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After
Some 100 Million Deaths -- What's Next?
K.H. Ginzel, M.D. (khginzel@yahoo.com),
is Professor Emeritus of
Pharmacology and Toxicology at the University of Arkansas for Medical
Sciences.
Other Papers by Dr.
Ginzel in this web site:
After Some 100 Million Deaths -- What's Next?
"In a time of universal deceit, telling the truth is a revolutionary act." — George Orwell
After
Some 100 Million Deaths—What's Next? written by K.
H. Ginzel, M.D.
To attempt an answer to this question, we must first assess the
current situation. As I see it, it is bleak to the extreme.
After more than 20 years of intense efforts in helping fight the
unparalleled human tragedy of disease and death caused by tobacco
use, I feel utterly frustrated, angry, defeated, hopeless, and cynical.
More so, I am inescapably losing respect for a society and a culture
that has permitted this state of affairs not only to materialize, but
also
to persist essentially unabated.
The admirable, untiring work of a dedicated tobacco control
community has in no way been matched by the actions that would
be necessary on the part of those individuals and institutions who
alone have the power and responsibility to stop the victimization of
the people of this nation and of the rest of the world. Governments
have largely remained aloof, while the tobacco cartel has been riding
out crisis after crisis—especially the one of the last decade—by
practicing and perfecting their well-seasoned deployment of cunning,
craftiness, and deceit. That Big Tobacco managed to survive the
most recent turmoil virtually unscathed is primarily reflected in its
success in securing the next generation of its customers. Despite all
the adverse media publicity that tobacco received during the 1990s,
teen smoking in America rose during that period, and overseas
expansion of tobacco trade has also been progressing at an ever
increasing pace. "Business as usual" continues to thrive, prompting
leading epidemiologists to predict worldwide tobacco-related
mortality to reach 150 million in the first quarter, 300 million in the
second, and a grand total of one billion (!) during the 21st
century—figures that dwarf any statistics from other known causes.
Not only is tobacco killing its direct users, at an annual toll of over
400,000 in the United States alone: it also claims the lives of an
estimated 60,000 nonsmokers who die from a similar range of
diseases as smokers, but in their case caused by exposure to
environmental tobacco smoke. It has now been 15 years since
Harvard epidemiologist John Bailar stated in The New England
Journal of Medicine that the "sharp and continuing rise in deaths
from lung cancer, nearly all from cigarette smoking, is now widely
recognized as a medical, social, and political scandal."
Who are the players in this gruesome drama?
Foremost, they are
the purveyors of the deadly merchandise. They also include the
nation's youth— targeted, tricked, and manipulated into lifelong
dependency; an army of biomedical scientists who dispassionately
measure, count, and transform human suffering into impersonal
numbers; and, at the other end of the spectrum, us—the tobacco
control advocates and activists, emerging from every part of society
and trying desperately to contain the mayhem. Sprawling across the
entire scene is finally the government—federal, state, and local
officials who duplicitously cater to both the sellers of death and their
frustrated opponents. All in all, we are witnessing an arrangement of
remarkable stability and continuity that, barring radical change,
offers little prospect for a resolution in the foreseeable future.
To grasp the enormity of it all and put a human face on the abstract
numbers, we only have to pause and envisage, however feebly,
the
dying and death of some of the estimated 100 million victims that
smoking has claimed thus far. The unspeakable agonies of dying
from cancer of the lungs or larynx, the slow suffocation of those
afflicted with emphysema, and the fatal heart attacks in the prime of
life conjure up visions of bodies lined up in endless rows, bodies
fallen victim to violence turned inward, ravaged by a product whose
dangers have been known but insidiously concealed by its
manufacturers for almost five decades. These images are
fundamentally no different from those of the death camps and mass
graves the last century has witnessed in Nazi Germany, the Soviet
Union, Cambodia, Rwanda, and Bosnia.
