-l- SUGGESTED REMARKS BY DR. KOOP AS DR. BRANDT HAS TOLD YOU, FIVE PREVIOUS SURGEONS GENERAL HAVE ISSUED REPORTS ON THE HEALTH CONSEQUENCES OF SMOKING. THE REPORT WHICH 1 INTRODUCE TO YOU TODAY, WHICH SECRETARY SCHWEIKER IS SENDING TO THE CONGRESS, IS IN SOME RESPECTS THE MOST SERIOUS INDICTMENT OF CIGARETTE SMOKING WHICH THE PUBLIC HEALTH SERVICE HAS YET MADE. — IN 1964, THE RELATIONSHIP BETWEEN CIGARETTE SMOKING AND DISEASE WAS INVESTIGATED IN GREAT DEPTH. IN THAT YEAR, IT WAS POSSIBLE FOR THE SURGEON GENERAL’S ADVISORY COMMITTEE TO COME TO ONLY TWO UNEQUIVOCAL CONCLUSIONS. THEY FOUND CIGARETTE SMOKING TO BE THE MOST IMPORTANT CAUSE@ OF CHRONIC BRONCHITIS AND OF LUNG CANCER IN MEN, IN THE CASE OF LUNG CANCER IN WOMEN, THEY WERE ABLE TO SAY ONLY THAT THE DATA POINTED IN THE SAME DIRECTION AS FOR MEN, IN THE YEARS SINCE, ADDITIONAL HUMAN EXPERIENCE AND ENORMOUS AMOUNTS OF NEW BIOMEDICAL AND EPIDEMIOLOGICAL RESEARCH HAVE ESTABLISHED THAT CIGARETTE SMOKING IS A CAUSE, Ao=siiiamiiliamaer DCSGGGae>» OF LUNG CANCER FOR BOTH MEN AND WOMEN, OF CANCERS OF THE LARYNX, ORAL CAVITY AND ESOPHAGUS, OF CHRONIC LUNG DISEASE AND CORONARY HEART DISEASE AND OF FETAL LOSS FOR, MOTHERS WHO SMOKE DURING PREGNANCY. CIGARETTE SMOKING IS CLEARLY IDENTIFIED AS THE CHIEF PREVENTABLE CAUSE OF DEATH IN OUR SOCIETY. -2- THE PRESENT REPORT TREATS ONLY THE RELATIONSHIP BETWEEN CIGARETTE SMOKING AND CANCERS. HERE ARE ITS MAIN CONCLUSIONS: J. APPROXIMATELY 30 PERCENT OF ALL CANCER DEATHS ARE ATTRIBUTABLE TO CIGARETTE SMOKING. 2. SMOKING IS A MAJOR CAUSE OF LUNG CANCER AND OF CANCERS OF THE LARYNX, ORAL CAVITY, AND ESOPHAGUS, 3, IT IS A CONTRIBUTORY FACTOR IN THE DEVELOPMENT OF CANCERS OF THE BLADDER, PANCREAS, AND KIDNEY. 4, AN EXCESS MORTALITY HAS BEEN FOUND AMONG CIGARETTE SMOKERS FOR CANCERS OF THE STOMACH AND UTERINE CERVIX, BUT EVIDENCE PRESENTLY AVAILABLE IS DEEMED INSUFFICIENT FOR CONCLUSIONS ABOUT THE NATURE OF THE ASSOCIATION, 5. IN THE CASE OF PASSIVE SMOKING, THE REPORT REVIEWS THREE STUDIES WHICH PRESENT EVIDENCE OF AN ELEVATED CARCINOGENIC RISK AMONG NONSMOKERS EXPOSED TO OTHER PEOPLES’ SMOKING. TWO OF THESE STUDIES REPORTED A STATISTICALLY SIGNIFICANT ASSOCIATION AND ONE DID NOT. THE DECISION TO DEVOTE AN ENTIRE REPORT TO CIGARETTE SMOKING AND CANCER WAS MADE FOR SEVERAL REASONS. -3- CANCER WAS THE FIRST DISEASE TO BE ASSOCIATED WITH CIGARETTE SMOKING. REPORTS LINKING SMOKING AND LUNG CANCER BEGAN APPEARING IN THE SCIENTIFIC LITERATURE 50 YEARS AGO. HOWEVER, THE