Testimony

Statement by
Richard H. Carmona, M.D., M.P.H., F.A.C.S.
Surgeon General, U.S. Public Health Service, Acting Assistant Secretary for Health, Department of Health and Human Services
on
"Can Tobacco Cure Smoking? A Review of Tobacco Harm Reduction"
before the
House Subcommittee on Commerce, Trade, and Consumer Protection, Committee on Energy and Commerce

Tuesday, June 3, 2003

Mr. Chairman, distinguished members of the Subcommittee, thank you for the opportunity to participate in this important hearing. My name is Richard Carmona and I am the Surgeon General of the United States of America.

Let me start with a few statements that were once accepted throughout society that have now been relegated to the status of myth.

  • Men do not suffer from depression.
  • Domestic violence is a ‘family' or ‘private' matter.
  • The HIV-AIDS epidemic is of no concern to most Americans.

All of us here know that these three statements are very dangerous public health myths.

My remarks today will focus on a fourth public health myth which could have severe consequences in our nation, especially among our youth: smokeless tobacco is a good alternative to smoking. It is a myth. It is not true.

As the nation's Surgeon General, my top responsibility is to ensure that Americans are getting the best science-based information to make decisions about their health. So I very much appreciate the opportunity to come before this Subcommittee today and help refute this dangerous idea.

First, let me emphasize this:

  • No matter what you may hear today or read in press reports later, I cannot conclude that the use of any tobacco product is a safer alternative to smoking. This message is especially important to communicate to young people, who may perceive smokeless tobacco as a safe form of tobacco use.
  • There is no significant scientific evidence that suggests smokeless tobacco is a safer alternative to cigarettes.
  • Smokeless tobacco does cause cancer.
  • Our nation's experience with low-tar cigarettes yields valuable lessons for the debate over smokeless tobacco.
  • Tobacco use is the leading preventable cause of death in the United States.

Each year, 440,000 people die of diseases caused by smoking or other form of tobacco use—that is about 20 percent of all deaths in our nation.

The office I lead as Surgeon General has long played a key role in exposing the risks of tobacco use. In 1986, the Surgeon General's Report The Health Consequences of Using Smokeless Tobacco reached four major conclusions about the oral use of smokeless tobacco:

  1. Smokeless tobacco represents a significant health risk;
  2. Smokeless tobacco can cause cancer and a number of non-cancerous oral conditions;
  3. Smokeless tobacco can lead to nicotine addiction and dependence; and
  4. Smokeless tobacco is not a safer substitute for cigarette smoking.

Recognizing these serious health consequences, Congress passed the Comprehensive Smokeless Tobacco Health Education Act in 1986. This law required the placement of Surgeon General's warnings on all smokeless tobacco products.

Mr. Chairman and Members of the Subcommittee, I respectfully submit that smokeless tobacco remains a known threat to public health just as it was when Congress acted in 1986.

Conversely, time has only brought more disease, death and destroyed lives.

The National Toxicology Program of the National Institutes of Health continues to classify smokeless tobacco as a known human carcinogen—proven to cause cancer in people.

As Surgeon General I cannot recommend use of a product that causes disease and death as a ‘lesser evil' to smoking. My commitment, and that of my office, to safeguard the health of the American people demands that I provide information on safe alternatives to smoking where they exist.

I cannot recommend the use of smokeless tobacco products because there is no scientific evidence that smokeless tobacco products are both safe and effective aids to quitting smoking.

Smokers who have taken the courageous step of trying to quit should not trade one carcinogenic product for another, but instead could use Food and Drug Administration -approved methods such as nicotine gum, nicotine patches, or counseling.

While it may be technically feasible to someday create a reduced-harm tobacco product, the Institute of Medicine recently concluded that no such product exists today. When and if such a product is ever constructed, we would then have to take a look at the hard scientific data of that particular product.

Our nation's experience with low-tar, low-nicotine cigarettes is instructive to the issue at hand. Low-tar, low-nicotine cigarettes were introduced in the late 1960's and widely endorsed as a potentially safer substitute for the typical cigarette on the market at that time. Within a decade, the low-tar brands dominated the cigarette market. Many smokers switched to them for their perceived health benefits.

Unfortunately, the true health effects of these products did not become apparent for another 10 to 20 years. We now know that low-tar cigarettes not only did not provide a public health benefit, but they also may have contributed to an actual increase in death and disease among smokers.

First, many smokers switched to these products instead of quitting, which continued their exposure to the hundreds of carcinogens and other dangerous chemicals in cigarettes. Second, to satisfy their bodies' craving for nicotine, many smokers unwittingly changed the way they smoked these low-tar cigarettes: they began inhaling more deeply, taking more frequent puffs, or smoking more cigarettes per day.

In fact, we now believe that low-tar cigarettes may be responsible for an increase in a different form of lung cancer, adenocarcinoma, which was once relatively rare. This cancer is found farther down in the lungs of smokers, indicating deeper inhalations, and appears linked to a specific carcinogen particularly present in low-tar brands.

