SPEECH TOBACCO CONFERENCE 1990 FORUM FOR PROFESSIONALS MISSOURI COALITION ON SMOKING AND HEALTH JEFFERSON CITY, MO MARCH t&l990 C. EVERETT KOOP, MD GREETINGS, ETC. 1 A THOUSAND AMERICANS WILL STOP SMOKING TODAY.. . . THEIR FUNERALS WILL BE HELD WITHIN THE NEXT THREE OR FOUR DAYS. THAT'S THE WAY I HAVE STARTED A NUMBER OF LECTURES ON SMOKING. IT GETS PEOPLE'S AITENTION. I FEEL I HAVE TO SAY SOMETHING DRAMATIC TO'GET THEIR ATTENTION. mI SHOULDN'T HAVE TO. WHAT IS IT ABOUT TOBACCO THAT NUMBS THE AMERICAN PEOPLE? IF ANYTHING ELSE KILLED 390,000 OF OUR FELLOW-CITIZENS EACH YEAR, THE PUBLIC WOULD DEMAND ACTION FROM OUR GOVERNMENT. INSTEAD, TOBACCO HAS, FROM THE BEGINNING, BEEN CODDLED BY OUR GOVERNMENT. THIS DISTINGUISHED AUDIENCE KNOWS ABOUT THAT, AND AS A PHYSICIAN AND FORMER PUBLIC HEALTH OFFICER, I DON'T WANT TO RAISE YOUR BLOOD PRESSURE --OR MAKE YOUR BLOOD BOIL- BY REVIEWING THE SORRY STORY IN GREAT DETAIL. BUT IN A FEW WORDS, I'LL REMIND YOU THAT TOBACCO HAS BEEN ASSOCIATED NOT ONLY WITH DISEASE AND DEATH, BUT ALSO WITH MONEY. THAT, OF COURSE IS THE REASON FOR ITS SPECIAL TREATMENT. TOBACCO WAS THE CASH CROP THAT FINANCED THE AMERICAN REVOLUTION --THOSE VIRGINIA PLANTERS FETCHED A GREATER RETURN FOR TOBACCO LEAVES THAN DID THE HARDY NEW ENGLANDERS FOR THEIR PUMPKINS. CONGRESS HAS BEEN HELD HOSTAGE EVER SINCE. DESPITE THE SINISTER ASSOCIATIONS, FIRST WITH SLAVERY, AND LATER WITH CANCER AND HEART DISEASE, AMERkAN TOBACCO HAS ENJOYED GOVERNMENT PROTECTION. TOBACCO MONEY EXPLAINS THE RELUCTANCE OF CONGRESS TO TOLERATE ANY REGULATION OF TOBACCO, SO IT HAS BEEN DECLARED TO BE NEITHER A FOOD, NOR A DRUG, NOR A COSMETIC. ANY SPEECH ON SMOKING BECOMES A "GOOD NEWS/BAD NEWS" STORY. THE GOOD NEWS IS THAT WE ARE --AT LAST-- WINNING THE WAR AGAINST TOBACCO. THE BAD NEWS IS THAT THERE ARE MANY BATTLES STILL TO FIGHT. IN MY FINAL YEAR AS YOUR SURGEON GENERAL I WAS PRIVILEGED TO COMMEMORATE WITH A SPECIAL REPORT THE 25TH ANNIVERSARY OF THE FIRST SURGEON GENERAL'S REPORT ON SMOKING. THAT FIRST, HISTORY-MAKING REPORT WAS TITLED "SMOKING AND HEALTH: THE REPORT OF THE ADVISORY COMMITTEE TO THE SURGEON GENERAL." IT WAS RELEASED TO THE PUBLIC ON JANUARY 11,1964, BY THE LATE DR. LUTHER L. TERRY, A COURAGEOUS PHYSICIAN WHO WAS SURGEON GENERAL OF THE U.S. PUBLIC HEALTH SERVICE AT THAT TIME. HOW MUCH DID WE REALLY KNOW IN 1944 ABOUT SMOKING AS A CAUSE OF CANCER? AND HOW MUCH DO WE REALLY KNOW TODAY? LET ME BEGIN BY OBSERVING THAT THE FIRST REPORT BY DR TERRY DID NOT INITIATE A RESEARCH PROGRAM LINKING SMOKING WITH MAJOR DISEASE CONDITIONS. SUCH RESEARCH WAS ALREADY GOING ON. MEDICAL CONCERN ABOUT SMOKING DID NOT POP OUT OF NOWHERE IN 1964. LONG BEFORE THAT THERE WAS A CORE OF CONCERNED PHYSICIANS, ESPECIALLY CONCERNED ABOUT THE CLEAR CONNECTIONS BETWEEN LUNG CANCER AND SMOKING IN THEIR MALE PATIENTS. DR. TERRY'S REPORT GAVE NEW ENERGY AND NEW DIRECTION TO AN ALREADY IMPRESSIVE RESEARCH EFFORT. IN FACT, AS OF 1964 THERE WERE 7,000 ARTICLES IN THE WORLD BIOMEDICAL LITERATURE DEALING WITH THE LINKAGE BETWEEN SMOKING AND HEALTH. AFTER REVIEWING THOSE RESEARCH PAPERS, THE SURGEON GENERAL'S ADVISORY COMMITTEE CAME TO THE FOLLOWING CONCLUSIONS ABOUT CIGARETTE SMOKING IN 1964: FIRST, THAT MEN WHO SMOKED HAD AN OVERALL HIGHER MORTALITY RATE THAN MEN WHO DID NOT SMOKE. SECOND, THAT SMOKERS HAD INCREASED MORTALITY RATES FROM CORONARY HEART DISEASE, CEREBROVASCULAR DISEASE, AND OTHER CARDIOVASCULAR DISEASE CONDITIbNS. 10 THIRD, THE ADVISORY CO MMITI'EE SAID CIGARETTES WERE A MAJOR CAUSE OF CHRONIC BRONCHITIS AND CONTRIBUTED TO THE HIGH MORTALITY RATE FOR EMPHYSEMA. FOURTH, THE COMMIT-TEE SAID -- IN 1964, REMEMBER -- THAT CIGARETTE SMOKING WAS THE MAJOR CAUSE OF LUNG CANCER IN MEN AND MAYBE FOR WOMEN, ALSO. 11 FIFTH, THE COMMITTEE ALSO SAID THAT SMOKING WAS, AT THE VERY LEAST, A CONTRIBUTING CAUSE OF ESOPHAGEAL CANCER, BLADDER CANCER, AND PANCREATIC CANCER, AND THAT PIPE SMOKING CONTRIBUTED TO CANCER OF THE LIP AND THE ORAL CAVITY. FINALLY, THE COMMWE CONCLUDED THAT "CIGARE'ITE SMOKING IS A HEALTH HAZARD OF SUFFICIENT IMPORTANCE IN THE UNITED STATES TO WARRANT APPROPRIATE REMEDIAL ACTION." 