ADDRESS BY C, EVERETT KOOP, M,D,, Sc,D, SURGEON GENERAL US PUBLIC HEALTH SERVICE AND DEPUTY ASSISTANT SECRETARY FOR HEALTH U,S, DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED AS THE ANNUAL AARON BROWN LECTURE TULANE UNIVERSITY SCHOOL OF MEDICINE NEW ORLEANS, LOUISIANA MARCH 17, 1987 1 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC,) I'M HONORED TO BE YOUR CHOICE AS TO PRESENT THIS YEAR'S AARON BROWN LECTURE, I'M ESPECIALLY DELIGHTED BECAUSE DRn BROWN WAS AN ALUMNUS OF MY OWN MEDICAL SCHOOL,,,CORNELL,,,AND, OF COURSE, HE ALSO FOUNDED OUR HOST ORGANIZATION, PHI DELTA EPSILON, WHAT A DIFFERENT AGE DR, BROWN LIVED IN, MEDICINE WASN'T THE BIG STORY THEN, IT WAS PHYSICS, wESPECIALLY RADIOACTIVITY AND ELECTRI- CITY a AND THE "BIG NAMES" OF HIS DAY, THE ONES THAT DOMINATED THE WORLD OF SCIENCE, WERE ROENTGEN AND MAX PLANCK, ,,THE CURIES, MARIE AND PIERREmAND MARCONIwAND EINSTEIN, BUT TODAY, THE WORLD SEEMS MORE DIVERSE AND THE DOMINATING "BIG NAMES" MAY STILL BE IN PHYSICSwBUT THEY'RE ALSO IN MEDICINE AND CHEMISTRY AND BIOLOGY AND PSYCHOLOGY, THE OPTIONS FOR YOUNG PEOPLE TODAY SEEM TO BE SO MUCH MORE VARIED, BUT THAT MAY ONLY REFLECT THE DEGREE OF COMPLEXITY OF MODERN LIFE IN GENERAL, AND, IN FACT, MY SUBJECT TODAY DEALS WITH JUST ONE ASPECT OF THAT COMPLEXITY a ,,BUT A VERY DISTURBING ONE NEVERTHELESS: I'M GOING TO TALK ABOUT HABIT OF SMOKING CIGARETTES, 2 YOUR COMMITTEE SUGGESTED THAT TOPIC AND I QUICKLY AGREED, BECAUSE SMOKING IS THE SUBJECT WITH WHICH I HAVE BEEN ASSOCIATED THROUGH THE YEARS I'VE BEEN SURGEON GENERAL, WAITING FOR ME IN MY NEW OFFICE AS THE SURGEON GENERAL, BACK IN NOVEMBER 1981, WAS MY OWN PERSONAL COPY OF EACH OF THE PREVIOUS 13 REPORTS BY FOUR SURGEONS GENERAL ON THE RELATIONSHIP BEWTWEEN SMOKING AND HEALTH, DURING MY TIME AS YOUR SURGEON GENERAL, I'VE BEEN GIVEN MANY NEW ASSIGNMENTS,,,THE "BABY DOE" CASE, ,,ORGAN TRANSPLANTS,, CARE FOR THE AGED-NOW AIDS, 3 BUT ONE ISSUE WAS WAITING FOR ME AND HAS BEEN A PART OF MY DAILY AGENDA FOR THE PAST FIVE AND A HALF YEARS: AND THAT ISSUE IS SMOKING, DURING ALL THIS TIME, I'VE BEEN IN THE FOREFRONT OF THE CAMPAIGN TO REDUCE, IF NOT ELIMINATE ALTOGETHER, SMOKING FROM OUR SOCIETY, AT FIRST, I HAD THE ASSIGNMENT BECAUSE IT BELONGED TO MY OFFICE, BUT NOW, AFTER BEING IMMERSED IN THE DATA FOR A FEW YEARS -- AND AFTER CLOSELY OBSERVING JUST HOW THE CIGARETTE INDUSTRY WORKS -- I'M KEEPING THE ASSIGNMENT BY CHOICE, IN FACT, IN ADDITION TO MY OWN ANNUAL REPORTS ON SMOKING AND HEALTH, I ANNOUNCED THE GOAL OF MAKING