SPEECH WORLD CONFERENCE ON LUNG HEALTH AMERICAN LUNG ASSOCIATION (AMERICAN THORACIC SOCIETY) . BOSTON, MA Pew MAY 21, 1990 RT +o [1-1 C. EVERETT KOOP, MD 14 22,23, 3% zor, F7 Ao) Fra GREETINGS, ETC. "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 ATTENTION. WHY DO I FEEL I HAVE TO SAY SOMETHING DRAMATIC TO GET THEIR ATTENTION? I 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. ASA 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, PLL 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 AND FOR ITS INTERNATIONAL POWER. 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 WHO GREW PUMPKINS IN THE NEARBY FIELDS AROUND BOSTON. CONGRESS HAS BEEN HELD HOSTAGE EVER SINCE. DESPITE THE SINISTER ASSOCIATIONS, FIRST WITH SLAVERY, AND LATER WITH CANCER AND HEART DISEASE, AMERICAN 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, NORA COSMETIC: A LOOSE CANNON ON THE DECK OF SPACESHIP EARTH. 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. OF PRIMARY CONCERN TO US TODAY IS THAT --RIGHT NOW-- THE TOBACCO INDUSTRY IS WINNING THOSE BATTLES OVERSEAS. WE NEED TO COMBAT THEM BOTH AT HOME AND ABROAD. IT IS A SPECIAL PLEASURE FOR ME TO BE WITH YOU TODAY, BECAUSE IT BRINGS BACK THE MEMORY OF A VERY SPECIAL DAY FOR ME. AND I HOPE IT HAS BECOME A SPECIAL DAY FOR ALL WHO WORK TO BREAK THE DEATH-GRIP THAT THE TOBACCO INDUSTRY HAS ON SO MANY LIVES AROUND THE WORLD. IT WAS 6 YEARS AGO, IN 1984, AT THE MEETING OF THE AMERICAN LUNG ASSOCIATION AND THE AMERICAN THORACIC SOCIETY IN MIAMI THAT I FIRST CALLED FOR A SMOKE-FREE SOCIETY IN AMERICA BY THE YEAR 2000. AT THAT TIME I SAID VERY CLEARLY THAT I WASN’T PROPOSING ANOTHER GOVERNMENT PROGRAM. THIS WAS NOT GOING TO BE A PUBLIC HEALTH SERVICE INITIATIVE...NOR WAS THIS GOING TO BE ANOTHER PET PROJECT OF THE U.S. SURGEON GENERAL. INSTEAD, I RAISED THE IDEA AS A CALL...A CALL FROM THE SURGEON GENERAL TO THE PEOPLE OF THIS COUNTRY. YOU MAY RECALL THAT I DESIGNATED CERTAIN GROUPS TO DO CERTAIN THINGS: THE BOY SCOUTS, THE CAMPFIRE GIRLS, RESPIRATORY THERAPISTS, THE COALITION ON SMOKING OR HEALTH. IN THE YEARS SINCE, EACH GROUP HAS RESPONDED, AND RESPONDED GENEROUSLY. 10 THE CALL FOR A SMOKE-FREE SOCIETY HAS BEEN STRENGTHENED BY THE RECEPTION AFFORDED A NUMBER OF SURGEON GENERAL’S REPORTS ON SMOKING. IN PARTICULAR, THE SURGEON GENERAL’S REPORTS ON INVOLUNTARY SMOKING, AND ON NICOTINE ADDICTION WORKED TOGETHER TO GIVE THE MILITANT ANTI-SMOKERS NEW AND POWERFUL WEAPONS. THE NONSMOKER WAS MERELY IRRITATED AT FIRST...THEN BECAME ANNOYED...AND THEN TURNED MILITANT. 