Tobacco Documents Online

i'4 _.~_ . _ _ . ..._ _ . , ~. . .. . Remarks by Jesse L. Steinfeld, M.D., Surgeon General of the U.S. Public Health Service at the National Interagency Council on Smoking and Health on the 1972 report, "The Health Consequences of Smoking."* Once again it is my pleasure to address the National Interagency Courac.il on Smoking and, Healr.h and to help inaugurate National Education Week on Smoking. This is the second such occasion and I wish every success to you who are attending this meeting as well as to those in the State and local interagency councils throughout the country who share responsibility for putting on_ this important educational campaign. As we all well know, this date also marks the anniversary of the Surgeon General's initial report on Smoking and Health. It has become something of a tradition to take this opportunity to assess where we stand in the matter of the health consequences of cigarette smoking - whether or not we have made any progress in bringing to a halt the heavy tol1 resulting from this rather grim national habit. The time has not yet come when we can say that over-all morbidity and mortality rates have been affected by changes in the smoking habits of our population. Cigarette smoking continues to be one of our major health problems. It is true that for a number of years there was a significant drop in per capita consumption of cigarettes but this now appears to have leveled off. Cigarette sales in 1971, appear to be close to the same level that they were in 1969. f•. Thus we can say that we are holding our own but no more than this. The Public Health Cigarette Smoking Act of 1969 was a long-term victory *Presented at the meeting of the National Interagency Council on Smoking and Health, National Education Association, Washington, D.C., January 11, 1972. TIMN 0113429 T115108 24799 H-

2 for the public health but it has had a short-term disadvantage for us. With cigarette advertising off the air, the number of "anti-smoking" announcements has been greatly reduced and this powerful educational m.ediumm has in p3rt beef}A dlosed to us.. Yes, we are holding our own; but this is not enough. We are together here as health professionals, as educators, as representatives of civic groups, as representatives of government agencies. Together we must work much harder to turn the tide and get'the consumption curve back on the downward trend. Quitting is the theme of this year's Smoking Education Week*and there is our challenge. I say this with some emphasis because of the content of the latest report to Congress. Once again our com- pilation of current research and knowledge on the health consequences of smoking confirms and validates our previous findings that cigarette smoking is indeed a hazard to health and once again, no significant re- search has come forth which would indicate anything to the contrary. Look at the matter of coronary heart disease, for instance. Back in 1964 a higher death rate was noted for male smokers as compared to nonsmokers, but at that time it was not clear whether the association had causal significance. Over the past eight years our understanding of the mechanism of this relationship has been greatly expanded; cigarette smoking has been clearly identified as-a risk factor in the development of coronary heart disease for both men and women. This year's report indicates that studies in various countries of the world have confirmed this fact. Another new note in this year's report is the demonstration that greater myocardial. arteriole wall thickness can be found in smokers compared to nonsmokers. T11510g TIMN 0113430

3 This suggests that cigarette smoking contributes to the process whereby coronary artery disease develops. As I have indicated several times earlier, the role of carbon monoxide in the smoking and disease relationship is becoming much more clearly identified. One of the highlights in the chapter on heart disease is the finding that the elevation of carboxyhemoglobin levels in smokers can be a contributor to the development of coronary heart disease and arteriosclerotic tr peripheral vascular disease. Another point ih the 1972 report is the conclusion that cigarette smoking is considered to be the primary cause of one form of heart disease, pulmonary heart disease, because smoking is the most important cause of chronic non-neoplastic bronchopulmonary diseases. The implications of these findings for preventive medicine are obvious. Heart disease is the nation's leading killer. Each year, one million people in the United States experience either a myocardial infarction or sudden death from coronary heart disease. About 165,000 of these coronary deaths occur in persons under 65 years of age. As far as middle-aged men are con- cerned, the United States has one of the highest CHD death rates in the world. A man in this country, has about one chance in five of developing clinical CHD before age 60. If he smokes cigarettes, has high blood pressure ... and a high cholesterol level, his chances rise precipitously. This is not an encouraging picture for it represents a waste of human resources we can ill afford. Clearly, one of the most important primary preventive health measures we can undertake in this country is , T115110 TIMN 0113431

