[Senate Hearing 107-552]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-552
 
 TOBACCO'S DEADLY SECRET: THE IMPACT OF TOBACCO MARKETING ON WOMEN AND 
                                 GIRLS
=======================================================================



                                HEARING

                               before the

                  OVERSIGHT OF GOVERNMENT MANAGEMENT,
              RESTRUCTURING, AND THE DISTRICT OF COLUMBIA
                              SUBCOMMITTEE

                                 of the

                              COMMITTEE ON
                          GOVERNMENTAL AFFAIRS
                          UNITED STATES SENATE


                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 14, 2002

                               __________

      Printed for the use of the Committee on Governmental Affairs








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                   COMMITTEE ON GOVERNMENTAL AFFAIRS

               JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan                 FRED THOMPSON, Tennessee
DANIEL K. AKAKA, Hawaii              TED STEVENS, Alaska
RICHARD J. DURBIN, Illinois          SUSAN M. COLLINS, Maine
ROBERT G. TORRICELLI, New Jersey     GEORGE V. VOINOVICH, Ohio
MAX CLELAND, Georgia                 THAD COCHRAN, Mississippi
THOMAS R. CARPER, Delaware           ROBERT F. BENNETT, Utah
JEAN CARNAHAN, Missouri              JIM BUNNING, Kentucky
MARK DAYTON, Minnesota               PETER G. FITZGERALD, Illinois
           Joyce A. Rechtschaffen, Staff Director and Counsel
              Richard A. Hertling, Minority Staff Director
                     Darla D. Cassell, Chief Clerk

                                 ------                                

OVERSIGHT OF GOVERNMENT MANAGEMENT, RESTRUCTURING, AND THE DISTRICT OF 
                         COLUMBIA SUBCOMMITTEE

                 RICHARD J. DURBIN, Illinois, Chairman
DANIEL K. AKAKA, Hawaii              GEORGE V. VOINOVICH, Ohio
ROBERT G. TORRICELLI, New Jersey     TED STEVENS, Alaska
THOMAS R. CARPER, Delaware           SUSAN M. COLLINS, Maine
JEAN CARNAHAN, Missouri              THAD COCHRAN, Mississippi
MARK DAYTON, Minnesota               PETER G. FITZGERALD, Illinois
       Marianne Clifford Upton, Staff Director and Chief Counsel
                 Kelly O'Brien, Senator Durbin's Staff
               Andrew Richardson, Minority Staff Director
                     Julie L. Vincent, Chief Clerk



















                            C O N T E N T S

                                 ------                                
Opening statements:
                                                                   Page
    Senator Durbin...............................................     1

                               WITNESSES
                         Tuesday, May 14, 2002

Cassandra Coleman, Chicago, Illinois, accompanied by daughter, 
  Nzingha Coleman................................................     4
Dr. Elizabeth Whelan, President, American Council on Science and 
  Health, New York, New York.....................................     6
Charles King III, J.D., Ph.D., Assistant Professor, Harvard 
  Business School, Boston, Massachusetts.........................     8
Dr. Cristina Beato, Deputy Assistant Secretary for Health, U.S. 
  Department of Health and Human Services, Washington, DC........    17
Diane E. Stover, M.D., FCCP, Head, Division of General Medicine, 
  and Chief, Pulmonary Service, Memorial Sloan-Kettering Cancer 
  Center, New York, New York, on behalf of the Amrican College of 
  Chest Physicians...............................................    21
Matthew L. Myers, President, Campaign for Tobacco-Free Kids......    23

                     Alphabetical List of Witnesses

Beato, Dr. Cristina:
    Testimony....................................................    17
    Prepared statement...........................................    89
Coleman, Cassandra:
    Testimony....................................................     4
King, Charles III, J.D., Ph.D.:
    Testimony....................................................     8
    Prepared statement with an attachment........................    74
Myers, Matthew L.:
    Testimony....................................................    23
    Prepared statement...........................................   105
Stover, Diane E., M.D., FCCP:
    Testimony....................................................    21
    Prepared statement...........................................    97
Whelan, Dr. Elizabeth:
    Testimony....................................................     6
    Prepared statement with attachments..........................    33

















 TOBACCO'S DEADLY SECRET: THE IMPACT OF TOBACCO MARKETING ON WOMEN AND 
                                 GIRLS

                              ----------                              


                         TUESDAY, MAY 14, 2002

                                     U.S. Senate,  
       Oversight of Government Management, Restructuring,  
               and the District of Columbia Subcommittee,  
                  of the Committee on Governmental Affairs,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:07 a.m., in 
room SD-342, Dirksen Senate Office Building, Hon. Richard J. 
Durbin, Chairman of the Subcommittee, presiding.
    Present: Senators Durbin and Carper.
    Staff Present: Marianne Upton, Majority Staff Director; 
Kelly O'Brien, office of Senator Durbin; and Andrew Richardson, 
Minority Staff Director.

              OPENING STATEMENT OF SENATOR DURBIN

    Senator Durbin. Good morning. The hearing will come to 
order.
    I apologize for being tardy, but I was on the floor of the 
Senate making a speech, deathless prose, which you will all get 
to read in the Congressional Record at your leisure.
    I am pleased to welcome you all to today's hearing before 
the Senate Subcommittee on Oversight of Government Management, 
focusing on ``Tobacco's Deadly Secret: The Impact of Tobacco 
Marketing on Women and Girls.''
    Since 1950, there has been a 600 percent increase in 
women's death rate from lung cancer. Lung cancer is now the 
leading cause of cancer deaths among women, surpassing breast 
cancer. Cardiovascular disease is the number one killer of 
women of all ages. More women than men die of stroke. Within 
the next few years, researchers believe that more women than 
men will die from chronic obstructive pulmonary disease, COPD.
    How did we reach this point? For starters, all of these 
life-threatening conditions have one thing in common. Smoking 
is a key risk factor for developing these illnesses. And on top 
of this, the tobacco industry has been pushing this deadly 
product on women for decades. Numerous studies have documented 
that tobacco industry marketing is a key factor influencing the 
susceptibility to and initiation of smoking among girls.
    As early as the 1920's, the tobacco industry started 
targeting women, taking advantage of social trends to make 
their point. Ads have been dominated by themes of social 
desirability and of independence. They feature slim, 
attractive, athletic, and famous models. They target women from 
a variety of ethnic backgrounds. They make misleading health 
claims.
    In fact, we know that increases in smoking rates among 
women and girls can be directly linked to these slick ad 
campaigns and to historical increases in the level of 
advertising aimed at females.
    In 1968, Philip Morris launched its first woman-specific 
brand of cigarette--Virginia Slims--with its ``You've Come a 
Long Way, Baby'' campaign. Six years after the introduction of 
Virginia Slims and other brands aimed at women, the smoking 
initiation rate of 12-year-old girls had increased by 110 
percent. And now Virginia Slims has launched a new slogan: 
``Find Your Voice.''
    Today, after decades of targeting lite and low-tar brands 
to women, women are more likely than their male counterparts to 
smoke lite and ultra-lite cigarettes, and women are more likely 
than men to switch to these cigarettes.
    We are here to counter years of marketing that have 
resulted in addicting generations of women with the facts about 
the epidemic of smoking-related disease among women. The 
cigarette companies continue to target women using the same 
themes in their advertising. New products are picking up where 
lite and low-tar left off. The image of smoking being tied to 
independence, weight control, sophistication, and power 
continues in many popular women's magazines.
    Unfortunately, still far too few voices are countering the 
messages these ads send and still fail to inform women of 
health risks of smoking. It has been shown that the number of 
tobacco ads in magazines compared to the number of articles 
about health risks and smoking has been astonishingly 
disproportionate.
    Recently, some companies have reduced their magazine 
advertising budgets, yet advertising and marketing directed at 
women and kids remains very high. The industry continues to 
sponsor and support women's professional and leadership 
organizations, domestic violence programs, and the arts. This 
attempt of the tobacco industry to position itself as an ally 
of women should not silence the critics. We need to do more to 
set the record straight.
    One place we can start is magazines, where many women get 
their health information. Just open a popular women's 
magazine--this one is called First For Women--and try to find 
an article about the dangers of smoking--or, worse yet, note 
the articles that actually do talk about women's health risks 
and see if they mention smoking as a contributing factor.
    In this women's magazine called First For Women, the 
February 11, 2002 issue, this page talks about ``Five Ways to 
Cut Your Risk of Stroke.'' They list: ``eat more veggies; 
prevent fluid retention; drink moderately; get more calcium; 
and take vitamin C.''
    Is there something missing from this list? Not one of these 
listed causes has anything to do with tobacco or smoking, 
despite the fact that cigarette smoking is the key preventable 
risk factor for stroke.
    We have a fact sheet here that was issued by Family 
Physicians, in which they talk about the risk factors for 
stroke. Compare it to the women's magazine. Instead of veggies, 
fluids, vitamin C, and calcium, they talk about diabetes, high 
blood pressure, high cholesterol, smoking, heart disease, and a 
variety of other specific medical problems.
    Is this just a coincidence that this women's magazine would 
not even mention not smoking as one of the things you can do to 
avoid stroke?
    Incidentally, this same magazine has a very nice ad on the 
back for Doral cigarettes, showing a very sophisticated woman 
in a leopard suit.
    Perhaps as a result of this shortage of articles covering 
the health risks of smoking, women do not have the facts about 
the health threats they face and the ways to prevent them. Just 
last year, a survey found that only 13 percent of women were 
aware that lung cancer is responsible for the major of cancer 
deaths among women. Last Sunday in Chicago and across the 
United States, we had the ``Why Me Run.'' And thank goodness--
had a great organization, focusing on breast cancer. I have so 
many friends who are involved in this, and they come forward 
every year to focus on this tragedy, this scourge of breast 
cancer across America.
    Yet I am certain that you could stop virtually anybody 
involved in that effort and ask them point blank, what is the 
No. 1 leading cancer cause of death among women in America, and 
they would get it wrong. It is lung cancer. Sadly, it is lung 
cancer. And it is because women's magazines and other sources 
of information for women just have not delivered this message.
    Another survey revealed that women lack understanding of 
the dangers of heart disease and stroke. Only 8 percent of 
women in America believe that heart disease and stroke are the 
greatest health threats to women.
    This lack of understanding about the serious health threats 
facing women needs to be overcome if we are to reduce the 
burden of these diseases. Approximately 22 percent of American 
women and at least 1.5 million adolescent girls still smoke, 
with prevalence ranking highest among American Indian and 
Alaskan Native women. Smoking among girls actually increased in 
the 1990's, increasing from 27 percent in 1991 to 34.9 percent 
in 1999. And despite increased knowledge of the adverse health 
effects of smoking during pregnancy, estimates of women smoking 
during pregnancy currently range from 12.9 percent to as high 
as 22 percent. This has to stop. We need to do more.
    We need to provide women with accurate information about 
the health risks of tobacco. We need to ensure that the FDA has 
the power it needs to regulate ads that make unfounded health 
claims and ads that target kids. We need to make more resources 
available to help addicted women quit. Smoking cessation 
programs must be more accessible and affordable.
    I hope that this hearing will be a wake-up call. I was told 
that a hearing focusing the smoking-related health epidemic 
among women would not get much attention from the media. That 
alone is a perfect example of why we are watching lung cancer 
rates among women on the rise.
    I challenge the media and magazines across America to talk 
straight with American women about this issue and to print the 
real truth: Smoking is killing women.
    I would like to welcome our first panel of witnesses. 
Cassandra Coleman, of Chicago, along with her daughter Nzingha 
are here. I want to thank you especially for making the trip to 
Washington.
    You may see in the back that there is a wall entitled 
``Their Story.'' This wall was created by the National 
Coalition for Women Against Tobacco. It was designed as a 
documentary for the real consequences of tobacco use for women. 
The wall will be in Illinois on June 5, and Ms. Coleman has 
volunteered to participate in the project. Your courage will 
certainly help others.
    Nzingha, you are welcome to come up and join your mom at 
the table.
    Dr. Elizabeth Whelan, of the American Council on Science 
and Health, is here, as well as Dr. Charles King, of the 
Graduate School of Business at Harvard University.
    I thank you all for coming. We are looking forward to your 
testimony this morning.
    It is customary in this Subcommittee--in fact, it seems to 
be the rule--that we swear in all the witnesses. Therefore, if 
I could ask you to please stand and raise your right hands.
    Do you swear the testimony you are about to give before 
this Subcommittee is the truth, the whole truth, and nothing 
but the truth, so help you, God?
    Ms. Coleman. I do.
    Miss Coleman. I do.
    Ms. Whelan. I do.
    Mr. King. I do.
    Senator Durbin. Thank you.
    Let the record note that the witnesses, including Nzingha, 
have answered in the affirmative.
    I would like to ask you if you would now make an opening 
oral statement, and if you could limit it to around 5 minutes, 
your entire written statement will be made part of the record, 
and we may have a few questions to follow from there.
    Ms. Coleman, would you like to start?

