Hhs Tobacco Strategy Announcement

>> Well, good morning, everybody. I want to start by thanking Ppresident Knapp and Dean Goldman for inviting us here today to George Washington, and so pleased to be joined by two of our departments, great health leaders. My Assistant Secretary of Health Dr. Howard Koh, and our FDA commissioner Dr. Peggy Hamburg to announce some new steps we're taking in the fight against tobacco use. For years, we watched tobacco rates fall in the country, and in 1965 we were at a situation where over 42 percent of Americans smoked. By 2004, the good news is it had fallen to just under 21 percent, a fairly significant drop. The bad news is that in recent years, despite the well-known health risks, utilize and adults smoking rates have been flat. They've been dropping for decades, and they've stalled at about 20 percent. Every day in America about 4,000 kids under the age of 18 try their first cigarette. And about 1,000 of those young Americans become life-time smokers. We have just under 450,000 Americans who die every year prematurely from smoking and second-hand smoke exposure. Making it our country's leading cause of preventable death. It also costs the health care system almost $100 billion a year, so we lose lives, we lose money, and we're not making any progress. So when this administration took office we decided that these numbers weren't changing, so our actions had to change. Over the last two years, we've accelerated our efforts to reduce tobacco use, taking a really coordinated approach that uses the many tools available to help tobacco users stop, and keep others from starting. The first step was historic legislation enacted last June. For the first time ever, the law gave the Food and Drug Administration the power to regulate tobacco products. The law includes a number of vital provisions, but some of the most important prohibit marketing practices aimed at children. Tobacco companies have actually been pretty clever at finding ways to market their products to youth. Giving out free samples, and advertising in youth oriented magazines, sponsoring various productions that are aimed at younger Americans. So under the new tobacco control law, we're bringing those practices to an end. We've banned misleading terms like "light" and "low" and "mild" from the use of tobacco products and from marketing. Secondly, as part of the Recovery Act that the President signed into law in we're funding some of the most promising state and local programs around the country for reducing tobacco use. Altogether, we're investing about $225 million in programs like the one in ringle county[11], Iowa, where they're using evidence based tobacco control interventions to decrease tobacco use in low-income, rural populations. And eventually these communities and places around the country for what really works, and we'll use them to promote best practices in the rest of the country. The third step was part of the affording care act, which produces a new opportunity to transform how our nation addresses tobacco use through a new $15 billion prevention and public health fund. The law is also giving Americans in private and public health plans access to recommended preventive care, like tobacco use cessation at no additional cost. And for the first time, Medicare is actually going to cover tobacco cessation for all beneficiaries. Now, previously Medicare beneficiaries actually had to demonstrate that they had lung disease in order to actually be provided with the benefit of tobacco cessation efforts. We think it maybe is smarter to help people stop before they present with disease, so that is now a part of the Medicare beneficiary package. So using this approach, we're using many tools at our disposal from the regulatory power to state and local investments to leading through examples of our government health insurance programs. And today we're very excited to announce some new initiatives that help bring us all the strategies together and achieve our tobacco control goals. We're unveiling the department's first ever comprehensive tobacco control strategic action plan, entitled "ending the tobacco epidemic." And you'll hear more about it in a few minutes from our wonderful secretary for health, Dr. Howard Koh." The plan lays out strategic actions based on science and real -world experience that serve as a road map for reaching our healthy people target of reducing adult smoking to 12 percent by 2020. This follows the administration's goals of coordinated and committed response to tobacco control. And to that end, along with Dr. Koh, we're going to hear from our FDA commissioner, Dr. Peggy Hamburg. Today, the FDA is announcing a proposed rule that will drastically change the look and message on a pack of cigarettes. The new graphic warning labels will the old warning phase with a picture showing the negative health consequences of smoking. Now, you're going to see some Dr. Hamburg, but I'll let you know that this rule becomes final, we want to make sure that every person who picks up a pack of cigarettes is going to know exactly what the risk is that they're taking. Because of the progress we've made in the last two years, and the strategic action plan we're unveiling today, I'm here today with a renewed sense of hope and momentum. Going forward, our department has charted a clear path to ending tobacco use in our country. And we've