Editorials

REINVENTING AMERICAN TOBACCO POLICY: SOUNDING THE MEDICAL COMMUNITY'S VOICE

1998 may be the most important moment in the history of the tobacco wars, a
moment when America chooses between a path toward social repair or one
toward irrevocable public loss. Winston Churchill said, "Americans can be
counted upon to do the right thing-after trying everything else." This
year, Americans may finally do the right thing. After years of growing
public and professional awareness of the addictiveness of nicotine of the
health effects of tobacco, and of the tobacco industry's extensive efforts
to target young children, federal laws may be enacted to seriously weaken
the grip of the industry on the public and on the nation's health.
Conversely, there is the risk that the tobacco industry could further
entrench its ability to stand outside the ordinary rules of commerce in
society.

In large measure the outcome depends on the strength of the voice and
message from the medical and public health professions. We must ensure that
protection of the public's health prevails as the foremost issue and
becomes the ultimate decision force.

Surely there is not a physician who is unaware that the tobacco industry
has increased its power and profits by securing a host of special
exceptions to the ordinary rules that regulate business practices. Surely
there cannot be a physician who believes that it is professionally ethical
or socially responsible to be silent as Congress begins to consider how the
tobacco industry should do business in the future. It is time to volunteer,
to learn, and to speak out.

What is achieveable by Congressional action has expanded significantly.
Policies once thought undoable are now possible. In part, this is because
of recent and growing disclosure of past tobacco industry misconduct and
mendacity. In part, this is also because of the extensive work behind
closed doors between the tobacco industry and state attorneys general over
Medicaid expenses for tobacco-caused illnesses(often referred to as 'the
settlement". For whatever r reason, the time has come to break the tobacco
industry's long-standing strangle hold on the major institutions of
political power in the United States; Now Congress, not the tobacco
industry, will determine how this country will clear with tobacco into the
next century.

But although "the settlement" helped move the public policy

clebate d hole it should be-to the US Congress-it is only a private
agreement constructed by lawyers. It has no legislative legitimacy. It is a
wish list of the parties involved. And it is too low a goal for the
nation's health.

Can a few hundred billion dollars of tobacco money be used to initiate
public health efforts? Of course. If the tobacco industry prevails in
Congress, will this money be sufficient and just compensation? Of course
not. Even if grossly insufficient, will funds become available? Perhaps,
but the tobacco industry is not known for living up to its promises. Why is
the tobacco industry so eager to be responsible for distributing funds?
Perhaps because such a mechanism bypasses Congressional authority and makes
recipients dependent on the tobacco industry no less than tobacco
advertising r revemles and philanthropy have done in a host of enterprises.

For years, the tobacco industry has marketed products that it knew caused
serious disease and death. Yet, it intentionally hid this truth from the
public, earl iecl out a deceitful campaign designed to undermine the
public's appreciation of these risks and marketed its addictive products to
children. The industry long ago knew that nicotine was addictive, but kept
its findings secret and consistently denied the fact, even as overwhelming
evidence to the contrary eventually emerged.

By these actions, the tobacco makers have shown themselves to be a rogue
industry, unwilling to abide by ordinary ethical business rules and social
standards. Other businesses operate differently. For example, design
defects in a motor vehicle are unintentional; when they are discovered,
steps are taken to correct them. Nevertheless, such manufacturers are held
liable for these mistakes.

By contrast, the tobacco industry has intentionally designed and marketed
addictive, lethal products and deliberately hidden their well-known risks.
These actions are morally r reprehensible. Yet, the tobacco makers have the
shamelessness to ask to be excused from om liability for their informed and
deliberate actions. How would we respond if the makers of cars knew their
gas tanks would explode and their brakes were defective, had hidden these
flaws, marketed these v ehicles, lied when caught, and then made a similar
request? To allow any industry to continue such acts without restriction,
indeed weakening or cutting the impediments of oversight and restraint that
exist, would be irresponsible in the extreme.

