Health Finance Commission Indiana General Assembly Wednesday, Sept. 19, 2012 Hearing on HR 59 Tobacco harm reduction strategies to reduce smoking-attributable death and disease Prepared Testimony By: Stephen E. Buyer Former U.S. Rep. for |ndiana's 4th and Congressional Districts 1 l\/lr. Chairman and members ofthe committee, I am very happy to be here in my home state and grateful for the opportunity to speak to this diverse group about something that is important to me and, i believe, should be important to the people of Indiana and its policymakers. Some of you may know my background, but for those who do not, will give you an idea of how I became involved broadly in tobacco issues and more specifically in the issue of Tobacco Harm Reduction (THR). I recently retired from the United States Congress after 18 years. I can now look back and recognize the immense commitment it takes to step forward to act as an advocate for the people who sent you to the state capitol. I compliment each of you for your willingness to enter into public office. Your service is of significant importance and much appreciated. l'm sure that when you first decided to enter into public sen/ice, many around you wanted to know why you had made the decision. l\/lost of you, including myself, could answer pretty quickly that we were doing so because we wanted to make a difference. I know that was true for me. As a long-standing advocate of Harm Reduction Strategies, introduced H.R. 1261 in 2008. This legislation was supported by more than 400 scientists who advise the American Council on Science and Health because my bill was a tougher, science-based alternative to Congressman Henry Waxman's H.R. 1256 which became law. The American Council on Science and Health, which endorsed my legislation, said of the Waxman bill, R. 1256 will not only fail to reduce the ravages of cigarette-induced disease and death will likely worsen it. The new regulation of tobacco 'additives' will not lower the toxic and carcinogenic mixture induced by the combustion and inhalation of cigarette smoke. The enhanced restrictions on lower-risk tobacco products, such as smokeless and 'clean' nicotine-which has been shown to assist addicted smokers in quitting -will condemn the over 40 million addicted smokers to the same old 'quit or die' pair of options." My bill was debated and voted down in the Energy and 2 Commerce Committee and on the House floor. The advocates ofan"abstinence only" anti-tobacco policy were too great for me to overcome. i still believe the time has come for harm reduction strategies to be appiied to tobacco health related policies. Once I left Congress I learned quickly that i did not need a title or a position of power to influence and improve public health policy. To be an agent of change you can do it from the outside and attack tobacco manufacturers like many anti-tobacco organizations do or you can do it from the inside. I have chosen to be an agent ofchange from the inside. iam now a paid consultant to Reynolds American, Inc, (RAI)the parent company of RJ Reynolds Tobacco Company as an advocate of Harm Reduction Strategies to promote healthier choices and improved health outcomes for smokers. I compliment RAl's operating companies for making investments in and offering for sale to adult tobacco consumers smokeless tobacco and nicotine products. Smokers may find these products as the path to tobacco altogether while others may transition to these less harmful products rather than continuing to obtain tobacco enjoyment from the tobacco product carrying the highest risk to one's health._.the legal tobacco product cailed "cigarettes/' Now, when I think about my background where I came from and where chose to serve the nation's interest, it has been primarily in the area of health policy. am not a doctor. I come from a family of dentists. I\/ly grandfather was a dentist, my father is a dentist, my brother is a dentist, my sister is a dentist, and my uncle was a dentist. I chose to be a lawyer. My exposure to a family ofdentists has taught me a lot about preventive medicine. In America, we are fiercely independent, and many have a mindset that we will smoke whatever we want. We will drink whatever we want. And we will eat whatever we want, regardless of the consequences to our yet, because of preventive medicine, we have great looking teeth. 3 With preventive medicine engrained in me, embarked on myiourney of working on pubiic health policy in Congress. My first assignment was to the Personnel Subcommittee of the House Armed Services Committee. This meant I was responsible for the military health delivery system. Then, I served on the House Veterans Affairs Committee and worked with the Veterans' Administration health systems, and I was also placed on a task force that was trying to figure out how to address some of the future financial issues of Medicare. I learned that one-third of our Medicare expenditures are diabetes related. This experience reinforced my early training at home about the importance of preventive medicine. We decided to get on the front end of this and to educate people and give them the tools to make informed decisions. First, we had to make them aware so people of high risk of diabetes or who had the disease could make healthier choices. We moved billions of dollars to the front end focused on prevention and education so we could save billions on the back end. That is public health policy. And, that is the same opportunity you have here to make sound public health policy to improve the quality of life, increase productivity of Hoosiers, while saving healthcare costs to this great state by embracing a harm reduction strategy for smoking, tobacco products, and nicotine products. You are discussing ways to educate and inform people about the comparative risks associated with tobacco in its various forms, and I commend you for that. I learned a lot on the task force through that process, as i am sure you are learning a lot here today about this topic. 