DDRESS By C. Everett Koop. M,.D., Sc.D. SURGEON GENERAL OF THE U.S, PuBLic HEALTH SERVICE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED TO THE FIFTH INTERNATIONAL SYMPOSIUM ON CANCER RESEARCH AND AIDS VENICE, ITALY JANUARY 13, 1989 1 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) T AM PLEASED TO BE HERE AND TO SHARE WITH YOU SOME OF OUR EXPERIENCES IN THE UNITED STATES IN THE MATTER OF SMOKING AND HEALTH, AS YOU KNOW, THIS WEEK WE IN THE UNITED STATES ARE OBSERVING THE 25TH ANNIVERSARY OF THE PUBLICATION OF OUR GOVERNMENT’S FIRST REPORT ON SMOKING AND HEALTH. WE’VE PRODUCED 19 MORE SUCH REPORTS SINCE THEN. IN FACT, BEFORE LEAVING THE STATES TO COME TO EUROPE, I RELEASED MY OWN 8TH ANNUAL REPORT ON SMOKING AND HEALTH, IT IS TITLED: “REDUCING THE HEALTH CONSEQUENCES OF SMOKING: 25 YEARS OF PROGRESS,” 2 THIS LATEST REPORT IS A DETAILED HISTORY OF OUR QUARTER- CENTURY CAMPAIGN AGAINST SMOKING, A CAMPAIGN I CAN ONLY SKETCH OUT FOR YOU TODAY. THE 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 1964 ABOUT SMOKING AS A CAUSE OF CANCER? AND HOW MUCH DO WE REALLY KNOW TODAY? 3 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. RATHER, 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: 4 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 CONDITIONS. THIRD, THE ADVISORY COMMITTEE SAID CIGARETTES WERE A MAJOR CAUSE OF CHRONIC BRONCHITIS AND CONTRIBUTED TO THE HIGH MORTALITY RATE FOR EMPHYSEMA. 5 FOURTH, THE COMMITTEE SAID -- IN 1964, REMEMBER -- THAT CIGARETTE SMOKING WAS THE MAJOR CAUSE OF LUNG CANCER IN MEN AND MAYBE FOR WOMEN, ALSO. EIFTH, 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 COMMITTEE CONCLUDED THAT “CIGARETTE SMOKING IS A HEALTH HAZARD OF SUFFICIENT IMPORTANCE IN THE UNITED STATES TO WARRANT APPROPRIATE REMEDIAL ACTION.” 6 SUCH “APPROPRIATE REMEDIAL ACTION” WAS TAKEN ALMOST IMMEDIATELY. THE UNITED STATES CONGRESS SOON PASSED A LAW RE- QUIRING ALL CIGARETTE PACKAGES TO CARRY THE FOLLOWING MESSAGE: “CAUTION: CIGARETTE SMOKING MAY BE HAZARDOUS TO YOUR HEALTH.” WE ALSO ESTABLISHED A CENTRAL FOCAL POINT IN GOVERNMENT THAT WAS BOTH HIGHLY VISIBLE AND HIGHLY ACTIVE. IT WAS FIRST CALLED A “NATIONAL CLEARINGHOUSE FOR SMOKING AND HEALTH,” INDICATING ITS PRIMARY FUNCTION OF PUBLIC EDUCATION. 7 TODAY IT 1S CALLED MERELY THE “QFFICE ON SMOKING AND HEALTH,” A MORE GENERAL TITLE EMBRACING PUBLIC EDUCATION, RESEARCH, EPIDEMIOLOGICAL STUDIES, TECHNICAL ASSISTANCE TO GOVERNMENTS, AND SO ON. 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 CIGARETTE SMOKING IS DANGEROUS TO YOUR HEALTH.” HOW DID THAT COME ABOUT? g 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 IDENTI- FYING CIGARETTES AS THE MAJOR CAUSE OF MORBIDITY AND MORTALITY ACROSS A BROAD SPECTRUM OF DISEASE CONDITIONS. THE NEW INFORMATION NOT ONLY CONFIRMED THE FINDINGS PUBLISHED IN 1964, IT LINKED CIGARETTE SMOKING TO PANCREATIC, GASTRIC, RENAL, AND CERVICAL CANCERS. CIGARETTES 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, 9 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 GAI MOKING. 10 AS | INDICATED A MOMENT AGO, I HAVE RELEASED 8 ANNUAL REPORTS SO FAR. 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. EACH ONE HAS ITS OWN SPECIFIC AND IMPRESSIVE DATA BASE, IN 1984, I WAS PERSONALLY SO CONVINCED BY THE DATA ACCUMU- LATED THUS FAR THAT I CALLED UPON MY FELLOW CITIZENS TO MAKE THE UNITED STATES A “SMOKE-FREE SOCIETY BY THE YEAR 2000.” 