Although our pro-health advocacy has steadily gained in
membership and momentum, the tobacco industry has been able
repeatedly to boast record profits and exports, matched only by the
rising toll of tobacco-related disease, disability, and death encircling
the globe. The industry has skillfully absorbed what, at first glance,
may have appeared a major setback, such as the 1998 Attorney
Generals' settlement, which amounted to some $240 billion to be
paid to the states over a period of 25 years. However, it simply
enticed the recipient governments to spend the windfall moneys for
anything they like except tobacco prevention, because reducing
smoking would contractually also reduce industry payments. The
most recent analysis attests to the industry's success: only a
miniscule 5 percent of the settlement has been used for the originally
stated purpose.
What Are the Antecedents to the Present Dilemma?
FIRST, it is the unceasing, undiminished pursuit of the
youth
market
by tobacco corporations, which employ ever changing strategies of
attack, aided by our stubborn persistence in the irrational (I will
explain later) belief that common ground and mutual trust can
eventually be found. During the past half-century, public health
groups as well as government officials have repeatedly tried to seek
some sort of accommodation with the manufacturers of tobacco
products. A case in point is the industry's voluntary code of
advertising, launched some 20 years ago, which promised not to
prey on the vulnerabilities of the young. Yet precisely the opposite
has happened, as thousands of secret company documents
summoned during recent court trials have chillingly revealed. Flying
in the face of such unabashed lies as "We don't want children to
smoke" or "Smoking is an adult custom," or "It is an adult
choice"—all craftily phrased to lure kids into lighting up—the
industry mounted a monumental marketing scheme bluntly directed
at teens and even preteens. Several other empty commitments were
voiced over time, each of them designed to rekindle confidence and
stir fresh, unrealistic expectations among tobacco control advocates
who were still hoping for change.
The tobacco industry has resisted true change throughout its long
history. The first opportunity for change offered itself most forcefully
when in 1942 Lennox Johnston's landmark report in the British
medical journal The Lancet identified nicotine as the active agent in
tobacco responsible for the pleasant sensations experienced by the
smoker. Johnston proposed that smoking tobacco was essentially a
means of administering nicotine, just as smoking opium was a means
of administering morphine. In 35 volunteers he found that nicotine
injections not only simulated cigarette smoke inhalation but were
also actually preferred to a cigarette. The second major opportunity
for change followed only eight years later, when the first solid
evidence surfaced that incriminated cigarette smoking as a cause of
lung cancer. At that juncture, the tobacco industry could have
followed the example of the pharmaceutical industry, which had
already scored remarkable breakthroughs by identifying, isolating,
and purifying active ingredients from natural products—such as
morphine from poppies, salicylic acid from the bark of willows,
reserpine from Rauwolfia (an ancient herb in India with medicinal
properties), curare alkaloids from South American arrow poison,
penicillin from mold, and many more. All of these can now be used
safely in specified dose ranges to treat a variety of medical
conditions.
The tobacco industry could then have concentrated on developing
nicotine preparations free of the unnecessary burden of thousands of
toxicants and carcinogens contained in the smoke of ordinary
cigarettes. Fifty years ago, the tobacco industry might even have had
a chance to obtain FDA approval, since the addictiveness of
nicotine, though alluded to by Johnston, was then far from being
generally recognized or experimentally confirmed. That the industry
failed to do what modern medical research in other areas had been
doing all along, suggests that addiction liability and FDA regulation
must have raised a red flag even then.
Rather than focusing on nicotine and removing the toxic
contaminants, the cigarette makers took the opposite course and
actually added several hundred chemicals as tobacco additives.
These additives served various purposes, but they especially helped
to smooth and aromatize the rough smoke of natural tobacco so that
kids and women would be able to tolerate it and become hooked
more rapidly as nicotine was made available to the huge surface
area of the lungs upon inhalation. The rest of
the
story is one of
unprecedented lies and deceit, denying and obscuring the truth
about the carnage wreaked upon this country and much of the world
by the cigarette makers.
