Tobacco Documents Online

288 CIGARETTE LABELING AND ADVERTISING-1988 military installation of the United States, including, but. not limited to, radio, television, and cinema commercials of all types, newspaper and maga- zine advertisements, billboards, posters and signs, subway and rail or bus car cards, automobile and truck decals, posters and signs, calendars, pam- phiets, handpills, matchbook advertising, and point-of-sale display material of all types; (b) Includes any written material or article or excerpt therefrom, not otllerwise advertising, when used for promotional purposes; (c) Includes labeling, Ilameiy, the display of written, printed, or graphic matter upon any portion of the package, carton, or other container In which cig_ arettes are packaged or shipped by the manufacturer; but (d) Does not include the entertainment portion of any television or radio program. 9r:c. 2. e3igarette" means any roll of tobacco wrapped In paper or In any substance other than tobacco. Rrx. 3. "Representation" means any statement, reference, or claim, express or implied, direct or indirect, whether in oral, written, printed or graphic form, or In any combination of such forms. AaTlcas II THE CODE ADMINISTRATOR $ForloN 1. There shall be a code administrator who shall be a person of rec- ognised independence, integrity, and intellectual achievement to the end that decision by him shall command public confidence and respect. The admin- ietrator shall have all of the powers and authority necessary and proper to enable him to discharge effectively the responsibilities entrusted to him by this code. Sea 2. The administrator shall have complete and final authority to de- termine whether cigarette advertising compliee with the standards of thia code and to enforce this code In all other respects. $eo. 3. The administrator shall appoint a staff adequate and competent to assist sist him in discharging his duties. S_ 60. 4. Neither the administrator nor any member of his staff shali be an officer, director, employee, or stockholder of any manufacturer of tobacco products, nor shall any such person have any financial interest 1n the business of any sucb manufacturer. Ssc. 5. The administrator Is authorised to convene scientific advisory panels to enable him to carry out his duties. Persons selected for such panels shall be of indelxndence, integrity, and competence In their particular areas of scientific discipline. In seiecting such persons, the administrator may consult with appropriate governmental and private agencies such as the U.S. Department of Health, Education, and Welfare; National Academy of 8ciences; National Research Council; American Medical Association; Scientific Advisory Board of the Council for Tobacco Research-U.S.A.; medical and scientific societies; colleges and unlversities • and nonprofit research inst[tutes. Bso. 6. The administrator shall by regulation establish procedures for the administration and enforcement of this code including, without limitation, procedure for- ;(a) The submission to him of proposed cigarette advertising which, to-r gether with Uny supporting data or docmnents, shall be kept confidential, except as otherwise provided In article IV, section 4, of this code are as agreed to by the submitting party , (b) The submission of protests by parties subject to this code concerning any determination by him ; (c) Hearings In connection with all submissions and protests; and (d) Reconsideration by him of any of his determinations. AsTral.s III ADVERTISING CLEARANCE SacTIoN 1. No cigarette advertising shall be used unless such advertising sball first have been submitt.ed to the administrator and determined by him to be In compliance with the standards of this code; provided that by regulation promul- gat.ed by the administrator specified advertising may be excepted from the requirement of such submission but not from the requirement of compliance with the standards of this code. CIGARETTE LABELING AND ADVERTISING-1965 289 AaTIOLic IV ADVERTISING STANDARDS SECTION 1. All cigarette advertising and promotional activities shall be subject to the following: (a) Cigarette advertising shall not appear- (i) On television and radio programs, or In publications, directed pri-o anarily to ixersons under 21 years of age; (ii) In_ spot announcements during any program break-tn, or during the program break immediately preceding or following, a television or radio progriam directed primarily to persons under 21 years of age ; (iii) In school, college, or university media (including athletic, theatrical, and other programs) ; ( iv ) In coalic books, or comic supplements to newspapers. (b_ ) tiample cigarettes shall not be distributed -to persons under 21 years of age. (c) No Kample cigarettes shall be distributed or promotional efforts con- ducted on school, college, or university campuses, or In their facilities, or In fraternity or sorority houses. ,(d) Cigarette advertising shall not represent that cigarette smoking is essen- tial to social prominence, distinction, success, or sexual attraction. (e) Natnral (K•rsons depicted as smokers In cigarette advertising shall be at least 25 years of age and Shall not be dressed or otherwise made to appear -to be less than 25 years of age. 1'ictitious persons so depicted in the form of draw- ingy, sketches, or any other manner shall appear to be at least 25 years of age In dress and otherwise. (f) Cigarette advertising may use attractive, healthy looking models, or il- luatrations or drawings of persons who appear to be attractive and healthy, provided that there is no suggestion that their attractive appearance or good health is due to cigarette smoking. (g) No cigarette advertising shall contain a picture or an illustration of a person smoking In an exaggerated manner. (h) Cigarette advertising shall not depict as a smoker any person well known as being, or having been, an athlete. ( i) Cigarette advertising shall not depict as a smoker any person participating in, vor obviously having just participated In, physical activity requiring stamina or athletic conditioning beyond that of normal recreation. (j) Testimoniats from athletes or celebrities in the entertainment world, or testimonialy from other lersons who, in the judgment of the administrator, would have special appeal to the persons under 21 years of age, shall not be used In cigarette advertising. SECcrION 2. No cigarette advertising which makes a representation with respect to health shall be used unless-- (a) The administrator ehall have determined that such representation is significant in terms of health and te based on adequate relevant and valid scientific data; or (b) If the administrator shall have determined it to be appropriate, a disclaimer as to significance in terms of health shall be set forth in such advertising in substance and form satisfactory to the administrator; or (c) The administrator shall have determined that the representation with respect to health In such advertising is not material. RF.cTION 3. The inclubion In cigarette advertising of reference to the presence or absence of a fllter, or the description or depiction of a filter, shall not be deeuicd a rePresenlation with respect to health unless the advertising including such reference, description or depiction, shall be determined by the administra- tor to constitute, through omission or inclusion, a representation with respect to health. If the administrntor ehaH have determined that such advertising constitutes a representation with respect to health, the provisions of section 2 of this article shall apply. RF:crlox 4. No cigarette advertising shall be used which refers to the removal or the reduction of any ingredient in the mainstream smoke of a cigarette, except that it shall be permissible to make a representation as to the quantity of an ingredient present in the mainstream amoke or as to the removal In toto of an ingredient from the mainstream smoke, or as to the absence of an ingredient normally present In the mainstream smoke, if- (n) The administrator shall have determined that such representation Ez~969?'OOt

290 CIGARETTE LABELING AND ADVERTISING--1985 is aignificant in terms of health and is based on adequate relevant and valid acientiHc data ; or (b) A diaclaimer as to signi6cance in terms of health shall be set forth in such advertising in substance and form satisfactory to the administrator; or (c) The administrator shall have determined that a disclaimer is nn- necessary for the reason that the repnwentatiim in such odvertisiug has no health Implication or that such implication is not material; and (d) The quantity of such Ingredient is determined and expressed in ac- cordance with uniform standards adopted by the administrator for Ineasur- ing the quantity of the ingredient present in the mainstream smoke, provided that., until sueh uniforiu standard is so adopted, the quantity of such in- gredieut may be determined and expreseed in accordance with any recol,lizt.d ticientitically valid method disclosed to the administrator without any re- quirement of confidential treatment. .qECTION b.Any advertising determined by the administrator to be iu con- formity with the crode may include the following legend: ''This advertising (label) conforms to the standards of the Cigarette Advertising Code." ARTICLE V PROCEDURES IN EVENT OF VIOLATION OF CODE SECTION 1. Any person, firm, or corporation subject to this code, who violates any provision of this code, ahall, in the discretion of the aduiinistrator with resilect to eaeh such violation, pay to the office of the atlniiniatrator as liquidated dumage5, and not as a penalty, a sum, not to exceed $100,000, as determined by the administrator after consideration by hhn of all relevant facts. The admiu- lstrator shall extablish regulations for the determination of such violation a[ul for the assessment and payment of such damages. No sanction shall be imposed without affording a hearing to the alleged violator. Ulxm written request from the administrator, an alleged violator of the code shall promptly deliver to the administrator any material and diicunlenta in its phs.yer4siou which are relevant and material to a determination by the administrator as to whether the code has been violated. SEOTION. 2. Nothing herein contained shall be construed to give any hersou, firm, or corporation, other than the administrator, any cause of action. SECTION 3. In the event of a violation of thiA code, tho administrator in his discretion may make public the fact of such violation in such manner as he may deem appropriate. The CiiAIRMnx. Do you know if Governor Meyner plans to come down and testify? Mr, IiAMM. 'the latest I heard- Mr. GttAY. This is Mr. Ratnm, general counsel of our company. The CHAIRMAN. 1 begyour pardoll ? Mr. GnAr. Mr. Ramm, who is general counsel of the Reynolds To- _ _ bacco Co., and I will turn Itt over to him. The CllnrxMAN. Identify yourself. Dir. RAaTrz. My name is IT. H. Ramm, vice president and general counsel of It. J. Reynolds Tobacco Co. Mr. Chairman, the latest information that I had wits the the Gover- nor would be glad to come if the committee desired his appea.rance here. IIe did not think it would be proper for him to conlo wltliout a request. The CHAIRMAN. The committee alway s leaves it to the discretion of the people who may have an interest in legislation whether or not they should come. We do not require anybody to come before this cont- mlttee on legislation. There n~ay be some other (;ircnnlstances untier which we require pe.ople to come but we do not, as a matter of polirv, do it in the case of legislation. I should think, however, a man with CIGARETTE LABELING AND ADVERTISING-19G5 291 the tremendous responsibility that he has, and in view of the fact that tlle code has only recently been adopted-what was the date of it? Mr. RAMM. It went into effect ofltcittlly on the 1st of this year. The CI[AluMAN. It would at)pea.r to me, speaking just as one indi- vidual, that without complete information on the self-regulatory pro-f gr~tm that is proposed the committee record will be incomplete. We llall the same kind of a situation in the television code of 195211 be- lieve. Mr. RAMDL Mr. Chairman, if I may say so- '1'he CHAIRMAN. If anyone with far-reaching responsibilities as we have here and with a program that has been proposed suc1l as this, or does not feel his testimony should be in the record so that we mi},*llt have the benefit of it, I am not too sure what can be expected if sueli a program and whether it should be considered to be too effective. Mr. RAMM. If I may say so, Mr. Chairman, I will convey these re- marks to hiin, and I am quite sure lIe will be happy to attend: The Cltn.ntMAN. Mr. t~rray, I am not altogether sure just what you have recommended, if you will pardon me for putting it this way. I suppose I have a right to be a little fuzzy right now in mind. You say, if there is anything done, you want the Congress to do it but you are against the G°ongress doing anything. Now, we are facing the situation here where the hederaT Trade Commission has already taken action. The Chairntan of the Commission has made it pretty clear to tlm committee in the last few days that they intend to go ahead. 1 wonder if I would be stating your position correctly that you would prefer for the Congress to consider this Inatter and to prohibit the Federal Trade Commission frotn doing oing what it is attempting to do. As an alternative, if that is not done, being faced with the proposition of the Federal Trade Commission going ahead, then you would want. the Congress to take some action requiring a specific warning on the label but not in advertisements? Air. GRAY. I am sorry; I did not, Mr. Chairman, make myself clear in my thinking on this. The CHAIRMAN. I think you have made yourself clear as to what yon would like to be done. But to me, we llave a paradox. '1'hat is whslt has me a little confused. Mr. GRAY. I think it would be only natural, sir, for me to-may I put it this way : If we are faced with the question not of whether, but of which, is this getting into the nrea that you are talking of here now, sir? If the question is not whether we are to have a labeling enact- ment or tracle rule reh ilation put on us, but rather that if it is going to be required, then I have said, sir, and I repeat c This is a matter, in my opinion, to be handled by the Congress and the Congress alone and in handling the matter, Congress should make it clear that its action preempts the field, that t•he label required should be spelled out by the Congress as well as its location and size and so forth, on the packages upon which tlie statute would require the label to be carried. Now, I am not, trying to confuse you, slr; this is my p(>t•sit.ion. This is not n t ime to tell fnlu)y st.ories-I just thought of one which would be applicable. The CIiAIRMAN. We will let you go off the record if it will give us a little levity at this time. [Laughter.] (Discussion off the record.) Dzs9ss~ ooZ

292 CIGARETTE LABELING AND ADVERTISING-198b hlr. GRAY. It seems fairly obvious, sir, I am back with you now, if I tuny be, that there is great pressure froni mn.nyareas for some kind of lalwel to be placed on packages of ci;arettes being of a c:wtiona.ry notice in the area of possible injury to the health of some people. .1a~uming that this is something has to be or is roing to be, now I will say that I greatly prefer-and I am certain it. is a position shared by t.ho other members of our industrv-I say that this is such a serious matder that it shoulcl be handled by the Con~,•Iess, determined hy the (bu;-rc:4s, spelled out, by the Congress, and preemlited from all ollier people by t,he Congress. Is that un answer, sir, that I may make to you? Does that clarify the sit.uation? The ('tlAHtrtAN. Well, I would get from that the implication that being, faceal witlt the situation of the aunouncentent of the Chairman of the Federal Trade Commission, •you would recommend that the cotn- nlittec, tl.y to work out so,ile kind of legislative approach in order to clear t.he matter up. ALr. Ginr. This is correct, sir. 'f he CHAIRMA N. Mr. Rtogers ? .llr. Iioi:ERS_ of Texas. Are you a lawyer? ~ir. GRAY. No, sir. DL•. IiooERs of Texas. The reason I asked that is this: In reading Yotu• statement and in listening to it, it occurre.cl to me that probably in view of the situation that has developed, though you did not antici- pate that the subject would ever come up, in view of what has oc- curred, you should probably anticipate the possible "alligator in the batLtttl;" if we can refer to it that way insofar as State governments or municipalities are coneerned in the future. As I uuclcrstttind Alr. Rand I)ixttn's position, it is this: That although lie is moving into the area of adopting trade rule regulations, which to me is legislating but which to him is not, that whatever he does in this respect, does not invoke the doctrine of preemption insofar as other agencies of the Gov- ermuent are concerned in making rules and regttlatic;ns. Ilence it would occur to Ine that if you take the position that no statute should be passed on this, you can find yourself in a situation of riinning tt very great risk of having souie of tliese things happen to you that, you do not, want to 1Iappen. 1Lr. GR.+Y. This, sir, I had lioped I had covered in the third recom nteud:>,tion on pages 16 and 17. That the statute should make it spe- cilir, .ve believe, thst. section 4, which deals with 1ireetnpt,ion, section 4 of S. 559, which deals with preemption, should be atnendcxl by the addition of a sentence which would make clear that no Federal, S"tate, or ]tx~al authority may impose a warning in advertising for cigarettes pacJ:agetil in confiormit.y with the labeling provisions of the act. Earlier I asked-I suggested that the statute, if written, preempt the field so far :ts labeling of any kind either on packages or advertts- iug is concerned, and the matter should be handled entirely by the Cont!ress, mr. ItalERS of Texas. But, as I understand you, you are asking-you a t e sa.y iii;; that no st;tt ute needs to be passed :in~l that you are in oppo- sition to the bills that have been offered requiring a labeling on the package. NIl'. I\E7RIrEG.\Y. Would the gentleman yleld ? i•Ir. hciutins of Texas. Yes; I would bellappy to. CIGARETTE LABELING AND ADVERTISING-1985 293 Mr, KoxNEOAr. I draw the attention of the gentleman to page 2: We do not Lelieve that any governmental action is necessarv or called for with r"xr:t to the cigarette advertising or labeling. I might ]'ust. sn~•gest. Mr. Gray means there any type of Government action by tlte FT~, C;onbress, or anybody else rather than anticipating Congress to act.. Mr. RoaERS of Texas. What I am going back to is the point raised by the chairinan is the situation the Congress is faced with at the present time is that there has been a statement by the Federal Trade Commis_sioil announcement that they intend to move into this field. If they do not move into this field or if they do move into this field, it occuts to me that the municipal corporations and the States could move in, whether either of these Federal bodies moved in. IIence it occurs to me, 11Ir. Gray, that to put it very bluntly, the Congress of the United States is being challenged insofar as their le;islative lwwers are concerned, and that is one of the very deep issues tiutt I have in nund in introducing legislation of this kind;tnd in trying to see that itt is brought into bearing. I do not smoke. It, does not make any difference to me one way or the other, I mean. I just wanted to clear that point, that I think we have here a situation that goes much deeper than the question of ec,clnomics or actually of health. Mr. GttAY. Do I understand you correctly, sir, that the challenge is from these other agencies? Dir. RocElts of Texas. Y es, sir. So I am simply pointing out, :1Ir. Gray, that I think it would be to the interest of everyone-and I am not talking about cigarette smokers or cigarette manufncturers-but I think it would be to the interest of every citizen of the United States that this matter be cleared up and this challenge to the legislative powers of the Congress, however you put it, ought to be answered and answered at this time. Tlult is all I ltave. T1lank you, Mr. Gray. Mr. GRAY. Thank you indeed, sir. The CHAIRMAN. Mr. Younger. Mr. YouxGLR. Thank you, Mr. Chairman. Mr. Gray, in view of the fact we are confronted with an nction that has already been taken and the date set, is it your idea that you might conth+st the action of Congress in the court better than you could cotitest the action of the Federal Trade Commission? Mr. GaAY. I don't believe I have been in that area at all, sir. I have no ideas of doing that. Mr. YOUNGER. You never discussed in your organization whether or not you woulcl contest the action if Congress did nothing and that you would allow the Federal Traule Comnlission order to stand and not go iut,o court d Mr. (i•RAY. I misunderstood your question sir. I thought you asked me had we planned to contest an action of Loitf;ress and it hael me off base a bit. I have already stated if the Federal Trade Commission does putt into etPect this trade regulation rule we will oppose it and oplwse it. in the courts, yes. sir. I wasc'onfuseaasto.vhttt,youasked. 11ir. YouNctt:it. You ha~•en't decided whether you would oppose the cout;ress ioual action i f(;onsyress acts ? szsss9zoot

294 CIGARETTE LABELING AND ADVERTI$ING-198b 11ir. GRAY. I have not heard it even discussed, sir. Mr. Youxcl:R. I thought maybe that in view of the, some of the Supreme Court. actions against Congress that you might feel that you would stand a better cllunce in the Supreme Court against (.',on- gress than you would against the Federal Trade Couunission ? Mr. (~RAY. That honestly is one that never has occurred to me. Mr. YouNar:R. Thank you, Mr. Chairman. `Phe CILURALAN. Mr. z17lTnntn? Mr. JAxMnrr. Mr. Gray, my concern is particularly in the field of the youtll of the country and the need for protection and education in that. field sis to all aspects of smoking when they come to the time of dec.idinl; whether tostartsmoking ornot. I wn particularly interested in that part of your statement where you s;Iy that tobacco colrLhanies lulve at;reed to adhere to the cigarette tldvertlsul=; code. In lookiilh over t,he code it sets out under adver- tising stsuldards under article 4, ciharette advertising shall not, appear on television and radio programs or in publications directed primarily to persons under 21,years of ~Ige. I{ave Governor 1lfeyner and others who have the responsibility of enforcing t he code, have they as yet come up with any list of programs that would fit thnt category . Mr. GR..Y. I think, 5ir, that the Governor's actions so far, and I believe his plans in the future, are to review, to look at, to judge, to assess each program, each advertisement each promotional advertising of eacli coiupany prior to t.he time it is ailowed to be printed or shown, and that, tht.rv is no, as far its I know, there are no broa<1 bases or specilications that govern this. You know, of course, that certain programs-I am sorry I don't look at, the younger ones very much, Lassie, for example, wouid not be a proper, in my opinion, I don'tt know the Governor's opinion, I have never dlscassect it with him, a proper program for us to sponsor. I think each one must be judged as to its content and so forth, and where it seems to be directed, what type of audience it seems to be directed toward. Mr. JAn-Mnrr. One great di0iculty I can see in trying to enforce an effective standard in t lat field, particularly with these words "directed primarily to persons under 21 years of age" being, would be, in so classifyinh programs on televislon and radio. I know Chairman Dixon at page 9 of his statement referred specificall to one program, the "Beverly IIlllblllies," as havin an audience ochildren 2 to 12 years of a1;e ec~ual to 12.6 million or aut 28.8 percent of the children of the United States of that age group. And yet with reference to that program and nearly every other, the westerns, the variety shows, I would think a very clear-cut argument could be made that the program itself has a widespread audience of all ages, and does not come under the prohibition of the code because it is not directed primarily to persons under 21 years of a e. I would think, to put it another way, that a very~imited number of programs would come within the definition of the code. Mr. GRAY. I have not. seen, I suppose it is available, Mr. Jarman, the infornultion available of breakdowns of audiences by all the shows on television, and I guess I should not make uneducated guesses here, should I, this is not t]Ie. place for that. But when an advertiser looks at a pilot film, perhaps in December or January, of a show that is pro- szsssszooi CIGARETTE LABELING AND ADVERTI$INQ-198ti 295 posed to go on the air in September, and he makes his judgment as to whether this is something that he thinks will be a good show, and this is the judgment which he has to make, and he contracts for a portion or all of that, show, he is taking a chance on a lot of things as to what will eventually turn out. 'I'lIe program to which you refer, it happens to be one of ours, and this in indicative of how infallible a man's knowledge-judg- me.nt-can be. When I found out that we had bought this show and I saw the pilot, I was not a very happy man-not from the reasons you ascribe to it but because I thought it was a terrible show. I just thought it was awful, and it went on that year as you may know turned out to be the No. 1 show. There isn't any slide rule to get at it, I am sure. Mr. JARMAN. Just one other question at this time, Mr. Gray. Since the adoption of the code by the tobacco companies has there been time enouah for the code to have any effect on the television pro- grammgof the companies? Mr. (xRAY. If by that you mean have any of us gotten off any shows as a result of this, no. I think, here may I speak for my own com- pany, I don't know about the other companies-I know the intent- I know their honor and int.egrity. I don't know the actual mechanics about how they go about these things. Naturally all of us knew this code was coming. We were hopeful it could be gotten into operation as soon as possible and I know we and I believe my competitors3 each were lookln- all through last year at• our prorrnlns, at our projections and our I~ans with the code in mind and, as a result of t}Iat, prior to its implementation a number of changes in our approaches toward advertising had already taken place. Further, if I could say, in the area of our participation in this code effort., this is a serious and wholehearted attem~pt by the industry and by each individual member of the industry, to do this ,'ob right. This is our intent and we plan to continue in that-on that basis. Mr. .JARMAN. I said a final question a moment ago, this will be the final question for me, sir: Do you know whether Governor M6yner in administering the code has in the field of advertising enforced this provision as to a television or radio program directed primarily tA-persons under 21 years of age? Iias there been occasion since the adoption of the code for him to on force the code_ in that area ? Mr. GRAY. I can speak to only one company here, sir. Perhaps the way- we communicate with the Administrator might be some- what clarifying in this situation. I nm the head of one company. I have shaken hands with the Administrator one time so I could put a name with a face. I have made no visits to his office, he none to mine. This is handled through the lawyers and through the adver- tisingmanaqers. So far as we are concerned we have had many ads which we sub- mit,ted for approval, which after consultation we,decided we wanted to make changes ourselves. We have not been told that I know of "You shall get x program off the air," or "Don't buy something that is contemplated." It may have occurred. I have no direct knowl- edge of it. I believe it would have been reported to me but I have .,~

296 CIGARETTE LABELING AND ADVERTISING-196b no such report. I think it is better for the heads of companies not to be yakking at the Governor's heelseveryday. Mr. J ARMAN. Thank you. Air. GRAY. Tllank ypou, sir. The CIIAIRMAN. E1r. Calter g Mr. CARTER. Certainly I think the tobacco industry is to be con- gratulated for the money which they have given to many scientists throughout our country to conduct research regarding tobacco smok- ing and health. it amounts to many millions of dollars. I think that it should be applauded for that. Mr. GRAY. i hank you, sir. The CuAIRMAN. lilr, I;;orneg ay. l1ir, KoeNEUAY. Th.~nk you, ltir. Chairman. First I would like to give welcome to my fellow North Carolinian here tocIa,y. I pelsonally thank you very much, Mr. Gray, for coming and for the fine statement which you presented to the committee. I think you have very ably pointed out the facts to the committee that this is a rather bi~;, broaa, and serious matter that we have under con- sideration hem and that it involves a good deal of people, not just in North Carolina-but throughout the country, from the standpoint of employment, from the standpoint of jobs, from the standpoint of taxes going into the Federal, Slat.e, and local treasuries. In light of this, certamly the Congress should exercise every ounce of -,%•isdom it has in approaching the matter. Now,llir. Gray, I would like to ask you severalqu~estions. First, I would like for you to amplify a little bit on the amount of money and the effort that the tobacco industry itself has put into the area of research insofar as cignrettes and smoking are concerned. Mr. GRAY. To amplify on this, sir? Mr. KORNEGAY. Yes. You made reference to it here in your statement concerning the council. Mr. GRAY. The Council for Tobacco Research which is supported by the manufacturers, most of the funds come from the manu- _ facturers. Mr. KoRxF.aAY. The funds that are used by the council come ex- clusively from manufacturers; do they notI l1ir. GRAY. Practically entirely, sir; yes, sir. I know of no other rontributions of any size that it has received. That is, as you know or as has been stated given to the council for use by or awards being made by the scientifie advisory board to the researchers, scientists, qnalified medical and scient.ific researchers throuMhoutt the country. 7'hey are free to publish what they find, are requested to publish what they find. There are no strings on these grants, there have not been any from ttle beginn;ng. I do not• know of any time when the scientific advisory board has been turned down on arequest for funds from this group. In addition to that I have mentioned the gn•ant, by the six major cigarette companies of $10 million to the TJducation and Research Fomndation of the American Medical Association. This was without strlllas. '1dditionnlly, many colnpaLmes, I snppose all of them, have over the p;l-t, few ,ye:u-s made in(lividual grants Io Sloa.n-Ketterint;, Danion 4zsssszooi CIGARETTE LABELING AND ADVERTISING--196b 297 Runyon Cancer Fund, and the specific projects that may be presented to these companies for research into this field. These are beyond the figures I have mentioned. Several of us, again perhaps all, have continuously given moneys to medical schools - for r research and for medical education. I do not have any total figures on this. It goes well into many millions of dollars more than we have talked about this morning. We feel this is proper, a proper use, of such moneys as we have in that area. Mr. KoRNEGAY. In addition to the money that you described going to actual research on tobacco programs, what other philanthropies, other areas of support of education, and cultural life has the tobacco indu5try participated in over the past years$ Mr. GRAY. Sir, getting into that in detailed fashion would take quite a lon~,• time. The various companies each individually are, have been for years, I think generous, proper in their contributions to education at, tlle university, at the college level. It is difficult for me to talk about all the companies because I am not as familiar with w1lat they do as I am with our own. If I anI not hurting anybody's feelings by talking about Reynolds a little bit and I will include them l>.y reference, there are just so many things that you can and do do. The opportunities are greo-tit. For example, in our own State, Mr. Kornegay, we have a joint col- lege appeal, as you know, for church-related colleges each year. This is a combined effort, I believe it is 22 colleges-24 colleges now-to which we, and I think the other tobacco companies, in some relation- ship to the activities in the State, give money each year. I believe our contribution for the past 3 or 4 years has been a hundred thousand dollars a year. This doesn't seem like much, but in these-in these halls but in North Carolina it is quite a few dollars.. Dir. KORNF.(3AY. Let me pinpoint two or three points, Mr. Gray. No. 1, the Reynolds family has endowed Wake Forest College, is that correct, sir? Certainly assisted in it. Mr. GRAY. A large portion of the endownment of Wake Forest College calne from the Reynolds famil~. Mr. lfoeNEa:~Y. Came €rom the family. Mr. GRAY. This is right, from the family. 11:r. I{o>;xrxsAY. The Wake Forest medical school which up to 1940 I believe was a 2-year medical school is now honored by having your name, the Bowman Gray School of Medicine, is that right, sir? :1Zr. GRAY. That was named for my father. D'Ir. hoRNEGa,Y. Yes, sir; it is now certainly one of the finer medical schools in the conntry. I will direct your attention to Duke $niver-y sity which was endoned b another company but still a tobacco_ com- pan,y; is that notright, sir~ Mr. GRAY. That is correct, sir, and has been supported by more than one company since then. Mr, KonxeaAY. Yes, sir. Mr. GRnY. More t han one company. Dir. KoRNEGAY. The University of North Carolina gets a consider- able ptimount. of inoiiey f ro]n the toll>tu,co companies. Mr. GRAY. Thore nre rraits being made all the time from manu- facturers to the North Carolina State College and its extension work 48-824-6b-20 . ~„ „ i

298 CIGARETTE LABELING AND ADVERTISING-1985 that they are now doing. I am talking all the way about North Carolina, and I am trying to figure out something we do in Virginia. We do give something to the Virginia Association of Church Colleges, too. There are just many of these. Mr. KoiiNFA)AY. My point was that for nearly over a week now we have heard people talking about tobacco and some of the sins they contend it is guilty of, and I thought it was time maybe to bring out some of the very fine things the tobacco companies have done. I want to thank you again, sir, for coming up and being with us today. Mr. GsAY. Thank you, sir. Mr. IioeNF,oAY. That is all, Mr. Chairman. 'I'he CIinniMAN. Air. Callaway. Mr. CALLAWAY. Mr. Gray, I want to join Mr. Kornegay in pointing out some of the notable contributions of the tobacco industry in Geor- gia. It is agricultural more than connmercial. I would like to go back to the point Mr. Jarman was making, and this is the problem of our youth. I think there are a great-many people in this country who are convinced and extremely worried be- cause_ they believe genuinely that tobacco is a serious hazard or there may be a serious hazard in smoking tobacco. The people I am talk- ing about are not so concerned about adults. Adults can read the record, they can read the Surgeon General's report. They can do- cide for themselves if they want to take this risk they can evaluate it. Most people are worried more about their children. Certainly the best way to solve this is with a voluntary code. But it seems to me this code may not go far enough for people who are concerned about their children. My children just love the_ Camel sign and it seems to m~-and I would like to ask this in all fairness, because I would like your reaction-how can you as a tobacco industry take any position except the position you have got to get the youth of today smoking tomorrow, and no matter what this code says and no matter what you do, how can you do anything except see to it that a large majority of today's children smoke tobacco. It seems to me that this is your obli~~a.tion as a businessman running the R. J. Reynolds Tobacco Co. IHow can you advertise without showing cigarettes to youth and without attempting to get youngsters to smoke F Mr. GRAY. Sir, we are not for getting the youth to smoket I want to make that plain right now. It has always been our feeling that smoking, the decision to smoke or not to smoke is one for an adult a person of adult stature, and it is his decision or her decision and theirs alone at that time. I would agree with you if this is part of your thinking that there is little likelihood that any advertising that any- manufacturer of any commodity might do not being seen, the likelihood of not being seen by just about everybody in the country who reads or looks at television. I know of no way that you can blackout this reaching, peo~le being reached by it or people seeing it. I-Iowever,the appeals in the advertismg the cigarette manufacturers are doing today are directed toward the adult mind and the adult popu- lation. Today the posture of advertising with us, the use of adver- tising, the meaning of advertising, the reason you spend your dollars in CIGARETTE LABELING AND ADVERTISING-198b 299 it, is not now to increase the number of people smoking. Millions, more than half the people, I suppose, in the country todayt adults, do smoke. I know what my intent, our company's intent is, which is to try to get some more business away from some of these guys we are fighting, and this is where we are going. This is basically where we have to get our growth. Our competitors are very nice people, but they st,illl are competitors, and I want to get every dime's worth of business awa from them that I can_ They understand that, this is nothing now. ~Laught.er.] But I sup se that-golly, you are getting down into psychological - evaluations here, Mr. Callaway, that I have had little experience and little training in. What does an advertisement do to a 3-year-old 9 I do not know. I am sure-.4ell, when lie is 6 he c:ui read, can he not4 Mr. CALLAWAY. Well, yes. My main confusion in this concerns your g ram which is bound to be approach to any kind of advertism rog predicated on the premise of "let us sellpmore cigarettes-of course you would like to take sales from your competitors, xou would like to take them anywhere you can. It is a com etitive busmess, but based on the premise "let us sell ~nore cigarettes,p'' which is ceitamly the premise of your advertising or you would not be doing it, how can it not be ap- pealing to the 14-, 15-, 16-year-old4 This seems to be the purpose of it, and I do not see how with any voluntary code we are going to solve this dilemma. It seems to me you are always going to do this with your advertising. Mr. GunY. I will agree with you there is no prohibition of anybod,y reading our advertisting as to age or as to sex; and I do not think there can be, and if that is where you are going, I think I will have to go with you. Mr. CALLAWAY. Let me ask you one final question if I may. We have had some testimony and you mentioned the fact if we take some kind of action requiring you to state in the advertising the fact that it may be hazardous, this kind of thing, it might be self-defeating and might in effect say there would be no cigarette advertising. If this happened, in your judgment what would be the effect on the sales-how drastic would it be;-how dramatic if there were no more cigarette advertising in the United Statesg Mr. GRAY. It would, No. 1, have a tendency-and I think here you are going against the philosophy of equal competition. It seems to me that if a man does not have an opportunity to advertise his product in an effort to increase his share of that market which exists, it would >ossibly and ve likely have a tendency toward freezing the sale by rands very muc : in the area where it is today, and this would mean that the man who had less business, his opportunity for getting more business away from the guy who had more, is greatly diminished. This stifles or restricts competition and the opportunity for competition. As to what overall impact it might have on the sale of cigarettes immediately or over the long term, I guess I would have to say that I remember a man named William Wrigley who made-he is dead now-e he founded a business making a now very famous consumer product. He was asked one time "What would happen to your business if you stopped advertising I" And, as I recall, his answer was "Did you ever think what would happen to a railroad train if you took the locomotive off ?" This happens. gzsssszooi

300 CIGARETTE LABELING AND ADVERTIBING-1986 I said in my statement that advertising is an essential commercial right.. Whether you do it by prohibition or by forcing the advertiser to so stultify, negate, disparage what he is trying to do is not too much different. In any of these events you put a businessman who is spend- ing his money for advertising into a situation where I think his judg- ment must be "I cannot spend this type of money advertising if thls is the kind of advertising I am going to have to have." You see, sir, a large amount of money spent in consumer goods ad- vertising today, whether it is tobacco or any other kind, goes into network television. This is a tremendous mediuin for us all. In tele- vision you have generally three types of commercial announcements. We all started out initlally, I suppose, with the 60 second, which was the longest you had. This is what you had, 60 seconds, and then as the pressure for time and mentions and impacts becamo greater, they got down to 30 seconds, now 20 seconds, now 8 seconds or identification situatlons which you have seen on television. In the case of a cigarette we use lots of the 8 second, we use lots of the twenties and the sixties. I have not timed it, but. I wonder how many seconas would be left in an 8-second or even in a 20-second spot for saying you will like Salems if meanwhile you had to read into this same 8 seconds the language which has been proposed in the various bills that are here. I think it would destroy the need for, the opportunity for, and the reason for our using this kind of advertising, and when you begin de- stroying the value of it, I think you destroy the interest in or the use- fnlness of or the intent or desire of a manufacturer to pay for it. Mr. CALLAWAY. Thank you, sir. Mr. GxnY. You are welcome. The CHAIRMAN. bir. Satterfield. Mr. SArrERl+IFa.D. I have no questions, Mr. Chairman. The CHAIRMAN. Mr. Farnsley. Mr. FARxsL>;;Y. Thank you, Mr. Chairman. All this money has been given to researchers, but I am sure you have given the mouse population a hard time. But this is a secondary effect. Mr. GRAY. I read a little bit about it this morning or was it yesterday. Mr. FARNBLEY. I have been getting one almost every day in the paper. I have been trying to find out what happens to the warnings you put on the product. The only information I have got from my psychiatric friend who testified for Bromo Seltzer some years ago, and they made them-the Iiromo Seltzer people said "What do you want us to do?" Well, the said "Cut: down the amount of bromine," they can but a warning la~ei. They may have played it smart,. It says new improved formula on that bottle, and then it has got. the warning, but my information is that their sales went up so much that their stock doubled in value in a year. Have you all got any dope, has anybody ever tried selling cigarettes with a warning label on it g Ilas it been done by law anywhere in the world ? Alr. GRAY. No, sir, not to my knowledge. I think not. And we have no firsthand knowledge ge of what would happen, because we have not t tried it. either. Mr. FARNSLEY. You have not tested the market of whether it is going to. sZS969zoot CIGARETTE LABELING AND ADVERTISING-196b 301 Mr. GRAY. No, we have not. Mr. FARNSLEY. Shucks, I do not want to tell you how to run your business, but. I have some psychologist's background ? 11'(r. GRAY. I did not, sir. Mr. FARNSLEY. I:xr>erlence, excuse me. Mr. GRAY. I have llnd no training in psycholo~y whatsoever. Mr. h'ARNSLEY. 1•:xcuse me. I thouhht you said you had. I understand in Italy they have stopped advertising, we were told this, they cut down the rate of growth froni 6 percent to 1 percent. Do you know anything about, that situation? Mr. GRAY. There are some figures available, sir. I do not have ihem here, sir; I think they are available at the Departnient of Agri- cult,ure oii just what did happen there. I have seen them. I was not aware thut• any such slow do«•n had taken place; at least the figures I s_ aw would indicate that. Mr. FARNSLEY. Could you send us some figures that you know about without too much trouble? Mr. GRAY. I will see we get those from Department of Agriculture :and get those to you. Mr. XORNF.(iAY. Vi'ould the gentleman yield? I have those some- where, and I understood they just label the imported cigarettes in Italy. The tobacco monopoly did not advertise, anyway. I Mr. GR.AY. They do not label anything, I believe, sir, as to health there. 'Mr. ICoRNEn:%Y. No, I am talking about the advertising. lFr. GRnY. Well, the history of that I can give you. I have the fi ~I1rPR. I do not know. The history is thnt some ,yeare ago the Inonopoly-and -,on nnderstand the cigarettes legally in Italy at least are sold throngh a Government monopoly- Mr. Mr. FARNSr.r:Y. I (lid not know that. Mr. GRAY. Mann factured and sold. They also sell a lot of cigarettes there that, are not• made there but are imported by the monopoly for sale in Italy and manufactnred in other areas. The monopoly dlscon-7 t inue~d advertising on its own brands, and the figures show. diat t.heir own brands did decrease but that was more than made up by splendid increases enjoyed by foreign manufacturers who were selling their cigarettes in Italy, and of course still advertising and so then they ruled that nobod,y coul~i advertise cigarettes hoping that this-i as- snlne hoping that this would cut down on the foreign ones, but I believe these figlres-if 11fr. Kornegay has theui-will show that the sale of the foreign-made cigarettes has continued to increase even though the advertising on them was forced to stop some years ago. 1[r. I'iARNFLEi-. Whrch would indicate that a new brand could pene- trate tlie market. Mr. GRAY. No, these were brands already on the marltet.. ~Ir. FARN9LEY. I see. But they have increased their share of the nia.rket, with no advertising. Mr. GRAY. As against others with no advertising. There you gret into qnality. I do not think-I am talking about my competition 1tQaln. Mr. FARNSLEY. Go ahead. Mr. GRAY. There is a great difference in the quality of cigarettes in aomo of the foreign countries that are for sale. I personally think

M 302 CIGARETTE LABELING AND ADVERTISING-.19t1b all the cigarettes that are manufactured in the United States and offered for sale here are good. Some are just better than others, but they are all good. Afr. FARNSLEY. Everything manufactured in the United States is good. Mr. GIt1.Y. No doubt about it. I think that is all I want to say about it. They do still have a great deal of smuggling going to there, that is another phase of this business. Mr. FARNaLaY. I talked with the Surgeon General with an idea there were many- problems that the social sciences could address them- selves to. Maybe you are getting visits from these people. It might be interesting and it mlght be fun. It looks to me as if all of us are flying blind. I am not fussing at you, but thank you so much. Mr. GRAY. Thank you. Mr. Koaxrxa:tY. Mr. Chairman, if the gentleman would yield, I have found those figures, and I can put them in the record if ~ou desire, for the years fiscal 1961 throu -li 1964, the percentage of increase in imports, domestic-Italian-ma%e cigarettes, and the percentage in- crease in the sale of domestic cigarettes. Mr. FARN6LEY. Put them in the record. A1r. KoRN>ranY. Mr. Chairman, I ask unanimous consent that they be placed in the record. . The CHAIRMAN. They will be included. (The document referred to follows:) 1. The Italian advertising ban affected only foreign made cigarettes which were imported into Italy because the Italian tobacco monopoly was not engaging in advertising of Italian-made cigarettes. 2. Figuros provided by the Foreign Agricultural Service of U.S. Department of AKril•uiture on Itatian cigarettes sales are as follows. Figures cover the fiHCal year, frow July of the preceKting year through June of the year stated. (The advertising ban on improrted cigarettes went lnto effect In May 1962.) - - ~ - - -~ ~ ~ Percentage Peroeatpge Impated increase over Italian made increase over previous year previous year Flncn11961 ----------------------------- 1.2YS.U00.000 -......-..~.... 60.671..000..000 ............. --- Flsen1962--------------- ------------- 1, 403, pID, 000 s. Ea 54,423,000,000 Z C Fiscal1ffif3--.-------------------------- 1,976,000,000 39.40 55.178,011U.U00 1.4 Fiscal 1984- ---------------------------- 2.207.000,000 11.69 bb, 892, alp. 000 12 These figures make clear that there was an increase In imported cigarette?+, the only ones actually affected by the ban. The decline In rate of increase ennne in Italian-made cigarettes, which were not affected by the ban since they were not being advertised. Mr:. FARNSLEY. Ilow much does your industry spend on advertising here in the United St.at,es, approxinlate1y? Mr. GRAY. Mr. Congressman, I don't think any of us ever published exact figures on it. It has been variously estimated from two to-I think the last figure I saw was $240 million for the industry. Mr. FARNBLEY. Innocent bvstanders very rarely get shot hut in that case, if the industry decided to quit the ilutocent bystanders mieht be sllnt-newspa lers and radio Mr. GRAY. said there are many endeavors, many walks of life in this country which are affected by this industry. Mr. FARNSLEY. Thank you, Mr. Chairman. CIGARETTE LABELING AND ADVERTISING-198b 303 The CHAInMAN. Mr. Gray, concerning this estimate of $240 million, do you know what year that was g Mr. GRAY. I don't think I have seen the figures yet for 1964. I bel ieve this was 1963, sir. The CIIAntMAN. Would you say that it would be about that or more in 19641 Mr. GRAY. If I may judge from my own com p- any's expenditures they were up in 1964 as compared with 1963 due to two reasons primarlly. One, that the costs of advertising, like other costs in this country, have been going up steadily for a number of years, so that even though you buy the same number of commercials or newspaper ads, maga- zine ads, the cost of that same number is greater eac1l year than it had becn in the prior year. Secondly, in our own company we introduced a new brand last year, and this added several million dollars to our expenditures for adver- tisinl; as is usual when you bring a new brand out. lt might be interestm here to know there were 14, I believe, new brands introduced in t~e market from the 1st of January 1964, through the recent, well, through last month. I believe each one of them klad advertising on it which would be, I would guess, in addition to the normal expenditures on the existing brands. The CHAIRMAN. Fourteen new brands from how many companies? Mr. GRAY. We had one, at least four-four at least, sir. I am not certain of the other two because of the timing element. They h:ave brands which are new in the recent few years but whether these others wore since J anuary 1964, I am not certain. The CHAIRMAN. There are a total of six companies in the United StAtes. Air. GRAY. Major companies, sir. The CHAIRMAN. That is what I mean. Now, could you give the committee an estimate of what part of the estimated $240 million or more last year was spent on broadcastmg Y Mr. GsAY. Again, judging from my own company only, sir, it would be more than 50 percent of the moneys we spend on network-on television. The CHAIRMAN. More than 50 percent of the total on television. Mr. GRAY. More than 50 percent of our total was spent in the medium of television; yes, sir. The CHAIRMAN. What percent on radio 4 Mr. GanY. I don't have the figure, Mr. Chairman. I would prefer not to guess. If you want me to provide you with this I will try to get it. The CHAIRMAN. I think it would be advisable if you could give us an estimate of what the whole industry is. Mr. GRAY. I might point out that some of the publications in the advertising field publish estimates on these things each year. I am reasonably certain the one which is the most widely quoted has not come out for last year. I think it was due yesterday. But it did not appear. Perhal>s it may appear next week. May I send you that as an authoritative source whlch gives you not only the tobacco indus- try but all other industries using the media 4 O~S969ZOOZ ;' -

