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Testimony
of
David Satcher, M.D., Ph.D.
Surgeon General and Assistant
Secretary for Health
U.S. Department of Health and Human
Services
Before the
Commerce, Science and Transportation
Committee
United States Senate
October 5, 2000
Good
morning, Mr. Chairman and members of the Commerce Committee.
I am Dr. David Satcher, Surgeon General and Assistant Secretary
of Health for the U.S. Department of Health and Human Services.
I am pleased to appear before you and present testimony on
our newest tobacco-related Surgeon General's Report, Reducing
Tobacco Use. I am accompanied by Dr. Terry Pechacek,
Associate Director for Science in the Office on Smoking and
Health at the Centers for Disease Control and Prevention (CDC).
Mr. Chairman, I want to express my appreciation, particularly
at what I know is a very busy time in the legislative session,
for your holding this hearing and for the concern and leadership
in tobacco control issues that you and this Committee have
shown.
This is the 29th report on tobacco issued by the
Surgeon General. It is the first-ever to provide an in-depth
analysis of the various methods to reduce tobacco use. Our
report shows that we have the tools, the knowledge and the
resources to cut smoking rates in half by the end of the decade.
The question is: Do we have the will?
In my testimony, I will refer to three important documents
that contain information that can be used to shape the future
of tobacco control. First is the Surgeon General's report
I just mentioned. This report provides a blueprint for achieving
the ambitious health objectives for the nation, which are
laid out in Healthy People 2010-the second important document,
which contains 17 tobacco-related objectives. Finally, CDC
has made this information more concrete with the Best
Practices for Comprehensive Tobacco Control Programs,
which was prepared to help states assess options for comprehensive
tobacco control programs and to evaluate their local funding
priorities. If you don't already have copies of these important
documents, all three are available on-line and I have a few
copies with me today.
Overview
As I am sure you are aware, the need to address the public
health consequences of tobacco use is urgent. Tobacco use
is responsible for more than 430,000 deaths each year, or
one in every five deaths. It is the single most preventable
cause of death and disease in our nation, and it is well documented
that smoking can cause chronic lung disease, coronary heart
disease, and stroke, as well as cancer of the lung, larynx,
esophagus, mouth, and bladder. Smokeless tobacco and cigars
also have deadly consequences including cancer of the lung,
esophagus, and mouth. In addition to this enormous health
burden, the economic burden of tobacco use is more than $50
billion in medical expenditures and another $50 billion in
indirect costs annually. The harmful effects of smoking do
not end with the smoker--environmental tobacco smoke causes
an estimated 3,000 deaths from lung cancer each year, and
causes up to 300,000 episodes of lower respiratory tract infections
in children each year.
Surveillance data reported in today's issue of CDC's Morbidity
and Mortality Weekly Report indicate that the prevalence
of cigarette use among adults has changed very little during
the 1990s-about one-quarter of adults reporting current cigarette
use. Among adolescents, smoking prevalence rates steadily
increased from 1991-1997, but preliminary new data show that
the rates have peaked and are starting to decline. However,
if tobacco-use patterns do not decline more rapidly than current
trends indicate, an estimated five million persons who were
less than 18 years of age in 1995 will die prematurely from
a smoking related disease.
Reducing Tobacco Use: A Report of the Surgeon
General
The good news related to tobacco is that although our knowledge
of tobacco control remains imperfect, we know more than enough
to act now. The Surgeon General's Report on Reducing Tobacco
Use is the first-ever report that provides an in-depth
analysis of tobacco intervention strategies. This reports
offers a science-based blueprint for achieving our Healthy
People 2010 health objectives to cut adult and teen smoking
rates in half. One of the key conclusions of our Surgeon General's
report is that existing state tobacco control programs have
provided evidence of the efficacy of a comprehensive approach
to reducing tobacco use.
This type of comprehensive approach--one that combines educational,
clinical, regulatory, economic, and social strategies--has
emerged as the guiding principle for future efforts to reduce
tobacco use. Evidence shows that multifaceted state tobacco
control programs are effective in reducing tobacco use in
part because they bring about a shift in social norms and
reduce the broad cultural acceptability of tobacco use. Comprehensive
approaches combine community interventions, counter-marketing,
and program policy and regulation.
The goal of a comprehensive tobacco control program is to
reduce disease, disability, and death related to tobacco use
by: (1) promoting quitting among adult and youth smokers;
(2) preventing young people from ever starting to smoke; (3)
implementing public health policies to protect citizens from
secondhand smoke; and (4) eliminating racial and ethnic disparities
in tobacco-related diseases.