11 AND I’M PLEASED TO SAY THAT MY COUNTRY MAY WELL BE SUB- STANTIALLY SMOKE-FREE BY THE END OF THIS CENTURY. THAT IS TO SAY, PEOPLE WHO WILL WANT TO SMOKE WILL HAVE TO GET PERMISSION TO DO IT. TODAY, THE SMOKING-AND-HEALTH RESEARCH BASE IS STILL GROW- ING. IT IS COMPRISED OF MORE THAN 55,000 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. 12 AS THIS RESEARCH BASE HAS EXPANDED, SO HAVE OUR EFFORTS TO EDUCATE THE PUBLIC ... TO GET THOSE WHO SMOKE, TO STOP ... AND THOSE WHO DON’T SMOKE, TO NEVER START. 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 ... 13 * 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 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, ... 14 * GOVERNMENT HAS RAISED EXCISE AND SALES TAXES 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, TAXES 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. 15 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 .1+ 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... 16 * IT HAS EXCLUDED TOBACCO AND TOBACCO PRODUCTS FROM CERTAIN REGULATORY ACTIVITIES COVERING HAZARDOUS OR TOXIC SUBSTANCES AND FROM MOST PACKAGING AND LABELING RESTRICTIONS, EXCEPT FOR THE SURGEON GENERAL’S WARNING, * 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, 17 * AND WHILE WE'VE MADE ADJUSTMENTS IN OUR AGRICULTURAL SUPPORT PROGRAM, WE STILL PROVIDE A GREAT DEAL OF ENCOURAGEMENT FOR THOSE WHO EXPORT AMERICAN TOBACCO AND TOBACCO PRODUCTS. THIS FINAL POINT IS AN EXTREMELY IMPORTANT ONE, FROM MY OWN PERSPECTIVE. 18 AS MOST OF YOU KNOW, I HAVE REPRESENTED THE AMERICAN PEOPLE AT THE ANNUAL WORLD HEALTH ASSEMBLY IN GENEVA FOR NEARLY EVERY ONE OF MY 7 YEARS IN OFFICE. AND EACH YEAR I HAVE LISTENED TO MY PUBLIC HEALTH COLLEAGUES FROM DEVELOPING COUNTRIES BECOME MORE AND MORE ALARMED OVER THE RISING INCIDENCE AMONG THEIR CITIZENS OF SUCH SMOKING-RELATED DISEASES AS HEART DISEASE, STROKE, AND LUNG CANCER, IN PARTICULAR. ] HAVE VISITED MANY OF THEIR COUNTRIES, ESPECIALLY IN ASIA AND SOUTHEAST ASIA. AND I’VE BEEN STRUCK BY THE UBIQUITOUS AND HEAVY-HANDED PROMOTION OF AMERICAN TOBACCO PRODUCTS ON BILL- BOARDS, AT KIOSKS AND IN SHOPS OF EVERY KIND, ON THE WALLS OF PUBLIC AND PRIVATE BUILDINGS, IN THE MEDIA, IN BANNERS STRUNG ABOVE VILLAGE MARKETS, AND SO ON. 19 THE APPEAL IS TO YOUNG PEOPLE ... TO SCHOOL-AGE CHILDREN, AS IT IS AT HOME ... AND TO YOUNG ADULTS, THE HEART AND SOUL OF ANY NATION’S WORKFORCE. IVE SEEN ALL THIS ... I KNOW MY GOVERNMENT HAS DONE NOTHING TO DISCOURAGE IT ... AND THAT HAS TROUBLED ME DEEPLY, BUT PLEASE LET ME BE CLEAR ABOUT WHY I AM RAISING THIS POINT. J DO SO BECAUSE IT IS VERY EASY FOR PEOPLE LIKE US, WHO HAVE LABORED SO LONG AND HARD FOR THE KIND OF MODEST INCREMENTAL VICTORIES WE’VE HAD OVER CIGARETTES .,. IT’S EASY FOR US TO RELAX A LITTLE AND TRY TO CATCH OUR BREATH. 20 BUT WE SIMPLY CAN‘T AFFORD TO RELAX. THE INDUSTRY WE ARE OPPOSING -- AND THE HABIT WE ARE TRYING TO CHANGE -- BOTH ARE FORMIDABLE, TRANSNATIONAL OPPONENTS, SMOKING IS NOT A PROBLEM FACED BY JUST ONE SOCIETY OR BY JUST A HANDFUL OF COUNTRIES. SMOKING HAS BECOME MANKIND'S PROBLEM, AND, THEREFORE, EACH OF US IS MORALLY AND ETHICALLY BOUND TO OPPOSE IT WHEREVER IT IS INDULGED, T AM ANGRY, OF COURSE, THAT CITIZENS OF MY COUNTRY ARE ENGAGED IN THE EXPORT OF A HABIT THAT PRODUCES SUCH PROFOUND ECONOMIC, SOCIAL, AND HUMAN DAMAGE. 