11 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. AS OF LAST YEAR MORE THAN 250 LOCAL COMMUNITIES HAD ADOPTED REGULATIONS RESTRICTING SMOKING IN PUBLIC PLACES, A THREE-FOLD INCREASE IN THREE YEARS. 12 A MOST SATISFYING VICTORY IS THE AIRLINE SMOKING BAN THAT BECAME EFFECTIVE LAST WINTER. 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. OTHER AIRLINES -- ALASKA, DELTA, EASTERN, AND U.S. AIR-- HAVE ALSO EXTENDED THE BAN BEYOND THE REQUIREMENTS OF THE LAW. Awecdo7F &? Aig CAWADA US BRUWES — Dare EPP 3s AIR CHMBPA Awd f£erge7 Arte w SANTIS YoLyw 7&2 res HELIER, COTOMIUWE ~ BA LrORE , Dekine, Pea cE va CH#BrK Noe CLA PAR PANT SEM ECA AA Fe COA TOM Corevew ¢ Mowe 3 Mone 4. LOWEER. -2¢ packs HFZER SPAvEQ nett AFT CAH oF wons7 13 AND REMEMBER, LAST NOVEMBER A TOUGH LOCAL SMOKING CONTROL ORDINANCE WAS APPROVED BY THE VOTERS IN GREENSBORO, N.C, , IN SPITE OF HEAVY OPPOSITION BY TOBACCO COMPANIES. IF THE TOBACCO COMPANIES CAN BE BEATEN IN NORTH CAROLINA, THEY CAN BE BEATEN ANYWHERE! 14 SMOKING HABITS HAVE CHANGED. FIFTEEN YEARS AGO, AT MEDICAL MEETINGS, WHERE DOCTORS SHOULD HAVE KNOWN BETTER, THE AIR WAS BLUE WITH SMOKE. NOW YOU RARELY SEE A PHYSICIAN SMOKE; THE ONLY SMOKE AT MEDICAL MEETINGS COMES FROM THE SPOUSES. IN 1964, BEFORE THE FIRST SURGEON GENERAL’S REPORT ON SMOKING, OVER HALF OF ADULT AMERICANS SMOKED. 15 WHEN I BECAME SURGEON GENERAL IN 1981, THE NUMBER HAD DECLINED TO 33 PERCENT. WHEN I LEFT OFFICE 8 YEARS LATER, THE NUMBER OF AMERICAN SMOKERS HAD SHRUNK EVEN MORE, TO 26 PERCENT. FEW THINGS GIVE ME AS MUCH SATISFACTION AS THAT DRAMATIC DECREASE, FROM 33 PERCENT TO 26 PERCENT. AND IT NOW APPEARS THAT DURING MY LAST YEAR IN OFFICE, SMOKING DROPPED ANOTHER ALMOST 5 PERCENT. 16 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. NEARLY HALF OF ALL LIVING ADULTS WHO HAVE EVER SMOKED HAVE QUIT. WITH THIS BACKGROUND, THE SMOKE-FREE SOCIETY THAT I FIRST CALLED FOR AS I STOOD BEFORE YOU IN 1984 IS AN IDEA ’ WHOSE TIME HAS COME. 17 YOU'VE SEEN THE IMPACT. HOSPITAL STAFFS ARE DEMANDING THAT THEIR FACILITIES BE MADE SMOKE-FREE. WORKING PEOPLE ARE ASKING FOR SMOKE-FREE ENVIRONMENTS WHERE THEY WORK. PROFESSIONAL PEOPLE ARE HANGING THOSE "THANK YOU FOR NOT SMOKING SIGNS" IN THEIR WAITING ROOMS. AND HOUSEHOLDERS ARE TACKING UP THE SAME SIGN OVER THEIR FRONT DOORBELLS. 