12 SUCH "APPROPRIATE REMEDIAL ACTION" WAS TAKEN ALMOST IMMEDIATELY. THE UNITED STATES CONGRESS SOON PASSED A LAW REQUIRING ALL CIGARETTE PACKAGES TO CARRY THE FOLLOWING MESSAGE: "CAUTION: CIGARETTE SMOKING MAY BE HAZARDOUS TO YOUR HEALTH." 13 SIX YEARS AFTER THE RELEASE OF THE FIRST REPORT ON SMOKING AND HEALTH, THE CONGRESS ENACTED A SWEEPING LAW THAT BANNED CIGARETTE ADVERTISING FROM RADIO AND TELEVISION. THE NEW LAW ALSO TOUGHENED UP THE HEALTH WARNING ON CIGARETTE PACKAGES. THE NEW LANGUAGE SAID... "WARNING: THE SURGEON GENERAL HAS DETERMINED THAT GIG-TI'E SMOKING IS DANGEROUS TO YOUR HEALTH." 14 HOW DID THAT COME ABOUT? BY 1970, WHEN THE NEW LAW WAS PASSED, THE ORIGINAL BASE OF 7,000 RESEARCH ARTICLES HAD ALMOST TRIPLED -- APPROXIMATELY 19,000 RESEARCH PAPERS WERE THEN IN THE INTERNATIONAL LITERATURE -- AND THE NEW MATERIAL WAS ALSO VIRTUALLY UNANIMOUS IN IDENTIFYING CIGARETTES AS THE MAJOR CAUSE OF MORBIDITY AND MORTALITY ACROSS A BROAD SPECTRUM OF DISEASE CONDITIONS. 15 THE NEW INFORMATION NOT ONLY CONFIRMED THE FINDINGS PUBLISHED IN 1964, BUT ALSO IT LINKED CIGARETTE SMOKING TO PANCREATIC, GASTRIC, RENAL, AND CERVICAL CANCERS. CIGARElTES WERE ALSO IDENTIFIED AS THE CHIEF CULPRIT. IN ATHEROSCLEROSIS . . . IN PEPTIC ULCERS . . . IN COMPLICATIONS OF PREGNANCY . . . IN INTERACTIONS WITH ALCOHOL AND CERTAIN PRESCRIPTION DRUGS . . . AND SO ON. 16 IN OTHER WORDS, 6 OR 7 MORE YEARS OF RESEARCH DID NOT WEAKEN.OR COMPROMISE THE EARLIER FINDINGS. IT MADE THEM ALL THE MORE FORMIDABLE. BY THE TIME I ARRIVED IN WASHINGTON IN 1981 TO TAKE UP THE POSITION OF SURGEON GENERAL, THERE WERE NEARLY 50,000 PIECES OF PUBLISHED RESEARCH WORLDWIDE. AND AGAIN, THE OVERWHELMING MAJORITY OF THAT RESEARCH ONLY STRENGTHENED THE PUBLIC'S CASE AGAINST SMOKING. 17 THE EVIDENCE AGAINST SMOKING BUILDS EVERY YEAR, AND THE AMERICAN PEOPLE ARE BELIEVING IT. AS YOUR SURGEON GENERAL I RELEASED 8 ANNUAL REPORTS ON SMOKING. THEY HAVE DEALT WITH CANCER, CARDIOVASCULAR DISEASE, CANCER IN WOMEN, SMOKING IN THE WORKPLACE, CHRONIC OBSTRUCTIVE LUNG DISEASE, INVOLUNTARY SMOKING OR WHAT IS SOMETIMES CALLED "PASSIVE SMOKING," AND THE ADDICTIVE QUALITIES OF NICOTINE. 18 EACH ONE HAS ITS OWN SPECIFIC AND IMPRESSIVE DATA BASE. TODAY, THE SMOKING-AND-HEALTH RESEARCH BASE IS STILL GROWING. NOW IT IS COMPRISED OF MORE THAN 60+000 PUBLISHED ARTICLES. AGAIN, THE VAST MAJORITY QUITE CLEARLY REINFORCES THE FACT THAT CIGARETTE SMOKING IS THE SINGLE MOST IMPORTANT FACTOR BEHIND ACUTE AND CHRONIC MORBIDITY AND PREMATURE MORTALITY AMONG ADULTS. OR, IN OTHER WORDS, CIGARETTE SMOKING IS THE SINGLE MOST IMPORTANT REASON WHY AMERICANS GET SICK, THE SINGLE MOST IMPORTANT REASON WHY THEY DIE BEFORE THEY SHOULD. 19 AS THIS RESEARCH BASE EXPANDED, SO DID OUR EFFORTS TO EDUCATE THE PUBLIC . . . TO GET THOSE WHO SMOKE, TO STOP . . . AND THOSE WHO DON'T SMOKE, TO NEVER START. IN 1984, I WAS PERSONALLY SO CONVINCED BY THE DATA ACCUMULATED THUS FAR THAT I CALLED UPON MY FELLOW CITIZENS TO lMAKE THE UNITED STATES A "1 BY THE YEAR 200Q." 20 WE'LL ACHIEVE THAT SMOKE-FREE SOCIETY BECAUSE WE WILL GRADUATE A CLASS FROM HIGH SCHOOL IN 2000 THAT WILL HAVE HAD 12 YEARS OF ANTI-SMOKING HEALTH MESSAGES. IT STARTED THE YEAR BEFORE LAST, IN THE FIRST GRADE. TEACHING CHILDREN THAT YOUNG WILL ENABLE US TO WIN. THE SURGEON GENERAL'S REPORTS ON SMOKING AND THE WORKPLACE AND ON INVOLUNTARY SMOKING WORKED TOGETHER TO GIVE THE MILITANT ANTI-SMOKERS NEW AND POWERFUL WEAPONS. 21 THE NONSMOKER WAS MERELY IRRITATED AT FIRST...THEN BECAME ANNOYElD...AND THEN TURNED MILITANT. STUDIES INDICATING THAT PASSIVE SMOKING LED TO 46,000 DEATHS ANNUALLY (3,000 FROM LUNG CANCER, 11,000 FROM OTHER CANCERS, 32,000 FROM HEART DISEASE) MADE THE NON- SMOKER MILITANT . ..AND SUCCESSFUL IN ACHIEVING CHANGES IN SOCIAL CUSTOMS AND IN LOCAL AND STATE LAW. 22 AS OF MID-1988 MORE THAN 230 LOCAL COMMUNITIES HAD ADOPTED REGULATIONS RESTRICTING SMOKING IN PUBLIC PLACES, A THREE-FOLD INCREASE IN THREE YEARS. THE MOST RECENT VICTORY IS THE AIRLINE SMOKING BAN THAT BECAME EFFECTIVE JUST LAST WEEK (FEB 25,199O). OF THE 16,000 DAILY FLIGHTS IN THE USA, ONLY 28 SLIP THROUGH THE BAN, ALLOWING SMOKERS TO FOUL THE AIR. AND NORTHWEST AIRLINES VOLUNTARILY KEEPS THE CABIN AIR SMOKE-FREE ALL THE WAY TO HAWAII. 