HEALTH AND SMOKING: A NATIONA STATUS REPORT Louis W. Sullivan, MD Secretary of Health and Human Services Washington, DC
When future historians write about health care in our time, one of their most fascinating stories will be their explanation of the strong hold that tobacco had on our society. They will wonder how millions of our citizens could ignore the overwhelming evidence of the deadly relationship between smoking and disease. They will try to comprehend how so many people could be persuaded to enter a "culture of cancer," knowing the inevitable outcome, and they will marvel at the power and persistence of the tobacco lobby. But the most striking sign will be if these historians are writing in a smoke-free society. The Department of Health and Human Services is working to make the United States smoke-free by the year 2000. It is my hope that more of our citizens who smoke will accept the vast scientific evidence on the dangers of smoking and stop this deadly habit. We are also working to make sure that our citizens who don't smoke will remain smoke-free. In this article, I will discuss the toll of smoking on our citizens and our nation, and I will argue that the adverse health consequences of smoking should compel a vigorous governmental and societal response. I will also address some of the issues raised by tobacco advocates and indicate why their arguments fail to address the central issue-that smoking is the most important preventable cause of death in our country. From the Department of Health and Human Services, Washington, DC. Requests for reprints should be addressed to Mr John Shosky, Consultant to the Secretary of Health and Human Services, Humphrey Building, Room 630E, 200 Independence Avenue, SW, Washington, DC 20201. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 9
On the basis of abundant scientific evidence, we know that smoking is a killer. After countless studies, now based on decades of research, the link between smoking and heart disease, cancer, and emphysema is undeniable. Hundreds of thousands of deaths each year could be prevented if Americans stopped smoking. Even the lingering questions about passive smoking have been answered by researchers and scientists. I am committed to ending the death-grip that cancer and other diseases have on our culture. As part of that effort, the glamorization of smoking must end. The real story must be heard and heeded-the serious personal health risks confronting the smoker and passive inhalers; the addiction, sickness, and death; the hidden personal tax that each American has to pay for the consequences of smoking; and the cumulative and devastating impact on our economy. Recently I released a report entitled Smoking and Health, a National Status Report. Again, as in past reports, the death rate-the national carnage-is shocking. Each year, smoking kills almost 400 000 Americans, more than 1000 a day. Of course, the toll doesn't stop with the morgue. Each and every American, including those who don't smoke, is paying a hidden tax of approximately $221 per person per year for the consequences of smoking-a tax that adds up to $52 billion annually. This cost, primarily in the form of increased health care and insurance costs, as well as lost productivity, demonstrates the far-reaching effects of smoking, effects that penalize nonsmokers as well. I do not want to dwell on the obvious. Tobacco is the only legal product that kills, when used as intended. 617
GUEST EDITORIAL
But I do want to discuss the current counterattack by the tobacco industry-the cascade of arguments currently used to justify the culture of cancer. Consider this example. After I began speaking about the 1000 Americans who die each day, some critics argued that our nation could not afford to let these people live. The argument went something like this: When Americans die prematurely, the nation benefits because we do not have to support them and their poor health later on. Hence, money set aside for Social Security and Medicare would be saved. I am not only incredulous of this line of reasoning, I am also outraged. The fiscally prudent and morally correct answer is to improve the health and productivity of Americans who use tobacco by helping them kick the habit and by trying to help nonsmokers remain smoke-free, not to stand idly by while they smoke themselves into an early grave. Fiscal good health and personal good health are not mutually exclusive; they are mutually dependent. Another example, some people say, "Smoking is a personal choice." Of course, smoking is a choice, but a bad one. I want to make sure that the decision to smoke or not to smoke is a fully informed choice, and that requires me to speak loud and clear to counterbalance the pressures from the tobacco industry and their alluring advertising. I am also concerned that the choice be made by those of mature judgment and legal age. I do not want youngsters lured into smoking. Studies have found that the younger the age at which a person begins to smoke, the more likely that person will become a long-term smoker and develop smoking-related diseases. In fact, 90% of smokers begin their cigarette addiction as children or adolescents. The result is predictable and devastating, unless we act now. If the adult smoking rate continues at present levels, at least 5 million American children who are alive today will die of smoking-related diseases. That is a catastrophe we must prevent. As a black American, I am also outraged that some tobacco executives are trying to increase their market share at the expense of the health of our poor and minority communities. At a time when minority health status lags significantly behind the population as a whole-when cancer, stroke, heart disease, and virtually every other disease are running rampant in our minority communities-we must work harder to promote good health and to prevent disease. We cannot allow the cynical, the unfeeling, and the profit-driven to further compound this serious health crisis by 618