TESTIMONY OF CASSANDRA COLEMAN, CHICAGO, ILLINOIS, ACCOMPANIED 
                  BY DAUGHTER, NZINGHA COLEMAN

    Ms. Coleman. Yes. Good morning, Chairman Durbin and Members 
of the Subcommittee.
    Let me begin by thanking you for holding this hearing and 
for inviting me to testify here today.
    My story is also the story of two wonderful children--my 
13-year-old son Nijell, and my 10-year-old daughter Nzingha, 
who is with me today.
    My son's name means ``success'' in Swahili, and Nzingha is 
named for a 16th century African queen who fought with strength 
and courage to free her people from the slave trade. I never 
realized how well I had named them until they helped me to stop 
smoking, because Nzingha and Nijell truly helped me quit 
smoking and helped free me from the addiction to nicotine.
    Growing up as a young girl in Chicago, most of the women 
around me smoked. One of my role models was my sister-in-law, a 
tall, beautiful woman with long hair. She smoked, and she was 
gorgeous. I remember thinking that I wanted to be just like 
her.
    I also remember watching television with my friends and 
seeing all the sophisticated and sexy ladies on my favorite 
programs; they all smoked, too. So everyone seemed to be 
smoking cigarettes, and I could not wait to try them.
    I was about 11 years old when I started smoking. My friends 
and I would buy cigarettes from the vending machines. In those 
days, a pack of cigarettes cost 50 cents. If anyone asked us 
what we were doing, we just said we were buying them for our 
parents.
    I had problems carrying Nzingha when I was pregnant with 
her, and she was born 5 weeks early. She had a low resting 
heart rate and other problems that placed her in the intensive 
care unit after her birth for 3 days. I remember seeing her 
with so many tubes running into her tiny body. It reminded me 
of a poster I had seen at Cook County Hospital just 4 days 
before her birth; it warned pregnant women what smoking could 
do to their children, and there was a picture of a little baby 
with all kinds of tubes, just like the ones in my daughter.
    Nzingha got out of the hospital and came home, but I kept 
smoking.
    In the months that followed, I had to take her to the 
emergency room over and over with breathing problems. The 
doctors told me she had upper airway disease. By the time she 
was 6 months old, she was getting nebulizer treatments four 
times a day.
    This went on year after year, and the doctors told me to 
quit smoking, but I kept on smoking.
    When Nzingha was almost 4, I took her to the emergency room 
with an especially bad asthma attack. They told me that her 
condition was so bad that if I had arrived just 5 minutes 
later, she probably would have died. A nurse pulled me aside 
and told me, ``You are killing her with your cigarettes.'' But 
I kept on smoking.
    Instead of quitting, I put air cleaning machines around my 
house and started smoking in the bathroom to try and keep the 
smoke away from my kids. But that did not help much. When 
Nijell was about 8 years old, he developed asthma and joined 
his sister in getting regular nebulizer treatments.
    And me? I just kept on smoking.
    Then, a couple of years ago, I began to have breathing 
problems of my own. I constantly felt weak, low on energy, 
short of breath, and I developed a cough that made me feel like 
there was always something in my lungs. When I went to get 
checked out, the medical people could never find anything 
really wrong with me. They would just tell me to slow down with 
my smoking. I remember one of the doctors found out how much I 
smoked and asked me, ``Do you want to live or die?''
    Well, of course, I wanted to live, but I also wanted to 
keep on smoking. So I did.
    And I continued to feel worse and worse. Finally, in 
January of last year, I was coming out of the bathroom after 
having a cigarette when I saw my daughter curled up on her bed, 
crying. When I asked her what was wrong, she said, ``Get away 
from me. You stink. You are trying to kill me with 
cigarettes.''
    Imagine hearing that from your own child. I promised her 
and myself then and there that I would quit smoking--and I knew 
I needed help. I called Cook County Hospital and made an 
appointment for the smoking cessation program. I went the next 
week--and I was motivated. I kept seeing Nzingha's face, and I 
knew I had to do it for her and for Nijell.
    I had the help of a wonderful doctor, Dr. Arthur Hoffman, 
who worked with me and taught me breathing techniques. He 
taught me how to relax and how to resist the urge to smoke.
    It was not easy, but I did it. I quit, cold turkey. I am 
proud to tell you that after 25 years of smoking two packs of 
cigarettes a day, I have not had a cigarette in a year, and I 
am never going to have one again.
    I am now working part-time in the smoking cessation program 
at Cook County Hospital, trying to help others quit. I cannot 
tell you how much better I feel every day. I had gotten to the 
point where I could not even walk up the steps to my house 
without difficulty. Now I can almost run up those steps. I 
walk, I exercise more, and I do not have coughs and colds like 
I used to.
    My children could not be happier. Nijell and Nzingha are 
doing so much better, and we have not been to the emergency 
room in over a year. And because I have quit, the rest of my 
life is going to be a lot longer than it would have been. That 
means more years raising and loving my children, and more years 
that I can help other women and girls avoid my mistakes.
    We have to help the women, but it is the girls we really 
have to talk to. I tell as many girls as I can that smoking is 
a nasty and dangerous habit, and I tell them how hard it is to 
quit. Sometimes in the smoking cessation program, I talk to 
people who have abused hard drugs, and they have told me that 
it is easier to kick a heroin or a cocaine habit than it is to 
quit smoking cigarettes.
    I also feel that young women need to resist the messages we 
get every day about smoking from the media; whether it is a 
soap opera or a magazine ad, images that make cigarettes seem 
attractive only lead women to an early grave.
    Again, Mr. Chairman, I would like to thank you for this 
opportunity to tell you my story. I hope that together, we can 
prevent many more women from becoming victims of tobacco.
    Senator Durbin. Thank you--really--thank you for coming. I 
will have some questions for you, and I will have a question or 
two for your daughter, too.
    Dr. Whelan.

 TESTIMONY OF DR. ELIZABETH M. WHELAN,\1\ PRESIDENT, AMERICAN 
       COUNCIL ON SCIENCE AND HEALTH, NEW YORK, NEW YORK

    Dr. Whelan. Good morning. I am Elizabeth Whelan, and I am 
president of the American Council on Science and Health, which 
is a consumer education and advocacy group in New York City. My 
background includes master's and doctoral degrees in 
epidemiology and public health from the Harvard School of 
Public Health and the Yale School of Medicine.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Whelan with attachments appears 
in the Appendix on page 33.
---------------------------------------------------------------------------
    I really appreciate the opportunity to address this 
critical issue here today, related to women's magazines and 
their dubious record in reporting on the dangers of cigarette 
smoking.
    Back in the mid-1970's, I began regularly contributing 
health-related articles to the popular magazines. Since 
cigarette smoking was then and is now the leading preventable 
cause of death in the United States, I necessarily had to 
include many references to smoking in my articles.
    I was astonished, at least at first, that my articles were 
regularly edited, and that the pejorative references to smoking 
were taken out. Sometimes the articles were simply spiked. For 
example, on one occasion, I was assigned a piece called 
``Protect Your Man from Cancer.'' Of course, I focused on the 
role of smoking in the causation of lung, bladder, pancreatic, 
oral, and esophageal cancers.
    The piece was returned to me with full payment, noting that 
there were too many ads in the magazine that month to run such 
a piece.
    With this personal experience on the difficulty of placing 
anti-smoking messages, I decided to take a very close 
quantitative look at the extent of coverage--or the lack 
thereof--of cigarette-related issues in these women's 
magazines.
    The first survey that my organization did was published in 
the early 1980's. We examined health-related articles in 18 
magazines dating back to 1965 and found that although the 
magazines covered an array of health-related issues, there was 
a near complete lack of coverage of smoking and health in most 
of the magazines. Only one-third of the magazines--the ones 
that did not take cigarette ads--covered this topic; the 
majority failed to mention the facts at all.
    This was happening at a time when there was an explosion of 
information in the medical literature about the dangers of 
smoking, so this finding was particularly disturbing.
    Following that, we did surveys in the 1980's and 1990's, 
and they only reinforced our findings. Incredibly, while 
ignoring cigarettes as a health risk, these magazines regularly 
warned women about remote or purely hypothetical risks such as 
reducing your risk of cancer by keeping your alarm clock 3 to 5 
feet from your bed so you are not exposed to the 
electromagnetic field, or they would warn us about the health 
risks of lead wrappers on wine bottles--but nothing about 
smoking.
    Surveys between 1997 and 2000 showed that there was a 
gradual improvement, but still relatively little coverage of 
smoking and health.
    In 1997, ACSH found that cigarette ads outweighed anti-
smoking ads 6 to 1. In 1998, the ratio doubled to 11 to 1. In 
2000, even with the addition of some anti-tobacco ads, the 
ratio of cigarette ads to anti-smoking messages was 10 to 1.
    In the year 2000, there were some 2,400 health-related 
articles published; cigarette smoking and health represented 1 
percent of that total.
    These magazines are guilty both of omission and commission. 
What I mean by that is they do not cover cigarette-related 
diseases in general. But in terms of commission, they edit out 
cigarette smoking mentions where it would otherwise typically 
be. For example, Glamour's list of ``Eight Simple Health 
Savers'' would include advice about taking calcium supplements 
and working out, but no mention of smoking. Elle's ``New Year's 
Resolutions'' made no mention of it, either.
    Our last survey was in the year 2000, a year that marked 
the beginning of the American Legacy anti-smoking ads and the 
withdrawal by Philip Morris of cigarette ads from some 41 
magazines. It will be interesting to see how these changes in 
advertising affect editorial content. There is reason to 
believe that things may improve. For example, just looking at 
the 2002 issue of Self Magazine, it contains a two-full-page 
article on smoking cessation.
    But we should keep in mind also that the presence of 
cigarette ads is just one factor--although an important one--in 
explaining why magazines have not covered cigarette hazards 
extensively. The topic of cigarette-related disease is a real 
downer, and these magazines seek to entertain.
    In conclusion, while the coverage may be improving--and 
this is yet to be seen--we must recall the astounding blackout 
on coverage demonstrated in our surveys between 1965 and 2000. 
Women who today are in their mid-fifties are being diagnosed 
with lung cancer, emphysema, and more, caused by cigarette 
smoking. These are the same women who were reading magazines in 
the 1960's and 1970's, magazines which withheld and distorted 
the health risks of smoking while using their pages to promote 
cigarettes as glamorous, sexy, and yes, even safe. Thank you.
    Senator Durbin. Thank you, Dr. Whelan. Dr. King.