23 AND REMEMBER, LAST NOVEMBER A TOUGH LOCAL SMOKING CONTROL ORDINANCE WAS APPROVED BY THE VOTERS IN GREENSBORO, N.C., IN SPITE OF HEAVY OPPOSmON BY TOBACCO COMPANIES. IF THE TOBACCO COMPANIES CAN BE BEATEN IN NORTH CAROLINA, THEY CAN BE BEATEN ANYWHERE! 24 SMOKING HABITS HAVE CHANGED. IN 1964 OVER HALF OF ADULT AMERICANS SMOKED. WHEN I BECAME SURGEON GENERAL IN 1981, THE NUMBER HAD DECLINED TO 33 PERCENT. BETWEEN 1964 AND 1985 APPROXIMATELY THREE-QUARTERS OF A MILLION SMOKING-RELATED DEATHS WERE AVOIDED OR POSTPONED BY DECISIONS TO QUIT OR NOT TO START SMOKING. EACH POSTPONED DEATH REPRESENTED AN AVERAGE GAIN OF 2 DECADES OF LIFE EXPECTANCY. 25 NEARLY HALF OF ALL LIVING ADULTS WHO HAVE EVER SMOKED HAVE QUIT. FIFI'EEN YEARS AGO, AT MEDICAL MEETINGS, WHERE DOCTORS SHOULD HAVE KNOWN BETI'ER, THE AIR WAS BLUE WITH SMOKE. NOW YOU RARELY SEE A PHYSICIAN SMOKE; THE ONLY SMOKE AT MEDICAL MEETINGS COMES FROM THE 26 FEW THINGS BRINGS ME AS MUCH SATISFACTION AS THE DRAMATIC DECREASE IN SMOKERS DURING THE LAST 8 YEARS, FROM 33 PERCENT TO 26 PERCENT. BUT THERE IS MORE TO DO. THERE IS STILL PLENTY OF BAD NEWS. 27 SMOKING IS STILL THE SINGLE MOST DEADLY "HABIT" . . . ASSOCIATED WITH HIGHER MORTALITY AND ILLNESS THAN DRUGS, AUTOMOBILES, AND AIDS COMBINED. ALL THE AIDS PATIENTS WHO HAVE DIED SINCE WE KNEW ABOUT THE DISEASE, 8 YEARS, EQUALS THE SMOKING DEATHS OF ONLY 4 MONTHS. THE NUMBERS OF DEATHS ANNUALLY ATTRIBUTABLE TO SMOKING HAVE RISEN WITH EACH SURGEON GENERAL'S REPORT. 28 THE NEWEST STATISTICS, THE NEWEST STUDIES ARE GRIM. THEY DOCUMENT CONCLUSIVELY THE CAUSAL RELATIONSHIP BETWEEN SMOKING AND CANCER OF SEVERAL ORGANS. SMOKING IS A CLEARLY ESTABLISHED CAUSE OF CANCER OF THE LUNG, LARYNX, ORAL CAVITY, AND ESOPHAGUS. SMOKING ELEVATES THE DEATH RATES FOR CANCERS OF THE BLADDER, KIDNEY, PANCREAS, STOMACH, AND CERVIX. 29 FURTHERMORE, PASSIVE OR INVOLUNTARY SMOKING HAS BEEN ESTABLISHED AS A CAUSE OF LUNG CANCER IN NON-SMOKERS. PIPE AND CIGAR SMOKERS SUFFER HIGHER RISKS --SOMETIMES EXCEEDING THE RISKS OF CIGARETTE SMOKERS-- FOR CANCER OF THE ORAL CAVITY, LARYNX, PHARYNX AND ESOPHAGUS. THE DATA BASE FOR THESE CONCLUSIONS IS VOLUMINOUS AND UNASSAILABLE, TRACKING MORE THAN 2 MILLION INDIVIDUALS IN ALL 50 STATES. 30 THE EVIDENCE MAKES CLEAR THE INCREASED MORTALITY RISK FACTORS CAUSED BY SMOKING: MALE SMOKERS EXPERIENCE A 22-FOLD GREATER LUNG CANCER MORTALITY RISK THAN MALE NON-SMOKERS; AMONG WOMEN SMOKERS THE LUNG CANCER RISK IS 12 TIMES GREATER. FORMER SMOKERS ENJOY LOWERED MORTALITY RISKS, THOUGH NOT AS LOW AS NON-SMOKERS. WHILE THE STUDIES REVEAL A DOUBLED LUNG CANCER RISK FOR MALE SMOKERS, AND A 41FOLD INCREASE LUNG CANCER RISK FOR SMOKING FEMALES, THE LUNG CANCER MORTALITY RATE FOR NONSMOKERS REMAINED UNCHANGED FOR BOTH MEN AND WOMEN DURING THE YEARS COVERED BY THE STUDIES. 31 THETOTALNUMBEROFSMOKING-RELATEDCANCERDEATHSWE CAN EXPECTIN1990WILLAPPROACH175,000. THISAMOUNTSTO35PERCENTOFALLCANCERDEATHS. THESEl75,000DEATHSWOULDNOTBEEXPECTEDTHISYEARIF TOBACCOUSERSEXPERIENCEDTHESAMEDEATHRATESAS THOSEWHODONOTUSETOBACCO. 32 OF COURSE, CANCER IS NOT THE ONLY PROBLEM. CIGARETTE SMOKING ALSO LEADS TO DEATH FROM CORONARY HEART DISEASE. AND ALTHOUGH THE SMOKING-RELATED RISK FACTOR FOR CORONARY HEART DISEASE IS LOWER THAN THAT FOR CANCER, THE NUMBER OF SMOKING-RELATED CORONARY HEART DISEASE DEATHS IS LARGE SIMPLY BECAUSE CORONARY HEART DISEASE REMAINS THE GREATEST SINGLE CAUSE OF DEATH IN OUR SOCIETY. SMOKING ACCOUNTS FOR ABOUT 21 PERCENT OF THOSE DEATHS. 33 HOWEVER, THIS DARK CLOUD HAS A SILVER LINING. THE PRESENT CORONARY HEART DISEASE AGE-ADJUSTED DEATH RATE IS 50 PERCENT LOWER THAN IN THE 1960s; THE REDUCTION IN SMOKING IS A MAJOR FACTOR IN THIS DECLINE. QUITTING SMOKING REDUCES MORE SIGNIFICANTLY THE RISK FOR CORONARY HEART DISEASE THAN THE RISK FOR LUNG CANCER. FM!, OR TEN YEARS OFF CIGARE'ITES GIVES A RISK FACTOR SIMILAR TO THAT FOR THOSE WHO NEVER SMOKED. 34 THIS DECLINE HAS PROGRESSED TO THE POINT WHERE LUNG CANCER, NO LONGER CORONARY HEART DISEASE, IS THE SINGLE LARGEST CAUSE OF EXCESS MORTALITY AMONG AMERICAN SMOKERS. CONTINUING OUR GOOD NEWS/BAD NEWS THEME, THAT GOOD NEWS --ABOUT LOWER RATES OF CORONARY HEART DISEASE BECAUSE PEOPLE HAVE STOPPED SMOKING-- IS FOLLOWED BY SOME NEW BAD NEWS, ESPECIALLY ABOUT WOMEN. 