18 I CANNOT NEGLECT THIS OPPORTUNITY TO SAY THAT THE COOPERATIVE EFFORTS OF THE AMERICAN LUNG ASSOCIATION, THE AMERICAN HEART ASSOCIATION, THE AMERICAN CANCER SOCIETY IN WORKING TOWARD A CURRICULUM AGAINST SMOKING THAT WOULD GRADUATE A HIGH SCHOOL CLASS IN THE YEAR 2000 SMOKE-FREE HAS BEEN EXTRAORDINARILY REWARDING. I’VE PARTICIPATED IN THE PROGRAMS FOR THE FIRST AND SECOND GRADES, AND I’M VERY ENCOURAGED ABOUT HOW MUCH THESE YOUNGSTERS KNOW, AND HOW SERIOUSLY THEY TAKE THEIR PLEDGE TO TURN THEIR BACKS ON ANYONE WHO OFFERS THEM A CIGARETTE, NOW AND IN THE FUTURE. /1(FE ANEcdo7l ~ AHAWATI “wu GCO0VERWMOR 19 SO, I WANTED TO START OUT WITH THE GOOD NEWS, REMINDING US OF HOW FAR WE HAVE COME, REMINDING US OF BATTLES WON. BUT THERE IS STILL A LONG WAY TO GO. THERE ARE STILL BATTLES TO BE FOUGHT. THERE IS STILL PLENTY OF BAD NEWS. 20 EVEN IN THE UNITED STATES, EVEN WITH ALL THE PROGRESS WE HAVE MADE,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, 9 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. 21 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... 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. 22 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. {2 SOME 49 MILLION AMERICANS STILL SMOKE, SO OUR EDUCATION CAMPAIGNS AND OUR SELF-HELP GROUPS MUST CONTINUE THEIR GOOD WORK. WE MUST GUARD AGAINST COMPLACENCY, AND INTEN SIFY OUR EFFORTS TO ELIMINATE THE GREATEST CAUSE OF PREVENTABLE DISEASE AND DEATH AFFLICTING OUR SOCIETY. ° 23 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. 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. 24 /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? 25 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. I DO NOT BELIEVE THE UNITED STATES WILL EVER AGAIN BE A GOOD MARKET FOR TOBACCO PRODUCTS. THE CURVE IS GOING DOWN AND ACCELERATING. 26 BUT IF WE FEEL GOOD BECAUSE WE HAVE BEATEN THE CIGARETTE INDUSTRY ON ITS OWN HOME TURE ... WE MUST REALIZE THAT WE’VE DRIVEN THEM TO SCOUR THE REST OF THE EARTH FOR NEW VICTIMS. WHILE RECENT STATISTICS BRING US THE GOOD NEWS THAT SMOKING IN THE UNITED STATES DROPPED ANOTHER 5% IN 1989, WE ARE SADDENED AND OUTRAGED THAT AMERICAN TOBACCO EXPORTS ROSE 20% LAST YEAR. 27 IN 1989 AMERICAN COMPANIES MADE 600 BILLION CIGARETTES; 100 BILLION OF THOSE CIGARETTES WENT OVERSEAS, OVER HALF TO THE FAR EAST. 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. 28 AS A RESULT, THOSE NATIONS ARE NOW BEGINNING TO EXPERIENCE THE SAME RISE IN SMOKING-RELATED DISEASES THAT WE EXPERIENCED A GENERATION AGO ... HEART DISEASE, STROKE, AND CANCER OF THE LUNG, MOUTH, ESOPHAGUS, AND STOMACH. AS AN AMERICAN CITIZEN I AM APPALLED BY THIS CORPORATE BEHAVIOR OF AMERICAN COMPANIES AND, FURTHER, I AM SHOCKED BY THE OUR OWN GOVERNMENT’S SUPPORT OF SUCH BEHAVIOR. 