targeting those most likely to be harmed by smoking. I am also concerned about the targeting of women. In women, lung cancer has surpassed breast cancer as the most prevalent cause of death from cancer. Women who smoke also court death from heart disease, emphysema, and other diseases. The New England Journal of Medicine recently reported that women who smoke are three times as likely to have a heart attack than women who never smoked. In addition, women who smoke during pregnancy are more likely to have miscarriages, low birthweight babies, and babies who die during infancy. Earlier this year I asked advertising agencies to voluntarily withdraw from their addiction to the blood money offered by the tobacco industry. It seems obvious that any ethical approach to business would factor in the source of the money and the consequences of the use of the products that advertisers urge the public to use. Some publishers and ad agencies, especially many involved with minority publications, showed a responsible concern, and I applaud them for doing the right thing. But some argued that we should not try to dictate their choice of clients, that "business is business." Well, it's that attitude I find intolerable. There must come a time when enough people have died, when we have had enough funerals, grieving relatives, and personal tragedies. There must come a time when passive smokers and those who pay for the cost of smoking must forcefully voice their own opinions. There must come a time when we ask the advertising industry to harness its creative talents in the promotion of health, not the promotion of illness. There must be a limit to what we will allow, and I believe that we have reached that limit. Some tobacco advocates, unable to address the fact that smoking kills, try to change the subject by accusing voices against smoking of violating the principle of free speech. But asking the advertising industry to consider the source of funding and to act responsibly does not violate the Constitution. The real wonder is how, as a society, we continue to let tobacco advocates distract our attention from the truth. Time and again, in the interest of fair play, we let the tobacco industry representatives run here and there offering us a steady diet of red herrings that divert attention from our simple, straightforward messagetobacco is shrouded in death. Tobacco has killed millions of Americans and it will kill more until we adopt a healthier lifestyle. Also, we often hear about the legality of cigarette JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 9
GUEST EDITORIAL
advertising. Certainly such advertising is allowed under current law, but that is not the point. I'm talking about the health of the user and those who come in contact with the user's smoke. I'm talking about the fellow who has to take money out of his own pocket to pay for the damage caused by smokers. It may be legally right, but it is morally wrong to promote a product which, when used as intended, causes death. This difference I will not let the industry spokespersons obfuscate. Finally, some of the tobacco advocates question our sincerity. They say, "This is all just talk." Well, I have made the Department of Health and Human Services buildings smoke-free. I have the authority to work with hospitals and health care providers to make their facilities smoke-free, which we are doing. I have asked our states and tobacco retailers, such as national convenience store chains, to enforce vigorously laws existing in 44 states prohibiting the sale of tobacco to minors. I have even asked our states to consider legislation to ban vending machines, which are often used by minors to purchase cigarettes. We will continue to give high priority to the many antismoking efforts that are ongoing in my department, such as prevention campaigns and epidemiologic research on smoking dangers, patterns of tobacco use, and effectiveness of antismoking efforts. We will
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 9
continue to provide state health agencies with assistance in implementing local antismoking interventions. We will continue to promote comprehensive school health education about the dangers of tobacco and to sponsor programs such as the Smoking Cessation in Pregnancy project that helps states integrate smoking cessation interventions into public prenatal services. And, I will also continue to talk about the health aspects of smoking. As a physician and Secretary of Health and Human Services, the most important thing I can do is continue to speak out. This is a battle of ideas, ideas that have serious health consequences for millions of Americans. I will continue to talk about responsibility-for individuals, advertising agencies, and the tobacco industry. Illness prevention is a responsibility we have, not only to ourselves, but also to each other. I hope that you, the readers of this journal, will join me in this effort. We cannot condone the premature death of 1000 Americans daily from tobacco use. We cannot ignore the disproportionate nature of these deaths. Tobacco is a killer of women, blacks, Hispanics and other minorities, and blue collar workers, and is an addicting substance for our young. One death should justify our outrage, and certainly more than 1000 a day demands our unwavering commitment to make America smoke-free by the year 2000.