   TESTIMONY OF CHARLES KING III, J.D., Ph.D.,\1\ ASSISTANT 
   PROFESSOR, HARVARD BUSINESS SCHOOL, BOSTON, MASSACHUSETTS

    Mr. King. Mr. Chairman, distinguished Members of the 
Subcommittee, my name is Charles King. I am an Assistant 
Professor at the Harvard Business School, and I am here today 
to talk about cigarette advertising to children.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. King with an attachment appears 
in the Appendix on page 74.
---------------------------------------------------------------------------
    Cigarette smoking is the leading cause of preventable death 
in the United States. Reducing smoking among adolescents is 
therefore a public health priority.
    According to the Centers for Disease Control and 
Prevention, (1) approximately 80 percent of adult smokers 
started smoking before the age of 18; (2) every day, nearly 
5,000 young people under the age of 18 try their first 
cigarette; and (3) more than 6.4 million children living today 
will die prematurely because of a decision they will make as 
adolescents--the decision to start smoking cigarettes.
    In 1998, the attorneys general of 46 States signed a Master 
Settlement Agreement with the four largest tobacco companies in 
the United States. The agreement prohibits tobacco advertising 
that targets people younger than 18 years of age. Last year, 
Dr. Michael Siegel of the Boston University School of Public 
Health and I published a study in the New England Journal of 
Medicine analyzing the effect of the Master Settlement 
Agreement on the exposure of young people 12 to 17 years of age 
to cigarette advertising in magazines. Our analysis was based 
on magazine advertising before and after the tobacco settlement 
by 15 major cigarette brands in 38 leading national magazines.
    What we found was disheartening. The Master Settlement 
Agreement appears to have had little effect on cigarette 
advertising in magazines and on the potential exposure of young 
people to these advertisements in the 2 years after it was 
signed.
    Our study showed that nearly all cigarette brands in our 
sample reached large numbers of young people in the United 
States with their magazine advertisements. ``Reach'' is a 
standard measure of audience penetration used in media planning 
and buying. It represents the percentage of a particular 
population that has at least one opportunity to see an 
advertisement in a magazine, not the percentage that actually 
does see the advertisement.
    Two years after the settlement, 11 of the 15 cigarette 
brands studied still reached more than two-thirds of all young 
people.
    Could I have Figure 1, please? Thank you.
    Comparing the reach of the three cigarette brands most 
popular among young people--Marlboro, Newport, and Camel--with 
the 12 other brands in our study, we found that on average, 
these three brands reached a significantly larger percentage of 
young people.
    Figure 1 presents the trends in the average proportion of 
young people reached by magazine advertisement for the three 
cigarette brands most popular among young people and the 12 
other brands from 1995 to 2000.
    In the 2 years after the settlement, Marlboro, Newport, and 
Camel on average continued to reach more than 80 percent, or 
18.4 million young people.
    We also found that the three brands most popular among 
young people consistently devoted a larger share of their 
magazine advertising budgets to youth-oriented magazines. For 
the purpose of our analysis, we defined ``youth-oriented 
magazines'' as those with more than 15 percent young readers or 
more than 2 million young readers.
    Could I have Figure 2, please? Thank you.
    Figure 2 presents the trends in the proportions of 
expenditures for magazine advertising of the three most popular 
brands and of the other cigarette brands that were allocated to 
youth-oriented magazines for 1995 to 2000.
    During the 2 years following the Master Settlement 
Agreement, Marlboro, Newport, and Camel continued to devote 
most of their advertising dollars to advertising in youth-
oriented magazines.
    For the 15 brands of cigarettes studied, overall 
expenditures for advertising in the 38 magazines studied 
actually rose 33 percent in 1999--the first year after the 
settlement was signed--to their highest levels during 1995 to 
2000.
    Despite reductions in expenditures for cigarette 
advertising in youth-oriented magazines in the second year 
after the settlement, the overall level of exposure for young 
people to this advertising remained high.
    The decline in advertising in youth-oriented magazines in 
2000 reflects in part Philip Morris' decision to discontinue 
advertising in youth-oriented magazines starting in September 
2000. Brown and Williamson also reduced its level of 
advertising in magazines with a high proportion of youth 
readers, but neither RJR Reynolds nor Lorillard substantially 
changed its level of advertising in youth-oriented magazines 
during the first 2 years after the settlement. Last month, a 
California superior court began hearing a lawsuit alleging that 
RJR Reynolds had violated the Master Settlement Agreement by 
targeting young people with its advertising.
    The voluntary policy adopted by Philip Morris does not 
appear adequate to protect young people from substantial 
exposure to cigarette advertising in magazines. If Philip 
Morris had eliminated youth-oriented magazines for all of 2000, 
we estimated that Marlboro would still have reached more than 
57 percent of young people, or 13.1 million young people, with 
its magazine advertising.
    Finally, magazine advertising remains but one small part--
4.6 percent--of the tobacco industry's total marketing 
expenditures of $8.2 billion in 1999. Other marketing tools 
include coupons, direct mail, internet advertising, newspaper 
advertising, point-of-sale advertising, promotional allowances 
to retailers, sponsorship of public entertainment, retail 
value-added programs (such as buy-one-get-one-free), the 
distribution of samples and the distribution of specialty 
items.
    Many of these promotional techniques have previously been 
found to have great appeal for young people. Yet most of them 
are neither measured nor monitored outside the tobacco 
companies. This makes the Master Settlement Agreement's 
prohibition against targeting young people difficult to 
enforce.
    No effort to reduce smoking among young people will succeed 
without a complete understanding of the entire marketing mix 
available to tobacco companies and the ability to monitor it.
    I would like to conclude with three main points. One, the 
goal of the national tobacco settlement to reduce the exposure 
of young people to tobacco marketing has not been met. Two, 
although the settlement explicitly prohibits targeting youth, 
young persons continue to be bombarded by cigarette advertising 
in magazines. And three, magazine advertising represents less 
than 5 percent of the total marketing and promotional 
expenditures of tobacco companies. Yet most of the other 95 
percent, which can also be directed at children, is not 
monitored.
    Thank you, Mr. Chairman, for this opportunity.
    Senator Durbin. Thanks, Dr. King. I appreciate it. Let me 
ask a few questions if I can.
    Could I start with you, Nzingha? Would you mind if I asked 
you a question or two?
    Could you tell me how old you are?
    Miss Coleman. Ten.
    Senator Durbin. And where do you go to school?
    Miss Coleman. Thomas Jefferson Elementary School.
    Senator Durbin. And where is that located?
    Miss Coleman. In Chicago.
    Senator Durbin. South Side, West Side, North Side?
    Miss Coleman. West side.
    Senator Durbin. OK. So you are 10 years old--would that put 
you in the fourth grade?
    Miss Coleman. Yes.
    Senator Durbin. A pretty good guess.
    Do any of your fellow students at school smoke now?
    Miss Coleman. Yes.
    Senator Durbin. How many do you think?
    Miss Coleman. I know there are two in my class who smoke--
--
    Senator Durbin. You are not going to get them in trouble--
just give us the numbers.
    Miss Coleman. There are two people in my class who smoke.
    Senator Durbin. Two people who smoke in the fourth grade.
    Were they smoking in the third grade?
    Miss Coleman. Yes.
    Senator Durbin. In the second grade?
    Miss Coleman. Yes.
    Senator Durbin. When did they start smoking?
    Miss Coleman. I would say when we were in first grade.
    Senator Durbin. In first grade they started smoking, and 
they are still smoking. Are they boys or girls?
    Miss Coleman. Boys.
    Senator Durbin. Boys in this situation.
    Do they ever talk to you at school about smoking and 
tobacco and how dangerous it is?
    Miss Coleman. Are you talking about the teachers?
    Senator Durbin. Yes.
    Miss Coleman. Yes.
    Senator Durbin. They do. OK. And do you think they tell a 
pretty good story about the danger of tobacco?
    Miss Coleman. Yes.
    Senator Durbin. How many of your fellow students in your 
class do you think have problems with asthma?
    Miss Coleman. Me and this other boy, Martel.
    Senator Durbin. And how big is your class--how many 
students?
    Miss Coleman. I would say about 20.
    Senator Durbin. OK. I learned when I went to the University 
of Chicago Hospital a few years ago that the No. 1 diagnosis 
for children in emergency rooms is asthma, which I did not know 
and have since learned.
    So as you have been growing up, you have been aware of the 
problem that tobacco smoking can create for children with 
asthma; is that right?
    Miss Coleman. Yes.
    Senator Durbin. OK. Do you realize what a big role you 
played in your mom's important decision?
    Miss Coleman. Yes.
    Senator Durbin. You should be very proud that you gave your 
mother the will to go through this very difficult change in her 
life.
    Miss Coleman. I am very proud that my mom quit smoking.
    Senator Durbin. You should be.
    Ms. Coleman, it is a tough addiction. You have talked 
about, and I have seen it in my family, up close, and I realize 
just how painful it is to go through it, but it takes that one 
event, that one thing that just scares you into quitting. For 
one of my parents, it was a diagnosis of lung cancer, and it 
was too late. But you were fortunate in that Nzingha got you to 
the point where you could change.
    Ms. Coleman. Yes.
    Senator Durbin. And you now work at the cessation clinic?
    Ms. Coleman. Yes. I have been there since May of last year, 
and I have another month. I am working on a grant right now, 
and the grant will be running out.
    Senator Durbin. How many clients participate in the smoking 
cessation program?
    Ms. Coleman. I would say that we make appointments for at 
least 50 new people a month; at least 50 people a month come in 
to get help for smoking.
    Senator Durbin. And how do they find the program?
    Ms. Coleman. From advertising; a lot of the pharmacists at 
Walgreen's let them know about the program; and basically, 
word-of-mouth.
    Senator Durbin. You must hear a lot of stories about 
women--and men, too, for that matter--who have gone through the 
kind of experience you have where they make this decision. What 
can you tell us about their experiences?
    Ms. Coleman. I just recently met a young man, 33 years old, 
who had had three heart attacks, and they were all due to 
smoking. He never drank, never did drugs, he worked out--
everything. It was from smoking.
    Since I have been there, I have also met a young lady, 32 
years old, who has had three open heart surgeries, and they all 
extended from smoking. She told me she was 27 years old when 
she had her first heart attack.
    I meet a lot of people with lung cancer.
    Senator Durbin. Could I ask your daughter one last 
question?
    Nzingha, do you ever go to the movies?
    Miss Coleman. Yes.
    Senator Durbin. Do you ever notice some of the actors 
smoking in those movies?
    Miss Coleman. Yes.
    Senator Durbin. I have noticed a lot of that, too. What do 
you think about that?
    Miss Coleman. I think it is making more people smoke.
    Senator Durbin. It kind of makes it look more glamorous, 
doesn't it?
    Miss Coleman. Yes.
    Senator Durbin. I think that was what your mom was saying 
earlier, that when she got started, she thought it was a 
glamorous thing to do.
    Thank you for being here. We appreciate it very much.
    Miss Coleman. You are welcome.
    Senator Durbin. Dr. Whelan, your surveys have been going on 
for a few years, and you have seen some changes. In fact, some 
magazines that were the bad actors in days gone by have started 
to change their policies in terms of the advertising and also 
in terms of the articles that they publish concerning lung 
cancer. What do you think is bringing this about?