We must learn the lessons of the low-tar cigarette experience. Not only did they fail to reduce an individual's risk of disease, but they also appear to have increased population risk by delaying quitting and potentially contributing to initiation among young people. This has taught us that we must move cautiously in recommending any supposedly safer alternative for people trying to quit smoking—because now, with more knowledge and the benefit of hindsight, the science does not support early recommendations on low-tar cigarettes.

Mr. Chairman, in the interest of time I will shortly ask that the remainder of my statement and the scientific information contained in it be considered as read and made part of the record. But before I do that, I would like to ask for this Subcommittee and the Congress' help in getting the message out about the dangers of the myth of smokeless tobacco.

All of us in this room are very concerned about our nation's youth. Kids growing up today have a tough time of it. In addition to the normal struggles of puberty, many kids are facing a host of other challenges. Many, especially minority kids, must struggle to find their way in unsafe neighborhoods.

So the temptation to engage in behavior that is not healthy, and the opportunity to do so, is very hard for our young people to resist.

According to a 2000 survey by the Substance and Mental Health Services Administration (SAMHSA) (The National Household Survey on Drug Abuse), about 1 million kids from age 12 – 17 smoke every day. Another 2 million kids smoke occasionally.

And we know that smoking is often not a ‘stand-alone' risk behavior; it travels with others. The SAMHSA survey found that youth who were daily cigarette smokers or heavy drinkers were more likely to use illicit drugs than either daily smokers or heavy drinkers from older age groups. More than half of 12 – 17 year olds who were daily smokers had also used illicit drugs within the past month.

Every day, more than 2,000 kids in the U.S. will start to smoke, and more than 1,000 adults will die because of smoking. We have to get youth to stop starting. But the answer is not smokeless tobacco.

We have evidence to suggest that instead of smokeless tobacco being a less dangerous alternative to smoking, just as smoking is a gateway to other drugs, smokeless tobacco is a gateway to smoking.

So we must redouble our efforts to get our youth to avoid tobacco in all forms.

We have some real work to do on the ‘culture' of smokeless tobacco, which is glamorized by some sports stars. Chicago Cub Sammy Sosa, who has made a public commitment to avoiding smokeless tobacco, is a great example for kids. Past baseball great Joe Garagiola is now Chairman of the National Spit Tobacco Education program, and regularly lectures young players against the dangers of smokeless tobacco.

As Members of Congress, you can lead by example too, not just in legislation, but in your own lives. I encourage you to avoid tobacco in all its forms. Do not fall for the myth – a very dangerous public health myth - that smokeless tobacco is preferable to smoking. Do not let America's youth fall for it, either.

From the perspective of individual risk, the cumulative effect on smokers of switching to smokeless tobacco is simply not known. But we clearly know that use of smokeless tobacco has serious health consequences. Overall, smokeless tobacco products have been classified as a known human carcinogen. And limited scientific data indicate that former smokers who switch to smokeless tobacco may not have as great a decrease in lung cancer risks as quitters who do not use smokeless tobacco.

From the perspective of population risk, there are even more unanswered questions. Even if there was some decreased risk for smokers who switch to smokeless tobacco, that benefit may be more than offset by increased exposure of the overall population to this known carcinogen.

The marketing of smokeless tobacco as a potentially safer substitute for cigarettes could lead to:

  • More smokers switching to smokeless tobacco instead of quitting tobacco use completely;
  • A rise in the number of lifetime smokeless tobacco users if more youth begin using smokeless tobacco;
  • A rise in the number of cigarette smokers as a result of more youth starting to use smokeless tobacco and then switching to cigarette use; and
  • Some former smokers returning to using tobacco if they believe that smokeless tobacco is a less hazardous way to consume tobacco.

Concerns about youth initiation are especially troubling. The scientific evidence is clear that use of smokeless tobacco is a gateway to cigarette use. Young people may be especially attracted to smokeless tobacco if they perceive it to be safer than cigarettes. Studies show that more than one in five teenage males have used smokeless tobacco, with age 12 being the median age of first use. Surveys also show that more than two in five teenagers who use smokeless tobacco daily also smoke cigarettes at least weekly. Finally, independent research and tobacco company documents show that youth are encouraged to experiment with low-nicotine starter products and subsequently graduate to higher-level nicotine brands or switch to cigarettes as their tolerance for nicotine increases.

Finally, we simply do not have enough scientific evidence to conclude that any tobacco product, including smokeless tobacco, is a means of reducing the risks of cigarette smoking. At this time, any public health recommendation that positions smokeless tobacco as a safer substitute for cigarettes or as a quitting aid would be premature and dangerous. With the memory of our experience with low-tar cigarettes fresh in our minds, we must move extremely cautiously before making any statement or endorsement about the potential reduced risk of any tobacco product.

Finally, my strong recommendation as Surgeon General is a call for sound evidence about tobacco products and their individual and population based health effects. We need more research. We need to know more about the risks to individuals of switching from smoking to smokeless; and we need to know more about the risks to the entire population of a promotion campaign that would position smokeless tobacco as a safer substitute for smoking.

Until we have this science base, we must convey a consistent and uncompromised message: there is no safe form of tobacco use.

Thank you. I would be happy to answer any questions.

Last Revised: June 4, 2003