and when everything failed, we succeeded in getting thousands out. pakistan cannot be declared a banana republic when the goverment is challenged. at least not under me. >> in the back. >> if you become the next leader of pakistan, will you stop all drone attacks? and allow them to exist for intelligence? >> we will cross that bridge when we get there. [laughter] first, get me there and we will see what we can do about it. we have to resolve this dilemma. we must target militants.

we must not do something that disturbs public opinion massively. so we must get to some solutions. the dilemma has to be resolved. it has to be resolved. >> mr. president, on behalf of my colleagues at the atlantic council, i would like to thank you. [applause] >> thank you. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010]

>> coming up next on c-span, the discussion about campaign finance and the role of money in politics. new initiatives to reduce tobacco use. then, research on the safety risk of older drivers. then, breaking for a disabled veterans memorial on capitol hill. >> this weekend, c-span3 visits the roosevelt papers project. here help the former first lady used the media for her ideas. then, a conference marking the 150th anniversary of the civil war and the experience of slave and free african-americans during the war.

then, a daylong symposium on the civil war from the national archives. american history tv, all weekend every weekend on c-span3. >> as the country march veterans day, the more about the holiday and the men and women who served in the military on the c- span video library. veterans day commemorations through the year. all searchable, all free on your computer any time. >> now, a discussion of the role of money in political campaigns. we will hear from charlie cook, editor and publisher of the cook political report. they spoke at this event at the national press club in arguing for a nonprofit advocacy group. this is one hour 10 minutes. remarks and introduce our first

guest. charlie ok is sitting just to my left and he will gi some brief remarks and we will open it up to questions. he has to run to a previously committed events right after that. then we will introduce our panel. each of them will speak briefly and we will open up for more questions. we have about an hour. we look forward to the conversation. on behalf of common cause, i am delighted to help frame this conversation and hope we can get a rich guy look on the importance of this issue. just a couple of facts to put this in context, the 2010 midterm election last week was the most expensive one ever. when all the spending reports are finally tallied, the spending on that election will probably exceed $4 billn. that compares to $2.6 billion in the 06 midterm electio. of that, almost $300 million came from groups erating independently of the candidates

and political parties. paris recalled -- they were free to spend without limits and except unlimited donations from wealthy individuals, corporations, trade associations, and unions. about half of that money, it came from groups not required to identify their donors. and it worked. independent expenditures donated in this last election were important to the results in seats that changed hands, democrats, republicans, independent groups spend an average of $764,000 on the winner. those supporting the loser only spend $273,000. this was an important topic and we look forward and engaging in this conversation and what follows the money. i would like to introduce a man that i am sure you already know.

is charlie cooke. he is the publisher of the cook political report. he writes regularly for the national journal magazine. he has a regular column for the washington quarterly. he is a political analyst for nbc news. let me turn it over to charlie. [appuse] >> when they ask me to do this, i was delighted to do this. i do not consider myself a hard- core reformer, but i do see somebo -- i am somebody sees the problems with the system as terrifically flawed. i do not have solutions, but i think the dialogue is importa.

i am not going to give my normal spill on what i would do. i want to rest of this topic. some of the lessons that we have learned again is that money is hugely important, but it is not determinative. in fact, there are times where there is a law of diminishing returns or where the public just says, no mosque. with the meg whitman's spending in california, it seemed to be working, working, working. and then suddenly, people to said know. they kind of rebelled against it r a little bit. there may have been a little bit of that with conn with linda mcmahon. it did not happen every were obviously. money is hugely important, but there does seem to be some

limits to what it does. i confess thiwhole area sort of unlimit/undisclosed money is discomfiting for me because frankly, i was not comfortable when we saw a lot of that on the democratic side in 2006 and to doesn't aid and i am not so comfortable with it on the republican side. i think it is important for every ready to be consistent. i do not know what the solutions are. i really do not. in the absence of amending the constitution, i do not know where we go. i think we cannot assume that there is a problem. beuse of the importance of money has gonto the point where i think it really is creating -- and i am not from the selling outside as much as it is harder and harder for elected officials to maintain any kind of connection with the voters when they are chasing

money so hard. there is not the time. i sat in on some focus groups and were watching a video dominant of some focus groups with a wal-mart moms. just sort of average and working place -- working-class mom suit all shops at walmart within the last month. the level of abandonnt that they felt from both parties and washington was really telling. this one woman, a schoolteacher in denver, she was passed -- the focus groups were done by walmart, but they had a democratic and republican pollster overseeing it. one of the questions they asked was, if elected officials in washington understood your lives, what would they do differently?

this one in london, the schoolteacher in denver, said, i cannot and imagine the elected officials in washington understanding my life. another one, i think it was in st. louis, another woman said, too bad this is not like on tv that shows of undercover boss. were elected officials could, live with us for a day or two and see what our lives are like. just sitting there, this was not a conversation about campaign money or anything, but it did reinforce a message to me of how abandoned and ilated so many americans feel. the ing about it is that i do not think in most cases these elected officials, these politicians e selling n some much as i do not think they have

time to talk to people in informal settings. you remember back in 1976, when jimmy carter was running for president. he would sleep on the sofas of families of homes to save money, but also to establish a connection. how quaint th sounds today when these folks and these terrific figures of how much a typical member of congress has to raise every single day of their two years of the house term or six years of the senate term. i do not have solutions, but at least i am encouraged that the biggest money does not always win. the biggest money does when a lot more often than not. there does seem to be limits for

of voters on how much or how much of a disparity they are willing to pluck up with before they sort of rebel. i think we did see that. this was obviously a huge election. i tell people that it -- typically, they are kind of ragged. they are not uniform. some parts of the country are worse than others. some demographicroups were worse than others. in terms of -- i would describe using the starbucks vernacular. that is the 20 downsized. the senate and governor's were grande. there were big wins for republicans, but not as much as they wanted to get. the biggest win for a party in

any election since 1948. the biggest midterm when since 1938. obviously, the economy played a huge role, but there was a lot more going on than just a horrible economy. to me, what i would look at it is independent voters and these are the voters that are the most disconnected from politics. look at what is -- what has happened the last three elections. in 2006, those independent voters voted by 88 -- an 18. margin for the democrats. in 2008, they voted by an a. margin favoring democrats. this clection, they voted by an 18-point margin in favor of republicans. at 56% for republicans. 38% f democrats. when you were talking about a 36

point swing from one midterm election to another, or a 26- int swing just from one election to ather, that is absolutely enormous. when you look at some of the other things -- what we are looking at is a house of representatives that is sort of a lot more aligned -- there will be a lot less fish out of water in this next congress and there has en. there will be very few -- only a dozen democrats. about 62 republican sitting in districts that barack obama 1. keeping in mind that the big john mccain was not exactly the high water mark for the modern republican party. this was not about turnout some much. democrats turned out a little bit less than before. republicans turned up a little bit more. it was not about defections.

democratic voters voted 93-7 in favor of democratic candidates. .'m sorry, i got that wrong 92-7. republican voters voted 95-4 in favor of republican candidates. it was the independence swinging making the biggest difference for this. i think that the great thing about making changes 10 years out is that it does not apply to most of the current people. it is easier to convince elected officials to do the right thing if it will not apply to them or a fool not apply to them anytime soon. getting over the next two or three years, getting people

focus, giving states and voters in the media more focused on redistricting reform and to do it for a time frame looking at the 2000 -- 2021 redistricting process. that would have accomplished more than almost anything we could do right now. why don't we stop and open it up for questions? whenever i can help talk about, i would be happy to do. thank you very much. [applause] >> thank you, charlie. i will open it up for some questions. we do not have microphones in the audience, so i will repeat the questions. make sure it is a question and not a speech. >> [inaudible] could you tk a little bit about its public opinion --

there is been a lot of back and forth about whether vots care about the money. >> what is the view of independent voters about reform? whats your feeling? >> they are the only ones to do really care about reform. democratic and voters are in favor of reforming republican and republican orienting groups. republican reformers are in favor of performing democratic groups. no one wants to go -- to do anything to cut in on their own side the independents are the what one sadr most disaffected from the political process. they are the most cynical. they are the ones you are a lot more open to ideas of reform, of

honest rorm, as opsed to trying to take advantage of the other side under the guise of reform, which is what partisans on the republican and democratic side too often do. i think there is a constuency for that. i think -- what is coming out of -- what will come out of this election is because there are so few liberal moderate republicans left, because there'll be so few conservative moderate democrats left in congress, the american people are sort of of an ideological and shape of a bell curve. slightly more right then left. most americans are between the a 30 yard lines. congress is now -- it is like a camel with to hopes -- to hans. the homes are getting further and further apart.