304 CIGARETTE LABELING AND ADVERTISING-196li The CHAIRMAN. I wish you would give us the best information you have as to the total sums spent by the tobacco industry in advertising in 1964, how much of it went to broadcasting, what part for television and what part for radio, what part for newspapers and what percent- ago of magazines, if you can get that information. Mr. GicAY. I will give you the best I can find on it, sir, or come up with. (The information referred to follows :) R. J. RaYNOCns TOBACCO CO., Winston-Salem, N.Cp., April E9, 1965. Hon. Osux IIAaaIS, Chairman, Ilouse Committee on Interstate and Foreign Commerce, RayLurn House Office Building, ii'aahington, D.C. I1h;Aa 11ia. HARRIS: I have now been able to assemble the published estimated figures on advertising expenditures for companies in the cigarette industry for 1964. These are from figures published or prepared by Advertising Age; Rora- baugh ; Radio Advertising Bureau ; and d the_ Bureau of Advertising, American Newspaper Publishera'Asaociation. CIGAItETTE LABELING AND ADVERTIBING-1965 305 Mr. GRAY. Drying up the participation or the use of that medium by a company such as ours. The CuAiRMAN. That is what I said. That is the way it appears to me. Mr. Farnsley g Mr. FARNSt EY. Mr. Chairman, let mo ask one more question. It is none of my business to tell you how to run your business but I can't help having ideas. But it looks to me like you ought to test some market, I know it is a horrible thing to think about, to see what happens, and then talk about it, lyou are worried that if there was no advertising some guy who didn t have a brand couldn't start one. He mi&ht run around giving out samples. It looks to me as if you are paying a terrible price to have the Surgeon General and Mr. I)ixon and Mr. Foote chasing you all around the United States, $240 million is a lot of money, that Is it is in my part of the world. Mr. GRAY. Mr. Congressman- Mr. FAerrsr,EY. You don't have to answer that. Television------------------------------.---------------------- Dlagazines------------------------------•---------------------- Farm lapers------------------------------- . - - --- $184,938,450 32,4a'J,677 Fi0'J 745 Mr. GRAY. I take that as a statement, not as a question. Mr. FAUNSLEY. All right.. ---- - - - ----------- - Supplements----------------------------------------------- - -_ , 122 804 3 That is a statement, and I quit. -- -- Radio----------------------------------•------------------- , , 10 765 000 The CHAIRMAN. What was the method they used in Canada 4 --- , , on rettes9 nad t i l C h i Did ' h a gR n a c ave some requ remen n t t ey Total--------------------------------------------------- ---- 240,765,676 Mr. GRAY. I have heard of none, sir. The figure given for expenditures in radio is for 9 months, this being the only one available at this time. No figures have been published as to estimated expenditures in newspapers. However, the total of such expenditures in 1963 was estimated at $17,414,827 by the Bureau of Advertising, American Newspaper Publishers' Association. On the basis of our own experience, I would assume that the expenditures in news- un{ier advertising for the industry were approximately the same In 1964 as in 190 The CHAIRMAN. You don't know of it. Any further questions 4 Mr. Gray, on behalf of the committee let me thank you very much for your appearance and your testimony. Mr. GRAY. Thank you for your courtesq, sir. The CHAIRMAN. Z'he Chair had hoped very much that this hearing . I think I should point out to you that the above figures include moneys spent for other items than cigarettes, since most of the companies in the industry advertise other products. All good wishes. Sincerely, BowxAx GRAY. The CHAIRMAN. Can you tell us whether or not in the broadcasting field that the greater part of the advertising was on spot annotuice- ments 9 Mr. GRAY. No, sir. The larger costs are on the regularly scheduled shows. '1'he CHAIRMAN. Sponsored programs 4 Mr. GRAY. This is right, sir. The CHAIRMAN. Ilow can you give a warning on a radio profirilm unless you just announce that smoking cigarettes is a health hazard and th will kill ou b c could be concluded this week. I am not sure just how many more witnesses we ha,ve left to be heard but we are going to undertake a meeting tomorrow afternoon at 2 o'clock or at such time after that as the schedule of the House will permit. The committee has an executive session in the morning and, there-, fore, will not be able to have a hearing in the morning. The committee will adjourn until tomorrow afternoon. (Whereupon, the committee at 4:30 p.m., adjourned to reconvene Wednesday afternoon, Apri114,1965.) ey y y ancer. Mr. GRAY. Are you asking me to tell you how that might be done, sir? 1'he CHAIRM.\N. Yes. Mr. GRnY. I think I have made it pretty clear I don't think it can be (lone or will be done. I think you would just have to quit. The CHAIRMAN. In other words, if such restrictions were placed on the radio industrv it would have virtually have the effect of drying tip cigarette advertising on radio. i~sssszooi

CIGARETTE LABELING AND ADVERTISING-1965 zCs969Zo0T WEDNE$DAY, APRIL 14, 1965 HousE or REPREBENTATIVEB, COHffiTfES ON INTEaBTATE AND FOHEIQN COMMEROFy Wa8hin.yton, D.C. The committee met, pursuant to recess, at 2;50 p.m., in room 2123, Rayburn House Office Building, Hon. Oren Harris (chairman) _ presiding. The Cz1ArRxax. The committee will come to order. Is Dr. Thomas Moran here4 I think in view of the time element, Doctor, and in view of the fact that you are here waiting, that we will proceed. There will be other memlx3rs along right away. STATEMENT OF DR. THOMAS J. MORAN, PATHOLOGIST, DANVIL.LE, VA. Dr. MoxnN. First of all, Mr. Chairman, I should like to thank you for the opportunity of appearing before this cominittee. I am Dr. Thomas J. Moran, a pathologist, of I)anvil.le, Va. I was born near Pittsburgh, Pa., and received my education atT.angley High School in Pittsburgh and at the University of Pittsburgh. I received my M.1). degree from the University of Pittsburgh School of Medi- cine in 1936. I interned at the Mercy Hospital in Pittsburgh and took my residency in pathology at the Pittsburgh city hospital. I have been in the practice of piithology for about 26 years. During this time I have also been director of the tumor clinics of the hospitals with which I have been associated. I was professor of pathology at the University of Pittsburgh School of Medicine and Directory Laboratories nt the Presbyterian-University IIospital of the Univer- sity of Pittsbur~h Medicai Center until Au~ust 1062, when I accepted t.he position of director o€ luborutories at the l~iemorial HospitA.i in Danville, Va I am a diplomate of the America n Board of Pathology and a member o€ six professional patholog~ cal societies in this country as well as t.he Int©rnataonal Academy of Patholo~y, the Pnt.hological Society of Great Britain and Ireltind, au~d t.he Colle~s of Pathologists (Great Britain). I have been president of the Pittsbur~h Pat,hology Society, the Pennsylvnnia Association of Clinical Pathologists, and vice president of the Virgina Society of Clinical Pathologists. I am a member of the publications committ,ee of two medie_a1 journals, Gerontology and the Gerontologist. I have published approximntAly 40 articles in 7nedical journals, most of them dealing with hing pathology. Several of my recent articles 307

308 CIGARETTE LABELING AND ADVERTISING-.1985 have dealt specifically with the reaction of the lung to various chemical injuries, including the comparison of the changes observed to the malignant changes seen in animal or human lung cancer. This re- search has been supported for a number of years by grants from the National Institutes of Health. Several other of my research projects have also been supported by the National Institutes of Health as welll as by other health agellcies. I have supervised for a number of years trainees of the National Cancer Institute and fellows of the Amerlcan Cancer Society. I have recently been invited to participate in an Internat.ional Conference on Lung Tumours in Animals in Perugia, Italy, in June 1965, at which time my experimental work in this field will be presented. My research work has dealt essentially with the reaction of the lung to various injected irritants; such as, food, milk, gastric juice, alcohol, and weak hydrochloric and nitric acid solutions. In many of these experiments, striking changes were observed in the bronchlall epithe- lium. Some of these changes were so severe that they looked like tumors and many areas closely resembled human cancer of the lung. They also resemhled the changes described by Auerbach and his co- workers in autopsies from lungs of heavy smokers. We then at- tempted to produce lung cancers by injecting nitric acid and studying the animals for long periods of time. We also modified the experi- ment by giving cortisone to the animals, in soine cases after the injec, tion of the chemical into the lung, in other cases by beginning cortisone treatment at different time intervals before the injection of the cheml- cal into the lun . In many animals a picture resembling human lung cancer was pro~ueed. Ilowever, in animals studied for long periods of time, both the lesions resembling cancer and those resembling the picture in human lungs of heavy smokers,gr adually disappeared. In connection with the question of a possil~le causal relationship he- twoon cigarette smoking and cancer of the lunt;, I shoidd like to snhmit. the following tlu~ee conclusions and a brief discussion of my reasons for arrivinl; at. the.5e c,oinslusions: (1) Statistical evidence accumulated thus far is strong enough to suggest, tho possibilit,y of a comiection between cigarette smokingand cancer of the lung. This possibility should be investigated furt.her bti= all available scientific methods including further clinical studies, statistical data, chemical analysis, and animal exlxiriments. (2) The evidence submitted thus far by proponents of the theory that lung cancer is caused by smoking (including the C'ommitteee ap- P ointed by the Surgeon General to analyze available data on the snl~-- ct) does not constitute scientific proof of this theor,y, Acceptance of this theory is not only unscientific but dangerons since accehtance of this theory will lead to complacency concermng the etiology of this disease and mlght•, well preyent fruitful investin ation along other lines. (3) Existing researcli programs should be continne.d and new ones developed in an attempt to determine the cause or causes of all cancers including those of the lun~,~. Among some of the possible causes of lung cancer needing further study are virnses, industrial or occupa- tional exposure, atmospheric pollution and chronic inflammation and scarring of the lung such as occurs alter influenza, bronchitis, bron- chiect.atiis, and many other benign lung conditions. . CIGARETTE LABELING AND ADVERTISING-1985 309 My reasons for conclusion No. 2, that it has not been scientifically proven that cigarette smoking causes cancer of the lung, can be sum- inn.rized as follows: Tbe evidence quoted by proponents of the "ei-arette-smoking lung- cancer theory" is generally of three types: (1) 9tatistical or epidemi- ological; (2) animal experiments; and (3) hulmin clinical and autopsy studies. It is my belief that the only strongl,y sngt;estive evidence taia;t smoking may be a factor in lun;g cancer lies in the field of epidemiol- ~Lry; in other words, the statistical evidence. There are a number of widely quoted studies siiggest.ing that people with a history of pro- longed and excessive cigarette smoking have a higher incidence of lnnl,• c.ancer than the general population. However, even among epi- demiolo;*ists and statisticians there are nnmerons diffPrencesof opinion and varions interpretation5 of these studies. In a recent. analysis of 1,229 lung cancers at the University of Bonn in WPst Germa.ny by Poche, Mittman, and Kneller, the authors found no connection at. all between smoking and cancer of the lung. They divided the patients with lung cancer into three groups-nonsmokers, light smokers, and heavy smokers-and found the same incidence of lung cancer in all three --roups and the averu.ge age of occurrence of the cancer in all tlur.e, groups was exactly the same. Of the different factors they st.ndied, occupation was the only important positive factor, sug~*e5t.ing to them that indnstrial exposure may be related to lnnr c.aaicer. This stuily dealt with all forms of lung cancer but espec.ially .vith the scluaanous cell or epidermoid type, which is the one most frequently cited in the reports by proponents of the smoking lmig-cancer link. Sinee I am not an epidemiologist or statistician I will not. attempt to analyze the statistical evidence critically or in detail. I will list, however, some of the more important general obje.ctions to the Gtatis- tica] conclusion that smoking is a cause of lung cancer. These objections have been recognized in many statistical studies. (1) Over 95 percent of smokers, including heavy smokers, do not develop lung cancer. (2) Lung cancer of all types including squamous cell (or epider- moicl t.ype) occurs in nonsmokers. (3) There is relatively little cancer of the mouth, nose, throat, or trachea, although these areas are more exposed to cigarette smoke than the lungs, and the incidence of cancer in these organs is not increasing. (4) Lung cancer occurs much more frequently among men than women, and the disparity is growing, although smoking among women hns been common now for about 40 years and smoking among -women has been increasing rapidly during that period. (5) The incidence of lung cancer varies widely between different localities, as, for example, between the States of New York and Idaho and the cities of New Orleans and Atlanta. There is also a 1ighe.r incidence of lung cancer in urban populations as compared to rural. (6) There is more lung cancer in England than in this country, •de:5pite the fact that heaty smoking is more common in this country. 'Many other criticisms, both of inethodology and interpretation of the statistica.l surveys, have been made by qualified statisticians and ,epidemiologist.s. E~'~'ss9zooT

310 CIGARETTE LABELING AND ADVERTISING-1965 The second type of evidence quoted by those who believe that cigarette smokin~ eauses lung cancer is animal experimentation. To mo the experinientail evidenco presented thus far has little or no ap- plicaLion to tlie probleiu of human lung cancer.. It is true that soine skin caneers have been produced by application of the so-called tobacco tar totlle skin of tumor susceptible animals. However, similar canceis can be produced in tlie sl:in of sensitive animals by painting the : l:in with a variet.y of substances including sonie conunon f«Nls. No oiie has produced lung cancers in experimental animals by ex- posing them to cigarette smoke, although this has been tried by many research workers and many animals have been kept in ali atmosphere filled with cigarette smoke for prolonged jieriuds. 1'liese animyls develop cerhiin chunges in the bronchial epithelium similar to those seen in tlie lungs of heavy smokers at autopsy. IIowever, none of the animals with these changes have developed lung cancer and when the animals are removed from the cigarette smoke the changes gr.ulu- ally disappear. Uu the other hanT cancers of the lung have been )roducetl in animals by inoculation of viruses (Rabson) and by in- ~iaiat.ion of viruses and aerosols of hydrocarbuns which are substances present in high concentration in ga,5oline fumes (1{otin). Changes similar to those seen in hiumn lungs of heavy smokers and changes even more suggestive histologically uf cancer can be produced in a variety of ways in experimental animals. For exainlile, in my own experiments which I have mentioned in which rabbit lungs were dai.niaged by a chemical agent such as gastric juice, hydrochloric acid, alcoliol, or nitric acid and especially in severall groups which were pre-. t.ieat.ed by administration of cortisone, there were striking changes in the bronchial lining similar to but more severe than those described in human sinokers' lungs. However, none of these animals developed lung cancer, and although the animals were studied for lonf; periods of (nne after exposure to the chemicals the changes gradually disup- peared. The importance of these observations is thiit it is not always possible to predict biologic behavior from histologic appearance, and in the case of the changes described in human smokers' lungs I do not believe it is proper to call these malignant or premalignant lesions. They occur in too many benign conditions. In brief, animal experi- rnents have contributed nothing directly applicable to the problem of cif;aret.t.o smoking and human lung cancer. 1'he third type of evidence quoted by proponents of the "cigarette smoking eiiuses lung cancer" theory is in a general group of clinical and autopsy studies. Here again the clinical evidence is statistical and the statistics are subject to the same defects and objections already described. The autopsy evidence quoted is confined largely to several studies carried out by Auerbach and others in which certain changes in the lining epithelium were described in the lungs of heavy smokers. `'he5e changes have been interpreted as premalignant or as leadin;; to lung cancer. There is no solid evidence to suphort this claim. The changes are not specific for stnokers; they ma l>d seen in a variety of beaiil;n conditions, and they may be produce~ex~~~erimentally bot~i in linigs of animals exposed to cigarette smoke and a variety of other materials without evor leading to lung cancer. In experimental ani- nnils, they can be shown to disappear after the irritant has been re- a CIGARETTE LABELING AND ADVERTISING--198b 311 moved. This, as far as I am concerned, elimi_nates the application of these observations to human lung cancer. I propose to show a few slides today which I hope will explain some of the things I have said. I have mentioned there are three 1wincipal types of evidence used by those who believe cancer of the lungs is caused by cigarette smoking-that is statistical, hurnan autopsy studies, especially the studies of Auerbach, and animal ex))ernuents. 1'lie observations and slides that I propose to show are concerned priinarily witli the second type, Auerbacti's report, but also involve sonic experimental observations. Auerb;icli's thesis briefly is in his studies of human autopsies certain changes were consistently demonstrated in the lungs of smokers, and that these changes showed a progressive development to cancer through the following stages: hyperplasia, metaplasia, carinoma in situ, and invasive cancer. Other pathologists have also found an in- creased incidence of squamous nietaplasia among smokers, but have not found the incidence of carcinoma in situ cited by Auerbach, and do not aurree with his conclusions. The slides will show several things. First, normal lung, and bron- cliial epithelium, second, squanious metaplasia of the type described by Auerbach, in people who have never smoked. And, then, the re- semblance of cancer of the lung in a nonsmoker to cancer of the lung in a smoker, and the resemblance of each of these to a cancer of the larynx in a nonsmoker. Fourth, metaplastic changes in animal lungs, resembling the changes described by Auerbach, except that they appear histologically even more malignant, in which long-term experinients have shown that these changes do not progress to cancer. I will try to show the slides. For purpose of orientation, I have here a normal lung from a 10- montli-old baby who died of meningitis. But the lung is not involved in the disease. This is just to try to give you an idea of the pattern of t,lie lung, so you can see the comparison with the slides I show later which show tumors. Slide i: This is the normal air space. This is a blood vessel here. This is the breathing space of the lung. In the next slide, I will show this under a little higher power. Slide 2: This is the actual air space. The air comes into this space, and this is where the oxygen passes through the lining of the alveolor wall and gets into the red blood cell. These orn.nge-stained bodies-here and here-are red blood cells. This is where tlie carbon dioxide passes out into this air space, and the oxygen passes into the bloodstream. Slide 3: This slide shows the air passage itself-in other words, the bronchial tube, or bronr.hus, and shows the structure with which we tLre concerned. Most of the clianges we talk about-squamous metn- p1:Lsia, lung caneer, and so forth, occur in this particular area. 1'his is the muscular wall of the brotu;hial tube, and this is the etii- tlieliuin. You can see the lining of tlie epitlieliuni here contains these structures whicli are called eilia. Ne hear a lot abo_ut the cilia, ]x.c.ause the cilia ltelp in the niechanism of clearing out tuiy foreign material that gets in t.he lung. r , C ., Ya I r i VC5969?'U0T

312 CIGARETTE LABELING AND ADVERTISING--1965 'I'his is the normal appearance, then, of the epithelium lining the bronchial wall. This is alll in the same 10-month-old baby and there is no change in this epithelium at all. Slide 4: This slide is from a woman 53 years old who had never smoked, but who had a condition called bronchiectasis. And this change, squamous metaplasia, in this woman corresponds to the change described by Dr. Auerbach. Over here we have the normal epithelium. Here is the cilia. And this is the normal lining up to here. And then we have this peculiar chan ge in appearance of the cells. You see that these cells in this are:% look different from this other area. And that is referred to as squamous metaplasia. But this occurred in a woman who had never smoked and who was 53 years old. The next slide, please. Slide 5: Now, this is a lung cancer, a squamous cell cancer, or epi- dermoid cancer, occurring in a 51-year-old man who was known to be a heavy smoker. I think you can see by comparison with the previous slides that there has been a complete loss of pattern or the architect,ure of the lung. T he normal lung is gone. And here we see these nests and sheets of cells. I think in the next slide we have a higher magnif cation. Slide 6: This again is from a lung cancer from a heavy smoker, showing a little higher power. You see these cells which are rather pink staming , and urauged without any definite pattern into sheets and nests. :1nd this is .vhat is called a squamous cell or epidermoid cancer. '1'he next slide, please. Slide 7: This comes from a 54-year-old man who had never suloked-had never smoked a cigarette in his life. This case came up several nlouths ago at one of our tumor clinic meetings in our hospital. Tlle man was still alive-the lung has been removed at surgery. We had several doctors go up and take independent histories. All doc- tors reported that this man stated very firmly lie had never smoked, and no one had ever seen him smoking. T his is asquamous cell carcinoma of the same kind as the previous one shown. It could not be distinguished by any pathologist from a squamous cell cancer occurring in a smoker. This sanle day that we were discussing this case at the tumor clinic, there was a young doctor present who said that that did not surprise him, because his father had just had asq-uamous cell cancer removed in a New 1 ork hospital and his father, because of religious reasons, had never smoked anything. The next slide, please. Slide 8: This is a higher power from this same man who had never smoked iit all, showing these same large pink-staining cells, and the nests and sheets of cells which have completely replaced t•he lung structure. So this is an example, then, of a squ:unous cell carcinoma in a man who haui necer smoked. The next, slide, please. Slide 9: Now, this is another squamous cell cancer. This cancer occurrml in the larynx. And this was from a 53-year-old man who had CIGARETTE LABELING AND ADVERTISING-I965 313 never smokeil at all-ci~nnr.ttes, pipes, or anything else. This sho~~s 1110 ries<,ml/lslnce again to the ap1>c,lrallce we saw til st in the cancer of I he Inan ~eho suloke~l aild, ~:colul, in the cancer of the lung of the man ai-ho:lid not. timoke. In these last sli~les we h;u•e sllown three examples of snuamous cell caucer-two of the lung nnd one of the larynx. One occurred in the lung of a smoker, one in the lung from a man who had never smoked, awd the cancer of the larynx was in a man who had never smoked. The next slide, please. Slide 10: Now, this is an example of what is called squamous meta- pl:lsia, rather severe squamous metaplasia, in a 63-year-old woman who had a disease called scleroderma. That is a disease avhicll involves the connective tissue of the body, and often involves the lullgs. And here are similar appearing cells, or similar cells-thev ~ :u•e not tlle same, but they are similar appearing cells all throuhh here. You see the loss of the pattern of the lung. It does not have Ille normal breathing space arrangement. And this is called stin.i- nlous metaplasia,. But this is in a benign condition and is not malig- naut at all. 'I'his change occurred in a nonsmoker. This woman had never smoked. Slide 11: This is another example of severe squamous metaplasia in n 45-yea..r-old woman. This woman had never smoked. She had severe rheluuatoid arthritis, and these changes here, all through here, are similar in appearance to t.he cells that we saw in the squamous cell cancer, and they are similar to what Dr. Auerbach has described in his studies as squamous metaplasia, or even carcinoma-in-situ, and yet this lesion is essentially benign-it does not progress to cancer. Next slide, please. Slide 12: 'tlll5 is a slide from a 14-year-old boy who died of a dis- ca~e c.tllc~cl Cutiliing'S disease. This boyhad never snloked. And here is an example of another area of inetaplnsia that might on casual in- sl,ex•tion look like a mnlitinlant gland or like a cancer. This is not Illal1g11:Lllt at 1Lll. - - Next slide, please. tilide 13: '1his is a nodule in a rabbit lung. We had givell these rabbits cortisone for aweek, and then injected a weak solution of nitric acid into the lung. Thisis a week later, showing this nodular tlhpeara.nce, the loss of a pattern of the normal lung, and an appear- suice resembling tumor. I think this could easily be mistaken for a cancer. Now, beginning at this point we will deal with experimental slides. I'llese are rabbits and all of this material, by the way, is from tuy oavll nuiterial, and I have done till this work, incltuiin; studyinl; the slides anll taking, the pictures. 't'he next slide. Slide 14: This is another area from the rabbit lung, showing a large no/hdo of tllese atypical cells. There are some features that look like a, Irnaligliant tumor In some of these. In fact, some of these slides were es:unmei by patholoh•ists who thoul;ht they w~ere malignant. But, o11 1011g-tel7n studies, and careful obserl-,itio_n, nll of the.5e chaulges di.ajll/ealyd over a periodo€ months. T le next slide. 48-824-65-21 SE~969ZOOt

314 CIGARETTE LABELING AND ADVERTISING-.1965 Slide 15: This is a higher magnification, from one of these rabbits in a similar area, 5howing the loss of pattern. This cell here shows what is called a rlutotlc figure. Ordinarily this is considered an indication of malignancy. An increase in the nmu- ber of lnitotic figiu'es is one of the characteristic features of cancer. This slide also shows large atypical cells. These red-staining bodies are called nucleoli. They are prominent here and they are also protui- nent in cancer. So )'ust looking at this pattern alone, you could easily calll this a can- cer when, in fact, it is not. The next slide, please. Slide 16: This is another area from the rabbit lung, showing the loss of norma..l pattern, and this is an area in which the npealYtuce could be mistaken for what is called an adenocancer, a glandular-t.ype caalcer, in contrttst to the others, which look more like a squamous cell cancer. This is the last of the slides. '1'he C1iA1RMAN. Doctor, the practical observation- Dr. MoRAN. Mr. Chairman, could I interrupt you just a minute? I have a few sentences more in my prepared statement. Tlte CIIAIR111AN. Very well. Dr. MORAN. The following conclusions may be drawn from the slides presented. (1) Cancers of similar type such as squamous cell cancer or adeno- cancer look and behave alike regardless of the site of origin in the hody (lung, larynx, esophagus, uterus, and so forth) and regardless of whether the patlentluid a history of smoking or not. (2) Changes of squamous metaplasia such as those described in lungs of smokers are also seen in many people who have never smoked. These changes are associated with a large variety of inflanunatory and reparative changes in the lung and are not to be considered as lnuli~-a- nant or premlignant or as part of a series of changes which eventunllu lead to lung eancer. Dr. Auerbach's thesis, then, of a progression ciP changes in smokers' lungs leading to invasive cancer is not substantiated. In summary, I wish to submit my opinion that there exists enough evidence of tt statistical association between cigarette sitlokiug and lung cancer to justify considerable additional research in this aI'ea, but that the cause or causes of lung cancer, as all human cancer, has not yet been scientilica.lly established and rep;earcl>, into its causation along atll pos- sible avenues of approach is urgently needed. (The attachments to Dr.lltoran's statement follow:) CUaR[CULUM VITAE-THOMAa J. MOBAN, M.D. Born : October 14,1912, Rennerdale, Pa. Residence: Creekside,l2anville, Va. Degrees: B.S. University of Pittsburgh, February 1936; M.D. University of Pittsbnrgh, School of Medicine, June 1936. ,ltotating internship: Mercy IIospital, Pittsburgh, Pa., 1936-37. Iter+ident in pathology, assistant pathologist, and director of laboratories at Pittsburgh City Home and Hospitals, Mayview, Pa., from September 1937 to April 1:142. U.S. Navy, April 1942 to January 1946. Patholol;lst, Welborn Memorial Hospital, Evansville, Ind., January 1946 to December 1946. Pathologist, the Memorial Hospital, Danville, Va., December 1946 to Sep- tember ep- tember 1960. f CIGARETTE LABELING AND ADVERTISING-.1985 315 Pathologist, St. Margaret Memorial Hospitnl, Pittsburgh, Pa., September 1950 to November 1954. Also, director, John C. Oliver Memorial Research Foun- datlon, Pittsburgh, I'a., uud assistant professor of pathology, University of I'ittKbarkh School of Medicine. .lyyociate professor of pathology, University of_ Pittsburgh, School of Medi- cine, +ind director of laboratories, Presbyterian, Woman's, and Eye and Bar Ilospitals of the University of Pittsburgh Medical Center, November 1954 to July 1958. !'rofe,sor of pathology, University of Pittsburgh School of Medicine and di- rw•tor of laboratories, Presbyterian, Woman'x, and Eye and Ear Hospitals, July 195S to Augast 19(i2. Director of laboratories, the Memorial Hospital, Danville, Va., August 1962 to present. :1leFnlmr: American Medical Association; American Association of Pathologists thologists & 13acteriologists; American Society for Experimental Pathology; American Soc iety of Clinical Pathologists • College of American Pathologists • Pennsyl- rnuia Association of Clinical Pathologista; International Academy of Pathology • Patholot;ical Society of Great Britain and Ireland; College of Pathologists (Great Britain). Diplomute: American Board of Pathology (pathologic anatomy and clinical pathology). I3IDLIOORAPHY-TIIOMAB J. MoaA:v, M.D. Chroinophobe Pituitary Adenoma with Simmonds' Disease: Case Report with Autopsy, J. Lab. and Clin. Med. 26:128t1, 19_ 46, with Dr. George H. ,Fetterman. Anomalies_ of the Circle of Willis in Relation to Cerebral Softening, Arch. Path. 3':251, 1941, with Dr. George xi. Fetterman. Food Aspiration 1'neumonia, Pennsylvania M. J. 45:810, 1942, with Dr. George If. Fetterman. Thi~ Cold Agglutination Test, U.q. Naval Medical Bulletin, 1944, with Dr. George II. Fett.erman and William li. tlews. Rapid 111ethrKl of Staining Tubercle Bacilli with Tergitol No. 7, Am. J. Clin. Paith. 17:75, 1947, with Merle L. Radcliffe and Isabelle 11. Tevault. Pulmonary Embolism in Nonsurgical Patients with Prostatic Thrombosis. Am. .I. Ciin. Path. 17:211; , 1947. Necropsy Incidence of Tuberculosis in a Hospital for the Mentally 111, Diseases of the Chest, 14 :132, 1948. RPiapcing Febrile Nodular Nonsnppurative Pannlcnlitis, Report of Case Treated %vith Penicillin, Ann. Int. Med. Y.9•958, 1948, with Dr. Alfred J. Niedermayer. Autoi.vy Incidence of Pulmonary Embolism in tloronary Heart Disease, Ann. Iut. Med. 32 :949,19si0. Autopsy Incidence of Pulmonary Embolism in Tuberculosis, Diseases of the eh est, 1 s :171,19:,0. Eslx'rimental Food Aspiration Pneumonia, AMA Arch. Path. 52:350. 1951. l;habdomyosurcoma with Fatal Ilemorrhage from Intestinal Metastases, Am. J. Clin. Path.22:401,1!1:;2, with Dr. Frederic C. Leshner. Congenital Goiter with Death from Milk Aspiration Pneumonia, AMA Arch. I'ith.54:213,1952. Milk Aspiration Pneumonia in Human and :lnhnal Subjects, AMA Arch Path. 55 :286, 19ri.4. Pulnuinary Edema Produced by Intratracheal Injection of Milk, Feeding Mix- hires, nnd Sugars, AMA Am. J. Dis. Qhild. 88:45.19ri3. T'ibro-ant.hracoHiq of the Lungs in Elderly erly Individuals in a Smoky City, Diseases of the Chest, 24 :C,58,19.ri3. Experiniental Aspiration Pneumonia lII. Pneumonia Produced by Intratracheal Injection of Carbohydrate Solutions, AMA Arch. of Path. 57:194, 1954. Granulomas of the Stomach 1. Granulomatous Reaction to Damaged Smooth itlusc•le and Fibrous Tiysue of the Human Gastric Wall. Am. J. Clin. 1'ath. 23:115, 13L4, with Dr. Frank E. Sherman. Granitlomas of the Stomach 2. Experimental Production by Intramural In- jection of Foreign Material Including the Animal's Gastric Juice, Am. J. Clin. Path,'14:922_,1954, with Dr. Frank E. Sherman. I:xperimental Aspiration Pnetunonia, Ain. J. Path. 31 :579, 1955, Abstract. Experitnental Aspirntion Pneumonia. IV. Inflammatory and Reparative Changes Produced by Intratracheal Injections of Autologous Gastric Juice and Ilydrochloric Acid, AMA Arrh. Path. 60:122,1955. 9~5969ZOOZ

316 CIGARETTE LABELING AND ADVERTISING-1985 l'lxlmrimental Aspiration Pneumonia. V. Acute Pulmonary I9dema, Pneumonia, nnd Bronehiolitis Obliterans Produced by Injection of Ethyl Alcohol, Am. J. Clin. I'ath. 27:3110, 1957, with Dr. Il:. Richard IIellstrnm. Studie~q on llrhronovi9, Aat. J. Path. 3.3:591,1967, Abstract. Studies on Ochronosis. 1. Report of Case with Death from Ochronotic Nephro- sis• AMA Arch. Path. (41:40, 1!)57, with Dr. Jeanne A. Cooper. rs. 18nthonlntons Biliary Cirrhosis, Tr. A. Am. Physicians 70:243_, 1957, with Drs. J. D. Myers, Jessica Lewis, and Robert Olson. PsE'udoxantlimua Elasticum. J. of Gerontology 12:429, 1957, Abstract, with Dr. A. I. Lansing. Studies on the Nature of the Abnormal Fibers In Pseudoxanthoma Elasticum. AMA Arch. Path. G5:e88, 1958, with Dr. A. I. Lansing. Asian Iulluenza and 111itral Stenosis. Report of a Case with Autopsy. JAMA 1G/i :1407, March 1958, with Drs. J. A. Rock, and A. i. Brande. The Ilistolo~;y of "Farmer's Lung." Arn. J. Path. 34:6t3.5, 1958, Abstract with Dr. R. S. Totten. Farmer's Lung: Report of Two Cases with Lung Blopsies. Am. J. Med. 25:803, 1958, with Drs. R. S. Totten, D. II. S. Reid, and Il. D. Davis. The 1'athoeenesik of Exlerimental lironehiolitis Obliterans. Am. J. Path. 34 :1100. 19;i8, Abstract, with Dr. H. R. Hellstrom. Bronchielitis ObliteranR. An Experimental Study of the Pathogenesis nnd Use of Cortisone In Modification of the Lesions, AMA Arch. of 1'ath. 66:091, 1958, with Dr. II. Ii. IIeilatrom. Studies on Enrlogenous Lipid Pneumonia and Blood Lipid Levels In Cortisone- treeted Rabbits. J. Clin. Path. 11 :6 51, 13).58, Abatract. Familial Muscular Subaortic Stenosis • An Unrecognized Form of "Idiopathic HCart Disease", with Clinical and Autopsy Observations, Circulation 21:11i7, 1!NiO, with Drs. L. B. Brent, A. Aburano, D. L. Fisher, J. D. Myers and W. J. Ta ylor. EtTects of Cortisone on Atypical Cellular Proliferation In Rabbit Lungs. Proc. Ain. As>9oc. Cancer Res. 3:157, 1900, Abstraet, with Dr. R. S. Tott.eu. Cortisone and Atypical Pulmonary "Epithelial" Hyperplasia. Effects of Pre- treatment with Cortisone on Repair of Chemically Damaged Rabbit Lungs, Ain. J. Path. 38:.ri75, 1961_, with Dr. R. S. Totten. Studies oa Ochronosis iI. Effects of Injection of Homogentisic Acid and Och- romMic Pigment In Experimental Animals. Am. J. Path. 40:359, 1lN12 with Eduardo J. Yunis, M.D. DiaM•tic and Cortisone-Induced Renal Lesions. A Morphologic and Immuno- hiqechemieal Study, Lab. Invest. 3:240, 1962, with Drs. Stanley M. Kurtz, and J. J. Vazquez. Cortio-one-InduccKi Alterations In Lipid Metabolism. Morphologic and Serologic Observations In Rabbits. Arch. of Path. 73 :300,1i1Fi2. Villous Tumors of the Rectoyigmoid Colon with Severe Electrolyte Imbalance. A t`,anRe of Unexplained Morbidity and Sudden Mortality, with Dr. C. L. Wens arid l)r. N: M: CooPer. The Am. J. of Cl: Path. 37'507, 1tN12. Weight Loss In Cortisone-Treated Rabbits-F.ffects of Streptomyvin and Penicil- liu. AitLi Arch. of Path. Sept. 1aR.4, vol. 78, pp. 330-332. I)r. DioeAx. Thank you.. '1'lre C'llMtcarnx. I)octor, thank you for this interesting presentation. I tiulrpose, we probahl•y could consider this a graduate study cotn'se. It hot5 Iteen ~'ety reveuling and interest ing to me. I qas alrout to ask earlier-as an ordinary layman-what,you have shown here clenlonstrntes the failnt•e of the lung to take sutPicient oxy- gen to surply the body because of the condition which you have stated to the committee; is that true$ Dr. MORAN. If the process involved enough of the lung. Usually in the ordinary lung cancer there is not enough of the lung involved at least at the lreginnln'-, to cut off oxygen to the entire lung, so the patient nlay live a long time with a lung cancer, unless it becomes so extensive thnt. almost all of tite lunfi tissue is lost. The CHAIRMAN. I had reference to cancer as well as the other con- ditions you showed. 4CS969?'00t CIGARETTE LABELING AND ADVERTISING-1985 317 Now, you showed a picture of a lun~r that was affected, these poclcets-the pockets where air was taken in were closed up with the cells that you showed. Dr. DIoIIAN. Yes, sir. The Ctrnlnrrnx. And the more of those-I buess with the under- standing I have, I call them cells-tite more of those cells thatt fill tip those pockets, the less room there is for oxygen to go into that lnnh; is that right? llr. MORAN. That is correct. However, in the animal slides which I showed, these nodules are not present everywltere. They occur irregularly in some parts of tllet llutt;. Tlte animals are still able to bretlthe. And the animals that do live- a few of them die. But the animals that do live, then lose these nod- ules, and the changes disappear. In other words, it is not a lulifornl pt oce.ss inv~olvinl; the cnt ire lungstrttcture. Tho CHAIRMAN. I realize that. iVe talk about the cituse and so forth. Would this indicate tltat. the man who has an enot'mous chest expansion has a very fine 1un~; that is capable of taking in at lot, of oxy;;en, and a mall who cloesu't have tunclt of a chest expansion better jpet his lnn~,~ analyzed? I)r. MORAN. I think this would be a dilficult, question to answer. I don't, think chest, expansion alone would be a complete index. I am afraicl my chest has heen expanding solne, iuld yet it doesli t mean thatt I_ cnn breat.he any better. '1'lte CtreeRltrnx. Well, it is a very interesting analysis. I personally w;tnt t.o thank ou for it. Mr. RogerY rir. l:rnir:es of Texas. Thank you, Mr. Chairman. 1)octor, I am sorry I was not here earlier, because I looked forward to your testimony. But there seems to be agreat deal of concern insofar as the legislative processes are concerned, that the words "tnay" "ma,y be detrimental to health," or hazardous to health, is not sufliclent. The people who have come in and undertaken to press this matter, including the Federal Tra.cie. Commission, take the position- and lhe scientists and some of the doctorr;---that they must have the word as a definitive straight statente.nt that cigarette smoking is haz;trclous to yonr health. Now, after listenin9 to the last part of your testimony, which was very interc6ting, it came to my attention some of the things that are in these summaries cost the taxpayers of this Nation apparently quite a bit of money to find out. Now, I notice in this booklet on smoking and health, by the nepart- ment of I[ealth, Education, and Welfare, on page 376-1 read a sti>.te- ment the other day whic•h we thought was a great find. It says: Although smokers are different from nonsmokers psychologically and4socially, there are mnny differeaces amoug Rmokers and atnons nonsinokers, so t1rat Rnwe smolcen, may be like sonre uonsmokerq. Would you at,ree thcn thatt finding was tlhte ? I)r. MORAN. I am afraid I ctllulotpas.g on that. particular statement. I,jnst don't know enout;Il about the psychology of either smokers or itonzmokerR. ;\Ir. R(Hn-:es of Texaq. I think it. is imporhlntt in that they lulve used the words "sotue smokers may be like solne nonsmokers,"'httt I don't.

318 CIGARETTE LABELING AND ADVERTISING-19t15 think it, required a lot of taxpayers' money to find this out. I could have told t.heni this before they went t.o all this trouble. Now, in No. 4 they say smeking a~pears to he not one behavior, but a range of psychoh>gtcally diverse liehaviors, ettcli of which mtiy be iuclncecl lty a dltl'ereut coiubination of factors and may serve ditferent needs. TLerefore, no single explanation can sullice. Then, otl N o. 6 they say : There is sugge.yted evidence that early stnoking may be linked with self-isteem and status tieedls, although the uature of this liukage is open to different itder- pretatious. Well, now, thatt was a profotmd finding if I ever heard one. But yett this s,uue group of hco1~le came in, after all of these stateutents-.uxl they are ,ill tln•ouhh the book. llere is another one: luerea,ixl mortality of smokery 1.'rom cirrho.,is of thee live.r has lwen rhown in the liruspectire studies. The data ute not sutti(•Ient to sulyi"rt at direct or causal association. Now, thosc• kind of statements are all through here. Yet those svue lx-ople ca..tne in here and stttted as a de,finite, tixed conelusioai, inany of them, that every person who sntohcs ci;;strette•s is u ITeet iu-, his health. 11'h,lt 117uukl he your orinion on it, sir? -ree with those who I)r. MottAN. Well, I can only say that I do not ag have re')orte~l that it is l~roven, that smokin+; causes cancer of the Ittn~. I dis i,ree with this viewi)oint. 1, too, have observed through the text, through the body of the report, that there are many qualifying statements in it, such ats "may be," "presunirtibly,° "presumptive" atnd that sort of thing, which do not appear in the conclusions which have been pretty widely hub- licized. While I think in general the report is a very fair one, I have no- ticed that it did not include those qualifying statements in the con- clusions. And Ithink this is one thnlg about the report that I would disa"ree.vith. Mr. Roea:RS of Texas. Now, Doctor, in some of the conclusions they say they have testified here that there is a definite connection between enihltysetua and smokin~,•. Now, the conclusion stated in this booklet, on page 302, says: A relationship existe between polmonary emphyAema and cigarette smoking, but It hns not been establiehedthatRhe relationshipis causal. 1\'ow.what. doesfihat mean ? I)r. AhMA:v. Well, I think it just means that a certain number of Peol>le ha.-e, emphysema, and a certain number of people smoke, and the stattstics do not show clearly .vhether this is just coincidence of nn occurrence of emphysema in people who smoke, who may have some- thing else n•hich is really causing the emrhysemaa or whether the cig- arette smoking presuniably causes it. In otlter words, they just don't know. 11fr. RO:FRS of Texas. Tsn't it a fact, Doctor, tltat if one man had emhhy~selna and also smoked, there would be a relntionshiP be.cmtse all of tlte activities are occurring in one body, although there mit;ht not he anyassoi-iat ion at all between the two? CIGARETTE LABELING AND ADVERTISING-1965 I)r. MORAN. I think that is correct; yes, sir. 319 Mr. iiooFns of Texas. So actuttilly the finding that they have said there is a relationship means nothing, insofar as the issue involved here is concerned. I)r. 11ioRA`. I would agree with that; yes, sir. Mr. Roaens of Texas. I think that is all the questions I have. Mr. l'ounger? ;1[r. Tou:.GSR. Tltankyou. I think, Da•tor, you, have made a very good contribution. But for a layu~an, it only adcs confusion and compounds it, because we have very goo(l doctors come in with reports that they are very rositi~•e ~that sn10king does cause lung cancer-and we have >ti nlunUer of other dnctors who testify ns ,you do, from the wealth of their experience. This puts us in a biul positioii of trying to reach a decision-when the e,xtwt^Is all clisarre_e.. That is one of the niost, confusing things that we have. And yet tlle Federal t'rade Cominission just took one side of the question. You clidn't testify before the Federal Trade Commission, did you? Dr. DIoR.uN\o_, sir. Mr. I oL*aca:r. T)o you know anything about the hearings they held ? I)r.11[oaA-,--. No, I do not, sir. Prr. Yorxclat. You don't know whether they were generally adcer- t iscd, or-the doctors wc•re not.ified so they coula testify $ I)r. AinttA`. I don't know a thing about it. 3 f r. YoUNCF.R. Tltank you very much. DFr. R4x:Fns oF Texas. Mr. Iiornegay ? D[r. IcoltNFOAY. Thank you very much. First I want to thank you, Doetor, for coming before the committee with your great, knowledge of the suh~'ect matter. It is very helpful to have this information and the benelit of your many and long years of experience. At the risk of showing the extent of my ignorance, I have two or three questions. Dr. Moran, you testified that there is a cancerous cell called the squamous cell, or squamous carcinoma, or whatever you term it, that is found in the lung-is that correct,sir? I)r. MORAN. Yes, sir. Mr. r. KORNEGAY. Is that the most common type of carcinoma found in the lung? Dr. MORAN. Yes, I think squamous cell cancer would be the most common type. :1fr. KcinNEOAY. Well, now teill the committee whether or not that same type of carcinomaa or cancer is found in other areas of the body. Dr. hfoltnN. Yes, es, it is very commonly found in many other areas. it is particnilarly-- Dfr. K(1RNF.(7AY. Are these areas such that they could have no possible irlationship between that area and cigarette smoking? Dr. MORAN. They are areas that certainly could have no possible exhcsure to cigarette smoking, the most common being cancer of the cervix of the uterus in women. 11fr. KnnxFOAY. This is the same_ type of cancer that is most cotn- nlon in the lungs, is that correct? sCsssszooi

320 CIGARETTE LABELING AND ADVERTISING-1985 Dr. blosAN. Yes, sir. Air. I10RNFAIAY. Now, you also state on page 4 of your statement that lung cancer occurs much more frequently among Inen than women, and the disparity is growing. By that I take it that you mean th;it, tlle clistance between the two, or the differential in the incidence of cancer between men and women is increasing each year. Dr. MoItAN. Yes, sir. Air. KoItNEG,tY. Is there any scientific reason for that, or do ,,ou have snty idea as to why men are more suscept ible to lung cancer t}ian women 4 1)r. MORAN. No, I do not have, and I don't think anybody knows. We know that nien are more susceptible to a nuutber of diseases, and this happens to be one of them. Tlle average life expec•tancy of nlen is a 1>prox nnatel,y 5 years less than for wommn. MI'. I1CORNF.(7AY. If you relate that to the percentage of men and the percentage of women who smoke, ]tow does it stand, or what is the cotnparison in that case? l)r. MORAN. I do not have the figures. I really don't know how many people in the country or how many people in any given area of the country smoke-men or women. I think this is one of the hard things to evaluate in any of the statistical studies. I believe that mauy more people smoh:e than do not snioke, and this makes it hard to evaluate the figure5. llr. hAItNF.(IAY. Now, the work that you have done and shown us llero in the area of lung cancer-did you, as a pathologist, perform tlte autopsies? Dr. MORAN. Yes, sir. Mr. I1ConNEaAY. Did you make the slides? Dr. MORAN. I dicl not cnt and stain the slides. That is done by technicians. But I have read a,ll the slides.-that is, I have looked at them personally under t.he microscope in all cases, selected'the areas for photographs, and took the photographs. 9Ir. iioxNEGAY. And who collected the histories? Dr. DioleAN. I collected the charts and reviewed the histories given by the doctors, and in some of the cases-in the one case in particular which I showed the slides of, the patient was still alive. Tllis was a surgical specimen. And we had several doctors go up and check on the history there. Mr. KoaNEtaAY. You have personally clone a considerable amount of .vork going into the process of the operation, the autopsy, the his- tory taking, and the reading of the slides? Dr. MottaN. Yes. All tlle pictures that I showed I went. over the sl ides personally and reviewed them myself, and took the pictures. Air. KORNEGAY. I don't know whether this is a fair question or not, Doctor. If it is not, yon just tell me so. The question Is-wouid it be extremely difficult for a medical man, assuming even that lie is an expert in this area, simply to take the slide, without having done any of the procedures before staining, and come to any accurate conclu- sions about what the slide showed, wllat were the results and what condition was depicted in t1le slicleF Dr. MORAN. Well, I am not sure that I can answer that question. I would say it. would depend on t.he circumstances, it would depend on who was handling the rest of the material, who selected the slides, anil -who did the autopsies. s~sssszoot CIGARETTE LABELING AND ADVERTISING-1965 321 11ir, KORNEGAY. Put another way-would you be in a much better position to come to some accurate conclusions if you were exposed to the case and had knowledge of the case from the standpoint of the liistory of tlle individual involved, the autopsy, and all the way down tlie line•I l)r. AIoRAN. Well, you would be in a better position, yes. But I wuiilil not want to say that it, is always possible to do it tllatway. I think in a l cr;e study you have to Iely-cert;linly for the histories-on soulehotl-v~ eltie. The patltologist has tot anyhow. Air. I1oRNEt.AY. Now, yon said that it is very easy to make a mistake in the appearance of solne of the conditions of the lung-that is, to call thein precancerous. I believe that was the term that Dr. Auer- l,aclt, who was here ,yesterdt y, used-precancerous lesions. Could one i»isl il:e a benign condition for a precancerous lesion? 1)I. MORAN. Yes; I think this is a very easy mistake to make: and it is one of the areas in which there is the greatest clitl'erellce of optnion .unonti pathologists. Mr. Kt,nNE(..tY. As I gather from your statement here today, based u>on your_ experimentation \~•ith animals palt__icularly, that inhalation of smolcemay change the appearance of the lung, but wllen that in- ha l,it ion is rentoved, tlteu the cluulge ;;oes away. Dr. 1folt.vN. That is correct; yes, sir. Al r. 11CuRNEC::cl. A nd it resumes its orlginal appearance. Dr. AIot::%,v. Yes sir. A ft. KoRNr.GAY. jliow, I)r. Aloran, are you familiar with anil have von studied the report of the Advisory Committee to the Surgeon (weneral on Smoking and 1-Iealth? Dr. MORAN. Yes, sir, I_ have. Air. KonNtx:AY. Now, based upon that report, Dr. Dioran, in your opinion is there sutlicient evidence to link cigarette smoking witll )ullg cancer and to justify and warrant the labeling of every package of cigr;irettes with a warning which has been proposed by the Federal Trade Commission to the effect that cigarette smoking is dant,rerous to health, and may cause death from cancer or other diseases? Dr. riolznN. Well, I think this is the problem that you e ntlemen have to decide. I have given my opinion to the best of my ability, which is that it is not proven that smoking causes cancer ofthe lun~, and other people have testified otherwise~ And I think this is the problem that ongress has to decide. I really cannot say on that. I can just give my opinion. Air. I1CoIINEGAY. Yes, sir; I understand. All I am asking for is your opinion-whether or not this report of the Advisory Committee of the Surgeon General on Smoking and Health is sutficient. proof that smoking-cirarette smoking causes cancer of the lung and that citarette packages should be labeled. Dr. MORAN. No, sir; I do not believe that. Air. KORNEGAY. Thank you very mucil. I aln very grateful to you, I)octor, for coming here. Thank yon, Mr. Chairman. The CHAIRMAN. Air. Satterfield? Air. :iATFERFIELD. No questions. 1'he CHAIRMAN. Mr. h'arnsley I Air. FARNSLEY. Thank you, Mr. Chairman.

