theory, hoti•ever, since the Florida Supreme Court case has declared in the Green case14 that a recovery on this theory is possible. This discussion indicates that the development of private law in i this area is of a very recent origin. It may be therefore too soon to anticipate the nature of any rules or duties that will be declared in the future, but the situation appears to be fluid. Fiscal Facts: Taxation and Revenue from Sale of Tobacco As mentioned in the last section, California has placed a tax on cigarettes only since 1959. At present, only six states have not yet enacted a sales tax on cigarettes. The three cents per package tax levied here is about two cents below the national average and, as mentioned, some states place a tax of 10 cents per package, and some nations tax up to 80 percent of the retail price. The funds accrued from the tax in California go directly into the General Fund. Since 1959, this tax (after.refund and discount) has yielded: Fiscal Year Fiscal Year Total 1959-60 $64,8o4,970.00 1960-61 66,02~+,076.00 1961-62 66;082,826.00 1962-63 70,569,915.00 1963-64 71,419,667.00 In fiscal year 1963-6+, during which both the reports of the '..alifornia State Department of Public Health and the Advisory Committee to the Surgeon General were issued, revenue is recorded at $71,419,667.00. While this reflects an increase in sales over the previous year, the figure fails to indicate the pronounced decline from January-through March 1964 and the upswing from April through June 1964. (See Chart #l.)

-55- The California tax, which yields about $25 million for each cent of tax, has not seemed to influence cigarette purchases adversely. In fact, until the subject of cigarettes being harmful to health gained momentum, sales of cigarettes were on the upswing. Increased population throughout this period should be noted. i The present practice of placing the revenues from the cigarette tax in the State General Fund is not the only feasible procedure. The Legislature may earmark funds for special purposes; for example, automobile registration fees go to the Department of Motor Vehicles for highway improvement. The possible.jultirr,ate loss of a portion of the State cigarette tax revenue, through depletion of sales, must be considered. Nowever, as Governor Brown specified in his charge to the Advisory Committee, any fiscal or other famifications of this issue are secondary to protecting the health of Californians. Health comes first; revenue second. While the State.r.:ay have become accustomed in recent years to having this sum in the General Fund, other sources of revenue could be found if this resource diminished over the years. Contrarily, consideration might be given to raising the present tax. DiscaEcion of such a measure appears in Chapter 4 under Fiscal Considerations. :71n Advisory Committee concerned itself only with those fiscal matters related to the State, and to the support of programs suitable for Celifornia. Therefore, the effect of reducinp the.amount of cigarettes consumed on the national econorrW was not considered germane to the Committee's review. CD V O N

-56- The Federal government and many state governments derive large revenues from tobacco taxes, paid both by the producer and the conswner. Tobacco, how- ever, has also been a subsidized crop. In the past few years, when the ciga- rette smoking and health issue was reaching its intensity, the Federal govern- ment and the industry have had reason for concern. In addition to the phenom- ment ~ . . enal sales of cigarettes in this country, yielding over $3 billion in all kinds of taxes, export sales of tobacco and cigarettes bring•another $500 • million in sales. Tobacco is big business. The principal worry of tobacco men is what are they going to do with all that tobacco -- not really where will the needed tax money come from. One suggestion, pressed more vigorously in recent years,has been to find what qualities in cigarettes are harmful to health and remove them. The cigarette smoking-health issue should have the effect.of stimulating the tobacco com- panies to perform research before more severe action has to be taken as has been done with other harmful products.' The tobacco industry has been severe]y criticized because of the dispro- portionate amount of monies expended on promotion and research. The annual expenditure on advertising and promotion of cigarettes exceeds $200 million. From 1954, (and until the grant of $10 million to the American Medical Association), the Tobacco Industry Research Coramittee has inade grants for research totaling only $6.25 million, each company contributing according to its sales. This is'about one-half of one percent of the amount appro- priated for advertising and promotion (and about half the amount spent for research by the far smaller West German cigarette industryl5). Additional sums'are spent on unpublished company research, but no information is available on whether this amount is large or small, expended on making a safer product or simply making another product. One reaction to the I

-57- publicity over the past ten,years about cigarette smoking has been to flood the market with new, dazzling brands, containing essentially the same tobacco surrounded perhaps by a filter, a different style box, or maybe only a new; suggestive brand name. Whether the companies should be performing more and making public their research is discussed in Chapter 4 under Legal Implications. Educational Facts The teaching of health to school children is a traditional curriculum requirement in California. The teaching of health is required in .elementary schools, and experience has indicated its value in secondary schools. The instructional program of health education in California schools is designed to complement the knowledge children may acquire at hoaae. The only statute requiring instruction related to smoking is Education Code section 9309, which has a quaint, outmoded flavor. It'specifies that: The State Board of Education shall include in the textbooks and teachers' manuals adopted such materials as it may deem neces- sary and proper to encourage thrift, fire prevention, and'the humane treatment of animals, and teach the evil effects of alcohol and tobacco and other narcotics on the human system. v The customary procedure for giving instruction on alcohol, narcotics and tobacco has been through classroom presentations. Instruction in these specified topics has been placed in various subjects in the curriculum often without regard to the preparation of teachers or their interest in providing this instruction. Inservice training workshops for teachers, including those teaching education in State colleges, have been conducted in recent years to update the materials developed in manuals and to give teachers as much current information and methodology as possible. That education of California's young people about the health effects of cigarette smoking is especially important has been borne out by studies

-58- conducted outside the State regarding teen-age smoking practices as well as by polls conducted in California. Informal polls conducted in the State indicate that about half of the students in high schools smoke cigarettes; this'number is high partially due to the indifference of youngsters who violate statutes in order to obtain cigarettes. The fact that the existing ~ section 308 of the Penal Code has not been enforced has permitted youngsters to purchase cigarettes quite easily with no apparent penalty either to themse]ves or the persons dispensing them. The Department of Education finds that the raling in the School Code prohibiting possession of tobacco on school grounds is not consistently upheld either. Until recently, cigarette smoking among teen-agers was not taken very seriously. Long-term epidemiological studies of adult populations'repeatedly find that the age of starting smoking is important: the younger a person begins smoking, as well as the amount he has smoked since that time, the greater the likelihood he will develop lung cancer or other harmful effects. Just when it became kno-un that cigarette smoking in youth is especially dangerous, the advertising of cigarettes began to concentrate on making 14 smoking appear desirable to youth. As one frank teen-ager said on a recent te]evision panel on.cigarette smoking, "if you believe the ads, you figure that smoking will get you the girl of your dreams, that you'1]l earn $50,000 a year and that you'll have a terrific life." Attitudes such as this one, honest and pentrating, have become a point of serious concern in several studies. There is need for even more investiga- tion of what makes people, especially young people, respond to cigarette's lure, and how this process can be reversed. Anaong the studies which tried to discern the motivation for beginning to smoke among young people are those of Dr. Eva Salber and her associates at Harvard University and that of Dr. Daniel Horn for the American Cancer Society in Portland-, Oregon.

-59- Dr. Salber's study began in 1960 and is still going on. 16-20 Her subjects are the high school students in Newton, Massachusetts. Dr. Salber has determined that k percent of the seventh graders smoke, with the proportion rising to 50 percent of the high school seniors. By the end of high school. 70 percent of the students are either present or discontinued smokers. In the last year of high school, 18 percei3t of the boys and 10 percent of the girls smoke as much as five packs a week -- 3,000 cigarettes a year. And what distinguishes the smoker from the nonsmoker? Parental example is apparently one of the chief factors. In families where neither parent smoked, roughly 25 percent of the students smoked; in families where both smoked, roughly 25 percent of the students smoked; in families where both parents smoked, about 50 percent did; in families where only one parent smoked, the proportion of student'smokers was nearly as great. Among-the heaviest student smokers, 13 percent of the total reported that both parents did so, whereas only !+ percent reported that their parents did not smoke. The smoking practices of siblings are also relevant. Frequency of smoking was much higher among children'whose older siblings smoked than r among those whose brothers and sisters did not smoke or where there were no older siblings. Dr. Salber also related intelligence and achievement performance to smoking habits. She found that nonsmokers had a higher average I.Q. than students who smoked cigarettes, and, that the light smokers performed better than the heavy smokers. Mean grade achievement was substantially higher for the nonsmokers and light smokers than for the heavy smokers. The d.fferences were particularly striking among boys. Dr. Salber conjectures that perhaps children who fail to'achieve a satisfactory measure of academic performace finQ the practice of smoking a technique of gaining acceptance in a peer group whose values differ from those of the academically more successft.]l students.

-60- Dr. Salber has investigated the correlation of smoking with leisure . time pursuits. Students who smoke spend a greater amount of time watching television and less time reading books then students who do not smoke. Their friends are more often smokers, they go more to movies and dances, and more of them are car owners. On the other hand, they participate less :. in sports and are less inclined to join organizations or clubs. More non- smokers than smokers (within each social class) consider smoking liable to increase nervousness, to cause lung cancer and to have a deleterious effect on groVrth, athletic ability and health. Dr. Daniel Horn, in his earlier study of students in Portalnd, Oregon21 schools also found that the children who smoke take less part in sports and in other school activities. His study, conducted among both public and private, including parochial~school students in Portland, also determined that the example of parents and siblings had a strong influence on smoking habits. What seemed to matter is whether or not smoking is accepted by the family and regarded as an expected form of behavior. When it is, smoking becomes part of growin$ up; this accounted for nearly half of the smoking among students in this survey. As in Dr. Salber's study, Dr. Horn found that smoking was higher among those students who had fallen behird their age equals in school, among those who did not participate in extracurricular activities or who take a less demanding course of study. Dr. Horn also found that a higher proportion of the students in parochial schools smoke cigarettes than students in public shcools. Dr. Horn carried his inquiry a step further -- an important step, for it may give some indication of what types of educational programs may be most effective. Using both experimental and-control groups, he exposed o ~ the subjects to a variety of educational approaches over some time. The .~'i _J o+ 0 v

-61- goal desired was to reduce the "net recruitment rate" -- the number of students newly attracted to smoking. The approaches were several: "contemporary," using those aspects of smoking which might have current meaning to high school studenis; "remotA," emphasizing the relationship of cigarette smoking to lung cancer and failing health in the future; the ~ . "both-sided;" the "authoriative'approach;" and the "adult role-taking" approach. Dr. Horn found that the "remote" approach, which might appear to adults more sophisticated and difficult to project meaningfully., actually met with the greatest effectiveness among both boys and girls.. This approach lowered the eight-month net recruitment rate from 13 to 7.7 percent among boys and from 6.4 to 2.1 percent among girls. While proportions may seem small, magnifying them over a period of four years means that about 20 percent of the high school students who might become regular smokers by graduation would not do so. The increasing need to encourage youth not to begin smoking means that many more studies should be conducted and the findings used as the basis for educational programs. A fqll discussion of educational and behavioral studies is contained in Chapter 4. Behavioral Considerations Behavioral science has become increasingly helpful in understanding and changing human conduct. Although a new science, it is already proving useful in health work. It is one matter to introduce a new concept of health practice to a population;,it is quite another to get it accepted'.• Knowledge of human behavior may be particularly valuable in any program to change the practice of cigarette smoking. The behavioral approach to the problem consists of several facets: 1

-62- 1) longitudinal studies of the natural history of cigarette smoking, its evolution among successive generations; how the practice increased in popularity and acceptance; bow it develops in some individuals and not in others;•arid cultural determinants in the adoption of cigarette smoking as an habitual activity. ~ 2) studying the personality traits of individuals who smoke cigarettes, their motivation to smoke and their other habits which might relate to smoking, such as dietary, drinking or recreational practices. 3) analysis of influences which promote cigarette smoking such As direct edvertisin¢, pulpi.icity from the tobaoFo industry+ and subliminal influences such as behavior displayed in ' movies. 4) analysis and evaluation.of various mechanisms used to change behavior, including regulations, legislation, instruction, example of peers, education, organized preventive activities. r 5) assistance in theory about learning to condition young people not to choose cigarettes as a habit. 6) as "curative" programs are instituted, such as withdrawal clinics, evaluation of the programs and determination of those factors which keep people from responding favorably. Studies of human behavior as it relates to this subject are essential- to any serious effort to change the present milieu in which cigarettt smoking is not only peraaissible, but regarded as healthy. At least until a safe product is found which offers the same satisfactions and habit- appeasement, it is necessary to operate on the principle that cigarette I

-63- smoking itself must change in value and popularity. To accomplish any sweep- ing change.in social mores will take extensive research, intensive programming based on research findings -- and,patience. Changing such a well-established habit is a stiff challenge. Consumer Considerations Closely related to behavioral considerations are those relating to the responsiveness of individuals as consumers. The Comcnittee has been mindful that in dealing with an issue as hotly contested as this one has been, one question is: What right has the government to tell me how to spend my money? The wise consumer recognizes, of course, that the government does directly or indirectly guide him in spending his money. The government operates many agencies and controls to assure the consumer of safety and quality in what he buys. The question here might be phrased somewhat differently: To what extent does the protection of the public's health require governmental participation in controlling the use of cigarettes? Today, the majority of American enjoyy a standaxiof well-being never . before known. Those segments of our population•still not.so advantaged are- receiving intensive attention so that `.hey, too, will share in this well-being. Yet, there is a curious enigma: for instead of succumbing to diseases due to past "unfavorable" conditions, Americans today continue to become ill and die 0 of conditions produced by our current style of life. We tend to overindulge in food and alcohol, to get insufficient exercise -- and to smoke cigarettes. Americans, working hard to earn these "better things of life," have redesigned their.patterns of health-and'disease. Besides favoring the genersLly better health which comes with widespread prosperity, public health also seeks to bring the highest standards nf well-being to as many people as.possible through specific improvements in the conditions of life. .

.64. . 0 In the particular case of cigarette smoking, the cause of improving the public's health has been thwarted on many sides. The consumer has not been helped to make a healthful decision. He is deluged with messages that cigarettes will please, satisfyp stimulate, sooth and possibly do a lot of other things. He hears ar sees messages about the product from his waking. . ~ hours until he goes to bed; he can purchase cigarettes cheaply and with little effort because they are so readily available. He can smoke them freely in most of the places he works or moves about. The tragedy is'that thousands of Americans have been smoking themselves to an early death because of the pervasiveness of cigarettes in a social milieu which encouraged their• use first by men, then women, and now by youngsters. About five percent of what the consumer spends on the-product comes back to him in advertising and promotion -- to keep on smoking: Probably no bther product used by half the adults in this country exerts such an effort to keep its customers and to win new ones. Against this panorama, the consumer has a difficult decision to make. 0 Will he respond to the bombardment of product messages or to the knowledge that the product is doing him harm? Much has alreacjy,boen said about why people smoke, why they begin, and why some are able to quit. But research will have to be intensified in the next decade if the voice of public health on this question is going to have much effect -- research on why people spend money on something which, while immediate].y pleasurable, has such a profoundly negative aftereffect. Is it that abundance has stifled the consumer's ability to discriminate? Is it the fallacy that the $100-300 he spends on cigarettes annually seems so petty compared to lifetime investments? Is it that he thinks illness and death are too far off? The mere admonitions of medical scientists are .

