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A NATIONAL DILEMMA: CIGARETTE SMOKING OR THE HEALTH OF AMERICANS Report of the National Commission on Smoking and Public Policy to the Board of Directors American Cancer Society, Inc. January 31,1978 TIMN 431947

NATIONAL COMMISSION ON SMOKING AND PUBLIC POLICY n David Baltimore. Ph.D. Bentamm F Byrd. Jr.. M.D. Merlin K. DuVal, M.D Charles 8 Et+ersol Marshall Evans Robert W. Holley, Ph.D. Alice S. Huang, Ph.D. Mrs. Robert W. Huff Allan K. Jonas George Kneeland Philip Lee. M.D. ChartesA. LeMaistre, M.D. Salvador E. Luria. M.D. Baldwin Maull J. Quigg Newton Comelius W. Owens Mrs. Martin Perkins H. Marvin Pollard. M.D. Robert E. Shank. M.D. Scott K. Simonds. Dr.PH. William H. Wendel Kerr White. M.D. VICTOR WEINGARTEN Executive Director Eileen Lanman Staff Associate Please Reply To: 801 SECOND AVENUE NEW YORK, NEW YORK 10017 212/897•1811 January 31, 1978 The Honorable Joseph H. Young Chairman American Cancer Society 777 Third Avenue New York, New York 10017 Dear Judge Young: The National Commission on Smoking and Public Policy was- created in October 1976 by the American Cancer Society to take testimony from knowledgeable persons regarding the problems caused by cigarette smoking, to assess the effectiveness of current anti-smoking activities, and, on the basis of its findings, to recommend possible new approaches to this majbr public health problem. The Commission's focus has been on public policy, particularly the role of the Federal government, state and local governments, and national voluntary health agencies. To perform its task, the Commission appointed Regional Planning Councils in eight parts of the country, and held Public Forums from March through June 1977 in each of these regions, at which time persons concerned with cigarette smoking were invited to testify. The Commission also invited the Tobacco Institute, the industry spokesman, to appear at any or all of its last seven Public Forums, but the invitation was declined. Ultimately, the Commission took testimony from 300 individuals from all fifty states. In addition, it examined data - both published and unpublished - from a variety of Federal and state agencies, the Library of Congress, and the 10-K reports filed with the Securities and Exchange Commission by the six major tobacco producing companies. It was also given access to a substantial amount of cigarette-related data from industry sources. TIMN 431948

The Honorable Joseph H. Young 2. It also drew upon the proceedings of the Third World Conference on Smoking and Health, and papers on various aspects of the cigarette smoking problem from a variety of scientific and medical journals. The Commission's findings are based upon this total input, and its recommendations are the result of its analysis and interpretation of all information and data collected. The Commission wishes to express its thanks and apprecia- tion to all who have helped with its task - particularly the 58 Divisions of the American Cancer Society that assisted the Regional Planning Councils, the witnesses who came to the Public Forums at their own expense, and the Society's Board of Directors for financing this activity and for giving the Commission full and complete freedom to pursue whatever avenues it wished. The Commission believes that cigarette smoking is a clear and present danger to all who smoke, and it hopes that the American Cancer Society and all other responsible forces in the Nation concerned with the well-being of its citizens will help to implement the recommendations contained in this report, which can help people, particularly youngsters, from starting to smoke and assist those who now smoke to stop. Sincerely, Philip R. Lee, M.D. Acting Chairman TIMN 431949

NATIONAL COMMISSION ON SMOKING AND PUBLIC POLICY David Baltimore, Ph.D. Professor of Biology Massachusetts Institute of Technology Center for Cancer Research Cambridge, Massachusetts Benjamin F. Byrd, Jr., M.D. Nashville, Tennessee Merlin K. DuVal, M.D. Vice President University of Arizona Health Science Center Tucson, Arizona Charles B. Ebersol Torrington, Connecticut Marshall Evans Former Vice Chairman, Westinghouse Pittsburgh, Pennsylvania Robert W. Holley, Ph.D. Salk Institute LaJolla, California Alice S. Huang, Ph.D. Harvard Medical School Department of Microbiology Mrs. Robert W. Huff Chairman Interagency Council on Smoking and Health Rome, Georgia Allan K. Jonas Los Angeles, California George Kneeland St. Regis Paper Company New York, New York Philip R. Lee, M.D. University of California School of Medicine San Francisco, California Charles LeMaistre, M.D. Chancellor University of Texas System Austin, Texas Dr. Salvador E. Luria Director, Center for Cancer Research Massachusetts Institute of Technology Cambridge, Massachusetts Baldwin Maull Former Chairman, Marine Midland Bank New York, New York J. Quigg Newton The Commonwealth Fund New York, New York Cornelius W. Owens Former Executive Vice President, AT&T Atlanta, Georgia Mrs. Marlin Perkins St. Louis, Missouri H. Marvin Pollard, M.D. Ann Arbor, Michigan Dr. Robert Shank Washington University School of Medicine St. Louis, Missouri Scott Simonds, Dr.P.H. University of Michigan Ann Arbor, Michigan William H. Wendel President The Carborundum Company Niagara Falls, New York Kerr White, M.D. United Hospital Fund of New York New York, New York Victor Weingarten Executive Director Eileen Lanman Staff Associate TIMN 431950

