Per Annette's excellent suggestion, this is a discussion thread where interested readers can participate in a discussion of the scientific evidence regarding the health effects of secondhand smoke. I will initiate discussion by presenting some of the reasoning that I and other researchers have used in concluding that secondhand smoke is the cause of various diseases. I will then make myself available to try to answer questions readers have in understanding the reasoning behind those conclusions or in responding to arguments against the conclusions.
However, I want to emphasize that I do not view this as an attempt to convince anyone of anything. Instead, it is intended more as a forum where people can discuss the issues, ask questions, and more importantly, hopefully come to a better understanding of why different people have come to various conclusions. Hopefully, by understanding where people are coming from, it will help to break down some of the stereotypes (largely derived from certain anti-smoking groups) that those who disagree with certain conclusions are merely tobacco industry fronts.
The first topic for discussion will be the California Environmental Protection Agency's conclusion that secondhand smoke is a cause of heart disease in nonsmokers. This conclusion, and the basis for it, is discussed in Chapter 8 of the Cal-EPA report.
A link to this discussion thread has been placed in the upper right-hand corner of my blog, so that you can come back and contribute to and/or read the discussion thread anytime, and so that we can move on to other topics as we go forward.
I will initiate the discussion by bringing up an important aspect of the process by which epidemiologists evaluate a causal hypothesis. Perhaps the first step is to determine whether there is a consistent relationship between the exposure and the disease in question and whether that association, if present, could simply be a result of chance.
The process by which the results of the studies are evaluated is called meta-analysis. This is an attempt to pool together all the relevant studies on a topic and to see if viewed all together, there is a consistent relationship between the exposure and the disease. Here, we are looking at studies that have evaluated the risk of heart disease in relation to exposure to secondhand smoke. The Cal-EPA report reviewed 24 studies.
Three different meta-analyses have been conducted of these studies. One meta-analysis, which included 18 studies, found that people exposed to secondhand smoke were about 1.2 times more likely to develop heart disease (this is called a "relative risk" of 1.2). Another meta-analysis, of 8 studies, found a relative risk of 1.3. And a third meta-analysis, of 19 studies, found a relative risk of 1.2. All of these relative risks were statistically significant, meaning that they could not likely be a result of chance.
From this analysis of all the studies taken together, the Cal-EPA concluded that there is an association betweeen secondhand smoke exposure and increased risk of heart disease, albeit a small one (the relative risk of 1.2-1.3 indicates that exposed nonsmokers are about 20-30% more likely to develop heart disease than non-exposed nonsmokers), and that this association cannot be explained by chance. It is not just a chance finding that the studies happened to find that secondhand smoke exposure is associated with increased risk of heart disease.
This is the point I'd like to stop at for now. It is important for people to understand this initial aspect of the analysis before getting into a discussion of the possible reasons for this observed association between secondhand smoke exposure and heart disease.
Sunday, March 19, 2006
Friday, March 17, 2006
The Rest of the Story Quoted on Calabasas
The Rest of the Story was quoted in an article appearing in today's New York Sun on the new outdoor smoking ban in effect in Calabasas.
In the article, Action on Smoking and Health is quoted as predicting that near complete outdoor smoking bans such as the one in Calabasas will within a year spread throughout California and will soon spread to New York.
The Mayor of Calabasas also defended the law, stating that "It will also set the right standard for what our kids will see."
I was quoted as questioning whether the science really supports such broad outdoor smoking bans, especially in areas where nonsmokers can easily avoid anything but transient exposure to the smoke:
"At least one anti-smoking activist has questioned the health benefit of bans on outdoor smoking. 'There is little evidence that smoking in open outdoor areas is a serious cause of disease or other adverse health effects,' a physician and behavioral sciences professor at Boston University, Michael Siegel, wrote on his blog. He said he fears calls for outdoor smoking bans could detract from or even derail efforts to ensure that bans on bar, restaurant, and workplace smoking are adopted nationwide."
The Rest of the Story
This business about setting the right standards for what our kids see by banishing smokers from the outdoors is really disturbing.
