Tobacco Documents Online

STATEMENT OF WILLIAM He FOEGE, MD TO THE COMMITTEE ON LAROR AND HUMAN RESOURCES 1 TIMN 0016298

I am William H. Foege M.D., Executive Director of the Carter Center and formerly Director of the Centers for Disease Control. Mr. Chairman, we are faced with many important problems in this world; poverty, the environment, the debt crisis, etc. Some of these problems will be very difficult to solve, others are totally the result of the action of people and are therefore potentially solvable. We are dealing with an increase in worldwide consumption of tobacco, which results in an increase in worldwide deaths. Multiple factors are in play, including addiction, greed, and a trade policy that, supports the export of death and disease to other countries while our own government's health policy condemns tobacco use. Nicotine addiction is one of the strongest addictions known to medicine. A few packs of cigarettes can put us into lifelong bondage. Greed allows some people to not only profit from this misery, but to actually calculate how to get those few packs consumed at an early age. We have only a quarter of a century of real experience in knowing the price tobacco extracts from society. The report of the Surgeon General in 1964 compiled the science, a science base that has only become stronger through the years. Of the 5500 funerals Americans will attend today, over 1000 will be because of cigarettes. (See attached editorial by Sue Rusche.) Any scientist will reach that conclusion, if they look at the evidence, unless they are in the employ of the tobacco industry. There is no 1 TIMN 0016299

scientific controversy. But it is not just losing a husband, or wife, or parent, or child, before their time. It is also the misery of years of gasping for oxygen, of limitation of activity because of angina, of an impaired quality of life. Recently, it has become clear that the international price extracted bi ~ tobacco is just as devastating as we find domestically. Rothman '1°obacco Co. once said they could justify the advertising of tobacco in the developing world because people didn't live long enough in the 'Ibird World to have the adverse effects of tobacco. It is estimated that India will this year experience 800,000 deaths as the result of tobacco. While global statistics are not as good as in this country, a conservative calculation presented at an April meeting of the seventh World Conference on Tobacco and Health by.Alan Lopez and Richard Peto on the results of a World Health Organization study on the effects of tobacco-related diseases, estimated 3 million deaths per year. Some estimates, extrapolating from countries with good statistics, go as high as 5 million deaths per year. Within the decade, tobacco will be the leading cause of death in the developing world and soon the annual toll of tobacco will exceed the total toll of the holocaust. Ivian's inhumanity to man is an ever current problem. While smoking is decreasing by about 1% per year in developed nations, it is increasing at least 2% per year in the developing world. Thus, by some time in the 2020s, Peto predicts that global tobacco mortality will begin to exceed 10 million a year, with about 7 million in less developed countries where tobacco use is rising so 2 TIMN 0016300

.S dramatically. Richard Peto predicts that in China, deaths from tobacco will increase from an annual rate of 30,000 in 1975 to 900,000 by the year 2025. Dr. S.T. Han, of the World Health Organization, has clearly stated, "The multi- national tobacco companies need 2 1/2 million new smokers each year to replace the 2 1/2 million or more smokers who die. To increase sales beyond the 2 1/2 million who die each year, the multi-national tobacco companies resort to high gloss sophisticated advertising, targeted to specific segments of the populationn in developing countries. In most developing countries where 5 percent or less of females smoke, women are a major target. Children are also targeted because of their desire to emulate adult idols and heroes as well as participate in a glamorized, Westernized culture. These young people become addicted early and will face the.health consequences of their addiction many years later." The World Health organization reports that 90 percent of all lung cancer and 30 percent of all cancers are the direct result of tobacco use. In addition, 75 percent of chronic bronchitis and emphysema, and 25 percent of ischemic heart disease are caused by smoking and tobacco. The lung cancer rates 'doubled from 1963 to 1975 and it is expected that lung cancer rates in women in developing countries will surpass other cancers as the leading cause of death just as it has recently done in the United States and other developed countries. Women smokers seem to be more susceptible to the cardiovascular complications if taking contraceptive pills. A recent Japanese study showed that female college students were four times as likely to smoke as their mothers. In a market in which women are specifically targeted, the implications are worrisome. 3 TIMN 0016301

