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SMOKELESS TOBACCO: IMPACT ON THE HEALTH 

OF OUR NATION’S YOUTH AND USE IN MAJOR 

LEAGUE BASEBALL 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

APRIL 14, 2010 

Serial No. 111–110 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANE HARMAN, California 

TOM ALLEN, Maine 

JANICE D. SCHAKOWSKY, Illinois 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 


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SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman 

JOHN D. DINGELL, Michigan 

BART GORDON, Tennessee 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

JANICE D. SCHAKOWSKY, Illinois 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

JANE HARMAN, California 

CHARLES A. GONZALEZ, Texas 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

NATHAN DEAL, Georgia, 

Ranking Member 

RALPH M. HALL, Texas 

BARBARA CUBIN, Wyoming 

JOHN B. SHADEGG, Arizona 

STEVE BUYER, Indiana 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 


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C O N T E N T S 

Page 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. John Shimkus, a Representative in Congress from the State of Illinois, 

opening statement ................................................................................................ 8 

Prepared statement .......................................................................................... 10 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 17 

Prepared statement .......................................................................................... 19 

Hon. Ed Whitfield, a Representative in Congress from the Commonwealth 

of Kentucky, opening statement ......................................................................... 25 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement .................................................................................... 26 

Hon. Steve Buyer, a Representative in Congress from the State of Indiana, 

opening statement ................................................................................................ 26 

Hon. Eliot L. Engel, a Representative in Congress from the State of New 

York, opening statement ...................................................................................... 28 

Hon. Phil Gingrey, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 29 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 30 

Hon. Marsha Blackburn, a Representative in Congress from the State of 

Tennessee, opening statement ............................................................................ 31 

Hon. Lois Capps, a Representative in Congress from the State of California, 

opening statement ................................................................................................ 32 

Hon. Joe Barton, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 33 

Prepared statement .......................................................................................... 35 

Hon. Donna M. Christensen, a Representative in Congress from the Virgin 

Islands, opening statement ................................................................................. 41 

Hon. Janice D. Schakowsky, a Representative in Congress from the State 

of Illinois, opening statement .............................................................................. 41 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 42 

WITNESSES

Terry Pechacek, Ph.D., Associate Director for Science, Office on Smoking 

and Health, Centers for Disease Control and Prevention ................................ 44 

Prepared statement .......................................................................................... 47 

Answers to submitted questions ...................................................................... 196 

Deborah Winn, Ph.D., Deputy Director of the Division of Cancer Control 

and Population Sciences, National Cancer Institute ......................................... 58 

Prepared statement .......................................................................................... 61 

Answers to submitted questions ...................................................................... 216 

Gruen Von Behrens, Stewardson, Illinois ............................................................. 83 

Prepared statement .......................................................................................... 86 

Robert D. Manfred, Jr., Executive Vice President, Labor Relations and 

Human Resources, Major League Baseball ........................................................ 89 

Prepared statement .......................................................................................... 91 

David Prouty, J.D., Chief Labor Counsel, Major League Baseball Players 

Association ............................................................................................................ 97 

Prepared statement .......................................................................................... 99 

Joseph Henry ‘‘Joe’’ Garagiola, Sr., Major League Baseball Announcer, 

Former Major League Baseball Player ............................................................... 106 


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Joseph Henry ‘‘Joe’’ Garagiola, Sr., Major League Baseball Announcer, 

Former Major League Baseball Player—Continued 

Prepared statement .......................................................................................... 111 

Gregory Connolly, M.P.H., D.M.D., Professor of the Practice of Public Health, 

Harvard University .............................................................................................. 114 

Prepared statement .......................................................................................... 116 

SUBMITTED MATERIAL

Statement of Dr. Cheryl Healton, President of Legacy, submitted by Ms. 

Capps ..................................................................................................................... 141 

Statement of the American Association for Cancer Research, submitted by 

Ms. Capps ............................................................................................................. 143 

Article entitled, ‘‘Under the Floorboards,’’ by the National Association of 

Convenience Stores, submitted by Mr. Whitfield .............................................. 148 

Article entitled, ‘‘Sex, drugs and BlackBerrys,’’ in The Washington Times,’’ 

submitted by Mr. Whitfield ................................................................................. 153 

Report entitled, ‘‘The Strategic Dialogue on Tobacco Harm Reduction: A Vision and Blueprint for Action in the United States,’’ submitted by Mr. 

Buyer ..................................................................................................................... 154 


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SMOKELESS TOBACCO: IMPACT ON THE 

HEALTH OF OUR NATION’S YOUTH AND USE 

IN MAJOR LEAGUE BASEBALL 

WEDNESDAY, APRIL 14, 2010 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The Subcommittee met, pursuant to call, at 10:08 a.m., in Room 

2123 of the Rayburn House Office Building, Hon. Frank Pallone, 

Jr. (Chairman of the Subcommittee) presiding. 

Members present: Representatives Pallone, Eshoo, Engel, Green, 

DeGette, Capps, Schakowsky, Matheson, Barrow, Christensen, Sarbanes, Waxman (ex officio), Shimkus, Whitfield, Buyer, Blackburn, 

Gingrey and Barton (ex officio). 

Staff present: Brian Cohen, Counsel; Alvin Banks, Special Assistant; Mitchell Smiley, Special Assistant; Brandon Clark, Minority 

Professional Staff; Clay Alspach, Minority Counsel, Health; Ryan 

Long, Minority Chief Counsel, Health, and Aarti Shah, Minority 

Counsel, Health. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. I call the meeting to order. 

Today the subcommittee is having a hearing on the prevalence— 

well, I should say the title of it is ‘‘Smokeless Tobacco: Impact on 

the Health of Our Nation’s Youth and Use in Major League Baseball,’’ and I will recognize myself for an opening statement. 

The subcommittee is examining the prevalence of smokeless tobacco products, diseases linked to the use of these products and the 

correlation between smokeless tobacco use by youth and Major 

League Baseball players. This is an important issue of longstanding interest to this committee, and it is my hope we can continue to raise awareness about the dangers of smokeless tobacco 

and shape future discussions both in Congress and in Major 

League Baseball. 

There are various names for smokeless tobacco. I have to say, I 

haven’t even heard of all of them. It is called spit tobacco, chewing 

tobacco, chew, chaw, dip, plug and probably many other things unknown to us in this room. But in all forms, the tobacco sits in the 

mouth while the user sucks on the tobacco juices, spitting off when 

they get rid of the saliva that builds up, allowing nicotine to be abVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00007 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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sorbed into the bloodstream without even swallowing. But no matter what name you call it, its use is clearly dangerous to your 

health. 

In the United States, both smoking and smokeless tobacco has 

long been associated with baseball. In the early days of the 1900s, 

baseball players chewed it to keep their mouths moist on dry and 

dusty fields or they would spit it into their gloves to soften up the 

leather and even use it to prepare the notorious spitball. Then during the 1950s, smoking tobacco became the product of choice. In 

fact, when baseball games were first broadcast on TV, cigarette ads 

became prominent features. Smoking was such a part of Major 

League Baseball that fan loyalty in New York could be identified 

merely by what cigarette brand an individual smoked. 

In the 1970s, things shifted again as the public became aware of 

the dangers of smoking and chewing tobacco crept back into baseball. During that time, the smokeless tobacco industry used celebrity baseball players as models in their advertisements, sent free 

samples to clubhouses in the major leagues, minor leagues and colleges, and ramped up efforts to reach a more youthful audience. As 

a result, sales rose by 55 percent between 1978 and 1985. Since 

then, smokeless tobacco use by baseball players appears on TV 

screens across the United States 7 months out of the year. It 

doesn’t seem too much of a stretch to consider that kids associate 

tobacco use as part of the game, and perhaps even believe that it 

is part of the game that enhances an athlete’s performance. I could 

easily imagine a child thinking well, last night Yankee Nick Swisher hit a home run with a wad of chew in his cheek, maybe I can 

do that too. And the hero phenomenon is a powerful mania that 

can have profound effects on our children. 

My own concern is that smokeless tobacco use in baseball presents a public health risk that extends beyond the baseball players 

themselves. Millions of teenagers and young adults in the United 

States use smokeless tobacco. The most recent survey results indicate that over 13 percent of high school boys and over 2 percent 

of high school girls currently use smokeless tobacco products. In 

fact, surveys by the Centers for Disease Control and Prevention 

have found that among high school boys, usage rates of smokeless 

tobacco increased by 22 percent between 2003 and 2007. 

Now, we all know that tobacco use causes cancer no matter how 

it is absorbed by the body. Smokeless tobacco is not a safe alternative to smoking, and I am worried that message is not reaching 

the youth of our country. A 2008 study by the World Health Organization’s International Agency for Research on Cancer concluded 

that smokeless tobacco users have an 80 percent higher risk of developing oral cancer and a 60 percent higher risk of developing 

pancreatic and esophageal cancer, and despite bans of smokeless 

tobacco in college and the minor leagues, there is no ban on it in 

Major League Baseball. 

So I look forward to exploring the reasons behind this exception. 

I am also anxious to hear from our witnesses about their recommendations on how Congress can better address this public 

health issue, and I would like to thank all of our witnesses for 

being here today. 

[The prepared statement of Mr. Pallone follows:] 


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CHAIRMAN FRANK PALLONE, JR. 

HEALTH SUBCOMMITTEE HEARING 

"Smokeless Tobacco: Impact on the Health of our Nation's Youth and 

use in Major League Baseball" 

OPENING STATEMENT 

April 14, 2010 

Good Morning. Today the Subcommittee will examine the 

prevalence of smokeless tobacco products, diseases linked to the use 

of these products, and the correlation between smokeless tobacco 

use by youth and Major League Baseball players. This is an important 

issue of long-standing interest to this Committee. It is my hope we 

can continue to raise awareness about the dangers of smokeless 

tobacco and shape future discussions, both in Congress and in Major 

League Baseball. 
4 


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Smokeless tobacco is also called spit tobacco, chewing tobacco, 

chew, chaw, dip, plug, and probably many other things unknown to us 

in this room. In all forms, the tobacco sits in the mouth while the user 

sucks on the tobacco juices, spitting often to get rid of the saliva that 

builds up, allowing nicotine to be absorbed into the bloodstream 

without even swallowing. But no matter what name you call it, its 

use is dangerous to your health. 

In the United States, both smoking and smokeless tobacco has 

long been associated with baseball. In the earlier days of the 1900s, 

baseball players chewed it to keep their mouths moist on dry and 

dusty fields, spit it into their gloves to soften up the leather, and even 

used it to prepare the notorious spitball. Then, during the 50s, 

smoking tobacco became the product of choice. In fact, when 

baseball games were first broadcast on TV, cigarette ads became 

prominent features. Smoking was such a part of major league 

2 
5 


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baseball that fan loyalty in NY could be indentified merely by what 

cigarette brand an individual smoked. 

In the 70s things shifted again as the public became aware of the 

dangers of smoking and chewing tobacco crept back into baseball. 

During that time, the smokeless tobacco industry used celebrity 

baseball players as models in its advertisements, sent free samples to 

clubhouses in the Major Leagues, Minor Leagues and colleges and 

ramped up efforts to reach a more youthful audience. As a result, 

sales rose by 55 percent between 1978 and 1985. 

Since then, smokeless tobacco use by baseball players appears 

on television screens across the United States 7 months out of the 

year. It doesn't seem too much of a stretch to consider that kids 

associate tobacco use as a part of the game, and perhaps even believe 

that it is part of the game that enhances an athlete's performance. I 

3 
6 


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could easily imagine a child thinking; "Last night, Yankee Nick Swisher 

hit a home run with a wad of chew in his cheek. Maybe I can too." 

The hero phenomenon is a powerful mania that can have profound 

affects on our children. 

I am concerned that smokeless tobacco use in baseball presents 

a public health risk that extends beyond the baseball players 

themselves. Millions of teenagers and young adults in the United 

States use smokeless tobacco. The most recent survey results indicate 

that over 13 percent of high school boys and over 2 percent of high 

school girls currently use smokeless tobacco products. In fact, surveys 

by the Centers for Disease Control and Prevention have found that 

among high school boys, usage rates of smokeless tobacco increased 

by 22 percent between 2003 and 2007. 

4 
7 


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Tobacco causes cancer, no matter how it is absorbed by the 

body. Smokeless tobacco is not a safe alternative to smoking and I'm 

worried that message is not reaching the youth of our nation. A 2008 

study from the World Health Organization's International Agency for 

Research on Cancer concluded that smokeless tobacco users have an 

80 percent higher risk of developing oral cancer and a 60 percent 

higher risk of developing pancreatic and esophageal cancer. 

Despite bans of smokeless tobacco in colleges and the minor 

leagues, there is no ban on in the Major League Baseball. I look 

forward to exploring the reasons behind this exception. I also am 

anxious to hear from our witnesses about their recommendations on 

how Congress can better address this public health issue. 

I would like to thank all of our witnesses for being here today. I 

now recognize our Ranking Member, Mr. Shimkus for five minutes for 

the purpose of making an opening statement. 

5 
8 

Mr. PALLONE. I will recognize the gentleman from Illinois, Mr. 

Shimkus, for the purpose of making his opening statement. 

Mr. SHIMKUS. Thank you, Mr. Chairman. I ask unanimous consent that my full statement be submitted into the record. 

Mr. PALLONE. Without objection, so ordered. 

OPENING STATEMENT OF HON. JOHN SHIMKUS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Mr. SHIMKUS. And then I will just briefly summarize. First of all, 

I want to welcome Gruen Von Behrens, who is from my district. He 

is a young man who will be testifying about the damages of smokeless tobacco, and I appreciate his testimony and his advocacy. Tobacco use is bad. I think we all know that in America today. We 

need to continue to tell the message. 

As a young kid who wanted to be a baseball player my whole life, 

of course we get to do that still here in Washington with the Congressional game, but athletes are role models to somebody, and 

professional baseball has to understand that they are a role model 

to the next generation of kids, and we want to encourage that good 

leadership by example style. 

I also want to mention and welcome Joe to the committee room. 

I am a St. Louis area Member of Congress residing in Collinsville, 

so as a St. Louis boy, we want to welcome you to the committee. 

I still remember fondly throughout Major League Baseball but especially in his hometown of St. Louis, Missouri. 

We had a master settlement with the tobacco companies that should have paid in $206 billion over 25 years. The Government 

Accountability Office states that only 30 percent of the settlement 

funds went to health care. Travesty number one. Only 3.5 percent 

of the funds went to tobacco control like smoking cessation and 

other educational programs. So when money was provided in a settlement to the States to do what we are talking about today, government didn’t do their job. Government always overpromises and 

we always underdeliver, and the master settlement is a perfect example of not delivering on a settlement with the tobacco companies. 

We have a lot of issues here to face in health care, the recently 

passed health care bill, 3,000 pages. There are already fixes that 

need to be done, whether it is preexisting conditions for kids left 

out until 2014, whether it is the doctor fix, which still hasn’t been 

done which cuts physician payments starting this month. It is 

going to be extended maybe a month. Can you imagine running a 

business on calculations of income on a month-to-month basis? 

That is what we should be dealing with our time today, addressing 

the health care needs of the country, applauding the work—I am 

not suggesting that using the bully pulpit to continue to say that 

tobacco use is not, I am not saying that is not a good use of time. 

I think when we are in an economy that people are calling the 

Great Recession and we are looking at ways to create and expand 

jobs, government underfunding health care delivery in this country 

or taking away Medicare Advantage from seniors or cutting $500 

billion from Medicare, there is probably a more critical use of our 

time. 

With that, Mr. Chairman, I yield back my time. 


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[The prepared statement of Mr. Shimkus follows:] 


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Opening Statement 

Honorable Ranking Member John Shimkus 

"Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" 

Subcommittee on Health 

Wednesday April 14, 2009 

Thank you Chairman Pallone. With the 2010 Major 

League Baseball season newly upon us I think a lot of our minds 

are on summer and our national pastime. Back home people are 

all a buzz about the St. Louis Cardinals who look posed to do 

well again this season. And even the Chicago Cubs still have a 

chance - at least mathematically. 

But aside from this excitement that normally surrounds the 

start of the season I find myself struggling with the timing of 

holding this hearing today. 
11 


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I certainly believe we must do all we can to prevent 

everyone, particularly our more impressionable youth from 

starting any tobacco use. And when it comes to smokeless 

tobacco attention should certainly be focused on prevention with 

our youth playing baseball as a target more likely to be exposed 

to these products. 

However, as we sit here just back from time in our districts 

I can tell you my constituents are concerns and want 

Washington focused on what the massive 3,000 page health 

reform legislation is going to mean for them. 

When they were promised by the President, "if you like 

what you have you can keep it." Seniors with Medicare 

Advantage plans want to know how they are going to keep the 

plans they have chosen with over $200 billion cut from the 

program. 
12 


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And those enrolled in the CHAMPV A- a health care 

program for spouses and dependent children of veterans who 

died, or are profoundly disabled, as a result of military service, 

they want to know if the new health care law does clearly 

includes them or not. 

When it comes to employers, companies small and large 

have told me they will pay the penalty and force their employees 

in the exchange, sooner rather than later. This will result in new 

insurance plans for all employees. For those low income earners 

it would mean being forced into Medicaid. From private 

insurance coverage into our dysfunctional and underfunded 

Medicaid program how is this, "if you like what you have you 

can keep it?" 

Meanwhile with millions more being placed in Medicaid 

our hospitals and provider community will struggle for proper 
13 


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reimbursement while facing more cuts and lower 

reimbursements coming down the line. In Illinois Medicaid is 

already 280 days behind in payments. Even then they are only 

paying providers 30 cents on the dollar. Forcing millions of 

more into Medicaid will only make these problems worse. 

At the same time our physicians face a looming 21 percent 

cut in their reimbursement as we continue to kick the can on a 

long-term fix. Physicians run small businesses just like anyone 

else. How can we expect them to pay their bills, hire new 

employees, and plan for the future on a monthly budget? 

Yet, despite these concerns we haven't had a hearing this 

Congress or last on a permanent solution to the physician 

payment issue. And the only discussion in this committee on 

health reform was one hearing with the Secretary of Health and 

Human Services. 
14 


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Even then she refrained from getting into specifics as the 

legislation had yet to be introduced. As the dust settles and the 

questions remain, I hope the Chairman can work with our side to 

now have Secretary Sebelius come back to address some of 

these concerns on the health reform legislation that is now law. 

On the topic at hand, while I appreciate Major League 

Baseball and its players association being represented here 

today, I hope we can broaden the scope beyond just the impact 

they have on smokeless tobacco use among youth. 

I myself play baseball for the Republican team under the 

masterful managerial leadership of Ranking Member Barton. I 

have played baseball for a long time, but I have never used 

smokeless tobacco. 
15 


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If our mutual goal remains decreasing the overall use of 

harmful tobacco products we should look to build on successes 

through cessation and education programs. 

I find it disheartening that according the GAO states are 

only using a little under a third of their Master Settlement 

Agreement funds towards health care costs. Even more 

alarming is the very small percentage dedicated to prevention, 

cessation and education programs. 

I hope to hear from our government witnesses today from 

the CDC and NCI on what more they feel could be done to 

encourage these types of programs at the state level. And if 

funding is needed, how Congress might take action to ensure 

Master Settlement Agreement funds are utilized towards these 

goals. 
16 


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Lastly, I'd like to specifically thank 

Gruen (GRARE - IN) Von Behrens from Stewardson, 

Illinois in my district for being hear. I look forward to hearing 

more of your story and thoughts on what we can do to end youth 

from even starting smokeless tobacco use. 

Thank you again Mr. Chairman, and I yield back the 

balance of my time. 
17 

Mr. PALLONE. Chairman Waxman. 

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you very much, Mr. Chairman. 

Last year, we passed a law out of this committee that finally was 

signed by the President, the Family Smoking Prevention and Tobacco Control Act, and it grants FDA authority to regulate content, 

advertising and marketing of tobacco products in order to protect 

the public health. This legislation marked a critical step in a long 

history of efforts to reduce tobacco use by teens, and we have seen 

progress. Teen smoking rates are down, and while we still have a 

long way to go, at least that trend is moving in the right direction. 

But there is one exception to this improvement, that is smokeless 

tobacco. With smokeless tobacco, the trends are moving in the 

wrong direction, and the tobacco companies know it. 

Throughout the 1980s and 1990s, the use of smokeless tobacco by 

teens declined at about the same rate as cigarette smoking. But 

over the last few years, the decline in smokeless tobacco use has 

stagnated, and use has increased. Last year, smokeless tobacco use 

among 10th graders reached its highest level since 2002. This is a 

serious health risk. The increased use of smokeless tobacco will 

mean millions more teens getting hooked on nicotine. 

That is why I want to thank you, Chairman Pallone, for holding 

today’s hearing. We will hear from some of the Nation’s leading experts in smokeless tobacco use, learn about its risks, and learn 

about how to stem the rising tide of use by young people. 

Two of our witnesses are not new to this Committee. In 1994, 

when I was chairman of the Subcommittee on Health and the Environment, I chaired hearings on the health effects of smokeless tobacco. At those hearings, we heard from Dr. Connolly and from Joe 

Garagiola, both of whom will be testifying today on the second 

panel. Mr. Garagiola’s 1994 testimony discussed the same subject 

we will focus on today: the impact of tobacco use by Major League 

Baseball players and how it influences young people. We appreciate 

the work they have done for decades now to reduce the use of 

smokeless tobacco by kids and by Major League Baseball players. 

Unfortunately, Major League Baseball, and the players’ union, 

have yet to take decisive steps to end this terrible scourge. Some 

progress has been made. In 1993, Commissioner Selig banned 

smokeless tobacco in minor league clubhouses and dugouts and 

therefore baseball no longer allows tobacco companies to provide 

free samples to players. And the league and the union continue to 

educate players and fund efforts to reduce tobacco use by youth. 

But at the Major League level, there continues to be no restrictions 

on the use of smokeless tobacco by players. This means that millions of young fans are exposed on a daily basis to the use of 

smokeless tobacco by their heroes. The camera shots are relentless. 

A recent study by Dr. Connolly’s colleagues at Harvard found that 

in just one game of the 2004 World Series, ballplayers provided 

$6.4 million worth of free advertising for smokeless tobacco. If you 

are a Major League Baseball player, and you are chewing tobacco, 

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players are watching you chew. Too many of them will take up the 

habit to be just like you. That is why Major League Baseball and 

the players association need to take action to end the use of smokeless tobacco by big league players. We are not saying they should 

ban the players from using it but not to use it when they are in 

public, when they are on the field. We don’t let baseball players in 

the leagues go stand out there in the field and drink beer. Major 

League Baseball won’t allow them to stand on the field and smoke 

cigarettes. So why should they be out there in the field in sight of 

all their fans on television and at the ballpark using smokeless tobacco? 

I think that baseball has the opportunity to protect players’ 

health and protect the health of millions of young adults. This committee will continue its vigorous and ongoing oversight of these 

issues. When Major League Baseball and the union get together 

and negotiate the next contract, I hope this will be on the table. 

I don’t know why there would be an objection from the players’ 

union to the same rules for Major League Baseball that apply to 

minor league baseball where they don’t allow the use of smokeless 

tobacco. The protection of young Americans from the ravages of tobacco in all its forms demands no less, and Major League Baseball 

and its players must step up to the plate to do their part. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Waxman follows:] 


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Opening Statement 

Chairman Henry A. Waxman 

Hearing on "Smokeless Tobacco: Impact on the Health 

of our Nation's Youth and Use in Major League 

Baseball. " 

Last year, the Family Smoking Prevention and 

Tobacco Control Act was signed into law. It grants the 

FDA authority to regulate the content, advertising, and 

marketing of tobacco products in order to protect the public 

health. 

This legislation marked one critical step in a long 

history of efforts to reduce tobacco use by teens. Today, 

teen smoking rates are down, and while we still have a long 

way to go, at least the trend is moving in the right direction. 
20 


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But there is one exception to this improvement: 

smokeless tobacco. With smokeless tobacco, the trends are 

moving in the wrong direction, and the tobacco companies 

know it. Throughout the 1980s and 1990s, the use of 

smokeless tobacco by teens declined at about the same rate 

as cigarette smoking. But over the last few years, the 

decline in smokeless tobacco use has stagnated, and use has 

even increased. Last year smokeless tobacco use among 

10th graders reached its highest level since 2002. 

This is a serious health risk. The increased use of 

smokeless tobacco will mean millions more teens getting 

hooked on nicotine. 

That's why I want to thank Chairman Pallone for 

holding today's hearing. We will hear from some of the 

nation's leading experts in smokeless tobacco use, learn 

about its risks, and learn about how to stem the rising tide 

of use among youth. 

2 
21 


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Two of our witnesses are not new to this Committee. 

In 1994, as Chairman of the Subcommittee on Health and 

the Environment, I chaired hearings on the health effects of 

smokeless tobacco. At those hearings, we heard from Dr. 

Connolly and from Joe Garagiola, both of whom will be 

testifYing on the second panel today. Mr. Garagiola's 1994 

testimony discussed the same subject we will focus on 

today: the impact of tobacco use by Major League baseball 

players and its impact on youth. 

We appreciate the work they have done for decades 

now to reduce the use of smokeless tobacco by kids and by 

Major League baseball players. 

Unfortunately, Major League Baseball, and the 

player's union have yet to take decisive steps to end this 

terrible scourge. 

3 
22 


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Some progress has been made. In 1993, 

Commissioner Selig banned smokeless tobacco in Minor 

League clubhouses and dugouts. Baseball no longer allows 

tobacco companies to provide free samples to players. And 

the league and the union continue to educate players and 

fund efforts to reduce tobacco use by youth. 

But at the Major League level, there continues to be 

no restrictions on the use of smokeless tobacco by players. 

This means that millions of young fans are exposed on 

a daily basis to the use of smokeless tobacco by their 

heroes. The camera shots are relentless. A recent study by 

Dr. Connolly'S colleagues at Harvard found that in just one 

game of the 2004 World Series, ballplayers provided $6.4 

million worth of free advertising for smokeless tobacco. 

If you're a Major League Baseball player, and you are 

chewing tobacco, you can bet that many thousands of 

young, impressionable ballplayers are watching you chew. 

Too many of them will take up the habit to be just like you. 

4 
23 


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That's why Major League Baseball and the players' 

association need to take action to end the use of smokeless 

tobacco by big league players. 

Mr. Manfred and Mr. Prouty: over the next year, you 

will begin to negotiate a new collective bargaining 

agreement for Major League baseball and its players. As 

part of that agreement, you will have the opportunity to 

make the same decision about smokeless tobacco that you 

made about cigarettes and cigars decades ago: banning its 

use by big league players in the dugout and on the field. 

You prohibited smoking on and off the field. It's time 

to prohibit smokeless tobacco on and off the field. 

You have the opportunity to protect your players' 

health ... and to protect the health of millions of young 

adults. 

5 
24 


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This Committee will continue its vigorous and 

ongoing oversight of these issues. The protection of young 

Americans from the ravages of tobacco - in all its forms -

demands no less. 

And Major League Baseball and its players must step 

up to the plate to do their part. 

6 
25 

Mr. PALLONE. Thank you, Chairman Waxman. I neglected to 

thank you in the beginning, but I want to now for all you have 

done over the years to bring to light the problems with smoking 

and the industry and championing and sponsoring the legislation 

that has the FDA regulate tobacco use, so you are going back to 

the 1990s and you have been doing this for so many years, so I just 

wanted to mention that. 

Next is the gentleman from Kentucky, Mr. Whitfield. 

OPENING STATEMENT OF HON. ED WHITFIELD, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF KENTUCKY 

Mr. WHITFIELD. Thank you, Mr. Chairman. 

Today’s hearing is titled ‘‘Smokeless Tobacco: Impact on the 

Health of Our Nation’s Youth,’’ and I don’t think any of us object 

to this type of hearing because it is imperative that we explore this 

issue, but I think it is also important, and I wish that we would 

be having a hearing on some mechanisms that are already in place 

that could probably do more on addressing this issue than this 

hearing would do. And what am I talking about? Well, first of all, 

I do want to mention that on March 19, 2010, FDA reissued its 

1996 rule and this rule becomes effective on June 22, 2010, which 

will prevent the sale of smokeless tobacco and cigarettes to those 

under 18 and prohibit distribution of free samples of smokeless tobacco as well. But what am I talking about? I think this hearing 

that we should be focusing on, for example, the language that was 

in the stimulus bill, and one of our complaints about some of that 

legislation was the fact that none of us really knew what was in 

it, but now are finding out, for example, that in the stimulus bill 

there is $650 million appropriated, made available to carry out evidence-based clinical and community-based prevention and wellness 

strategies. So the federal government is already giving out money 

to States if these States will use that money to address certain 

things like sugar in drinks, tobacco products and so forth. And yet 

none of us really knew anything about that, and I think it would 

be beneficial to all of us we could get into that in more detail. 

The second thing is the House also when it approved the health 

care bill approved—not only did we authorize but we appropriated 

$5 billion between 2010 and 2015 and then $2 billion a year forever 

on programs that would allow States to submit application for 

grants from the federal government. And in those grants, they are 

doing things like saying that they are going to increase taxes on 

certain products, that they are going to be involved in zoning in 

where, for example, tobacco products or other unhealthy products 

could be marketed. They are also even talking about reducing the 

density of fast-food establishments, and what does that actually 

mean? Are we going to be determining where fast-food restaurants 

are located? 

So while this hearing is worthwhile, I think our time would be 

better spent on examining thoroughly what happened in the stimulus bill and the health care bill and the money appropriated for 

that relating directly to this issue. Thank you. 

Mr. PALLONE. Thank you. 

The gentlewoman from California, Ms. Eshoo. 


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OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Ms. ESHOO. Good morning, Mr. Chairman. Thank you for holding 

this hearing on the health impacts of smokeless tobacco, especially 

its effect on the young people of our country, which I really think 

goes to the heart of this issue. This committee has spent a great 

amount of time examining the health risks of smoking, and I am 

pleased that we are focusing on this issue of smokeless tobacco 

today. 

While cigarette smoking has declined substantially in our country, which is very good news, especially in the last 10 years, smokeless tobacco use has decreased only slightly over that period. This 

suggests that smokeless tobacco use is not a substitute for smoking 

but instead is adding to the number of tobacco users. Increased 

education and awareness about the health risks of smoking along 

with tougher regulations have led to a significant decrease in 

smokers in the United States. This has been a Herculean effort and 

I think it really signifies real progress. 

As the tobacco industry sees sharp declines in sales, it is obvious 

that they are looking toward alternative products to hook young 

customers. Smokeless tobacco is inconspicuous. Kids can use it at 

school or in class without causing much attention. Smokeless tobacco is also a gateway substance because kids who chew it are 

three and a half times more likely to start smoking cigarettes. Both 

R.J. Reynolds and Phillip Morris have introduced snus products, a 

less messy version of what chewing tobacco used to look like. These 

small, contained mesh packages are placed just under the upper 

lip, making it more difficult to detect and eliminate the need for 

a spitting cup. It really sounds pleasant, doesn’t it? 

While the research is not definitive, many claim that smokeless 

tobacco is less harmful than smoking. A recent 60 Minutes investigation on the use of smokeless tobacco claims that because tobacco manufacturers are not allowed to advertise that it is any 

safer than cigarettes, their ads focus on smokeless tobacco as a way 

to get around smoking bans, using smokeless tobacco in the subway or at work. 

I think that smokeless tobacco is a serious health hazard. I think 

we have to do more to prevent young people from forming these 

early addictions, and I look forward to hearing from our witnesses 

today, most especially from former Major League Baseball player 

Joe Garagiola, Sr.—it is really an honor to have you here and to 

see you, I am a great fan of yours—and to understand how our Nation’s role models can set good, healthy examples for the younger 

generation who look up to them. 

Thank you, Mr. Chairman, and I look forward to the testimony. 

Mr. PALLONE. Thank you. 

Next is the gentleman from Indiana, Mr. Buyer. 

OPENING STATEMENT OF HON. STEVE BUYER, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF INDIANA 

Mr. BUYER. Thank you very much. 

First of all, I would like to express my disappointment that no 

one from the Center for Tobacco Products is here to testify today, 


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and now that the Center is up and running, we do not have a single witness from what is to be the premier tobacco regulator in our 

country, so I am very disappointed, and I have a sense that the 

Center has been deliberately disregarded in this hearing. 

I continue to remain very interested in the issue of smoking cessation in country. Chairman Waxman and I feverishly debated this 

matter last year and I continue to follow the science behind smoking cessation with hopes that we can share valuable information 

with 45 million Americans who continue to smoke today despite 

strong public health campaigns that have been in operation for 40 

years. We know that today over 70 percent of the tobacco users 

want to give up smoking, and treatments for the diseases related 

to tobacco are costly for our country. However, according to the 

Surgeon General’s report in 2008, of the 45 percent of smokers who 

reported trying to quit in 2008, only 4 to 7 percent were successful 

and I believe that that is failure, and what is really disappointing 

is, is that the bill that was passed locks America into a system of 

failure. Americans have no access to information about the alternative methods of smoking cessation. For decades we have left 

them with the understanding that they must either quit smoking 

or die. However, this is not the only option for them, and there is 

a vast schism in the public health community that is crying out for 

the FDA and government officials to acknowledge the scientific research which continues to show that individuals throughout the 

world are finding tremendous success through harm-reduction 

strategies yet we continue to ignore harm-reduction strategies with 

regard to smoking. Oh, we will apply them to everything else in life 

but not to smoking, and I think that is pretty ridiculous. If we continue to employ harm-reduction strategies and give Americans this 

information showing the respective risks of tobacco products ranging from cigars and cigarettes to smokeless products and eventually pharmaceutical smoking products and complete cessation, we 

can give Americans who cannot or will not quit smoking new options to obtain the nicotine that they are dependent on or from 

products that are up to 99 percent less hazardous than cigarettes 

in terms of risk of tobacco-related illness. We must acknowledge 

the growing public health community that is acknowledging the 

differential risks between cigarettes and non-burning tobacco products including almost 80 peer-reviewed scientific and medical publications over the last 25 years of which four of them, Mr. Chairman, 

I am going to ask be submitted for the record. 

The FDA stated on its Web site that it will perform its duties by 

using the best available science to guide the development and implementation of effective public health strategies to reduce the burden of illness and death caused by tobacco products. In carrying 

out its responsibilities to implement the bill we passed last year, 

while neither the FDA nor the Center for Tobacco Products are 

here to testify, I look forward to asking the CDC and NCI about 

their initiatives to incorporate the latest science into our Nation’s 

tobacco control programs so that we can most effectively reduce 

death and disease attributed to tobacco. I yield back. 

Mr. PALLONE. Thank you, Mr. Buyer. 

Next is the gentleman from New York, a big fan of Major League 

Baseball, from what I remember, Mr. Engel. 


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OPENING STATEMENT OF HON. ELIOT L. ENGEL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW 

YORK 

Mr. ENGEL. Well, thank you very much, Mr. Chairman, for having this important hearing today to examine the prevalence in use 

of smokeless tobacco products, the health effects from use of these 

products and the correlation between smokeless tobacco use by 

youth and Major League Baseball players. 

It is fitting, Mr. Chairman, that we hold this hearing in April as 

our Nation has once again embraced the start of a baseball season. 

I represent the Bronx. I am from the Bronx, and I grew up less 

than half a mile from Yankee Stadium, and I love the Mets as well, 

so know how much joy the game can bring for so many families including my own three children. I can’t even count how many games 

I have brought them to, and thank you, Mr. Chairman, for remembering that I am a big baseball fan. And these players rightly or 

wrongly are someone kids are fascinated with for their athleticism 

and accomplishments for the best of the best in baseball. Kids are 

like sponges soaking up everything around them, and whether or 

not it seems subtle, they pick up on one of the more unfortunate 

aspects of baseball, which is the prevalent use of smokeless tobacco. Today we have reports that up to a third of Major League 

players report using this highly addictive drug. Smokeless tobacco 

puts people at risk for oral cancer, gum disease, heart attacks, cardiovascular disease and cancer. It also causes leukoplakia, a disease of the mouth characterized by white patches and oral lesions. 

I want to commend Major League Baseball for trying to 

proactively help our players and in turn the kids that look up to 

them through their efforts. The 1993 minor league tobacco policy 

has banned the use and possession of all tobacco products by club 

personnel and by players in minor league ballparks and during 

team travel as well. Major League Baseball established the National Spit Tobacco Education Program, called NSTEP, to curb the 

use of smokeless tobacco products through public service announcements featuring popular players and education and treatment programs for players, but there is a major gap in MLB. While personnel are barred from smoking with a uniform in view of spectators, they can still chew tobacco. MLB has said that this policy 

is one that the players association has sought to protect in collective bargaining. I am concerned that the players association continues to contend in their written testimony today that baseball 

players should not be prohibited from using substances that are 

legal and available to the general public. Mr. Prouty has even said 

that it is impossible for most fans to tell if players are using 

smokeless tobacco while playing baseball or in the dugout. I have 

to say I am disappointed in this response. There have been well 

documented instances of players on TV being clearly shown to be 

using smokeless tobacco. In fact, in one World Series game in 2004, 

at least 9 minutes of such footage was shown, so kids do see it. And 

secondly, while smokeless tobacco may be legal, there is a difference between players who want to use it in the privacy of their 

own homes and when they are on TV being paid very generous salaries to provide entertainment to millions of families each night. 

Every workplace has rules about what their employees can and 


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cannot do. Such is a matter of respect for the institution of Congress. We have to wear suits and ties or other appropriate attire 

when on the floor of the house. So therefore, it seems quite fair and 

reasonable that players abstain from using smokeless tobacco on 

the field, and I urge the players association to continue to consider 

these facts. 

I want to welcome Joe Garagiola, who is one of my personal heroes, and the other people testifying today, and I thank you, Mr. 

Chairman. 

Mr. PALLONE. Thank you, Mr. Engel. 

Next is the gentleman from Georgia, Mr. Gingrey. 

OPENING STATEMENT OF HON. PHIL GINGREY, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Mr. GINGREY. Mr. Chairman, thank you. 

According to a 2007 CDC study, 20 percent of high school students smoke cigarettes and 8 percent of them use smokeless tobacco. While smokeless tobacco may not be as prevalent among 

teenagers as cigarettes, it can be no less damaging to their health. 

All forms of oral tobacco have chemicals known to cause cancer of 

the mouth, pancreas and esophagus. Oral and smokeless tobacco 

also cause many other health problems such as gum disease, destruction of bone sockets around the teeth and eventually tooth 

loss. 

All of us here today have experienced the pain and the loss that 

comes with the onset of cancer. The mother of one of my staff, her 

name is Mrs. Margaret Horn, was diagnosed with leukemia a year 

and a half ago. There are many like Margaret in communities and 

cities across this country that will face cancer in their lifetime. It 

is a deadly disease and one for which a cure is long, long overdue. 

It is with this thought in mind that I want to thank Chairman Pallone for his interest in this subject. Even one death from cancer is 

one too many. 

Today we understand the impact that advertising and pictures 

can have on our youth. Early movie stars of the 20th century made 

smoking so fashionable. I even remember seeing ads in magazines 

like Look and Life where there would be physicians in their white 

coats and the stethoscope in their pocket. They kept in the pocket 

back in those days. They didn’t drape it around their neck. But 

they would have a cigarette in their hand. It was just amazing, and 

I am sure all of you have seen those ads. 

And of course, there are some baseball players who will always 

in part be remembered for the amount of tobacco that they could 

stuff into their cheek. Like anyone up on stage, heroes can be memorable for the big things and for the little things they do. With any 

impressionable child comes a chance that they could emulate their 

heroes. To deny it is to deny the importance that our heroes have 

to us as adults looking back. The number of people on both sides 

of the dais of the committee members paying tribute to Joe 

Garagiola, I do the same. I remember when I was a kid growing 

up, and I loved catchers. I never played catcher but I loved to follow the career of Joe Garagiola and Clint Courtney and of course 

Yogi Berra. So, you know, we all look back on our heroes and look 

up to them. If smokeless tobacco was not something readily associVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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ated with baseball players, I don’t believe that bubble gum today 

would be sold in packages that resemble these tobacco pouches. 

When I was a kid, that is not how you got bubble gum. So in short, 

there is an obvious correlation between the two. 

I do want to make one point in light of all the testimony that 

we are going to hear today. I do not doubt that children may look 

up to baseball players or movie stars. However, I think it is fair 

to say that parents can and should be their greatest heroes. There 

will be many things in life, many choices that are our children will 

face, many influences they will have to weigh. It is the parents who 

have the greatest opportunity and ability to educate our children 

about things not only tobacco but alcohol and drugs and a lot of 

bad behavior. With this thought in mind, Mr. Chairman, I would 

like to encourage this committee not to forget the role that an informed and engaged parent can have on the health of their children. 

I look forward to hearing from both panels of witnesses. Thank 

you so much for being with us today. I yield back. 

Mr. PALLONE. Thank you. 

The gentlewoman from Colorado, Ms. DeGette. 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you very much, Mr. Chairman. 

I have to say, I completely agree with the gentleman from Georgia about the role of parents, and that also is my view, that parents need to have a strong oversight over their kids. But also in 

addition to that, I think the gentleman will agree with me on this 

too. Study after study has shown that advertising influences for tobacco and tobacco products are particularly strong among minors, 

and in the past in the many hearings that this committee has had, 

we have seen the effects of advertising by tobacco companies on minors. In fact, in my home State of Colorado, the tobacco industry 

is spending $171 million per year, and they will say that they are 

not targeting that at minors, but as we have seen in many hearings, much of that advertising is accepted by minors. 

I will also say, being the parent of two young daughters, teenage 

and young adults, I see that we have to revisit these issues with 

every generation. My older daughter, who is in college now, tells 

me that she is seeing many of her friends who are highly educated, 

intelligent young people smoking and using smokeless tobacco because they think it is cool, and so we have to revisit these issues 

generation after generation and we have to make sure that the people who these kids look up to are not using tobacco products with 

the assumption that they are OK for the kids. 

I am especially concerned about the smokeless tobacco because in 

places like Colorado, kids now are told from an early age that 

smoking can kill them, but in many areas the kids turn toward 

smokeless tobacco because they are not getting that same message, 

and so I really look forward to working with Major League Baseball 

and with all of my colleagues on this committee to make sure those 

same messages are getting out to kids and to make sure that our 


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role models for these kids including baseball players are also giving 

that consistent message. 

My younger daughter, who is 16, is the biggest Colorado Rockies 

fan who exists. Her whole room is filled with posters of these players, and it is pretty cute to me because she is a girl, but she loves 

these players, she looks up to them as her peers and her friends 

and she goes to every game, so I want to make sure she gets the 

right messages from them, just like I want to make sure she gets 

the right messages from anybody else who is appealing to the teen 

market. 

Mr. PALLONE. Thank you. 

The gentlewoman from Tennessee, Ms. Blackburn. 

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE 

Mrs. BLACKBURN. Thank you, Mr. Chairman. 

Welcome to all of our witnesses today. We are pleased that you 

are here and we appreciate the time that you have taken to prepare your testimony and be with us. 

Mr. Chairman, I will have to tell you, I do find it a bit perplexing 

that we are here once again to discuss youth tobacco usage when 

I have offered my bill, H.R. 1423, as an amendment in this committee not only this Congress but also last Congress to address this 

very issue, and unfortunately that request has fallen on deaf ears 

but we have had it here in committee and in subcommittee and 

looked at this during the markups in the 110th and the 111th Congress. H.R. 1432 is a good government piece which focuses on 

strengthening existing programs to prevent illegal tobacco use. The 

bill strengthens the existing work that States and localities are 

doing to reduce underage access to and use of tobacco products 

through the evolution of SINAR, a current successful and effective 

program to lower teen smoking. The legislation takes the next step 

in the evolution towards protecting youth and informing the public 

regarding tobacco products. Mr. Shimkus mentioned the use of the 

MSA funds, and it would have required States to use at least 10 

percent of those MSA funds on smoking cession and prevention 

programs. In addition, it would require the States to enforce their 

laws prohibiting the sale of tobacco products to minors or risk losing 40 percent of their federal subsidies. So when you say, those 

of you on the other side of the aisle say you are not sure about 

what to do, let me tell you, we have some things that have been 

offered and we should be doing them, and I do feel that if the Democrat leadership was serious about reducing youth tobacco usage, 

surely there would have been thoughtful debate given to that legislation. 

But yet we are going to blame Major League Baseball for the ills 

of youth smokeless tobacco usage so let us be clear. If the MLB 

wants to change its policy on smokeless tobacco, an agreement will 

be reached between the MLB and the MLB players association. As 

the former president of the Middle, Tennessee, Lung Association, 

and as a grandmother with a 23-month-old who gets up every single morning and says go outside, play baseball, it is his favorite 

thing to do, I am very fully aware, I am fully aware of the risk of 


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youth usage of tobacco. I just find it a little bit of grandstanding 

that you would pass not only in the 111th Congress but also in the 

110th Congress to take action and at a time when we should be 

dealing with a budget that the Democrat leadership does not want 

to deal with and when we should be looking at the problems that 

have already been found with the health care that passed, we are 

here once again addressing this issue when the solution is clearly 

in front of you. I yield back. 

Mr. PALLONE. Next is the gentlewoman from California, our vice 

chair, Ms. Capps. 

Mrs. CAPPS. Thank you, Chairman Pallone, for holding this extremely important hearing. I wish to introduce for the record two 

important statements from our non-governmental organizations, 

one being Legacy and the other, the American Association for Cancer Research, in support of this hearing. 

[The information appears at the conclusion of the hearing.] 

Mr. PALLONE. Without objection, so ordered. 

OPENING STATEMENT OF HON. LOIS CAPPS, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mrs. CAPPS. It is common knowledge that tobacco is unhealthy, 

dangerous and deadly. While we as a Nation have taken great 

steps to reduce tobacco use, especially cigarette smoking, we should 

all be alarmed by recent studies showing an increase in smokeless 

tobacco use among young people. In my field of public health, I am 

especially concerned that smokeless tobacco products are somehow 

seen as a safe alternative to cigarettes. We know conclusively that 

tobacco is an addictive substance in any of its forms. It causes numerous types of cancer, gum disease, oral lesions and increases 

one’s risk of cardiovascular disease. What is worse is that some of 

these health repercussions can occur within just a few years of use. 

Tobacco companies have a history of targeting their marketing 

campaigns to children and youth, encouraging them to start using 

their products at an early age. One particularly effective strategy 

was to get celebrity baseball players to endorse and use their products both on and off the field. We continue to deal with the negative repercussions of this today. 

I commend the work that baseball has done to curb the use of 

smokeless tobacco. I salute you for that. In particular, the ban on 

its use in the minor leagues was a bold step to improve the health 

of both their players and the public. Despite these efforts, Major 

League Baseball continues to be a venue where smokeless tobacco 

usage is glamorized. At best, it is free advertising for the tobacco 

industry. At worse, it is putting the lives of America’s children at 

risk. 

On a personal note, I have seen how my own grandchildren look 

up to athletes with such admiration. Children and adolescents 

watch these games to see their heroes compete. They try to mimic 

their throws and their swings. What else will they copy? While I 

sincerely hope that children who look up to baseball players can 

learn to filter out the negative messages they are receiving about 

smokeless tobacco use, you know, they really shouldn’t have to do 

that. So I look forward to hearing from our witnesses today and appreciate the fact that you are here, and I yield back my time. 