Apparently, the Mayor of Calabasas find smoking to be not only a health hazard, but as a moral affront to the citizenry, and smokers must be confined to places where kids will not see them.
I would only note that the same reasoning could easily be used to banish fat people from public places so that the town sets the right standard for body weight. And as long as the state is in the business of controlling what kinds of people kids are exposed to in public, the reasoning could also be used to ban gay couples from public places, since there is a large segment of policy makers who view homosexuality as a moral affront.
This is scary and dangerous reasoning, and needs to be quashed immediately and definitively by all anti-smoking groups involved in the clean indoor air movement. I expect it is only a matter of days before these groups begin to issue their public denunciations of the Calabasas mayor's comments.
As far as my own comments go, I'm just glad that there was at least some indication that not everyone in the anti-smoking movement is crusading for laws like this ridiculous policy in Calabasas. And I'm glad that the paper gave some attention to my concern that this is going to harm the credibility of the anti-smoking movement and actually bring a halt to the progress that has been made in protecting workers from secondhand smoke exposure.
I seriously doubt that these policies will spread throughout California within a year, and that they will ever spread to New York, but if I am wrong, then what I am quite sure about is that it will mark the near end of the smoke-free movement. I don't think we can withstand the spread of such laws, because it will expose the perception (true or not?) that this is not about public health protection, but that it is simply a crusade to clear smokers out of public view.
In the article, Action on Smoking and Health is quoted as predicting that near complete outdoor smoking bans such as the one in Calabasas will within a year spread throughout California and will soon spread to New York.
The Mayor of Calabasas also defended the law, stating that "It will also set the right standard for what our kids will see."
I was quoted as questioning whether the science really supports such broad outdoor smoking bans, especially in areas where nonsmokers can easily avoid anything but transient exposure to the smoke:
"At least one anti-smoking activist has questioned the health benefit of bans on outdoor smoking. 'There is little evidence that smoking in open outdoor areas is a serious cause of disease or other adverse health effects,' a physician and behavioral sciences professor at Boston University, Michael Siegel, wrote on his blog. He said he fears calls for outdoor smoking bans could detract from or even derail efforts to ensure that bans on bar, restaurant, and workplace smoking are adopted nationwide."
The Rest of the Story
This business about setting the right standards for what our kids see by banishing smokers from the outdoors is really disturbing.
Apparently, the Mayor of Calabasas find smoking to be not only a health hazard, but as a moral affront to the citizenry, and smokers must be confined to places where kids will not see them.
I would only note that the same reasoning could easily be used to banish fat people from public places so that the town sets the right standard for body weight. And as long as the state is in the business of controlling what kinds of people kids are exposed to in public, the reasoning could also be used to ban gay couples from public places, since there is a large segment of policy makers who view homosexuality as a moral affront.
This is scary and dangerous reasoning, and needs to be quashed immediately and definitively by all anti-smoking groups involved in the clean indoor air movement. I expect it is only a matter of days before these groups begin to issue their public denunciations of the Calabasas mayor's comments.
As far as my own comments go, I'm just glad that there was at least some indication that not everyone in the anti-smoking movement is crusading for laws like this ridiculous policy in Calabasas. And I'm glad that the paper gave some attention to my concern that this is going to harm the credibility of the anti-smoking movement and actually bring a halt to the progress that has been made in protecting workers from secondhand smoke exposure.
I seriously doubt that these policies will spread throughout California within a year, and that they will ever spread to New York, but if I am wrong, then what I am quite sure about is that it will mark the near end of the smoke-free movement. I don't think we can withstand the spread of such laws, because it will expose the perception (true or not?) that this is not about public health protection, but that it is simply a crusade to clear smokers out of public view.
ANR Once Again Deceives Its Constituents
In an electronic communication sent to its constituents, Americans for Nonsmokers' Rights (ANR) has once again presented deceptive and misleading information about the smoking ban enacted in New Jersey (click here to see post on first deceptive campaign to promote the New Jersey smoking ban).
