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:
- 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;
- Express reaffirmation that the FDA has full authority to regulate tobacco products;
- Changes in the way the tobacco industry does business;
- Progress toward other critical public health goals, such as the expansion of smoking
cessation and prevention programs and the reduction of secondhand smoke; and
- Protection for tobacco farmers and their communities.
Conclusion
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.