there will be nothing left in the metal in terms of congress. -- nothing left in the middle in terms of congress. the ideological nature of the parties is such that the feeling of estrangement that people in the middle have is enormous and it will be growing after the selection, even worse than a was before. -- after the election, even worse than it was before. >> [inaudible]

>> i am not a lawyer and that is not my field. i have never seen any felony committed in my presence. i think there is no chance of any reform measures being done during the lame duck session. that is really not what lame- duck sessions are for. i cannot respond to that because i think the system is screwed up, but it is not felonious behavior. >> you talked about the independencys.

nts. [inaudible] could you talk to that? could that encoure participation across the political spectrum? >> i think the american people have long been open to the idea of a third party. i think they are increasingly would love to see that happen. i think a fundamentally do not trust and have good reason not to trust either party. they are incredibly open to it. the problem is that it is rare that you find an independent or third-party candidate setter not sort of fringe characters that cannot get broadbased support. most cases that i've ever seen

are not deserving of broadbased support. in 1996, if colin powell had run, that would have banned aid -- an interesting case. was a majorige, someone who could draw a broadbased support and someone who would be worthy of a great deal of support. >> [inaudible] >> excuse me? what ministry to bloomberg. -- let me go straight to bloomberg. i do not want to get into -- i think there is a thin line between independent and flaky. independent is a good thing. i do not think anybody has referred to michael bloomberg as flaky. you can like him or dislike him, i spent an hour with him one time and he is one of the most impressive people i've ever met in my life.

to hear them talk about what he is doing in new york city is amazing. the fact is, i cannot come up with a single other name of someone who could be incredible, a formidable third-party candidate in to a dozen 12. -- 2012. if there is another name, please let me know, but i cannot think of one. i think that with the economy, we will be looking at economic growth of probably somewhere between 2 and 3% through 2012. unemployment and a 8.5 or 9% range of 32012. economic climate is going to be a very, very difficult one for presidentbama seeking reelection. the honeymoon period will run out early next year.

there is a possibility of problems on the -- with the afghan war. he is going to be in a weakened condition and lord knows what republicans will come up with. if i were president obama, i would be on my knees every night prank for the afghan surge to work and for sarah palin to get the nomination. >> [inaudible] >> to be honest, i have not looked much at the environmental -- the ballot initiatives on the environment. i cannot speak to that.

the thing is, at timing in politics is critically important. there is a good time when people are open to debate and dialogue and new ideas on things like climate change and then there are unfortunate times. i do think that cap-and-trade played a very significant role and what happened in this election. when i go back and looked at where did he will star wobbling on the democratic party, it was before the focus shifted to health care and it was soon after the cap-and-trade vote. one member started coming back from the fourth of july recess of 2009, that was the first sign that things were going wrong and that was preceding the real focus on health care. last year, i think the american people would be open to a

conversation about health care reform. th would be open to discussion on climate change. but when you've got unemployment that was heading up toward 10%, at they wanted a laser beam like a focus. it was a matter of -- there is a time and a place to focus on things, but when unemployment is skyrocketing, that was not the time. i think it was -- cap-and-trade was a contributing factors to that election. in the midwest heartland, and south. in terms of the ballot

inittives, i cannot address that. in another time, that would of been a conversation that people would have welcomed. it is not that they're close to the idea of addressing the problem of climate change. don't do it in the face of a recession. >> we have time for a couple more questions for charlie. >> [inaudible] >> do you see and the 2012 time frame a largeurge n independent groups on the

democratic side as well? >> i do not think it is the beginning though. we have seen in the last dece -- i do not know that there is a dierence between george soros and peter lewis on the left or the brothers on the right. to me, and there is a sense in this country that money spent on behalf of the people i like is an investment in democracy. monespent on the against people i like this special interest a corruption. well, that is a framing that i don't care for. to me, democrats exploited the law and a left exploited the law to its fullest extent in 2004 and 2006 and 2008. republicans did this time.

-- did this time. it is like an arms race. beachside is pushing -- each side is pushing. this was a cycle when it was republicans that raised the bar of how far to go over democrats. before -- it is just going to keep getting worse. i look point is the system so it strange -- at what point does the system so strained? >> [inaudible] >> there was a lot of big money. go up to wall street and look around at how many people wrote

a big checks to the democratic party. they got -- e idea that this was fuelled by a small dors -- know. that is delusional. i really do. it was money going into -- to narrow the focus down on just one into which campaigns. i do not buy that. i do not buy that at all. the democratic machine -- both parties apparatus has been funded by large donations. you know, i do not buy that for a second. [applause]

>> we have an opportunity to have a conversation with a distinguished panel of folks with real experience and campaign finance issues. i will introduce them briefly and ask before opening remarks. to my immediate left is sheila who is the executive director of the center for responsive politics. she has been the executive director since 2006. prior to that, to serve as the research director and oversaw the analysis for -- was the assistant etor for their flagship magazine. to her left and in the center is a butler derrick. he is a south carolina and washington-based lawyer. he is a former u.s. congressman, serving 20 years in the south carolina house before that. he is also a member of the

national governing board. to his left its peers sen. he was the direct vice- president of programs for common cause. he has had experience of the citizen of leadership fund. with that, let me turn it over to our distinguished panel. sheila, we will start with you. [applause] >> good morning, everyone. let me just at the many of the same comments that charlie made. money was certainly a big story in 2010, but it was not -- outside spending is not new. it was just more free-flowing

after the citizens united and speech now decision. more of that was hidden this time around. it is not a guarantee of success. th are relying too heavily on their money and not enough on their own candidate skills. once again, we saw not just record fund-raising but shattered records. far, far in excess of the rising inflation. where will this end? what will this mean for democracy? let me start by saying that crp has been predicting that the election would cost $3.7 billion throughout this year. based on the numbers that we're seeing, and expenditures, we appear to be at least on target to meet that $3.7 billion and likely exceed that.

for that matter, there is little doubt that spending is much higher than what is included in the reported expenditures. when you looked at to -- if we could look at the unreported expenditures by outside interest groups, some of this is for issue advocacies, some of it is going to be termed operation costs, but additional large sums were directed at influencing politics. only the sources of this camp -- of this money will never be disclosed. even the expenditures themselves will be reported. day of announce that they have raised $71 million in these elections, way beyond their target. they only disclose expenditures for half that amount, $38.6 million.

pbs funding sources for political ads remain anonymous. th an anemone was critical for their ability to raise that 71 -- that anonymity was critical for their ability to raise that money. more than $3 billion have been spent. we will not know what the final tally is and where that money was coming from for the last several weeks before the election and until early december. a great deal of focus has been justifiably placed on these outside groups that have grabbed the spotlight and drive considerable fear and loathing. this spending amounts to $437 million. a 13% of that total of $4 billion. all spending is not created equal. this is less valuable to the candidate, this outside

spending, it is not money in their pockets. it is not money they can control. it is far more negative, less accountable, often misleading, and en containing an outright lies. of course, people want to know who put up this money. they also have an obligation to note, to guard the democratic process. a huge chunk of this was bankrolled bynonymous donors. of the $293 million, alt outside groups have reported spending about 47% came from groups and are not required to disclose information. 52% has been on a general election, communications. 47% of been on independent

expenditures that overtly advocate for a candidate. some of these groups, it is logical to assume -- and there has been anecdotal evidence that corporations are providing the bulk of the funds. the u.s. chamber has received a big contributions from a small number of large corporate donors. companies that can give an have given millions of dollars at a time. in the last cycle, the chamber received a gift of $15 million. we're not talking chump change right here. this is serious money. the bottom line is that this is pretty big money. between $400,000,000,000.1783793664 dollars. -- $400 million and $500

million. the overall also spendin was a balance between liberal and conservative groups. when you separate the primary from the general, there was much more balance between the groups. most of the gop advantage was an election and communications. the real imbalance was and the primary. a lot of the messaging happens prior tohe geral on hot- button polical topics played a critical role. these to play a role in how campaigns were waged. what the messages were that were emphasized during the election, what messages were hammered hundred groups may save a exists to educate the public, but then

their messages are highly political and they limit their spending to immediately before the election. how the suspect, i think. this money played a role in exnding the territory that the democrats had to defend the cycle. it had a big influence in specific races. much of it is anonymous. it is hard to quantify the effect ofhe enemy. money is not the be all and end all of politics. this is one that has enormous significance because of the huge dollar fires. this is a warm-up for a much bigger onslaught in 2012. it is not just the donors, but the groups themselves, that are unaccountable and hidden and secret. no bricks and mortar presence. the persons that can be contacted. because these gros are often irresponsible actors, flooding

the airwaves with half truths, and because their message to grace the level of discord and obscures' more important policy matters. tohe anonymity has to be public enemy number onfor campaign finance. if you did not have the chamber, the topics would of been different and the outcomes would of been different, too. the biggest concern is not known who is funding these efforts. the impact of anonymous sources is difficult to quantify. how might things have changed if we knew the source of cash? americans have a right to know. i want to turn now to looking at the harvard by industry. a very quickly. lawyers and law firms lost.