According to the communication: "New Jersey's new smokefree law passed in January, and will cover all workplaces and public places (including restaurants and bars). New Jersey's law will go into effect on April 15th. Enjoy the smokefree air, New Jersey!"
This follows a previous communication to ANR's constituents which stated: "Today, New Jersey took one step closer to becoming a smokefree state! The New Jersey Assembly Health Committee voted 10-1 to pass Senate Bill 1926, which would make all workplaces, including restaurants and bars, 100% smokefree throughout the state."
The communication closes by stating: "Thank you for protecting everyone's right to breathe smokefree air indoors!"
The Rest of the Story
There's only one problem with today's communication: it is false (or at very least, misleading).
The New Jersey smokefree law which passed in January does not cover all workplaces and public places. It specifically excludes casinos (at least casino floors). And this is no small exception, as there are approximately 48,000 casino workers in New Jersey and the problem of secondhand smoke exposure among casino workers in that state is a huge one.
ANR exclaims: "Enjoy the smokefree air, New Jersey!" Somehow I don't get the feeling that the casino workers in New Jersey are going to be enjoying the extremely smoky and very hazardous conditions to which they are being subjected. And it's only going to get worse from the law that was enacted, as some smokers from Atlantic City bars switch over to casinos where they are still allowed to smoke. ANR might as well have declared: "Enjoy the heart disease, lung cancer, and asthma, New Jersey casino workers!"
ANR's communication congratulates advocates on protecting everyone's right to breathe smokefree air indoors. Apparently they don't consider casino workers to be included as being in the population of people who have a right to breathe smokefree air indoors, because these individuals were denied protection by the law supported by advocates in New Jersey (and will most likely be denied protection by the Colorado legislature as well).
It's not clear to me why ANR would choose to omit this important piece of information. Perhaps they are trying to make the accomplishment seem greater than it was. Or perhaps they think that the more momentum they can convince the public is occurring in support of smoke-free air, the more likely laws are to be passed in the future. Or perhaps they are simply trying to draw attention away from the inaccuracy of their previous communication. Or perhaps this was just a careless mistake (but if that's the case, I expect it will be corrected promptly and I'll let readers know if that happens).
For now, we are left with another deceptive communication from an anti-smoking group. Ironically, it comes just as I posted about the ethical principle of accurate health communications and the basis for this principle in public health practice.
Is it a coincidence that ANR has failed twice now to be honest and forthright about the massive exemption in the New Jersey smoke-free law? Or is there something they are trying to hide, whether consciously or unconsciously? I don't know, but I can tell you that ANR is an organization that prides itself on the provision of accurate information about smoke-free laws throughout the country. And it is the chief source for this information. So when it is providing deceptive information, you know the anti-smoking movement is in trouble. You know that we are having problems with the honesty and accuracy in our communications.
I apologize for that. I'm doing everything I can to try to restore some accuracy and scientific integrity and truthfulness to the movement, but I can't even finish a post on scientific accuracy before yet another public communication comes through that is grossly misleading if not inaccurate.
My bad. I'll see if I can do a better job getting my house in order. In other words: "We are aware of the problem, and we are doing everything we can to correct it. We apologize for any inconvenience this may cause."
According to the communication: "New Jersey's new smokefree law passed in January, and will cover all workplaces and public places (including restaurants and bars). New Jersey's law will go into effect on April 15th. Enjoy the smokefree air, New Jersey!"
This follows a previous communication to ANR's constituents which stated: "Today, New Jersey took one step closer to becoming a smokefree state! The New Jersey Assembly Health Committee voted 10-1 to pass Senate Bill 1926, which would make all workplaces, including restaurants and bars, 100% smokefree throughout the state."
The communication closes by stating: "Thank you for protecting everyone's right to breathe smokefree air indoors!"
The Rest of the Story
There's only one problem with today's communication: it is false (or at very least, misleading).
The New Jersey smokefree law which passed in January does not cover all workplaces and public places. It specifically excludes casinos (at least casino floors). And this is no small exception, as there are approximately 48,000 casino workers in New Jersey and the problem of secondhand smoke exposure among casino workers in that state is a huge one.