Dr. Paul Wangai, in Kenya, reports that 40 percent of 6-13 year olds smoke compared to 2 percent 10 years ago. In the Phillipines, between 1970 and 1955, the smoking rate rose 71 percent. 64 percent of males smoke, and among Manila schoolchildren, the rates are 40 percent for boys and 19 percent for girls. Most young people start before age 19. When U.S. manufacturers enter a market in a developing country, they not only bring cigarettes, they bring marketing and advertising techniques that are far superior to those existing in that country. A falling dollar and aggressive negotiations on the part of the U.S. government with Japan and other Far Eastern countries have almost doubled the overseas market for American cigarettes in the past three years. Some 15 percent of all cigarettes manufactured in the U.S. are now shipped overseas (CDC; Office on Smoking and Health Fact I3ook), accounting for about 30 percent of the world export of cigarettes (USDA Foreign Agriculture Service World Tobacco Situation trircular). Dr. Greg Connolly estimates that in Japan, since American cigarettes entered the market after the 1986 agreement, there has been a 3 percent increase in consumption. In Taiwan, the consumption has increased an estimated 4 percent since 1987, when American cigarettes became available. Cigarette advertising in Japan jumped to number two in total advertising time on television up from a 40th place position prior to the introduction of American brands. In addition, sports events and rock concerts have been sponsored by cigarettes as well as young women handing out free cigarettes on the streets 4 TIMN 0016302

.; of Japan -- all practices that did not exist prior to the introduction of American brands. The Japanese tobacco companies have therefore increased their advertising campaigns to keep up with the American competition. During this initial intensive ad campaign war, the World Situation and Tobacco Report (which is a U.S. Government publication) indicated that Japanese cigarette sales increased 2 percent, over this early period, which reversed a 20 year downhill trend. In less developed countries, cigarettes are promoted as examples of sophistication, Western affluence, and as a sign of status. In Taiwan, a singer much idolized by local teenagers was retained by R. J. Reynolds for a local concert. The admission price was 5 empty packs of Winstons. Smoking increases when U.S. tobacco companies penetrate a protective market. According to an article in World Watch, September 1988, the per capita consumption increased 37 percent in Argentina in the decade following U.S. penetration in 1966. There had been a 5 percent increase the decade before. A September 1986 issue of the tobacco industry journal World Tobacco stated that the Asian Pacific region is promising and seen as growth potential for more smokers. The article stated that a conservative estimate for sales in Asia will increase by 18 percent by the year 2000. This is due to increased population, increased availability of cigarettes at lower cost, a demand for western manufactured (over hand-rolled) cigarettes and intensive advertising campaigns. In addition, the methods to educate the public of 5 TIMN 0016303

?2TER PRES CNTR TEL No. 4 0 4 421 0 ~196 May u~ S health risks and provide legislative controls are inadequate. Increases in consumption are predicted in developing areas in the absence of advertising but in countries with advertising, the predicted rates are even higher. In January 1986, the World Health Organization issued the following statement, "Whereas in most industrialized countries the smoking habit is decreasing and becoming socially less acceptable, in developing countries, it is on the increase, fueled mainly by intensive and ruthless promotional campaigns on the part of the transnational tobacco companies. In most developing countries, unfortunately, the legislative controls and other measures which in industrialized countries succeed in limiting the use of tobacco, do not exist, or are at best, inadequate. Smoking disease will appear in developing countries before communicable disease and malnutrition have been controlled and thus the gap between wealthy and poor countries will widen further." China produces more tobacco and consumes more cigarettes than any other country. The Multinational Monitor has reported that the multimational tobacco companies are eager to capitalize on China's seemingly insatiable appetite for cigarettes, a market estimated to be worth $6 billion each year. In the early 1980s, R.J. Reynolds became the first company to sign a successful agreement with China. Philip Morris and Gallaher (U.K.) followed immediately. All three brought modern manufacturing and packaging machinery into the country, provided training in its use, and taught Western methods of tobacco blending. In exchange, the companies were allowed to stay and manufacture their cigarettes on Chinese soil. 6 TIMN 0016304