RELA- TIONSHIP HAS NOT BEEN EXAMINED, AT LEAST IN THE DEPTH OF THIS REPORT, SINCE 1964, CANCER IS THE SECOND MOST FREQUENT CAUSE OF DEATH IN THE UNITED STATES AND ALMOST A THIRD OF THESE DEATHS ARE ATTRIBUTABLE TO SMOKING, TOTAL DEATH RATES FROM CANCER, ALONE AMONG THE MAJOR CAUSES OF DEATH, HAVE SHOWN NO MAJOR DECLINE DURING A PERIOD WHEN AGE-ADJUSTED DEATH RATES FOR HEART DISEASE, COMMUNICABLE DISEASE AND ACCIDENTS HAVE FALLEN. AGAIN, AS THIS REPORT SHOWS, THIS LACK OF CHANGE IN THE CASE OF CANCER IS ALMOST SOLELY DUE TO CIGARETTE SMOKING, TOBACCO USE, ESPECIALLY CIGARETTE SMOKING, IS A MAJOR CAUSE OF CANCERS OF THE LUNG, LARYNX, ORAL CAVITY AND ESOPHAGUS. THE PERCENT OF DEATHS FROM CANCERS OF THESE SITES TO ALL CANCER DEATHS IS SHOWN IN THIS CHART (PIE CHART). FROM 1950 TO 1975, THE PERCENT MORE THAN DOUBLED. NOT COUNTED AMONG THE SMOKING- RELATED CANCER DEATHS ARE CANCERS OF THE BLADDER, KIDNEY, AND ) PANCREAS, SOME PROPORTION OF WHICH CAN BE ATTRIBUTED TO CIGARETTE SMOKING, -4y- OUR SECOND CHART (LINE CHART) SHOWS THE REMARKABLE INCREASE IN LUNG CANCER DEATHS. IF IT WERE NOT FOR THESE DEATHS, THE OVERALL CANCER MORTALITY WOULD HAVE FALLEN, REFLECTING IMPROVED DIAGNOSIS, TREATMENT, AND SURVIVAL TIMES FOR CANCER SITES NOT ASSOCIATED WITH CIGARETTE SMOKING, SUCH AS PROSTATIC, COLORECTAL, AND BREAST CANCERS, THE AVERAGE ANNUAL INCREASE IN LUNG CANCER DEATHS FOR MALES HAS SLOWED IN RECENT YEARS, WHILE THAT OF FEMALES HAS ACCELERATED. THIS IS A MAJOR PUBLIC HEALTH PROBLEM, AND A MAJOR REASON WHY CANCER WAS CHOSEN AS THE TOPIC FOR THIS REPORT, AN EPIDEMIC OF LUNG CANCER AMONG MEN HAS EXISTED FOR MANY YEARS; NOW IT IS BEING REPEATED AMONG WOMEN. THIS IS BECAUSE OF WOMEN’S LATER UPTAKE OF SMOKING, MEN BEGAN SMOKING DURING AND AFTER WORLD WAR I, WOMEN DURING AND AFTER WORLD WAR II, ANOTHER POIGNANT REASON FOR A NEW SCIENTIFIC REVIEW OF CIGARETTE SMOKING AND CANCER IS THE CONTINUING POOR SURVIVAL RATE FOR AT LEAST TWO OF THE CANCERS ASSOCIATED WITH CIGARETTE SMOKING. THE FIVE-YEAR SURVIVAL RATE FOR CANCER OF THE LUNG IS 1O PERCENT AND FOR CANCER OF THE ESOPHAGUS, 4 PERCENT. OUR CHOICE OF CANCER AS A SUBJECT OF THIS REPORT SHOULD NOT DISTRACT ATTENTION FROM THE EVEN LARGER COSTS OF CIGARETTE -5- SMOKING, WHICH BECOME APPARENT WHEN DEATHS FROM CORONARY HEART DISEASE, CHRONIC LUNG DISEASE AND OTHER DISEASES AND CONDITIONS ARE TAKEN INTO ACCOUNT. OVERALL, IT HAS BEEN ESTIMATED THAT SMOKING IS RESPONSIBLE FOR SOME 340,000 DEATHS IN THIS