322 CIGARETTE LABELING AND ADCERTISING-19t15 Doc•tc~r, the nearest I ean figure out, giving the bene..fit of the doubt to the report of the Surgeon-General-which is 18 uwnths ola has there been ntuch research in the field siuce then, public•ations available4 1)r. MORAN. I think there has been a~*reat deal of research in the area. I cloir't think there have been any significant c•nntributions to tlie tmclelstandin g of the problem, or any further adclitional experi- mental or clinic.al work which wonld help one way or the other. Mr. F.%RN6LEY. You feel that the facts were in at that timc and they have not chan;~ed, is that right-the best knowledge in the fiekl 1 Dr. MoR:%x. I feel that the information that, was available to them then is the same information that is available now to anyone who tries to evaluate the situation. AIr. FA1;NL8EY. I brought a clipping in the other dat~-it is in the record-psychologists saylng they thought-one t*roup' of 72 percent that had had cancer had had a history of depression when they were young. And they felt there was a correlation. Ilad you ever heard of thattheory$ I)r. MoRnx. Well, I have heard of such, yes. I cannot say I am very enthusiastic about them. But I cannot deny them, either. Sir. FARNSLEY. I)o you feel you are competent to have an opinion iu t hat field $ I)r. A[oRAx. No, sir, I do not. Mr. FARNSLEY. I found another one. Another one is that some of them think it may be virus that Inay be the cause. Is this a new theory $ Has this been going on a lond tilne $ IIow do you hold with that one ? Dr. MORAN. 'the virus theory of causation of cancer is not a new theory. It is an old theory. It was dropped for some years or par- tially dropped. But there has been a revival of it, and at the present time there is considerable evidence that at least solne cancers are caused by viruses. Experimentally cancers can be produced by viruses. There has been some recent research work in human cancers now that indi- cate that viruses are probably responsible for certain human cancers. So I personally feel that the virus study is a wide-open field. I think this is shown by the development of interest in this field by some very outstanding scientists. For instance, the men who developed the polio vaccines-Dr. Salk and Dr. Sabin-they are both working now on the relationship, or a possible relationship, between viruses and cancer, and both feel strongly enough that this may be the cause that they are doing experimental work in this field. Mr. 1•'AnNSLEY. You say this theory is old and it was dropped and then has been taken up again. When would you say it was taken up a~ain $ Dr. 31foRAx. Well, I probably shouldn't have said that it was dropped. All 1 can say is that probably for a period of about 15 years or so there was no additional evidence to help support it, and in the last I or 5 years, a number of things have developed which have revived interest in it, and now many people are working on the re- lationship of viruses to cancer. Mr. FARNSLEY. More now than any time in the last 20 or 30 years d Dr. MoRnN. Yes, sir. Mr. FARNSLLI.YY. All ll I can find is clippings. I don't have the learned journals you have. OVS969700Z CIGARETTE LABELING AND AD1'ERTISING-1965 323 I found another one. Somebody thought male hormones were mixed up in this thing. I-Iow do you feel about thnt $ I)r. MORAN. Well, this is one of the theories that has been ad- vanced, and I think there is no question that the hormones altect cet•- taut types of cancers. Sometimes_ favorably, sometimes unfavorably. As far as the relationship to cancer of the lung, I don't know whether there is any evidence to indicate a hormone relationship. It has been discussed. But I don't know what the answer is. Mr. FARNSLEY. Can one man keep up with the literature in this fieid $ Dr. MORAN. No, sir; I am sure of that. At least I cannot. Mr. FAI.NHLEY. That is what has been going through ncy mind, with the smattering of social science I have got.. We are tohl-I (10 not kuow-08 percent of the members of the AM.1 agree with the Surgeon's report. I do not know if they agree or disagree. Dr. 11[ounN. I would say first of all I doubt very much that. 98 per- c•ent, of Hre members of the AMA agree with the Surgeon General's report. I doubt this very strongly. I do not.. know what percentage agree. I;ut I think many of the Inen, for instance, who are not keeping np with the specific literature in cancer of the lung have to accel->t something like the Surgeon General's report. The fact that a certain number of men who are in practice of surgery or general practice, or internal medicine, may accept this cloes not necessarily prove that they know anything about t it, any more than at)elson who reads it in the newspaper. l~ir, FARnrsr.EY. You have an interest in this field, obviously. You have testified well, and you work in the field of cancer of the lung. And you say you are unable to keep up with the literature. Or is that all caneer liferature, or just cancer of the lung$ I)r. Afounx. 11'ell- Mr. FnRNSLr:Y. I am not trying to trap you. I am just trying to learn. 1)r. MORAN. I was thinking specifically of cancer in general, all aspe,-t,s of it-the experimental aspects of viral studies, the experi- mental a.spects of chemical studies. I try very hard to keel) up with all the literature on cancer of the lung. But even there I have diffi- culty. And I resort to not only agreat, number of patholop• jonrlials which I read all the time, but certain abstract journals which are published which deal with abstracts of the cancer literature. Even then I find it impossible to keep ttp with all of it. Mr. Fnexsl.EY. Iiow many scientists-that is scientists in tite health sc•.iences-would you say try as hard as you do to keep up with the literatnre on cancer of the lcmg$ Would you want to guess on that $ Dr. MORAN. I think it. would depend on the interest of the indi- vidnal. A man who is interested in lung cancer specifically would certainly make the same efCort that I do to keep up .rlth it. A man wh0 may be interested in diabetes or pneumonia or some other disease probably would only read occasional articles dealing with cancer of the lung. Afr. FAnxsLEY. I know we cannot get exact figures. Rnt ac a la,ymnn I do not know whether it would be 10,000 or 10 or 100 that niight keeli nh with the literature on cancer of the lung. ])r, MORAN. Iwonkl guess nott more than 1 percent of the doctors in t he c•ountly keep up with all the liternture on cancer of the lunh. .. (d. F E~ t ~, A . Y 4 p . t

324 CIGARETTE LABELING AND ADVERTiSING-1965 Mr. FARNSLEY. In tlie social sciences some men talk of aa cultairstil lag, and getting a vested iiiterest-they might feel sonle people get a vested interest in theories and reports and so forth. But you re- assln•ed me if there was a new committee to study this thing willl a completely ol)en mind that you do not feel a sihniticant change of philosophy since the Surgeon General's people stucliecl it? Ih•. Mors.XN. I said I did not think there was any additional infor- nialion that might Lelp any. Now, if you choose an entirely ne%v colunlittee, I think it would delencl upon the menibers you happened to uhoose wlu)t conrlu5icin they mifihtilrawt lint I do not: think that is the iuiportautt thint; that we need 1o c1o. I think ,.%•e have huc! enonl;h counnittees, and what we ought to do is develop the research progrquus and find out what the facts are. Mr. FAnxsl,r,r. I.Ij;ree Ai~itli that. I am not proposing another c•oln- Iuittee. I.uu just tryint; to tind out how valid tlle inforlnation before us is. .1re there any other theories as to what causes cancer or lung cancer that. we have not meiitioned? ])r. MorsAN. Well, I mentioned in the text the possibility of atmos- phericc pollatioll. Mr. FAIS'.,LSV. Ilow do you feel about t1latt one? ])r. MoIIAN. I just (10 not know the answer. I think it is agood ' pnssibilit~•. ;~onle of the experimental work, work by Dr. Icotin and I)I. 11'isel•y, where they have crombined viruses and oxidized -aso- 1ine, and have producer lung canceis in animals, I think may Le iL substantial Ste ) along this direction. I certainly 3o not, feel that smoke, industrial smoke, is any better for ns than cigarette smoke. 11f r. F.xei,st.r:v. I low ~Iboirt: automobile fumes? ility, I)r. MonaN. Well, I just do not know. I think that is a possibility, but I do not know the answer. Mr. FARNSLEY. Any other theories running around loose in your profession as to what causes cauc•er? I)r. MORAN. I think I have fouched on all the important ones. Mr. FAIeNSLEY. Thank you. Thunk •yotl, Mr. Chairluan. The CIiAIRMAN. I)(X`tor, I presume your grave concern about this problem is that if what has been proposed in the so-called Surgeon General's report is taken with full faith and credit-I do not.. indicate you nre taking any position but what there is scxne substantial that, c•redibility in the report-but as I gather from what you have said, this is only one of the probable causes of cancer. and if we proceeded, or if this is carried out, that it will no doubt relax efforts to try to overcome the other causes which you feel exist. Am I correct in that $ nr. MoaAN. I think,you have expressed itver•y well. My feeling is that• if everyone accepts the idea that cancer of the lung is caused by cigarette smoking, and that all we have to do is to putr on a big campaign to stop smoking, that we will not make any further progress on what really causes cancer of the lung. And I think that, research should be continued along all lines-fnrther in- vestigation of the possibility that cigarette smoking does cause cancer of the lung should be carried on. But also research into viral causes, chemical causes, or anything else that might be worth while. CIGARETTE LABELING AND ADVERTISING-1965 325 I do not think we should stop at this point because of a committee report which says that there is an assoclation. 'hhe CHAIIIDfA1T. l1'ell, now, would you disagree with this statement, 8 "As a matter of fact," as laymen we understand this a little bit better than we do these highly technical problems that you have men- tiuned here, "cigarette smoking is dangerous to health tuld may cause death from cancer~ and other diseases." ])I•. MonnN. 1Ve11, I cannot see any objection to a statenlent that ci;; Irette smoking Inay cause cancer of the hmg. I think this is one of the things that we are investigating as a possibility. I do not ob•jec•t to that statement. That ls, ttlat part of it. '1'IIe CIIAIRaiAN. Would it not'be more factually shLted-I am ask- ing if this would be correctly or not-that cigarette sulokinb, among other causes, is dangerous to health. What I have in inind, to see if I do understand it correctly-you are not sure that in a given case that the causation of that condition n is dno to cigarette smoking or something else. l)r. MORAN. That is corlect; yes sir. 1'lle CIIAIR1IAN. And do I Iulclerstand you correctly that there is no way now, with tLe research that you have, that you can tell whether it is caused from cigarette smoking or something else. I)r. MORAN. That is cc)rreot •, yes, sir. The CHAIRMAN. I believe it was the Chairman of_ the Federal Trade Commission who objected to using the language in aa so-called warning that it may be dangerous to your health, and lie stuck with the ti1711 conviction that cigarette smoking is dangerous to health. In otller words, there is no question about the-it is just a matter of fact, according to him. I lun not trying to argue one way or the other on the thing myself. I anI merely trying to make a record and get from you-you seem to have made such an outstanding contribution in this field, and I along with other people hopa you are able to continue yonr very fine Acork and your research and experimentation, because I feel it would be very valuable (town the road. And I hope whatever happens here, it does not in any way relax our efforts, through research, to get to tlle facts. 1 hope someday we may know. Irave you ever discussed this wit)h the committee of the American Medical Associat ion tha.t has given thought to this Proble.m ? l)r. MolraN. No, sir, I have not. '1'lIe CIInIRntAN. I think it would be an interesting tllin- if people sucll as yourself clid have a conference or a meeting for t7te purpose of discussing this whole matter. I must agree with you. I think we are trying " to arrive at a oint where we hope by passing a law or a rule down In the Federul 7~~ade Commission Ave c:ul do away with cancer of the iunl;-just by saying that, cigarettes are the cause of all of it. I agree with you. I think probably cigarette smoking does cause some difficulties. That is my own suspicion, shall I say. That is about all I can depend on. That is the w:Iy I feel about it. ])r. McinAx. I did not quite llear wha:t you said about what you agreed with me, sir. On wha.t? The CIIAIIeuaN, I agree witll you that I think some cigarette smolcing in some cases does cause some diHiculties. iVS969700Z

326 CIGARETTE LABELING AND ADVERTISING-1965 I)r. MoRAN. The most I am willing to say is that cigarette smok'tng - nt:cy cautie cancer of the lunn. I cannot say that it causes it in some cau•s, or It, does not cause it in some cases. I think it is a possibility i u ti~,me cases. But I cannot say for sure that it causes it. 11ir. Iiair:ns of Texas. Would the gentleman yield I I)octor, there are a great number of people who smoke cigarettes NO ho are healthy, are there not $ I)r. MORAN. Yes, sir. Mr. Ro(:ERs of Texas. And there are great numbers of people who are uuhealthy. who smoke cigarettes and would be just as unhealthy if they did not smoke cigarettesg I)r, NfoRaN. I think that is true, yes, sir. Mr. 114 x:rres of Texas. Thank you. Mr. `iA•iuTReIr:LD. Doctor,T would like to ask you one question. In listening to your statement and your answers, you indicated that the phrase "may cause lung cancer" would be acceptable. Would this be t he more acceptable way to phrase it, or would it be more acceptable to sny that it, maybe a cause of lung cancerY I)r. MORAN. Well, I have not actually said, as far as aa warning ]alxd-I have not even thought very much about that. I would cer- tainly say it would be more acceptable and more scientific to say it nuay be a cause of lung cancer than it is to say it is a cause of lung cancer. Mr. SATIFRFIra.D. Or that it may cause lung cancer? I)r. MORAN. I think that that is a statement I would be willing to make-that it may cause lung cancer. But I would not be willing to say it is a cause or the cause of lung cancer. Afl. S:%TTeRr•IFLO. Would you say it may be more accurate to say it may be a cause of lung cancer than that it may cause lung cancerf I)r. DIoRAN. I think either of those statements would be all right.. May be a cause of lung cancer would probably be the best statement. Mr. SA7I~:RFIr:r.n. Thank you. Thank you, Mr. Chairman. The CHAIRncAN. Doctor, thank you very much. We appreciate your presentat ion. I)r. \foRnN. Thank you, sir. The CIIAIR11fAN. Dr. Douglas Sprunt. STATEMENT OF DR. DOUGLAS H. SPRUNT, PROFESSOR OF PATH- OLO(3Y AND CHAIRMAN OF THE DEPARTMENT OF PATHOLOGY, UNIVERSITY OF TENNESSEE Dr. SPRIINT. My name is Douglas Ii. Sprunt. I am professor of pathology and chairman of the department of pathology at the Uni- versity of Tennessee. I received my undergraduate aegree at the Uniyersity of Virginia and my M.D. at Yale Unlverslty. I also re- ceivecl a master of science degree from Yale University, and stayed on at Yale on the faculty as an assistant, then instructor and then a Ster- ling research fellow. Thereafter, I was on the staff at Rockefeller Institute and, in 1932, I went to Duke University School of Medicine as an associats professor of pathology, before coming to t.lie University of Tennessee in Memphis in 1944. In addition to my positions at the University of '1'enne.%we., I have been chief of the laboratories of the city of Memphis hospitals. CIGARETTE LABELING AND ADVERTISING-1965 327 During World War II, I was consultant to the Secretary o€War on epidemic diseases and for several years I was consultant in niedicine to t.he Oak Ridge Institute for Nuclear Studies. I served for 4 years ou the Committee on Growtll of the National Research Council. I a,n a member of all five national pathology societies and have served as an oflicer for four of them, including the presidency of two of tliem, T IIe Association of Pathologists & I3acterlologlsts auid the Anier- ic,ul Society ociety for i.xperimental Pathology. I nnm a menlber of many other professional societies, all of which tire listed in tlie attached cur- ricululn vltae. I have published 93 articles oII the subject of pathology, ~u:uly of whicll dealt with cancer. A list of my publications is also attached. I have been interested in cancer of the lung for many years. Some of my early work involved studying the respiratory eplthelium and its reaction to various infectious agents and, in addition to my continuing work in this field I__ have followed the literature and 'the work of others in the field. ~ There is a considerable amount of statistical data which show an as.sociation between smoking and cancer of the lung. Statistical data is extremely valuable. I have used such data extensively in my own work and we have in our department at Tennessee a fuY-time statis- tician and several workers trained in the use of computer and other electronic equipment to aid us in analyzing clinical and experimelltal data. Statistical data, sllowing a high association between two factors, however, does not necessarily mean that there is a causal relationship between them. A statistical association may mean one of three thinb . It may be the result of chance, it may mean that the two related fact,ols uiay both be the result of some third factor or the relationship nlny I~e that one ne causes the other. To determine the meaning of a statistical association, it is necessary to go beyond the statistical evidence to the laboratory and clinical ex- 1wrience. In the labolatory, we do not accept statist.icti.l evidence alone, hut believe that if statistics show a close ussociation of two factors, we must show that one cau cause he other in the experimental animal before we can be certain a causal relationship exists between the two. To date, no one has prcKluced cancer of the lung in an experimental anitnal with tobacco snioke or with condensates extracted from tobacco smoke. Thus, laboratory confirmation of the statistical association 15 stilll lacking. It is true that cancers have been produced on the skins of aninlals by various condensates of tobacco smoke, but skin cancer in experimentul animals can also be produced by a number of innocuous substances, sucll as sugar, beef, et cetera. I c_lo not think one can attach any breat significance to this work. The clinical data likewise do not support the suggestion that ciga- rette smokin« causes lung cancer. There are maiiy observed incon- sistencies in t~te pat.tern of lung cancer incidence, which cannot be er- plained by any presently known facts relating to cigarette smoking or, for that matter, other suspected causal agents. The geograpllicatil dis- crepancies in lullg~ cancer incidence do not follow observed differences in cigarette constunption. For example, even though the annual con- sumption of cigarettes in England is less than in this country, the in- - -_ ZD5969700Z

328 CIGARETTE LABELING AND ADVERTISING-I965 cidence of lung cancer in England is approximately double that in the United States. Also, lung cancer seems to strike more than often among poor people, although there is no proof that poorer people sunoke more than those who are relatively more aflluent. If anything, it seeins that more alllu- ent people smoke more. It is interestingtbat the same relationship ah- pears in cawicer of the cervix. In a study of more than 5t)t),0(10 women, we have observed that this particular cancer of the reproductive orhans occurs about 2 to 3 times as frequently in the lower socioeconomic group as it does in the upper. Cancer of the huig seems to be more common among people who have never married than alnon~,• inarriea people and likewise among those who have been divorced. We do not have any explanation for these lindings; I am not able to explain theni by ci¢arette smoking patterns. It has been stated by one group of investlgators-llr. Auerbach- that histological changes in the respiratory el)ithelium occur in smokers more frequealtly than in nonsmokers. I liese changes ranhe from simple changess in the respiratory tract epithelium ~callel hypet•- plasia, and mettLp.la,sia-meaning either an increuse in tie number of cell5 or a change in the type of cells) to a more striking change which has been called intraepithelial cstrcinoma or carcinonia in situ. ThiS lesion is thought by some pathologists to always progress to cancer and by others to be a Inislomer as it can revert to nornial eplthelium. In our studies we have never seeu intraepithelial carcinowa of the ]wih either in smokers or nonsmokers except where there was also already adefinite cancer of the lung. Other pathologists concur in this point of view. The other changes, hyperplasia and nietaplasia, are found not only in smokers Lut also mI)eople with a variety of other condi- tions such as acute and chronic infections. Another interesting fea- ture about these lesions is that they occur in the trachea quite com-_ monly while cancer is almost unheard of in this location. To summarize: 1. The stune changes as described in smokers are also seen in persons who do not smoke. 2. 1'hese changes have been produced in experimental animals by inducing both acute and chronic infections, without the use of any tobacco smoke or condensate at all. 3. They are more commonly found in the trachea and in parts of the lung where cancer is rare. 4. We have not been able to find carcinoma in situ except where reai cancerr was also present. 5. No one has shown that cigarette smoking causes these changes. In n the study I mentioned previously of the epithelium of the cervix of uterus which is similar to the respiratory epltheliuwn, in more than half a million women, we have observed that, in many instances, hyper- plasia and metaplasia frequently return to normal and that cu.rctnoma in situ probably sometimes reverses to a normal epithelium. We tire still studying the exact relationship of these changes in the cervix to cancer of the cervix. Our experience with the cervlcal epithelium, however, dictates caution in coming to any conclusions regarding the sifinificnnce of the changes in the lung. For some years now, I have been studying the various s types of lesions which can be made to occur in the respiratory tract in the expel•Imentul animal. In particular, I have been very interested in the relationship CIGARETTE LABELING AND ADVERTISING-1965 329 of previous infection, especially multi)ile previous infections, to cancer. While there is not any persuasive evidence that a single 1>revioiis in- fecton, such as influenza, would play any significant part ni lung can- cer causation, there have been indications that multiple previous infections, involving multiple damage to the respiratory system, may be important. To stucly this possibility, I have begun experiments with rabbits over tlie past few years. Liwg cancer in the rabbit is exh•emely rare auid, in fact, I do not know of any case where it has been reportecl ,Ls arising spontaneously. For this reason, the rabbit was a useful st.u•tina point for this stu<ly. In tlie course of our study, we have repeatedly infected the respira- tory system of rabbits with substances known not to be cancer causing vrhen used individually in experimentation. By repeated exposure to these substances (bacterial toxins, cow pox virus, iund dilute acids), we have produced cancers of the lung in two rabbits. Our work is continuing, ;iud we have just begun the study of the effect of repeated experimentally produced pneumonia in the mouse oil tlle incidence of ltuiL; cancer in this animal. I am hopeful that this work in the rabbit and in the mouse will cast further light upon the problem of lung cancer causation in luunans. 1lfany persons who formerly died of pneiunonia now recover because of antlbiotlc therapy, and these people may have pneumonia several times. There have been rehorts of a relationship between cancer of the ltmg and repeated incidence of pnetunonia. Other re-. l,orts have linked cancer of the lung to various other previous respira- tory infections. Diuch .more work needs to be done in this area before any conclusions can be reached; and our work should provide_ an experimental test in t.he laboratory for these observations. At this stage, we do not know enough about the basic biological mechanisms of cancer to come to any conclusions based upon statistical observations of populations. Thus, while cancer of the lung has been increa.sing in recent years, cancer of the stomach-which was the com- monest form of cancer in the male when I graduated from medical school almost 40 years ago--has been decreasing. 11'e do not know the reason or reasons for these observed trends. D_ fucli work on the biological mechanisms involved is presently being done and the out- look for major contributions to our knowledge iii the near future is bright. In summary, before we can come to any conclusions concerning the causation of lung cancer, we need much more researcll both in the nature of cancer generally and in the study of lung cancer in the la[xmtory. Statistics undoubtedly can play an important part in this study, but we should be careful not to draw extensive conclnsions on the basis of statistical associations unless we can support them with experitnental data. 1lltliough laboratory findings in animals cannot be directly translated to man, before re we accept claims of identification of causal factors, we should see these claims tested, and the causal efficacy of the factors demonstrated in the laboratory. This has not been done in the case of cigarette smoking and cancer of the lung. For all of these reasons, I do not believe that cigarette smoking has been een proved to be causally connected with lung cancer. 98-824-e5-22 EVS969Z00Z

330 CIGARETTE LABELING AND ADVERTISING-1985 CIGARETTE LABELING AND ADVERTISING-1985 331 (The attachments to Dr. Sprunt's statement follow.) CURRICULUM VITAE Sprunt, Douglas H. E Ilamilton ): Pathologist, Born : Wilmington. N.C., August 2, 1!N)0. Son: William llutchison and Bettie Massie (Hamilton) Sprunt. B.S.• U. Va., 1:122. M.D., Yale 1927. 111.S. Yale 1929. 11larried : Edith Churleacruft Lucas, (lvt. 17, 1!):33. C'hildren : Alice Hamilton S.• b. Nov. 4, 19:37: Edith Lucas S., b. March 27, 1!N0. Asat., 1J':7-28, Instruc. 1928-29-Yale U. Sch. Medicine. Sterling Reyearch Fellow, 1!V_NJ-30. Acting Resident In Path., 1927--28; Resident in Path., 192tt-29-New Haven, Conn. Hos)r. Asst. Hosp. Rockefeller Inst. for Med. Research, 193(i-32. Assoc. Prof. Path., Duke U. Sch. of Medicine, 1J3•1-14. Professor of Path., U. Tenn., 1944- . Chief of Laboratory, City of Memphis Hos- pital, Memphis, Tenu., 1944- Consultant to Sec'y of War for Epidemic INs- eases, W.W. II. Consultant in Med., Oak Ridge Inst. Nuclear Physics, Inc.,1J4:.- Gy. Member • Pathology Section of USl'HS, 194s)-53; Cancer Control ConL, Nat'1. Cancer 7nyt.,~USPHS, 19,53-1'J(30. Member; Com• on Growth, Nat'l Research Council, 1J47-:,(l. Member: Am. Soc. Expt'1 Path. (Pres., 1!li7 .',8) : Am. Soc. Clin. Path.; Ain. Assn. Path. & Bact. (Mem. Council, 1955-1962; VIce-President, 1959, Pres. 1960, See. 1961) ; Asan. of Immunologists, Soc. Expt'l. Biol: and Med. ; A.M.A. ; A.A.A. S. ; So. Med. Assn. (Chairman, Sect. on Med. Educ. and Iloalf. Training, 1945-40) ; Tenn. Society of Path. (Sec: Treas., 1!}u7-09) ' Memphis and Shelby County Med. Society. Fellow: Am. Col. Physicians; Fellow: Col. Amer. Pathologists ( ltd• of Gov., 1948-51). International Academy of Path. (Member Council, 11)47-:i3). Chairman : 2d Teaching Institute, Pathology, Microbiology, Immunology & Geoetics, A.A.M.C., 1cJG4. Chairman • Parke-Davis Award Coin., Aen. Soc. Expt'l. Path. 10:i8-59. Member: Lederle Medical Faculty Award Committee, 1954- . Chairman Nat'l Research Council Coordinating Citiit- mittee for International Illtersociety Committee on Pathology, 1950- . Vic•e- Ch_ airman International Committee on Pathology, 1980. . N'raternitie5: Kappa Alpha (South). Nu Sigma Nu. Religion: Presbyterian. Clubii : Memphis Country; • Cosmos (Washington, D.C. )• University (New York City). Author: Articles in science journals on viruses, toxins, endocrines, antibiotics and gerontology. Ilhme: l!)1 P.. Parkway S., Memphls_, Tenn. OOice: Institute of Pathology, University of Tenn., 858 Madison Ave., Memphis, Tenn. PUeLIOATIOVa oe DouoLAs H. SPRUxT, M.D. Underhill, F. P., and Sprunt, D. H. ; Influence of Amytal upon Blood Sugar Con- tent. Proe. Soc. Exper. Blo. & Jled., 23: 137, 1927. Spruut. D. H. ; Carcinoma and Tuberculosis of the Stomach, Surg. Gyn. & Obs., 51 : 245, 1930. SSprunt, b. H.; Renal Damage Following Administration of Merbaphen (Rova- surol). Arch. Ind. Med.• 40 c 3!)3, 19:30. Rivers, T. M., Berry, G. P., and Sprunt, D. H.; Psittacosis: 1:. Experimentally Induced Infection In Parrots. J. Exp. Med., ti4: 91, 19:30. Waketuan, A. DI., and Sprunt, D. H., and others; Metabolism and Treatment of Blackwater Fever ; Am. J. Trop. Med. 12 : 407, 1332. Sprunt, 1). H.; Influence of Roentgen R ys on Acid-base Quilbrium. J. Biol. Chent., 92 : W5, 1931, SSprunt, D. H.; Infectious Myxomatosis (Sanarelli) I.n Pregnant Rabbits. J. 13xik r. Med., .'di : 601, 1932. RRivers, T. :1I., Sprunt, D. H., and Berry, G. P. • Observations on attempts to Pro- duce Acute Disseminated Encephalomyelltls in Monkeys. J. Exper. Med.; 58 : 3J. Sprunt, 1). H., Martin, D. S., and Williams, J. M. ; Interstitial Bronchopneumonia ; I. Similarity of a Toxin Pueumonia to that Produced by the Viruses. J. Exper. Med 52: 73,1935. Sprunt, D. IL. Martin, D. S., and Williams, J. M.; Interstitial Bronchopnenmonia: II. Production of Interstitial Mononuclear Pneumonia by the Bordet-Gangou Bacillus. J. I:xPer. Med.• 0:3: 4•19,17.3a. Smith, S. G. and Sprunt, nrunt, D. II. ; Pathological Skin Changes in the Tall of the Albino Rat on a Diet Deficient in Vitamin G. J. Nutrition, 10: 481, 1935. Sprunt, D. II. and McBryde, A.; Morbid Anatomic Changes in Brucella Infection In Dlan with Report of a Necropsy. Arch. Path., 11 :•117, 1930. AmosH, 11. L. and_ Sprunt, D. II. ; Talaremia-Review of the Literature of Cases Contracted by Ingestion of Rabbit and the Report of Additional Cases with a Nc'crophy. J. AIn. Med. Assoc.,10tt: 1078, 1'J36• Sprunt, D. H., and Berry, U. P.; Psittacosifa--A Review of the Literature of the l.e•xions in t.ho Central Nervous System with a Relxtrt of a Case. J. IuL Dis., 58: 1'J(l. 1936. _ Sprunt, 1). 11., and DlcDearmnn, S.; Effect of Iodides on Interstitial Mononuclear I'netunonia. Arch. Path., 22: 273, 1tA3(3 (Abstract). Sprunt, 1). II.; 1'art of a Round Table Discussion on Pulmonic Alveolar Epi- thMinni• J. Thoracic Surg., 0: 83, 1J30. Sprunt, 1). II., Martin, 1). S., and \lcDearman, S. • The Results of Intratracheal cheal ,tu)ec•tion of Bordet-Gengou Bacilli in Monkeys ~and Rabbits. J. Exper. Dted., 67 • 3U!l, 1938. Spruut, D. Il., 11icDeurman, S., ancl Raper, J.; Studies on the Relationship of the. Sex Hormones to Infection. I. The Effect of the Estrogenic and Gonado- trophic liot•mones on Vaccine and the Spreading Factor. J. Exper. Med., 137:57, 1938. Sprunt, D. H.: Simple Atrophy of the Liver. Its Relation to Increased Resist- ,unce. Arch. Path., 24:7:3li, 1938. Sprmtt, 1). H; The Significance of Interstitial \fononuclear Pneumonia. So. Di(•e1. J., 31 302, ltl:3ti. Ihniublen, B C and Sprunt, D. H.; Fatal Functional Uterine Bleeding. Endo- criuology, 21 : 553, 1937. Sprunt, I). II. ; The Part Played by Age and Female Sex Hormones in Resistance to Infection. Endocrinology, 25: 625, 1cJ39. Sprunt, 1). H., and McDearmun, S• ; Studies on the Relationship of the Sex_ Hor- munes to Infection. 11. The Effect of Pseudopregnancy on the Spread of India ink in the Skiu of the Rabbit. Endocrinology, 25: 308, 1939. SSprunt, D. II., and Mcllearman, S.; Studies on the Relationship of the Sex Hor- auoues to Infection. III. A Quantitative Study of the Increased sed Resistance to Vaccinal Infection Produced by the Estrogenic Hormone and Pseudopregnancy. 3. I mmunol., 323 : 81, 1?l0. Sprunt, D. H., and McDearman, S.; Studies on the Relationship of the Sex Hor- tuones to infection. IV. A Study of the Dispersion or Concentration of India ink in Skin by Certain Sex Hormones. Endocrinology, 27: £i'J3, 1!)40. Sprunt, D. II.: Effect of Varying the Volume of Injection in Calculating Number of Iufections Particles of Vaccinia. 1'roc. Soc. Exp. Bio. and Med., 4:.':718, 1!)30. Sprunt, D. If., Marx, W. W., and Beard, J. W. • Studies on the Infectivity of Vaccinial N letnentary Bodies, J. Infect. Dis., (38 c 53, 1940. Sprunt, 1). II., Ilooke, C. W., and Raper, J. S.; Relationship of Spermatogenesis to ihe Factor in the Testis Which Increases Tissue Permeability. Proc. Soc. Exp. Bio. and Med., 4l : t34R, 1!);J. Spritut, D. 1_I., The Effect of the Feulale Sex Hormones on Infection and Inflam- mat.iony. So. Mexl. J., March 1941. SSprunt, I). H. ; The Effect of the 1`irus-host Cell Relationship on Infection with Vaccinin. J. Exper. Med., 74: 81, 1941. SSprunt, 1). II.; The Effect of Uiidernourishment on the Susceptibility of the Unbbit to Infection with Vaccinia. J. Exper. Med., 75:207, 1!)42. Sprtmt, I). Ii.; Rcrluction of Pulmonary Resistance to Infection by Circulating Toxinrg• Arch. 1'ath., 34: 801, 1942. SSprunt, D. II. ; Inhibiting Effect of rIethionine Choline and Betaine on Rabbits' Susoeptibilit.y to Infection with Vaccinia. Proc. Soc• Exp. Bio. and Med., 51 :2::0, 1!)42• Sprunt,. 1). II.; Invivo Neutralization of Pertussis Toxin with Pertussis Anti- toxin. Am. J. Path., 1'J•25:,, 1943. Taylor, II. Af., and Sprunt, D. H. • Increased Resistance to Viral Infection as a Hesult of Increased Fluid in Tissues. J. Exper. i11ed., 78: 91, 1943. Sprunt, D. H. ; Increased Susceptibility of Dlice to Swine Influenza as a Result of Mt•thinnnine ]n,ieetions• Proc. Soc. Exper. Bio. and Mcd., 07: 31!>-321, 194g. Sprunt, 1). II.; The Rnle of the I'athologist III Medical Education So. Med. J., Vul. 40, August, 1!li7. MvV;iy, L. V., Guthrie, F., Mic•helson, 1. D., and Sprunt, D. II. • Isolation of Brucella from Apparently lIealthy Individuals. Soc. for Exp. Bio. and 11Ied., (t9 : G07-008, 1948. ~t7sssszooi

332 CIGARETTE LABELING AND ADVERI'ISING-1905 Sprunt, D. Ii.; l:ffect of Maluutrition on the Infection of Mice with Influenza Virus. Fed. Proc., March 1tMltl. JI(Va,v, L. V., (:uthrie, F., and Sprunt, D. H.; Selrtieentia due to I;acteriode>3, .>.ureomycin Hydrochloride Therapy ln Two Cases Due tu 1ttu4eriodw Funtluli- furmia. J. A. M. A., AuRntst 19-t71: McVay, L. V., Laird, Flanagan, Sprunt, D H., The Treatment of Trichomonas Vaginulis Vaginitis with Aureomycin. Yruc. 5rx. Exp. Ilio. & Med., 1!)-19. Sprunt, D. H.; Evaluation and Application of Tests for the I)itignosia of Caucer. l'rcwrntcyl at Cancer Day, 1>rcember 12, 19:A), Puerto llico Mrxlical Association. MeVay, L. V., Laird, Sprunt, D. H.; The Treatment of Amebiasitz with :\u- rcouryc,iu. So. Med. J., April 1950. \IcVuy, L. V., Ihtnavunt, L., Guthrfe, F., and Sprunt, D. H.; Treatment of :letiuoiuyeoecis with Aureranycin ; J. A. M. A., 143:101i7-100it, July 1". McVay, L. V., Guthrie, N'., Michelson, 1. ll., and Sprunt, 1). II.; The Isolation of Brucella Organisms from Apparently Healthy Iudividuala, Yale J. of Blo. & Med., Vol. 22, No. 6, July 1950. Sprunt, 1). II The Ground Substance in Infection. Annals of the N.Y. Acad. of Sciences. 52:1052-1060, Art. 7, May 1950. Sprunt, i). H., Itogers, W., Dulaney, A. 1).; Autoantibodies to in vivo Damaged Kidney. Relationship to Nephrotoxin Fed. 1'roc., Vol. U, March 7!Y,'A). Spruat, I). II., Kyle, J. W., oud Richmond, S. (,.; The Reproducihility of the lorloacetate Index in the Huggins' Test. Cancer Research, Vol. 10, No. 4, April 1950. McVay, L. V., and Sprunt, D. H.; Streptokinase and Strep_todornas_e in the Treatment of Diabetic Gangrene. A. M. A. Arch. of Int. Med. 1+7::,;,1-.r:,9, April 17)GI McVay, L.lr., Evans, Larey, and Sprunt, D. H.; Concentration of AureotnycIu in the Intenstine. Vol. 10, No. 1, Mal'.ch 1951. Fed Proc. Sprunt, L. Ii.; Effect of Autolytic Changes on Autigenic Properties of Kidney Preparations. Fed. Proc., Vol. 10, No. 1, March 1951. McVay, L. V., Guthrie, F., amI Sprunt, D. H.; Aureomycin in the Treatment of Actinomycor{ia. New )Jng. J. of 11iEa1., `145 :J1-J0, July 19:d. \IcVay, L. V., and Spruut, D. H.; Aureomyciu in Male TrichoutoniasIs. Sn. ,\led J., 44 112P.-112.1, 19nL McVay, L. V.; and Sprunt, 1). II.; A Study of 11lonilia4is in Aureomycin Therapy. 1'rc><. of the Soc. for Exper. Blo. & Med., 78:75!1-7(i1, 1!151. 111cVay, L. V., Evans, Larey, and Sprunt, D. II.; A New Method of Treatment of Tricltomouua Vagiuali:3 Vaginitis. Surg. Gyn. and Obs., ll3:177-181, August 1951. Spniut, D. IT.; Pathology and the Pathologist iu Relation to the Clinician in a Tutnur Program. As.woc, Medica De Puerto Rico. Vol. KLIi, No. 1, 1Ji1. Sprunt, D. If., Kyle, J. W., and Richmond, S. G. ; Comparative Study of Severa Tests which May be useful as Health Clearance Teata, Cancer Research, 2:2R2, 1951. Sliriutt, 1). 11., Dulaney, A. D., and Conger, R.; Methods of Preparation and Aut!genic Activity of Estrogen Protein Conjugates. Cancer Research, ':282, 1951. McVtty, L. V., and Sprunt, D. H. • Btlcteroides Infections. Annal of Int. Med., Vol. 3fi, No. 1, January 17):id. ~ M(1'ay, L. V., and Sprunt, D. H.; A Long Term Evaluation of Aureomycin lu the Treatment. of Amebiusis, S. M. J., Vol.45, No. 3, March 1!K,`_'. Spruut, I). If., Wood, J. L., and Schunutn, II. L.; Action of Meihiouine in Viral InfrvN/NIs, Ft4L t'roc, No. 1, Vol. lI, March 1Wi2. Sprnnt, 1). IL, Sands, S., h:ffect of Low Protein Diet on Rous Sarcoma In Chickens. Fed. Proc., Vol. 12, March 1953. McVay, L. V., and Sprunt, D. H. ; A Long Term Evaluation of Aureomycin in the Treatment of Actinomycoais, Annals of lut. Med., Vol. 38, No. 5, May 19:rii. McVay, L. V., and Sprunt, D. H.; Treatment of Actinomycosis with Isoutazid. J. A. M. A.. Vol. 1fi3, September 1953. Mc1'ay, L. V., and Sprunt, D. H.; A Long Range Study of the Use of Broad Slwrrtrtun Antibiotics In Elderly People, AntiLiritics Annual, 1953-ro4 Medical Eur;vvlopedia, Inc. McVay, L. V., and Sprunt, D. H. ; Antibiotic Prophylaxis In Chronic Respiratory I)inearea A. lif. A. Arch. of Int. Med., Vol. 92. I)ecrmber 1!1.IZ. McVuy, L. V., and Sprunt, D. II. ; Aureomycin In the Prophylasi.y of Rheumatic Fever. New Uug. J. of Med., Vol. 249, No. 10, Septetnher 1953. CIGARETTE LABELING AND ADVERTISING-1985 333 McVa-v. L. V., and Sprunt, 1). If.; Antibiotic Prophylaxis in Chronic Congestive Fallure. Ant. J. of 5ta1. Sciewrc, 2'G:491-+i07t, November 19:i ;. Itichmr~ud, S. (,-, and Rl,i~uut, 11. II.; The Need for 1'roperiy Trained DRtilical Ter~lntningists in the OOloe Laboratory. Tenn. St. Med. J., November 1!k5::. Kyle, J. W., Richmond, S. G., and Sprunt, D. H.' Evaluation of Several Cancer Tests. l'S1'1i?{ Monoq;rmn, No. 1'l. 1!I:r3. ~ Mcl av, L. V., Sprunt, I). If., Stern, 1'. N., Tatnm, F. F., and Idpscomb, A., Anli- fiintic. 1'revcntinn of lul~~rciu'rcut Iufeetions in I)labetea Dlellitus. Anuals of lut. JIcd., Vol. 40, No. 2, Fcbruatry 1953. Sprunt, D. II.; Present I)ay Concepts of Pneumonia. J. So. Med. Assoc., 47:-184-- 4,11i, No. 5. Dtay 1!I:rt. Sprnnt, A. II., and Chang, F. f?.: Sernflnecnlating Steroids. I. Ethyl 3 Beta- ('hloro-Delta"-Cholenate, J. of the Am. Chem. Soc., 70 •3213,. 1954. A:11ethoHl of Fvaln:ttmti ( am•r r Teytn, Sprnnt, D, 11. and Ilaie, Win., Proc. Amer. .1..n. for C t. Voi. 2, No. 1, April 1955. Sin•mit, 1). 11., Ilah', Win., ('hanyt, 1•'., ltlchmon(l, S. (:., Erickaon, C. C., Pre'<cnt Stntns of Eanccr Tc>itx. 5cience, 12`d:'.7:: 274, No.:p1Ka, August 12, 1!li.i. Dunn, John E., and aprrtnt, DnuGlny II, T'tecine Canccr Cat;e 1'iuding by Vag- inal Cytology, I'nhlic7lonlih Report, r0::-0-1t_-a4R, No- 4, .lpril 19,n5). Sprmrt, 1)- II., l'he (:.ronml Snbvtam'e of the Mesenchytnn und Ilyalnrontdave. 5pr1mt, 1). Il., I)ou:;ats. .1. 111., Rnuforrl, ('„ ClinopaLhoiogic Conference. 1lalhes, (.nrdon, ltichmwn(l, tiarn Crace, Rproutt, I)ont;hiR Ii., The iFse of L- 1'attrate in I)plcumtniu{; "d rcititatic" Sernm Ar!rl Phosphatuyc A lteport of fil-i Cnscy, J. of Tlrolo} y, 75:14.i-1Pi0, January 1956. 1'acker, Henry, Arunult, :1I. Blake, Sprunt, Douglas H., A Study of Hemolytic titrcptiN•cul Infcction> iu Rclation to Ant!streptolyxltn 0 Titer Changes in nrphnna>;e Cluldren, J. of Ih Q 4S:nt-i-S1;2, No. 5, Mtty 1956. Flrir•ksun, C. ( Everett, ltt'nm tt ( rnceu L!oy4 \I., Kaiker, Itaymnntl, \falmgren, ]tichard A., Ruhe, Irma, Schrr•ter, P. C., Cutler, Sidney, aprunt, Douglas II., I'opnhUion Ceref'ning for T'terine Cancer by Vaginul ('ytulogy' 1'relitninary hammnry of RPPnItv of Tirvt Examination of 1(IR,Il1N/ lfiotnen nnd tirr•nnrl 'I't~.ting of 3.3.000 )1'omen, .T. of th(, A. 1f. A., 162:167-173, September 15, 1956. Sprtmt, 1). II., 1'Ianit;•ut, Clyde C., The Effect of Malnntrition on the Susecpti- hility of the IIoet to Viral Infection, J. of Ex. Med., 10d:687-706, No. 5, Novemher 1956. Sont;. Y. S. and Sprunt, D. If.. Nonbacteripl Diffuse Myncardltis Axsru'iaterl with Inlerstitial Pneumonia, A. M. A. Arch. of Path., 85:0(18-074, June 1958. Coleman, Sidney A., ltnhe, Irma F., Caroll. Phil C., Schreier, Shrunt, D. IT. IEni.er, Raymond F., Erickson, C. C., An Evalnatinn of the Sensitization Rc- sponke as a Method for I)etermining Radiation Sensitivity, Am. J. of (_'linical I'ath., 3R:20-2n, Nn. 1, Jannary 1!)EiO. Kniser, Ita,vmond, I+lrickqnn, C C., Everett, Rennett, f:illiam, Graves, Lloyd M., Walton, Mary, Rprtutt, Ikmglns II., Initial Effect of Community Wide Cyto- locic Screeninfi on Clinical Stage of Cervical Cancer Iletected in an Fntire (`ommunity. Results of Afemphis-Shelhy County, Tenn. Study, J. of Nat. ('an. Inst., 25:Sf.`;-8R1, No. 4, llctnber 1960. Chnn;;, Frederic (?. ; Bliekenslnff, Robert 'P. • Feldatein. Aaron Gray, Jane Ran- 9mn : MeCaleb, George S., and Sprunt, Douglas H. ; Seroflocculating Steroids, I1T, Chloro and Other Bile Acid Derivatives, J. of the Am. Chem. Soc., 79:2164, 1957. Chana, Frederic C-' Feldstein. Aaron; Gray, Ransom, Jane• McC.,aleh, George S.: Sprunt, Douglas If.; Sernflnrculating Steroids, IV. Unsaturated Aile Acid Esters; J. of Atn. Chem. Society. 7!1:2167, 1!/57. Sprunt, DouFla9 11. and F'lningan, Clpde C.; The Effect of Nutrition of the Prn- rlnetinn of Dkenae by Ilncteria. R!ckettsine, VirnReRt Advances in Veterinary Medicine VT, pp. 0!1-110, Arndemic i'recq, New York-1!Nt1. Sprunt, Douglas H.. The Autopsy In Training of "Clinical" Pathologists, Bull. of the Am. Path. SIV :141-142, No. 11, Novem'ber 1!)80. Coleman, Sidney A., Rnbe, Irma F.. Sprunt. Donglaa I;., and Erickson. ('.yrnc C. Abnnrmal Vaginal Cytology with Exceptional Pathologic Correction. Am. J. of Clinicnl 1'atholnGy. a7:2(;R-?7R, No, a, March, 1!N12. Smith, James F. and Sprimt. Tlonglna If. The Early DiagnoAis of Cancer of the Oral Cavity. 4onthern Mal!cnl Jgarnal. f5:502-`•i0!1, No. 5, May 1!)fi2. fiprnnt. Douglas IT. nnd Tlertnn, William 11f. The Relatinnqhip of Sncicrl'co- nomic nnd Racial Factnre to Carcinnnma of the Cervix nq lndicnted by a Mwq Screening Progrnm. Avin: t'nin International is contra Cancratn (Louvain). 10 :17GR-1770. 1960. SVS969Z00T