    Dr. Whelan. Well, I think that bringing attention to the 
paucity of coverage over the years has quite frankly 
embarrassed them. I think more and more readers are bringing 
this to their attention.
    This is a very tricky issue in the sense that I think we 
have to separate what I call the omission versus the 
commission. Starting with the commission, what is most 
egregious is the example like the one you just gave about 
stroke, where they take on a health issue, they choose to take 
it on, and then they absolutely misrepresent the role of 
smoking. They can do an article on 100 ways to live a long and 
healthy life, and there will be no mention of smoking. I think 
this has become quite intolerable, and hopefully, we will see 
less of those.
    The second topic, though, is the omission of articles on 
cigarette-related disease. This is going to be trickier 
because, No. 1, the magazines are under no obligation to cover 
this topic. On the other hand, given that they have chosen to 
cover all topics, it seems odd that they are leaving this out. 
But the question they will ask, and they have asked me, is how 
much is enough. They say that we assume our readers are 
intelligent adults and know the dangers of smoking, and we do 
not want to be their nanny.
    So we need to find a balance here, but the most important 
thing is I think they learned their lesson about omitting 
references to smoking when it is glaringly obvious that they 
should be there.
    Senator Durbin. I mentioned earlier, and I want to make 
sure it is clear for the record--I was comparing breast cancer 
and lung cancer. It is my understanding that breast cancer is 
the most prevalent cancer among women, but lung cancer is the 
most prevalent cause of cancer deaths among women. So both are 
extremely serious, and I don't want to diminish one for the 
other; they both should be focused on.
    But let me ask you a question relative to that. Do you find 
these same women's magazines writing more articles about breast 
cancer than lung cancer?
    Dr. Whelan. Oh, definitely. The ratio is probably 10 or 15 
to 1 the coverage of breast cancer over lung cancer. But that 
is true in many aspects of disease prevention in terms of the 
marches that you mentioned, the campaigns. They are focused on 
breast cancer or women's cancers, which by their definition 
means ovarian and breast cancer.
    Lung cancer, as you correctly pointed out, is definitely a 
woman's cancer and deserves that attention. It is the No. 1 
leading cause of cancer death in American women.
    Senator Durbin. I am trying to draw a conclusion here as to 
why they reach this point in their policy about health 
articles, and certainly, it appears that money had something to 
do with it at some point when ad revenue may have been 
jeopardized by articles about lung cancer among women. But is 
it also a situation that, when you are talking about lung 
cancer, you are talking about changing your personal life 
style, that is the kind of scolding or nagging part that they 
do not want to engage in, as opposed to breast cancer where, 
sadly, we are still stretching and looking for connections 
between environment and life style that might lead to breast 
cancer?
    Dr. Whelan. Yes. First of all, there is no doubt in my mind 
that the cigarette advertisements play a major role in the 
failure to cover this topic over the last 50 years. This was 
clear when we looked at magazines that did not take cigarette 
ads. Reader's Digest comes to mind right away; they took a 
leadership role beginning in 1952, bringing these facts to 
their readers.
    But beyond the revenue, which plays a major role, is that 
so-called nanny factor, that magazines do not want to take on 
this nagging kind of role. And certainly, lung cancer is 
perceived and should be perceived as largely self-induced 
through smoking morbidity, and it is something that they have 
difficulty covering.
    Senator Durbin. How can we influence magazine editors to 
tell the whole story?
    Dr. Whelan. They are doing that now. We are influencing 
them. The American Council on Science and Health surveys have 
influenced them for over 20 years. They are well aware that we 
are watching and counting and looking, and I think that type of 
putting a light on it is the way that we have to do this. But I 
think the magazine editors are focusing on the reality that 
there is something enormously inconsistent about taking on the 
role of providing health information and telling your 
constituency that you are dedicated to helping them have good 
health and then to fill your magazine with advertisements for 
the leading cause of preventable death. There is a disconnect 
there, and I think they realize that.
    Senator Durbin. Can you give us a list of the good 
magazines when it comes to these issues and those that have a 
bad record?
    Dr. Whelan. It is really hard to do that other than to list 
magazines like Good Housekeeping or Reader's Digest, which are 
magazines that do not take cigarette ads. It is difficult 
because it changes from year to year.
    Self Magazine, for example, has generally covered more 
smoking-related issues than have, for example, Vogue or Glamour 
or Harper's Bazaar, but again, there is variation.
    Senator Durbin. We are going to have testimony later from 
Dr. Beato from the Department of Health and Human Services that 
smoking prevalence is higher among women living below the 
poverty line--nearly 30 percent of those women smoke--but level 
of education also plays a key role here.
    In your magazine research, have you ever examined the 
readership of women's magazines to determine more specifically 
which populations they reach?
    Dr. Whelan. We have not done so by poverty or income level, 
but only in terms of demographics. These magazines are very 
much targeted toward a young audience, and we can see from the 
models that the young women are the target of the ads. Middle-
aged women, sadly, are addicted and perhaps do not need as much 
advertising to keep them smoking.
    Senator Durbin. Most of these magazines have websites. If 
some of those who are following this hearing or this issue 
wanted to send email messages to the magazine editors, asking 
why they have not written more articles about the No. 1 cause 
of cancer death among women--lung cancer--do you think that 
might have an impact?
    Dr. Whelan. It will have an enormous impact. Even one 
letter, the editors have told me, catches their attention; five 
letters causes a meeting. Definitely I would encourage people 
to go to the websites and express this view. We just want the 
facts, that is all.
    Senator Durbin. That is a good point, and maybe if there is 
something positive I can recommend to the CSPAN viewers who are 
watching this, it is if you have a favorite magazine, and you 
have not seen an article in it about cancer and women that you 
can remember, get on the website and send a letter to the 
editor of that magazine. I might recommend that.
    We are going to have to recess so I can go vote on the 
floor. I am sorry that I am going to have to step away probably 
for about 10 or 15 minutes, so we will stand in recess until I 
return.
    Thank you.
    [Recess.]
    Senator Durbin. The Subcommittee hearing will resume. My 
apologies for the vote on the floor, but I made it.
    Dr. Whelan, we were just talking about magazine websites. 
If the readers have a concern about the issue that we are 
discussing at this hearing, whether the magazine that they are 
subscribing to is covering in a fair and comprehensive way the 
cancer threats to women and whether it has enough focus on 
smoking and lung cancer, that the readers should get on the 
website to the magazine and send an email to the editor. I 
agree with you completely. As you said, one gets their 
attention, five calls for a meeting, so 10 may change editorial 
policy. So let us make a point of recommending that to those 
who are following this.
    Dr. Whelan. We encourage that.
    Senator Durbin. Definitely. Thank you.
    Dr. King, let me thank you for your testimony. Your study 
shows that even though some adult magazines may not have much 
of a youth readership, their advertising reach was significant 
enough to expose a large number of young people to tobacco ads 
that they carried. Give me an example of the kind of magazine 
you are talking about.
    Mr. King. We classify magazines like Cosmopolitan and 
Glamour, for example, as being adult-oriented magazines because 
they fail the 15 percent/2 million rule. But if you look at the 
number of young readers that those magazines have, Glamour has 
1.95 million young readers, and Cosmopolitan has 1.79 million 
young readers. Although they are adult magazines, those numbers 
are much larger than the absolute numbers of young readers that 
we find in all of the youth-oriented magazines that we include. 
Elle, Mademoiselle, and Vogue all have fewer absolute numbers 
of youth readers.
    So many of what we classify as adult-oriented magazines in 
fact, because of their large subscription base and large 
readership, have, although a much smaller percentage of young 
readers, much larger numbers in absolute terms.
    Senator Durbin. Is it accurate to say that according to 
your findings, some of the most significant expenditures for 
tobacco advertising of youth brands took place among women's 
magazines?
    Mr. King. Certainly the women's magazines represent a 
significant amount of advertising, particularly if you are 
concerned with exposure to young women, because these are 
magazines that are targeted. I am sure that not many women read 
Hot Rod, and I am also sure that not many young men read 
Mademoiselle and Elle--although, of course, there will be a few 
exceptions.
    So in terms of exposure to young women, these are magazines 
of particular interest.
    Senator Durbin. Is it accurate to say that since the Master 
Settlement Agreement, magazine advertising expenditures for 
youth brands of cigarettes have actually risen in both adult- 
and youth-oriented magazines?
    Mr. King. Yes. We found that for the three brands most 
popular among young people--Marlboro, Newport, and Camel--that 
in the 2 years following the settlement, their advertising 
expenditures in both the adult-oriented magazines and the 
youth-oriented magazines increased over the levels prior to the 
settlement.
    Senator Durbin. And what do you infer from this finding?
    Mr. King. I infer from this finding that the Master 
Settlement Agreement has not met its goal of reducing exposure 
to adolescents and children.
    Senator Durbin. Are the tobacco companies spreading 
themselves thinner but wider in their effort to sustain their 
access to kids?
    Mr. King. I think that is a little bit difficult to tell 
from the nature of the studies such as the one we have done 
here. Remember that we only sample 38 magazines, and the 
tobacco companies typically advertise in between 100 and 150 
magazines. So we do not actually see all the magazines in our 
sample. It is certainly possible.
    Senator Durbin. Well, I thank you all for testifying. I 
particularly want to thank Ms. Coleman and her daughter 
Nzingha. When I came back into the hearing room, there was a 
lady standing outside who said, ``Nzingha Coleman stole the 
show in there,'' and that is exactly the way it should be, 
because we are talking about the impact that this advertising 
has on people your age. And again, thank you for missing a day 
of school and coming out to testify. It wasn't a bad day, was 
it?
    Miss Coleman. No.
    Senator Durbin. We are glad you could be with us today.
    Ms. Coleman, your story is an important one, and we thank 
you for sharing it with us.
    Dr. Whelan, we will continue to work with you.
    Dr. King, thank you for your analysis, too.
    Let me at this point invite the next panel to come up to 
the table.
    Dr. Cristina Beato is Deputy Assistant Secretary for 
Health, U.S. Department of Health and Human Services.
    Dr. Diane Stover is head of the Division of General 
Medicine and Chief of the Pulmonary Service at Memorial Sloan-
Kettering Cancer Center in New York City--one of the best.
    And an old friend and colleague of mine, Matt Myers, is 
president of the National Center for Tobacco-Free Kids.
    Now that you have all comfortably sat down, I am going to 
ask you to stand for the oath.
    Please raise your right hand. Do you swear that the 
testimony you are about to give to this Subcommittee is the 
truth, the whole truth, and nothing but the truth, so help you, 
God?
    Dr. Beato. Yes.
    Ms. Stover. Yes.
    Mr. Myers. I do.
    Senator Durbin. Let the record note that the witnesses 
answered in the affirmative.
    At this point, I will invite you to give your opening 
remarks. Dr. Beato, if you would proceed first.