29 THIS EXPORT OF DEATH AND DISEASE HAS BEEN CARRIED OUT WITH THE SUPPORT OF OUR TRADE REPRESENTATIVES, OUR STATE DEPARTMENT, OUR COMMERCE DEPARTMENT, AND OUR AGRICULTURE DEPARTMENT. IT’S NOT A VERY PRETTY STORY. BUT THERE IT IS. LAST FALL, IN MY LAST OFFICIAL ACT AS SURGEON GENERAL, I WAS ONE OF MORE THAN 30 WITNESSES AT A PUBLIC HEARING ON INVESTIGATION INITIATED UNDER SEC. 302 OF THE TRADE ACT OF 1974. 30 I MADE MY POINT, AND CONCLUDED BY SAYING, "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." 31 THIS NICOTINE DRUG CARTEL, THE TRANS-NATIONAL TOBACCO COMPANIES TRAVEL FROM COUNTRY TO COUNTRY WITH A GREAT DEAL OF CASH --NOT CREDITS, NOT PROMISES, BUT HARD, COLD CASH. THEREF ORE IT IS VERY DIFFICULT FOR ANY GOVERNMENT STRUGGLING TO GET ITS ECONOMY IN ORDER TO TURN AWAY SUCH WELL-PAYING GUESTS. THESE COMPANIES BUILD FACTORIES AND EMPLOY MANY PEOPLE. THEY SPEND LARGE SUMS ON ADVERTISING AND SPECIAL EVENTS. IN SOME AREAS THEY VIRTUALLY SUBSIDIZE THE MEDIA. 32 IN MY VIEW THE SEVEN MAJOR TRANS-NATIONAL TOBACCO COMPANIES --FOUR AMERICAN AND THREE BRITISH-- ARE TOGETHER THE VERY MODEL OF A COLONIAL POWER. THEY OSTENTATIOUSLY PUMP#@@ LARGE AMOUNTS OF MONEY INTO THE ECONOMIES OF A POOR NATION, ONLY TO EXACT LARGER SUMS OF WEALTH IN THE FORM OF CROPS, MANUFACTURED GOODS, OR CASH. 33 UNFORTUNATELY THESE COMPANIES ALSO EXTRACT THE PHYSICAL HEALTH OF THE PEOPLE OF EVERY COUNTRY THEY COLONIZE. YOU CAN SEE IT IN THE RISING MORBIDITY AND MORTALITY RATES FROM WESTERN SMOKING-RELATED DISEASES. THE ALARMING THING ABOUT THIS HABIT OF CIGARETTE SMOKING IS THAT, WHEN IT INVADES A NEW MARKET, IT DOES SO WITH IMMENSE SPEED AND IMPACT. 34 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. THE PEOPLE’S REPUBLIC OF CHINA, FOR EXAMPLE, REPORTED THAT 90 PERCENT OF ITS MEN SMOKE. ... PAPUA NEW GUINEA REPORTED THAT 85 PERCENT OF ITS MEN NOW SMOKE... THE PHILIPPINES, 78 PERCENT ... AND SO ON. WHo, () Dorveé 4 Coof Jer! ~ et Ute WHEW LPR Hinesh( vMAKAIIMA , A-~G- | FEMEN. eC Our wportss ED THE 2 Worco cow TitE watnvsiom OF Tr ae MI PLaas Zo BE -stLEaet d, FE APP ERLED To NAMOVTeL AuTioe@ine> wWvo pec Cg CELWED— a7 tt LEv tS ~— Fy Jorw Fovhees cu aA CF FEW suv & AIMED -~ | SWEC Pl iH’ = ERE i555 Ae SCCM AUT CE Typteco AS A Meson FR EYO Fo , ~ We S Hoe Fire tb Eatin” OF ECTGNEe C6 Ew ears * Jota prem AND LISTEN CAREFULLY TO THIS: IN CHINA, WHERE COUPLES ARE SUPPOSED TO HAVE ONLY 1 CHILD PER FAMILY, THERE ARE AT THIS MOMENT AN ESTIMATED 50,000,000 CHILDREN WHO WILL DIE PREMATURELY FROM SMOKING. THE RECENT NEWS THAT IN 15 ASIAN COUNTRIES COMMUNICABLE DISEASE WAS NO LONGER THE NUMBER ONE PUBLIC HEALTH MENACE WAS NOT REALLY GOOD NEWS. WHY? BECAUSE IN THOSE ASIAN COUNTRIES TODAY, THE TOP THREE CAUSES OF DEATH ARE -- CAN YOU GUESS? -- THE SAME THREE SMOKING-RELATED CAUSES OF DEATH THAT PREVAIL HERE IN THE UNITED STATES: HEART DISEASE, CANCER, AND STROKE. 