the biggest winner and the senate was retired people and the house. did ready for part reform. -- gets ready for tort reform. >> thank you very much. it is good to be here. i think the greatest issue for us to date is money. it -- if you take any problem that this country is having today end trace it back to the rates, you will get to the money. i do not care if it is military, private sector, government, or what it is. i will tell you that as we have elected 68 new members, -- 60 new members, and having been there myself for 20 years, they have absolutely no idea what they're about to face.

i had no idea when i came. and i only spent less than $200,000 and half of that i mortgaged my home to raise. i sa no idea that one of these days, i would become a money raiser and nine to a congressman. i went back to south carolina this past weekd and i went to my son is " class. it is mostly smal businessmen and a carpenter or two. i tried to get the sense of what they were thinking about. what i found out is that most of them voted for obama. two years ago. most of them voted for a democratic ticket. he is a retired chief and the navy. he said, those people are

ruining my country. who are the people? he was not sure who it was, but he knew one thing, that it was obama and nancy pelosi. you give me enough money and i can turn the bible into pornography. did enough money and you can make anyone into what you wanted. unfortunately, that is where we are today. i hated raising money. hated it. that is after 20 years, i did not run again and that is one of the reasons i did not. it just got to the point where it was simply ridiculous. congress is a microcosm of our

society. most of the people, with the exceptions of a few bad apples, are very decent hard-working people who are trying to do the best to represent their constituents. they came to congress with a wonderful idea. all the sudden, they met this wave of -- that came over them where they had to spend half of their time raising money. most of them hated it just as i did. this past election, i go back and i think about teddy roosevelt. he busted up the trust back in the first part of the 20th- century, bute never got elected to another public office. i think the business community has turned on those who helped

them when they were drowning. they turned on those to save their lives. of course, when you talk about a free enterprise society, we do not have a free enterprise society. we never have. what we have is a free enterprise society that is regulated. throughout our history, depending on which party was can and what particular the situation was, the regulation was listened. provincially, we into pretty much in this situation the we are in tay. those of us to are close to the system here in washington did not think a whole lot about it. but i will tell you that the average person out there is convinced that to this is the

corrected -- crookedest city in the world. no one up here is honest. they keep sending people appear and they keep getting dishonest. they pull them back and they send another one. we know that is not true. we have to do something to stop this flow of money. i thought about it a great deal and i have equivocated from time to time about what we need to do. there is no perfect answer to it. i think the best answer that i can think of is that we need some form of public financing. when i sayublic finaing, i mean the financing together with a limitation on the amount to of the nation.

think how wonderful it would be if a congressman in a perfect world did not have to go out and raise all this money until obligated. when i raise money, i consider myself a very honest person, i've never been accused of being otherwise. when somebody gives me a big check for my campaign or right solicited a donation, i am not going to tell you that i did not feel a little bit to -- a little bit not exactly what i had in mind for my future. i ended up having to spend too much time do not. this past year, the supreme court ruling on an opening the corporate treasuries of this country was like pouring

gasoline on our roaring fire. i think public finance is not a perfect answer to the problem. but i think it is the only answer that is reasonable to expect that the congress might take seriously and do something with. although that is wishful thinking. >> can i get you to wrap up? >> you want to hear one of my long speeches. [laughter] anyway, common cause -- we are headed in that direction. on the leadership of our -- of bob edgar and hopefully, we will be able to bring some sort of final resolution to this problem because it is a big problem.

i think it is close to being the biggest problem that we have. thank you. [applause] >> ok, so now we know what a $4 billion election looks like. it was not pretty. i think this one goes in the record books. it is not only the most expensive election in american history, but it is our first secret election since the watergate scandal and is our first election since 1907 were corporations and unions were allowed to spend unlimited amounts of money to influence the outcome. i do not think anyone really believes that people were better served as a result. airways were flooded with attack ads.

what does this meanor our democracy? first of all, to paraphrase thomas hobbes, ourlections will become a nasty, brutish, and very long. karl rove have alreadytarted planning for the kid doesn't fall election cycle. bait -- for the 2011 -- to doesn't fall election cycle. we are in an era of a new arms race. the e result is going to be that the people who were sent to washington to grapple with our nation's problems and serve the american people are going to spend more and more time fundraising. the conflicts of interest revolt -- resulting from that will become more intense.

within the next year, we may have to start a leration program for the members. it there will be locked -- they will be locked in the cubicles, dialing for dollars. the biggestroblem with -- what happens after the election is the biggest concern to us. we spent the last two years documenting how the major industries in this country target their millions of dollars of campaign cash to members of different committees. pick any one of those industries, all parts of $1 million a day on lobbyists. you had to that, -- u. add to the climates of conflict of interest. add to that a new fear factor.

those who vote their conscience in this next session of congress on the tough challenges that face us know that they will be persecuted by two dozen 12 from unlimited spending. this is clearly not what american voters want. i think charlie painted the picture there. we have seen big swings last three elections. we've had three change elections in a row. it is safe to say that the voters are not looking for one party er the other. they're looking for a change in how our government works. i am not optimistic about what they're going to see this time around. we have done a lot of falling over the last year. you have one of the memos to

your press packet that tries to summarize it. what we found repeatedly is that large majorities of people, 75% of people from across party lines, want to see spending limits. they want less special interest influence. in almostthe party's equal disregard. they have completely lost space and congress. the exit polls in 2006 -- those issues pulled strongly in the last two eleions as well. we did a poll on election eve and found that three of four of voters were very concerned that all this was yttrium -- just as many want to see congress take

immediate action. what is next and where do you go from here? i will lay out our 20-point plan. [laughter] the challenge here is that the roberts court made it extremely diffict to have any impact on politica spending from a regulatory approach. we need to be looking for new solutions. solutions that raise up the voices of small donors instead of focusing on trying to hold down spending by her straight common cause is going to be working for the next seval months by pulling folks together to generate another grass- roots uprising. i will mention three things that i think our key to that effort.

one is no more secret elections. it is time for the parties to get together and put an end to what we saw this year and make sure we have full transparency moving forward. second, we need to change the way we pay for elections. it is a grossly inefficient system. it creates huge conflicts of interest. we have worked hard on a model for small donor public funding that change is how that operates. third, i think it is important to say that the citizens united decision just cannot stand spread like the dread scott decision, citizens united is base on the ideologies that has no basis in reality. it will eat away at the soul of our democracy if it is not changed. corporations are not people. their role is to maximize

profits, not to serve the national interest. it may take a constitutional amendment to win this fight ultimately, but it is a fight that we must win. thanyou very much. [applae] >> we have time for about 10 minutes of questions. it wants to go first? -- who wants to go first? >> i am not sure of what percent of the reform our community is engaging in this constitutional amendment activity to change what the corporation [inaudible]

>> will be efforts to try and make a constitutional change delayed efforts or is there a way that can be done to get attention on the other reform topics? anyone to answer? >> they do not need to be in competition with each other. they are all part of a comprehensive solution and there is a natural time sequence do that. we could do something about sensible action. we could do something about the disclosure issue right away. we have worked for years on a model for how the elections can be run that is different from the way there are now. we have successes and the states. the constitutional amendment is clearly a long-term proposition. it is having that discussion is part of what it takes for people to come to a shared understanding of what the problem is.

