The Nation's Number One Health Problem

THE NATION'S NUMBER ONE HEALTH PROBLEM

The SPEAKER pro tempore (Mr. Isakson). Under the Speaker's announced policy of January 6, 1999, the gentleman from Iowa (Mr. Ganske) is recognized for 60 minutes. Mr. GANSKE. Mr. Speaker, the number one public health problem facing the country today is the death and morbidity associated with the use of tobacco. Tonight, I want to discuss why the use of tobacco is so harmful, what the tobacco companies have known about the addictiveness of nicotine in tobacco, how tobacco companies have targeted children to get them addicted, what the Food and Drug Administration proposed, the Supreme Court's decision on FDA authority to regulate tobacco, and bipartisan legislation that will be introduced tomorrow in the House to give the Food and Drug Administration authority to regulate the manufacture and marketing of tobacco. Mr. Speaker, let me repeat. The number one health problem in the Nation today is tobacco use. It is well captured in this editorial cartoon that shows the Grim Reaper, Big Tobacco, with a cigarette in his hand, a consumer on the cigarette, and the title is

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"Warning: The Surgeon General Is Right."

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Here is some cold data on this peril. It is undisputed that tobacco use greatly increases one's risk of developing cancer of the lungs, the mouth, the throat, the larynx, the bladder, and other organs. Mr. Speaker, 87 percent of lung cancer deaths and 30 percent of all cancer deaths are attributable to the use of tobacco products. Tobacco use causes heart attacks, strokes, emphysema, peripheral vascular disease, among many others. Mr. Speaker, more than 400,000 people die prematurely each year from diseases attributable to tobacco use in the United States alone. Tobacco really is the grim reaper. More people die each year from tobacco use in this country than die from AIDS, automobile accidents, homicides, suicides, fires, alcohol and illegal drugs combined. More people in this country die in one year from tobacco than all the soldiers killed in all of the wars this country has fought. Treatment of these diseases will continue to drain over $800 billion from the Medicare trust fund. The VA spends more than one-half billion dollars annually on in-patient care of smoking-related diseases. But these victims of nicotine addiction are statistics that have faces and names. Mr. Speaker, before coming to Congress, I practiced as a surgeon. I have held in these hands lungs filled with cancer and seen the effects of decreased lung capacity on those patients. Unfortunately, I have had to tell some of those patients that their lymphnodes had cancer in them and that they did not have very long to live. As a plastic and general surgeon, I have had to remove patients' cancerous jaws like this surgical specimen, showing a resection of a large portion of a patient's lower jaw. This, Mr. Speaker, is the result of chewing tobacco. The poor souls who have to have this type of surgery go around like the cartoon character Andy Gump. Many times they breathe from a tracheostomy. I have reconstructed arteries in legs in patients that are closed shut by tobacco and are causing gangrene, and I have had to amputate more than my share of legs that have gone too far for reconstruction. The other day, Mr. Speaker, I was talking to a vascular surgeon who is a friend of mine back in Des Moines, Iowa. His name is Bob Thompson. He looked pretty tired. I said Bob, you have been working pretty hard. He said Greg, yesterday I went to the operating room at about 7 in the morning, I operated on 3 patients, finished up about midnight, and every one of those patients I had to operate on to save their legs. I said, were they smokers, Bob? He said, you bet. And the last one that I operated on was a 38-year-old woman who would have lost her leg to atherosclerosis related to heavy tobacco use. I said, Bob, what do you tell those people? He said, Greg, I talk to every patient, every peripheral vascular patient that I have and I try to get them to stop smoking. I ask them a question. I say, if there were a drug available on the market that you could buy that would help you save your legs, that would help prevent your having to have coronary artery bypass surgery, that would significantly decrease your chances of having lung cancer or losing your larynx, would you buy that drug? And every one of those patients say, you bet I would buy that drug, and I would spend a lot of money for it. You know what he says to those patients then? He says, well, you know what? You can save an awful lot of money by quitting smoking and it will do exactly the same thing as that magical drug would have done. Mr. Speaker, my mother and father were both smokers and they are only alive today because coronary artery bypass surgery saved their lives. I will never forget the thromboangiitis obliterans patients I treated at VA hospitals who were addicted to the tobacco that caused them to thrombose one finger and one toe after another. I remember one patient who had lost both lower legs, all the fingers on his left-hand, and all the fingers on his right hand, except his index finger. Why? Because the tobacco caused those little blood vessels to clot shut. This patient, even though he knew that if he stopped smoking, it would stop his disease, he had devised a little wire cigarette holder with a loop on it to fit around his one remaining finger so that he could smoke. Statistics do show the magnitude of this problem. Over a recent 8- year period, tobacco use by children increased 30 percent. More than 3 million American children and teenagers now smoke cigarettes. Every 30 seconds a child in the United States becomes a regular smoker. In addition, more than 1 million high school boys use smokeless chewing tobacco, primarily as a result of advertising, focusing on flavored brands and youth-oriented themes. For heaven's sakes, Mr. Speaker, we got rid of the tobacco spittoons in this place a long time ago, and we now have 1 million kids working on developing the type of cancer that would result in surgical resection of half of their jaw. The sad fact is, Mr. Speaker, that each day, 3,000 kids start smoking, many of them not even teenagers, younger than teenagers, and 1,000 out of those 3,000 kids will have their lives shortened because of tobacco. So why did it take a life-threatening heart attack to get my parents to quit smoking? I nagged on them all the time, but it took a near death experience to get them to quit. Why would not my patient with one finger, the only finger he had left, quit smoking? Why do fewer than one in 7 adolescents quit smoking, even though 70 percent regret starting. I say to my colleagues, it is sadly because of the addictive properties of the drug nicotine in tobacco. The addictiveness of nicotine has become public knowledge, public knowledge only in recent years as a result of painstaking scientific research that demonstrates that nicotine is similar to amphetamines, nicotine is similar to cocaine, nicotine is similar to morphine in causing compulsive drug- seeking behavior. In fact, Mr. Speaker, there is a higher percentage of addiction among tobacco users than among users of cocaine or heroin. But recent tobacco industry deliberations show that the tobacco industry had long-standing knowledge of nicotine's affects. It is clear that tobacco company executives committed perjury before the Committee on Commerce just a few years ago when they raised their right hands, they took an oath to tell the truth, and then they denied that tobacco and nicotine was addicting. Internal tobacco company documents dating back to the early 1960s show that the tobacco companies knew of the addicting nature of nicotine, but withheld those studies from the Surgeon General. A 1978 Brown & Williamson memo stated, "Very few customers are aware of the effects of nicotine; i.e., its addictive nature, and that nicotine is a poison." A 1983 Brown & Williamson memo stated, "Nicotine is the addicting agent in cigarettes." Indeed, the industry knew that there was a threshold dose of nicotine necessary to maintain addiction, and a 1980 Lorilard document summarized the goals of an internal task force whose purpose was not to avert addiction, but to maintain addiction. Quote: "Determine the minimal level of nicotine that will allow continued smoking. We hypothesize that below some very low nicotine level, diminished physiologic satisfaction cannot be compensated for by psychologic satisfaction. At that point, smokers will quit or return to higher tar and nicotine brands."

