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Testimony on Tobacco by Michael P. Eriksen, Sc.D.
Office on Smoking and Health
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the Senate Committee on Labor and Human Resources
February 10, 1998

Good morning. I am Dr. Michael P. Eriksen, director of the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC) in Atlanta, Georgia. Thank you for the opportunity to talk about ways that we can address the staggering public health impact of tobacco use.

Tobacco use is the single most preventable cause of death and disease in our society. Since the release of the first Surgeon General's Report on tobacco in 1964, scientific knowledge about the health consequences of tobacco use has increased dramatically. It is now well documented that smoking cigarettes causes cardiovascular disease, lung cancer, chronic lung disease, and many other diseases. Consequences of using smokeless tobacco include heart disease and cancers of the mouth, larynx, and esophagus. Environmental tobacco smoke (ETS) threatens the health of nonsmokers, increase the risk of sudden infant death syndrome (SIDS), and increases the severity of asthma in children and the risk for new cases of asthma. Smoking during pregnancy significantly increases maternal and fetal risk and is a significant cause of low birth weight births, the leading cause of death among infants in the United States.

Tobacco products cause more than 400,000 deaths in the United States each year. Each person who dies of tobacco-related lung cancer loses an average of 14 years of expected life. Those who live with diseases such as emphysema often endure prolonged suffering and disability, financial hardship, and frequent hospitalizations that also have an adverse impact on the lives of family members. Tobacco use costs the Nation more than $50 billion every year in medical expenses alone. Added to these costs are the loss of income caused by illness and premature death and other indirect costs incurred by both the patient and family members.

Of particular concern is the fact that teen smoking is on the increase. In 1995, more than one-third of high school students were current smokers, up from one-quarter of high school students in 1991. Each day, more than 3,000 young people become regular smokers, adding approximately one million new smokers each year. Tobacco use is as addictive as cocaine. Nearly 70 percent of smokers want to quit smoking completely, but less than 3 percent are able to do so each year. The consequences of these increases are dire. If current tobacco-use patterns in this Nation persist, five million children currently alive today will die prematurely from a smoking-related disease.

CDC's Current Activities to Prevent Tobacco Use

For more than a decade, CDC's Office on Smoking and Health has been fighting the public health threat posed by tobacco use. CDC provides national leadership by spearheading the establishment of active, focused partnerships of governmental, professional, and voluntary organizations to reduce and prevent tobacco use. CDC provides technical assistance to all 50 States, and currently provides limited funding support to 32 States and the District of Columbia (average annual awards are $360,000) to build their capacity to sustain broad-based tobacco control programs. We provide extensive technical assistance and training through site visits, conferences, workshops, and teleconferences on planning, developing, implementing and evaluating tobacco control programs.

CDC coordinates national health communication campaigns to educate the public on the health hazards of tobacco use. CDC makes high-quality tobacco control and prevention advertising materials from across the country available to States, localities and organizations through the Media Campaign Resource Center. CDC also provides limited funding support to 15 State departments of education to implement comprehensive school health programs which incorporate strategies proven to reduce tobacco use among youth.

CDC expands the science base of tobacco control through surveillance and epidemiologic studies, laboratory research, and Surgeon General Reports. CDC conducts surveillance through the Behavioral Risk Factor Surveillance System to monitor smoking trends, attitudes and behaviors among adults, and the Youth Risk Behavior Surveillance System to monitor tobacco use and related risk behaviors among youth. CDC's Pregnancy Risk Assessment Monitoring System provides information on the relationship between smoking, birth outcomes, and prenatal care in 15 States. CDC's Air Toxicants Laboratory examines the link between tobacco product components and disease. These efforts are limited in scope and fall far short of what is needed.

As the Nation's prevention agency, CDC is dedicated to improving the health of the Nation's public and uses a comprehensive scientific model to address public health problems. CDC is applying this model to reduce the burden of tobacco use, but much more work remains to be done.