36 IN OTHER WORDS, THE TOBACCO EPIDEMIC AND ITS LETHAL CONSEQUENCES HAVE HIT ASIA ... AND -- THANKS TO OUR OWN CIGARETTE INDUSTRY -- HAVE HIT ASIA HARD. AND HERE’S WHERE WE DESERVE TO SQUIRM IN SHAME -- IN 10 OF 15 ASIAN COUNTRIES, AMERICAN CIGARETTES WERE THE MOST COMMON KIND IMPORTED. 37 BUT THOSE AMERICAN CIGARETTES ARE A LITTLE DIFFERENT OVERSEAS: FOR ONE THING, THEY DON’T CARRY THE SURGEON GENERAL’S WARNING. AND FOR ANOTHER, MANY AMERICAN CIGARETTES MANUFACTURED FOR EXPORT HAVE A HIGHER TAR CONTENT AND ARE, THEREFORE, EVEN MORE DANGEROUS THAN THE LOWER-TAR, FULLY-LABELLED PRODUCTS SOLD HERE IN THE UNITED STATES. 38 35 A We ALY ftw THAT Le. Jane Meow - MG DIO M7 Fes7ry = =6BEFONE Ve CANC HESS GOMME Co lfHMm 7 7EE 4437 WES, oV ME ErPIA7 CF ZH bieECY, J4E Sete 1Feecert) WHAT HE SYD (| PERU Ex tltoba Fee) YS (L YOS7EnG AY — ow FMCE Fite. rtd w- FSFE SELF AS HUE SACO / FEAT ott. JS « SATO | 1% wets fA *tRAOE STOLE Wot Ye HEACTIH JIVE. Lil tn-7 rt- Sees STHAJE of AF Hf. Jt1WE we Atlee R- CvE Fehon 2HE TY PNClLb6 cYemepAwes ”. Wit we Ose THE(l. Dovpee-SPEHE 7. (7 SEemM) ZF WE 1 We CHM [(C@fwE Fe ExGoere7 Td Somt CcovaThiet? WekPowS, WE ChH fetve f-- PEYELINE Whpow Tv Néfxt Ze pmponT CobMeo. NOW, LET ME MAKE SURE YOU UNDERSTAND WHAT I JUST SAID. I SAID THAT SOME AMERICAN CIGARETTE MANUFACTURERS -- AS KNOWLEDGE-ABLE AS I AM, CONCERNING THE HEALTH RISKS OF Dg SMOKING -- KNOWINGLY PRODUCE A MORE HARMFUL CIGARETTE FOR EXPORT THAN THEY PRODUCE FOR DOMESTIC consumption. GE |} Am EMGeRa580 AS aH AMencnN ~ RAD | low THERE AhE mMicctows OFF DECEWS FOLKS Whe FES FE SATE HHL, OUR EXPORT OF TOBACCO PRODUCTS Isa MORAL OUTRAGE, Not swe 39 SD IT IS ALSO FOOLISH. WE MUST CONVINCE OUR GOVERNMENT THAT THERE IS NO SENSE IN PLANNING FOR THE LONG-TERM ECONOMIC HEALTH OF A FOREIGN SOCIETY A) PROVIDING THAT SOCIETY WITH FOREIGN AID G37 FHE-ONE-HAND, IF THE PHYSICAL HEALTH OF THE PEOPLE OF THAT SOCIETY IS FUNDAMENTALLY ENDANGERED DURING THAT SAME LONG TERM. AGAINST THIS INTERNATIONAL OFFENSIVE OF THE TOBACCO FIRMS THE INTERNATIONAL COMMUNITY IS FIGHTING BACK, EVEN THOUGH THEIR RESOURCES ARE SLIGHT. 