35 THE CONTINUING INCREASE IN LUNG CANCER AMONG WOMEN SMOKERS IS PARTICULARLY ALARMING BECAUSE THE MAGNITUDE OF THE RISK IS SURPRISING. WOMEN BEGAN TO SMOKE IN GREAT NUMBERS ABOUT THREE DECADES LATER THAN MEN, SO WE ARE SEEING ONLY NOW THE CONSEQUENT INCREASE IN SMOKING-RELATED ILLNESS. RECENT STUDIES REVEALED A DECLINE IN MORTALITY RATES FROM LUNG CANCER IN MALES UNDER 55, WHILE AMONG WOMEN THE RATE INCREASED BY 30 PERCENT. LUNG CANCER HAS NOW SURPASSED BREAST CANCER AS A CAUSE OF DEATH IN WOMEN. 36 WE MUST ENVISION A CATASTROPHIC EPIDEMIC OF LUNG CANCER AMONG WOMEN IN COMING YEARS. THIS EPIDEMIC IS AS PREVENTABLE AS IT IS PREDICTABLE. DISCOURAGING STUDIES INDICATE THAT SMOKING IS ACTUALLY INCREASING IN SOME SECTIONS OF THE FEMALE POPULATION, AND THAT OVER-ALL SMOKING PREVALENCE AMONG WOMEN MAY EXCEED THAT AMONG MEN WITHIN 5 YEARS. 37 A FINAL CONCLUSION OF THE NEWEST RESEARCH IS THAT SMOKING A MAJOR CAUSE OF STROKE (CEREBROVASCULAR DISEASE). WE ESTIMATE THAT SMOKING IS RESPONSIBLE FOR ABOUT HALF OF ALL STROKES OCCURRING IN PERSONS UNDER 65 YEARS OLD. SO, EVEN THOUGH WE'VE MADE PROGRESS, AS A SOCIETY WE'RE STILL BURDENED WITH THE TREMENDOUS AMOUNT OF SUFFERING AND HARDSHIP THAT GOES ALONG WITH ALL THESE DEATHS... 38 THE PEOPLE OF AMERICA ARE STILL BURDENED WITH THE ECONOMICS OF SMOKING. WE STILL HAVE TO COME UP WITH THE MONEY TO PAY THE ANNUAL SMOKING-AND-HEALTH BILL OF $39 BILLION. THAT'S FOR PERSONNEL AND MEDICAL TECHNOLOGY AND INSURANCE AND LOST WAGES...ALL THE REAL, BASIC COSTS LEVELLED AGAINST US ALL BY DISEASE AND DISABILITY. 39 SOME 50 MILLION AMERICANS STILL SMOKE, SO OUR EDUCATION CAMPAIGNS AND OUR SELF-HELP GROUPS MUST CONTINUE THEIR GOOD WORK. WE MUST GUARD AGAINST COMPLACENCY, AND INTENSIFY OUR EFFORTS TO ELIMINATE THE GREATEST CAUSE OF PREVENTABLE DISEASE AND DEATH AFFLICTING OUR SOCIETY. 40 AND THE TOBACCO INDUSTRY HAS NOT GIVEN UP. I DOUBT THAT YOU CAN FIND A MORE HEAVY-HANDED, OBTUSE, IMPOLITIC, AND UNTRUTHFUL GROUP OF CORPORATIONS ANYWHERE IN THE GREAT PANOPLY OF AMERICAN PRIVATE ENTERPRISE. 41 ALMOST FROM MY FIRST DAY IN OFFICE, THE INDUSTRY REMINDED ME AGAIN AND AGAIN -- AND NOT VERY SUBTLY EITHER -- THAT I OUGHT TO GET OFF MY ANTI-SMOKING "HOBBY- HORSE," AS ONE TOBACCO LOBBYIST CALLED IT, AND PAY ATTENTION TO OTHER, ALLEGEDLY MORE IMPORTANT PUBLIC HEALTH MATTERS. ECHOES OF THEIR COMPLAINTS WERE RELAYED TO ME FROM THE WHITE HOUSE, THE CONGRESS, AND EVEN FROM MEMBERS OF THE PRESS, WHO HAVE OFTEN BEEN THE GULLIBLE CARRIERS OF THE INDUSTRY'S DISASTROUS MESSAGE. 42 I ALSO READ THEIR DECEPTIVE, FULL-PAGE ADVERTISEMENTS THAT LIFTED MENDACITY AND HALF-TRUTHS TO A NEW AND HIGHER LEVEL OF FAUSTIAN ART. TO BE PERFECTLY HONEST, I DID NOT ASSUME THE POSITION OF SURGEON GENERAL WITH THE CLEAR INTENTION OF BEING SO PRO-ACTIVE AN OPPONENT OF TOBACCO AS I HAVE BEEN. BUT THEN I BEGAN TO STUDY IN SOME DEPTH THE INCONTROVERTIBLE TRUTHS ABOUT THE HEALTH HAZARDS OF SMOKING. 43 AND I MUST TELL YOU THAT I WAS AT FIRST DUMBFOUNDED AND THEN PLAINLY FURIOUS AT THE TOBACCO INDUSTRY FOR ATTEMPTING TO OBFUSCATE AND TRIVIALIZE THIS EXTRAORDINARILY IMPORTANT PUBLIC HEALTH INFORMATION. HOW COULD THE TOBACCO INDUSTRY DARE TO DISMISS AS UNFOUNDED AND UNPROVEN THE ABSOLUTELY CLEAR CONNECTION BETWEEN SMOKING AND HEART DISEASE . . . BETWEEN SMOKING AND DEATHS FROM STROKE . . . BETWEEN SMOKING AND CANCER OF THE LUNG, THE MOUTH, THE ESOPHAGUS, AND OF THE STOMACH . . . AND BETWEEN SMOKING AND A DOZEN OR MORE SERIOUS, DEBILITATING, EXHAUSTING, EXPENSIVE, AND HUMILIATING DISEASES? 44 HOW COULD THEY DARE TO DO THAT? I WONDERED. THE ANSWER WAS . . . THEY JUST DID. AND THEY FLAUNTED THEIR ABILITY TO BUY THEIR WAY INTO THE MARKETPLACE OF IDEAS AND POLLUTE IT WITH THEIR FALSE AND DEADLY INFORMATION. AS RECENTLY AS TWO WEEKS AGO, REPRESENTATIVES OF THE TOBACCO INTERESTS COMPLAINED THAT THE WORD "ADDICTION" IS INAPPROPRIATELY APPLIED TO SMOKING BECAUSE IT MAKES TOBACCO SEEM LIKE HARD DRUGS. 45 THEY KNOW THAT ITB ADDICTIVE LIKE HARD DRUGS. THEY ARE AS SLEAZY AS EVER. THE 1988 SURGEON GENERAL'S REPORT OFFERED IRREFUTABLE EVIDENCE THAT NICOTINE HAD ALL THE ATTRIBUTES OF AN ADDICTIVE DRUG . . . IN OTHER WORDS, CONSTANT SMOKING WAS CLINICALLY AN ADDICTION. 