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Mr. PALLONE. Thank you, Ms. Capps. 

The gentleman from Texas, our ranking member, Mr. Barton. 

OPENING STATEMENT OF HON. JOE BARTON, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. BARTON. Thank you, Chairman Pallone. 

There is a famous poem about Casey at the bat that starts out, 

and I am trying to quote it from memory, so if I miss it, I apologize 

to those who know it by heart. But it says, ‘‘Somewhere birds are 

singing, somewhere people shout but there is no joy in Mudville, 

mighty Casey has struck out.’’ This is a hearing that appears to 

have struck before we have even started it, Mr. Chairman, not that 

I don’t like baseball, I love baseball. I remember when Joe 

Garagiola was actually a catcher for the Pittsburgh Pirates. That 

shows how far back I go. We are glad to have him here. I am not 

a big fan of tobacco. I have never smoked a tobacco cigarette. I 

have never used smokeless tobacco. I don’t allow smoking in my office. That has been a policy since I got elected in 1985. So I am 

not an apologist for the tobacco industry. I don’t accept and never 

have political action contributions from tobacco companies. But I 

don’t see the need, Mr. Chairman, on this particular hearing the 

way it is structured. We have passed a law regulating tobacco products. I didn’t support that law. Under that, the FDA has issued 

rules prohibiting the marketing of tobacco products to people under 

the age of 18. Their rule has been put on their Web site. It appears 

to me to be pretty explicit and fairly exhaustive in its attempt to 

prevent tobacco products getting to our youth. There may be a few 

Major League Baseball players that are under the age of 18. I am 

not aware of any but I guess it is technically possible. If a Major 

Leaguer wants to use a tobacco product, he still has that right 

under our Constitution to do so. If that product happens to be 

smokeless tobacco, he has the right to use it, and so far as I know, 

there is not a prohibition against a Major League Baseball player 

being a sponsor or somehow a spokesperson or being used in an advertising campaign for that product. Again, I am not defending the 

product, but even under the new law, it is a legal product. 

So we are going to have a hearing today, Mr. Chairman, where 

we appear to be trying to intimidate Major League Baseball into 

prohibiting or discouraging their players from engaging in either 

the use of these products or serving as spokespersons and in some 

sort of advertising situation for those products. I think that is a 

misuse of the subcommittee’s time, Mr. Chairman. I think time 

would be better spent if we began to investigate and oversee this 

recent mammoth 3,000-page health bill that is now the law of the 

land. I was given yesterday a draft, a 55-page draft of the mandates and the timelines in that bill that are now law. There are 

many mandates that become effective date of enactment, which is 

March 23, 2010, that are already not being honored by the Obama 

Administration. I think our time would be better spent, Mr. Chairman, if we began immediately to see what the pluses and minuses 

are of the new health care law and spent less time appearing to 

do a grandstand hearing simply because Opening Day was a couple 

weeks ago and people are beginning to focus on the diamond and 

what activities are going on in Major League Baseball. 


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I do thank the witnesses for appearing. I know you are here sincerely to express your position and that there are issues to be addressed. I don’t think it should the subject of a Congressional hearing at this point in time. 

With that, Mr. Chairman, I yield back. 

[The prepared statement of Mr. Barton follows:] 


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Opening Statement 

Honorable Ranking Member Joe Barton 

"Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" 

Subcommittee on Health 

Wednesday April 14, 2009 

Mr. Chairman, somewhere there is laughter, and 

somewhere children shout. But here today in Rayburn, the 

committee has struck out. 

I love baseball. It IS the great American pastime. I 

don't play much anymore, but I don't use tobacco and I 

doubt my son will ever feel the need to use tobacco to be a 

ballplayer. 

I do wonder why we are having this hearing. Kids are 

informed directly by their parents and teachers, but they 

also draw lessons from all sorts of media, and they follow 

sports other than baseball. Yet it appears that the Majority 
36 


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has concluded that it is Major League Baseball that molds 

our children into the adults they will become. 

The baseball season has just started and the false 

hopes of fans in towns like Oakland, Los Angeles and 

Seattle will be high until they travel to, oh, let's just say 

Arlington, Texas. So this is the moment to have Major 

League Baseball testifY because it constitutes a grand 

opportunity for us to get some press while spring is in the 

air and Casey is just coming up to bat. But I am concerned 

that America may think we are sneaking off the to 

ballgame. I went home during recess and in multiple town 

hall meetings, not a single person asked me a single 

question about baseball, much less about ballplayers and 

tobacco. 

I did, however, receive a cascade of questions about 

the effects of the 3000-page health care bill on the lives of 
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Americans. People want to know if their taxes will 

increase. People want to know whether the bill will hinder 

the creation of new jobs. People want to know whether 

they would lose their current health coverage. People want 

to know what insurance qualifies for the individual 

mandate. 

It seems bizarre that we can probe the health concerns 

of ballplayers chewing tobacco, but only managed a single 

hearing on a one-day-old, 3000-page health bill that will 

touch the lives and pocketbooks of every living American, 

and with witnesses who weren't even expected to discuss 

its substance 

I believe it is fair to say that this hearing is a 

distraction. Seniors ask me how their Medicare plans will 

be changed by the $500 billion in cuts that will be used to 

pay for a new entitlement. We can't know for sure because 
38 


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this Committee has not held a single hearing on how these 

cuts will affect seniors and the Medicare program. Seniors 

ask me if their Medicare Part D premiums will increase or 

if their access to Medicare Advantage plans will be 

affected. This Committee has not held a single hearing on 

the issue, so who knows? 

Today, physicians are experiencing a 21 percent cut in 

their Medicare reimbursement rates and face future cuts of 

5 percent annually. Because the Democrats relied on 

budget tricks to pass their health care bill, they refused to 

put a long-term fix to this problem in their bill, thereby 

pretending to reduce the deficit. Rather than solve the 

problem, Democrats enact a series of one-month fixes that 

provide no certainty to doctors treating patients around the 

country. This approach can only be generously described 
39 


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as irresponsible. Of course, this Committee has yet to hold 

a hearing on the issue in the last two congresses. 

Turning to the substance oftoday's hearing, according 

to a recent report from the Campaign for Tobacco Free 

Kids, only one state currently funds a tobacco prevention 

program at the level recommended by the U.S. Centers for 

Disease Control and Prevention (CDC). Only nine other 

states fund tobacco prevention at even half the CDCrecommended level, while 31 states provides less than a 

quarter of the recommended funding. 

A peer-reviewed article from the July 2007 Preventing 

Chronic Disease found "Significant reductions in smoking 

prevalence among Washington residents following the 

implementation of a comprehensive tobacco control 

program funded at a level near that recommended by the 
40 


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Centers for Disease Control and Prevention indicate that 

tobacco control programs are an effective investment for 

states committed to improving public health." We already 

know what works. But it seems we are opting to ignore 

that report so we can hold a media-grabbing hearing about 

Major League Baseball, instead. 

I will end by thanking the CDC for being here today. 

We also have legislation before the Committee related to 

the 9111 health program that affects your Agency. In fact, 

that bill has been marked up in the Health Subcommittee. 

Unfortunately, we held a hearing last year, but CDC was 

not asked to testifY. Hopefully, before we move that 

legislation through Full Committee, we will have your 

Agency testifY. I would hope that the Chairman would be 

willing to make that commitment. 

Thank you, I yield back the balance of my time. 
41 

Mr. PALLONE. The gentlewoman from the Virgin Islands, Ms. 

Christensen. 

OPENING STATEMENT OF HON. DONNA M. CHRISTENSEN, A 

REPRESENTATIVE IN CONGRESS FROM THE VIRGIN ISLANDS 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. 

When we passed the Family Smoking Prevention and Tobacco 

Act, we did so to control and hopefully reduce all tobacco use, so 

I want to thank you, Chairman Pallone and Ranking Member 

Shimkus, for holding this hearing because we are seeing companies 

trying to redirect their marketing to the smokeless tobacco market 

and it is important to remind everyone that smokeless tobacco is 

also addicting and has harmful effects such as oral and throat cancer and increased risk for esophageal, stomach and pancreatic cancers as well as heart disease and stroke. So smokeless tobacco is 

by no means a safe substitute for cigarettes. Therefore, the increasing use of smokeless tobacco among anyone but especially today’s 

youth is quite troubling to me as a physician, a mother and a 

grandmother of a 3-year-old who is now in tee ball. 

The history of smokeless tobacco use in Major League Baseball 

only exacerbates the problem in today’s youth because of the influence that athletes, celebrities and entertainers have on them. However cool, exciting or glamorous these athletes or celebrities may 

seem, there is nothing cool, exciting or glamorous about the harmful effects caused by using smokeless tobacco that could impair or 

cut short the potential of a young person before they even get the 

chance to experience all that life has to offer. 

The bill we passed and the President signed will restrict marketing and advertising of tobacco products near schools and playgrounds beginning this summer as well as implement other limitations, but that is not enough. We do appreciate the actions that the 

minor leagues have taken and look forward to stronger action from 

Major League Baseball and to working together around this Act 

and any additional legislation or initiatives that will work to reduce and prevent the use of smokeless tobacco and all tobacco in 

today’s youth. 

We appreciate our witnesses being here. We would like to welcome also especially Joe Garagiola and we look forward to the testimonies. Thank you. I yield back. 

Mr. PALLONE. Thank you. 

The gentleman from Utah, Mr. Matheson. 

Mr. MATHESON. Thanks, Mr. Chairman. I will waive my opening 

statement. 

Mr. PALLONE. The gentlewoman from Illinois, Ms. Schakowsky. 

OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Ms. SCHAKOWSKY. First of all, Mr. Chairman, I want to thank 

you for holding this hearing. It is never a waste of time for us to 

focus on health risks that are posed to our children and to have a 

thorough discussion over what may be done either within this Congress or outside of in order to make sure that our children are protected. 


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We know that on March 31st President Obama signed the PACT 

Act into law, and this new law is a huge step forward in our fight 

against the underage use of tobacco products and was built on decades of advocacy and public outreach, and I applaud this victory 

but I know that we have much work ahead. Big Tobacco is still 

finding its way into the lives of our youth. I think everyone in this 

room knows that chewing tobacco is just as dangerous as lighting 

a cigarette, and we have heard over and over what those risks are, 

but we have also started to see a resurgence in the use of these 

products among young people, particularly among young men, and 

prevention is an ongoing process, as my colleague, Congresswoman 

DeGette, said. Every generation we always have to keep repeating 

this. 

As I was preparing for this hearing, one of my wonderful interns, 

Michael Cottler, told me stories about his college baseball team. 

Half of his team used tobacco products. Most of them would chew 

but not smoke, and according to him, the players chewed during 

games, not off the field. His experience tells me we still have work 

to do and that a big chunk of the responsibility to stop use of tobacco products by underage kids comes from the role models that 

they look up to. And every time I watch a baseball player spit before stepping up to the bat, I know there are young ballplayers who 

dream of becoming pros who see those images too. 

According to the Harvard study of public health, just one World 

Series game in 2004 had over 9 minutes of free advertising for the 

tobacco industry because of shots of players chomping on chew. I 

mean, you know, sometimes it surprises me that this is looked at 

as attractive in any way but apparently to young men, it does look 

very cool and authentic. 

Smokeless tobacco is not a healthier substitute for cigarettes. It 

destroys lives and kills just as effectively as its smoked counterpart. There has been an incredible grassroots effort to educate the 

public about the dangers of smoking and we have seen a significant 

reduction in underage smoking because of it. Without that same 

commitment, I worry that young people like my intern’s baseball 

team will see chewing as an OK substitute for cigarettes. 

I applaud the minor league tobacco policy which has taken 

smokeless tobacco out of the clubhouses and ball fields of the minor 

leagues. We are going to need that same type of aggressive action 

at the major league level if we are going to get tobacco products 

out of the game, and I yield back. 

Mr. PALLONE. Thank you. 

The gentleman from Texas, Mr. Green. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for holding the hearing 

on smokeless tobacco and the impact on our Nation’s children and 

use in Major League Baseball. 

Each year millions of teenagers use smokeless tobacco. According 

to the CDC, 13.4 percent of U.S. high school boys and 2.3 percent 

of high school girls currently use smokeless tobacco products. 

Youth prevalence data from the Centers for Disease Control also 

shows that while cigarette smoking has declined substantially in 


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the last 10 years, smokeless tobacco use has decreased only slightly 

over that period. The CDC found that among high school boys, 

usage rates of smokeless tobacco increased by 22 percent between 

2003 and 2007. There is a perception that smokeless tobacco is a 

safe product and we should be clear that studies have found that 

smokeless tobacco can contain as many as 28 different carcinogens 

and smokeless tobacco causes oral cancer, gum disease, increased 

risk of heart attack, cardiovascular disease and nicotine addiction. 

The World Health Organization’s International Agency for Research on Cancer concluded that smokeless tobacco users have an 

80 percent higher risk of developing oral cancer and 60 percent 

higher risk of developing pancreatic and esophageal cancer. Smokeless tobacco can be an alternative to smoking cigarettes and may 

be perceived as safer than smoking cigarettes but there are still 

significant health risks associated with smokeless tobacco. 

Today we are discussing the use of smokeless tobacco in Major 

League Baseball and how that impacts our youth. Like my colleagues, there is nothing more American than baseball. I am a fan 

of the Houston Astros. I actually worked there. I had the ideal job 

for a 7th grader. I could sell soda water and earn $10 a night and 

see all the baseball I wanted. In fact, I skipped school to be able 

to go to Opening Day when we had the Colt 45, so I remember it 

very well. But we still have to provide the leadership from the 

players. Major League Baseball has banned cigarette use by major 

league players in uniform and in view of the public, has been 

banned for over 3 decades. However, there are no restrictions on 

the use of smokeless tobacco. Steps have been taken to restrict 

smokeless tobacco use by players in uniform in minor league baseball but these measures have not been in place in the major 

leagues. We do know that in 2003 approximately 36 percent of the 

baseball players in the league reported using smokeless tobacco. 

These players are idolized by our children and seen using smokeless tobacco which certainly we do not want to encourage our youth 

to begin using a harmful product because they see a sports hero 

using it. 

I look forward to the testimony of our witnesses, Mr. Chairman, 

and I yield back my time. 

Mr. PALLONE. Thank you, Mr. Green. 

Next is the gentleman from Georgia, Mr. Barrow. 

Mr. BARROW. I thank the chairman. I will waive an opening. 

Mr. PALLONE. Thank you. 

I think that everyone has had an opportunity to—— 

Mr. SHIMKUS. Mr. Chairman? 

Mr. PALLONE. Yes? 

Mr. SHIMKUS. I ask unanimous consent that my statement be 

submitted into the record. Would that go for everyone? 

Mr. PALLONE. Yes. Without objection, it ordered that every member’s statement in full will be submitted for the record. 

Mr. SHIMKUS. Thank you. 

Mr. PALLONE. We are now going to turn to our witnesses, our 

first panel. I want to welcome them. Let me introduce the two of 

you. First is Dr. Terry Pechacek, who is associate director for 

science for the Office on Smoking and Health within the Centers 

for Disease Control and Prevention. And on my right is Dr. DeboVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00049 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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rah Winn, who is deputy director for the Division of Cancer Control 

and Population Sciences with the National Cancer Institute. Thank 

you both for being here. You know the drill. You have 5-minute 

openings that become part of the record, and of course, if you like, 

you may in the discretion of the committee submit additional statements in writing for inclusion in the record. 

We will start with Dr. Pechacek. 

STATEMENTS OF TERRY PECHACEK, PH.D., ASSOCIATE DIRECTOR FOR SCIENCE, OFFICE ON SMOKING AND HEALTH, CENTERS FOR DISEASE CONTROL AND PREVENTION; AND DEBORAH WINN, PH.D., DEPUTY DIRECTOR OF THE DIVISION OF 

CANCER CONTROL AND POPULATION SCIENCES, NATIONAL 

CANCER INSTITUTE 

STATEMENT OF TERRY PECHACEK 

Mr. PECHACEK. Mr. Chairman, Ranking Member and distinguished members of the subcommittee, thank you for the opportunity to participate in this hearing. My name is Dr. Terry 

Pechacek and I am the associate director for science in the Office 

of Smoking and Health at the Centers for Disease Control and Prevention. Today I will provide an overview of smokeless tobacco including health effects, trends and product use, and use of smokeless products and their marketing. 

I want to begin by emphasizing a very important point. There is 

no safe form of tobacco use. Use of any tobacco product is hazardous to health. The only proven way to reduce the staggering toll 

that tobacco use takes on our society is to prevent people from ever 

starting to use tobacco and to help those who already use these 

products to quit as early in life as possible. 

What is smokeless tobacco? Smokeless tobacco products come in 

two forms: chewing tobacco and snuff, or ground tobacco. In recent 

years, a new generation of smokeless tobacco products has entered 

the U.S. market. They include snus, a form of moist snuff, and dissolvable products such as lozenges, sticks and strips. The questions 

in national surveys that I will cite in this testimony generally ask 

respondents about the use of smokeless tobacco products without 

disaggregating information by specific product types. 

The scientific evidence clearly shows that using smokeless tobacco products is hazardous to health. They contain at least 28 carcinogens and are known to cause oral, pancreatic and esophageal 

cancer. Some studies have also linked smokeless tobacco use to 

fatal heart attacks and certain adverse productive outcomes during 

pregnancy. Like cigarettes, smokeless tobacco contains nicotine and 

is highly addictive. As individuals use smokeless tobacco over time, 

they typically change products they use to get more nicotine. In 

doing so, they may be increasing their exposure to carcinogens and 

other toxic agents. 

The National Survey on Drug Use and Health, or NSDUH, which 

is conducted by the Health and Human Services’ Substance Abuse 

and Mental Health Service Administration, indicates that about 3.5 

percent of persons in this country age 12 and older, or approximately 7.8 million persons, used smokeless tobacco in the past 

month. Men are more likely than women to use smokeless prodVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00050 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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ucts. In fact, the highest prevalence of smokeless tobacco use in recent years has been among young adult men. Therefore, this testimony will focus on recent trends related to this population. The 

NSDUH survey reported a significant increase in smokeless tobacco use among persons 12 years and older from 3 percent in 2004 

to 3.5 percent in 2008. During these years, patterns of use among 

persons 26 and older have remained relatively stable at about 3 

percent. Patterns of use among adolescent girls have also remained 

stable at a very low level. The observed increase primary comes 

from an increase among men 18 to 25 years of age, especially in 

two demographic groups. Among non-Hispanic white men, rates increased from 13.6 percent in 2003 to 15.4 percent in 2008. Among 

Hispanic men age 18 to 25, rates of smokeless tobacco use increased from 1.9 percent to 3.4 percent during that same time. Recent data from Monitoring the Future also confirms an increase 

among young males with the rate increasing from 15.8 percent in 

12th-grade boys in 2008 up from 11 percent in 2007. Data from 

CDC’s 2009 youth risk behavior survey, which will be released this 

summer, also is showing significant increase in smokeless tobacco 

use since 2003 among both male high school students overall and 

non-Hispanic white high school students. 

As with smoking, most smokeless tobacco use begins during adolescence and young adulthood. Data from NSDUH shows that in 

2002, about 950,000 Americans 12 years and older used smokeless 

tobacco for the first time. By 2008, that number had increased to 

1.4 million. Almost half of those first-time users were under 18 and 

almost three-fourths were male. Traditionally, cigarette smokers 

and smokeless tobacco users have been fairly distinct groups. However, several national surveys show that a large proportion of 

smokeless tobacco users are also smoking cigarettes. This pattern 

is most common among adolescents and young adults than among 

older Americans. In fact, the data indicates that two-thirds of 

males between 18 and 25 who use smokeless tobacco also smoke 

cigarettes. These trends need to be placed in the changing context 

of tobacco use in the United States including lower smoking rates, 

increased restrictions in smoking in public and increased social acceptability of smoking. 

Mr. Chairman, am I over my limit? 

Mr. PALLONE. You are, but you can wrap up if you like. 

Mr. PECHACEK. So the marketplace has been changing with the 

promotion of tobacco products increasing from 200 million in 2005 

to 300 million in 2006, and particular concern is that many of these 

smokeless products are being marketed in ways to satisfy and sustain their nicotine addictions when they are settings that do not 

allow smoking. 

So what is the public health harm? This dual use raises potential 

concerns. More than half of adolescents and young adults who are 

using smokeless tobacco also are smoking cigarettes. I have submitted my written testimony, which provides greater details on 

these important issues, but it is important to emphasize that recent increases in smokeless tobacco use by adolescent boys and 

young men as well as increasing dual use of cigarettes and smokeless tobacco are reasons for serious concern. Together these may 

portend a leveling off or even reversal in the decline of smoking 


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and the perpetuation of nicotine dependence including high levels 

of tobacco-related disease and death in this country. 

Thank you for the opportunity to participate in this hearing and 

I would be happy to accept questions. 

[The prepared statement of Mr. Pechacek follows:] 


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Testimony 

Before the 

Subcommittee on Health 

Committee on Energy and Commerce 

United States House of Representatives 

Hearing entitled, "Smokeless Tobacco: Impact on the Health of 

our Nation's Youth and Use in Major League Baseball" 

Statement of 

Terry F. Pechacek, Ph.D. 

Associate Director for Science 

Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health 

Promotion 

Centers for Disease Control and Prevention 

.U.S. Department of Health and Human Services 

For Release on Delivery 

Expected at 10:00 a.m. 

Wednesday, April 14, 2010 
48 


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Mr. Chairman, Ranking Member, and distinguished members of the Subcommittee, thank you 

for the opportunity to participate in this hearing. My name is Dr. Terry Pechacek, and I am the 

Associate Director for Science of the Office on Smoking and Health at the Centers for Disease 

Control and Prevention (CDC), an agency of the Department of Health and Human Services 

(HHS). I will provide a brief overview of the health effects of smokeless tobacco products, 

recent trends in the use of these products, and the evolving forms in which these products are 

available and marketed. 

No Safe Form of Tobacco Use 

I want to begin by emphasizing a very important point. There is NO safe form of tobacco use. 

The use of ANY tobacco product is hazardous to health. As a result, the only proven way to 

reduce the staggering toll that tobacco-related disease, death, and economic costs take on our 

society is to prevent people from ever starting to use tobacco products and to help those who 

already use these products to quit as early in their lives as possible. 

What Is Smokeless Tobacco? 

Smokeless tobacco products consist of tobacco or a tobacco blend that is chewed, placed in the 

oral cavity outside the gums, or inhaled or snorted through the nose, rather than smoked. 

Smokeless tobacco includes chewing tobacco and snuff. Chewing tobacco comes in several 

forms, including loose leaf, plug, twist, and roll. Snuff, which is finely ground tobacco, also 

comes in several forms, including moist, dry, or packaged in sachets. 

Smokeless tobacco in the United States has traditionally been available in the form of chewing 

tobacco and dry snuff. During the 1980s, moist snuff became more widely available and more 

heavily marketed in the United States. The moist varieties, sold either in tins or in sachets, 

accounted for 97 percent of sales of snuff by weight in 2006. These moist snuff products were 

heavily advertised and promoted, including through ads featuring popular athletes that were 

likely to appeal to youth. Since the mid-l 980s, smokeless tobacco use spread beyond its 

traditional base of older rural white men, and rates of smokeless tobacco use increased 

substantially, especially among young white males. 

CDC Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page I 
49 


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The questions in national surveys that we will be relying on to report on trends in smokeless 

tobacco use ask respondents about use of all smokeless tobacco products, without disaggregating 

this information by specific product types. 

Smokeless Tobacco Use is Hazardous 

The scientific evidence clearly shows that smokeless tobacco use is hazardous to health. At least 

28 carcinogens have been identified in smokeless tobacco products. The International Agency 

for Research on Cancer (IARC) and HHS's National Toxicology Program have concluded that 

smokeless tobacco is a known human carcinogen. IARC has concluded that smokeless tobacco 

causes oral cancer, which can require disfiguring surgery, and pancreatic cancer, which is an 

especially deadly form of cancer. Smokeless tobacco use also has significant cardiovascular 

effects, and has been linked to fatal heart attacks. Some studies have also linked smokeless 

tobacco use to adverse reproductive outcomes during pregnancy, including preeclampsia, 

premature birth, and low birthweight. Finally, smokeless tobacco use is associated with 

leukoplakia (a precancerous lesion in the mouth), gum recession and disease of the gums, and 

tooth decay. 

Smokeless Tobacco is Addictive 

Like cigarettes and other tobacco products, smokeless tobacco products contain nicotine and are 

highly addictive. Like smoking, smokeless tobacco use can lead to nicotine dependence. As 

individuals continue to use smokeless tobacco products over time, they typically increase their 

intensity of use in order to increase their nicotine dose, in the process also increasing their 

exposure to the carcinogens in these products. Smokeless tobacco users also tend to switch 

brands to increase their nicotine intake as they become more experienced users, "graduating" 

from brands with lower nicotine levels to brands with higher levels. 

Smokeless Tobacco Use by Demographic and Geographic Characteristics 

Smokeless tobacco use is not spread evenly through the U.S. population. In 2009, data from the 

National Survey on Drug Use and Health (NSDUH), which is conducted by HHS's Substance 

Abuse and Mental Health Services Administration, provided an overview of recent patterns in 

CDC Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 2 
50 


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smokeless tobacco use in the United States. Combined 2002 to 2007 data indicated that an 

annual average of3.2 percent of persons 12 years of age or older (an estimated 7.8 million 

persons) used smokeless tobacco in the past month. Certain demographic subgroups were more 

likely to use smokeless tobacco than others. Smokeless tobacco was more likely to be used 

among persons 18 to 25 years than among 12- to I 7-year olds and those 26 years or older. Males 

were more likely than females to have used smokeless tobacco (6.2 vs. 0.4 percent). American 

Indians or Alaska Natives were more likely than persons in any other racial/ethnic category to 

have used smokeless tobacco. 

Rates of smokeless tobacco use also varied geographically. Past month smokelcss tobacco use 

was highest among persons who lived in completely rural and less urbanized counties in nonmetropolitan areas and lowest among persons who lived in large metropolitan areas. Persons 

who lived in the South and Midwest were more likely than persons who lived in the West and 

Northeast to have used smokeless tobacco. 

The highest prevalence of smokeless tobacco use in recent years has been observed among 

young adults, especially males. As with use of other tobacco products, NSDUH finds that 

smokeless tobacco initiation rates are highest among adolescents and young adults. These 

patterns have also been observed in other major national surveys. Therefore, this testimony will 

focus on recent trends in smokeless tobacco use among adolescents and young adults, especially 

males. 

Recent Trends in Smokeless Tobacco Use 

Three HHS national data sources provide the best available data on these trends: (I) NSDUH, 

which tracks tobacco use among persons 12 years and older; (2) Monitoring the Future, 

supported by the National Institute on Drug Abuse, which tracks tobacco use among 8

th, lOth, and 

12th grade students; and (3) CDC's Youth Risk Behavior Survey (YRBS), which tracks tobacco 

use among high school students. 

NSDUH 

CDC Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 3 
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NSDUH reported a significant increase in smokeless tobacco use among persons 12 years of age 

and older, from 3 percent in 2004 to 3.5 percent in 2008. During these years, patterns of use 

among persons 26 years of age and older have remained stable at around 3 percent. Patterns of 

use among adolescent girls and women have also remained stable at low levels. The observed 

increase appears to have arisen primarily from an increase among men 18 to 25 years of age, 

especially men in two specific demographic groups. Among non-Hispanic white men, rates 

increased significantly, from 13.6 percent in 2003 to 15.4 percent in 2008. Additionally, among 

Hispanic men aged 18 to 25 years of age, rates of past month smokeless tobacco use increased 

significantly, from 1.9 percent in 2003 to 3.4 percent in 2008. 

Monitoring the Future 

While the NSDUH does not show significant increases among 12- to 17-year-olds, recent data 

from Monitoring the Future survey suggest that smokeless tobacco use may be increasing among 

male students in the 8t

h, loth, and lih grades. For example, the prevalence of smokeless tobacco 

use in the past 30 days among male 8th grade students increased from 4.7 percent in 2007 to 6.3 

percent in 2009. Also, among 12th grade boys, rates of use in the past 30 days increased overall, 

from 11.0 percent in 2006 to 15.8 percent to 2009. 

Data on perceived risk of harm has been found to be a reliable leading indicator for emerging 

trends in adolescent cigarette smoking, marijuana use, and alcohol use. In 2009, perceptions of 

health risk from smokeless tobacco use declined among 8th, 10th, and 12th grade students, with 

the decline among lOth graders being significant. This decrease reversed a previous trend toward 

increased perceived risk. 

YRBS 

Data from the YRBS show similar trends. Smokeless tobacco use among female high school 

students remained unchanged and very low from 1995 to 2009, at about 2 percent. However, the 

most recent data indicate that rates of use among male high school students are increasing 

significantly. Unpublished analyses of trends in smokeless tobacco use within the YRBS, 

including data for 2009 which will be released by this summer, show recent significant increases 

CDC Statement for hearing entitled. "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 4 
52 


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in smokeless tobacco use among males overall and among non-Hispanic whites overall from 

2003 to 2009. 

Most Smokeless Tobacco Users Initiate Use as Teens or Young Adults 

As with smoking, most smokeless tobacco use begins during the adolescent and young adult 

years. Combined data from the NSDUH from 2002 to 2007 indicates that few adults 26 years or 

older reported initiating smokeless tobacco use. Data from the NSDUH also show that the 

number of Americans 12 years and older who used smokeless tobacco products for the first time 

in the past 12 months increased significantly, from 951,000 in 2002 to 1.4 million in 2008. 

Almost half of the first-time users in 2008 reported that they were younger than 18 when they 

first used smokeless tobacco products, and almost three-fourths of them were male. From 2004 

to 2007, rates of smokeless tobacco use initiation increased significantly for males 12 to 17 and 

18 to 25 years of age. 

Many People Are Using Both Cigarettes and Smokeless Tobacco 

Traditionally, cigarette smokers and smokeless tobacco users were fairly distinct groups. 

However, in recent years there appears to be a trend toward dual use of these products. In 

looking at patterns of smokeless tobacco use across several national surveys, we find that a large 

proportion of smokeless tobacco users are also smoking cigarettes. This pattem of dual use is 

more common among adolescents and young adults than among older Americans. 

An analysis of data from CDC's Behavioral Risk Factor Surveillance System from 10 states 

found a pattern of current smoking being associated with current use of another tobacco product, 

particularly smokeless tobacco, particularly for males 18 to 29 years of age. This analysis found 

that 26 percent of adult male smokers used another tobacco product, particularly smokeless 

tobacco. The proportion of adult smokers using other tobacco products was twice as high among 

18- to 29-year-olds as among those 45 years and older. 

In 2008 NSDUH data, 23.9 percent of persons 12 years and older were current cigarette smokers, 

and 3.5 percent used smokeless tobacco. Data reported from the NSDUH for the years 2002 to 

2007 show that more than a third (38.8 percent) of all past-month smokeless tobacco users 12 

CDC Statement for hearing entitled, "Smokeless Tobacco: hnpact on the Health of Our Nation's Youth and Use in 

Major League Basehall" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 5 
53 


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years of age and older had also used cigarettes in the past month. Thus, the proportion of the 

overall population 12 years and older of both genders that reported using both products was 

about 1.4 percent. 

However, patterns of use of both cigarettes and smokeless tobacco are not evenly distributed 

across the U.S. population. The proportion of past-month smokeless tobacco users who also 

used cigarettes in the past month increased to more than one half (52.8 percent) for persons 12 to 

17 years and to two-thirds (66.9 percent) for persons 18 to 25 years of age. In 2008, 15.4 percent 

of non-Hispanic white men 18 to 25 years of age reported past month use of smokeless tobacco. 

Therefore, about 10 percent of this population of young men report past month use of both 

cigarettes and smokeless tobacco. 

A recent, more detailed study examined this pattern of current smokers also using smokeless 

tobacco products using data from four national surveys. This study found that this association 

appears to be different for younger people than for older men who use smokeless products daily. 

This report found that the prevalence of daily smoking is very high among male students in 

middle school and high school who use smokeless tobacco. Additionally, these researchers 

found that non-daily, or "some day," users of moist snuff were more likely to be current smokers 

than any other group, and that this pattern was especially common among adolescents and young 

adult users of smokeless tobacco products. 

The Changing Context of Tobacco Use in the United States 

These patterns of use of smokeless tobacco products need to be placed within the changing 

context of tobacco use in the United States, including declining cigarette use, increasing smoking 

restrictions and decreasing social acceptability of smoking, and a change in the cigarette and 

smokeless tobacco industry and in marketing of these products. 

CDC Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 6 
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Cigarette Use 

Per capita cigarette consumption has decreased to its lowest point in over 60 years, and 

prevalence of current cigarette smoking among youth is at its lowest point since consistent public 

health tracking began in 1975. 

Smoking Restrictions 

Additionally, the number of Americans living under state or local laws banning smoking in 

workplaces and public places has increased significantly in recent years, reducing opportunities 

to smoke in many indoor settings. 

The Changing Smokeless Tobacco Market 

Researchers have pointed out that the smokeless tobacco product market has changed in recent 

years. In contrast to the situation that existed until 2006, when the smokeless tobacco market in 

the United States was represented primarily by companies that did not manufacture cigarettes, 

recent mergers and acquisitions have resulted in most of the production and sales of smokeless 

tobacco products concentrated in major cigarette manufacturing companies. 

Smokeless Tobacco Is Available in a Number of New Forms 

In recent years yet another new generation of smokeless tobacco products has entered the U.S. 

market. These products are now widely available in a number of new forms, including snus, a 

form of moist snuff, and "dissolvable" products such as lozenges, orbs, sticks, and strips. These 

novel smokeless products are available in a range of flavors, which research suggests makes 

products more attractive to youth. Like snus, these products may also be more appealing than 

traditional smokeless tobacco products to youth and females because they do not require spitting 

and can be used discreetly. In fact, young people can use these products in school or at home 

without their teachers or parents being aware that they are using tobacco. The appearance of 

these products, some of which look like breath mints, may also lead children and teens to 

perceive that they are harmless and may even disguise the fact that they contain tobacco. 

CDC Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 7 
55 


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Smokeless Tobacco Products Are Heavily Promoted 

These moist snuff varieties and more recent variations of smokeless tobacco products are heavily 

advertised and promoted. Sales of the "moist snuff' category of smokeless tobacco products 

have increased annually since 1986, with the volume sold doubling over this period. 

Additionally, the advertising and promotional expenditures for this moist snuff category of 

smokeless tobacco products increased from $210 million in 2005 to $308 million in 2006, the 

most recent year for which these data have been reported. The timing of this increase is 

significant, since, as noted above, 2006 was the year when U.S. cigarette manufacturers began 

acquiring large smokeless tobacco concerns and marketing smokeless tobacco and snus named 

after leading cigarette brands. Researchers have suggested that test marketing of new smokeless 

tobacco product lines and other promotional campaigns have been concentrated in areas with 

large college student populations and in large urban areas with recently implemented smoke-free 

laws. There is also evidence that youth continue to be exposed to smokeless tobacco advertising 

in magazines, including sports-oriented magazines. 

Professional athletes in certain sports, including baseball and rodeo, have traditionally had high 

levels of smokeless tobacco use. Athletes serve as role models for youth, and smokeless tobacco 

manufacturers have used advertising, images, and testimonials featuring athletes and sports to 

make smokeless tobacco products appear attractive to youth. Children and teens closely observe 

athletes' actions, including their use of tobacco products, and are influenced by what they see. 

Adolescents tend to mimic the behaviors of those they look up to and identify with, including 

baseball players and other athletes. Research suggests that male high school athletes may be at 

especially high risk for smokeless tobacco use. 

Of particular concern, many of the new smokeless tobacco products are being marketed as a way 

for smokers to satisfy and sustain their nicotine addiction when they are in settings where they 

cannot smoke. In fact, ads for snus and other smokeless tobacco products explicitly promote 

these products as a way to use tobacco in workplaces, restaurants, sports arenas, airplanes, and 

other locations covered by smoke-free policies. Smokers may readily interpret these advertising 

CDC Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 8 
56 


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messages to mean that they can use smokeless tobacco products when they are in locations 

where they are not allowed to smoke while continuing to smoke in other locations. This may 

contribute to the trend towards dual use of cigarettes and smokeless tobacco discussed 

previously. 

Potential Impact on Population Public Health 

These emerging trends toward dual use of cigarettes and smokeless tobacco products among 

young adults raise some potentially serious concerns. First, public health researchers have 

suggested that many smokers who would otherwise have quit in response to the widespread 

implementation of smoke-free policies in workplaces and public places will continue smoking, 

since they can use smokeless tobacco products where smoking is prohibited and still continue to 

smoke where such bans are not in effect, thereby eradicating any beneficial behavioral 

modification that smoke-free policies would encourage. Second, the emerging trends suggest 

that the behavior pattern of using both cigarettes and smokeless tobacco products is changing 

among adolescents and young adults. This is of concern because long-term use of both of these 

products may pose health risks beyond those posed by smoking cigarettes alone. Even if dual 

use of cigarettes and smokeless tobacco products delay quitting rather than preventing it 

altogether, this would still pose a significant threat to public health. Duration of smoking is a 

key factor determining risk of adverse health effects, especially with regard to lung cancer and 

other forms of cancer. Even if concurrent use of smokeless tobacco leads smokers to smoke 

fewer cigarettes per day, the fact that they are continuing to smoke results in an increased risk for 

many diseases caused by smoking, particularly heart disease. The longer dual use of cigarettes 

and smokeless tobacco postpones complete cessation of smoking and tobacco use, the greater 

smokers' risk of developing lung cancer and other serious diseases. 

Conclusion 

Significant progress has been made toward ending the tobacco epidemic in the United States in 

recent decades. However, the data I have presented on the national trends in smokeless tobacco 

product use raise concerns that could potentially put this progress in jeopardy. Again, the bottom 

line is that there is NO safe form of tobacco use, including smokeless tobacco use. The best way 

CDC Statement for hearing entitled, "Smokeless Tobacco: tmpact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 9 
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to protect one's health is to refrain from using ANY tobacco product or, if one is already a user, 

to quit ALL tobacco use. The recent increases in smokeless tobacco use by adolescent boys and 

young adult men and the increasing dual use of cigarettes and smokeless tobacco products may 

portend a leveling off or even a reversal in the decline in smoking, the perpetuation of nicotine 

dependence, and continuing high levels of tobacco-related disease and death in the country. 

Thank you again for this opportunity. I would be happy to answer any questions. 

CDC Statement for hearing entitled, "Smokeless Tobacco: hnpact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 10 
58 

Mr. PALLONE. Thank you, and thank you for being mindful of the 

time. I appreciate it. 

Dr. Winn. 

STATEMENT OF DEBORAH WINN 

Ms. WINN. Thank you. Good morning. I am Deborah Winn, deputy director of the Division of Cancer Control and Population 

Sciences, National Cancer Institute, National Institutes of Health. 

Thank you, Chairman Pallone and distinguished members of the 

committee for the opportunity to be here to discuss smokeless tobacco and its health consequences. 

It is well established that the use of smokeless tobacco causes 

cancer of the mouth and throat, esophagus and pancreas. As far 

back as 1985, the Advisory Committee to the U.S. Surgeon General 

examined literature on health consequences associated with use of 

snuff and concluded that the evidence is strong that the use of 

snuff can cause cancer in humans. The evidence for causality is 

strongest for cancer of the oral cavity. The excess risk of cancer of 

the cheek and gums may reach nearly 50 fold in long-term snuff 

users. Global health authorities have also reached similar conclusions. The World Health Organization’s International Agency for 

Research on Cancer, which I will call IARC, convenes expert panels 

to evaluate the world’s scientific literature on environmental 

agents to determine whether those agents cause cancer. Those reports are considered to be highly authoritative and are used extensively worldwide to provide the scientific basis for public health action. This group has evaluated the carcinogenicity of smokeless tobacco three times over the past 25 years and I served as a member 

of all three panels. In 2009, IARC concluded that the use of smokeless tobacco causes cancer of the mouth, throat, esophagus and 

pancreas. These findings were based on international data from 

North America, Scandinavia and Asia, among other places. Using 

smokeless tobacco is associated with at least a fourfold increased 

risk of oral cancer. 

Scientists have a fairly clear understanding of how smokeless tobacco causes cancer. It contains carcinogens, the most common of 

them being the tobacco-specific nitrosamines. Cancer may develop 

when metabolites of nitrosamines attach to DNA causing a genetic 

mutation. This mutation leads to other cellular disruptions and ultimately results in cancer. Nitrosamines are found in all tobacco 

products and are not safe at any level. 

In addition to cancer, smokeless tobacco users are more likely 

than non-users to develop leukoplakia, or white patches in the 

mouth that can lead to cancer. Other changes in the lining of the 

mouth related to smokeless tobacco include wrinkling of the inner 

cheek and gums and color changes. In the 1980s, a national survey 

of teens found that more than 25 percent of children who used 

smokeless tobacco have these changes compared to less than 1 percent of children who did not use smokeless tobacco. 

Cancer and leukoplakia are not the only adverse health effects 

linked to smokeless tobacco. It is also associated with gum disease, 

dental caries and reproductive effects such as decreased fetal 

growth, increased risk of preterm delivery and stillbirth. Other serious effects may include increase risk of heart attack and stroke. 


rfrederick on DSK6VPTVN1PROD with 
59 

A recent summary of data regarding this subject showed that 

smokeless tobacco increased the risk of fatal heart attack by 13 

percent and death from stroke by 40 percent. Although more research is needed to firmly establish whether smokeless tobacco is 

a risk factor for heart attack and stroke, these studies suggest that 

smokeless tobacco may lead to serious health consequences other 

than cancer. 

Smokeless tobacco should not be substituted for cigarettes. A 

large study done by the American Cancer Society examined the 

health impact of quitting cigarette smoking versus substituting 

smokeless tobacco for cigarette smoking. It compared more than 

110,000 cigarette smokers who quit smoking and did not use any 

other tobacco products with 4,400 smokers who switched from 

smoking cigarettes to using smokeless tobacco. After 20 years of 

follow-up, the risk of dying was 8 percent higher among those who 

switched to smokeless tobacco than among those who quit tobacco 

use entirely. Those who switched from smoking to smokeless also 

had a 46 percent higher risk of dying from lung cancer, a 13 percent higher risk of coronary heart disease and a 24 percent higher 

risk of death from stroke compared to those who quit tobacco entirely. In another study, using both smokeless tobacco and cigarettes had a higher risk of heart attack than the risks of using either one or the other. 

It is important that people understand that there is no scientific 

evidence that using smokeless tobacco can help a person quit smoking. It does not provide a safer alternative to cigarettes. All tobacco 

products are harmful and cause cancer and there is no safe level 

of tobacco use. 

I want to switch to media findings. Research findings show that 

when adolescents associate a particular behavior with people or 

personality characteristics they admire, they are more willing to 

try that behavior because adolescents identify with such people. 

Baseball players like many athletes serve as role models and are 

probably considered the quintessential users of smokeless tobacco. 

There are high rates of smokeless tobacco advertising in magazines 

such as Sports Illustrated. Considerable research has demonstrated 

that smoking in movies or on TV increases positive attitudes towards smoking and intentions to smoke in update of tobacco use 

among adolescents. There is also evidence that positive role models 

can help prevent smoking onset. Several studies show that celebrity health behavior such as Magic Johnson’s announcement of his 

HIV status or Katie Couric’s televised colonoscopy on the Today 

show have immediate positive impacts, so actions taken by baseball 

players to discourage the use of smokeless tobacco could also have 

positive impact on youth behaviors. 

We focus today on smokeless tobacco. However, the scientific evidence continues to confirm that tobacco use in any form causes 

cancer. All tobacco products contain harmful chemicals, and no 

matter how they are presented in advertisements, be warned that 

all tobacco products are dangerous. The only way to reduce death 

and disease caused by tobacco use is to prevent youth from starting 

to smoke and to help current smokers to quit. These must remain 

our highest priorities, and I appreciate the opportunity to talk to 

you today. 


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[The prepared statement of Ms. Winn follows:] 


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Testimony 

Before the 

Subcommittee on Health 

Committee on Energy and Commerce 

United States House of Representatives 

Hearing entitled, "Smokeless Tobacco: Impact on the Health of 

our Nation's Youth and Use in Major League Baseball" 

Statement oj 

Deborah M. Winn, Ph.D. 

Deputy Director, Division of Cancer Control and Population 

Sciences 

National Cancer Institute 

National Institutes of Health 

U.S. Department of Health and Human Services 

For Release on Delivery 

Expected at 10:00 a.m. 

Wednesday, April 14, 2010 
62 


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Good morning, Chairman Pallone and Members of the Subcommittee. I am Dr. Deborah Winn, 

Deputy Director of the Division of Cancer Control and Population Sciences, National Cancer 

Institute (NCI) at the National Institutes of Health, an agency of the Department of Health and 

Human Services. Thank you for the opportunity to be with you today to discuss smokeless 

tobacco and its health consequences. I will also provide scientific evidence demonstrating the 

impact that media and celebrities' health behaviors have on tobacco use among youth. 

Effects of smokeless tobacco on health 

Use of smokeless tobacco is an established cause of cancers in the mouth (cancer of the oral 

cavity) and pharynx (part of the throat), esophagus, and pancreas. In 1985, the Advisory 

Committee to the U.S. Surgeon General examined literature on the health risks associated with 

use of snuff, a type of smokeless tobacco, and coneluded that: "The scientific evidence is strong 

that the use of snuff can cause cancer in humans. The evidence for causality is strongest for 

cancer of the oral cavity, wherein cancer may occur several times more frequently in snuff 

dippers compared to non-tobacco users. The excess risk of cancer of the cheek and gum may 

reach nearly fifty fold among long-term snuff users." 

The International Agency for Research on Cancer (known as IARC), a part of the World Health 

Organization, routinely convenes expert panels to evaluate the world's scientific research 

literature on environmental agents to determine whether exposure to those agents causes cancer. 

It evaluated the carcinogenicity of smokeless tobacco three times. I participated as an invited 

expert on all three panels. These reports are considered to be highly authoritative and are used 

extensively worldwide to provide the scientific basis for public health action. In 1985, !ARC 

convened an international working group of experts in smokeless tobacco that concluded that 

smokeless tobacco is a cause of oral and pharyngeal cancer. In 2004, the lARC panel reaffirmed that using smokeless tobacco causes oral cancer and also concluded that smokeless 

tobacco is a cause of pancreatic cancer. In 2009, IARC added esophageal cancer to the list of 

cancer types caused by smokeless tobacco use. 

NCI Statement for bearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page I 
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The evidence that smokeless tobacco causes cancer is based on studies in human populations, 

studies in animal models, and studies that help us understand the biological mechanisms 

involved in the development of cancer. First, I will tell you about the findings in studies in 

human populations, called epidemiology studies. Researchers conducting epidemiology studies 

rely on a variety of study designs to learn more about risk factors, such as smokeless tobacco 

use, for disease. For example, case-control studies compare past smokeless tobacco use in a 

group of people with the cancer of interest to smokeless tobacco use in people without the cancer 

of interest. Cohort studies ask people about their tobacco use behaviors and then follow these 

people for a period of years or decades to determine the rates of developing cancer among groups 

with different tobacco use behaviors. Both case-control and cohort studies show that use of 

smokeless tobacco products for at least 6 months is associated with a 4-or-greater-fold increased 

risk of oral cancer. Some studies demonstrate that risks of oral cancer increase with increasing 

times per day or years of use of smokeless tobacco products. 