619
When future historians write about health care in our time, one of their most fascinating stories will be their explanation of the strong hold that tobacco had on our society. They will wonder how millions of our citizens could ignore the overwhelming evidence of the deadly relationship between smoking and disease. They will try to comprehend how so many people could be persuaded to enter a "culture of cancer," knowing the inevitable outcome, and they will marvel at the power and persistence of the tobacco lobby. But the most striking sign will be if these historians are writing in a smoke-free society. The Department of Health and Human Services is working to make the United States smoke-free by the year 2000. It is my hope that more of our citizens who smoke will accept the vast scientific evidence on the dangers of smoking and stop this deadly habit. We are also working to make sure that our citizens who don't smoke will remain smoke-free. In this article, I will discuss the toll of smoking on our citizens and our nation, and I will argue that the adverse health consequences of smoking should compel a vigorous governmental and societal response. I will also address some of the issues raised by tobacco advocates and indicate why their arguments fail to address the central issue-that smoking is the most important preventable cause of death in our country. From the Department of Health and Human Services, Washington, DC. Requests for reprints should be addressed to Mr John Shosky, Consultant to the Secretary of Health and Human Services, Humphrey Building, Room 630E, 200 Independence Avenue, SW, Washington, DC 20201. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 9
On the basis of abundant scientific evidence, we know that smoking is a killer. After countless studies, now based on decades of research, the link between smoking and heart disease, cancer, and emphysema is undeniable. Hundreds of thousands of deaths each year could be prevented if Americans stopped smoking. Even the lingering questions about passive smoking have been answered by researchers and scientists. I am committed to ending the death-grip that cancer and other diseases have on our culture. As part of that effort, the glamorization of smoking must end. The real story must be heard and heeded-the serious personal health risks confronting the smoker and passive inhalers; the addiction, sickness, and death; the hidden personal tax that each American has to pay for the consequences of smoking; and the cumulative and devastating impact on our economy. Recently I released a report entitled Smoking and Health, a National Status Report. Again, as in past reports, the death rate-the national carnage-is shocking. Each year, smoking kills almost 400 000 Americans, more than 1000 a day. Of course, the toll doesn't stop with the morgue. Each and every American, including those who don't smoke, is paying a hidden tax of approximately $221 per person per year for the consequences of smoking-a tax that adds up to $52 billion annually. This cost, primarily in the form of increased health care and insurance costs, as well as lost productivity, demonstrates the far-reaching effects of smoking, effects that penalize nonsmokers as well. I do not want to dwell on the obvious. Tobacco is the only legal product that kills, when used as intended. 617
GUEST EDITORIAL
But I do want to discuss the current counterattack by the tobacco industry-the cascade of arguments currently used to justify the culture of cancer. Consider this example. After I began speaking about the 1000 Americans who die each day, some critics argued that our nation could not afford to let these people live. The argument went something like this: When Americans die prematurely, the nation benefits because we do not have to support them and their poor health later on. Hence, money set aside for Social Security and Medicare would be saved. I am not only incredulous of this line of reasoning, I am also outraged. The fiscally prudent and morally correct answer is to improve the health and productivity of Americans who use tobacco by helping them kick the habit and by trying to help nonsmokers remain smoke-free, not to stand idly by while they smoke themselves into an early grave. Fiscal good health and personal good health are not mutually exclusive; they are mutually dependent. Another example, some people say, "Smoking is a personal choice." Of course, smoking is a choice, but a bad one. I want to make sure that the decision to smoke or not to smoke is a fully informed choice, and that requires me to speak loud and clear to counterbalance the pressures from the tobacco industry and their alluring advertising. I am also concerned that the choice be made by those of mature judgment and legal age. I do not want youngsters lured into smoking. Studies have found that the younger the age at which a person begins to smoke, the more likely that person will become a long-term smoker and develop smoking-related diseases. In fact, 90% of smokers begin their cigarette addiction as children or adolescents. The result is predictable and devastating, unless we act now. If the adult smoking rate continues at present levels, at least 5 million American children who are alive today will die of smoking-related diseases. That is a catastrophe we must prevent. As a black American, I am also outraged that some tobacco executives are trying to increase their market share at the expense of the health of our poor and minority communities. At a time when minority health status lags significantly behind the population as a whole-when cancer, stroke, heart disease, and virtually every other disease are running rampant in our minority communities-we must work harder to promote good health and to prevent disease. We cannot allow the cynical, the unfeeling, and the profit-driven to further compound this serious health crisis by 618