-65- r 0 are not very effective in convincing a man to cease spending money on a product which will make him sick twenty or thirty years later: We tend to tolerate human behavior when it is not destructive of others, even when it may be self-destructive. Yet we must continue to assume that man's welfare is also a matter of public responsibility. Man, as a consumer, gives a sizable portion of hisk income to governmental agencies which seek to establish higher standards in many fields -- not least of these being health. Through governmental activities, the consumer has been assured safety in his food, his drink, his living and working situations, and often his pleasures. He does not expect to be harmed in any of his daily activities even if he is not thoroughly careful. With respect to ciga- rette smoking, however, government has done little to protect the consumer. He is allowed -- even encouraged -- to keep on smoking, to have his offspring smoke and to take the gamble that his habit will not do him in. The consumer is in a position, of course, to decide whether or not he is individually going to act on the evidence before more stringent measures are taken to insure that the evidence is a~plied in the marketplace. However, it is a large role to expect of the consumer by himself. The government in the interest of public welfare may have to regulate the sale and use of cigarettes further. The consumer may wonder how the Federal government can logically provide price supports to tobacco and impose large taxes on the same product. There is no question that the Federal government must reexamine its entire interest in tobacco, in the light of the evidence propounded in the Report of the P.dvisory Committee to the Surgeon. General. This case is no different from that of many, in which one agency of the Federal government may stand to change its operation because of the findings of another agency. What is different I

-66- is that for the present the Fvdezal government is apparently giving the public an opportunity to reshape the consumption of tobacco voluntarily. The consumer may by individual judgment reduce thq consumption of ciga- . rettes -- producing a form of obsolescence fsmiliA:r in o*er consumption tre,nrl` _ k 1 I

1. 2. 3. 4. • , 5. 6. . 7. 8. 9. 10. 11. 12. 13. ~ 14. ~ 15. 16. -67- References CiiAPrER 3 The Consumer's Union Re rt on Smoki and Ruth and Edward Brec er,* et a. Consumers 1963, P. 132. Ibid., p. 132. p. 132. P• 133. P• 139 p. 134. Ibid., pp. 139-1k0. Ibid., p. 140. Ibid., p. 135. 14, the Public Interest. Union, Mt. Vernon, N. Y..q Cigarette Smoking and Health. State of California, Department of Public Health. Berke ey, California. July, 1963, p. 13. Report of a Ten-Year Follow-Up Stuk of -San Francisco Lmshoremen: Mortality from Coronary Heart Disease and from a auses. N. O. Borhani, H. Hechter, and L. Breslow. Journal•of Chronic Diseases, 16:1251-1266, 1963. Smoking in Relation to Mortality and Morbidit (Findings in First 3 Months of Follow-up in a Prospective Study Started in 1959)• E. Cuyler Hammond. Presented: Meeting of the American Medical Association, Portland, Oregon, December 4, 1963. 109 F. 2nd 598 (9th Cir. 1940). Green v. Amer;can Tobacco Co., 325 F.2d 673 (5th Cir. 1963), 154 So.2d 169 (1963).. 30 F.2d 70 (5th Cir. 1962); Iarti ue v. R. J. Reynolds Tobacco Co., 317 F.2d 19 (5th Cir. 1 ; itch -. Liggett & Meyers Tobacco Co., 295 F.2d 292 (3d Cir.Y9613 ; Coo per v. R. J. Reyno s Zb acco Co., 256 F.2d 464 (1st.Cir. 1958),-f5tS F. Supp. 22 (D. Mass. 1957 , 234 F.2d 170 (lst Cir. 1956); Ross v. Phillip Morris Tobacco Co.~ 164 F. Supp. 683 (D. Mo. 19581. The Consumer's Union Report on 9noking and the Public Interest, PP• 1 - 15• Smoking Habits of High School Students in Newton Massachusetts. Eva Sal er, E. Go dman, M. , B. We s. New Eng d Journa of Medicine, 265:969-97k, 1961. I

-68- • Refcrences (cont.) CIIAPTIIt 3 a 17. Smoki Habits of Hi School Students Related to Intelli ence and Achievement. EVa Sa er, B. MacMahon, B. We s. Pe iatrics, 29::780-797, 9 • 18. Influence of Sibli s on Student Smoki Patterns. Eva Salber, B. MacMahon, S. Harrison. Pediatrics, 3::5 9-57 , • 19. Smoking Behavior Recreational Activities•and Attitudes Toward Smoki Among Newton Second School Chi dren. Eva Sa er, R. Ree ,. Harr son, . J. Green. Pediatrics, 32:5:91 -9 , 1963• V 20. Personalit Differences Between Smokers and Nonsmokers. Eva Salber, J. E. , 7::3-5, 9 • Roc . Archives of vironmenta ea t, : , 1964. 21. Modifying Smoki Habits in High School Students. Daniel Horn. Children, 14 I 1 3

-69- CHAPTER k PROGRAMS OF ACTION . 0 i Health Planning and Withdrawal Clinics Legal Implications Public Law Private Law The Relationship Between State-Enacted Legislation and Contemplated Actions by Federal Agencies Fiscal Considerations } , a Education Needs Research Consumer Studies , .

-70- NEAL2H PLANNING AND WITHDRAWAL CLINICS Although the influence of cigarette smoking on man's health has been investigated for many years, it is only in the last year that large-scale national attention has been attracted and that concern has been expressed among responsible agencies. Many health-conscious individuals have been trying to alert the resistant public to c~hange its smoking practices. The proponents have met largely with frustration; the'patterns of life least receptive to change are those most taken for granted. As Evarts Graham, the first surgeon to remove a lung for cancer and one of the first to note the connection with cigarette smoking, once remarked, "It's too bad it isn't spinach." Conditions of life which are linked to personal behavior patterns giving some immediate pleasure are harder to change than others. A great .deal depends on the times in which the change is being effected and the responsiveness of the public. Certain matters also have more emotional impact than others, e.g. purifying milk•for babies. The public tends to appreciate improvements in life which lower the risk of damage to children. r But improvements to lengthen life or make it safer for adults do,not meet the same response. Despite this, dramatic changes in the manner in which _ most people live have been taking place quietly over the years. Today, people take for granted that the quality of their food is' effectively controlled from growth through processing and distribution -- illness resulting irom contaminated food is comparatively rare. The principal source of such illness today is the careless housewife. When a food processor is at fault, the news is startling; consumption of the product is immediately halted, and the product.is removed from the market. :

-71- The safety of the public is uppermost in the complex system of envir- onmental safeguards which have become so much a part of daily life: adequate sewage disposal; control of pollutants in the air and water; mechanical.safety gadgets used in industry, in our transportation systems, in schools and hames. Disease control is furthered not only by application of new technology ~ in therapy, but largely by prevention. Today, the public takes for granted the immense benefits of longer life afforded them through simple innoculation procedures in early childhood. And in this country the great scourge of malnutrition has been controlled to a great extent. Americans in this century, like most Western peoples, have new patterns of longevity -- and of disease. The way they live predicates the disease entities from which they will ultimately die. Today, Americans die of coronary artery disease ~.nd other forms of heart disease, cancers of the lung, larynx, breast and other organs, and they die of other chronic conditions associated with patterns of daily living. It is a better life -- and a longer one -- in many.respects. But it'could be even better is the philosophy of people con- cerned with the health of the public. r At the root of almost all long-term improvements in patterns of health is prevention. One form is-primary prevention, the absolute avoidance of the, occurrence of disease, e.g. by vaccination against poliomyelitis or control of dust to prevent silicosis. These two diseases, which until recently caused many deaths and a substantial amount of chronic disability, can be completely controlled through application of available knowledge. And there is secondary prevention, the early detection and prompt'adequate treatment after the disease has occurred, to prevent disability or premature death. Early detection of diabetes or cancer of the uterine cervix are examples of secondary prevention to greatly delimit the unnecessary disability and death from these diseases.l

-72- Curtailing the smoking of cigarettes would be a major preventive measure, in that it would control one of the known causes of lung cancer and other chronic lung disease, and control a factor in disability and premature death from many other diseases. Because the impact of cigarette smoking,appears only after long periods of use, prevention is the most hopeful attitude to . ~ ' adopt. There is no question that the person who discontinues smoking has a better chance of avoidirlg many of these diseases and its consequences than the one who continues, but the person who has the greatest advantage is the one who never begins to smoke cigarettes at all. (In response to the dis- couraged smoker who says, "Well, I have to go some way," assuredly there are far less early and painful ways to die than by having lung cancer. Un- fortunately, it is the'nature of this disease to be recognized usually in its later, and then almost always, fatal stages. If one could choose, having lung cancer is not a happy choice.) Planning for improving health through control of cigarette smoking should begin with preventive measures. In California, because of the great interest already gener ated in the subject~, preventive measures will no doubt . gain increasing acceptance. Prevention: Programs for Youth The group most receptive to changing the.esteem attached to cigarette smoking is young people who have not yet tried to smoke. Programs of health education which emphasize, by demonstration and other techniques, the folly of smoking should be introduced into all school curricula beginning no later than the fifth grade. Supportive programs could include exhibits, dissemi- nation of information in mass media, campaigns similar to those dramatizing other forms of disease prevention, and continuing revitalization of teaching i

-73- materials.' Supportive programs which reach children outside of the school environment should also be developed-and encourageds recreational, community and church groups, guidance counselorF and informal;groups should be able ;., to have-information available to reinforce the practices being taught in school, much as other habits of hygiene are reinforced both in and out of school.: To provide adequate, specialized educational materials suitable for diversified application, a formally organized program in education should be initiated in the State. Because of California's peculiarly rapid growth, it is vital that such a program be incorporated into the curriculum design of all schools -- both new and old. Through the education of children and through follow-up evaluation of their subsequent smoking practices and those of their families, some parents will be reached. However, the goal to be sought in this particular measure is to instruct those in school about the effects of cigarette smoking on their own health. Changing the orientation that smoking is "immoral" to that of' being "unhealthy" and therefore unwise can be done through repeated and imaginative educational techniques: This appears to be the most prom- ising way of preventing young people from beginning to smoke at all, and perhaps making them question the type of allure which presently promotes its practice. To be effective and of long-term benefit, the school educa- tional program must be varied, comprehensive and fully developed, carried out with conviction that ideas can be changed -- and carefully evaluated to guide it toward optimum effectiveness. Prevention: Pro&rams-for Adults. The great hope that cigarette smoking practices will change cannot rest alone on young people who are told that smoking is bad for them -- and

then come home to find their parents smoking up a storm. This is the uneasy atmosphere in which previous educational efforts have had to work. But this, too, must be changed. The change will be more gradual, because smokers do find cigarettes hard to give up. However, there are a number of measures which can be instituted simultaneously with those described above to make ~ the setting more favorable. Adult education,through conventional social institutions -- parent-teacher groups, recreational, church,-occupational and professional organizations -- should be greatly intensified. And dissemination of information through all forms of mass media especially should be stressed. Again, because changing a habit as commonplace as cigarette smoking is going to take many years of reshaping attitudes, a variety of presentations and approaches is going to be required. Any•type of presentation should include evaluation procedures so that its durability and influence can be precisely measured before it is broadly applied. Educating adults, no less than young people, will require all the skills and resourcefulness of experts in public information and indoctrination. One important resource will be physicians. Physician Education The personal practice of an individual physician and his ability to convey his attitude to patients are fundamental in effective change of ideas about health. The physician today advises his patients on many habits: diet,- exercise, consumption of drugs and alcohol, rest, work. And if he is adept at understanding each patient's'medical-social profile, the physician can give his patients the type of constructive advice to keep them•healthy. Physicians have an obligation to patients to give them sound advice. Most physicians take pride in this ability. Today, many of them are telling their patients -- stop I

. smoking cigarettes. If you must smoke, smoke a pipe or cigars, but if you can give it up, do so.. But ttie numbers of such,physiCians are still too small. And their method is too commonly'"post facto," i.e. after the develop-. ment of the diseaee. •Providing physicians with evidence thiough demonstrations, . 0 8 . infftation WA meterial~ which they can pass on to patients,anQ stimulating theri to set & suitable Axample are extremely lmportant. No program of reshap- ing the attitudes of laymen and children can hope to succeed without convic- tion and example on the part of physicians. Therefore, special attention should be given to fostering a strong program of physician education, reaching not simply those specialists'lrho treat particularly the victims of cigarette smoking, but all physicians, in• cluding pediatricians, who can emphasize the importance of not smoking to children. Physicians can also be an important profeisional health resource for teaching: they can perform valuable community service by being avail- able able as speakers, and in their formal teaching activities.to students in the health professions also transmit the importance.of this matter. With- out personal example, however, as in the case of any person respected as a teacher, these efforts will not be effective. Therefore' it is important to recruit both physicians and teachers into any curative programs which . . might help those unable to give up smoking independently. Physicians in local medical societies should strive to assume pro- fessional responsibility toward this issue and to provide a potentially r valuable resource to assist groups and individuals in helping to control cigarette smoking. Curative Programs ...~_. As in many matters of health change, there are two directions where S improvement may be achieved: through prevention and through cure. The .1

-76- very newness of the cigarette smoking problem and the indifference to early admonitions have retarded any "miracle" cure for the habit. However, for those persons who want to give up smoking -- as well as those who must -- but find it difficult, resources must be found to assist them. Smoking withdrawal clinics, so-called because the procedure is a grad- : ual one, have been developed in both Sweden and in this country, namely at Roswell Memorial Park Institute for Cancer Research. The Swedish clinical method developed by Dr. Borje Ejrup has been in use for over 6 years, with reports of substantial success, measured by the numbers of patients who gave up cigarettes not only during the 10-day program but sustained their. abstinence after it ended. The procedure at Roswell Park is of more recent origin, but preliminary findings are also encouraging. A number of requesU directed to governmental officials and the State Department of Public Health have inquired specifically about withdrawal clinics. A recent survey of the Department's own employees2 indicated that more than 10 percent of all employees (about one-third of the smokers) would like assistance in giving up cigarette smoking. It is clear that; if clinical programs were developed, medical staff trained to conduct them, and appropriate publicity arranged, many thousand of smokers would participate. The 5-day clinical program developed by a religious group has already attracted thousands of participants who are not identified with the•religious sect but are just seeking remedy for their smoking difficulty. The method of therapy used is largely group instruction and example. No drugs, hunger-arrestants or anti- .s depressants are administered, and unfortunately no records are kept to evaluate the overall success of the clinic. The State Department of Public Health does havE considerab3e inforasation on the needs and organization of medically super- vised withdrawal clinics, and is developing a program to try tbem in California.

.-r .77. 0 t Attracting a sufficient number of physicians to supervise these clinics is a further reason why physician education is so'essential. At present, these withdrawal clinics are the most promising methods for aiding many smokers who are unable to give up the practice by them- selves. For this reason, and the reported success of the clinics already ~ . in use elsewhere, the Governor's Advisory Committee strongly recommends that a clinical program be mobilized, tested first on a pilot basis, and then instituted statewide. Clinical programs of this type are probably the best hope of curbing the deteriorating effect on the human system which takes place in regular, long-term smokers. Cigarette smokers who discontinue have a much better chance of avoiding disability and premature death from a host of illnesses. Clinical programs can serve them when they cannot serve ` themselves. In addition to using the procedures already tested, research on the clinical problem should be initiated to ascertain whether there are other means by which cigarette smoking can be reduced or stopped abruptly without disturbing side-effects. There may wellbe a number of other methods, not requiring the strict supervision of medical personnel, which could be admin- istered safely and investigation into such techniques should be encouraged. Service Centers for Comnunity Efforts Withdrawal clinics, their development and support, would be but one of several activities'pertinent to consolidate in community Service Centers. . , Within the Service Centers would be conducted those activities'affecting the community at large: withdrawal clinics; professional education of physicians, nurses, teachers and others; community education programs; and consultation to industry, other agencies and institutions concerned with the matter. The Governor's Advisory Committee feels that these centers .

-78- might well be integrated into existing cocmnunity facilities, such as hospitals, voluntary health agencies, health departments, or other health-motivated organi- zations. Possibly as many as twenty-five Service Centers throughout California would probably be required to initiate services broadly and yet with the inten- sity needed for effectiveness. (Details of financing of.Service Centers is ~ . contained in the Budget appended to this repqrt.) . I

-79- LF7GAL IMPLICATIONS . PUBLIC IAW Legislation Designed to Restrict Access to and Use of Cigarettes by Minors One important avenue through which cigarette smoking could be dis- couraged is by reaching youth on the issde more forcibly than at present. Existing-legislation prohibits furnishing cigarettes to persons under age 18 and smoking cigarettes on the premises of a public school, and requires instruction of the young in the effects of tobacco and other substances harmful to health. Penal Code section 308, which prohibits furnishing cigarettes to minors, should be more extensively and intensively enforced. It would be difficult to locate a case in which an individual was prosecuted under this section for furnishing cigarettes to a minor. And yet it is knoMm that about half of the youth who graduate from high school in California do smoke cigarettes. A further inquiry indicates that about 17 percent of their cigarette pur- chases are made through vending machines and about 50 percent over the counter. r Young smokers, while they use vending machines less often than do adults (perhaps because of the higher cost), nonetheless do obtain cigarettes easily in this manner. Any procedures of obtaining them are in direct violation of Penal Code section 308. The Advisory Committee was concerned both with means to limit the access of young people to cigarettes and to insure that the places where cigarettes could not be smoked were sufficiently specified and, where desirable, ex- tended. The presence of existing legislation, although outdated for the seriousness of the current situation, is an aid to any legislative develop- ment needed to meet the problem.