THE UNITED STATES 4 SMOKE-FREE SOCIETY BY THE YEAR 2000, 4 I ANNOUNCED THAT BACK IN MAY OF 1984 AND THE RESPONSE WAS IMMEDIATE AND STRONG -- AND IT'S GOTTEN CONSISTENTLY STRONGER EVER SINCE, TENS OF DOZENS OF VOLUNTAYR AND PROFESSIONAL ORGANIZATIONS, INCLUDING ALL THE MAJOR ORGANIZATIONS IN MEDICINE, PLUS LITERALLY MILLIONS OF ORDINARY CITIZENS, HAVE TAKEN UP THE CHALLENGE OF MAKING AMERICA SMOKE-FREE BY THE YEAR 2000, AS A RESULT OF THIS KIND OF RESPONSE ALL ACORSS THIS COUNTRY, I AM CONVINCED THAT MOST AMERICANS REALLY UNDERSTAND THE SIGNIFICANCE OF THE ANTI-SMOKING CAMPAIGN, AND JUST WHAT Is THAT SIGNIFICANCE? IN ITS SIMPLEST TERMS, THE ACHIEVEMENT OF A SMOKE-FREE SOCIETY WILL INSURE THAT WE WILL HAVE RESCUED THE PEOPLE OF AMERICA FROM THE PREVENTABLE BURDEN OF SMOKING-RELATED ILLNESS AND DEATH, ,.A BURDEN THEY HAVE BEEN CARRYING FAR TOO LONG AT A FAR TOO HEAVY A PRICE, 5 AND I WANT TO EMPHASIZE THOSE KEY WORDS -- "PREVENTABLE BURDEN OF SMOKING-RELATED ILLNESS AND DEATH" -- FOR TWO VERY GOOD REASONS: FIRST, SMOKING IS A PERSONAL CHOICE, NO ONE IS REQUIRED TO SMOKE, IN FACT, ANYONE CAN -- AND SHOULD -- CHOOSE NOT TO SMOKE AS THE FIRST AND MOST IMPORTANT ACT OF PERSONAL, PREVENTIVE HEALTH CARE, SECONDLY, THE SCIENTIFIC RECORD IS CLEAR ON THE RELATIONSHIP BETWEEN CIGARETTE SMOKING AND ABOUT T'dO DOZEN SERIOUS DISEASE CONDITIONS, MOST OF THEM WITH HIGH FATALITY RATES, 6 OVER THE PAST 30 YEARS BIOMEDICAL RESEARCHERS, PHYSICIANS, AND PUBLIC HEALTH PERSONNEL FROM MORE THAN 80 COUNTRIES HAVE GENERATED MORE THAN 50,000 STUDIES ON SMOKING AND HEALTH, ABOUT 2,000 MORE ARE ADDED EACH YEAR, IT'S AN EMBARRASSMENT OF RICHES, AND INCIDENTALLY A GOOD DEAL OF THAT INFORMATION HAS BEEN GENERATED RIGHT HERE IN LOUISIANA BY RESEARCHERS FUNDED NOT ONLY BY THE NATIONAL INSTITUTES OF HEALTH BUT ALSO BY YOUR OWN STATE'S MILLION-DOLLAR "CANCER AND LUNG TRUST FUND," DRAWN APPROPRIATELY ENOUGH FROM CIGARETTE TAX REVENUES, ONE OF THE MOST IMPORTANT ON-GOING STUDIES FUNDED BY NtI,Ha IS, OF COURSE, TULANE'S "BOGALOOSA HEART STUDY," WHICH IS A RICH MINE OF BEHAVIOR-RELATED DATA ON SMOKING AND HEALTH, IF ANYONE IN THIS AUDIENCE IS PARTICIPATING IN THIS RESEARCH, PLEASE ACCEPT MY PERSONAL WORD OF GRATITUDE, 7 THOSE 50,000 STUDIES HAVE GENERATED A GREAT DEAL OF INFORMATION, BUT THEY ARE INTERESTING FROM ANOTHER POINT OF VIEW, ALSO, THE OVER- WHELMING MAJORITY OF ALL THE STUDIES THAT HAVE BEEN DONE CONCLUDE THAT CIGARETTE SMOKING EITHER IS A CONTRIBUTING CAUSE OR IS THE PRIMARY CAUSE OF ILLNESS AND DEATH, THANKS