334 CIGARETTE LABELING AND ADVERTISING-1965 CIGARETTE LABELING AND ADVERTISING-19t35 335 Lyons, Jones, Qninn and Sprunt. Proteln-i'olysaccharid Comhlexm of Normal and Llerniatirl Human Intervetebral 1)isc . Yroc. Soc. N:xp. Biol. & 111e1. 115 :tt11N314, 111(4. Cinnun, ISland, Picaza, Jorge A. and Snrunt, D. II. (by invitation). Study of the Itehationship of liloial Uric Acid and Herniated Intervertebrul Disc. 1're- ,euteKi at the Eighteeuth Annual Meeting of the Neurusurgical Society of .lmerica. San Juan, Puerto Ilico, Jannury _'(3-311, 1JU5. The CnnutanN. Doctor, thank you very much. llr. RooEnn of Texas. I want to compltnlent the doctor on his st.ate ment. I think it is very clear, concise, and easily understood. I have no (luestiolls. DIr. YouxGER. I have no questions other than to congratulate the doctor. Mr. IIORNECIAY. I want to compliment the doctor also on a vel.y fine statement and say that he put this statistical propositioll in a go(xdlight which well explains a lot of the things we have hettird ]tere-the #act that you just cannot take two factors and airtonlat.ically come ul) «•itlt a third. This is like the story I heard the other day. Statistically speaking, since they put Smoky Bear posters in the \Tew Y ork subways, they ha.ve Ilot had a single forest fire Llt Manhattan. ''ILalik you very much, Doctor. l he CHAIRMAN. Mr. Ftu•nsley. Mr. FARN:;LI:Y. Thank you, Dtr. Chail•man. 1)octor, we have only had one man that I can remember who was competent in any of the social sciences before us; a psychologist work- ing for the Surgeon General. He said lie had made no studies, but he h.ul read the literature, and, in his opinion, the warning on the package would cause the sale of cigarettes to be reduced. And agen- tleman with great experience in the advertising field thought t,he s:une tlting. IIe thought it would virtually eliminate ei;;al•ette advertising , althongh he later said maybe this would not happen. I nm conrinccd a study ought to be made as to the effect of the labeling, as to whether it would cause consumption to go up or down. IIowever, it seems almost certain that if the warning on the advertis- ing is passed by the Congress, we will be presenting a windfall of almost a quarter of a million dollars a~•ear to the tobacco companies. I Iave you found anything in the studies to the effect they are ent itled to tltat.? It is a trick question. Do not answer it. Dr. SrRUNT. I would like to say the ]ttbelin se.etns to me might be the old fable-if you call attention of the public-like the shephertl boy that yelled wolf so ma.nytimes, and the people came out to be,lp him, and there was not any wolf. And tinally when there was it wolf, lie got ate up. It seems to me if you start labeling things now with no more proof than we have now, you may get in the same thing when sonletltinh really comes along. I~~o not think tltee roof is here now. Mr. FARNSLEY. ~V e used to say familiarity breeds contempt. The first time the Surgeon General told us to quit, a lot of us did. If lie tells us several hundred times, it may lose its effect. I)r. SPRUNT. I think we ought to spend more money on research- we should get more facts. Mr. FARNSLEY. Thank you, Doctor. I have no further quest ions. 9DS969ZOOz The CIIAIxirnx. Doctor, thank you very much. We apl>reciate your present,ttion. The committee will adjourn until 10 o'clock in the mornin~•. I k We havenat leastsethefopueople,r witnessesecause on•e ]lopeo b thatf pw.ie c1onsnthe~et to in the niornin~. ow the sity hold, are anxious to get back to their daily chores. (Whereupon, at 4:25 p.m., the committee recessed, to reconvene at 10 n.m., Thursday, Apri115,19G5.) '""MROW,

CIGARETTE LABELING AND ADVERTISING-19G5 4V~gs9%ooZ THIIRSDAY, APRIL 15, 1905 IIOCSE OF IiEPRF:SENTATI\"ES, COm\f11TF.E ON INTERSTATE AND FOREIGN COMMERCE, WCL3hYlb/J'f0)1, D.Ci. The committee met, pursuant to rececs, at, 10 a.m., in rootu 21?3, Rayburn IIonse Office Building, Hon. Oren IIarris (chairman) pre- siding. Tlie CIIAIUaraN. The committee Nvill come to order. We are pletLsed this morning to have as our first witness in connee- tion witli the cigarette hearings, Dr. William Ober. I)r. Ober, will you come nroutitl, please. 1)r. Ober, I believe you are also a pathologist from t1le Iiuiclcer- boa.l:er I{ospitui in New YoI•1.. I)r. Ouw>;. That is right, sir. rlie (vIIAIRMIN. You may proceed. STATEMENT OF DR. WILLIAM B. OBER, PATHOLOGIST, AND DIREC- TOR OF LABORATORIES, SNICBERBOCSER HOSPITAL, NEW YORK Dr. Oi;ES. With your permission, it is a very f,n•eat privilege to flp-r pear before this committee which has given such excellent attention to this intelrsting problem. I willl read my prepared statement, and I may digress from it as the occasion warrants. The LIIAIRMAN. Thank you, Doctor. We are pleased to have you. You may proceed as you desire. Dr. Our,II. Thank you very much. I am Dr. William B. Ober, of Tenafly, N.J., and New York. I am a doctor of medicine specializing in patllology. I am director of labo- ratories at I~nic.ke.rbocker Iloslittal in New 1'ork, assistant professor of pathology at the Albert, Einstein College of Medicine, associate pro- festior of hatllolory at New York .lfedical College, and eonsulting ~atllolol;ist to the lst U.S. Army Medical Laboratorv in New Yorl:. iliy curriculum vitae and list of publications are attaclled to my state- ment and will be filed with t1le committee. I have been interested in a number of problems relating to caneel• ever since 1948-50 when I was aa research fellow at the National Cancer Institute. As a pathologist I have had tbe opportunity to examine about 10,000 cases of cancer in one organ or another ovet• the past. 18 years. I have probably examined abont.1,?00 cases of lung cancer bot h as surgically removed specimens and at autopsy. I am eonvelsatnt with n reasonable proportion of the published literature regarding cancer of the lung. I should like to c1il•ect my statement to the question of tlle relationship of smoking to cancer of the lttng. 337

CIGARETTE LABELING AND ADVERTISING-19G5 CIGARETTE LABELING AND ADVERTISING-1965 339 338 With ret;ard to smoking as a possible cause of lung cancer, I do not feel thatt the evidence which has been accumulated to date has any- tlting ntore than a limited statistical value to indicate that excessive Sntotcing may have a statistical association with lung c:uicet•. It is one tliiti~- to say that if one anal,yzes the smoking history of a great many patients with cancer of the lung one finds that a large proportion of them have been heavy cirarette smokers for 20 or 30 years or lonner. It is quite a ditl'erent nnatter to say that a large proportion of those lieoplee who snoke heavily will develop cancer of the lung. Yet, the proponents of the "smokinn causes lung cancer" theory who have utade the first statement would have us all believe that the second statentc.utt is tt ne xnd that they have proved it. If I ma~• clitre~s for a moment, I think what these people are trying to do is tn in,lilY there is a clear and present danger to excessive smok- in(V . I think they have sinrnlau~ly failed to prove this, and I do not tlainl: there is :ut}• clear andprehent danger. I think the entire situa- f ion is cerc unclear indeecl. I rema'in slcepticnl and unconvincecl by this sort of reasoning. As 31 tnatter of fac•t, the vast majority of people who smoke cigarettes he;ivily ~ ilo not. Pmt cancer of the lunf; nor do they seem to be prone to develop othei• lunn diseases to any greater eatent than people who srnoke tuo~leratrly, oecasionally, or not at a1L It is :txiotmitic• that any scientific theory which attempts to explain any natural phenomenon must take into .cccount all the known facts, Loth pro and con. A scientist is not permitted to choose the facts shiclc support his theory and then disregard the ones which do not fit. 'I'o tlo this is tantamount to suppressio veri, a suppression of the truth, a. type of illogic pardonable in electioneering speeches but not permissil,le in reasoned sctenttfic statements. For example, in such conntt•ies as I[ollaitd, Switzerland, and Great Britain which have as aiccur.ite vit;il 5tatistics as our own country the per capita consumption of cigarettes is significantly lower than in the United States, yet the tnortality from lung cancer is siignificantly higher, almost twice as high in Great. Britain as here. From this one observation alone it is apparent that. some other factor or group of factors is operating to liroclnce lung cancer. Nonetheless, the proponents of the "cigarette sniokiti~" scliool have studiously avoided taking this weil-docurnented fac.tt into account. Another item which is rarely mentioned by the anticigarette adher- ents is t,he distribution of cancers throughout the entire oral and respirabry tract. If we limit this point to squamous carcinoma, that is, a variety of cancer which is claimed to be induced by such inhalants as cigarette stn~d:e, we rapidly discover that those areas which are exposed to the hi(hest concentration of cigarette smoke are not the uto5t, frequent sites for sqnamous carcinoma to develop. Cancer of the larynx is much less common than cancer of the lung, and cancer of the trachea (~rindpihe) is extremely rare; yet both those structures receive aa greater vo'ume of smoke than the bronchi. Actually the tna~or brot,clti are direct branches of the trachea and their histoiogic nnd cytolotic structures are identical, yet the trachea which receives twice as much smoke as either major bronchus develops squamous carcinoma so rarely that many experienced chest surgeons and pathol- ogists have never seen a case of it. Actually, it is truly a medical curiosity. SPv .Jss9zooZ As one goes fati.lter along the bronchial tree, the proportion of smoke gets le-_;s;uid less, as the air passages continue to subdivide and ramify. Also, there is conflicting oltinton regarding the site of the usual scluantons broncltotieuic carctttotna in the bronchial tree within the lung. When I\~~'ati iL student in the 1940's I was taught that most bronchogenic carcinomas arose in secondary branches of the bronchial tree; i.e., fairlvi centrally within the 1un-, near t.lte hilus, or the root of the Iung. I Iowever, morc recent studies, notably by 1)r. L. Henry (;a.rlancl, of San httuieisc<r--Dr. Garland is professor of ladiolo-v tl; Iho iTnivet-ity of (',aliforiia-and Dr. Averill A. Liebow, of \e~t~ I[aven, have shown t.hat a much greater number of bronchial c,u•oi- nsmtas arise peripherally: i.e., in the outermost parts of the bronchi:d trce. 'rhis is the Irart of tlte ]tui~ which receives t,he least esho5ure to sntoke. f)ver the pa4 15 or 20 years there has been a slow but steady decline in tlte o~currence of Scluamous carcinoma of the montlt, pharynx, and naso,tharynx, yet these tissues also are in contact with as n-iuch of the inhaled smoke a5 tho larynx and trarhea. I do not think it unreason- aide to ask that tho anatomic cli~tribution of lesions conform to the clistrilmt ion of exlwsnre to a suspected causative agent before one con- c•ludes that surli an a„,mnt has a real causative relationship. It is not ntere Ifiuntemi entpiricisnt which makes me deny cause and efTect, reln- t iiitiships in this qnestion; what I eapect of the proponent5 of :t scien- t.itic theory is that tlteir propc,xd cause bear a rattional relation to the effect they claim it pn•ocluces, not merely a statistical associ;ition. The prctponents of the "°smokin(v causes lnnti cancer" theory have been conspicuously weak in explaininh the mec,hanism whereby cigarette sntoke allegedly procluces these ]mig cancers. One piece of evidence that pt•opotients of the smokinfi theory rely on heavily is that, they have leen able to extract certain chemical com- pcntnds fibm cigarette smoke which they have applied to the skin of certain inbred strains of tnice and actually produce a few small epi- ile.rmoici cancers. They hnven't been able to produce lun~ cancer in tltese niice. It is always chuigerous to extrapolate dat.a from one spe- cieti to another, even when the s.vne organ in involved. There is al- most no histologic similarity between the skin of a mouse and the hronchial lining of a.a humnn being. The argument is very much like the old saw, "A drop of this fluid on the tongue of a dog will kill a man." What is more, if one is interested in the relationship of cigarette smoking to skin c,ancer in general, I can only observe that the index finger and third finger of a cigarette smoker's hand are exposed to heavy concentrations of tobacco smoke. Yet one almost never sees cancer arising in the skin of the fingers. In fact, almost a,ll of the ehidertnoid cancers of the skin of the hand arise on the back of the hancl which is hardiy ex posecl to cigarette smoke at all. In fact, can- cer of the skin of the hand is cluite uncommon. Historically, our knowledge of lung cancer in relation to possible external causes developed from exposure to industrial inhalants. The classical example came from central Europe where it was noted that there was a high incidence of lung cancer in the miners of Schueeberg and .To.~,chimsthal.,chimsthal. It took a nutnber of years to ascertain the facts, bnt, the consensus of medical opinion now is that the lung cancers were

340 CIGARETTE LABELING AND ADVERTISING-1965 probably due to inhaling radioactive dust from the ore in t.hese mines. 1 wottld emphasize that because a very high proportion of the niiners so esposed did develop 1initr cancer this seeius to be ai reasonable cause- uud-etfect relntionshil>. By wny of contrast, not even the st.ron;;etit opponent of cigarette smoking has claimed that anything but a sinall herc•,entage of cigarette smokers develop hwh cancer. Likewise, in the United States there have been several well docu- niented reports of a high incidence of lung cancer among men working in ee~ lain parts of the chron~ate processiiin indust~y. `1'he mat.ter has been investigated with thoroughness bv the U.S. Public IIealth Serv-, ice, and I believe it is generally agreed that men who are exposed to t he ore in a certain st age of t he ir,fin mh process httves a high ]tutgca ncA r I isk. Again, I would emphasize that this is a situation in which a hi ~r,h proportion of the men exposed developed lung csuicer, consider- ably in contrast to the cigarette smoking situation. I might also add that some support was obtained for this high rate of issociation in liuni:uis by animal experiments; some aniuials similarly exposed developed cancer of the lung. I would like to digress at t,his point to read it sentence from a report by 1)r. Hueper. This is a rehort tliat, conies ont of n Public Ilealtll Service monograph called "A uest Into the Environmental (':uises of Cancer of the Lung" and Dr. William C. Ilueper is, I think, this country's leading authority on occupational cancer and the cause of cancer due to external causes in general. The last sentence in his report on page 45 is as fol low•s : Finally, it may be noted that the evidence on hand justitlieA the viewpoint that in arriving at a judgment in any mirlico legal dispute requiring the a»essment of liability for the development of a respiratory cancer, any evidence incriwinnt- ing specitlc occupational factore should be given preference over that possibly provided by a cigarette smoking history. I think that is a very cogent statement and one very well worlh remembering. Even long before people got agitated about cigarette smoking in relation to lunt,~ cancer, it was well recognized by cancer epidemi- ologists that lung cancer was much less common in the rural popula- tion than in t.he urban population. This is as t,rue today as it was 40 years ago. It is reasonable to believe that there is just as much cigarette smoking per capita in rural areas of this country as in cities. One obvious point to be investigated is atmospheric pollution. 'I'he most promising angles, of course, are automobile exhausts and chimney smoke. A number of studies have already bee.n carried out, and most people would agree that it would be agood Idea, to reduce tiir pollution, not only in terms of possible cancer prevention, but for general esthetic reasons as well. IIowever, control of air pollution lacks the emotional appeal of an ant.i-cigarette-smoking drive. Tn any event, air pollution has certainly been increasing in the United States for the past 40 years or more, and I think it would probably yield useful results if further study was undertaken and preventive measures adopted. Simple justice would dictate tliat,we approach air pollution first. The pet•son who may get, lung cancer from polluted :~ir is exposed willyaitlly, the cigarette Finoker has his choice of sinokinl; or not. 6V5969?'OOt I I 1 1 CIGARETTE LADELINC AND ADVERTISING-1965 341 '1'he last point I shall make about cigarette smoking and lungr cancer is this: I have examined niany hundreds of lungs from smokers and nonsmokers. I cannot tell the difl'erence grossly or inicroscopically bet~~ een the lungs of a smoker and a nonsmoker. I:ven when _I examino the lungs of a, patient with lung cancer who was known to be a very heavy smoker, I cannot see_ any changes in the other lung or in the cancer-bearing lung which would point to the fact that lie smoked. Some studies have been made of the bronchial lininti of the lun"s of 4mokers as contrasted with nonsmokers. It has been stated that a lesion known as squamous metaplasia of the bronchial epitheliurn is more common in smokers than in nonsmokers, and the view has been presented that squamous metaplasia is a"precancerons chan-e°D in the el,ithelium, and that somehow this supports the idea that~ci-arette smoking causes lung cancer. Unfortunately for those v.•ho le;tn strongly on this sort of evidence, it, cannot be taken at its face value. S finamous metaplasia is found in the lining of the trachea just as it is in the bronchi, yet cancer of the trachea is among the r:uest_cancers of the respiratory tract. The term "precancerous change" in a segment of epithelimn is very much like the small lesions that Dr. Moran showed you yesterday, I think it is a scientificnllv unjustified term. It puts the supposition Into the conclusion, and I tliinl: this flies in the fnce of logic. I think the neutral term "squamous metnplasia" " is much moro np~~ropriate. There is no proof that this sryuamous metap]asia does wlth uny degree of re~il;~rity pro~ress inevitably inlo invasive carcinoma. As a matter of fact, sryuatnous metaplasin is observed very frequently at autopsy if you talce enoutih seetions of ]un~, ats very small patclies in the bronchial linin~, a fe« cells here and few cejls there, usually fairly well-se.pnrated in the bronchis~l tree. Their detection in lung tissues from autopsied subject depends; as Dr. Auerbach pointed out, on taking a large number of sections. That was an excellent study by I)r. A nerbach. If I may digress for a moment, Dr. Anerbach, and I are both mem- bers of the Department. of Pathology at the New York Medical College and I have a great deal of respect for him as a colleague. IIe is n, veiy diligent and hard-working man, and lie and I have looked at very much the same sort of material, although in slightly different places and we have come to completely opposite conclusions. I can say this withaut intending any professional disrespect for a learned colleamne. Considering the presentt state of scientific kno.vledgme regarding can- cer of the lung and its relation to any sort of possible cause, it is per- fectly permissible and perfectly reasonable to expect that• two men of approximately the same age and same type of ; eneral interest could have completely different views and still maintain a good deal of pro- fessional respect and even affection. If one takes just a few routine random sections from lungs at autopsy, one can miss the occasional patch of squamous metaplasiati since over 80 or 90 percent of the lung is entirely normal in both smokers and nonsmokers. I hope no one will get the idea that this change is diffuse or tliat a single high-powered photomicrograph of squamous metaplasia represents the bronchial lining as a whole. I am sure Dr. 1luerbach did not intend to give that sort of impression atall.

342 CIGARETTE LABELING AND ADVERTISING-1985 As I have said one finds occasional minute fields of squamous meta- p]usia in the lungs of nonsmokers with some frequency. They may represent the healing stage of a chronic puhnonatry tuflamnuttiou or infection. In essence these c,hanges are a form of healing rather than an inher- ently neoplastic change. They may be the result of exposing the bronchial lining to an7 number of air pollutants, industrial toxins, or infectious processes. I'here is no real proof that any given focus of squamous metaplasia will inevitably progress and develop into cancer. As a matter of fact, if you look at Dr. Auerbach's studies, you will have to bear in mind they were all done on antopsied patients, and it is quite a different thing from the putting together the, picture which some people would have you believe. You don't take a look at the bronchial epithelium of a man in 1950 and say, "Aha, there is sqtut- ntous metaplasia; ° and then sew him tip again and take a look in 1954 nand say, "Oh, there is more squamous metaplasia and itt looks worse," and then 4 years later open up the satne piece of bronchus and say, °`.1%ty God, this is going to turn into cancer any minute," and then 3 years later, "See, here is the cancer." It, isn't like this at all. It is an observation on this dead body and that dead body and another dead body; this is not the remorseless an(l inevitable progression of a minor change into a greater change then to a major change into a real cancer. It is quite a different type of ob- servation. They are separate and distinct individual observat.ions. I do not think you c.•vn add these up and gain any great degree of cumulative weight from such an addition because they are not lnher- entl,y and necessarily related by a logical or n biological nexus. Also, there seem to be a number of lung cancets developing in lungs of known sriokers without squamous metaplasia, and of course theee are many instances where a few small patches of squamous meta.plasia are found but no cancer. By the same token we also see squamous metaplasia in the bronchial lining of patients who have had chronic 1 ung infections but no evidence of cancer; .ve even find squamous metaplnsia surrounding at•eas of lunh tissue which have been damaged by having a blood clot or embolus squamous metaplasia, I do not think one can say with any assurance. lodge in a nearby vessel, thereby producing a so-called pulmonary infarct.. As a matter of fact, I think one of Dr. bforan's slides yesterday showed just a lesion, a very active area of squamous utet.aplasha whiclt was a liealing phenomenon. In view of t,he diversity of circumstances which may give rise to squamous metahlasia, I do not think one can say with uu,y, aassurance that its presence indicates that a man has been a heavy smoker. As for t.lie prerancer aspect of squamous metaplasia, it seems to be a meta- pltysteai and Ppist.emologtcal probletn rather than a scieutific one, as very few people can agree what the term means and imrlies. I do not t>elteve that cigarette smoking could lx+ anywhere near so iml~ortant a possible rause of ]nng cancer as rec,ent reports indicate. I do not exclnde it as a pos5ible cause in c.ertain hi~ltly susceptible indiviihutls, ltut I do not thmk it ~ase ot accntnte Fo fnuet•alize this into a s~s.ientihc rule. Naturally, one can never entirely exclude any inhalant as a pos5ible cau5e of lung cancer. Ilowever,1 can only point out that there niay exist tt multiplicity of rossible etiologic agents or , t CIGARETTE LABELING AND ADVERTISING--1985 343 causes which ntay induce a morphologically similar lesion by means of a pathogenetic mechanism common to them all. 1'nt ntore simply, a given tunior in a given organ in one patient tuay look very nnuch like it tuuior in the same location in a different pittlent, look so much alike that one cannot tell them apart gt•os.51y or niict•oscol~ically, yet t11a~y ltave clevelolted from diffet•entcausest lf one exiunines 100 cases of hronchogenic squa,mous carcinoma, most of the specimens will look pt•etty much ]ike one anotlter. There will be difCerences .unong theiu, to be sure, but they are no greater than the ditTerenc•es among hmnt;ut IJeings whiclt enalJle us to recognize e(Lclt other as individuals, yet we all look reasonably human. I don't think anyone Is smart• enough to be able to sot•t out of that group of 100 bronchogenic cat•cinomas those which he would claim could be attributed to rfldio-nctive mine dust. Clu•otnate ore being refined automobile fumes, cigat•ette smoke, a hy~I>othetical virus, or Lord ~Cnows what. T1te tumors look so much alilze tltat one ciin't tell them apart. I lose patience witli people who pretend they can. Lastly, I submit that there is a psychology peculiar to many of the sincot•e adherents to the "cigarette smoking causes ]ttng cancer" theory. They belong to what I call the Puritan school of carcinogenesis. They tell us thatt stnoking causes lung cancer, sexual intercourse causes can- c•.er of the cervix, and drinking causes cancer of the throat. Lot•d help us all 1 What will they find next$ I think if one starts off with the notion that anything a mau cloes which gives him pleasure is prob- ubly sinful, it is only one step to t.hink it is hariufnl, nud the next thing to ~lo is pass a law against it or to ask Congress to pass a law against it. It is all very well and good to be againststn, but I wisl>, they would define it better. 1'Ite only really scientific statement one can make at the present time is t.hat no one really knows what causes lung cancer. There are many external influences and inhalants which could possibly cause lung cancer, but the evidence that cigarette smoking does so is rather weak. The cigarette is only one of tlte numerous items present at the scene of a crime; that does not prove guilt. In fact, the (>t»honents of tlte cigarette smokin{,~ theory ttire only trying to prove guilt by associa- t.ion, tt phrase as distasteful to me ns a scientist as must be to figures in public life. Thank you very much for your kind attention. The CirntRalAx. Doctor, thank you very Inuch. Tlte information to which you refer will be included in the record along with your statement. Dr. OnEa. Thank you. (The information referred to follows:) wILLIA1f B. oBER, ~I.D. CUaEIC_IILIIM VITAE Born : Boston, Mass., May 15, 1920. Education Brookline, Mass., Public RcAools • Harvard College, A.B. 1941 cum laude; Boston University School of Dledicine, M.D. 1940. Training: Intern in patholoay, Beth Israel Hospital, Boston, 1t?47-48 • assietant resideut pathologist, Boston Lying-In Hospital, 1948; research fellow, National Cancer Inatitute, 1948-50; assiAtant pathologist, Armed Forces Institute of Path- ology, 1950-52. os~sssZooi

344 CIGARETTE LABELING AND ADVERTISING-1965 Positions: Chief, 1)ivisi.on of Research and Training, American Registry of Pathology, Armed Forces Institute of Pathology, 195:{ 53; pathologist, Boston Lyint;-In Hospital, 1J53 G5; pathologist, Hacken»ack Hospital, 1953-55; director of laboratories, Knickerbocker Hospital, 1J57-date. Teaching: Instructor in pathology, Howard University, 19:,? 53; Instructor In pathology, Harvard Medical School, 1933-55; Instructor In surgery (surgical pathology), Cohimbia University College of Physici+ws and Surgeons, L15:.-1;0; assistant professor of pathology, Albert Einstein College of Medicine, 19'u7-date; associate professor of pathology, New York Medical College, 1961-date. Consultant: Sloane llospital for Women, 1957-W; First U.S. Army Medical Laboratory, 13~,~8-date; National Cancer Institute, 19G1)=aate; Bronx Veterans' Administration Hospital, 1:)lil)-date; Margaret Sanger Research Bureau, 1J(i0- date; New York Fertility Institute, 1'JO'1-hate. IHplomatc.: National Board of Medical Examiners, 1947; American Board of Pathology, 1952. Societies : American Association of Pathologists and Bacteriologists ; American Society of Clinical Pathologists; International Academy of Pathology; College of American Pathologists; Fellow, Royal Microscopical Society; Fellow New York .\cademy of Mediciue; New York Academy of Sciences; New York Cancer 5a+iety; New York Pathological Society; New England Pathological Society; Washington, h.C. Society of Pathologists; New Jersey Society of Pathologists; The Ilurvey Society; Sigma .l'i. Licensey : New York, New Jersey, Massachusetts, California. WILLIA)t B. OBEB, M.D. LIST OF PUBLICATIUNB 1. Boas, N. F. and Ober, W. B.: Hereditary exophtbalmic goiter; report of eleven cases in one family. J. Clin. Endocrinol. 6: 575-588, 1940. 2. Ayres, W. W., Ober, W. B., and Hamilton, P. K.: Post-traumatic subcutaneous granulomas associated with a crystalline material. Am. J. Path. 27: 31k1- 31 5, 1951. 3. Morrismn, H., Mixter, C. G., Schlesinger, M. J., and Ober, W. B.: Tuberculosis localized in the vermiform appendix. New England J. Med. 2,16: 3LNJ-331, . 1952. 4. Blumberg, J. M. and Ober, W. B.: Carcinoma 1n situ of the cervix : recur- rence in the vaginal vault. Am. J. Obst. & Gynec. 66: 421-425, 1953. 5. Ober, W. B. and Jason, R. S.: Sarcoma of endometrial stroma. Arch. I'ath. 46: 301-311_, 17nb. 6. Ober, W. B., Palnter, R. E., and Glassy, F. J.: Rhabdomyosarcoma of the vulva and vagina. Arch. Path. 56: 364-373, 19:i3. 7. Oher, W. It. and F.dgcomb, J. H.: Sarcoma botryoides In the female genital tract. Cancer 7: 7:-91, 19;r1. 8. Ober, W. B. and Reiner, L.: Cancer of the cervix In Jewish women. New England J. 11ied. 2:i1 5.;:rL.S!1, 1tY.i}. (Reprinted as part of Transaction 5th Merting Intl. Soc. Geog. Path. In Schweiz. Ztsch. allg. Path. u. Bakt. 10: 774-780, 1fl.i5.) 9. Ober, W. Il. and Black, 11f. B.: Neoplasms of the subcoelomic mesenchyme, A rch. Path. 59: 6'J8-70S, 1965. 10. Ober, W. B. and Moore, T. E., Jr.: Congenital cardiac malformations In the neonatal period. New . ng and . lt ed. 253: 71-. 5, 1955). 11. Ober, W. il., Velardo, J. T., Greene, It. C., and Taylor, R. J.: Desmoid tumor of the lmpllteal space occurring during pregnancy: report of a case with bioassyu. J. Nat. Cancer Iust. 16: 5Cl1-G77, 1tki5. 12. Ober, W. B. and Bernstein, J.: Observations on the endometrium and ovary of the ni•wborn. 1'edlatrics 1G • 44:r_4(30, 1!k"r.i. 13. Olx>r, W. B. and LeCompte, P. M.: Acute fatty metamorphosis of the liver associated with pregnancy. Am. J. Med. 19: 743-758, 1955. 14. Jewelt, J. F. and Ober, W. B.: Primary pulmonary hypertension as a cause of matennai death. Am. J. Obet. & Gynec. 71: 1.33fi-1341,19Fi(l. 15. Roby, C. C., Ober, W. B., and Drorbaugh, J. E.: Pregnanediol excretion In the urine ot new born male infants. Pediatrics St: 877-R81, 19tifl. 16. Ober, W. R. and Wharton, R. N.: On the °I'hrygian Cap." New England J. 11ted. 255: 571-572, 1ffi(i. 17. Ober, W. Il., Reid, D. E., Romney, S. L., and Merrill, J. P.: Renal lesions and acute renal failure In pregnancy. Am. J. Med. 81: 781-810, 19b13. CIGARETTE LABELING AND ADVERTIBING-1965 345 18. Ober, W. B., Grady, H. G„ and 8choenbucher, A. K.: Ectopi.c overian decidua without pregnancy. Am. J. Path. 33: 199-`117,1tY7. 19. Brown, D. E. and Ober, W. B.: Slckle-cell thalasaemia (microdrepanocytic disease) In pregnancy. Am. J. Ubst. & Gynec. 73: 773-784, 1tY,i8. 20, Ober, W. B. and Kaiser, G. A.: Hamartoma of the parathyroid. Cancer 11: (t01-(506, 1'J38. 21. Ober, ber, W. B., Smith, J. A., and Rouillard, F. C. : Congenital e_ni_tal sarcoma botry- oides of the_ vagina. Cancer 11: 820-625, 1958. 22. Ober, W. B.: Uterine sarcomas: Histogenesis and taxonomy. Ann. N.Y. Acad. Sci. 75: a68-,°d35, 1959. 23. Ober, W. B. and Tovell, H. M. M.: Mesenchymal sarcomas of the uterus. Am. J. Obwt. & Gynec. 77t 246-2ti8,1flfil/. 24. Ober, H'. B.: The Endocrine Pathology of the Female Reproductive Tract. Ch. 10 In Essentials of Human Reproduction, ed. J. T. Velardo, Oxford Univ. Press, 1959. 25. Ober, W. B., Bruno, M. S., Simon, R. M., and Weiner, L. • Hemoglobin 8-0 disease with fat embolism. Am. J. Med. 27: ®47-0.58, 1". 2& Ober, W. B.: Historical -perspectivee on trophoblast and its tumors. Ann. N.Y. Acad. Set. 80: 3-20, 1959. 27. Ober, W. B. and Tovel, H. M. 3i.: Malignant lymphoma of the uterus. Bull. Sloane Hosp. for Women. 5: 6:r-75, 19;59. 28. Ober, W. B. : Solid ovarian teratoma with struma ovaril, theca eca lutein reac- tion, and endometrial hyperplaeia. J. Obst. & Gynec. Brit. Emp. 67: 451-454, 19(i0. 29. Ober, W. Il., Berg, P., Tuchman, M., and 'Itedner, W. J. ' Acute trichinosis, B'eAtsehrift, Rudolph Vitthow Soc., pp. 320-.362, 1900. 30. Ober, W. B., Brmio, M. S., Jones, F. M., Jr., and Weiner, L.: Fatal intravaa- eular Aickling In a patient with sicklecell trait. New England J. Med. 263:. tR17- RA), 111410. 31. Bailey, O. T., Ober, W. B., and Bruno, M. 9.: Central pontine myellnolysis. Am. J. 11fed. 2A: 90`:,-t1(/0. 1f)(10. 32. Ober, W. lt. and h`ass, R. 0.: The early history of choriocarcinoma. J. HiAt. Med. & Allied 1Sci. 16r 4>a-73, 19Q1. See also: Proc. Rudolph Virchow Soc. 19: 12-1-129, 1t)f,0. 33. Ober, \V. B. and Aaiser. 0. A.: Pregnanedlol: Methods, limitations, and applications. Am. J. Olin. Path. S5: 207_318, 1961. 34. Narasimban, P. and Ober, W'. B.: SarcoidosiA: report of a fatal case with myocnrdial involvement. Indian Pract. 14: 20u-213. 1tx11. 35. Ober, W. B. and Grady, H. G. c Sub_ involution of the placental site. Bu1L N.Y. Acad. 11ied.,47: 713-730,1961. 36. Ober, W. B.: Sarcoidosis. GP 24: 88-89,1981. 37. Ober, W. B.: Seminar on Obstetrical and Gynecological Pathology. Armed Forces Institute of Pathology, Washington, D.C. 1901. 38. Janoveki, N. A., Sclaulenfrei, R., and Ober. W. B. • Adenocarcinoma of the endometrium: Report of a case developing_ after pelvic Irradiation aasoci- ated with ovarian hilus cell hyperplasia. Am. J. Obat. & Gynee. 8L: 118G-. 1191, 1961. 39. Cutier, A., Ober, W. B., Epetein, J. A., and Kupperman, H. S.: The effect of 1-(p-2-diethylaminoethoxynbenyl)-1-phenyl-2-p-nnisyl ethanol upon rat pituitary and uterine response to estrogen. Endocrinology 69: 473-482, 1961. 40. Ober, W. B.: Guest Editorial: Information for the pathologist. (iP 25: 80- 81. 1962. 41. Ober, W. B.: Embryonal carcinoma of teaticnlar type arising In the gonad of a true hermaphrodite. Bull. Jewish Memorial I3osp. 6:. 9&t-102, 1902. 42. Berg, P. and Ob_er. W. B.: Endocardial flbroelastoeis_ associated with hypo-a i~lasla of the ~righ~t coronary artery In an adult. New England J. Med. 206: 8(33-806, 1962. 43. Salomon, 14I. I., NarasiLnhan, P., Bruno, M. F., and Ober, W. B.: Renal leaions in essential hypertension : The problem of correlation between renal liiopsy and clinical parnmeters. Angiohn;y 1Jt 21~27,5, 11102. 44. Buckingham, J. 0., Iletz, H., and Ober, W. R.: {7arcinosarcoma of the endo- metrium, Am. J. Obat. & Gynec. 83: 15&!-1rO),1962. 45. Berg, P., Tuehman, M., Redner, 1V. J., and Ober, W. B.: Acute trichinosis, GP 26: 82-90, 1902. 48-824-65--23 issss9z0oi

346 CIGARET'r!: LAB€LING AND ADVERTISING-1965 46. Bruno. '.%l. S., Oher, \i". B., Kupperinan. 11.S., and Epstein, J. A.: Coexistent Addison's disease and thyrotoxicodis. Arch. Int. Med. 110: 155-161, 1962, -47. Ober, \V. Il.: t:yurrologic bioluciEm in office practice. l.l' .?G: 11'.{-IY//, Itl(l`,d. 48. Ober, W. B.: The endonietrial biopsy in office pra<Kice. G1' 27: 1(It(-112, l!Ni;i. 4t/. Ober. W. Ii., 1'ollak, A., Gerdttuan, K. E., and icuppermitu, H. S.: Krukenberg tumor with nndrogeulc and progestational effects. Atu. J. Ob4t. & Gynec. 8.f : 73t1`744, 14Ni'l. 50. Salonion, AI. E., Bruno, M. S., and Ober, W. B.: Percutaneous renal biopRy: Its nuportance in research and clinical medicine. New York 5hrle J. Mttil. f12t'-15-32:rt, 1tNCl. 51. Barnn H. C. and Ober, W. B.: Parotid gland atrophy. Arch. Surg. 8fi: 1(Ftir.- 11N-1, 1fNrl. 52. Janovski, N. A., Weiner, L., and Ober, W. B.: :loap intoxication following criminal abortiou. New York 4tate J. Med. 6J:141t3-14t47, 19(Kt. :wt. Daino, J. A., TchertkotI, V., Akhavan, T. H., and Ober, W. B.: Leydig cell tumnr of testis in male paeudohertnapbriHUte with teeticular feminization. New York State,l.'.Ued. tp3::•2:d_=IY, 1963. l!.l. Roland. \L and Ober, W.B.: The endoinetropic efCeetu of I'rovect In ovulatory and rurmnlotury p~itir~itH. Internat. J. FPrti1. N: (l1!1-ai3-l, 19133. 55. Roinnd, M. and Ober, IV. B.: Iwks prokeytngeurw sintetiam en la infertilldad eudo(•riua y en listraHtormw menKtrnaleH. Memoria 4e Cong. Mex. di Gin. y. Ob.t. 35tl-3(i3, June 1tMt3. t'i6. Brtnin, M. ti.. Crier. W. R. N.. nnd (Nrer, W. B.: Spontaneous laceration and rupture uf the eKOphagua anfl Htontni~h. ArciL, Int. Med. 111: :,7•t-1)$3, 1!I(Gi. 57. Ober,. W. B.: Endocrine Pathology. Ch. 3,3 in Kuplk+anan, H. S. Human EndoH•rinulogy. 3 vol. N`. A. Davis Co., Philadelphia, 1fNk1. 59. Ober, lt'. B. (unsgined) : Editorial. The Boerhanve syndrome. J.A.M.A. 187: 57, 1964. 59. Roland, M., Clyman. M. J., Decker, A., and Ober, W. B.: Clast;iflcation of endomet.rial reHlion.ne to synthetic progestagen-estrogen compounds. I!'ertil. & Steril. 1:i: 1•I'3-1tI8, 1!N14. 60. Ober, W. B., Clymau. M. J., Decker, A., and Roland, M.: EReets of aynthetic progextagens on endometrial morphology. 7nte rnat. J. 1?'ertil. (In pnws. ) 61. Ober, W. B., Bruno, 11LS., and Rankow, I.t.: Congenital pharyngeal pouch lnalfuruintinn with hylierlHtrathyroidism. (In preparation.) - t.2. Ober, W. B., Price, E. B., Jr., and Hertz, R.: Tlre pathology of choriocarci- nown. (In preparation.) f.4. Ober, W. B.: Luteinization: Notes toward a critical definition. (In prep- aration. ) The Ctt:A>!RMAN. We observe your background with agre,at deal of interest, and, of course, appreciate halvang that along withthe informa- tion in order to ni;ike tilid record. I miist confe,s wit.ll all of these outstanding people like yourself te':tifving on both sides, and, as you so appropriately sa,i(l a moment ngo, since rreutt ntinds nnil nble lienple rui disul;ree and honestly so, I am nfrn id our task is not made any easier. Ido want the record to be made as clear as possihle. Now, in view of this scientific controPersy over tale exact causal rela- tionship between smoking and certain diseases, as ttn example, cancer, Lc.art. (l.i,ease, s4nt1 so fotih, would you sny that there is presently enouflh informat.ion to warrant putting peoj.lle, that is, individuals, on notice that solne hazard does exist? nr. OttF>rl. No, sil'. I wottld not t.hink so. The CIfA1RrfAN. You woidd not think soH Dr. OnER. I would think that there is s1116cient scientific doubt, so that it would not, be a good idea to transform the doubts of scientists into legislative action. _~s you say, the scientific douhts (1o not make the tasks of legislators es~.~ier, they make them more difl'ic•ult. What you have to (10 and what you have been doing with great. pat.ience and f,meat interest is to listen zssssszooi CIGARETTE LABELING AND ADVERTISING-1965 347 to a suct <sssion of scientists presenting divergent views. Your respon- sit,ilit.y is to absorb it, assitnilate it, and make legislative sensc+ out of it, which is a very difficult ta.sk and which I for one, would not be able to do. But I think in an atmosphere of such dotlbt and indecision aud with so many conflicting opinions to c/7llle out with a statute is not a very meaningful legislative act. In the first plac.e, if you will put people on notice, what would you be warning thent tignluistg Not very tmlch, if anything, as far as I Call see. `1'he CIIAlIIMAN. ti1'ould I be correct in say-ing that, and I am asking for tui opinion now, from your own knowledf;e and background and experience, which is rather extensive, should the Congress require solne kind of notice on the label or in advertising that a hazard does exist, do you think that that would be a legislative requirement that could not, be sustained by the facts and, t•herefore, would be a legislative ilunrorality ~ 1)r. On£.R. I\Collldn't sa,• it would be legislative immorality, because immorality depends largely upon the intents of the legislator, and I am sure that the people here intend well. I hope at least t.o be able to otter an opinion which is meaningful in terms of avhntt is known and what.t is not known, and I don't think we know enough to urge Congress, our elected representatives, to pass any sort of law because I don't think the medical profession can make any really firm declaratory statement about the cause of lung cancer or of the relationship of smoking to it. There are of collrse many doctors who do not share this point of view. They will advise you to the contrary. On the other hand, I might point out that if a doctor really believed that smoking cigarettes caused lung cancer, he shouldn't, just ask you to put. a label in small type of a package. He should ask for a lnw to outlaw the sale., manufacture, and dist.ribution of cigarettes. They don't do this. They come with t.his weak-kneed little business of puttinti a label on a package of cigarettes. This is so inconsist.ent- Tlle CHAIRMAN. I posed that. very question to Dr. Terry, and his reply was that he didn't think that people would accept it., indicating t.hatt that wa.s the reason why lle didn t, advocat,ee it. Dr. O1sF;R• Well, I think moqt. people are reasonably int.elligent; at least, most of the Americnn public is tlccustomed to making up its own minrl about things. In view of the fact that doctors disagree, I think the public is going to say, well, until they st.raighten the matter out., we are goinr to do as we cltoose. I don't think that is an unreasonable point of view for a lay person to adopt•. I think it, is a very sensible one. 'rhe C'ItAIRMAN. Thank you very much. IN'1 r. Rogels ? 11[r. Iio(1r;Rs of Texas. I reserve my time to you, Mr. Kornegay. Mr. KoxNr:oAY. Thank you. '1'he CffATRMA'. 11'tl•.Kornegay A Mr. KoeNFOnY. Dr. Ober, I want to first thank you very much for r'oming here and for the splendid formal statement you mnde on a very ditTiwllt, subject. Now,do you see any.danf,•er, any social danger, Doct.or in pursuing a course trse of, stiy,';tatliping guilt on cit'arette stnokint; and saying that ca uses l ung cancer ?