46 POPULAR FOLKLORE HAD PREDICTED SCIENCE: FOR A LONG TIME PEOPLE HAD TALKED ABOUT GETI'ING "HOOKED" -- AS THE SAYING GOES -- ON CIGARETTES, AS THEY GET "HOOKED" ON HEROIN, COCAINE, MARIJUANA, AND ALCOHOL. THE ADDICTION REPORT PRESENTS CONVINCING EVIDENCE THAT THE PHARMACOLOGIC AND BEHAVIORAL PROCESSES THAT DETERMINE TOBACCO (NICOTINE) ADDICTION ARE SIMILAR TO THOSE PROCESSES THAT MAKE COCAINE AND HEROIN ADDICTIVE. 47 THE DEFINITIONS USED IN THAT REPORT ARE NOT MINE. THEY ARE NOT IN ANY SENSE ARBITRARY. TOBACCO IS AN ADDICTIVE DRUG, ACCORDING TO THE STANDARD DEFINITION OF DRUG ADDICTION ADOPTED BY THE WORLD HEALTH ORGANIZATION, THE AMERICAN PSYCHIATRIC ASSOCIATION, AND THE A.M.A. 48 IN OTHER WORDS... * TOBACCO IS A "MOOD-ALTERING" SUBSTANCE . . . * SMOKERS ARE COMPULSIVE IN THEIR USE OF TOBACCO . . . * TOBACCO REWARDS THE USER -- IT IS, THEREFORE, A "REINFORCING" SUBSTANCE . . . * SMOKERS BUILD UP A TOLERANCE TO NICOTINE AND, FROM TIME TO TIME, WILL REQUIRE HIGHER DOSE LEVELS TO GET THEIR NICOTINE "HIGH" . . . 49 * PHYSICAL DEPENDENCE CAN OCCUR, WHICH MEANS A WITHDRAWAL SYNDROME FOR THOSE WHO QUIT . . . * AND -- AS WITH HEROIN, COCAINE, AND OTHER ADDICTIVE DRUGS -- THE USER WILL VERY LIKELY RELAPSE AND RETURN TO THE USE OF THE DRUG. I FEEL VERY STRONGLY THAT THE PEOPLE OF AMERICA NEED TO BE WARNED REPEATEDLY ABOUT THE ADDICTIVE NATURE OF L TOBACCO. AND THE NON-SMOKERS NEED TO DO ALL THEY CAN TO GET THE SMOKERS TO STOP. 50 NOW, LET'S TALK SPECIFICALLY ABOUT WHAT WE CAN DO. IF YOU HAVE A BUSINESS, SIT DOWN WITH YOUR EMPLOYEES NOW, AND SET A TIME-TABLE TO MAKE YOUR WORKSITE SMOKE- FREE. DON'T WORRY ABOUT THE IMPACT ON YOUR BUSINESS. ONLY GOOD THINGS WILL HAPPEN. 51 ABOUT TEN YEARS AGO MR. WILBUR MCPHERSON, THE OWNER OF.RADAR ELECTRIC CO. OF SEATTLE DECIDED TO RID I-IIS BUSINESS OF SMOKERS. HE KNEW THAT SMOKERS WERE LESS EFFICIENT, LOST MORE TIME IN ABSENTEEISM, COST MORE IN HEALTH BENEFITS. SO HE SIMPLY SAID, "NO SMOKING". MOST OF HIS SMOKING EMPLOYEES QUIT SMOKING. ABSENTEEISM DROPPED, MAINTENANCE COSTS DROPPED, PRODUCTMTY WENT UP. 52 YOU ALL PROBABLY KNOW THE SUCCESS STORY OF THE NON- SMOKERS INN, LOCATED IN DALLAS, ON THE WAY INTO TOWN FROM THE DALLAS-FORT WORTH AIRPORT. ALTHOUGH SCOFFERS PREDICTED BANKRUPTCY FOR A NON- SMOKERS INN, WITHIN SIX WEEKS THE OWNER USED ONLY BLACK INK. THE SUPPORTING FIGURES SHOW WHY. BUSINESS ECONOMISTS HAVE CALCULATED THAT A SMOKING EMPLOYEE COSTS A FIRM ABOUT $4,600 PER YEAR MORE THAN A NON-SMOKING WORKER. AND THE SAYINGS ON MAINTENANCE, CLEANING, ETC. CAN AMOUNT TO 41 PERCENT A YEAR. 53 DOCTORS HAVE AN ESPECIALLY IMPORTANT, PIVOTAL ROLE TO PLAY IN THE FIGHT AGAINST SMOKING IN THIS COUNTRY. AND IT IS A PROFESSIONAL RESPONSIBILITY DEMANDING A PERSONAL COMMITM ENT AND A PERSONAL APPROACH. THOSE OF US IN THE ANTI-SMOKING MOVEMENT, THOSE WHO ARE DOING ALL THEY CAN IN CESSATION PROGRAMS SEE THE YEAR 2000@ A GOAL FOR MANY OF US. 54 MYCALLFORASMOKE-FREESOCIETYBYTHEYEAR2000HAS BEENMATCHEDBYTHENATIONALCANCERINSTIWTE'SCALL FORA50PERCENTREDUCTIONINCANCERMORTALITYRATESBY THETURNOFTHECENTURY. WEAREALREADYINTHE1990s,SOWEHAVEALOTTODO,FAST. 55 NOW FOR SOME GOOD NEWS. THE AIM OF OUR EDUCATIONAL EFFORTS HAS CHANGED RECENTLY. FOR THE LAST 25 YEARS WE HAVE TRIED TO CONVINCE AMERICANS TO STOP SMOKING --AND NEVER TO START. NOW WE KNOW THAT MOST SMOKERS --PERHAPS AS HIGH AS 90 PERCENT-- WANT TO STOP. THEY DON'T NEED CONVINCING. THEY NEED HELP IN SMOKING CESSATION. 56 SINCE 1982 THE NATIONAL CANCER INSTITUTE'S SMOKING, TOBACCO, AND CANCER PROGRAM HAS FOCUSED ITS RESEARCH ON METHODS OF INTERVENTION: AMONG THEM ARE: -SCHOOL-BASED PREVENTION: WE KNOW THAT THE AVERAGE AGE FOR THE INITIAL SMOKING EXPERIENCE GETS LOWER EACH YEAR. ANTI- SMOKING EDUCATION MUST BEGIN IN THE ELEMENTARY GRADES. 57 -SELF-HELP METHODS: SEVERAL NATIONAL MAGAZINES RECENTLY HAVE HIGHLIGHTED THESE UNIQUELY AMERICAN INSTITUTIONS. THE ADDICTED SMOKERS NEED TO QUIT THEMSELVES. BUT IT CAN TAKE ABOUT 5 TIMES TO QUIT, SO THEY NEED HELP. 58 THEY CAN GET IT IN -COMMUNITY INTERVENTIONS: AMONG THE MOST PROMISING ARE THOSE OF COMMIT (COMM-UNITY INTERVENTION TRIAL FOR SMOKING CESSATION). THIS IS A MULTI-FACETED EFFORT BASED ON 11 COMMUNITIES IN THE USA AND CANADA, USING EXISTING COMMUNITY ORGANIZATIONS LIKE WORKSITE GROUPS, HEALTHCARE FACILITIES, CMC GROUPS, LOCAL MEDIA, AND SCHOOLS. 