Other important risk factors for oral and pharyngeal cancers, esophageal cancer, and pancreatic 

cancer are smoking and heavy alcohol intake. However, these factors do not account for the 

effect of smokeless tobacco on the risk of these cancers. Additionally, obesity is a risk factor for 

pancreatic cancer; but smokeless tobacco remains associated with pancreatic cancer risk even 

after we take the effect of obesity on pancreatic cancer into account. 

Smokeless tobacco products are vastly different around the world. In some geographic regions 

such as Scandinavia, smokeless tobacco use is quite common. The IARC panel found that 

smokeless tobacco use was associated with an increased risk of oral cancer regardless of how the 

tobacco products were formulated or used in places across the globe ranging from North 

America to Scandinavia, Africa, and Asia. 

In addition to periodontal (gum) and dental caries (tooth decay) effects, smokeless tobacco users 

more frequently than non-users develop leukoplakias, white patches in the mouth, and frequent 

and longer-term users have more patches. Leukoplakias can be pre-cancerous and, in some 

adults who have leukoplakia, cancer may arise. Changes in the lining of the mouth related to 

NCI Statement for hearing entitled, "Smokeless Toba~co: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 20 I 0 

House Energy and Commerce Subcommittee on Health Page 2 
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smokeless tobacco can occur in young people as well. A national oral examination survey of 

children ages 12 to 17 years in the 1980s found that 27% of children who used smokeless 

tobacco but only 0.4% of children who did not use smokeless tobacco had changes in their 

mouths that involved wrinkling of the surface of the lining of the mouth and color changes 

ranging from normal to white, or gray. 

Potential reproductive effects of smokeless tobacco include decreased fetal growth and increased 

risk of preterm delivery and stillbirth. 

Studies in laboratory animals including rats and mice also show that smokeless tobacco causes 

cancer. Smokeless tobacco contains tobacco-specific nitrosamines. Nitrosamines are a chemical 

family that includes some known carcinogens. Tobacco-specific nitrosamines are found only in 

tobacco products. These include 4-(methylnitrosamino )-1-(3-pyridyl)-I-butanone (NNK) and 

N'-nitrosonomicotine (NNN). !ARC has determined that there is sufficient scientific evidence 

that NNK and its metabolite 4-(methylnitrosamino)-I-(3-pyridyl)-I-butanol (NNAL) and NNN 

are carcinogens in experimental animals. NNN and NNK, or their metabolites, can be found in 

the saliva and urine of smokeless tobacco users. 

Scientists have a fairly clear understanding of the biological mechanisms whereby smokeless 

tobacco use causes cancer. One main pathway to carcinogenesis occurs when metabolites of 

chemicals found in smokeless tobacco attach to DNA, causing a genetic mutation. This mutation 

leads to other cellular disruptions and ultimately results in cancer. Other carcinogens found in 

small amounts in smokeless tobacco are aldehydes and metals. 

Smokeless tobacco is addictive. The landmark 1988 report, The Health Consequences of 

Smoking: Nicotine Addiction: A Report of the Surgeon General, which focused on nicotine 

addiction, had three major conclusions: 

1. Cigarettes and other forms oftobacco are addicting. 

2. Nicotine is the drug in tobacco that causes addiction. 

NCI Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 3 
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3. The phannacologic and behavioral processes that determine tobacco addiction are similar 

to those that determine addiction to drogs such as heroin and cocaine. 

Cancer is not the only adverse health affect associated with the use of smokeless tobacco. A 

recent report summarized the data from relevant studies in the medical literature regarding use of 

smokeless tobacco and myocardial infarction (also known as "heart attack") and stroke. Of the 8 

studies, primarily studying men, "ever use" of smokeless tobacco was associated with a 13% 

increased risk of fatal heart attack. Of the 5 studies examining the incidence of stroke, ever use 

of smokeless tobacco was associated with a 40% increase of stroke. If non-fatal heart attacks or 

strokes were included in the analyses, the risks were somewhat lower. The risks did not appear 

to increase with greater years or frequency of smokeless tobacco use. More research is needed to 

assess smokeless tobacco use as a risk factor for heart attack and stroke and to determine the 

preventive value of strategies designed to aid cessation of smokeless tobacco use. 

The American Cancer Society Cancer Prevention Study II focused on the consequences of 

quitting cigarette smoking versus substituting smokeless tobacco for cigarette smoking. This 

study compared 111,952 cigarette smokers (with no other tobacco use behaviors) who quit 

smoking entirely with 4,443 smokers who switched from smoking to using smokeless tobacco. 

After 20 years offollow-up, the risk of dying from lung cancer, coronary heart disease, stroke 

and obstructive pulmonary disease was higher among those who switched from smoking to 

smokeless tobacco use than among those who quit smoking entirely. A case-control study of risk 

of myocardial infarction showed that persons who smoked tobacco and used snuff had a greater 

risk of heart attack than those who only smoked. Even light and intermittent cigarette smoking 

NCI Statement for hearing e~iitled, "S;;-'okeless Tob~cco: Impact on the He~ith~fO;;;:-Nation's YouthlmdUse in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 4 
66 


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increase the risk for cardiovascular diseases, lung cancer, certain other diseases, and all-cause 

mortality. Because of these findings regarding increased heart attack risks in those who switched 

from smoking to smokeless and the health risks even among light and intermittent smokers, there 

is great concern about health consequences to persons who both smoke cigarettes and use 

smokeless tobacco. These additional risks could significantly impact the manner in which the 

risks of smokeless tobacco use would be communicated to the pUblic. 

Effects of media and celebrities' health on youth risk behaviors 

Research findings show that adolescents engage in more risky behaviors, including tobacco use, 

to the extent that they endorse positive prototypes of individuals who engage in those behaviors. 

In short, when adolescents associate a particular behavior with people or personality 

characteristics they admire, they are more willing to try that behavior. This happens in part 

because adolescents identifY with the prototype. Baseball players, like many athletes, serve as 

role models and prototypes, and are probably considered the "prototypical" user of chewing 

tobacco. There is also corollary evidence that positive role models can help prevent smoking 

onset. There are high rates of smokeless tobacco advertising in magazines read by youth, several 

of which are sports-related. Considerable research has demonstrated effects of smoking in the 

entertainment media (e.g., movics and television characters) on uptake of tobacco use among 

adolescents. Exposure to smoking in movies increases positive attitudes toward smoking and 

intentions to smoke. Epidemiologic studies consistently demonstrate a dose-response 

relationship between exposure to smoking in movies and smoking initiation, after controlling for 

peer and family smoking, parenting style, sensation seeking, and demographic characteristics 

such as gender and ethnicity. These findings have also been replicated in other cultures. 

Several opportunistic studies show that celebrity health behaviors (e.g., Magic Johnson's 

announcement of his HIV status and Katie Couric's televised colonoscopy on the Today show) 

have immediate behavioral effects. 

NCI Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 2010 

House Energy and Commerce Subcommittee on Health Page 5 
67 


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Although I have focused today on smokeless tobacco, the scientific evidence continues to 

confirm that tobacco use in any form causes cancer. NCI encourages anyone who does not use 

tobacco not to start and encourages anyone who does use tobacco to quit. There are many 

effective approaches at the community and the individual level to prevent tobacco initiation and 

to quit. 

Thank you for this opportunity to present this information to you. I would be happy to answer 

any questions. 

NCI Statement for hearing entitled, "Smokeless Tobacco: Impact on the Health of Our Nation's Youth and Use in 

Major League Baseball" April 14, 20 I 0 

House Energy and Commerce Subcommittee on Health Page 6 
68 

Mr. PALLONE. Thank you, Doctor. 

We are going to now take questions, 5 minutes from those who 

gave opening statements, and we have a few members who passed 

so they get 8 minutes for questions, and I will start with myself. 

Both of your testimony indicates strongly that smokeless tobacco 

causes cancer, and we have talked a lot about smoking tobacco and 

the different chemicals that make up a cigarette that cause cancer. 

Now, you started how it works with chewing tobacco when there 

is no smoking relation and how that causes cancer, but just explain 

it to me again because it wasn’t too clear to me. What is it that 

causes the cancer? And then you specifically mentioned pancreatic 

which, you know, I often mention pancreatic at our hearings because my mom passed away from pancreatic cancer, and most people don’t know, you know, when you ask what is the cause of pancreatic cancer, generally speaking, the answer is, we don’t know, so 

if you would just reiterate some of that. 

Ms. WINN. Sure. I will start with pancreas cancer first, and important causes of pancreatic cancer are smoking and smokeless tobacco. Heavier weight is also associated with pancreatic cancer risk 

but there is certainly a great deal more than we need to learn regarding pancreatic cancer risk because we know that it is often 

identified at an advanced stage. 

With regard to how smokeless tobacco causes cancer, tobacco-specific nitrosamines are—nitrosamines are a category of carcinogens, 

and tobacco-specific nitrosamines are found only in tobacco products, and tobacco products contain these. They have been found in 

experimental animals to cause cancer. We also have done experiments that show the progression from metabolites of these 

nitrosamines, which attach to DNA that causes a replication error 

in the DNA when the DNA—— 

Mr. PALLONE. But in other words, you don’t inhale it, so how 

does it get into your system? 

Ms. WINN. Because you are ingesting. 

Mr. PALLONE. Just through your stomach, in other words, 

through your digestive system? 

Ms. WINN. Right. 

Mr. PALLONE. And then, you know, we get these muddled messages about substituting smokeless for tobacco for just smoking. I 

mean, you have made it quite clear that you think that they are 

both dangerous, but what about this idea that somehow you can 

substitute smokeless and that somehow weans you off actually 

using cigarettes? 

Ms. WINN. There certainly are differences in risks between 

smokeless tobacco and smoking. However, what counts is the potential effect on the population of giving advice to recommend 

using smokeless tobacco. We have to consider that that type of a 

message may delay or halt some people from quitting smoking who 

might have quit smoking through some other means. We also know 

that smokeless tobacco is a gateway to smoking among young children. For example, in one study of adolescent boys, the boys who 

used smokeless tobacco and no other tobacco product were three 

times more likely 4 years later to be using—— 

Mr. PALLONE. Because there are studies that show that the perception of risk from smokeless tobacco is declining among youth, so 


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bottom line, they may figure well, I better not smoke a cigarette 

but I will chew instead, and then they get addicted. We can’t give 

the impression out that somehow that is OK because what you are 

saying is, it often leads to smoking cigarettes. 

Ms. WINN. Absolutely, and there are no safe levels, and smokeless tobacco causes a variety of diseases. 

Mr. PALLONE. Let me ask Dr. Pechacek, your testimony explains 

how the scientific evidence clearly shows that smokeless tobacco is 

hazardous, that 28 carcinogens have been identified in smokeless 

tobacco. They cause specific physical feelings and effects, cardiovascular effects, fatal heart attacks. I mean, it seems to me that 

this is totally contrary to what a baseball player or any athlete 

would want to do, so how does tobacco use specifically affect the 

performance of an athlete, in particular a baseball player? Because 

young athletes, if they are paying attention, it would seem to me 

that it would hurt their athletic performance, not enhance it in any 

way. So what is the message there in terms of what it means if 

you are young and you start using this stuff? 

Mr. PECHACEK. Well, first of all, our advice to both major league 

or youth baseball players is that like any other person, anyone who 

is using any form of tobacco, we would encourage them to quit as 

early in life as possible. It is especially important for the baseball 

players who are setting an example because like parents, teachers 

and coaches, they serve as role models to children and adolescents. 

With respect to the specific aspects on performance, I can provide 

you more detail on that from the previous work that has been done 

in the Surgeon General reports but the key point is that all users, 

particularly young adolescents and young adults who are following 

those role models, need to be aware that all forms of tobacco are 

addictive and cause cancer and serious health effects and that quitting all forms of tobacco use as early in life as possible will be very 

beneficial to their long-term health. 

Mr. PALLONE. But I think they almost get the impression, young 

people, that somehow it enhances athletic performance and clearly 

it is the opposite in terms of performance. 

Mr. PECHACEK. Well, the aspects of this and how youth perceive 

the product have been reviewed in past Surgeon General reports, 

most in detail in the 1994 Surgeon General report on the impact 

of tobacco on youth and young people. We are currently updating 

that report, which will be out next year, and are going into how 

these current patterns of smokeless tobacco are being perceived by 

youth and are impacting their overall decisions about what they 

are doing with using all tobacco products. 

Mr. PALLONE. Thank you. 

The gentleman from Illinois. 

Mr. SHIMKUS. Thank you, Mr. Chairman. 

Dr. Pechacek and Dr. Winn, I am getting conflicting briefing 

things. You are listed as doctors but in here it says Ph.D.’s. Are 

you medical doctors that have Ph.D.’s, or what is the title here? 

Mr. PECHACEK. Ph.D., so I am an epidemiologist. 

Ms. WINN. I have a Ph.D. in epidemiology. 

Mr. SHIMKUS. Great. Thank you. 

Dr. Winn, we have had hearings, and I am new in the ranking 

member position, on the NCI and we appreciate the great work 


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that the cancer institute does and we really are starting to focus 

on cost-benefit analysis, where the money goes, biggest return on 

investment versus the politicizing of some research dollars, and we 

will get more involved in that in the future, but what is the deputy 

director of the Division of Cancer Control and Population Sciences? 

For the layman, what does that mean? 

Ms. WINN. That means that we are the division that is responsible for understanding environmental exposures and genetic factors that may be linked to cancer in human population studies. We 

are responsible for the cancer registry system. We are responsible 

for understanding the effects of cancer on people’s outcomes in 

terms of quality of life, physical functioning after cancer. We are 

responsible for understanding the access to cancer care, quality of 

cancer care in the United States. 

Mr. SHIMKUS. Thanks. I think that helps. But in this hearing, we 

are focusing on Major League Baseball but there are other environmental issues that we could probably address. I don’t want to get 

raked over the coals but I represent deep southern Illinois, and of 

course NASCAR is well known for its advertising. Country and 

western music—I think most people identifying chewing tobacco 

use with the West and cowboy use and all those. Have you done 

similar focuses on or has our committee or are we just focusing on 

one area, Major League Baseball, and not looking at other environmental impacts? 

Ms. WINN. Most of the research that I presented was not done 

in tobacco in baseball players. Virtually all of the research that I 

have presented has either been in national surveys of schoolchildren or other populations. 

Mr. SHIMKUS. Great, and let me follow up with this, and then I 

will go to Dr. Pechacek. In your testimony, you said any tobacco 

use—I mean, my colleague, Mr. Buyer, is really on this risk avoidance and mitigation stuff but your testimony says that patches or 

nicotine gum is not any help in reducing nicotine and tobacco use 

for anyone. 

Ms. WINN. No, there are effective ways of quitting use of tobacco. 

Mr. SHIMKUS. That is fine. That is really I wanted to get record 

of. What you stated, I thought that you—and I think a lot of us 

would say, no, we want to encourage people to eliminate nicotine 

input over time, and most people can’t do cold turkey. Some can’t. 

But I think there are some risk avoidance and mitigation-type stuff 

and I know my colleague will follow up on that. 

Dr. Pechacek, according to a December 2009 report from the 

Campaign for Tobacco Free Kids, only one State currently funds a 

tobacco prevention program at the level recommended by the CDC. 

Do you agree with that assessment? 

Mr. PECHACEK. We are continuing to work with our States, and 

it depends on what year. The most recent put out by the Campaign 

for Tobacco Free Kids, their criteria found that only one State met 

our guidelines for recommended funding. 

Mr. SHIMKUS. And so our focus probably should be, if we are serious about this, is calling in the States and asking them why aren’t 

they fully funding the tobacco cessation plans as recommended by 

the CDC. Don’t you think that would be another good approach? 


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Mr. PECHACEK. The CDC is very clearly on this recommendations 

to the States and about what works and what levels of investment 

would be most effective. We are in regular dialog with our States 

about comprehensive State programs and local tobacco programs 

that use the evidence-based approaches that have been shown to 

be effective and to be reducing rates of both youth and adult tobacco use. 

Mr. SHIMKUS. Thank you. That goes to my opening statement 

where I talk about the master settlement agreement, which would 

be about $206 billion over 25 years that the tobacco companies 

would pay. Don’t you think it is pretty egregious that only 30 percent of that money has gone to health care and only 3.5 percent 

of those funds go to tobacco control like smoking cessation and education programs? 

Mr. PECHACEK. CDC has been very consistent in providing evidence both to policymakers and individual States and to the other 

groups. 

Mr. SHIMKUS. You are being very political, and I appreciate that. 

My point is, the State attorneys general have a master settlement 

agreement which should have brought billions of dollars into 

States. The States have used that money to do other things other 

than health care and education. You have also testified that you 

have recommended to States that they do an educational program, 

believing that an exponential decrease in tobacco use by kids would 

occur if they would at least fully fund tobacco cessation and educational programs. I think if you go to the conclusion here, we have 

States who received billions of dollars who have not funded health 

care, who have not done cessation programs, and now to a point 

of we see an uptick in at least chew tobacco increase by kids, which 

is another example of us failing to do the job that we are asked to 

do and in essence took money for, thus showing how inept we are 

at doing the jobs we are asked to do by the public, and I yield back 

my time. 

Mr. PALLONE. Thank you. 

Ms. Eshoo. 

Ms. ESHOO. Thank you. 

Dr. Winn and Dr. Pechacek, can you tell us what CDC and the 

National Cancer Institute have observed with regard to use of 

smokeless tobacco by teenagers? 

Mr. PECHACEK. In my testimony, I reviewed the latest evidence 

that multiple surveys have shown an increase in smokeless tobacco 

use overall in youth populations. The data that we are going to be 

releasing this summer is the National Objective Youth Use Tobacco 

Survey showing an increase in smokeless tobacco use among adolescent males, high school males overall and white students. 

Ms. ESHOO. And in the minority community? 

Mr. PECHACEK. The NSDUH survey has found that when it is 

looking at the recent increases nationwide in smokeless tobacco use 

over the last 4 to 5 years, that the greatest increases have been in 

non-Hispanic white and Hispanic males. So while there have been 

traditionally higher rates of use in some other demographic groups, 

non-Hispanic white males and Hispanic males are the ones who appear to be showing the greatest increases in recent years. 


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Ms. ESHOO. Do you have any thoughts on what accounts for 

these increases in smokeless tobacco use? I mean, obviously we 

have representatives from baseball here today. I think that everything that adults do from being a parent to obviously anyone in 

sports is a—you know, they are the gladiators of the 20th and the 

21st century. So they heavily influence young people. I think we do 

as well. Congress isn’t always known for putting forward all of its 

best but certainly when there is something that goes wrong here, 

by example of an individual member, that says something to the 

people of our country and obviously young people. So do you have 

anything that you want to tell us about what you think accounts 

for these increases in smokeless tobacco use? 

Mr. PECHACEK. Yes. As the comments that in my written testimony which we submitted is that these recent upticks need to be 

placed in the changing context of tobacco use in this country. 

Smoking rates are down and restrictions on smoking in public 

places are increasing, particularly in your State of California. And 

overall we have observed that there is an increasing social acceptability of smoking. 

However, while these things are occurring, there have been significant changes in the smokeless tobacco industry and how smokeless tobacco products are marketed. Until 2006, smokeless tobacco 

was largely produced by companies that did not manufacture cigarettes. Now major cigarette manufacturing companies produce and 

sell most smokeless tobacco products in the United States. In recent years, these companies have been marketing smokeless tobacco and snus named after their leading cigarette brands. The advertising and promotional spending on these types of moist snuff 

products increased by 50 percent between 2005 and 2006, the latest 

year in which these data have been reported. This timing is significant because it was at this point in time that this transfer from 

the smokeless tobacco manufacturers being independent of cigarette makers started. Of particular concern is that many of these 

new smokeless products are being marketed in a way for smokers 

to satisfy and sustain their nicotine addiction when they are in settings that they cannot smoke. 

Additionally, to your point, while we do not have any new and 

more detailed studies with respect to sources of influence, the two 

largest groups where we are seeing the increase are in non-Hispanic young men and in Hispanic men. Additionally, we know from 

other data that—— 

Ms. ESHOO. Let me just ask you about that. It is a little confusing. Non-Hispanic young men and Hispanic older men? 

Mr. PECHACEK. No, 18- to 25-year-old white and Hispanic. We 

call it non-Hispanic white to separate it from Hispanic that selfidentify Hispanic. So both Hispanic and non-Hispanic young men 

who are—— 

Ms. ESHOO. You know what? It is got to be a little simpler. It 

sounds—I don’t understand what you are saying. Let me put it 

that way. Name the groups. Name them. 

Mr. PECHACEK. White and Hispanic young men 18 to 25 years 

old. 

Ms. ESHOO. Increase? 

Mr. PECHACEK. Are increasing more than anybody else. 


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Ms. ESHOO. All right. Well, I think that these are really disturbing trends. I just leaned over and I said to my staffer a little 

while ago, when it comes to baseball players, why don’t they just 

chew gum, I mean, if they feel like they need to chew something, 

and she responded because they are addicted. So clearly I think 

there is a nexus here. I don’t think it has everything to do with 

those that play baseball but on the other hand, they are individuals 

that are really looked up to and young people always want to look 

in the mirror and see the reflection of their heroes. So I think that 

we need to work hard to find a way to reverse these trends and 

make sure that smokeless tobacco really—when you come back in 

succeeding years, that we can claim that there is a huge decline. 

This isn’t something that is healthy. 

Anyway, thank you very, very much for your testimony. Dr. 

Winn, I am over my time so I don’t know if you wanted to add 

something to it, but maybe you can when someone else questions 

you. Thank you very much. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. 

The gentleman from Kentucky, Mr. Whitfield. 

Mr. WHITFIELD. Thank you all for being with us today. I think 

that Congress has given the regulators a lot of opportunities to 

make great progress in this area. It is true, Mr. Pechacek, isn’t it, 

that on June 22, 2010, it will be illegal to sell a smokeless tobacco 

product to anyone under the age of 18? Is that correct? 

Mr. PECHACEK. Yes, that is my understanding of the bill, yes. 

Mr. WHITFIELD. Now, many of us were not aware of it but in the 

stimulus bill, which certainly was about creating jobs, there was 

$650 million set aside in there to address clinical and communitybased prevention and wellness strategies, and it is my understanding that that money was given to HHS and CDC to get this 

money out there. So my question would be, number one, of that 

money, how much went for tobacco strategies in the States or the 

local communities? 

Mr. PECHACEK. I don’t have those detailed numbers. We would 

be happy to provide those to you and your staff in this committee. 

Mr. WHITFIELD. When this money became available, did you in 

your regulations set out how much money should be spent on nutrition and how much money on tobacco, how much money on obesity 

or anything like that? 

Mr. PECHACEK. Well, yes, we can provide you the details on the 

funding announcement. The priorities were smoking prevention 

and obesity—— 

Mr. WHITFIELD. You said a certain amount of money for each one 

of those in your regulations? 

Mr. PECHACEK. There were funding guidelines that were put out 

to the States and the actual numbers we can get you in terms of 

how the breakdown on that—— 

Mr. WHITFIELD. How much money remains to be spent of that 

$650 million? 

Mr. PECHACEK. The application awards I believe are completed 

now and are available that we can make available to you. I think 

it all has gone through funding announcements and awards. 


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Mr. WHITFIELD. Well, how much money has already been sent 

out? 

Mr. PECHACEK. I would have to get our administrative people to 

give you the details on that since the—applications have been reviewed. However, the process of actually getting the money into 

States budgets, you know, is an administrative function. 

Mr. WHITFIELD. So you don’t know how much is going to be going 

out in grants and you don’t know how much money has already 

been distributed to States and local government under this program? 

Mr. PECHACEK. With respect to that $650 million, all of that 

money was put into funding announcements, so yes, all of that is 

going out. 

Mr. WHITFIELD. Well, you know, one of the things that—I mean, 

this is a big problem obviously, smokeless tobacco and its impact 

on health, but to put this money in the stimulus bill, and then I 

read an article that in Washington, D.C., they received $977,000 

and created one full-time job, and what did they do with that 

money? They bought BlackBerrys for people so that they could be 

in touch with their smoking counselors. Now, do you consider that 

a good utilization of the money? 

Mr. PECHACEK. I don’t have any details on that specific case. 

However, there is very specific guidance that is provided in the 

funding announcement from CDC with regard to the most efficacious, comprehensive strategies that have been shown to be effective and cost-effective in reducing tobacco use. 

Mr. WHITFIELD. Although we were not aware of it, in the health bill itself that passed, in the first 5 years there is over $5 billion 

set aside for a grant program to go out addressing the so-called 

maps intervention for communities program. Where are you all in 

developing the regulations for that? 

Mr. PECHACEK. Well, first of all, a point of clarification, CDC is 

not a regulatory agency. We are a public health agency. With respect to—— 

Mr. WHITFIELD. Well, HHS, you know, where they are on it. 

Mr. PECHACEK. The specific aspects of that overall program—— 

Mr. WHITFIELD. Will you be involved in distributing that grant 

money? Will CDC be involved? 

Mr. PECHACEK. CDC has a role in working with HHS and the 

White House with respect to guiding the evidence-based interventions that have been found to be most effective. 

Mr. WHITFIELD. Well, I know in your position, you are involved 

with smoking and health. I want to ask one other question. One 

of the guidelines that they put in the area of nutrition in spending 

this money is urging communities, local communities to reduce 

density of fast-food establishments. How do you propose that that 

be done? How do you hope that will be accomplished? 

Mr. PECHACEK. That is outside of my division. With respect to 

issues of tobacco, I can give you more specifics, but we can provide 

you feedback on what we are doing on density of fast-food restaurants if you would like. 

Mr. WHITFIELD. Thank you. I see my time has expired. Mr. 

Chairman, if there is not an objection, I would just like to insert 

for the record a publication of the National Convenience Store AsVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00080 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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sociation going into some detail about the health portion of the 

stimulus bill as well as the Washington Times article about the 

BlackBerry. 

[The information appears at the conclusion of the hearing.] 

Mr. PALLONE. Without objection, so ordered. 

Mr. Engel. 

Mr. ENGEL. Thank you, Mr. Chairman. 

Dr. Winn, your testimony describes baseball players, and I am 

quoting you, ‘‘as the prototypical user of chewing tobacco.’’ You also 

note that, and again, I quote from your written testimony, that 

‘‘adolescents engage in more risky behaviors including tobacco use 

to the extent they endorse positive prototypes of individuals who 

engage in those behaviors.’’ I know that Mr. Manfred from Major 

League Baseball and Mr. Prouty from the Major League Baseball 

players’ union are in the audience for this testimony and we will 

hear from them later, but I want them to hear your views on this 

matter, so let me ask you this very simple question. When teenagers and young adults see Major League Baseball players using 

smokeless tobacco, does it make it more likely that these young 

people will themselves become users? 

Ms. WINN. That is likely based on evidence that shows that peers 

and parents and other role models for children influence their use 

of smokeless tobacco. 

Mr. ENGEL. So it was an obvious question. I know that would be 

your answer. So let me also ask another obvious question. Do you 

believe that if Major League Baseball and the players’ union were 

to agree to ban the use of smokeless tobacco on the field and in the 

dugout, would that result in a reduction in smokeless tobacco use 

among teenagers? 

Ms. WINN. Well, certainly the evidence from Katie Couric’s 

colonoscopy and Magic Johnson’s HIV status definitely had a positive impact on the U.S. public in terms of taking preventive measures, so it seems likely by analogy that that would have a positive 

effect on youth in the United States. 

Mr. ENGEL. Thank you. 

Dr. Pechacek, do you have any thoughts of the impact of the use 

of chewing tobacco by Major League Baseball players? 

Mr. PECHACEK. The evidence that we have reviewed in the 1994 

Surgeon General report as well as other documents since then 

shows that professional athletes in certain sports including baseball have traditionally had high levels of smokeless tobacco use. 

Athletes serve as role models for youth and smokeless tobacco manufacturers have used these imageries in advertising testimonials by 

featuring athletes in sports to make smokeless tobacco products appear attractive to youth. Teens to mimic the behaviors of those who 

they look up to and identify with including baseball players and 

athletes. While smokeless tobacco use was prohibited in minor 

leagues in the early 1990s, this policy has not been extended to 

major leagues. 

Mr. ENGEL. Thank you. 

Dr. Winn, I have heard reports that in Sweden, significant numbers of people are quitting smoking and using smokeless tobacco 

and that the country’s rates of lung cancers have gone down. This 


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might seem to support the argument that smokeless tobacco is a 

form of harm reduction. This argument rests on the idea about the 

use of smokeless tobacco is good because the risks of death and disease from using smokeless tobacco are less severe than the risks 

of death and disease from using cigarettes. So I want to ask you 

about that. Does that idea match up with reality? Is smokeless tobacco really a form of harm reduction, especially when we are talking about children who are not using any form of tobacco? I think 

that this notion of harm reduction becomes even more untenable in 

the case of young athletes in general. My understanding is that 

young athletes are less likely than the general population to smoke 

cigarettes but they are more likely to use smokeless tobacco. I want 

to hear your thoughts on that. 

Ms. WINN. Well, I have reviewed the report, the Swedish statistics, and I want to note that the claim that because the rates of 

smokeless tobacco have gone up that that has influenced the rates 

of smoking going down. Well, I want to emphasize three fundamental facts. One is that all tobacco products are hazardous and 

there is no safe level, and what we need to do is prevent its use 

and help them quit. But with regard to the Swedish situation, the 

Swedish National Institute of Public Health found in their survey 

that of Swedish women who use snuff, that is a relatively small 

portion of women in Sweden use snuff, but smoking rates have dramatically declined in Swedish women, indicating that snuff is actually not responsible for the decline in smoking. There is a continuum of risk associated with both smokeless tobacco and smoking 

but we are most concerned about issues related to dual use of 

smoking and smokeless tobacco and on smokeless tobacco as a 

gateway for children. 

Mr. ENGEL. So in the case of young athletes who don’t smoke 

cigarettes but use smokeless tobacco because they see Major 

League Baseball players using it, would it be fair to say that 

smokeless tobacco use significantly increase their health risks? 

Ms. WINN. Yes. It increases their risk of oral lesions in their 

mouth and many oral lesions have the potential to develop oral 

cancer. 

Mr. ENGEL. Thank you. 

Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. 

The gentleman from Indiana, Mr. Buyer. 

Mr. BUYER. Thank you, Mr. Chairman. 

Dr. Winn, I am trying to reconcile a couple of comments. You acknowledge that there is a continuum of risk within tobacco products, smoking to smokeless, pharmaceutical and quitting, a continuum of risk. You acknowledge that, correct? 

Ms. WINN. There is a continuum of risk associated with—— 

Mr. BUYER. From very high risk to very low risk. You acknowledge that? 

Ms. WINN. Quantitating it at the higher load, they all have risks. 

Mr. BUYER. You acknowledge that there is a continuum of risk 

from very high risk to very minimal risk. Do you acknowledge? 

Ms. WINN. Very high risk to moderate risk. 


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Mr. BUYER. To moderate risk, so if I can say in proving science 

that there is a product on the market that would remove 99 percent of the nitrosamines, you would define the 1 percent as moderate? 

Ms. WINN. All smokeless tobaccos have some risk of health effects. 

Mr. BUYER. That is correct. I concur with that. Now, let me go 

back and acknowledge this, and let us not play games. Do you acknowledge that there is a continuum of risk from very high risk to 

very low risk? 

Ms. WINN. Of specific—— 

Mr. BUYER. The health effects and the use of tobacco products. 

Ms. WINN. Some tobacco, for example, chronic obstructive pulmonary disease is not caused by smoking tobacco. 

Mr. BUYER. I am not going to quibble with you, because it appears that if you won’t even acknowledge that there is a continuum 

of risk, then you are placing yourself in a camp of complete abstinence. Now, I will concur with you that tobacco products are not 

healthy. I concur with that. But to ignore that there is a continuum 

of risk from very high risk, cigars, to very low risk, which would 

be a product—let me ask you this question. If you able to put a 

product on the market that reduces the nitrosamines, does that improve the chances of one’s, or does that eliminate then health 

risks? 

Ms. WINN. What causes us concern under those circumstances is 

the population effect that might be influenced by people smoking 

and adopting smokeless tobacco—— 

Mr. BUYER. Do you acknowledge that if I can reduce the 

nitrosamines in a product that I can reduce the risk? 

Ms. WINN. There is no epidemiologic evidence that shows that 

that is the case. It is important that nitrosamine levels be reduced. 

Mr. BUYER. So are you saying to me then that an orb or a stick 

that has reduced 99 percent of the nitrosamines is just as harmful 

as smoking a cigar? That is what your statement is saying. 

Ms. WINN. Yes. 

Mr. BUYER. And you concur with that? 

Ms. WINN. Assessing nitrosamine levels or reduced nitrosamine 

products is under the purview of FDA so I would—— 

Mr. BUYER. All right. Great. Your staff just gave you that so you 

could read it. But just answer the specific question. 

Ms. WINN. We don’t know that there is any—there is no level of 

nitrosamines that is known to be safe. 

Mr. BUYER. Wow. So you are unwilling to recognize differentials 

of risk within tobacco products? I guess that is what I am hearing 

from you. You do not acknowledge that there is a differential of 

risks among tobacco products? 

Ms. WINN. There is a continuum of risk. 

Mr. BUYER. Thank you. We got there, didn’t we? We got there. 

There is a continuum of risk. Now, why is that important? It is important because as a country, those of whom are the advocates of 

an abstinence approach are locking us in to a system of failure. If 

we only have up to 7 or 8 percent of whom want to quit, that is 

failure in my eyes. And so if we can actually migrate a population 

from smoking to smokeless to eventually quitting, that is imporVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00083 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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tant. Now, no one wants our teens or adolescents or youth or you 

name it to gain access to these products. So I concur with you on 

that point. 

Mr. Chairman, I respect you because you are open to many different distillations of thought and I believe in personal cultivation, 

I believe in the scholarship maintenance of our knowledge. It improves our self-worth and it is our quest for a greater understanding and ration and reason and tolerance to ameliorate. I am 

going to offer some differing views and I would like to offer them 

for the record. So what I would like to offer for unanimous consent 

to be placed into the record, first is a report called a Broken Promise to Our Children. It is an 11-year analysis of how the States are 

not spending the MSA settlement on tobacco prevention. I ask 

unanimous consent this be placed into the record. 

Mr. PALLONE. Can I just ask, are some of these things going to 

be part of the printed record or can we just do them—how does it 

work? It looks like it is pretty extensive. We can? OK. 

Mr. PALLONE. Without objection, so ordered. 

Mr. BUYER. I would also ask unanimous consent that the Strategic Dialog on Tobacco Harm Reduction: A Vision and Blueprint 

for Action in the United States by Mitch Zeller and Dorothy 

Hatsukami also be entered into the record. 

Mr. PALLONE. Can I look at that? Go ahead. Why don’t you continue? 

Mr. BUYER. I would also ask unanimous consent that the SmokeFree Tobacco and Nicotine Products Reducing the Risk of TobaccoRelated Diseases and by Scott Ballin be entered into the record. 

And last, I would unanimous consent—not last. I would ask 

unanimous consent that the brief report on evidence against a 

gateway from smokeless tobacco use to smoking by Dr. Brad Badu 

also be entered into the record. 

Mr. PALLONE. I am just taking a minute here because I noticed 

they are pretty extensive and I just want to make sure—OK. Is 

that everything? 

Mr. BUYER. Yes. 

[The information appears at the conclusion of the hearing.] 

Mr. PALLONE. Without objection, so ordered. 

Mr. BUYER. Thank you. 

Mr. PALLONE. Next is our vice chair, Ms. Capps. 

Mrs. CAPPS. Thank you, Mr. Chairman. 

I want to thank our witnesses for their excellent testimony. I 

particularly want to thank the second panel for your patience in 

waiting through this first one, which is our process here in this 

subcommittee. 

I have a question for each of you and I am going to start with 

Dr. Pechacek. I was particularly alarmed by your statement during 

your testimony that the perceived risk of harm from smokeless tobacco has decreased, actually decreased among teenagers. You 

know, we have taken such, I think, quite significant steps through 

enactment of recent health reform legislation to invest in greater 

wellness and prevention strategies as a whole. We have this opportunity with some of these new parts of the reform legislation. I 

would like you to give us some advice of what strategies we could 


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take in our local communities through our health clinics expansion 

and so forth to reverse this very alarming trend. 

Mr. PECHACEK. Comprehensive State and local tobacco control 

programs that we have defined in our multiple CDC documents 

give evidence-based approaches that have been shown to be effective in reducing tobacco use overall as well as smokeless tobacco. 

These approaches change environmental cues in ways that make 

tobacco use in any form less acceptable and quitting easier. These 

types of programs include educational strategies as well as public 

policy changes that send a clear message to youth that smokeless 

tobacco along with all product use are dangerous to their health. 

On a concrete level, CDC has been communicating a clear message 

that there is no safe form of tobacco use and that any tobacco product is hazardous to health. For example, the CDC has recommended since the mid-1990s that schools implement 100 percent 

tobacco-free policies that eliminate all tobacco products by faculty, 

staff and students including smokeless tobacco on school grounds, 

at school events including sporting events. CDC is closely monitoring trends in the smokeless tobacco use and how different marketing campaigns are impacting youth and providing this information to our States so they can more effectively provide informational campaigns that can turn around this negative trend. 

Yes, we are concerned about this downturn in perceived risk 

which is in 8th, 10th and 12th graders with the largest drop in 

10th graders. This indicator has been a very reliable leading indicator of this type of question, not only for smokeless tobacco but for 

cigarettes, alcohol, marijuana and other behaviors. Therefore, this 

downturn does indicate reason for concern. 

Mrs. CAPPS. Thank you. I have a feeling our second panel is 

going to elaborate on some of the specific ways that we can really 

get this message across at such a key age group and their habits 

of course will impact their health for a lifetime. I appreciate that 

from the CDC. 

Now, a question for you, Dr. Winn. During our committee’s debate on giving the FDA authority to regulate tobacco products, 

some of our colleagues were advocating policies promoting this socalled lower risk of tobacco products. I think you heard some of 

that voiced today as well. In your testimony, you clearly outline 

that transitioning from cigarettes to smokeless tobacco actually 

contributes to more negative health outcomes in many cases, and 

just for the record, I would like to have you elaborate a bit more 

on this strategy because this is a myth that keeps rearing its head, 

and doesn’t it make more sense to provide comprehensive education 

about all tobacco kind of in line with what Dr. Pechacek was saying 

to include information about why it is all dangerous and how to be 

empowered to resist and reject it? 

Ms. WINN. Right. Certainly the evidence to date, and it is a 

growing literature, indicates that using both behaviors increases 

risk of several chronic diseases, and that is a great concern that 

we have with regard to some of the trends in youth using both 

products together. This is a very concerning trend that we have. Is 

there an additional specific question? 

Mrs. CAPPS. No. Well, I think you are highlighting the goals for 

having comprehensive education. In other words, if you are talking 


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about stopping smoking of cigarettes or never starting with young 

people, you want to also make sure that they don’t see an alternative. It all has to be presented at one time. Otherwise they are 

going to fall prey because the targeting of advertising, and we have 

seen this with cigarettes as well, is so insidious with young people, 

the targeting of just the right images using athletes, which is understandable. They are heroes. My grandkids look up to them. If 

they even see them without even saying a word chewing, that will 

be in their subconscious to be tempted to try, so I appreciate that 

very much. 

Thank you. I yield back. 

Mr. PALLONE. Thank you. 

The gentlewoman from Tennessee, Ms. Blackburn. 

Mrs. BLACKBURN. Thank you, Mr. Chairman. I appreciate that. 

I have got just a couple of questions that I want to direct to the 

two of you together, and again, thank you for your patience for this 

morning. The CDC’s youth risk behavior survey measures smokeless tobacco among high school students. That is correct, right? 

Mr. PECHACEK. Yes, 9th through 12th graders. 

Mrs. BLACKBURN. OK, and it also publishes data for individual 

States and a number of major cities, and as we were getting ready 

for the hearing, I looked at the data that was there for several 

Major League Baseball cities including Baltimore, Boston, Chicago, 

Detroit, Houston, L.A., Miami, Milwaukee, New York, Philadelphia, 

San Diego, San Francisco and Washington, D.C. I wish that Nashville or Memphis was included in that list but it is not, but we will 

talk about that another day. So given the topic of this hearing and 

what we were going to be discussing and looking at your survey, 

I found something very interesting. Every single one of those major 

league cities, every one of them, every single one of them, believe 

it or not, had a teenage smokeless tobacco rate that was below the 

national average, and I found that so interesting. The major league 

cities have a smokeless tobacco rate that is below the national average. And the same is true when you go back and you look at the 

previous CDC surveys, which are published every 2 years. It was 

true in 2007, it was true in 2005, it was true in 2003, it was true 

in 2001. You know what? There is not one single exception, not 

one. Every single Major League Baseball city in every single year 

where the CDC survey measured, it was lower than the national 

average. So if baseball players are having such a dramatic impact 

on teenage smokeless tobacco use, why would evidence of this impact only occur in places where there is no Major League Baseball 

team? I want to know if there was any finding in your work that 

would shed some light on that, and I would love to hear from both 

of you on that. 

Mr. PECHACEK. Thank you for your question. Yes, there is evidence that will help explain that. 

Mrs. BLACKBURN. Wonderful. Elaborate. 

Mr. PECHACEK. First of all, rates of smokeless tobacco use traditionally have been higher in more rural and other parts of the 

country. We can provide you more detail on the geographic breakdown. Additionally, the rates of smokeless tobacco use among African American populations is much lower than overall in other demographic groups. So those two factors alone just by the demoVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00086 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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graphics of the major cities that you have mentioned result in a differential. 

When we are looking at the influence of any factor, what we are 

looking at is the exposure. One of the main things that we have 

to be aware of in the exposure is the primary exposure is not necessarily attending the baseball games but watching them on the 

media so that the geographic distribution of the imagery exposure 

is quite different than the location of the stadium. Now, we do not 

have any published studies with respect to number of minutes 

watching Major League Baseball and its impact but the data that 

has been done will show that it is the youth that are paying attention to baseball that may be at the greatest risk. 

Mrs. BLACKBURN. OK. So let me ask you this. Looking also at 

your surveys, you see that the use went down from 11.5 in 1993 

to 7.9 in 2007 and from 20.4 among teenage boys the smokeless tobacco rate has dropped from 24.4 in 1993 to 13.4 in ’07. So what 

factors have been working so well in recent years? What is it that 

is being done in recent years that is causing young people to choose 

not to use smokeless tobacco? Is it education? Is it parents? Is it 

outreach? Was it the tobacco settlement agreement? What do you 

think has helped to spur that kind of drop in usage? 

Mr. PECHACEK. First of all, the types of programs that work for 

smokeless tobacco are very similar to those that work for preventing all tobacco use, cigarettes and other forms. What we have 

found is that the comprehensive types of programs that focus on 

public policy change such as smoke-free environments and other 

types of things that are sending a clear message that all tobacco 

use is harmful is reaching youth. The programs in the mass media 

are particularly effective that are providing broad messages about 

the risk of tobacco use such as the legacy media type of campaign 

as well as the State-specific campaigns. All of those types of things 

are effective in preventing cigarette use and smokeless tobacco use. 

One of the things that is of concern is that while we have been seeing a decline in both cigarettes and smokeless tobacco use through 

about 2005, the data that will be published this summer from the 

youth risk behavior shows a reversal of those trends that you were 

citing, and then when you look at all the data points including the 

2009 data point that will be released this summer, that the rates 

of smokeless tobacco use among high school males has reversed 

and is now increasing with the point of deflection or the statistical 

point of change being 2003. So for a number of years the pattern 

in multiple surveys is showing an increase of smokeless tobacco use 

among youth in general, particularly males, particularly white and 

Hispanic males. 

Mrs. BLACKBURN. Thank you very much. I am over my time. I 

will yield back. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. 

The gentleman from Maryland, Mr. Sarbanes. 

Mr. SARBANES. Thank you, Mr. Chairman. I have a couple of sort 

of random questions here. 

Just following up on the surveys, the cities that my colleague 

mentioned where the rate of smokeless tobacco use is lower than 

the national average, is it however the case that if you looked at 

the use among the two populations you cited in Hispanic youth and 


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non-Hispanic white youth that in those cities you would find evidence of this trend of an increase even if it wasn’t carrying a statistic above the national average? 

Mr. PECHACEK. The individual data will be released this summer 

with respect to all of the locations including the national data. 

What we are seeing in the overall pattern is yes, across the Nation 

in non-Hispanic white and Hispanic youth we are seeing the uptick. This uptick has been going on for several years now. With respect to patterns in specific communities, we have not had those 

levels of analyses yet but we certainly are willing to look into that. 

Mr. SARBANES. So it is at least possible that even though the increase hasn’t taken the statistic above the national average in 

some of those places cited that the fact that there is an increase 

could be connected to the use by role models such as Major League 

Baseball players. 

A lot of the discussion is focusing on Major League Baseball, you 

know, responsibility to implement restrictions on the use of smokeless tobacco because of the role model status that the players have. 

This isn’t really a question, it is just kind of an observation, and 

I guess the second panel is in a position to speak to this better. I 

would just think that the owners and team management and the 

league itself would be interested, given the kind of investments 

they make in their players financially and otherwise to put these 

kinds of limitations, regardless of the impact it is having on youth 

or other members of the public, given the litany of effects that you 

have been able to describe today in terms of how harmful it can 

be and how quickly the conditions that it causes can develop. That 

is the other thing that is striking when you look at the testimony 

that you have presented, so I just want to introduce that theme 

here that it is not simply about the example that is being set that 

ought to cause us to call upon Major League Baseball. I would just 

imagine that as a matter of good practice and good business management on the part of the league and the owners that they would 

want to institute this. It has been done at the minor league level 

so somebody has figured out that it is not a great thing because 

it is not the role model aspect of the minor league baseball players 

that led to that ban being put in place. It must have been some 

other consideration like the health of the players. So I just don’t 

understand why that wouldn’t apply to the major league players. 

Let me ask you, is the restriction on advertising on television 

and so forth that applies to smoking tobacco, does that apply as 

well to smokeless tobacco? 

Mr. PECHACEK. The new FDA legislation signed last year extends 

the restrictions more completely to smokeless tobacco. 

Mr. SARBANES. OK. So when you think about—I mean, I was 

reading some of the testimony, one World Series game somebody 

calculated there was 9 minutes of tobacco use that would have been 

viewed by someone who watched the whole game on the part of the 

players. That is like a giant loophole, isn’t it, in terms of being able 

to distribute this kind of imagery over the airwaves? Is it fair to 

characterize it that way? 

Mr. PECHACEK. I believe our next panel is going to go into that 

in more detail, but in general as we have reviewed in recent SurVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00088 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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geon General reports from 1994 on, those types of imageries do 

reach youth and do have an impact. 

Mr. SARBANES. And more sinister, arguably, because it is more 

kind of just woven into the fabric of what they are seeing than a 

full-force advertisement might be. 

Thank you, and I yield back my time. 

Mr. PALLONE. Thank you, Mr. Sarbanes. 