© -80- In the wake of growing concern over the influence of cigarette smoking on the health of both youth and adults, legislators recently have submitted bills which would have regulated one form of access, through cigarette vending machines. An example of such proposed legislation is Senate Bill 1005, which was proposed in the 1963 Regular Legislative Session (See Chapter 3, p.49.) Such bills have rare]iy been enacted. In view of this fact, the Committee is of the opinion that efforts to regulate or limit the use of vending machines might meet with more success if existing leg-• islation is fully utilized, amended to be sufficiently precise in its language and no broader in scope than necessary to obtain its objective. These "ground rules" were used by the Advisory Committee in the formula- tion of the following recommendations relating to the access to and use of cigarettes by minors. Legislation Designed.to Restrict Access to Cigarette'Vending-Machines by Minors A. The Utilization of Existing Legislation Penal Code section 308,it' zealously enforced, may be helpful in making cigarette vending machines less accessible to minors under the 0 age of 18. This section, in relevant part, provides: "Every person, firm, or corporation which sells or gives or in any wa furnishe's to another person who is in fact under the age of ei teen years any tobacco, cigarette or cigarette papers or any other preparation of tobacco is guilty of a misdemeanor..." (F2nphasis added. ) It is certainly arguable that every person who places cigarette vending machines in such a manner that minors have unrestricted access to them, or who otherwise allows minors to use them.. "furnishes (ciga- rettes) to another person who is in fact under the age of eighteen years..." If this interpretation is accepted by the courts, the Advisory Committee agrees that the enlightened enforcement of section 308 could be quite

-81- instrumental in making cigarette vending machines less accessible to minors. Section 308 literally applies to all methods whereby cigarettes-are furnished to minors. However, applying section 308 to vending machine sales raises several problems. For example, section 308 was enacted in 1891, a time when cigarette vending machi,nes were unknown. A11 sales were made personally between seller and buyer: When a sale was made, therefore, there was, on the part of the seller, a specific intent to make the sale to the particular buyer. If, however, section 308 is applied today to sales made through a cigarette vending machine, a sale to an underage buyer'may arise though the seller had no specific intent . to do so. Thus, this application of section 308 could produce strict penal liability. The argument advanced above might mean rejection in court, thereby limitingsection 308 to the type of sale its drafters foresaw. Another difficulty with applying section 308 to vending machine sales is that the only way the owners of yending machines or the propri- etors of premises upon which the machines"are located could be certain of avoiding tbe penal sanctions provided in section 308 would be to keep the machine under continual observation and control. This would strike at the fundamental utility of cigarette vending machines which are designed and used to make sales on a twenty-four hour basis with low overhead. Again, a court might conclude that the application of section 308 to vending machine sales is unreasonable-and reject the argument advanced above. There is yet another difficulty with the proposed application of section 308 to vending machine sales. This difficulty is simp]y that such an application will render the section ambiguous in scope. For . • ~ - . . •

.,. -82- example, assume that a parcel of realty., used as a restaurant, is owned by A and leased by B, the restaurant proprietor. A cigarette vending machine is installed on the premises by C, is owned by D and is serviced by E. Proprietor B hires several waitresses and.cooks.-A minor under eighteen years of age buys a package of cigarettea while being observed by one of the waitresses. If section 308 is applicable to vending machine sales, every one of the above mentioned persons might fall within the purview of the section. A and B allowed the machine to be made available to the minor; C actually made it available by installing it; D, by buying the machine, made it available; E, by servicing and refilling the machine, made the ciga- rettes available; the waitress who observed the sale and did nothing enabled the minor to canplete the acquisition of the cigarettes; and the other wait- resses and cooks, by not keeping the machine under observation, perhaps contributed to the minor's use of the machine. Because of this ambiguity which would arise if section 308 were applied to machine sales, therefore, t he courts might conclude that such an application is unreasonable and thus refuse to so &pply.,the section. Because of the difficulties indicated above, section 308 is not a suf- ficient means of restricting minors' access to cigarette vending machines. However, the section is valuable because it is already law and the.potential problems-mentioned above might be obvr.ated to some degree by enlightened enforcement and careful prosecution. B. Drafting of New Legislation . In considering new legislation for the Advisory Committee to recommend., the Attorney General's Office briefed the Ccmanittee on the traditional content of legislation which includes prohibited conduct, class addressed and sanc- tions provided. The Comanittee, in considering proposals for new legislation I

.-r .g3ft evaluated each of these elements. hnong the various types of conduct vhicb .could be prohibited in order to prevent minors' Qccess to cigarettes are: location; failure to observe; failure to supervise; installing or alloving to be installed; continuing to be located near a school or other facility where minors primarily are present. Parties considered as "the class addressed" include: the proprietor of a~business upon whose premises a vending machine is located; the owner of a machine,• the persons receiving net proceeds from its sales; the persons installing and serving the machine; the child users; any adult responsible for a child's conduct; the proprietor of a business which sells cigarettes over the counter. The "saactiona pro- vided" include:. fine, imprisonment, seizure or incapacitation of machine; licensing provisions and injunctions. (The impractical aspects oP licensing vere explored and reported upon both by the legal and financial representa- tives to the Comittee.) In drafting the proposed legislation on p.85., the Ccaadaittee evaluated sanctions carefully. One likely sanction would be to empower State inspec- tors to seal or otherwise incapacitate vepding machines being used in a forbidden manner. Accompanied by a proce$ure of a rapid judicial review to protect the proprietor, this procedure would involve some costs to the State.though far beneath those estimated to operate a licensing progrem. The other prime advantage of this measure is that the State's first regu- latory step is extrajudicial and therefore rapid., the first litigous move would have to be made by the proprietor whose machine was in question. A further type of sanction which would take iamediate effect would be a physical seizure of the machine. Roxever.. this would require karehouse space in which to store the seized machinep a method of keeping track of those machines which were so stored., and a warehouse staff. It is felt

y 1 0 -84- that seizure would do little more than the sealing sanctions proposed above. In addition to or in lieu of the foregoing proposed sanctions., the Cor,anittee considered proposed fines and imprisonment for engaging in the proscribed P - onduct. For example, n proprietor who has a cigarette vending machine within the forbidden distance "fon a school may be liable for a fine of X dollars or may be sent to prison for six months. Neither of these sanctions could be imposed without a trial, of course, and thus this remedy would take oome time to apply. Furthermore, if a fine or imprison- ment were the sole sanction, the machine could be used until final judgment had been entered. Thus, a fine alone would not appear to be as adequate as the sealing sanctions noted above. A fine rmy be used in addition to the sealing provision, however. For example, if a proprietor's vending machine were sealed by a State inspector and the proprietor thereafter broke the seal in order to continue to use the machine, he could be made thereby liable for a fine or imprisonment. Finally, injunction sanctions could be created whereby a designated State officer could institute proceedingd'in a court of equity to enjoin discovered violations of the proposed legislation. T'he difficulty with this sanction, however, is that in addition to inspectors it would,require the services of State-paid counsel to even commence sanction application procedures. By contrast, the sealing remedies would place the burden of judicial appeal upon the proprietor, and therefore would produce a smaller legal burden for the State. The language of proposed amendment to Penal Code section 308 specif- Scnlly includes vending machines and a party assigned responsibility for infractions. To impede uncontrolled access to cigarette vending machines by minors the amendment to this statute therefore states:

-85- EVery person, firm or corporation which sells or gives or in any way furnishes to another person who is in fact under the age of eighteen years any tobacco, cigarette or cigarette papers, or any other preparation of tobacco is guilty of a misdemeanor, and upon conviction thereof shall be punished for the first offense by a fine of not less than.twenty-five dollars nor more than one hundred dollars, or by imprisonment for not more than sixty days; and for the second offense by a fine of not less than fifty dollars nor more than two hundred dollars, or by imprisonment for not more than ninety days; and for each subsequent offense by a fine of not less than one hundred dollars and not more than three hundred dollarso or by imprisomnent for not less than ninety days nor more than six months, or by both such fine and imprisonment. In the event that ar~y tobacco, cigarette or cigarette .._..~.... papers or aM other vre;paration of tobacco is sold or given or furnished, by means of a cigarette vending•machine or mechanical r cigarette dispensing device, to a person who is in fact under the age of eighteen years, the provisions of this section 308 shall apply to any or all of the following persons and to no others: (1) Ly person who owns the premises on which such machine or device is located, who has control of the location of such machine or device, and who has not used all reasonable means to prevent uncontrolled access to such machine chine or device on the part of any person who is in fact under the age of eighteen yearsj I

M -W- (2) Any person who owns the business conducted upon the . . premises on which such machine or device is located, who has control of the location of such machine or device, and who has not used all reasonable means to prevent uncontrolled access to such machine or device on the part of ary person who is in fact under the age of eighteenweara; (3) Any gerson (a) Dnployed, or obligated by contract, to render more than sporadic personal services to the.owner of the premises on which the machine or device is located or the owner of the business s conducted upon such premi'se.b. and. (b) In whose preseme and awareness there was fur- . nished, given or sold by means of a cigarette vending machine or a mechanical cigarette dispensing device to a person in fact under the age of eighteen Sroars atly . . .. . . • , . tobacco, cigarettes or cigarette papers,•or any other 0 0 preparation of tobacco. ' . ~ . Every person, firm or corporation which sells., pr deals in tobacco or any preparation thereof, shall, within ninety days after this act becomes effective, post conspicuously and' keep so posted in his'or their place of businessj a copy of this act,, and any such person failing to do so shs11 upon con- viction be punished bya fine of five dollars for the first offense and twenty-five dollars for each succeeding violation of this provision., or by imprisoment for not-more than thirty days.

•87- . The Secretary of State is hereby authorized to have printed suf`ficient copies of this act to enable him to furnish dealers in tobacco with copies thereof upon their request for the same.- 0 ,The preceding underlined addition to section 308 corrects and clarifies problems which presently arise when the $ection is applied to cigarette vending machine sales. By defining the classes of people subject to the section,;'Ehie language eliminates the addressee ambiguity presently in- herent in section 308. Furthermore., this language reduces the strict penal liability potential of section 308, by limiting the addressees to those people who have an interest in the property or business associated with the,vending machine but who have failed to take preventive steps to restrict minors' uncontrolled access to the msschine. The preceding statutory draft clearly places affirmative duties upon the addressees: this would perhaps seem unfair if the addressees were not put on notice. However, the cartersts of section 308 are required to be posted in the place where the tobacco is pold, and since the class of ad- dressees is limited to those who are or should be familiar with the physical 0 aspects of the business location, the lack of notice objection mentioned above becomes insignificant. Finally, since the addressees are quite likely 0 to become aware of their duties under this proposed amendment, there remains the likelihood of voluntary canpliance presently inherent in section 308. The conduct prdscribed by section 34has not been,changed by.the amend- ment: the furnishing of tobacco to minors under- the age of•eighteen rems,ins the prohibited act. The penalties provided also remain the same: fine and imprisonment. 1

Legislation Designed to Limit the Locations Where Cigarettes MM Be~Sold on State-SupervisePremises . A statute preventing, for example, the sale of cigarettes either through vending machines or from a store or canteen, would be valid as . long as it is a reasonable statute. As long as such a statute would prevent or restrict the sale of cigarettes by all methods, it would very . ~ . probably be held to be a reasonable statute. Such a statute would, how- ever,necessitate the repeal of Govereunent Code section 6900 which autho- . rizes licensed blind persons to operate vending stands, snack bars, cafeterias and vending machines for the purpose of selling, among other things, cigarettes. The Governor, through his executive rule-making poWers, would be unable generally to prevent the sale of cigarettes on State-owned prop- erty, because such an order would conflict with the above-mentioned 'Government Code section 6900. Therefore, it is not recommended that the goal of restricting or abolishing the sale of cigarettes on State- owned property be accomplished by executive order. Unique issues are presented in considering the question of whether 14 the location and sale of cigarettes should be limited or prevented on State university campuses. Under Article IX, section 9 of the California State'Constitution, the Regents of the University of California are "vested with the legal title and the management and disposition of the property of the university...." (IMphasis added.) Because the Regents are constitutionally invested with the power to manage university property, legislative ability to regulate the management of such property is in doubt. Therefore, the Comznittee does recommend that the 8oarh of Regents be requested themselves to resolve to limit or prevent the sale of ciga- rettes on university campuses. ~

PRNATE LAW Proposed Statutory Provisione to Make Civil Suits Against Tobacco Com ies y L Cancer Victims More Fieadi Actiona e In.the area of private law, the arousal of public interest in the association between cigarette smoking and illness has been accompanied by several attempts of lung cancer victims or their survivors to recover damages in a civil suit against tobacco companies, whose products the victims smoked over a period of time. A11 of the cases which have reached appellate3 tribunals have involved the smoking habits of persons who smoked for many years prior to the prevalence of the knowledge that smoking was .harmful to health. None of these cases has arisen in California. To date, recovery has not been received in any of these cases. It is through changes in the principles of negligence and warranty law that the tobacco companies may be forced into intensifying their search for a safer product. The Advisory Committee explored this sub- ject in great detail under the guidance of the Attorney General's Office. The proposed legislation later in the text is the product of the Committee's opinion that legislation may in fact be one of the most effective techniques 4 of stimulating the tobacco companies to perform this type of research, as a means of saving their industrial strength. Lung cancer plaintiffs have had difficulty, regardless of what theory they assert, in proving in court the* the cigarettes were an actual cause een5 of the injured party's lung cancer. However, the Prit~ and the Green5 cases offer some aid to future plaintiffs, since the Prit~ chard_ case held actual cause was a jury question and in the Green case the jury expressl,y found that cigarettes were an actual cause of the decedent's lung cancer. It would appear, therefore, that judicial development for cigarette-lung cancer plaintiffs has begun to reach a point of nonhostility on the question ,

of actual cause. It would seem unwise to propose any statute which would do away with the requirement that actual cause be proven, wo roven, for such a statute would meet with undoubted constitutional difficulty. There are other areas, however, in which statutes may perform a genuine service to cigarette lung cancer plaintiffs and at thg same time foster sound social policy. . In the reported cigarette-lung cancer cases,3 plaintiffs have advanced several theories against the cigarette manufacturer. The theories used have been (1) express warranty, (2) deceit or misrepresentation, (3) negligence, and (4) implied warranty. The cases advancing a theory of express warranty have done so on the basis that the defendant cigarette manufacturer in its advertising expressly warranted that its cigarettes could cause no harm.. Such an advertising assertion has also served as the factual predicate for a theory of deceit and misrepresentation. Since these two theories, therefore, are dependent upon'facts not ccmanon to alJ.'cases, it would appear that any remedial legislation should be based on the more qften applicable theories , of implied warranty and negligence. v A. Statutory Provisions Based on the Negligence Theory When proceeding on a theory of negligcnce, plaintiffs have been.faced with the two related defenses: (1) contributory negligence and (2) assumption of the risk. Several legal writers have suggested that both of these de- fenses may be inapplicable in a cigarette-lung cancer case.6 However, this .view is not shared by all attorneys, and a statute removing these defenses from a cigarette lung cancer case would obviously-settle the controversy. Such a statute wrould not be novel, for the State Workmen's Compensation Act has removed these two defenses in workmen's compensation suits.? ,

A statute to abolish the defenses of contributory negligence and assumption of the risk, and producing the results described in the follow- ing pages, would provide as follows: (1) In any suit brought entirely or in part on a theory of negligence to recover damages for harm sustained as a result of using, in a foreseeable manner, the defendant manufacturer's . ti cigarettes, it shall not be a defense to such a theory that the injured party was contributorily negligent or assumed the risk of the hazard complained of, if the plaintiff proves by a pre- ponderance of the evidence that the harm was caused to a substantial degree by such use afer , 196 , of the defendant manufacturer's cigarettes manufactured after such date; (2) The preceding section shall have no effect whatso- ever as to a defendant mentioned in such section where such defendant by a preponderance of the evidence proves (a) that it has engaged in good faith in research to discover a process for rendering its cigarettes less likely to cause the harm complained of, and (b) if research produces such a process which may reasonably be utilized in the manufacture of cigarettes, that it has so utilized the process in the manufacture of the cigarettes which caused the plaintiff's.harm, or that it utilized the process in the manufacture of a cigarette similar to that consumed by the plaintiff and made such similar cigarettes available to the public. I

-92- (3) For the purpose of determining whether a cigarette manufacturer has engaged in good faith in research to discover a process for rendering its cigarettes less likely to cause the harm complained of, consideration shall be given but not limited to the following factors: (a) a comparison of the ratio that the defendant k manufacturer's advertising expenses.bear to its gross income, with the ratio that the defendant manufacturer's research expenses bear to its gross income, and (b) the standing in their profession and the other qualifications of.those individuals who carry on the research supported by the defendant manufacturer. The desirability of any statute depends, of course, upon the merit of the objective, the likelihood that it will achieve that objective, and the severity of the burdens and administrative difficulties it creates. The objective of the foregoing statute is to reduce or elim- inate the ill effects of tobacco use on the human system. This objective could be achieved by taking some action designed to reduce the consump- tion of tobacco products, namely the adoption of the "caution" legend statute. Not necessarily inconsistent with this approach is that adopted by the above statutory draft, which is to encourage the tobacco product manufacturer to engage in research directed toward discovering some way to render its tobacco product less harmfuL Whether this approach is desirable depends upon several assuxnptions and value judgments, among which are: (1) that a process may exist whereby tobacco products can be rendered less harmful than they presently are. (2) that the search for such a process ought to continue until the process is found or it appears fairly certain that it does not exist. r

-93- (3) that if the process exists, the chances for its discovery will be increased if a continuing good faith effort is made to discover it. The statute is designed to encourage the manufacturer to engage in research by altering certain principles of negligence law. Under present law, if a manufacturer were proven to have acted in an unreasonable man- ner in manufacturing the tobacco product, and this unreasonable conduct were proven to be the actual and proximate cause of the plaintiff's harm, the manufacturer would be proven negligent. Notwithstanding this fact, however, the manufacturer would still be able to argue that since it is common knowledge that tobacco products cause harm, the plaintiff by con- suming the product.acted without due regard for his own safety and was therefore himself contributorily negligent, or assumed the risk of the harm suffered. If the manufacturer preyailed under either of these defenses, he would avoid liability even though the plaintiff proved the manufacturer negligent. The statute would alter this result by providing that unless the manufacturer proved he had;engaged, in good faith, in research designed to discover a method of rendering its prod- uct safer, these two defenses would be wAavailable. The desirability of this conditional abolition of defenses also rests on several assumptions and value judgments. The first is that since tobacco companies benefit directly froaa the sale of tobacco, these companies should bear some of the burdens of research. The second is that if a tobacco company knows that it will lose tort•defenses unless it engages in research, the company will engage in research. The de- sirability of the conditional abolition is also affected by the manner in which it comports with'the concept of fair play. Nowever, since tobacco product manufacturers go to great lengths to encourage .