got a long way to go, but we won't rest until we've eliminated tobacco- related disease and suffering. The prosperity and health of our country depends on it. So now I'd like to turn over the microphone to the assistant secretary of health, who has been a terrific leader throughout HHS to coordinate our efforts on tobacco control. Dr. Howard Koh. (Applause.) >> Dr. Koh: Thank you so much, mad am secretary, for your leadership on so many fronts and it's really a great honor to be here today. We are truly at an unprecedented time in our nation's public health history. While our country has made great progress in reducing tobacco dependence, this devastating challenge remains far from solved. Tobacco use remains the leading cause of premature and preventable death in our society. Worldwide, the tobacco epidemic is projected to kill 1 billion people. 1 billion people. In the 21st century. In the United States, as you heard from the secretary, smoking causes almost half a million deaths a year. Over 1,000 people a day. Over 8 million in the United States suffer from chronic illness related to smoking. And lung cancer should be an uncommon disease in this country, but instead, fueled by the tobacco epidemic, lung cancer is tragically the nation's leading cause of cancer death among men and women. This is all preventable. For too long, the nation has had to suffer preventable suffering caused by this epidemic. For too long the nation has been forced to tolerate the intolerable, and accept the unacceptable. We have the evidence and the science to end the tobacco epidemic. We know what works. We know that the more states spend on comprehensive tobacco control programs and the longer they invest, the larger the impact. We know that most smokers want to quit, and that cessation programs can help. We know that aggressive media campaigns prevent initiation, improve cessation, and change the social norm. We know that comprehensive smoke-free policies reduce exposure to second-hand smoke, and improve health, reducing heart attacks and improving lung health. And we know that every 10 percent increase in tobacco price, decreases consumption by about 4 percent. And this can have an even greater effect among youth, low income, and other price-sensitive populations. But it will take more than knowledge to end the tobacco epidemic, it will take renewed commitment from every sector of society to move us toward a vision of a nation free from tobacco-related suffering and illness. So in this context, early in her tenure, the secretary identified tobacco control as one of her strategic priorities, and charged the department with creating a plan for moving forward. It has been a great privilege, as assistant secretary for health to chair the working group that created the plan, and I want to take this opportunity today to recognize the substantial and un precedented commitment of public health experts from across the department who stepped forward to help create this framework. I am very pleased that this document represents the first ever comprehensive strategic action plan for tobacco control for the department. It will align our efforts both internally and also externally with partners from around the country to achieve our healthy people objective of reducing the adult smoking rate, currently around 20 percent, to 12 percent by 2020. There are four pillars to this plan. The first pillar is to engage the public to change social norms around tobacco use. This action is sorely needed because the major U.S. cigarette manufacturers spend approximately $12.5 billion a year, or more than $34 million every day, to attract new users, retain current users, increase consumption, and in general, generate favorable attitudes towards smoking and tobacco use. To counter this, the department has already begun investing in media efforts to support state and local tobacco control, and these efforts will lay the ground work for future mass media campaigns. In addition, the FDA has started to conduct public education efforts to discourage public perceptions that any tobacco products are safe, and you'll be hearing more about such efforts from commissioner Hamburg in just a couple of minutes. The second pillar is improve the milk's health by Supreme Courting communities, in evidence based tobacco control in the past 18 months, through the Recovery Act, and the affordable care act funding, the department has invested more than $250 million to support proven tobacco control activities in states and communities. These funds are essential when states have had to make severe cut backs to their programs, given the current The goal is to expand comprehensive cessation services in states to make it as easy to quit as it is to buy a pack of cigarettes. Most smokers want to quit, and can call 1 -800-quit- now to get the assistance they need and deserve. Another goal is to ensure protection from secondhand smoke for Americans in collaboration with state and community efforts, and in that regard, we recognize the people of South Dakota for overwhelmingly improving a comprehensive state-wide smoke-free law which takes effect today. The third pillar, is for the department to lead by example, and leverage every possible resource. One example, as noted already by the secretary, was to have Medicare expand smoking cessation coverage to users of tobacco, and not just those with disease. And