TO THE RESEARCH OF THE PAST 25 YEARS,,, WE KNOW, ,,THAT A PERSON WHO SMOKES HAS A RISK OF SUDDEN CARDIAC DEATH THAT IS 1. TIMES THE RISK OF THE PERSON WHO DOES NOT SMOKE, WE KNOW-THAT ABOUT 85 PERCENT OF ALL LUNG CANCERS IN THE UNITED STATES ARE CAUSED BY CIGARETTE SMOKING, PEOPLE WHO SMOKE A COUPLE OF PACKS A DAY HAVE A LUNG CANCER DEATH RATE THAT IS AS MUCH AS 25 TIMES GREATER THAN THE RATE FOR PEOPLE WHO DON'T SMOKE AT ALL, 8 WE KNOWwTHAT CIGARETTE SMOKING IS THE MAJOR CAUSE OF CHRONIC OBSTRUCTIVE LUNG DISEASE, ESPECIALLY EMPHYSEMA AND CHRONIC BRONCHITIS, IN FACT, EMPHYSEMA IS QUITE COMMON AMONG OLDER PEOPLE CJHO'VE SMOKED, BUT IT'S RARELY FOUND AMONG OLDER NON-SMOKERS, AND WE KNOW, a ITHAT WOMEN WHO ARE PREGNANT HAVE AN INCREASED RISK OF DELIVERING THEIR BABIES PREMATURELY a, ,OR OF ABORTING THE FETUS SPONTANEOUSLY maOR OF DELIVERING A STILLBORN CHILDwOR OF GIVING BIRTH TO A CHILD WHO IS UNABLE TO SURVIVE MORE THAN A FEW DAYS OUTSIDE THE WOMB, THOSE ARE THE FACTS THAT HAVE BEEN GENERATED SINCE 1964 BY FIVE SURGEONS GENERAL -- LUTHER TERRY, WILLIAM STEWART, JESSE STEINFELD, JULIUS RICHMOND, AND I -- AND PUBLISHED IN 18 OFFICIAL REPORTS, I REGARD THE SCIENTIFIC CASE AGAINST CIGARETTES AS BEING AIR- TIGHT, AND I AM JOINED IN THAT OPINION BY THE VAST MAJORITY OF THE MEN AND WOMEN IN MEDICINE AND PUBLIC HEALTH TODAY, 9 THROUGH THE YEARS, THOSE REPORTS BY THE SURGEONS GENERAL HAVE DOCUMENTED THE RELATIONSHIP BETWEEN, 8, SMOKING AND CANCER,, n SMOKING AND CARDIOVASCULAR DISEASE,, , SMOKING AND LUNG DISEASE, n, SMOKING, CANCER, AND CHRONIC LUNG DISEASE AMONG WORK1 NG PEOPLE, AND -- THE MOST RECENT ONE -- ON THE EFFECTS OF PASSIVE SMOKING, 10 THE CONCLUSION OF EACH REPORT HAS BEEN UNEQUIVOCAL: SMOKING IS A MAJOR CONTRIBUTOR TO THE INCIDENCE'OF SIGNIFICANT FATAL DISEASES IN THE POPULATION, AND I MIGHT ADD THAT THIS PROCESS OF RESEARCH AND PUBLIC EDUCATION HAS CONTINUED, ,n THROUGH 5 PRESIDENTS, T'dO DEMOCRATS AND THREE REPUBLICANS,,, THROUGH 10 SESSIONS OF THE UNITED STATES CONGRESS,,, AND RIGHT THROUGH GRAMM-RUDMAN-HOLLINGS, AND NOW, FOLLOWING THE MOST RECENT LAW PASSED BY THE CONGRESS AND SIGNED BY PRESIDENT REAGAN, THE MANUFACTURERS OF CIGARETTES MUST PUT NEW AND STRONGER WARNINGS ON THEIR PACKAGES AND IN ALL THEIR ADVERTISING, 11 THERE ARE 4 VERSIONS AND YOU'VE PROBABLY SEEN ALL OF THEM BY NOW, SINCE THEY MUST BE ROTATED EVERY 3 MONTHS, THERE'S NOTHING FANCY ABOUT THESE WARNINGS, THEY'RE IN THE SAME PLAIN ENGLISH THAT ANY FAMILY PHYSICIAN WOULD USE -- AND SHOULD USE -- WITH A