-94- consumption, it does not seem unfair to prevent a manufacturer from basing his defense on that very conduct, until he has proven that rea- sonable effort has been expended to make his product.safer. The abolition of the two defenses is qualified, as mentioned above#- by the fact that the manufacturer must fail to prove that he engaged in research before the defenses are denied.; The abolition is further qual- ified by the fact that the plaintiff will have to show that his injuries resulted from the use of the manufacturer's product after the effective date of the statute. This limitation prevents the statute from having any immediate effect, since some time will have to lapse after the effec- tive date of the statute in order for the plaintiff to have any chance at all of meeting this qualification. And during this interval, the manu- facturers, being duly warned, can begin to set up research programs if they have not already done so. As the statute•is drafted, the plaintiff has the burden of proving that he meets this qualification. By contrast, the manufacturer has the burden of proving that he engaged in research.• Where the manufacturer proves that ho did engage in research, the statute provides that "the preceding sectIon shall have no effect what- soever..." This language is intended to prevent the statute fram being construed as a legislative endorsement of the two defenses in cases where the statute does not abolish them. Several legal scholars doubt that the two defenses ought to be available to manufacturers in any event.6 It i!ould be ctrange if a statute dcsigned to conditionally abolish these deferses were held to prevent 3iidicial reevaluationof the validity of these defenses in cases falling outside the scope of the abolition stat- ute. The language stated therefore preserves the possibility of such reevaluation.

-95- The waiver of defenses is so conditioned that, where the manufacturer• proves he engaged in research but did not find anything which would make the tobacco product safer, he is not deprived of the benefit of the de- fenses. A manufacturer will have to prove that he used the results of the research only if there were results and that they could reasonably be used in the manufacturing process. 9~he manufacturer can prove he utilized such results in one of two ways: (1) in the manufacture of the tobacco product consumed by the plaintiff; or (2) in a tobacco product similar to that consumed by the plaintiff, that similar product also be- ing made available to the public. Finally, and most importantly, the statute is'drafted in such a manner that it will produce as little change as possible in the present law of negligence. Thus, the statute alters no part of the basic theory of negligence: the elements of the prima facie case remain the same; and it remains incumbent upon the plaintiff to prove that the manufacturer was negligent before any recovery will be possible.. In addition to the foregoing statute, the Advisory Committee proposes a statute which would place defendant maAufacturers under an affirmative duty to warn consumers of the fact that cigarettes may cause a health problem. This statute would require that the cigarette manufacturer print, on every package of cigarettes, a legend similar to the following: "CAUTION EXCESSIVE USE IS DETRIMENPAL TO HEATJI`Ir • (The suggested language of the legend is not as strong as it might be. For example, the legend could read "Danger: Cigarettes may cause lung cancer." Ilowever, since any legislation•which may adversely affect ciga- rette sales will undoubtedly meet opposition,which has proven in the past

to be quite effective, such legislation must be drafted in such a manner that it pleases as many persons as possible. Since it is believed that more persons would agree with the proposition that excessive use of ciga- rettes poses a health problem than would agree with the more narrow propo- sition that cigarettes may cause lung cancer, the foregoing legend is' recosmnended. ) a If such a statute were enacted, and a cigarette manufacturer did not place the required legend on his cigarettes, then the plaintiff could use. this failure as evidence of negligence (See 2 Harper and James, the Law of Torts, 987-1 014 (1956)). B. Statutory Provisions Based on the Implied Warranty The implied warranty theories most commonly advanced in the reported cigarette-lung cancer cases frequently have been based upon the warranties ' contained in the Uniform Sales Act, statute 15~(1) and (2),8 which-in rele- vant part provide: Implied warranties of quality: Subject to the provisions of this act and of any statute in that behalf, there is no implied warranty or condition as to the quality or fitness for any particu- lar purpose of goods supplied under e contract to sell or a sale, except as follows: 14 (1) Where the buyer, expressly or by implication, makes known to the seller the particular purpose for which thc goods are required, and it appears that the buyer relies on the seller's skill or judg- ment (whether he be the owner or manufacturer or not), there is an implied warranty that the goods shall be reasonably fit for such purpose. (2) Where the goods are bought by description from a seller. who deals in goods of that description (whether he be the grower or manufacturer or not), there is an implied warranty that the goods shall be of inercantable quality.. Basing their suits on these sections or on tort principles independent of sales law, cigarette-lung cancer plaintiffs have argued that the implied warranty is breached if the manufacturer's cigarettes sold to and con- sumed by the plaintiff are not wholesome or fit for humau consurqption.

.97. The cases reveal several problems which face a plaintiff when this argument is made. The chief problem, of course, is that of actual cause, which has been discussed earlier. Another major problem has been the apparent judicial reluctance to impose liability on a warranty theory in a case where all sales of cigarettes were made to the plaintiff at a time. when human knowledge did not suspect the~causal relationship between ciga- rettes and lung cancer.9 In recent proceedings,the Green case has held that warrant liability may be established even though all sales were made at a time when the cigarette-cancer causal relationship was unknown.l0 Whether or not California judges Would arrive at the same conclusion is unclear. Nowever, since any statute creating a new warranty could proba- bly not be retroactively applicable, and since no cigarette manufacturer in 1964 could argue ignorance of the supposed causal relationship, this . hurdle is probably best left for jud:cial development. There has also been judicial reluctance to impose liability on the theory of warranty where the court felt the harm suffered was due to (1) excessive use ofthe product by the plaintiff, or (2) a unique v physiological makeup of the plaintiff. For example, in Lartigue the court likened cigarettes to alcohol and stated that no recovery would be allowed in a case where the injured died from having consumed too much alcohol, the cause of the death being intemperance rather than a deleterious product. The same court also wondered whether the lung can- cer could have been caused by a cmbination of the cigai*ette smoking and peculiar physiological characteristics of the injured party. The Larti ue_ court, therefore, observed that though breach of warranty entails strict liability, the scope of the warranty was limited by the proposition that the article must be unreasonably dangerous to the ordinary consumer. 9

.-r -~- Certain non-cigarette-lung cancer cases in California indicate that cigarette-lung cancer plaintiffs have additional problems in California before recovery will be allowed. For example, it has been held that a product destined for ultimate human consumption is wholesome and fit for human consumption as long as it is free of harmful foreign substances. Thus, in a case where a plaintiff was injured by a chicken bone which was in her chicken pot,pie, recovery was denied, for the chicken bone was regarded by the court as a"natural" substance.ll If the'deleterious' substance ha4 been a nail, recovery would have been almost automatic since a nail is clearly a foreign substance. Therefore, since the cancer- causing agents may be regarded as substances natural to cigarette tobacco~ recovery may be denied in cigarette-lung cancer cases on this ground. There is a further difficulty in this area, for on January 1, 1965.. the Uniform Sales Act will be repealed and the Uniform Commercial Act. adopted. Thus, in ten months, cigarette-lung cancer cases advancing a theory of implied warranty based on sales law in California will be predicated upon sections 2314 and 2315 of the.Uniform Concnercial Code.12 These two sections provide as follows: Section 2314. (1) Unless excluded or modified (section 2316), a warranty that the goods shall be merchantable is implied in a contract for their sale if the seller is a mer-. chant'with respect to goods of that kind. Under this section the serving for value of food or drink to be consumed either on the premises or elsewhere is a sale. ~2) Goods to be merchantable must be at least such as a) Pass without objection in the trade under the contract description; and (b) In the case of fungible goods, are of fair average quality within the description; and ;c) Are fit for the ordinary purposes for which such goods:are used; and %d Run, within the variations permitted by the agreement, of even kind, quality and quantity within each unit and among all units involved; and .

99- 0 fe) Are adequately contained, packaged, and labele&' as the ar.rPement may require; and ;f} Conforro to the promises or affirmations of fact made Pn the container or label if any. ;3) Unless exc'uded or modified (section 2316) other implied warranties may arise from course of dealing or usage of trade. > Sccti.on 2315. Ohere the seller at the time of eon- . tracting has reason to know any particular purpose for which the goods are required and that the bt~yer is relying on the,. -•. seller's skill, or judgment to select or furnish suitable . goods, there is unless excluded or modified under the next section ar. imTi1d ed warranty tt,:at the ooods 3hall be fit for such purpose. ' Because these statutes are new and have not been construed by the Cali• fornia cotirts, it is unclear whether section 2314(2)(c) definition of ~ "merchantable" will be construed to refer to smoking alone, or wili be more broadly construed to inclu.de sa.fe smoki . Also, nothing in the above-quoted new sections.expressly solves the problems presently fac3,ng lung cancer plaintiffs under the Uniform Sales Act•section. The Advisory Cora:nittee, therefore, recommends enactnment of a s#,Atute, designed to meet the foregoing difficulties which specifiesr (1) There is in every sale of cigarettes i3q this state - ; 4 an implied warranty, running directly frea4-the manufacturer' to; are rea- the consumer of such cigarettes, that the cigarettes . •4 sonably wholesome and fit for human consumption. (2) The existence of the warranty-created by section'obQ sh::]': not be affected by any contractual provision. (3) ;7iether the cigarettes to which this. warranty e~pp116S' ;:. . .. ~. are reasonably wholesome and fit for human consumption shall be•~: ;~ . determ.tned without regard to whether deleterious substances•$re- naturul or foreign to such cigarettes. This lenp;uage, by the use of the words "reasonably wholesome' aM 'itR . for hun:an consumption," will have the effect of leaving to the fact-finder

-100- questions of whether the plaintiff consumed an unforeseeably large number of cigarettes per day or whether the plaintiff had a peculiar physiological characteristic rendering him uniquely susceptible to lung cancer. The natural-foreign test is express],y rejected by the proposed language and makes unmistakable the nature of the warranty`to which cigarette manufac- turers must adhere. As indicated above, this proposed statute, which'creates a new warranty, probably will operate prospectively only. It is probably unconstitutional to attempt to make the statute applicable to sales completed prior to its effective date, since it has been held that imtnunity from a successful .suit is equivalent to a vested right which cannot constitutionally be abrogated by a statute.13 THE REIATIONSHIP BETWEEN STATE-ENACTED 7EGISLATIOft AND CONTEMII'LATED ACTIONS BY FEDERAL AGENCIES Activities of the Federal Trade Commission Within a week after the Surgeon General's Report was released, the Federal Trade Commission began hearings on regulating the sale and adver- tising of cigarettes. Under present jurisdiction, the Federal Trade 14 Commission is authorized to regulate trade practices or advertising which seek to promote the purchase of consumer goods. Pursuant to this power, the Federal Trade Commission considered various proposals, chiefly the labeling of cigarettes to indicate the health hazard and limitation of suggestion through advertising that cigarettes might have a healthful benefit. The proposed trade regulation rules, which were modified by the Commission, are contained in Appendix III. They explicitly specify ter- minology recommended to be displayed in both advertisements and on all containers of cigarettes offered for public sale; they further'limit

-101- advertising content which may misrepresent the healthfulness or suggest claims founded on ingredients of.cigarettes. The regulation ultimately adopted by the Commission is not as broad in scope nor as detailed in direction. It states: "...in connection with the sale, offering for sale, or dis- tribution in commerce...of cigarettes it is unfair or deceptive ~ act or practice...to fail to disclose, clearly and prominent]y, in all advertising and on every pack, box, carton or other container in which cigarettes are sold to the public that cigarette smoking is dangerous to health and may cause death from cancer and other diseases."14 In proposing the original three rules, the Federal Trade Commission encouraged opinion from both proponents and opponents. The interests of California, in a communication from the State Director of Public Health, were conveyed to the Federal Trade Commission during their pub- lic hearings, March 1964. More than 500 individuals and organizations, including the cigarette industry, submitted documentation or provided testimony. The cigarette manufacturers were granted a one-month exten- sion within which to express their views and arguments. In formulating its decision to adopt the above regulation, the Commission noted a number of salient facts. Comparisons between ciga- rette consumption and cigarette advertising expenditures indicate that advertising expenditures in recent years have consider4bly exceeded in- creases in cigarette consumption. During the decade 1950-60, while total cigarette consumption increased by 30.5 percent, and per capita consumption of persons age 18 and over increased 18.5 percent, adver- tising expcnditures (as reported by the Jnternal Revenue Service) •

-102- increased by 178.7 percent. Tt~e increasing popularity of filter and men- thol-filter brandsand the abso 66.1 percent of total cigarett direction in which promotion c The Commission reviewed not only promotional expendit currently stressing "pleasure" advertising. Moreover, the C disruption and,industry bias protect consumer interests. the Commission made a number ute increase in advertising of them (currently advertising expenditures) indicate the dramatically sway consumer behavior.15 1]y the scope of the problem, considering es but also shifts in content emphasis -- as opposed to previous themes in cigarette ® ission balanced arguments of econonic ainst its own regulatory responsibility to foundation for developing its decision, ' observations pertinent to the interests 0 of the Governor's Advisory Co ® ttee. The obligation of a vend~r to fully inform his customers, in the light of advertising's pervasi eness, produced this comment from the Commission: The cigarette indus and forceful advertising ry's massive, continuous, mounting, coupled with the refusal to acknowl- r edge or take any steps t~ inform the consuming public of the hazards to health has blµnted the public awareness and appre- ciation of these hazards and has tended to maintain demand for the product in the f'ce, of growing public concern. Not only has the industry fa public the dangers of ci advertising has camoufla r'or the ambivalent individual, appeals may well be decisive. opinion: led to disclose to the consuming ,arette smoking; its past'and present ed them.l6 the impact of advertising and comnercial The Commission cites as reasons for this .

-103- .It is a prevalent view in our society that the Government protects the public against advertisements to promote the sale of dangerous products.... While no single kind of coaanercial, such as one promoting the sale of one'brand of cigarette over another, can be ex- pected to have much influence, the cumulative effect of a ~ constant bombardment by many kinds of cigarette conunercials and advertisements is a different matter., Together with smoking heroes and heroines...it would tend to create a general image of smoking as a typical if not desirable cultural trait in our society. This would reinforce the social influences toward smoking that may exist among adolescent groups ments. as well as weaken any rational argu- The mere fact that millions of dollars are spent yearly on advertisements for cigarettes reflects a con- viction on the part of cigarette manufacturers that such advertisements are effective.17 The CoaIInission, in hearing arguments against its proposed regulation, delineates the atmosphere surrounding the promotion and sale of two other potentially dangerous goods, alcoholic beverages and automobiles. Com- parison of cigarettes and alcoholic beverages the Commission feels is "inexact," one fundamental distinction being "the advertising, labeling and sale of alcoholic beverages are'subject to an elaborate network of public and private regulatior that has no parallel in the cigarette industry. It is common knowledge that advertisements for hard liquor are not broadcast on radio or television, that liquor advertising has

•104• constantly eschewed the themes of ro®ance, contentment and sociability that figure so prominently in cigarette advertising, and that alcoholi e beverages are labeled to disclose the alcoholic content." Furthero the Commission cites the complex regulations respecting place of sale, price, and even prohibition of sale of alcoholic beverages.l8 Compliance with the FTC regulation;proaulgated is desirable, and encouraged, on a voluntary basis. For this reason, the Cormnission amended its proposed regulations to allow cigarette manufacturers to select the phrasing of the required disclosure. The Commission will, on request, advise whether proposed forms of disclosure comply with the requirements of the.rule. Further, a procedural provision perniits the rule-making proceeding to be reopened in certain circumstances, such as contest. Because the Co¢arnission desires to encourage voluntary compliance, reasonable time periods were specified to permit the industry to implement the rule. Both portions of the rule take effect July l, 1965, providing the industry and the public sufficient time to adapt to the stipulations. In conclusion, the Commission reflects onyits role -- its moderation, yet conviction -- by stating that it•has "endeavored to prescribe a program of compliance that will involve a minimum of uncertainty, dislocation, and formal enforcement, and at the same time fully protect the public interest."19 Activities of the Federal Conanunications Commission ~ The Federal Communications Commission regulates broadcasting. The Commission has the power to withhold broadcast licenses if public con- venience, interest or necessity require. The Cownission, however, is prevented by law from censorsbip of ideas presented on broadcasts. 0 I

hlrident]y fearing this restriction, the Ccmmission refused to prosecute a case brought to limit the amount of time per program which could be devoted to coaanercial presentations. Where the actual content of cigarette adver- tisements was being questioned, the reaction of the Comnission would also likely be negative. The introduction of the new tobacco industry code on advertising, which proposes to remove,a number of questionable aspects from advertising content, was in itself the most definitive change under- taken to alter the "exhuberant health" character of cigarette advertising. The code stated that cigarette advertisers would no longer permit content which displayed youthful persons or claimed that cigarette smoking was healthy. The Present Extent of the Pure Food and Drug Administrations's- JurisTiMion to Regulate To acco Products There are presently two statutes enforced by the Pure Food and Drug Administratiorr which may be applicable to the sale of tobacco products. The first is the Federal Food, Drug and Cosmetic Act, mentioned earlier. As the statutory definition of the terms, "food," "drug," and "cosmetic" indicates, however, the main thrust of t~e statute is directed at commod- ities other than tobacco. However, the Pure Food, Drug and Cosmetic-Act has been held to be applicable to cigarettes which are sold under an assertion that their use has some therapeutic effect, since in such a case the cigarettes are treated as drugs under the Pure Food, Drug and Cosmetic Act. The other statute is the Federal Hazardous Substances Labeling Act.20 This statute;is so looase]y worded that it is literally applicable to tobacco products. Section 1263 prohibits, among other things, "The introduction or delivery for introduction into interstate commerce of any misbranded package of a hazardous substance." The key terms in the r