To assist states in achieving these goals, the CDC has prepared
guidelines to help states determine funding priorities and
to plan and carry out effective comprehensive tobacco prevention
and control programs. In CDC's Best Practices for Comprehensive
Tobacco Control Programs, CDC recommends that states
establish tobacco prevention and control programs that are
comprehensive, sustainable,
and accountable.
The guidelines draw on best practices determined by evidence-based
analyses of excise tax-funded programs in California, Massachusetts,
Oregon and Maine and in the four states that individually
settled lawsuits with tobacco companies (i.e., Florida, Minnesota,
Mississippi, and Texas).
Evidence from California, Massachusetts, and Oregon--and
more recent results from Arizona and Maine-- indicate that
increasing the price of cigarettes reduces tobacco consumption
rates. In addition, evaluations have shown that an adequately
funded, comprehensive tobacco prevention and control program
can result in even more dramatic reductions when coupled with
price increases. Data from California provide the best example
of this. The state excise tax was increased from $0.10 to
$0.35 in January 1989 to fund the new tobacco control program.
There was an initial and rapid reduction in consumption as
a result of the January 1989 price increase. If price were
the only factor in contributing to the declines in California,
we would expect the rates to drop initially and then follow
the similar pattern of slow decline experienced by the rest
of the country. However, as a result of the tobacco control
program implemented in California, the rates of tobacco use
in California continued to decline two to three times faster
than in the rest of the country throughout the 1990s. Between
1988 and 1999, per capita cigarette use in California has
declined by almost fifty percent while in the rest of the
country, rates have declined by only about twenty percent.
CDC is conducting an in-depth
analysis of state tobacco control programs for all 50 states.
Evaluation data from the statewide comprehensive tobacco control
programs indicate that there is a dose-response relationship
between investment in tobacco prevention and control and reductions
in tobacco use in the state.
"Best Practices"
-- Program Components
CDC recommends that states establish
tobacco control programs that contain the following nine elements:
- Community Programs to Reduce
Tobacco Use
- Community Programs to Reduce
the Burden of Tobacco-Related Diseases
- School Programs
- Enforcement
- Statewide Programs
- Counter-Marketing
- Cessation Programs
- Surveillance and Evaluation
- Administration and Management
The Surgeon General's report
provides further discussion on the specific strategies that
might be adopted in each of these areas, and reviews the scientific
literature about their efficacy, so I will limit my remarks
to describing the programmatic components included in the
CDC guidelines and briefly touch on the extent to which they
are currently being implemented by states.
Community Programs
to Reduce Tobacco Use
To achieve the individual behavior
change that supports the non-use of tobacco requires whole
communities to change the way tobacco is promoted, sold, and
used while changing the knowledge, attitudes, and practices
of young people, tobacco-users, and nonusers. Effective community
programs involve people in their homes, work sites, schools,
places of worship and entertainment, civic organizations,
and other public places. To achieve lasting changes, programs
in local governments, voluntary and civic organizations, and
community-based organizations require funds to hire staff,
provide operating expenses, purchase educational materials,
provide education and training programs, support communication
campaigns, organize the community to debate the issues, establish
local plans of actions, and draw other leaders into tobacco
control activities. While most states are supporting community
programs, these programs are not yet reaching the entire state
population. Evaluation reports from the states of
California, Massachusetts, and Oregon indicate that very encouraging
progress has been made by local communities in these states
to protect nonsmokers from environmental tobacco smoke, limit
youth access to tobacco products, and restrict local tobacco
advertising.
Community
Programs to Reduce the Burden of Tobacco-Related Diseases
Another element of community
programs reflects the fact that tobacco use increases the
risk of development of a number of diseases. Even if current
tobacco use stopped, the residual burden of disease among
past users would cause disease for decades in the future.
Community programs can focus attention directly on these diseases,
both to prevent them and detect them early. Comprehensive,
state-based tobacco prevention and control programs can address
diseases for which tobacco use is a major cause, such as cancer,
cardiovascular disease, stroke, oral cancers, and asthma.
School Programs
The recent Surgeon General's Report, Reducing Tobacco
Use, concluded that educational strategies, conducted
in conjunction with community- and media-based activities,
can postpone or prevent smoking onset in 20 to 40 percent
of adolescents. Because most
people who start smoking are younger than age 18, school-based
programs that prevent the onset of smoking are a crucial part
of a comprehensive tobacco prevention program. Several studies
have shown that school-based tobacco prevention programs,
which identify the social influences that promote tobacco
use among youth and teach skills to resist such influences,
can significantly reduce or delay adolescent smoking. Because
many students begin using tobacco before high school and impressions
about tobacco use are formed even earlier, tobacco use prevention
education must be provided in elementary school and continued
through middle and high school grades.