PATIENT WHO SMOKES, AND THERE'S NOTHING VAGUE ABOUT THEM EITHER, 9 ONE CATEGORICALLY SAYS THAT ' ,,,SMOKING CAUSES LUNG CANCER, HEART DISEASE, EMPHYSEMA, AND MAY COMPLICATE PREGNANCY," * ANOTHER WARNS THAT fi an ,PREGNANT WOMEN WHO SMOKE RISK FETAL INJURY AND PREMATURE BIRTH," 9 A THIRD SAYS THAT n ,,,CIGARETTE SMOKE CONTAINS CARBON MONOXIDE," 12 * THE FOURTH WARNING SAYS THAT ",,,QUITTING SMOKING NOW GREATLY REDUCES SERIOUS HEALTH RISKS," THIS IS A TOUGH ONE, BECAUSE WE KNOW THAT NICOTINE IS PROBABLY THE MOST ADDICTIVE DRUG IN OUR SOCIETY, STILL, SMOKERS MUST TRY, BECAUSE, AS THIS LABEL IMPLIES, IT'S NEVER TOO LATE TO QUIT, THAT, BRIEFLY, IS THE CASE OF "THE PEOPLE VERSUS TOBACCO/' IN MY OPINION, IT'S OPEN-AND-SHUT, BUT, AS YOU MAY HAVE GATHERED ALREADY, THE CASE THUS FAR HAS DEALT MAINLY WITH THE HEALTH RISKS OF PEOPLE j&& SMOKE, THE SO-CALLED MAINSTREAM SMOKERS WHO INHALE SMOKE DIRECTLY FROM THE CIGARETTE, HOWEVER, BEHIND THE CLOUD OF MAINSTREAM SMOKE IS NO SILVER LINING BUT ANOTHER CLOUDwAND IT'S KNOWN AS SIDESTREAM SMOKE, THE CIGARETTE SMOKE THAT NON-SMOKERS INHALE INVOLUNTARILY FROM THE AMBIENT AIR, 13 RESEARCH IN SIDESTREAM SMOKE HAS EVOLVED SLOWLY BUT STEADILY OVER THE PAST 10 YEARS SO THAT, BY NOW, WE HAVE A PRETTY GOOD IDEA OF ITS EFFECTS, AND WE PUBLISHED THAT DATA AND OUR CONCLUSIONS IN THE 18Tti SURGEON GENERAL'S REPORT, WHICH WE RELEASED LAST DECEMBER THE 16Ti-1, THAT REPORT INDICATES, FOR EXAMPLE, THAT- THE CHILDREN OF PARENTS WHO SMOKE HAVE A MUCH HIGHER U,R,I, RATE, COMPARED TO CHILDREN WHOSE PARENTS DO NOT SMOKE, AND THE NONSMOKING WIFE OF A SMOKER RUNS A HIGHER RISK OF LUNG CANCER THAN DOES THE NONSMOKING WIFE OF A NONSMOKER, I BELIEVE WE'LL SOON FIND THE SAME THING ALSO TRUE FOR THE INCIDENCE OF HEART DISEASE, EMPHYSEMA, AND CONGESTIVE LUNG DISEASES AMONG NONSMOKING WIVES OF SMOKERS, 14 ALSO, "SIDESTREAM" SMOKERS EXPOSED TO OTHER PEOPLES' HEAVY SMOKING IN THE SAME OFFICE SPACE OR WORKROOM ABSORB AS MUCH SMOKE AS IF THEY THEMSELVES WERE "MAINSTREAM" SMOKING TWO OR THREE CIGARETTES PER DAY, AND SO ON, NOW, JUST WHAT Is IT IN CIGARETTE SMOKE THAT IS SO HARMFUL FOR EVERYONEmWHETHER YOU'RE A "SIDESTREAM" OR A "MAINSTREAM" SMOKER? FIRST OF ALL, YOU BOTH BREATHE IN THE SAME 4,000 OR SO CONSTITU- ENTS OF CIGARETTE SMOKE: YOU BOTH INHALE THE SAME TARS, THE SAME NAPTHALENE, AND THE SAME PYRENE AND BENZOPYRENE, mm 15 YOU ABSORB THE SAME CARBON MONOXIDE, METHANE, AMMONIA, AND ACETYLENE,, a AND YOU INHALE THE SAME HYDROGEN CYANIDE, ODDLY ENOUGH, SCIENTISTS HAVE DISCOVERED