Scientific Model to Approach Public Health Problems

For more than 50 years, CDC has used its scientific capacity and intervention expertise to design, implement, and assess programs that protect the public's health. CDC uses a scientific model we call the public health approach. CDC's public health approach involves:

  • defining the problem through surveillance systems, epidemiologic studies and laboratory
  • research;
  • identifying causes;
  • developing and testing promising prevention strategies; and,
  • implementing nationwide prevention programs.
Applying the Public Health Approach to Tobacco

The same public health approach that can be used to address the hantavirus in the United States and the Ebola virus in Africa can be applied successfully to prevent and control tobacco use.

Defining the Problem

Surveillance, or information gathering, forms the basis for defining the problem by measuring tobacco-related trends and assessing the impact of prevention efforts. CDC collects information on tobacco use behaviors, attitudes regarding tobacco use, exposure to environmental tobacco smoke, prevalence of tobacco control policies, implementation of tobacco control programs, and the effect of media campaigns. Our surveillance efforts also address both adult and youth use and attitudes. Surveillance includes monitoring of health behaviors and outcomes related to tobacco use, including: cancer, cardiovascular disease, SIDS and asthma. Special efforts can also be made to ensure that we have accurate data on special at-risk groups, including pregnant women, infants and children, and racial and ethnic groups. Finally, both national and state-specific data would be useful.

Enhanced Laboratory Research on nicotine, additives, and other potentially toxic components of tobacco products and tobacco smoke can be useful. Laboratory research can characterize and evaluate the chemical and physical properties of tobacco products, and help to identify further the causative agents of disease in tobacco and tobacco smoke. Testing the product and actual levels of exposure among users of the product also provides researchers and policy makers with information they need to further promote the public's health.

Identifying Causes and Developing and Testing Prevention Strategies

Continued research on why people use tobacco and effective tobacco control interventions can also be useful to refine prevention programs. Six broad categories of research are necessary, including biomedical, clinical, behavioral, health services, public health and community, and surveillance and epidemiology. Innovative approaches include qualitative research using focus groups and marketing research. These research programs may explicitly address gender, racial, and socioeconomic differences in tobacco use and its consequences. Opportunities are also available to expand the science base on the health effects of tobacco use (through publication of Surgeon General reports) and secondhand exposure to tobacco smoke.

Implementing Nationwide Prevention Programs

Throughout the nation, state and community programs work to:

  • prevent and reduce the use of tobacco products, especially among children and adolescents, and address the health outcomes related to tobacco use including, cancer, cardiovascular disease, and asthma.
  • Support to state programs includes core funding for staffing, training and technical assistance, projects for special populations and multi-cultural groups, and program evaluation.

These programs would carry out essential activities that science has shown to be effective, such as public and professional education and adoption of policies that promote good health. CDC is working to implement "best practices" and evidence-based approaches learned from the National Cancer Institute's ASSIST and CDC's IMPACT programs and from state programs funded through tobacco excise taxes. Local coalition and community-based activities, conducted through States also permit local input, assuring that these programs are locally determined and consistent with community values. Local level activities can include:

  • establishing state and local coalitions to implement programs that address retailer education and tobacco access programs;
  • conducting community-based youth prevention programs in coordination with local schools;
  • encouraging implementation of existing state and local smoke free laws and ordinances; and
  • enhancing utilization of smoking cessation resources.

Environmental tobacco smoke exposure is a national problem resulting in lung cancer and heart disease deaths in non-smokers and hundreds of thousands of respiratory illnesses in children. CDC needs to expand efforts to educate the public about the risk of exposure and to identify strategies to reduce exposure.

Funding for national organizations to reach out to constituencies at high risk for tobacco use including minority populations, women, and youth also helps to support state and local efforts to reach communities at risk.

Targeted programs can also address special populations. These groups suffer a disproportionate burden of tobacco-related disease and are among the greatest users of tobacco products. Smoking rates are highest among American Indian/Alaska Natives (36 percent) and those, regardless of race, who are living below the poverty level (33 percent).