Why would people put up with this? Why don't they stop smoking? Why don't they use the free will so touted by the tobacco industry? Because they can't. The nature of addiction is to take that out of their hands. For many people, the only time they can really make an informed choice is at the beginning of their addiction -- at age 13 or 14 or 15, at a time when social pressures make it difficult to make a long term decision that is in their best interest. Thus it has always been. Our science is ahead of our politics, ethics, sociology or even our full understanding. We must clearly differentiate what is legal from what is moral. The legality of selling cigarettes is unlikely to change because of our history. The morality changed when we found tobacco hurt and killed people. We cannot let the legality of the product protect us from feeling any moral obligation to protect health and life. We can't afford to have this on our conscience, whether we are in the health field or in the position of providing political leadership. Will this be the net result of U.S. involvement in the problems of the developing world? Will all of our assistance in agriculture, science, public health, smallpox eradication, etc. be more than offset by the deaths resulting from our exportation and promotion of tobacco? When I look at the efforts by the U.S. Trade Representative (USTR) and the General Agreement on Tariffs and Trade (GATT) to force Thailand to reverse its restrictions on the importation, distribution, sale, advertising and promotion of cigarettes, I cannot help but compare the position of the U.S. today to that of Britain in 1757. In that year, Britain captured the opium monopoly in India. In 1796, when 7 TIMN 0016305

China made importation of the drug illegal, the growth of an illegal trade in opium, fostered by the British East india Company, resulted in open conflict between China and Britain -- the Opium Wars. By 1880, Britain had forced China to capitulate, importing as much as 11,000 tons of opium a year. History has condemned Britain. Now, the U.S. and Thailand have re-invented the opium wars. Without the input of public health experts, the U.S. Trade Office is attempting to enact policies that have tremendous implications for international health. Unfortunately, the United States has lagged behind other countries such as Thailand, Canada, Nigeria, the Gambia, Burkina Faso, and Senegal which have enacted bans against all cigarette advertising. In our own country, although it is the explicit domestic health policy of the U.S. government to discourage tobacco use, rve continue to hold tobacco companies to different standards and treat them with different rules. Their products need not meet the safety standards applied to other products, their advertising need not adhere to the truth in advertising laws imposed on others, they are immune from the product liability requirements imposed easily on toys, tools,, or vacuum cleaners, and tobacco production is subsidized by the same government that discourages its citizens from using it. Now we are trying to export this double standard to other countries -- particularly those in the developing world. What of the argument that poor people in developing countries have so few pleasures that we shouldn't take this one away from them? A woman in lndia or Bangladesh cannot afford to lose a husband at age 55 due to lung cancer. a TIMN 0016306

,-n(.,i C.-, r i.aJ '...iV 1 f. + CL lVU . -+U4 _ly0 1'IXy VJ,'Z) U l~ ~b t.11 How can we put this all together? It is fair for the United States to take a careful look at the economic implications of trade and tobacco sales. It is not appropriate to do this outside of the context of the implications of these products. We must be willing to compare the dollar impact of our overseas sales of tobacco to the cost in terms of health and lives, as well as the environment. The United States government must know what the profit is per foreign death and consider it is worth it to our economy before they make that decision. The economic loss in the U.S. from cigarette smoking is significant, and when added to human suffering, far exceeds the economic gains touted by the cigarette export association - $22 billion in medical costs and another $43 billion in lost production. Medicare and Medicaid pay out at least $4.2 billion each year due to cigarette-related diseases (CDC Fact Book). Compare this to the total of $4.2 billion mentioned as combined income from cigarette and tobacco sales abroad, and then calculate the health cost to the foreign country receiving the product. If we were exporting chemical weapons to another country we would have calculated the possible effects of those weapons. Because we are dealing with other toxic chemicals which have longer incubation periods before they extract their disease and death does not excuse us from making the full calculations. In general, Ministries of Health cannot stand up to the power of the tobacco industry. When the power of the tobacco industry is joined to the power of the US government, the combination is too formidable for any Ministry. These countries simply do not have the infrastructure or the resources to launch widespread health promotion 9 TIMN 0016307