To address this need, CDC collaborates
with more than 30 professional and voluntary organizations
to assist schools and agencies in developing model policies
and guidelines. States are using these to implement effective
school health programs. However, less than 5 percent of schools
nationwide are implementing the major components of CDC's
School Health Guidelines to Prevent Tobacco Use and Addiction.
Of the states that are working to follow the guidelines, such
as Maryland and Oregon, they struggle to reach all school
age children. Furthermore, despite Oregon's intensive efforts
to implement the guidelines, they reach only 30 percent of
the school districts.
Enforcement
The Surgeon General's report
concluded that enforcement of tobacco control policies enhances
their efficacy both by deterring violations and by sending
a message to the public that the community believes the policies
are important. The primary areas addressed by local and state
policies that require enforcement strategies are restrictions
on minors' access to tobacco and restrictions on indoor smoking
in public places. As other policy changes (e.g., local restrictions
on advertising and promotion) are adopted, they also will
need to be enforced. The state of Florida is implementing
an enforcement program consistent with CDC's Best Practices.
Statewide Programs
Also consistent with the Surgeon
General's report, funding to support statewide programs is
a major element of CDC's recommended comprehensive approach
to the prevention and reduction of tobacco use. Statewide
projects can increase the capacity of local programs by providing
technical assistance on evaluating programs, promoting media
advocacy, implementing of smokefree policies, and reducing
minors' access to tobacco. Supporting organizations that have
statewide access to diverse communities can help eliminate
the disparities in tobacco use among the state's various racial
and ethnic groups. Statewide and regional grants to organizations
representing cities, business and professional groups, law
enforcement, and youth groups inform and involve their membership
about tobacco control issues and encourage their participation
in local efforts. Arizona, California, Maine, Massachusetts
and Oregon currently have statewide programs that serve as
"best practice" models to reach diverse communities.
Counter-Marketing
One of the major conclusions
of the Surgeon General's report is that efforts to prevent
the onset or continuance of tobacco use face the pervasive
and countervailing influence of tobacco promotion by the tobacco
industry. During the last decade, the industry has spent more
than $20 billion in imagery advertising and promotions to
create a "friendly familiarity" for tobacco products and an
environment in which smoking is seen as glamorous, social,
and normal. This is of particular concern since studies show
that children buy the most heavily advertised brands and are
three times more affected by advertising than adults.
To counter this influence, tobacco
control programs should undertake counter-marketing activities
that can promote smoking cessation and decrease the likelihood
of initiation. In addition, counter-marketing messages can
have a powerful influence on public support for tobacco control
intervention and set a supportive climate for school and community
efforts. Counter-marketing attempts to counter pro-tobacco
influences and increase pro-health messages and influences
throughout a state, region, or community. Counter-marketing
consists of a wide range of efforts, including paid television,
radio, billboard, and print counter-advertising at the state
and local level; media advocacy and other public relations
techniques using such tactics as press releases and local
events and pro-health promotional activities; and efforts
to reduce or replace tobacco industry sponsorship and promotions.
Some states are initiating significant
counter-marketing efforts. Multifaceted prevention programs,
such as the Minnesota Heart Health Program and the University
of Vermont School and Mass Media Project, have shown that
comprehensive efforts that combine media, school-based, and
community-based activities can postpone or prevent smoking
in 20 percent to 40 percent of adolescents. Although the relative
effectiveness of specific message concepts and strategies
is widely debated, research from all available sources shows
that counter-marketing must have sufficient reach, frequency,
and duration to be successful. The Vermont youth campaign,
for example, exposed 50 percent of the target population to
each TV and radio spot about six times each year over a 4-year
period. This level of exposure is possible only through paid
media placement.
The Florida TRUTH campaign has achieved high levels of exposure
among target aged youth that their evaluation reports suggest
are related to the their impressive declines in rates of youth
tobacco use. The award-winning Massachusetts counter-marketing
campaign has focused on prevention of initiation, promotion
of cessation, and protection of non-smokers and reports both
high levels of exposure to its multiple message themes as
well as direct impacts on adult attempts to quit and prevention
of youth initiation rates.
Cessation
Programs
You may be aware that the Public
Health Service (PHS) has recently published evidence-based
clinical practice guidelines on cessation. Tobacco dependence
is a chronic condition that often requires repeated intervention.