4 the reduction in cigarette smoking. This is not to imply, however, that reduction of other health risks should be overlooked. Another area of importance in relation to cigarette smoking is.that of the chronic obstructive bronchopulmonary diseases - primarily chronic bronchitis and pulmonary emphysema. Previous reports have established that cigarette smoking is the most important known cause of this group of diseases, a more important cause than either air pollution or occupational exposure. This year's report reviews research which confirms these facts as well as the finding that both men and women cigarette smokers have an increased prevalence of respiratory symptoms and diminished pulmonary function compared to nonsmokers. Other investigations, these involving high school students, have demonstrated that abnormal pulmonary function and pulmonary symptoms are more common in young smokers than in nonsmokers of comparable ages. It does not take 20 to 40 years for smoking to damage its unsuspecting victims. This has occurred in teenagers. Physiological changes in'the lungs were also noted in experimental studies which confirm that smoking exerts an adverse effect on pulmonary clearance and macrophage function and that some cells obtainable from the lungs of cigarette smokers exhibit character- istic morphologic differences when compared to those of nonsmokers. It is true that it is not really news anymore that smokers have more respiratory symptoms than nonsmokers. "Smoker's cough's-.is not only a topical joke, but a recognizable symptom. What is most distressing to me, in this summary of highlights, is the information relating to the effect of cigarettes on young people, most of whom have had only a limited exposure. It is particularly disturbing in light of the somewhat permissive attitude toward student smoking we are seeing in many of our high schools T115111 TIMN 0113432

5 throughout the country; and in view of a new pitch to youngsters that is becoming apparent in some cigarette advertising. My own views on smoking in the schools were made public some months back when the press obtained a copy of a letter I wrote to my local school board in support of the re-institution of a long-standing ban on smoking in the-schools my children attend. I still stand by my statement to the board that "Implicit encouragement of this pernicious habit by school authorities through officially condoned smoking areas is not in the best interest of our children or of our citizens." I feel very strongly that the nation's schools can and must - play a major role in encouraging youngsters not to embark on the smoking habit both through an honest educational program from the earliest grades and a firm commitment to no smoking rules in and around school property. As far as advertising is concerned we recently became aware of a new campaign which has surfaced in a market test area in the northeast. This newspaper ad was headlined "Should a girl skinny smoke on her first date?" The text goes on to say "If she doesn't, she doesn't know what she's missing. Like the beautiful, frankly sensual feel of a skinny cigarette. (Silva Thins are the skinniest cigarettes. A girl should know what she's about, even if she's not about it yet.) Like the surprisingly rich taste of skinny ,:. Thins - all the full flavor her folks found in the old 'Fats.' Like the reality of Silva Thins low 'tar' content -- less, in fact than most Kings. Like the keen alternative of Silva Thins Menthol. (Sometimes it pays to keep her cool on that first date.) Or like the neat ploy of flashing her Silva pack and inviting him to skinny smoke with her into the night. But then, if she doesn't the first time, there's always a second. Isn't there. . .?" TIMN 0113433 T1151j.2