to be ready to move forward. >> i think it would be a positive thing. i do not see it as negative. >> what effect does citizens united actually have? [inaudible] >> the customer is about the effect that citizens united has. >> there was a psychological effect that voters no longer had to worry about illegalities. it is possible that disclosure would not be an issue for the irs, but mating taxes would. if they were an organ that -- but pay in taxes would. there were spending too much of their expenditures on political

activities, the threats just kept growing smaller and smaller. it opens up the field for new players to spend and these are players with deep, deep pockets. ere was a sense of -- they could look at a more ample set of opportunities for them to have -- >> [inaudible] >> we of god pretty much -- we have pretty much a sense of what has been spent. i do not think there has been enough of a race by race analysis on whether or not they played a role.

some of the action really took place before -- in determining who will win the primary. >> i should point out that the citizens united decision was a combination of a series decisions that has deregulated campaign finance. that started with wconsin right to life. the constraints on all sides spending have been chipped away. but we have seen is an escalation of that spending. i do not know if we can quantify that because a lot of it is not reported. there is been some good reporting work done going back in ifrom the other end. if you look at what the chamber

of commerce spent, iis hard to tell how much of that was money that was freed up under citizens united. short answer. >> [inaudible]

[inaudible] >> the question was, to what extent is there direct disruption and to what extent public financing will hp with that and smallonors and the ability to support small candidates were not part of a large donor system. do you want to try that? >> sure. one of the big fights that we will have immediately this year is preserving the office of congressional ethics, which is the only independent watchdog that we have on the hill, and clearly any time you see the

amount of money spent on elections that we saw this time, the opportunities for correction are ripe. who knows what k street and others are going to want to call in for the spending, and it is important to have an independent watchdog look into that. just on public financing, the fair elections act, i think if we want the government to be accountable to the people, then the fund needs to come from the people in from the voters. that is the only way that you get rid of that conflict of interests. i>> other questions in the back? >> i am wondering what e panel thinks realistically [inaudible] being passed between now and the 2012 election? and second, with the chipping

away of campaign finance laws, how much effect does this have? >> the realistic prospect for disclosure laws before 2012 and what impact they could have. >> i am all for disclosure law, but i don't think that is the answer to the question because the folks out there are not paying that close attention, frankly, and i thinkhe answer is, as i said earlier in my remarks, is public financing. i think disclosure is good, and i support it, but i don't think it comes anywhere near close to what we need. >> you think it will happen? >> our best shot at it is clearly in the lame-duck. we have majorities in both chambers that supported it before. we did not win it because of the filibuster by the republicans.

we have the incoming senator from illinois who will be seated this fall who supports disclosure. i have sat in the past with senator olympia snowe and talked about these issues and she has been a strong proponent of campaign finance reform and the past and feels that the system has gotten out of control. i think our best prospect would be for a stripped-down version of this disclosure bill to pass before the end of is year. i have not done the math on the prospects for next year. but it is challenging. >> ok, in the back. >> [inaudible]

>> the question was the impact on state disclosure laws and court cases about citizens united being applied at the ste level for disclosure in water the prospects there -- and what are the prospects there. >> i think it will have a positive effect. the last question before this, i don't think the lame duck session is goingo do a darn thing. i think the last about a week, and i will tell you why. because the democrats have had, as the president said, a shellacking. they are uneasy about who they are and so forth, and you'll like it anything positive out of it. it -- and you will not get anything positive out of it. >> citizens ited not only over

turned out the law but spending in 24 states. others have had a very concerted long-term plan to dismantle o campaign nance laws and have set their sights on disclosure. bob has filed suits in probably 10-plus states, challenging disclosure laws. he has not gotten much traction on that yet, and i think of any of the areas, this is where we have the most support on the current supreme court. so what will be a big fight and will be a big fight to improve the disclosure laws in the states to keep pace with the new realities of spending. >> yes, and the front? >> [inaudible]

the constitutional amendment, the citizens vs. united, was there a clerical error that set that out? [inaudible] >> i have seen in a number of

places [inaudible] and my question is, what about the president? doesn't he have a role to do some corrective action? >> the question was what role does the press play in combating the misinformation that may be out there? >> there has been the health care reform legislation, in particular, incredibly complex, and there is a lot of effort on the part of the media to distill it for people, but there have also been efforts by groups like factcheck.org that have tried to do very factual, hard-

hitting, truth telling to a lot of the misinformation about health care reform or about financial reform or the stimulus or the bat out, but -- or the bailout, to inform the voters. when an organization is outright lying. there have bn a numberf efforts. i don't know if it has risen to a level of notice of the voters, particularly in the din of information about the races by these groups. >> last question. >> i was wonderingf you thought there would be in the interest in the next congress to focus on the appropriations process? it has something that has been discussed and it picks up on some of the concerns of the conservatives who have been swept into office and who have

talked about trying to control earmarks. there is a story recently about group contributions. >> is there any likelihood of reform on earmark legislation in the next congress? >> i think there will be. the new speaker of the house has been there i don't know how many years, 20, 22 years, and he has never gotten an earmark as i understand it and he is adamantly opposed to them. i think whether it will be legislation passed or what not, i think this will be part of it. i think in the senate, jim dement it was having a bay got row in south carolina about getting an earmark for the port

of charleston, whether i agree with him or not, he is consistent. i think you will see quite a decrease in earmarks. >> ok, tnk you. unfortunately, we have reached the end oour time. please join me in thanking our panel. [applause] thank you all for joining us for the conversation, and thank you to common cause for putng this event on. [captions copyright national cable satellite rp. 2010] [captioning performed by national captioning institute] this is 50 minutes.

>> good morning, everybody. i want to start by thanking the president and the dean for inviting us here today to george washington. so pleased to be joined by two of our department's. health leaders, my assistant secretary of health, dr. howard koh and are fda commissioner, dr. peggy hamburg, to announce new steps that we're taking against tobacco use. for years, we have watched

tobacco rates fall in the country. in 1965, we were at a situation where over 42% of americans smoked. by 2004, the good news is it had fallen to just under 21%, fairly significant drop. the bad news is that in recent years, the spike to well-known health rests, youth and adult smoking rates have been flat. they had been dropping for decades and have stalled at about 20%. every day in america, about 4000 kids under the age of 18 try their first cigarette. about 1000 of those americans become lifetime smokers. we have just under 450,000 americans who die every year prematurely from smoking and secondhand smoke exposure,

making it our country's leading cause of preventable death. it also costs the health-care system almost $100 billion per year. so we lose lives, we lose money, and we are not making any progress. when this administration took office, we decided these numbers were not changing, so our actions had to change. over the last two years, with accelerated our efforts to reduce tobacco use, taking a coordinated approach that uses the many tools available to help tobacco users stop and keep others from starting. the first that was historic legislation enacted last june. for the first time ever, the law gave the fda 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 of finding ways to market their products to use, giving out free samples and advertising in youth oriented magazines, sponsoring various productions that are aimed at younger americans. under the new tobacco control law, we're bringing those practices to an end. we have banned misleading terms like "light," "low," and "mild." as part of the tobacco act in 2009, we're funding some of the most promising state and local programs around the country for reducing tobacco use. altogether, we are investing about $225 million in programs like and i a while when they're using evidence-based -- like in iowa, where they are using

evident-based programs. eventually, these communities in places around the country will become models for what really works, and we will use them to promote best practices in and around the country. the third step was part of the affordable care act, which produces a new opportunity to transform our nation addresses tobacco use through a new $15 billion prevention and public health fund. it that law is also giving americans and private and public health plans access to recommended preventive care is, like tobacco use cessation, at no additional cost. for the first time, medicare will actually cover tobacco cessation for all beneficiaries. previously, medicare beneficiaries actually had to demonstrate that they had one disease in order to -- they had to demonstrate they had one disease in order to be able to

get the cessation efforts. we think it is smarter to help people before they get the disease. that is part of the medicare beneficiary package. using this approach, we are using many tools at our disposal, for me dilatory power to state and local investments to -- from regulatory power to state and local investments. today, we're very excited to announce new initiatives that help bring us all the strategies together and achieve our tobacco control goals. we are unveiling the department's first ever comprehensive tobacco control strategic action plan, entitled and in tobacco epidemic. you'll hear more about that in a few minutes from our wonderful assistant secretary of health, dr. howard koh. it lays out strategic actions based on science and world experience that served as road

maps for reaching are healthy people target of reducing adult smoking to 12% by 2020. this follows the administration's goals of coordinated and commit it response to tobacco control. to that end, along with dr. koh, we will hear from our fda commissioner, dr. peggy hamburg. today the fda is announcing a proposed rule to drastically change the look and a message on a pack of cigarettes. the new graphic warning labels will replace the old warning phase with a picture showing the negative consequences of smoking. you will see some examples from dr. hamburg, but 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 they are taking. because of the progress we have made in the last two years and

the strategic action plan we are unveiling today, i am 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. we have a long way to go, but we will not rest until we have eliminated tobacco-related disease and suffering. the prosperity and health of our country depends on it. now i would like to turn over the microphone to the assistant secretary of health, who has been a terrific leader h hhs to coordinate our efforts on tobacco control, dr. howard koh. [applause] >> thank you so much, madame secretary, for your leadership on so many fronts. it is a great honor to be here

today. we are truly at an unprecedented time and our nation's public health history. while the 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 academic -- the tobacco epidemic is protected to kill 1 billion people in the 21st century. in the united states, smoking causes almost half a million deaths per year, over 1000 people per day over 8 million in the united states suffer from chronic illness related to smoking. and at long cancer should be an uncommon disease in this country -- and lung cancer should be uncommon disease in this

country, but it is tragically the nation's leading cause of cancer deaths 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 to prevent initiation, improved cessation, to change the social norm.