TESTIMONY OF DR. CRISTINA BEATO,\1\ DEPUTY ASSISTANT SECRETARY 
   FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
                        WASHINGTON, DC.

    Dr. Beato. Thank you, Mr. Chairman.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Beato appears in the Appendix on 
page 89.
---------------------------------------------------------------------------
    Good morning, and thank you for inviting me to participate 
in this panel. My name is Cristina Beato, and I am the Deputy 
Assistant Secretary for Health. Before joining the Department 
of Health and Human Services, I served as the Associate Dean 
for Clinical Affairs and the Medical Director at the University 
of New Mexico Health Sciences Center.
    President Bush and Secretary Thompson have made women's 
health, prevention, and eliminating health disparities a top 
priority. As the 2001 Surgeon General's Report on Women and 
Smoking indicated, smoking-related diseases have truly become a 
women's health issue. Women who smoke are subject to all the 
same risks as men, including cancer, cardiovascular disease, 
and chronic obstructive pulmonary disease. In addition, women 
are at risk of infertility, adverse reproductive outcomes, 
altered menstrual function, lower bone density leading to 
osteoporosis, and increased fracture risk.
    As you are very well aware and have brought to our 
attention, Mr. Chairman, lung cancer surpassed breast cancer as 
the leading cancer death among women in 1987, and this is a 
totally preventable illness.
    However, we know what works to prevent initiation and 
promote cessation of smoking, and we believe that, working 
together, we can achieve the administration's goals of reducing 
the prevalence of smoking among women to 12 percent or less and 
among girls to 16 percent or less.
    We have seen some successes. The prevalence rate of smoking 
among women has declined since it peaked at 33.9 percent in 
1965. By the year 2000, smoking prevalence among women was at 
21 percent. Most of this decline occurred from the years 1974 
to 1990. While the decline slowed in the early 1990's, the 
rates have begun to decline more rapidly in recent years.
    Smoking prevalence is higher among women living below the 
poverty level--nearly 30 percent--as compared to those women 
above the poverty level--20 percent. The education level among 
women plays a key role. Among women with 9 to 10 years of 
education, there is a 31 percent prevalence; among women with 
over 16 years of education, there is only an 8 percent 
prevalence.
    Prevalence rates among racial and ethnic populations adds 
another dimension to our need to better understand women and 
smoking. In the year 2000, 42 percent of American Indian or 
Alaska Native women, 22 percent of Caucasian women, 21 percent 
of African women, 13 percent of Hispanic women, and 8 percent 
of Asian women were still current smokers.
    The prevalence rates among women are still much too high, 
but we believe that through our expertise, programs, and 
funding, we are continuing to work on lowering these rates. The 
Surgeon General's Report on Women and Smoking includes a number 
of practical recommendations that will move us toward these 
goals. Today I would like to share with you just some of the 
ongoing and planned activities at the national and state levels 
that are designed to implement these recommendations.
    Addressing the burden of tobacco within specific 
populations is essential if we are to achieve the President's 
and the Secretary's goals and eliminate the disparities that 
exist in tobacco use and tobacco-related disease. This is one 
of the reasons why the Surgeon General recommended expansion of 
the diverse constituency that is working on tobacco issues.
    Women of all ages, races, and ethnic backgrounds are 
affected by tobacco. To this end, the Department has engaged in 
collaborations with a number of nonprofit organizations through 
our Centers for Disease Control and Prevention National 
Networks Program. These networks represent priority populations 
to prevent and reduce the use of tobacco and exposure to 
secondhand smoke. These nonprofit organizations reach women and 
girls, and one organization focuses exclusively on women.
    In addition, the CDC funds seven tribal-serving 
organizations. They have been funded to begin to build capacity 
in our Native American/Alaska Native community, where the 
prevalence of tobacco use among women is the highest.
    The Surgeon General's Report on Women and Smoking states 
that success in reducing tobacco use will require 
implementation of programs that focus on prevention and 
cessation. Women who stop smoking greatly reduce their risk of 
dying prematurely, and quitting smoking is beneficial at all 
ages.
    The Task Force on Community Preventive Services provides a 
solid scientific foundation upon which to build our efforts to 
promote cessation among women. We know that women are more 
likely than men to be willing to access assistance when they 
try to quit, and that using assistance increases the likelihood 
of success. Therefore, the Department and its partners are 
working to improve the availability of cessation treatments to 
all of the women who smoke.
    Some States have developed quit lines that are designed to 
increase access and reduce the cost of cessation treatments. 
States are also taking steps to ensure that an increasing 
number of women have access to these services. Research has 
demonstrated that behavioral counseling is effective alone and 
can enhance the efficacy of pharmaceutical treatment; however, 
rates of utilization and most counseling options have been very 
low. Experience has shown us that smokers are more likely to 
use a telephone quit line than to attend classes. Telephone 
counseling is attractive because it is more accessible and also 
more private. Counseling by telephone has also been shown to 
reduce the ethnic disparities in the use of smoking cessation. 
In California, African American and Hispanic smokers are active 
participants in a statewide quit line, with the latter 
encouraged by the availability of Spanish language services and 
materials.
    Very particularly, smoking can affect a woman's ability to 
get pregnant, increasing the risk of conception delay and 
infertility. The good news is that smoking among pregnant women 
has declined 19 percent, from 89 percent to 13 percent in 1998. 
Sadly, however, 13 percent is still too many pregnant women and 
girls who continue to smoke.
    Infants born to smoking women have a lower than average 
birth weight. Women smokers are also less likely to breastfeed 
their infants. It is estimated that eliminating material 
smoking may lead to a 10 percent reduction in all infant deaths 
and a 12 percent reduction in deaths from perinatal conditions.
    Furthermore, because women are more likely to stop smoking 
during their pregnancy than at any other time in their lives, 
it is vital that we seize the opportunity to reach out to women 
during pregnancy and assist them in quitting for good.
    The age of initiation of smoking is an important indicator 
of smoking behavior. Smoking initiated at an early age 
increases the risk of smoking-related illness or death. The 
risks associated with smoking at an early age makes it 
imperative that we focus on young girls and make sure that they 
never start smoking.
    Comprehensive programming at the State level plays an 
important role in reducing smoking among women. The CDC has 
come out with ``Best Practices for Comprehensive Tobacco 
Control Programs,'' an evidence-based analysis that can help 
States determine their funding priorities, plan and execute 
effective comprehensive tobacco control and prevention 
programs.
    Following the start of the statewide tobacco control 
program in 1989, the lung cancer rate among women in California 
has declined, even though it is still increasing for the rest 
of our country. This decline underscores the importance of 
investing in tobacco control at the State level. Other States 
are seeing dramatic results as well. For example, in the State 
of Massachusetts, the rates of smoking during pregnancy have 
dropped sharply from a prevalence of 25 percent in 1990 to 13 
percent in 1996. Most of the decline occurred after 1992, when 
the Massachusetts Tobacco Control Program was implemented with 
funds from an increase of the tobacco excise tax. Nationwide 
prevalence of smoking during pregnancy declined much more 
slowly during the same period.
    Several of the Surgeon General report recommendations focus 
on increasing awareness of the health effects of tobacco on 
women and on boosting knowledge that non-smoking is the norm 
among women. Without increasing this type of awareness, we are 
unlikely to see expanded efforts that address this growing 
epidemic at either the individual or the societal levels.
    At the State and local levels, activities designed to 
promote awareness are increasing. For example, the Wisconsin 
Tobacco Control Board, drawing on the revenue from Wisconsin's 
settlement with the tobacco industry, funds the Wisconsin 
Women's Health Foundation to implement the First Breath 
Program, which offers counseling to pregnant women at regional 
prenatal care units, coordinated with the Department of 
Agriculture's Women, Infants, and Children sites. The program 
includes educational materials, information about how to use 
the telephone quit line, and opportunities for pregnant women 
to join local support groups. These program sites have been 
established in all the regions of Wisconsin, including two 
tribal clinics. These initiatives are implemented on a pilot 
basis.
    The Department continues to be a leader in tobacco counter-
marketing efforts and is pleased to have enlisted the aid of 
numerous celebrities in our counter-marketing initiatives. This 
year, we unveiled a new poster campaign featuring celebrity 
spokes-model Christy Turlington. The poster is entitled, 
``Smoking is Ugly.'' It illustrates that lung cancer kills more 
women than breast cancer, uterine cancer, and ovarian cancer 
combined.
    We are also proud of our forthcoming television public 
service campaign staring Esai Morales of NYPD Blue. This new 
initiative, which will be launched later this month, will be 
aimed at decreasing tobacco use in our Hispanic communities.
    Secretary Thompson has urged the entertainment industry to 
expand its role in discouraging women, and girls in particular, 
from smoking. In a speech before the National Council for 
Families and Television in January of this year, the Secretary 
stated: ``We need help in reaching our young women with a very 
simple message: Smoking is not glamorous, smoking is deadly, 
and we as a society must not glorify smoking--ever. The 
television industry and the Federal Government can be powerful 
partners in delivering that message to women and girls 
throughout America and around the world.''
    In conclusion, there are some exciting innovations in 
tobacco prevention and cessation that have already begun to 
reap results. However, many challenges remain. Nowhere is this 
more clear than in the area of research. The National 
Institutes of Health, and in particular the National Cancer 
Institute, are leading the research effort for the Department. 
To move the research effort forward, NCI is working with both 
public and private partners to set priorities and promote 
action on effective intervention strategies. These efforts 
include the Transdisciplinary Tobacco Use Research Centers, 
which are public-private collaborations, at seven sites around 
the country, to understand the biological, behavioral, and 
cultural factors that explain why women smoke and, most 
important, if they do, how to help them quit. In addition, we 
will encourage the reporting of gender-specific results from 
studies of factors influencing smoking behavior, smoking 
prevention and cessation interventions, and the health effects 
of tobacco use, including new products. The Surgeon General's 
report reviewed some of the literature on women and smoking, 
but there is still much more that needs to be done.
    As science advances, I think it is critical that we 
continue to address this totally preventable women's health 
issue. President Bush, Secretary Thompson, and the Department 
with all of our partners can be successful in meeting the 
challenges ahead.
    We appreciate your interest in this very serious issue, and 
we are looking forward to working with you. I would be happy to 
answer any questions.
    Senator Durbin. Thank you very much, Dr. Beato. Dr. Stover.