6 This is a blatant effort to encourage a youngster to smoke. Returning to the health aspects of cigarette smoking, the current report,reveals some very significant data on lung cancer. Preliminary results from a major prospective epidemiological study in Japan have demon- strated overall effects and dose-response relationships similar to those observed in previous studies. The importance of this study lies in the fact that it is the first large-scale smoking study to be conducted in a population characterized by genetic,'dietary,,behavioral and cultural in- fluences distinctly different from those in previously examined Western populations. The one common factor in all-population groups that have been studied is, of course, cigarette smoking. And the Japanese are finding that the more a person smokes the greater is the risk of incurring lung cancer. Thus we have yet another confirmation of the smoking-lung cancer relationship which has been recognized in the Western world for 20 years. Another significant fact brought out in the current review is that ex-smokers have significantly lower death rates for lung cancer than continuing smokers. This decline in risk appears to be rapid both for those who have smoked for long periods of time and for those with a shorter smoking history; with the sharpest reductions taking place after the first two years of cessation. This should provide ammunition to those who are responsible for carrying out the national education week on smoking campaign. This is pretty good proof that quitting smoking pays off and an answer to those who try to justify their habit by claiming that it is too late to stop, the damage is done. In contrast to this hopeful note the 1972 report further reveals.that the risk of development of lung cancer appears to be higher for smokers who have chronic bronchitis. This additional'risk appears to be independent of age and the number-of cigarettes smoked. Other evidence is cited which TIMN 0113434 T115113

7 demonstrates a significant association between cigarette smoking and cancer of the urinary bladder in bdth men and women and with cancer of the pancreas. In previous reports, the relationship between smoking and pan- creatic cancer was not so clear cut. Other areas of the digestive system are also affected by cigarette smoking. Earlier reports indicated that smokers have higher rates for peptic ulcers than nonsmokers and, in addition, that their continued smoking appeared to reduce the effectiveness of standard'-'ulcer treatment and to slow the rate of healing. New evidence from studies with dogs provides a possib le clue to this relationship. Nicotine was found to inhibit pancreatic and hepatic bi- carbonate secretion which could lead to peptic disease by depriving the duodenum of sufficient alkaline secretion to neutralize gastric acidity. Studies involving human volunteers also suggests that smoking decreases the effectiveness of the lower-esophageal sphincter as a barrier against gastro-esphageal reflux. This suggests that smokers may experience "heart burn" more frequently than nonsmokers. Last year I called attention to the plight of the woman smoker, who finds it harder to quit than the man. I noted the growing evidence that she, too, takes a risk when she smokes, even though her rates of illness and death are not quite as high as those of men who smoke. I have seen nothing which alters this picture. Indeed, in the matter of smoking and pregnancy new studies confirm the wisdom of our earlier advice, that it is not "prudent" for pregnant women to smoke. I am most distressed that advertising aimed at women continues at a high rate and I am certain that this is not helping those who are wavering in their decision to quit. TIMN 0113435 i T115114

8 This is, of course, exactly what the tobacco industry wants and if we cannot come up with something stronger, that is exactly what it will get. With this in mind, perhaps the time has come to examine more closely what the tobacco industry is up to. Yesterday at a press briefing, I said that I hoped that in this next year, each citizen will review for himself the summary findings of ,..to what is no longer an honest disagreement among medical scientists about the hazards of cigarette smoking. There is no disagreement, I said; smoking is deadly. Yesterday afternoon the Tobacco Institute replied. It said that -- *I quote -- "once again HEW has failed to make the objective report on smoking and health research required by Congress. The Surgeon General's statement that there is no honest disagreement among experts on effects on smoking is false. It is a gross insult to the scientific community. .. Those who prepared the Surgeon General's report for him were careful to have it reviewed prior to publication by a number of persons known to share his opinion of smoking. They were just as careful not to submit the report to any of the many scientific experts who disagree with it." What is behind this self-serving statement from the tobacco industry? ,.. It is a statement which continues one of the underlying, defensive postures of the tobacco industry. This is the posture that there is a substantial number of physicians and scientists who do not believe that cigarette smoking is hazardous. It is true that from time to time, the tob acco industry has marshalled witnesses to appear in its behalf in courts, before Congressional committees, and before television cameras, TIMN 0113436 T115-11_5