This is the same industry that several lawmakers, during the
tumultuous congressional negotiations in 1997, considered worthy of
protection from legal liability in return for $350 billion and certain
concessions, whose effectiveness in reducing tobacco use was still
largely in doubt. Fortunately, the concerted effort of our nationwide
coalition "Save Lives Not Tobacco" averted the passage of any
such bill. It would be truly unthinkable that the U.S. Constitution
should ever be so subverted as to fit the schemes of an industry that
wants to continue selling death with impunity. In a letter printed in
The Washington Post on September 21, 1997, I wrote in the
closing paragraph: "If this type of mind-set had prevailed at the end
of World War II, we probably would have stopped our advance on
the beachhead at Normandy, made peace with Hitler and argued
about the least offensive way to keep the concentration camps
operating."
In its most recent PR ploy, the tobacco industry, faced with a
mountain of undeniable revelations about its conduct, tried to
portray itself as a reformed industry. Because it has reformed, so the
industry implied, it should not be judged by its past actions. In June
2001, the Campaign for Tobacco-Free Kids and Action On
Smoking and Health in London released a report, entitled "Trust Us:
We're The Tobacco Industry." It contains over 250 quotes from
internal tobacco industry documents on topics from addiction and
advertising to women and youth smoking, and indexes the dozens of
countries mentioned in the documents.
The evidence is overwhelming that the tobacco industry has not
changed.
While they claim they have reformed and are now "nice" and
"responsible," their own documents tell a different story.
All this is just a repeat performance. The few allegedly corrective
actions the industry and its allies have taken over the years were
either evasive or merely feigned changes in attitude. Noisy
ostentations of tobacco company CEOs vowing to keep kids from
using tobacco, have repeatedly misled naive observers who were
willing to detect a trait of responsibility in the industry's actions
and
even entertain variations on the theme "Can the tobacco industry be
trusted to protect our children?"
Industry efforts to emasculate public health initiatives are now being
aimed at the current WHO agenda—the Framework Convention on
Tobacco Control—which is seeking worldwide consensus to stem
the tide of the tobacco pandemic. Here the industry found an
unexpectedly new ally in the U.S. delegation, which was lately
directed to relax its earlier stance of firmly supporting a global
treaty
with teeth in it. Representative Waxman accused administration
negotiators of doing everything they could to prevent the creation of
strong global standards. During the third round of negotiations in
November 2001, the United States continued to take positions on
tobacco advertising, consumer protection, trade, and other issues
that would protect the interests of the tobacco industry rather than
public health. Philip Morris had this to say on its web site: "We do
not agree . . . that tobacco use is an 'epidemic.' And we are
concerned that certain proposals by WHO fail to recognize tobacco
consumption as a legitimate choice that adults should be free to
make." Tobacco giants admitted in Geneva in 2000 that smoking
cigarettes was dangerous and addictive, but defended their right to
sell and advertise them freely.
That year, after reviewing all of the new postures adopted by Philip
Morris, BAT, Japan Tobacco, Imperial Tobacco, and Gallaher, the
U.K. House of Commons Health Committee concluded that the
tobacco industry had not really changed, but rather had only
enhanced its public relations machinery. The industry continues to
aggressively promote tobacco use in every corner of the globe,
often in ways most effective at reaching youth. In the U.S., tobacco
industry marketing expenditures have achieved a new annual high of
over $8 billion, according to the latest report.
The SECOND most important factor leading up to the present
situation is the failure to achieve FDA regulation of tobacco
products. The push for such regulation as envisaged by Dr. David
Kessler, then Commissioner of the FDA, and widely supported by
the health community, President Clinton and some members of
Congress, was unfortunate. It contained the seeds of failure from the
start.
In a letter to Dr. Kessler of May 3, 1994, which I also sent to the
President, I stressed that the shape that such regulation would take
seemed to be highly problematic. Then I asked: "How would a
tobacco product that contains nicotine and is used for the sole
purpose of satisfying a craving prone to lead to serious health
consequences qualify as a 'drug,' defined 'to include all medicines
and preparations recognized in the U.S. Pharmacopoeia or National
Formulary for internal or external use, or any substance intended for
the cure, mitigation, or prevention of disease in man or animals'
(Arthur H. Hayes, MD, Commissioner of FDA: Food and Drug
Regulation After 75 Years, JAMA: 246, 1223, Sept 11, 1981)?