348 CIGARETTE LABELING AND ADVERTISING-1985 Dr. OisER. Well, I don't think it would be an accurate- Jfi•. KoRNFGAY. Let me restate the question: Suppose your view iu t]le matter would not prevail, and that the view that it does cause lung cancer prevailed. What could be the scientific results of that sort of l~ropositlon? 1)r. ORr:R. I am not sure that I follow your thought. 1lir. Kouxr3G.1Y. Let me put it to you another way. Suppose that the (`ongress and most of the people agleed that cigarette smoking causes llln~ CaI1CR1. Then, wouldu't sment~sts and mau~ otiler people and the ge~leral public supporting rescarch ptograms lnto the area of lung c:incer~~erha',ls oonclude that the answer had been found? Af r. KoR~ r:~+,~Y. Is that a realistic danger, t.his idea? I)r. Uisriii. 1"ou niean if you decide one© aud for all t.hat smoking is the major ctluse of lung cancet•4 ?tir. KoeN ec;.tY. That is right. I)r. ( hcr:R. T o some extent, yes, research would be diverted. Mr. KonNF:aai. I am prompted to ask you that question because we hall quite a good expert to testify last year at these hearings and he was a statistician and lie sald back many years ago in Europe when pellagra was a very common disease there was a great deal of evidence, statistical in nature, that that wa5 caused by eating corn. Of course, it was later found out, and I~•,ue.5s everybody knows now that eating corn (lues not. cause pellagra. But if that Prulciple had beeu accepted at that time by the peo]lle, and no further inquiry had been made into the ;;ulx, lhen we would never have found out what caused pellagra, would we? . Dr. ORrs. Now, I see your point very clearly, and I think that is quite trne. I think if there were a law passed which says that the major proportion of the medical profession thinks smoking causes lung cancer, Congress agrees, and passed this law, and there is no point in investiga.tin further. We wouh~lc>se out on all our studies of air pollution and industrial exposure and all our pursuits and alll of our virologic rescearch~I wouldn't say suffer, but would be directed into different sections, cause virologic- Mr. KonNEOAY. If there was an answer to that problem, it. would cause people to drop research in that problem, isn't that rightH Dr. Onr:R. Yes; I think it would be a net loss to society. Mr. KoaxF,o..r. Your answer prompts me to the next question : You pointed out very beautifully in your statement the incidence of lung caicer varies from country to country and from rural areas to city areas. Let me ask you, doesn't it also vary or the incidence enc_e of lung cancer vary from city to city in the United Stat.es? Dr. OaFR. Oh, yes; it does, quite considel•ably As a matter of fact, t.his is one point which is so clear to lne because I live there, and it may not be so clear to you gentlemen, I live right beside New York City in Tenafly, N.J., which is just across the I'alis,.n.des. Dr. Anerbach's hosiptal is 20 or 30 miles south of me in East Orange, and if you h,ti.•e ever driven up the New Jersey Turnpike approaching New York City, and you drive through that industrial zone, you will see the densF+ nall of smoke that hangs over it, somethinry like Pittsburgh use(1 to be before they cleared up the atmosphere. It is really a dreadful CIGARETTE LABELING AND ADVERTISItiG-196b 349 air. And this, I think, would account for much of the squamous met.aplasia that he sees ln the patients in that part.icular area. Also, he is at a veterans' hospital and many of the,5e patients are workers in the industrial plants. Not nlany of his subjects work out. in t,he ruu•al areas of SussIM C'ounty and up in Middlesex County. They work in and around the heavlly populated area of Essex County and that is an area of great smoke density and also an area where t here is agreat deal of lung cancer. This is also true in New York City, in which the. atmospheric pol- lution is very high. There was a t.nne you know when you used to be able to drive down the West Side Highway and see al the way down on a sunny duy. 1"ou (•.iln do this if yon get np early in the morning. 13utt if you leave your house by 8:30 as most people do, there is a faint haze over the citt- and by 10 o'clock you can't see downtown t.oo well. I think that is one reason why there is tul awfid lot of lung callcer in New York (':ity. But if you go to a place like Columbus, Ohio, or you go to a city like Washington, D.C., which I kuow somewhat better, the air hei e is quite a good deal cleaner and purer as there is Very little heavy industry in and around Washington, as you all know. And I thinlt there is less lung cancer iu Washina-ton than there is in New York. Mr. Ko1cNFAIAY. I3ase(1 itpon that Stiiteinent, in your findin„s there is some relationship between the incidence of lung cancer and the smog. ])t•.Oitrac. Yes. Afr. FoRnEsAY. AtmoShherlc (.-on(ht.lolls. 1)r. Oi;ra(. I think t.hat is a very important point to im-estigilte. Mr. KoRNFnnY=. I agree with you, and I have been somewhat sur- llrised and disappointed at the same time that many of the experts, solne of them anyway, wanted to push thatt aside and not give it any consideration. Dr. OI(FR. Well, I return to a basic point. of morality. With air pollution or atmos1~heric pollution, the entire population is exposed willy-nilly. They have no choice in the matter except giving up their jobs nnd moving to another community. Whereas, a person who smokes, like myself or any number of other people, we do this out of our own free choice. I think it is more im- ]lortuut to protect the public at large and to investigate air pollution than to concentrate on the fairly narrow issue of cigarettes. Mr. KoRxEOnY. Dr. Ober, if a person inhales cigarette smoke, as- snnullt; that he, the health of a person in that his c.hest and his body is normal, wouldn't the smoke go into each lung with approximately t lie same densit,y ? 1)r. OREIt. Yes; that is quite true. ~Ir. KoxNF:oAY. Now, when we find cancer of the lung, do we find it in both lungs? I)r. OnM:2. Well, cancer of the lung may be found, of course, in either lung. ITr. IioRxEaAY. Yes. 1)r. OSRR. It is uncommon, very, very uncomon, and I must say that I don't think I have ever personally seen a case in which a man had two se )al7ite primaly cancers, one in each lung. ir. KoaNFaAY. That is the point. Ussssszoot

350 CIGARETTE LABELING AND ADVERTISING-1985 Dr. OsER. What you usually see is that a man will have one cancer here, and that the other lung will be essentially normal. By the time you get it at autopsy there lnay be a little secondary pneumonia in it or something else that killed a man in a debilitate,d state. But. it is cer- ta.iuly not a cancerous lung and there is nothing in it that will enable you to tell that he smoked or he was likely to get cancer. He might llave a few areas of squamous metaplasia the same as other peo1~le do. Mr. KORNEGAY. Don~t you find squamous metaplasia in people who do not smoke? Dr. OBr:R. Yes, indeed. Mr. KORNEGAY. I think Dr. Auerbach, who was here the day before yesterday, described that condition as a precancerous lesion. Dr. Our:R. That is right. That is what he said. Mr. KoRxEGnY. But as I undelst,and you, you do not agree with that theory at all ? Dr. OBER. Let me put it this way: I don't think the theoryy is so well established that I could agree with it. It is, of colu-se, concelvable that in some cases squamous metaplasia does go on and get worse and turn into cancer; that could happen. Mr. Koaxrx}AY. But it is not the natural and irrevocable conclusion "+ Dr. O1sER. That is right. I don't think it is the usual course of events. I don't think it is inherent in the nature of the lesion. Squ:t-s mous metaplasia is a healing process and the place where we first begnui to learn about uamous metaplasia was not in the lung but in the neck of the uterus. ~t is such a common lesion that any woman who has borne children is going to have some form of squamous metaplasia, be it mild or fairly extensive. But most of these women don't develop cancer of the cervix. Mr. KORNEGAY. Almost to the contrary, isn't it true that the in- cidence of cancer is greater in women who have not borne children than those who have? Dr. OnF.e. No, with regard to the cervix, this is not true, sir. Mr. KoRrrpsanY. It is not? Dr. Oer;R. Cancer of the cervix is characteristically more common in women who have borne children, but it is not necessarily related to the fact that they have squamous metapiasia. The cervix, of course, is ex- M Sed to any number of possible insults and is actually exposed to the cterial flora of the vaginal canal. It does develop low-grade chronic infections which heal automatically, I shouldn't say automatically, but they heal without symptams. Almost any time you take a biopsy of the cervix for one reason or another, there is a mild degree of inflammation and you sign it out in your pathology report as chronic cervicitis with squamous metaplasia. Very few of these women develop anything resembling caulcer• as a matter of fact, the death rate from cancer of the cervix has fallen very sharply during the past `?0 years, all over the country. Mr. KoRxEOmY. Are,you acquainted with Dr. Hueper? Dr. f)nr;R. Yes, sir; yes indeed. Mr. KoRxr;anY. Is he not an outstanding recognized scientist in this arehti? I)r. Onr:R. Yes: I think lIe is one of the ont4nndinh scientists in the world in this tield, Wid I have the greatest msleot for his opinions. He is the gentleman I quoted froul. CIGARETTE LABELING AND ADVERTISING-1985 351 Mr. Konxr:GAY. Yer. I had occasion to read one of his latest vol- ulues. I hive,vou seen the latest, hook ? Dr. Onr:R. No; I haven't had an opportunity to exanliue, it. Mr. KoHYlsGAY. I think that is all. 'I'hank you very much. Mr. Roc:r.RS of'Y'exas. Mr. Younger? Mr. YouNG1.:R. Thank you verx much. Dr. Ober, you are familiar with this report "Smoking and Health" by the Advisol~y (`onunitt,ee of the Surgeon General ? I)r. OsFR. l es; I have looked at it i.n t1le past. Mr. YavxGt:R. Were you asked at all or were you advised of the hearing or given an opportunlty to testify before that Committee when they investigated? 1)r. Oier:R.. No, sir; I was not advised that hearings were being held. I did not know t.ha.t this report was in preparation until approxinuitely a few days or a week before it was distributed by mail to, I think, every physician in the country as well as.a large number of other ill- terest.ed people. Mr. YOUNGER. In other words, the medical profession was not noti- fied at all that the Surgeon General and his comnuttee was conducting this investigation $ Dr. OBER. I can only speak for myself. I was not informed. May- be other people were. I don't know. I don't know how they went about it, and I don't know how the Commitee operated. Mr. YOUNGER. Now, how about the President's Comnlittee on Can- cer and Stroke? lh OnxR. I knew about that Committee, yes; because certain of the physicians who were involved are known to me personally. Knowing them, I felt. no gre,lt compulsion to coming down to testify because they all knew my views, anyhow. Mr. YoUxoHR. But they didn't follow them. Dr. OlsFrc. 'I'hev are entitled to their opinion, sir. This is what I have told many of my resident4. "You ou are entitled to your opinion, yount; ma.n, but you are wrong." 11Zr. YOUNGER. I notice the conclusion here in regard to cancer- where, No. 1, cigarette smoking is causally related to lang cancer iIi men. The magnitude of the effect of cigarette smoking farr outweighs all other factors. The data on women, though less extensive, point to the same direction. You have used examples of other factors that come into the cause of cancer. Do you believe cigarette smoking far outweighs? Dr. OI;aR. No, sir; I do not. I think that the statement which you have read is a statement which reverses my conception of proper pro- portion in this matler. I think other things are much more impor- tant than cigaret.t.e smokinl;. Un the other hand, you know, the person who attacks cigarette smoking has a very intellectually easy task. He stands there, and it is a very nice stance t.o be able to adopt, pointing an accusing finger at a cigarette. "7'his does it, this is the culltrit," and then the rebnttal is, the sort of lnild Irhuttal, "it, is very interesting to hear you say that, Doctor, but I aun not. so sure of your evidence," and this never sounds so convincing as the prosecution. I am sure many of you gentlemen have legal experience, and you know the difficulty of the neutral Vs~ssszoot

352 CIGARETTE LABELING AND ADVERTISING-1965 stance and the sort of dispassionate sort of weighing of evidence, "well, that was a fine speech and certainly amI area N~~orth studying, but is it as convincing as l~e makes it out to be Y" I frankly don't think it is. I have to adopt this sort of neutral at-. titude. It reminds me of a cartoon I once saw that dealt with twopeo- ple comint; back from some demonstration. They were carrying their picket signs at half-mast and they arrived at their home or apartment and the woman was there to greet them, "How did it go?" "Oh, we .vere doing fine until cooler heads prevailed." Well, what I am trying to do is present the attitude of a cooler head. I hope I am right. Air. YoiiNoFR. Another conclusion which they make is rather in-g teresting to mc: "The casual relation of the smoking of pipes to the development of cancer of the lip app ~ars to be established." Yet nothing is said about pipe smoking. There is no recommendation at alll about putting a label on pipe tobacco. But in their conclusion they say t.hu.t it ap ~i,e,ai:s to be a cause of cancer of the lip. Dr. nBER. V1' ell, you see this is characteristic of that Puritan type of mind. They have got a culprit. They really believe in it. It is like burning a heretic. They are not interested in minor things like cancer of the lip and pipe tobacco. They have got their culprit and they are fixed on it. It has really become a symbol with many of these people, and they get very emotional about it, in faculty meetings, and depart;ment, proceedings. Instead of presenting it with a view to rational and normal logic and the necessar,y steps of a logical chain of events, their emotions override their scientific judgment. Mr. YOUNGER. Thank you very mucht Doctor. Mr. Roor:Re of Texas. Wir. Van I)eerhng Mr. VAN DEERLIN. Thank you, Mr. Chairman. I hope, Doctor, that no one reading the penultimate paragraph of your testimony will judge that Congress is about to move against all sinful lusts of the flesh, and I'm sure I speak for my colleagues. Dr. OuER.. That is a very encouraging note. I will carry it home with me. Mr. VAN DEERC.IN. Just to keep the record straight, Doctor, inas- much as earlier witnesses have been asked questions regarding their sources of support, and I imply nothing by putting the question, have you received fees for, performed research #or, or have you shared in grants provided by any element of the tobacco industry 4 - Dr. IJnER. No, sir. Mr. VAN DEERLIN. This would cover honorariums for lectures or fees for written articles or anything along this line 4 I)r. DRER. That is correct. I have received no fees. Mr. VAN DERnLINa. Now, there is some suggestion in some of the te-timony offered here this morning that a law placing labels on cigarettes, or labeling advertising with warning of health hazards, would somehow result, in a cessation of research into air pollution and other possible sources of lung cancer. You don't suggest that this would be true, do you 4 Dr. OBER. Yes; I think that could happen. You see, research peo- ple have to be supported by funds. You just can't go out and do re- searrh without basis of support If the etiology of lung cancer be- comes a legislative fixed point, funds for research into the possible CIQARETTE LABELING AND ADVERTISINCi--1985 353 causes of lung cancer will inherently diminish because the available funds will be diverted into other fields, such as cancer of the stomach, the liver, the intestine, the cervix, corpus uteri, all of which are very important, very interesting and certainly useful. I wouldn't say that people who go into research do so because they are trying to wheedle money out of people, but if it becomes very difficult to get retiearch funds for a given project, the same technique is often directed at an or~*an or disease which is more attractive to the granting anenc~~. '1'here are a good many people who are doing research on cancer of the lung because it is an important thing and there are funds avail- able for it. But they are really interested not in the fact that it is lung cancer per se; they would just be as happy as working on cancer of the st,omacll or salivary glands or whatever. I.et us say they are virologists or cytogeneticists and they are interested in brenkint,g up nuclei into their component parts and studying chromosones and they are rca,lly interested in their own particular discipline, whatever it happens to be, and the object of study is merely the field of operations, and they are perfectly willing to choose another field, if another field is more attractive, but not for the sake of their discipline. Now; somebody raised yesterday a very interesting point which is something we all know about, and that is the distribution between males and females of lung cancer and it is much more common in men. Everybody knows this, and there was a vague hint in the background yesterday afternoon that this mi ht have some endocrinologic basis, and this, of course, is something w~ich should be studied. There has been little work done on endocrinology in relation to lung cancer because the endocrinologists have found other areas which are more interesting to study such as the adrenals, such as the ovaries- a great deal of work has been done on them. Such as in the field of human fertilit.y • as a matter of fact, animal fertility as well, because there is a good deal of money available from agricultural colleges and institutions and a great deal of endocrinologic knowledge has come from this source. - If the problem of fertility were discontinued or if some miracle were to happen and we could suddenly unravel all the tangled processes involved in human reproduction, these endocrinologists would then have to look for something else to apply their discipline to. It might be lung cancer. But that is not their primary concern at the moment. If you pass a law which sort of resolves in the public mind the issue of lung cancer you will divert these people to studying cancer of some other organ, which may be a very important thing to do. B_ ut it may stop them from studying air pollution and industrial toxins and things of that sort. That is where the loss will be. It will be a diversion of interests. 11ir. VAN DEERUN. Of course people in urban centers like Los An- geles that are suffering heavily from smog and air pollution are going to want to keep alive pretty effective research into all aspects of this problem. Dr. OBER. Yes, but you see it lacks the drama of the cigarette smok- ing. These people get up and say that the little white cylinder does it all. It is something so very real and tangible whereas air pollution is so vague-a little haze over the city-and people don't pay much attention to it. sssssszooi

354 CIGARETTE LABELING AND ADVERTISING-1965 Mr. VAN DEERLiN. Of course we, as Members of Congress except - , for one rne~nber of the commlttee, who is an M.D.-he is-not here to- day-can't really pass ~udrment on the fine points of medical testi- mony. We have to juelge these people who are offering it to us. I gact her that your re~nird is not. high for the men who made up the panel of the Surgeon General's Advisory Committee. I)r. OnEIZ. Oh, I wouldn't say that. No; I have a very high per- sonal regard for those particulur members with whom I am acquainted. I just don't happen to tigree with their scientific results or the way they formulated them. Mr. VAN Dr;NncaN. Well, you have offered testimony which sug- ge.sts an opinion that they are bluenoses. Dr. OnEa. Well, I come from Boston originally, so I am quite used to that. [Laughter.] I)r. OgrJC. I grew up with such people. That. is why I know them. I don't think an,y the less well of them. They just can't help it. Mr. VAN DEf:RLIN. It is not my view of holding high regard. Just one final question: Would you, as a doctor, advise any non- smolcing patiento to take up smoking? Dr. ()nER. No; I don't advise patients about smoking. I think tha.t, is the sort of thing that every man ought to be able to decide for himself. Mr. VAN 1)e.r:niaN. Well, as a pathologist, you don't usually reach them until after they have passed to their reward, anyhow. Dr. nnrat. This is not entirely true. Although I do a fair number of autopsies, I also do a fair amount of nonautopsy work, and one of the things I have been doing lately is working with some pat,ient in ret,rnrrl to a certain specific problem, so I do see some patients, although I clon't., see them as private I)at,ients in the accnstomed sense of the word, but I do deal wit h them as living hnman beinhs. 1fr. VAN Dr:ERLiN. Do you know any physician, doctor, who would contiider smoking heneficisi.l g Dr. Unr:u. No; I think that my attitude and the attitude of most of the her»le who agree with me, is that it is a matter of indifference. ]1f r. AN DI:ERLIN. It can't help you or hurt you F I)r. nnER. That is ri~,•bt. Mr. VAN DERRi.1IN. Thank you. Mr. R,octERS of Texas. DIr. Callaway H Mr. CALLAwAY. We did have some testimony by Dr. Auerbach who tried to point out son)e specific things that smoking does. You dis- agree N-ith his testimony and certainly I am not qualified to judge that. I can only listen to both of you. But most of the testimony has been, as you said, statistical. I wonder, is your main objection to the statistical evidence itself or do yon agree with the statistics, but object to the conclusion. Dr. OnER. I challengE two points: One, the use to which it has been put; and second, the general matter of scientific logic. A statistical association merely defines an area to be investigated more fully and more careftilly and I think dispassionately. No scientific theory of cause and effec,t is complete without some statement as to mechanism, be it. a physical nyechanism, a chemical mechanism, a biochemical mech- anisni,a physiological mechanism. To magnify statistical association to the proportions which it has been done in the report which is before CIGARETTE LABELINQ AND ADVERTIBINQ--198b 355 you, the Surgeon General's report, and in the published reports of similar nature, I think, is doing a disservice to the cause of scientific reasoning. Mr. CALt.AwnY. I understand yourobject,ion on tha:tba.sisbutdoyou have any objection to the actual figures that a certain percent of these people did smoke cigarettes, a certain percent did smoke cigars and a certain percent did get lung cancer, do you know of any objection to the st-at.iStlcs themselves? Dr. Onrae. You me,~tn were the facts correctly and accurately gathered good so far as you know? I have no opinion on it because I wasn't there when the facts were gathered. ,1Ir. C.ALLAWAY. But. you have no reason to doubt them g Dr. OBF.R. I have to abide by my faith in the integrity of my col- leagues. I can merely criticize them on the more general grounds of the" interpretation. Mr. CALL.AwAY. A statistician likes to get into what is called a sta- tistical significance which means under the law of chance it is un- likely that such a relationship wonlc] happen. As large as these sta- tistics are, you can almost rule out a chance relationship between lung cancer and smoking. I f you feel it hasn't been shown scientificallv that cigarette smoking does relate to lung cancer, what are your snggestions a.s to the cause.. since it can hardly be chance. I)_ r. OnFR. That is one of the troubles of sta.tisticy, and I think you are probably better at them than I flin, sir, because I am not_ good at theni at. all. I read these tables and I look at them and there are a lot of numbers, but they are not• terribly meaningful egcept, in this busi- ne..ti of defining an area and that.. is as far as I can go. Mr. CALLAWAY. These figures, as I understand them, show that a certain percent of people who smoke cigars get cancer, and a certain higher hercentage smoking cigarettes get cancer. There is no cause and eff(Tt shown by these statlstics-it could be something el.% but apparently it has got to be something--it is not likely to be chance. Dr. OuFR. Let me put. it this way. I.et me give you an analogy. Many years ago there was a thing known as a miasmiL which we now reco~,•nlze as malaria. It. was noted that, it occurred chiefly in people who lived in the swampy areas. If you are familiar with the P..oman marshes, you know the elaborate system of drainage they developed many, many years ago during the time of the Roman F.mpIre. They trieci to dra[in these areas because the}~ gave off offensive odorsbut the miasma persisted through the :1Zidc7le Ages and persisted through Itenaissancee medicine until all of a sudden in the 19th centurv a chap by the name of Sir Ronald Ross discovered the malarial parasite. It was not because of people living in the swanipy area but the mos- quito that lived in the area. All of the statistical associations about whel'e tlle4e people lired and plotting out. R map of Rome as to high lands, wet lands, low lands was nonsensical. It merely defined an area to be investigated scientifically and when the Seientific investigation was done they did find the reason and you could have all the resid- ential statistics and all the barometric deter- mina.tions, and so forth, but it was meaningless; the problem had to do wilh m"uitoes. Mr. CALLAWAY. I would hope if we could find some mosquite in the cigarettes, we could get it. out of cigarettes. Large scale research is I 9SS969%00Z

356 CIGARETTE LABELING AND ADVERTI$ING-198b now being conducted on this. But if these people in Italy cleaned up the swamps, although tliey didn't know anything about mosquitos, it would ltelp cleau up malaria. By the same token it seems logical that anything we do to cut down on cigarette sniolcing .vih probably cut down our mosquito, whatever it t urns out to be, and should logically cirt down on lung cancer. Dr. OnrR. I don't think a legislative act is likely to induce people to stop snnokinc. I think the desire to smoke or to stop smoking has to come from within. I don't think it is the sort of thing you can imp~ose on a population by niedical edict or by legislative edict. :1fr. C.u.cAwAi'. IIow about limitingadvertismg? I)r. Onr:R. I don't know. 1ye certainly don't advertise reefers for sale bllt. in the area around Ilarlem where I work there are certainly an awful lot of reefers being smoked. Nfr.CnLt ~w.%Y. Thank,you,llLr.Chairman. 11Zr. l:ocn~au; of Texas. Mr. Satterfield. Mr. SA•rrF.aPtFa o. I have no questions at this time Mr. Chairman. Mr. l;(1qElts of Texas. Mr. F arlasley 9 Mr. F.vcxrr.eY. I told one of the witnesses, you have shown, a high inyi~;ltt into the sociall sciences by pointing out the possibility Puritans were mixed into this. I think thatt probably has a lot to do with it. Does a doctor get any training in the scientific method or does any- body for that niatter? I don't know. I have heard about it all my life. Dr. Oisex. That is a very good point. As a matter of fact, apolnt, which has come up in curriculum com- mittee meetings a good bit more in recent years than in past years. We all pay lipservice to scientific methodology and we try in our daily life to adopt methods which are proved, which are carefully chosmn, and which are accurate. But if you look in the curriculum of a medical school or a graduate school in any depa.rtmenfi, of science, there is no real seminar or course or l i Gt of hooks on sclent i fic methodology as such. I th i nk that is one of the defect s in our curricuhtm. Mr. FAaxst.EY. Thank you, Doctor. Mr. Roor:es of Texas. Doctor, I want to express my appreciation for your participation in these hearings. I am sorry I was lntc+ but i lbad your statement witli agreat deal of interest and especially in its reference to the questions on statlst•ics. I listened with great interest to t.he st.atelnents on statistics which I don't think are borne out in the findings, in the publication on smoking and health. I think that if there was a method fixed that lung cancer was the result of smoking cigarettes and the mechanization as you have stated was determined, I think both you and I would be leading the fit,•ht to ban the snle of cigarettes or perhaps the growing of tobacco if it had to go that far. But I think that the statistics that we have are somewhat like the story of the scientist who supposedly was making some determination and he pulled half the legs off a grasshopper and said, IIop. And tlie grasshopper hopped.wlth what he hatl left. He pulled the other legs off and said to tlce grasshopper, he said, "Hop." And the ,$rass- l>.opper, of course. couldn't move. Another scientist said, "Well, what does this prove g" 4s9ss9zooZ CIGARETTE LABELING AND ADVERTISING-1966 357 Iie said, "It proves when a grasshopper doesn't, have nliy legs lie can't Lear." 7)r. Onen. T think that is a very good analogy. I like t.hat analogy. Mr. RooFes of Texas. I appreciate your p-aper on it and your con- tribution. You did say that you did not feel that a law should be passed by the Congress on this sitbject. Ipresume you were basing your conclusion in that respect on the iluestcon of tlte scientific basis for need for such law. Of course, this is ont of your field, but when we get out of the scientific field into the political field, there llas been a development over the past few years that attempts have been made to encroach upon the domain of Congress, made up of the duly elected representatives of the people, and sometimes we have to act in self- defense, and I think that this is a matter that is more the basic issue before this committee right today, as to whether or not this is a matter to be determined by the people's representa.tives or by an appointed bureau ureau alid I_ think it is a matter we have to face. Dr. (~1;r;ie. I place my faith in the people's representatives. I have always done so a.nd they have very rarely failed me. 111r. Roo>:as of Texas. Thank you very much. (The following letter was later received from Dr. Ober:) KNIC_KENROCKF.R IIOQRITAL_, 11'eta York, N.Y., April $S, 1965. CCongressman ORP:N HARRIB, C,ommfttce on Interstate and Foreipn Commerce, ffotixc, of Itcprear,ntatiroes, 1Va-Mtnpton, D.C. DFAR D7R. HARnte : Let me take this opportunity to thank you and the other members of your committee for the courtesy which which I was received. It was a great pleasure to see at 8rst hand the intellect and hard work that goes into the legislative process. There are two points I would like to make whlch_ I did not think of when ap- pearing before you. One often has afterthoughts. First, I think there is solid medical evidence that circumcision at birth will eliminate carcinoma of the penis and materially reduce the incidence of carcinoma of the cervix uteri. The evidence is much stronger than that which alleges that cigarette smoking causes lung cancer. Yet no one to date has s proposed that Con- gress pass a law In the intereat of public health that all male infante be cir- cumcised. Apparently, the puritanical mind can only go so far. I would like to see a little more intellectual consistency on the part of the people who disagree with me. 8econd, regarding the matter of labeling: I understand thnt somebody has suggested that cigarette packages nnd cartons be labelled with words to the effeet that excessive or prolonged use will cause_ cancer of the lung (or will hr inJurious to health). I don't think that "will" is a valid word at all In this context. Even stncking the statistical cards against me, the evidence is that !)il.ti percent of smokers will not develop lung cancer. An alternative suggestion for the label would use the word "may" instead of "will." Technically, this In not_ an Incor- rect statement. However, In view of the considerable uncertainty that any considerable number of lung cancers are actually caused by excessive cigarette smoking, and In view of the probability that many other factors may also cause lung cancer, I suggest that the only semnntically correct s_tatement which could be made at the present time is: Excessive or prolonged use may or may not cause lung cancer. I do not think the antieigarette faction would be happy about inclndinR the negative. Their emotional bias prevents them from looking at both sides of the coin. Nonetheless, a true scientist must always take negative observationa and negative results into account. We must look to our legislators to maintain the balance and equitable judgment that characterizes the legislative process at its best. _ Sincerely yours, Wn.r.zmr B. Oars, M.D., Director of Laboratortea.

358 CIGARETTE LABELING AND ADVERTIBIN(i-196fi Mr. RooF.as of Texas. Our next witness is Mr. William J. E. Crissy professor of niarketing and associate dean of the Graduate School oi 13usiness Administration of Michigan State University of East Lan-. sing, Mich. Mr. Crissy. STATEMENT OF WILLIAM J. E. CRISSY, PROFESSOR OF MARBETING AND ASSOCIATE DEAN OF THE GRADUATE SCHOOL OF BUSINESS ADMINISTRATION, MICHIGAN STATE UNIVERSITY Mr. CRissY. Mr. Chairman, my name is William J. E. Crissy. I am a professor of marketing and associate dean of the Gradilate School of Business Administration, Michigan State University. I joined the faculty at Michigan State in 1960. Like most of my~ professional contemporaries, I did not receive my own university training in the field of marketing. When I attended college and graduate school, marketing wits not recol,nlized as a dis- tinct academic discipline as it is today. My master's degree, which I received from IIarvard in 1937, is in the field of education; my doc- torate, from the University of North Carolina in1J42, is in psychology. Ysycholo~ has alawys been of great interest to me, even apart from its application to business and marketin . I am a licensed psychol- ogist ogist and a fellow of the American Psyc hological Association. I)urinf; World War II, I served in the Navy as a line officer on both suhuiariues and destroyers. I am currently a commander in the Un ited States Naval Reserve. In tile years since \1'orld «'ar 11, 1 have divided my time between teaching, writing and consulting in the fields of psychology nnd mar• keting. I was an associate professor of psychology at Queens College in New York, from 1947 to 1950. During this period I also lecturel at Fordham, New York University and Columbia. I have written extensively in the field of marketing and have pub- lished more than 50 articles. I am the coauthor of two series of sales and management booklets-one entitled "The Psychology of Selling," the other "'I'lie Psychology of 141anagement " From 1954 to 1960 I served as the head of my own consulting firm in New York, known as Personnel Development, Inc. As someone who has devoted much of his professional life to the study of marketing, I am deeply interested in the subject matter of the hearings which this committee is now holding in connection with pro- posed tobacco legislation. Among the questlons before this commit- tee is whether cigarettes sold in interstate commerce should be re- quired to bear some kind of warning with respect to the possible risk to health in smoking. As I view it, this question resolves itself into three subquestions: First, as a matter of medical science, is there a significant health risk in smoking$ Second, if there is such a risk, does the public interest iecluire that manufacturers be required to state this fact in connection with the sale of ci"rettesY Third, if the public interest does so re- quire, what shoulc~ be the nature of the required notice and where should it appear 1 Medicine is not my field, and I am therefore not competent to testify with respect to the first question. CIGARETTE LABELING AND ADVERTISIN(l-196b 359 Nor can I offer much that would aid this committee in dealing with the second question it may have to face: Whether, if it should be con- cludecl that smoking may involve a risk to health, the degire of tlult risk and what is known about it warrant requiring cigarette manu- facturers to warn of the risk. This is a policy question for Conl,n•ess. I would note, however, that there are a great many products and services on the inarket which involve some risk to users but which are not required to beitr tuly kind of warning statement at all. The ea- plftinatlon, I assume, is tlult ecnl.5umers are believed to have, finnl gmn- c+r:.d knowledge, aclequaitee inforlna.tion to rlvtect. themselves from un- ant,icipated injury. Evidence exists from which Congress might conclude that this is the ease with respect to cigarettes. Tllere are frequent and repeated refelr.nc,es in the public press to the various health charges that have been macle against. cigarettes. Whether st>uie kind of warning notice should he required, howet er, is again n question on which professors of market,ing have no special conlpetence to advise this conunittee. The third question-in what manner cigarette m,uulfactin~ers should be required to warn of health risks in smokinr, assuming ('onhre~ de- termnles that. manufactttrers should he so reitilmecl-fulls into a solne- what clitlelrnt eatefioly. It is a tlnestion which has important mau•ket- ing implications, and on which I should imagine mcnt, persons who llave devoted their lives to the study of marketing mi ht. bee expected to have rather definite opinions. I certainly clo, ai1c~I anl giateful for this opportunity to present them. h'ilst., let me address m,y5elf to the question of where any warnings that nli;~ht be required should appea r. In my opinion, there is only rlace for such warnings, and that is on cigarette packages; that is, on tlle label. Labelind is where consumers expect tA find warnings, if at all. The especta,tion comes from condi- tioning, the conditioning from tradition, the tradition from common- sense-t,he commonsense of providing infolmiLtion where it will be most useful. The Federal Trade Comnlis,sion has issued a "Trade Regulation Rule" which would impose a recluirement, that warning statements ap- pear not only in ci~nl.rette labeling but in cig:~ret.te advertising ils well. A bill which woulc~ have this effect has been introduced in t.he Senate. In my judgment, it is inappropriate to ask that cigarette manufac- turers include in cigarette advertising a statement with respect to t.lie possible health risk8in smoking. First of all, if warnings should be required in labeling, there would be no need for them in advettising. I am assuming that the purpose of warnings whether in labeling or advertising, would be to remind cigarette smokers, or potential smokers, of possible health risks in smoking. A warning on cigarette packages would certainly perform this c,a.a- tioning and reminder function adequately. A pack-a-day smoker, such as myself, would be confronted with the caution notica 20 times a day. It is difficult to believe that anything further would be neces- sary to communicate to smokers the message that smoking may be harmful to health, if indeed that message is one which Congress con- cludes ought to be communicated. 8~~ssszooi

360 CIGARETTE LABELING AND ADVERTI$ING-1985 Of course, if mandatory warnings are looked upon not really as a way of infotTninn smokers of possible health risks in smoking but as a way of rendering cigarette advertisements so unappealing as to drive them out of existence? then we are talking about a different problem. But while sotnc might welcome mandatory warnings in ad-g t•ert.isinh ae uI indirect way to abolish :i,11 cigarette adveitisint;. I can- not believe that the majority of persons would sympathize with such an undertaking, either as a means or an end. To m,y knowledge, there is no responsible body of opinion in favor of prohibiting the manufacture or ssLle of eif;arettes_. Moreover, I thiuk most persons would a;;ree that the right to do business should c:u•iy with it the right to enihloy in the conduct of that business nor- mal, everyday business techniques, including advertising. Certainly no advertasinfi embargo should be emposed in an indirect, covert man- ner and without full awareness of what is really being attempted. Assuming then that the purpose of mandatory health warnings would be to warn and to rennnd consumers, not to punish cigarette manufacturer5, the lack of need strikes me as a controlling argument against requiring their inclusion in advertising, particularly if a warn- inf; should be i~culuired to appear on the ]tibel. 13eyond that, however, I cannot help but view mandatory warnings in advertising as basicall~y incongrous and at odds with the traditional and accepted role of ad-g vertismg in our economy. This role is to remind consumers of the advertised product's virtues and benefits, whether tangible or intan- gible. In the case of cigarettes, of course, the benefits are intangible: taste and psychological satisfaction. The fact that advertising's long-accepted role has been to remind consumers of the adv ertised~ produc,t's attributes, not its possible draw- backs, does not me;in that advertising is not subject to important legall and moral statnd,u•ds. It is. Advertising is expected to be honest; it is exlwcted to be in good taste. Advertising is not, however, expected to be impartial. What the consumer expects from advertising is vitally important in distinguishing it from labeling. I believe that an understanding of consunier expectation leads inescapably to the conclusion that it would be inappropriate to require cigarette advertising to contain health warnings. For one thing, because consumers do not expect to find warnings in advertising, they do not intelinet the absence of a warn- ing as an assurance of safety. Certainly there could be no doubt on tliis score if cigaret te packages contained warnmgs. In this connection, I understand that proponents of mandatory cigaretts health warnings have sought to justify them on the grounds that they would symbolize governlnental concern with the problem of smoking and he,tilt.h and would stand as evidence of an authoritative overmnent;tl determination that smoking may be a health hazard. ~ do not entirely dismiss this argument, but it seems to me that a man- datory warning in labeling would be just as significant a symboll of governmental concern and just as unambiguous evidence of an official determination that cigarettes may be dangerous to health as mandatory warnings in advertisin-. Moreover, it would te a symbol that was consistent with consumer exl)ectation-the expectation of finding warnings, if anywhere, on the label, not in advertising. sss%szooT CIGARETTE LABELING AND ADVERTISING.-1985 361. This leads me to a slightly different but related point. One who, would attempt administratively or legislatively to reshape the role of cigaretts advertising in relation to the marketing of this product should ask himself what the impact of such a reshaping could be on the niarket.ing of other products. In my judgment, mandatory warn- ings in cigarette advertising would constitute a significant step toward encouraging consumers to relax the healthy, self-protective skepti- cism with which they now regard all advertising. Consumers would be invited to reason as follows: The Government requires warning statements in certain advertisements because it has concluded that the product may carry some risk to health; failure of the Government to require warnings in the advertising of other products must reflect an oflicial judgment that use of those products involves no health risks. Such reasoning could be dangerous. The problem is not merely that a precedent would be established whereby liquor manufacturers could be required to warn in advertis- ing of the dangers of drunkenness and alcoholism, whereby airlines could be required to warn in advertising of the ever-present threat of crashes. Rather, a situation would be created whereby the Govern- ment could find itself forced to require such warninf,.s--forced to do so to prevent misunderstanding where misunderstanding did not pre- viously exist. In short, I think this is a case where an inch of "remedy" could easily produce a foot of need. There is another quite different reason why I think it would be a serious mistake to require cigarette manufacturers to includ_ e health warnings in advertising. I think it is entirely possible that the com- bined offect of warnings ln labeling and advertising could be such as to undermine the basic purpose of the warning. There are many persons who, for one reason or another, react to warnings or admonitions in a contrary or perverse fashion. This group includes young people who are rebelling against authority; it also includes those who may have some subconscious wish to cause injury to thems_elves. It is my view that persons of this type would actualy smoke more if health warnings were required to appear in cigarett.e advertising. I think health warnings in advertising would have a significantly ~reater backlash effect of this type than health warnings in labeling.s i'liis is because health warnings in labeling would not constitute a de- viation in principle from current commercial practices. Though in- formative, they would be less likely to trigger a perverse reaction. This leads to my final observation, which is directed to the language of any required warning statement. It seems to me axiomatic that any statement should accurately reflect the known scientific facts. It should not, however, be unduly inflammatory. In this connection, I am familiar with the Federal rrade Commission's proposed warning requirement, with its reference to "death from cancer and other dis- eases." In my judgment, a warning expressed in such language would, by virtue of its distastefulness and intended shock effect, pre- cipitate a far greater backlash reaction that a quieter, more restrained warning statement. .e-aa.--e5-z. ~.

362 CIGARETTE LABELING AND ADVERTISING-1965 On the other hand, I believe that a warning statement like that ap- parently prescribed by the FTC would have no greater or offsetting etl'ectivenevs among persons not given to the type of perverse reaction I have described. This is because, generally speaking, those persons who react rationally in the face of possible risks need only be informed of the risks; they do not need to be beaten over the head with them. I appreciate the opportunity to present these views, Mr. Chairman. Dir. Hoc;rai5 of Texas. 'I'hank you, Mr. Crissy, for your statement. `I'lle chair recognizes the gentleman from North Carolina. Mr. IioRNr:u:i,Y. 'I'hank you, Mr. Chairman. Mr. Crissy, I want to thank you very much for a very fine state- ment and say I have only one regret about it and that is that my good friend, 'Air. 1)ixon, was not here to hear it. I know lie is bound to be very much impressed with it because based upon your back- ground and experience, as a psychologist, it points out some things very graphically which I had thought existed in this area and in this problem for some tinle. Mr. CR1ssY Thauk you. Air. Iimtx>•:oAY. '1'lle fact that you put a label on the package, par- tic.ularlv as you point, out, in advertising, it seems to me you iuay be presenting a problem to the people, and particularly the young people, I lie people wLo the opponents of smoking want to get to-they say-to try to stop thenl froni smoking. Mr. CRISBY. 1 es, sll'. Afr. KoRNxGAY. I read the newspaper, and I see these ads about movies, you know, the midnight. movie, st scary movie, not for t.he weak at heart, not for the scared; it is a come-on etfect, and I don't know but what this is, as you say, calling it a backlash; that is, would it not be a come-on-particularly for young people? Air. CRIssY. Yes, sir. Mr. K(1RNEGAY. That maybe you-not me because I am big and strong, and I am not afraid. I believe that is an excellent point that you ntade: And, I want to also comment on one other one that I think is very valid and that is when the Goverlunent starts, through legis- lation or edict, putting labels of this nature on any product, that it would tend to relax the consumers' feeling of caution about other products. Mr. CRISsY. Yes, sir. Mr. KoICNEaAY.. Because you read every day and see on the TV that this product is the best. We understand, as you so well pointed out., I think the public understands, it is the seller's puff. A manu- facturer of a product, regardless of what it is, wants to put his best foot forward. Mr. CRIssY. Y es, sir. Mr. KoRNxGAY. That is understood, and expected, and I don't think too many people are disappointed if it maY not be the best coffee in town. We may prefer another brand, but it is a matter of opinion, and I think that was a very good point. I take it, also, Mr. Crissy, that you are familiar with advertising that is the advertising of tobacco companies on television, radio, anc~ newspapers and mn~,.uzines, and as a psychologist? Mr. CRTRAY. Yes, sir. Mr. KORNF.GAY. What would be your thinking as to whether or not they would continue to do that type of advertising if the Government, CIGARETTE LABELING AND ADVERTISINt.l---198b 363 t.hrouglt legislation, or through edict of the Federal Trade Commis- sion satd, "h~ow it is all right, to advertise but you are going to have to put in a very prominent position in any ad you put in the magazine or the newspaperr or you are going to have the announcer on radio or television say at the conclusion that "cigarette slnokin~ is dangerous t.o your health and may cause death by cancer or other disease." Iiow much advertisint; do you think they are goin~ to do? Mr. CniasY. Well, sir, 61s_ t, I think tlutt advertising would be less- ened. Warnings would be so incongruous with the ot,jective of ad- vertising that they would surely cut it, down. Also, it is significant to meas a student of marketingthat the cigarette market is a mature industry, and what they are after is selective demand. No one says, "Take up smoking.°7 They say, "Smoke Winston, smoke this, smoke t.ha.t..°"I# warnings should be required, they should be on the label, which is informational, and not, invade the persuasive domain of ad- vertising. And it certainly should bo done uniformly lest unwittingly there be some alle~ed diticrimination toward one company. But, in a Inat,ure market, I dolr t think the purpose of any of the mau'keting effort iti primary demauld; it is selective denland, preference of one brand over another. 'I'o come back to ,your question, it is so incongruous that I would suppose you would Find a lessening, and you mightl-again this is hypo- thet.lcal-freeze the existing market or tend to freeze it. Mr. ItouNr:o.LY. Would ,you feel that the cigarette companies-I can't speak for them, it, is a. matt,er of oIlinion for you just. as it is to Ine, do you feel if ,you were doing-would do any advertlsinl; ? Mr. CRISSY. `irell, puttin~ myself into the shoes of an executive in this industry, or any other Industry, I don't think I would want to advertise where leryislat,ively orr administratively I am prevented from putting my best ~oot forward. For example, I am concerned with attracting young men and women to the Naval Reserve. I can tell you this, that. our spot commercials on radio and television don't. con- tain the death toll in South Vietnam and they don't tell the fellow he may have to swab a few decks. Now, the presumption is before he holds ulp his hand he understands that lie is serving his country in a domain of risk. But in our advertising we try to put our bestt foot forward. Mr. ICORNF.(IAY. You don't consider that unfair advertising? Mr. CRIssY. I don't. I would do everything I can to present an attractive image of the Naval Reserve, as many as we can use. Mr. KORNEIiAY. The FTC hasn't approached you or served notice on you that you are going to have to say something else? Mr. CitlssY. No, sir. As a matter of fact we are doing very well in our unit. We are No. l in the 9th Naval District. Mr.. KORNEGAY. As I understand the testimony came out during the Senate hearings last week or the week before in this matter that the top 10 TV shows in this country were sponsored by ci~*arette com- panies. I don't know whether that is right. I just heard that. Do you have any knowledge of it.? Mr. CRISSY. I don't know. Of course there, again, you have so many different wnys of ranking them. Mr. KoRNEGAY. There is. As a marketing expert would vou venture the opinion if labeling went on advertising to the point that it made 09~969200l

364 CIGARETTE LABELING AND ADVERTISING-1965 it prohibitive for the cigarette companies to advertise on TV, and I understand about $1 ~~-to $250 million a year go into advertismg that is about the quickest way I know of to bring around, get us around to pay '1'V-do you have any thoughts on this? In other words, if this great source of revenue is suddenly cut off in order to get quality programs, isn't it sort of reasonable that. we would be confronted with a situation that would compel the development of payTV9 Mr. CRIsBY. It could be. I think the general problem is that it would set a pre<•.edent for disrupting established business practice in our private economy generally. It is incongruous. Advertising per- sua<les. Labeling informs. i think there is an important difference t l ie,I•e. Mr. KORNEGAY. Yes, sir. There is, and you put it exceptionally well. We had before the committee the other day an erstwhile advertis- ing man who has recently dedicated himself to stamping out smoking, and he said he was opposed to prohibiting the advertlslnt; of cig- arettes on TV but that he wanted to place such severe restrictions upon theadvertising that it would be self-defeating. noes that. make sense to you $ Mr. CnlsAV. Not as a busines,5man, not as a professor of business; no, sir. I think that is an inconsistency. I don't know how anyone co_ n 1d arrive rationally at, that position. Air. KoaNEaAY. Is that consistent with the American principle of free enterprise and freedom of choice, and the right to advertise? Mr. CRlssr. It is contrary, it seems to me. Mr. KORNEOAY. Thank you very much for a very fine statement and I appreciate it. bI r. C<'RissY. Thank you, sir. Mr. ROGERS of Texas. Mr.. Younger $ Mr. YOUNGER. Thank you, Mr. Chairman. Air. Crissy, do you know I)r. John Hoagland, of your faculty $ Mr. CxissY. Yes, sir. He is a very dear friend of mine, Mr. Younger. Air. YOUNGER. I watched him grow up as a youngster. Mr. CrussY. We are very proud to have him at MSU, I can tell you that. Mr. YovxaER. A very able man. I notice that you are a member of the U.S. Naval Reserve. The Secretary of Defense hasn't shot your unit out from under you yet, ha.s he $ Mr. CRI88Y. No, sir. We have the best recruiting record and the third best retention record in the Ninth Naval District. We are going to be No. I on both counts by June. Air. YOUNGER. The one up here on the Hill, they shot it out from under the Naval Reserve officers. Mr. Clussr. Maybe we are too far away to get under fire. Mr. YOUNGER. t71e order hasn't reached you up there yet$ Air. (`RIssY. No, sir. [Laughter.j Mr. YOUNGER. Are you familiar with the advertising code of the cigarette manufacturers $ . Mr. Calssr. Yes, sir; I am. Z9S969zOOZ CIGARETTE LABELING AND ADVERTISING-1985 365 Mr. YOUNGER. Do you think it is a good code $ Do you think they have covered the field pretty well $ Mr. CRIB$Y. I think, not only that it is spelled out fairly and in good taste, but I think it is always part of our private enterprise way of doing business to encourage self-policing if we can. I think that has been the stance of our Government, without being at all remiss in any responsibility, to try to encourage business to keep house itself. It seems to me that the code and the very able person they have to admin- ister it, who happens to be an acquaintance of mine, Governor Meyner, whom I met years ago, when he was Governor of New Jersey-that the combination of an able administrator and a well-conceived code is excellent. Mr. YOUNGER. j't'ere you consulted in connection with the prepara- tion of the code? Mr. CRIssY. No, sir; I_ was not. Mr. YOUNGER. Have you been employed by the tobacco people at all? Mr. CRIssY. Yes, sir. Mr. YOUNGER. In advertising or what $ Mr. CRIs_sY. Yes, sir; years and years ago when I operated my firm I had the privilege of a major company as a client. We related to their marketing group on strategy of advertising and packaging, test marketing, that sort of thing. Mr. YOUNGER. That is all, Mr. Chairman. Mr. ROGERS of Texas. Mr. Van Deerlin $ Mr. VAN DEF:ei>:N. Thank yout Air. Chairman. You have no pres- ent ties of any kind to the tobacco industry $ Mr. CRIssY. No, sir. I am speaking here freely as a professor of marketing. Let me add, lest there be any misconception, that I was consulted in anticipation of these hearings, and I get a normal per diem for such time, as I do with any other client. Mr. VAN DEERLIN. Travel $ Mr. CRissY. But r am speaking as Crissy interested in marketing both from a practitioner and scholarly standpoint. Air. VAN DI..F.RLIN. But your appearance7iere is on a per diem, and you receive travel from Rast Lansing, and so forth $ Mr. ClussY. Yes, sir. Mr. VAN DEt:RLlr. From the industry $ Mr. Ciussr. Yes, sir. Mr. VAN DEERIaN. Dr. Crissy, you are familiar with the Advertising Council, the work that it does in promoting as a public service on funds snpported by the advertising profession various public interestt causes $ Mr. CRissy. Yes, sir. Mr. VAN DEERLix. Causes like the sale of savings bonds, the preven- tion of forest fires, the untilittercampaigns? Air. CnlasY. Yes, sir. VAN DEERLIN. Do you think there is a peril there as suggested by your testimony that advertising campaigtIs in which Smokey the Bear warns you to put out the caI11pfire or wllich you are urged not to tlu•ow banana peels and beer cans along the Nation's highn ays; do you think this has a perverse effect and encourages people to mar the countlyside $ 01 ". 1" 1 1, " I .