59 ALL THESE GROUPS COOPERATE IN CESSATION EFFORTS AIMED ESPECIALLY AT PEOPLE WHO SMOKE 25 OR MORE CIGARETTES A DAY, THOSE WITH THE GREATEST CANCER RISK, THOSE WHO HAVE THE TOUGHEST TIME QUI'ITING. THE IDEA IS TO SURROUND THEM, EVERYWHERE THEY GO, WITH REMINDERS --AND ASSISTANCE-- TO TAKE CHARGE OF THEIR LIVES BY CEASING TO SMOKE. 60 COMMIT ALSO URGES PHYSICIANS TO ASSUME THEIR NATURAL ROLE AS COMMUNITY LEADERS BY BECOMING PART OF THE LOCAL MEDIA. COMMIT CALLS PHYSICIANS TO BECOME "SMOKING CONTROL MEDIA ADVOCATES". COMMIT SPOKESMEN ASSERT THAT DOCTORS NEED TO APPEAR ON TV, ESPECIALLY LOCAL TV, TO CARRY THE ANTI-SMOKING MESSAGE, TO URGE PEOPLE TO QUIT. L 61 PEOPLE BELIEVE DOCS ON TV. (REMEMBER HOW WHEN ROBERT YOUNG TOOK THE JOB OF PLUGGING SANKA, MOST AMERICANS THOUGHT IT WAS DR. WELBY, AND THEY PAID ATTENTION.) TELEVISION AND RADIO ARE WHAT SHAPE THE AMERICAN MIND. SMOKING ADS MAY HAVE LEFT THE AIRWAYS, BUT AGGRESSIVE ANTI-SMOKING MESSAGES NEED TO TAKE THEIR PLACE. MEDIA ADVOCACY IS ACTIVIST, SURMOUNTING THE THRESHOLD OF MEDIA RESISTANCE OR INDIFFERENCE, SURMOUNTING THE OBSTACLES OF PHYSICIAN RELUCTANCE OR INDIFFERENCE. 62 THE NATIONAL CANCER INSTITUTE ASSIST PROGRAM -- AMERICAN STOP SMOKING INTERVENTION STUDY FOR CANCER PREVENTION-- FOCUSES ON COMMUNITY-BASED COALITIONS DEALING WITH ENTIRE STATES OR LARGE METROPOLITAN AREAS. THESE CENTERS ARE FUNDED IN EXCESS OF $100 MILLION TO ENSURE A SUSTAINED IMPACT ON THE LIVES OF MORE THAN 50 MILLION AMERICANS. ASSIST AMOUNTS TO THE LARGEST INTERVENTION EFFORT EVER UNDERTAKEN BY AN AGENCY OF THE US PUBLIC HEALTH SERVICE. THERE &!$ HELP OUT THERE FOR THE SMOKER WHO WANTS TO STOP. 63 AND FINALLY, -PHYSICIAN/DENTIST INTERVENTIONS. THAT LAST-MENTIONED METHOD SHOULD BE OF SPECIAL INTEREST TO ALL THE PHYSICIANS HERE THIS MORNING. WE KNOW THAT NOTHING IS AS EFFECTIVE IN STOPPING SMOKING AS WHEN A DOCTOR LOOKS A PATIENT STRAIGHT IN THE EYE AND SAYS, "IF YOU CONTINUE TO SMOKE, YOU'RE GOING TO KILL YOURSELF. YOU NEED TO STOP....NOW." 64 THAT CAN WORK WHEN ALL ELSE SEEMS TO FAIL. THERE ARE NEW METHODS TO ASSIST QUI'ITERS, RANGING FROM AVERSION THERAPY USING ELECTRIC SHOCKS TO EXPERIMENTAL PHARMACEUTICAL AGENTS. BUT, STILL, 85 PERCENT OF THOSE WHO QUIT.. JUST DO IT! I CALL UPON THE PHYSICIANS WHO ARE HERE TODAY TO CARRY THAT MESSAGE TO EACH OF YOUR PATIENTS WHO STILL SMOKE. 65 FINALLY, THERE ARE A NUMBER OF PUBLIC POLICY ISSUES THAT DEMAND OUR RESOLUTE ATTENTION AND ACTION. ONE OF THEM IS CIGARETTE ADVERTISING. THE ADS HAVE GONE FROM TELEVISION, THANK GOD, -- ALTHOUGH THEY ARE SNEAKING BACK THROUGH VIDEOS-- BUT CIGAREXTE ADVERTISING STILL ASSAULTS OUR SOCIETY IN PRINT AND BILLBOARDS. 66 THE TOBACCO INDUSTRY SPENDS $4,000 PER MINUTE ON PROMOTION ($2.5 BILLION A YEAR) ONLY THE GROTESQUE ECONOMIC POWER OF THE INTERNATIONAL TOBACCO COMPANIES CAN SUSTAIN THIS OUTRAGE, AS THEY USE ECONOMIC BLACKMAIL TO INTIMIDATE PUBLISHERS AND GOVERNMENTS. 67 I AM PARTICULARLY DISTURBED BY CIGARETTE ADVERTISING THAT TARGETS VULNERABLE GROUPS WITHIN OUR POPULATION: YOUNG PEOPLE, WOMEN, AND MINORITIES. CIGARETTE F'IRMS MANIPULATE MINORITIES, WOMEN, AND YOUNG PEOPLE BECAUSE THESE PEOPLE HAVE THE STRONGEST ASPIRATIONS TO CHANGE THEIR STATUS. 68 SO THESE ADS ASSOCIATE SMOKING WITH MAKING IT... IN THE WHITE, OR ANGLO, OR MALE, OR ADULT WORLD. THEY ASSOCIATE SMOKING WITH A HIGHER ECONOMIC STATUS (WHEN REALLY HIGHER INCOME GROUPS ARE NOW SMOKING LESS). 69 WE KNOW THAT THOSE WITH MORE EDUCATION TEND TO QUIT MORE READILY. "THE MORE YOU KNOW, THE LESS YOU SMOKE." BUT TOBACCO ADVERTISERS ASSOCIATE SMOKING --CONTRARY TO ALL EVIDENCE-- WITH ROBUST ACTIVITY, ATHLETICS, SOCIAL ACCEPTABILITY, SUCCESS, OUTDOOR LEISURE, AND EVEN GOOD HEALTH. 70 ONE OF THE MORE OUTRAGEOUS ADVERTISING GIMMICKS IS ONE CIGAREmE COMPANY'S "ALIVE WITH PLEASURE" THEME. THIS IS CLEARLY AN EFFORT TO UNDERMINE THE SURGEON GENERAL'S WARNING ON EACH PACK TRUTH IN ADVERTISING SHOULD REQUIRE, NOT "ALIVE WITH PLEASURE", BUT "DYING IN AGONY". 