Mr. Speaker, we also know that for the past 30 years, the tobacco industry manipulated the form of nicotine in order to increase the percentage of "free base" nicotine delivered to smokers. As a naturally occurring base, and I have to say, Mr. Speaker, that this takes me back to my medical school biochemistry, nicotine favors the salt form at low pH levels, and the "free base" form at higher pHs. So what does that mean? Well, the free base nicotine crosses the alveoli of the lungs faster than the bound form, thus giving the smoker a greater kick, just like the druggie who free bases cocaine, and the tobacco companies knew that very well. A 1966 British American tobacco report noted, "It would appear that the increased smoker response is associated with nicotine reaching the brain more quickly. On this basis, it appears reasonable to assume that the increased response of a smoker to the smoke with a higher amount of extractable nicotine, not synonymous

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with, but similar to free-base nicotine, may be either because this nicotine reaches the brain in a different chemical form, or because it reaches the brain more quickly." Tobacco industry scientists were well aware of the effect of pH on the speed of absorption and on the physiologic response. A 1973, 1973 R.J. Reynolds report stated, "Since the unbound nicotine is very much more active physiologically and much faster acting than bound nicotine, the smoke at a high pH seems to be strong in nicotine."

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Therefore, the amount of free nicotine in the smoke may be used for at least a partial measure of the physiologic strength of the cigarette." Indeed, Mr. Speaker, Phillip Morris commenced the use of ammonia in their Marlboro brand in the mid 1960s in order to raise the pH of its cigarettes, and it subsequently emerged as the leading national brand.  By reverse engineering, other manufacturers caught onto Phillip Morris' nicotine manipulation. And they copied it. The tobacco industry hid the fact that nicotine was an addicting drug for a long time, even though they privately called cigarettes "nicotine delivery devices."  Claude E. Teague, Junior, assistant director of research at RJR, said in a 1972 RJR memo, "In a sense, the tobacco industry may be thought of as being a specialized, highly ritualized and stylized segment of the pharmaceutical industry. Tobacco products uniquely contain and deliver nicotine, a potent drug with a variety of physiologic effects. Thus, a tobacco product is, in essence, a vehicle for the delivery of nicotine designed to deliver the nicotine in a generally acceptable and attractive form. Our industry is then based upon the design, manufacture, and sale of attractive forms of nicotine."

