Remarks as prepared; not a transcript
Testimony
Before the Subcommittee on Commerce, Trade,
and Consumer Protection
Committee on Energy and Commerce
United States House of Representatives
"Can Tobacco Cure Smoking? A Review of Tobacco Harm
Reduction"
Statement of
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
For Release on Delivery
Expected at 10:00 am
on 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.
- Smokeless tobacco is not a safe 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:
- Smokeless tobacco represents a significant health risk;
- Smokeless tobacco can cause cancer and a number of non-cancerous oral
conditions;
- Smokeless tobacco can lead to nicotine addiction and dependence; and
- 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.
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Last revised: January 8, 2007
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