366 CIGARETTE LABELING AND ADVERTISING--1985 DTr.'CtttssY• I think that such campaigtts have been pretty carefully conceived and are not really advertising so much as mass media infor- mat.ion sharing. I suppose, however-and I am speculating only, for I have no re- searclt evtdence-t.hat even with those noni.nfLttnmatory infortnational warnings, sonte of which, as you know, have utilized a kind of a humor, live cartoon kind of thing, might even trigger off a few people per- verse enough to say, "Well, there is something to do." But they have been pretty much informational. I would drawn analo~y between those and what we would speak of in marketing as institutional advertising, as distinguished from selec- tive demand cultivation. Mr. VAN Dt;r,Rt.xx. Well, as an offhand opinion, do you think that maylx~ if Congress acted on labeling, as you have suggested, and left a~l~'ert,itiing aloite thitt, it might be a worthwhile enterprise for the Advertising Council itself to carry sonte advertising campaign as a public service keeping alive the inquiry into the menace of smoking and calling attention of the public to the possibility of a health hazard ? Mr. CRtsFY. Well, as I tried to say in my statement, my judgment as a layman in t he medical field makes it difficult for my opinion to be worth much. Even on that, policy issue whether after Congress weighs the evidence it should take a stanci, I can't. be very helpful.. I~~ould rather stay in m,y own profes,sional $cld where I can speak n•ith a little more confidence. There is commercial precedent, based on contmonsense and t,radit ion, that if labeling is needed it ought to be on the package. Advertising has a mission, particularly selective demand advertising, of persuading you about the benefits that will ? accrue to you if you buy this brand instead of another. So tltat. is getting to a kind of a policy domain where I haven t done enough thinkm;. Even if I did I would still only be a layman, a citizen offeringan opinion. The thinl; t~tait triggered off my interest in this whole thing was t,his invasion of advertising, frankly. I am not taking a stand that there ought to be a label. You have to weigh the medical evidence. But I feel very strongly, and I suspect most marketing people feel very strongly, that invading advertising runs contrary to everything that, we know from our re5earch, everything that we teach, everything that we see in commercial practice. Mr. VAN DEERLIN. Well, in the light of the information that has been provided by the Advisory Council, the Advisory Committee on Smoking and Health in this fat book, do you think Congress could do anythin ~r less call for labels? Mr. C RissY. Well, I have had the privilege of hearing'some of this medical testimony that, was presented yesterday and today. As an interested laym an I felt, as one Coiibre"inan a;aYd, I re(°:tved an education by being in the audience. It, would seent t.o me that you have to weigh out this wide spectrum of medical opinion and medical research and draw your own con- clusions. It is a pretty awesome task, but I would not want to step in on that one. Mr. VAN 11EFRtax. Thank you, Mr. Chairman. i1ir. RoaERa of Texas. Mr. Callaway4 CIGARETTE LABELING AND ADVERTISING-I965 367 Mr. CALLAWAY. Mr. Crissy, I want to contmendyou for a most out- standing presentation. I am getting an education not only from medical testimony but from yourself today. Mr. CRISSY. Thank you, sir. Mr. CnLr,AwAY. And I certainly share with you a love for free en- terprise and a love for everythin~l, that has made this country great with voluntary participation and I am concerned as you are about the invasion of advertising but I wonder if you would agree with me we are really speaking more of a question of degree rather than a black and white principle. For example, I recall a number of years ago, I believe there was a hair tonic called "West Point" hair tonic and I saw in the advertise- ment "not affiliated with the U.S. Military Academy." I assume they were required to do this. Only a day or two ago, I heard an advet•tise- nu+nt on the radio for "Government Employees Insurance Company" and even on the radio there was a disclaitner "not. aftiliated with the U.S. Government." Is this not a matter of degreef! In other words, these were not statements for putting the best foot forward, the best foot forward would require leaving these statements out but they were put in I assume by Government regulation. 11fr. CRIssY. Well, sir, I think that is an example of where failure to be explicit, from the standpoint of your reaction as a rational hu- man being, or mine, would constitute fraud and deception. The very name, like "West Point," would connote for us-it would for me-in the absence of that exclusion that there was this hookup. That is why I say, I thin~ advertising must be honest, it has to be in good taste. But it is inherently a persuasive kind of communica- tion tion rather than an objective inforinational kind. Now you are right, there are examples where the possible deception would be so likely that they may have to put something in the ad to prevent deception. On the other hand, I would have to say this, I don't know what your observation has been,l4lr. Congressman, but since this report catme out from the Surgeon GeneraPs office, I have scarcely picked up a daily paper that didn't convey some aspect of it. I thtnk that through public media almost every person must have been exposed to this, and this is good. If this encourages increased researclt, tticreased con- cern, fine. -But I think that this eliminates the need to put it in the ad. Silence is not something which is inherently deceptive. Mr. CALLAWAY. Well, I certainly agree with most of your conten- tions but I don t agree with you on the lack of need. It has been brought out by almost every witness that our concern, and certainly my concern, is not with the adult who can evaluate, who can read or not read, or can smoke or not smoke. My concern is with children. Advertising peoJtle from the tobacco industry have admitted there is no way of keeping children from seeing tite advertising. Now as- sume we did have proof that cigarette smoking was estt•emely t~an- gerotts to cltildren. Do we have no responsibility here ? Ctr tret.te advertisers are certain to show aavertisements of obvi- ously healthy people having a good time smoking ci ;atettes. Is there any deception here? Assume that we feel that smoking is dangerous, , . h zssss9zooZ

.3f'j$ CIGARETTE LABELING AND ADVERTISING--1985 and is a genuine health hazard. We know that we are showing these advertisements to 14-year-old children who cannot be expected to read the newspapers and really evaluate the health hazard. Is there some deception in showing these attractive things happening in a very ap"ealin~~~,• Way to this young mind? As a marketing man you cer- tainly advise your clients to make advertising as appealing as possible. Is this gray, or black, or white? Is this perhsups deception? Air. CRIssY. If I can, sir, make two statements. First, one of the significant things to me in the Surgeon General's re port-I believe it was in chapter i4, I am not sure, where they had a lot of data from psychology, from behavioral scientists, where they stated many causes for a youngster starting to smoke. But you know the interesting exclusion? They didn't find adver- tising as one of those causes. They find imitation of parents, they saw people in status positions smoking, and so on. But not aelvertising. Now, that is one datum. The o(her is that, in a mature industry such as cigarettes, you are aiming at selection demand. There is no statement that I have ever heard on the air or on the television screen or printed media saying, "timoke cigarettes." On the contrary, it is always selective demand. So, I am not so sure that the point is too valid a one. Take the Surgeon General's prett.y carefully compiled report, which summarizes the psychological studies and the sociological studies. There was on notoble absence of :advertising as an influence on youngsters commencing to smoke. Mr. CALLAWAY. Well, as a marketing expert, would you tend to agree that this sophisticated advertising, the best that Madison Avenue knows how to produce, has significant Iniluence on getting people to smoke ? Mr. CRISSY. I would say it is selective demand advertising. And under this code, which the industry lias, there certainly is not going to be any encouragement of anyone to commence smoking. But if you are going to smoke cigarettes, smoke brand X or brand Y. Air. CALLAWAY. I understand they always say smoke Winston or smoke Luckies, never just smoke cigarettes. But certainly it is their job to make it as attractive as they possibly can while smoking Winstons or smoking Luckies. But did I understand you to say in your judgment you feel that with very attractive ads I)eing put out on the very lar ~Te scale they are-well-conceived, well-planned advertising every single day to chil- dren-did I understand you to say in your opinion this would not have a significant effect on whether these children start smoking or not? Mr. CRISSY. I would just go by the research evidence on this, which I read with some care, and I am sure you did, that in these studies about children's inception of the smoking habit, the habit was at- tributed to a whole host of causes, but no one mentioned advertising. Mr. C.ir.LAw.iY. And you would tend to agree with that? Mr. CRIssY. I would take those research data at face value; yes, sir. Mr. CALLAWAY. I thank you. Air. RooERs of Texas. Mr. Satterfield? Mr. SArrERFlra.u. Thank you, Air. Chairman. cssss9zooZ CIGARETTE LABELING AND ADVERTISING-1965 369 I)octor, I notice that one technique in advertising involves the utili- zation of seals of approval. In your opinion is this to give a specific product just a little bit more boost to Inake it more-appealing to people? Mr. CRISSY. Yes, eir. For es:unple, Good lIousekeeping's seal of approval on an appliance used in the home or something; yes, sir. Mr. SATTERFIELD. Do you know of any previous instance in which there have been seals of disapproval ? Mr. CRissY. No, sir; I do not. Mr. SATrERFiEI.D. That is what we are talking about here, are we not? Mr. CRissY. I think you put it very well. I hadn't thought of it in those terms but that is correct. Yes sir. Mr. SA•1-rERFIELD Isn't it being a~ vocated that we approve a system of counteradvertism ; isn't this really what we are talking about? Mr. CnlssY. Yes; ~think so. Of course, again, I come back to the image I get, which really hor- rifies me, of a complete shift in commercial practice that is implicit should advertisin~ be invaded. Mr. SATTERFIELD. `i'e11, what is being suggested here flies squarel~y in the teeth of the whole nature and purpose of advertising itself; isn t that correct? Mr. CRISSY. Yes, sir; that is why I am here, as a matter of fact. It runs counter to marketing theory and marketing practice. And I would suspect you would hear the same from any marketing scholar or practitioner in the United States. Air. SATPERFIELD. Do you know of any incident which has occurred in the past or any precedent which would be similar to this approach in advertising? Mr. ClussY. No, sir; I do not. Mr. SATTERFIELD. From ~ our standpoint as an expert, analyzing advertising as we see it toaay particularly pertaining to cigarettes, would you say that the basic pItch of advertising is to encourage peo-e ple to smoke or is it more in the nature of encouraging people to shift bra.nds ? Mr. CRIssY. Brand shifting. That is a characteristic of a mature market. We could cite many others. The automobile, I suppose1 is one. Again I aln not saying that there might not have been a period in the pioneering stage of the development of this market where it was otherwise. But today I would say no one in marketing would describe this market as other than a mature market where selective demand is the marketing key. Mr. SATTERFIELD. Analyzing all that we have talked about, if these warnings are used in advertising it would constitute counteradvertis- ing ancT the net result would be that advertising in this area would dis- appear, would it not 9 Mr. CRrAsY. Well I would think that it would because you would be asking businessmen in effect to misuse a business tool. Mr. SATTERFIFa.D. You are being asked to use it differently from the way it was intended? Mr. CRIssY. Yes, sir. Mr. SnTTaRrzr:a.D. That is all I have, Mr. Chairman. Mr. RooERs of Texas. Mr. Farnsley. . ~~ r,Imp ~

370 CIGARETTE LABELING AND ADVERTISING-1985 Mr. FARNrzr:Y. I ani the low man on the totem pole. The bells al- ways start ringing when they get to me, so try to answer as fast as you can. Mr. CRrssY. 1 es, slr. Mr. FAaxsI.FY. The only direct evidence we have had on the effect of requiring labels, I brought in a bottle of Bromo-Seltzer, which a psychiatric consultant told ine about when he was consulted as an expert witness some yeaas ago, where the Government w:urted them to put warning labels on. They said, "We will do what you want," and my friend was told that a year later the value of that stock had doiiLled because theirsalesliad gone up so fast. II;iv~e you suty experience in this or do you have any knowledge of what has happened where the warning labels were put on productsR .llr. CRrssY: No, sir; execi)t that there is some evidence, not of the kind of warning we are talking about, but about prohibitions gen- eral ly.- \Ir. F.urNsr.Ea•. What? 3fr. CRTssv. Of prohibitions generally. When you start telling people, "You must not. do something," there are x number thatt will think creatively of ways to do exactly what you told them not. to do. I remember «•hen my ,youngster was growing up, the surest way to gett her to misbehave was to tell her not to do something. She would think creatively of at way to outsmart nre and my wife. I do not mean that is everyhody, but I think there are a fair number that. will react that .va,y. Dir. FARNSLEY. That is, in fact, what you were talking about in yoi i r paper. Mr. (.'RIssY. Yes, sir. Mr. FAexsLEY. One other man in the behavioral sciences has been before us, a full-time psychologist in the Surgeon General's Depart- ment, IIe said he t.liou~ht this warning would cause the sales to go down, and I asked him what he based that on, and he stated that, well, the literature in the last 10 years has contained articles to that effect. Are you familiar with any of those? Iiave you seen anything like that. g Mr. CRrssY. Yes, sir. I keep reasonably nbreastt of research and articles related to tltese kinds of issues. 1ir. FAriNRLEY. WarhTint,~9 Mr. CrtIf;ftY. l;(rth marketingnnd psychology. Mr. FARNSLF.Y. This article says that. these warnings would cause sales to drop, or they had. Have you found anything like that9 i1ir. CRrssv. I luive heard allegations, but I think t.he possible flaw in that speculation-and it is speculation only- D[r. FAisNsr.FY. There is not any experimental work? Mr. CarsRV. No, sir. But the speculation is that people will always behave completely rationally. Well, I think there is an abundance of evidence that there are other forces that will influenee- Air. FARNfiL1':Y. They do not show ads to mice or rub them on their back4 or an,yt.ltin~. 'hey just. tlmu;:ht about them. You say that maybe the warning on the label will eau`:e the Pales to P0 im: r think so, too. Of coutre, I think t.he htbeling in t.he aclvertisinr ruit;lrt cinrse tlre wrl.es to go up, in which case the advertiser would not quit. 'I'hey mi~,•ht even advertise more. There are only three things that can hap- CIGARETTE LABELING AND ADVERTISING-1965 371 pen if they put the warnings in the ad. Things do not change so far .:is sales are concerned or the sales go down or the sales go up. Of ,course, if sales go down, the tobacco people, being reasonable people, I guess reasonable and rational men, they would duit advertising, but has anybody ever experimented with this? Don't tell me what soure I,nTy tlroul,rht about it. Tell rne about some research, even if it is on mree, I do not care. Mr. CxrssY. I know of no lirsthand empirical investiga.tion, for a very good reason, that a business would not knowingly jeopardize its position by that kind of an experiment. They would follow the best possible practices. Mr. FArcxsr.r:Y.. 'I'hey will try new brandsr all kinds of things in a stnall ma,rket,, but t;hey won't even try labeling in a small market; it is too ]torri fying for them to think about. If this tlun4, did cause it, the man who is promoting it. most thinks it will cause advertising vlrtually to disappear, in which case the (•1raLre.t.te people,, of courtie, would'be getting a windfall, a quarter of a bill ion dollitt-s a ye.ar, which is not hay. What is your opinion as to what. would hatipen then to the sale of their cipTrettes, if thoy quit ad-vertisint; altonetlrerl Mr. CItIBRy. Well, again, I can reason from a' marketing theory. ly. ?1fr. FARNRLF.Y . IIiTs anybody tried t.lTis I Mr. C'.nrssY. No, sir. Mr. FARNl;t.vr. No business has ever-it would have to be all of them. In other words, the Government would r:t.ss a law. WhetT I was a boy the re+tail merchants in Louisville got the State to pass a law that they could not give away trading staT.mps. Suppose the tobacco boys rott really on »s to pass a law that, they could not, advertise. What would happen to the market if we pro- hibited advertising? Mr. Caissy. I would speculate there would be a frozeu market, with about the snme se~,nnentation, market shares, if you please, that now exists. I could give you a rationale of why I would think that. Mr. FARNSLEY. I think so, too. The only experiment we have got on that is in Italy where the proponents of this legislation say adver- tising was not, such a big factor. 'I'hey say it caused the rate of growth to drop, and other people s:t.y it did nott cause it. Mr. CRTBAY. I was in Italy after such legislation, and here you have another factor which, fortunately, we do not have, and that is a Gov- ernment monopoly in the cigarette industry. There are some private brands. But I think there is danger from extrapolating from one country, one culture- where there is a Government, a bT Government share, against ours, which is a privat,e enterprise kind o~ structure. Mr. FARNSr.r:Y. My contention is that the industry, the Government, and the Surgeon General's office are flying blind as far as knowing what effect the recommendations will have. Mr. CRISSY. Yes, sir. Air. FARNStFY. Guys are willing to guess, you are willing to guess. Is this the kind of thing to experiment with? I am not advocating delay, but is this the kind of a thing that can be explored by the social and krehavorial scientists, and come up with recoinmendationsH Mr. ClussY. Yes, sir. It would be amenable to research and test markets. V9s9s9zooz

372 CIGARETTE LABELING AND ADVERTISING-1985 Mr. FARKHLF.Y. Excuse me for interrupting. You have answered my qneGtions. We have to work fast. The bells have rung on us. My contention is the people who say we should do this, say that we are killuig a quarter of a million of people a year. I say, with a smat- tering of social science, that all the evidence of what they are asking me to do indicates that the sales will increase. I do not want to kill 250,000 people. If we kick up the sales we are going to kill a lot more g -eople. I say we ouglit to find out. I do not want to dehiy things, ut I say these are valid questions that ought to be answered. There are a lot of aspects of puritanism in the.se findings we have been get., ting. But so far as you know, nobody-there has been no experimentnl evidence except one thing in the Surgeon General's report, where the social and behavorial sei ence people (lid not• offer advertising as one of the t hint,*s that caused children to smoke. :%ir. CRIRRY. Yes, Clr. ' Mr. FARNSLEY. If you are right, this perverse effect would apply, I am repeating, to laheling on cigarettes, then it. could apply to warn- ings in advertisements, could itnot4 Mr. CrussY. Even more so, Mr. Falnsley, because I think by tradi- tion, you see, we have looked at labels as inforruation-aharing, how properly to use the product, and so on. You see, it is informational and it is descriptive very often. In fact, some legislation requires full description, et cetera. But if you start getti»gmto advertising you are in a different kind of area, because that is demand cultivating, sele.ctive demand cultivating. If you start invading that., I will tell you, you have opened Pandora's box, It seems tome. lfr. FARNLSEi . I thank you. l1ir. CRlssy. Yes, sir. Mr. Itocr:as of Texas. Mr. Crissy, with regard to advertising. I presume you are well founded in thlatit as a marketing analyst. and ex- pert, is not it it fact t.hat a lot of information going to sell a product does not alwaiYs come from the commercial ltself? What I am referring to is ;r•hat we have heard called in this committee, I believe, as piggybacking where, we will say that they have a show, take "Gmi- smoke." for instance, and the beer advertisements get a lot of free advertising when Matt Dillon walks up to the bar and says. "Give me a beer:" Air. f"RrNSY. Yea, 5ir. Mr. ItcK+F.as of Texas. He does not, say what brand, hut he says, "Give me a beer." I have been told, I do not know whether this is true or not.. becnuse I aur not. a marketing specialist, that that. same thing is true with regard to whiskev and is one reason why the whiskey people do not find it, necessary to aclve.rtise, that cocktail parties are so frequent in most of the shows on television that everybody gets the point without interrupting the show. :1Ir. CRIssY. Yes, sir. Mr. Rf)6FIRS of Texas. Is there anything to that t.Leon-4 Mr. CRussY. Well, sir, certainly one demand-cultivating force which is pretty dillic.nlt, to nail down, as compared to knowing how many ads you arc+ rimning and so on, is this general use of the product in nn entertainment situation, in your own home, and so on. CIGARETTE LABELING AND ADVERTISING-1965 373 Of course, people are observing, and again going back to the Sur- beon General s report, if I coustrue the data correctly in that one chapter, children tend to do what parents do, what they see friends of their parents doing in the home, et cetera. I would, yes, sir; there is a general impression that all of us get from people around us. Mr. ItoGERS of Texas. My experience with children has been that they pay a: lot more attention to shows than they do the commercials. As a matter of fact, we did not let them testify in this controversy as to whether or not the Federal Communications Commission should cut down on commerciuls. I think we would have gotten a lot of testimoiiy to let them regulate theln further. Mr. CRissY: Yes, sir. li-lr. ROGERS of Texas. But, for instance, we have had some refer- euce made here to the show, the "Beverly IIill.billies" that children wat.c.h. If you get into this advertisin g- field and undertake to try to brand ever,y product with something that is good or bad about it in order to get away from deception would not you in the ordinary situation be recluired that every time grandpappy or whoever it is lirhts his pipe that you would have to flash a sign under him during the show, "Not recommended for children." i1ir. CiussY. That is.i possibility; yes, sir. Mr. RoGr:RS of Texas. Or if tLe griiucLnother gets out the wine which, I think, she has done two or three times in the show-I do not see it very much-you would have to say, "Not recommended for auvone under 21." 14o«-, the fact is that it is a violation of t.he law in most States at the present time to sell beer to minors, is it not g Mr. CRrssY. Yes, gir. Mr. ROGERS of Texas. And is not that same thing true about ciga- rettes? Mr. CRrssY. Yes, sir. It is in my State, I know; yes, sir. Mr. ROGERS of Texas. Thank you very mnch, Mr. Crissy. Mr. FARNHLr;Y. Mr. Chairman, can I ask one more questron? Now that we have adjourned, I have a couple of more questions. Mr. CRISSY. Yes, sir. Mr. FARNaLEY. Doctor, I think it_ has been said with some validity, that by putting on a white coat a man does not get away from his socioeconomic background. It is a factor, and I think maybe as rigorous a scientist as you are, you may be getting into this trap a lit•tlo bit, and I think the cigarette mamiates may be. You have been sitting around tellin each other it is right to advertise. It is a noble thing that we will fight for the right to advertise, and if we cannot advertise some poor guy won't be able to start a new brand. I think this is just. not true. I thinlc aguy could start a new brand. I submit that the chances are, from the evidence available, that the cigarette companies are willing to spend a quarter of aa billion dollars a year to advertise, and the main thing they get out this is the doubtful privilege of having Mr. Foote and the Surgeon General and a lot of people go aro1m(i and call them bad names, and_ I do not think this is an admirable mirable reaction. What do you think g Mr. CRis$Y. I agree with you, Air. Congressman. S9S9s9z00l

374 CIGARETTE LABELING AND ADVERTIBING-1985 . It just seems to me, as I said, that you have three interrelated questions that are going to bother you ancl bother the Senate aom- nllttee, and it is an awesome responsibility with your public trust to resolve t.lleut. nn tl eose tirst two, I cannot• he of any service. Mr. FARNraI.I:Y. 1Vhich are tlx+lil•st two? Mr. CRIsyY. One is, is t.hero in reality a proven causal- Mr. FARNBLRY. That is not your problem. That is somebody else's. Mr. CRISSY. That is right. And the second one is uniquely yours, that is, delrendiug on your answer to the first, does the public Int,erestt require legislative enactment4 That. is a tough one. 'Ml•. FARNeI.FY. A'ait• a n4inute. It is worse than you think. They htlve ~,''ot surl,e,ys t•hat, show 2 to 1 the public wants legislative enact- nient. We can vote it politically without•. being convinced that it• is going to do anybody an,y good, or could we, or is tluit a violation of our ItIF)r7ll duty? 'M r. CRrasY. Yes, sir. Mr. FARNRLra. It is beyond your province. Mr. CInRsY. Yes, sir. It is ot+ly on this third ques'tioll that I have a potential contribution, and that is, if the first two are nnswet•ed allirmatively, yes, there is a threat and we ought to do something, theit it gets right down to what,. IVel1, in terms of sound business practice, precedents, et cetera, if a watntn~ is to be given there is only one place for ;t, on the label; and there is one place I would exclude, the advertising. It is just incon- gruous. Mr. FARNSI.EY. But you just admit either one might cause the sales tot,Vou~>~. Mr. (`RIs6Y. This is speculation; yes, sir. Mr. FARNNL>•:Y. If you had to guess, which way would you guess, up, down, or sideways g Air. CtlrssY. I justt would hesitate to stick my marketing neck out.. Mr. FnRxar.eY. That is a good answer. I will tell you who are menaced by all this, the television and radio stations, and the mice. I do not see where it. is going to hurt these cigarette companies. Mr. Cnt4sY. I do not know. Mr. FAnNsFarY. You answered that, you do not know. I quit. M r. CtlrssY. Yes, sir. 11tr. RtxtFns of Texas. Thank you very much, Mr. Crissy. ?1Tr. CRrrsY, Thank you. sir. Mr. RoeFRS of Texas. Without objection, the record will include at t.he appropriate place a letter from Dr. John Ii. IIickam; a letter from the American Newspaper Publishers Association: a statement of the National Tuberculosis Association; a stat,ement of the American Public Health As.sociation; a statement by Mr. John K. Herbert, 1~re~i~lent of Ma~azine Publishers Association, Inc.; and a statement of New York City hy Dr. (~eorge James, commissioner of health Health Department., New York City. Without objection those will be included. 99S9f,9%401 CIGARETTE LABELING AND ADVERTISING-1905 (The doculnents referred to follow:) llall. nRF.N IIARRI6, 375 INDIAxAPOLIe, INn., April 8, 1965. Chairman, Ilouae Intcratate and Foreign Commerce Commtttee, U. S. Conpreaa, Washington, D.C. DF.AR RP:PRb;l3kNTATIVE HARRIS: It has been brought to my attention that teAti- mony before your committee dealing with the proposed legislation on labeling lobacca products has indicated that I may have changed my mind about the findings of the Surgeon General's Committee on Smoking and Health since that report was published. I wiyh to respectfully request that It be made a part of the record of the committee beurings that I agreed completely with the report of the Surgeon General's committee at the time 1t was iseued and that I continue to agree completrly with the flndingd of the report. Sincerely, JOHN B. HICHAY, M.D. ' AMERIOAN N_ EWRPAPEa PIIRLI6IiERB AasOCIATION, New York, N.Y., Aprtl $8, 1965. Hon. nREN HARRIB. Cha4rman, Committee on Inte,ratate and Foreipn Commerce, Houae Office Building, Washington, D.C. DEAR tilR: The American Newspaper Publishers Association desires to express ItH views for incluxion In the record of hearings on certain bills now under consideration by your committee relating to cigarette advertising and labeling. Our concern is with reAtrictious on advertising. ANPA Is a membership bership association of daily newspapers pnbiished 1n cities and communities throughout the United States and Canada. Its members Include more than 930 daily newspapers with approximately 90 puercent of the total daily newspaper circulation in the United States. As we understand It, your committee has now under consideration the fol- lowing bills: I3.R. 2248 by Representative Udall; H.R: 3014 by Representative Rogers ; fLR. 41107 by Representative Nelson ; H.R. 7051 by Representative Iiemney; and H.R. 4244 by Representative Fino. As for bills II.R. 3014, ILR. 4007, and H.I;. 7051, these would require that all packages and cartons of cigarettes sold In the United 8tates bear a warn- ing label to the effect that cigarette smoking may be Injurious to health. At the same time, they would preclude the Federal Trade Commission from requiring warnings in cigarette advertising and would also foreclose the impwsition by State or local governments of warnings in either cigarette labeling or advertising. Bill Ii.R. 2248 would make cigarattes subject to certain provisions of the Federal Food, Drug, and Cosmetic ct, including provisions relating to adul- teration and misbranding. Tbe bill would leave the Federal Trade Commis- sion free to proceed with its announced intentlon to enforce its cigarette "Trade Regulation Rule" in the absence of an unambiguous congressional directive not to do Ro. That rule would require warnings In cigarette advertising as well as labeling. Bill II. R. 4244 would require a warning on cigarette packages and In addition n quantitative ntutement with respect to tar and nicotine. Like bill H.R. 2248, Ihis bill would leave the Federal Trade Commissiou free to require warnings in cianrette ndvertising in accordance with itA announced Intention. 'rwo Rdditinnnl bills have just recently been introrluced and referred to your ccmunittcr. They are bill ILR. 7393 by Representative King of Utah, and H.R. 7560 by RepresentGetive Corman of California. These bills would direct the Federal Trade Commission, with the cooperation of the Secretary of Health, Education, and Welfare, to establish standards and requirements for the lnbel- !ng and ndvertising of cigarettes. In the came of advertising, the t+tandards would require a health warning and also "provide for the elimination of all advertising whic_h teuds to make cigarette smoking attractive to children." The measurea now in your committee which would impose special restrictions on the advertising of cigarettes raise serious constitutional and public policy queNt.ions First and foremost, this association wishes to emphasize that it takes no INoxition as to the merits or demerits of cigarette smoking. The association M!

376 CIGARETTE LABELING AND ADVERTISING-1985 recognizes and appreciates the legitimate interest of the Federal Government in matters which may be found to affect the health of citizens. It cigarette sLtok•inK is found to be a national health hazard, we think that the problem should be attacked directly. it is difficult to follow t]ie logic or the precise reasons for the proposed ad- verti.ing restrictions. The Government would be placed in a strange position. It subsidizes the farmers who grow tobacco, then it taxes not only the growers but also the tobacco manufacturers, wholesalers, and retailers, then imposes additional taxes on the smokers themselves. To follow that with a Government requirement thatt every advertisement state affirmatively that smoking is in- juriuus to health puts the Government in the untenable position of simul- tant+tusiy subsidizing and taxing an item which the Government says will destroy its citizens' health. When the U.S. Surgeon General early in 1964 issued his report on smoking and health, newspapers and other media gave that report the widest possible di:csemination. No c1aLn can be made that there has been an information failure. The general cctnclusions of the Surgeon General's report were widely dissemi- natcKl to the public by newspapers and other media. Since then a national cigarette advertising code sponsored by the Nation's major cigarette tnanufacturers has been adopted. The code provides that ad- vertising may not be used in any media, including newspapers, unless it has been HubmitlCVl to the administrator and cletermined by him to be in compliance witb the code. The code also bars the use of testimonials or endorsements from athletes or celebrities, if such use would have a special appeal to young people, and categorically prohibits all advertising designed to appeal to persons ander 21. This association believes that the code is praiseworthy in that it provides seif-lKAiciny; by an important taxpaying segment of American industry. The code should be given tln eplwtrtuaity to itrove its worth. Now as to the duestions of constitutional law. It is a fundamental belief of our association that it should be legal to ad- vertise truthfully tiny product or service it is legal to sell. No instrumentality 4)f Government should adopt any law or rule to prohibit or curtail dissemination of information through truthful advertising. Cigarettes are legitimate articles of commerce. The tobacco Industry Is an important segment of our economy. 1Ve respectfully submit that fundamental •questions of constitut.iunal law as well as of public policy are raised when Government seeks to regulate the right to publish truthful advertising con- .cerning legitimate articles of commerce. We believe each publisher has not only the right but the duty to determine individually the content of his news- paper. This applies_ as much to the advertising content as to the news content. 'Phe ANPA txkes no position on bills relating to labeling requirements. But we do believe that restrictions on advertising such as are proposed in the bills mentioned above invade areas of individual choice of expression which are protected under the Constitution. Those bills offer a dangerous precedent. We are living in a complex society and all of us are subject to many risks every day. People die in automobile accidents. Should the automakers be required to Insert warnings in their advertisements? Airplanes crash. Should we force the airlines to Include warning statements in their ads to that effect? It is said to be harmful to eat too much rich food. Should we require food producers and sellers to mention this fact in their advertisements? Diany doctors say that it is hazardous to some adults to drink milk or to eat .egga. Perils are associated with liquor and beer, electric light sockets, gasoline, engaging gaging in athletic activities, using products in aerosol containers. All these may be dangerous. Yet itcan hardly be required that advertisements for these products must contain warning statements. If the advertising legislation now proposed should be enacted, the precedent would be established that could lead to totalitarian restrictions on the right of businessmen to advertise their products and the right of newspaper and other nicdia to decide independently their policies as to the content tent of advertisements which they will accept for publication. Please let us emphasize the obvious. Our association does not condone mis• leading or untruthful advertising. The members of our Association have a long ~~r.qWlgryjeytwoltl1y record of rejecting advertisements which are not truthful CIGARETTE LABELINQ AND ADVERI3SING--1985 377 and responsible or which misrepresent the product advertised. Many publishers prefer not to advertise particular products. But we cannot agree that Congress or any governmental agency should determine the contents of advertisemeuts of legitimate articlesofcom_ commerce. It there is any further information this association can supply, please let us know. With high esteem. Sincerely yours, , STANFORD $MITIt, - General dl anaper. $TATEMBNT oB TIIR NATIONAL TVDEaOVLOBIR AsBooIATIo1P IN sUPPORT oa LFAIaLATION RF.LATINo TO TIIS LABELINO AND ADvERTIBINO or (J'IOARETTEa (Presented by Daniel E. Jenkins, M.D., Houston, Tex.) The National Tuberculosis Association and its medical section, the American Thoracic $ociety, are increasingly concerned by the effect of cigarette smoking on health, particularly on the respiratory system. Our emphasis on the respira- tory system is not intended to Ignore the damage that smoking may-and does- do to other organs. We stress the respiratory system because control of respira- tory diseases is the target of the NTA and ATS. Before we get into the question of whether smoking is related to certain dis- eases of the respiratory tract, perhaps we might refresh our memory regarding the physiology of our breathing system. As you know, the respiratory system contains the organs responsible for breath- ing air Into and out of the lungs. The traches, or windpipe, and its branching extensions, the bronchi, and the lungs might be considered the chief organs of the system. Inspired air passes down the main bronchus Into its branches and still tiner subdivisions, known as bronchioles, whence it reaches the air sacs of the lung. These are the alveoli and there are literally hundreds of millions of them in the-lungs. It is In the air sacs that occurs what we call gas exchange; that Is, oxygen from the air is diffused into the small blood vessels known as capillaries and carbon dioxide Is expelled from the lungs. The cnpillaries carry the oxygen to the larger blood vessels which distribute It to tissues throughout the body. The respiratory system__ has its own cleaning apparatus which, on the whole, operates quite efficiently. An important component of this cleansing machinery is the mucous lining of the bronchial tree. Attached to the mucosa are very small hairs, called cilia, which normally are in constant motion, pushing upward with a rhythmic beat extraneous matter that might clog the nirways. With this brief review, we should like to discuss some of the most serions chronic diseases of the respiratory tract which, we believe. are adversely effected by cigarette smoke, whether or not causally related to the smoking habit. You have all read "Smoking nnd Health," the report of the Advisory Commit- tee to the Surgeon General of the Public Health Service. You will recall that the report states unequivocally: "Cigarette smoking is the most important of the causes of chronic bronchitis In the United States, and increases the risk of dying from chronic bronchitis" (p. 38). What is chronic bronchitis? Chronic bronchitis has been defined by the American Thoracic Society as "a clinical disorder characterized by excessive mucous secretion in the bronchial tree. It is manifested by chronic or recurrent productive cough." Certain speciAcs relating to the period of time over which coughing occurs follow but need not concern us here now. Chronic bronchitis is caused by prolonged irritation to the mucosa, by Infec- tion, or, most commonly, by both. Such irritants as heavy smoking, air pollu- tion, and long term Inhalatlon of dust damage the delicate mucosa-cillary mechan- ism, thus weakening an important defense of the respiratory tract. Under stress of the irritants, the cells responsible for producing mucus become overly active, the membrane becomes thickened, and some of the cilia are injured. With the defenses down, bacteria find lodging in the airways and Infec_tion sets in. Through the years in8ammation tlares-up during acute episodes of Infection. There is a chronic cough and the amount of phlegm rnised tends to Increase with the years. Frequently chronic bronchitis progresses to pulmontnry emphysema and heart failure. 48-82s- 45----a.:

378 CIGARETTE LABELING AND ADVERTISING-1965 And this leads us to another disease of the respiratory system to which we. want to call your attention. This is pulmonary emphysema which has far too rapidly become a major health problem in this country, particularly among men. Emphysema does not lend itself to easy de8nition. The etiology is unknown. In fact, many factors are probably involved In its pathogenesis. The beginning is insidious and the condition may not be recognized clinically until it is well advanced. It is characterized by difficulty in breathing that becomes so acute that the patient literally gasps for breath. Anyone who has ever heard the labored, rnsping breathing of the patient in the late stages of emphysema will never forget It. Emphysema may be preceded by chronic bronchitis, but this is not always the case. An anatomical change may take place in the lung because of factors not as yet identifled. The organ loses its elasticity. A breakdown of normal mcchanism causes anexpelled air to become_ "trapped" 1n the air sacs, which then become overdistended and their stralned walls break down. The small blood vessels collapse. Waste carbon dioxide clogs the lung. Breathing becomes more and more difficult. Death ensues from-sutIocation or heart failure. This is a pulmonary condition that was given as the first cause of death on 1,974 death certificates In 1952. iTt was given as the primary cause of death on 12,368 death certifleates In 1962.' These deaths are in addition to approximately 3,000 deaths due to chronic. bronchitis and to deaths to which chronic bronchitis and emphysema were con- tribut ing causes. '1'he Surgeon General's committee had this to say about the relationship' betwec•n cigarette smoking ,intl emphyaema :"A relationship exists between' pulmonary emphysema and cigarette smoking but It has not been established that the relationship is casual. 9The smoking of cigarettes is_ associated with an increased risk of dying from pulmonary emphysema" (p. 38). Please note the latter sentence-"The smoking ot cigarettes Is associated with an increased risk of dying from pulmonary emphysema." We do not knoww wbat causes emphysema. Many of us suspect that smoking !s a cause, but we do not know. Iiowever, it is doubtful whether there is any doctor in this country who has ever treated an emphysema patient and who has not, the very, first thing, prccribed that his patient stop smoking. No, we do not know that smoking is a cause of emphysema, but we do know. that rarely does a death from emphysema occur among a nonsmoker. ~Pho National Tnhercninsis Association and its medical section are deeply concerned by the increase in chronic respiratory diseases and the close connec- tion between this Increape and cigarette smoking. The NTA and Its 1,900 afflli-. ated associations throughout the country are engaged in health education activi- ties to call to the attention of the American people the importance of early recop- nition of the symptoms of respiratory distress and of appropriate action to pre- vent serious disease. The NTA is sponsoring basic reearch in the field of respiratory diseases. It has initiated a series of seminars to keep science writers, an important segment of the press, up-to-date regarding respiratory diseases. The American Thoracic Society, our medical group, has recently sponsored an Independent study on the relationship between smoking and health. The tindings. have not as yet been published, but in all particulars they corrobate those, of the Surgeon General's committee. Conscious of its responsibility as a health organization, the NTA is working In close collaboration with other agencies to warn our people, particularly young people, of the threat to health represented by cigarette smoking. Our efforts may well be in vain unless the Federal Government acts. We look to the Federal Government to take appropriate action to protect future genera-s tions from the dangers inherent in cigarette smoking. CIGARETTE LABELING AND ADVERTIBINa-1985 379 CURRICULUM VITAL' Or DAIPISL_ t• JEt7gIgS Born : Omaha, Nebr., July 19, 1916. h:ducation c B.A., University of Texas,1938; M.D., University of Texas Medical Branch, 1940. Graduate hospital clinical experience : Intern, University of Michigan Hospital, 1940-41; resident, University of Michigan Hospital, 1941-45. Academic positions: Instructor In medicine, University of Michigan Medical School, 1944-46; assistant professor in medicine, University of Michigan Medical School, 11l•IO-47; assistant professor in medicine, Baylor University College of Medicine, 1!#7-4cJ; associate professor 1n medicine, Baylor University College of Medicine, 1J43„8; professor in medicine, Baylor University College of Medicine, 1950 to present. Hospital appointments: Chief, pulmonary disease section, Jefferson Davis Hospital; consultant In pulmonary medicine: Veterans' Administration hospltal, Houston; Veterans' Administration hospital, Temple; consultant in medlcine, Brooks Army Hospital. Licensure: Texas, 1940; Michigan, 1941. Certiflcation : Internal Medicine, 1947. Membership in societies: Alpha Omega Alpha Honor Medical Society, 1940; American Medical Association and Harris County Medical Society, 1948; Ameri- can Thoracic Society, 1945 (president, 1tf68 to 1959) ; American College of Physicians (fellow) 1!);1 ; American College of ChestPhysicians (fellow In IS)b0) (president, southern chapter, 1959) ; American Association for the Advancement of qcience, 1";; American Federation for Clinical Research, 1951; New York Academy of Sciencrq 11:;1; IIouston Society of Internal DledicLie. 1947; _Texas Club of Internists, 19592, Texas Society of Internal Medicine, 141; .lmerican Clinical and !Climatologieal Association, 1958; International Union Against Tnberculosis, 1i)<i8; and Association of American Medical Colleges, 1959. Posltions on editorial boards: American Review of Tuberculosis, 195,•rb(l. Special committee appointments: Ad Iloe Committee on Smoking and Health, American Thoracic $ociety, chairman ; Committee on Policy, National Tubercu- losis A4voclation ; Governor's Committee on Eradication of Tuberculosis in Texas, 1984-65. PUaLrCATioxs (1) Benedryl In the Treatment of Hay Fever and Asthma (with E. O. Schreiber and J. M• Sheldon), Univ. of Mich. Hospital Bulletin, 18:80-81, April, 1940. (2) Tuberculosis Control In the University IIospital (with W. H. Shull), Univ. nf Mich. Hospital Bulletin, 13: 3l1_;31, April, 1917. (3) The Effect of 9treptomycln on Early Tuberculous Pulmonary onary Lesions; A Preliminary Report (with W. Df. Peck, J. J. R. Reid, and Ii, 8. Willis), Amer. Rev, of Tuberc. 5G: 387-395, November,19-17. (4) The Effect of 'Streptomycin on Early Lesions in Pulmonary Tuberculosis (with W. M. Peck, J. J. R. Reid, H. S. Willis, and'8. A. Yannitelli), Chapter in "Streptomycin and Dihydrostreptomycin in Tuberculosis," Pages 1711-. 1ti4, National Tuberculosis Association, 1949. (5) The F.rarly Ttaberculous Pulmonary Lesion and Its Management, Texas State Journal of Medicine, 44 • 671-580, December,11118. (6) Ineiticacy of I'rophylactic 8tremptomycin in an Outbreak of Salmonella Gastro-enterttia (with J. J. R. Reid and 0. R• Owen). Amer. Jour• of Med. Sciences 218-145-148, August, 1949. (7) Mycomycin, A New Antibiotic with Tuberculostatlc Properties, Jour. Lab. and Clin. Med., 36: 841-,842, November, 1956. (8) Mycomycin, Its Present Status in Tnberculosis, Transactions of the Ninth 3treptomycin Conference, Veterans' Administration, Araav, Navy, 179-186, April, 1950. 89sss9zooZ