How would a tobacco product comply with the 1962 Amendment
requiring manufacturers to prove on the basis of substantial evidence
that the drug is safe and effective, when such a product is in fact
unsafe, and effective only in killing more than 400,000 Americans
each year?"
In an invited presentation, entitled "Science-Based Tobacco Use
Control: The Future Is Now," at the Dixy Lee Ray Memorial
Symposium on Science-Based Environmental Management, in
Seattle, August 30 to September 2, 1994, I again took issue with
the proposed FDA regulation of tobacco in conjunction with two
1994 bills, HR 2147 and S 672, seeking to amend the Federal
Food, Drug, and Cosmetic Act to include tobacco products. I
reasoned that such an amendment "would totally subvert the
well-defined, time-honored charge of the FDA to provide the
American consumer with safe and effective therapeutic agents and
non-harmful food and cosmetic products. The regulation by the
FDA of a prodigious mixture of a few thousand chemicals, replete
with potent poisons and powerful carcinogens, which are smoked or
ingested for no purpose other than to satisfy a craving for nicotine,
would seriously undermine the credibility of a federal agency known
and respected for its health-oriented mission."
A year or two later, an almost identical argument was raised by
attorneys for the tobacco industry who filed a lawsuit trying to
prevent an FDA rule. If the court says the FDA has jurisdiction over
tobacco, the industry argued, the FDA must ban tobacco, because
the law insists that products under the FDA's purview must be "safe
and effective"—a standard no tobacco product can meet. The case
finally reached the U.S. Supreme Court, which, on March 21,
2000, rejected FDA jurisdiction over tobacco, stating that the
government lacks authority to regulate tobacco as an addictive drug.
Ruling 5 to 4, the justices said the FDA overreached when it
reversed a decades-old policy in 1996 and sought to crack down
on cigarette sales to minors. During their deliberations, some justices
were skeptical that an agency charged with monitoring "safe and
effective'' products could bring cancer-causing tobacco products
into its domain. "It just doesn't fit,'' said Justice Sandra Day
O'Connor. "It strains credibility to see how these products can be
safe,'' she added.
O'Connor and other moderate and conservative justices suggested
that the FDA would have no choice but to ban cigarettes and
smokeless tobacco if it did begin to regulate them.
In the same May 3, 1994, letter to Dr. Kessler, in which I
questioned the appropriateness of proposing FDA jurisdiction over
tobacco, I pleaded for the placement of nicotine—an agent with
proven addictive potential—under Schedule II of the Controlled
Substances Act of 1970, along with morphine and other opioids of
clinical usefulness, thus permitting the continued use of nicotine in
the
treatment of nicotine addiction. As a consequence, nicotine-free
cigarettes and other tobacco products would quickly fall out of
favor and bring an end to the 20th century nightmare of self-inflicted
disease and death.
The THIRD integral factor in this analysis is the failure of the federal
government and the majority of state legislatures to protect
summarily the nonsmoking majority of this country from exposure to
environmental tobacco smoke (ETS). Next to keeping its
foothold
on the youth market, the tobacco industry's major concern has been
to preserve "smokers' rights" to smoke in the workplace, in the
public arena, and especially in restaurants and in bars. This is why
Big Tobacco viewed the nonsmokers' rights movement as "the most
dangerous development to the viability of the tobacco industry that
has yet occurred" (1978 Roper Report).
It is imperative that the Occupational Safety and Health
Administration (OSHA) finally live up to its charge to protect
employees from harmful exposures, which include those to tobacco
smoke. The general duty clause of the Occupational Safety
and
Health Act of 1970 states in Section 5 (a): "Each employer shall
furnish to each of his employees employment and a place of
employment which are free from recognized hazards that are causing
or are likely to cause death or serious physical harm to his
employees." In the past, OSHA has consistently dodged its
responsibility. Despite persistent efforts and repeated lawsuits
against OSHA by the Action on Smoking and Health (ASH),
OSHA continues to procrastinate and delay action on a nationwide
workplace smoking ban.
