REMARKS BY C, EVERETT KOOP, M,D, SURGEON GENERAL U,S, PUBLIC HEALTH SERVICE AND DEPUTY ASSISTANT SECRETARY FOR HEALTH US, DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED AT THE PANEL ON SMOKELESS TOBACCO AT THE ANNUAL MEETING OF THE AMERICAN PUBLIC HEALTH ASSOCIATION LAS VEGAS, NEVADA SEPTEMBER 29, 1986 1 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETCJ I WANT TO THANK YOUR PRESIDENT, DR, BILL FOEGE, AND OTHERS ON YOUR PROGRAM COMMITTEE FOR PUTTING THIS PANEL TOGETHER AS PART OF THE ANNUAL MEETING, CLEARLY THE HEALTH EFFECTS OF SMOKELESS TOBACCO ARE SERIOUS, ,,THEY ARE MEASURABLEwAND THEY ARE PREVENTABLE, THE IRONY IN THIS SITUATION IS THAT THE PRODUCTION AND USE OF SMOKELESS TOBACCO PRODUCTS HAS BEEN CLIMBING RIGHT AT THE TIME THE TREND LINE FOR CIGARETTE SMOKING IS NOW STEADILY DOWNWARD, OUR DATA INDICATE THAT IN 1985 AN ESTIMATED 12 MILLION PEOPLE AGE 12 AND OVER -- MALES FOR THE MOST PART -- USED SOME FORM OF SMOKELESS TOBACCO, AND ABOUT HALF THAT NUMBER, OR 6 MILLION PEOPLE, USED SMOKE- LESS TOBACCO ON A REGULAR DAILY BASIS, 2 FIRST OF ALL, WHAT IS "SMOKELESS TOBACCO" ANYWAY? SMOKELESS IS ESSENTIALLY THE SAME LEAF THAT'S USED IN CIGARETTE, CIGAR, AND PIPE TOBACCO, BUT INSTEAD OF BEING BURNED, SMOKELESS TOBACCO IS CHEWED, SQUEEZED, OR SNIFFED, CHEWING TOBACCO IS SOLD AS EITHER A POUCH-FULL OF LOOSE, SHREDDED LEAF OR AS A COMPRESSED "PLUG" OF TOBACCO, BOTH FORMS ARE MOVED ABOUT THE ORAL CAVITY AND CHEWED, SNUFF IS FINELY GROUND TOBACCO THAT'S SOLD EITHER DRY OR MOIST, THE DRY, GRANULAR FORM IS EITHER SNIFFED -- A RARE HABIT IN THIS COUNTRY -- OR IS BRUSHED ONTO ONE'S GUMS, OR "PAINTED" ON, THIS IS A COMMON PRACTICE AMONG SOME SOUTHERN RURAL WOMEN BUT RARELY SEEN ELSEWHERE, 3 THE MOISTENED FORM OF SNUFF IS THE MOST WIDELY PROMOTED AND ADVERTISED, A "PINCH" OF IT IS TAKEN FROM THE TIN AND PRESSED BACK INTO THE MOUTH BETWEEN THE CHEEK AND LOWER GUM, CONTINUAL MODERATE SQUEEZING RELEASES THE NICOTINE, WHICH PASSES IMMEDIATELY THROUGH THE THIN BUCCAL MEMBRANES, INTO THE BLOODSTREAM, AND RIGHT TO THE HEART AND BRAIN, FOR THOSE NOT ADEPT AT HANDLING A "CUD," SMOKELESS COMES WRAPPED LIKE TEA IN A BAG, ONE BRAND, FOR EXAMPLE, IS APPROPRIATELY CALLED "BANDITS," FOR INDEED IT DOES ROB THE USER OF CONTROL OF HIS OWN BEHAVIOR AND LATER OF HIS HEALTH AS WELL, EARLIER THIS YEAR I ASKED AN ADVISORY COMMITTEE TO TELL ME "THE HEALTH CONSEQUENCES OF USING SMOKELESS TOBACCO," THE COMMITTEE WAS HEADED BY DR, JOSEPH CULLEN OF THE NATIONAL CANCER INSTITUTE, A NUMBER OF EXPERTS FROM BOTH WITHIN AND OUTSIDE THE US, PUBLIC HEALTH SERVICE HELPED PULL TOGETHER THE DATA, THE COMMITTEE REPORTED BACK TO ME ON MARCH 25TH, THEIR OVERALL CONCLUSION WAS THAT, .I 4 "THE ORAL USE OF SMOKELESS TOBACCO REPRESENTS A SIGNIFICANT HEALTH RISK, IT