71 IN THE ADVERTISING WARS YOU HEAR A LOT ABOUT PROOF. THE TOBACCO COMPANIES SAY THAT IT HAS NOT BEEN PROVEN THAT ADVERTISING INCREASES CIGARFXIE SMOKING. OF COURSE, THE COMPLEXITY OF THIS ISSUE OF HUMAN BEHAVIOR WILL PROBABLY PRECLUDE THE ESTABLISHMENT OF A SCIENTIFIC PROOF OF A CAUSAL LINK. BUT TO MY MIND THE BURDEN OF PROOF SHOULD BE ON THE TOBACCO INDUSTRY TO SHOW THAT ADVERTISING DOES NOT INCREASE CONSUMPTION OF A PRODUCT THAT WE KNOW LEADS TO DEATH WHEN USED AS INTENDED. 72 IN THE 1850s JOHN SNOW ENDED THE CHOLERA EPIDEMIC IN LONDON BY REMOVING THE HANDLE OF THE BROAD STREET WATER PUMP, 30 YEARS BEFORE THE BACTERIUM CAUSING CHOLERA WAS DISCOVERED. FORTUNATELY HE DID NOT NEED TO CONTEND WITH A CHOLERA INSTITUTE THAT DEMANDED THE PUMP KEEP WORKING UNTIL IT WAS PROVED THAT WATER FROM THE PUMP WAS CAUSING THE CHOLERA. 73 AT THIS POINT THE CIGARETTE COMPANIES TROT OUT THE OLD LINE THAT THEIR ADVERTISING IS INTENDED ONLY TO ENFORCE BRAND LOYALTY, AND TO GET CONSUMERS TO SWITCH TO THEIR BRAND. NO ONE REALLY BELIEVES THAT. BRAND CHANGERS FORM ONLY A TINY FRACTION OF THE MARKET. THE REAL PURPOSE OF CIGARETTE ADVERTISING TO IS HOLD ON TO THOSE SMOKERS ALREADY HOOKED --ADDICTED-- AND TO A'ITRACT NEW ONES. 74 IT WORKS. RECENT STUDIES CONFIRM THAT INCREASED ADVERTISING BRINGS ABOUT A HIGHER DEMAND FOR CIGARETTES IN GENERAL, NOT J-UST FOR THE BRANDS ADVERTISED. WE KNOW ADVERTISING IS EFFECTIVE, AND THEY KNOW IT IS EFFECTIVE, BECAUSE OF THE BRIEF EXPERIENCE WITH COUNTER- ADVERTISING IN THE 1960s. 75 EARLY IN THE DEBATE ABOUT CIGARETTE ADVERTISING ON TV, THE PUBLIC HEALTH SERVICE RECEIVED EQUAL TIME FOR COUNTER-ADVERTISING ABOUT THE HEALTH PROBLEMS CAUSED BY CIGARETTE SMOKING. THE RESULTS WERE SO DEVASTATING TO THE TOBACCO INDUSTRY, THAT THE CIGARETTE FIRMS DECIDED THEY WOULD RATHER HAVE NO ADVERTISING AT ALL ON TV, RATHER THAN HAVE THE TRUE EFFECTS OF SMOKING BROUGHT BEFORE AMERICAN VIEWERS. 76 (I WILL ADD PARENTHETICALLY THAT WE ARE NOW AT ABC THE SAME STAGE WITH ALCOHOL ADVERTISING NOW. FOR THE SAKE OF THE AMERICAN PEOPLE, LET'S HOPE WE CAN MOVE EVEN FASTER TO RESTRICT ADVERTISING FOR THIS OTHER ADDICTIVE DRUG.) 77 IN CALLING FOR RESTRICTIONS ON CIGARETTE ADVERTISING I STAND ON COMMON SENSE AND PROVEN HEALTH STUDIES. I DON'T NEED TO HIDE BEHIND THE FIRST AMENDMENT. I DON'T NEED TO USE OUR CONSTITUTION AS A SMOKE SCREEN. AND THE "FREE SPEECH" ARGUMENT USED BY TOBACCO ADVERTISERS Is A SMOKE SCREEN. YOU DON'T SEE THESE PEOPLE OUT IN FRONT ON OTHER FIRST AMENDMENT ISSUES. 78 FREE SPEECH HAS NEVER BEEN AN UNLIMITED RIGHT: WE ALL KNOW YOU CAN'T YELL "FIRE" IN A CROWDED THFATRE. FREE SPEECH CANNOT INJURE THE COMMON WELFARE TO SERVE THE COMMERCIAL INTERESTS OF A FEW. THE FIRST AMENDMENT WAS NOT INTENDED TO ALLOW LIES TO BE FOISTED ON THE PUBLIC. MOST CIGARETTE ADVERTISING IS LIES. IT ASSOCIATES WITH ROMANCE, GLAMOUR, ATHLETICS, SUCCESS SUBSTANCES WHICH INSTEAD LEAD TO DISABILITY AND DEATH. 79 FIRST AMENDMENT PROTECTION IS NOT EXTENDED TO SPEECH ENCOURAGING ILLEGAL ACTIVITY. TOBACCO ADVERTISERS DEPEND UPON REACHING YOUNG PEOPLE. MOST OF THOSE WHO SMOKE BEGAN BEFORE THEY WERE TWENTY, OR EVEN 15. IN OTHER WORDS, THE CONTINUED STRENGTH OF THE TOBACCO MARKET DEPENDS ON THOSE TO WHOM THE PRODUCTS CANNOT BE LEGALLY SOLD. 80 THEREFORE, RESTRICTIONS ON TOBACCO ADVERTISING MEET THE CONSTITUTIONAL TEST IN AT LEAST TWO WAYS: 1. IT IS APPROPRIATE TO BAN COMMERCIAL SPEECH THAT IS MISLEADING OR FRAUDULENT. AND 2. IT IS APPROPRIATE TO BAN COMMERCIAL SPEECH RELATED TO ILLEGAL ACTIVITY. 81 FOR ALL THEIR TALK ABOUT "FREEDOM", TOBACCO INTERESTS ARE GREAT ENEMIES OF FREEDOM. FAR FROM BELIEVING IN FREE SPEECH, TOBACCO ADVERTISERS USE THEIR ECONOMIC CLOUT TO FORCE PUBLISHERS NOT TO PRINT ARTICLES ABOUT THE REAL CONSEQUENCES OF SMOKING. CIGARETTE ADVERTISING, FAR FROM ALLOWING FREE CHOICE, ACTUALLY UNDERMINES FREE CHOICE. NICOTINE ADDICTS DO NOT ENJOY FREE CHOICE. 82 FINALLY, LET'S BE UP-FRONT ABOUT THE SPECIAL CHALLENGE FACING TOBACCO ADVERTISERS: MOST PEOPLE WHO USE THEIR PRODUCT WOULD RATHER NOT USE IT. AS MANY AS 90% WISH TO QUIT. MANY TOUGH IT OUT, BREAK THEIR ADDICTION, AND SUCCEED IN QUITTING. 83 THE ADVERTISERS NEED TO REPLENISH THE DIMINISHING SUPPLY OF TOBACCO USERS: REMEMBER THOSE 1,000 SMOKERS WHO DIE EVERY DAY. MEANWHILE, ADVERTISERS RECRUIT MORE VICTIMS. 