I guess that concludes our questions for the first panel, but we 

do want to thank you, and you may get questions from us, written 

questions, within the next 10 days that we will ask you to get back 

to us as soon as you can, so thank you very much. 

If I could ask the second panel to come forward and see where 

your nametags are there. Take your seats and we will proceed. Let 

me introduce each of you. First on my left is Gruen Von Behrens, 

who is from Stewardson, Illinois. Thank you for being here. And 

then we have Robert D. Manfred, Jr., who is executive vice president of labor relations and human resources for Major League 

Baseball. And then we have David Prouty, who is chief labor counsel for Major League Baseball Players Association. And then the famous, it says here Joseph Henry, but Joe Garagiola, Jr., who is a 

Major League Baseball announcer and a former Major League 

Baseball player. And then finally is Gregory Connolly, who is a professor of the practice of public health at Harvard University. I 

again thank all of you for being here today. Try to keep the comments to 5 minutes. Your statement becomes part of the record. Of 

course, you can submit additional written statements or comments 

if you will after you leave here today. 

So I will start with Mr. Von Behrens. I hope I am pronouncing 

that correctly. 

STATEMENTS OF GRUEN VON BEHRENS, STEWARDSON, ILLINOIS; ROBERT D. MANFRED, JR., EXECUTIVE VICE PRESIDENT, LABOR RELATIONS AND HUMAN RESOURCES, MAJOR 

LEAGUE BASEBALL; DAVID PROUTY, J.D., CHIEF LABOR 

COUNSEL, MAJOR LEAGUE BASEBALL PLAYERS ASSOCIATION; JOSEPH HENRY ‘‘JOE’’ GARAGIOLA, SR., MAJOR 

LEAGUE BASEBALL ANNOUNCER, FORMER MAJOR LEAGUE 

BASEBALL PLAYER; AND GREGORY CONNOLLY, M.P.H., 

D.M.D., PROFESSOR OF THE PRACTICE OF PUBLIC HEALTH, 

HARVARD UNIVERSITY 

STATEMENT OF GRUEN VON BEHRENS 

Mr. VON BEHRENS. That is correct, and thank you for allowing 

me to be here today. I appreciate the opportunity and I really hope 

that this message I bring to you will make you all a lot smarter 

on about what tobacco can do to you. 

My name is Gruen Von Behrens and I am a national spokesperson here today on behalf of Oral Health America and NSTEP 

and also myself. I travel throughout the United States as a motivational speaker to youth about the dangers of tobacco use. I have 

currently been in 46 of the 50 States of America, every province of 

Canada and spoke to over 2 million kids across North America 

about this topic. I work with different collegiate and minor league 


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athletic programs. I work with different media across the United 

States. So I have a lot to say when it comes to this topic. 

Now, first things first. I always apologize to my viewers because 

I understand I can be kind of hard to understand. I have had 34 

surgeries to my mouth and to my neck to get rid of the cancer I 

had. And not everything I say always comes out the way I want 

it to, so I apologize to the panel. 

Nobody tells me that I have to do this. I didn’t get in trouble in 

my home State of Illinois and they are like, all right, Gruen, for 

your punishment, you have to go out in public, show people your 

face and tell them that tobacco did that to you. That is not the reason I do this. I don’t do this as an authority figure as somebody 

who is going to preach to anybody for using a tobacco product because me as an ex-tobacco user realizes how powerful the addiction 

is on its victims. I am not out there knocking cigarettes out of people’s hands and I am not knocking two hands out of their back 

pockets. I want people to have a fair choice with their life. I want 

my viewers to be able to look at my face and to my words and my 

story, understand what I have been through so they can make an 

educated and thoughtful choice for themselves about whether or 

not they want to take up this position or not. 

I come from a very small town in the Midwest, 750 people in my 

hometown, and that is counting farm animals and small dogs so it 

is a very rural area, and as a part of the culture of our area, we 

use tobacco. My grandfather used tobacco. My uncle used tobacco. 

Why do these two men who loved me dearly and helped bring me 

up offer me a product that could hurt me this bad? So I was very 

naive that this could happen to me. And I hope that by traveling 

around the country and educating youth about the dangers of tobacco, not only youth but parents, certain forms of government, all 

different forms. You know, we are sitting here with Major League 

Baseball and I think it is great to be part of baseball. I think that 

as a baseball player growing up, and I idolized the people I was 

watching on TV and that led a small part to my tobacco use but 

not to the main reason why I used tobacco. Across the United 

States there is a culture out there where people pick up these habits at a very young age because just being naive to what this product can do to you. The amount of kids and people that I see victimized by this drug is phenomenal. You know, I see 8-year-old kids 

using spit tobacco. I see mothers wiping their babies’ gums with 

spit tobacco wrapped in a nylon stocking to cure a toothache. I see 

10-, 11- and 12-year-old kids coming up to me after my presentation and handing me their chew and saying I don’t want to use 

this no more because I didn’t know that that could do that to me. 

As I said, I really appreciate the opportunity to be here today. 

I hope that this message brought to America can educate them 

about the dangers of tobacco. I see our government sometimes almost telling us that spit tobacco is a safer alternative to cigarettes, 

and numerous States, they raised the taxation on cigarette sales 

but they will not raise the taxation on tobacco sales. So as a whole, 

is that them telling us that this is a safer alternative when I know 

it is not? Every bit of spit tobacco that somebody puts in their lip, 

into their oral cavity has the same cancer-causing ingredients in it 

as three to five cigarettes smoked. So they are hurting their oral 


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cavity. This is as bad as whether they would be if they ingested 

a cigarette. And then we talk about harm reduction. Harm reduction. I laugh at the face of harm reduction, guys. You get lung cancer, you get oral cancer. What is the difference? You have still got 

cancer. You still have a very deadly disease that you have to fight 

for your life to fix. 

I stared using tobacco at the age of 13. At 17 I was diagnosed 

with a full-blown oral cancer. So often people come up to me and 

say oh, Gruen, spit tobacco only hurts the person using it. I wish 

each and every one of you in here who are interested, seriously interested in this cause, to have been with me the day that my mom 

found out I was sick, the day my mom sat in that doctor’s office 

with me and bawled her eyes out because her son had been diagnosed with this disease because of trickery and misconception that 

this thing was a safe thing to do, and the impact that had on my 

mother—I mean, I had people come up and say to me that it only 

affects the person using it. That is not right. It affects everybody 

in the community. It affects each and every one of us. People are 

getting sick from this. As the government, do what it takes to fix 

this problem. I don’t care if it baseball. I don’t care if it with health 

care. Mr. Barton says this isn’t a very important thing, we ought 

to worry about health care. I think we are worrying about health 

care, guys. We are starting on this level. All right? Let us make 

it this level. 

Thank you for your time. I appreciate the opportunity to be here. 

[The prepared statement of Mr. Von Behrens follows:] 


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Statement of 

GRUEN VON BEHRENS 

Stewardson, IL 

Hearing: Health Subcommittee, House Energy and Commerce Committee 

"Smokeless Tobacco: Impact on the Health of our Nation's Youth 

and Use in Major League Baseball" 

April 14, 2010 

Chairman Pallone and distinguished Members of the House Energy and 

Commerce Health Subcommittee, good morning. My name is Gruen Von Behrens, and I 

am a resident of Stewardson, IL. I am a survivor of oral cancer from smokeless tobacco 

use, and I travel throughout the country speaking to young people about the health risks 

of smokeless and spit tobacco use. I serve on the speakers bureau for NSTEP® (the 

National Spit Tobacco Education Program) of Oral Health Amelica, a national non-profit 

organization dedicated to improving the nation's oral health. Ijoin my colleagues, 

including fonner NSTEP Chainnan, Joe Garagiola, in speaking up about the devastating 

effect that smokeless tobacco can have. 

I wish to thank the Committee for bringing this important, but overlooked health 

issue to the table. So much attention is paid to the health effects of smoking. Smokeless 

tobacco is not "hannless" as advertising would have you believe. It has ruined my life. I 

am 32-years-old, and I have experienced 34 surgeries, including one radical surgery that 

removed half of my neck muscles, lymph nodes and a third of my tongue. 

I first tried smokeless tobacco at age 13 to "fit in" on a camping trip. I grew up in 

a rural fanning community where smokeless tobacco use is everywhere. My first 

experience with smokeless tobacco resulted in a powerful addiction that affected my life 
87 


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in a way I never imagined. Back then, I hit a .400 for the local Comets baseball club, and 

I wanted to play for the Chicago Cubs when I grew up. Baseball was the center of my 

world. But as much as I loved baseball, smokeless tobacco was my biggest habit. I had 

to have it in my lip when I was playing baseball. I liked the way it made me feel and I 

liked the way it tasted. The risks didn't worry me. We all know that smoking can cause 

lung cancer, but tobacco advertising fools people into thinking that smokeless tobacco is 

harmless. It didn't occur to me that I would get cancer-that just happened to old people. 

When I was 17-years-old, I was diagnosed with squamous cell carcinoma. The 

cancer in my mouth spread. Doctors told me there was an 80 percent chance I was going 

to die. You can not imagine how this news alTected my mom. The first surgelY lasted 13 

hours. This was followed by a painful round of radiation, which finally broke my 

addiction to smokeless tobacco. Aftcr radiation I thought my cancer was over but I had 

another 33 surgeIies to go. Before, there were colleges that were interested in me. But at 

17, my baseball days were over. 

Anyonc who tells you that they can't or won't stop using smokeless tobacco is an 

addict. I have spoken to professional bascball players who hate the fact that they use it, 

are scared that what happened to me will happen to them, and still have to fight their 

addiction. The most important thing we can do is to prevent young peoplc from starting 

to use, and to help users quit. 

I am honored to share my story with you, a story that I have shared with over 2 

million youth across the country. Please keep my testimony, and those of others you 

heard today, close to your hearts as you consider steps to improving America's health. 

Smokeless tobacco is not harmless, and I ask you to promote smokeless tobacco 
88 


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education and cessation, encourage policies that limit the ways that tobacco eompanies 

reach youth through advertising and promotion of this highly addictive and harmful drug. 

It is not a safe altemative to smoking. 

Thank you for your time. 
89 

Mr. PALLONE. Thank you, and let me thank you also. I didn’t realize how often you go around and how many States and how much 

you have become a spokesman for this, and we really appreciate 

that. Thank you. 

Mr. Manfred. 

STATEMENT OF ROBERT D. MANFRED, JR. 

Mr. MANFRED. Chairman Pallone and members of the committee, 

thank you for the opportunity to be here to address our shared 

commitment to the reduction of the use of smokeless tobacco products. I would like briefly to review Major League Baseball’s past 

and ongoing efforts to reduce or eliminate the use of such products 

by players, as well as the legal framework within which Major 

League Baseball’s efforts have been undertaken. 

For almost 2 decades, Major League Baseball has worked on 

multiple fronts to reduce the use of smokeless tobacco products and 

educate members of the baseball community accordingly. The centerpiece of our effort is the Minor League Tobacco Policy, which 

was issued by Commissioner Selig in 1993. That policy bans the 

use and possession of all tobacco products by club personnel, including players, n minor league ballparks and during team travel. 

We believe that our efforts at the minor league level are crucial because players must learn at an early age to avoid these product. 

The minor league policy is displayed in all minor league clubhouses, and each minor league player contract requires the player 

to represent that he is aware of the policy and agrees to its provisions. To ensure compliance with the policy, Major League Baseball’s resident security agents conduct roughly 100 random security 

inspections of minor league ballparks annually. Players and field 

managers who violate the policy are subject to game ejection and 

incur substantial monetary penalties. 

Major League Baseball has also administered a formal policy regarding tobacco products at the major league level for well over a 

decade. Pursuant to the major league policy, clubs may not permit 

the distribution of tobacco products in major league clubhouses. 

The major league policy likewise encourages clubs not to permit 

club personnel, clubhouse attendants and the like, to buy tobacco 

products on behalf of players. 

I should also point out that club personnel are barred from smoking when in uniform in view of spectators, and contrary to a suggestion that was made in the earlier panel, our athletes are not allowed to participate in tobacco advertising while in uniform, and I 

am not aware of a single major league player who endorses tobacco 

products publicly. 

Our efforts to reduce the use of tobacco products extend beyond 

formal disciplinary measures and into education and treatment. To 

that end, the minor league policy encourages field managers to 

hold tobacco education meetings with their clubs and waives fines 

for first-time offenders who complete cessation counseling programs 

that are provided by the club’s employee assistance professionals. 

Major League Baseball has also collaborated extensively with its 

partners to raise public awareness. 

In 1994, Major League Baseball helped establish the National 

Spit Tobacco Education Program to curb the use of smokeless toVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00095 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

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bacco products. Major League Baseball has provided NSTEP and 

its partners with over $100 million in cash contributions, television 

exposures and other support to conduct public service activities and 

announcements, which featured players including stars like Hank 

Aaron and Derek Jeter. 

Within the baseball community, NSTEP has served major and 

minor league players via numerous education and treatment options. These options include oral examinations, brush biopsies, educational seminars, cessation programs and training for club employee assistance professionals. Through 2003, Major League Baseball, at times on conjunction with the Major League Baseball Players Association, sponsored NSTEP programs with the assistance of 

grants from not-for-profit organizations including the Robert Wood 

Johnson Foundation. Clubs continue to administer oral examinations and smokeless tobacco education programs as part of their 

annual spring training activities. Highmark Blue Cross Blue 

Shield, the insurance provider for minor league players, also conducts an annual spring training presentation for players that addresses tobacco cessation options. 

Largely because of these efforts, the use of smokeless tobacco 

products has declined substantially in baseball over the last 2 decades. Commissioner Selig nevertheless remains committed to exploring additional opportunities in conjunction with the Safety and 

Health AdvisoryCommittee, a joint committee of baseball and the 

MLBPA. Last November, at Commissioner Selig’s urging, the committee hosted a presentation on smokeless tobacco use prevention 

by Dr. Ashok Shaha, a head and neck surgery specialist from Memorial Sloan-Kettering Cancer Center. During the 2010 season, the 

Commissioner’s Office will be surveying players to develop other 

educational and treatment programs. 

As we carry these initiatives forward, however, it is important 

for the Committee to bear in mind the legal framework that applies 

to smokeless tobacco. Like drug testing, the regulation of player 

use of tobacco products is a mandatory subject of collective bargaining. But unlike performance-enhancing substances, smokeless 

tobacco products are legal in all 50 States and for sale to and consumption by adults. And even the most ardent critics of smokeless 

tobacco use as a public health matter would argue that it compromises the competitive integrity of our game in a manner analogous to performance-enhancing substances. While an outright ban 

on the use of smokeless tobacco in the major leagues is a laudable 

goal, it will have to be pursued against the backdrop of these legal 

realities. 

I thank you for your time. 

[The prepared statement of Mr. Manfred follows:] 


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ST A TEMENT OF ROBERT D. MANFRED, JR. BEFORE THE HOUSE 

OF REPRESENTATIVES COMMITTEE ON ENERGY AND 

COMMERCE, SUBCOMMJTTEE ON HEALTH, APRIL 14,2010 

Chairman Pallone and members of the Committee, thank you 

for the opportunity to address our shared commitment to reduce the 

use of smokeless tobacco products. I would like briefly to review 

Major League Baseball's past and ongoing efforts to reduce or 

eliminate the use of such products by players, as well as the legal 

framework within which Major League Baseball's efforts have 

been undertaken. 

For almost two decades, Major League Baseball has worked 

on multiple fronts to reduce the use of smokeless tobacco products 

and educate members of the Baseball community accordingly. The 

centerpiece of this effort is the Minor League Tobacco Policy, 

which since 1993 has banned the use and possession of all tobacco 

products by club personnel including players - in Minor League 

ballparks and during team travel. We believe that our efforts at the 
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Minor League level are crucial so that players learn to avoid these 

products early in their careers. The Policy is displayed in all 

Minor League Clubhouses, and each Minor League contract 

requires the player to represent that he is aware of the Policy and 

agrees to its provisions. To ensure compliance with the Policy, 

Major League Baseball's Resident Security Agents conduct 

roughly one hundred random security inspections of Minor League 

baIl parks annually. Players and field managers who violate the 

Policy are subject to game ejection and incur substantial monetary 

fincs. 

Major League Baseball has also administered a formal policy 

regarding tobacco products at the Major League level for well over 

a decade. Pursuant to the Major League policy, Clubs may not 

pennit the distribution of tobacco products in Major League 

clubhouses. The Major League policy likewise strongly 

encourages Clubs not to permit Club personnel to buy tobacco 

products on behalf of other Club personnel, including Players. I 

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should also point out that Club personnel are barred from smoking 

when in uniform in view of spectators. 

Our efforts to reduce the use of tobacco products extend 

beyond formal disciplinary measures and into education and 

treatment. To that end, the Minor League Policy encourages field 

managers to hold tobacco education meetings with their clubs and 

waives fines for each first-time offender who completes a cessation 

counseling program approved by the club's Employee Assistance 

Professional ("EAP"). Major League Baseball has also 

collaborated extensively with its partners to raise public awareness. 

In 1994, Major League Baseball helped establish the National Spit 

Tobacco Education Program ("NSTEP") to curb the use of 

smokeless tobacco products. Major League Baseball has provided 

NSTEP and its paltners over $100 million in cash contributions, 

television exposure, and other support to conduct public service 

activities and announcements, which featured Players including 

Hank Aaron and Derek Jeter. 

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Within the Baseball community, NSTEP has also served 

Major and Minor League players via numerous education and 

treatment options. These options include oral examinations, brush 

biopsies, educational seminars, cessation programs, and training 

for Club EAPs. Through 2003, Major League Baseball sponsored 

NSTEP programs with the assistance of grants from non-profit 

organizations including the Robert Wood 10hnson Foundation. 

Clubs continue to administer oral examinations and smokeless 

tobacco education programs as part of their annual Spring Training 

activities. Highmarl< Blue Cross Blue Shield, the insurance 

provider for the Minor League players' medical plan, also conducts 

an annual Spring Training presentation for players that addresses 

tobacco cessation options (among other things). 

Largely because of these efforts, the use of smokeless 

tobacco products has declined substantially in the Baseball 

community over the last two decades. Commissioner Selig 

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nevertheless remams committed to exploring additional 

opportunities in conjunction with the Safety and Health Advisory 

Committee, a joint committee of Baseball and Major League 

Baseball Players Association representatives. Last November, at 

Commissioner Selig's urging, the Committee hosted a presentation 

on smokeless tobacco use prevention by Dr. Ashok Shaha, a head 

and neck surgery specialist from Memorial Sloan-Kettering Cancer 

Center. And during the 2010 season, the Commissioner's Office 

will survey all Minor League players to develop other educational 

and treatmcnt programs. 

As we carry these initiatives forward, however, it is 

important for this Committee to bear in mind the legal framework 

that applies to smokeless tobacco. Like drug testing, thc regulation 

of Player use of tobacco products is a mandatory subject of 

collective bargaining with the Players Association. But unlike 

performance-enhancing substances, smokeless tobacco products 

are legal in all fifty states for sale to, and consumption by, adults. 

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And not even the most ardent critics of smokeless tobacco use as a 

public health matter would argue that it compromises the 

competitive integrity of our game in a manner analogous to 

performance-enhancing substances. While an outright ban on the 

use of smokeless tobacco in the Major Leagues is a laudable goal, 

it will have to be pursued against the backdrop of these legal 

realities. 

Thank you again for this opportunity. 
97 

Mr. PALLONE. Thank you, Mr. Manfred. 

Mr. Prouty. 

STATEMENT OF DAVID PROUTY 

Mr. PROUTY. Thank you. Chairman Pallone and members of the 

committee, thank you for the opportunity to testify today. My name 

is David Prouty. I am the chief labor counsel for the Major League 

Baseball Players Association. I won’t repeat verbatim my written 

testimony but I just want to make a few points based on the testimony and also what we have heard today. 

First, no one disputes the health risks of smokeless tobacco. You 

have heard the medical evidence today. You will hear more. And 

you have heard the compelling testimony of Mr. Von Behrens. The 

players association completely agrees that smokeless tobacco poses 

a huge health problem for this country. 

Second, and it is for that reason that the players association has 

long discouraged its members from using smokeless tobacco. We 

have participated in educational programs to alert the players and 

the public to its dangers. For players, we have run educational 

seminars and offered medical screenings in spring training. We 

have participated in the NSTEP program that Mr. Manfred referred to, to offer cessation workshops. We have worked with Mr. 

Garagiola, in fact brought him to address a meeting of our executive board to talk about this topic. 

For the public, we have worked again through NSTEP on various 

outreach programs including the taping of a series of public service 

announcements involving prominent players including Derek Jeter, 

Hank Aaron and also Jeff Bagwell and Alex Rodriguez. 

We have also embarked on a new program with the Partnership 

for a Drug Free America called Healthy Competition, which is focused on helping parents and children make smart decisions regarding health and nutrition. The players want to help kids choose 

what to do, not just tell them what not to do. Through this program, we hope to educate young people, both athletes and non-athletes, to make smart choices when it comes to fitness, supplements, 

drugs, alcohol and tobacco, including smokeless tobacco. 

Third, the obvious question, why isn’t smokeless tobacco banned 

in baseball? Remember that smokeless tobacco is a legal product 

available for all adults to purchase everywhere in the United 

States but we can and we will educate players as to why they 

should not use it. There is a tension here because many players do 

not think they should be banned from using a product which Congress has so far deemed to be legal. If Congress were to ban smokeless tobacco, the players association would not object and might 

even support such a measure. Would the players association agree 

to ban smokeless tobacco in baseball as part of our next round collective bargaining negotiations? Well, we are a union. We pride 

ourselves on having a democratic structure and a democratic process, much like this Congress. It is up to the players, the members 

of this union, to decide what issues they want to bring to the table. 

I can guarantee you that I will bring back to the players the concerns that have been raised here today, and I am sure more will 

be raised, back to the membership of the union and that this issue 


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will get a full airing. That is how a union works and that is how 

collective bargaining works. 

Lastly, since this is the Health Subcommittee, I want to raise 

with you another health hazard that affects our members and the 

public at large, and that is the issue of dietary supplements. Simply put, the existing regulatory scheme is not working. There are 

many quality products on the market but there are also many that 

contain dangerous ingredients that aren’t labeled as such. In fact, 

the Food and Drug Administration just released a list of over 100 

dietary supplements that can be bought over the counter that contain performance-enhancing substances which are banned under 

baseball’s drug-testing program. Our members have suffered the 

consequences by testing positive and receiving suspensions as a result of ingesting these products that contain such unlabeled substances. We realize this may be a politically sensitive issue for 

some on this committee, but without your help, millions of Americans, young and old, athletes and non-athletes, will continue to be 

at risk from taking supplements that contain steroids, pharmaceuticals and other dangerous substances. We hope that you will 

give this issue as well the attention that it deserves. 

Thank you for your time. I will be happy to answer any questions 

at the conclusion. 

[The prepared statement of Mr. Prouty follows:] 


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BEFORE THE UNITED STATES 

HOUSE OF REPRESENTATIVES 

COMMITTEE ON ENERGY AND COMMERCE 

SUBCOMMITEE ON HEALTH 

STATEMENT OF DAVID PROUTY 

CHIEF LABOR COUNSEL 

MAJOR LEAGUE BASEBALL PLAYERS 

ASSOCIATION 

APRIL 14,2010 
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Mr. Chainnan and Members of the Committee: 

My name is David Prouty, and I serve as the Chief Labor Counsel of the 

Major League Baseball Players Association. Thank you for the opportunity to 

testify today about smokeless tobacco products and their use by major league 

baseball players. 

There is no doubt that smokeless tobacco products are dangerous, and that 

the long-tenn use of chewing tobacco and other smokeless tobacco products can 

cause serious health problems. These products are addictive. They greatly 

increase the risk of cancer, including esophageal and oral cancer, and cancers in 

the mouth, throat, cheek, gums, lips and tongue. It is impossible to listen to or read 

Mr. Von Behrens' testimony and not appreciate just how dangerous these products 

can be. 

For these reasons, the Players Association has long discouraged its 

members, and everyone else, from using smokeless products. We have worked 

with Major League Baseball to educate players about the realities and 

consequences of using smokeless tobacco products. 

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As Mr. Manfred indicates in his testimony, Major League Baseball created 

the National Spit Tobacco Education Program (NSTEP) in 1994. The program's 

purpose was to encourage both players and the public not to start using smokeless 

tobacco products, to help those already using these products to quit, and to help 

educate all Americans on the dangers of smokeless tobacco. 

The first chair of this program was Joe Garagiola, a well-respected former 

player and nationally respected broadcaster and someone with whom we worked in 

the effort to educate players about the dangers associated with the use of smokeless 

tobacco. Additionally, over the years, current and fonner players, including Derek 

Jeter, Henry Aaron, JeffBagweU and Alex Rodriguez, have assisted with a variety 

of educational efforts sponsored by NSTEP. In addition, in 2000 and 2001, Major 

League Baseball and the Association worked together to give smokeless tobacco 

special emphasis during spring training. Under the leadership ofNSTEP, we held 

educational seminars, oral medical exams, and developed cessation programs that 

highlighted the addictive nature ofthese products. 

As some of the members of this subcommittee know, each year we meet 

with every member of the Players Association during spring training to discuss a 

variety of issues of importance to the membership. Topics range from the state of 

collective bargaining, to issues involving competition and rules changes, to 

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developments concerning health issues, including smokeless tobacco. As you can 

expect, the subjects we discuss vary from club to club. 

Over the last few years, much of the discussion in these meetings has 

focused on our drug testing program, and the ongoing changes we have made in its 

operation and administration, but through the leadership of our new Executive 

Director Michael Weiner, we have already begun working with the Partnership for 

a Drug Free America on a new program we call Healthy Competition. The purpose 

of the program is to begin to address the difficulties in getting both parents and 

children to focus on how to make good choices our health and nutrition. Our 

members understand that it is not enough simply to say to young people "do not do 

this" or "do not take that." Such advice begs the question of what one should do. 

Consequently, we are working with the Partnership on the development of a 

variety of different educational materials utilizing different mediums to explain 

how we all can do a better job of making the right choice when it comes to fitness, 

exercise, dietary supplements, drugs, alcohol and tobacco. Obviously, educating 

young people, especially young athletes, about the dangers of smokeless tobacco 

products is a key component of this effort. 

I realize there are some who believe that the key to eradicating the use of 

smokeless tobacco products is to ban their use by baseball players during games or 

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in the clubhouse. After all, it is argued, baseball has banned smoking of cigarettes 

during games and in the clubhouse. We respectfully disagree. 

First, we believe baseball players should not be prohibited from using 

substances that are perfectly legal and available to the general public. Congress 

and the federal government are the ultimate arbiters of what products may be 

consumed or used by the adults, regardless of their wealth or celebrity. Should 

Congress in its ultimate wisdom decide that smokeless tobacco should be banned, 

the MLBP A would not oppose that effort, and might very well support it. 

Reaction among our members would undoubtedly be similar to the reaction in the 

general public. Many would applaud the decision. Some would oppose it. 

Second, on a practical level, the use of smokeless tobacco is not the same as 

the use of cigarettes. Cigarettes impact the ability to play the game, are banned 

from public use under a variety of state and municipal laws, and may endanger the 

health of those in the immediate area. 

Third, there are a variety of smokeless tobacco products that can be used 

without any of the telltale signs normally associated with the use of chewing 

tobacco. In fact, it would be impossible for fans either at the stadium or watching 

on television to know whether a player was using one of them. Our objective, 

however, is not to hide the use of smokeless tobacco but to convince players 

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through education that it is in their long term interest to stop using any tobacco 

products, visible or not, both at work and at home. But until a player reaches that 

decision, we do not believe he should be banned from using products Congress has 

thus far concluded may be used by all other adults. 

I would be remiss ifI did not use this opportunity to raise, once again, 

another problem of singular concern to our Association. As our Executive Director 

noted in his testimony last November before the Subcommittee on Commerce, 

Trade, and Consumer Protection and, as our former Executive Director noted in a 

series ofletters to members of the full Committee last year, the current regulatory 

scheme for dietary supplements is not working. 

Nearly half of all Americans claim to use supplements, many on a daily 

basis. Those individuals are worthy of the same basic protection promised those 

who consume traditional food - the assurance that the products regulated by the 

FDA, that are sold without restriction throughout the country to adults and 

children, are safe and that the products' labels can be trusted. 

There are many reputable supplement manufacturers who provide quality 

products but, unfortunately, our country is still awash with supplements that 

contain pharmaceuticals and other dangerous ingredients. In many instances, 

there is no indication on the label of products sold on the shelves of national chain 

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nutrition stores that indicate what is really inside the bottle. There is no warning 

that the supplement may contain substances prohibited by the FDA which also 

happen to be banned under our drng testing program. Indeed, members of our 

union have suffered the consequences of positive tests and the resultant 

suspensions under just such circumstances. 

The MLBP A has done what it can to advise our members when we become 

aware of such dangerous supplements and the substances they contain but, as a 

private organization, we are limited in what we can by ourselves. We believe a 

broader effort is necessary if this problem is to be effectively curtailed. Until that 

happens, countless Americans of all ages, athletes and non-athletes, will be misled 

about what is inside the supplement products they are taking. It is has been over 

a year since we first raised this problem with the Committee and asked for 

assistance. We hope you will find time to give this matter the attention it deserves. 

Again, thank you Mr. Chairman. I appreciate the opportunity to testify, and 

I look forward to answering any questions you may have. 

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Mr. PALLONE. Thank you. 

Mr. Garagiola. 

STATEMENT OF JOSEPH HENRY ‘‘JOE’’ GARAGIOLA, SR. 

Mr. GARAGIOLA. Thank you, Chairman and the committee 

and—— 

Mr. PALLONE. I think your mic, you have to bring it closer and— 

there we go. 

Mr. GARAGIOLA. I have never been around a microphone before. 

I don’t know what to do. I just holler. 

You are not going to hear a bunch of numbers from me, and don’t 

start the clock yet because I have got all kind of notes here on my 

papers. These guys come with typewritten sheets and all that, but 

I made some notes are listening to this. Six hundred and fifty million dollars, when we started out with—and I hate to hear that 

word ‘‘smokeless.’’ That belongs to the tobacco companies. I could 

use a word that would get me kicked out of a game when I hear 

that, but I will not. I watched 60 Minutes like you did and it was 

scary. 

Let me just throw a few things out. In 1993—and I keep hearing 

numbers and it is true. In 1993, 21 percent of the players in the 

World Series used tobacco, spit tobacco. That is what I call it, spit 

tobacco. That is what it is. In 2000, 7 years later, it was zero. Why 

was that? I was in the trenches with a bunch of guys who went 

with me, and I called the producers. I said why do you guys stay 

on that shot, get off that shot. I called the guys who—the presidents of the networks. Lenny Dykstra, who was the poster boy, just 

to give you a story, I went up to him and I said Lenny, why do 

you use that garbage, what did they give you? Did they give you 

any money? He said no, I have to have it. Why do you have to it? 

I just have to have it. And I said just tell me you won’t use it during the World Series. I will talk to my guys at CBS and we will 

make an impact. No, I can’t do that. Lenny Dykstra has quit using 

it, guys, because he ran into a problem. So I don’t know about 

numbers and all that kind of stuff but I just want you to know that 

that is where it got started. 

Six hundred and fifty million dollars—when I was with NSTEP, 

I made speeches across this country. I will never forget going into 

Connecticut with the attorney general, and that is when the tobacco company, they were going to use it as a safe alternative to 

cigarettes. Oh, come on. Give me a break. I am not going to go 

through all this. I am just going to tell you some of the things that 

I have learned. 

In my day, we called it chew. I chewed. Why did I chew? Because 

the others players chewed. I thought it was part of baseball, and 

that is what it is all about. I mean, the things that you do because 

the other guys do it. They used to give us salt tablets. Salt tablets, 

they used to give us. I think they were trying to kill us is what 

I thought they were trying to do. But it has improved so much, and 

now, I got so much I want to say I am choking on myself. 

Like many other players, I thought being a major league player, 

you had to chew. You watch those guys, Lon Warnicke, who I grew 

up with, that kind of—I chewed until my daughter came home 

from school one day and said Daddy, are you going to die? I said 


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sweetheart, sure I am going to die, we are all going to have to die. 

She said I mean are you going to die. I said yes, but not now. I 

am not looking forward to it. And she said no, and she had that 

look in her eyes. And I said sweetheart, why are you asking me? 

And she said because we’re studying about tobacco and we are 

studying about lungs and they said if you use tobacco you are going 

to die. I stopped. I stopped. I wish you guys could walk with me 

on a field because I have been called everything from a Nazi antitobacco chew zealot. I mean, come on. This is what these ballplayers do. I mean, forget the numbers and all that. Get in the 

trenches and watch them. And with the minor leaguers, baseball 

has done a great job, and baseball is taking a beating here. They 

really have, and I am sitting next to the guy that I wanted to romance here, put some Chapstick on and get him to do the job. But 

to me, in my 20 years of working to spread the word about the dangers of smokeless tobacco, many of my friends, Jack Crowl, a coach, 

he lost half his tongue like my friend Gruen. I have a tape here, 

and I am all over the place I know. I am going to tell you about 

this tape. This is Gruen Von Behrens’ tape, and if any of the people 

on the committee would like to have a copy, we will get it to you. 

I will get it to you. The Diamondbacks paid for this. We didn’t have 

any of that 650 million. There is a booklet that Bud Selig, the commissioner, gave out to people, and I mean, it is nothing but little 

cartoons that kids can see. Here is one. It is easy to quit smoking 

cigarettes, you just take them out of your mouth. No, Daddy, let 

us make him a nonsmoker—he is working on a snowman—he will 

last longer. I mean, I was begging everybody to help us, and they 

did. But I lost Jack Crowl, lost part of his tongue, couldn’t talk, and 

in a year he was dead. Bill Tuttle—Bill Tuttle died one piece at a 

time. Bob Leslie, a high school coach—and I never asked anybody 

to make a tape or a DVD. Bob Leslie called and he said Amy and 

I, we want to make a tape, and we went out there and made this 

tape, and I will never forget when Bob Leslie died, I spoke at his 

funeral, and here was Amy right where that chair is, the second 

chair, holding a baby, and I said to myself, in her 20s, holding a 

baby that can’t even stand up by himself or walk, she should be 

enjoying it, and instead of being a mother and a wife, she is a 

widow. She hadn’t even seen 30 years old. They all died too soon. 

That lit the fire, guys. I want to tell you, that lit the fire, and 

that is why I agreed—in 1994, that is how long I have been going 

out there—and I never got paid a nickel. Never got paid a nickel. 

I didn’t want to get paid. If they wanted to hear my speech, they 

had to pay my flight there, and I am going to tell you, sitting in 

the middle seat sucks. That is not in the script, by the way. But 

anyhow, I agreed to chair the National Spit Tobacco Education Program, and we had some money from the Robert Wood Johnson 

Foundation. I worked with them and now I haven’t heard from 

anybody. It is almost like I got leprosy. 

Anyhow, I lobbied Major League Baseball to ban the distribution 

of tobacco products in major league clubhouses, a rule that is still 

in effect, and I am going to tell how that started. Rob knows it. I 

went to the Diamondbacks and I said to them, you guys hired the 

clubhouse guy, tell him he can’t put that tobacco there and don’t 

let the tobacco companies give you free tobacco, and kind of looked 


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at me and he said what do you mean. I mean clean it out, let them 

stop, make it inconvenient to buy the tobacco, which they did, and 

that was good. But you know what? When the kid comes up from 

the minor leagues, he knows he shouldn’t use it but I see it. The 

first thing they know, they don’t even pick the bat first, they throw 

a chew in their mouth. We have to educate, educate, educate, and 

Commissioner Selig is behind it 100 percent. 

Hey, U.S. tobacco, if you look at it, they don’t call themselves a 

U.S. tobacco company anymore, they are a U.S. smokeless tobacco 

company. Now, if that isn’t a subtle commercial, I don’t know what 

is. 

I have letters from Commissioner Selig and Donald Fehr both 

who are backing what I am doing. Why can’t baseball and the players association right here get together and ban it? Take it off the 

field. I think it was Mr. Waxman who said something about we 

don’t see a player going out there with a cigarette in his hand. I 

know where he got that line, when I testified before his committee. 

I mean, Arnold Palmer used to play golf, walk on the green, flip 

a cigarette and putt, but we don’t have that in baseball. Tobacco 

is tobacco is tobacco. Get together. The players association, baseball, get together, guys, ban tobacco and anyone who uses it is penalized. I don’t care if it is a suspension. I don’t care if it is fines 

or what. Get it out of our game. It is a great game, greatest game 

going. I have heard all kinds of things about it. 

I almost forgot the most important thing. We have a club in Arizona that I went to the Diamondbacks and I said you know, why 

don’t we let the kids in free. I wanted to call it Let’s Kick Their 

Cans, and this is what Bill Keane did for me. We call it the No 

Chew Crew, and they get a red tee shirt with No Crew Chew and 

they sign a pledge that they are not going to use tobacco. Well, you 

don’t know if they are going to use it or not but they are going to 

be aware of it, but they get into the game free if they come chaperoned. 

This is Gruen Von Behrens’ tape. We got this in every school in 

Phoenix, Arizona. How I would love to see that in every school in 

Arizona, the whole State. 

Spit tobacco. I would like the players—and boy, do I get it from 

them—who are role models, and I don’t care what anybody says, 

whether they agree, Charles Barkley notwithstanding, they are 

role models. I want them to quit carrying a can of dip in their uniform pockets and especially where the youngsters see them. I just 

had an incident last Saturday. I did a broadcast. I am just getting 

out of surgery. I had three major surgeries. I didn’t work at all last 

year and I was in the hospital all of 2009, but when I got this invitation, that is how important this is to me. I was in the Diamondback clubhouse and one of the players, I don’t want to name him, 

he is sitting there with a laptop and he is dipping. I go around the 

corner and they got a kitchen now. We never had a kitchen. If you 

had a bologna sandwich, you were lucky. These guys sit there and 

watch Days of Our Lives or whatever instead of taking batting 

practice and then they wonder why they can’t hit and they are 

going to be broadcasters. I saw him using that stuff. I said why are 

you using it now? Oh, it feels good. Until they find something. I 

can name players. Curt Schilling, we took him in for a brush biopsy 


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that Rob was talking about. He came out, he was as white as this 

towel because they found a lesion and he had to have it biopsied. 

Curt Schilling, who pitched in the World Series, I don’t know if he’s 

using again. He may or may not. But it is a deadly, addictive habit, 

and it is an uphill battle, this spit tobacco, and I am going to tell 

you why. Nobody has mentioned it, but I will. 

I have made speeches before the firefighters, police officers, anyone who works with the public, they can’t smoke. They can’t smoke. 

So what do they do? They use spit tobacco. And when I told them 

about it and the reaction that I got was tremendous, and they start 

early because the tobacco companies advertise to them at a very 

early age. These companies mislead you. You want to talk about 

advertising? Here is a catalog that they put out, OK? I know you 

have got a bunch of books there, Chairman. I will give you this if 

you want it. In fact, one of them got me mad. Brad Roudeaux— 

Brad Roudeaux is from the University of Alabama Birmingham. He 

is on the payroll of the tobacco companies. So if you want to burn 

it, you can burn it. You have my permission. Here is a catalog of 

gifts. Here is a pool table. Do you know how many lids you need 

to get this pool table? Ten thousand lids. You use 10,000 cans of 

tobacco, you would have cancer of the feet. And, you know, they 

talk about cowboys and westerns and all that. They do that. 

We were at a NASCAR—one of the people here talked about 

NASCAR. I went there and we put a sign up there, smokeless does 

not mean harmless. They came and said that it was insulting to 

them. I said insulting? I can’t believe it. They made us take it 

down. 

It is not a safe alternative to cigarettes. Fewer people die from 

it. That is the song of the tobacco companies. You know what it is 

like? And this is what I said to the attorney general in Connecticut. 

It is like saying don’t jump out at the 50th floor, what are you 

nuts? Jump out of the 30th floor. You got 20 floors on your side. 

The result is going to be the same. It is a dangerous, deadly habit 

and baseball can’t solve the problem by itself. We need help. The 

players association—Commissioner Selig encourages everything 

that I do. Donald Fehr, he is gone now, right? 

Mr. PROUTY. Still around but he is retired. 

Mr. GARAGIOLA. But you are here. 

Mr. PROUTY. I am here. 

Mr. GARAGIOLA. OK. You go back with this message. 

Let me just say this. We need truth in advertising. That is important. I can’t think of the Congressman’s name, he was from 

California. He called me and he said he is going to have a press 

conference in California and could I get a ballplayer because he 

wants to have stronger words on the can, and I wasn’t too smooth 

with him and I said is this a photo op or do you really mean. He 

said no, I am really going to do it, and I said what are you going 

to do. He said make a stronger message black print, big print. I 

said OK. We came out there. A kid named Mike Watson from Denver, he is a firefighter now, kid was on a Friday, he quit. Monday 

he went back to using it. And, you know, what can I tell you? 

Smokeless does not mean harmless. 

I don’t know what my time is but I am very emotional about 

this—— 


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110 

Mr. PALLONE. Your time is up but we appreciate the fact that 

you—— 

Mr. GARAGIOLA. Thank you very much. 

[The prepared statement of Mr. Garagiola follows:] 


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STATEMENT OF JOE GARAGIOLA BEFORE THE HOUSE OF 

REPRESENTATIVES COMMITTEE ON EN ERGY AND COMMERCE, 

SUBCOMMITTEE ON HEALTH, APRIL 14,2010 

Good moming, Chairman Pallone and members of the Committee. Thank you for 

letting me participate in this important discussion about the dangers of smokeless tobacco 

products. Smokeless doesn't mean harmless. In my day, we called it chew. Like many 

generations of Major League baseball players, I started using spit tobacco because I saw 

other players doing it and I thought it was pat1 of being a Major League player. I chewed 

during my playing career, and I did not quit until my daughter saw a presentation about 

the dangers of tobacco in elementary school and begged me to stop. I am so grateful to 

my daughter for saving me from the pain and suffering that I would have risked if I had 

continued my habit. 

But in my twenty-years-plus working to spread public awareness about the 

dangers of smokeless tobacco products, many tomler Major League coaches and players 

-- like my t)'iends Jack Krol and Bill Tuttle - died too soon. Their storics and thcir loved 

ones "lit the tire" in me to do my pmi to steer our young people away t]'om this deadly, 

addictivc products. 

That is why I agreed, beginning in 1994, to chair the National Spit Tobacco 

Education Program ("NSTEP"). Through the years, I have worked with NSTEP to raise 

public awareness and encourage carly diagnosis of tobacco-related health problems. 

lobbied Major League Baseball to ban the distribution of tobacco products in Major 

League clubhouses, a rule that is still in effect today. I continue to encourage Major 

League Clubs to raise public awareness through activities like the "No Chew Crew," a 

youth club sponsored by the Arizona Diamondbacks that has gotten over twenty thousand 
112 


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children in the Phoenix area to pledge not to use spit tobacco, And 1 have spent countless 

hours urging Major League and minor league players to stay away Irom smokeless 

tobacco - or as J call it, spit tobacco, Calling it smokeless tobacco is a subtle 

commercial: it is spit tobacco, 

Of course, J continuc to urge Baseball to do more, [would like to see the Major 

League players ah'TCC to the terms of the Minor League Tobacco Policy, which bans Club 

personnel from using and possessing tobacco products in ballparks and dUling team 

travel. I would like the players who arc role models - to quit carrying cans of dip in 

their unitonTI pockets, where espccially the youngsters can see them. Even more can be 

done to educate young players about the facts and images of spit tobacco. 

But in the bigger picture, this is an uphill battle because smokeless tobacco is not 

just a baseball problem; it is a problem for all of society. Many ballplayers are addicted 

to smokeless tobacco, but so are many people from other walks of life - Wall Street 

executives, tireHghters, and police officers. They start carly because tobacco companies 

advertise to them at an early age, and they do not tell thc truth, These companies mislead 

our young people future ballplayers, but also future lawyers and future bankers to 

bclieve that smokeless tobacco is a safe alternative to cigarettes. 1t is not. "Fewer people 

die from it" is the song of the tobacco companies, It's like saying don't jump out of the 

50th tloor; jump out of the 30th tloor. You've got twenty floors to your beneH! but the 

answer is the same. This is a dangerocls, deadly habit, and Baseball cannot solve the 

problem by itself. We need make sure the tobacco companies do not target our young 

people. We need truth in advcl1ising and stronger warnings on packages, They need to 

realize that smokeless is not harmless. 

2 
113 


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I thank the Committee tor focusing its attention today on this very important 

issue. We need help. 
114 

Mr. PALLONE. No, I appreciate that you spent so many years 

dealing with this and trying to make a difference, and I know you 

are making a difference, so thanks a lot, really. I appreciate it. 

We will go to Dr. Connolly. 

STATEMENT OF GREGORY CONNOLLY 

Mr. CONNOLLY. Thank you very much. It is really hard playing 

cleanup witness to Joe Garagiola, believe me. 

I did have the opportunity to testify 25 years ago before Mr. 

Waxman on this very issue, and I think the only difference I can 

see is that at the time Mr. Waxman had no hair and I did have 

hair. 

I am a dentist. I teach at Harvard. I had the opportunity to work 

with Major League Baseball Players Association for spring training 

and conducted surveys on why they used the product, also did examinations of the oral cavities. 

I just want to go through with what the players risk. If I represented a union, I would be concerned with the health of my union 

members. The Teamsters put efforts into protecting the health of 

their union members and I think other unions in the United States 

of America should worry about their union members. 

[Slide shown.] 

But just turning over here, if you take the dip out you see something called leukoplakia. This is a grade III, and I used to have a 

game with the Blue Jays, I can guess how many dips you use a 

week game. Just by looking at these lesions, you can identify is it 

one can, two cans, three cans, four cans. And I remember one player said I beat you, doc. I said one can. I said look over here. It was 

two cans here and two cans here. The University of San Francisco 

screened 52 players and found two precancerous lesions in those 

white lesions, and those are precursors to cancer. They are present 

in about 50 percent of the players. The players tell me they want 

to stop, they can’t because they are addicted and they are doing it 

in spite of a known health problem. 

[Slide shown.] 

This is another famous baseball player who spent literally 

$10,000 to treat another condition. This is where the nicotine and 

the ingredients get in and destroy the bone tissue. He had to have 

grafting, and unfortunately midlevel of the season he is back using 

again. Next slide, please. 

[Slide shown.] 

This is use rates. We monitor use rates over time, and we see 

about one-third of the players use it, minor leaguers less, maybe 

because of the ban with minor leaguers. I am really not sure. But 

this really hasn’t changed. So we are still seeing players at risk of 

developing disease not during their careers in baseball but most 

likely later in baseball. And I think you have to protect the health 

of the players. That is the basic element here. Next set of slides, 

please. 

[Slide shown.] 

So then we also look at reasons why the players use it, and I 

asked them. We did a survey among 556 players and the respondents who were heavier users primarily used reasons for addiction. 

It was for, ‘‘I was hooked,’’ ‘‘I was treating relaxation, withdrawal.’’ 


rfrederick on DSK6VPTVN1PROD with 
115 

Not one player said I used it to enhance my performance. Players 

are not proud of using this, and that is the reality. They wish they 

didn’t start as Little Leaguers or as high school ballplayers or as 

minor league ballplayers. Next slide, please. 