we look forward to other prevention announcements by the centers for Medicare and Medicaid services going forward. In addition, the department will work toward reducing tobacco-related for high- risk populations and locations such as community health centers, rural health facilities, public housing, and other settings. And the fourth and final pillar is to advance knowledge and accelerate research to expand the science base, and this is especially critical, given the FDA's new authority to regulate tobacco. The department looks forward to working with partners around the country to make this vision come alive. And we are also very grateful for the tremendous opportunities for prevention and public health that are in the affordable care act. We are committed to reinvigorating national momentum toward tobacco prevention and control, and move us toward a healthier society. Together, we can achieve a vision of a society free from preventable tobacco related suffering. Thank you very much. (Applause.) And now it's my great honor to welcome my very good friend and colleague, the FDA commissioner Dr. Peggy Hamburg. (Applause.) >> Dr. Hamburg: Thank you. Thank you very much, Howard, and it's really a pleasure to be here. Thank you, Washington university for welcoming us here, and thank you, mad am secretary and Dr. Koh for your extraordinary leadership on this important public health issue. As secretary Sebelius and Dr. Koh have already so eloquently pointed out, the strategic plan has one overoftening [12]objective to make the suffering of disease from tobacco use part of America's past not part of America's future. That's why Congress passed and President Obama signed the family smoke prevention and control act and why FDA has been working so hard to implement it.) Many of you are familiar with some of the actions we've taken to date, and the secretary mentioned some of the important ones, we banned candy and fruit- flavored cigarettes. We prohibited cigarette labels with misleading terms, like light, low, and mild. We're requiring the tobacco industry to provide us with lists of product ingredients. And this past summer, FDA issued a number of restrictions to limit both the access and marketing of cigarettes and smokeless tobacco products to young people. It has been a very busy first year. Today, we're pleased to announce a new historic initiative, consistent with FDA's mandate under the tobacco control act, we're proposing a series of new health warnings to appear on both cigarette packages and in cigarette advertising. The warnings, which you're now seeing, are examples of the kind that will replace those that are now printed on the narrow sides of cigarette packages. These warnings have in fact not been changed for 25 years. The new warnings will be much large exper more[13] prominently placed on the packs. And they'll contain graphic images as you're now seeing. We believe that they will be much more effective. Under FDA's proposal and as required in the law, health warnings will cover 50 percent of the front and back panels of every pack of cigarettes . For advertising, these warnings will occupy 20 percent of the top part of the ad. But it's not only the size and position of the warnings that will be a change. So will the messages be changed. For the first time ever, they will say that tobacco products are addictive. And they will say, in the bluntest of terms that tobacco can kill. And FDA's proposal will also require the use of graphic images that depict the negative consequences of smoking. Obviously, some of the images are very powerful. That, after all, is the point. We need to make sure that anyone who is considering smoking fully appreciates the consequences of cigarette use. That means presenting the facts directly and bluntly. Our objective is to raise public awareness of the profound health risks of smoking; encourage current smokers to quit; and discourage young people from ever starting. That's our goal, and what these health warnings will help achieve. FDA is currently considering 36 different images that will be coupled with 9 different warning statements. The images vary in style and design, as you can see. Some are illustrations, while others are graphic. The type sizes, styles and layouts vary. They're designed to elicit responses from the diverse range of audiences that the warnings are meant to target, including youth, young adults, and adult smokers, and potential smokers. Our plan is to identify the combination of statements and images that best resonate with Americans from all walks of life. They'll be available for the public, including all of you, to view and comment on through the federal register and on the FDA's website at at FDA.gov/ cigarette warnings and if you go to the wept website you'll find a wealth of information about this initiative as well. FDA is also conducting a study to assess the relative effectiveness of these images. This study will evaluate all of published today with the proposed rule. That research, as well as the public comments that FDA receives on the proposed rule, will help us select the 9 graphic images that will be used, one to a company, each of the required health warning statements. And this is what will appear on cigarette packages and in advertising. The final rule with these 9 images will be published in June of next year, and tobacco companies will then have until