THAT SOME OF THESE TOXIC AGENTS ARE FOUND IN GREATER CONCENTRATIONS IN SIDESTREAM SMOKE THAN IN MAINSTREAM SMOKE, 0 TAR, FOR EXAMPLE, THE SUBSTANCE THAT IS THE MOST CARCINO- GENIC, IS 70 PERCENT MORE CONCENTRATED IN SIDESTREAM SMOKE THAN IN MAINSTREAM SMOKE, ,n 0 CONCENTRATIONS OF CARBON MONOXIDE ARE TWO AND A HALF TIMES GREATER IN SIDESTREAM SMOKE THAN IN MAINSTREAM SMOKE,,, 16 0 NICOTINE IS 287 TIMES GREATER IN SIDESTREAM SMOKE,,, 0 AMMONIA IS 73 TIMES GREATER IN SIDESTREAM SMOKEwAND SO ON, AND THE MOST RECENT RESEARCH IN THIS AREA INDICATES THAT NONSMOKERS RETAIN THESE POISONS IN THEIR BLOODSTREAMS TWICE AS LONG AS SMOKERS DO, I HOPE THAT MY LECTURE TODAY WILL CONVINCE AT LEAST THOSE PHYSICAL CHEMISTS IN THE AUDIENCE WHO NOW SMOKE THAT IT REALLY IS TIME FOR THEM TO QUIT, BUT THIS IS EXACTLY THE KIND OF INFORMATION THAT HAS SPURRED ON THE MOVEMENT BY NONSMOKERS TO BAN SMOKING IN VIRTUALLY EVERY PUBLIC SPACE AND IN ALL PUBLIC TRANSPORT, 17 IT'S THE KIND OF DATA THAT CONVINCED THE TOWN COUNCILS OF ASPEN, COLORADO, AND BEVERLY HILLS, CALIFORNIA, TO BAN SMOKING IN PUBLIC SPACES WITHIN THEIR RESPECTIVE JURISDICTIONS BUT THIS IS MORE THAN JUST A FIGHT FOR CLEAN AIR IN RESTAURANTS OF EVEN MORE SIGNIFICANCE IS THE GROUNDSWELL THAT'S DEVELOPING TO BAN SMOKING WHERE PEOPLE WORK, WE ADDRESSED THIS ISSUE IN OUR DECEMBER 1985 REPORT OF THE SURGEON GENERAL, THAT REPORT DEALT SPECIFICALLY WITH THE WAY SMOKING CONTRIBUTES TO THE INCIDENCE OF CANCER AND CHRONIC LUNG DISEASE AMONG THE MEN AND WOMEN OF THE AMERICAN WORKFORCE, CLOSE TO 110 MILLION MEN AND WOMEN GO TO A FULL-TIME JOB EVERY DAY SOMEWHERE IN THE UNITED STATES, UNHAPPILY, ABOUT 38 PERCENT OF THAT TOTAL -- OR SOME 41 MILLION WORKERS -- ARE CIGARETTE SMOKERS 18 THE WORKERS MOST AT RISK, OF COURSE, ARE THOSE IN INDUSTRIES THAT MINE AND PROCESS COAL, ASBESTOS, SILICA, AND RADIUM, FOR EXAMPLEwAND THOSE THAT MANUFACTURE OR HANDLE TEXTILES, PETROCHEMICALS, PESTICIDES, AND AROMATIC AMINES,,,OTHERWISE KNOWN AS THE "CLEANING AND DYING INDUSTRY/' WORKERS IN THESE INDUSTRIES -- WHO ARE ALREADY AT RISK ON THE JOB, WHETHER THEY SMOKE OR NOT -- MAKE MATTERS WORSE FOR THEMSELVES IF THEY SMOKE, AND OUR 1986 REPORT GIVES THE DATA TO PROVE IT, AMONG THE MOST DRAMATIC ILLUSTRATIONS OF THIS IS THE SITUATION AMONG ASBESTOS WORKERS, IF YOU'RE AN ASBESTOS WORKER WHO HAS NEVER SMOKED, YOUR CHANCES OF GETTING JOB-RELATED LUNG CANCER IS 50 TIMES GREATER THAN IF YOU'VE NEVER SMOKED AND HAD NEVER WORKED WITH ASBESTOS EITHER, SO IT'S OBVIOUSLY A HIGH-RISK