4 I\/ly next effort deal with Post-Traumatic Stress Disorder (PTSD) for our service men and women coming back from the first Gulf War. i learned about individuals who are suffering from stress and who are also smoking cigarettes and consuming alcohol. In order to treat these individuals, you have got to get them off of the alcohol and cigarettes before you can then begin to work on the stress-related issues they have. So during all of this, I began to learn more about tobacco and alcohol and how all of these are related. At the same time, also worked to create what is called for Life" for military retirees. Why is all of this significant? Because it taught me about taking on really big issues and being able to do exactly what you are doing here today. And, i assure you reducing the death and disease caused by cigarette smoking is a really big issue, and unfortunately, Tobacco Harm Reduction has some very powerful opponents. l\/ly message is that one person, and in this case 23 legislators, can actually stand up and exercise leadership and make a difference. You all learned that in your communities, otherwise you would have never run for office. While I was in public office, I took on one of the most controversial issues for this country - tobacco. I don't use tobacco products, but I do believe the people you represent deserve to know the truth. I am here today because I believe that the public has been, and continues to be, misinformed by the public health community about risks presented by tobacco in its various forms. I do not understand completely why so many embrace "abstinence only "as a public health policy; but I do know, if you truly care about our state and you want to embrace a health policy that 5 saves lives, reduces risks, and could potentially save money, you will take a look at Tobacco I-farm Reduction policies and implement them in this state. There is a significant misinformation campaign taking place right now in the public health community, and I want to give you a couple of examples of how this is taking place at the national level and at the state level. The U.S. Centers for Disease Control and Prevention states, "Smokeless tobacco is not a safe alternative to smoking cigarettes." You see this printed on web sites and even on containers of smokeless tobacco. This is a misleading staternent. The U.S. Food and Drug Administration states, date, no tobacco product has been scientificaily proven to reduce the risk of tobacco-related disease, improve safety or cause less harm than other tobacco products." This is the FDA stating this. This is a false statement. Here at the state level, you have the india na State Department of Health echoing this misleading information. On a health department fact sheet titled, "Spit Tobacco Use in Indiana," it states "Spit tobacco is not a safe alternate to cigarettes." This fact sheet is available on the departments web site. in addition, the web site for lndiana's Tobacco Prevention and Cessation Commission web site uses the terms "tobacco" and "smoking" interchangeably. I would submit to you that the language matters on this issue if you want residents to have complete and accurate information and to make informed decisions about cigarette smoking. Unfortunately, tobacco consumers are now confused and many believe that smokeless tobacco products are just as harmful as cigarettes. This is a false premise. All of this raises the question: "Why are the federai government and the state department of health putting out false and misleading information about tobacco products." Tobacco control advocates believe that all tobacco related products are equally harmful despite science that proves otherwise. 6 Well, allow me to speak from my own experience in this area. ln 2009, when Congressman Henry Waxman wanted the FDA to take control of regulating tobacco products, I stood up and submitted an alternative plan that would educate the public on the health risks associated with various tobacco and nicotine products. For this effort, I was marginalized and mocked. I faced opposition from well-known societies and foundations like the American Lung Association, the American Cancer Society, and the American Heart Association. I am not disparaging these organizations because I believe they have each done many wonderful things for this country, but on the issue of tobacco, these groups have staked a position that abstinence is the only way when it comes to tobacco. It's a strategy called "Quit or Die." You either stop using all tobacco or you face your chances with deadly diseases like lung cancer, heart disease, and They have embraced this public health policy for the nation and they use a powerful lobbying effort for federal and state public health departments to promulgate this policy. Now, I would like to challenge you to think about other things that go on in this nation, like sexual behaviors. We promote abstinence when it comes to sexual behaviors, but you know that this in itself is not enough. "Abstinence only" public health policy to address the pandemic of sexually transmitted disease will not work. it needs to be coupled with sex education so people can make healthier choices regarding their sexual behaviors. Over the years, 1 have advocated the full spectrum. I have voted to invest the public treasury for abstinence programs, but I'm also pragmatic, and think we ought to educate and promote safe sex. This is the application of abstinence policies coupled with a harm reduction strategy to reduce the risks and promote better public health in our society. 