9 but even these witnesses seldom say categorically that cigarettes are not hazardous. Their testimony instead is usually to the effect that supporting data is not adequate or that some unknown factor links cigarette smokers to disease independent of cigarettes, or that the relationships linking cigarettes to death are inconsistent, or that the relationships in any case are only "statistical" in nature. -These are primary defenses of the cigarette industry and have been commented on before. It is not necessary to impugn the integrity of these tobacco in- dustry witnesses to say that they represent no substantial medical opinion so far as the key question is concerned; whether cigarettes are hazardous to_health. In seeming to do so, however, they do great damage. They undercut the efforts of parents and teachers to dissuade young people from taking up smoking and they imperil the health of present smokers by seeming to suggest that it is no serious danger to keep on smoking. What we are doing they call irresponsible, demogogic, and a disservice to our government. Is it irresponsible to warn children against smoking? Or is it irrespon- sible to invite a 14-year old girl to "skinny-smoke" on her first date? Is it demogogic to tell smokers that cigarette smoking constitutes a hazard to their health? Or, to spend hundreds of thousands of dollars in advertising that "The question about smoking and health is still a question." Is it a disservice to our government to attempt to do something about a health problem that involves billions of dollars in costs to our people, and death to thousands of thousands of our citizens? Or is it a diservice to attempt to discredit these efforts and along with them, the efforts of TIMN 0113437 T115116

the thirty-five other public and private agencies represented in this Interagency Council on Smoking and Health? At some point in time, 15 or 20 years ago, a great American industry was given a tragic and terrible problem - the product it manufactured, however profitable it was, however pleasurable to the user, however important to the farmer who grew the tobacco - this product was a serious hazard to health. In the years since, the evidence has continued to grow that cigarette smoking is a cause of cancer, a major risk factor in cardiovascular disease, the chief cause of death from chronic bronchopulmonary disease, and that smoking by pregnant women poses a hazard to the unborn child. It is a hazard of sufficient importance, as the Surgeon General's Committee said eight years ago, "to warrant appropriate remedial action." In some ways the industry has responded to this problem. It has protected its stockholders by diversifying, until it is now involved in products ranging all the way from corn products and whiskey to containerized shipping and safety razors. It has responded to public taste - and public worry about its product - by fashioning cigarettes which on the average have far less tar and nicotine than a generation ago. It has supported public and private research and it has acquiesced, however reluctantly, in a series of controls over its advertising - most spectacularly, in the banning of its advertising on radio and television. Why then, does it continue to discredit itself with a calculated campaign to confuse the public and endanger the public's health? The time has come for the tobacco interests to stop fighting as if it were the I960's. The year is 1972. In the preface to this year's report on the Health Consequences of Smoking, I pointed out that millions of Americans have stopped smoking -TIMN 0113438 T115117

because they have persuaded themselves that it is in their own self-interest to do so. I said that we must: continue to encourage cessation as the only certain way to protect both the individual and society from the harmful effects of smoking. But I believe we must also work towards reducing the harmful effects of smoking. It is perfectly clear that however successful we may be in the future in persuading young people not to take up smoking, many present smokers will continue to smoke. The health and lives of these millions of present smokers are at risk and we must do what we can to protect them. We can do this by developing less hazardous cigarettes and encouraging less hazardous ways of smoking. An important section of the new report is devoted to a review of the harmful constituents of cigarette smoke. An array of compounds'are presented. The first series are compounds in cigarettes judged most likely to contribute to the health hazards of smoking, they comprise carbon mon- oxide, nicotine, and "tar", the last-named being the particulate matter collected from smoke after nicotine and moisture have been removed. The second series are six substances, judged as probable contributors to the health hazards of smoking; they comprise acrolein, cresol, hydrocyanic acid; nitric oxide, nitrogen dioxide, and phenol. A final, third series, 3. comprises a larger numb er of compounds judged as suspected contributors to the health hazards of smoking. This chapter on harmful ingredients is more than a simple "state of the art" review. To my mind it brings us closer to a suggestion by a number of persons, more recently by Drs. Fletcher and Horn in their report to the TIMN 0113439 T 1151 a-8