-1p6- foregoing quotation are "hazardous substance" and "misbranded package." The term "hazardous substance" is defined as followst "Any substance or mixture of substances which...is toxic" (see. 1261(f)(1)(A)(i)), The term "toxic," as used in the foregoing quotation, applies to any substance - tv to produce personal iniursr or illness to man "v...----- ----1,ieT, has- the- canac-i--- -----~.. -- ~-------- ~ -- - - through...inhalation..." (sec. 1261(g)):, The term "misbranded package" is defined in section 161(p) as follows: (p) The term 'misbranded package' or 'misbranded package of a hazardous substance' means a hazardous substance in a container intended or suitable for household use which, except as otherwise provided by or pursuant to section 1262 of this title, fails to bear a label -- (1) which states conspicuously (A) the name and place of business of the manufacturer, packer, distributor or seller; (B) the common or usual name or the chemical name (if there be no no~unon or usual name) of the hazardous substance or of each component which contributes substantially to its hazard, unless the Secretary by regulation pe nnits or requires the use of a recognized generic name; (C) the signal word 'DANGER' on sub- stances which are extremely flammable, corrosive, or highly toxic; (D) the signal word 'WARNING' or 'CAUTION' on all other hazardous substances; (E) an affirmative statement of the prin- cipal hazard or hazards, such as 'Flammable,' 'Vapor Harmful,' 'Causes Burns,' 'Absorbed through Skin,' or similar wording descriptive of the hazards; (F) precautionary measures describ- ing the action to be followed or avqided except when modified by regulation of the Secretary pursuant to section 1262 of this title; (G) instruction, vhen necessary or appropriate, for first- aid treatment; (H) the word 'poison' for any hazardous substance which iA defined as 'highly toxic' by subsection ;h) of this section; (I) instructions for handling and storage of packages which require special care in handling or storagej*and (J) the statement 'Keep out of the reach of children.,' or its practical equivalent, and (2). on which any statements required under subparagraph (1) of this paragraph are located prominently and'are in the IInglish language in conspicuous and legible type in contrast by typography, layout, or color'with other printed matter on the label. Based on the foregoing definitions., therefore, it is possible to argue that since tobacco products have the capacity to produce personal injury or illness,to man through inha]ation, the sale, through interstate commeree, I

•l07- of such a substance in a package not bearing, inter alia,'the signal word "WARNING" or "CAUTION," would involve an introduction or delivery into interstate cozmnerce of a misbranded package of a hazardous substance. Such an act would be punished by fine, imprisonaaent, and seizure of the tobacco product (sees. 1264 and 1265). Apart from the foregoing statutory definitions, however, it is un- ~ clear whether tobacco is intended to*be included within the term "toxic." No case has determined this question and the Pure Food and Drug Adminis- tration has taken no official or widely publicized position on the issue. The precise limits of the Pure Food and Drug Administration's regulatory jurisdiction in the field of tobacco products, therefore, must await future judicial determination. Activities of the U.S. Department of Health, Dducation and Welfare Although the Public.Health Service was quite aware that the Advisory Comanittee to the Surgeon General might take a firm stand on cigarette smoking's adverse influence on health, at the time of the Report's re- lease the Service was not prepared to announce definitive follow-up plans. The very complexity of the issue and the immense political implications required time to be aired; the other Federal agencies were given time to investigate their own positions in the matter; the industry was given time; and the consumer public was given an opportunity to make some decisions for itself before more formal action would be taken. While the Service might be criticized for releasing the Report with no plans for folloWup, the example of the British campaign which had been so remarkably unsuccessful might have been in mind. Getting millions of cigarette smokers to think about changing their habits and convincing millions more not to begin smoking could not be done in hurried., half-way gestures. Without the .

support and backing of many Federal agencies, no program would be imple- mented with optimism. On the other hand, the release of the Report gave impetus to many local actions which penetrated directly to the ranks of people making personal decisions about eigarette smoking. The efforts of the California Interagency Council and a number of county medical societies were vital- ized ized by the confirmation from the Report. But the Public Health Service recognizes that a major change such as that desired cannot be achieved solely by volunteers with zeal. In a statement several weeks following the release of the Report, Surgeon General Terry announced that the Public Health Service was developing programs embracing education, public information and research in light of the findings and conclusions of the Report. Among the early activities of the Public Health Service has been notification of the medical officers in charge of the 16 Public Health Service hospitals and 50 Indian Hospitals that: 1) acceptance of free cigarettes for distribution to patients iqust be discontinued incnediately; 2) medical officers are urged to epnduct educational programs for patients on the harmful effects of smoking; 3) physicians are urged to counsel individual patients on the dangers of smoking.21 Later in 1964, Surgeon General Terry elaborated on more extensive plans of the Public Health Service. In giving testimony before the House Coaarnittee on Interstate and Foreign Coaarnerce, a body considering the jurisdiction needed to require warning labels on cigarettes, Surgeon General Terry reminded the Coamittee that cigarette smoking and health was not altogether a new problem faced by the Service. Since 1957., the ~

-109- Public Health Service, in both disease control and research programs, has sponsored a variety of projects concerned with smoking and health problems. During.the fiscal year 1964, Dr. Terry indicated, the bervice supported 85 projects largely in basic research, at a cost of $3.5 million, all of which bad some bearing on this problem.22 Plans for action will take matLy directions. The Public Health Service proposes programs for public and professional information and education, disease control and research. A National Clearinghouse on Smoking and , Health is being established, cooperative'educational efforts with the Children's Bureau and State Committees on Children and Youth are planned. Disease control programs.will be intensified in the chronic respiratory, diseases, as they are presently developed for cancer and heart disease. The National Institutes of Health vill also plan to enlarge their research scope on this problem, coordinating with the Department of Agriculture to close some of the gaps in existing scientific knowledge. More comprehen- sive statistical information will become available after efforts of the National Center for Health Statistics are promulgated.R3 While these are noble beginnings, they are only beginnings. Con- tinued research, of the type described later, surely must be conducted on many aspects of the problem. And coordination, strongly backed by adequate resource materials and qualified directors, must come from this Federal agency if the problem of cigarette smoking is going to have the attention it deserves everywhere in the nation. Not every state has mobilized interagency councils, local committees, inservice training workshops or speakers' bureaus. Guidance and direction must come from this Federal agency if the problem is going to be faced forthrightly. Because the problem is fundamentally one relating to the health of Americans, the Department of Health, Education and Welfare will be under . .f ~

-110- continued pressure to initiate corrective steps of action and to keep the issue in the forefront of those other Federal agencies xhich can be of assistance. As voluntary and public agencies in California have alread.y demonstrated so much enthusiasm and activity on the matter, it is expected that the Department of Health, Education and Welfare will maintain close relationships here, giving support and personnel assistance on pilot pro- 3ects, and seeking evaluation of demonstration programs being conducted in the State. The Governor's Advisory Committee anticipates that the De- partment of Health, Education and Welfare vill maintain its duty to the public in this as in other health matters. As many of these programs tirill take considerable time to implement and yield benefit, California must move ahead regardless. Activities of the Departments of Agriculture and Commerce As suggested earlier, there have been no public statements from either the Departments of Agriculture or Commerce which anticipate a change in the present consumption of cigarettes. It appears to the Governor's Advisory Committee that both these Federal agencies 'should not only be concerned r with such change, but also anticipate it by encouraging research perhaps to find alternative uses of tobacco. The threat of economic displacement, -Which has been a principal bulWerk against vigorous action until recently, certainly needs serious consideration now. Arguments about economic dis- ruption in the "tobacco states" involved, the industry, the advertising industry, and even the tax loss to Federal, state and local governments have begun to pall as the impact of the health problem is affirmed. To pre- tend that changes are not going to take place -- or that they should not take place -- is hardly reasonable. Since the Departments of Agriculture and Commerce have responsibilities for maintaining sound national policies.9

to deley planning for sdjustments is to avoid the issue vhich certainly `+•ill erupt even more disturbingly in the future. The 4overnor's Advisory Committee, therefore, strongly urges these tvo Federal sgencies to develop and publicise efforts to meet the problem before it beccaies more complicated. I

FISCAL CCNSIDRRATICNS Tobacco products have been subject to taxation for several hundred years in most nations where they are consumed. Fiscal considerations therefore figure prominently in ary•discussion of changing present patterns of consumption. In most European and Asian %. countriesp the production and . distribution of tobacco products is controlled by state monopolies; there- fore, any radical change in the sale or use of tobacco products-directly affects these economies. The governments of Japan and areece have actually been promoting cigarette consumption as sources of revenue despite scien- tific research indicating that cigarettes are hazardous to health. In a number of other nations which operate state tobacco monopolies., efforts have been made to curtail cigarette smoking because of the scientific knowledge. These nations have obviously felt that the welfare of their people ccmes before economic gain. The Soviet Uniono Rumania and Ita]y.have all banned advertising of cigarettes; the Swedish Tobacco Monopoly gave funds to sup- port an educational program but did not raise the established 83 percent , tax on cigarettes. 11 In the United States there is no tobacco monopoly. There is., however., a very powerful tobacco industry which enjoys annual sales exceeding.eight__ billion dollars. Forty-four percent of the cost paid by a California eon• sumer is represented by taxes to the Federal and State governments. In California,, a package of cigarettes typically costs the eopsumers Cost per pack before taxes . 140 Federal Tax 80 California State Tax ,~ Retail Price 230. In a number of states, the State tax is as auch as seven. cents higher. Six states 3-ipqy no special taxes on cigarettes. '

~w -113- Compared vith other countries, the cigarette taxes in this country are very low, particularly in California. The British consumer gives 79 percent of his smoking money to the governments the Dane gives 80 percent and the Sxede gives 83 percent. An 80 percent tax on cigarettes at their present price level in the United States would amount to 56 cents and raise the average retail price to 70 cents a pack.24` California xas one of the last states to establish a tax on cigarettes. The tax was initiated in 1959 and is now at 3 cents per package. Each cent of tax yields roughly $25 million. Since the tax was levied, the amount realized has risen from $64,804,970 in fiscal 1959-60 to $71,419,667 in fiscal 1963-64. This revenue is placed in the General Fund. Upon release of the report of the Aclvisory Committee to the Surgeon General in January, first quarter sales across the nation declined. Ciga- rette sales declined by 13 billion cigarettes during the first quarter of 1964, the greatest decline coming in February. Sales-did rebound in March, but not to the level recorded in January or in December 1963. The net loss of tax revenue to the Federal government during this interval Was $59,ODO,000• . California sales reflected this decline. Net decline in State revenue from cigarettes over the previous quarter was $2,179,187. In the second quarter of 1964, the situation reversed, California tax receipts returning to xithin $250,000 of the sum collected in the quarter just prior to the release of the Surgeon General's Report. As the year progressed, and the impact of the Surgeon General's Report waned, cigarette sales resumed their climb. If the present three cents per p ack tax Were maintained, it is estimated that tax revenue from cigarette sales in California vould exceed $74,000,000 by 1970. This estimate does n ot inclu3e any reduction wbich might be achieved by an effective-program of action, but only upon current consumer practice. (See-Chart 0.)

Should Taxes on C arettes Be Raised? The Federal government has made no comment on what provisions xould be made to find other sources of revenue if cigarette sales dropped off simply by lowered consumption, or by legislation which would effect a reduction in cigarette consumption. This possibility, which would be opposed vigorously by the tobacco industry; does not appear immediately likely, despite increasing public awareness of the health hazard. Speculation about the consequences of a higher'tax has run high. There are both ethical and practical objections to a general increase in cigarette taxes. The ethical objection arises out of the fact that a cigarette tax, like any other sales or excise tax, is weighted heavily toward those persons least able to pay... For example, a%0-a-package- tax might mean relatively little to a wealthy American bachelor, but it could constitute a real hardship for a cigarette-addicted, low-income family.25 On the practical side, there is little reason to believe that raising the price of cigarettes through taxation would ~Z itself curtail consump- tion tion very nuch., Economists regard cigarette consumption relatively "in- elastic"in relation to price: it neither increases nor decreases when 26 The British have kept on smoking despite the high ,prices fall or rise. cost, and from ttiis British scientists have learned something disturbing. To conserve their cigarettes, which are so costly, smokers salvage partly- smoked ones, relighting them later. Recent studies on this procedure verify that this is tantamount to doubling or trebling the carcinogens contained in the smoke vhich increases health risks. The British tend to smoke their cigarettes down to the very end which also increases.the relative amount of carcinogens in the smoke.

-116- The British situation is not completely.analagous to our own, for the government there depends much more on its revenue from tobacco than do we, the initial tax base being so much larger. Tobacco excise taxes in Great Britain annually yield 900 million pounds (about $2.5 billion).$ more than the cost of the National Health Service and just half of the British defense budget. The opinion of the U.S. Treasury and other Federal agencies con- cerned with consequences of reduced consumption in this country appears to be one of caution. It msy well reflect other attitudes and pressures. Individual states have reviewed the matter, as is being done in California. A New York legislator has recommended increased taxation to help curb cigarette smoking. The prerogative of states to increase taxes or place selective taxes on cigarettes certainl,jr`+ill influence Federal policy and vice versa. At this point, it appears that individual states will be moving first. arnis Proposed Measures for California A number of possible changes in the prisent California fiscal policy r concerning cigarettes were reviewed and discussed during the meetings of the Governor's Advisory Committee. They included licensing of vendors or vending machines, raising the tax rate simply to emphasise the luxurious quality of cigarettes, and raising the tax rate with the purpose of sup- porting educational and other action programs. There have been few cases where taxation actually did curb a public health hazard. Most memorable is the incident occurring in England in 1725:Wfien the Royal College of Physicians in London became chagrined at .., the dropsy-ridden character of the country. Gin was then priced so cheaply that even beggars could get drunk and stay drunk. A tax was levied on gin, ,

-117- sufficient to change drinking from a daily preoccupation to a luxury.27 The present high taxes on alcoholic beverages in most countries derive in part from this motive as vell as other fundamental practical factors (e.g., protective tariffs, enforcement of alcohol lavs). To a question- able extent, high taxes may serve to control excessive use of alcohol. But alcoholism has become more of a p?oblem tode`yy ahen prosperity is relatively high. In California, for example, funds are appropriated from the taxes collected on alcoholic beverages to•support alcoholic rehabilitation -- hopefully to reduce the present rate of alcoholism. Buch earmarking of funds, while not xidely used, does have precedent. With the monies collected from motor vehicle registrations, the Depart- ment of Highways carries out a highway improvement program. It seems reasonable that some of the monies collected through cigarette taxation might be utilized to mount and maintain the Btate's program of action to reduce cigarette smoking. It is assumed that per capita consumption of cigarettes `rill decline in a gradual manner. There trill be sufficient - consumption to launch a campaign which is aimed at reducing consumption •- and henoe the need for this type of revenue. If monies for this purpose are to be raised from cigarettes themselves, it is felt that an increase in the present tax would be required. This tirould then not jeopardize the resources vhieh revert to the General Fund but would probably effect two changes: by making cigarettes sommlhat more luxurious, induce some fence•sitting smokers to choose not to smokef and enable the smoking population to support a program whieh discoursges emok- ing, especially among children still free to make the ehoioe. The Committee, in discussing the nature of tax increase, vas advised that a simple one-half •oent or one cent tax vas not the best technique. When the tax vas first

-118- levied in 1959 at three cents per pack, vending machine operators adjusted their price upward by five cents, thereby increasing their profits. Rais- ing the tax up to eight cents would still keep it less than that levied in a number of states; each cent of tax would bring revenue of about $25,000,000 annually,assuming that present consumption rates stabilize. Even a portion of this sum could finance a tremendous amodnt of needed education, clinics and research. (The proposed Budget to support the entire program of action recommended by this Committee is appended to this report.) If the tax were raised, designating funds for anti-smoking education, withdrawal clinics and research of many.types, the State would be subsi- dizing a counter-program by consumer purchase. Smokers might say they are being penalized for their habit, and in a sense they are, as mch as persons who buy alcoholic beverages are purchasing efforts to control alcoholism or drivers are being "penalized" into financing better roads. Even in hard cash terms, the expenditure of substantial sums on a ciga- rette program can be justified. Tally up the economic costs of smoking -- add together the cost of medical care for illnesses resulting from smoking, ~ days lost from work during illness, loss through premature death, public assistance to families because of the death of the breadrrinner, fires set by cigarettes and matches28 -- $3,000,000 a year seems like a modest°sum indeed for a program to curb such losses. Selective Taxation - The efficacy of selective taxation, based on varying amounts of tar and nicotine content in different brands, was raised in discussion. It is possible this procedure would influence people to buy in relatively greater volume the "milder," less expensively taxed brands, but this technique is not likely to discourage cigarette smoking per se. The

•u9- health effects of smoking various types of cigarettes are not clear. And selective taxation is not likely to influence revenue remarkably. A raise in State taxes could alter distribution patterns, however. Vending machine operators*might raise their price another five cents, there- by lowering their overall profit percentage. If sales through vending machines were reduced, the industry vould feel a more sensitive loss. A number of other outlets for cigarettes may feel this is an opportunity to give up retailing cigarettes. Chain grocery stores and shopping center markets report the sale of cigarettes a greater nuisance than the profit they gain from sales. Cigarettes must be sold directly by a clerk to the customer, as a check against sales to minors. Some stores, in the Wake of the Surgeon General's Report last January, considered whether they.•should s top selling cigarettes, but few if any have done so. Licensing of Vending Machines and Vendors Finally, discussion took place on the wisdom of licensing vendors of cigarettes and vending machines (by owner or location) much in the manner of licensing for the sale of alcoholic beverages. It is clear that those v vendors who find the sale of cigarettes just barely profitable would not be interested in licensing -- they would probably stop selling cigarettes rather than submit to this type of mechanism. The major difficulty, hoaever., vould be enforcement. The establishment of a fully enforced licensing pro- gram to inhibit illegal sales of cigarettes to minors, at present the only grounds on which licensing would be based, would be a very costly procedure. The Committee did not consider licensing a technique that would really discourage people from buying cigarettes or smoking them. At best, it would help reduce violations of section 308 of the Penal Code. Strengthening this section, perhaps by levying greater fines or longer sentences, is.probably r~

a more effective means.. Enforcement is still the greatest problem. A program of self-enforcement by the vending machine industry has already begun. A similar procedure could be undertaken by other tobacco retailers. The Advisory Committee concludes, therefore, that the most effective fiscal policy would be to increase the State cigarette tax sufficient to finance the many-pronged State program to cbmbat cigarette smoking. 14 I