Studies have shown that research-tested school-based programs can produce consistent and significant reductions or delays in adolescent smoking. A very small proportion of schools, however, currently are implementing proven, effective tobacco-use prevention programs. Priority must be given to broad-scale dissemination of programs with established efficacy and the provision of technical assistance to school systems in the design of curricula.

To deliver effective school-based tobacco prevention programs, national, state, and local education agencies and organizations can also be of assistance. These groups can disseminate effective curricula, train teachers, develop policies, collect and analyze data, provide access to cessation services, involve families, and foster coordination among other youth-serving agencies. Diffusion of the CDC "Guidelines for School Health Programs to Prevent Tobacco Use and Addiction" and curricula, proven effective in the CDC-identified "Programs that Work," are integral to program success. School tobacco programs should be provided as part of broader school health programs and be integrated with community-wide strategies for tobacco prevention. National organizations can serve as leaders in promoting school tobacco prevention educational programs to assist the nation's schools, institutions of higher education, and youth-serving agencies in efforts to prevent tobacco use.

Training and Education. It is useful for health professionals and educators receive training, education and ongoing scientific and technical support to understand emerging scientific issues, learn from others what works and why, and implement effective interventions. National organizations have an important role to play in such efforts by educating their constituents and bringing to bear their expertise in addressing special populations.

Public Awareness. Tobacco control media campaigns counteract tobacco advertising and remove the air of glamour and normality surrounding tobacco use. Campaigns that address the health consequences of tobacco use (e.g., cardiovascular disease, cancer, asthma) would raise awareness about these leading killers and cripplers and draw the link between these diseases and tobacco use. An intensive, sustained media campaign can be useful to denormalize and deglamorize tobacco use among young people. Research findings from the U.S. Fairness Doctrine experience, well-designed community intervention studies, and current campaigns in California and Massachusetts show that counter-advertising can lead to significant changes in youth attitudes and behaviors related to tobacco use.

Media campaigns also can increase the effectiveness of school-based programs, provide smoking cessation motivation and assistance to adults, and foster public support for smoke-free environments. Messages and programs delivered to entire communities -- adults and adolescents, users and non-users of tobacco -- can affect the general norms of the community on tobacco control, which in turn can influence young people to decide against starting to use tobacco. The exposure of young people directly to messages and appeals intended for adults (e.g., smoking cessation, risks of ETS) can have a strong influence on adolescents' normative perceptions of the prevalence and acceptability of tobacco use. Parents can be stimulated by community programs to become more involved in tobacco prevention efforts both within and outside the family.

An effective tobacco control media campaign should have national, state, and local components. The national campaign can deliver messages widely and frequently at great cost efficiencies. Some media channels, especially those that target teens, are available only at the national level (e.g., MTV, syndicated "early fringe time" TV programs). Nationally originated messages can have a powerful influence on the public and set an overall supportive climate for state and local tobacco control efforts. State and local campaigns are the best way to target messages and counter an increasingly important part of tobacco companies' marketing campaigns.

These efforts would be particularly effective when coupled with an increase in price of tobacco products. Price has a large impact on youth smoking. Studies conducted by CDC and others clearly demonstrate that increases in the price of tobacco products reduce the use of both cigarettes and smokeless tobacco among adults and youth. In fact, economic studies show that a 10 percent increase in the price of cigarettes will reduce overall smoking among adults by about 4 percent and that a 10 percent increase in cigarette prices leads to a 7 percent reduction in teen smoking.

Evaluation of national, state and local efforts is essential and is an integral part of any effective public health program. Otherwise, it is not possible to determine if intended effects are being achieved. Information gained from evaluation efforts can be used to continually modify and enhance prevention programs.

Comprehensive tobacco control programs should also include strengthening of international tobacco control efforts to offset projected increases in tobacco consumption in emerging global markets. According to researchers at Harvard University and the World Health Organization, the number of deaths per year caused by tobacco use around the world is expected to increase from 3,000,000 deaths in 1990 to 8,400,000 deaths in 2020. By 2025, tobacco will be the leading global cause of death and preventable illness. CDC can play a critical role in providing technical assistance and training to help other countries with their tobacco control efforts.