September, 2012, to begin displaying them on cigarette packs, and in their ads. Once that happens, every single pack of cigarettes in our country will in effect be a mini-billboard that tells the truth about smoking. We're convincing that not only will these warnings help discourage non-smokers, particularly kids, from ever trying cigarettes, but they'll also help strengthen the resolve of current smokers who want to break the habit. FDA's proposal is consistent with the approach embraced by Canada, Australia, and the European Union, among other countries, and supported by every major health organization, including the world health organization itself. And as you've heard this morning, our to educate consumers about the dangers of tobacco use will be executed on many different fronts. But underlying all of our efforts is the understanding that the best single strategy to reduce smoking among adults is to prevent kids from ever starting in the first place. When the new labels take effect in September, 2012, Secretary Sebelius and I believe these warnings will help discourage nonsmokers, particularly kids, from ever trying cigarettes. They will also help strengthen the ability and commitment of current smokers who are trying to quit. And both are terribly important to our nation's efforts to stop this devastating epidemic. We want to make sure that people get the real message about smoking whenever they see an ad for cigarettes, or pick up a pack of cigarettes. And that is exactly what these health warnings will do. At FDA, we're proud to be able to provide tools like graphic pack warnings that will support the efforts of millions of Americans working for healthier future. And let me close by recognizing that there a long way to go to reduce the enormous burden of death and disability caused by tobacco products. But we can make progress. Progress that will be marked by many steps taken by many people across the country. Doctors, nurses, community leaders, teachers, students, and parents. Many of you in this room have been leaders in this effort over many, many years. Thank you for your important work in this area, and thank you for the support that you've given to FDA and to HHS, as we pursue our important activities in this area. To for once and for all really stop the epidemic of tobacco use in this country. And to help, also, affect tobacco use around the world. There is a lot to be done. I think this day's announcements represent an important step forward, and we really are excited by the opportunity that it represents for public health in our nation. Thank you, and I think we'll do question and answers now. (Applause.) >> Thanks so much, Dr. Hamburg. So we're now going to open for questions for the secretary or the commissioner or myself. >> Professor John van saf on [14]smoking and health since we know restricting smoking banning smoking is the most effective way to get people to quit, I'd like to ask the secretary whether the department institution that gets grants, anyplace where you hold conferences or anything elsewhere you have some contact, would have qualify for grants and support. That I think would be at least as effective as everything you presented this morning, with all due respect. >> Dr. Hamburg: Well, I certainly appreciate the idea. I don't know that that has been a discussion, certainly the buildings that we have leased or have our workers in are smoke-free. The facilities where we engage in dialogue are smoke-free. We are working closely with states around the country, I was really pleased that last year, after years of effort, my home state of Kansas passed a very comprehensive smoke-free law that will be incredibly effective. So I think we're working in that direction, and I think that's an idea that we'll take back and continue to >> Good morning, I'm Linda Bayly with the North American quit line consortium and really want to congratulate you on a really plan that I think will make a lot of difference in this country. I especially want to thank you, Dr. Koh for your words people to quick, as to pick up a pack of cigarettes. And to that end, just wanted to ask, in putting together the warning labels, I know my organization and many others in this room have asked 1-800 quit now be put on the warning label. We think it's one of the things that will make it easier for smokers to quit, not only to have a graphic picture of the harm done by tobacco but the way to get services to quit, and we're wondering why that wasn't >> Well, I think that's probably a question to me. And that, of course, is a very important question to raise. The 1-800 line was not part of the legislation, wasn't one of the requirements that would be in the graphic warnings, but it is very much under consideration, and as we collect comments on the notice of proposed rule making. we hope that people like yourself and others will give us important input on the value and role that such an addition to the warning label might have. Because those decisions are still under consideration. >> And I can add that in looking at the international experience, countries that combine these graphic health warnings with resources for smokers to access, such as a phone number or a website, show more efficacy in reaching smokers and helping them make a decision to quit. So that's a discussion, as the commissioner pointed out will be taken under consideration in