we know that comprehensive smoke-free policies reduce exposure to secondhand smoke and improve health, reducing heart attacks, improving long health. and we know that every 10% increase in tobacco price decreases consumption by about 4%, and this has an even greater effect among the youth, low income, and other price sensitive populations. but it will take more than knowledge to end at the tobacco epidemic. it will take renewed commitment from every sector of society to move us forward a vision of a nation free from tobacco-related suffering and illness. in this context, early in her tenure, the secretary identified tobacco control as one of her strategic priorities and charge the department with creating a plan for moving forward.

it has been a great privilege as the assistance occurred of health to chair the working group that created this plan, and i want to take this opportunity today to recognize the substantial and unprecedented commitment of public health experts from across the department who have stepped forward to help create this for a more. 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 helping people objective of reducing the adult smoking rate, currently around 20%, to 12% by 2020. there are four pillars to the plan. the first 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 per year, more than $34 million every day, to attract new users, retain current users, increased consumption, and in general generate physical attitudes toward 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 will lay the groundwork for future mass media campaigns. in addition, the fda has started to conduct public education efforts to discourage public perception that any tobacco product is safe, and you'll be hearing more about such efforts from commissioner hamburg in just a couple of minutes. the second pillar is to improve

the public health by supporting states and communities in the implementation of evidence- based tobacco control and prevention. in the past 18 months, through the recovery act, and the affordable care act funding, the department has invested nearly $250 million toupport proven tobacco control activities in states and communities. these are essential one states have had to make severe cutbacks to their programs -- when states have had to make severe cutbacks to their programs. the goal is to expand comprehensive cessation activities to make it as easy to quit as it is to purchase 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 prevent such enhancement for americans in collaboration with state and community efforts, and in that regard we recognize the people

of south dakota for overwhelmingly approving a comprehensive statewide 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 the smoking cessation coverage to users of tobacco and not just those with diseased, 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 disparities by providing services for high-risk populations at community health centers, or health facilities, public housing, and other settings. the fourth and final public is to advance knowledge and accelerate research and expand

the science base. this is especially critical given the fda posset authority to regulate tobacco -- given the fda's authority to regulate tobacco. the department's export to working with partners around the country to make this vision come alive. we're also very grateful for the tremendous update that are in the affordable care act. we are committed to reinvigorating national momentum towards tobacco prevention and control that move us toward a healthier society. it together, we can achieve a vision of society free from preventable tobacco-related suffering. thank you very much. [applause] and now it is my great honor to welcome my very good friend and

colleague, the fda commissioner dr. peggy hamburg. [applause] >> thank the. thank you very much, howard. it is really a pleasure to be here. thank you, george washington university, for welcoming us here, and think the madame secretary and dr. koh for your leadership on this public health issue. as has already been so eloquently pointed out, the strategic plan has won over arching objective, to make the suffering, the disease, and the death caused by tobacco use part of america's past, not part of america's future. that is why congress passed and president obama signed a family smoking prevention and tobacco control act, and why the fda has been working so i hard so it. many of you are familiar with

the tax we have taken to date, and the secretary mentioned some of the important ones. we banned the sale of candy and fruit flavored cigarettes. we have prevented cigarette advertising with misleading terms. we are required the tobacco industry to provide us with lists of product ingredients. this past summer, the fda issued a number of restrictions to limit both the access and marketing of cigarettes and smokeless tobacco products to young people. and has been a very busy first year. it today, we are pleased to announce a new historic initiative, consistent with the fda's mandate under the contract under the tobacco control act, with new health warnings on cigarette packages and advertising. the warnings which you are now seeing are examples of the kind that will replace those that are

not printed on the narrow side of cigarette packages. these warnings have not been changed for 25 years. the new warnings will be much larger and more prominently placed on the pact, and they will contain graphic images, as you are now seeing. we believe that there will be much more effective. under the proposal, as required in the law, health warnings will cover 50% of the front and back panels of every pack of cigarettes. for advertising, these warnings will occupy 20% of the top part of that have had. but it is not only the size and position of the ones that will be changed. 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 most plain terms that

tobacco can kill. the fda 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 is the point. we need to make sure that anyone who was 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 is our goal, and what these health warnings will help achieve. the fda is currently considering 36 different images that will be coupled with nine different warning statements. the images vary in style and design.

some are illustrations, others are photographic. the type, size is, stiles, and layoffs ferry. they're designed to elicit a reaction from the audience, including youth, young adults, and adult smokers and potential smokers at. our plan is to identify a combination of images that best resonate with americans from all walks of life. they will be available to the public, including all of you, too few and, on -- to view and commwent on. you'll find world of information about this initiative on the website. the fda is also conducting a study to assess the relative effectiveness of these images. this will evaluate all the images with the proposed rule. that research at the proposed

comments will help us select nine graphic images that will be used, one to accompany each of the required health warning statements and this is what will appear on cigarette packages and in advertising. the final rule with these nine images will be published in june of next year, and tobacco companies will then have until sept. 2012 to begin displaying them on cigarette packs and in their ads. once that happens, every single pack of cigarettes in our country will affect become a miniature billboards that tells the truth about smoking. we are convinced that not only will these warnings helped discourage nonsmokers, particularly kids, from ever trying cigarettes, but the will also help strengthen the resolve of current smokers who want to. break to.

the proposal is consistent with the approach embraced by canada, australia, and the european union, among other countries, and supported by every major health organizations, including the world health organization itself. as you have heard this morning, our effort to educate consumers about the dangers of tobacco use will be executed on many different fronts. underlying all of these efforts is the understanding that the best single strategy to reduce smoking among young 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 that these warnings will help discourage nonsmokers, particularly kids, from ever trying cigarettes. there will also help strengthen -- they will also help strengthen the ability and commitment of current smokers who try to quit, and both are

terribly important to our nation's efforts to. stop the to. -- to stop the devastating epidemic. we'd want to get the real message across about smoking whenever they see an ad for cigarettes or pick up a pack, that is exactly what these health warnings will do. at fda, we're proud to be up to provide tools that will support the efforts of millions of americans working for healthier futures. it but me close by recognizing that there are still -- there is still a long way to go to reduce the enormous burden 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 emcor work in this area and thank you for your support that you have given to the fda and hhs as we pursue our import activities in this area -- are important activities in this area to once and for raw stop the epidemic of tobacco use in this country, and to also help affect tobacco use around the world. there is a lot to be done. i think today's announcements represent an important step forward, and we are really excited by the opportunity that it represents for public health in our nation. thank you. i think we will do questions and answers now. [applause] >> thank you so much, dr. hamburg. we will now open for questions.