In a written testimony submitted to the Senate Hearing on ETS on
April 1, 1998, I tried to spell out the multifaceted aspects of lacking
or providing a smoke-free environment. The
physical
harm inflicted
by many of the more than 4,700 chemicals and 60 carcinogens in
ETS has its greatest impact during pregnancy. This is when
nicotine,
a neuroteratogen, can interfere with fetal brain development, and
when potent carcinogens, such as nicotine-derived NNK, invade
growing organs not yet protected by mature DNA repair
mechanisms. Impeccable research defining ETS-related morbidity
and mortality, conducted by reputable scientists at prestigious
institutions, has been maliciously attacked by tobacco interests,
including industry front groups, with no letdown at a time when the
industry pretended to reform. The industry vigorously and viciously
opposes a smoke-free environment most probably because the
absence of smoking in the public domain, which could eventually
spill over into private residences and family automobiles, would
eliminate a crucial incentive for children to experiment with and start
smoking cigarettes themselves. It would also help smokers quit. The
exposure of children to ETS has inflicted widespread physical and
psychological harm, prompting Dr. William G. Cahan of Memorial
Sloan-Kettering Cancer Center to call it, in a March 1985 New
York Times editorial, the most prevalent form of child abuse.
Although smoking in enclosed air spaces has diminished, as more
and more local clean-indoor-air laws have been enacted—often
requiring an undue amount of time, energy, dedication, and nerves to
implement their passage—smoking on the television and movie
screen has recently taken off, obviously to keep smoking behavior
well in the public eye.
The need to provide a smoke-free environment is not less important
than the need to help smokers quit and to keep children from
starting to smoke. All are integral parts of the same problem and
should not be separated from one another. The disappointing
outcomes of our past and present programs in prevention and
cessation are no doubt a consequence of the fragmented and
restrained approach that varying circumstances beyond our control
have forced upon us.
So, Finally, What Are We Going to Do Now?
As a general guideline: We need a total turnaround from the manner
in which we have been dealing with the tobacco issue in the past.
We need uncompromising honesty. We need to recognize and end
the reassuring self-delusion we have so comfortably indulged in. We
need to acknowledge once and for all not just the obvious—that the
tobacco industry has never kept its commitments—but also the
hidden fact that it actually CANNOT be expected to behave
differently.
The reality is simply this: The tobacco industry makes and markets a
product that is highly addictive and maims or kills when used as
intended. No other product officially traded on world markets
shares this unique notoriety with tobacco. The continued prosperity
of the industry depends on three basic requirements: Most
importantly, it depends on the successful recruitment of children and
adolescents into the ranks of smokers. Statistics have compellingly
shown that very few people ever start to smoke after age 21. This is
why the industry has vehemently opposed any legislation that would
have raised the legal age for buying tobacco products above the age
of 18. Since many high school seniors are 18 years or older, they
can legally buy cigarettes and sell them to their younger classmates.
Secondly, the cigarette business depends on the pervasive visibility
and the continued social acceptance of smoking as part of normal
human behavior. And thirdly, the industry
depends
on the calculated
presence of nicotine in tobacco in amounts sufficient to produce
and/or maintain addiction and thus to assure customer loyalty in the
face of alarming news from the health front.
To expect that one of the most powerful industries—and probably
the most lucrative enterprise on the planet—would voluntarily
compromise or make serious concessions in any one of these vital
preconditions for its survival is totally unrealistic; in fact, it
would
be
tantamount to expecting the industry to commit suicide.
Finally, we need to admit that, by deluding ourselves, we have all
been playing an unending game—call it "enabling" or call it
"co-dependency"—whose outcome is counted in millions of children
starting, and millions of smokers dying from, tobacco use. The
perennial question asked in this game of life and death has been this:
How do you plan to stop the tobacco companies from targeting
kids? The fact that we have asked this very question unremittingly
over the past half century is the root of our failure. It is a
no-brainer!
But it surely has helped retain the status quo.
This question is, in fact, as absurd as to ask
whether
the tubercle
bacillus can be persuaded not to cause tuberculosis, or HIV not to
cause AIDS. The "business," so to speak, of the tubercle bacillus is
to cause tuberculosis; the "business" of HIV is to cause AIDS; the
business of the tobacco industry is to market a product that
inadvertently kills. To be sure, the manufacturers would be
pleased
if it wouldn't, but it does. At the least, the delayed onset of disease
guarantees many years of profitable consumption.