40 THE WORLD HEALTH ORGANIZATION IS TO BE CONGRATULATED FOR CONFRONTING HEAD-ON THE TOBACCO INDUSTRY’S BRAZEN CHALLENGE TO THE PHYSICAL WELL-BEING OF MILLIONS UPON MILLIONS OF THE WORLD’S MEN, WOMEN, AND CHILDREN. THE CIGARETTE SMOKING EPIDEMIC BEING WHAT IT IS -- A CROSS BETWEEN PUBLIC HEALTH AND INTERNATIONAL COMMERCE -- WE FIND, COUNTRY-BY-COUNTRY, THAT THE STRONGEST OPPONENTS ARE OFTEN CONSUMERS AS WELL AS PHYSICIANS. 41 IN FACT, THE I.0.C.U., OR INTERNATIONAL ORGANIZATION OF CONSUMERS UNIONS -- NOT A U.N. GROUP, BY THE WAY -- HAS A SEPARATE ANTI-SMOKING SUB-GROUP THAT GOES BY THE NAME OF "ACTION GROUPS TO HALT THE ADVERTISING AND SPONSORSHIP OF TOBACCO" -- OR "AGHAST." ONE OF "AGHAST’S" KEY ACTIVITIES IS TO SUPPORT THE WORLD HEALTH ORGANIZATION’S ANNUAL "WORLD NO-TOBACCO DAY". AFFILIATED MEMBERS OF "AGHAST" -- MOSTLY NATIONAL CONSUMER COUNCILS -- HAVE HAD ROUSING AND SUCCESSFUL "NO SMOKING DAYS" IN PLACES LIKE FIJI, HONG KONG, INDIA, MALAYSIA, AND THAILAND. 42 IF THIS SOUNDS SUSPICIOUSLY LIKE OUR OWN "GREAT AMERICAN SMOKE-OUT," WHICH WE SPONSOR HERE EVERY YEAR IN NOVEMBER, THAT’S BECAUSE IT IS. AND I’M PLEASED TO SAY THAT OUR P.H.S. OFFICE ON SMOKING AND HEALTH HAVE HAD SOMETHING TO DO WITH SPREADING THE IDEA TO OUR FRIENDS OVERSEAS. 43 THE IDEA OF A SMOKE-FREE SOCIETY IS GETTING SERIOUS CONSIDERATION IN ISRAEL AND GREAT BRITAIN, FOR EXAMPLE. IVE TRAVELED TO BOTH COUNTRIES TO BE PART OF THE EFFORT. BUT SO FAR THESE EFFORTS ARE TOO SMALL TO BLUNT THE TOBACCO OFFENSIVE. THEY ARE TOO WEAK TO LOOSEN TOBACCO’S ECONOMIC GRIP ON THE WORLD. 44 SO, WHAT CAN WE DO? I'M SURE THAT IN THE SESSIONS TO FOLLOW, YOU WILL HEAR AND THEN DISCUSS A NUMBER OF VERY SPECIFIC SUGGESTIONS. PLL OFFER JUST A FEW. OUR CONFERENCE THEME RECOGNIZES THE GLOBAL CHARACTER OF THE STRUGGLE AGAINST SMOKING AND THE POWER OF THE TOBACCO INTERESTS. 45 WE AMERICANS MUST CONDUCT THE BATTLE ON THE HOME FRONT AS WELL AS OVERSEAS. HERE AT HOME, WHILE WE WORK THROUGH THE LEGISLATIVE AND REGULATORY PROCESS TO CHANGE AMERICAN TRADE POLICIES, WE MUST CONTINUE THE ECONOMIC PRESSURE AGAINST THE TOBACCO COMPANIES IN THE UNITED STATES. . 46 EVEN THOUGH THE TIDE IS RUNNING AGAINST THEM, WE CANNOT GIVE THEM A RESPITE. WE MUST CONTINUE THE MOMENTUM TOWARD A SMOKE-FREE SOCIETY BY THE YEAR 2000. OUR EDUCATIONAL EFFORTS ARE SUCCESSFUL, AND THEY MUST BE EXPANDED. WE MUST TARGET INDIVIDUAL ISSUES, FOCUS OUR EFF ORTS, AND PREVAIL. 