>> since we know that restricting smoking, banning smoking is probably the most effective way to get people to quit, i like to ask the secretary of the department would require that any institution that its grants or holds conferences or anything else were you have contact would have to be smoke-free to qualify for grants and support. i think i would be at least as effective as everything you've presented this morning, with all due respect. >> i certainly appreciate the idea. i don't know that has been a discussion, certainly the building that we have our workers in our smoke-free. we engageties ouwhere in dialogue are smoke-free. we're working closely with states around the country. i was pleased last year, after

years of effort, my home state of kansas passed a very comprehensive smoke-free law that will be incredibly effective. i think we are working in that direction and that is an idea that we will check back and continue to discuss, . >> good morning. i just want to congratulate you on a strong plan that it will make a lot of difference in this country. i especially want to thank you, dr. koh, to make it as easy to quit as to pick up a pack of cigarettes. but this one to ask in putting together the warning labels, i know my organization and many others in the room have asked to have 800-quit-now put on a warning label. we think it would help smokers quit not only to have the graphic picture but to have a way to get services to quit.

we're wondering why that was not put on thearnings. >> that is probably a question to me, and that is a very important question to raise. the 1-800 line was not one of the requirements of what was in the graphic warnings, but it is very much under consideration. as we collect comments on the proposed rule making, we hope people like yourself and others will goes important input on the value and role that such an addition to the warning label could have because those decisions are still under consideration. >> 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 web site, show more efficacy in

terms of reaching smokers and help them make a decision to quit. that is a suggestion we're taking it under consideration. >> hello, i am a reporter. i'm wondering if he could discuss where the fda is with an electronic cigarettes and if there is any concern these graphic warnings may move people to try electronic support instead. >> electronics cigarettes are a different activity, and we are here to discuss the graphic warnings. electronic cigarettes are an area of public health concern. we have been examining very carefully, and there is also the vacation around the future of electronic cigarettes, and we are 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, is it a tool to help people quit. but i think we don't know that these graphic warnings will have any impact on the use of electronic cigarettes, and i think the graphic warnings have enormous importance and value in helping people that are either smoking or considering smoking to get a very powerful visual and message reminder about the negative consequences of smoking, and that is why it is very important we are going forward today to begin the process of getting those graphic warnings on cigarette packages and part of cigarette advertising. i>> good morning. images are selected, will the companies be able to choose which images the what to put on the packages?

>> no, the ones that are selected they will be required to use, and there will be a mandate for them to mix them up. so when you go to the store, there will be the combination of the different nine pictures and warnings. i should also say that over time, there will be changed. a part of what is important getting people's attention is novelty, and we know that we're going to need to keep updating the pictures. we will have continuing research efforts to deepen our understanding about what kind of graphic images and messages have the most impact on people, and over time, in addition to changing the graphic images, if we feel there is a reason to do so, we can also modified the specific warning messages used.

>> i want to say a great job. i think we're all very appreciative that this is happening. my question is the parent. i have three kids. the 12-year-old started smoking despite the level of education and the home and by type of work. i love the pillar about changing social norms, but mass media is one way to affect teenagers faster. that is challenging to find any curriculum at the elementary school level that addresses this successfully. i'm wondering if there's any thought of collaborating with the department of education or to bring this into the school system? >> i could take that, were if you would like to? i can provide some perspective.

that is an excellent question. these are issues that require a partnership at the state and local level between health officials and education officials, but is really tremendous that you in your kids want to raise your voice. i think having young people be champions for smoke-free environments, smoke-free society as a wonderful way to get the next generation involved and have them demand a smoke-free future and work with the educational system. i think this is a theme that is part of our action plan and complements the pillars that we have described. >> i would just thesay that thee is a group assembled that includes a prevention council

representing government. every deptment representative is coming to the table with an eye towards what kind of contributions that can make. the discussion so far has been very exciting. there is discussion about curricula and updating curriculum, both nutrition efforts and tobacco 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. there is a move underway with a lot of parks and open spaces to have a promotion of smoke-free areas, to make sure that when people a try to access the beautiful outdoors, they are not subjected to second-hand smoke. i think those kinds of discussions with education, with hud, with the department of

transportation, with the department of the interior are very much part of this plan moving forward and tried to asset -- trying to leverage the assets going forward, so it is not just the fta, but a variety of agencies putting their lands to bear on what we can all do to reduce this preventable death. when we are losing almost 450,000 people per year in the united states, it is clearly an effort that needs a government- wide response. >> good morning, i am richard windsor. my question relates to organizations. to the extent there is the discussion about new mothers, infants, it seems in the context of populations -- and i appreciate the population approach -- i would be interested in a special focus on

pregnant women and infants and children. >> i think, again, one of the efforts that is under way is preparation of a rule that will provide medicaid benefits for pregnant women to make sure that can access smoking cessation treatment, the same kind of effort that is under way in medicare and has been promoted. that should be announced in the not too distant future, and that will highlight in the discussion of the affordable care act. howard, you may talk and little about what healthy people is recommending in terms of pregnant women and children. >> the secretary has very appropriately sited one of the many provisions in the affordable care act which will

make cessation services more affordable to pregnant moms, in medicaid and new smokers and health plans, and also to smokers and medicare. this is part of the ongoing conversation to make our country healthier over the next 10 years and beyond. when we unveil healthy people 2020, we will hear much more about targets for women and youth on tobacco and many other areas where prevention plays a key role. that is a very import question. thank you for asking. >> i am susan campbell, the national coalition for women with heart disease. in the beginning you mentioned that there had been a change in the rights of women who smoke and have long cancer, and that is reflected as well with heart disease. i am very pleased to see some of the statements specifically

referring to heart disease, because i think people really don't understand that smoking -- you might dief heart disease before you die of cancer. when you select the final nine warnings, don't forget about heart disease. >> very important point. i just wanto underscore, and 9 warnings are definite. those are set in law, in terms of what will be going forward. it is the graphic pictures that the company those warnings that are currently under study. as i mentioned before, the nine warnings can be modified overtime as is appropriate, based on our a valuation of the impact the warnings are having, and also perhaps our understanding about the patterns and changes in smoking as well. >> i think that is a great

point. smoking underlies not just cancer but a series of chronic diseases which kill people, which shortened lives, which have serious impact not only on health and longevity but on medical costs. so we need to make sure that message is not just about cancer, it is about the effect of smoking and the impact it has on a whole series of health conditions. >> in some ways your question circles back to another question about the importance of educational messages and quality information being available in all kinds of settings. whenever we do, through whatever mechanisms we are involved in, to reinforce some of those critical public health message is that people need to really hear and understand and act on. >> i am carolyn sparks, with the

school of public health. i wanted to ask, ought to these warnings appear on all tobacco promotions, like on the internet? as you may know, there are thousands of internet sites that are promoting tobacco. and also to ask if he had plans to redistrict -- if you had plans to restrict youth access to the internet sites. >> the internet issues are complex. the specific set of activities 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. it is a key area, especially talking about youth and how to get information, but it is a much harder.

to provide oversight and control -- it is a much harder area t provide oversight and control and it extends across the government and the ftc and other components of government. >> there was an initiative. but this summer with p.a.c.t., where there are provisions to block illegal sales of tobacco through the internet. that was a public health advance as well, but you are right, this is another avenue where kids get access and we need to make sure that kids state tobacco-free, so that initiative starts is down the right road. >> wen name asdy. wendy.ame is i was wondering if the talk about the methodology behind the

images and if there are certain demographics and if they will be aligned with the majority of people who purchase them. in addition to educating children about the detrimental effects of smoking, if you are also showing them the images and allowing younger populations to say what would be effective for them. i was also curious what cost this would be to cigarette companies? it was paying for everything? -- who is paying for everything? >> we have been undertaking what i believe is the largest consumer research initiative around consumer understanding, graphic warnings, and 18,000 individuals have been involved in this activity using, what i

overstand, are 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. >> those 18,000 people are broken into various age groups. there is a definite outreach to young -- >> absolutely, we're looking very much at the summer population of youth who are not smoking -- at the sub population of you who are not smoking and younger adults. 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 will continue our research and hopefully in reaching our own research activities as these products go into the marketplace. we will also be working . colleagues and regulatory authorities around the world to deepen our understanding. this will be a dynamic process, but one that is very important will truly inform our decision making . packs. with respect to the cost issues, the tobacco program at fta is supported by user fees from the tobacco industry -- the tobacco program at fta is supported by user fees from the tobacco industry. >> we have time for one more question.