OCCUPATION, 19 HOWEVER, IF YOU'RE AN ASBESTOS WORKER AND YOU SMOKE A PACK OF CIGARETTES A DAY, YOUR CHANCES OF GETTING LUNG CANCER IS 87 TIMES GREATER THAN IF YOU NEVER SMOKED AND NEVER WENT NEAR ASBESTOS, THAT'S WHY BOTH ACTIVITIES -- ELIMINATING CIGARETTE SMOKING AND REDUCING THE EXPOSURE TO HAZARDS IN THE WORKPLACE -- ARE SEPARATE BUT NEVERTHELESS COMPLEMENTARY ACTIVITIES, WE'VE GOT TO DO BOTH AND DO THEM WITH MAXIMUM EFFECT,,,-AGAIN, WITH THE TOTAL HEALTH OF THE AMERICAN WORKER IN MIND, AND HERE, I BELIEVE, IS ONE OF THE MOST IMPORTANT CHALLENGES TO THE FAMILY PHYSICIAN AND TO THE PRACTITIONER OF GENERAL MEDICINE, YOUR PATIENTS, WHO WORK AND WHO ALSO SMOKE, NEED YOUR CONCERN AND YOUR GUIDANCE -- AND YOUR TENACITY TO GET THEM TO QUIT, ASSUMING, OF COURSE, THAT YOU'VE ALREADY DONE THAT DONE FOR YOURSELF, 20 AS I SAY, WE SHOULD DO WHATEVER WE CAN -- RIGHT NOW -- TO ELIMINATE SMOKING AMONG WORKERS IN THOSE INDUSTRIES AND OCCUPATIONS WHICH WE ALREADY KNOW PRESENT RISKS TO THEIR HEALTH AND WELL-BEING, AND NEXT, WE MUST MOVE AHEAD WITH SMOKING CESSATION PROGRAMS AMONG THOSE OTHER INDUSTRIES WHERE THE HEALTH DATA MAY BE LESS CLEAR, BUT WHERE THERE'S ENOUGH SUSPICION OF TROUBLE THAT THEY REQUIRE OUR ATTENTION, AND HERE I'M TALKING ABOUT OCCUPATIONS THAT ARE RELATIVELY NEW AND THE WORKPLACE HAZARDS ARE STILL NOT WELL UNDERSTOOD, FOR EXAMPLE, 8, 9 WORKERS IN THE COMPUTER INDUSTRY ARE POTENTIALLY EXPOSED TO OVER 400 DIFFERENT TOXIC AGENTS, INCLUDING ARSENIC, NITRIC ACID, AND FREON DE-GREASING AGENTS, 21 + THE NEW SEMI-CONDUCTOR INDUSTRY HAS SOMETHING LIKE 300 POTENTIALLY HARMFUL AGENTS PRESENT IN ITS WORK ENVIRONMENT, THESE INCLUDE LEAD SOLDER, FLUXES, PHOTOCHEMICALS, AND HIGHLY TOXIC DOPING COMPOUNDS SUCH AS HEXA-METHYL-DISILAZANE, 3 AND THE RADIO &lD- TELEVISION EQUIPMENT INDUSTRY IS ANOTHER ONE, WITH NEARLY 400 AGENTS, INCLUDING EXOTIC METALS AND CHEMICALS, AMONG THESE WORKERS, IT IS CONCEIVABLE THAT SMOKING IS THE MORE SERIOUS HAZARD,,,WE DON'T KNOW THAT FOR SURE, BUT, EVEN WITHOUT SUPPORTING DATA, WE KNOW ENOUGH TO GUESS THAT THE WORKER WHO SMOKES ONLY MAKES MATTERS WORSE FOR HIMSELF OR HERSELF AND FOR OTHER CO- WORKERS IN THE SAME CLOSE ENVIRONMENT, THAT5 WHY I BELIEVE THAT WE'VE GOT TO RE-DOUBLE OUR EFFORTS IN TWO AREAS: 22 FIRST, WE NEED TO ESTABLISH SMOKING CESSATION PROGRAMS RIGHT ACROSS THE SPECTRUM OF AMERICAN EMPLOYMENT, BETTER THAN 50 PERCENT OF WORKERS IN BLUE-COLLAR OCCUPATIONS NOW SMOKE, JONSTRUCTION WORKERS, TRUCK DRIVERS, MAINTENANCE MEN, AND SO ON, WE'VE GOT TO FIND A WAY