IS NOT A SAFE SUBSTITUTE FOR SMOKING CIGARETTES, IT CAN CAUSE CANCER AND A NUMBER OF NONCANCEROUS ORAL CONDITIONS AND CAN LEAD TO NICOTINE ADDICTION AND DEPENDENCE," THAT WAS THEIR GENERAL, OVERALL STATEMENT RIGHT UP FRONT, BUT THEY HAD SEVERAL SPECIFIC POINTS THAT I'D LIKE TO EMPHASIZE AT THIS TIME, FIRST, THERE IS A STRONG ASSOCIATION BETWEEN THE USE OF SMOKELESS TOBACCO AND CANCERS OF THE ORAL CAVITY, THE CHEEK, AND THE PHARYNX, THEY ESTIMATED ABOUT 11 CASES OF SUCH CANCERS PER 100,000 POPULATION, IN ADDITION, THEY SAID SUCH CASES ACCOUNTED FOR ABOUT 3 OUT OF EVERY 100 CANCER-RELATED DEATHS, 5 WHAT'S IN SMOKELESS TOBACCO THAT SEEMS TO CAUSE THESE CANCERS? 9 POLYCYCLIC AROMATIC HYDROCARBONS, FOR ONE THING, 9 RADIATION-EMITTING POLONIUM, FOR ANOTHER, 9 AND TOBACCO-SPECIFIC NITROSAMINES, FOR STILL ANOTHER, IN FACT, THESE NITROSAMINES ARE PRESENT AT LEVELS 100 OR MORE TIMES HIGHER THAN GOVERNMENT-REGULATED LEVELS OF OTHER NITROSAMINES PERMITTED IN COMMERCIALLY AVAILABLE FOODS, THESE ARE THE CANCER-CAUSING CULPRITS, BUT WHAT KINDS OF CANCER DO THEY CAUSE? 6 THE COMMITTEE SAID THAT THE MOST PREVALENT FORM IS KNOWN AS "SNUFF-DIPPER'S CARCINOMA," THE USER TAKES A PINCH OF SNUFF -- "DIPS" FOR IT -- AND PLACES IT BETWEEN THE CHEEK AND GUM, A PHRASE BEAMED OVER AND OVER AGAIN IN TJ, COMMERCIALS BY A CALF-ROPING FORMER MEMBER OF THE DALLAS COWBOYS, ,,A REAL "HE-MAN" IMAGEwA KIND OF "MARLBORO MAN" RE-VISITED, AND LIKE THE HARD-RIDING MARLBORO MAN, WHO DIES FASTER AND SOONER OF LUNG CANCER AND CIGARETTE-RELATED HEART DISEASE, THE SNUFF-DIPPERS ALSO GO FASTER: ACCORDING TO THE ADVISORY COMMITTEE, USING FIGURES EXTRAPOLATED FROM A STUDY OF NORTH CAROLINA WOMEN WHO "PAINTED" DRY SNUFF ON THEIR GUMS, THE RISK OF CHEEK OR GUM CANCER FOR LONG-TERM SNUFF USERS APPEARS TO BE 50 TIMES THAT OF THE RISK OF THE POPULATION AT LARGE, 7 AS WITH SMOKING AND LUNG CANCER, THE USE OF SMOKELESS TOBACCO BY WOMEN ACCOUNTS FOR THE ABNORMALLY HIGH RATES OF ORAL CANCER MORTALITY AMONG SOUTHERN WOMEN, THE USE OF SMOKELESS TOBACCO ALSO SEEMS TO BE RESPONSIBLE FOR A FAIR AMOUNT OF ORAL LEUKOPLAKIAS IN BOTH TEENAGE AND ADULT USERS, THE TELL-TALE WHITE PATCHES TEND TO APPEAR ON THE ORAL MUCOSA RIGHT WHERE THE CHEWING TOBACCO OR THE SNUFF IS TUCKED AWAY BY THE USER, STUDIES IN BOTH THE UNITED STATES AND SCANDINAVIA HAVE SHOWN THIS TO OCCUR, IN ADDITION, AMONG SOME LONG-TERM SNUFF USERS THESE LEUKOPLAKIAS UNDERGO TRANSFORMATION TO A DYSPLASTIC STATE AND, FINALLY, TO A CANCER, 8 WE SUSPECT MANY OTHER ADVERSE EFFECTS TO GINGIVAL AND PERIODONTAL TISSUE AND TO TEETH -- THE DEVELOPMENT OF PLAQUE, FOR EXAMPLE, OR PERMANENT STAINING -- BUT SO FAR WE DON'T HAVE STUDIES WITH UNEQUIVOCAL RESULTS IN THESE AREAS, IN ADDITION TO ITS ROLE IN CAUSING ORAL CANCERS AND LEUKOPLAKIAS, THERE