ANR exclaims: "Enjoy the smokefree air, New Jersey!" Somehow I don't get the feeling that the casino workers in New Jersey are going to be enjoying the extremely smoky and very hazardous conditions to which they are being subjected. And it's only going to get worse from the law that was enacted, as some smokers from Atlantic City bars switch over to casinos where they are still allowed to smoke. ANR might as well have declared: "Enjoy the heart disease, lung cancer, and asthma, New Jersey casino workers!"
ANR's communication congratulates advocates on protecting everyone's right to breathe smokefree air indoors. Apparently they don't consider casino workers to be included as being in the population of people who have a right to breathe smokefree air indoors, because these individuals were denied protection by the law supported by advocates in New Jersey (and will most likely be denied protection by the Colorado legislature as well).
It's not clear to me why ANR would choose to omit this important piece of information. Perhaps they are trying to make the accomplishment seem greater than it was. Or perhaps they think that the more momentum they can convince the public is occurring in support of smoke-free air, the more likely laws are to be passed in the future. Or perhaps they are simply trying to draw attention away from the inaccuracy of their previous communication. Or perhaps this was just a careless mistake (but if that's the case, I expect it will be corrected promptly and I'll let readers know if that happens).
For now, we are left with another deceptive communication from an anti-smoking group. Ironically, it comes just as I posted about the ethical principle of accurate health communications and the basis for this principle in public health practice.
Is it a coincidence that ANR has failed twice now to be honest and forthright about the massive exemption in the New Jersey smoke-free law? Or is there something they are trying to hide, whether consciously or unconsciously? I don't know, but I can tell you that ANR is an organization that prides itself on the provision of accurate information about smoke-free laws throughout the country. And it is the chief source for this information. So when it is providing deceptive information, you know the anti-smoking movement is in trouble. You know that we are having problems with the honesty and accuracy in our communications.
I apologize for that. I'm doing everything I can to try to restore some accuracy and scientific integrity and truthfulness to the movement, but I can't even finish a post on scientific accuracy before yet another public communication comes through that is grossly misleading if not inaccurate.
My bad. I'll see if I can do a better job getting my house in order. In other words: "We are aware of the problem, and we are doing everything we can to correct it. We apologize for any inconvenience this may cause."
The 20-30 Minutes Fiasco: Why Anti-Smoking Groups Providing Inaccurate Health Information is Unethical
While I have been arguing for some time that making fallacious scientific claims ("health" claims) is wrong, there has been, so far, no response from anti-smoking groups or advocates, other than ad hominem attacks on me, a defense of the organizations in question, and a questioning of why it is such a big deal anyway.
In this post, I will address the issue of why this is a big deal.
I have already discussed why I think this is a big deal in terms of its implications for the effectiveness of the tobacco control movement. I believe it will undermine the credibility and reputation of the movement and therefore make it increasingly more difficult to be taken seriously when we do make legitimate scientific claims.
Here, however, I argue that regardless of any effect on the movement's credibility, it is wrong simply because it is unethical.
For those who may not be regular readers of this blog:
ASH's fallacious claims are that 30 minutes of exposure to drifting tobacco smoke increases a nonsmoker's risk of a fatal heart attack and actually increases that risk to the level of a smoker.
SmokeFreeOhio's fallacious claims are that 20 minutes of exposure to secondhand smoke increases the risk of a heart attack in nonsmokers and reduces the ability of the heart to pump, and that 120 minutes of exposure increases the chances of suffering a fatal or catastrophic arrhythmia.
The Rest of the Story
It is important to recognize that the principle of providing accurate health information is a basic ethical principle of public health.
An editorial in the American Journal of Public Health, entitled "The Challenges and Opportunities of Ethics" (see: Dickens BM. Am J Public Health 2005; 95:1094), emphasizes "the responsibility of public health practitioners and scientists to conduct their practices ethically."
Specifically, the editorial suggests that the kind of ethical concerns that apply to individual research with human subjects should also apply at the collective level, and not only to research, but to the very practice of public health.