TO REACH THEM WITH OUR ANTI-SMOKING MESSAGE, AND SECOND, WE NEED TO WORK WITH MANAGEMENT AND WITH STATE AND LOCAL GOVERNMENTS TO NEGOTIATE THE ORDINANCES AND AGREEMENTS NECESSARY BOTH TO ENCOURAGE SMOKERS TO QUIT AND TO PROTECT NONSMOKERS FROM THE EFFECTS OF SIDESTREAM SMOKE IN THE WORKPLACE, IN BOTH AREAS, THE COUNTRY NEEDS THE INVOLVEMENT OF ITS HEALTH PROFESSIONALS, AS I SAID AT THE BEGINNING OF MY REMARKS TODAY, SMOKING IS THE SINGLE MOST SIGNIFICANT AND PREVENTABLE CAUSE OF DISEASE AND DEATH AMONG OUR CITIZENS, I'M NOT IMPLORING YOU TO JOIN SOMEBODY'S ELECTION CAMPAIGN OR SIGN A PARKING PETITION, I'M ASKING YOU TO BECOME PART OF A CAMPAIGN THAT IS VITALLY IMPORTANT TO THE PRESENT AND FUTURE HEALTH OF THE AMERICAN PEOPLE, 23 THE ANTI-SMOKING CAMPAIGN NEEDS ALL THE INFORMED AND INVOLVED ASSSITANCE IT CAN GET BECAUSE IT'S A TOUGH FIGHT ALL THE WAY, WE'RE TAKING ON MORE THAN JUST DISEASEwWE'RE TAKING ON THE CIGARETTE INDUSTRY,, ,AND YOU AND I KNOW THAT THE CIGARETTE INDUSTRY IS A VERY FORMIDABLE ADVERSARY, THAT INDUSTRY ACCOUNTS FOR ABOUT 2,5 PERCENT OF THE NATION'S GROSS NATIONAL PRODUCT, OR ABOUT $60 BILLION, EACH YEAR, IT SPENDS ABOUT $2 BILLION A YEAR JUST ON ADVERTISING ALONE, THAT'S A LITTLE OVER $8 FOR EVERY PERSON IN THE UNITED STATES,,,SMOKER AND NONSMOKER ALIKE, BUT SOME AMERICANS ARE GETTING MORE OF THIS ADVERTISING ATTENTION THAN ARE OTHERS, 24 WOMEN ARE ONE SUCH TARGET GROUP, AND IT SEEMS TO BE EFFECTIVE, WOMEN SMOKERS ARE ALSO GIVING UP CIGARETTES, BUT AT A MUCH SLOWER QUIT-RATE THAN THE ONE FOR MEN, FOR EXAMPLE, MEANWHILE, LUNG CANCER IS NOW THE LEADING CAUSE OF CANCER DEATHS AMONG WOMEN, SURPASSING BREAST CANCER, I FIND IT QUITE DEPRESSING THAT THE EDITORS AND PUBLISHERS OF THE MAJOR WOMEN'S MAGAZINES ARE HAPPY TO CARRY LAVISH, FULL-COLOR CIGAR- ETTE ADS, BUT DECLINE TO RUN THE LIFE-SAVING, ANTI-CIGARETTE ARTICLES THAT COULD HELP SAVE THE LIVES OF THEIR READERS, AND FRANKLY, IT'S BEYOND ME WHY ANY SELF-RESPECTING WOMAN TENNIS STAR WOULD PLAY IN THE "VIRGINIA SLIMS" TOURNAMENT, YOUNG PEOPLE ARE ANOTHER MAJOR TARGET GROUP, AND WHY NOT, SINCE 90 PERCENT OF ALL PEOPLE WHO SMOKE STARTED THEIR HABIT WHEN THEY WERE IN THEIR TEENS, 25 I'M ALSO TRULY CONCERNED ABOUT THE CONCENTRATED BARRAGE OF CIGARETTE ADVERTISING AND PROMOTION THAT'S DIRECTED AT MINORITIES, AMONG BLACKS, FOR EXAMPLE, IT TAKES THE FORM OF FULL-COLOR, FULL-PAGE ADS IN ALL MAJOR MAGAZINES WITH A PREDOMINANTLY BLACK READERSHIP, THE INDUSTRY ALSO PUBLICIZES ITS DONATIONS TO BLACK AND HISPANIC COMMUNITY