TESTIMONY OF DIANE E. STOVER, M.D., FCCP,\1\ HEAD, DIVISION OF 
GENERAL MEDICINE, AND CHIEF, PULMONARY SERVICE, MEMORIAL SLOAN-
 KETTERING CANCER CENTER, NEW YORK, NEW YORK, ON BEHALF OF THE 
              AMERICAN COLLEGE OF CHEST PHYSICIANS

    Dr. Stover. Mr. Chairman and Members of the Subcommittee, 
good morning.
---------------------------------------------------------------------------
    \1\ The prepared statement of Dr. Stover appears in the Appendix on 
page 97.
---------------------------------------------------------------------------
    I am pleased to have the opportunity to appear before you 
today and to address the serious threat to women's health of 
smoking and the marketing effects of the tobacco industry.
    My name is Diane Stover, and I am Chief of the Pulmonary 
Service and Head of General Medicine at Memorial Sloan-
Kettering Cancer Center in New York City. I appear before you 
today on behalf of the American College of Chest Physicians and 
its philanthropic arm, the CHEST Foundation. And I am proud 
that the College and the CHEST Foundation were able to sponsor 
Ms. Coleman and her daughter's first trip to Washington to be 
here with you today.
    Senator Durbin. Thank you for that.
    Dr. Stover. The ACCP is a 15,000-plus-member international 
and multi-specialty medical society comprised of 
pulmonologists, cardiologists, thoracic surgeons, intensivists, 
and many other members of the health care team. We are the 
physicians who treat people worldwide suffering from lung 
disorders, the majority of which are caused by tobacco use.
    As a physician working on the front lines, I have seen 
first-hand how lung cancer can ravage a life, both a man's as 
well as a woman's. The number of women we are treating is 
increasing at an alarming rate, and in fact, the saying ``Smoke 
like a man, die like a man,'' is becoming more and more of a 
reality.
    I must confess that I am here today not only as a 
professional but as a parent. Several years ago when I was 
driving my daughter to middle school, there, standing outside 
the school were many of her classmates--smoking. These were the 
same children who several years before were in grammar school, 
thought it was disgusting, and were begging their parents to 
stop.
    I knew then, not only as a physician but as a parent, that 
I had an obligation not only to my daughter and her friends but 
also to all girls and women, to educate them on the disastrous 
and devastating health impact of tobacco.
    It was at that time that the ACCP created the Task Force on 
Women, Girls, Tobacco and Lung Cancer, whose mission simply is 
to make women and girls tobacco-free worldwide.
    Smoking-related disease among women is truly a fullblown 
epidemic. As cited by the Surgeon General, smoking among high 
school girls in the 1990's increased to a high of 35 percent.
    Why should we care? Because along life's continuum, smoking 
impairs the ability of girls and women to fully realize their 
potential--in the classroom, as mothers, in the workforce, and 
at life's end.
    There is accumulating data to suggest that, cigarette-for-
cigarette, females may be more susceptible than males to the 
cancer-causing agents of tobacco, putting women at nearly twice 
the risk of men to develop lung cancer. In recent years, 
mortality among men has decreased, yet in women it continues to 
increase dramatically.
    Smoking among women and girls causes unique health problems 
and diseases throughout their lives. As you have heard, among 
adolescent girls and women who smoke, they can have reduced 
rates of lung growth; increased rates of wheezing and asthma; 
and they are more likely to have menstrual abnormalities.
    Women of childbearing age have reduced fertility, and if 
they take birth control pills, a greatly increased risk of 
heart attack and stroke, particularly if they are over the age 
of 35.
    During pregnancy, the incidence of spontaneous abortions 
and many other catastrophes are increased. The fetuses of women 
who smoke or who are exposed to secondhand smoke are more 
likely to suffer growth retardation, premature birth, 
stillbirth, and neonatal death. There are higher rates of 
sudden infant death syndrome, bronchitis, asthma, and ear 
infections in their children, as you have very well heard from 
Ms. Coleman and her daughter.
    Older women who smoke are more likely to suffer early onset 
of menopause, higher rates of osteoporosis, and an increase in 
lung cancer and many other cancers. In fact, one-third of all 
cancers are related to smoking.
    In response to this horrific epidemic, the Women's Task 
Force, with the support of the ACCP and the CHEST Foundation, 
have launched many educational initiatives. These include a 
speaker's kit which is now on CD-ROM, with an accompanying 
website which is a versatile educational tool addressing four 
key audiences: Health care professionals and lay educators, 
girls, teens, and adult women.
    We have created a Speakers Bureau of more than 400 ACCP 
members, and we have developed school-based pilot programs 
which educate kids through various methods about the dangers of 
tobacco use.
    Let me close by saying a few words about smoking cessation 
programs. These include self-help programs, behavior 
modification techniques, clinical interventions with nicotine 
and non-nicotine replacement therapy, as well as community and 
educational-based efforts.
    Although quitting on one's own is the choice made by many 
smokers--as you know it, ``cold turkey''--smoking cessation 
programs with or without nicotine replacement therapy can 
increase the success rate of smoking cessation many-fold. And 
although studies show that there are no major differences 
between men and women when it comes to the effectiveness of 
smoking cessation methods, women may have a higher relapse 
rate.
    Pregnant women who smoke offer a unique opportunity to 
emphasize the smoking cessation message since these women never 
had more frequent contact with the health care system than 
during this particular life event. The American College of 
Obstetricians and Gynecologists has advised that a five-step 
counseling session, together with pregnancy-related educational 
materials, increases success rates by 30 to 70 percent.
    But as underscored by the Surgeon General's report, there 
is a need for more research to determine the effect of nicotine 
replacement therapy on pregnant women and their offspring.
    As a physician on behalf of my patients and as a parent on 
behalf of the children, I would like to thank you for bringing 
attention to and raising awareness of this horrific epidemic of 
nicotine addiction and tobacco use--the No. 1 preventable cause 
of disease worldwide and the No. 1 cause of lung cancer in both 
men and women worldwide.
    We are hopeful that with your support and the support of 
your colleagues, we can save the one out of three children who 
start smoking today and who will die as adults sometimes 30 to 
40 years prematurely solely because they smoked.
    Thank you again for this opportunity to address this 
distinguished Subcommittee. I would be happy to answer any 
questions.
    Senator Durbin. Thanks, Dr. Stover.
    Matt Myers is President of the Campaign for Tobacco-Free 
Kids, and as long as I have been fighting this battle on 
Capitol Hill, he has been my ally and friend.
    Matt, we want to welcome you to the Subcommittee and invite 
your testimony.