The PHS Guideline, "Treating Tobacco Use and Dependence,"
provides recommendations which are both clinically effective
and cost-effective relative to other medical and disease prevention
interventions.
Cessation is a particularly
important component of tobacco control programs, because programs
that successfully assist young and adult smokers in quitting
can produce a quicker and probably larger short-term public
health benefit than any other component of a comprehensive
tobacco control program. Smokers who quit smoking before age
50 cut in half their risk of dying in the next 15 years. In
addition, the cost savings from reduced tobacco use resulting
from the implementation of moderately-priced, effective smoking
cessation interventions would more than pay for these interventions
within 3 to 4 years. Unfortunately, no state currently has
fully implemented the best practices recommendations in this
area. However, the states of California, Oregon, Arizona
and Massachusetts have developed innovative approaches to
increase access to evidence-based treatments for nicotine
addiction. We encourage other states to follow their lead.
Surveillance and
Evaluation
The Surgeon General's report stressed the importance of expanding
the science base in support of comprehensive tobacco control
programs. Hence, a statewide programs must have a sound surveillance
and evaluation system both to monitor fiscal accountability
for state policy makers as well as to increase the efficiency
and effectiveness of program activities.
For this reason, the establishment of surveillance and evaluation
systems must have first priority in the planning process.
With technical assistance from CDC, California, Massachusetts,
Oregon, Arizona, Maine, and Florida have established comprehensive
surveillance and evaluation systems based upon CDC's Best
Practices' recommendations.
Administration and
Management
An essential component of an
effective tobacco control program is a strong management structure.
Experience California, Massachusetts and Oregon has shown
the importance of having all of the program components coordinated
and well-managed. A comprehensive program involves multiple
state agencies (e.g., health, education, and law enforcement)
and multiple levels of local government, as well as numerous
health-related coalitions, voluntary and community groups.
Coordination of these groups requires high quality program
administration and management. Many states have difficulty
maintaining a comprehensive tobacco control program and rely
on federal support to maintain key management and administrative
personnel.
Conclusion
Only three years ago, tobacco control spending in almost
all states averaged pennies and nickels per capita. Now all
states have a sound core funding, and current allocations
in those states with expanded
programs range from $2.50 to more than $10 per capita. While
these funding sources and levels have contributed to the development
of a basic capacity within states to conduct tobacco prevention
and control programs, no state is currently implementing all
the components recommended in CDC's Best Practices.
Approximate annual costs to implement all of the recommended
program components have been estimated to range from $7 to
$20 per capita in smaller states (population under 3 million),
$6 to $17 per capita in medium-sized states (population 3
to 7 million) and $5 to $16 per capita in larger states (population
over 7 million).
While the focus of today's discussion
is on state efforts to address tobacco use, a comprehensive
national tobacco control effort requires strategies that go
beyond state programs. A comprehensive national effort should
involve the application of a mix of educational, clinical,
regulatory, economic and social strategies. In each of these
areas, some of the program and policy changes that are needed
can be addressed most effectively at the national level. That
is why the Administration has sought FDA authority to restrict
advertising and sales of tobacco products to children, and
taken actions such as establishing smoke-free workplaces to
protect the health of federal employees and visitors to federal
buildings. Even as we have encourage states to use their settlement
funds to help support tobacco prevention programs in states
and local communities, we also have increased federal support
for those programs.
Progress is being made, but a great deal remains to be done.
States such as California, Massachusetts, Arizona, Oregon,
Maine, and Florida are demonstrating that significant reductions
in tobacco use rates among young people and adults are possible.
However, our Healthy People 2010 objectives, including cutting
in half the rates of tobacco use among young people and adults,
will require a sustained and comprehensive effort at both
the federal and state level. The Surgeon General report and
CDC's Best Practices provide the blueprint for what
needs to be implemented. Prevalence of cigarette use among
adults in this nation has changed very little during the 1990s.
Each year, more than 1 million
young people continue to become regular smokers and more than
400,000 adults die from tobacco-related diseases. We know
what strategies are effective in controlling tobacco use.
What we need now is a stronger, sustained effort by government
at all levels to implement these proven tobacco control strategies.
Tobacco use will remain the leading cause of preventable illness
and death in this nation and a growing number of other countries
until tobacco prevention and control efforts are commensurate
with the harm caused by tobacco use. We look forward to working
with you and our other partners, some of whom will be addressing
you shortly, to address this urgent public health issue.
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