this public comment period. >> Hi I'm Emily Walker, doctor I'd like you to ask what's the discussion with electronic cigarettes right now and if there's in my opinion thing that might move people to try electronic cigarettes instead. >> You know electronic cigarettes is a really different activity and we're here today to discuss the graphic warning. are an area of public health concern. We have been examining very carefully -- and of course there's also been some litigation around the future of electronic cigarettes, and we are, you know, continuing to really take a very hard look at electronic cigarettes and the role they play in recruiting and encouraging people to smoke versus the issue that has been raised, the tool in helping people to quit. But I think we don't know that these graphic warnings will have any impact on the use of electronic think that the graphic warnings really have enormous importance and value in helping people that are either smoking or considering smoking to get a very powerful visual and message reminder of the [15]negative consequences of smoking. And that is why it is very important that we're going forward today to getting those graphic warnings on cigarette packages, and as part of cigarette advertising. >> Good morning, my name is Shany McLendon I'm masters of public health at George Washington. My question once the 9 images are selected will the companies be able to choose which images they want to place on there, on >> No. The ones that are selected, they'll be required to use. And there will be a mandate for them to mix them up, so to speak, so that when you go to the store there will be the combination of different of the 9 pictures and warnings. I should also add that over time, there will be change, though. Part of what is important, I think, in getting people's attention is novelty, and we know that we're going to need to keep updating the pictures used, we're going to have continuing research efforts to deepen our understanding about what kind of graphic images and messages have the most impact on people, and actually, over time, in addition to changing the graphic images, if we feel there's a reason to do so we can also modify the specific warning messages used. >> My name is scouts from tobacco control network, first I want to say great job. I think we're all very, very appreciative that this new level of coordination is happening. And also great job for inclusion of the disparity -- My first question is kids. I have three kids started smoking despite my level of education in the home and my lifetime wore, so I love the pillar about changing social norms, but mass media is one way and teenagers, a much faster way is you have access to the schools they go to and required health education. It's very curriculum at the elementary school level that actually addresses this successfully. So I'm wondering if there's been any any thought on actually bringing that education changes into the school system instead of necessarily the mass media >> I can take that, or secretary would you like to? >> You can take it, and I'll provide some additional-- >> I can certainly provide some perspective. First of all, scout, that's an excellent question, and I can as a former state health commissioner that oversaw a state tobacco control program. So these are issues that are requiring partnership at the state and local level of health officials and education officials, but it's really tremendous that you and your kids want to raise your voice, and I think having young people be champions for a smoke-free environment and smoke-free society is a wonderful way to get the next generation involved, and have them really demand a smoke-free future, and work with the educational system. So I think this is a theme that's part of our action plan, and I think it complements the pillars that we described, the secretary would like to say more. >> Well I would just say that there's a group assembled according to the direction of the affordable care act that includes a prevention council representing departments across government. And every department representative is coming to the table with an eye toward what kinds of contributions they can make. And the discussion so far has been very exciting around this area. There is a discussion about crick la, and curricula and up dating curriculum, certainly about smoke cessation issues. The department of housing and urban development is already moving ahead with some very exciting projects about smoke-free public housing and consumer education and environment, and there's a move underway with a lot of parks and to have, again, a promotion of smoke-free areas to make sure that when people are trying to access the beautiful outdoors, they're not subjected to secondhand smoke. So I think that those kinds of discussions with education, with HUD, with Department of Transportation, with the Department of the interior, are -- department of the interior are very much part of this plan moving forward and trying to leverage the access across and not just our public health officials, but a variety of agencies bringing their lens to bear on what we can all do to reduce this preventable death. And, you know, when we're losing almost 450,000 people a year in the United States, it's clearly an effort that needs a government-wide response. >> Good morning, I'm Richard Windsor profess of public health