Recognizing these self-evident facts calls for a fundamental revision
of our approach. We must stop treating the
tobacco
industry as a
partner in negotiation, as an organization run by people like
ourselves with whom we can talk and reason. We must confront
them as a quasi-nonhuman entity, as a carrier or vector of disease, a
pathogen like the tubercle bacillus or HIV. We don't make a "deal"
with the germs that produce disease and death—we try to eradicate
them.
In the case of an epidemic in the conventional sense, we turn to the
Centers for Disease Control and Prevention (CDC), which swiftly
mobilizes a concerted effort to stop the outbreak. The CDC and
several other institutions under the umbrella of the U.S. Department
of Health and Human Services (U.S. DHHS) are also involved in
fighting the epidemic of tobacco-related illnesses, but here their
options to act are severely limited. For one thing, this epidemic is
not caused by a simple microbe, but rather by a product legally
manufactured and sold by American industry. The major constraint
the U.S. DHHS faces, however, is imposed by the same
government of which it is a constituent. A quote from a court
opinion in the Cippolone lung cancer trial refers to the intention of
the U.S. Congress as "seeking a carefully drawn balance between
the purposes of warning the public of the hazards of cigarette
smoking and protecting the interests of the national economy."
Obviously, the carrier of tobacco-related diseases has infiltrated the
very institution elected by public vote, whose sworn charge and duty
it is to uphold the tenets of the Constitution, mindful of the
Unalienable Rights to Life, Liberty and the Pursuit of Happiness that
the founding fathers have proclaimed for the people of this nation. A
recent commentary from Downing Street, with respect to a
proposed workplace smoking ban in Britain, also invokes the
concept of "balance" that has to be "achieved between desirable
health objectives and being sensitive to the problems of restricting
business practice."
There is still another economic perspective: Tobacco business
allegedly saves the treasury billions by killing people before they
deplete social security and pension funds. Calculations of this kind,
however flawed, have been attempted not only by industry but also
by governments.
Here are a few examples from the industry:
Philip Morris vs. Czech
economy analysis that made headlines in 2001, stating that the
premature deaths of smokers saved the country millions in health
care costs; a 1993 report commissioned by Imperial Tobacco
stating that tobacco-related deaths are an economic advantage to
Canadians because cigarettes kill people before they become a
burden to the healthcare system; and a November 1978 secret
document from the British American Tobacco Company, talking
about what they call the "social cost" issue in rather chilling
language:
". . . with a general lengthening of the expectation of life we really
need something for people to die of. . . . In substitution for the
effects of war, poverty and starvation, cancer, as the disease of the
rich, developed countries, may have some predestined part to play."
According to Milton and Rose Friedman, corporate officials have
only one "social responsibility," i.e., to make as much money for
their shareholders as possible. The best guarantors of maximum
profitability in the long run are product quality and product safety. In
the case of tobacco, however, these market forces are suspended
by the addictiveness of the products. Here, governmental
intervention is necessary to protect the consumer. In their wisdom,
the Framers of the Constitution granted Congress the right to
regulate commerce, empowering the U.S. government by the
"Commerce Clause" of Article 1, Section 8, of the Constitution to
stop the interstate trade of dangerous merchandise. If this authority
would be exercised in the case of tobacco, it could usher in the
beginning of the end of tobacco marketing. Such action must clearly
be distinguished from prohibition, since individuals would still be
able to grow tobacco strictly for personal use.
It would, indeed, be a bold move. Yet extraordinary challenges
require extraordinary responses, whose feasibility and whose legal
and legislative ramifications must be seriously explored. The
inescapable truth, sadly affirmed by past experience, is that no
intervention of any kind can be expected to protect children fully
from being targeted by Big Tobacco. Recruitment of children as
future consumers is the sine qua non of the survival of the tobacco
industry.
Therefore, if government and society honestly want kids not to
&nbs