>> good morning. -- iwhat the nationallatino am with the national latino tobacco control network. i was wondering on that area where minorities are disproportionately affected and poor communities, to ensure that the implementation of these efforts are really hitting the community and to be sure we are building the capacity in the community so the committee is engaged in this process. i would like to see if you have considered how you will do specific outreach in minority communities on the implementation of these new regulations. >> i would say that part of the funding for the outreach and

treatment programs began as a pipeline and 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 57 of the is community projects in various regions across the country to try to examine this. it a lot of them are in minority or underserved areas, looking at what really works, how the out reaches. that is a portion of the plan. i think one of the strategies also will be as we look across the 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. i think the out reach with our other government partners in areas, such as public housing and the effort to move into more smoke-free environments, that people choose to live then. so it is not only smoking cessation directly, but making sure people are protected from secondhand smoke, regardless of where they're living. so i think those efforts are very much underway and have to be part of the outreach, because of the disproportionate impact of smoking and the effects of tobacco on populations. 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 the behavioral health committee -- health community, about half of our deaths are folks who have some kind of serious mental illness. spending time and attention on a particularly out reach a net population, where often still to this day, cigarettes are still looked at as a reward system in too many environments. we're getting very mixed messages. we know the impact is hugely important in different communities, so looking at this strategy as a nuanced strategy is very important, but everybody who buys a pack of cigarettes will now, i think, have an opportunity to be faced with some dramatic warnings and it dramatically billing that has not -- and dramatic labeling

that has not ever existed before. >> it is so germaneand one of tp the people goals for the next 10 years and beyond. it is a perfect thing to include today. they you, everyone, for coming. [applause]

the screening is part did the

big guy you nation. that is reimbursed i see it into the sub-specialty -- as you get into the sub-specialty area. these are things of occupational therapist can do bigge. many things are handled by a number people and oncology. and he is been people to the specialist. i believe as we get more efficient, it also helps make it more financially appropriate. >> as a follow-on, it to insurance companies pay for the evaluation? how do we get more to buy into this a violation? >> reimbursement is variable. it is an answer that does not please people.

it varies by state and interpretation of the statute. some areas have reimbursement for occupational therapists. they really describe the by the functional component of ths. tynes for convenience they have pulled the whole program out of the reimbursement system and ask for people to pay for it privately. what can help is the demand of trying to make share we are gaining reimbursement. >> thank you very much. it looks like the alliance. it to be questioning. >> i met aaa.

the first question is a departure. the panel stated there is no one expected screening tool. what did they recommend as screening system? what elements are known to be ineffective? will the public view it as profiling, especially in minority communities? how can possibly be mitigated. >> i will take a stab. in terms of what would be the optimal screening tool, i think the challenge is that the silence right now lives behind the need of practitioners for tools that they can use right away. we know -- we have talked about the various functional abilities

that are important in driving. de on some of the early work that came out on screening tools for licensing agencies. that steady identify -- study identified abilities that are associated with crash risks. i think that is one starting point that we know we have to look at the abilities that are driving. part of the challenge in implementing this has been a lot of other considerations in terms of constraint on time, constraint on costs and the

resources that are available. we do need to think about which are related to say driving. and the king about coming up with the good screen, we really need to think about the kind of research that is necessary. it is time-consuming and expensive. many cities that have sufficient samples. we have barely been able to do these kind of studies. it is promising that there has been a lot more collaboration in recent years. there are some efforts under way to get out what could be the

kind of screening tool, particularly in officers. they have funding for five years. it is recruited from seven sites across canada as low as one in australia. i think this is really exciting. in the next the years, hopefully we might have some more definitive results. >> one of the best protections is making sure it is screening.

the purpose of these -- if we develop screening tools, they should be referring somebody to the next level of expertise. i under stand population base screening. i do not believe in screening everybody for things. i think that is too costly and not warranted. we need some kind of different entry points. the dmv will have a different set of schools -- different set of skills. these almighty places were screening tools will be used. we need to get people with any still be met for them >> i think

these are key. we have a lot about -- have a lot of skills. alternately, i think policymakers have to decide what is acceptable. it a screening tool can identify drivers who would have failed a road test but also identify a considerable number of people who passed the test and passed those people on as well, those are ones that your neighbors need to think about. what is the trade-off?

these issues go well beyond the state of the research. >> it is a multi factorial issue. there is a narrow set of tests that will cover the full range of that. the trickiest issue is profiling. do not think that in terms of -- i think age is the equivalent here in terms of royalty that correct addictive viable.

this needs to be guarded. how would you identify who is at increased risk? >> the next question is, when they are presented with information for an evaluation suggesting they may not be safe to drive, what resources are available to transition them to drivers to non drivers. >> it varies from location to location. there is no set answer. part of the difficulty is that is hard to generalize. one needs to figure out what the resources are the -- are.

the question is, who does that? this anybody do that? there is no group of individuals to whom that rep -- responsibility balls. kenny mustard those resources? it did help to have a better approach. >> from a research perspective, of the past several years there has been an emphasis on research to help facilitate the move from driving to non-driving prepare -- driving.

we need to have more evidence of bell this. we need drivers to have something to transition to prepar the provided alternative transportation. they are also making that information available. we had a license a workshop. the consensus was that licensing agencies do need to think about

they can participate. >> it is a net will be a capturing a lot of people that are facing medical conditions. >> there are a number of tools that have been created that we had been distributing. see what would be appropriate and what safeguards will need to be in place. they have been gaining strength

there are support services they need. travel services have been gaining. they are trying to bridge if the person should be using transportation. they are trying to increase the number of professionals that know about this epidemic. we need a number of groups and professionals in different areas. it may differ in dferent communities. if each were son services, we hope that will be an important way toward a solution. >> will go to the last table. >> i am with the association of motor vehicles.

she is spun the highway association. why haven't we made progress in developing assessment tools that have been generally accepted and widely used? can there be anything done to do this? >> i think we are making some progress. some of the challenges aren't that the research that is needed to come up with valid tools it often expensive and time- consuming. we are not always able to do the trial but are the basis of

work in other areas. we can not necessarily randomly select older drivers. older driver research depends on recruiting volunteers prepare. apart from that, there is some disagreement on the best way to validate measures and the gold standard. should it be crashed risks? should it be differentiating scores by crash involvement? them weeny large samples. what is required? there is a lot of discussion. it goes the golan -- beyond

having this. we talked about licensing agencies bega. physicians have a small amount of time with patients prepar. there are a lot of these different issues that i think maybe a little messier than in other areas. >> elected the issues apply to screenings as well. the need individual impairment of prevalent in the community you are looking at to find it began . it uridine with an uncommon condition -- if you are dealing with an uncommon condition,

linking that requires a large sample to do capiit. they can test a number of things but then they will have records available to monitor that. the downside is gathering that information sufficiently. particularly have a limited amount of time. we are told me considering larger scales studies to try to narrow that a bit. >> is there a danger of using screening tools that have not been evaluated? >> i think that is a tough one.

i think there can be negative consequences when screening tills are not valid. it is a dilemma. people need resources to use burda i think with screening, that is one reason why it is so important to confine the outcome to being the first step. i think this would be extremely dangerous. >> it is a little bit like the anti-jeopardy. >> there is a danger to

labelling. it is something that has elected banks. if the label someone as being impaired, that can affect them adversely. there is a wide range. even me get there, there is manifestations. distinguishing that becomes difficult. the difficulty is not labeling based on the present staff using it to stop but that level.

>> the cost is about over interpreting. we have to be careful of the language we are getting people but >> they are intended for people that are cognitively intact they like insight into their abilities prepare.

in using sunscreen, there needs to be comnication about who to recommend that screening to and to make sure that hopefully it is done by people who can properly use it. >> when we are talking about assessments, are there any indicators and abide by those who memay not be able to dry or continue to drive? >> it would identify those that

would be able to be disqualified. >> some of the work is lopping off the ends. people really do not have any impairment in the sub areas. that might be enough to make that determination. it is the really mild to none decision that could be made. it does not push them to the next level. people that fall within a gray area has the next level of access to looking at their needs.

i'm not sure that answers the question. >> are there some that have more ability to drive performance and others? >> there are different demand for thes they have been demonstrated. the difficulty is narrowing it down to a single measure. >> in one of the previous flights, looking at the battery that came aout, there were 6 t

hat were linked with crazsh risks. a lot had to do with visuals. there are at least some evidence that is relat ively strong. the first one. these are the ability that had odd ratios of about 2.69 to 4.9. those, areas g ag at are in the domain and looking toward the stopping. you can have severe impairment and be able to compensate them.