World Health Organization. This is that governments consider setting maximum limits on the harmful ingredients to be contained in cigarettes offered for sale. Such a provision is contained in legislation now before the Canadian government and it is a suggestion that I believe we in the United States should begin studying most carefully. Our chapter on harm- ful ingredients suggests three ingredients of smoke which might immediately be made subject to this control -- these being tar, nicotine and carbon monoxide. te There is an alternative method of encouraging the use of lower yield cigarettes, and that is through taxation. The City of New York now has a graduated tax on cigarettes based on their tar and nicotine content and this experiment should be watched carefully. New York City is not a typical market for cigarettes because so many persons employed there live in other jurisdictions and, I understand further, because a black market exists in cigarettes brought in from States where taxes are lower. This suggests that if the system works at all in New York City, it should be even more effective elsewhere. Research is going 'on towards developing a less hazardous product and we must applaud this research for the reasons I have already given - a great many persons will continue to smoke cigarettes, at least in our gen- eration, and their health is at risk. There need be no.:conflict, in my mind, between a search for less hazardous ways of smoking and our basic effort to encourage no more smoking at all. Those of you who were here last year on this occasion may remember that I concluded my address with a call for a Bill of Rights for the Non- smoker, which would include a ban on smoking in public places such as. restaurants, public transportation, and theaters, to provide respite for those who are allergic to smoke or.who are simply annoyed by having to TIMN 0113440 T115119

- 13 - breathe smokey air. I wasn't quite prepared for the response that followed. ;There was considerable editorial comment, both pro and con. Hundreds of letters were sent to me and to editnrial offices around the United States in enthusiastic support of the idea~tiiat the'nonsmoker 'Ecas 'at least as great' a right to a clean environment as the smoker has to pollute it. There were very few dissenting views. The time appears to have come in our free society for nonsmokers to assert their rights. Letters to newspapers, ,.,.. to Congress, to voluntary organizations and to me will all speed the day when the non-smoker's bill of rights -- his right to clean air -- will be accepted universally. That will be an accomplishment for health -- and we should strive toward it. Already we can see change. Many of the major airlines now provide separate_seating for smokers and nonsmokers. The Interstate Commerce Commission has made an initial determination that smokers must occupy seats separate from nonsmokers; however, this is still open to appeal and I fear that the bus companies will not look kindly on such a ruling. However, at least one state has passed legislation that requires virtually all railroads, bus firms and airlines to provide separate seating for nonsmoking passengers. Smoking was banned on the Staten Island Ferry. In yet another state legislation was I introduced to forbid smoking in restaurants; I reqret that I do not know the ` outcome of this effort, although it would be most surprising if such ` legislation could be put into effect. I We are making some progress in this direction within the Department of Health, Education, and Welfare, and I am proud that our Secretary, Mr. Richardson, has taken leadership in banning smoking in conference rooms and auditoriums in buildings occupied by HEW; in reserving separate areas in our cafeterias for nonsmokers; and in asking supervisors, to arrange smoke-free work areas for employees where this can be arranged rt TIMN 0113441 T115120

- 14 - without undue inconvenience. This is a bold step and one I hope other Department heads in the government and the leaders in industry will take to protect the well-being of their employees. Support for action such as this lies irx the information contained in two chapters of the 1972 report. Although we cannot say with certainty that exposure to tobacco smoke is causing serious illness in nonsmokers -- the long term research necessary for such a finding has not yet been done -- it is clear that such exposure can conttibute.to the discomfort of the nonsmoking individual and can produce exacerbation of allergic symptoms in those who are suffering from allergies of various other causes. There is ample proof that those who complain of discomfort in smoke-filled rooms are not disagreeable malcontents, but can have a legitimate cause for their complaint. This year, for the first time, data has been included in our report to Congress on the role of tobacco smoke as a source of air pollution for the nonsmoker. Experiments are cited in which measurements have been made of carbon monoxide in smoke filled rooms. In these studies the level of carbon monoxide has been shown to equal and at times to exceed the legal limits for maximum air pollution permitted for ambient air quality in several ~ localities. Under certain conditions these levels can albo exceed the occupational Threshold Limit Value for a normal work period presently in effect for the United States as a whole. The CO levels in these "smoked" rooms which ranged from 20 to 80 ppm may be associated with adverse health effects as measured by impaired performance TIMN 0113442 T115i21 ~