No other industry even begins to approach the tobacco industry's ability to
market a product of such mass lethality. No other product so massively and
effectively injures and kills people as does tobacco, especially
cigarettes. Moreover, the industry does so while reaping huge profits by
shifting tobacco related health, social, and environmental costs onto the
public's shoulders.

Incredibly, even though some in the tobacco industry have now acknowledged
some smoking-related health consequences and addictive properties, they
have offered no apology and have the audacity to deny wrongdoing. Even
worse, manufacturers have launched the greatest lobbying campaign ever
known, tens of millions of dollars just in 1997, in an attempt to receive
from Congress pardons for all its past and future liability. Some of its
audacious requests would require making exceptions to the fundamental
rights of due process for individuals, while others would override state
and community rights.

The tobacco industry is doing so in part because it is fearful that damning
evidence will be disclosed in trials.2 It is willing to pay any price to
prevent internal industry documents fi om surfacing. Thus, besides its
Congressional lobbying, the tobacco industry agreed to pay $14.7 billion to
settle the attorneys general suits with Mississippi and Florida, and $15.3
billion with Texas in part because it cannot bear to have its true behavior
see the light of day before it secures protection from Congress. If the
whole truth were known (and much more may come out during the Minnesota
court case), we believe members of Congress would have to distance
themselves completely from the industry.

Yet, even as public condemnation of the tobacco industry becomes louder and
as the public becomes better informed, the industry is continuing with
business as usual. It claims that it does not w ant children to smoke ancl
then promotes advertising that appeals primarily to children. It says that
it is prepared to live with meaningful government oversight and then fights
every local initiative and every tough public health proposal. To keep
going, it hires lawyers, advertising agencies and lobbyists at enormous
cost and increases campaign contributions w ith an intent to maintain its
influence v ith state legislatures and Congress.

But Congress is now aware of choices that were not once so apparent.
Political leaders from both parties have called for strong action and have
introduced far-reaching legislative proposals. However, is the voice of
reason being heard against the loud blare of tobacco industry propaganda?
How can we ensure that the tobacco industry does not, with its effective,
time-proven lobbying effort, undermine effective, comprehensive legislation?

In the final analysis, it is the medical and public health community that
must take esponsibility for keeping the focus on the public's. We must
clearly define issues so that both the public and members of Congress
understand them and are moved to take the socially responsible course of
action. For example, in December 1997, the House of Delegates of the
American Medical Association (AMA) aclopted policies that enable its
leaders to more effectively engage in the legislative development process
calling for strong, effective national legislation without kow-towing to
the tobacco companies or acquiescing to their demands for legal protection.
Such steps give voice to all AMA members ancl distinguish the organization.
Although such steps are essential and commendable, they alone are
insufficient.

This spring Congress will finally begin to take a serious look at
comprehensive tobacco control legislation. We believe each physician has a
responsibility to seize this moment in history and to use every means at
his or her disposal to convince members of Congress to enact meaningful
tobacco legislation.

Tobacco use is the ultimate underlying cause of nearly 1 of every 5 deaths
in the United States year after year. Our voices should scream with outrage
against the fundamental unfairness of the legislative loopholes and special
privileges that have allowed the tobacco industry to become the gargantuan,
extraordinarily proftable business that it is. It has done so only by
discounting horrendous public health losses. We must be persistent in our
demand for socially responsible Congressional action.

The medical profession and public once reluctantly accepted as fact that
half of smokers will die of a smoking-related disease because clinicians
could not do much to help smokers quit, avoid relapse, or never start. That
attitude is fading away as scientifically sound smoking cessation methods
are increasingly integrated into clinical practice.4 Likewise, it was once
accepted that the Congress would not act without the acquiescence of the
tobacco industry. But that attitude should also fade as the facts about the
industry become increasingly known through the exposure of previously
secret documents. The Congress need not feel that it has to make any more
concessions to this rogue industry.

Major issues that each physician should know well, teach, and advocate include:

* The protection of Food and Drug Administration (FDA) authority to
regulate all areas of nicotine and other constituents and ingredients in
tobacco.