47 IN SOME CRITICAL AREAS THERE IS STILL LITTLE MORE THAN LIP SERVICE PAID TO STOPPING SMOKING. FOR EXAMPLE, MEDICAL SCHOOL CURRICULA SPEND TOO LITTLE TIME ON ADDICTION AND THE WAYS THAT DOCTORS CAN TEACH THEIR PATIENTS HOW TO STOP SMOKING. THE SAD FACT IS PROBABLY ONE HALF THE DOCTORS IN AMERICA FAIL TO PROVIDE ADVICE AGAINST SMOKING, EVEN THOUGH WE KNOW THAT A DOCTOR’S ADVICE IS THE SINGLE MOST EFFECTIVE STIMULUS TO STOP SMOKING. 48 THERE IS NO MONETARY INCENTIVE FOR PHYSICIANS TO TREAT SMOKING. ALTHOUGH STATES REQUIRE INSURANCE COVERAGE FOR ALCOHOL AND DRUG TREATMENT, NO STATE OFFERS COVERAGE FOR NICOTINE CESSATION PROGRAMS, EVEN THOUGH THE HEALTH COST OF NICOTINE ADDICTION ON MUCH HIGHER. FOLLOWING THE SURGEON GENERAL’S REPORT OF 1988, THERE WAS CLEAR EVIDENCE OF THE SKYROCKETING COST OF HEALTH CARE, AND YET THE HEALTH INSURANCE INDUSTRY HAS RESPONDED LIKE NERO. 49 THEY SAY THEYUSUALLY DON’T COVER PREVENTIVE PROGRAMS. WHAT SENSE DOES IT MAKES TO SPEND $150,000 ON THE TERMINAL CANCER ILLNESS OF ONE OF THEIR IN SURED, BUT NOT BE WILLING TO FORK OVER ABOUT $200 TO GET THE SPOUSE OF THAT PERSON TO STOP SMOKING AND PREVENT THE SAME DISEASE DOWN THE ROAD? WITH OVER 90% OF THE SMOKERS WANTING TO QUIT, IT IS AN OUTRAGE THAT THEIR IS NOT LEGISLATION REQUIRING REIMBURSEMENT FOR APPROVED SMOKING CESSATION PROGRAMS. 50 WE ALSO NEED TO WEAKEN THE INTERNATIONAL TOBACCO INDUSTRY BY ELIMINATING CIGARETTE ADVERTISING, HERE AND ABROAD. THE ADS HAVE BEEN BANNED FROM AMERICAN TELEVISION, THANK GOD, --ALTHOUGH THEY ARE SNEAKING BACK THROUGH AAD TFoBAacco-—SPowSeHtED SPeR7IS Elwes VIDEOS-x BUT CIGARETTE ADVERTISING STILL ASSAULTS OUR SOCIETY IN PRINT AND BILLBOARDS. THE TOBACCO INDUSTRY SPENDS $4,000 PER MINUTE ON PROMOTION ($2.5 BILLION A YEAR). ~~ 51 ONLY THE GROTESQUE ECONOMIC POWER OF THE INTERNATIONAL TOBACCO COMPANIES CAN SUSTAIN THIS OUTRAGE, AS THEY USE ECONOMIC BLACKMAIL TO INTIMIDATE PUBLISHERS AND GOVERNMENTS. I AM PARTICULARLY DISTURBED BY CIGARETTE ADVERTISING THAT TARGETS VULNERABLE GROUPS WITHIN OUR POPULATION AND ABROAD. HERE IN AMERICA THE CIGARETTE ADVERTISERS HAVE SET THEIR SIGHTS ON YOUNG PEOPLE, WOMEN, AND MINORITIES. 52 CIGARETTE FIRMS MANIPULATE MINORITIES, WOMEN, AND YOUNG PEOPLE BECAUSE THESE PEOPLE HAVE THE STRONGEST ASPIRATIONS TO CHANGE THEIR STATUS. SO THESE ADS ASSOCIATE SMOKING WITH MAKING IT... THEY ASSOCIATE SMOKING WITH A HIGHER ECONOMIC STATUS (WHEN REALLY HIGHER INCOME GROUPS ARE NOW SMOKING LESS). 53 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, BUSINESS AND SEXUAL SUCCESS, OUTDOOR LEISURE, AND EVEN GOOD HEALTH. 54 ONE OF THE MORE OUTRAGEOUS ADVERTISING SLOGANS IS ONE CIGARETTE 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". 