-121- EDUCATIClN NEEDS • Changing the attitudes and habits of individuals concerning cigarette smoking implies re-education. People must relearn what they know about the practice of smoking cigarettes. In a sense, people have been acquiring the practice of cigarette smoking throughout the past half-century. Until then . the practice was virtually unknown: smoking was a pleasure enjoyed mostly by aristocratic men using pipes or cigars. Less wealthy men chewed tobacco. or used snuff. But with the invention of the cigarette-making machine, smok- ing habits.changed. The popularity of cigarettes gained momentum during the First World War. In the rollicking postwar decade, the moral stigma attached to smoking faded -- even women could smoke cigarettes without being duly criticized. Cigarette consumption soared even higher during the Second World War and thereafter. IN 1960 ALONE, AMERICAN SMOmS CONSUMED HALF A TRILLION CIGARETTES -- enough for every man or woman over age 15'to smoke half a pack a day. Until the scientific evidence confirmed that cigarette smoking is an unhealthy practice, there was no reason to consider chitnging its•popularity. Smoking is permitted in most public places; ashtrays are standard decorative accesso- ries; society has established its mores about the matter. Most reservations are exercised on youth: schools are considered an improper place to dis- pense cigarettes or in which students can smoke, and laws exist to punish those who sell cigarettes to minors. Because cigarettes have an addictive quality, learning to live without them in an environment which still favors them is not easy at all. Because of wide social acceptance, education must be central to affect any bold change in people's habits. The needs for education are great, both immediate and long-lasting, and specially devised to motivate different types

and ages of the population. The greatest hope of changing current smoking practices would seem to lie with those who have never tried smoking, the youth -- teen-egers and pre-teens. As in any program of education, the most responsive subjects are those whose attitude and practice have not yet been firmly established. There are other groups as vell who can be taught to think differently about smoking, to reconsitier the wisdom of becoming habit- ual smokers. There are those light or occasional smokers who are uncommitted, who could "take it or leave it." They may be encouraged to leave it. There are confirmed smokers who should give up smoking cigarettes or who really want to; they, too, may be encouraged through both education and clinical support to reduce consumption, to switch to a less dangerous type of smoking, or give up the practice altogether. There are persons who set an example -- parents, teachers, recreational and guidance counselors, physicians -- to whom special thought must be given. They can be instrumental not only in improving their own states of health but in setting the proper tone for children who respect them. Most Americans must relearn the consequences of cigarette smoking. v People have been experiencing a curious state of knowledge in the last decade, v here,questions about harmfulness are introduced but obscured by product promotion, where scientific insight is undermined by cornmercialism. At other periods in history when fresh knowledge came to the fore,' reaction often included skepticism, fear and apathy. Evon maw discoveries which improved standards of living, such as electrici.ty, water porrer and various developments in medical technology, matconsidorable disapprobation until the benefits were displayed and people conditioned to appreciate them. Today, in addition to the traditional hurr" resistance to change, there is another factor -• the immonso influenoe of mass media favoring continua• tion of cigarette smoking. Leerr,ing Is no longer a process fostered only

-123- in the classroom, in the home, on the job. It is reinforced.by our present dependence on techniques of mass media. The creed of the product manufac- turer is to win brand support. He has the means to pay for attracting new customers as part of perpetuating his business. Therefore, consideration must be given to the various means by which influences on habits are being disseminated~.currently. In addition to the tremendous potential inherent in organized educational institutions -- schools, churches, recreational and professional organizations -- there is need to utilize the forms of mass media by which ideas are also being intro- duced and reinforced. Wholesale educational planning must focus on the needs of the particular groups who should be reached, and all established mechan- isms which may be helpful. Present Educational Status on the Issue As was suggested earlier in this report, the legal.provision for in- struction on the subject of cigarette smoking is an outdated, moralistic section of the Education Code. The effects resulting from use of cigarettes, alcohol or narcotics have been construed as :'evil." Teaching materials on r these subjects have, in recent years, become factual rather than moralistic. PoWever, no manual on smoking has been available.and, due to shortage of both staff time and funds, revisions, reprinting and redistribution of the basic guidelines on narcotics and alcohol have had to be deferred. One positive measure, however, has been the initiation of inservice training workshops in "Alcohol, Tobacco and Drugs," where many teachers have re- ceived current information on these sub3ects and therefore have learned to give their pupils greater understanding of them. The health hazards of cigarette smoking in particular have received further emphasis recently through films and other materials distributed by the American Cancer Society.

M But attendance at workshops and use of resource materials are undertaken voluntarily by individual teachers according to their degree of interest in the subject and a feeling that the clae..room is an effective place to teach it. The anxiety of medical scientists and health educators in California that the issue of cigarette smoking is not being pressed adequately in the curricula of both elementary and secondary schools is confirmed by the knoW?.e.ige that half of the high school graduates in California are regular smokers. This habit, established so early in life, is certain to create severe health problems twenty or thirty years from now, prqblems which might be averted by more intensified and imaginative education of young people to discourage imitation of adult smoking practices. Because tne State Department of Education was unable to provide on short notice new teaching materials for an intensified program on the health hazards of cigarette smoking, its representatives presented this need to the California Interagency Council on Cigarette Smoking and Health. Through ~:he combined resources of member agencies, the Council made staff and funds 0 avai'.able to the.Department of Education -- when public interest was first The Council assembled Teacher's Resource Kits on Smoking and Health in sufficient quantity to supply every teacher in grades five through. eight in California's elementary schools and approximately one-fifth of the :c:achers in junior high schools and high schools. All the kits contain: a Teacher's Guide on Smoking and Health; a Summary of the Report of the Advisory Committee to the Surgeon General; a copy of the California report, "Cigarette Smoking and Health;" a number of medical illustrations and charts suitable for overhead proSection; an annotated list of resource materials Q . ~ (e.g., pamphlets, books, etc.); and an annotated list of films and-filmstrips, ~ -4 o, ~ 0

-125- specifying agency suppliers. The principal distinction between the two grade level kits is the special Teacher's Guide, compiled by educators to answer the types of questions students will ask about the problem and including descriptions of projects and experiments to perform whieh am- plify the points. The Council also initiated two regional inservice training workshops, where health educators in teacher education institu- tions and in consultant and coordination positions (in county school offices and school districts) were provided the opportunity to become familiar with the materials and the experiments. They were urged to return to their com- munities to provide leadership in developing similar workshops locally. The kits were distributed by the State Department of Education in May 1964 to allow teachers to use them in designing curriculum for the fall. semester. Workshops and other types of inservice education programs con- tinued through the summer and fall to provide help in effective utilization of the materials. The State Department of Public Health•has been able to secure a Public Health Educator to be assigned to follow the-progress of this intensified educational effort in close cooperation with the State Department of Educa- tion. The effectiveness and applicability of materials and teaching methods should be evaluated in order to select those which are most successful in motivating the student. Future Programs for Youth Education The school program must be supplemented, however, by activities con- ducted by agencies serving youth outside of school. As one move in this direction, it seems desirable that organized recreational groups be stiumu- lated to further the instruction in the effects of cigarette smoking on health both by teaching and practice. Regional conferences should be staged

-126- to which recreational leaders (e.g., Boy and Girl Scout Troop Leaders, Boys' and Girls' Club Directors, playground supervisors, YMCA and YWCA instructors, etc.) are invited to learn how to transmit this knowledge through far.dliar social mechanisms. These conferences woukt have aaxch the same flavor and purpose as those for teachers. It is desired that from regional conferences and training sessions, participants will return to their communities stimulated to continue in- structing others unable to attend. Local interagency councils can be of great support, providing funds, personnel, and direction, in sponsoring training at the local level where, after all, it must ultimately take place. In a more direct manner, there are two directions which could provide a more salutary milieu for youngsters in their formative period. The Com- mjttee feels that no program of cigarette.smoking education will be ade- quately based unless the entire health education program in the public s•:hools is made more vital and meaningful. To this end, the Committee recommends a reappraisal of the entire current health education program r in schools and development of means to strengthen health instruction in the regular curricula. The State Department of Education recognizes the need to improve the teaching of health education, and has suggested development of a Framework for Health Instruction, providing continuity for all health instruction. The present lack of a Framework results in duplications and omissions, and does not create completely comparable teaching environments in which to introduce new content, such as that needed on the health hazards of ciga- rette smoking. The value of a Framework would be reflected in every classroom vhere healtYi education is taught. Guidance would be provided by a Task Force

-127- representing public health, medicine, dentistry, education, voluntary health agencies and parent groups. The Task Force would determine the major concepts to be tested at various grade levels and refined and, fol- lowing approval by both the Task Force and the Curriculum Commission, the recomnended Framework for Health Instruction would be published and dis- tributed to schools. (Details of the finartcing of this proposal are contained in the Budget appended to this report.) To enable a strengthened program of health education to be conducted fully in California schools, several changes in the Education and Adminis- trative Codes are desirable. These pertain largely to enlarging the scope of students to whom health instruction should be given. Education Code section 7604, which currently provides that instruction in health shall. start no later than the sixth grade, should be amended to require that health instruction be required in all elementary grades, as was required until 1961. Section 7700 of the Education Code should be amended to require health instruction at the secondary level. *Section 7852 should be amended to include instruction about the effects of•smoking and section 9309 should y be amended to remove the word "evils," substituting "health,hazards" for the concept presently stated. One further amendment is recommended: section 6130 of the California Administrative Code, Title 5, Education, should be amended to require all teachers qualifying for a teaching cre- dential with specialization in elementary education to be prepared to teach statutory subjects, which include health, alcohol, narcotics and safety. Preparation was required prior to January 1, 1964, and the Com- mittee feels this requirement should be reinstated. The second direction to enhance the environment of youth concerns recreation and its continuity with knowledge acquired in the classroom.

-128- The period of the day when youngsters are most idle and receptive to smoking cigarettes (or indulging in other testing experiences) is that Interval be- tween the close of school and the dinner hour. Providing more adequate opportunity during these hours for structured recreation may tirell limit the inclination of youngsters to begin smoking. While every comminity in Cali- fornia does maintain a recreation program, it seldom involves the "hard to reach group," and is not necessarily supportive to the content of classroom health instruction. The Conanittee, therefore, recommends that training be provided for recreational leaders now in serviee, especially stressing the value of face-to-face counseling regarding the health hazards of cigarette smoking. Where recreational programs are not fully active, the Committee recommends training of competent recreation leaders be provided, and assur- ance that facilities are available where youngsters may have the opportunity to participate in after-school recreation. It is felt that filling the time gap through constructive, healthful activities will support knowledge derived in the classroom and further provide youngsters with needed exercise, team play and Well-directed recreational guidance: For-youngsters from deprived r backgrounds, this extension of a structured day may deter them not only from adopting cigarette smoking,.but also provide them with a more enduring, stable hold on life. The need to integrate more closely the total educational-recreational experience suggests that a pilot program in this direction be under the guid- ance of the State Department of Education. The objectives of the recreational program would be three: to encourage the wholesome use of leisure time in a• good atmosphere, in which activities offering an educational potential con- cerning the hazards of cigarette smoking could be offeredj guidance and . counseling by a recreation leader in a direct relationship to studentsj and

-129- .t continuance of the educational program originating in the classroom through incidental teaching, training, and use of supportive materials. To test these objectives, the State Department of Education proposes that seven pilot programs, lasting approximately one year, be implemented in a variety of school districts in differing geographical locations. Es- tablished recreational programs in Pasadenei, El Monte, Los Altos, Monterey and Watsonville, plus new programs in Al Tahoe and Esparto, could be used for pilot development. (Details on financing the recreational program may be frvund in the Budget appended to the report.) Beyond actual intensification on the subject of smoking and health, students, too, should be encouraged to regard the problem of cigarette smoking seriously. One effective method is by organizing student confer- ences on the subject. In the spring of 1964, the Children's Bureau spon- sored a national youth conference on smoking and health attended by high school students of all states. California sent three delegates'who returned from the conference able to share their knowledge with others. A similar youth conference held in WashingtOn State was reported to be v well-received. The Governor's Advisory Committee feels strongly that student participation -- not just learning -- can help to change the present esteem of smoking. The Committee, therefore, urges the Governor to initiate a periodic California Youth Congress on Smoking and Health, where young people can express and exchange their views and constructive• insight on this issue. The delegates who attend, similarly, can return as potential leaders to their local schools and share with other students the fruits of productive group exchange. Future Programs for Adult and Specialized Education For adults, education rrill be more difficult and response cannot be• expected to be as positive as `ritb younger people. Ye,t, major efforts .. M ,..

-13D- must be exerted. It is known, for instance, that the smoker who discon- tinues the habit gradually reassumes the state of health of the person Who never smoked in the first place. Therefore, it.is crucial to try to convince adults to switch to another less harmful form of tobacco con- sumption or to abandon the habit altogether. The clinical programs des- cribed earlier vill only be successful if fndividuals are receptive to the idea of giving up smoking; to do this, adults, too, uust re-educate themselves. The fact that cigarette smoking is declining among physicians gives promise that other adults may follow. Adults are not neatly grouped into recognizable "classes" or "schools." They are more diffuse and harder to reach. But there are many formally organized groupings through which they can be reached: organizations • established for common recreational, professional, occupational, religiousj or social pursuits. This is a nation•of organized leisure, and through this flexible social structure education can be achieved. Again, panel discussions, exhibits, presentations, conferences -- the spectrum of dis- seminating information to groups -- can play important parts. The leader- p ship of these many groups should be first enlisted and instructed; follow- up activities in regional, county and local settings can then take place. The process of mass learning for adults, more so than with children, 'is a. pyramid approach: tell a feW, who tell a few more, and soon, a mass of people have been exposed -- not once, but often. The most critical specialized group is the medical profession. For it is physicians `+ho must 1) set an exaaiple, 2) advise their own patients, 3) serve as staff for withdrawal clinics, 4) encourage and often conduct research, 5) serve as qualified experts at presentations where the issue is aired. Only by the effective cooperation and interest of physicians can the educational material have convincing impact. ~ a-

-131- in a recent survey among physicians, conducted by Modern Medicine magazine,29 94.8 percent of the 60,202 physician-respondents stated that cigarette smoking is a health hazard. In actual application, hoveveir, 52.2 percent are nonsmokers, 22.5 percent smoke cigarettes and the balance smok;: pipes or cigars. Comparing these results vith those of previous studies conducted since 1954 among state medical societies, a steady de- cline in physicians smoking cigarettes is demonstrated. Moreover, 79.4 percent of this group indicated they had smoked in the past, substantial numbers of them having cut down or stopped cigarette smoking altogether. Just over half the physicians said they advised all their patients not to smoke; still another large segment, 44.2 percent indicated they advised only those patients "with specific conditions" not to smoke. However, after providing patients with information, 71 percent indicated they leave the decision up to the patient. PYLysician,education and its corresponding direct influence on personal behavior and indirect influence on patients' behavior is therefore of considerable value. Since cigarette smoking has such a profound bearing on man's health, 4 the physician who does not consider this aspect of behavior either in diag- nosis or personal example is not doing the best job. )4obilizing physicians by conventional professional educational ctiannels and professional organizations may not be as effective as stiaaulating them to act outside as well as inside these organizations. Physicians must give the entire State program vigor and responsible strength. They could be invited to form a special interest group devoted to working on cigarette smoking. A"Commmittee of One Thousand" -- reflecting roughly four percent of the medical community in California -- is proposed. This pioneer group can then be instrumental in educating other physicians and laymen by active

-132- participation in the marLy activities which are needed to further this objective, constituting a force for positive leadership against the causes of many conditions seen in everyday practice. L . ~ 0 . ~ aD v .~ r o~ v 00

-133- RESEARCx Cigarette smoking is not only a pervasive practice but also is stub- y bornly resistant to attempts at reducing its hold on the individual. In part, this appears due to its addictive`character; in larger part, it may be due to the social milieu which has encouraged'its use. The recommendations k of the Governor's Advisory Committee, therefore, take cognizance of the anticipated difficulties in changing the habit. Altering the widely practiced smoking of cigarettes clearly depends on a thorough understanding of how cigarettes affect the human system and of the behavioral and social phenomena which condition acceptance -- and change. To gain understanding, research should be conducted on many facets of the situation, exploring in depth those factors which influence the use and unfavorable effects of tobacco. Without a sound, scientific basis, it is unlikely that means will be found to ameliorate the.current situation. . Research need not delay taking action in other'directions -- health education, legislative changes, consumer education, etc. -- but should bc developed simultaneously with these activities in order to strengthen them. By filling in the gaps in our present state of knowledge, research will complement other forms of action, enabling the entire program to be con- stantly improved. Closely related to basic research pursuits is program evaluation, a monitor mechanism to detect the effectiveness of a particular program. Research investigators, moveover, provide a trqining experience for skilled scientists, but the more irpmaediate training needs for competent professional staff can be realized by integrating an evaluation$demonstration and training component into overall research planning. Therefore, the Governor's Advis•ory Committee recommends a plan for re- search which embraces two types of activity: (1) fundamental research in

=134- both medical and behavioral sciences to enrich knowledge and comprehension of the entire situation; and (2) applied research -- evaluation, demonstra= tion and training -- to test techniques in cigarette smoking control and to .provide a corps of individuals able to give guidance to other aspects of the overall control program. Research investigations without application and a appraisal are of little value in combatting a health problem of this dimen- sion; demonstration and training, unsupported by basic research,, can be mis- directed. The Committee further recognizes that research activjties on the health consequences of cigarette smoking will not only magnify knowledge on the imme- diate situation but also enrich general understanding and insight whieh,may be useful in other health-predicated behavior patterns. Despite the immense amount of scientific inquiry which has taken place during the past two decades relating to the health effects of cigarette smok- ing, the pattern of in quiry has been diffuse rather than concentrated. The evidence of cigarette smoking's harm to health has been compounded from findings of many different types of studieo. At this juncture, what is needed is both a review of previous findings and new research investigations which coordinate the many factors involved. Possibly scientific inquiry will produce answers to some of the more elusive questions: What ingredient(s). actually cause harm to health? By what process(es)? Can a safe cigarette be developed? What motivates people to smoke cigarettes?. What factors enable some persons to stop while others seem unable to? A list of questions is endless. Research activity may find some of the answers.