targeting those most likely to be harmed by smoking. I am also concerned about the targeting of women. In women, lung cancer has surpassed breast cancer as the most prevalent cause of death from cancer. Women who smoke also court death from heart disease, emphysema, and other diseases. The New England Journal of Medicine recently reported that women who smoke are three times as likely to have a heart attack than women who never smoked. In addition, women who smoke during pregnancy are more likely to have miscarriages, low birthweight babies, and babies who die during infancy. Earlier this year I asked advertising agencies to voluntarily withdraw from their addiction to the blood money offered by the tobacco industry. It seems obvious that any ethical approach to business would factor in the source of the money and the consequences of the use of the products that advertisers urge the public to use. Some publishers and ad agencies, especially many involved with minority publications, showed a responsible concern, and I applaud them for doing the right thing. But some argued that we should not try to dictate their choice of clients, that "business is business." Well, it's that attitude I find intolerable. There must come a time when enough people have died, when we have had enough funerals, grieving relatives, and personal tragedies. There must come a time when passive smokers and those who pay for the cost of smoking must forcefully voice their own opinions. There must come a time when we ask the advertising industry to harness its creative talents in the promotion of health, not the promotion of illness. There must be a limit to what we will allow, and I believe that we have reached that limit. Some tobacco advocates, unable to address the fact that smoking kills, try to change the subject by accusing voices against smoking of violating the principle of free speech. But asking the advertising industry to consider the source of funding and to act responsibly does not violate the Constitution. The real wonder is how, as a society, we continue to let tobacco advocates distract our attention from the truth. Time and again, in the interest of fair play, we let the tobacco industry representatives run here and there offering us a steady diet of red herrings that divert attention from our simple, straightforward messagetobacco is shrouded in death. Tobacco has killed millions of Americans and it will kill more until we adopt a healthier lifestyle. Also, we often hear about the legality of cigarette JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 9
GUEST EDITORIAL
advertising. Certainly such advertising is allowed under current law, but that is not the point. I'm talking about the health of the user and those who come in contact with the user's smoke. I'm talking about the fellow who has to take money out of his own pocket to pay for the damage caused by smokers. It may be legally right, but it is morally wrong to promote a product which, when used as intended, causes death. This difference I will not let the industry spokespersons obfuscate. Finally, some of the tobacco advocates question our sincerity. They say, "This is all just talk." Well, I have made the Department of Health and Human Services buildings smoke-free. I have the authority to work with hospitals and health care providers to make their facilities smoke-free, which we are doing. I have asked our states and tobacco retailers, such as national convenience store chains, to enforce vigorously laws existing in 44 states prohibiting the sale of tobacco to minors. I have even asked our states to consider legislation to ban vending machines, which are often used by minors to purchase cigarettes. We will continue to give high priority to the many antismoking efforts that are ongoing in my department, such as prevention campaigns and epidemiologic research on smoking dangers, patterns of tobacco use, and effectiveness of antismoking efforts. We will
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 82, NO. 9
continue to provide state health agencies with assistance in implementing local antismoking interventions. We will continue to promote comprehensive school health education about the dangers of tobacco and to sponsor programs such as the Smoking Cessation in Pregnancy project that helps states integrate smoking cessation interventions into public prenatal services. And, I will also continue to talk about the health aspects of smoking. As a physician and Secretary of Health and Human Services, the most important thing I can do is continue to speak out. This is a battle of ideas, ideas that have serious health consequences for millions of Americans. I will continue to talk about responsibility-for individuals, advertising agencies, and the tobacco industry. Illness prevention is a responsibility we have, not only to ourselves, but also to each other. I hope that you, the readers of this journal, will join me in this effort. We cannot condone the premature death of 1000 Americans daily from tobacco use. We cannot ignore the disproportionate nature of these deaths. Tobacco is a killer of women, blacks, Hispanics and other minorities, and blue collar workers, and is an addicting substance for our young. One death should justify our outrage, and certainly more than 1000 a day demands our unwavering commitment to make America smoke-free by the year 2000.
619