[Slide shown.] 

We estimated use over time, and it has been about 9 minutes of 

game use from 1987, 1986 to 2004. It hasn’t changed. What has 

changed is the use now is being concentrated by a handful of players. It is only one or two. The vast majority of baseball players do 

not want to be bad role models, and the only way one is going to 

deal with those one or two players, and I can just look at—you 

know, we banned advertising through the MSA. We banned it 

through the FDA Act. But all you have to do is pick up the front 

of Sports Illustrated, and fortunately this guy is wearing a Dodgers 

uniform and not a Red Sox uniform, to see what type of advertising 

reaches kids across America. I told the Jays, I said, you know, 

based on the use you used just in the World Series, that equals the 

salary of the entire club, and you guys are deemed to be greedy by 

Americans. The one guy got up and said I am going to call my 

agent. And it is spreading. This is Facebook. We are seeing dozens 

and dozens of groups on Facebook with high schoolers extolling the 

virtues of using smokeless tobacco products, and it is all related to 

Major League Baseball players. We see two groups on steroids, one 

opposed and one saying maybe it is OK, but we are seeing widespread use of adding a drug, nicotine, to users. Next slide, please. 

[Slide shown.] 

You know, when we take an oath as health professionals, we 

take an oath to do no harm. That is called the Hippocratic Oath. 

It is not an oath to do less harm. I want to make that perfectly 

clear. We take an oath to do no harm. We have medications called 

Nicorette that are outselling these newer products 1,000 to one. 

They are being used effectively. They are approved by the FDA. 

They increase quit rates. They double quit rates and they don’t 

have cancer-causing chemicals in them. We have tens of thousands 

of baseball fields across this Nation and it is banned on virtually 

every one except 30 yet those 30 fields are the most important 

fields to the health of American children, only those 30. You can’t 

dip in high school. We got NCAA to stop it. Major League Baseball 

stepped to the plate and stopped it, and we have a problem right 

now in America. We have a problem in America, and that is protecting the health of the union and letting the members do what 

they want to do and not be victimized by one or two players who 

think somehow it is glamorous to throw it in your mouth and look 

like who knows what. 

I want to thank you very much for giving me the time to testify, 

and the last time I was with Joe was at the Red Sox game where 

he announced the whole gang to me and my son. It was a wonderful experience. Thank you, Mr. Chairman. 

Mr. GARAGIOLA. No spit tobacco, either. 

[The prepared statement of Mr. Connolly follows:] 


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Testimony Before 

Committee on Health and the Environment 

On the Public Health Effects of Smokeless Tobacco 

Gregory N. Connolly, D.M.D., M.P.H. 

Professor 

Harvard School of Public Health 

April 14, 2010 
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Background and Qualifications 

My name is Gregory Connolly. I am a professor of public health practice at the Harvard 

School of Public Health and a dentist. I have conducted research and educational 

programs on smokeless tobacco use for over 20 years including spending three Spring 

Trainings in Florida surveying players on use, screening oral lesions and providing 

counseling on how to quit. 1.2 In collaboration with the Professional Baseball Players 

Training Association, we developed a self-help quit guide for athletes on quitting 

smokeless use which was later used at high school, college and professional baseball 

team levels 2 

I and others have also conducted research on the impact that public use of smokeless 

tobacco by Major League Baseball (MLB) players has on youth exposure to messages 

about the use of smokeless tobacco and its free advertising value 3 ,4,5 I have also worked 

with the NCAA and MLB on developing and implementing policies that prohibit use by 

college and minor league players while on the field. 

My testimony will review the health effects of smokeless tobacco, the use by MLB 

players, reasons for use, and youth exposure to use based on televised World Series 

Games from 1988 to 2005. 
118 


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Health Effects of Smokeless Tobacco on Major League Baseball Players 

Smokeless tobacco (SL T) causes disease including nicotine addiction, oral and 

pancreatic cancer, periodontal disease and possible unknown systemic disease associated 

with toxic compounds such as tobacco specific nitrosamines, benzopyrenes and heavy 

metal s 6.7 

Use of Smokeless Tobacco by Major League Players 

There has been traditional use of chewing tobacco by a few players since the game was 

first invented. But, today chewing tobacco has been replaced by moist snuff, a finely 

ground tobacco placed as a dip between the check and gum. This form of SL T is highly 

addictive and causes serious health problems. Its introduction into baseball was only a 

few decades ago and a direct result of heavy sports marketing by the tobacco industry. 

Regretfully, the practice rapidly spread throughout baseball but is a relatively new 

phenomenon which should be eliminated. Presently, use of SLT is banned from every 

baseball field in America, Little League, Babe Ruth and NCAA and the Minors. There 

are only 30 baseball fields which use is unrestricted and they are the most important to 

American youth. 

Baseball players are at major risk of this disease because of their high level of use 

whether it be in high school or as professional ball players. 1

,9,1O.1l Both my and other 

research has found that about one third of maj or league players report using SL T, in 

particular, moist snuff and one quarter of minor leaguers. The lower rate among the 

minors could be due to the ban on use in 1993. 
119 


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Players primarily use smokeless tobacco because of its drug effects that cause 

dependence or addiction and players do not report that use enhances performance or 

ability. 1.8 

Finally, the vast majority of players want to quit and seek assistance to do so. 1 Below are 

some of the examples of the clinical effects of smokeless tobacco use on player's health 

that I have seen during Spring Training sessions. 
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Oral Leukoplakia 

Periodontal Disease and Leukoplakia 

Use of Smokeless Tobaeeo (SLT) by Players is Heavily Seen by Children and 

Contributes to Their Use of SLt 

The use of SL T by players has a powerful role model effeet on youth partieularly among 

young males in sport, some of whom ironieally remain addieted in future eareers as 

professional athletes. From 1988-2005, we and others have studied televised use of SL T 

during seleeted games of the World Series and on average, we observe from 24 to two 

minutes of use with an average of nine minutes per game.3A,5 
121 


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The televised value of just one game is on average worth millions of dollars in free 

advertising reaching millions of adolescents. 

Extrapolate the advertising over a season; the free advertising value to the manufacturers 

of SL T is probably worth more than the combined salaries of all MLB players combined. 

There can be no doubt that public use by MLB players directly contributes to youth 

smokeless tobacco use in the u.s. Of major concern is that SL T use is increasing 5% per 

year nationally and among adolescent males, ages 12-17, has increased 25% from 2004-

2008. This group only shows a significant increase in use. 
122 


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~ 0.015 1 ..__.-.... - ..... . 

f 0.010 .f.-.~~~.~ 

£ I 0.005 

Another major concern is the spread of messages about MLB baseball players through 

internet social networking sites visited by teenagers on sites such as Facebook. We found 

many groups on Facebook dedicated to MLB players using smokeless tobacco with a 

total of thousands of members all extolling the virtues of SLT use. This is alarming. 

Below are typical list of quotes from this site. 

Quotes from Facebook, Baseball and Chew Clubs 

Nick: "yo who saw the game 4 of the yank and indians .... towards the end the camera guy 

had damon and jeter...and all u see is damon gettin rid of his bomb . .1ol" 

Source: http://ww>\.faccbook.com/homc.php·)# !/group.php'>y=wall&rcf=scarcb&gid=23654I +5+ 1 

IAccessed 4/12/2010] 

Matthew: "nothing like a nice fat lip when your playing baseball" 

Source: http://mn,.faccbook.com/holllc.phpO#!/group.php'ly=wall&rcf =scarch&gid=2365414541 

[Accessed 4/12/20 lO] 

Joe: "Dustin Pedroia packs bombs, so does Youlk they are probaly 2 of the biggest up 

and coming stars of the red sox" 

Source: http://www . faccbook.colll/homc.php?#!/ group. php"v=wall&rcf =scarc h&gid=2J 654145 .. 1 

[Accessed "/12/20lO] 
123 


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Todd: "man threw in my first roofer when i was 11. the best stuff is citris with big league 

chew or theres always copenhagen with a bit of whisk." 

Source: http://www.facebook.comlboll1c.php?#!lgroup.pbp.?v=wal1&rcf=scarch&gid=236541-1541 

[Accessed 4112120101 

.. God Bless 

(See Appendix for more quotes) 
124 


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Oral Carcinoma at the Site of SL T Placement 

Smokeless Tobacco Use is Incompatible with the Mission of Professional Baseball 

Sport is the vehicle by which we pass values down to the young, how to compete, respect 

your fellow man, and accept winning or losing graciously, but most of all value personal 

health and fitness. When a professional baseball player uses SL T, condoned by MLB, we 

do not pass values down, only the potential for future addiction. Leadership is needed 

now by both the Players Association and MLB to protect not their own interests but the 

interests of American youth and become true health players for America. 

Major League Baseball and the Players are Expecting A Ban on Use and are Ready for It 

A major finding from our research is that public use of SL T is declining, but still is 

unacceptably high. It is being confined to fewer athletes today than 20 years ago. For 

unknown reasons, these athletes are more heavily using the product and they account for 
125 


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the bulk of televised exposure. The television cameras seem to be overly focusing on the 

use ofSLT. 

I'd like to end my testimony by showing a one minute video I did a few years ago with 

ABC news on this problem. 

(Show Video) 

Conclusion 

Based on these observations, I feel strongly that the vast majority of professional athletes 

do not want to use these products on the field, particularly in front of children, but are 

addicted and a few unwittingly may believe it makes them more appealing on camera. 

The majority of players do not use the product and the problem is now among a handful 

of players that only a complete ban could address. I conclude that the athletes are 

expecting a ban, like the ban on smoking instituted in the 1950s. It is in the interest of 

the health of the millions of young boys in Little League, Babe Ruth or High School 

baseball for MLB and the Players Association to step up to the plate and take a lead on 

oral cancer prevention as they have for other cancers and prevent not foster disease by 

stopping SL T use on the field. 
126 


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References 

L Connolly, G" Orleans, T" and Kogan, M, "Use of Smokeless Tobacco in MajorLeague Baseball." New England Journal ()f Medicine, 1988; 318(19): 128-1285, 

2, Beat the Smokeless Habit, ROW Science MD, 1991, P 1-13, 

3, Jones, R. "Use of Smokeless Tobacco in the World Series, 1986 through 1993," 

American Journal of Public Health. 1995; 85(1): 117-118, 

4, Jones, R, "Use of Smokeless Tobacco In the 1986 World Series," New England 

Journal of Medicine , 1987; 316(15): 952, 

5, Johnson, A, Rothman, 1., (2004), Televised Images of Smokeless Tobacco Use 

During Game Four of the 2004 World Series: Analysis and Implications, 

Unpublished, 

6, Critchley, l, Unal, B., (2003), Health effects associated with smokeless tobacco; 

a systematic review, Thorax, 58:435-43, 

7, US, Department of Health and Human Services, The Health Consequences ()f 

U5ing Smokeless Tobacco: A Report of the AdvisOlY Committee to the Surgeon 

General, 1986. Bethesda, MD: US, Department of Health and Human Services, 

Public Health Service, NIH Pub, No, 86-2874, Available at 

http://profiles,nlm,nih,gov/NN/B/B/F/CI. Accessed: December 2004, 

8, Robertson, p" DeRouen, T., Ernster, V" Grady, D" Greene, l, Mancl, L., 

McDonald, D" and Walsh, M, "Smokeless Tobacco Use: How It Affects the 

Performance of Maj or League Baseball Players," Journal ()fthe American Dental 

Association. 1995; 126(8): 1115-1121. 

9, Cooper, J" Ellison, J" and Walsh, M, "Spit (Smokeless)-Tobacco Use by 

Baseball Players Entering the Professional Ranks," Journal of Athletic 

Training 2003; 38(2): 126-132, 

10, Cummings, K., Michalek, A, Carl, W" Wood, R., Haleym N, Use of Smokeless 

Tobacco in a Group of Professional Baseball Players, Journal l?fBehavioral 

medicine, 1989; 12 (6): 559-567. 

11, Siegel, D" Benowitz, N" Ernster, Y, Grady, D" and Hauck, W, "Smokeless 

Tobacco, Cardiovascular Risk Factors, and Nicotine and Cotinine Levels in 

Professional Baseball Players," American Journal ()f Public Health. 1992; 82(3): 

417-421. 
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Appendix 

Quotes on Facebook 

Phil: "Gotta love Swisher tho. I want him to sign my tin and pack one with him" 

Source: http://mnY.faccbook.com/homc.php?#!/group.php?,·=wall&ref=search&gid=2365-lI-lS4 1 

[Accessed 4!l2120 10 I 

Elliott: "im a big fan of citrus i dont know what i would do if i didnt have dip during 

baseball" 

Joe: "Dustin Pedroia packs bombs, so does Youlk they are probaly 2 of the biggest up 

and coming stars of the red sox" 

Source: http://www.facebook.com/hollle.php?#!/group.php?y=.\all&rcf=scarch&gid=23654 14541 

[Accessed 4/12/2010] 

Donny: "i was at a sox game a while ago and got swishers autograph and he didn't spit 

for like the whole 20 minutes he was now thats a champ" 

Todd: "man threw in my first roofer when i was 11. the best stuff is citris with big league 

chew or theres always copenhagen with a bit of whisk." 

Source: http://www.faccbookcom/homc.php··#!/group.php·iY=wall&ref=scarch&gid=2365-l1-I5-lI 

[Accessed 4112/20 lO] 

Elliott: "last night my summer team was sitting around in a hotel and 2 kids put in a 

whole tin at one time and it was the funniest ive ever seen" 

Derek: "no joke, i got my first rip from chase utley when i was ll .. greatest thing that ever 

happened to me" 

Source: http://www.faccbookcom/homc.php?#!/group.php'\c=waU&rcr=scarch&gid=23654 1 4541 

[Accessed 4/12/2010] 

Joseph: "ant nothin better than sittin in the duggout with a fatty in hangin out with ur 

Nick: "skoal citrus makes the day better 101 half the baseball team rocks a dip, of course 

we just cant get caught by the coach kind of a bummer" 

Sourcc: http://\\\\,\\.faccbook.com/hol11c.pl\p''#!/group.php'/y=wall&rcf=scarch&gid=236541-l54I 

[Accessed -1/12/2010] 

Travis: "The bigger the dip, the better he playsl!" 

Source: http://www Jacebookcom/group.pJip?Y=wall&rcf=search&gid=23 17662091 

[Accesscd 4/12/2010] 
128 


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Miles: "ahh .. .i put half of my red man big in today during my game .. .i dedicated it to this 

great group" 

Source: http:/Annv.faccbook.colnlllomc.php"#!/group.php')v=waJl&rcf=scarch&gid=2364882221 

[Accessed 4/12/2010] 

Sheldon: "chipper jones pokes his lips and gums with a pin before he lips in 

and he mashes, so him or swisher is the biggest dipper" 

Source: http://www. faccbookcom/homc.php')# !/group.php')Y=wall&rcf=scarch&gid=2365-11-15-1 1 

[Accessed 4/12/2010] 

Dustin: "man theres nothin like a big pinch right before the game, during the game, and 

after on the way home haha .... helps me drop bombs .. .it was mine and pres' JUICE haha" 

Source: http://www.faccbook.com/ho me. php?#!1 group.php "y=wall&rcf=scarc h&gid=2:1 (,4S82221 

[Accessed 4/12/2010] 

Kyle: "Chris Duncan=Best Dipper in Baseball" 

Source: http://\\,,,, . faccbook. co tn/home. php'i#!1 group. php"y=\ rall& ref=scarc h&gid= 2365-1 ! -I 5.\ I 

[Accessed 4/12/2010 I 

Christian: "u gotta like the redman chew and dubble bubble mix that francona does too" 

Source: http:/Annv.facebook.conllholllc.php'7#lfgroup.php')y=wall&rcf=scarch&gid=2365.\ 14541 

[Accessed 4/1212010] 

Rob: "dustin pedroia paks bigga bombs then ne one on the field" 

Source: http://www.faccbookcom/homc.php .• #!/group.php.lv=wall&rcf =scarch&gid=2365.\ 14541 

I Accessed 4/12/20101 

Nick: "i have a poster of bonds with a lipper in his mouth and a tin in his back pocket 

hittin a ball now thats talent 101" 

Source: htlp:l/www.faccbook.colll/homc.php?#l/group.php.iy=wall&ref=scarch&gid=2365-1 1 .. 5-1 I 

IAccessed 4/12/2010 I 

Mark: "the cool thing is that my coach doesnt even care .. we pack the biggest bombs 

right in front of him and he doesnt say anything" 

Source: http://www.facebook.com/home.php .• #!igroup.php..v=wall&rcf=search&gid=236541-1541 

[Accessed 4/12!20 101 

Nick: "watermelon?! damn that should be good .. but does it keep the t1avor and buzz 

goin? thats key" 

Source: hllp:/lwww.faccbookeom/homc.php?#!/group.pi1p.)y=wall&rcf=scarch&gid=236541-1541 

[Accessed 4/12/20101 

dips i love kayak 
129 


rfrederick on DSK6VPTVN1PROD with Insert graphic folio 135 76022A.075

Ryan: "baseball and skoal make the best combo out there. a nice lip of spearmint while 

taking bp, theres better" 

Source: lillJRlLlDlCl'Lf.'ill;<~cQk&Q!!l.lllIQ!I!SUt!.lli?J!l!lm2.!J]!J1!!@aY1ll!!;ltr§t:§9!j!L£l~lli!::1J22:illi±l 

Patrick: "hahah ya he does i was watcihng a sox game and after he hit a homrun he went 

to the dug out and packed him slef a nice lip of skoal" 

Source: http://wwvY.facebookcom/homc.php?#lJgroup.php·)Y=waU&rcf=scarch&gid=2365414541 

[Accessed 4/1Z/201Oj 

Cameron: "Hurray Dipl I've got a fatty in right now before I go to class. Now only ifI 

was watching a ballgame. 

Source: http://wwv •. facebook.com/home. p11po#1 / group. php')y=waJl&rcf=search&gid=2365414 5~ ] 

[Accessed 4/12/2010) 

Drew: "Troy Glaus hands down throws in the biggest daggers. And whenever its a rookie 

pitcher starting he throws in an extra one for intimidation factors." 

Source: lillJRlLlDlCl'Lf.'ill;<~cQk&Q!!l.lllIQ!I!SUt!.lli?J!l!lm2.!J]!J1!!@aY1ll!!;ltr§t:~!L£l~lli!::1J22:illi±l 

Nick: "yo who saw the game 4 of the yank and indians .... towards the end the camera guy 

had damon and jeter...and all u see is damon gettin rid of his bomb . .1ol" 

Source: http://www.faccbookcom/homc.php·)#!/group.php·)v=wall&rcf=search&gid=2365~ 14541 

[Accessed 4112/20 10 I 

Joe: "i saw a sox game a couple monthes back, beckett was pitchin and he was sittin in 

the dugout and all he was doin was takin a bomb out, and donnaly was also doin an 

interview with Nesn in the locker room in his locker was protein and a straight tin it was 

sick" 

Source: http://mnv.faccbookcom/ho111c.php·)#!/group.php·)y=wall&ref=search&gid=236541454J 

[Accessed 4/12/20]0] 

had the new skoal 

Nick: "sitting in the bullpen the other day with a big league chew of grape bubbleicious 

and levi, it occurred to me that skoal should come out with grape dip .... yeah? no?" 

Source: hllp:/ 1m,,,. faccbook. com/home .php·)# I I group.php ')y=wall&ref =scarch&gid= 2365414 541 

[Accessed 4/12/20101 

Cory: "how is dustin pedroia in this group he packs an atomic bomb that could blow up 

all of japan every game" 

Source: http://,,,,,,.faccbook.co 111/110111e. php?#!/ group. php')y=wall&ref =scarch&gid= 2365414541 

[Accessed 4/12/201 () I 
130 


rfrederick on DSK6VPTVN1PROD with Insert graphic folio 136 76022A.076

Dustin: "who would ever thought j ohnny damon dips 101 saw him spittin out a fatty over 

the rail in the dugout it was hilarious haha" 

Source: htlp://www.faccbook.com/holllc.php?#!/group.php ... y=waU&ref=search&gid=236-1882221 

[Accessed: -111212010] 

"josh hamleton ive never seen him without one in ever" 

Drew: "Common guys, have you ever seen a Brewers Game? Prince takes the cake on 

this award. At least a quarter of a tin every time he is up to bat" 

Source: http://www.faccbook.comlbomc.php··#!/group.php·lv=wa!J&ref=search&gid= 236S':; I':;S':; 1 

(Accessed 4/12/2010J 

Dean: "1m gonna hav to second Josh Beckett. he always has a tin in his pocket a nice big 

lip in" 

Source: http://www.faccbook.com/homc.php··#!/group.php·)y=wall&rcf=scarch&gid=23GS-Il':;541 

[Accessed 4/12/2010] 

Jason: "chipper jones is the best dipper" 

Source: http://\\\\,\\Jacebook. com/home. php?#! 1 group.php '" '=wall&rcf =search&gid=2365-1!-I 54 I 

(Accessed 4/12/2010 I 

Justin: "If you're not playing baseball, the best place to pack a fatty is definitely in the 
131 

Mr. PALLONE. Thank you, Dr. Connolly. 

We are going to take questions from the members and I am going 

to start with myself. 

I am not trying to be difficult in any way, Mr. Prouty, but you 

took a lot of time to explain that the smokeless tobacco was essentially banned in minor leagues but you said in major league it is 

not and you cited the fact that basically it is legal and so why 

should we be pressured or whatever, I guess, to ban it. But it is 

obvious that you ban a lot of other things. I guess players aren’t 

allowed to open a beer or mix themselves an alcoholic drink in the 

dugout, and also you banned the smoking of cigarettes, or Major 

League Baseball has banned the smoking of cigarettes in uniform 

in view of the public. I mean, cigarettes are legal, alcohol is legal. 

What is the difference? Why is it so important to continue the use 

of smokeless tobacco but not these other things? Why is it any different? 

Mr. PROUTY. Well, Congressman, first of all, let me say that 

there is a difference between cigarette smoking and smokeless tobacco insofar as smoking affects the game. You can’t smoke while 

you are playing. Cigarette smoking also has secondhand effects on 

other players. But I don’t think we are here today to defend smokeless tobacco. What we are saying is that it is a legal product and 

it is legal in the United States for use. If you want to go about banning it, Congress should go about banning it. 

Mr. PALLONE. No, I understand that, but I guess what I am saying is that is just seems strange to me. I guess when you negotiate 

a collective bargaining agreement, why is there not an effort to say 

pursuant to the collective bargaining agreement that smokeless tobacco would be banned as well? I guess I am asking from the point 

of view of the players as well as from the point of view of the 

union. It doesn’t make sense to me that you would have a lot of— 

that you wouldn’t press to do the same thing. Is this coming from 

the players? Are they demanding that it not be prohibited? What 

is the reason? 

Mr. PROUTY. Well, you know, in any organization, there are varying views. We have people who are all for using smokeless tobacco. 

We have people who are against it. We have a round of collective 

bargaining negotiations coming up. We can only look forward on 

this. We are just beginning to formulate our proposals on all kinds 

of issue. I am not the union. We represent the players. The players 

will get together and decide what issues to bring to bargaining. Mr. 

Manfred’s side will get together and decide what issues they want 

to bring to bargaining. As he said, smokeless tobacco is a mandatory issue so if either side brings it up, we have got to talk about 

it. We hear what you are saying. We will take the concerns of everyone here back to the players. It is for the players to make a decision about what to go ahead and bring to the bargaining table, 

but rest assured, I will make sure based on the hearing today that 

they hear what you are saying. 

Mr. PALLONE. I appreciate that. And then I wanted to ask Mr. 

Von Behrens, and again, I appreciate your being here today. When 

you said that you reached over 2 million kids in the course of your 

speeches and presentations, that is really amazing. But I wanted 

to go back. You mentioned when you first started using tobacco. 


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How much did your decision to start and use correlate with your 

passion for baseball, which actually you have, and do you think if 

you had known more about the health effects when you were a 

young person you still would have used it? 

Mr. VON BEHRENS. You know, I tell kids every day that if somebody like myself would have came and spoke to their school or my 

school whenever I was a young man, there is no way I would be 

sitting in front of you guys here today because I would have made 

an educated choice and I would have stopped using. This would 

have scared me enough into not using these products. You know, 

baseball had, like I said, marginal effects of why I used tobacco, 

guys. We are sitting here today and we are talking about baseball 

and spit tobacco, baseball and spit tobacco, and yes, I believe that 

they should not be able to use it on the field. It is like smoking 

a cigarette on the field. I am not going to get into that because that 

is not the type of person that I am. 

But there are so many other things that we are overlooking. I am 

a competitive bass fisherman. I fish all over the Midwest. There 

are boats out there selling ads. They are boats advertising Longhorn tobacco. The guy who got second place in the Bassmasters last 

year fished out of a boat sponsored by Longhorn tobacco products. 

So there are so many other forms and there is a lot more of these 

types of people out there than there are potential baseball players. 

There is more hunters, there is more fisherman, there is more 

farmers, kids, people who aren’t really that associated with baseball that are being affected by the advertisements and the ploy that 

tobacco is a safer alternative to cigarettes. 

Mr. PALLONE. But you are convinced that if we had more education and awareness, a lot of these young people would not start 

using it? 

Mr. VON BEHRENS. Definitely. You know, it irritates me when we 

talk about education because there is so many budgets cut that are 

in effect across the United States. There is people out there fighting to do their jobs to prevent you from using these products. They 

can’t even do their job anymore because somebody wanted to build 

a road with the money donated to them from the master settlement 

agreement. So we need to first make sure that the master settlement agreement money goes into education. That is what it is 

meant to be used for, not to fix the roads, not to get somebody out 

of trouble, to educate youth. And if we educate youth, I think in 

the long term we will see our health and our financial well being 

get better. I spent almost $3 million in medical expenses from what 

this product did to me, 3 million bucks to have surgeries, to have 

radiation treatment, to lay in the hospital for two months at a 

time, $3 million. I don’t know of one person who spent $3 million 

or how much taxation you will make off of one person in their lifetime selling this product. It is a very harmful drug and we just 

need to put guidelines in and make it better and make kids understand what it can do to them. 

Mr. PALLONE. Thank you. 

Mr. Shimkus. 

Mr. SHIMKUS. Thank you, Mr. Chairman. 

Mr. Von Behrens, you have made Illinois proud. 

Mr. VON BEHRENS. Thank you. 


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Mr. SHIMKUS. I appreciate you coming, and Mr. Garagiola, of 

course, you made St. Louis proud. 

Mr. GARAGIOLA. Before you start, I have this DVD. It is the best 

piece of equipment I have to talk to people. It is all about Gruen 

and nobody else, and he talks to high school kids, and the 

Diamondbacks were good enough to make sure that it was distributed and the schools got it. Gruen was great, and I wish you could 

see the effect he had on the young people because when he walked 

out there, there was a collective ‘‘huh’’ and then he started, and 

boys, he knocked their socks off. I will never forget that, Gruen. 

Mr. VON BEHRENS. You know, I was—— 

Mr. PALLONE. Would the gentleman yield? And I am not going 

to take away your time. I will give you more time. What I was 

going to suggest, Mr. Garagiola, is that you have or can get us 

extra copies of that, we will circulate them to the members of the 

committee. 

Mr. GARAGIOLA. You tell me how many you want. 

Mr. PALLONE. We will get back to you. And also I don’t know if 

there is a transcript of it. We could enter that in the record. But 

we will look into that, all right? 

Mr. GARAGIOLA. I will tell you what. I am going to give you that 

and the Bob Leslie tape when I ask Bob Leslie what is the toughest 

part of the day. 

Mr. PALLONE. OK. Thanks. 

Mr. SHIMKUS. And let me just follow up on that. You did talk 

about the No Chew Crew program with Arizona. Has that been accepted or replicated in any other ballpark organizations and stuff? 

Mr. GARAGIOLA. I have been frustrated a lot. I am going to answer that question as honestly as I can. Only one other club called 

the Diamondbacks and said tell us more about it. That was the 

Marlins. And nobody else. This booklet, I want to give it to the little guys because I thought they could read it because it is a tobacco 

message but they could also color it, and Commissioner Selig, he 

gave me $50,000 to make the distribution. One club, and I don’t 

want to embarrass them, the girl says I am going to throw them 

away because we don’t have any room to store them. I said no, you 

are not going to throw them away. I called the president of the club 

and we got them distributed. No, it was met with industrialstrength apathy. 

Mr. SHIMKUS. Dr. Connolly, when you talk about the addictions, 

I believe there are social kind of addictions, peer pressure. Are you 

making a determination because social kind of addictions and peer 

pressures or the physical addiction? 

Mr. CONNOLLY. Well, I think we have to understand that you 

have two different dosing mechanisms for nicotine. The cigarette, 

you get a rapid dose of nicotine and it falls off and sets a spike effect. It is very, very attractive because it is reinforcing and it has 

central nervous system effects. With smokeless, it is a slow effusion 

across the oral cavity, about 20 cell layers, and you get a general 

background dose. And then with a product like Copenhagen, you 

get a bolus of nicotine into the central nervous system. So it is a 

chemical addiction. The Surgeon General described it as such. And 

then we look at quitting patterns. We find it is about the same. It 

is equally hard for smokeless tobacco users and cigarette smokers 


rfrederick on DSK6VPTVN1PROD with 
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to quit. They are about the same because they are dealing with a 

chemical addiction. Finally, what is disturbing is the increase in 

dual use that we are seeing in the American public, people using 

cigarettes and using smokeless, and what we may be observing is 

the emergence of dual dependency, someone being dependent upon 

cocaine and heroin at the same time. It is extremely hard because 

of the difference in dosing to treat dual dependency. This is a major 

concern that we have for the Nation is that young people seem to 

be using both now in particular parts of the country and it is going 

to be harder, I believe, to treat those dependencies. 

Let me point out too, the players association has to step up to 

the plate here. I mean, we have to—— 

Mr. SHIMKUS. My time is—— 

Mr. CONNOLLY. I am sorry. 

Mr. SHIMKUS. I am going to address that, and we have been here 

a long time already, but I do think my colleague from Maryland, 

it does make sense if you have got an asset as the players’ union 

does and as Major League Baseball does to protect the asset. I am 

a Republican. We believe in competitive markets. We want to protect collective bargaining and we want you all to work it out. I am 

not one to want government to intervene with a national law to 

say—because if we ban tobacco products, then we would have the 

underground economy, we would have the products just like we 

have illegal drugs, et cetera, et cetera. But it is always better, 

gang, if you do this and work this out, and I think you hear collective agreement by the panel that we would hope that in the next 

round you all would step up and lead by example and then you 

wouldn’t be called back up here anymore for this issue. 

Mr. CONNOLLY. 

Mr. SHIMKUS. Yes, sir. 

Mr. CONNOLLY. There is no silver bullet here. We need education 

for the kids, education for the players. We need treatment for those 

players. We need counseling. But we also need policies. You can’t 

say one is going to work without the other. It is a combination of 

efforts. 

Mr. SHIMKUS. Well, and Mr. Von Behrens mentioned the family, 

and leadership is not just professional sports. It is family. I caught 

in the hot summers of St. Louis and my parents gave me salt tablets because of sweating, and that was what was thought at the 

time. 

We do appreciate your time and effort, and Mr. Chairman, I will 

yield back. 

Mr. PALLONE. Thank you. 

Chairman Waxman. 

Mr. WAXMAN. Thank you very much, Mr. Chairman. 

As I understand the situation, if Major League Baseball wanted 

to ban the use of smokeless tobacco or cigarettes, they can just go 

ahead and do it when it comes to the minor leagues, but when it 

comes to the major leagues, they can’t just go ahead and do it because you have to have a collective bargaining. The union represents the players in the major leagues but not in the minor 

leagues. Is that right, Mr. Prouty? 

Mr. PROUTY. Yes, that is correct. 


rfrederick on DSK6VPTVN1PROD with 
135 

Mr. WAXMAN. So the only way you would get to talk about the 

major leagues would be through collective bargaining agreement? 

Mr. PROUTY. That is correct. It is a mandatory subject of bargaining. 

Mr. WAXMAN. So you have to bargain this question out and have 

it as part of your contract. 

Mr. Prouty or Mr. Manfred, do either of you disagree with the 

harm that comes to the players after all the testimony you have 

heard today from the use of smokeless tobacco? 

Mr. PROUTY. No, Congressman, we don’t disagree at all. 

Mr. WAXMAN. And Mr. Manfred, you don’t disagree, do you? 

Mr. MANFRED. No. As a matter of fact, we put extensive effort 

into trying to encourage our players at all levels, minor and major 

league, to not use smokeless tobacco. 

Mr. WAXMAN. Do either of you disagree with the idea that children, young people are influenced by seeing behavior of players on 

the field? Mr. Manfred? 

Mr. MANFRED. No, I don’t. 

Mr. PROUTY. No, we don’t disagree. Players are role models. We 

don’t dispute that. 

Mr. WAXMAN. So then the question is, if there are health risks 

to the users and there is a problem in the message that is sent to 

the kids, you seem to both agree with that. Wouldn’t you both be 

in favor of agreeing to not allow players to be using smokeless tobacco on the field? 

Mr. PROUTY. Congressman Waxman, it is not as simple as Mr. 

Manfred and me just agreeing. We both represent constituencies. 

The union is a democratic organization. We have to go back to our 

members. We have to hear what—— 

Mr. WAXMAN. I understand that. What would be the argument 

against it? 

Mr. PROUTY. The argument against it is that it is a legal substance which can be used in this country. 

Mr. WAXMAN. So are cigarettes. 

Mr. PROUTY. So are cigarettes. 

Mr. WAXMAN. Your members don’t want to reopen that issue, do 

they? 

Mr. PROUTY. No, they don’t. 

Mr. WAXMAN. So you have two legal products. No one is disputing that. How about drinking beer or other alcoholic beverages? 

It is perfectly legal, may or may not be harmful, depending on the 

circumstance. Do any of your players think that they ought to be 

allowed to drink on the field? 

Mr. PROUTY. No, they don’t. I don’t believe so. 

Mr. WAXMAN. So I am trying to understand an argument they 

might make on smokeless tobacco. If it hurts the health of the players and it influences adversely kids to use a product that is going 

to harm their health, I would hope you would take back to your 

members that they shouldn’t stand in the way of what Major 

League Baseball did when it came to the minor leagues and put in 

the same policy for the major leagues. 

Mr. PROUTY. Absolutely, Congressman. You can be assured we 

will take back the concerns that we have heard here today and the 

players will continue that along with all the other issues and we 


rfrederick on DSK6VPTVN1PROD with 
136 

will bring it up in the next round of bargaining if that is what they 

decide to do. It is a democratic organization. I can’t promise you 

here today it will be brought up. I can promise you that I will bring 

back and make them understand as we did with steroids and other 

issues you are aware of exactly what Congress feels about this. 

Mr. WAXMAN. What if your players said to you I don’t want to 

have a ban on steroid use because we think it helps us improve our 

performance? Would the players advance the argument in the collective bargaining agreement that there shouldn’t be any ban on 

performance-enhancing drugs? 

Mr. PROUTY. Congressman, that is not where we are. As you 

know, we went through a series of—— 

Mr. WAXMAN. I remember. I remember it well. I am just obviously pointing out the illogic. 

Mr. PROUTY. But, no, I understand that. But if you remember, 

the process that we went through every time was, we went back 

and held meetings with players and developed a consensus about 

this is what has got to happen, these are the risks, this is the testing program and frankly, if we don’t act, Congress is going to act 

but we would rather settle it by collective bargaining. In the end, 

that is what we did was settle it by collective bargaining, and you 

endorsed what came out of that. 

Mr. WAXMAN. Let me ask you if you will be willing to start this 

process of consultation with your members now so you can be ready 

with a consensus position to allow this to be part of the collective 

bargaining when your contract is next up. 

Mr. PROUTY. Yes, we will, as I said before, bring this back to the 

membership and start consulting. 

Mr. WAXMAN. Good. 

Thank you very much, Mr. Chairman. I appreciate everybody’s 

testimony today. 

Mr. PALLONE. Thank you, Chairman Waxman. 

The gentleman from Indiana, Mr. Buyer. 

Mr. BUYER. Thank you very much. 

I want to agree with the comment, educate, educate, educate. I 

think you are right. And in a free society, I believe there are always going to be differences of opinions based on differing values, 

beliefs, perceptions and also due to the imperfections of reason. So 

in the effort to educate, educate, educate, we also have to nourish 

the hope that how do we achieve improvements to public health. 

Now, when you make that effort, you cannot ignore science. Now, 

what was challenging from the first panel was to have an individual who would not acknowledge that there is a continuum of 

risk among tobacco products. Now, I don’t smoke. I don’t advocate 

for people to smoke. I also recognize that it is a lawful adult product and that it is a product that we don’t want in the hands of children. So I also acknowledge as a worthy effort to prevent role models from using such a product and what can we do to make sure 

that children don’t gain access. 

Well, you know, we have done a lot of things. Not only have we 

made it illegal for individuals under the age of 18 to gain access 

to these products, but you know what? The master settlement 

agreement. I am surprised by the advocates of this panel that you 

haven’t talked about the master settlement agreement and the fact 


rfrederick on DSK6VPTVN1PROD with 
137 

that the States out there are not utilizing monies collected not only 

from the MSA but also from cigarette taxes to be spent on education programs. So in fiscal year 2010 alone, and this is according 

to the document that I have now submitted to the record titled A 

Broken Promise to Our Children. It states that in the current fiscal 

year 2010, States will collect $25.1 billion from the tobacco settlement and tobacco taxes and they will spent just 2.3 percent of it, 

which is approximately $560 million, on tobacco prevention and 

cessation programs. Now, when we passed Mr. Waxman’s bill, I 

had offered an amendment. I had offered an amendment for us as 

a Nation to improve public health to acknowledge the continuum 

of risk and is it possible to migrate people from smoking to smokeless to finally quitting. Is that possible? When in fact there is a 

crucible out there for which we can look at, which is called the 

Swedish experiment. Incorporated in that amendment was also the 

advocacy on behalf of Ms. Blackburn to actually state that, you 

know, States, you should be required to spend a portion on education, a portion of the MSA. That was defeated. That effort was 

defeated here on the committee and it should not have been. Because those of whom will acknowledge and actually say that smoking a cigarette is just as bad as utilizing a smokeless tobacco product ignores science. Because there is truly a difference in the continuum of risk. 

Now, I don’t advocate the use of either of those products but to 

say that a snus product that eliminates 99 percent of the 

nitrosamines and you have got a 1 percent of health risk versus the 

100 percent from a cigar ignores science. And so it is challenging 

for me because I look at this and say I agree with the testimony 

of educate, educate, educate but why would the advocates of abstinence then not be willing to educate tobacco users that there truly 

is an opportunity to lessen the risk, that if you can reduce the 

thousands of constituents and toxins from smoking to move to 

smokeless, that that in fact can make your healthier. But the complete goal here is actual cessation of the tobacco product. To ignore 

that is also then to ignore science and ignore the advocacy to educate, educate, educate. A nation cannot be ignorant sustain freedom. So as a government when you ask government for its help 

and assistance, we as a government need to be honest with regard 

to is our advocacy with regard to availability of tobacco products. 

Now, for those of whom are advocating abstinence, if you want to 

advocate the complete outlawing of tobacco products, go ahead and 

say that if that is what the advocacy is. But that is not what this 

committee has chosen to do. It is not as a country what we have 

chosen to do. 

So I just—I want to thank all of you for your efforts. It is unfortunate with regard to Major League Baseball and the players’ 

union that my sensing is that you have been brought here to testify 

and the committee is somehow strong-arming you with regard to 

what should occur or not occur within collective bargaining. I think 

that is wrong if we are going to actually say that the marketplace 

is a sacred place. And so that is unfortunate. You can choose to do 

what you believe is morally right, and I believe that you have that 

sense and that can happen at the table, but for us to strong-arm 

you and to dictate as to what you should and shouldn’t do and supVerDate Mar 15 2010 04:27 Dec 12, 2012 Jkt 076022 PO 00000 Frm 00143 Fmt 6633 Sfmt 6633 E:\HR\OC\A022.XXX A022

rfrederick on DSK6VPTVN1PROD with 
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plant our moral understanding upon you, wow, if that is what we 

want to do, then we should have made tobacco products illegal instead of passing that bill. 

With that, I yield back. 

Mr. CONNOLLY. Could I just comment? 

Mr. PALLONE. I think we should probably let them respond if 

they want. 

Mr. BUYER. I did not ask a question. I yielded back. I made a 

statement. 

Mr. CONNOLLY. As a person—— 

Mr. PALLONE. He has yielded back, Dr. Connolly. 

Ms. Blackburn. 

Mrs. BLACKBURN. Thank you, Mr. Chairman, and mine is more 

of a statement than a question. I do appreciate that all of you are 

here, and Mr. Buyer mentioned some of the frustration that we 

have with this issue. As I said in my opening statement and in my 

questions, in the 110th Congress, in the 111th Congress, there was 

an opportunity to expand SINAR and to take care, special care, 

extra care to address this issue of teens and smoking. 

Now, I was interested in the testimony of a couple of you, Mr. 

Manfred, in your testimony, and Mr. Garagiola, in yours. You talk 

about education and the importance of education, and why this 

needs to be expanded, and I liked the example of the No Chew 

Crew. 

Mr. GARAGIOLA. But you need money. 

Mrs. BLACKBURN. OK. Then is this a program that would function well with some of the master settlement dollars? Have you 

looked at that? Are you seeking to move forward with expanding 

that program through the—the money is there. I mean, that is—— 

Mr. GARAGIOLA. The money is there but I think it is—I have a 

clipping that I have saved. This is from 2001. In North Dakota, legislators have been criticized for considering using a portion of the 

settlement money to built a state morgue. In Alabama, legislators 

allocated a portion of the settlement to fight gangs and satanic 

worship in public schools. In Montana, officials funded a juvenile 

delinquent boot camp. Tobacco-growing States like North Carolina, 

South Carolina, Virginia, funds have been set aside to compensate 

tobacco farmers for losing crop revenues as smoking declines. The 

problem comes when you call these people. Mike Moore, the attorney general from Mississippi, we thought we had the money, and 

when you call the line is busy, they will get back to you. I am still 

waiting for calls from some of these guys. 

Mrs. BLACKBURN. Well, and the legislation I have brought before 

this body that action was not taken on would have addressed the 

usage of some of these master settlement funds and would have required the States to meet certain expanded criteria. There is a way 

to address this. 

Mr. Manfred, I think you had a couple of thoughts, and I do appreciate your testimony, and when you talked about the minor 

league policy that is there on smoking and tobacco products and 

the compliance rates on that, and I wanted to know if the smoking 

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ful and if you all are doing outreach specifically geared toward children. 

Mr. MANFRED. Let me start with the employee assistance programs. I think when you talk to our employee assistance professionals as a group, the 30 of them, we get them together twice a 

year, and I think that in all candor, they feel that they have very 

good programs. They feel that they have a moderate degree of success, and the single biggest frustration that you hear from them is, 

people go through the programs, they do well, they stop and then 

they return to use. You know, if I had to summarize what our very 

long discussions with this group, that is how I would summarize 

it. 

In terms of outreach, Major League Baseball has been committed 

to the NSTEP undertaking for years and years. I think Mr. 

Garagiola referred to the fact that Commissioner Selig allocated 

$50,000 recently for a specifically child-directed program. He is 

holding up the pamphlets from that program. Commissioner Selig 

himself sees this as a public health issue, and I think that it is fair 

to say that our efforts in this regard both internally and externally 

will continue. 

Mrs. BLACKBURN. I appreciate that. 

I will just close by saying from our perspective, there has been 

an opportunity to address this. We have legislation. The SINAR 

language has worked. We don’t need to reinvent the wheel. The 

goal is to make certain that children are educated and realize the 

dangers of tobacco use. As a mom, as a former Lung Associate volunteer, as the former president of that board, the education programs have been vitally important and that is how we are going 

to change this, and there does exist an avenue for that and I think 

it is regretful that this committee did not take up the opportunity 

to address that and I would have preferred out time today be spent 

on some other components that addressing some things in the 

health care bill that need to be done or addressing getting a federal 

budget together which I am understanding the Democrat leadership in this body does not want to do. 

With that, I yield back. 

Mr. PALLONE. Thank you. 

There are only a few of us left so we are just going to have a 

second round for whoever wants to ask questions, and I am going 

to yield myself some time. 

I asked Mr. Prouty before about a commitment to bring this up, 

and I think Mr. Waxman did also, to bring up the issue of smokeless tobacco in the context of collective bargaining agreement, and 

I just wanted to ask Mr. Manfred the same thing, if you would be 

willing to say that you would make the issue of smokeless tobacco 

a priority when you negotiate with the players over collective bargaining? Would you and the commissioner fight to try to end the 

use of smokeless tobacco by major league players? I mean, I know 

that you don’t have—you know, a lot of this depends on what happens but we are still trying to at least get you and Major League 

Baseball to say look, we will try to make this a priority, we will 

bring it up, we are committed to putting an end to it in the same 

way you have with the minor leagues. 


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Mr. MANFRED. We have begun our preparations for 2011 already. 

I think that Commissioner Selig’s directive that Dr. Shaha make 

a presentation to the safety and health committee is indicative of 

his commitment to the idea that this issue needs to be addressed 

in 2011. I can also tell you that in our conversations with individual teams, we have had a number of teams raise this issue as 

something that we need to be putting on the table in 2011. 

Mr. PALLONE. But can you just go beyond that and say that it 

is a priority for that purpose? 

Mr. MANFRED. I can say—certainly I can say this, that for Commissioner Selig it is a priority in terms of the issues that we have 

discussed so far. I think that is an accurate statement. 

Mr. PALLONE. I appreciate that. 

I am going to yield back and ask Mr. Shimkus if he would like 

to say anything or ask any more questions. 

Mr. SHIMKUS. No, I just appreciate the panelists. I think my colleague, Congresswoman Blackburn, makes a good point, and I 

would request that maybe the full committee chairman bring in the 

States and ask them to use their master settlement money on the 

tobacco to print your brochures, to print the DVDs and get them 

in all the schools across the country. That might be a good use of 

that instead of some of the other things that Mr. Garagiola highlighted in that old article. I mean, if we are serious about educating, we ought to be about the business of educating, and I appreciate those who are doing their part with their own ability, but 

again, I think government has dropped the ball on some of these 

aspects, and I yield back my time. 

Mr. PALLONE. Mr. Buyer, no additional questions? OK. 

Let me thank all of you, really. I thought that his was very 

worthwhile today. It is obviously an issue that Mr. Waxman in particular but many members of the committee have cared about for 

a long time, and I also appreciate the fact that some of you are 

willing to take it back with the major leagues and try to address 

it. I think it is very important to us, so thank you very much. 

The way we operate is that you may get additional written questions within the next 10 days or so that we would also ask you to 

respond to as quickly as possible. 

Thank you. And with that, the subcommittee hearing is adjourned. 