• •M -135- Medical Studies and Programs The extent of study yet needed in the basic sciences remains formidable. Epidemiological (statistical) researcho while it has been able to isolate the situation, nonetheless needs to be broadened. At present# many studies of health include questions about smoking practices. This helps to determine whether there are some factors which condition people to smoke and which're- late to consequent patterns of disease. Epidemiological research, in order to penetrate more fully into the subject, should take two directions: longi- tudinal studies of the pathogenesis of those illnesses influenced by cigarette smoking; and surveying large population samples diversified in age., occupation,•~ living conditions and habits, to form a definitive profile of California's smoking trends and their effects. The longitudinal studies could well be extensions of current prospective studies, and related to them should be a restudy of prior data developed in California and elsewhere to ascertain statistical reliability. Findings from'both types of epidemiological studies will provide clues on how to reach people.in reshaping their attitudes and , also supply a continuing resource of information useful in developing instruc- tional materials. The ultimate scientific valuep of course# is to improve and measure the changing health of Californians. Chemical studies may well produce answers to the more pragmatic questions. Research is needed to identify the carcinogenic agents contained in tobacco, its smoke, or a combination of the two. The biochemical,effects of the smoking process must be scrutinized very carefully to detect at what stages the act of smoking a cigarette actually introduces harm into the human system. Yet another study should involve observations of the molecular alterations of structural lung tissue due to tobacco smoke inhalation and the nature of immune effects which may be produced. The presence of trace elements in tobacco

. 1P .136 e smoke needs study. Their cumulative levels in lung tissue and consequent effects may produce clues to the destructive mechanism inhere:it in cigarette smoking. Closely related to chemical studies are those of physiology. At best$ physiologic research has but suggested certain systemic changes which are manifest by smoking cigarettes, but the subject needs far more exploration. Adverse effects on parts of the body not yet known to be involved may also• be detected. Pertinent physiologic studies should include: a determination of the mechanism by which cigarette smoking causes cardio-pulmonary disease, including the cumulative effects on air flow through the bronchi; determination of the effects of cigarette smoking, especially when combined with caffeine, on the gastrointestinal tract; and further extension of imnunologic studies to determine physiologic predictors of cigarette smokers who are likely to. sustain adverse effects. Supportive to chemical and physiologic studies should be pathologic studies, including specialized examination of the pathologic effects which I both cigarette smoking and viruses have on''the development of neoplasms. Medical investigations should also consider techniques which assist smokers in giving up the practice; evaluation of withdrawal clinics and their methods should include consideration of the medical responsiveness produced, as well as the behavioral changes which occur. Behavioral Research . Despite the very personal nature.of cigarette smoking, only a modest amount of behavioral and social research has been conducted into the "per- tonality" of the smoker. No study has been conducted with particular ref- erence to California's population or even a sepnent of it. Consequently, the gaps in detailed knowlege about the population of prime concern are great.` ,

-]37- In the Report of the Advisory Committee to the Surgeon General, Chapter 14 is devoted to the findings of psycho-social studies performed in the last ten years. It reports on demographic variables (age, sex, race, religion, education, occupation, etc.) and personality concepts reflected in sample groups of smokers, but there is a severe Raucity of materials. These studies, however, suggest directions for further investigations, particularly those crucial to embarking on a broad program of cqordinated action.. The%objectives of behavioral research are many: developing insight into man's psychic need for a habit such as cigarette smoking, his motivations for continuing, his inability to change, factors which predispose to habtt forma= tion of this type -- all of which may provide guidelines for action to help him readjust his habit patterns. Behavioral research into this matter will also enhance knowledge of"habituation generally and be of value in understand- ing more of man's complex nature.- The Governor's Advisory Comanittee recognizes that no single group or method of action will change the current tr,end of cigarette smoking. Each person, however, may be regarded as part ot a group which may be observed and guided. For example, nonsmokers and beginning smokers are predominantly youngsters and young adults; established smokers, whether in sound health or impaired, tend to be persons in their middle or older years, at work or retired, whose roles may be both as parent and breadwinner. By concentrating efforts on separate "target" groups -- persons showing similar characteristics of age and roles -- programs of action-may be constructed to be more meaning- ful. How cigarettes figure in a person's daily activities must also be recognized. Among the factors to be considered are: accessibility (e.g. face- to-facE, vending machine salesq supplies at home); and "temptation".faetors, ..

-138- such as addiction, which influence continuance- of- cigarette smoking. Contribu= .ting to habit maintenance, of course, are many disparate variables: grayp conformity pressures, mass media advertising, esteem of one's peers and con- yersely, the support provided by idleness. The interplay of these factors in human experience presents a remarkable challenge. The conduct of behavioral research and its actural application in pro- grams requires a breadth of inquiry essentially at three levels: basic re- search, operational research and program evaluation. Basic research can provide guidelines to curb the practice of cigarette smoking and also unfold data useful in changing a variety of health- and disease-related behaviors. Clues might be obtained to indicate why people fail to acknowledge warnings of impending ill health, why they ignore early .detection or preventive measures, why they delay in seeking treatment or adjusting their behavior to illness. The revelations which may come from basic inquiries will be useful in guiding human responsiveness to health education generally, and perhaps indicate techniques to further enlighten . • men's awareness of their health needs. r Amonq the factors which require study are: 1) The natural history of cigar ette smoking: longitudinal studies of the development and adoption of the habit in some individuals and not in others. 2). Smoking as part of a behavior system (e.g. related to .patterns of eating; drinking coffee, tea, alcohol, soft - drinks; physical activity; personality and emotional states; decision-making ability, etc.). 3) Cross-cultural studies of the natural.history and epidemiology of the cigarette smoking habit, penetrating the sub-cultural ~ ...........:--;,,:^; . ~ . v~i'riants iri Ce~lifornia camaunities.

-134"' ) 5) Educational responsiveness and achievement as related to ciga- rette smoking practices. Demographic and psychological profiles of individuals seeking curative assistance. 6) Influence patterns: parental influence on youth; peer group . influence; sibling influence; "hero" influence on youth. Basic research will be productive over the long-range in delineating those personality characteristics which influence habituation to cigarette smoking and probably other pr actices. MoQeover, it may open up possibilities for combatting cigarette smoking through other forms of action. Opeiational research, on the other hand, would function within the con- text of the action program. The fundamental purpose in conducting operational research would be to test the effectiveness of methods developed and used in evaluation of program components. Research of this nature would consist of controlled studies under experimental conditions -- pilot testing -- to test the actual methodology. Adequate research design would be essential. Studies of this nature could be conducted within the context of a pro- gram in progress,*but could also be performed in frank,testing situations. The effectiveness of methodology can then be measured under stringent con- ditions to affirm the capabilities of a prograrp. An example would be studies of the compar ative effectiveness of education methods employed at varying grade levels in schools. Operational analysis would determine whether evalu-,, ation procedures would be wholly successful in isolating decisive factors in the education process. The efficacy of evaluation has been mentioned before. especially with respect to educatiorial programs. Only through evaluation can a specific phase of action be measured and improvements be made. ,

-l4o- It is recomnended that programs of all types directed toward influencing the cigarette smoking habit have, so far as practicable, built-in evaluation procedures. Agencies and groups contemplating the conduct of such programs should seek expert advice on evaluation techniques at the planning stage. Liaison with a reservoir of qualified consultants and university faculties expert in these procedures would be provided through the Evaluation-Demon- k stration-Training units reco:ronended for development by the Committee. Among the programs requiring evaluation are several discussed else- where.in the report including: 1) Programs of Preventive p2tion: a) concerned essentially with reducing the adoption of smoking in the young; b) studies of parental influence on the young with respect to formation of this habit and others; c) parent education; d) teacher education; e) education of children at dif,ferent gradess comparatively evaluated to determine responsive qualities*, f) programs developed among college age youth, especially re- g) lated to the influence of adults on habit formation; analysis of the influence borne by athletes and other adult "heroes" -- with consideration of their testimony in non- smoking drives; h) comparison of the effectiveness of various educational tech- niques, e.g. permissive, authoritative, etc.; i) studies of change in the adoption of the habit conditioned by changes in'the accessibility of cigarette8, iA'the homep from vending machiries, etc.; '

-141- 3) analysis of effectiveness produced through youth-slanted and youth-viewing times on television and other mass media methods to produce a change in the general climate of attitudes and opinions about cigarette smoking. ----- -- ---- - 2) Programs of Curative Action: . ~ a) analysis of the effectiveness of withdrawal clinicsp per'se; b) comparison of effectiveness of various types of.,clinical approaches; c) studies of demographic and psychological profiles of.persons seeking curative assistance; d) comparison of those persons seeking assistance because they are "under doctor's orders" or under anxiety with those persons whose decision is not made on the bais of ans obvious personal ' crisis. Research Program in Tobacco Studies IFri~~~, if To fulfill the immense research potential considered necessary to sup- port i- broad program of action, the.f3overrjor's Advisory Committee considered a number of alternatives. It was agreed that research investigations should •not take place in a vacuum, but should be part of a well-coordinated program whose prime objective is controlling the practice of cigarette smoking. ' California is fortunate to have attracted a large number of scientists, many of whom are allied to our universities, institutes and State agencies. In'terdisciplinars" research has become quite refined in California: one may observe behavioral scientists collaborating with chemists, geneticists, law- yers, and in turn laboratory scientists working closely with social scientists and businessmen. Clearly, California has a reservoir of competent scientists ~ to whom the studies described above migt:t be of great•interest.* The State I

r -142- also provides an interesting social framework for study: a highly mobile population in a rapidly changing society. The problems posed by this combination are innumerable, not least of which is a higher propensity for cigarette smoking. Smoking habits in turn are reflected in many social dimensions: overall health status; ability to work;'needs for medical care, 1 facilities, staff; legal infringements; consumer preferences; vocational preferences. The repercussions of a habit, as trivial as cigarette smoking may appear on the surface, are enormous. And the need'to enhance knowledge about the cigarette smoking process is no less imperative. The presence of able scientists and institutions geared to conduct research is extremely helpful. However, the most expeditious way to consolidate research endeavors on the subject -- and be assured that results are further applied to other forms of action -- may be through organization of a special- ized research program. The program would encourage and support comprehensive research activities related to smoking and health -- chemical, physical, physiological, epidemiological, educational, sociological and consumer. Such a program would not only stimulate research activities by awarding grant s, but r also coordinate the evaluation, publication and application of findings. The, Research Program in Tobacco Studies would be comparable to the Center for Alcoholic Studies formerly at Yale, now at Rutgers, or the Drinking Pr actices* Studies or Air Pollution Studies of the California State Department of Public Health. The Committee feels that, despite any scientific investigations sustained or directed by the Federal government, a coordinated research program in California is timely and valuable. The extent of the problem in California exceeds that in many other states, and the State may well have to assume

-143- individual leadership in sponsoring research which will help resolve the situation everywhere. Studies would be undertaken by individual investigators applying for support. The studies would be conducted on Californians, later correlated with findings of other population groups. The Committee recommends that ~ responsibility for allocating the research funds be delegated to a research advisory committee placed administratively in the State Department of Public Health, with representation from th,. Scientific B:~ard of the California' Medical Association. Tne allocations committee would function in a manner similar to that of a study section, critically examining applications for support, determining their scientific merit and relevance to the problem, and recommending the allocation of appropriate funds. The Research P:ogram would attempt to provide the customary administra- tive and operational assistance necessary to expedite the data collection and analysis. But the bulk of research, it can be expected, will be under- taken outside of the program by scientists around the State, much as the National Institutes of Health are organized,r Research findings would be published by independent researchers receiving support, but be incorporated actively into programs of action. The Committee feels that while some funds are available from the Federal Government and tobacco industry for certain types of research, the studies described in this chapter need to be conducted now. The aggressive position taken in California toward advancing needed research, especially that spon- sored in an unbiased, purely scientific framework, will further the entire effort wnich must be made in this state in handling the health consequences of cigarette smoking. .

-144- EvalAation-Demonstration-Training Units .. As the merits of evaluation, demonstration and training relate to 0 0 0 all other aspects of the total action program, the Governor's Advisory Committee recommends that these activities be consolidated and be placed administratively in university settings, much as demonstration schools and practice-teaching programs are handled. ` The Committee recognizes the potential to be found in the university setting, where scientists and educators are accustomed to conducting these types of activities. From EDT Units, development and testing of new tech-' niques in cigarette control, both preventive and curative, could be imple- mented. Evaluation of school health instruction, adult education, and all control activities stimulated by the Service Centers could be effected by EDT staff. And most important, training of personnel skilled in strengthen- ing educational and recreational activities could be accomplished through this integrated unit. Training by observation and demonstration will be especially valuable. Through both a coordinated Research'Program in Tobacco Studies and development of Evaluation-Demonstration-Training Units, the entire program '4 of action will be reinforced and well-knit. (Details on the financing of these programs are contained in the Budget appended to this.Report:) 0

-145- CONSUNM STUDIES AND P.LANNING The very fact that the cigarette is a commodity exchanged for money in the marketplace indicates that yet another dimension in the cigarette- health issue must be considered: consumer behavior. For while it may be that a smoker is predisposed to smoke because he has a certain body chemis- ti try or lives in the city inhaling certain vapors, or has a certain type of neurosis (none of which may be true), there is also serious need to under- stand his motivations to purchase cigarettes and obstacles which could be created to make that purchase less attractive. In a society where free enterprise is zealously prized and asserted, interference in the privilege of choice is not popular'. Once a product has been introduced to the market, it is presumed safe for consumption, and merchants are given free rein to win customers. The limitations on promo- tion or advertising of a product, even giving it away, are scant. Regula- tions on advertising content are often loosely framed. The man making a sale is inhibited from absorbing the entire market mainly by budgetary considerations and competition. The way in,,which such factors are manipu- lated to achieve results is the key to commercial success. 'Ar~y change in the commercial status quo may be irritating, not only to the product's maker but also to the consuming public. The fact that the public continues to buy a product after it is held in disrepute but not actually removed from the market attests to the phe- nomenal conditioning of consumers by vendors. The advertising and promo- tional industries can take some of the credit; the product manufacturer can take some; but the public, reacting positively to the bombardment of messages to buy, is mainly responsible. The schemata of "supply and demand" which is basic to commercial interchange ultimately is reflected by consumer .