380 CIGARETTE LABELING AND ADVERTISINf}-196b CIGARETTE LABELING AND ADVERTISING--19B5 381 (9) Recent Advances In the Treatment of Tuberculosis, Texas State. Jour. Med., (80) Summary of Symposium on the Problem of Atypical Acid-Fast Bacili l, BuIL 47: 803-809, 19h1. _ Interuut. Union Against Tubere., 29: 7% Oetober-Decetuber, 193J. (10) A Progress itelrort on Mycomycin, Transactions of the TenRh Streptomycin (81) The Clinical Problem of Infection with Atypical Acid-Fast Bacilli (with (11) Ccmference, Veterans' Administration, Army, Navy, January, 1951. Aiuithiozone Treatment uf 1'ulmonary Tuberculodis, a Pilot Study of 21 D. Babar, I. Chofuas, R. Foster, and H. '1. Itarkeiey), Transact. Amer. Clin. and Climatol. Association, 71: `11-33, 1059. - (12) Patients (with II. S. Sandhaus, K. L. Burdon, and Bela Halpert), Amer. Rev. Tubere. 64: 170-181, August 1951. Blood Volume and N7xtracellular Fluid in Tuberculosis (with E. B. Hay and (82) Current Concepts of Pulmonary Disease Due to Atypical Mycobacteria (with I. Chofnas and D. Bahar), Transact. of the 19th V.A: Armed Forces Conference on the Chemotherapy of Tuberculosis, 22•1-233, 1J60. (13) C. R. Ilay), J. Thor. Surg., 21: 42-47, January, 1951. Laboratory and Clinical Studies on Terryamycin (with E. M. Yow, H. Men- (83) Preaent Coucepta About Atypical Acid-Fast Bacilli. Bull. of the Nat. Tuberc. Asso., 46: 11-12, April, 1960. dell, 1i. 11. Skaggs, and Il. Hipp), American Practicioner, 2: 089-1i93, 1951 Au ust (84) Comparison of Wet and Dry Intlation Techniques for Fixing, Staining and 1llounttnb Lung Specimens (with D Bahar and H G B A r. (14) . g , Current Status of Antimicrobial Therapy In Tuberculoais-Report of the . . . oren), me 1tev. liesp. Dis., 84: 120-121, 1961. (15) Clinical Subcommittee of the Committee on Medical Research and Therapy (with W. B. Tucker et al), Anier. Rev. Tuherc. 63: 617-(123, May, 1951. Mycomycin, A Final Report. Transactions of the Eleventh Conference on (86) Variations of Disease in Humans Caused by Scotochromogens (with M. liunsuker, I. Chofuas, E. Whitcomb, K. H. K. Hsu, and D. Bahar), Amer. ltev ltesp. Dls., 86: 114, 19tP1. the Chemotherapy of Tuberculosis Veterans Administration, Army, Navy, (36) The Tuberculin Reactions Associated with Tuberculous Infections (with January,1952. (10) The Effects of an Intermittent Dosage Schedule of Viomycin on Renal Function and on PIRem_ R Electrolytes (with J. H. Moyer, P. O. Jones, It. 31i. Ford, and L. C. Mills), Amer. Rev. Tuberc., 68: 541-547, October, 1953. K. H. K. IISu and L. Soriano), Amer. Rev. Resp. Dis., 86: 121, 1962. (87) The significance of Low-Grade Tuberculin Sensitivity (with K. li. K. Hsu), Canad. J. Pub. Health, 55:-313, 19(i2. (38) The Tuberculin Reaction Associated with Tuberculoua Infection (with K. H. K. Hsu and L. lt. Soriano), Amer. Rev. Resp. Dis., 87: 493, 1963. (17) Cultural Properties of M. Tuberculosis In Resected Pulmonary Lesions of Patients Treated with Streptomycin and Para-aminosalicylic Acid (with G. E. Granville, D.A. Cooley, M. E. DeBakey, F. C. Whitcomb, and B. (39) Scotochromogen Mycobacterial Disease In Man (with S. D. Greenberg, D. Bahar, K. 11. K. Hsu, M. Hunsaker, and R. J. Jones), Texas State J. Med. 59: ;?4'J. 191 i:3_ . Halpert), Amer. Rev. Tuber., 68: 727-733, November, 1'J5:1. (18) The role of Isonicotinic Acid Derivatives in the Treatment of Tuberculosis, Southern Mc41ica1 Journal, 46: 1(R",ul-1S1i7, November, 1953. -- (40) Varions Lung Inflation-Fixation Techniques !n the Study of Pulmonary Tuberculosis (with S. D. Greenberg, and D. Bahar), Amer. Rev. Resp. Dis. 88: 1ft 1963. (19) Changing Concepts and Modern Treatment of Tuberculosis (with W. B. Tucker et al), Amer. Rev. Tuberc., 70: 93(-i>a8, Novemher, 1954. (20) Treatment of Empyema, Current Therapy, 8(1-88, 1953, W. B. Sanders and Co., Philadelphia, Pa. (21) Changes in ConilHosition of Pneumoperitoneum Air in Humnn Subjects Following Injection of Ambient Air (w)th II. (3. Boren and Clark Silver- thorne), Jour. I.ab. and Clin. Med., h?: 788, November, 1953. (22) A Pilot Study of the Thiocarbanilide SU-1900 In Human Pulmonary Tuber- (41) ChuPter S. Mycobacterial Diseases of the Lung and Bronchial Tree. Clinical and Laboratory Aspects of Tuberculosis, Chapter 9. Treatment of Tuher- culosis, Chapter 10. Tuberculosis-like Diseases Caused by Other Mycor bacteria (all with E. Wolinsky), In a'I'extboolc of Pulmonary Diseases, edited h,y Gerald i.aum, M.D., Boston, Mass.: Little, Brown and Co., 1904. (42) Surgical Experiences in the Management of Atypical Mycobacterial Lifeo tions (with S. W. Law, I. Chofnas. D. Bahar, Frances Whitcomb, H. T. Barkiey, and M. E. DeBakey), J. Thorac. and Cardiovasc. Surg. 46: 689, culosis (with P. O. Jones and S. C. Yin), Amer. Rev. of Tuberc., 7.(: 468- 1963. 470, September,1956. (23) In Vitro and In Vivo Studies of the Anti-Tuberculosis Activity of Cynnactic (43) Coexistence of Carcinoma and Tuberculosis of the Lung (with S. D. Greenberg, D. Bahar, H. I. Schweppe, Jr., and H. Block, Jr.) Amer. Rev Acid Hydrazide (with P. O. Jones and S. C. Yin), Amer. Rev. of Tuberc., . Resp. Dis. 90: 67, 1964. 74: 417-427, September, 1956. (44) A Rapid Method of Inllation-Fixation for Morphologic Study of Chronic Pul (24) Treatment of Atelectasts, Current Therapy, 73-76,1958, W. B. Sanders & Co., monary Disease (with S. D. Greenberg, and R.-M. O'Neal) Tech - I'hiladelphia, Pa. (25) The Need for Augmentation of Tuberculosis Case Finding, Transactions of , . Bull. Registry 11ied. Technol. 3.): 82, 3f1114. (45) Studies on the Specific Tuberculin Reaction (with K. H. K. Hsu, and the Commonwealth Chest Conference, London, England, July 1958, Pg. 3 57-359. F. Jeu), Tuberculin Conversion In Tuberculosis Contacts. Amer. Rev. Resp. Dis. 90: 36, 1J(14. (26) Tuberculosis In the Unexpected Areas. Bulletin of the National Tuber- culosis Association, 44: 163-165, December, 1958. (27) Review of Recent Clinical Studies In the United States on Atypical Acid- fast Bacilli. Bull. of the Internat Union Against Tuber., 29: 295-3t)g, 1959. (46) Results of Needle Biopsy of the Parietal Pleura In 124 Cases (with N. V. Rao, P. O. Jones, S. D. Greenberg, D. Bahar, A. D. Daysog, and H. I. Schweppe), Archives Int. 11fed. Arch. Int. Med. 115: 34, 1965. (47) Treatment of Pulmonary Tuberculosis. A chapter In "Textbook on the Management of Tuberculosis". Editor, Carl A. -Pfuetae, M.D., Chicago, Ill A (28) Patterns of Disease Associated with Atypical Mycobacteria In Texas (with D. Bahar, I. Chofnas, M. Foster, E. Jones, and M. McGee), Amer. Rev. of Tubere. & Pul. Dis., 79: 822, 1959. (29) Exhibit: The Lung In Three Dimensions, A Technique of Formaldehyde Fume Fixation (with H. S. Boren, B. Blumenthal, and E. Erickson) Ez- bihited at Annual Meeting of National Tuberculosis Association, ~ay, .. mer. College Chest Physicians, 1965 (In press). (48) Today's Concept of the Tuberculin Test. (with K. H. K. Hsu, A. T. Carreon, and F. Jeu), Dis. Chest, 46: 648, 1964. 1959. 69S9S9zOOZ

I 382 CIGARETTE LABELING AND ADVERTISING-198S THE •IRESPIRATORY SYSTEM lb. MAXILLARY SINUS ll. LYMPH NODE 7. EPIGLOTTIS 9. ESOPHAGUS 6. PHARYNx_~\ f 5. TONSILS ~ ~ 4. ADENOIDS le. SPHENOIDAL SINUS o4Isssszooi la. FRONTAL SINUS ^.8. LARYNX 10. TRACHEA 12. RIBS 13b. LEFT MAIN BRONCHUS CIGARETTE LABELING AND ADVERTISING-198b 383 TIIE RE8PI8ATORY SYSTEM This chart of the respiratory system shows the apparatus for breathing. Breathing is the process by which oxygen In the air Is brought into the lungs and into close contact with the blood, which absorbs it and carries it to all parts of the body. At the_ same time the blood gives up waste matter (carbon dioxide), which is carried out of the lungs with the air breathed out. 1. The sinuses (frontal, maxillary, and sphenoidal) are hollow spaces In the bones of the head. Small openings connect them to the nasai cavity. The functions they serve are not clearly understood, but Include helping to regulate the temperature and humidity of air breathed in, as well as to lighten the bone struc:ture of the head and to give resonance to the voice. 2. '`he nasal cavity (nose) is the preferred entrance for outside air into the respiratory system. The hairs that line the inside wall are part of the air- cleansing system. 3. Air also enters through the oral cavity (mouth), especially in people who have a mouth-breathing habit or whose nasal passages may be temporarily obstructed, as by a cold. 4. The adenoids are overgrown lymph tissue at the top of the throat. When they interfere with breathing, they are generally removed. The lymph system, consisting of nodes (knots of cells) and connecting vessels, carries fluid through- out the body. This system helps to resist body infection by filtering out foreign matter, including germs, and producing cells (lymphocytes) to fight them. - 5. The tonsils are lymph nodes in the wall of the pharynx that often become infected. They are an unimportant part of the germ-fighting system of the body. When infected, they are generally removed. 6. The pharynx (throat) collects incoming air from the nose and mouth and passes it downward to the trachea (windpipe). 7. The epiglottis is a flap of tissue that guards the entrance to the trachea, closing when anything ie swallowed that should go Into the esophagus and stomach. 8. The larynx (voice box) contains the vocal cords. It is the place where moving air being breathed in and out creates voice sounds. 9. The esophagus is the passage leading from mouth and throat to the stomach. 10. The trachea (windpipe) is the passage leading from the pharynx to the lungs. 11. The lymph nodes of_ the e lungs are found against the walls of the bronchial tubes and trachea. 12. The ribs are bones supporting and protecting the chest cavity. They move to a limited degree, helping the lungs to expand and contract. 13. The trachea divides Into the two main bronchi (tubes), one for each lung, which subdivide Into the lobar bronchi-three on the right and two on the left. These, In turn, Aubtlivide further. 14. The right lung is divided into three lobes, or sections. Each lobe is like a balloon filled with spongelike lung tissue. Air moves in and out through one opening-a branch of the bronchus. 15. The left lung is divided into two lobes. 18. The pleura are the two membranes, actually one continuous one folded on itself, that surround each lobe of the lungs and separate the lungs from the chest wall. 17. The bronchial tubes are lined with cilia (like very small hairs) that have a wavelike motion. This motion carries mucus (sticky phlegm or liquid) upward and out Into the throat, where it io either coughed up or swallowed. The mucus catches and holds much of the dust. germs, and other unwanted te_d matter that haw Invaded the lungs and thus gets rid of It. 13. The diaphragm is the strong wall of muscle that separates the chest cavity from the abdominal cavity. By moving oving downward, it creates auction to draw in air and expand the lungs. 19. The smallest subdivisions of the bronchi are called bronebioles, at the .end of which are the alveoli (plural of alveohis). 20. The alveoli are the very small air sacs that are the destination of air breathed in. The capillaries are blood vessels that are imbedded in the walls of the alveoli. Blood passes through the capillaries, brought to them by the pulmonary artery and taken away by tbe pulmonary vein. While in the capil- laries the blood discharges carbon dioxide into the nlveoli and takes up oxygen from the air in the alveoli. (Published by the National Tuberculosis Association.)

384 CIGARETTE LABELING AND ADVERTI$1NG-198b STATEMENT OH THE AME6ICAN PUBLIC HEALTH As900IATION ON H.R. 4244, H.R. 3014, AND H.R. 4007 (Presented by Morton L. Lcvin, M.D., chief, department of epidemiology, Roswell Park Memorial Institute) I am Dr. Morton L. Levin, of Buffalo, N.Y. I am here to testify on behalf of the American Public Health Association regarding H.R. 4244, H.$. 8014, and H.R. 4007. I am a doctor of medicine with a postgraduate degree of doctor of public health. In 1939, 1 first became interested in and started a study of the relation of smoking to cancer. I was at that time assistant director, and subsequently director of the Division of Cancer Control of the New York State Department of Health. From 1947 to 1959, I was assistant commissioner of health In the New York State Department of IIealth, and since 1960 1 have been_ chief of the department of epidemiology at Roswell Park Memorial Institute, which is the cnncer research hospital and institute of the New York State Department of Health. I have published, as senior or associate author, 11 papers on the rela- tion of smoking to cancer. A detailed list of my experience and publications Is attached to my statement filed with the committee. The American Public Health Association is a nntional organization comprised of prnfessional workers primarily concerned with public health and the preven-n tion of disense. The health hazards of continued cigarette smoking have long been the subject of study by members of the associntioa The association is com- prised of public health officials and related personnel who are charged by law to evaluate new methods for the prevention of disease and to advise the public regarding the advisnbility and imlrortance of ailopting such methods. In 1054, the Public Health Cancer Association, an affiliate of the Ameri- can Public Health Association, adopted a resolution calling attention to cigarette smoking as the major cause of lung cancer and urging that the youth of America "count the cost" before starting to smoke. In 1959, the governing council of the American Public Health Association adopted a similar resolution, citing the probability that more than 1 million present schoolchildren would deveiolilung_ cancer during their lifetime If present trends continue. The resolu- tion urged tbat, health authorities undertake a broad educational effort "to prevent cigarette smoking." In 1963, the council called attention to the increased risk of other diseases, such as coronary artery disease and chronic respiratory disease associated with cigarette smoking and proposed that educational activi- tiey he conducted based "on the fact that the level of cigarette smoking In the United States constitutes n serious health huzard."The resolution also urged legislative bodies "to consider taking action to regulate the advertising of cigarettes." (Copies of these resolutions are attached, app. A and B.) Since 1954, a large number of other professional health organizations, medioal societies, voluntary and governmental health agencies, and research organizations In this country, Canada, and abroad, have reviewed the evidence on the effect of smoking on health (app. C). This evidence includes data gathered from chemical analysis of_ tobacco smoke, animal experiments on the cancer-producing effect of various chemicals contained In tobacco tar and of whole tobacco tar, the effect of smoking on human lung tissue, studies of per- sons ill with cancer and other diseases, studies of well persons to determine subsequent incidence of discase !n relation to smoking habits and other character- Istics, and vital statistics regarding changes In the mortality and incidence of discase. All the reviews of this evidence made by these health agencies ba_ re concluded that cigarette smoking ts an impurtant health hazard. Ilow great is this health hazard? One way of gaging Its magnitude is by estimating the excess deaths among male cigarette smoke.rs ; i.e., the deaths among cigarette smokers in excess of the mortality experience of nonsmokers. Dr. Paul qheehe and I have made such an estimate, taking into account the age distributtott of the male lapulation, the numbers of smokers and nonsmokers, and the number of deaths from various causes In 1902. Over 200,000 deaths, about 1 In every 4, are due to the excess mortality among cigarette smokers. Of the estimated 658,000 deaths among male cigarette smokers, over 33 percent were excess deaths. Lung cancer, oral cancer, laryngal cancer, chronic bronchitis, and coronary heart disease accounted for the largest number-131,000---of the excess deaths among cigarette smokers. These are the diseases designated by the Surgeon General's advisory committee as casually related or which should be considered as casually related to cigarette smoking. Allowing for approxl- Z4sss9zooZ T CIGARETTE LABELING AND ADVERTISIN('r-1985 385 mately 20 percent over estimate due to nonresponse bias_ leaves a minimum esti- mate of over 100,000 deaths each-year among males from diseases casually related to cigarette smoking. It is clear that the excess mortality nmong cigarette smokers today is one of our greatest health problems and, fortunately, one for which a_ great deal can be done In the future-if the proper public action is taken. The most Important practical aspect of the health hazard of cigarette smoking is In lts preventive possibilities. Numerous studies have shown that persons who stop smoking cigarettes experience, within 5 years, a reduction of over 50 percent In the risk of developing lung cancer. Recent studies reported by Doyle and his associates (Journal of the American Medical Association, Dec. 4, 1Ul',•}) show that whereas moderate to heavy cigarette smokers observed over an 8- to 10-year period experience three times as many attacks of coronary artery rtery disease, persons who bad stopped smoking had no greater incidence of heart attacks than (lid nonsmokers. At present there is little that can be offered medically to counteract the effect of cigarette smoking other than prevention, by stopping smoking, smoking less, or by reducing the amount of tar intake. To achieve this requireswidespread public education In order to provide individuals with sufficient motivation to chauige their smoking habits or not to acquire them. Enactment of the proposed legisla- tion now under consideration would tend to provide such motivation. Reaaona for adopting health warning and tar and nicotine labeling 1. Animal studies conducted at the Roawell Park Memorial Institute by Dr. Fred I3ock and others have shown that the cancer producing effect on animals Is directly proportional to the amount of tar contained in each brand of cigarette. A reduction of 30 to 60 percent In tar content resulted In an equivalent reduction in the percentage of animals (mice) which developed skin cancer as a result of application. We do not, however, have direct evidence of any differential effect on humans. 2 The proposed labeling would remind the consumer of the health hnznrds of smoking, in relation to tar intake, and encourage the use of cigarettes with lower tar content. 3. The proposed legislation would indicate to the general public the extent of governmental concern over the health hazards of cigarette smoking. In Buffalo, N.Y., we have been conducting smoking clinics for almost 2 years to help smokers who want to stop smoking and educational activities among schoolchildren. One of the most frequently asked questions has been : Since smoking is a serious health hazard, why doesn't the Federal Government do something about it? Enactment of the proposed legislation would provide at least a partial answer to that, pertinent question. 4. The cost of a broad-scale public educational program regarding smoking on a scale comparable to the expenditures for cigarette advertising would be great; the type of labeling proposed In these bills would be an effective, less costly, although ugh partial substitute for such an educational program. It is our view that enactment of the proposed legislation would constitute a• molerate, even minimal, but nonetheless effective response of the Congress In attempting to counter the continued drain on our human resources resulting' from the widespread use of cigaretteshy our population. The American Public IIealth Association accordingly urges favorable consideration of the proposed legislation which will require labeling cigarette packages with R warning as to the poteutial injury to health, the tar and nicotine content, and which will regulate advertising which portrays cigarette smoking as a wholesome or safe activity. APPENDIZ A LIIIYa CANCER AND CIaAEETT6 S1lUSINa Whereas lung cancer In a rapidly increasing fatal disease which now kills more than 25,000 people In the United Staes each year and if present trends continue will claim the lives of more than 1 million present schoolchildren in this country before they reach the age of 70 years ; and Whereas scientific evidence haa established -that excessive cigarette smoking is a majorfactorln the disease; and Whereas public health officials of the United States and many other countries have pointed out the relationship between cigarette amoking and lung cancer: Therefore be It

386 CIGARETTE LABELING AND ADVERTISIN4--198b Resolved, That the American Public Health Association call upon health au- thorities to undertake a broad educational etfort, especially among young people to prevent cigarotte smoking: and be it further Resolved, That the American Public Health Association urge health authori- ties to collaborate with voluntary health organizations and_ with educational authorities In this effort. Adopted by the APHA Governing Council on October 21, 1959. APPENDIZ B CiIGAaETfE SMOKING AND HF.ALTH The size of the lung cancer problem In this country at the present time is such as to warrant urgent luiplementation of any and all preventive measures that have reasonable prospects of success. Evidence indicates that cigarette smoking is an important factor in the etiology of squamous carcinoma of the lung, and that the most reasonable explanation for the increase In the frequency of this form of cancer since 1920 lis the increase in cigarette smoking that has occurred in the same period. Moreover, the desirability of public health action in relation to cigarette smoking is augmented by evidence that cigarette smoking Is assod- at.ed with increased risk of other disease states, In particular coronary heart disease, chronic respiratory disease and cancer of the urinary bladder. Additional Informntion is needed on the mechanism or mechanisms whereby cigarette smoking Increasea susceptibility 'to these disorders. But until these niechanigms are identified and are shown to be susceptible to manipulation, pre- ventive action can be directed only at reduction of the total amount of cigarette smoking oking prevalentin the population. Believing that the above considerations require immediate and serious action to reduce cigarette smoking by the American people, the American Public Health A_%sociation : 1. Urges its members, in their professional activities and by private example, to provide leadership in the Nation, the States, and In their individual communties in educationat activities on the fact that the level of cigarette smoking in the Unit~ed States at the present time constitutes a serious healh hazard. 2. Offers to the Surgeon General of the U.S. Public Health Service, to other official and voluntary health agencies and professional health organizations, to schools and other community agencies, the support of the association in Initiating, planning and Implementing an educational program, and other measures that may be devised-to deal with this problem. 3. Urges the tobacco industr,p, their advertising services, and the National A_%wociation of Broadcasters to continue taking voluntary steps for the control of cigarette advertising in print media and on television and radio, particularly but not exclusively that directed at young people. 4. Urges those legislative bodies and bureaus that have appropriate functions to consider taking action within their legal powers to regulate the advertising of cigarettes that by its content or implications portrays cigarette smoking as being a wholesome or safe activity. 5. TJrges continued research and demonstration of educational and action pro- grams In schools and communities based on research in methods of deterring young people from beginning the smoking h_ abit and/or encouraging adults to give up or cut down on!their smoking. Adopted by the APHA Governing Council on November 13,1963. APPENDIx C BOME SOIENTIHTO BODIES AND GOVERNMENTAL AUTItoRITIF.s WHO HAVE MADE STATEMF.NTa LINKING ()IaARE'rTE SMOKING WITH LUNO CiANCEB AND OTHES HEALTH HAasans STATE MEDICAL 9OpIETIEa 1. California State Medical Society, 1963 2. Connecticut State Medical Society 3. Medical Society of Delaware 4. District of Columbia Medical Society 5. Florida State Medical Society, 1963 6. Ihiwaii Public Health and Medical Society 7. Idaho State Medical Society CIGARETTE LABELING AND ADVERTISING-191i5 8. Maine Medical Society 9. Michignn State Medical Society 10. New Jersey Medical Society 11. New Mexico Medical Society 12. New York State Medical Society,1903 13. North Dakota State Medical Association 14. Pennsylvania State Medical Society 15. South Dakota State Medical Association 16. Utah State Medical Society,19cs 17. Vermont State Medical Society 18. Washington State Medical Association 387 NATIONAL AGENCIES United States: 1. American Association for Thoracic_ Surgery 2. American Cancer Society 3. American College of Chest Physicians 4. American Heart Association, 1963 5. American Public Health Association,1959,1988 6. Commissioner of Health, New York State, Herman E. Hilleboe, 1958 7. Commissioner of Health, New York State, Hollis S. Ingraham,19(13 8. Director, Department of Public Health, California, Malcolm Merrill, 19ti3 9. Michigan State Department of Health 10. National Tuberculosis Association,19fi0 11. Ohio State Dental Association 12. Oregon State Board of Health 13. Public Iiealth Cancer Association, 1954 14. Study Group on Smoking and IIealth, sponsored by the American Cancer Society, American Heart Association, National Canc_er Institute, titute, 1957 15. Surgeon General of the United States, Leroy E. Burney 16. Surgeon General of the United States, Luther Terry,19tY1 17. Surgeon General's Advisory Committee on Smoking and Health, 1904 18. Surgeon General. U.S. Air Force, R. L. Bohannon,1902 19. U.S. Public Health Service 20. U.S. Veterans' Administration 21. World Health Organization tion Expert Committee, 1959 Foreign : 1. British Medical Research Council,1_ 1957 2. British Ministry of IIealth,1954 S. Canadian Cancer Society 4. Canadian Heart Association 5. Canadian Medical Society,1983 0. Canadian Minister of National Health_ and Welfare 7. Cnnndian Pubiic Health Association 8. Canndian Thoracic Society 9. Danish Cancer Society 10. Danish Medical Association 11. Finland Medical Association 12. Government of'Itai.v 13. Health Council of Holland d 14. Iceland Cancer Society 15. International Union Against Cancer, Subcommittee on Tobacco and Air Pollution 16. Joint Tuberculosis Council of Great Britain 17. Medical Research Council of Great Britain 18. National Cancer Institute of Canada 19. Netherlands Ministry of Social Affairs,1__957 20. Paciflc Northwest Radiological Society 21. Research Council of Sweden 22. Royal College of Physicians, Lon_ don,1982 23. Scotland Department of Health 24. Swedish Medical Research Council, 1958 25. World Health Organization, Special Study (iroup,198t1 z41V 4ssszooi

388 CIGARETTE LABELINl3 AND ADVERTIBINQ-198d APPENDIZ D Ct1B8I0ULIIM VITAE, IMtOSTON L. LEYIN, M.D., D.P.H. Born : 1903 Educated at Johns Hopkins University, 1920-22; University of Maryland, Ph. G., 1922-24 ; M.D., 1930 (Summa Cum Laude) ; Johns Hopkins School 01 Hygiene and I ubilc Health, M.P.H., 1933 • D.P.H., 1934 ; interned at Sinai Hos- pital, Baltimore, 193(1-31 • assistant resident, 1931-32; aesiatant disl,ensary physician, Johns Hopkina Hospital, 1932-33; fellow, Johns Hopkins University School of Hygiene and Public Health, 193•1--34 • Coinmissioner of Health, Ottawa, 111jch., 1934; instructor, Department of Epidemiology, Johns flopkins Uni- versity School of Hygiene and I'ublic Health, 193:.-30; associate physician, Roswell Park Memorial Institute, Buffalo, N.Y., 193"'J; associate director, New York State Legislative Cancer Survey Commission, 1938-39; assistant director, Division of Cancer Control, New York State Department of Health, 1J3f1-40; research consultant (11N0); medical director (1947), New York State Legislative Commission To Formulate a Long-Range Public Health Program; assistant commissioner for medical services, New -York State -Department of Heulth, 1947 -0 ; director, commission on chronic Illnesa, 1ll50-Li ; assistant tant commissioner for medical services, New York State Department of Health, 1051 to November 1959 ; chief, Department of Epidemiology, Roswell 1'ark Memorial Institute, November 1059 to present (Charles Hayden Foundation-American Cancer Society) : assocpte research professor, Department of Preventive Medicine, University of Buffalo, School of Medicine, 1969 to present. itfembershipa : Delta Omega ; American 1liedicai Association • American Public Health Association; American Association for the Advancement of Science (council 1955 to date) ; Public Health Cancer Association (President, 1947) ; American Epidemiological Society • New York State I•Jpidemlological Society, president, 1948; American $tatistical Association; American Association for Cancer Research. APpointments: Associate professor of preventive medicine, Albany Medical College (1952-59) ; Statistics Committee, American Cancer Society (vice chaio- man, 1958) ; Committee on Etiology of Cancer, Atuericun Cancer Society (1960- (30) ; Subcommittee on Carcinogenesls, Food Protection Couunittee, National Research Council, 1957; consultant, World Health Organization, Cancer Re- eearch, January-February 1959; member and rapporteur, World Health Organi- zation, Study Group, Lung Cancer, November 1959; Subcommittee on Geographic Pathology, National Research Council-Academy of Science, 1961; consultant, President's Commission on Heart Disease, Cancer, and Jtroke, 19(34. STATEMENT ON PROPOSED CIOABErrE ADVEaTISINO AND LABELING LEaISLATIOlf (By John K. Herbert, president, Magazine Publishers Association, Inc.) The Magazine Publishers Association is an association of 109 magazine pub- lisbers of the United States publishing over 300 different magazines of general interest, most, of which accept advertising. The Magazine Publishers ublishers Association appreciates the opportunity to testify because among the questions before this committee la that of the proper role of advertising In our Nation and the appro- priate relationship which should exist between Government and advertising. As carriers of advertising, magazines are interested In legislation which effects advertising. I hope to convey to you our views on the role of advertCs-. ing In the business community, the extent of induatry self-regulation which now prevails, and the_ need for restraint In imposing new and novel advertising requirements. In our view the role of advertising In our Nation ia that it promotes the economic goals of our free enterprise by- 1. Stimulatingproduct competition and improvement; 2. Reducing consumer prices through competition over a nationwide market ; 3. Helping the growth of the economy, in terms of more jobs and greater national productivity, keep pace with the growth of population; and 4. Providing the economic foundation for essential communications media. c4sssszooi ; CIGARETI'E LAB11j,ING AND ADVERTI$INQ- 198b Advertising is a vital inatrum 389 rMtlatlon avertisfn ent in our whole com legitimqte aim ot Gove ~ a° r~trire it to meet its oblt ~ttttve proco~, The Played a sign(ticnntof ent. Theadvertisingtnrlustr art°ns to the publlc is a which, In ~ie tn the eatabllshment of the 1'e(1 a~Trade Corn accordance with traditional ~d and and reslx,nstbtl(ty to prevent false andjnijHjiel_t nmisslon The nredia which de ylc pr°cedures• hasi the authority pend in v ading advertising• their judgment as to arying deQrees on advertIcin deemed a the Propriety oP uu g tor euPt~ort ex proposed advertisement or line of aaae tiHin n1e11k Where the erciae I Public inGerest In either taste or truthfulneya, y have i retused. These decisions are baa thESe g tO be detrimenfal to tbe tlstug ia to ed on the assum ,tion pdvertisements have been established persuade inforraatively Without I that the function of adver, aro against acce tin II1isineorming; Some rrragazinea have ~ businessode~es ecisiona, whieh p g any advertising of certain-products. declafons, we woulrl submit stem from social These reFUlaiton. they should not be replaced ltoh8ness' As business has been accepted substitution of governnientai >± tly by Roverntnental epted only as a last resort, where the but ines® Involved business has itself unwilling or unable to serve the interes jud~nenC Last gear the tobacco indust ta of the Droved ards of advertising for rit;arett ~ystArlt(a ~Yl tt volu pabllc• - former Gnvernor llteyner, of ntary code w.hlch aets ptand- bo imposE~ under the c New Jerso •, °de jN under the administration of than ~e for vlolattops~ TheY~ ilies of ns much as $100 pW can those whteh may be irnJw_sEyi nnder ~ualtfesareaubstan- apiK'nrs to-be a vubstunttal etlort tw the t°bucc~~elu~u trntor t)nlly more and eorrrrtion ot utinsev. It has alrcady resulteEl Iu chpn,e ~es The CYNIe sign and udvertisint;, both us to Er,nteut and nppc,U. y toward sel!-regnlation 1'ht' code has bE en in eff b s in ppekaging de_ fndnstry should be given nn ol` "" than u yeur. We believe that the ci•frrtive. Last yeatr an . I lx,rtupity to prove that aelf-regitlatlon cnbn be Corumerce, ldvertfAinr; Advisor•v ('`ommittee ot lat[~~n In on which I was plE•aNed to sert•e, issu~Yl p Adrerttsing" q.bich the Department of regulati°n and commended rilscussed tnnn ~[Kort entitled '~yelt-Regn. The report indicated the need for snchst.ries wh ~h't Indnatry's e!lorta at self- The entire structure Pro a Iwrticipated In the programs. regulatlot, of p.hich it 1 o~Eivertisin ~ n;e and atated: g aelf-regulatfon, and of the business self- respect, and'toguideour only a part, retlects a desire to stimulate honor and TLe question for thi® society by principles of social and All consnmers have nn COn'nllttee is how best moral responsib(lity.'• nr contn(ner of °Pportunity to reud or 1 to protect the Public lntPrest a commodity whlE•h Indtcate wh~the_r ts markings involved a pr~sutions to r,bserve. ~ on the package a warning messp$e, if auE•h !s ~ elet~' the best K•uy to reach the risk and what eelf. Whether a gtveu commodity n~~IHe" a warning label consumer with (le y~ would seem to be the label It the In°st careful assesament of scienti is a subject requiring cholo , , gv and judgtnent. Thla is the ~~•zsee t evidence, statistical ral;nrding flammable proEiucts, w yIK' °f 1?rojecttona, jey- A reryulretuent that Wlena, action that Confiress has taken project the advE:rtiein frlW drugs. Governntent over g contain such a warning would nnjustiflably the rrgulatlon and wriNn tIte thrrahold into an entirel narning -requinmtent !H hnsot aElvertisint( copy. We believe th new anea iq~'olvinQ advertising as dlstlnet trom on a rnichtterpretatlon of the functlonaolvertising urge that, whatevar may bethe functioa of prodnct ]nbelin product clear that !t does not sanction decided with res g Accordlngly, we On behalf of the ator w 1'~t to IabellnR. Congresv make the prlvtle e Mngazine Publfaheey Ay~nfnga In advertlsing, g~Presenting our views to this ° comCm~~t~. I want to thank you for Ta9TIMONY OP GEOR06 JAME9, IIEALTIr DePASTarENTM.D., COMMIagIONE$ O! HyALTn[ , CoNOEBxirro H.R. 4244, 8014, e oa g007 ~~ I am Dr. George James, of health of the cit of commfssl°ner of health and chalrman Pet'lence has been y New York. A detailed review of of the IMp~ publie health fleld forv2e,,n to the cotnmittee. In my iratnln of achoois of ' yeare and have been a Reneral, I have beenp~n ~he and hav® held evjsj~j~g ~~tu~bl~lth at HarvarEmlem~r of the teaching faculty Y~ PnPors dealing wtth subjectsfn ~hQ fleld of epldemloloolumbla, and Aibany , • dozen othera. I have pobllshed pb°nt • gy and Public healtlt

390 CIGARETTE LABELING AND ADVERTISINd-198b I have held positions in local and State public health work for the States of Tennessee, Ohio, Maryland, and New York. I am pleased to have this oppor- tuuity to testify before this distinguished committee on a subject of such great importance to the public health. During 1964 there were 2,761 deaths from lung cancer In New York City. This represents nearly 100 more than occurred the year before. At the most con- servative estimate now available, at least 70 percent of these deaths can be 1 charged to cigarette smoking. This means that cigarettes killed nearly 2,000 of our citieena from lung cancer alone. If we consider the excess mortality from the other diseases associated with cigarette smoking, this means that cigarettes were one of the major agents causing death In our city last year. I am pleased to see that efforts are being made to solve the cancer-cigarette problem by Federal enactment, since a multiplicity of State and/or local laws is not advisable. Since the cancer-cigarette problem is of such great immediacy and urgency for us all over the country, I hope and urge that the Congress continue its efforts and enact legislation which will insure that every cigarette user fy fully and unequivocally made aware that cigarette smoking is endanger- ing his life and health. While we are very much concerned with older 7n- dividuals who are long-term users of cigarettes, we have directed our educational activities in the city of New York primarily toward young boys and girls who are beginning to be exposed to the ciFarette-smoking habit. I therefore urge Immediate action on legislation providing for warnings on cigarette packakes and cigarette advertising. In recent studies of cigarette smokera it has been reported thnt by the time they reach the 12th grade, 50 percent of schoolchildren have already become habitual smokers and even 10 perermt of seventh graders have begun smoking habitually. Since the duration of smoking increases the risk of lung cancer, postponement of the age when the habit begina could be a major step toward prevention of this highly fatal disease. Wit.h specific reference to H.R. 3014, 4007, 4244, I believe that both the health warning and the tar and nicotine content yield per cigarette should be on the label. A statement of the average tar and nicotine yield is useful for the con- sumer for the following reasons • 1. It indicates that the tar and nicotine content is of importance to the health of the consumer. 2. it puts pressure on the industry to develop cigarettes of increasingly lower tar and nicotine content. Substantial lowering of the content of these substances would be equivalent to a reduction of cigarette smoking, which in turn would reduce the health hazards of cigarette smoking. I would urge that the Federal Trade Commission be specifically empowered to establish standards for the measurement of tar and nicotine content of cigarettes and publish data periodically on the tar and nicotine content of brands of ciga- rettes used in the United States. This would permit the consumer to know which brnndaare rated lowest In tar and nicotine content. I preside over the Board of Health of New York City. This board has broad lawmaking powers. We are the legislative agency responsible for passing lawa to protect the health of 8 million citizens in this largest city of our Nation and of the millions of other Americans who pass through it either as commuters, trav-, elers, or visitors. We, as individual members of this responsible body, do not always know the correct answers to the latest scientific developments, but we do know how to find out what they are. We rely on the overwhelming weight of expert opinion. We must also always be aware of the implicatlons of our actions on induatry, commerce, and the freedom and legal rights of our citizens. In meeting these responsibilities our mission for_ 8 million people appears to be similar to yours for 200 million. Various reputable physicians and other scientists have testified before the Con- gress that cigarette smoking does not present a serious health bazard. I believe these men are sharing their considered opinions honestly. We are quite familiar with differences in expert opinion. But if we waited for a unanimous opinion on health matters among the 18,000 physicians In New York City, we would have no health program at all. Within my own professional lifetime I can recall a famous medical school pro- fessor who believed that poliomyelitis was caused by a certain strain of Atrepto- coccus, and another who published extensive research studies proving that the disease was_ due to cyanides in the soiL One year ago we held an open hearing in our city on the desirabiiSty of adding fluorides to our water supplies in order CIGARETTE LABELING AND ADVERTISING--196b __ 391 to prevent dental caries. A number of noted physicians and scientists testified against this procedure. A Nobel Prize winner sent a letter Indicating that he, too, had reservations. Yet this is a chemical that has been added both ssfely and successfully to the water supply of this city of_ Washington for the pas_t 33 ears and is piped Into every tap within the very building where we are now meeting. A few chest physicians have testified against the findings of the Surgeon Gen- eral's report, but the thousands who make up the membership of the American College of Chest Physicians have passed and maintainerl on their books a firm resolution on the health hazards of cigarettes. A few chest surgeons have also testified In opposition, yet the many who make up the Society of Thoracic Sur- geons and the American Association for Thoracic Surgery have passed resolu- tions indicating the danger to health of cigarettes. Certain heart disease ape- cinlists have testified on the barmlessness of cigarette smoking to the heart, but thousands of cardiologists are members of the American Heart Association which has officially indicted cigarettes as a danger to health. Individual physicians have testified that cigarettes are safe, but 37 State medical societies and the American Medical Association, representing 200,000 physicians, disagree with them and have said so. One of the strongest resolutions is that of the American Medical Association, passed unanimously by its honse of delegates last June. There is now available no more reliable or effective method of weighing the testimony of experts than by the e jury of their own peers. The overwhelming weight of scientifle opinion has agreed that cigarette smoking In hazardous to health. We must no longer be diverted from our task of saving lives by decreasing and, as far ns children are concerned, pre- venting or at least - postponing, the eigarette habit. The inck of action against cigarettes now as a cause of disease is really effective action In favor of lung cancer and the other deadly diseases caused by cigarette smoking. The youth of our Nntion are constnntl,y bombarded by advertiaing In the press, radio, television, billboards, and magazines with what they consider to he the desirable and attractive features of cigarette smoking. It is t.here- fore essential thnt such advertising include a warninQ of the undesirable fen- tnres as well. The recent Federal drug legislation and Food and Drng Admin- iatration regulations have provided snfeguards on the ndvertising of drugs, and such warnings of adverse reactions are now being included. Cigarettes present a dnnger at least comparable if not greater thnn that assoeiated with the vast majority of drugs now advertised In complinnce with these new regulations. Cigarette advertising should include such warniniz statements prominently dia- plnyed. The impressionable youth of our Nntion, not yet mature enough to understand the bazards of smoking must be constantly reminded of them when- ever they are confronted by advertising strongly suggesting that_ smoking is a pleasurable, de.rirable, adult type of sophisticated activity. Those who oppose the warning labels on cigarettes and cigarette adver- tising suggest that such a program would be similar to requiring health warn- ings on a host of common substances whose use may on occasion be hazardous. Frequently listed are such Items as whisky, nutomobiles or household ehemienls. First of all, many of these items are well regulated both by law and,by indus- trinlI code with pnrticular emphasis on prevention of their use by children. This has not happened with cigarettes. I know of no instance where a family bas been penalized severely by a court for offering cigarettes at a teenage party similar to the recent Connecticut episode relating to alcoholic beverages. Yet cigarettes are responsible for more denths In this Nntion than alcohol. Even more importnnt is the fact thnt these other things are enfe In noriunl use. Usual so- cial drinking, safe driving, and the proper use of household chemicals are the rule and do-not offer risks anywhere as great as those of cigarette smoking. The key baznrd of cignrettes is the great risk they provide In ordinary nse. The usual cigarette smoking habit In the vast majority of instances lends quickly to the dangerous level of at least one pack per day, with millions smoking two or more packs per dny. Advertising the pleasant features of smoking, there- fore, without at the same time indicnting the dangerous aspects of the ordi,mry habit is iike describing the beautiful markings on a rnttlesnnke to a gronp at- tracted to them without at the same time mentioning the dendly fangs-even if the group is supposed to know this. The New York City Department of Health has used labeling, and In a way has also used advertising effectively to drive home the dnngers of certain com- monly used substances when the dangerous side of their use has been largely I V4sss9zooZ

392 CIGARETTE LABELING AND ADVERTISING-1985 ignored by the population. The labels on lead paint must indlcate that they be used only on the outside portions of the home. More recently when plastic bugs became common playthings for children, with serious results, we required not only that these bnt;s be labeled as hazardous but also mounted, with the aid and support of the industry, an extensive campaign of public education about their dangers. I am pleased to report that this campaign has been etYec- tive. Thousands of ordinary household chemicals bear the label, "Keep away from children" and other appropriate warnings. Another commeut of the opponents of regulation notes that the great majority of per.uns who smoke cigarettes ilo not get lung cancer, therefore it is foolish to wcirn everyone about the hazard. This is a completely spurious ari;ument. If thn logicc were followed we would have no regulation at all. In 1812, its peak year as our No. 1 cause of death, tuberculosis killed only 700 persons per 100,000 pupulution per year In New York City. Since t1t),300 people out of each 100.000 failed to succumb to tuberculosis even during Its worst year, does that negate our vast public programs for tuberculosis control, our pasteurization of milk, our exlN-nsive isolation and treatment of infected persons? How many of those who travel above the speed limit on the highway end up as fatal accidents? In a dtucly dune in New York State we found that 50 percent of the driving popula- tion admitted exceeding the speed linilt. Would that suggcstt that we-abandon all speed control regulations? Thalidomide caused serions-difflculty among only a tiny fraction of those persons who took the drug. In this instance we did not lubel, we did not add warnings to advertisements-we banned the drug entirely. ln 1906 tuberculosis was the leading cause of death In New York City. At that time our department found that 75 percent of the dairy herds supplying the city with milk included cows infected with tuberculosis and 10 percent of routine milk samples collected in the city contained live tuberculosis germs. Ilc~re. too, the agent (contaminated milk) was not the only cause of the spread of the diseatie-but it was an tmportantone. Our department pressed the milk industry to accept pasteurization and the industry reacted violently. They stated that it would bring ruin to the entire Industry, put millions of employees and dairy farmers out of work, put the price of milk beyond the reach of most con- sumerK, and lead to the starvation of thousands of babies dependent upon this perfect food. All of this is rather similar to the comments being made today abnut the harm which cigarette regulation will bring to the tobacco industry. The city of New York put pressure upon this industry--stern pressure. Milk was not priced out of the market, farmers were not ruined, pasteurization was establinced, babies did not starve, milk-borne tuberculosis has vatdshed from the city. Yes, industry adopted codes too, but not until Government acted and acted strimngly and continuously. This is not an isolated example-it Is the rule In public health, and it ie becoming more so. A similar experience has occurred with the restaurant in- duhtry, now cooperating so well with enhanced health safety design and self' Inspection programs. Air lMllution control, the control of the drug industry, and' of ionizing radiation are all examples of the control of health hazards by the cooperative cfforts of Industry and government-but su_ch_ cooperation has re- quired stern, forceful, and effective Government action. The cigarette industry has promulgated a code under threat of Government action which does represent a step forward. But the provisions of these bills (II.R. 3014 and 1T.Ii. 4007) preempt the control of advertising to the Federal Covernment and then fail to provide a mechanism to regulate it. This would be situilar to passing a law that no governmental agency except the Congress. catt control restaurant sanitation and then relying solely upon the restaurants theuiselves aud their trade assoeiations to do the job. The history of health hazard regulation proves that this does not work. A leader among the Nation's experts in environmental health noted that it In amazing how industry learns bow to adapt to changes even while Aghting them. Industry apparently must have something to flght, or it will not adapt adequately to health progress. Evidence relating to cigarette smoking as hazardous ta bealth has been accumulating for nearly two decades, and the cigarette i.ndustry advertising code was created only after the threat of direct governmental action• last yeitr. We have reached that stage In the cigarette smoking Problem when for a time there should be a major shift of effort away from advertising and toward greater research to produce a cigarette with less and less tars. I urge that your honor able committee create pressures for this by strengthening the ability of tht SZ,S%9Z00l CIGARETTE LABELING AND ADVF.RTISING-1985 Federal Trade Co i i m 393 m $s on to regulate the advertising of cigarettes and provide for r theandlnclumsion of heaith warnings In all advertising. y colleugues on the New York City Board of Health have sworn to uphold the public health of our citizens. With at least 2,000 lung cancer deaths per year caused try cigarettes we must be permitted to take action. We bave been awaiting Federal action requiring health hazard warnings on cigarette packages and advertising because this would be the most uniform and efiective method of control. If, however, such Federal action is not forthcorning our board of health should not be thwarted by Federal legislation from taking action on a local level to control the one-sided advertising which helps to tnuke our youth believe that smoking is a pleasurable, adult, sophisticated, friendly, and ordinary habit of life. Therefore, until the routine, commonly practiced habit of smoking one pack or more per day of cigarettes begins to show a dramatic decrease In this Natiou, until our youth proves by actual practice its real understandinl; that this habit is dangerous to life, you and we who are guardians of the public health must strive to achieve the greatest possible connection at all times in the public's mind between the pleasures and the dnnsers of smoking. The Anierican Cancer Society has estimated that I million American children now In school are dootned to develop lung cancer from cigarette smoking, and that every day 5,000 more chil- dren start this deadly habit. New York City's share of this million doomed children it3 approximately 40,000. Warning statements on all cigarette packages and on all advertising can help save these children and millions more to come. Mr. RoaFRs of Texas. The subcommittee will stand in recess until 1 :30 this afternoon. (Whereupon, at 12 :25 p.m. the subcommittee recessed to reconvene at 1:30 the same day. ) AFTERNOON SESSION Mr. ROGERS of Texas. The Committee on Interstate and Foreign Commerce will come to order for a€urt.her consideration of the pending business. I believe our first witness this afternoon is Mr.. K. A. Brown- lee, professor of statistics, University of Chicago. Mr. Brownlee, if you will come forward, the Chair will recognize you. STATEMENT OF K. ALE%ANDER, BROWIALRE, PROFESSOR OF STATISTICS, UNIYEER,SITY OF CHICAQO, OBICA(I0, ILL. Mr. I3ROWNLEE. I wish to express my appreciation to this committee for the opportunity to appear before it. . I am I. Alexander I3rownlee. Since 1956 I have served as associate professor of statistics at the University of Chicago. From 1952 to 1956 I was research associate (assistant professor) at that institution. I received the M.A. degree from the University of Cambridl,*e In England in 1943. 1 was technical assistant to the Director of Ordnance Factories (Explosives) of the Ministry of Supply of Great Britain in 1943-45, statistician with the research department of the Distillers Co. Ltd. of Great Britain in 1945-48, biometrician with the Squibb Institute for Medical Research, New Brunswick, N.J., in 1049-51, and Chief, Test. Design Branch, Dugway I'rovin Ground of the Army Chemical Corps in 1951-52. ~ I am a member of the Institute of Mathematical Statistics, a mem- ber of the Biometric Society, a fellow of the Royal Statistical Society of London, and a fellow of the American Statistical Association. I have acted as a statistical consultant in many areas of science, and served on the Statistical Advisory Panel to the Ilighway Research 48-824-E6-26