[Whereupon, at 1:28 p.m., the Subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 


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The Good News and the Bad News about Smokeless Tobacco and Sports 

Written Statement of Dr. Cheryl Healton, Dr. P.H., CEO and President of Legacy 

Submitted to the Health Subcommittee of the Committee on Energy and Commerce 

of the House of Representatives 

April 14, 2010 

Mr. Chairman and other members of the subcommittee, I appreciate the opportunity to submit this testimony today and 

would especially like to thank Mrs. Capps for alerting me to the topic of today's hearing, the impact of smokeless 

tobacco on our nation's youth and its use in Major League Baseball. 

like many issues in health, there is good news and bad news surrounding smokeless tobacco use. First, let me address 

the bad news: 

Smokeless tobacco use is on the rise among teenage boys. According to the Substance Abuse and Mental Health 

Services Administration's (SAMHSA) most recent National Survey on Drug Use and Health, while overall usage levels of 

smokeless tobacco were stable between 2002 and 2007, certain subpopulations experienced increases. Chief among 

those were increases among boys aged 12-17, moving from 3.4% in 2002 to 4.4% in 2007.' This increase highlights the 

need for strong messages to counter act the industry's advertiSing, and for strong role models - including professional 

baseball players - to prevent youth from starting to use these highly addictive products in the first place. It is important 

not to forget that nicotine is still the main ingredient in smokeless tobacco and it is one of the most addictive agents on 

earth. 

Tobacco Companies have increased their marketing and advertising spending. According to the most recent Federal 

Trade Commission Smokeless Tobacco Report, advertising and promotional expenditures for smokeless tobacco 

increased from nearly $251 million in 2005 to just over $3S4 million in 2oo6.H 

o Direct mail spending and pOint-of-sale advertising increased slightly from 2005 to 2006;H 

o Spending on promotional price discounts jumped from $99.7 million in 2005 to $203.7 million in 2006;" 

o Expenditures in connection with sports and sporting events rose from $15.7 million in 2005 to $16.9m in 

2006." 

Tobacco control programs cannot begin to compete with the level of funding promoting the use of smokeless products. 

Tobacco control programs are truly David to the industry's Goliath, and have an uphill battle to counteract industry 

messages. In particular, baseball players and other sports role models should not give the tobacco industry free 

advertiSing during games by being shown on television using tobacco products. It is critical to promote messages that 

resonate with young people about the dangers of smokeless tobacco and to ensure that everyone knows that there is no 

such thing as a safe tobacco product. 

There is evidence that a new generation of smokeless users is emerging. An important study of tobacco industry 

documents has shown that in recent years there has been a subtle shift in both the marketing and use of smokeless 

tobacco users from a rural, older-user focus, to a younger, urban, user. Additionally, the tobacco industry markets 

smokeless products as a solution to smoking bans by providing tobacco users with a way to get their nicotine fix when 

they can't smoke. H, This has had a particular resonance with youth. This is startling when you learn that in 2007, 52.8% 

of past month smokeless users ages 12-17 also smoked cigarettes in the past month.' Many tobacco control experts 
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have raised concerns about this "dual use" of smokeless tobacco and 

cigarettes which maintains nicotine addiction while reducing important incentives to quit using tobacco. 

The Good News 

Despite these disturbing trends, there is some good news, particularly in regard to the sports and smokeless tobacco 

connection. 

Smokeless tobacco use among baseball players may be becoming less prevalent There are at least two studies that 

confirm a reduction in smokeless use by several professional baseball organizations"" In 1993 Major League Baseball 

instituted a ban on tobacco products in the minor leagues However, there are no such bans in the major leagues. More 

needs to be done and I encourage MLB to issue a similar ban on tobacco products in the major leagues, 

New legislation restricts tobacco sponsorships of sporting events. The new law granting FDA the authority to regulate 

tobacco also contains restrictions on sponsoring sporting and other cultural events in the United States. This will mean 

that smokeless tobacco companies will no longer be able to sponsor rodeos, baseball games, or automobile races, 

Indeed just this week, it was announced that the largest rodeo in Wyoming will, for the first time in decades, not be 

sponsored by US Smokeless Tobacco. The state health department will be sponsoring the event instead, with a message 

promoting the state's quit tobacco program, This is a victory for the health of the people of Wyoming as well as for the 

young athletes partiCipating in the rodeo. 

While these are encouraging developments, there is still much more work to be done, I look forward to working with all 

interested parties to ensure that effective programs are available to encourage youth not to start using all tobacco 

products, very much including smokeless products, in the first place, and to help those who do use it to quit. Hearings 

like this that highlight the tobacco problem and the importance of role models such as baseball players and other 

athletes in influencing our youth to make healthy choices are a step in the right direction. Thank you again for holding 

this hearing on such a timely and important topic. 

, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, (February 19, 2009), The NSDUH 

f!.eport: Smokeless Tobacco Use, Initiation. and Relationship to Cigarette Smoking: 2002 to 2007. Rockville, MD. 

~l Federal Trade Commission (August 2009). The Smokeless Tobacco Report Jor the Year 2006. Washington, DC. 

HI Mejia, A et a1. Tobacco Industry Consumer Research on Smokeless Tobacco Users and Product Development. American Journal 0/ Public Health. January 2010, Vol. 100. No. I 

lY Sinusas K., Coroso 1. A 10-year Study of Smokeless Tobacco Usc in a Professional Baseball Organization. Medicine and Science in 

Sports and Exercise 2006. 

v SEVERSON, H. H., K. KLEIN, E. LtCHTENSEIN, N. KAUFMAN, and C. T. ORLEANS. Smokeless tobacco use among professional baseball 

players: survey results, 1998 to 2003. Tob. Control. 14:31 Y36, 2005. 
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American Association 

for Cancer Research 

Written Testimony from the American Association for Cancer Research on 

"Smokeless Tobacco: Impact on the Health of our Nation's Youth and Use in Major 

league Baseball" 

April 14, 2010 

Submitted by: 

Margaret Foti, Ph.D., M.D. (h.c.) 

Chief Executive Officer, American Association for Cancer Research 

615 Chestnut Street, 17th Floor Philadelphia, PA 19106 

Phone (215)440-9300; Fax (215) 440-9313 

On behalf of the American Association for Cancer Research (AACR), the world's oldest and largest 

professional organization dedicated to advancing cancer research, thank you Chairman Pallone and 

Members of the Committee on Energy and Commerce Subcommittee on Health for holding this 

important hearing to bring attention to the serious problem of smokeless tobacco. 

Smokeless tobacco use causes cancer and other serious health problems, leading to death or substantial 

reduction in quality of life. Despite decades of solid scientific evidence to the contrary, the gross 

misperception that smokeless tobacco is harmless still thrives, and new users are becoming hooked 

daily. 

Currently, tobacco kills more than 440,000 people in the United States and more than five million 

worldwide every year. Tobacco use is on the rise globally, and the death toll is expected to top eight 

million a year by 2030 if current trends continue. We must do everything in our power to stem the 

global tide of tobacco-related death and suffering and improve public health. A special emphasis on 

eliminating tobacco use by children and young adults is imperative, and efforts to call attention to the 

harms of tobacco, such as this Subcommittee's hearing today, are commendable. 

The AACR is proud to offer the expertise of its membership of over 31,000 cancer researchers, physician· 

scientists, other health care professionals, and survivors and patient advocates to this Subcommittee in 

its efforts to protect young people from the dangers of smokeless tobacco products, and more broadly, 

to curb the deadly tobacco epidemic. 

cm"vn'C"'3> Tobacco 

In the United States alone, cancer kills more than a half a million people every year. Sadly, nearly a third 

of those deaths are attributable to tobacco use, a completely avoidable loss of life. 
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Testimony of the American Association for Cancer Research 

Smokeless tobacco, in particular, contains at least 28 cancer-causing agents' and its use increases the 

risk of developing cancers of the oral cavity (which includes the lip, tongue, cheeks, gums, and the floor 

and roof of the mouth), esophagus and pancreas.' Leukoplakia, white patches and oral lesions on the 

cheeks, gums, or tongue that can become cancer, receding gums and gum disease, and decay of tooth 

structure are also possible consequences of smokeless tobacco. 

Nearly a quarter century ago, the U.S. Surgeon General declared that use of smokeless tobacco "is not a 

safe substitute for smoking cigarettes.,,3 For decades, the National Cancer Institute has also warned the 

public to avoid and discontinue the use of all tobacco products, including smokeless tobacco.' Yet the 

common myth that smokeless tobacco is a safe alternative to smoking persists, and the dangers of 

smokeless tobacco remain largely unknown or dismissed. All the while, smokeless tobacco has 

continued to wreak harm and addict new generations of tobacco users. 

In 2007, an estimated 8.7 million Americans, aged 12 or older, were current users of smokeless 

tobacco.' This number is evidence that a renewed and more concerted effort is needed to identify 

effective approaches to reaching the public with the message that all forms of tobacco can be lethal. The 

AACR believes that we must develop evidence-based strategies for more effective public communication 

to prevent, reduce and eliminate tobacco use and to guide public health policies and clinical practice. 

While the prevalence of smokeless tobacco use remains lower than cigarette smoking, there are several 

reasons it earns special attention, including a recent increase in prevalence among youth, suggesting it is 

a growing problem, as well as the fact that use of smokeless tobacco can be a gateway to cigarette 

smoking. 

According to the recent "Monitoring the Future Study," prevalence of smokeless tobacco use increased 

over the past three to four years in 10th and 12th grades to thirty-day prevalence of 6.5 percent and 8.4 

percent among 10th and 12th graders, respectively, in 2009. 6 Concomitant with increased prevalence 

was a decrease in perceived risk of regular use. 

Once experimentation with smokeless tobacco begins, addiction and dependence soon take hold. 

Smokeless tobacco, similar to virtually all tobacco products, contains the highly addictive drug nicotine. 

According to the National Institutes of Health, the amount of nicotine absorbed from smokeless tobacco 

is three to four times the amount delivered by smoking a cigarette. Research suggests that more 

nicotine is absorbed from smokeless tobacco than from cigarettes and that the nicotine stays in the 

1 National Cancer Institute. Monograph 2; Smokeless Tobacco or Health; An International Perspective. 1992 

2 Secretan B, Straif K, Baan R, et al. A review of human cardnogens--Part E: tobacco, areca nut, alcohol, coaismoke, and salted fish. lancet 

Onco! 2009; 10: 1033~4 

~he U.S. Surgeon General. The Health Consequences of Using Smokeless Tobacco. 1986 

4 www.cancer.govjcancertopics/factsheet/Tobacco/smokeless 

5 Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National 

Findings. Rockville, MD; 2009 

6 www.monitoringthefuture.org/pressreleases/09cigpr.pdf 

Page 2 
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Testimony of the American Association for Cancer Research 

bloodstream for a longer time.7 Upon quit attempts, smokeless tobacco users exhibit nicotine 

withdrawal symptoms similar to cigarette smokers. 

Studies indicate that smokeless tobacco users are more likely than nonusers to become cigarette 

smokers.8 High school students who are frequent users of smokeless tobacco are also more likely to try 

illicit drugs including marijuana, cocaine or inhalants.' Because smokeless tobacco can serve as a 

gateway to smoking, it is critically important to include strategies related to smokeless tobacco use in 

comprehensive prevention and cessation programs. 

Prevention of tobacco initiation is central to avoiding lifelong addiction and increased risk of disease. 

The AACR believes that we must develop new evidence-based strategies to more effectively prevent the 

initiation of tobacco use, especially for youth and young adults. 

The AACR applauds the Congress for approving the Family Smoking Prevention and Tobacco Control Act 

of 2009 (FSPTCA), which grants the U.S. Food and Drug Administration (FDA) authority to regulate 

tobacco products. The law presents the United States with an historic opportunity to dramatically 

reduce tobacco use-including smokeless tobacco use. 

Restrictions on marketing and sales to youth are already being implemented and requirements for 

larger, stronger warning labels on all smokeless tobacco packages and in advertisements will take effect 

this summer. Notably, the FDA was also given authority to further restrict or prohibit tobacco product 

advertising and marketing, as necessary, to promote public health. 

The law prohibits the use of the descriptors "light," "low," and "mild" because they are deceiving to the 

consumer. Claims of reduced health risks for new smokeless and other tobacco products will now have 

to be substantiated by scientific evidence and evaluated by the FDA before such claims can be made. 

Importantly, the FDA was granted authority to require changes to tobacco products that the agency 

finds to be appropriate for the protection of public health. Extensive disclosure by the tobacco industry, 

including product ingredients and any studies on the effects of the ingredients, such as toxicology, is 

required and will help the FDA determine what components contribute to tobacco harm and addiction. 

Through its new product standard authority, the FDA may require the elimination or reduction of certain 

ingredients or byproducts of tobacco products to promote public health. This could have a tremendous 

impact on public health if, for example, the FDA required the reduction of the addictive agents in 

tobacco to levels that are not addictive to anyone, which would both stop the progression from 

experimentation to addiction and foster complete cessation. 

FDA authority over tobacco products is a huge step forward in tobacco control; however, the FDA will 

need support from the scientific community as it develops a comprehensive framework for the 

7 www.cancer.govjcancertopicsjfactsheet/Tobaccojsmokeless 

8 Centers for Disease Control and Prevention. Preventing tobacco use among young people: a report of the Surgeon General. 1994 

9 Everett, Sherry et at "Other Substance Use Among High School Students Who Use Tobacco." Journal of Adolescent Health 1998 

Page 3 
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Testimony of the American Association for Cancer Research 

evaluation of tobacco products and manufacturer claims. The AACR believes the framework should 

include all relevant validated approaches for evaluation, including laboratory studies, clinical trials, and 

epidemiological studies, and surveillance. The evaluation of manufacturer claims will need to be 

assessed through human studies of sufficient size, scope and duration. This framework should provide a 

means to evaluate the impact on both toxicity and consumer perception and use in order to assess 

individual and population health effects. 

While tobacco use has declined dramatically in the last half century, an estimated 70.9 million 

Americans still currently consume tobacco in some form. More disheartening is that, globally, tobacco 

use is on the rise, with a current estimate of 1.3 billion smokers. Given that tobacco accounted for 

approximately 169,000 cancer deaths-nearly a third of all cancer deaths-in 2009 in the United States 

alone, the AACR is intensely interested in working to combat the tobacco epidemic. 

Last fall, the AACR convened the AACR Task Force on Tobacco and Cancer, a twelve member body of 

experts from disciplines across the spectrum of tobacco-related research, to identify and pursue 

tobacco-related policies and scientific priorities for the AACR. The task force developed a comprehensive 

policy statement on tobacco,lO published yesterday in Cancer Research, a journal of the AACR, as a call 

to action to the broad research community and all who are concerned about public health to work 

together toward eliminating the burden of tobacco use and attendant disease. 

The AACR believes there is a clear imperative to eliminate the burden of tobacco use and attendant 

disease by advancing science and communicating scientific breakthroughs to the public, funders and 

regulators. Efforts to reduce tobacco use must go hand in hand with efforts to reduce the disease and 

suffering caused by tobacco. The AACR urges the adoption of a robust research agenda that supports 

the development of the most effective policies for tobacco and cancer control and promotes advances 

in approaches to addiction and tobacco-related disease. The AACR calls on its members and the research 

community at large to address the tobacco problem through transdisciplinary approaches, looking 

across the entire tobacco use and harm continuum, from preventing initiation and facilitating cessation 

to elucidating biological mechanisms to improve prevention, early detection, diagnosis, and the 

treatment of diseases caused by tobacco use. 

The AACR recognizes that while smoking is currently the largest problem, other forms of tobacco 

consumption, including use of smokeless tobacco products or smoking of cigars, pipes, and waterpipes, 

warrant increased attention and vigilant surveillance. Enhanced and better coordinated surveillance 

efforts are necessary to monitor all tobacco products, tobacco use, and tobacco-related disease, both in 

the United States and globally. Such surveillance is essential to understand the full scope of the 

problem-who is using which tobacco products, why they use them, and what problems result from 

their use-and the resulting knowledge will facilitate the development of effective approaches to 

countering tobacco. 

10 Available at: cancerres.aacrjournals.org/cgi!rapidpdfjOOO8-5472.CAN-l0-1087v1.pdf 

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Testimony of the American Association for Cancer Research 

Much needed progress in the prevention, diagnosis and treatment of tobacco-related cancer will come 

from supporting research that addresses the following: the potential harms of current and new tobacco 

products; the impact of altering the levels of addictive components in tobacco products; the 

identification of risk and risk-reduction measures for current and former tobacco users; enhanced early 

detection methods for tobacco-related cancers; and effective treatments against tobacco-related 

cancers tailored to the unique effects of tobacco on cancer. 

The AACR strongly advocates for an increased investment in tobacco-related research, commensurate 

with the enormous toll that tobacco takes on human health, to provide the scientific evidence to drive 

the development of effective policies and treatments necessary to dramatically reduce tobacco use and 

attendant disease. With particular regard to the important subject oftoday's hearing-the impact of 

smokeless tobacco, the AACR urges an increased investment in research to identify effective approaches 

for reducing smokeless tobacco initiation and use, and to pioneer new methods for reducing the toxic 

and adverse health effects of smokeless tobacco. 

The AACR has been moving cancer research forward since its founding in 1907. The AACR and its more 

than 31,000 members worldwide strive tirelessly to carry out its important mission to prevent and cure 

cancer through research, education, and communication. Celebrating its 101" Annual Meeting this 

coming weekend in Washington, DC, an estimated 17,000 attendees will share in exciting advances 

across the spectrum of cancer research. The AACR has dedicated a special policy session to the global 

tobacco epidemic to bring attention to the issue and cultivate interest among cancer researchers. 

The AACR urges all stakeholders worldwide to work together to develop and implement effective 

tobacco control and cancer control strategies. The AACR stands ready to help Congress and the 

Administration in their efforts to reduce tobacco use in all populations. 

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Floorboards 

When t1te $787billion stimulus package passed in early 

2009, it was held up as a solution to America's mounting 

economic woes, one that would buoy the economy, create 

jobs and steer America clear of economic Armageddon. 

At the time, little was said publicly about other goals 

tucked away deep within the bill's 1,072 pages. Now, 

more than a year after the bill was enacted, some of its 

lesser known provisions are coming to light, indudinga 

$650 million grant program designed to encourage state 

and local governments to try and force lifestyle changes 

on their citizens. 

The program devotes almost halfMRbillion dollars to grants for state and 

local programs to discourage the use 

of tobacco and to steer people away 

from sugary soft drinks and junk food. 

And the grants come with strings 

states only receive the money if they 

promise to take action in each of the 

('MAPPS" categories: media, access, 

pricing, point of pUl'chnse !lnci social 

support/services, 

Of course, cash-strapped states 

jumped at the opportunity to enrich 

their treasuries by submitting grant 

applications for programs and projects 

that could have sweeping effects on 

the convenience retaiHngindustry. 

Money for Nothing 

The program envisions new state initiatives to restrict how and where tobacco is sold and how to djsplay and 

advertise tobacco, food and other 

items, Ttalsowill fund initiatives to require new signagc at retail, including 

posting the nutritional content of food 

and alerting consumers to the levels of 

fat, salt and other substances in the 

products they buy. In short, the program envisions a raft of new state and » 

APRIl2010 NACS Mag.nine 35 
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"It's very difficult 

to see how encouraging people to 

quit smoking. or 

to eat better, does 

anything to stimulate the economy 

or create jobs." 

-lyle Beckwith. NACS senior vice 

president of government relations 

36 nil{;;onUne-.tom APRrL 2010 

local regulations to force convenience 

storesl restaurants and other businesses 

to take steps to guide consumer choice. 

To be sure,discouraging smoking and 

fighting obesity al'e laudable goals, but 

should they really be part of a bill designed to create jobs and stimulate the 

economy? 

f'It's very difficult tu see how encouraging people to quit smoking, or to eat 

better) does anything to stimulate the 

economy or create jobs. It's like they're 

saying, IOkay, Joe Six Pack, you're out of 

work, you can't support your family, but 

at least we can help you quit smoking 

and stop drinkingsoda/' said Lyle Beckwitht NACS seniorvice presidentof government relations. 

with less than one-third. of the grant 

money awarded, state nod local governments arc already preparing to implement their plans, And Beckwith said 

convenience store operators should mobilize to educate policy makers about 

A Few State "Winners" 

the effects these programs could have 

on local economies and convenience 

stores. 

Specifically, the stbulus package, 

called the American Recovery and Reinvestment Act of 2009, contained $650 

million for the U,S. Department of 

Health and Human Services and the 

Centers for Disease Control and Prevention (CDC) tosetup a program called 

Communities Putting Prevention to 

Work (CPPW), The program calls for 

grants totaling $493 million through the 

"States and Territories PoHcy and Environmental Change" and uCommunity" 

initiatives. 

Who Gets What'? 

In February! the government issued the 

first $120 million in awards for states 

and territories. All 58 applications 

from all 50 statesl Washington, D.C,) 

Puerto Rico, American Samoa, Federated 

States of Micronesia, Guam, Marshall 

Some of the state programs selected for additional grant awards include: 

Colorado: $1 ,2 mlillonto advance a comprehensive st.atewide youth tobacco 

access policy; Increase statewide awareness oftrie health implications of excess 

salt; reduceconsumptionofsugar·sweetened beverages; and deve!opand implew 

ment model food policies for schools statewide 

Massachusetts: $1.2 million to increase restrictions-on retail and outdoor advertisIng; ban outdoor advertising of cigars within 1~OUO fi=et of schools, parks and 

playgrounds; Include all tobacco products in other advertising restrictions; and 

require a health message for every tobacco advertisement in any retail store 

New York: $3 million to promote theeffec!lve Implementation of statewide 

menu·la.beling requirements, jndudhig calorie postings, for menus and menu 

boards of chain resta'urantsi promote the Implementation 'Of a ban on the sale of 

items containing trarisfat; and reduce consumptionofsugar~sweetened beverages 

Delaware: $1 million to promote plansto for<:e an increase in the prkc of tobacco 

products other than cigt!re-ttes, such as cigars and smokeless tobacco 

Texas: $2.8 million to promote and support breast~feeding statewide 
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Islands, Northern Mariana and Palaureceived funding for "nutrition, physical activity and tobacco controln Each 

state got at least $335,80J and the territories got a minimum of $99,980 in 

i~base>l funding. 

In addition to the "base" grants, part 

ofthe$120millionwnsdoledoutascompetitive grants, with states submitting 

widely varying plans in the competition 

forfunding. 

Applicants for a slice of the stimulus 

pie were encouraged to develop a program not only to increase access to 

healthy food and drinks, but also to try 

and reduce the availability of less 

healthy products. States wishing to get 

in on the cash flow were also asked to 

try and influence pricing to discourage 

people from buying tobacco products 

and to work toward tobacco usage bans 

through zoning restrictions. 

The application also cal1s for Us ales 

restrictions" that ban certain retailers 

from selling cigarettes altogether and 

pricing regulations aimed at discoul'-

agi:1g purchases. Bans on free samples 

and price discounts were suggested as 

well. 

The program aspires to tell retailers 

how to price tobacco products, and it 

also suggests restrictions on how they 

can display tobacco. Restrictions on instore promotion and advertising could 

include banning behind~the~counter 

stacked cigarette ~helvingl which is spe~ 

cifically cited in the grant announcement as tobacco '(power walls." 

The government's grant announce~ 

mentcontained a wide runge of suggest~ 

ed programs that state and local governments could implement at the taxpayer's 

expense. The announcement was re~ 

marl<able in its specificity, pointing out, 

for example, that: 

• (jHealthier foods are generally more 

exp{~nsive than less healthy foods! 

posingan economic barrier to healthicr eating, particularly among low~ 

income populations. Pricing strate~ 

gies can be used to promote healthier 

foods and beverages through decreasingtheirrelative cost." 

• 'ILess healthy foods and sugnr-sweet~ 

ened beverages (SSBs) are readily accessible in homes, schools! work sites 

and communities. Limitingavailability and accessibility of SSBs can decrease SSBconsumptjon and increase 

the consumption of more hea1thful 

beverages." 

• ~(Signage for healthi~r vs. less healthy 

items can be implemented in a num~ 

ber of settings, including restaurant 

programs, stores where food is pur~ 

chased and in theworkplace." 

While convenience stores are not 

specificaUymentioned in the announcement or in the grant summaTIes) they 

would dearly be targets of many of the 

restrictions - and with the help of federal funds. The announcement contains 

no definition of restaurants, for exam~ 

pIe, so rules created by states presu:nably would apply to any establishment 

that serves food. 

Many of the states made clear they 

would be seeking new regulations on 

products that Ilre the maillstays of convenience store sales, 

Hidden Agenda 

According to NACS State of the Industry data, more than 60 percent of all cigarettes are purchased in convenience 

stores and tobacco products make up, 

on average, 34 percent of jn~store sales. 

Pre-packaged beverages make up more 

than 11 percent of the indi.lstry's in-store 

s(11e,~, which is more than beer, wine and 

liquor combined. 

Oddly, the millions of dollars reserved 

for federally funded lifestyle guidance 

While convenience 

stores are not specifically mentioned in 

the announcement, 

they would clearly 

be targets of many 

of the restrictions 

- and with the help 

of federal funds. 

APRIL 2010 NAC5 Magaz;ne 37 
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was stashed away in the deep recesses of 

the mammoth piece oflegislatlon - even 

aftet' a public ful'Or forced Senate Demo~ 

crats to remove $75 million in funds designated to help people quit smoking. 

Republicans and other opponents of 

the bU1 cited that funding as an example 

of wasteful spending aimed at certain 

lawmakers' pet issues rather than at the 

overarching goal of boosting the economy, Democrats agreed to abandon the 

original anti-smoking language, along 

with $400 million to fight sexually 

transmitted diseases and HIVI after it 

became dear the pUblic was nor intel'~ 

ested in funding programs outside the 

hill's stated intent. 

Challenged byCNN on the wisdom of 

putting millions for anti-smoking pro~ 

grams into a bill intended as an economic stimulus, the language's leadsponsor, 

Senator Tom Harkin (D-rAJ could not 

even predict how many Americans 

might end up quitting as a result of the 

spending. 

(Well, I don't know, the money goes 

to the secretary of Health und Human 

Services and that will go out to various 

progrnms that are effectivej that are 

proven effective in the past. I can't give 

you a number right now but for every, 

for every} I don't know the exact number, but for every 10 dollars or so we 

spend on smoking cessation programs, 

we can see the effect of people getting 

off ofsmokfng," Harkin said, 

Kate Cyrul. Harkin's spokeswoman, 

told ABC News that the senator ubelieves we must reduce health-care costs, 

but the arguments over the smokingcessation funding created a distraction, 

We are commi\t~d to getting this to the 

president's desk. In that spirit, the 

smoking cessation funding came out of 

thebi]!." 

The Center for Consumer Freedom, 

a non-profit group that advocates for 

personal responsibility and consumer 

38 nacsontne.com APRt12010 

So what we have 

here is a $650-

million program 

stashed away in a 

major piece of 

legislation that 

funds lifestylechange programs, 

despite sustained 

objections to anti· 

tobacco language. 

choice, says the grants are yet another 

government effort to prevent people 

from makinguptheirown minds about 

the products they consume: IIThese 

Irecovery' grants may simply be a new 

food-police approach to the familiar 

goals/' the group said. (lIt's hard to see' 

how job loss fits into the feds' plan for 

economic stimulus. Maybe the grants 

are just a way to help diet dictators (recover' from hinging on heavy~handed 

nay-saying and stay gainfully employed.lt 

A Contradiction in Terms A dose examination of the more-thanlOO-page grant announcement and the 

project summaries submitted by state 

and local governments points to a clear 

contradiction on whether 01' not the 

funds can be spent to hire consultants 

and lobbyists to shepherd lifestyle regulations through various government 

agencies and legislative bodies. 

Some of the gTants awarded in Febru~ 

al'y seem clearly aimed at lobbying. In 

their award announcements, for examplel both New York and Delaware say 

money wlll go to {(educate leaders and 

decision makers," 

The grant annQuncement states, at 

one point, that applicants may lIestabUsh and maintain other part-time or 

ful1-time staff, contractors and con~ 

sultants sufficient in number and expertise to ensure project success and 

have demonstrated skills and experience in coalition and partnership deve1opment,communitymobilization." 

policy and environmental interven~ 

tions ... and the policies related to tobacco control." 

That sounds a lot like lobbying. 

Yet read furtber and you'll find this 

language: liND part of the appropriated 

funds sball be used to pay the salary or 

expenses of any grant or contract re~ 

cipient, or agent acting for such recipp 

ient, related to any activity designed 

to influence legislation or appropriations pending before the CongTess or 

any St',te or locallegi,lature. Any activity designed to influence action in 

regard to a particular piece of pending 

legislation would be considered lobbying:' 

Sowhat we havehel'e isa$650-million 

program stashed away in a major piece of 

legislation that funds lifestyle-change 

programs, despite sustained objections 

to anti-tobacco language (which totaled 

a mere $75 million). And when the federal government went to implement the 

program, it told applicants that they 

should hire folks to build coalitions and 

mobHize communities - but that hiring 

lobbyists was expressly forbidden. 

Michelle MalIan, a conservative blogger and author, noted that the plan to 

devote stimulus money to try and con~ 

vince smokers to quit comes atthe same 

time the government is raising taxes on 

smokes to pay for health care. It seems, 

she said, another contradiction. 

<iThese people can't keep their Big 

Nannyagendasstraight:lshewrot('~ ~ 

Scott Orr is a freelance writer based in 

Washz'ngton" D.C. 
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ij' AM.""''',,, ~ .... n'~' 

5ex,dtllgs>and' 

Blacfllerrys ' 

([oney to help the private sector . tasted on governmentbureaucra.cy-
154 


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The Strategic Dialogue on Tobacco Harm Reduction: A Vision and 

Blueprint for Action in the United States 

Strategic Dialogue on Tobacco Harm Reduction Group* 

Corresponding authors: 

Mitch Zeller, J.D. 

Pinney Associates 

3 Bethesda Metro Center, Suite 1400 

Bethesda, MD 20814 

mzeller@.pinneyassociates.com 

Phone: 301718-8440, Fax 301718-0034 

Dorothy Hatsukami, Ph.D. 

University of Minnesota 

Transdisciplinary Tobacco Use Research Center 

2701 University Ave, SE, Suite 201 

Minneapolis, MN 55422 

hatsuOO I @umn.edu 

Phone: 612 627-1808, Fax 612 627-4899 
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Abstract 

The issues related to tobacco hann reduction continue to challenge the tobacco control 

research and policy communities. The potential for com busting tobacco products to 

reduce exposure and risk remains largely unknown, but this has not stopped 

manufacturers from offering such products making these claims. The role of oral tobacco 

products in a hann reduction regimen has also been a source of dialogue and debate. 

Within the last few years, major cigarette manufacturing companies have begun selling 

smokeless products for the first time, claiming to target current cigarette smokers. Other 

cigarette manufacturers are also offering smokeless products in markets around the 

world. The hann reduction debate has at times been divisive. There has been no unifying 

set of principles or goals articulated to guide tobacco control efforts. In particular, the 

research needs are extraordinarily high in order to drive evidence-based policy in this 

area and avoid the mistakes made with "light" cigarettes. This paper discusses 

recommendations from a strategic dialogue held with key, mostly U.S.-based tobacco 

control researchers and policy makers to develop a strategic vision and blueprint for 

research, policy, and communications to reduce the harm from tobacco for the U.S. 

Short- and long-tenn objectives are described. 
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Preface 

For more than two years a group of tobacco control researchers, policy and 

communications experts participated in a process called the Strategic Dialogue on Harm 

Reduction (the Dialogue). The purpose ofthis document is to distill a wide variety of 

views that emerged from the Dialogue into a platform of principles for examining the 

future of harm reduction in the tobacco control context. Because this document reflects 

input almost exclusively from U.S. tobacco control experts, its application and 

acceptability is primarily pertinent within the United States. The intention was not to 

exclude input from the rich experiences of other countries. At the same time, it would be 

presumptuous to suggest that this document can answer the difficult questions of harm 

reduction in an international context. Nevertheless, we hope this document will spur 

other nations to examine tobacco harm reduction within their own boundaries. 

Background 

Most smokers in the United States want to quit [1] and a significant number have 

tried to quit.[2] Although research shows that with repeated attempts, smokers can 

successfully quit, a new generation of tobacco products has entered the marketplace in 

the last decade that may jeopardize these efforts. Offering promises of reduced exposure 

to toxicants in tobacco smoke and oral tobacco and even making implied or direct claims 

to reduce the risk of cancer or other diseases, these products raise important public health 

policy questions. 

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The new tobacco products that are being offered take various forms. Some use 

conventional means to burn tobacco, while others employ novel technologies such as 

computer chips and heating blades to burn or heat tobacco. Advertisements for a number 

of novel combustible products promise to reduce or eliminate exposure to a subset of 

toxicants in tobacco smoke or to reduce exposure to secondhand smoke. Increasingly, 

non-combustible oral tobacco products, many low in nitrosamines compared with 

conventional products, are being marketed with promises oftobacco satisfaction in 

situations (e.g., at work or at home) where smoking is not possible. However, whether 

they combust or not, all ofthese products are apparently aimed at health-concerned 

smokers and/or addicted smokers unable or not wanting to quit. 

From a public health perspective, there is concern about tobacco products bearing 

unsubstantiated claims to reduce exposure and risk.[3] They have entered the 

marketplace without governmental scrutiny and in the absence of any independent 

scientific evaluation of their claims. The greatest danger is that these products may pose 

a significant threat to tobacco cessation and prevention efforts. Health-concerned 

smokers who see the claims for novel combustible products may now think that a safer 

cigarette genuinely exists, making them less interested or less inclined to try to quit 

smoking. There is the added concern that ex-smokers may start smoking again, thinking 

they can now safely consume tobacco products. Likewise, those who never used may 

initiate tobacco use with one ofthese new products under the assumption that a safe 

tobacco product exists. 

In theory, the application of harm reduction principles to the tobacco control 

armamentarium has potential to reduce tobacco's toll. In its broadest conception, tobacco 

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harm reduction consists of all methods used to reduce tobacco-related morbidity and 

mortality. The most effective efforts to reduce harm from tobacco use are those directed 

at preventing initiation of tobacco use, encouraging cessation among existing users, and 

protecting nonsmokers from exposure to second-hand smoke. For the purposes of this 

report-and more generally within the field of tobacco control-we use the term 

"tobacco harm reduction" much more narrowly to refer to strategies that would reduce 

morbidity and mortalitv, at both the individual and population levels,~resulting from 

continued use of tobacco or other nicotine-containing products. 

There is a very pronounced continuum of risk depending upon how toxicants and 

nicotine, the major addictive substance in tobacco, are delivered. Cigarette smoking is 

undoubtedly a more hazardous nicotine delivery system than various forms of noncombustible tobacco products for those who continue to use tobacco, which in turn are 

more hazardous than pharmaceutical nicotine products.[4, 5] There is potential for an 

ever-wider range of consumer-acceptable alternatives to the cigarette for smokers who 

will not otherwise cease their dependence on nicotine. With U.S. status quo trends in 

smoking estimated to lead to 10 million additional deaths in the next 25 to 30 years, with 

virtually all of these to occur among people already smoking, and with the vast majority 

of them motivated to reduce their risks, the primary reduction in tobacco-related death 

will come from increased cessation. But the intelligent application of harm reduction 

principles has the potential to achieve public health gains. 

For other perspectives on harm reduction see Reuter P, Caulkins JP. Redefining the 

goals of national drug policy: Recommendations from a working group. Maer J Public Health 

1995;85:1059-63; International Harm Reduction Association. What is harm reduction? 

(discussion paper). September 18,2002. http://www.ihra.net/popups/articleswindow.php?id=2 

(Accessed July 30. 2005); Harm Reduction Coalition. Principles of Harm Reduction. New York, 

New York. Available at:http://www.harmreduction.org/(AccessedJuly 30, 2005); Marlatt GA. 

Harm reduction: come as you are. Addictive Behaviors 1996;21 :779-788. 

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However, in the absence of public health-based regulation, there is no way to 

know whether the promotion of any of the new or existing products will actually reduce 

exposure and risk when used by smokers or increase the number of tobacco users and 

weaken the impact of prevention and cessation efforts. The major concern held by some 

public health experts is that these new products may be nothing more than a more 

scientifically sophisticated version of the "light" cigarette. Experts learned -- decades too 

late to be of any help to the health-concerned smoker who switched to "lights" -- that 

"lights" were deliberately designed to reduce tar and nicotine emissions when tested by 

smoking machines, but not necessarily when smoked by human beings, because they 

allowed for compensatory smoking.[6] 

Worse, these so-called "light" products did not reduce the morbidity and mortality 

from smoking. Thirty years ago, because of the unregulated marketplace, tobacco 

companies controlled much ofthe information related to cigarette design, product 

performance, and consumer behavior. Well-intentioned public health officials, without 

the necessary scientific information, followed the industry's message and encouraged 

health-concerned smokers to switch to "lights".[7] Today, "lights" and "ultralights" 

account for nearly 85 percent of all the cigarettes sold in the United States.[8] Yet data 

now show little or no reduction in deaths and perhaps an increase in adenocarcinoma of 

the lung.[6] With today's products, we must avoid repeating the mistakes made with 

"lights" decades ago. That experience, and the need to look at population-level impacts, 

must inform our deliberations and analysis of the new generation of products purporting 

to reduce individual exposure or risk. We also recognize that at the time this report is 

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being written there exists an unregulated marketplace where the tobacco companies 

continue to control the information related to cigarette design and consumer behavior. 

Goals and Objectives ofthe Dialogue Process 

The topic oftobacco harm reduction is complex and, at times, contentious. No 

unified vision or strategy has guided research and policy. No opportunities have existed 

for individuals with diverse perspectives, such as researchers, policy experts, 

communications experts, and advocates to come together to produce a strategic vision on 

issues related to this area. Instead, while there is broad support for the need to regulate 

tobacco products, there has been a fractured and sometimes divisive debate over issues 

such as the appropriate role of regulation as it relates to harm reduction and, particularly, 

the roles of smokeless tobacco and nicotine replacement therapy (NRT) in harm 

reduction. 

A forum was needed to identify strategies to avoid the previous mistakes with 

"lights" and not lose another generation of health-concerned smokers to the potentially 

false hope offered by the tobacco industry. Such a forum would examine ways in which 

effective product regulation and appropriate consumer information could lead to 

significant reductions in the predicted deaths and disease from tobacco use. At the same 

time, it was important to ensure that the public health community explored whether 

and/or what possible role existed for some tobacco-based products or pure nicotine 

containing medicinal products in a harm reduction regimen. Other pharmacological 

agents can also playa role in harm reduction, but in order to limit the focus or our 

deliberations, we considered only nicotine -containing products. 

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In 2005, with funding from the American Legacy Foundation and the Robert 

Wood Johnson Foundation, such a forum for discussion, debate, and strategic planning 

was created: the Strategic Dialogue on Harm Reduction (the Dialogue). The goals and 

objectives of the Dialogue included systematically addressing critically important aspects 

of the harm reduction debate including research priorities, communication methods, 

policy recommendations, and overarching strategic considerations. The Dialogue was 

launched in the spirit of attempting to build a shared blueprint that would lead to betterdefined roles, responsibilities, and opportunities for collaboration between researchers, 

policy makers, and advocates. Although the deliberations of the dialogue were focused on 

the United States and we acknowledge that the application of some of our 

recommendations may not apply in some countries, we hope that some of these principles 

will have world-wide applicability. 

The Dialogue Process 

Four Dialogue meetings took place between December 2005 and August 2007. 

The participants included policy and communications experts and scientists representing 

different areas of expertise including toxicology, biomarkers across disease states, risk 

and consumer perception, nicotine addiction, behavioral pharmacology, epidemiology, 

and clinical sciences. (See Table 1.) They also had differing views on tobacco harm 

reduction. At the initial meeting, key questions emerged that guided the work ofthe 

Dialogue and the end product, this report. Additional participants and areas of expertise 

were identified for inclusion in subsequent meetings. At the final Dialogue meeting, this 

report was reviewed and all participants had the opportunity to comment on each of the 

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multiple drafts of the final report. This vision and the report were endorsed by all the 

members of the group and the report is being released as the collective vision of Dialogue 

participants. 

The strategic goal of the Dialogue process was to discuss the development of a 

long-term vision for tobacco harm reduction and short-term policy objectives to begin the 

lengthy process of achieving the shared long-term vision. Discussion of these short-term 

objectives yielded an identification of key issues to research in order to properly evaluate 

all products in the tobacco marketplace. Research will also help to determine the 

feasibility and potential impact of the proposed long-term vision. 

The Policy and Regulatory Context 

The Dialogue process took place when -- for the first time -- there were legitimate 

prospects for comprehensive tobacco product regulation. Globally, the Framework 

Convention for Tobacco Control mandates such regulation.[9, Article 9-11] In the 

United States, legislative efforts have been mounted to give regulatory authority over 

tobacco products to the Food and Drug Administration (FDA).[I 0] FDA had previously 

asserted jurisdiction over tobacco products in the mid-I 990s, but that action was 

overruled by the Supreme Court in 2000. 

Effective product regulation has the potential to be an important complement to 

the evidence-based policy interventions already in place that have helped drive down 

U.S. tobacco use over the past 40 years. These existing policies include proven 

prevention programs such as aggressive counter-marketing efforts, encouragement of use 

and provision of cessation products and services to help tobacco users quit, legislative 

initiatives to raise excise taxes, implementation of comprehensive smoke-free air laws, 

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restrictions on tobacco marketing, stronger and more visible graphic warning labels, and 

improvement of access to treatments for tobacco dependence.[9, II] The primary goal of 

product regulation would be to reduce morbidity and mortality associated with the use of 

tobacco products. 

The Long-Term Vision and Short-Term Policy Objectives ofthe Strategic Dialogue on 

Harm Reduction 

Throughout the Dialogue process, participants engaged in a discussion and 

exploration of key principles to guide a unified approach to dealing with issues 

surrounding harm reduction. The following four principles were identified as an essential 

foundation for subsequent discussions and recommendations: 

I. The primary goal of tobacco control is to reduce mortality and morbidity 

associated with tobacco use. 

2. "Tobacco-free" should be the norm. Policy interventions such as clean indoor 

air laws, sustained media campaigns, and excise tax hikes, coupled with 

expanded prevention and treatment efforts, should continue to be at the 

forefront of tobacco control efforts to denormalize tobacco use. 

3. Achieving the primary goal might entail continued use of selected nicotinecontaining products if doing so would deter the use of more toxic tobacco 

products and would result in a significant reduction in tobacco-related morbidity 

and mortality. 

4. Any company marketing nicotine-containing products needs to be accountable 

for the toxicity of its products and must bear the burden of proof for any product 

claims. There needs to be an adequate science base to support claims, and they 

must be truthful and not misleading. 

If the primary goal of tobacco control is to eliminate morbidity and mortality 

associated with the use of tobacco products, the most effective means is abstention from 

all tobacco products. This was judged to be a population outcome that would take time to 

accomplish. In this context, Dialogue participants with differing views on the role of 

smokeless tobacco use in harm reduction were able to reach a consensus on one long9 
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term vision: a world where virtually no one uses combustible tobacco products. This is 

not a recommendation to ban cigarettes and embrace a policy of prohibition, nor does it 

reflect any agreement about recommending that smokers switch to smokeless tobacco 

products. Rather, it is a clarion call to alter the current marketplace to reduce the number 

of people who use cigarettes. Given the currently widespread use of combustible tobacco 

products, this is obviously a highly ambitious long-term vision, subject to controversy 

and skepticism regarding its feasibility. 

Dialogue participants also identified two key short-term policy objectives to help 

achieve the primary goal of reducing the morbidity and mortality from tobacco by 

reducing tobacco use and the number of tobacco users. These are: 

1. Establish effective public health-based regulatory control of all tobacco products. 

2. Shift current tobacco users who are unable or unwilling to become nicotine free 

toward the least harmful products, i.e., medicinal nicotine. 

Rationale for the Long-Term Vision Where No One Uses Combustible Tobacco Products 

A world in which no one uses combustible tobacco products would have a 

profound impact on reducing death and disease from tobacco use. Perhaps in response to 

the prospect of significant reductions in tobacco use, tobacco product manufacturers have 

introduced many new products known as Potential Reduced Exposure Products [PREPs; 

3] with the dual goals of appearing to address the health concerns of smokers while 

simultaneously maintaining overall tobacco use. 

The discussions and controversies evolving around the recent introductions of 

PREPs have led to a closer examination of the health risks associated with all tobacco 

products. This examination has caused many to conclude that combustible PREPs are 

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unlikely to significantly contribute to a reduction in the death and disease from tobacco 

use.[4, 5,12-15] 

How to determine the likely reduction in individual-level risk and populationlevel harm across various PREPs is still an open scientific question. Research in several 

areas is being conducted to evaluate the following factors as potential determinants: (1) 

toxic constituents in tobacco products and smoke emissions, (2) preclinical cytotoxicity 

and genotoxicity in cell cultures and animal models for toxicity and disease, (3) 

biomarkers of exposure and effect in humans, and (4) actual health outcomes across 

various morbidity factors. The convergence of the results in all these areas of testing is 

likely to constitute the evidence base for determining the reduced risk potential of a 

product, with the ultimate evaluation criteria resting on actual health outcomes. 

Because of the many years that would be required to directly observe the health 

effects of a PREP, evaluation currently relies on shorter-term clinical and laboratory 

measurements, including assessment of toxic chemical delivery, biomarkers of exposure, 

and biomarkers of effect. Toxic chemical delivery is a measure of the level of chemical 

constituents of concern to which a user ofthe product is exposed. Usually these 

measurements are carried out using external devices that smoke or extract the chemicals 

of concern before analysis of their amounts. Preferably, the delivery process is designed 

to mimic how people use the product; however, all too often this has not been the case 

and has led to false estimates of exposure.[ 6, 16] This is also complicated because of 

both intra- and inter-individual variability in product use. Biomarkers of exposure 

measure a "constituent or metabolite of the product that is obtained in biological fluid or 

tissue." Biomarkers of effect refer to "a measured effect including early subclinical 

II 
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biological effects, alterations in morphology, structure or function; or clinical symptoms 

consistent with the development of health impairment and disease".[17] To date, a few 

clinical trials that have used these biomarkers suggest that there is a spectrum of potential 

harm across different types of tobacco or nicotine-containing products ,[4, 18, 19] with 

the greatest harm associated with the conventional combustible tobacco products and the 

least harm associated with therapeutic nicotine replacement products. 

Based on current knowledge, novel combustible products are unlikely to 

substantially reduce risk for disease because of the number oftoxic combustion 

constituents associated with cigarette smoke. Human studies on modified, reducedtoxicant cigarette products have shown only moderate or modest reductions of some 

toxicants, no significant reductions of other toxicants, and even some increases in other 

toxicants.[20-23] 

Some have concluded that a cigarette product that may lead to significant 

reduction in risk is one with a nicotine content that is too low to promote initiation, 

sustain addiction, or lead to compensation. * The harm reduction potential from such a 

product is not a consequence of a reduction in toxic constituents, but rather a reduction in 

the addiction potential of the product. A gradual reduction in the nicotine content of all 

cigarettes was proposed in 1994 by Benowitz and Henningfield.[24] This approach could 

theoretically lower the prevalence of smoking by reducing initiation by adolescents and 

increasing abstinence rates among addicted adult smokers . 