-146- behavior. By proper conditioning, the consumer is primed for the actio^ of buying. Thus it is that he buys one automobile or another, one brand of canned soup or another; thus it is that he is constantly introduced to new products to make his existence more comfortable, more serene, more convenient -- but most emphatically "more." In a time of unparalleled prosperity for many Americans, a.principal goal of commerce is to keep people spending. The introduction of "new" and "better" products keeps the consumer's appetite sharpened -- and the wheels of business humming. Occssionally into this scene a kink is introduced. There is the auto- mobile s;hich lost, or never gained, favor; the line of canned•gourmet foods which cost too much. Then there is the product with undesirable side-effects:• the agricultural pesticides; the batch of polio vaccine which boomeranged; the horror of thalidomide, and others. In all of these recent instances., the product was either voluntarily or forcibly removed from the market. The overconditioned consumer either rejected it, hastening its demise, or was not given a chance to use it because it produced harm. Analagous to these experiences should bg that of cigarettes. Scien- tific evidence indicates that cigarettes increase the risk of disability and premature death from a number of diseases. The effects show up decades , after consumption, not months, as in the case of thalidomide. And yet the overwhelming persuasion of a powerful industry which has spent billions of dollars convincing consumers that its product will not produce harm is delaying effective action by consumers. The initial impact of the several reports issued in recent years has been to reduce cigarette sales somewhat. But the effects have not been long-lasting, for while some consumers heeded the reports and stopped smoking, a neW crop of smokers was testing the sen- sation, being wooed by a steady barrage of advertisement, free cigarettes,

-147- contests, and other incentives. The sales of cigarettes, if they did not rise, remained stable: The paradox of the mighty consumer suggests one course of action recom- mended by the industry which practices it best: the advertising industry.. Consumer practice studies should be consulted or initiated, to under- stand the underlying motivations of why consumers spend money on cigarettes or alternative items and how they do spend it. Some information of this nature already exists; it forms part of the research foundation on which current advertising campaigns are mounted. A further inquiry would be to measure the extent to which consumers act in response to advertising solici- tations. This information now exists for many products. _The advertiser would not think of releasing a product nationwide or statewide without surveying the market, estimating the responsiveness of the public and pre-. testing his product. Studies of this nature could be conducted by independent market re- searchers who receive grants from the Research Program in Tobacco Studies. The data could then be correlated with findings from other types of surveys -- behavioral, epidemiological, etc. -- so that the "image" of the smoking popu- lation can be :':;lly defined. The further objective, and of more immediate value, would be to ascertain the ways in which the consumer is actually persuaded to buy cigarettes. It will be essential to direct some attention to the media industry itself: management and staff of newspapers, magazines, radio, television, and outdoor advertising organizations. 'The various official reports have generally received proper treatment by the media; public service programs have been presented. on television, for cxample. But there is room for the media industry to become more involved in presenting both sides of the story. The tobacco industry has taken a small step by imposing its own

-148- code, apparently to dampen the hero-romantic allure of cigarette smoking. But other devices just as persuasive to the susceptible teen-age mind ma,y be expected, and it will not be long before these approaches too will be found sales-worthy though less blatant. The tobacco companies have volun- tarily withdrawn advertising from a number of periodicals seen predominantly by teen-age and college age youth. And they have indicated they will cease t,•r.car practice of paying students to distribute free cigarettes around college campuses. Yet, even with these direct means,removed, the consumer and the potential consumer are nonetheless enveloped in a"culture" which encourages cigarette smoking. Ultimatel,jr, it will be the consumer who will dictate the extent of cigarette smoking. The California consumer market represents 10 percent of the national market today; in 10 years, it will be even larger. Mar- keting advisors attest that California has tremendous economic impact -- it is a consumer yardstick. (Products are often pre-tested in California; a deceptively packaged product prohibited from sale in California was subse- ^•-tntly removed from the market by the manufecturer elsewhere; other mar- keting episodes verify the strength of the C4alifornia market position.) Therefore, it can be expected that consumer behavior in California will have repercussions elsewhere. The tobacco industry will be suitably advised that cigarettes have sales volatility. This, too, might stimulate the industry to greater research which is so desirable. The citizens of California, who are the consumers in California, have an exemplary role to play in demonstrating that the practice of cigarette smoking can be curtailed in the interests of health. The action of indi- viduals, while seemingly diffuse, can have a remarkable cumulative effect. Individual consumer behavior will directly influence the tobacco industry where it means the most.

-149- References CHAPTER 4 1. Prevention of Chronic Disease. Lester Breslow. Canadian Journal of Public Health, 52:375-379, 1961. 2. A Survey of Smoking Practices Among Employees of the California State De artment of Public Health. William J. Peeples. California's Health, • 22: : 1- , September 15, 1964. , 3. Green v. American Tobacco Co., 325 F.2d 673 (5th Cir. 1963), 15k So.2d . Statler Corp., 132 F. Supp. 891 (1955). . , 12. California Commercial Code sections 2314 and 2315. 13. See enerally 3 Witkin, Summary of California Law, 109, p. 1911 (7th ed. 19601. 14. Trade Regulation Rule for the Prevention of Unfair or Deceptive Adver- tising and Labeling of Cigarettes in Relation to the Health Hazards of Smoking and Accompanying Statement of Basis and Purpose of Rule. 15. Federal Trade Commission, Washington, D.C., June 22, 19 +~,, p. i. Ibid., p. k3. 16. Ibid., p. 105. i69 (1963), 30 F.2d 70 (5th Cir. 1962)' Lartigue v. R. J. Reynolds Tobacco Co., 317 F.2d 19 (5th Cir. 1963j' Pritchard v. Liggett & Meyers Tobacco Co., 295 F.2d 292 (3rd Cir. 19611 ; Coo r v. R. J. Re olds Tobacco Co., 256 F.2d 464 (lst Cir. 1958), 1 F. Supp. 22 (D. Mass. 1957), 23 F.2d 170 (1st Cir. 1956); Ross v. Phillip Morris Tobacco Co., 164 F. Supp. 683 (D. Mo. 1958). Pritchard v. Liggett & Meyers Tobacco Co., 295 F.2d 292 (3rd Cir. 1961). 5. Green v. American Tobacco Co., 154 So.2d 169 (1963). 6. The Ci arette Cancer Problem: Plaintiff's Choice of Theories E lored. Anthony J. Rossi. 3 So. Cal. L. Rev. 399 19 1. 7. California Labor Code 3708. 8. California Civil Code 1735 (1) and (2). 9. Green v. American Tobacco Co., 154 So.2d 169 (1963); Lartigue v. R.,. J. Reynolds Tobacco Co., 317 F.2d 19 (5th Cir. 1963)• 10. 325 F.2d 673 (5th Cir. 1963); 154 So. 221 169 (1963)• 11. Mix v. Ingersoll Candy Co., 6 Cal. 2d 674 (1936). See Shapiro v. Hotel

-150- References (cont.) CHAPTER 4 17. Ibid., pp. 111-112. 18. Ibid., p. 121. 19. •Ibid., p. 153. 20. 74 Stat. 372 (1960); 15 U.S.C., 1261-1273 (Supp. III 1958). Citations hereafter are to U.S.C. sections only. 21. Action on Smoking Report. Public Health Reports, 79:4:295, -196+• 22. Statement by Surgeon General Luther L. Terr Presented Before the House Committee on Interstate and Foreign Commerce, June 23, 1964, p. 5. 23. Ibid., pp. 8-12. 24. The Consumer's Union Report on Smoking and the Public Interest. Ruth and Edward Brecher, et al. Consumer's Union, Mt. Vernon, N.Y., 1963, p. 181. 25. Ibid., p. 181. 26. Ibid., p. 182. 27. Ibid., p. 180. 28. Ibid., p. 209. 29. 60,000 Answer Modern Medicine Surve . March 2, 1964. Modern Medicine, 32:5:18-30, v

-151- 4. APPENDICES 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 r

-152- APPENDIX I RF.SOLUTION Adopted by the California State Board of Health July 19, 1963 The scientific data and authoritative statements in "Cigarette Smoking and Health," submitted by the Department of Public Health to the State Board of Health on July 19, 1963, demonstrate that: .. 1. The risk of dying from lung cancer is 14 times as high among ciga- rette smokers as among non-cigarette smokers, and 26 times higher for those who smoke two or more packs a day. 2. If the trend of lung cancer death rate continues in California, 100,000 California children now of school age will die frorn lung cancer before reaching the age of 70. 3. Deaths from coronary heart disease are almost twice as high among cigarette smokers as among nonsmokers. 4. Men in the 25-64 year age group who smoke cigarettes suffer more activity-limiting chronic disease and disability than nonsmokers. 5. According to a 1955 survey, Californians, both male and female, smoke more cigarettes than in the nation at large; of particular significance is that smoking among persons under 24 years of age is substantially greater than in•the nation as a whole. These and other data in the paper provide a firm, compelling basis for action to control.cigarette smoking in California as a severe hazard to health. r Therefore, be it resolved that the State Board of Health favors initia- tion of a Statewide campaign to control cigarette smoking along the lines outlined in the above-mentioned paper.

-153- . APPIIIDIX II CALIFORNIA STATUTES RELATING DIRECTLY OR INDIRECTLY TO THE SALE OR USE OF TOBACCO PRODUCTS

-154- 0 0 0 r Penal Code section 308. Every person, firm or corporation which sells or gives or in any way furnishes to another person who is itn fact under the age of eighteen years an,y tobacco, cigarette or cigarette papers or any other preparation of tobacco is guilty of a misdemeanor, and upon conviction thereof shall be punished for the first offense by a fine of not less than Urer.ty-five dollars nor more than one hundred dollars, or by imprisonment for not more than sixty days; and for the second offense by a fine of not less than fifty dollars nor more than two hundred dollars, or by imprisonment for not more than ninety days; and for each subsequent offense by a fine of not less than one hundred dollars and not more than •three hundred dollars, or by imprisonment,for not less than ninety days nor more than six months, or by both such fine and imprisonment. Every person, firm or-corporation which sells, or deals in tobacco or any preparation thereof, shall, within ninety days after this act becomes effective, post conspicuously and keep so posted in his or their place of business a copy of this act, and any such person failing to do so shall upon conviction be punished by a fine of five dollars for the first offense and twenty-five dollars for each-succeeding violation of this provision, or by imprisonment for not more than thirty days. The secretary of state is hereby authorized to have printed suffi- cient copies of this act to enable him to furnish dealers in tobacco with copies thereof upon their request for the same. ' Penal Code section 308a. 2dotwithstanding any provision of section 308, the Director of Corrections or the Youth Authority may sell or supply tobacco and tobacco products, including cigarettes and cigarette papers, to any person confined in any institution or facility under his or its- 3urisdiction who has attained the age of 16 years, if the parent or guard- ian of the person consents thereto, and may permit smoking by any such person in any such institution or facility. No officer or employee of the Youth Authority or the Department of Cbrrections shall be considered to have violated said section 308 of this code by any act authorized by this section. a high school. Dducation Code section 10602. Continued willful disobedience, open and persistent defiance of the authority of the teacher, habitual profanity or vulgarity, upon school premises, constitute good cause for suspension or expulsion from school. Smoking or having tobacco on school premises constitutes good cause for the suspension or expulsion of a puuil except when permitted as provided in this section. The governing board'of any school district maintaining a junior college may adopt rules and regula- tions permitting the smoking and possession of tobacco on the campus of a junior college by pupils of the junior-college 18 years of age and over and enrolled in grades above the twelfth, if the campus is not shared with

-155- I California Administrative Code, Title 5, Chapter 1, Subchapter 1, article 3, section 24. Principals and teachers shall exercise careful supervision over the moral conditions in their respective schools. Gam- bling, immorality, profanity, frequenting public pool rooms, the use of tobacco, narcotics, and intoxicating liquors on the school grounds, or elsewhere on the part of pupils shall not be tolerated. Education Code section 9309. The State Board of Education shall in- clude in the textbooks and teachers' manuals adopted such materials as it may deem necessary and proper to encourage thrift, fire prevention, and the humane treatment of animals, and teach the evil effects of alcohol . and tobacco and other narcotics on the human system. Labor Code section 1294. No minor under the age of 16 years shall be employed or permitted to work in any capacity: * * * * (f) In assorting, manufacturing, or packing tobacco. Labor Code section 1303. Any person, or agent or officer thereof, • employing either directly or indirectly through third persons, or any par- ent or guardian of a minor affected by this article who violates any pro- vision hereof, or who employs, or permits any minor to be employed in violation hereof, is guilty of a misdemeanor, punishable by a fine of not less than fifty dollars ($50) nor more than two hundred dollars ($200) or imprisonment in the county jail for not more than 60 days, or both. Health and Safety Code section 28686.' A11 employees preparing, serv- ing, or handling food shall wear clean, waehable outer garments or other clean uniforms and shall keep their hands clean at all times while engaged in handling food, beverage, or utensils. All such food ha:ndlers shPll wash their hands and arms with soap or detergent and warm water before commencing work after using toilet facilities, and before returning to work, and at such other times as are necessary to prevent contamination of food., Female employees shall wear hairnets, caps, headbands, or other suitable coverings which confine the hair. Wherever practical, employees serving food shall use tongs or other implements rather than their hands. The use of to- bacco in any form by any employee while handling or serving food, beverage, or utensils is prohibited. No employee or other person shall use tobacco in' any form in any room or space used pri;arily for the preparation of food, and the employer shall post and maintain "No S~noking" signs in such rooms or places.

-156- a . 4 Labor Code section 2651. The manufacture by industrial homework of any of the following materials or articles shall be unlawful, and no li- cense or permit issued under this part shall be deemed to authorize such manufacture: Articles of food or drink; articles for use in connection with the servi.na'of food or drink; articlea of wearing apparel for use of children 10 years of age or under; toys and dolls; tobaceo.... Government Code section 6900. For the.purpose of providing blind persons with remunerative employment, enlarging the economic opportunities of the blind, and stimulating the blind to•greater efforts in striving to make themselves self-supporting, blind persons licensed under the provi- sions of this chapter, except as otherwise provided, may operate vending standsr-snack_bars_and-cafeterias-in-arv-building-owned-or-occupied-by the State or by any county or city for the vending of articles pursuant to this chapter. As used in this chapter, "vending stands" shall include vending machines. Government Code section 6901. This chapter does not apply nor authorize the installation of vending stands in any building wholly used by any educational•institution of any type supported in whole or in part from public funds unless such educational institution is of university or college or junior college grade. Government Code section 6907. A vending stand operated pursuant to this chapter shall be used for the vending of newspaper¢, periodicals, candies, chewing gum, tobacco products, picture post-cards, hot and cold foods, and such other articles as are approyed by the bureau and by the persons, governing board, or legislative body having the eare, custody, and control of the building in which the stand or vending machinE, or both are operated. Hot and cold beverages may be sold pursuant to chis section only if they are sold through a vending machine. Welfare and Institutions r^d•e section 6564. The Director of Mental Hygier.e may set aside and designate any space on the grounds of any of the institutions under the jurisdictior, of the department that is not needed for other authorized purposes, to enable such institution to establish and maintain therein a store or canteen for the sale to or for the benefit•of inmates of the institution of candies, cigarettes, sundries and other arti- cles. The stores shall be conducted subject to the rules and regulations of the denprtment and the rental, utility and service charges shall be fixed as will :ei.mburse the institutions for the'cost thereof. The stores when conducted under the direction of a superintendent shall. bP operated on a nonprofit basis but any profits derived shall be deposited in the benefit fund of each such institution as set forth in section 165.

-157- © Beforc any store is authorized or established, the Director of Mental }~ygiene shall first determine that such facilities are not being furnished adequately by private enterprise in the comunity where it is proposed to locate the store, and the director may hold public hearings or cause sur- veys to be made to determine the same. The Director of Mental Hygiene may rent such space to private indi- viduals, for the maintenance of a store or canteen at any of the sai d institutions upon such terms and subject to such regulations as are approved by the Department of Finance, in accordance with the provisions of section 13109 of the Government Code., The terms imposed shall provide that the r ental, utility and service charges to be paid shall be fixed so as to reimburse the institution for the cost thereof r.nd any additional charges required to be paid shall be deposited in the benefit fund of such institution as set forth in section 165. Revenue and Taxation Code section 30101. -Eyery distributor shall pay a tax upon his distributions of cigarettes at the rate cf one and one-half mills ($0.0015) for the distribution after 4 o'clcck a.m. on July 1, 1959, of each cigarette. a

-158- June 1964 t I RULE 1. Either one of the following statements shall appear, clearly and prominently, in every cigarette advertisement and on every pack, box, carton and other container in which cigarettes are sold to the public: (a) "CAUTION -- CIGARETTE SMOKING IS A HEAIlTH HAZARD: The Surgeon General's Advisory Committee on Smoking and Health has found that 'cigarette smoking contributes substantially to mortality from certain specific diseases and to the overall death rate; "' or APPENDIX III TRADE REGUTATION RULES Proposed by the Federal Trade Commission (b) "CAUTION: Cigarette smoking is dangerous to health. It may cause death from cancer and other diseases." c RULE 2. No cigarette advertisement* shall state or imply, by words, pic- tures, symbols, sounds, devices or demonstrations, or any combination thereof, that smoking the advertised cigarettes (a) promotes good health or physical well-being, (b) is not a hazard to heal.th, or (c) is less of a hazard to health than smoking other brands, except that a specific and factual claim respecting the health ; consequences of smoking the advertised cigarettes may be adver- tised if '' (1) the advertiser, before making the claim, has substantial and reliable evidence to prove the accuracy and signifi- cance of the claim, and . 0 (2) all facts material to the health consequences of smoking . the advertised cigarettes are clearly, prominently and intelligibly disclosed in close conjunction with the claim. RULE 3. No cigarette advertisement shall contain,any statement as to the quantity of any cigarette-smoke ingredients (e.g., tars•and nicotine) which has not been verified in accordance with a uniform and reliable testing procedure approved by the Federal Trade Comunission. ~ For purposes of Rules 2 and 3, "advertisement" includes labeling.

r-. COMAZITTEE STAFF Technical Staff 1 Lester Breslow, M.D. Chief, Division of Preventive Medical Services State Department of Public Health William J. Peeples, M.D. Chief, Bureau of Chronic Diseases State Department of Public Health Robert Capron, LL.B. Deputy Attorney General State Department of Justice Patricia Hill Consultant in School Health Education State Department of Education John J. Klumb Consultant in School Recreation State Department of Education Van Burch Consultant, Program and Policy Office State Department of Finance W. R. Currie Chief Financial Economist State Department of Finance Robert Baker, LL. B• .Deputy Attorney General State Department of Justice N . Editorial Staff Devra Mt ller, 'M. A. Writer State Department of Public Health Secretarial Staff Mary F. Laughlin Renee Hanson Signorina Tucker Inge Thompson Bertha Byes