at George Washington university. My question relates prioritization. To the extent that there has been discussion related to pregnant women, new mothers, infants, it seems to me that they're in the whole context of populations, and I certainly appreciate the population approach but I would be interested, perhaps, and others in the audience would, of a special focus on pregnant women and infants and children. >> Well, I think again one of the efforts that's underway is the preparation of a rule that will provide Medicaid benefits for pregnant women to make sure that they can access smoking cessation treatment, the same kind of effort that was underway in Medicare, and has been promoted. So that should be announced in the not too distant future, and that again was a highlight in the discussion of the affordable care act. And Howard, you might talk a little bit about what healthy people is recommending in terms of the pregnant women and children. >> Sure. The secretary has very appropriately cited one of many provisions in the affordable care act that will more available to pregnant moms in Medicaid and to smokers in new health plans, and also to smokers in Medicare, as you already heard. And this is all part of an ongoing conversation to make our country healthier over the and beyond. When we unveil healthy people 2020 next month in this auditorium, actually, we're going to be hearing much more about targets for women and for youth on tobacco, and many other areas where prevention is playing a key role. So that's a very, very important question. And thank you for asking. >> Hi. I'm Susan Campbell with women hearts national coalition for women with heart disease. And in the you mentioned that there's been a change in rates of women who smoke and have lung cancer, and that change is reflected as well with heart disease. So I was very pleased to see some of the statements specifically referring to heart disease. Because I think that people don't really understand that smoking, you might die of heart disease before you die of cancer, so it's just a pitch for women and heart disease. And when you select the final 9 warnings, not to forget about heart disease. >> Very, very important point. Just want to under score the 9 warnings are definite. The 9 warnings are set in law. In terms of what will be going forward. It's the graphic pictures that accompany those warnings that are currently under study. But as I mentioned before, the 9 warnings can be modified over time, as is appropriate, you know, based on our evaluation of the impact that the warnings are having. And also, as perhaps some our understandings about the patterns and trends in disease and smoking change, as well. But I think your point is a great one because smoking underlies not just cancer, but a series of chronic diseases which kill people, which shorten lives, which have serious impact not only on health and longevity, but on medical costs. So we need to make sure that that message isn't just about cancer, it's about the effect of smoking and the impact that it has on a whole series of health conditions. >> And in some ways your question I think circles back to another question earlier, about the importance of educational and quality information being available, in all kinds of settings. And that whatever we do, through whichever mechanisms we're involved in, to reinforce some of those critical public health messages that people need to really hear, need to understand, and need to act on. >> I'm Carolyn Sparks, the director of health promotion in the school of public health here at GW, and I wanted to ask you, do these warnings appear on all tobacco promotion sites on the internet? Because as you may know, there are thousands of internet sites that are promoting tobacco. And also to ask you if you have any plans to try to restrict youth access to these sites. >> You know, the issues around the internet are very challenging and complex. This specific set of activities really has to do with cigarette packages and print ads. But there are activities underway to address how to provide appropriate oversight as well as appropriate warnings on internet advertising sites. And it's -- you know, it's a key area, especially when you're talking about youth, in terms of how they But it is a much harder area to provide oversight and control, and it's an area where responsibilities extend across government and FTC and other components of government are also actively involved in this. >> In fact, there was an initiative promoted and passed this summer with the acronym PACT, P-a-c-t, where there are provisions to block illegal sales of tobacco through the internet. So that was a public health as well. Addressing your point. But you're absolutely right, this is another avenue where kids in particular can get access, and we make sure that kids can stay tobacco-free so that PACT initiative and law really starts us down the right road. >> Hi, my name is Wendy house I work for delight consulting I'm also a part-time faculty member in the school of health and I was wondering if you could talk a little bit more Dr. Hamburg about the methodology in choosing the images and if there are certain demographics that, you know, purchase of, say, children by Marlboros more than the other and will then be aligned with the majority of people that purchase those, and whether or not you're talking to, in