• Compensation occurs when smokers engage in behaviors to defeat product modifications such as lowered 

nicotine content. Such compensatory behaviors include smoking more cigarettes, taking more puffs, or 

taking larger puffs. [6] National Cancer Institute. Risks associated with smoking cigarettes with low 

machine-measured yields oftar and nicotine. Smoking and Tobacco Control Monograph No. 13. Bethesda, 

MD: U.S. Department of Health and Human Services. National Institutes of Health, National Cancer 

Institute 200 I. 

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Preliminary evidence has suggested that smokers using specially designed test 

cigarettes with lowered nicotine content in the tobacco show a dose-related reduction in 

nicotine intake, with only modest compensation.[25, 26] This finding points to the 

potential feasibility of reducing nicotine addiction through reduced-nicotine cigarettes. 

The test cigarettes used are different from the commercial "low-yield" cigarettes that 

have similar levels of nicotine as the higher yield cigarettes but achieve lower machinedetermined yields due to ventilated filters. Ventilated filters have one or more rings of 

small perforations that allow air to dilute smoke, thereby reducing machine-based yields 

of tar, nicotine, and carbon monoxide.[6] Unlike machines, smokers can achieve higher 

levels of nicotine by smoking harder on a cigarette and/or blocking the ventilated 

filters. [6] 

Considerable research needs must be addressed before the nicotine reduction 

approach can be recommended. Reducing the nicotine content in cigarettes should be 

pursued only if it reduces smoking prevalence and does not lead to a significant increase 

in toxicant exposure in continuing smokers due to compensatory smoking. It should also 

only be considered in a regulated environment where addicted adult smokers would be 

provided easily accessible products, programs, and services to stop using cigarettes.[27] 

The State of the Science on Other Tobacco and Nicotine-Based Products 

Cigarette-like delivery devices that heat rather than bum cigarettes, such as Philip 

Morris' Accord and Reynolds American Inc.'s Eclipse, are being sold in the United 

States and other countries. To date, there have not been sufficient studies of these 

products to determine their value in reducing exposure and disease. The results from 

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studies conducted by Roethig and associates, testing one of the cigarette-like delivery 

devices, showed significantly lower levels of some carcinogen-related toxicants 

compared with conventional combustible products in both residential and non-residential 

settings and in short and long-term trials.[28-31] One study also showed significant 

improvements in some of the cardiovascular risk factors that were measured.[30] To 

date, it is unknown if the extent of the observed reductions and if reductions in some but 

not all biomarkers would lead to relative reductions in disease risk compared to continued 

smoking on conventional cigarettes. Furthermore, not all of these devices are alike. For 

example, in studies with another electronically heated cigarette-like device, significant 

increases in some of the biomarkers of exposure and effect were observed.[see 18,32] 

On the continuum of risk, non-combustible tobacco products are more likely to 

reduce harm than a smoked form oftobacco for individuals who would otherwise be 

using conventional cigarettes. Though Dialogue participants did not fully agree on the 

role of smokeless tobacco products as a harm reduction agent, there was a consensus 

about the value and the concept of this continuum of risk. 

To reduce harm, these non-combustible nicotine-containing products will need to 

expose users to significantly fewer and lower levels of toxicants than cigarettes, and their 

use should not discourage or delay quitting combustible products. Any discussion of the 

harm reduction potential of smokeless tobacco products must take into account a series of 

individual and population-level policy issues including (I) the relative toxicity and risks 

of any oral tobacco products compared with cigarettes; (2) concomitant use of oral 

tobacco products and cigarettes with the potential for increased exposure to toxicants; (3) 

increased prevalence of oral tobacco use due to increased uptake among those who would 

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otherwise never use tobacco. maintenance of oral tobacco use in consumers who would 

have otherwise quit, and/or relapse to tobacco use; and (4) potential as a gateway product 

to or from cigarette smoking.[See, for example, 19, 33,34, 35] 

Smokeless tobacco companies and cigarette manufacturing companies in the 

United States are marketing reduced-toxicant (lower tobacco-specific nitrosamines, 

TSNAs) and spitless oral tobacco packets or lozenges. Some of these newer U.S. 

products are lower in TSNA levels than some conventional and most popular brands of 

smokeless tobacco sold in the United States or in other parts of the world such as India 

and comparable to or lower in TSNAs than the smokeless tobacco products sold in 

Sweden.[19, 36, 37] One study showed that tobacco carcinogen exposure (NNK) can be 

reduced when smokers switch to smokeless tobacco products;[38] however, human 

clinical studies on the effects of oral tobacco products on biomarkers of exposure and 

effect are limited. 

Smokeless tobacco has been found by the U.S Surgeon General, the American 

Cancer Society and fARC to be a cause of oral cancer and possibly pancreatic cancer 

[39]. Nonetheless, if smokers who cannot or will not quit their dependence on nicotine 

switched completely to smokeless tobacco products, they would likely experience a 

reduction in tobacco-caused mortality and morbidity. The extent of this reduction is 

unknown. Nevertheless, these persons would not be risk-free, and their risk would be 

higher than if they switched to medicinal nicotine. 

Several published reports and articles describe a significantly lower risk for 

disease from using smokeless tobacco compared with cigarettes.[e.g. 5, 19, 34, 40] 

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Unlike cigarette smoking, smokeless tobacco use has not been linked to many of the 

smoking-related cancers [39] or to pulmonary disease.[ 41] 

Interestingly, those who believe that smokeless tobacco can be used to reduce 

population-level harm caused by tobacco and others who challenge these claims as 

unproven have both cited the so-called "Swedish experience." Those who contend that 

the Swedish experience supports the use of smokeless tobacco for harm reduction cite 

studies that have found, for example, that rates of lung cancer in men in Sweden were 

significantly lower than the rates found in men in Norway, which has higher rates of 

cigarette smoking. Authors of those studies attributed this dramatic reduction in lung 

cancer to increased prevalence of consumption of snus, Sweden's low-nitrosamine form 

of smokeless tobacco, which was associated with and may have led to reduced prevalence 

of cigarette smoking.[42] A study conducted in Sweden with males in a twin study 

observed that the use of the form ofsnus sold in Sweden was associated with smoking 

cessation but not initiation,[43] suggesting to the authors that there were no adverse 

effects of snus on smoking prevalence and smoking-induced disease. Further, proponents 

of the use ofsnus for harm reduction point to studies that demonstrate that snus switchers 

achieve greater health gains compared with smokers who did not switch, and similar 

gains to those who quit all tobacco products.[ 44] It is important to keep in mind that the 

Swedish studies were conducted in an environment with stronger tobacco regulation that 

included an advertising ban. Some experts question whether these results, even if widely 

accepted, are generalizable to other countries. 

Other researchers have pointed to other tobacco control factors that may have led 

to reduction in lung cancer rates in Swedish men and which may have contributed to the 

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low smoking prevalence rates in places such as Califomia.[e.g., 45, 46] Tomar [45] also 

notes that some U.S. states have high rates of smokeless tobacco use without a 

corresponding reduction in the prevalence of cigarette smoking. This finding is likely to 

be true in a culture that aggressively markets both cigarettes and smokeless tobacco 

products. Furthermore, unlike the switchers to snus products, in one study smokers who 

switched to U.S. smokeless tobacco products were found to be at greater risk for 

mortality compared with smokers who quit completely.[47] 

The safest nicotine-based products are likely to be therapeutic nicotine products 

such as the gum, patch, and lozenge. They contain nicotine but none of the other 

toxicants found in tobacco. These products are not considered absolutely safe because of 

the risk for fetal toxicity and increased levels of cardiovascular risk factors, such as 

effects on blood lipids, endothelial dysfunction, and insulin resistance.[ 48, 49] Still, 

these products are less hazardous than tobacco products. Medicinal nicotine and other 

approved products are at a significant marketing disadvantage compared to tobacco 

products. They must undergo a rigorous federal approval process and are designed to 

minimize addiction. By contrast, tobacco products are currently subjected to no product 

regulation.[50] 

To facilitate a transition of smokers from the most toxic to the least toxic form of 

nicotine delivery, consideration should be given to looking at the nicotine market as a 

whole and developing a more coherent policy that explores the impact of promoting the 

use of the least toxic forms of nicotine delivery and discourage the most toxic forms. 

This should include the possibility of making the therapeutic nicotine products more 

consumer acceptable and effective.[51] Technically, this can be done by making the 

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products more palatable through improved taste and sensory perception, and by 

increasing the amount and the delivery speed ofnicotine.[4] However, the health and 

behavioral risks of a pure nicotine delivery that has these characteristics are unknown and 

require study; although the occurrence of greater health risks, with the exception oflong 

term or dependent use, seems unlikely. 

In summary, the consensus among Dialogue participants and other researchers [5] 

is that the use of combustible tobacco products will always pose the greatest risks. The 

tobacco harm reduction approach that will lead to the greatest reduction in tobaccorelated morbidity and mortality is cessation of use of all tobacco products. Short of this 

goal, shifting from combustible tobacco products to the long-term and exclusive use of 

non-combustible products, particularly therapeutic products, with the right controls and 

post-market surveillance is likely to create less harm among continuing users. This 

shifting of product use should be part of a comprehensive approach that includes the 

regulation of all nicotine products, whether or not they contain tobacco. For cigarette 

users who switch to smokeless tobacco products, maximal potential reduction in harm 

could only occur with products that result in the lowest exposure to toxicants, are subject 

to government regulation, and that avoid adverse consequences such as increased 

initiation of tobacco use or decreased cessation. 

Key Elements to Achieve Short-Term Policy Objectives 

Dialogue participants identified two short-term policy objectives in addition to 

prevention and cessation likely to achieve harm reduction as defined in this report: (I) 

effective tobacco product regulation, and (2) promoting a shift by tobacco users toward 

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the least hannful products, i.e., medicinal nicotine. Product regulation is a critical 

component in the efforts to reduce harm associated with tobacco use and is a mechanism 

to facilitate the long-tenn vision of the Dialogue, where no one uses combustible tobacco 

products. As stated in the 200 I Institute of Medicine (10M) report, Clearing the Smoke, 

"Regulation of all tobacco products ... is the necessary basis ... for assuring that the health 

of the public is protected".[3, page 6] 

Dialogue participants reached a consensus on a series of key elements in a 

regulatory scheme for tobacco products. The regulatory tools that have been recognized 

by the World Health Organization Study Group on Tobacco Product Regulation 

(TobReg, http://www.who.int/tobacco/globaljnteraction/tobreg/tsr/en/index.html) and in 

the legislation pending in the U.S. Congress in 2008 that would grant regulatory authority 

over tobacco products to the Food and Drug Administration provide useful guidance.[l 0] 

The consensus regulatory elements include: 

a) Disclose all known toxicants to regulatory agencies. Disclosure of the type and 

amount of all toxicants in tobacco products by brand and brand subtype is not 

currently required from tobacco companies, although most other consumer 

products are subject to such requirements. Disclosure of all toxicants would serve 

several functions: (1) educating public health officials and policymakers about the 

types and relative amounts of toxicants contained in tobacco products, (2) 

providing a basis for monitoring toxicants in tobacco products by the government, 

and (3) establishing a platform for regulating these toxic constituents. Regulators 

would have to make a science-based decision on whether and how this 

infonnation should be disclosed to consumers. 

b) IdentifY toxicants targetedfor reduction. Toxicants should be identified based on 

whether they are known to cause adverse effects and the extent to which they are 

linked to tobacco-related disease and/or addictive behavior.[3] The World Health 

Organization Committee on Tobacco Product Regulation (TobReg) has been 

working to identify known emissions toxicants that should be reduced in cigarette 

products. Toxicants were identified by TobReg based upon their carcinogenic 

and toxic activities, their known effects in humans, and their concentrations in 

cigarette smoke. The toxicants identified by TobReg for regulation are 

acetaldehyde, formaldehyde, benzene, 1 ,3-butadiene, acrolein, benzo[aJpyrene, 

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carbon monoxide, NNN, and NNK. Several other toxicants were also 

recommended as candidates for reporting to govemments.[52J They are 

acrylonitrile, 4-aminobiphenyl, cadmium, catechol, crotonaldehyde, hydrogen 

cyanide, hydroquinone, 2-naphthylamine, and nitrogen oxides. As products and 

science evolve, these targeted toxicants will need to be revisited. 

c) Develop a science-based rationale for reducing toxicants in all tobacco products. 

Cigarettes and smokeless tobacco products vary tremendously in their toxicant 

levels. This is a function of the type of tobacco leaves in the product, the curing 

and manufacturing processes, and how the products are consumed. For example, 

the variability in tobacco-specific nitrosamines -- a potent carcinogen -- can range 

over a 20-fold difference in cigarettes worldwide [53] and greater than a 48-fold 

difference among U.S. oral tobacco products.[O.l9 to 9.2 I1g/g product wet 

weight, 36] Although no studies have been conducted on the relationship 

between tobacco-specific nitrosamine levels in different brands of cigarettes and 

uptake of these carcinogens in humans, preliminary results in an experimental 

setting show a relationship with smokeless tobacco products.[19] Therefore, 

depending on factors the preliminary tests did not examine, it may be that 

reducing levels of toxicants in smokeless tobacco products can potentially result 

in reduction of exposure to these toxicants.[23, 54] Smokeless tobacco products 

(snus) in Sweden tend to be lower in tobacco-specific nitrosamines and other 

toxicants compared with the most popular brands in the United States, primarily 

because the Swedish tobacco companies have self-imposed performance 

standards. As a result, in Sweden there are studies that conclude that the risk for 

disease associated with snus tends to be lower, particularly in contrast with risk 

for disease observed in India and the United States, where the smokeless tobacco 

products tend to have higher levels oftoxicants.[19] 

Because of nicotine's role in cigarette use,[55] reducing levels of toxicants 

without taking into account nicotine levels may not lead to significant reduction in 

toxicant exposure. In the case of higher ventilation cigarettes, both machinemeasured tar and nicotine were reduced over the past 30 years and, as a 

consequence, smokers increased their intake of toxicants per cigarette to 

compensate for the reduced levels ofnicotine.[6] Reducing toxicants on a permilligram-of-nicotine basis, as proposed by TobReg, may circumvent this 

problem, although no proof of concept study has been conducted. Furthermore, 

measures must be taken to ensure that nicotine yields are not increased in 

cigarettes in order to maintain a specified toxicant-to- nicotine yield ratio. While 

increasing nicotine levels might reduce the number of cigarettes smoked and lead 

to reduced exposure,[56] this method may increase the number of tobacco users 

addicted to their product. Any adjustment of nicotine levels - up or downrequires careful study and monitoring and should only be done in a regulated 

environment. 

d) Establish a standardfor the maximum level of specific toxicants and prohibit the 

sale o.ftobacco products that exceed the established standards. Although 

Dialogue participants were not asked to endorse the quantification of toxicant 

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reduction during the Dialogue process, it is important to note that performance 

standards should be determined by a body of experts independent of the tobacco 

companies and that Gray et al..[4] commented that the performance standards can 

become more stringent over time. At this point, there are no mandatory 

performance standards in the United States or globally, thus leaving the 

companies free to deliver any level ortoxicants they choose. Once in place, 

tobacco companies should not be allowed to publicize mere compliance with any 

such standards. 

e) Establish a standardfor nicotine yields across tobacco products. This regulatory 

approach would prevent tobacco companies from independently increasing 

nicotine in tobacco products, as has been observed over several years in a study 

conducted by the Harvard School of Public Health.[57] Furthermore, it would 

give regulatory authorities the power to alter levels of nicotine in tobacco 

products based upon the best available seience.[24, 27, 58] 

f) Assess the human exposure impact for toxicant reduction. The recommendations 

to develop performance standards must remain fluid. Determination as to whether 

the proposed standards result in exposure reduction must be based on evidence 

from human clinical exposure trials and will evolve from data produced by the 

tobacco companies and by independent scientists. Results from studies may 

necessitate revisions to previously established performance standards. 

g) Prohibit exposure reduction claims associated with reductions in level of 

toxicants. Exposure reduction claims are likely to mislead consumers into 

thinking that a product is "safer" or ·'safe".[59, 60] This is one of the lessons 

learned from the experience with "light" cigarettes.[61-65] Until there are data to 

demonstrate that specific levels of toxicant exposure lead to reduction in risk at 

the population level, tobacco companies should not be allowed to make exposure 

reduction claims alone. Post-marketing surveillance of any approved risk 

reduction claims will be necessary to determine the impact of these claims on 

initiation, relapse, cessation. and health. 

h) Educate the public about exposure vs. risk reduction. Regulation of tobacco 

products, and efforts to reduce toxicant levels in tobacco products could lead the 

public to perceive the tobacco products as "safer" or "sate" or "endorsed" by the 

government. A well-designed public education program, grounded in sciencebased information, needs to be developed. It should include media campaigns 

that explain the differences between exposure and risk reduction and emphasize 

the benefit of total cessation of tobacco use. 

i) Regulate the promotion, advertising, and labeling of tobacco products. The goal 

of this regulation is to prevent false or misleading claims, implied or direct. 

Studies will be needed to provide the evidence base for a proper evaluation of 

promotion, advertising, and labeling. 

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j) Establish research priorities to achieve regulatory elements a-i. Research needs 

for the assessment of PREPs and tobacco products in general have been clearly 

described in other reports and articles.[3, 34, 66] These include development of 

(1) animal models and in vitro assays of the pathogenesis of tobacco-attributable 

diseases; (2) human biomarkers of exposure and effect and the relationship 

between these biomarkers with disease risk; (3) methods and measures for shortterm clinical and epidemiological studies, including consumer perception testing; 

and (4) post-marketing surveillance or long-term studies to determine the impact 

of PREPs on a population level. 

Research is needed to provide guidance for regulation addressing such issues 

as (I) whether and how to best educate consumers about the toxicant level in 

tobacco products so that an informed decision can be made on product use or 

choice of products and so the consumer is not misled; (2) the impact of reducing 

toxicants on machine-determined yields and in preclinical (animal and in vitro 

assays) and clinical human exposure studies; (3) the process, impact, and viability 

of gradually reducing nicotine yields of tobacco products, particularly in 

conjunction with reducing toxicant yields per milligram of nicotine; and (4) the 

best way to educate the public on reduced exposure vs. reduced risks and on 

relative risks, without compromising public health. In all these research questions, 

the effects on a heterogeneous popUlation (e.g., gender, racial/ethnic, SES, 

tobacco use status, concern about health, motivation to quit) must be considered. 

To shift the population who cannot or will not quit altogether toward the use of 

the least harmful products (the second short-term policy objective), a number of methods 

were identified for further exploration. These were: 

a) Substantially raise the tax on combustible tobacco products on a regular basis 

over time. Increasing the cost of the most dangerous compared to the least 

dangerous products (e.g., medicinal nicotine) can switch preferences toward the 

less costly products. For example, studies have been conducted with unhealthful 

vs. healthful food products in schools and worksites in which low-fat, low-calorie 

foods were priced lower than high-fat, high-calorie foods.[67] An increase in 

intake was observed for the more healthful foods with a decrease in consumption 

of less healthy foods. 

b) Institute difforenl levels of availability and packaging based on risk in accordance 

with a system established by an independent regulatory agency. More toxic 

products should be made less available. For example, tobacco products could be 

placed below the counter at retail outlets, completely out of view of the public, 

especially from children and adolescents. In addition, research on label 

statements should be conducted to more effectively communicate relative toxicity 

(e.g., tobacco products vs. medicinal products). 

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c) Consider providing appropriate incentives and/or disincentivesfor 

manufacturers. No company should be able to make an exposure reduction claim. 

However, if there is a documented decrease in risk, it may be possible to create 

appropriate incentives. These could include granting a "pioneer" company a 

period of time where it has exclusive use of an approved claim, or ordering 

mandatory cross-lieensing oftechnologies that have been proven to reduce 

exposure and risk with royalty payments guaranteed to the "pioneer." This could 

create a financial incentive for innovators of genuinely reduced-risk products. 

Other potential financial incentives should be explored. 

d) Expand anti-tobacco advertising. label all cigarettes as deadly and addictive. and 

educate the public accurately on the precise risks of different products. All of 

these steps should be taken in a regulated environment. The third of these 

recommendations stems from the principle that eonsumers deserve accurate and 

evidence-based information on the toxicity and relative risk for disease of 

different products.[68] For example, the public has misconceptions that 

medicinal nicotine products are associated with risks for certain tobacco-caused 

diseases that should be corrected. [61,69.70] 

e) Strong messages and programs for cessation of all tobacco products. No tobacco 

product should be considered safe. Tobaeco users who are unable or unwilling to 

quit tobacco should be eneouraged to move toward the least hazardous form of 

nicotine delivery available, therapeutic nicotine products, or other therapeutic 

products for cessation. Cessation programs and products should be universally 

available and widely promoted. 

f) Establish research priorities to achieve elements a-e. The critical research 

questions to address for these short-term policy recommendations are the 

following; (I) the relative risk across different types of tobacco products and 

methods to determine relative risk; (2) a better understanding of the relationship 

between increasing the cost of a highly toxic product and consumers' decisions to 

switch to less toxic products; (3) optimal methods to educate the public and to 

correct consumer misperceptions about the relative risk of products; and (4) the 

population impact of the proposed measures on increasing initiation or decreasing 

cessation. 

Three additional initiatives were identified by Dialogue participants as worthy of 

further exploration and research. 

1. Explore whether reducing nicotine exposure in combustible products to nonaddicting levels is likely to lead to a reduction in smoking prevalence; 

accounting for the potential unintended consequences of such a strategy, 

including whether such a step would result in the creation of a black market for 

higher nicotine cigarettes. 

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2. Explore the effects oflow-toxicant smokeless tobacco products as a harm 

reduction tool, and determine the safety and impact, on individual and 

population levels, of informing the public about the relative risk of oral tobacco 

products compared with combustible tobacco products. 

3. Explore issues surrounding long-term use of nicotine at the population level; 

account for the trade-offs that may be inherent in this approach, such as a 

reduction in overall disease toll but an increase in initiation or persistence of 

nicotine use due to the knowledge that a "safer" alternative exists. 

Finally, the following significant infrastructure needs were identified by Dialogue 

participants: 

a) Enhanced sun'eillance of tobacco product use. Surveillance to assess population 

impact (e.g., rates of initiation and cessation, and concurrent product use) is a 

critical component to achieve a short-lenn rapid response capability that will 

support the long-term vision of the Dialogue. As described in several 

publications,[3, 66] both short-term and long-term continuous surveillance is 

critical to assess the patterns of tobacco use and impact of policies and products 

on health outcomes. Surveillance should include an assessment of biomarkers of 

tobacco toxicant exposure in individuals using different products and whether 

there is any correlation between those measurements and health outcomes. 

b) Creation of a research consortium. In the United States, this would ideally 

include relevant government agencies -- the Centers for Disease Control and 

Prevention (CDC). Environmental Protection Agency (EPA), National Institutes 

of Health (NIH) -- and a range of private and academic research facilities for 

product testing. human exposure studies, and consumer perception studies. The 

CDC can contribute its expertise in product testing. toxicology, and surveillance; 

the EPA can contribute hazard identification, risk assessment, and risk 

management; and the NIH can generate the research base for addressing critical 

questions about viable and effective methods for tobacco harm reduction. The 

contracted research centers would be composed of a consortium or network of 

independent scientists and testing facilities to test tobacco products using animal 

and human protocols. This research consortium would closely interact with 

international efforts in this area, including WHO's Committee on Tobacco 

Product Regulation and Tobacco Laboratory Network initiatives. 

Summarv and Conclusions 

Dialogue participants reached a consensus that, based on the currently available 

evidence, significant tobacco harm reduction can be achieved over the long term only in a 

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world where virtually no one uses combustible tobacco products. In such a world, 

smokers would either quit completely or switch to the least harmful form of nicotine 

delivery, i.e., medicinal nicotine. Steps toward achieving this ambitious vision would 

include policies that discourage the use of combustible products through taxation and 

access, marketing, and promotion. It might also be possible over time to employ product 

regulation to permit the sale only of nonaddicting combustible tobacco products so that 

young people who experiment with cigarettes would not become addicted. 

Decreasing tobacco initiation and increasing tobacco cessation are proven harm 

reduction strategies. Current efforts in these areas are woefully underfunded. 

Implementing the recommendations of the recent 10M report [11] to fully fund 

comprehensive tobacco prevention and control funding at CDC-recommended levels is a 

required first step. Tobacco product regulation is also needed to provide a mechanism to 

reduce the harmfulness of tobacco products. In a regulated environment: 

a) Tobacco constituents and additives should be disclosed to and monitored by 

regulatory agencies. 

b) Performance standards should be established so that all tobacco products would 

have maximum limits on nicotine and toxic tobacco constituents and emissions. 

c) Exposure reduction claims should be prohibited in the absence of adequate 

evidence.ofrisk reduction. Mechanisms should also ensure that claims are 

examined based on the impact on the population as a whole as well as individual 

consumers. 

d) Risk reduction claims should have an adequate scientific base, including evidence 

of anticipated population-level effects (e.g., on initiation and cessation). 

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e) Any risk reduction claims should be evaluated and approved by a regulatory 

agency on a pre-market basis. 

f) Post-marketing surveillance should be used to re-evaluate the claims. 

g) Consumers should be accurately informed and educated about relative risks of the 

use of different types of nicotine containing products. 

h) Combustible products that reduce nicotine exposure to non-addictive levels 

should be investigated. 

i) Individual risk and population health impacts oflong-term use of nicotine-only 

products should be examined. 

j) Policies that shift the population to less harmful products should be explored 

taking into account their impact on prevention and cessation efforts and overall 

tobacco-related mortality. 

k) The effects of regulatory policies on prevalence oftobacco use and tobaccocaused mortality and morbidity should be monitored. 

In thc short tenn, the following action steps need to be taken: (I) Pass effective 

legislation for tobacco product regulation, (2) develop the proposed infrastructure and 

network for product testing and scientific inquiry, (3) coordinate national and 

international efforts, and (4) address the research questions necessary to determine the 

feasibility and impact of fulfilling the long-term vision. Much is already known about 

the building blocks required to achieve the long-term vision and short-term policy 

objectives identified by the Dialogue. What is missing is the requisite degree of public 

and political support to dare to envision a future world where almost no one uses a 

combustible tobacco product. 

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Acknowledgments: This Dialogue process was funded by Robert Wood Johnson 

Foundation, American Legacy Foundation and with administrative support from the 

University of Minnesota, Transdisciplinary Tobacco Use Research Center (P50-

DAO\3333). 

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Table 1 

Strategic Dialogue on Tobacco Harm Reduction Participants* 

Cathy Backinger, Ph.D., M.P.H., National Cancer Institute, Bethesda, MD 

Neal Benowitz, M.D .. University of California, San Francisco, CA 

Lois Biener, Ph.D., University of Massachusetts, Boston, MA 

David Burns, M.D., University of California, San Diego, CA 

Pamela Clark, Ph.D., Battelle Center for Public Health, Baltimore, MD 

Greg Connolly, D.M.D., M.P.H., Harvard School of Public Hcalth, Boston, MA 

Mirjana Djordjevic, Ph.D., National Cancer Institute, Bethesda, MD 

Thomas Eissenberg, Ph.D., Virginia Commonwealth University, Richmond, VA 

Gary Giovino, Ph.D., University at Buffalo. SUNY, Buffalo, NY 

Dorothy Hatsukami, Ph.D., University of Minnesota, Minneapolis. MN (Dialogue cochair) 

Cheryl Healton, Ph.D., American Legacy Foundation, Washington, DC 

Stephen Hecht, Ph.D., University of Minnesota, Minneapolis, MN 

Jack Henningfield, Ph.D., Pinney Associates, Bethesda. MD 

Corinne Husten, M.D., M.P.H., Partnership for Prevention. Washington, D.C. (during the 

Dialogue process, Dr. Husten was with the Centers for Disease Control and Prevention, 

Atlanta, GA) 

Kimberly Kobus, Ph.D., University of Illinois, Chicago, IL 

Scott Leischow, Ph.D., University of Arizona, Tucson, AZ 

David Levy, Ph.D., Pacific Institute for Research & Evaluation, Calverton, MD 

Stephen Marcus, Ph.D., National Cancer Institute, Rockville. MD 

Matthew Myers, J.D., Campaign for Tobacco-Free Kids, Washington, DC 

Mark Parascandola, Ph.D., National Cancer Institute, Rockville, MD 

Prabhu Ponkshe, Health Matrix Inc., McLean. V A 

Peter Shields, M.D., Georgetown University, Washington, DC 

Paul Siovic, Ph.D., Decision Research, Eugcne, OR 

David Sweanor, J.D., University of Ottawa, Ottawa, Ontario 

Kenneth Warner, Ph.D., University of Michigan, Ann Arbor, MI 

Mitchell Zeller, J.D., Pinney Associates, Bethesda, MD (Dialogue co-chair) 

*Dialogue members participated in their individual capacity. Organizational affiliations 

are provided for informational purposes only. The views expressed here arc those of the 

authors only and do not represent any official position of the National Cancer Institute or 

National Institutes of Health. 

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Tob Control 2003;12(3):317-321. 

31 
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[23] Hatsukami D, Lemmonds C, Zhang Y, et aJ. Evaluation of carcinogen exposure in 

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smoking of progressively reduced nicotine content cigarette. Cancer Epidemiol 

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tobacco use as a harm reduction strategy, Am J Public Health 2006;96(11): 1934-1939, 

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smokeless tobacco users. Am J EpidemioI2002;156(S):730-737. 

[42] Foulds J, Ramstrom L, Burke M, et al. Effect of smokeless tobacco (snus) on 

smoking and public health in Sweden. Tob Control 2003;12(4):349-359. 

[43] Furberg H, Lichtenstein P, Pedersen NL, et al. Cigarettes and oral snuff use in 

Sweden: Prevalence and transitions. Addiction (Abingdon, England) 2006;101(10): 1509-

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reduction: an epidemiological modelling study. Lancet 2007;369(9578):2010-2014. 

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Am J Prev Med2002;23(3):143-149. 

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men who switched from cigarettes to spit tobacco. Tab Cantro/2007;16(l):22-2S. 

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[48] Benowitz NL. Snuff, nicotine and cardiovascular disease: Implications for 

tobacco controL JAm Coil CardioZI999;34(6): 1791-1793. 

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and implications for treatment. Prog Cardiovasc Dis 2003;46(1 ):91-111. 

[50] Henningfield JE, Slade J. Tobacco-dependence medications: public health and 

regulatory issues. Food Drug Law J 1998;53 suppl:75-114. 

[51] Russell MA. The future of nicotine replacement. Br J Addict 1991 ;86(5):653-658. 

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[53] Ashley DL, Beeson MD, Johnson DR et aZ. Tobacco-specific nitrosamines in 

tobacco from U.S. brand and non-U.S. brand cigarettes. Nicotine Tob Res 2003;5(3):323-

331. 

[54] Hatsukami 0, Ebbert JO, Anderson A, et al. Smokeless tobacco brand switching: 

a means to reduce toxicant exposure? Drug Alcohol Depend 2007;87(2-3):217-224. 

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smoking: nicotine and addiction. A report of the Surgeon General.: U.S. Department of 

Health & Human Services 1988. 

[56] Russell MA. Low-tar medium-nicotine cigarettes: a new approach to safer 

smoking. Br Med J 1976;1(6023):1430-1433. 

[57] Connolly GN. Alpert HR, Wayne GF, et al. Trends in nicotine yield in smoke and 

its relationship with design characteristics among popular US cigarette brands, 1997-

2005. Tob ControI2007;16(5):e5. 

[58] Henningfield JE, Benowitz NL, Connolly GN, et al. Reducing tobacco addiction 

through tobacco product regulation. Tob Control 2004;13(2):132-135. 

[59] Shiffman S, Pillitteri JL, Burton SL, et al. Smoker and ex-smoker reactions to 

cigarettes claiming reduced risk. Tob ControI2004;13(l ):78-84. 

[60] Shiffman S, Jarvis MJ, Pillitteri JL, et al. UK smokers' and ex-smokers' reactions 

to cigarettes promising reduced risk. Addiction (Abingdon, England) 2007;102(1): 156-

160. 

[61] Cummings KM, Hyland A, Giovino GA, et al. Are smokers adequately informed 

about the health risks of smoking and medicinal nicotine? Nicotine Tob Res 2004;6 

SuppI3:S333-340. 

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[62) Cohen JB. Smokers' knowledge and understanding of advertised tar numbers: 

health policy implications. Am J Public Health 1996;86(1): 18-24. 

[63] Etter JF, Kozlowski L T, Perneger TV. What smokers believe about light and 

ultralight cigarettes. Prev Med 2003;36(1 ):92-98. 

[64] Kozlowski L T, Goldberg ME, Yost BA, et al. Smokers' misperceptions oflight 

and ultra-light cigarettes may keep them smoking. Am J Prev Med 1998;15( 1 ):9-16. 

[65) Shiffman S, Pillitteri JL, Burton SL. et al. Smokers' beliefs about "Light" and 

"Ultra Light" cigarettes. Tab Control 2001 ;10 Suppll:i17-23. 

[66] Hatsukami D, Giovino GA, Eissenberg T, et al. Methods to assess potential 

reduced exposure products. Nicotine Tob Res 2005;7(6):827-844. 

[67] French SA. Pricing effects on food choices. J Nutr 2003;133(3):841 S-843S. 

[68] Kozlowski LT. Harm reduction, public health, and human rights: smokers have a 

right to be informed of significant harm reduction options. Nicotine Tab Res 2002;4 

Suppl 2:S55-60. 

[69] Bansal MA, Cummings KM, Hyland A et al. Stop-smoking medications: who 

uses them, who misuses them, and who is misinformed about them? Nicotine Tob Res 

2004;6 Suppl 3:S303-31 O. 

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[70] Mooney ME, Leventhal AM, Hatsukami OK. Attitudes and knowledge about 

nicotine and nicotine replacement therapy. Nicotine Tab Res 2006;8(3):435-446. 

39 
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Appendix 1. Strategic Dialogue on Tobacco Harm Reduction Participants 

Financial Disclosure Responses* 

Cathy Backinl!er, Ph.D., M.P.H. No conflicts of interest 

Neal Benowitz, M.D. Serves as a paid consultant to several pharmaceutical 

companies that market or are developing smoking cessation 

medications. Also serves as a paid expert witness in 

litigation against tobacco companies. 

Lois Biener, Ph.D. No conflicts of interest. 

David Burns, M.D. Testified against the tobacco industry in multiple lawsuits 

Pamela Clark, Ph.D. No conflicts of intercst. 

Grel! Connolly, D.M.D., M.P.H. No conflicts of interest. 

Mirjana Djordjevic, Ph.D. No conflicts of interest. 

Thomas Eissenberg, Ph.D. Consulted with the National Association of Attorney's 

General on issues related to PREPs and PREP testing. 

Received free of charge smokeless tobacco products from 

RJ. Reynolds to test them in his laboratory. Neither RJ. 

Reynolds nor any other company has ever had any input 

into any work done in his laboratory nor have they had any 

input into any reporting of results. 

Garv Giovino, Ph.D. No con1licts of interest. 

Dorothy Hatsukami, Ph.D. Consulted for pharmaceutical companies (Pfizer. Abbott) 

that are marketing or developing smoking cessation 

medications. No honorarium received. Received research 

grant from Nabi Biopharmaceuticals for c1inicaltrial. 

Cheryl Heaiton, Ph.D. No conflicts of interest. 

Stephen Hecht, Ph.D. Served as an expert witness for the plaintiff in a case in 

which United States Smokeless Tobacco Company is being 

sued by the family ofa man who died from oral cancer after 

years of using smokeless tobacco. 

Jack Henningfield, Ph.D. Pinney Associates provides consulting services to 

GlaxoSmithKline Consumer Healthcare on issues related to 

treating tobacco dependence. lias interest in a nicotine 

delivering smoking cessation product under development. 

Corinne Husten, M.D., M.P.H. Owns pharmaceutical stock (Johnson and Johnson, Pfizer). 

Kimberly Kobus, Ph.D. No conflicts of interest. 

Scott Leischow, Ph.D. Consultant! Advisory Committee member, speaker for Pfizer 

Pharmaceutical Company; consultant for Johnson and 

Johnson 

David Levy, Ph.D. No conflicts of interest 

Stephen Marcus, Ph.D. No conflicts of interest 

Matthew Myers, J.D. No personal conflicts of interest. The Campaign for 

Tobacco-Free Kids has received donations from 

phannaclJihtical companies that make cessation products. 
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albeit those donations are a very small percentage of the 

Campaign's budaet 

Mark Parascandola, Ph.D. No conflicts of interest 

Prabhn Ponkshe No conflicts of interest 

Peter Shields, M.D. Served as expert witness in tobacco litigation. 

Paul Siovic, Ph.D. No conflicts of interest 

David Sweanor, J.D. Receives, directly or indirectly. fees from the marketers of 

smoking cessation medicines. None of this money is 

significant enough in relation to his personal financial 

resources to be considered material. 

Kenneth 'Varner, Ph.D. Chair of the Pfizer Tobacco Independence Glohal Policy 

Advisory Board. for which an honorarium is received 

(which is immediately endorsed to my School to a 

scholarship fund). 

Mitchell Zeller, J.D. Pinney Associates provides consulting services to 

GlaxoSrnithKline Consumer Healthcare on issues related to 

treating tobacco dependence. 

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QUESTIONS SUBMITTED FOR THE RECORD 

HEARING ENTITLED, 

"SMOKELESS TOBACCO: IMPACT ON THE HEALTH OF OUR NATION'S YOUTH 

AND USE IN MAJOR LEAGUE BASEBALL" 

SUBCOMMITTEE ON HEALTH 

COMMITTEE ON ENERGY AND COMMERCE 

UNITED STATES HOUSE OF REPRESENTATIVES 

APRIL 14,2010 

Terry F. Pechacek, Ph.D. 

Associate Director for Science, Office on Smoking and Health 

National Center for Chronic Disease Prevention and Health Promotion 

Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

The Hon. Edward Whitfield 

l. What evidence did the CDC rely upon to award a grant for $977,346 so smokers in the 

District of Colnmbia could receive a free blackberry? 

Funding for the Blackberry phones was not provided by the Centers for Disease Control and 

Prevention (CDC) and is not part of the Communities Putting Prevention to Work program. 

CDC's understanding is that funding for these phones came from the Schroeder Institute for 

Tobacco Research and Policy Studies, supported by the American Legacy Foundation. 

2. Have any studies been pnblisbed in a peer reviewed jonrnal demonstrating the effectiveness 

of such a program? 

CDC has not undertaken studies in this area. This is an emerging field and there is not a great deal 

of evidence available. However, the National Cancer Institute at the National Institutes of Health 

has sponsored some studies on the topic, including: 

• Obermayer JL, Riley WT. AsifO, Jean-Mary J. College smoking-cessation using cell 

phone text messaging. J Am Coli Health. 2004 Sep-Oct;53(2):71-8. 

• Vidrine DJ, Arduino RC, Gritz ER. Impact of a cell phone intervention on mediating 

mechanisms of smoking cessation in individuals living with HN I AIDS. Nicotine Tob 

Res. 2006 Dec;8 Suppll:S103-8. 

In addition, the use of reminder systems for tobacco cessation is recommended by the CDC Task 

Force on Community Preventive Services, whether used alone or as part of mUlti-component 

intervention. 
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Job Creation 

1. How many jobs has the program created? Are those jobs government or private sector 

jobs? 

Communities Putting Prevention to Work will put people to work reducing tobacco use and 

obesity by expanding opportunities for physical activity and improved access to nutritious foods 

and beverages in schools, workplaces, and other settings. 

Communities Putting Prevention to Work awards to states and communities are expected to 

create jobs in the public health and private sectors, through subcontracts to local businesses and 

nonprofit organizations in support of program goals. 

Recipients of Recovery Act awards are required to report quarterly on the number of jobs paid for 

with Recovery Act funds with a specified fonnula provided by the Office of Management and 

Budget (OMB). Recipients are required to submit quarterly reports to the Recovery 

Accountability and Transparency Board's FederalReporting.gov system, containing a direct and 

comprehensive count of jobs created and the number of jobs retained by the project or activity as 

prescribed in Section 5 ofOMB guidance M-09-21. 

2. In the proposals submitted, were grant applicants required to estimate how many jobs they 

would create? 

The Funding Opportunity Announcements (FOA) stated that recipients of the Recovery Act funds 

must comply with all requirements specified in Division A of the Recovery Act (Public Law 1 11-

5), including reporting requirements outlined in Section 1512 of the Act and designated Recovery 

Act outcome and output measures. 

Recipients are required to submit quarterly reports to FederalReporting.gov, containing a direct 

and comprehensive count of jobs created and the number of jobs retained by the project or 

activity as prescribed in Section 5 of the Office of Management and Budget (OMB) guidance M09-21. Recipients are required to use a specified fonnula provided by OMB, which is based on 

actual number of hours worked. See Section 5.3 of the OMB guidance for more information on 

calculating jobs, including job estimation examples. For the full OMB guidance, please visit: 

3. Was job creation a factor in the decision making process that selected grant award 

recipients? If yes, how big of a factor was it? 

CDC adheres to a defmed and rigorous process for selecting all grantees. Applications were 

scored by objective review panels using the evaluation and scoring criteria published in the 

Funding Opportunity Announcements (FOA). Job creation was not included in the application 

review criteria, since it was not in the published review criteria in the FOA. Per the published 

criteria, applications were scored on the extent to which the proposed plan provided a robust 

combination of interventions with broad reach, and provided evidence that the applicants' plans 

were likely to produce the long term outcomes of the Communities Putting Prevention to Work 

Program. Applications were evaluated against the following criteria: program infrastructure and 

fiscal management, leadership team and community coalitions, intervention area, community 

action plan, and intervention strategies, plan for project monitoring and evaluation, and 

programmatic support needs. 

Responses to Questions for the Record following April 14. 2010, hearing entitled, "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Basebalr' •• Terry F. Pechacek. Ph.D. Page 2 
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Applications were reviewed for responsiveness by CDC's Procurement and Grants Office (PGO) 

and the National Center for Chronic Disease Prevention and Health Promotion. 

4. Can you provide the Committee with the total number of jobs that the grant recipients 

promised to create? 

Applicants were not required to estimate the total number of jobs that will be created and/or saved 

in their application. 

Recipients of Recovery Act awards are required to report quarterly on the number of jobs paid for 

with Recovery funds with a specified formula provided by the U.S. Office of Management and 

Budget (OMB). Recipients are required to submit quarterly reports to HHS containing a direct 

and comprehensive count of jobs created and the number of jobs retained by the project or 

activity as prescribed in Section 5 of the Office of Management and Budget (OMB) guidance M09-21. 

Each funded State, Territory, and commWlity will calculate jobs based on the actual number of 

hours worked and report this to federalreporting.gov. CDC expects to have figures on jobs created 

and/or saved after the FY 2010, Quarter 3 reporting period in July 2010. Data from the FY 2010, 

Quarter 3 reporting period will be available publicly in early August 2010. 

S. What are the oversight tools HIlS (and the CDC) has in place to ensure that the grants are 

spent to create the jobs promised? 

The American Recovery and Reinvestment Act guides HHS and CDC regarding obligations to 

provide oversight for job creation. The ARRA reporting requirements provide a helpful structure 

to ensure oversight and appropriate use of federal funds. Grantees are required to comply with all 

reporting requirements specified in Division A of the Recovery Act (Public Law 111-5) 

including reporting requirements outlined in Section 1512 of the Act and designed Recovery Act 

outcome and output measures. Section 1512 requires grantees to provide an estimate ofthe 

number of jobs created and the number of jobs retained by the project or activity as specified by 

Office of Management and Budget (OMB) Guidance M-09-21 (June 22,2009). HHS and CDC 

will review this data quarterly as reported by recipients on federalreporting.gov. 

Lobbying 

1. How can the CDC both charge grant recipients with "supporting" and "implementing" 

"legislative and regulatory" policy changes while at the same time commanding them to "be 

careful to prevent CDC funds from being used to influence or promote pending 

legislation"? 

Communities Putting Prevention to Work provides states and localities with resources to create 

healthy environments for residents, such as increasing availability of healthy foods and 

beverages, improving access to safe places for physical activity, discouraging tobacco use, and 

encouraging smoke-free environments. 

Communities Putting Prevention to Work accomplishes this by supporting communities in their 

work to promote policy, systems, and environmental changes which result in sustainable 

improvements in public health. Work on policy, systems, and environmental change encompasses 

a wide range of community activities. 

Responses to Questions for the Record fonowing April ]4,2010. hearing entitled, "Smokeless Tobacco: impact on the Health of our Nation's 

Youth and Use in Major League Baseball" ~~ Terry F. Pechacek, Ph.D. Page 3. 
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Policy change includes many types of strategies that do not require legislative or regulatory 

changes. Examples of policy that do not involve changing laws include school districts choosing 

to require daily physical education for their students, local businesses implementing smoke-free 

work place policies, and cities and towns working with vendors to ensure healthy food options in 

vending machines in govemment buildings. 

Changing systems for the better is also an effective way to improve health and wellness in our 

communities. Systems are all around us court systems, systems of care, agricultural systems, 

and business organization systems. Examples of systems changes include farm to table initiatives 

such as increasing the number of farmers markets in a community or using locally grown fruits 

and vegetables in meals prepared by local schools; hospital systems supporting and encouraging 

breastfeeding for patients and employees in the hospital, at home, and in the community; and 

providing multiple links and referrals to smoking cessation services across government systems 

(e.g. at the Department of Motor Vehicles or when applying for public benefits). 

Similarly, our health and well-being is impacted by our immediate surroundings and our extended 

environment. Some communities are working with urban planners to increase the number of 

sidewalks and bike paths in a city or town to promote physical activity. Others are encouraging 

traffic calming strategies that improve safety for pedestrians and bicyclists, such as narrowing 

traffic lanes, adding bike lanes, and planting trees along the street Many communities are 

engaging with law enforcement to improve safety in public parks and increase access to safe 

places to exercise. 

2. Have grant recipients been told how important it is they do not violate federal lobbying 

restrictions? What exactly have they been told? 

• All CDC grantees including the Communities Putting Prevention to Work grantees are educated 

on all federal laws relating to funding awards including applicable anti-lobbying provisions. 

Specifically, CDC Additional Requirement (AR) 12 entitled "Lobbying Restrictions" is set forth 

in the Funding Opportunity Announcement and lays out in detail the restrictions on applicants' 

use oHmS funds for lobbying. (Funding Opportunity Announcement CDC-RFA-DP09-

012ARRA09. See specifically, SectionVI.2, Administrative and National Policy Requirements, 

Additional Requirement 12.) 

• Funded communities were explicitly reminded of the prohibition against using federal funds for 

lobbying activity on an all-hands budget call on Tuesday, February 17, 2010. 

• The Notice of Grant Awards sent to communities on March 18, 2010 again included written 

notice about the prohibition against using federal funds for lobbying activity. (See note 16 in the 

Notice of Grant Awards). 

• CDC reiterated the prohibitions against lobbying at the program kick-off meeting in April, 

including a presentation by a representative from the US. Department of Health And Human 

Services Office of General Counsel, who directed all the communities to the Additional 

Requirement 12 for additional guidance. 

Responses to Questions for the Record following April 14, 20l0, hearing entitled, "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" -- Terry F. Pechacek, Ph.D. Page 4 
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3. Are grantees expected to be able to meet the policy goals of getting legislation and 

regulations passed without lobbying? How? 