21 BUT I HOPE EACH OF YOU FEEL THE SAME WAY ABOUT THE INDIVIDUALS IN YOUR OWN COUNTRIES WHO ARE SIMILARLY ENGAGED, INDIVIDUALS WHOSE LIVELIHOODS -- IF YOU CAN USE THAT TERM -- ARE ROOTED IN THE TOBACCO AND TOBACCO PRODUCTS INDUSTRIES. THEY ARE DOING EXTRAORDINARY HARM TO THE HEALTH OF MEN, WOMEN, AND CHILDREN. ONE DAY -- THE SOONER THE BETTER -- THEY MAY REALIZE JUST HOW MUCH HARM THEY ARE DOING, LET’S HOPE THIS REALIZATION COMES SOONER RATHER THAN LATER ... AND LET’S HOPE THAT THEY STOP. 22 T AM TRYING TO STATE THE CASE AS FORCEFULLY AS POSSIBLE BECAUSE, AS GOOD A JOB AS WE’VE DONE IN THE UNITED STATES AND AS GOOD A JOB AS SOME OF YOU HERE TODAY HAVE DONE IN YOUR OWN COUNTRIES, THE IMPACT OF TODAY'S LEVEL OF SMOKING IS STILL ENORMOUS AND WILL REMAIN SO WELL INTO THE 21st CENTURY, IN FACT, CIGARETTE SMOKING HAS ALREADY DONE SO MUCH TRREPARABLE AND IRREVERSIBLE DAMAGE THAT, EVEN IF EVERY ONE OF TODAY'S SMOKERS DECIDED TO QUIT RIGHT NOW, THE NET GAINS IN OVERALL NATIONAL HEALTH STATUS FOR THE NEXT DECADE OR TWO WOULD STILL BE RELATIVELY SMALL, 23 BUT EVERY SMOKER IS NOT GOING TO QUIT RIGHT NOW AND WE WILL JUST HAVE TO SETTLE FOR A MORE MODEST GOAL ... BUT NOT [00 MODEST. THE ALARMING THING ABOUT THIS HABIT IS THAT, WHEN IT INVADES A NEW MARKET, IT DOES SO WITH IMMENSE SPEED AND IMPACT. ACCORDING TO THE WORLD HEALTH ORGANIZATION, BETWEEN 1971 AND 1981 CIGARETTE CONSUMPTION INCREASED IN ASIA AND LATIN AMERICA AT A RATE 30 PERCENT AHEAD OF THE RATE OF POPULATION INCREASE ... IN AFRICA, IT ROSE 77 PERCENT AHEAD OF THE RISE IN POPULATION. 24 CLEARLY WE'VE GOT TO DO WHATEVER WE CAN IN THE YEARS IMMEDIATELY AHEAD TO STOP -- AND REVERSE -- THE RISING CURVE OF CIGARETTE CONSUMPTION IN THE THIRD WORLD, BUT NOT ONLY IN THE THIRD WORLD. WE'VE GOT TO DO THAT RYW » NO WESTERN INDUSTRIALIZED DEMOCRACY IS RICH ENOUGH TO CARRY THE BUDGET-BUSTING BURDEN OF ILLNESS THAT CIGARETTES PLACES ON ANY NATIONAL TREASURY. NO NATION CAN AFFORD TO BE SMUG. AS PROUD AS WE ARE OF OUR ANTI-TOBACCO ACHIEVEMENTS OF THE PAST QUARTER OF A CENTURY, WE DARE NOT EASE UP OUR EFFORTS FOR ONE MOMENT. 25 THE YEARS AHEAD WILL LOOK VERY MUCH LIKE THE YEARS PAST -- EXCEPT MORE SO: THAT IS... ve MORE SMOKING CESSATION CLINICS AND PROGRAMS ... vee MORE ANTI-~SMOKING CAMPAIGNS IN OUR SCHOOLS, ESPECIALLY OUR ELEMENTARY SCHOOLS, WHERE LIFE-LONG HABITS -- GOOD AND BAD -- ARE LEARNED FIRST ... vee MORE LAWS AND REGULATIONS RESTRICTING THE SMOKING OF ANYTHING IN ANY PUBLIC PLACE ... oe» MORE RESTRICTIONS ON SMOKING IN THE WORKPLACE -- IF POSSIBLE, ELIMINATING IT ALTOGETHER FROM ANYPLACE WHERE ANYONE WORKS ... 26 »++ AND MORE RESEARCH INTO THE BIOMEDICAL AND BIOBEHAVIORAL EFFECTS OF THE USE OF TOBACCO PRODUCTS OF ANY KIND. WILL IT BE AN EASY ROAD AHEAD? IT WILL NOT. WILL WE ABLE TO COAST TO VICTORY? WE WILL NOT. WILL WE EVER WIN THIS BATTLE? YES, WE WILL. YOU AND I MAY NOT BE AROUND AT THE FINAL MOMENT OF VICTORY, BUT -- YES -- I BELIEVE ABSOLUTELY THAT THE PEOPLE OF OUR RESPECTIVE COUNTRIES AND PEOPLE EVERYWHERE IN THE WORLD WILL -- ONE DAY AND ONCE AND FOR ALL -- BE RID OF TOBACCO, THE CAUSE OF SO MUCH WORLDWIDE SICKNESS AND DEATH, 27 ] BELIEVE THAT. I’M GOING TO CONTINUE TO WORK FOR THAT TO HAPPEN. AND I ASK EACH AND EVERYONE OF YOU TO JOIN ME IN THAT EFFORT. THANK YOU, #HHE Ht