7 Similarly, programs meant to reduce the risks associated with drug use have been widely used. Congressman Waxman himself has been a vocal proponent of needle exchanges for individuals addicted to heroin. These exchanges provide clean needles to addicts to keep them from contracting deadly diseases associated with dirty needles. This is a harm reduction strategy. There ate ways to also reduce the risks associated with tobacco use. When Abstinence programs fail, Harm Reduction programs should be sought. believe we need to migrate the population of cigarette smokers to less harmful, smokeless tobacco and nicotine product options. commend the organizations that have had a hand in moving us from a time in 1965 when 42 percent ofthe population smoked cigarettes to now when you see that number at 19-22 percent of the population. Some of the population has migrated and the nation has become healthier. The problem now is that fewer people are quitting. ln fact, since 2003, the smoking rate has fiuctuated between 19 and 22 percent. We have not seen any significant change in the percentage since the early days of the anti-tobacco movement. lt appears that the roughly 43 million Americans who smoke have made a choice to smoke regardless of the known health risk. Remember, that many have been wrongly mislead to believe that smoking a cigarette is just as harmful as smokeless tobacco thereby robbing them of making an informed decision of migrating to a iess harmful smokeless tobacco product. lt is also conceivabie that a strong percentage of that total number have tried to quit. If you are an American who wants to quit, you now have two choices. You can try to quit cold- turkey or you can use pharmaceutical Nicotine Replacement Therapies (NRTS). These are products like 8 the patch, gum and lozenges. Scientific studies have shown that these products have an effectiveness rate of about 7 percent. In Indiana, the state department of health will actually provide to eligible individuals a two-week supply of i\iRTs free of charge. Now, think about that, the state is giving away a nicotine product with a 7 percent effectiveness rate to residents. That doesn't sound like success to me. Seven percent sounds like a failure. For the 7 percent who quit that is great; however, for the other 93 percent who failed to quit and for the ovei' 40 million smokers, the present public health policy for tobacco is locking these smokers into a system of failure instead of embracing a compassionate approach to public policy that will educate tobacco consumers to make informed choices of safer alternatives to obtain their nicotine. We need to move smokers to less harmfui tobacco products to nicotine products to eventually quitting. Now, I mentioned moving or migrating the population of smokers. How do you do that? The only way you can migrate a population of smokers to eventually quit is move them down the continuum of risk from the most harmful to the least harmful tobacco and nicotine products. No tobacco product is safe. Tobacco and nicotine are legal products. I have an illustration here today of a continuum of risk for tobacco -products. Nicotine is what people are seeking through a wide range of delivery systems. You wiil see that at the top of the continuum of risk is the most deadly form of tobacco - cigarettes. Smoking cigars, cigarettes, and pipes are by far the most harmful ways to deliver nicotine in conjunction with hundreds of carcinogens that are mainly for the major adverse health effects such as lung cancer, heart disease, and chronic obstructive pulmonary disease. Then there are the smokeless oral tobacco products that have low nitrosamines. Health experts are now claiming that the risk of adverse effects associated with Swedish snus for example is lower than that associated with smoking, by an overall 90 percent. Then there are products that don't contain tobacco but rather provide nicotine extracted from tobacco. And then there are the medicinai nicotine products used in therapies to assist people in quitting. 9 According to the large body of science out there on this topic, it is the smoke from cigarettes that causes most of the health-related issues - em physema, lung cancer, heart disease. Simply put, it's the smoke stupid. So, if people want to gain access to nicotine you have to change the delivery system. You do that by educating them so that they can migrate. Migrate to a different less harmful and safer tobacco and nicotine product. This will take a serious education effort because people have already been inundated with so much false information about smokeless tobacco products. In fact, several studies show that roughly 85 percent of smokers believe that smokeless tobacco is just as or more harmful than cigarette smoking. This issue of educating tobacco consumers is made even more complicated because when the Congress passed the tobacco bill, tobacco companies are prohibited from communicating to consumers about the relative risks of specific tobacco products. The anti-tobacco lobby is pugnacious and zealous to its abstinence policy, and I am very hopeful that someday they will recognize and accept Tobacco Harm Reduction because if they truly want less risk and healthier outcomes it can only be accomplished through coupling abstinence goals with tobacco harm reduction strategies. I would submit that some of you already practice harm reduction in your own personal life today. Many of us trim the fat away before eating a piece of meat. Some of us choose a salad for lunch instead ofa bacon cheeseburger. Others might simply drink water rather than sugar-sweetened soft drinks. We practice harm reduction in our lives every day, but cigarette smokers don't know that there are less risky products. 