CONTENTS page Letter of Transmittal National Commission on Smoking and Public Policy INTRODUCTION 1 THE REPORT IN BRIEF ... 3 FINDINGS 3 The Health Hazards 3 The Economic and Social Costs 4 How Many Cigarettes? How Many Smokers? 6 The Government Has Determined That Smoking Is Dangerous to Your Health, But ... 7 Cigarette Advertising Versus Health Education 9 How Many Smokers Have Quit? 10 Non-Smokers' Rights 10 Smoking and the Schools 11 Smoking and the Health Care Community 11 GOALS AND OBJECTIVES 12 RECOMMENDATZONS 14 SMOKING AND THE FEDERAL GOVERNMENT: ISSUES AND ACTIONS 25 CONGRESS 25 DEPARTMENT OF HEALTH, EDUCATION AND WELFARE 34 Food and Drug Administration 40 FEDERAL TRADE COMMISSION 46 DEPARTMENT OF LABOR 51 DEPARTMENT OF DEFENSE 54 SMOKING AND STATE AND LOCAL GOVERNMENTS: ISSUES AND ACTIONS 55 SMOKING AND THE SCHOOLS: ISSUES AND ACTIONS 58 TIMN 431951

page SMOKING AND THE HEALTH CARE COMMUNITY: ISSUES AND ACTIONS 61 SMOKING AND THE AMERICAN CANCER SOCIETY: ISSUES AND ACTIONS 63 LEGISLATION 63 EDUCATION AND INFORMATION 67 SMOKING CESSATION 68 RESEARCH IN SMOKING 69 OTHER ACS INITIATIVES 70 SMOKING AND OTHER VOLUNTARY HEALTH AGENCIES: ISSUES AND CTI NS 71 SUMMARY 73 APPENDIX 77 Names of Witnesses at Regional Public Forums 77 Who Smokes? 94 Cancer Epidemiology, A Summary of Current Information on the 17 Most Common Malignancies 99 Morbidity and Mortality Statistics: National Center for Health Statistics 108 Report of Advisory Committee on Intergovernmental Relations: Cigarette Bootlegging - A State AND Federal Responsibility (May 1977) 124 Federal Trade Commission Report of Tar and Nicotine Content of the Smoke of 166 Varieties of Cigarettes (June 1977) 134 TIMN 431952

A NATTONAL DILEMMA: CIGARETTE SMOKING OR THE HEALTH OF AMERICANS - Report of the National Commission on Smoking and Public Policy rrIMN 431953

1. INTRODUCTION This Report addresses the issues and actions surrounding a single problem -- cigarette smoking -- that represents the most unnecessary and most preventable cause of illness, disability, and death in America. Illness related to cigarette smoking accounts for nearly 10% of the Nation's total health expenditures. In November 1977, Secretary of Health, Education and Welfare Joseph A. Califano, Jr. estimated the current cost of cigarette-related illness to society at a minimum of $18 million. This figure did not include any amounts lost as a result of premature permanent disability or death due to cigarette-related illness or any of the human and economic costs of cigarette-related fires. The Secretary's arithmetic was incomplete because the Federal government has never undertaken an analysis of the real cost of cigarette smoking to society. This Commission was created to take testimony from knowledgeable persons regarding the problems caused by cigarette smoking, to assess the effectiveness of current anti-smoking activities, and, on the basis of its findings, to-recommend new approaches to this major social problem. The Commission's focus has been on public policy, particularly the role of the Federal government, state and local governments, and national voluntary health agencies. The Report is divided into two major sections. The first section is a brief summary of the Commission's Findings, Goals and Objectives, and Recommendations. The second section features a more comprehensive TIMN 431954

2. discussion of current issues and actions in the area of cigarette smoking at the level of the Federal government, state and local governments, schools, and voluntary health agencies. The Commission has also included its recommendations for future action by these governmental and private agencies. The pursuit of health is both a public and a private enterprise. Solutions to the many problems posed by cigarette smoking will require action by individual Americans as well as a continuum of effort by government, business and industry, the health care community, and the major voluntary health organizations. However, the rights of informed adults to smoke if they choose must be recognized. To suggest otherwise would be to imply a prohibition that is neither enforceable nor desirable in a democratic society. TIMN 431955

THE REPORT IN BRIEF ... FINDINGS SMOKING -- THE HEALTii HAZARDS The Commission reaffirms the 1975 finding of the U.S. Public Health Service report, The Health Consequences of Smoking: "Cigarette smoking remains the largest single unnecessary and preventable cause of illness and early death." 1. Cigarette smoking was related in 1977 to: # more than 320,000 deaths; ~ 145,894,000 days of excess bed disability (almost three days more per-smoker than per non-smoker); # 81,360,000 lost workdays. 2. Thirty deaths per hour -- one death every two minutes -- are attributable to cigarette smoking. 3. Cigarette smoking is estimated to be related to 20% of all cancer deaths. ~ 4. Cigarette smoking is estimated to-be related to: # 80% of lung cancer; ~ 80% of emphysema; ~ 75% of chronic*bronchitis; ~ 30% of coronary heart disease. 5. Cigarette smoking is a major factor in most cases of oral cancer and cancers of the larynx, pharynx, and bladder. 6. Cigarette smoking among pregnant women is a major cause TIMN 431956