The FDA should have the authority to increase its tobacco research and
scientific communication authority, have greater scope of its regulatory
authority as evidence suggests, ancl have adequate funds to implement all
its various regulatory, enforcement, public education, and research
activities.

* The protection of children and youths from wanting and using tobacco.

Federal statutes should include measures such as strong and effective
warning labels on products; substantial penalties for distributing to
youth; increased public education; effective school policies; research
including behavioral research on underage tobacco use and countermeasures;
an effective system of excise taxes, fines, enforcement methods; and
funding for organizations that protect children and youth from tobacco.

* The funding of sound programs, established scientifically, are used to
help nicotine-dependent individuals quit, be they adults or minors.4,5

Such programs should include meclical financing systems, professional and
public education, and behavioral ancl cessation research. Programs should
be funded by the tobacco inclustry, but not by means that the tobacco
industry could influence.

* The refinement and expansion of the regulation of environmental tobacco
smoke.

Provisions shoulcl include policies and funds for establishing and
enforcing smoke-free public and U-ol k environments, public education, and
risk assessment research.

* The protection of the justice system by disclosure to the public of
evidence of past tobacco inclustry misdeeds, such as the recent revelation
of the planned marketing to children.

This should include preventing the tobacco inclustry from receiving
protection against past, present, or future wrongdoing and the funding of
systems to investigate misdeeds and deliver justice.

* The prevention of federal law from overriding stronger and/or more
diverse state and community regulations.

Federal law designed to protect public health should always be a floor that
state and local governments can and to and strengthen.

* The establishment of groundwork for much better accountability and
broader control of the tobacco industry in the future, ie, international
issues, protection of tobacco farmers and farmland, and the like.

Historically, state and local laws have been as effective as, if not more
so than, federal statutes. Thus, legislation should include specific
statements that ensure that state and local laws that strengthen public
health are not vaguely supported in large print and
specifically destroyed in small print. Federal public health legislation
must be expressed in terms that establish a minimum level of protection
above which states and communities are able and encouraged to do much more
and to innovate where federal laws are silent.

Basically, the tobacco industry seeks 3 fundamental refuges. First, it
seeks to protect itself from accountability for past, present, and future
wrongdoing. Second, it seeks to diminish or weaken individual and group
access to the fundamental right of due process. Third, it seeks to limit
federal agencies from having oversight and regulatory authority. It also
seeks, through 'the settlement," to obtain a measure of social
respectability-to be seen as a responsible member of the business world
rather than a group of Corporate renegades that operate outside the bounds
of social norms. The extent that the tobacco industry has gone to secure
special privilege and protect itself, individually and collectively, from
liability from past and future health effects from tobacco use has raised a
red fag in the public health community. With such a glaring difference
between what is right and wrong for the public, Congress should have little
difficulty in choosing a course that contains no deals and no trades. We
support tobacco legislation by Congress, but are opposed to granting any
concessions to the tobacco industry

C Everett Koop, MD

David C. Kessler, MD

Geolge N. Lundberg, MD

1. Todd JS, Rennie D, McAfee RE, et al. The Brown and Williamson
documents: where do we go from here? JAMA 1995;274: 256-258

2. Brandt AM, Richmond JB, Settling short on tobacco:let the trials
the trials begin JAMA 1997;278:1028.

3. McGinnis JM, Foege WH, Actual causes 0f death in the th United
States. JAMA 1993;270:2207-2212.

4. Cromwell J, Bartosch WJ, Fiore MC, HasseIblad V, Baker T.
Cost-effectiveness of the Clinical Practice Recommendations in the
AHCPR Guideline for Smoking Cessation. JAJI.1997;278:1759-1766

5. The Smoking Cessation Clinical Practice Guideline Panel and Staff.
The Agency for Health Care Policy and Research Smoking Cessation
Clinical Ptactice Guideline. JAMA 1996;275:1270-1280