55 IN THE ADVERTISING WARS YOU HEAR A LOT ABOUT PROOF. THE TOBACCO COMPANIES SAY THAT IT HAS NOT BEEN PROVEN THAT ADVERTISING INCREASES CIGARETTE 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. 56 ‘ 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 PROVEN THAT WATER FROM THE PUMP WAS CAUSING THE CHOLERA. 57 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. 58 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. THE ADVERTISERS NEED TO REPLENISH THE DIMINISHING SUPPLY OF TOBACCO USERS: REMEMBER THOSE 1,000 SMOKERS WHO DIE EVERY DAY. 59 ANOTHER ISSUE OF PUBLIC POLICY WHERE WE CAN ATTACK THE TOBACCO INDUSTRY CONCERNS CIGARETTE 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. 60 WE WOULD NEVER TOLERATE SELLING ALCOHOLIC BEVERAGES IN VENDING MACHINES, BUT SOMEHOW WE TOLERATE CIGARETTE 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. 61 EVEN AS WE ARE CONCERNED TODAY ABOUT THE INTERNATIONAL ASPECT OF TOBACCO, I RAISE THESE AMERICAN ISSUES BECAUSE IF WE FOCUS OUR ENERGY ON SPECIFIC ISSUES, IF WE MARSHALL OUR GROWING STRENGTH, WE CAN CHOOSE OUR BATTLES, AND WE WIN THEM ONE BY ONE. FINALLY, I WANT TO STRESS THE POWER OF OUR GREATEST WEAPON. IT MAY SEEM A DAUNTING TASK TO ATTEMPT TO CHANGE THE DEEPLY ENTRENCHED AND SINISTER AMERICAN TRADE POLICIES THAT PROMOTE TOBACCO EXPORTS. 62 IT MAY SEEM BEYOND OUR ABILITY TO INFLUENCE FOREIGN GOVERNMENTS WHO ARE DESPERATE FOR AMERICAN INVESTMENT AND CASH. THESE STRUGGLES WILL TAKE POLITICAL ACUMEN BOTH HERE AND ABROAD. BUT IT CAN BE ACCOMPLISHED, BOTH HERE AND ABROAD, IF WE MOBILIZE THE POPULAR RESOURCES THAT CAN BE TAPPED BY MORAL SUASION. 63 WHEN I WAS YOUR SURGEON GENERAL, I FREQUENTLY SAID THAT I HAD NEITHER POWER NOR BUDGET. THAT WAS CERTAINLY TRUE, FOR I HAD ONLY A TINY STAFF AND - -IN WASHINGTON TERMS-- A TINY BUDGET, ENOUGH TO KEEP US IN PAPER CLIPS AND PHOTOCOPIES. BUT I THINK I WAS ABLE TO ACCOMPLISH A LARGE AGENDA SOLELY THROUGH THE POWER OF MORAL SUASION. 64 IN THE RIGHT HANDS, AND IN ENOUGH HANDS, MORAL SUASION CAN OVERCOME OBDURATE BUREAUCRACIES, ENTRENCHED ECONOMIC POWER, AND THE INCREASINGLY DESPERATE INTERNATIONAL TOBACCO COMPANIES. I MAY HAVE HUNG UP THE UNIFORM OF THE SURGEON GENERAL, BUT I HAVEN’T RETIRED FROM THE FIGHT AGAINST SMOKING. TOGETHER, WE CAN WIN IT, IN AMERICA, AND AROUND THE WORLD. THANK YOU. HEHEHE 65 [7 (3 S4D 747 THE Atyy Wd 7 71 00/ HAS Suéweto ~QYA- Simo MASaow: ow SmgtiNb: WtAd He SAD AD PERTH I) WHAT HE bEabve) , | py OMb& Told MOT Fo SPEC ROMWsS7T =—Toh deco A-DUT. 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