addition to in schools, educating them about the detrimental effects of smoking if you're also showing them the images and allowing sort of weigh in on what would be -- you know, effective for them. And I was also curious on another side, what cost this would be to cigarette companies if -- who is paying for everything? >> Well, in terms of the question about research, we actually have been undertaking what I believe is the largest consumer research nirtive [16]around consumer understanding of graphic warnings, and 18,000 individuals have been involved in this activity using, you know, what I understand are sort of the cutting edge approaches to consumer surveys. And the results of that data will be used as we select the graphic images for the first round of graphic warning labels on cigarette packs. And we're looking -- >> To clarify, you did make those -- 18,000 people are broken into various age groups. >> Right. >> There is a definite outreach to younger. >> Absolutely. Now, we're looking very much at the subpopulation of youth who are not smoking, to see what they respond to, and also looking at young adults and older adults who are also -- we're also looking at gender, geography, smoking status, race, ethnicity, a range of demographics that we know are related to smoking behavior and patterns of smoking. And we're going to be continuing our research, and hopefully enriching our own research activities as these products go into the marketplace. And we also will be very much working with colleagues in the academic community, and colleagues in regulatory authorities around the world, to really deepen our understanding as well. So this will be a dynamic process, but one that will be very important, and will truly inform our decision-making, and the graphic warnings that will appear on advertising and on cigarette packs. With respect to the cost issues, the tobacco program at FDA is supported by user fees from the tobacco industry, so they have a direct investment in this important public health activity. >> We have time for one more question. >> Good morning, I'm gen neat lopenius [17]with the Latino tobacco control network, we are absolutely delighted of this announcement and on this plan. And I just was following up on the need to assure that at the level, where minorities are, and they are being dis proportionately affected in poor communities, to assure that the implementation of these efforts are really hitting the community. And to be sure that we're building the capacity in the community, so that the community is engaged in this process. So I would like to see, you know, if you have considered how you're going to do specific outreach in minority communities on the implementation of these new regulations. >> Well, I would say that the part of the funding for the outreach and treatment programs began as a pipeline in the Recovery Act, and there were specific resources given to every state in the country to expand quit-lines, to ramp up their efforts. And then we have I think there are 57 of these community projects in various regions across the country, to try and determine best practices. A lot are in minority or underserved areas, looking at what really works, or how -- what the outreach is. So that's a portion, I think, of the plan. And I think one of the strategies also will be as we look across our department, the expansion of community health centers can play a very key role in this. And that is going to double the footprint of providers in often underserved areas. Certainly school curricula could help in this effort. I think the outreach with our other government partners in areas that, for instance, impact public housing, and the effort to move into a more smoke-free environments that people can choose to live in. So it's not only smoking cessation directly, but making sure that people are protected from secondhand smoke regardless of where they are living. So I think those efforts are very much underway, and have to be a part of our outreach. Because of the dis proportionate, I think, impact of smoking and the effects of tobacco, on populations. And another population that we have to pay very careful attention to, and I think my expert colleagues will be spending a lot of time and energy, are Americans with mental health issues. Because behavioral health community is twice as impacted -- about half of our deaths are folks who have some kind of mental illness or serious mental illness. So spending some time and attention on a particularly outreach in that population, where often, still to this day, cigarettes are still looked at as a reward system in too many environments. So we're giving very, very mixed messages. But we know the exact is hugely important in different communities. So looking at this strategy is a really nuanced strategy is really important, but everybody who buys a pack of cigarettes will now I think have an opportunity to be faced with some pretty dramatic warnings and some pretty dramatic labeling that has not ever existed before. >> My final comment is that your question and the secretary's responses are so germane to the whole issue of true health equity. That's a major theme for the secretary, for the department, for the country, and one of the overar people goals in 2010 and beyond, so it's very important way to conclude this important day. So thank you very much, everyone,for coming. (Applause.)