   TESTIMONY OF MATTHEW L. MYERS,\1\ PRESIDENT, CAMPAIGN FOR 
                       TOBACCO-FREE KIDS

    Mr.  Myers. Thank you, Mr. Chairman.
---------------------------------------------------------------------------
    \1\ The prepared statement of Mr. Myers appears in the Appendix on 
page 105.
---------------------------------------------------------------------------
    It is a particular pleasure to be here. It is a particular 
pleasure to be here because you have been a leader as long as 
we have been working on this issue. And one of the things that 
distinguishes your leadership is that it always translates into 
action, so that we have faith that the words we speak today 
will be translated into something that will make a difference 
in people's lives.
    And Senator Carper, we are also delighted that you are 
here. You have been a long-time leader as well, first as 
Governor and then as a member of the board of the American 
Legacy Foundation. So we appreciate your interest.
    I will ask that my whole statement be put in the record and 
will instead just focus on a couple of key points since I am 
the last witness in a long hearing.
    The three points that I really would like to make are that, 
first, looking at today's marketing and advertising, despite 
the rhetoric of the tobacco industry, the problem of tobacco 
marketing targeting women is no less severe today than it has 
been in all of the historic ads that you showed, Senator 
Durbin, during your earlier presentation.
    Second, we have a potentially new and emerging crisis with 
regard to women and smoking, and that is, while women have not 
yet learned that low-tar tobacco products are not safer, the 
tobacco industry is already introducing a whole new generation 
of products that are designed to keep America's women smoking, 
because America's women switch to low-tar in much greater 
numbers than men out of a concern for their health and safety.
    Third, we need to focus on solutions, and we have solutions 
that this body can address as well as the kind of important 
voluntary solutions that we have discussed earlier in terms of 
reaching directly out to magazines and others that affect 
women, and I would like to talk about each of those.
    Let me start with today's marketing. We have heard a good 
deal of rhetoric from the tobacco industry subsequent to the 
Master Settlement Agreement that they do not want to target our 
children, that they do not want to target nonsmokers. From Dr. 
King, we have seen that the numbers do not tell the same story; 
but when you look beyond the numbers, it is even worse.
    When you look at the themes that we see in tobacco 
marketing today targeting women, they are even more offensive 
and even more blatant than those we saw before. It was after 
the Master Settlement Agreement that Philip Morris introduced 
the ``Find Your Voices'' campaign. Not only is that theme 
disturbing, its targets were disturbing. It was targeted at 
ethnic women from populations that have traditionally not 
smoked.
    Those ads were not designed to get people to switch brands; 
those ads were to reach new ethnic populations with low smoking 
rates among women and designed to get them smoking.
    When confronted with that advertising theme in a court 
case, a Philip Morris executive switched the theme, but not the 
overall message. ``Find Your Voices'' simply became ``A Voices 
Campaign.'' The message was still designed to associate smoking 
with freedom, independence, and the types of themes that 
emerging populations would care about most.
    Second, we wish that the move of the tobacco manufacturers 
out of magazines represented a real decline in their targeting 
of women. It does not. It represents a switch in their 
marketing dollar. In the most recent Federal Trade Commission 
report on tobacco marketing, not only does it show an increase 
in tobacco marketing in magazines--it shows a 67 percent 
increase in the kind of promotional expenditures and free 
giveaways that have the greatest impact on our young people.
    What kinds of things am I talking about? Go to a local 
store. We picked this up just about 3 weeks ago. It is from 
Camel--``Buy Two Packs, Get One Free''--but with the imagery 
that is clearly designed and aimed at men or women of that age 
population. There is no question whom these are targeted at, 
and there is no question that the ``Buy Two, Get One Free'' is 
part of a very broad marketing campaign designed to make these 
cigarettes both more attractive and more accessible to our 
young people, with the tragic results that you have heard from 
all of the others.
    This is just the tip of the iceberg. I hope that today's 
hearing is the start of a long-term focus on how the tobacco 
industry is targeting our young men and women.
    There is a second issue that I hope this Subcommittee will 
focus on, and that is the fact that the National Cancer 
Institute last November found that lite and low-tar cigarettes 
actually produce no health benefit to our population. What the 
report did not focus on but what is important for this hearing 
is the fact that it is women who switch in much greater numbers 
to lite and low-tar tobacco products because they believe that 
these products are safer.
    Eighty-seven percent of the cigarettes smoked in this 
country today are lite and low-tar; over 60 percent of the lite 
and low-tar smokers are women. They were concerned about their 
health, and they did something about it that they thought would 
make a difference. It did not.
    We are about to emerge on the same crisis all over again. 
With the release of the National Cancer Institute report, the 
tobacco industry has taken a new tack--new products. It is not 
lite and low-tar; it is a whole host of new products with broad 
promises. You showed some of them in your presentation.
    Omni cigarettes--what does a full-page ad for Omni 
cigarettes look like? ``Name another brand that significantly 
reduces carcinogens as much as Omni, the only cigarette to 
significantly reduce carcinogens that are among the major 
causes of lung cancer.''
    The tobacco company says that that is not a health claim. 
Find me a consumer who will not take away the message that says 
you have a choice not to quit, just as you did 40 years ago 
with lite and low-tar cigarettes.
    Another one is Advance cigarettes--``All of the taste, less 
of the toxins.'' If history is a predictor of the future--and 
we know that it is--it is women who will switch in massive 
numbers to these products designed to do something about their 
health and safety.
    That is why we get to solutions, and that is why we truly 
ask this Subcommittee's help. First and foremost, these things 
would not happen if we had meaningful FDA regulation over 
tobacco products. If the regulations that the FDA proposed in 
1996 were in place today, the kinds of ads that we have seen 
would not have been allowed today. They would not be allowed in 
magazines with heavy youth readership. If the FDA had authority 
over tobacco, before they made outrageous claims like these, 
they would have to substantiate them, so that when people who 
were concerned about their health and safety switched, they 
would know that those products were in fact safer, and there 
would be restrictions on the advertising to make sure it was 
not designed to encourage young people and young children to 
start.
    There is a second area that we would ask this Subcommittee 
to focus on, and you have been a leader, Senator Durbin. That 
is to ensure that poor people who want to quit smoking are not 
prevented from doing so because they lack the resources. We 
need to ensure that smoking cessation is covered by our 
Medicare and Medicaid programs. We cannot afford not to do 
that. Medicare and Medicaid costs are skyrocketing. Smoking is 
a significant portion of those costs. It is the poor people in 
our country who smoke at disproportionate rates. If we are 
concerned about health care costs, there is nothing we can do 
that would help drive those costs down and save the American 
taxpayer money more effectively than to pass the legislation 
you have proposed to provide smoking cessation coverage.
    Last, we would ask you to work with us to do just as you 
have said--to have a joint effort, to ask those who advertise 
tobacco products to do so in a more responsible manner, to 
ensure that these stories are covered and to ensure that 
advertisers take the voluntary steps that they could take on 
their own to decrease youth exposure and the exposure of young 
women to tobacco products.
    We conducted a survey only 1 month ago looking at youth 
exposure to tobacco marketing. We had hoped that over 3 years 
after the Master Settlement Agreement, we would see a 
significant decline. Sadly, we did not. Youth are still exposed 
to tobacco marketing at three times the rate as adults. And if 
you look at the cigarette brands that are up at the top, they 
are the same ones that our kids smoke, and Marlboro, smoked by 
more young girls and more young boys than all other brands 
combined, tops the list.
    There are things that we can do to address this problem, 
and we thank you for your leadership in holding this hearing 
today as a next step. Thank you.
    Senator Durbin. Thanks a lot, Matt.
    Mr. Myers. Senator, can I just add one thing which is 
really quite important--and this relates to Senator Carper as 
well; he can take some credit.
    Senator Durbin. Yes.
    Mr. Myers. There are some good things happening that we 
have not talked about. We have talked a lot about magazines. In 
this month's issue of Good Housekeeping is the beginning of a 
new campaign by the American Legacy Foundation which I think is 
very important for people to understand.
    This is called The Letters Campaign, featuring real people 
with real problems, suffering from tobacco use, designed to 
encourage women to smoke. It is accompanied, fortunately, by a 
first-rate editorial in Good Housekeeping talking about these 
issues. It is the American Legacy Foundation using the power of 
our advertising dollar to get magazines to do the right thing. 
We will never be able to match the tobacco companies dollar-
for-dollar, but our hope is that women's magazines will take 
this opportunity to liberate themselves from the slavery of 
tobacco marketing and use this as an opportunity to begin to 
send the right message to our citizens.
    Senator Durbin. Thank you.
    Dr. Beato, let me say that you have made a compelling 
argument in your testimony for a bill that I have introduced, 
and I would like to ask you to comment on it.
    We know that a significant percentage of women on Medicaid 
smoke and that indeed the smoking prevalence among pregnant 
women on Medicaid is 23.8 percent, nearly twice that of all 
pregnant women.
    Are you aware of the fact that Medicaid does not require 
State Medicaid programs to cover smoking cessation therapies or 
smoking cessation counseling?
    Dr. Beato. Some States do not, Senator, but there are other 
States that do, through a HRSA program--there are 67 programs 
currently around the country--in 37 States--that do offer 
smoking cessation programs. ACOG's Five Steps counseling 
session is covered under their prenatal care.
    Senator Durbin. Do you think it should be a requirement 
that all State Medicaid programs offer smoking cessation 
programs and counseling?
    Dr. Beato. I believe that States should strongly be 
encouraged to follow that, yes.
    Senator Durbin. But strong encouragement and making it 
mandatory are two different things. Do you think it should be 
mandatory?
    Dr. Beato. I believe for a public health issue, yes, States 
should make this mandatory.
    Senator Durbin. OK. Let me ask you about another aspect of 
this which you alluded to in your testimony. When Nzingha 
Coleman was up here, I asked her about the prevalence of 
smoking in movies and on television, which drives my wife 
crazy. She said, ``I cannot believe that the producers in 
Hollywood are letting this happen in movies that kids are 
seeing.'' It just glamorizes smoking to see some beautiful 
young actress smoking.
    I know we have a tricky assignment here in dealing with our 
historic constitutional protections of free speech and so on, 
but what do you think we can do, Congress working with this 
administration, to highlight and deal with this challenge?
    Dr. Beato. I think really trying to approach it as a 
public-private partnership, as Secretary Thompson has alluded 
to; also, I believe, exploring more the in-depth research on 
behavior science, especially among adolescents. We know that 
adolescents who get adequate and very good information still 
choose to smoke or do other unhealthy behaviors. How do we 
study that problem from a behavioral aspect to address that.
    I think there is a lot of promise looking at those research 
components, and NCI is going to have some of that in their 
gender-specific studies for particularly women and smoking. But 
I have a 14-year-old daughter and I, like my colleague sitting 
next to me, am very concerned about the messages that our 
children are getting. And I can tell you that when the movie 
``Erin Brockovich'' came out, and Julia Roberts was lighting up 
all the time, that was a very powerful message that swayed 
girls in the wrong direction, because this was a liberating 
film, you might say, but was certainly giving the wrong message 
in that way.
    Senator Durbin. I think I am going to write Julia Roberts a 
letter. She and I do not correspond regularly, but she was here 
just last week on Capitol Hill testifying about her concern 
about Rett's syndrome, a very serious disease. I would like to 
suggest to her that she also take a look at this public health 
issue. We need an actress like her to step up and say something 
publicly. It could make a difference.
    Dr. Beato. I think those kinds of partnerships are what 
will give us success.
    Senator Durbin. Dr. Stover, the most compelling part of 
your testimony--and I was not aware of it, and I have studied 
this issue a lot--is the suggestion that women are more 
susceptible to lung cancer with the same exposure to tobacco as 
a man. Has this been tested and written about over a long 
period of time?
    Dr. Stover. The data are accumulating and they suggest that 
women may be more susceptible. There are epidemiologic data, 
and now there are molecular biologic data emerging. It is 
really not understood why, but the theory is that the 
carcinogens in tobacco smoke are handled differently between 
the sexes, and generally, there are two things that can happen 
to the carcinogens, the cancer-producing substances. They can 
be excreted, or they can be changed into more cancer-producing 
materials.
    Men are thought generally to excrete them more easily, and 
women are thought to hold onto them for a longer period of time 
and change them into more cancer-producing products. And 
hormones are thought to perhaps play a role; androgens make 
them go out in the urine, and estrogens make them go the 
opposite way, to be changed or transformed into more serious 
substances.
    Senator Durbin. This seems like a very significant fact. 
Again, when we talk about women's magazines that focus on 
health, this would seem to be an obvious issue that they should 
highlight to their readers to let them know that if you smoke 
the same number of cigarettes as your husband, for example, 
according to the studies, you are more likely statistically to 
develop lung cancer than he is. I think this is worth pursuing, 
and I hope that the chest physicians will consider contacting 
some of the leading women's magazines to see if they would 
accept an article on this subject. I think that would be a 
valuable thing to do.
    I might also add parenthetically, since Dr. Beato and you 
have both made reference to your adolescent children, that I 
have said during the course of debating this issue over the 
years that I have never met a parent who has said, ``I got the 
greatest news last night--my daughter came home and told me she 
started smoking.'' I have never heard a parent say that, 
because we all live in dread of that possibility. Luckily, my 
wife and I raised three who do not smoke, and we are very happy 
with that outcome, as most parents would be.
    Matt, I am going to save my questions because Senator 
Carper has arrived, and I want to give him a chance to ask some 
questions.