84 WE MUST ALSO CONCERN OURSELVES WITH THE EXPORT OF TOBACCO PRODUCTS. I DO NOT BELIEVE THE UNITED STATES WILL EVER AGAIN BE A GOOD MARKET FOR TOBACCO PRODUCTS. THE CURVE IS GOING DOWN AND ACCELERATING. BUT IF WE HAVE BEATEN THE CIGARETTE INDUSTRY ON ITS OWN HOME TURF WE'VE DRIVEN THEM TO SCOUR THE REST OF THE EARTH FOR NEW VICTIMS. 85 THE TOBACCO INDUSTRY -- AS YOU ALL KNOW, I AM SURE -- HAS TARGETED THE LESS DEVELOPED AND DEVELOPING COUNTRIES OF THE WORLD AS THEIR MOST PROMISING MARKETS FOR THE 1990s. IT IS THE HEIGHT OF HYPOCRISY FOR THE UNITED STATES, IN OUR WAR AGAINST DRUGS, TO DEMAND THAT FOREIGN NATIONS TAKE STEPS TO STOP THE EXPORT OF COCAINE TO OUR COUNTRY WHILE AT THE SAME TIME WE EXPORT NICOTINE, A DRUG JUST AS ADDICTIVE AS COCAINE, TO THE REST OF THE WORLD. 86 ANOTHER ISSUE OF PUBLIC POLICY ON WHICH WE NEED TO SET OUR SIGHTS CONCERNS CIGARETIX VENDING MACHINES. HERE IS ANOTHER EXAMPLE OF THE CODDLED CIGARETTE COMPANIES. IT IS ILLEGAL TO SELL BOTH ALCOHOL AND CIGARETTES TO MINORS. THAT IS BECAUSE ALCOHOL AND NICOTINE ARE THE TWO MAJOR LEGAL ADDICTING DRUGS IN OUR SOCIETY. 87 WE WOULD NEVER TOLERATE SELLING ALCOHOLIC BEVERAGES IN VENDING MACHINES, BUT SOMEHOW WE TOLERATE CIGARE'ITE VENDING MACHINES. IT IS SAD EVIDENCE OF OUR FAILURE TO TAKE SERIOUSLY THE DANGERS OF SELLING THIS ADDICTING DRUG NICOTINE TO MINORS. THE CIGARETTE VENDING MACHINES SHOULD BE THE NEXT TARGET IN THE CRUSADE AGAINST SMOKING. 88 NO DOUBT IN THE SESSIONS THAT FOLLOW, YOU CAN DEVELOP MORE COMPLETE TACTICS FOR THESE AND OTHER STRATEGIC ISSUES. I MAY HAVE HUNG UP THE UNIFORM OF THE SURGEON GENERAL, BUT I HAVEN'T RETIRED FROM THE FIGHT AGAINST SMOKING. TOGETHER, WE& GOING TO WIN IT. THANK YOU. ## # 89 extra stuff in case you need/want to slip it in somewhere: AND THOSE EFFORTS HAVE BEEN HIGHLY SUCCESSFUL, THANKS TO THE COMBINED EFFORTS OF . . . * GOVERNMENT ALL LEVELS -- FEDERAL, STATE AND LOCAL . . . * THE HEALTH PROFESSIONS, WITH THE AMERICAN MEDICAL ASSOCIATION ITSELF LEADING THE WAY . . . * MANY PRIVATE, NON-PROFIT ORGANIZATIONS SUCH AS THE AMERICAN CANCER SOCIETY, THE AMERICAN HEART ASSOCIATION, AND THE AMERICAN LUNG ASSOCIATION HAVE ALSO BEEN INVOLVED NOT ONLY IN EDUCATION BUT ALSO IN SMOKING CESSATION PROGRAMS . . . * AND PRIVATE INDUSTRY HAS 90 BECOME A PARTNER AS WELL, ESPECIALLY THE INSURANCE INDUSTRY, WHICH OF COURSE LOSES MONEY ON PEOPLE WHO SMOKE. THE ROLE OF GOVERNMENT HAS BEEN VERY IMPORTANT OVER THE PAST 25 YEARS . . . IMPORTANT IN BOTH POSITIVE AND NEGATIVE WAYS. FOR EXAMPLE, ON THE POSITIVE SIDE, . . . * GOVERNMENT HAS RAISED EXCISE AND SALES TAXES 91 ON CIGARETTES, MAKING CIGARETTES MORE AND MORE OF A PAINFUL POCKETBOOK ISSUE FOR SMOKERS, ESPECIALLY THOSE SMOKERS WHO ARE STILL UNCONVINCED BY THE OVERWHELMING RESEARCH DATA AVAILABLE. EVEN SO, TAKES WOULD HAVE TO BE DOUBLED TODAY, JUST TO KEEP UP WITH INFLATION. * GOVERNMENTS -- FEDERAL, STATE, AND LOCAL -- HAVE SEVERELY RESTRICTED THE AREAS WHERE PEOPLE CAN SMOKE IN PUBLIC. AT THIS TIME, ALL 50 STATES PLUS THE DISTRICT OF COLUMBIA HAVE SOME KIND OF LAW RESTRICTING SMOKERS IN SOME WAY OR PROHIBITING SMOKING IN CERTAIN PUBLIC PLACES ALTOGETHER. IT. IS NOW ILLEGAL TO SMOKE ON MOST PUBLIC CONVEYANCES . . . IN MOST RETAIL STORES AND RESTAURANTS . . . IN VIRTUALLY ALL GOVERNMENT BUILDINGS . . . IN ALL THEATERS AND SPORTS CENTERS . . . 92 AND IN MANY PLACES WHERE PEOPLE WORK. * GOVERNMENT HAS ALSO ORDERED NEW AND STIFFER HEALTH WARNINGS TO BE ROTATED AMONG CIGARETTE PACKAGES AND ALL ADVERTISEMENTS. AND I LOOK FORWARD TO "ADDICTION" BEING ADDED TO LABELS BY THIS CONGRESS. THAT'S QUITE A GOOD RECORD . . . AND I'VE JUST TOUCHED UPON A FEW HIGH SPOTS. BUT GOVERNMENT -- AND HERE I MEAN JUST OUR NATIONAL GOVERNMENT -- HAS ALSO DONE A FEW NEGATIVE THINGS. FOR EXAMPLE... * ITHASEXCLUDEDTOBACCOANDTOBACCOPRODUCTS FROM CERTAIN REGULATORY ACTIVITIES COVERING HAZARDOUS OR TOXIC SUBSTANCES AND FROM MOST PACKAGING AND LABELING RESTRICTIONS, EXCEPT FOR THE SURGEON GENERAL'S WARNING. 93 * TOBACCO, BY FEDERAL LAW, IS ALSO NOT CONSIDERED TO BE EITHER A FOOD, A DRUG, OR ANY OTHER KIND OF CONSUMER PRODUCT. IT REMAINS A UNIQUE SUBSTANCE, VIRTUALLY OUTSIDE THE REGULATORY ENVIRONMENT. AND IN OUR SYSTEM OF GOVERNMENT, THAT MEANS OUTSIDE STATE AND LOCAL REGULATION AS WELL. 94