COUNTRY ANNUALLY, AND THAT IT EXACTS MONETARY COSTS OF OVER $13 BILLION IN HEALTH CARE EXPENSES AND OVER $25 BILLION IN LOST PRODUCTION AND WAGES. SINCE 1965, AGENCIES IN THE PUBLIC HEALTH SERVICE HAVE BEEN INVOLVED IN EDUCATION AND RESEARCH RELATED TO CIGARETTE SMOKING, AND FROM THE BEGINNING THEY HAVE HAD THE SUPPORT AND ENCOURAGEMENT OF THE PRIVATE SECTOR. THE SPIRIT OF VOLUNTEERISM WHICH IS SO MUCH A PART OF THIS ADMINISTRATION’S PROGRAM IS NOWHERE BETTER EVIDENCED THAN IN THIS PUBLIC HEALTH AREA. THERE ARE AT PRESENT 34 HEALTH, MEDICAL, EDUCATIONAL, GOVERNMENTAL AND CIVIC ORGANIZATIONS BANDED TOGETHER IN THE NATIONAL INTERAGENCY COUNCIL ON SMOKING AND HEALTH. THREE OF THE MOST ACTIVE MEMBERS OF THIS GROUP ARE THE AMERICAN CANCER SOCIETY, THE AMERICAN HEART ASSOCIATION AND THE AMERICAN LUNG ASSOCIATION. THIS WINTER THESE THREE AGENCIES HAVE TAKEN THE UNUSUAL STEP OF FORMING A COALITION FOR SMOKING MBL HEALTH TO WORK WITH-THE CONGRESS AND THE GOVERNMENT, OR -6- THE PRIVATE AND PUBLIC SECTORS HAVE ACCOMPLISHED A GREAT DEAL OVER THE YEARS IN HELPING CHANGE THE SMOKING BEHAVIOR OF THE AMERICAN PUBLIC. AN EARLY EVIDENCE OF THIS MAY BE FOUND IN THIS REPORT -- A DECLINE IN MALE LUNG CANCER DEATH RATES AT YOUNGER AGES. ~~ AT THE PRESENT TIME, PER CAPITA CONSUMPTION OF CIGARETTES IS AT THE LOWEST LEVEL SINCE 1957, THE PREVALENCE OF SMOKING HAS DECLINED FROM 42 PERCENT OF THE POPULATION IN 1965 TO 32 PERCENT TODAY, AND THE CIGARETTE ITSELF HAS CHANGED GREATLY IN ITS YIELDS OF TAR AND NICOTINE. THE MOST ENCOURAGING TREND IS AN APPARENT CONTINUING DECLINE IN SMOKING AMONG YOUNG PEOPLE. IN A FEW DAYS, THE NATIONAL INSTITUTE ON DRUG ABUSE WILL ANNOUNCE THE 1981 RESULTS OF ITS ANNUAL HIGH SCHOOL SURVEY, ONE OF THE MANY FINDINGS OF THIS IMPORTANT SURVEY WILL BE THAT DAILY SMOKING AMONG HIGH SCHOOL SENIORS HAS DROPPED FROM 29 PERCENT IN 1977 10 20 PERCENT IN 1981. YET HOWEVER ENCOURAGING THESE CHANGES IN SMOKING BEHAVIOR MAY BE, THE FACT REMAINS THAT 53 MILLION ADULTS IN THIS COUNTRY STILL SMOKE CIGARETTES AND YOUNG PEOPLE ARE STILL TAKING UP THE HABIT. ON THE EVIDENCE OF THE REPORT WE SUBMIT TO YOU TODAY, -7J- THIS CAN ONLY PRESAGE HUMAN TRAGEDY IN THE YEARS AHEAD AND ENORMOUS ECONOMIC LOSS TO OUR COUNTRY. I WOULD NOW LIKE TO OPEN THIS CONFERENCE TO QUESTIONS. I WILL ENTERTAIN THEM FROM THE WORKING PRESS ONLY. AS DR. BRANDT HAS SAID, WE HAVE DR. LUOTO AND THE THREE CONSULTING SCIENTIFIC EDITORS TO HELP US, THEY ARE DOCTORS BURNS, GRITZ, AND HOLBROOK.