>> we use aid as a marker. i turned 50 years old. i have a barbaric screening. i met risks for certain kinds of diseases. we always hear function and not h. because there is a concern about discrimination but ther is there any reason why we cannot determine age as and benefactor -- as a factor? correct one thing we observed with respect to age is a tremendous amount of variability.

it increases the function of , what age isests i not the best marker. it is clearly a deficiency for. i'm not sure we could set a chronological age. when you get too extreme ages, maybe this will be a more reasonable thing to do. in the general category of old age, there is tremendous variability in everything we measure and the. >> i'm looking at age based

mandatory screening. some more has come out of australia. the only state that did find a safety benefit was one that found that in person renewal among drivers age 85 and over was associated with benefit. i think there is widespread consensus among people that assessment should not be based on age. at the recent licensing workshop that brought together workshops, one that -- one recommendation was that there might be some room for a to based screening in the form of in person renewal. so people would have to come into the licensing agency and could be observed. >> thank you burd

>> most of us have had that question asked of us. what formal training deficiencies in medical school or through requirements or of their residency programs? how do they assess drivers? >> no formal training in general. it is variable in terms of the extent to which they had training in geriatrics. many times it will be covered within the context. otherwise, it is sporadic in terms of where the information

is predictive -- is. the issue comes up a lot. there is not any background information that is provided to prepar >> there are some guys available -- guides . available to what extent is a getting out to the physician community? >> there has been an effort to do outreach with that on a local level and more broadly. it would encourage effort to get that information out there.

there is an awareness that the information is there. there are major step forward for them. >> when the big problem with dementia -- one of the big problems was dementia. many folks are aware of when their vision starts to fail. to what extent is that really the major problem? to what extent the thing is that should be focused on?

>> deficit is common to many functional changes. they attenchange very gradually. with physical changes, one can be made aware of the deficit but thers that is less commonly the case in dementia. if things are pointed out, you can affect changes in the point out the deficit to them and

explain why they are likely to have a negative affect on their driving. it is a matter of going through the process. i do not think it is unique. >> one thing we were worried about was the screening. it seems to be a one-way road. it the panel talked about self awareness and letting people to make the choices. education experts should be the majority extra for this subgroup of dementia.

we want people to make good choices. they are making sure their seat belts are on the right but then. they are afraid if they expose themselves they are putting one tell and that getting the license taking away. we are all quite universally agreed that we want people to continue to drive us safer of

longer. we want access to people to share with them things we think will be useful. >> you have been talking about the mediation for an offense that occur in people like that affect their abilities to dry. he mentioned at the arc. there is an easy solution to that. if you can use your becoming user hands but there would also talked about solutions to a number of these problems we are not as far as having the driving completely where you could sleep on your way to work.

there are a lot of pential solutions here today. they may compensate for some of the things you are talking about. precognition issues are pretty difficult. to what extent do you consider and looking at assessment tools the availability of technological solutions to old take it up the table. if you know the extent to which engineering companies are looking at your material to try and find the solutions to your problems. >> i think the technological advances hold promise of the

dire consequences. if the head gps and on start in the vehicle with a person can be located, maybe that will assist with making some of these decisions of how far we can wait for a person to be able to drive with diminishing abilities. if we can employ the uses some of these devices, and might be able to assist them with the fear of getting the state of not knowing to. not knowing -- the fear of not knowing.

what is good for one and could for all. quite the word about pushing too hard. >> often there are technological solutions proposed for difficult aspects. there are over engineering solutions that may lead -- we do not know theythe nature.

>> i think there is an opportunity that allows us to get an objective that it to use that technology to do provide information about the driving. we have been involved and a few studies using people's lives early stages of dementia and having them dry as they normally would for a couple of months, collecting their data on their trip taking, exposure, self- regulatory behavior's, and then having them come back in and showing them essentially a summary of their driving in talking to them about problems they may have experienced. this is just some pilots work we have done. i do not know where it might go.

rather than thinking about technology to replace screening, what we need to move to thwart is much more of a systems approach similar to what is used in other countries. australia has a safe system approach to get it is based on the assumption that drivers are always calling to make honest mistakes and they need to make the road and vehicles as forgiving as possible the hallmarks of the systems are safe. it is, say vehicles. there will always be situations where drivers will this capability. >> in general, we are not very

good end getting into individualized assessment for t it is difficult. this is when you start school for them. this is when you start collecting social security. this is a colossal responsibility to try to figure how to do. there are different parts of

this that had to come together. we have a mandatory retirement age for a pilot may plea it is misguided. it was recently raised from 8 to 62 age 55 prada you have rigorous oversight. they get medical exams. we are not so good at trying to figure how to choose these things and other areas and medical exams allow people to be screened out early.

what can we do that is feasible? that is small comparatively. what is an older driver? what can you realistically expect society to do as far as screening and assessment? screening is not -- you are cutting of the curves. you haveiate that and giv to connect to all these things. you have to get additional assessments. had to make sure they are talking to each other? we have not figured it out.

what is it going to take to get this to the point where it actually does work? do any national legislation? we do have bidding stations for child states -- child seats. what do we need to do for older drivers th >> and deciding that those that do not do not have problems. policymakers are going to set those thresholds. it probably won't be the scientists. it often isn't.

it should be reliable across the population. i am not an expert from what i have read, we may not have those tests with this degree of confidence. first, we need those tests. we need your help. we do not have sample sizes that are sufficient we do not have those that transpire over this bill we need those kinds of studies in different instruments to predict the outcome. policymakers have to decide what is appropriate.

we have gone a chronological age. before we can get to using functional measures, we need a functional measures that have the credibility that we have confidence in. we need to decide what the cut of should be that some people in different directions. >> the you have any confidence that the studies that they could agree on the measure by 2025? >> they are pursuing some of these issues.

in national institutes of health has designed studies. it is possible to put together could the experts in different areas. we can start to collect the data. we can come to some conclusion. i think it is possible. >> in the meantime, i think it is a reasonable approach. we are defining what the response abilities are.

the family should be made aware of what they can look for. it did not be all on one group. having everyone be aware and setting the threshold at a high level. they can determine whether that threshold will be moved down to minimize the risks. >> and a lot of other countries that have system approaches, the issues of other drivers are in a broader strategic vision. i have been reading about the

effort and the u.s. which involves trying to come up with the same kind of strategic vision for transportation safety as exist in other countries for them i think that offers an opportunity to think about all these pieces and how they need to fit together brita. >> funding is a barrier. we put the burden on the licensing agencies. there are inconsistent funding approaches. some french people have to fund their own a valuation.

if we see someone at risk, where is the funding become our response ability to make sure we understand their abilities? it is a barrier. >> we have very clear guidance when it comes to drug and alcohol use. i'm curious. do we have any good guidance that. -- do you have any guidance on that? maybe we have a list the medications that can be a pairing -- in paring -

impairing that physicians need to be aware of. >> there are potential risks. there are some driver rehabilitation programs where people understand the impact. we take them out driving when they are a blow on the medications to assist with their

self awareness and helping people that must take a number of medications be able to self regulate. we are able to offer them that assistance. >> led the challenges that you identified is the role of physicians think they play a number of commercial drivers and not feel like they have a current obligation to report that they believe the primary is to do with their patients. trying to understand how you in part to then be a societal obligations. maybe i will close with a good news/bad news.

this is just from some personal experience. this is about how separated the system is. i went in to get my commercial driver's license renewed. i do not have any issues fell prevent me from getting a license, but i had to go to an audiologist ellis separate from the optometrist. it is clear to me that all the individuals were not talking to each other. i had my exam formed signed before the vision was completed. it is clear to me the primary person and not someone needed to be done.

i was a little bit of a guinea pig. i asked him about vision tests for drivers. well, and he made to me was, it is hard for him of he is asked to do is saying, can you read the charts. they can not comply with the direction when i'm trying to explain what they are trying to be doing. i think it is an example of how difficult it is when you have lots the news is that my mother is one of the drivers that is self selected for their to is

not to try and night or in bad weather. she always hands the keys to me. she said she does not see. she had cataract surgery not too long ago. she called me on the phone. she said he kids see. what struck me yesterday was that i'd bet my mama's fell point to go back and say now i can drive and night. his article tercel down. now that she had gained it back, i do not know what decision she makes coming after that. i would love to be able to see a screening program work for people who can go in reverse.

it tells people who may have more performance than they know. this is the real challenge to have as policymakers. we are a little bit late on the schedule. i hope you would be a favorable for the questions that cannot get asked to share with our researchers. >> thank you for being here. what time is it? we are going to have the movie again. this is lent to show at 12:00. we actually have a lunch break

until 12:30 p.m. today. [captioning performed by national captioning institute] [captions copyright national cable satellite corp. 2010]

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