on certain psychomotor tests. Other investigators have noted that exposure to CO levels of 50 ppm and up has resulted in altered auditory discrim- ination, visual acuity and the ability to distinguish relative brightness. The average individual probably may not often be exposed to such high concentrations of smoke for long periods of time without relief; but the fact that such dangerous conditions can develop should sound a warning to us. We can not overlook the.fact that exposure to these con- centrations of carbon monoxide may be especially hazardous for those who are suffering from heart disease or chronic bronchopulmonary disease. And to what extent may this affect driving performance in a poorly ventilated car with several occupants smoking? There is no question that cigarette smoking continues to be a major public health problem. New data in the current report to Congress establishes that there is a hazard in this habit for those who smoke and for some who do not. The challenge ahead for those who have the responsibility for Smoking Education Week is a great one, but I think we are equal to it. Let me return to a matter I touched upon at the beginning of my'talk today, cigarette consumption. On the positive side, 29 million Americans have stopped smoking. In great part, I believe we can say this is the result of the efforts of the member organizations of their Interagency Council. But on the negative side, 44 million Americanp, continue to smoke. I said at yesterday's press briefing that the Department of Health, Education, and Welfare intends to follow the curve of"consumption most carefully. If it curves upward, or even if it continues at its present level, it will be a sign to us that we are not doing enough to control TIMN 0113443 T115122

- 16 - what is clearly one of this country's most important public health p rob lems . Traditionally, our society has been most successful in combatting public hzalth problems when the citizen has been passive. That is, we have purified our water supplies, prevented sewage from entering our drink- ing water, pasteurized our milk, made certain that meat products did not transmit trichinosis, brucellosis, and'tuberculosis, and immunized our citizens with vaccines against smallpox; polio, measles, and the like. But we have not been successful when the citizen has to take an active .and responsible role: when he must exercise, when he must choose foods to avoid obesity and arteriosclerosis, when he must restrict his alcohol intake and when he must restrict or eliminate smoking of cigarettes. What is the role of government beyond education, when education doesn't do the job? Without.question, this Government and other Governments in the industrial world will be considering new action in the years to come to try to reduce the death and disability which cigarette smoking brings. The World Health Organization has circulated among its member nations a series of recommendations. Two which I have already mentioned are setting upper limits for various constituents of tobacco smoke and adopting a system of differential taxation so as to discourage the smoking of cigarettes with a high tar or nicotine content. Another major recommendation is taking action to curtail the adver- tising of cigarettes with a view to its eventual elimination. Canada is considering eliminating advertising at the present time. And still another recommendation is raising taxes on cigarettes. Many of our State and.Iocal governments have done this for revenue purposes, TIMN 0113444 T115123

although the Federal Government has not changed its rates for some nearly 20 years. The fundamental purpose of this Council is education, and the event we are celebrating today marks the beginning of a Smoking Education Week. By all means, let us pursue our efforts. But let us be prepared to do even more than this, if the need continues. . ,•. TIMN 0113445 T115129~ ~: -

- 17 - although the Federal Government has not changed its rates for some nearly 20 years. The fundamental purpose of this Council is education, and the event we are celebrating today marks the beginning of a Smoking Education Week. By all means, let us pursue our efforts. But let us be prepared to do even more than this, if the need continues. TIMN 0113446 . T115125