10 In addition to educating the public and putting out complete and accurate information to smokers, we as policymakers should move to a tax policy that does not create artificial barriers to switching from cigarettes to smokeless products. I am pleased to say that in Indiana, there has been progress on this. In 2011, the legislature recognized the relative risk of tobacco products when it adjusted the smokeless tobacco tax rate. This was a step in the right direction, and the legislature should seriously consider reducing the rate on smokeless tobacco. I\/lost scientific studies show that smokeless tobacco is at least 90 percent iess risky than cigarette smoking, so an appropriate ratio between cigarettes and smokeless would be 10 to 1 or greater. Another area where we should be using policies to help incentivize smokers to make better decisions is in the areas of health and life insurance. ln Indiana, the state provides a $25~per-pay-period "non-tobacco use incentive" to employees who do not use any tobacco products. A better approach would be to provide a tiered incentive plan that recognizes that smokeless tobacco is not the same as cigarette smoking. Smokeless tobacco consumers could receive the full $25 incentive or receive a smaller incentive. Some insurance forms ask individuals if they are smokers or if they are tobacco users. They do this to calculate risk and to determine how much to charge. A better system would recognize a difference in risk for cigarette smoking and smokeless tobacco products and charge a lower premium for products that do not cause any ofthe deadly diseases associated with cigarette smoking. This would provide yet another education opportunity and offer an incentive for people to migrate from the most risky form of tobacco to the least risky form. Anti-tobacco 11 advocates argue against smokeless tobacco fearing these products will be a gateway for people to smoke. The Swedish experience proves otherwise. Another example would be the Indiana department of health issuing an updated fact sheet providing accurate information about the health risks posed by smokeless tobacco products. I have spoken about making a difference and about the powerful forces that will attempt to prevent you from embracing tobacco harm reduction. Let me give you some examples from my own personal life. I am a Republican, and as I went through the process of introducing an alternative approach to tobacco regulation, I was trying to get individuals to sign on to my bill and to advocate exactly what I have been talking about. I encountered leaders who wouid tell me that they could not support my legislation because their wives or good friends raise money for organizations like the American Cancer Society or the American Lung Association or the American Heart Association. I understand this because when I was practicing law in I\/Ionticello, EN, before I went to Congress; I raised money for the American Cancer Society. There are socialites within the community who assist and participate in these Association fundraisers. I get that, but I just want you to know that on the inside there will be people you can explain harm reduction to them and they will understand it, but because of these social relationships, they may be unwilling to take a position. That's why they call it politics, right? All of those different issues, you face that. don't care what the issue is. There is something that drives them away from pragmatism and common sense, and I assure you that you will find the social interaction obstacle in this issue. 12 Frankly, before embarking on myjourney, I had the same conversation that I am having with you with all of my relatives who are dentists. They are on the frontline of preventative medicine and treat many smokers. admit that many were skeptical when I first broached this topic. If nothing else, most people believe that smokeless tobacco causes oral cancer and must do so at a higher rate than cigarette use. But when I presented them with the facts, they understood that smokeless tobacco products presented less risk than cigarettes. You have that same opportunity today to educate yourself and others, despite the social obstacles and legislative challenges in creating a science based balanced approach to public health policy. believe we should seek to minimize harmful effects of smoking cigarettes rather than condemning all tobacco products. It is time to couple the public health goal of abstinence with a harm reduction strategy that will migrate tobacco smokers down the continuum of risk from use -to safer use - to managed use -to abstinence. 13 Risk Continuum for Tobacco Products Product Switching C|garcttes j? 1 c.ctu 4 Smsess is( i no Nicotine Proglucts <1 3 . N, (For i//ustra poses only)