The Nation's Number One Health Problem

by John Greg Ganske

 
                 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

[Page H1848]

"Warning: The Surgeon General Is Right."

                              {time} 2115

  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

[Page H1849]

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."

                              {time} 2130

  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.