A 1972 Phillip Morris document summarized an industry conference attended by 25 tobacco scientists from England, Canada, and the United States: "The majority of conferees would accept the proposition that nicotine is the active constituent of tobacco smoke. The cigarette should be conceived not as a product, but as a package." Then they said, "The product is nicotine." Mr. Speaker, does anyone believe that the tobacco CEOs who testified before Congress that tobacco was not addicting were telling the truth? Mr. Speaker, most adult smokers start smoking before the age of 18. This political cartoon shows big tobacco over here lighting up one cigarette from the other, and one cigarette says, "Victims" and the other cigarette that is about ready to start is "Kids." The title of the cartoon: "Chain smoker." As I said, Mr. Speaker, most adult smokers start smoking before the age of 18. That has been known by the tobacco industry and its marketing divisions for decades. A report to the board of directors of RJR on September 30, 1974, entitled "1975 Marketing Plans Presentation, Hilton Head, September 30, 1974," said that one of the key opportunities to accomplish the goal of reestablishing RJR's market share was to "increase our young adult franchise. First, let's look at the growing importance of this young adult group in the cigarette market. In 1960, this young adult market," and this is the clincher, what did they call the young adult market, young adult? The 14 to 24 age group. They say, "This represented 21 percent of our population. They will represent 27 percent of the population in 1975, and they represent tomorrow's cigarette business." An adult, Mr. Speaker? They are 14-year-olds, pretty young adults. In a 1980 RJR document entitled "MDD Report on Teenager Smokers Ages 14 Through 17," a future RJR CEO G.H. Long wrote to the CEO at that time, E.A. Horrigan, Junior. In that document, Long laments the loss of market share of 14-to-17- year-old smokers to Marlboro, and says, "Hopefully, our various planned activities that will be implemented this fall will aid in some way in reducing or correcting those trends." The trends were they were losing market share in the 14-to-17-year-old age group. Mr. Speaker, the industry has indisputably focused on ways to get children to smoke: in surveys for Phillip Morris in 1974 in which children 14 or younger were interviewed about their smoking behavior; or how about the Phillip Morris document which bragged, "Marlborough dominates in the 17 and younger category, capturing over 50 percent of this market." Mr. Speaker, when Joe Camel is associated with cigarettes by 30 percent of 3-year-olds and nearly 90 percent of 5-year-olds, we know that marketing efforts directed at children are very successful. Here is another political cartoon. We have a billboard. It says, "Joe Camel says, cancer is cool." We have an antismoking advocate saying, "Huh, not exactly the honest disclosure we were hoping for." Mr. Speaker, children that begin smoking at age 15 have twice the incidence of lung cancer as those who start smoking at the age of 25. For those youngsters who start at such an early age and have twice the incidence of cancer, for them Joe Cool becomes Joe Chemo, pulling around his bottle of chemotherapy. If that is not enough, it should not be overlooked that nicotine is an introductory drug, as smokers are 15 times more likely to become an alcoholic, to become addicted to hard drugs, or to develop a problem with gambling. Mr. Speaker, in response to this, the Food and Drug Administration in August of 1996 issued regulations aimed at reducing smoking in children on the basis that nicotine is addicting, it is a drug, manufacturers have marketed that drug to children, and tobacco is deadly. Most people by now are familiar with those regulations. They received a lot of press at the time. It is hard to think, Mr. Speaker, that 4 years have gone by since those regulations came out. Those regulations said, tobacco companies would be restricted from advertising aimed at children, that retailers would need to do a better job of making sure they were not selling cigarettes to children, that the FDA would oversee tobacco companies' manipulation of nicotine. But the tobacco companies challenged those regulations, and they ended up taking it all the way to the Supreme Court. Just 2 weeks ago, Justice Sandra Day O'Connor, in writing for the majority, five to four, held that Congress had not granted the FDA authority to regulate tobacco. However, her closing sentences in that opinion bear reading: "By no means do we," and this is the Supreme Court, "question the seriousness of the problem that the FDA has sought to address. The agency has amply demonstrated that tobacco use, particularly among children and adolescents, poses perhaps the most significant threat to public health in the United States." Justice O'Connor is practically begging Congress to grant the FDA authority to regulate tobacco. Therefore, Mr. Speaker, tomorrow the gentleman from Michigan (Mr. Dingell) and I will introduce our bipartisan bill The FDA Tobacco Authorities Amendment Act. I call on my colleagues from both sides of the aisle to cosponsor this bill and join us for a press conference on the Triangle at noon. Our bill simply says that FDA has authority to regulate tobacco, that the 1996 tobacco regulations will be law. This is not a tax bill. This is not a liability bill. This is not a prohibition bill. This has nothing to do with the tobacco settlement from the attorneys general. This bill simply recognizes the facts: tobacco and nicotine are addicting. Tobacco kills over 400,000 people in this country each year. Tobacco companies have and are targeting children to make them addicted to smoking. The FDA should have congressional authority to regulate this drug and those delivery devices.