SERVICE ORGANIZATIONS AND ITS SPONSORSHIP OF LAVISH FESTIVALS, FASHION SHOWS, AND OTHER EVENTS FEATURING POPULAR MINORITY ENTERTAINERS AND SPORTS FIGURES, I WISH THOSE ORGANIZATIONS AND PERSONALITIES WEREN'T SO WILLING TO TAKE THE MONEY, I WISH THEY KNEW -- JUST AS CLEARLY AS WE KNOW AND AS THE TOBACCO INDUSTRY ITSELF KNOWS -- THAT THE RATE OF LUNG CANCER AMONG BLACKS IS 119 PER 100,000 POPULATIONunOR ALMOST 50 PERCENT GREATER THAN THE WHITE RATE OF 81 PER 100,000 POPULATION, 26 THE TOBACCO MONEY GIVEN TO THOSE COOPERATING BLACK ORGANIZATIONS AND PERSONALITIES IS PART OF THE HIGH PROFIT THAT THE INDUSTRY IS SQUEEZING OUT OF THE DISEASED LUNGS OF BLACK MEN AND WOMEN WHO SMOKE, IT'S A TERRIBLE SITUATION, FOR THE MEN AND WOMEN WHO DIRECT THE FORTUNES OF THE CIGARETTE INDUSTRY, I SAY IT IS ALSO AN UNFORGIVABLE SITUATION, BUT I EXPECT IT TO CHANGE, BECAUSE THE INDUSTRY'S DAYS ARE NUMBERED, DESPITE THE BILLIONS OF DOLLARS IT SPENDS AND DESPITE THE MERGERS AND BUY-OUTS OF FOOD COMPANIES AND REAL ESTATE AND BEER AND WINE, THE CIGARETTE INDUSTRY ITSELF IS NOT NOW -- AND WILL NEVER AGAIN BE -- A GROWTH INDUSTRY, 27 YES, IT IS A FORMIDABLE ADVERSARY TODAY, BUT IT BECOMES LESS AND LESS FORMIDABLE WITH EVERY TOMORROW, PER CAPITA CIGARETTE CONSUMPTION CONTINUES TO DECLINE AND THAT CURVE WILL NEVER AGAIN GO UP, WE KNOW THAT,, ,AND THE INDUSTRY DOES, TOO, AND, DESPITE THE ADVERTISING PRESSURE, YOUNG PEOPLE IN GREATER AND GREATER NUMBERS REALIZE THAT, IN THEIR JARGON, THE COMPANIES ARE JUST "RIPPING THEM OFF," CIGARETTE SMOKING IS NOW RIGHT UP THERE WITH SUCH OTHER TEEN-AGE DISASTERS AS BAD BREATH, PERSPIRATIONieAND PARENTS, THAT'S WHY I PREDICT THAT THE AMERICAN CIGARETTE INDUSTRY, FOR ALL ITS ENORMOUS ECONOMIC POWER, WILL VIRTUALLY DISAPPEAR OVER THE NEXT 20 YEARS, 28 HISTORY, MY FRIENDS, IS CLEARLY ON THE SIDE OF THE NONSMOKER, AND IT'S ON OUR SIDE, AS HEALTH PROFESSIONALS, THEREFORE, I BELIEVE THAT WE WILL INDEED ACHIEVE OUR GOAL, WHICH IS TO MAKE OUR HOMES, SCHOOLS, AND WORK ENVIRONMENTS SMOKE-FREE BY THE YEAR 2000, IT'S NOT AN IMPOSSIBLE DREAM, AND I WANT TO EMPHASIZE THAT THE US, PUBLIC HEALTH SERVICE AND ITS SURGEON GENERAL -- I AND WHOEVER ELSE COMES AFTER ME -- WILL DO WHATEVER WE CAN TO MAKE THE DREAM OF A SMOKE-FREE SOCIETY COME TRUE, I INTEND TO MAKE SURE THAT ON MY DESK, WAITING FOR MY SUCCESSOR, WILL BE NOT JUST THE 13 SMOKING-AND-HEALTH REPORTS THAT I FOUND BUT THE ADDITIONAL 8 THAT WILL BE MY CONTRIBUTION TO THIS COUNTRY'S LIFE- SAVING CAMPAIGN AGAINST CIGARETTES, THANK YOU, #####