IS SOME EVIDENCE THAT SMOKELESS TOBACCO MAY CONTRIBUTE IN SOME WAY TO THE DEVELOPMENT OF CORONARY ARTERY AND PERIPHERAL VASCULAR DISEASE, HYPERTENSION, PEPTIC ULCERS, AND FETAL MORBIDITY AND MORTALITY, THE USE OF SMOKELESS TOBACCO HAS OTHER EFFECTS, TOO, OF A MORE PYSCHOLOGICAL AND PHYSIOLOGICAL NATURE, THE NICOTINE FOUND IN TOBACCO, FOR EXAMPLE, WHETHER SMOKED OR CHEWED, IS AN ADDICTIVE DRUG, LIKE MORPHINE OR COCAINE, AND WE ALREADY KNOW THAT CIGARETTE SMOKERS ARE CLINICALLY ADDICTED TO THEIR HABIT, 9 NOW WE FIND THAT NICOTINE LEVELS IN THE BODIES OF SMOKELESS TOBACCO USERS ARE AS HIGH AS THE LEVELS IN CIGARETTE SMOKERS AND WE HAVE TO CONCLUDE THAT A SIMILAR ADDICTION IS, THEREFORE, PRESENT, AND, IN FACT, WE DOFIND AMONG BOTH SMOKERS AND SNUFF-DIPPERS THOSE SAME TRANSIENT, DOSE-RELATED CHANGES IN THE USER'S MOOD AND FEELING AND OTHER ASPECTS OF DRUG ADDICTION, FOR THESE AND OTHER COMPELLING REASONS, THE UNITED STATES CONGRESS ENACTED AND THE PRESIDENT SIGNED P,L, 99-252, "THE COMPRE- HENSIVE SMOKELESS TOBACCO HEALTH EDUCATION ACT OF 1986," IT WAS DEVELOPED BY THE SENATE COMMITTEE ON LABOR AND HUMAN RESOURCES AND RECEIVED STRONG BIPARTISAN SUPPORT FROM COMMITTEE CHAIRMAN ORRIN Gm HATCH AND RANKING MINORITY MEMBER EDWARD M, KENNEDY, 10 THE LEGISLATION RECEIVED STRONG SUPPORT IN THE HOUSE OF REPRE- SENTATIVES AS WELL, WHERE CHAIRMAN HENRY An WAXMAN AND CONGRESSMAN MIKE SYNAR OF THE HOUSE SUBCOMMITTEE ON HEALTH AND THE ENVIRONMENT WERE AMONG THE BILL'S LEADING SPONSORS, SINCE THE PASSAGE OF THE BILL THE CENTER OF INTEREST HAS SHIFTED TO THE FEDERAL TRADE COMMISSION, WHICH IS CHARGED WITH PRODUCING THE GUIDELINES FOR COMPLIANCE, SO FAR THE F,T,C,'s PROPSALS, PUBLISHED IN THE FEDERAL REGISTRER, LEAVE SOMETHING TO BE DESIRED, THERE IS A QUESTION IN MY MIND -- AND IN THE MINDS OF SENATORS HATCH, KENNEDY, AND LUGAR AND REPRESENTATIVES WAXMAN AND SYNAR, I MIGHT ADD -- AS TO THE DEGREE OF CARE WITH WHICH THE F,T,C, STAFF IS FOLLOWING THE LETTER, THE SPIRIT, AND THE LEGIS- LATIVE HISTORY OF THIS PARTICULAR LAW, 11 WE HOPE F,T,C, WILL BE A GOOD DEAL MORE CAREFUL IN ITS FINAL VERSION THAN IN ITS PROPOSALS THUS FAR, NOW THE REPORTS OF THE COMMITTEES ARE INwTHE ADVISORY COMMITTEE'S REPORT ON WHAT WE KNOW FROM THE POINT OF VIEW OF SCIENCE AND THE I,G,'S REPORT ON HOW MUCH THE PUBLIC KNOWS -- YOUNG PEOPLE SPECIFICALLY -- ABOUT THE HEALTH HAZARDS OF SMOKELESS TOBACCO, THE REPORTS ALL POINT CONCLUSIVELY IN ONLY ONE DIRECTION: THE USE OF SMOKELESS TOBACCO PRESENTS SERIOUS HEALTH RISKS TO THE AMERICAN POPULATION, 12 THOSE RISKS APPEAR TO BE EVERY BIT AS SERIOUS AS THE MORE WIDESPREAD RISKS OF CIGARETTE SMOKING, IT IS CLEARLY A MATTER THAT REQUIRES THE VIGILANCE OF ALL PUBLIC HEALTH WORKERS AND THE CONCERN OF THE PUBLIC AT LARGE, THANK YOU, #####