Comments on Discussion Draft

First of all, we should point out that our comments on the Discussion Draft are based on a preliminary CDC review. The discussion draft has not been fully reviewed by all of the other Executive branch agencies affected by the proposed legislation. We believe that this draft is a good start in providing for the public health infrastructure necessary to prevent and control tobacco use. We would like to highlight several of our major concerns with this discussion draft. We would be happy to continue working with your staff to address these and other issues, and providing assistance as you develop the remaining sections of the bill.

First, the bill takes a narrow approach to tobacco prevention and control. Important public health efforts necessary to prevent the burden of tobacco use in our society are not included. For instance, although state and community programs should place a strong emphasis on youth tobacco use, we believe that such programs should also target the 47 million adult smokers in this country. In addition, the bill should be broadened to address the prevention of the health problems associated with tobacco including cardiovascular disease, asthma, lung cancer, and chronic lung disease.

Second, the discussion draft requires that every dollar of funding designated for state and community-based tobacco control programs go directly to States. Funds may be needed to provide States and communities with consistent, up-to-date scientific information, technical assistance, training and other activities necessary to conduct an effective prevention program.

Third, funds are not included for conducting surveillance and other necessary programmatic functions, either at the state or the national level. Surveillance is vital, not only in the look-back provisions, but to obtain much needed information on trends in tobacco use and the health burden related to tobacco use. Surveillance also helps us monitor industry marketing practices and changes in tobacco products.

Fourth, we are concerned about aspects of the proposed look-back provisions. To be effective, the look-back provisions need to provide penalties that are based on marketing practices toward youth, as reflected by youth market share.

Fifth, we recommend that the Food and Drug Administration be designated the lead agency to implement the prohibitions for tobacco product marketing. CDC is not a regulatory agency and does not have the capacity or experience to administer a regulatory program. Consistent with the scope and mission of our agency, we believe CDC should be designated as the lead agency for administering and coordinating a nationwide tobacco control program, including state and community-based programs, school programs, counter-advertising campaigns and surveillance and evaluation efforts.

Sixth, minority groups and other special populations suffer a disproportionate burden of tobacco-related disease and are among the greatest users of tobacco. As such, minority groups and other special populations need to be assured full access to targeted, community-appropriate programs, including smoking cessation.

In addition to these concerns, we also have a few technical issues for your consideration. We look forward to continuing to work with you on this important piece of legislation.

The Administration's Position on Tobacco Legislation On September 19, 1997, the President called for comprehensive tobacco legislation with a goal of reducing the smoking rate among young people by 50 percent within seven years.

The President stressed that the following five key elements must be at the heart of any national tobacco legislation:

  1. A comprehensive plan to reduce teen smoking, including a combination of penalties and price increases that raise cigarette prices up to $1.50 per pack over the next 10 years as necessary to meet youth smoking targets;
  2. Express reaffirmation that the FDA has full authority to regulate tobacco products;
  3. Changes in the way the tobacco industry does business;
  4. Progress toward other critical public health goals, such as the expansion of smoking cessation and prevention programs and the reduction of secondhand smoke; and
  5. Protection for tobacco farmers and their communities.

Reducing tobacco use requires a concerted, coordinated, and collaborative effort at the national, state, and community levels. The desired outcomes of this effort are clear. We should prevent young people from starting to use tobacco, help current tobacco users to quit, protect the health of non-smokers by eliminating exposure to environmental tobacco smoke, change the environmental and social factors that support the use of tobacco, and address the health consequences of tobacco use--cancer, cardiovascular disease and asthma. A nationwide program should also address the various populations affected by tobacco use, including school children, adults and minority groups. We cannot prevent teens from adopting this high-risk habit unless we have a robust, consistent public health strategy in place. It should address the contributing factors to tobacco use such as advertising and the media, and the addictive nature of the product. It can also include tailored interventions in diverse venues where tobacco prevention programs can have an impact, including schools and the workplace. It is through this comprehensive effort based on rigorous science that the public health approach succeeds.

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