              OPENING STATEMENT OF SENATOR CARPER

    Senator Carper. Thank you, Mr. Chairman, and to each of our 
witnesses, thanks for joining us today. I know some of you by 
reputation, and the reputations that you have are good ones. We 
are mindful of your contributions on these fronts and very 
appreciative.
    Senator Durbin and I came to the House together almost 20 
years ago, and almost from day one, he made his mark as a 
champion in the House of Representatives, and now in the Senate 
and across the country, to discourage people from smoking and 
for those who do, to try to get them to stop. I do not know how 
many lives have been saved because of your efforts, but my 
guess is quite a few.
    He and I kid a lot about all kinds of things, but on a very 
serious note, I would say thank you for a wonderful 
contribution in this area.
    As Mr. Myers suggested, I got to be involved a little bit 
in the American Legacy Foundation as outgoing chairman of the 
National Governors Association. The American Legacy Foundation 
was created under the Master Settlement Agreement, and about 
$1.5 billion was to be directed to the efforts of the American 
Legacy Foundation to try to convince young people, just like 
these young people sitting right over here to our left along 
the wall, from ever starting to smoke, or if they are getting 
started, to try to convince them to stop.
    I served as the founding vice chairman of the American 
Legacy Foundation for about a year and a half, and it was a 
great privilege to be a part of that start-up. seeing the two-
page advertisement that you just showed us, Mr. Myers, reminds 
me of why were we excited when we got that going.
    I called the American Legacy Foundation in preparation for 
this hearing and asked if they had any recent statistics on 
teen smoking. I had read about some encouraging statistics in 
the media, and I called Shelley Hilton, who was the president, 
to congratulate her and the Foundation. They sent me over some 
information, and I just want to read it into the record if I 
can, because I find it encouraging that the numbers on teen 
smoking, after going the wrong way for a number of years, are 
now going the right way.
    ``In December 2001, the principal investigators of 
`Monitoring the Future,' a national youth survey conducted 
annually since 1977, reported the continued decline of 
cigarette smoking among youth in grades 8, 10, and 12.''
    Let me just ask the young people over here what grade you 
are in. Eighth grade. OK. I have an eight-grader at home, 13 
years old.
    Anyway, the data from the survey indicated that current 
smoking rates among students in grades 8, 10, and 12 have been 
declining since 1977 and that smoking among younger students 
like the ones who are here today began to decline in the 
previous year, in 1996.
    Let me just mention a couple of the numbers. Current 
smoking among students in grade 12 declined from 31.5 percent 
in 2000 down to 29.5 percent in 2001. Among eighth-graders and 
tenth-graders, smoking declined from about 14.6 percent among 
eight-graders to 12.2 percent, and from 24 percent among tenth-
graders down to 21 percent. That is in a span of a year.
    Now, those may not sound like huge drops, but to see that 
kind of decline literally in the space of a year suggests to me 
that something positive and something good is happening. I 
think it is a combination of things--the efforts of some of the 
people who have been before us here, and certainly the efforts 
of our Chairman, but also, as States scrap for dollars to try 
to balance their budgets, one of the places they look is sin 
taxes, and one of the sin taxes that comes to mind for a lot of 
people is the tax on tobacco. In Delaware, we are trying to 
balance our budget, and one of the places we are going to do it 
is to significantly increase the tax on tobacco products. So 
that is going on.
    We have cigarette companies themselves that have raised 
prices in order to pay for the cost of the Master Settlement 
Agreement. And we have seen some very, very effective media 
campaigns. To our young people here, I would say that the 
American Legacy Foundation does not rely on guys like Senator 
Durbin and me to come up with ideas to connect with young 
people--they rely on the young people. The young people 
literally conceive the ideas and help direct the creation, 
whether it is stuff we put on the website or TV ads, radio ads, 
and even some of the print media. It comes from the young 
people, who are better able to figure out how to connect. And 
the long and short of it is that it is working.
    Every now and then, I do not know that we need to stop and 
smell the roses, but we need to stop and realize that something 
good is happening here, and I just wanted to underline that 
fact today.
    Mr. Myers, you mentioned the FDA proposal from 1996 that 
was not adopted. Do you have any idea what the position of the 
Bush Administration is on those broad proposals or some 
portions of them?
    Mr. Myers. I am not a representative of the Bush 
Administration, so I would hesitate to speak for them. 
Secretary Thompson has said that he generally supports FDA 
regulation, but he has made that statement on his personal 
behalf.
    We would hope that this would be an issue that we could all 
unite behind. If there is one thing we ought to be able to 
agree on, it should be that the most deadly product in this 
country should not be the least regulated product. And at the 
same time, the kind of marketing that counteracts the work of 
the American Legacy Foundation and counteracts the money that 
the States are spending to discourage tobacco use should not be 
permitted. We ought to have those kinds of controls over it so 
that when a mom and dad sit across the kitchen table from their 
kids, they should not have to face $22.5 million of tobacco 
advertising that is giving the opposite message.
    Senator Carper. Yes, Dr. Stover.
    Dr. Stover. I would just add that nicotine is definitely a 
drug, and it not only has psychologic effects but definite 
physiologic effects on the body. And it is a very addicting 
drug, as we all know.
    Senator Carper. Thank you.
    Mr. Chairman, thanks for your good work, and thanks for 
holding this hearing. And thanks to each of you for being here 
today.
    And to the young people, those eight-graders who showed up 
to join us at this hearing, we are delighted that you are here 
and hope that you will be setting the right kind of example for 
my eighth-grader and my sixth-grader.
    Thank you.
    Senator Durbin. Thanks, Senator Carper.
    Dr. Stover, you made reference to a website. Can you tell 
us what that is, so that those who are following this hearing 
may access it for the Chest Physicians program?
    Dr. Stover. The speakers kit is speakerskitchestnet.org. 
But the Chest Foundation and the ACCP also has a website. 
Everything is on the CD-ROM, which you can get on the table 
here.
    Senator Durbin. OK. I just thought you might be able to 
read it into the record; maybe you might want to search for it 
for a moment while we proceed with some other questions. I will 
go to Mr. Myers, and maybe we can come back to you.
    Matt, let me ask you about the one advertisement that you 
showed us, the full-page advertisement for Omni. This is 
amazing, and I think most people need to be reminded why we are 
talking about FDA regulation. Here, we have a full-page ad--and 
where was that published?
    Mr. Myers. This one is in USA Today, but they have run 
these full-age ads everywhere in the country.
    Senator Durbin. So imagine for a minute that this company--
whoever makes this cigarette--is saying that they are selling a 
product that causes less cancer, contains less cancer-causing 
agents, than other products.
    Mr. Myers. Correct.
    Senator Durbin. Now, we have the strange situation in 
American law where tobacco is treated neither as a food nor as 
a drug; it is somehow in between, exempt from regulation. If I 
wanted to put an advertisement together for apples that I was 
growing in my orchard that said ``has fewer cancer-causing 
agents than other apples,'' I would have to go through rigorous 
testing to establish the truth of that claim before I could 
possibly publish it without having some repercussions; is that 
not correct?
    Mr. Myers. That is absolutely correct, and the other thing 
that they, of course, do not tell us is that there are 69 known 
carcinogens. They have taken out four. What about the other 65? 
And in this case, they have added a metal called palladium 
metal which people are smoking. Do we have tests about the 
health effects of that?
    Think of yourself as a food manufacturer or a drug 
manufacturer. If you added palladium metal and then smoked it, 
you would have to tell the Federal Government how much you have 
added, and you would have to do tests on it, you would have to 
disclose it to the public before you could market it let alone 
make these kinds of totally unsubstantiated claims.
    Senator Durbin. So this is the only product in America 
where they can make claims like this without any truth or any 
background testing, where they do not have to disclose 
ingredients, including ingredients that may be lethal or toxic, 
and they are totally above any government regulation in that 
activity.
    Mr. Myers. That is the law today, sir.
    Senator Durbin. And of course, that is one that we have 
been battling for a long, long time.
    Dr. Stover, you have seen the net result of all of this 
when you have people who turn to this product and end up in 
your hospital.
    Dr. Stover. Yes. One of my teachers, a very astute man, 
said of the low-tar cigarettes ``If you are run over by 10 mack 
trucks or 100, you are still dead.'' I think that says it all.
    Senator Durbin. Dr. Beato, speak to this issue for a moment 
if you will. I know this may be a little delicate for you to 
talk about new FDA jurisdiction, and I do not know if you come 
here with any message from your Secretary on the issue. But you 
can understand from what we have said here the concern we have 
that if we do not take over some form of regulation of this 
industry that this kind of advertising, this kind of activity, 
this lack of disclosure to consumers, is going to continue on 
to the peril and danger of young people and men and women 
across America.
    Dr. Beato. You are absolutely correct. The first thing, Mr. 
Chairman, the Department of Health and Human Services has a 
website as well for women, and that is www.4women.gov, where we 
also have preventive measures of which smoking cessation is 
one. So I wanted to make that available for women in the 
audience or other family members to use that.
    Second, to answer your question, it is definitely a 
sensitive issue. There is a Supreme Court ruling that also 
complicates the picture. So I think it is a very complex 
picture, but I can certainly assure you that from a public 
health perspective, this Secretary and this President want 
public health and prevention to be a priority.
    The issues of the legal component are left up to you, sir, 
and your colleagues, but we certainly welcome anything that we 
can help with to really bring out the message that this is a 
cancer-causing event and we want to emphasize prevention.
    Senator Durbin. Let me mention something else that may come 
as a surprise to some. There is not unanimity among the tobacco 
companies on the FDA issue. There are some tobacco companies, 
major tobacco companies, that support FDA regulation and others 
that oppose it. So to say that they have put a united front 
against this concept of FDA regulation is not a fact, and I 
know that personally, having spoken to some of their 
executives. It was a strange day when a tobacco company 
executive asked for an appointment in my office some months ago 
and came in to tell me that; I did not know what to expect, but 
I was encouraged by it.
    So I think it really opens the door for us to be more 
forthright in addressing this issue, and I hope we can work 
with the administration to do that. Secretary Thompson's 
statements on this subject have been very encouraging, so we 
hope we can work with you on that.
    Dr. Stover, did you find your website?
    Dr. Stover. Yes, I did. It is www.chestnet.org.
    Senator Durbin. Thank you.
    Matt, I will give you the last word on this since you have 
followed this for so long and you were in on these negotiations 
leading up to the Master Settlement Agreement. Can you comment 
on the way you see it today, the progress that Senator Carper 
noted and the challenges ahead?
    Mr. Myers. Mr. Chairman, we have seen real progress in the 
last 4 or 5 years, but we have a long way to go. If we are 
going to succeed, we do need the administration's help to pass 
good and meaningful FDA jurisdiction. It is good that Philip 
Morris supports one form of FDA jurisdiction, but what they 
propose is riddled with loopholes, as you know.
    We think that working together, we can do something about 
this kind of advertising of these kinds of products in a way to 
protect the American public, but it is going to require 
everyone to support meaningful and effective FDA jurisdiction, 
passed promptly. With your leadership, we are really hopeful 
that maybe we can get it done.
    Senator Durbin. Thank you all very much. I thank this 
panel.
    I also want to thank my staffers, Kelly O'Brien and 
Marianne Upton, who worked very hard to put this hearing 
together.
    The Subcommittee will stand adjourned.
    [Whereupon, at 12:05 p.m., the Subcommittee was adjourned.]







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