0 394 CIGARETTE LABELING AND ADVERTISING-1985 Board of the National Academy of Sciences in 1955-61. I have writ- ten two widely used st.ihsticiLl'textbooks. "Industrial Experimenta- tion," published by the British Government's TTis Majesty's Stationery Oflice, ran throu~h four editions in 1946 to 1948. The second text, "Statistical Theory and Methodology," was published in 1960 and a second edition has appeared in 1965. I have had 16 papers published in 10 different scientific journals. These include two review articles invited by t.he editor of the Journal of the American Statistical Association, one on the "1954 Polio Vaccine Trials" and another on the °°Final Report of the Advisory Commit- tee on Weather Control." A third review article invited b,y that jour-l nal but not yet, published, is on "Smoking and IIealth," the Report of the Advisory Committee to the Surgeon General of the Public Health Service. The report "Smoking and Health," (1) the Report of the Advisory Committee to the Surgeon General of the Public Health Servic.e, ap- pears to be receiving acceptance ns a final resolution of the controversy over the association between smoking and nurtlerous diseases, including cancer of the lunh. I wish to present to this committee a number of considerations that indicate that any claim to a solution of these ques- tions is grossly premature. Tt, is 12 years or so Grnce statisticians generally became aware of the possibility of an association between cigarette smokinjr and lnn,fr can- cer, and 10 years since this was ext.ended to virtually all causes of death. The sampling proc,edures used to establish this association were hy no means as rigorous as statisticians like to see as a basis for scientific inference. The ma;n difficulties were that in those studies in which there was a clearly defined population the percentage nonresponse was seriously high, of t.he order of 30 percent, and in those studies in which there was no clearly defined population there was clearly selectivity. It is notorious tha,t these defects can, and usually do, produce serious biases, and therefore delicate and speculative calculations of the prob-e able bounds of these possible biases nre necessary. The consensus ap-s nears to he that though the association between cigarette smoking and increased death rate is probably overstated as regards the general population, nevertheless it does exist. This association between cigarette smoking and lun cancer has been interpreted by many, including the authors of "~moking and Health," as indicatinL, aa causative relationship. One might have ex- pe.cte~l t.hat this brilliant and important discovery would have been widely acclaimed by the statistical profession as an example of the power and utility of their t.echniqnes: It is therefore cnrious thnt the statistical nrofession have been largely silent on this issue. For ex- ample, .T. 0. Irwin (2) in his 1962 presldential address to the Royal Sr„ti-t.;ca1 Soc;ety of London commented on the existence of the con- troversy, and the difficulties in resolving it, but expressed no opinion on it. T.ikewise, J. Nevman (3) in a paper in "Science" nointing out pos-n cihln fallac~iPs in this area emphasized that.. he was de.aling only with the methodolnaical issnes and not expressing any opinion on the sub- stnntive mlestion. Very few paners have been rnblished on this topic in the ".Tournal of the American Statistical Association," or the "American Statistician," and noteworthy among them are contribu- CIGARETTE LABELING AND ADVERTISING-1965 395 tions by Dr. Joseph Berkson, of the Mayo Cl inic vigorously disputing the alleged establislunent of a causative relationship (4), (5). I think that this abstention from comment on the part of the statisti- ,cai profe.ssion is due to the fact that experienced statisticians are well aware of the difficulty well expressed 40 years ago by one of the most distinguished statisticians of his generation, G. Yu_ elney Yule (6) : "You can prove anything by statistics" te a common gibe. Its contrary is more nearly true-you can never prove anything by statistics. The statistician Is dealing with the most coniplex_ cases of multiple causation. IIe may show that the facts are In accordance tvith this hylothesie or that. I3ut It is quite another thing to show that ail other possible hypotheses are excluded, and that the facts do not admit of any other interpretation than the particluar one be may havein mind. Sir Ronald Fisher 30 years ago expressed the same idea (7) : For the logical fallacy of believing that a hypothesis has been proved to be true, merely because it is not contrndicted by the avaiiable facts, has no more right to insinuate Itself In statistical than in other klndH of scientific reasoning. These remarks of three and four decades ago bear on the weakest point of the report "Smoking and Ilealth." It is clear that the authors of the report recognized that to establish the hypothesis that smoking causes lung cancer they had to eliminate competin hypo- theses, in particular that put forward by Sir Ronald Fisher that cigarette smoking and lung cancer, though not mutually causative, are both Influenced by a cowumon cause, In this case the individuai genotype. There are several items of information that make the genetic hypo- thesis plausible. (1) Several workers, Fisher (9), Friberg et al. (10), and Raaschou- Nielsen (11), have independently assembled data showing thatidenti- cal twins more frequently have the same smoking habits than do non- identical twins. To date_ the data are not very extensive, but are cer- tain- ly suggestive of the hypothesis that the taste for tobacco in its various forms is genetically linked. (2) Data assembled by Seltzer (12) suggests that nonsmokers, ers, cig- arette smokers, etc., differ in several morphological indices. Seltzer measured young men, Harvard undergraduates, and then ascertained their smoking habits more than 15 years later. He found that smok- ing habits in the midthirties were associated with physical build at 20. The natural inference is that they are linked genetically. (3) Foreign-born immigrants to the United States differ in their cancer death rates in many ways from native-born U.S. citizens. It may be contended by some that some of the differences might be due, for example, to malnutrition in early life, but this does not seem a plausible explanation for such a disease as cancer. (4) This indication is strongly reinforced by the observation in the report : The several ethnic gronps in the United States display their own characteris- tic patterns of successes and deficits in risk by site. (5) Data of Eysenck (13) shows that smokers and nonsmokers dif- fer psychologically. Very significantly, a dose response relationship was observed, heavy smo)Cers being more extroverted than medium smokers, and also pipe smokers resembled nonsmokers in being least extroverted. These relationships are the same as those obse.r~%ed be- tween smoking and death rates. Again, it could be that smoking in- 94~ssszooi

396 CIGARETTE LABELING AND ADVERTIBIN(3-198b fluences the personality or that the personality influences the smoking habits, but they are pro~ably jointly associated with a genetic trait. - (6) It is well known that certain cancers have very strong genetic association in some laboratory animals. (7) Yerushalmy (14) has prescnted data showing that whether or not t.he husband smokes is associated wifh the incidenee of premature births in the wife. This might bo caused by smoke in the air around the home, but seems much more likely to be a genetic trait. (8) Hammond (15) gives data showing many odd features that can best be interpreted in terms of the genetic hypothesis. For exam- ple, his data show that the increase in age adjusted death rate for males associated with the use of tranquilizers is almost as great as that as- s(clated with cigarette smoking:-Furthermore, the two apparent ef- fects are approximately additive. The obvious interpretation of this is that people in such shape that they need cigarettes or tranquilizers are going to have an increased death rate, and it does not make much difference which they turn to, and if they are in such shape that they neRd both cigarettes and tranquilizers then their death rate increases still further. Hammond's data also show a very strong association of death rate with the eating of fried foods. ILather suprisingly, those who abstain have a much higher death rate than those who eat fried foods about four times a week. This could be interpreted causa- tively: I suppose that one could hypothesize that those who abstain from fried foods suffer from some unknown nutritional deficiency. But I regard it as unlikely that nutritional deficiencies at~e at all appreciable in Hammond's population, because this was largely mid- dle and upper class people selected by volunteer workers of the Amer- ican Cancer Society from among their acquaintances. This associa- tion of death rate with fried-food eating I regard as a surface mani- festation of some genetic property of the human organism. (9) Hammond s data also shows the well-known difference in death rates between married, single, widowed, and divorced persons. At- tem{tt.s have been inade in the past to interpret these phAnomena causatively; for example, bachelors may be subjected to greater stress than married men because they have no wife to cook dinner for tbem, or soniething. Rut no matter how pla.ttsibly t,hese atteml>ts at constructing causative hypotheses start out, they always end in a tangle of absurdities. (10) Hammond's data also show a marked association of death rate with height, which is most probably a genetic effect.. (11) Hammond's data show marked association between death rate and lon~evity of parents and grandparents, obviously a genetic effect. In my opinion, therefore, the genetic hypothesis is perfectly plRusible, and we must examine the report "Smoking and Health" to see on what grounds they reject it. On my reading of the report, it gives only two substantial alleged reasons. The first is that the genetic hypothesis has to be complicated to explain differences between nonsmokers, moderate cigarette smokers, heavy cigarette smokers, pipe and cigar smokers, cigarette smokers who dtscont+nue the habit, et cetera. I grant the necessat;v complexity but dispute the inference. I be-.e lieve that the genetic hypothesis has to explain Qeneral hereditary differences in death rate, in death rates for specific diseases such as diabetes, in rates for, if one may call it a disease, baldness, in height, 44sssszooz CIGARETTE LABELING AND ADVERTISINa-1966 397 intellectual ability of various forms, the obvious genetic traits such as color of skin, hair, etc., and an absolute myriad of other properties of the human organism. The genetic code is most certainly in-y credibly complex and I do not see why amongst the many thousands of traits that it carries it does not include the various forms of taste for tobacco. The second reason the report gives for rejecting the genetic hypothesis is that it is unlikely that the genetic pool has changed su0iciently in the p ast 40 years to account for the observed increase in lung cancer. Tliis argument has two weaknesses which render it unconvinc_ ing. (1) In the past 40 years there has been a tremendous increase in accuracy of diagnosis due to the invention and introduction into wid_ e- spre;id use of new diagnostic techniques. Fashion and habit of dilgnosis will also play a large part. b orty years ago very Probably man cases of lun cancer were d~iat;nosed as tuberculosis. Therefore a ln ~e part of the apparent historical increase is probably an artifact of the reporting. (2) I_ believe comparisons of death rates between different eras are subject to a classic fallacy. The generation born in 1880 reached the age of 20 in 1900, and a substantial fraction, 24 percent, had died by this time, presumably lar5ely on account of the traditional infectious s diseases of childhood. 1 he generation born 20 years later, in 1900, reached the age of 20 in 1920, and a lesser fraction of these had (lied by that age; namely 15 percent, this fraction being smaller presumably because the traditional childhood diseases were more under control. Therefore, the 1900 cohort at the age of 50 repre,sents a significantly different population from the 1880 cohort at the age of 50, since the_ former cohort-that is the 1900 cohort-includes the "weaklings" who were eliminated from the latter cohort, that is, the 1880 cohort. The relatively large number of cases of lung cancer observed in the 1900 cohort can be merely largely those who would not have survived to run the risk of lung cancer if they had been born 20 years earlier. On this model, the alleged historical increase in age adjusted lung cancer rate can be easily accounted for. I cannot accept., therefore, the rejection of the genetic hypothesis by the report "Smoking and Health." I would also like to point out that the hypothesis that cigarette smoking causes lung cancer, which the report accepts, has certain nontrivial difficulties. (1) The report quotes one of the criteria of what it calls the epi- demiolo~ic method as "Specificity." It uses two definitions of "Specificity." The first is- the precision with which one component of an associated pair can be utilized to predict the occurrence of the other. The report admits that the association of cigarette smoking with lung cancer has extremely low specificity in this sense. In other words, enormous numbers of people smoke cigarettes and never develop lung cancer. The second definition of specificity is similar to that of Yerushalmy and Palmer (18) : The basic assumption of such a test for specificity ts that if the characteristic fs not related to the disease In a causal way, then the relationship should not

398 CIGARETTE LABELING AND ADVERTISING-1965 be restricted to the disease under study but should also be present with other disease entities. If the characteristic can be shown to_ be related only or mustly to the disease under study and not to many other disease entitles, then our confidence that it is a cause-carrying vector for that disease is greatly increased. The report "Smoking and Health" states (p. 185): The number of diseases in which the ratios remain significantly high, after- consideration of the nonresponse bias, is not great enough to cast serious doubt on the casual hypothesis. This is really a preposterous statement. Table 26 of the report (pp. 109-110) tabulates the mortality ratios for 25 causes of death• for the 7 major prospective studies, and they are all consistent in showing that the mortality ratio is greater than one for virtually alil causes of death. In the light of the conslstenc'y of the seven studies• there is virtually no doubt that in almost every instance the mortality ratio is "significantly high." It is true that for 1 out of the 25 causes• of death the mortality ratio is less than 1, being 0.9, but this is for a cause of death with relatively small expected number of deaths and hence with a high sampling error. We therefore see that the associa- tion between cigarette smoking and lung cancer is monumentally non- specific yet the report "Smoking and Health" states that it has a "liigh dtefiree of specificity" My only comment on this is that it is a splendld example of the technique of flatly denying the existence• of an inconvenient fact if you cannot explain it away. It is perfectly clear, in my opinion, that the association between ci fiarette smolang and virtually all causes of death has to be ex- plained on physical-chemtcal and biological grounds if the causative• hypothesis is to be accepted. The protagonists of the causative hypothesis have had at least 10 years to wra p- up this part of the- pral~lem huthave so far failed, even as regards lnng cancer. The most potent carcinogen identified-in cigarette smoke is benz- (a)pyrene and "it is present in much larger quantity than any of the other carcinogens." Cigar smoke has almost 4 times as much benz (a) pyrene, and pipe smoke about 10 times as much benz(a)pyrene• as cigarette smoke, yet pipes and cigars have been pretty well exon- erated by the Surgeon General's Advisory Committee of any charge of causing lung cancer. Apart from the above measurements on smoke, the difference be- tween cigarettes on the one hand and cigars and pipes on the other is a puzzling and unexplained feature of the indictment of tobacco_ It could be, of course, that the variety of tobacco used differs signifi- cantly, that the tobaccos are cured dlfferently, that cigurs and plpes may burn at different temperatures from that of clgarettes, that pipes and ci ars do not inelude paper, or that some cigarette smokers are suppose~ to inhale whercas few pipe or cigar smokers do. But if inhalatlon was the crucial factor, then analyses differentiating be- tween inhalera and noninhalers of cigarettes should have disclosed this, whereas these analyses have reached very inconsistent results and have been very confusl,n;. The hypothesis that cigarette smoking causes lung cancer would be• substantially more convincing if experiments to induce lung cancer by cigarette smoke in laboratory animals had proved successful, but so far only negative results have been reported. CIGARETTE LABELING AND ADVERTISIN(i--I96b 399 While explanations for a causative relation between cigarette smok- ing and lung cancer are still totally unsatisfactory after a decade of research, the situation is even emptier for the other causes of death. The report "Smoking and Health" uses the apparent historical increase of lung cancer and the historical increase in cigarette smok- ing as an argument to buttress its conclusion of causation. However, all statisticians know that the presence of a positivel zero, or negative correlation between two variables observed over tlme has been the basis of more ludicrous nonsense than any other statistical technique. For example, the incidence of cancer of the stomach has been deciin- ing for many years, but only a madman would infer from this that the increased smoking has caused the decreased cancer of the stomach. The report "Smoking and Health" also attempts to use correlations between different countries in the same way, and this is equally absurd. To sum up, firstly there are quite a few difficulties currently present to bedevil the hypothesis that cigarette smoking causes lung cancer. Future research may clarify the situation and dispose of them, but this remains to be seen. Secondly, the genetic hypothesis is very much in the running. Thirdly, the hypothesis that cigarette smoking causes lung cancer cannot be accepted as established, even if its own diff culties are dis- posed of, until the genetic hypothesis has been proven false. There- fore, to reach a decision at this time is completely unjustifiable. For the reasons I have given, I do not believe that the existing statisticall evidence is sufficient to justify any scientific conclusion that cigarette smoking causes cancer. (The attachments to Mr. Brownlee's statement follow:) 86H'ESENCEs (1) "Smoking and Health," report of the Advisory Committee to the Surgeon General of the Public Health Service. Public Health Service Publication No. 1103. Undated. (2) Irwin, J. 0., "The Place of Mathematice in Medical and Biological Sta- tistics," Journal of the Royal Statistical Society, series A, 126 (1963), 1-45. . ~i~ Neyman, J., "$tatistics-Servant of All Sciences;' Science, 122 (1955), (4) Berkson, J., "Smoking and Lung Cancer: Some Observations on Two Recent Iteports," Journal of the American Statistieal Association, 53 (19fi8), 28-38. (5) Berkson, J., "Smoking and Lung Cancer," American Statistician, 17 (1903), 15-22. (6) Yule, 0. Y., "The Function of Scientific Method in Scientific Investiga- tion," Industrial Fatigue Research Board Report, 28 (1924). (7) Fisher, Sir Ronald, Letter to the Editor, Nature, 136 (1935), 474. (8) Fisher, Sir Ronald, Letter to the Editor British Medical Journal, 2 (1957),297-8. ~ _ (9) Fisher, Sir Ronald, "Cancer and Smoking," Letter to the Editor, Nature, 182 (19.~ti), 0.10. (10) Friberg, L., Hai), L., Dencker, S. J., and Tonsson, Bl., "Smoking Habits in Monozygotic and Diaygotic Twins," British Medicnl Journal, 1(1f15i1), 109a2, (11) Raaschou-Nielsen, B)., "Smoking Habits in Twins," Danish Medical Bul- letin, 7 (1960), 82-8. (12) Seltzer, Carl C., "Morphologic Constitution and Smoking," Journal of the American Medical Association, 183 (1963), 639-45. (13) Eysenck, H. J., Tarrant, M., Woolf, M., and England, L., "Smoking and Personality," British Medical Journal, 1(1960), 1456-80. g4sssszooi

400 CIGARETTE LABELING AND ADVERTISIN(3-1966 (14) Yerusbalmy, J., "8tatistical Considerations and Evaluation of Epidemi- oloaical Evidence," in James, George, and Rosenthal, Theodore, "Tobacco and I3ealth:" Springfield: Cbarles C. Thomas, 19(i2, 208-30. (15) Hanimond, E. Cuyler, "Smoking in Relation to Mortality and Morbidity: Findings in First 34 Months of Followup in a Prospective Study Started in 1959." Statistical Research Seetion, Medical Affairs Department of the American Cancer Bociety. (1fi) Yerusbalmy, J., and Palmer, Carroll E., "On the Methodology of Investl- gations of Etiologic Factors In Chronic Diseases," Journal of Chronic Diseases, 10 (1959), 27-40. K. A. BaownLSa. , PIIDLIOATIONB or K. ALEEAftDE6 B80W1YLEE (1) Doosa "industrial Experimentation." London: His Majesty's Stationery Office. First edition, 1946. Second edition, 1946. Third edition, 1948. Fourth editlon, 19,18. Also Brooklyn, N.Y. : Chemical Publishing Co., 1949. '"Statistical Theory and Methodology in Science and Engineering." New York: John Wiley & Sons. First edition, 1900. Second edition, 1965. (2) PAPERS With C. S. Delves et al.: "The biological assay of streptomycin by a modified cylinder plate method," Journal of General Microbiology, 2 (1948), 40-53. Vith P. K. Loraine and J. Stephens: "The biological assay of penicillin by a modi0ed plate method." Journal of General Microbiology, 3(1949), 347-352 With P. K. Loraine: "The relationship between finite groups and completely orthogonal squares, cubes, and hypercubes," Blometrika, 36 (1948), 277-282. With Il: K. Kelly and P. K. Loraine: "Fractional replication arrangements with factors at two levels," Biometrika, 35 (194tt), 268-276. "A plant-scale experiment in penicillin production," Annals of_ the New York Academy of Sciences, vol. 52, art. 6(19:,0), 820-826. 'With Dorothy Ilamre: "Studies on chemotherapy of vaccinia virus, I: An ez- p~rimental design for testing antiviral agents," Journal of Bacteriology, 61 (11)51), 127-134. 'Wlth I)orothy Ilamre and Richard Donovick: "Studies on the chemotherapy of vaccinia virus, II : The activity of some thiosemicarbazonea:' Journal of Im- munology, 67 (1951), 305-312. Vith D. N. Lapedes: "The effeete of design upon the error of a microbiological assay for vitamin Journal of Bacteriology, 62 (1951), 433-444. "Construction and use of statistical control char_ts on continuous variables," Industrial and Engineering Chemistry, 43 (1951), 1303-1310. "Correlation methods applied to production process data," Industrial and Engineering Chemistry, 43 (1951), 206f-2071. "Some examples of the use of the analysis of variance in interpreting chemical data," Fifth Annual Convention of the American Society for Quality Control, 76-82. "A statistical analysis of the 1950 collaborative study on the USP method for vitamin B,. assay,`Drug: Standards, 20 (1952), 48-56. With J. L. Hodges and Murray Rosenblatt: "The up-and-down method with small samples," Journal of the American Statistical Association, 48 (19Ci3), 2(12-277. "Experiments with many factors," Chemical Engineering Progress, 49 (1989), 617-(i21. '"Statistics of the 1954 Polio Vaccine Trials," Journal of the American 8tatls- tical Association. 50 (11i55), 1005-1013. "A note on the effects of nonresponse on surveys," Journal of the American Statistical Association, 52 (1957), 29-32. "The Principles of Experimental Design," Industrial Quality Control, 18 (1957),12-20. •"6tatistical evaluation of cloud seeding operations," Journal of the American Statistical Association, 55 (1900), 446-4G3. K. A. Bsownrae. 6~,5969?,'001 CIGARETTE LABELING AND ADVERTIBINQ-196b Mr. ROGERS of Texas. Thank you very much, Mr. Brownlee. Mr. Kornegay g Mr. KORNEGAY. Thank you very much Mr Chairman 402 . Mr. Brownlee, I want to thank ou for coming and giving us this splendid statement. I understandyyou are a member of the Ameri- can Statistical Association and that you have been requested by that association to make a report. Mr. ItROWxr,EE. More exactly by the editor of the journal. Mr. KoRNEaAY. How is that, sir $ Mr. BROWNLEE. More exactly by the editor of the journal. Mr. KORNEOAY. Yes; by the editor of the journal to make a report on the document "Smoking and fieal.t.h." I take it, based on your statement, you made a rather detailed study of the Advisory Committee's report to the Surgeon General on "Smoking and Health." Mr. IiROwxLEE. Yes, sir. Mr. ICORNEOAY. And that your conclusion is that the report_ of the Advisory Committee to the Surgeon General fails to state a case against the hypotheses that cigarette smoking is the cause of lung cancer4 Mr. BROWNLEE. It states the case, a completely inadequate case. I mean that it attempts to make a case but one completely uncon- villctn and unttcc8 p- table. Mr. ~ioeNEaAY. Unconvincing and unacceptable. Mr. I3ROWNLEE. Yes. 11-f r. KORNEG_ AY. Thank you very much, sir. Mr. R<x)Etts of Texas. Mr. Younger 4 Mr. YOUNaEn. No questions. Mr. RoaERs of Texas. 1llr. Van Deerlin Y Mr. VAN Dt:ERtaN. No questions. Mr. RoGERS of Texas. as. Mr. Satterfield F Mr. 5AZ-rERrlEr.n. No questions, Mr. Chairman. Mr. RoGERS of Texas. Mr. Farnsley F Mr. FARNBLEY. Iiave you seen any reports of warning on effect of' sales? I have been trying to find out what happens when you put warnings on packages. The only evidence I have is on Bromo Seltzer. Do you have any information ? b1 r. RnowNLEF. No information, sir. Mr. FARNSLEY. Thank you. Mr. RooERS•.of Texas. Mr. Brownlee, thank you very much for your contribution to the record in this matter. Our next witness is Mr. Frank M. Bass, professor of industrial administration, Purdue University, Lafayette, Ind. Mr. Bass Y STATEMENT OF FRANS M. BASS, PROFESSOR OF INDUSTRIAL ADMINISTRATION, PURDUE UNIVERSITY Mr. BASS. Mr. Chairman, members of the committee, my name is Frank M. Bass. I am professor of industrial administration at the• Krannert School of Industrial Administratio_ n at Purdue University where I am principally concerned with the fields of marketing an& quantitative methods. I appreciate this opportunity to present my

402 CIGARETTE LABELING AND ADVERTIBIN(3-198b views on the probable effect of a warning in cigarette advertising upon cigarette consuwuption and competition in the industry. I received a Ph. D. degree in business from the University of Illi- nois in 1954, and have studied at the University of Texas and I-Iar- vard Univerity. I have taught at the Universities of Illinois, Texas, and at Ohio State, and since 1961 at Purdue. I am author with other of two books, "Frontiers of Marketing," "Thought and Science," Chicago (1958), and "Dfathematical Models and Methods in Market- ing," IIomewood (1961), as well as numerous articles on marketing, advertising, and sales behavior in periodicals. I am a member of the American Marketing Association, the Ameri- can Economic Association, The Institute of Management Sciences, and the Operations Itesearch Society of America. I consult on a regular basis with McGraw-Ilill Book Co., serving as an editor of one of their technical series. Congress has before it at least one bill which would impose a health warning in cigarette advertising. This bill is necessarily based on the premise that cigarette smoking constitutes a haza.rd to health. I understand that the Federal Trade Commission has issued a rule which would imposed such a warning on advertising. I am neither a medical doctor nor a scientist, and hence have no training permitting me to evaluate evidence related to cigarette smoking and health. Accordingly, I cannot assess the need for gov- ernmental action affecting cigarette smoking at this time. My testl-y mony will be concerned solely with analyzing the probable effect of a health warning in cigarette advertising from the standpoint of a marketing expert. Before discussing the effect of a warnin in cigarette advertising, it mav be helpful to mention briefly some ~asic principles governing the advertising of products such as cigarettes, including the influences which affect the demand for such a product. These principles do not represent merely my own point of view, but would, I believe, be geny erally accepted by marketing specialists and economists. CI(IAnE'iTE ADVERTISING AND TID': OVERALL DEMAND FOR CIGARETTF.B The purpose of cigarette advertising is primarily competitive, in that it is designed to promote the sales of a particular cigarette brand rather than stimulate the demand for cigarettes in general. The cigarette industry itself sponsors no cigaret.t,e advertising. All such advertising is sponsored by individual companies and is focused on a particular brand of cigarettes. This is, of course, also true of the advertising of most other consnmer convenience products. This type of competitive advertising may, at an early stage of the development of a product, increase aggregate demand. For example, competitive advertising of synthetic detergents contributed to the overall acceptance of these products by housewives in the postwar period. Likewise, as Neil Borden has shown, comPetitive cigarette advertising durmg the 1920's undoubtedly influenced the demand for cigarettes, particularly among women durmg that period.' I Neil Borden, "The Economic Effecte of Advertfeing^(1947), p. 222. ossssszooz CIGARETTE LABELING AND ADVERTISING-196b 403 When a product matures, however, marketing experts believe that competitive advertising has relatively little effect in stimulating overall demand. 'lhus, the competitive advertising of liquor at pres- ent probably does not induce a person to buy more of it, but rather to buv one brand rather than another. It is also a fundamental principle in marketing eting that advertising cannot create a demand for a product. It can only serve to accelerate demand for a product which is desired by consumers for reasons independent of advertising; that is, advertising is more a response to social conditions than it is a shaper of them.' The most massive and skillful advertising expenditures could not induce the public to buy the Edsel automobile, since the public at that point was not interested in cars of the I:dsel ty . This lack of interest was determined by social factors which coui not be reached by the Ford Motor Co.'s advertising. The decisions to begin to smoke and to continue smoking are sim- ilarly governed by factors independent of advertising which can be described as psychological or social in the most basic sense. While it is probably true that advertising may have some minor influence in today's cigarette market in inducing those who smoke to continue smokln and in attracting nonsmokers into the market, social atti- tudes atout smoking are of far greater importance than advertising in determining these choices. TIBH EFFECT OF A wARNIN(i IN CIOARETTE ADVERTISING ON CIOARETl'E CONSUMPTION Applying these generally agreed upon principles, I believe that it is possible to make some predictions as to the effect of a health warning in cigarette advertising. There is a high degree of probabil- ity that the ultimate effect of a compulsory health warning in ciga- rette advertising on the demand for cigarettes generally would be so marginal that it could not be measured. This conclusion is supported by two basic premises:~ (a) Most, if not all, smokers are aware of the alleged health haz- ards in eigrn,rette smoking. The wide publicity given the Surgeon General's report and earlier reports in all media forms, including television, radio, magazines, and newspnpers, insures a high degree of consumer awareness of this issue. Those consumers who are not aware of the issue are not likely to be informed by a warning in Advertising: because they do not watch or read advertising, or if they do_ see it, they do not attend to it. (b) An advertising warning ould have little impact on consumers who would actually see it. As I will point out later in more detail, consumers do not expect to see health warnings in advertisinp. Con- sumers are highly selective in the advertising messages to which they pay attention, as many advertisers have found to their cost. Since the warning would be jarring and unpleasant, it would tend to be rejected or blocked out by the smoker. Also, the basic conflict be- tween a positive advertising message and a negative warning would tend to neutralize the impact of the warning on the viewer. $Borden, op. dk, sopr.. p. 484. 0, ,PW..,~,..

404 CIGARETTE LABELING AND ADVERTIBING--1885 It follows that if a health warning is imposed in cigarette advertis- inl; in order to reduce cigarette smoking, it will have no measurable efl`ect on the overall demand for cigarette products. Assuming that governmental action is indicated, it appears inadvisable to impose such a warning, since it would have no significant impact on smoking habits. THE EFFECT OF A WARNINO IN CIGARE'iTE ADVERTI8IN0 ON COMF'E'IZTION A warning in cigarette advertising would not only be ineffective to reduce cigarette smoking, but it would have undesirable conse- quences which should be carefully considered by Congress before it imposes such a warning. I have already pointed out that competition among ci garette brands is maintained in large part through adver- tising: Compulsory-- inclusion of a warning in advertising would constitute a radical departure from existing a,dvertising practices. The purpose of cigarette advertising is to stimulate demand for a particular brand of cigarettes. Since the purpose of a warning is presumably to diminish demand for that brand and for other ciga- rettes, it is obvious that a warning would be anticompetitive and at cross-purposes with the intent of the advertising. Advertising at- tem~ts to create a favorable impression for the brand, to induce the smolcer to purchase that brand rather than other brands. A health warning would reduce the effectiveness of the individuall advertise- ment because it contradicts this basic advertising message. Since the warning presumably would be uniform in each advertisement, its presence would tena to blur the product differences or advantages which the advertisement seeks to convey to the smoker. IIence, a health warning would tend to restrict, if not to nullify, the effective- ness of advertising as a competitive mechanism. I cannot, of course, predict exactly what would be the effect of a compulsory health warnin~ on the advertising of various brands or types of cigarettes. However, certain probable consequences can be deduced from the nature of the various media. The impact of a warning would be greatest in television and radio advertising, which is by far the most significant form of cigarette advertising. Radio niig7it be eliminated as an advertising medium for cigarettes, since advertisers might not want to produce the warning in verbal form. Many television commercials might be eliminated since the warning would occupy a significant portion of the time of the commerciai,. Competitive effectiveness of other television advertising would un- doubtedly be reduced. It is probable that a compulsory health warning would have a smaller impact on printed media than on broadcast media. Obvi- ously, however, the effectiveness of these media as advertising vehicles would be reduced by the existence of a warning. Brand advertising is one of the principal competitive weapons in the cigarette industry. To the extent that imposition of a warning would reduce competition, existing market shares would tend to freeze. The leading brands in the industry would tend to retain their existing positions since they would be far less vulnerable to inroads on their markets through advertising of competitive brands.. Com- panies would be handlcapped zn introducing new brands of ciga i8sssszooi CIGARETTE LABELING AND ADVERTISING-1986 405 rettes. These results would be contrary to sound economic principles, and to principles of free competitlon embodied in the antitrust ]aws.' _ Since I have already pointed out that there is a great deal of parallel evidence indicating that health warnings would not reduce cigarette demand in general, it would seem inadvisable to Impose a requirement which would be ineffective, and at the same time, have such drastic ant.icompetitive effect in this industry. WILAT CONBPMF.Rti EXPECT TO BEE IN ADVF.a17gIN0 It has been argued that consumers are misled as to the safety of cigarettes because of the absence of a warning in advertising. Even assuming that cigarettes are proved to be haznrdous, I believe that ~nsumers are not misled by the absence of health warnings in cig- arette advertising. This is because consumers do not expect to see health warnings in advertising. Consumers expect to see praise, or affirmative claims, in advertising. They expect to find warnings as to hazards, or limitations on use,-m the instructions which accompany the product either on the label or in brochures. It follows that the absence of a warning in advertising does not mislead a consumer as to any alleged health hazards in smoking cigarettes. That is, a smoker does not conclude from the absence of a warning in advertising, that there are no hazards in the use of the product. - Further, I believe that consumers read label warnings and, in fact, pay more attention to them than they do to individual advertisements. Accordrn ly, if the object of a warning is to inform consumers of the possib~e danger to health from cigarette smoking, a label warning would be a more appropriate and possibly more effective place for such a warning than in advertising. A label warning would also have few or none of the undesirable effects which I have already described. In conclusion, I would like to summarize the foregoing testimony as follows: 1. Cigarette advertising has little effect on the overall demand for cigarettes. 2. The effect of a health warning in cigarette advertising on cig- arette demand generally in all probability would be so slight as not to be measurable. 3. A warning in advertising would reduce competition in the in- dustry, tend to freeze market shares, and restrict product innovation.. 4. Consumers are not misled by absence of warnmgs in advertising. They expect warnings on package labels. A label warning miglit possibly be more effective than one in advertising, and would have fewer disadvantages Thank you. Mr. ILoaERs of Texas. Thank you, Mr. Bass, for your statement in the record. Mr. Kornegay is recogn ized. Mr. KORNEGAY. Dr. Bass, I want to thank you for coming today and making a very fine statement. • Report of Attoraey Oeaersl's Commlttee os the Antltrust Laws (1966), pp. 830-Q81.

4Q('j CIGARETTE LABELING AND ADVERTIBIN(I--196b You certainly made a good sound logical case against any law or reFulation requiring warnings on cigarette advertising. I'lia.nk you very muc1l. Mr.I3ASS. Thank you. Air. RooERS of Texas. Mr. Younger? 11ir.1'ouxaES. No questions. Air. PuicERs of Texas. Air. Van Deerlin i! Mr. VAN Dr:ERr.IN. Dr. Bass, do you have any suggestion as to the manner in which cigarette labeling might be more effective, whether on the side panel or on the face of the package, and also what the woriling might a,)propriately be? Air. BASS. Nell, I think that with respect to the latter question first, tho question of wording is something which involves two elements,. one is medical and I am not qualified in that area, and the other is le„ ai and I am not qualified there, either. So I don't think I could olfe.r anynseful informatron about the wording. Now, with respect t.o the location on the package, I don't have an opinion, I just haven't thought about that very much. I think that cleariy it should be some place, if the purpose is to convey information, tia hich would accomplish that result. It shouldn't be buried some place, but some place which will be clearly evident to the smoker. Mr. VAN DE}:RLIN. Of course, a package label will convey the con- clusion by Congress that there is, at least, a potential health hazard in smokin;, andI should think that as a man who is an expert in the field of inerchandising and packaging, that you wouldn't have to have legal experience. IIow sharp a warning would it have to be 4 Xre tive going to have to jolt them g Mr. BASS. 'What is the purpose of the advertising warning- If the purpose is to convey information, that is one thing. Now, if you are interested in affecting the demand for cigarettes, that may be something else again. Air. VAN DEERr.IN. Well, surely one of the objectives is going to be to influence new smokers, to stop them before they start. Do you have any advice that init;ht be helpfwl to the committee in t1I i s refiaird ? Air. RASS. Well I think there are other methods which would be much more effective than any advertising warning being proposed here to try to diminish the number of new smokers coming into the market, such as, for example, educational campaigns aimed at this group. Mr. VAN DEERLIN. In schools? Mr. BASS. Yes. Films, brochures, that sort of thing, I think would be much more effective than the warning. Frankly, I don't think any a.dver4,isin~ warning which the Congress is likely to come up wit.h is going to be very effective in terms of in- fluencin g, people to smoke or not to smoke. Air. VAN DEERiax. Thank vou, Mr. Chairman. Mr. ROGERS of Texas. Mr. Aatterfield S D ir. S A-I-rr:RH-IEr.D. I have no questions, Mr. Chairman. Air. Rcxir:RS of Texas. Mr. Farnsley4 Mr. FARNSLEY. Thank you, Mr. Chairman. CIpARETTE LABELING AND ADVERTIBIId(}-1966 407 Doctor I appreciate your paper. This isn't based on research, is it Y It is just hased on your opinion; not that there is anything wrong with your opinion, I am grateful for it. Mr. BASS. Well, it is based on a certain amount of research h relating to behavior of sales of various products through time. I have_ done some research in this area on sales behavior tlirough time; it is not based on any experimental evidence. Mr. FARNSLEY. Any studies of products that have had warning labels put on them, the effect on salest if any g Mr. I3ASS. No. I know of no specific experiments. Air. FARNSLEY. As you I)robably know if you were here this morn- ing I am one up on you. T have one product that they did put warn- ings on that doubled its value of stock. IVhat is your opinion, Doctor, what if the Congress passed a law prohibiting all advertising of cigarettes, let them give away samples, what do you think that would do to the total consumption of cigarettes in the United States? Mr. BASS. I don't think it would be greatly affected. Mr. FARNBLEY. Up or down or sideways? Mr. BASS. I would think that over a long enough period of time it might have some small influence. I think if you look at the im- mediate impact, I think it would be very diflicultto judge. Let me put it this way, sir, if you looked at sales of cigarettes in time series data, and suddenly all advertisin g- were abolished, and you brought in a person who didn't know w31en this had happened and you gave him the data and said, "Look at the data and tell me when t1lo advertising was abolished." I don't think this person would be able to tell you when it was abolished by looking at the data. Mr. FARNsiEY. You think in the long run it would go up, down, or sldeways 8 Not sidewa,ys, up down, or have no effect 9 Mr. BASS. i'Pell~~I~ believe it would have a marginall effect. Air. FARNSr.F.Y. W nic_h way 8 Mr.I3ASS. Down. Air. FARxsL>;Y. Over a period of what 4 Mr. BASS. Over a period of time. Mr. FARNSry.Y. Ten years B Mr. BASS. Yes. Perhaps longer. Air. FARNAr,EY. My information is that the industry spends a quarter of a billion dollars and maybe will this year in advertising. If they- how long would it take, how much would it have to drop before they would ho even, in other words, if they save that much money and are ahead of the game, for how long, for how much of a drop g Air. BASS. Well, in general, I think cigarette companies, as is true for all convenience goods, firms, look at the advertising in this way: You do not expect to recover from the customers you induce t.o'buy your brand this year the cost of the advertising, whicll you spend this year. Let s look at that this way. Suppose yon spend $10 for advertising, and suppose as a result of spending that $10 you induce, let's say, one customer to buy a brand, and suppose the profit per unit is, exclusive of fihe advertising cost, let's say, $2.50. tiVell, you spent $10 to get t2.50. However, we have overlooked the average length of t.imo that customer will stay with the brand. Z8S969ZOOZ

408 CIGARETTE LABELING AND ADVEftTISING-198b Suppose he stays with the brand on the average for five periods. So now we have generated $12. 50 worth of profit contribution for our $10 advertising expenditure. So, using this reasoning, it is clear that the profits of the cigarette industry would sk,yroclcetif all advertising were abolished. It is so stagV,ring it is hard to contemplate, but the profits in the industr ywould go up enormously if the cigarette adver- tising were completely eliminated. The market shares would tend to be frozen, the primary demand for cigarettes would not be greatly affected one way or the other, and the profits in the industry would be just enormous, and this is one reason, of course, for not. interfering with the competitive practices in the industry. For the same reason I n ould think you would want to interfere with the competitive practices in any industry unless the public interest is severely damaged; and usually we think of competitive activity as being beneficial to the public interest.. You see, it might be instructive to apply the logic which apparently the Federal Trade Commission has applied to cigarettes, to automo- biles. Let's take a product where the emotional content is not quite as great. You might reason something like this : a great many people are killed in automobile accidents every year, a fireat many others are mainned and injured, more I should imagine, I don't have the statistics, but more I should imagine than is the case for lung cancer. Air. KoRNr•.aAY. Let me interrupt you just a minute, sir. Air. Ilnss. Yes. Mr. I:oRNFOAY. Following your logic a couple of st.eps further, that is a series of statements that you made, to stop advertising would freeze the markets, the money going into advertising would-go into ~rofits, the profits would become enormous, then wouldn't there also he an inclination to meet. competition or to further the market or reduce the price of the individual companies, reduce the price and in reducing the price making ci arettes cheaper, and if they are cheaper they willl sel.ll more and, there5ore, we will have more smokmg? Air. BASa. Yes, sir. Mr. KORNE6AY. Is that apossibility? Mr. BASS. Yes, sir•, I think there is. I think the price reduction would not be extremely great, thou h, because the advertising costs var anyywhere from two and a half cents to 7 or 8 cents a carton so Iydon t think you could count on any really great reduction in price. But I think that it is certainly true that if you try to circumvent one area of competition, the inevitable result of that is that the firm searches for other areas of competition, and so that would be a l.ogical consequence, I think. Air. KORNEGAY. Thank you. Mr. FARNSLEY. Is there any evidence that price decrease would increase sales? Air. BAes. The demand for cigarettes is generally regarded to be what economists call inelastic, which simply means that a change In the price either up or down produces a less proportionate inverse change in the quantrty demanded. So that a price reduction would, economists would think ingeneral, other things being equal, increase the demand for cigarettes, but the increase would not be in proportion to the price reduction. USsssszooi CIGARETTE LABELING AND ADVERTISING_--I988 4()9 Mr. F:+RNSr,EY. Well, now, when I %vas a boy we knew cigarettes were bad for you and we called them coffin nails and some of the doctors have caught up with us although they smiled at us at the time. I-fow many times have you read in the last 2 or r 3 years that ciga- rettes are bad for you or cause cancer or kill you? IIow many times have you read it? Mr. I3nss. A great many times. A(r. FARNhLr;Y. Just casually? Air. BASS. 1 es. Air. FARNSr.FY. You wouldn't have to be studying it? Air. B.%ss. Yes. Air. FAnxrsr.kY. Why do you think somebody can put out a parn- phlet that will convince young people after all that to do in the news- E apers and television and radio, what makes you think-wouid there e some niagic word you say to him ? Mr. RASS. I don't. know, sir. 11ir. FARNSLEY. Ilave you got any ideas on how to slow up smoking a cigarette, any other ideas ? Air. B."s, l1~'ell, I think one thing you could do is abolish the pro- duction and sale of cigarettes. I think that would slow it up. 11ir. FARNSLEY. It sure would. Mr. I3ANS. I think that, as I said, if you don't want to go that far, educational campaigns would be in fact a more effective way to influence the demand for clgarettes than any direct or indirect inter- ference with the advertising practices of the industry. Air. FARNSLEY. 1Vhat real reason can you figure thatt the companies mpanies have for not wanting t.o pass the law to helt)the Surgeon General. Ife would be willing to go for a law to prohibit advertisin 1Vhy (10 they fight that? g Mr. BASS. I am not privy to the thinking of the_ management. Mr. FARxsr,r:Y, jVhat would you think? Mr. BASS. I would guess it would be that they don't want inter- ference in the competitive mechanism in the industry, and I would think that. particularly the companies with smaller market shares would be especially mindful of the probable effects of any interference with competltion in the industry, the tendency to freeze the market shares nnd that sort of thing. Air. I+Anvsr.EY. You say the profits would be astronomical and it staggers the imagination. Maybe we have been going under t,he false impression that the profit factor is a big factor in the operat.ion of the industry. Mr. I3ASs. I think it has been overstated at times. I think that is right. There are a great many other factors which are important, other motives aside from immediate profits. 31fr. FARNSIa,Y. Thank you, sir. Mr• Itooi';RS of Texas. Thank you very much. ]ttr. I3ASS. Thnnk you, sir. Mr. ILcKir:Rs of Texas. Thank you, Mr. Bass. Our next witness is Dr. George L. Saiger, biostatistician, New Y ork, N.Y. Dr. Saiger, if you will come forward the Chair will recognize you. Dr. SAIoER. Thank you, Air. Chairman. Mr. RooFRs of Texas. You may proceed, Dr. Saiger. 48-.82"6-27