Generally. Federal law prohibits the use offederal funds to lobby a member of Congress, a 

jurisdiction, or an official of any government, to favor, adopt, or oppose any legislation, law, or 

policy whether before or after its introduction or to engage in indirect or "grass roots" lobbying. 

Anti-lobbying provisions, however, do not prevent communication designed to educate officials 

or the public regarding the science, nor do they prevent agencies from communicating to officials 

at their request or to Congress through the proper official channels. All CDC grantees are 

educated on all federal laws relating to funding awards including applicable anti-lobbying 

provisions. Specifically, CDC Additional Requirement (AR) 12 entitled "Lobbying Restrictions" 

is set forth in the Funding Opportunity Announcement and lays out in detail the restrictions on 

applicants' use ofHHS funds for lobbying. 

The prohibition against lobbying does not mean that communities are prohibited from interacting 

with policy makers such as legislators in order to promote the goals of the Communities Putting 

Prevention to Work program. There are many activities that are allowable under federal law 

which community leaders may decide to pursue. Public health organizations nationwide 

including CDC - regularly engage in these activities as part of their normal duties and 

responsibilities. 

Some examples of allowable activity include: 

• Publishing and disseminating research and public health surveillance data 

• Responding to requests from legislators for analysis of public health implications of 

potential or pending legislation 

Providing information about a specific public health issue 

• At the invitation or request of a legislator, representing the health agency before a 

legislative committee 

• Promoting public health interventions through education, coalition-building, and 

partnerships 

4. Do "education campaigns" that support specific policy goals -like soda taxes and zoning 

restrictions - violate the federal anti-lobbying policy? 

No, education campaigns that support specific policy goals do not violate the federal antilobbying policy. It is the obligation and responsibility of public health professionals to widely 

disseminate to both the public and policy makers the latest information on evidence and practicebased strategies shown to be effective in preventing disease and promoting health. For example, 

there is no question that raising the price of tobacco products is effective in reducing tobacco use 

and therefore the burden of tobacco-related disease and death. It is incumbent upon public health 

professionals to share such evidence-based information with the public and policy makers to 

improve and protect the health of communities while still complying with the lobbying 

restrictions. 

Responses to Questions for the Record following April 14, 2010, hearing entitled, "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" ~H Terry F. Pechacek, Ph.D. Page 5 
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5. What oversight mechanisms does the CDC have in place to ensure that grant monies are not 

used to lobby? 

The Communities Putting Prevention to Work program has a robust plan for perfonnance 

monitoring in order to insure that federal funds are used effectively and appropriately. The plan 

is designed to ensure CDC staff are positioned to identify early warning signs that a program is 

falling off track or using federal funds for unauthorized and inappropriate activities. 

An electronic perfonnance monitoring system provides a central repository for coHecting 

infonnation from a number of program monitoring sources: 

1) Budget Reviews and Reviews of Community Action Plans and Statelferritory Work Plans 

2) Project Officer Monitoring System that includes instructions derived from a number of 

sources including a tracking sheet of outcome objectives and key milestone activities that are 

completed quarterly by each Project Officer, including: monthly conference caHs and project 

management reports, annual site visit reports completed by Project Officers and submitted to 

the record at CDC's Procurement and Grants Office (PGO) upon return from each site visit, 

substantive correspondence providing support, and reports submitted to PGO as part of the 

record such as budgets, personnel, community action plans, etc. 

In addition to the robust perfonnance monitoring described above, PGO provides additional and 

specific budgetary oversight to ensure the appropriate use of federal funds. PGO staff will 

participate in annual site visits to all funded communities. 

6. Are grantees required to certify that they have not used any funds for advocacy and 

lobbying efforts - either direct or indirect lobbying? Will you require this? 

Grantees are required to certify that they will not use fund for lobbying at the time they apply for 

funding from CDC. The Funding Opportunity Anoouncement provided a link to the full text of 

the certification and assurances that grantees agree to when they sign the application. 

Please see the actual certification 

language below. 

"3. Certification Regarding Lobbying 

Title 31, United States Code, Section 1352, entitled "Umitation on use of appropriated 

funds to influence certain Federal contracting and financial transactions," generally 

prohibits recipients of Federal grants and cooperative agreements from using Federal 

(appropriated) funds for lobbying the Executive or legislative Branches of the Federal 

Government in connection with a SPECIFIC grant or cooperative agreement. Section 

1352 also requires that each person who requests or receives a Federal grant or 

cooperative agreement must disclose lobbying undertaken with non-Federal (nonappropriated) funds. These requirements apply to grants and cooperative agreements 

EXCEEDING $100,000 in total costs (45 CFR Part 93). 

The undersigned (authorized official signing for the applicant organization) certifies, to 

the best of his or her knowledge and belief, that: 

Responses to Questions for the Record following April 14, 2010, hearing entitled. "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Ba.~eball" - Teny F. Pechacek. Ph>D. Page 6 
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Applications 

(a) No Federal appropriated funds have been paid or will be paid, by or on 

behalf of the undersigned, to any person for influencing or attempting to 

influence an officer or employee of any agency, a Member of Congress, an 

officer or employee of any agency, a Member of Congress, an officer or 

employee of Congress, or an employee of a Member of Congress in connection 

with the awarding of any Federal contract, the making of any Federal grant, the 

making of any Federal loan, the entering into of any cooperative agreement, 

and the extension, continuation, renewal, amendment, or modification of any 

Federal contract, grant, loan, or cooperative agreement. 

(b) If any funds other than Federally appropriated funds have been paid or will 

be paid to any person for influencing or attempting to influence an officer or 

employee of any agency, a Member of Congress, an officer or employee of 

Congress, or an employee of a Member of Congress in connection with this 

Federal contract, grant, loan, or cooperative agreement, the undersigned shall 

complete and submit Standard Form- lll, "Disclosure of lobbying Activities," in 

accordance with its instructions. 

(c) The underSigned shall require that the language of this certification be 

included in the award documents for all sub-awards at all tiers (including 

subcontracts, sub-grants, and contracts under grants, loans and cooperative 

agreements) and that all sub-reCipients shall certify and disclose accordingly. 

This certification is a material represe'ntation of fact upon which reliance was placed 

when this transaction was made or entered into. Submission of this certification is a 

prerequisite for making or entering into this transaction imposed by Section 1352, U.S. 

Code. Any person who fails to file the required certification shall be subject to a civil 

penalty of not less than $10,000 and not more than $100,000 for each such failure." 

1. Please provide copies of all grant applications that were selected for awards. 

As requested, copies of the applications will be provided to Earley Green, Chief Clerk, 

Committee on Energy and Commerce. Due to the large size of the files, compact discs containing 

the funded State and community applications will be provided to Earley Green by our CDC 

Washington office. 

Please note that these are the original applications submitted by the States, Territories, and 

communities, and the funded activities may differ substantially from those outlined in the 

applications. To the extent that proposed activities violate the anti-lobbying provisions, such 

activities have not been and will not be funded by the CDC under this award. CDC is still 

providing technical assistance to some grantees to fmalize their revised work plans and to ensure 

that all activities are in compliance with Federal law. 

Responses to Questions for the Record following April 14,2010, hearing entitled, "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" - Teny F, Pechacek, Ph.D. Page 7 
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Reports Submitted to the Appropriations Committees 

1. The stimulus bill requires that the Secretary of HHS provide both the House and Senate 

Appropriations Committees with an "operating plan for the Prevention and WeUness Fund 

prior to making any Federal obligations offunds.» 

a. Was the operating plan submitted? 

Yes 

b. When was it submitted? 

On May 15, 2009, HHS submitted a preliminary operating plan consistent with the 

Recovery Act's mandate to submit required operating plans for the Prevention and 

Wellness Fund within 90 days of the law's enactment. HHS transmitted a fmal operating 

plan on September 16, 2009 

c. Would you provide a copy ofthe operating plan? 

As requested, a copy of the final operating plan is attached to this response. 

2. The bill also requires the Secretary of HHS to update the Appropriations Committees with 

a report on the actual obligations, expenditure, and unobligated balances for each activity 

not later than November 1, 2009 and every 6 months thereafter. That would mean that the 

second report is due on May 1". 

a. Was the November report submitted to the Appropriations Committees on time? 

Yes 

b. Please provide a copy of the November report. 

As requested, a copy of the November report is attached to this response. 

c. Please provide a copy ofthe upcoming May report. 

As requested, a copy of the May report is attached to this response. 

Fast Food Densitv 

1. What exactly is the CDC suggesting that states and localities do if they want to use zoning to 

reduce the density offast food establishments? 

Zoning may be a feasible strategy for reducing exposure to uuhealthy foods and improving diet 

quality based on science that indicates those who live in areas with greater exposure to fast food 

outlets near their home are 11 %-61 % more likely to eat fast food and 3%-17% less likely to have 

a healthy diet (Moore et aI AJE 2009). There is also evidence to show that those never eating fast 

food are 2-3-times more likely to have a healthy diet versus those eating fast food I or more times 

per week (Moore et al AJE 2009). 

Responses to Questions for the Record following April 14, 2010, hearing entitled, "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" - Terry F. Pechacek. Ph,D. Page 8 
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CDC suggests that states and communities considering zoning to reduce the density of fast food 

establishments use the resources listed below to aid them in their efforts. 

The Strategic Alliance has an ENACT database for local policies. Searching with the key term 

"fast food," will list the different communities that have enacted policies around fast food. 

http://eatbettermovemore.org/sa/policies/search results.php?s Search=fast+food+ 

Other Resources: 

The City Planner's Guide to the Obesity Epidemic: Zoning and Fast Food 

http://www.publichealthlaw.netiZoning%20Citv%20Planners%20Guide.pdf 

The Use of Zoning to Restrict Fast Food Outlets: A Potential Strategy to Combat Obesity, from 

The Center for Law and the Public's Health at Johns Hopkins and Georgetown Universities 

http://www.publichealthlaw.netiZoning%20Fast%20Food%200utlets.pdf 

The City of Detroit, MI, requires a minimum distance of 500 ft between specified standard, carryout, fast-food and drive-in restaurants and elementary, junior high and high schools. 

http://www.preventioninstitute.orgisa/policiesipdftextlDetroitZoning%20and%20Fast%20Food.pdf 

American Planning Association: Policy Guide on Community and Regional Food Planning. 

http://www.planning.org/policy/guides/adoptedlfood.htm (HTML version) 

http://www.planning.orglpolicy/guides/pdflfoodplanning.pdf 

"A Planners Guide to Community and Regional Food Planning: Transforming Food 

Environments, Facilitating Healthy Eating" by Sarnina Raja, Branden Born & Jessica Kozlowski 

Russell, 2003. hUp:llmyapa.planning.orgiapastoreiSearch/Default.aspx?p=3886&a=J003 . 

Planning for Healthy Places explores community planning solutions to increase access to healthy 

foods and physical activity through improvements to the built environment. 

http://www.healthyplanning.orgi 

"Access to Affordable and Nutritious Food: Measuring and Understanding Food Deserts and 

Their Consequences." United States Department of Agriculture (USDA), June 2009. 

http://www.ers.usda.gov/publications/ap/ap036/ 

The Food Environment Atlas, a web-based mapping tool developed by USDA's Economic 

Research Service, currently assembles information on over 90 indicators of the food environment, 

including number of food stores and restaurants and expenditure on fast foods. Data is available 

by county. http://ers.usda.govlFoodAtlas/about.htm 

Selected Journal Articles: 

Moore LV, Diez Roux AV, Nettleton JA, Jacobs DR, and Franco, M. Fast-Food Consumption, 

Diet Quality, and Neighborhood Exposure to Fast Food: The Multi-Ethnic Study of 

Atherosclerosis. American Journal of Epidemiology. 2009 

Responses to Questions for the Record following April 14. 2010. hearing entitled. "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball" -- Terry F. Pechacek, Ph.D. Page 9 
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Austin SB, Melley SJ, Sanchez BN, et al. (2005). Clustering of Fast Food Restaurants Around 

Schools: A Novel Application of Spatial Statistics to Study of Food Environments. American 

Journal of Public Health, 95(9):1575-1581 

Crawford D, et al. Neighborhood fast food outlets and obesity in children and adults: the CLAN 

Study. International Journal of Pediatric Obesity, 2008; 1 

Macdonald, L. Neighborhood fast food environment and area deprivation-substitution or 

concentration? Appetite 2007; 49: 251-254 

Stunn, R. Body mass index in elementary school children, metropolitan area food prices and food 

outlet density. Public Health 2005; 119: 1059-1068 

Currie, J, DellaVigna, S, Moretti E, Pathania V. The Effect of Fast Food Restaurants on Obesity. 

Food planning Digest January, 2009; 52 (20). 

http://www.econ.berkeley.edul-sdellavilwp/fastfoodJan09.pdf 

National Policy and Legal Analysis Network; Model Healthy Food Zone Ordinance, 

htlp:llwww.npJanonline.orginplaniproducts/model-healthy-food-zone-ordinance 

National Policy and Legal Analysis Network; Creating a Healthy Food Zone Around Schools, 

htlp:llwww.nplanonline.orglnplanlproducts/creating-healthy-food-zone-around-schools 

2. Under this strategy would it be appropriate for a zoning law to permit only 5 total fast food 

establishments within a 1 mile radius of any school? 

Commurtities have full discretion to detennine the extent and use of zoning as a component of 

this strategy to address access to healthy food. 

Responses to Questions for the Record following April 14. 2010. hearing entitled, "Smokeless Tobacco: Impact on the Health of our Nation's 

Youth and Use in Major League Baseball"~· Terry F. Pechacek. Ph.D. Page 

10 
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1. Purpose of Funding 

American Recovery and Reinvestment Act 

Commnnities Putting Prevention to Work 

The American Recovery and Reinvestment Act of 2009 states that "$650,000,000 shall be provided 

to carry out evidence-based clinical and community-based prevention and well ness strategies 

authorized by the Public Health Service Act, .. that deliver specific, measurable health outcomes 

that address chronic disease rates." The Department of Health and Human Services (HHS) has 

proposed a robust initiative in response to the Act. The goal of this initiative Communities 

Puttillg Prevention to Work is to reduce risk factors and prevent/delay chronic disease and 

promote wellness in both children and adults. Commullities Putting Prevention to Work will 

expand the use of evidence-based strategies and programs, mobilize local resources at the 

community-level, and strengthen the capacity of states. The initiative has a strong emphasis on 

policy and environmental change at both the state and local levels and will: (I) increase levels of 

physical activity; (2) improve nutrition; (3) decrease obesity rates; and (4) decrease smoking 

prevalence, teen smoking initiation, and exposure to second-hand smoke. Powerful models of 

success are expected to emerge to inform health refonn. 

Recipients will put the following five strategic interventions into practice (MAPPS Interventions), 

described in a community tobacco plan or obesity, physical activity and nutrition plan: 

• Use media to promote healthy foods/drinks and increase activity; restrict advertising and 

employ counter-advertising for tobacco and unhealthy foods/drinks; 

• Increase ~ to healthy food/drink choices and safe locations to be active and improve the 

built environment; reduce the availability of tobacco and unhealthy food/drinks; 

• Use of point of decision labeling/signage/placement to discourage consumption of tobacco, 

increase consumption of healthy foods/drinks, and prompt physical activity; 

• Usc price to discourage consumption of tobacco and to benefit consumption of healthy 

foods/drinks; and 

• Use social support/services to promote tobacco cessation, breastfeeding, and increased 

activity. 

2. Means of Execntion 

Community Program ($449.4 million; 69.1%) - The Centers for Disease Control and Prevention 

(CDC), will support intensive community approaches to chronic disease prevention and control in 

selected communities (urban and rural), to achieve the following prevention goals: 

• Increased levels of physical activity; 

Improved nutrition (e.g. increased fruit/vegetable consumption, reduced salt and 

transfats); 

• Decreased overweight/obesity prevalence 

Decreased smoking prevalence and decreased teen smoking initiation; and 

• Decreased exposure to secondhand smoke. 
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The five evidence-based MAPPS strategies (media, access, point of decision infonnation, price, 

and social support), when combined, can have a profound influence on improving health behaviors 

by changing community environments. Communities will implement a focused set of prescribed 

interventions, to be outlined in the funding opportunity announcement, in tobacco and/or obesity 

and related risk factors to achieve broad reach, high impact, and sustainable change. The specific 

amount of funding per community will be detennined by mix of interventions, population size, 

ability to reduce health disparities, and likelihood of success. The official local, state or tribal 

health department (or its bona fide agent, equivalent, or other fiscal intennediary as designated by 

the mayor, county executive, or other equivalent governmental official), will serve as the 

lead/fiduciary agent on behalf of an effective community-wide consOliium. Consortium partners 

could include local and state health departments and other governmental agencies, health centers, 

schools, businesses, community and faith-based organizations, academic institutions, and health 

care providers. Mental health/substance abuse organizations, health plans and other community 

pm1ners working together to promote health and prevent chronic diseases are encouraged. 

Applicants should clearly articulate how activities will be sustained after Recovery Act spending is 

complete. Applicants will also be asked to demonstrate through letters of support that they have 

political support and connections with other conmmnity development and livahility efforts, and 

that they build on and leverage existing place-based revitalization and reform projects funded by 

the US Goven11l1ent, including the OS Department of Health and Human Serviccs (HHS), and 

programs SUPPol1ed by other agencies such as the US Department of Housing and Urban 

Development, the EnvirOlU11ental Protection Agency, the OS Park Service, US Department of 

Transportation, US Department of Agriculture, the Corporation for National and Community 

Service, and the US Department of Education. Applicants will also be cncouraged to coordinate 

with other US Government-funded Recovery Act efforts in multiple sectors, such as transportation, 

education, health care delivery, agriculture and others, as well as coordinating with HI-IS Regional 

Offices. 

This component also includes a robust support plan to ensure funded communities are successful, 

and that the agencies are able to evaluate the impact of their efforts, The plan consists of a threepronged approach: 

(I) Community Programmatic Support (S27.1 Million) - intervention design, expertise, 

implementation support, and national dissemination and training. These activities will occur 

before, during, and after the program implementation period. Elements of this support will be 

embedded in communities based on community needs; 

(2) Community !Vienioring (S10.0 Million) - fund up to 10 conununities to provide mentoring to 

less experienced communities based on their previolls success in specific policy strategies; and 

(3) Evaluation (S39.5lvfillion) - through a multi-component evaluation strategy that includes 

community and statc level risk factor surveillance, case studies in funded communities and states, 

cost tracking, and modeling. Plans will focus on a small set of behavioral outcomes linked to 

chronic disease and eonununity-Ievel policy and environmental change. Program logic models will 

be developed to illustrate how the set of chosen intervcntions and the processes encompassed by 

these interventions will drive outputs which, in turn, will drive the policy/environmental and 

2 
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behavioral outcomes of interest. These models will guide decisions about what aspects of 

interventions, outputs, and outcomes to measure. Modeling will also be used to extrapolate the 

expected impact of expected proximal outcomes to make progress during the duration of the 

funding on the more distal chronic disease outcomes for which change may not be seen until later. 

Behavioral outcomes will be tracked using existing BRFSS and YRBSS tools, and the CDC 

CHANGE Tool data collected in funded communities. Applicants will be asked to participate in 

monitoring and evaluation eff0l1s within funded communities, including pre and post 

measurement. This includes the use of biometric measurements for those applicants who wish to 

improve the quality of those efforts, already in place, as they relate to collection of height and 

weight in school-age children and youth. 

National Prevention Media and National Organizations Initiative (540.0 million; 6.2%) - To 

foster ellective and hard-hitting prevention and well ness messages and advertisements, investments 

will be made by the CDC in national media to provide communities with high-quality 

communications expertise to assist in achieving measurable health outcomes. Communications 

materials will be tailored to address the unique needs of communities and will provide materials 

and templates to give the initiative a powerful brand. The communications component will draw on 

the full array of materials available across HI-IS, the Federal Government, and non-goverrunental 

organizations, ensure consistency and quality, provide support, and aggregate outreach materials so 

that they can be easily and widely accessed. National organizations will be funded as part of the 

cffort to support community outcomes. Under the direction of CDC and HHS Office of Public 

Health and Science, this nationally coordinated investment will fOCllS on community-linked 

prevention and wellness media. 

States alld Territories (5]57.3 milliol1; 24.2%) - The total initiative has three major State and 

Territory components: 

(I) Policy alld environmental change ($75 lI1illiol1j - under direction of CDC. states will 

receive funding to promote state-wide policy and environmental changes in support of the goals of 

this initiative. These policy activities, applying the five strategies, will support and institutionalize 

healthy behaviors related to nutrition, physical activity, obesity control and tobacco use. Strategies 

should be grounded in evidence. All states and territories will be eligible for a base funding amount 

determined by population, and additional competitive funds for special policy initiatives; 

(2) Tobacco cessation ($50 milliol1) undcr direction of CDC, all currently funded states and 

territOlies will be eligible to apply for and expected to receive funding to expand tobacco quit lines, 

in concert with expanded media campaigns. States and territories would receive funding based on 

the number of smokers in their jurisdiction. Additional funds will be used for national efforts to 

support surge capacity, additional quit line monitoring and quality improvement measures; and 

(3) Chronic disease se!fl71anagemenl program (CDSMP) ($32.5 Alii/ion) expands the 

Administration on Aging (AoA) and Centers for Disease Control and Prevention (CDC) 

partnership to leverage fhe public health and aging networks at the state and community level to 

deploy evidence-based prevention programs targeted at the elderly. 
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States will have the option of applying for funds, and Governors will decide through which state 

government entity the funding would now (State Units on Aging or State Health Departments). 

Regardless of which state agency is designated the lead; these projects must involve a full 

partnership between the public health and aging networks. Applicants will be asked to include 

sustainability plans in their applications for the Chronic Disease Self-Management Program. 

Outcomes will be measured and tracked using program milestones, a prc- and post survey of 

participants to measure changes in behaviors and health status, and self reported hospital use a 

prototype system will be developed and tested for using Medicare claims data to track the actual 

health care utilization of participants served through these program and comparing it with the 

claims data of comparable groups of Medicare beneficiaries who did not participate in the program. 

States will subsequently be able to use this system as part of their own quality assurance programs. 

Management and Ol'ersight ($3.25 million; 0.5%) 

A total of$3.25 million will be used for management and oversight ofthc entire Communities 

Putting Prevention to Work initiative. This amount is equal to 0.5% of the S650 million 

appropriated for the initiative: $3,087,500 for CDC and $162,500 for AoA. 

3. Method of Selection 

Activity Method of Selection 

Community Program New competitive funding opportunity announcement, 

~Community Awards new and existing contracts, and supplement to an 

~ Mentoring A wards existing funding announcement 

i 

~ Programmatic Support 

~ Evaluation 

i National Prevention Media and New and existing contracts and new funding 

i National Organizations Initiative opportunity announcement 

States and Territories Supplement to existing funding announcements and 

~ Policy and Environmental Change new and existing contracts 

~ Quitline Efforts 

~CDSM 

4. Intcnded Award Recipients 

Funds disbursed through this program will be obligated through a combination of new and existing 

cooperative agreements and contracts, as well as transfers to other operating divisions within HHS. 

Funds will be awarded in accordance with the applicable provisions of the Recovery Act, and all 

applicable HHS-specific and government-wide policies related to such actions whether the policies 

are general or specific to Recovery Act funds. 

Activity 

I

commnnity Program 

, ~Coml11unity Awards 

, ~ Mentonng Awards 

~ Programmatic Support 

~ Evaluation 

Intended Award Recipients 

Official local, state or tribal health department (or its 

bona fide agent, equivalent. or other fiscal intennediary 

as designated by the mayor, county executive, or other 

equivalent governmental official) on bchalf of an 

established community coalition: contracts; and nonprofit organizations 

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National Prevention Media and Contracts and non-profit organizations 

National Organizati~~Initiative 

States and Territories States, District of Columbia, Pueli0 Rico and Virgin 

~ Policy and Environmental Change Islands, Pacific Island Territories; contracts; National 

~ Quitline Efforts Institute of Health; Center for Medicare and Medicaid 

~CDSM Services; non-profit organizations; and Universities. 

5. Fiscal Year of Expenditure 

All funds will be obligated in fiscal year (FY) 2010. 

6. Designation of funding bv organizational structure 

Funding will be provided to the Centers for Disease Control and Prevention (CDC), the 

Administration on Aging (AoA), and the HHS Office of this Secretary (OS) for this effort. Funds 

will be provided to CDC and AoA via Intra-Departmental Delegation of Authority (!DDA) by 

HHS. 

7. Accountability Measures 

The Department of Health and Human Services Office of the Inspector General reviewed this 

spend plan and no significant problems were identified. CDC, AoA, and HI-IS OS will use the 

Recovery Act risk assessment tool to be provided by the HHS-Office of Finance to mitigate any 

risk. In accordance with currcnt practice, there will be frequent communication between grant 

recipients and program staff, including regular conference calls. Program staff will ensure site 

visits are conducted according to Recovery Act requirements, and that technical assistance is 

provided. Approved allowable and unallowable expenditures will be clearly communicated to 

grantees, according to the statutes and the Federal Acquisition Regulations (F AR). 

5 
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U.S. Department of Health and Human Services 

Centers for Disease Control and Prevention (CDC) 

Report on Actual Obligations, Expenditures, and Unobligated Balances 

American Recovery and Reinvestment Act of 2009 

Prevention and Wellness Fund 

Thomas R. Frieden, M.D., M.P.H. 
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Report on Actual Obligations, Expenditures, and Unobligated Balances 

American Recovery and Reinvestment Act of 2009 

Prevention and Wellness Fund 

Period Covering February 17,2009 to September 30, 2009 

The American Recovery and Reinvestment Act 0(2009, Pub. L. lIt-S (Feb. 17, 2009), Page 

180-181: 

"PREVENTION AND WELLNESS FUND 

(INCLUDING TRANSFER OF FUNDS) 

For necessary expenses for a "Prevention and Wellness Fund" to be administered 

through the Department of Health and Human Services, Office of the Secretary, 

$1,000,000,000: Provided, That of the amount provided in this paragraph, $300,000.000 

shall be transferred to the Centers for Disease Control and Prevention ("CDC") as an 

additional amount to carry out the immunization program ("section 317 immunization 

program") authorized by section 317(a), 0), and (k)(l) of the Public Health Service Act 

("PHS Act"): Providedfurlher, That of the amount provided in this paragraph, 

$650,000,000 shall be to carry out evidence-based clinical and community-based 

prevention and wellness strategies authorized by the PHS Act, as determined by the 

Secretary, that deliver specific, measurable health outcomes that address chronic disease 

rates: Provided further, That funds appropriated in the preceding proviso may be 

transferred to other appropriation accounts of the Department of Health and Human 

Services, as determined by the Secretary to be appropriate: Providedfurther, That of the 

amount appropriated in this paragraph, $50,000,000 shall be provided to States for an 

additional amount to carry out activities to implement healthcare associated infections 

reduction strategies: Pl'ovidedfurlher. That not more than 0.5 percent offunds made 

available in this paragraph may be used for management and oversight expenses in the 

office or division of the Department of Health and Human Services administering the 

funds: ... Providedfurther, That the Secretary shall provide to the Committees on 

Appropriations of the House of Representatives and the Senate a report on the actual 

obligations, expenditures, and unobligated balances for each activity funded under this 

heading not later than November 1,2009, and every 6 months thereafter as long as 

funding provided under this heading is available for obligation or expenditure. " 

Background 

As requested by the House and Senate Appropriations Committees, the Secretary of Health and 

Iluman Services provides semi-annual reports on the actual obligations, expenditures, and 

unobligated balances for each activity funded by the $1,000,000,000 Prevention and Well ness 

Fund. This report includes a description of the prevention and well ness fund activities as well as 

the requested financial information. This report includes information and activities from 

February 17,2009 to September 30, 2009. 
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Description of Prevention and Wellness Fund Activities 

The three activities that comprise the $1,000,000,000 Prevention and Wellness Fund activities 

are detailed below: 

Section 317 Immunization Program 

The American Recovery and Reinvestment Act (Recovery Act) appropriated to the Department 

of Health and Human Services Office of the Secretary $300 million and specified that these 

funds be transferred to the Centers for Disease Control and Prevention (CDC) for its Section 317 

Immunization program (Section 317). The Section 317 Program funds 64 immunization 

programs that include all 50 states, Washington DC, 5 urban areas, the U.S. Territories, and 

selected Pacific Island nations. 

The majority of Section 317 program funds are dedicated to routine childhood programs, with a 

small portion remaining for adolescent and adult immunization programs. Most children served 

with Section 317-funded vaccines are under-insured or their parents cannot afford the out-ofpocket costs required to fully vaccinate their children. 

The Recovery Act program funds will expand access to vaccines and vaccination services by 

making more vaccines available, increase national public awareness and knowledge about the 

benefits and risks of vaccines and vaccine-preventable diseases, and strengthcn the evidence base 

for vaccination policies and programs. 

Healthcare-Associated Infections Reduction Strategies 

The American Recovery and Reinvestment Act (Recovery Act) appropriated $50 million to the 

Department of Health and Human Services (HHS) Office of the Secretary. These funds will be 

provided to states for the execution and implementation ofhcalthcare-assoeiated infection (HAl) 

reduction strategies. They will also be used for state prevention activities and enhancing 

oversight and accreditation of ambulatory surgery centers (ASCs) at the state level. 

This program is aligned to the HHS Action Plan to Prevent Healthcare-Associated Infections, 

which represents a culmination of research, deliberation, and public comment to identify the key 

actions needed to achieve and sustain progress in protecting patients from the transmission of 

serious, and in some cases, deadly infections. For more information, visit: 

http://www.hhs.gov/ophs/initiativesihai/infection.html. 

Traditionally, state health departments have had limited activities or workforce to address HAls. 

However, in recent years more than 20 states have passed laws requiring reporting of hospitalspecific HAl data to state health departments with public disclosure of hospital infection rates. 

In 19 states thus far, the CDC's National Healthcare Safety Network (NHSN) has been identified 

as the tool for reporting and NHSN participation has grown from 300 hospitals nationally to 

approximately 2, I 00 hospitals in two and a half years. This program will provide state health 

dcpartments with the necessary workforce, training, and tools to rapidly scale up to meet this 

new effort to prevent HAls, support the dissemination of HHS evidence-based practices within 

hospitals, support targeted efforts to monitor and investigate the changing epidemiology ofHAls 

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in populations as a result of new prevention collaboratives, and address overall HHS HAl 

prevention priorities. 

This program will provide funds for improvement of State Survey Agency (SA) inspection 

capability of ASCs nationwide and also enable SAs to identify and correct infection control 

deficiencies in these centers. 

Evidence-based Clinical and Community-Based Prevention and Wellness Strategies 

The American Recovery and Reinvestment Act of2009 states that "$650M shall be provided to 

carry out evidence-based clinical and community-based prevention and wellness strategies 

authorized by the Public Health Service Act that deliver specific, measurable health outcomes 

that address chronic disease rates." HHS has proposed a robust initiative in response to the 

Recovery Act. The goal of this initiative - Communities Putting Prevention to Work - is to 

reduce risk factors and prevent and/or delay chronic disease and promote well ness in both 

children and adults. Communities Putting Prevention to Work will expand the use of evidencebased strategies and programs, mobilize local resources at the community-level, and strengthen 

the capacity of states. The initiative has a strong emphasis on policy and environmental change at 

both the state and local levels and will; 

(I) increase levels of physical activity; 

(2) improve nutrition; 

(3) decrease obesity rates; and 

(4) decrease smoking prevalence, tecn smoking initiation, and exposure to second-hand smoke. 

Community and StateITerritory Recipients will put the following five strategic interventions into 

practicc, or MAPPS Interventions, described in a community tobacco plan or obesity, physical 

activity and nutrition plan: 

• Use Media to promote healthy foods/drinks and increase activity; restrict advertising and 

employ counter-advertising for tobacco and unhealthy foodsfdrinks 

• Increase ~ to healthy food/drink choices and safe locations to be active and improve the 

built environment; reduce the availability of tobacco and unhealthy food/drinks; 

• Use of Point of decision labeling/signagefplacement to discourage consumption of tobacco, 

increase consumption of healthy foods/drinks, and prompt physical activity. 

• Use f!!£! to discourage consumption of tobacco and to benefit consumption of healthy 

foods/drinks. 

• Use Social support/services to promote tobacco cessation, breastfeeding, and increased 

activity. 

Actual Obligations, Expenditures, and Unobligated Balances 

The table below shows the total appropriation, as well as obligations, unobligated balances and 

outlays for these funds through September 30,2009, the end of Fiscal Year 2009. Note that 

expenditures are defined as Federal outlays in the table below. 
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Table: FY 2009 Recovery Aet Prevention and Wellness Fund Appropriation: Obligations 

and Outlays, As of September 30, 20091 

Unobligated 

Program Amount Appropriated Obligations Balance Outlays 

Section 317 

Immunization Program $}OO,OOO,OOO $154,458,870 $145,541,130 $30,334,585 

Healtilcare Associated 

Infections Reduction 

Strategies SSO,OOO,OOO $4Q,621 ,083 $9,378,917 $142,861 

Evidence-based Clinical 

and Community-Based 

Prevention and Well ness 

Strategies $650,000,000 SO S650,000,000 SO 

Total Management and 

Oversight (non-add) $5,000,000 $305,736 $4,694,264 $246,767 

Prevention and 

Well ness Fund Total $1,000,000,000 $195,079,953 $804,920,047 $30,477,445 

I U.S. Department of Heallh and Human Services Unified Financial Management System validated against the 

Office of Management and Budget SF 133 and U.S. Treasury report. 
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DEPARTMENT OF HEALTH IlL HUMAN SERVICES Public Health Service 

May 20, 2010 

The Honorable Henry A. Waxman 

Chainnan, Subcommittee on Health 

Committee on Energy and Commerce 

House of Representatives 

Washington, D.C. 20515 

Dear Mr. Waxman: 

National Institutes of Health 

Sethe.da, Maryland 20892 

Thank you for the opportunity to testify at the April 14, 2010 hearing entitled "Smokeless 

Tobacco: Impact on the Health of our Nation's Youth and Use in Major League 

Baseball" before the Committee on Energy and Commerce Subcommittee on Health. 

I appreciate your interest in the health consequences of smokeless tobacco and the impact 

that media and celebrities' health behaviors have on tobacco use among youth. The 

enclosed responses to your questions for the record provide additional information on the 

health implications of smokeless tobacco and NCr s efforts in the area of tobacco 

cessation. 

Thank you again for your interest and support of cancer research at the NCI. Please do 

not hesitate to contact me for additional information. 

Enclosure 

Sincerely, 

Deborah M. Winn, Ph.D. 

Deputy Director, Division of Cancer Control 

and Population Sciences 

National Cancer Institute 
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Questions for the Record 

Hearing on Smokeless Tohacco 

April 14, 2010 

Energy and Commerce Committee Subcommittee on Health 

We have heard reports that in Sweden more people are giving up cigarettes and 

using smokeless tohacco, and that the rate of lung cancer has gone down. What 

about using smokeless tobacco as a way to help smokers quit cigarettes? 

The Swedish data on tobacco use do not support the conclusion that smokeless tobacco 

aids people in quitting smoking cigarettes or that use of smokeless tobacco has 

contributed to the decline in lung cancer in Sweden. Sweden has the lowest male 

smoking prevalence of any European country (14% of adult men are daily smokers)1 and, 

not surprisingly, the lowest level of tobacco-related mortality (about half that of the 

European Union overall).2 However, a significant portion of men (19%) report using oral 

smokeless tobacco, typically in the form of snus, a moist oral tobacco product.3 

Advocates of snus maintain that the experience of Sweden demonstrates that snus has 

served as an effective harm reducing substitute for cigarette smoking in the Swedish 

population. They argue that the lower smoking prevalence in Sweden, and thus the lower 

disease rates, can be attributed to the availability of snus and its use in place of cigarettes. 

Moreover, some advocates claim that snus has acted as an aid to smoking cessation by 

providing Swedish smokers with an acceptable alternative nicotine delivery product. 

However, observing that a downswing in the trends for one behavior (e.g., smoking 

prevalence) occurred during the same period of time that an upswing occurred in another 

(e.g., smokeless tobacco) does not imply that one caused the other. Rather, it is likely that 

many factors played a crucial role in reducing the prevalence of cigarette smoking in 

Sweden since the 1950s. Cigarette smoking gained popularity relatively late in Sweden, 

and the smoking prevalence there never reached the levels of some other European 

countries. In the early 196Os, Sweden was one of the nrst countries to fund an organized 

tobacco control effort, including the development of cessation clinics and anti-smoking 

education programs, and the popUlation also had early access to some nicotine 

replacement therapies.4 Changes in popular culture also likely had an impact on smoking 

behavior and national smoking trends, as popular portrayals of smoking shifted from 

acceptance to rejection.5 Importantly, similar dramatic reductions in smoking prevalence 

were seen in Swedish women, despite the fact that only 4% of Swedish women use 

smokeless tobacc03

. Additionally, the pattern of decreasing smoking rates with 

increasing use of smokeless tobacco has not been seen in Norway, where smokeless 

tobacco use has increased, but cigarette smoking prevalence has remained constant over 

time. 

Furthermore, there is a serious risk to promoting smokeless tobacco as a substitute for 

cigarettes, because smokeless tobacco is often a gateway to cigarette smoking among 
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adolescents. Two studies from the United States illustrate this point. In one study6, 

adolescent boys who used smokeless tobacco (and no other tobacco product) were more 

than 3 times more likely to be cigarette smokers four years later, compared to boys who 

used no tobacco products. In the other U.S. study?, boys in the 7th to 9th grade who were 

smokeless tobacco users (with no other tobacco use) were compared to boys who had 

never used tobacco. After two years, 58% of the boys using smokeless tobacco at the 

start of the study were cigarette smokers. and the majority were also using smokeless 

tobacco - i.e., they were dual users. In contrast, among boys who did not use smokeless 

tobacco initially, only 34% had become cigarette smokers two years later. 

What is meant by the term "harm reduction" within the tobacco context? 

Harm reduction is generally defined as a program or policy designed to reduce the harms 

related to an exposure or behavior without requiring complete cessation of the exposure 

or behavior. Harm reduction strategies include promoting condom use to prevent 

sexually transmitted diseases, methadone programs for heroin addicts, needle exchange 

programs for illicit drug users to prevent transmission of HIV and other infections, and 

use of seatbelts to reduce injuries from auto accidents. While harm reduction approaches 

are not incompatible with abstinence, they are generally contrasted with programs 

primarily aimed at prevention or cessation of drug use. 

Potential approaches to tobacco harm reduction that have been suggested include 

modification of cigarettes to reduce emissions of toxicants, counseling smokers to switch 

to non-combustible tobacco products (smokeless tobacco), and long term use of 

therapeutic nicotine (normally used only for limited periods as part of a cessation 

program) to replace nicotine obtained from cigarettes. Therapeutic (or medicinal) 

nicotine is commonly referred to as nicotine replacement therapy. While none of these 

strategies have been proven effective in practice, they vary substantially in the amount of 

evidence supporting them and the potential risks they pose. 

In NCI's view, a tobacco product would be "harm reducing" if it actually reduced disease 

and death for both individuals and the population as a whole. This is an important 

distinction because even if a tobacco product is shown to reduce an individual's disease 

risk, the availability of products that claim to reduce harm may have harmful 

consequences at the population level - causing a greater burden of disease in the 

population. Examples of potential harmful consequences are: (1) smokers who might 

otherwise have quit smoking may see products that claim to reduce harm as a viable 

alternative to quitting; (2) smokers who have quit will return to using tobacco because 

they think it is safe or safer to do so; (3) youth or adults who otherwise might not have 

initiated tobacco use will do so because of perceived safety of the products; and (4) 

smokers who attempt to use smokeless tobacco as means to reduce or stop smoking may 

instead flnd themselves using both products. 

There are many important differences between tobacco harm reduction and harm 

reduction around other public health issues. In particular, tobacco harm reduction is 

2 
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complicated by the involvement of a multi-national industry that aggressively promotes 

its products and has a well-documented history of misleading consumers regarding the 

health effects of its products. Any tobacco harm reduction efforts must take in to account 

potential tobacco industry responses, and how these responses could negatively impact 

the public'S health. 

NCI continues to emphasize that (1) all tobacco products are hazardous, (2) there is no 

safe level of tobacco use, and (3) the only proven way to reduce the enormous burden of 

disease and death due to tobacco use is to prevent youth from starting to smoke, and to 

help current smokers to quit. Smokeless tobacco use causes cancer, and other negative 

health effects; NCI does not support the use of smokeless tobacco as a harm reduction 

strategy. 

Do the limitations of current tobacco cessation strategies justify placing greater 

emphasis on tobacco harm reduction? 

The vast majority of smokers want to quit, and more than half of all Americans who have 

ever smoked have succeeded in quitting. Data collected by the U.S. Centers for Disease 

Control and Prevention indicates that 70% of smokers say they want to quit and 41 % had 

made a quit attempt in the previous year.8 Quitting smoking can be extremely 

challenging, and only a little more than two percent of smokers successfully quit each 

year.9Tobacco dependence is best viewed as a chronic disease, with periods ofremission 

and relapse, requiring multiple attempts to achieve long term cessation. 

However, individual smokers' cessation efforts can be made more effective. While less 

intensive interventions, such as brief physician advice to quit smoking, produce cessation 

rates of 5 to 10 percent per year, more intensive interventions that combine behavioral 

counseling with pharmacological treatment of nicotine addiction, can produce cessation 

rates of 20 to 25 percent per year. 10 Moreover, through a combination of anti-tobacco 

marketing, public education, treatment programs, and policy measures, some countries 

and U.S. states have achieved low smoking rates. For example, in 2006, the prevalence 

of cigarette smoking in California was 14.9%.11 This low prevalence is widely attributed 

to the state's exemplary comprehensive tobacco control program, which has been in place 

for more than 20 years. 

There is no "magic bullet" for smoking cessation; but most smokers want to quit, and 

there are effective treatments for tobacco dependence. Therefore, it is crucial to ensure 

that smokers who want to quit are better informed about and have better access to 

treatments that can actually help them. Currently, no harm reduction interventions have 

been proven to be effective. Rather than suggesting that smokers use unproven harm 

reduction strategies, we should focus on enhancing knowledge of and access to effective 

treatments and promoting the development of new, more effective interventions. 
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Some have suggested that declining to endorse smokeless tobacco as a tool of harm 

reduction without scientific data on its population-wide impact is eqnivalent to 

advocating a "quit or die" or "just say no" policy. Do you believe that is an accurate 

cbaracterization of tbat perspective? Is that perspective tbe equivalent to ignoring 

smokers' individual rights for information or their access to interventions that are 

proven to reduce risk? 

No. Evidence based non-tobacco treatments are already available to help smokers quit 

and to treat tobacco dependence. At the same time, evidence is lacking to support the 

effectiveness of any smokeless tobacco product as part of a harm reduction strategy. As 

with any medical or public health intervention, rigorous evaluation and proven efficacy is 

required before implementation as a strategy. Similar to pharmaceutical therapies to treat 

nicotine addiction, harm reduction strategies must be evaluated based on science. 

Research is underway to measure and understand how purported harm reduction 

strategies may affect health and tobacco use behaviors. Unless smokeless tobacco is 

found through rigorous research studies to effectively reduce harm, it is inappropriate to 

promote smokeless tobacco use as a harm reduction strategy. 12 

What factors contribute to the harm of a particular tobacco product? What is 

meant by the "continuum of risk" of tobacco products? 

Tobacco products present a continuum of risk, with combusted (burned) tobacco products 

dramatically increasing susceptibility to a very wide range of health effects, both from 

their direct use, and from their indirect use (exposure to secondhand smoke). Smokeless 

tobacco is a cause of oral and pharyngeal, esophageal, and pancreatic cancer; !3 and may 

also increase the risk of heart disease and strokel4 and reproductive problems. 15 

Compared with tobacco products, pharmaceutical products that deliver nicotine (patch, 

gum, etc.) have a low risk of health consequences because they deliver only nicotine and 

none of the many other hazardous constituents found in tobacco products. 

Many factors contribute to the harm caused by a particular tobacco product. One 

important factor is the inherent risks of the tobacco product itself. Other key factors are 

tobacco industry marketing for the product and the patterns of product use; importantly, 

these are interrelated. For example, current marketing for smokeless tobacco products 

often encourages smokeless tobacco use in places where cigarette smoking is prohibited. 

Laws that prohibit smoking in workplaces and public places have been shown to decrease 

cigarette consumption and promote smoking cessation. Marketing smokeless tobacco as 

a way to circumvent smoking bans is highly likely to promote dual use of cigarettes and 

smokeless tobacco, and to deter or delay smoking cessation. The effect of such 

marketing would be that smokeless tobacco use would result in net harm to the individual 

and the population as a whole. Finally, harm is influenced by the number of people who 

use a particular product. with those products used by large numbers of people responsible 

for greater harm at the population level than those used by small numbers of people. 
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References 

1. Reduced Use of Tobacco - How Far Have We Come? Part of Sweden's Public 

Health Objective no. 11. Statistics, December 2004. National Institute of Public 

Health, Sweden. Available at: www.fhl.se (Accessed July 30,2005) 

2. Peto R, Boreham J, Thun M. Mortality from Smoking in Developed 

Countries, 1950-2000. (2ndedition: updated June2(06). Oxford 

3. http://www.fhi.se!Documents/ AktuelltIN yheterISNIPH%20response%20to%20sn 

uff.pdf. Accessed May 17,2010. 

4. Mitchell K, Wellings K. Improving health status in Europe: a case study approach 

to the identification of best practice. Best practice in smoking: the Swedish Case 

Study. London School of Hygiene and Tropical Medicine. September 1998. 

5. ToreH U. Den rokande manniskan: bilden av tobaksbruk i Sverige meHan 1950-

och 1990-tal. Stockholm, Sweden: Carlsson bokforlag, 2002. 

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U.S. experience. Nicotine Tob Res. 2003 Aug5(4):561-9. 

7. Severson HH, Forrester KK, Biglan A. Use of smokeless tobacco is a risk factor 

for cigarette smoking. Nicotine Tob Res. 2007 Dec;9(12):1331-7. 

8. Cigarette smoking among adults - United States, 2000. MMWR 2002;51 :642-

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9. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Georgia: U.S. 

Department of Health and Human Services, Centers for Disease Control and 

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10. Treating Tobacco Use and Dependence: A Clinical Practice Guideline. U.S. 

Department of Health and Human Services, June 2000. 

11. MMWR. State-Specific Prevalence of Cigarette Smoking Among Adults and 

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12. Tomar S, Fox B, Severson H. Is smokeless tobacco use an appropriate public 

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13. Secretan B, Straif K. Baan R, Grosse Y, EI Ghissassi F, Bouvard V, BenbrahimTallaa L, Guha N, Freeman C. Galichet L, Cogliano V; WHO International 

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Agency for Research on Cancer Monograph Working Group. Review of human 

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Lancet Oncol. 2009 Nov;1O(1l):1033-4. 

14. Boffetta P, Straif K. Use of smokeless tobacco and risk of myocardial infarction 

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Bemert JT, Tita AT, Winn OM, Ojordjevic MV, Lambe M, Starnilio 0, Chipato 

T, Tolosa JE. Non-cigarette tobacco use among women and adverse pregnancy 

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o