It is easy to see why it would be unethical to mislead an individual subject in a public health intervention about the reasons for such an intervention. But perhaps it is not as easy to see why it might also be considered unethical for a public health organization to mislead a community of individuals (e.g., the public) about the underlying facts regarding the scientific justification for a public health policy proposal.
But the principle of informed consent, if viewed to apply to communities as well as individuals, dictates that the same level of care and scrutiny that is given to communications to individual human subjects also be given to public communications that are attempting to influence the development and adoption of public policies, especially if those communications are designed to stir the public to political action.
The American Public Health Association's code of ethical practice specifies the "community-level" equivalent of the individual-level ethical principle of informed consent:
"Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community'’s consent for their implementation. ... there is a moral obligation in some instances to share what is known. For example, active and informed participation in policy-making processes requires access to relevant information. ...Such processes depend upon an informed community. The information obtained by public health institutions is to be considered public property and made available to the public."
Thus, just as public health organizations must provide individuals with full and accurate information before enrolling these individuals in research studies, public health organizations must also provide the public with full and accurate information that is necessary to make decisions on policies that affect them.
A second core ethical principle of public health practice is truthfulness itself. This was spelled out nicely in a Tobacco Control article (see Fox BJ. Framing tobacco control efforts within an ethical context. Tobacco Control 2005;14[Suppl II[:ii38-ii44).
While it may seem obvious, I think it is worth being explicit about the fact that truthfulness is an important aspect of ethical behavior, not only by individual practitioners but by public health organizations. As Brion Fox points out in his outstanding review of ethical principles in tobacco control practice, if organizations fail to be truthful, they will actually be doing a disservice to the public: "Hence the tobacco control community must hold this principle sacrosanct and strive for disclosing the whole truth, otherwise it may lose its credibility."
These two ethical principles (the community-level equivalent of informed consent and the principle of truthfulness itself) form the essential basic requirement for all public health communications, especially those designed to influence public policies.
One important aspect of these principles that needs to be emphasized is that they condemn not just the dissemination of scientifically false information, but also the publicizing of incomplete information that may distort or hide the whole truth.
Thus, it is not only unethical to provide false health information to the public, but it is also unethical to mislead the public by omitting certain essential information that may result in a distorted or incomplete view of the scientific facts.
An article in last year's Tobacco Control provides a very nice articulation of the basis of the public's right to accurate health information from public health organizations (see: Kozlowski LT, Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tobacco Control 2005; 14[Suppl II]:ii3=ii7).
Kozlowski and Edwards describe the public's right to accurate health information as deriving from the principles of autonomy and self-determination, and note that this right is supported by the Universal Declaration of Human Rights. The principles of autonomy and self-determination also are the basis of the doctrine of informed consent. As a result, "a right to be 'properly informed' suggests that the very act of informing must be undertaken with care and consideration."
According to Kozlowski and Edwards: "Individuals have a right to health relevant information; without it they cannot make meaningful health choices. Promoting and ensuring access to available knowledge is an obligation that follows from this right. ... Tobacco control information campaigns have sometimes fallen short of meeting the obligation of health relevant information. Failure can take many forms. Not informing that a product or activity involves health risks is one obvious example. Providing wrong or incomprehensible information would be another. Saying too little can also be deceptive and a violation of rights."
The authors of this paper specifically address the issue of web-based health communications: "Much of the health communication we discuss employs the internet, and ethical guidelines have been established specifically for the internet (as is discussed in the US Healthy People guidelines in health communication and health literacy). These guidelines are unambiguous on honesty: 'Be truthful and not deceptive.' They emphasize the importance of providing accurate and well supported information. There is no allowance for the use of deception in web based health communications."
Here, another important ethical concern deserves emphasis. It is not enough, according to these ethical guidelines, to simply provide information that is devoid of factual misrepresentations. Public communications must also be well supported by scientific evidence and should not be misleading, even if they are factually accurate.
Conclusion
It should be quite clear that the public communications presently being disseminated by Action on Smoking and Health and SmokeFreeOhio are disrespectful of the individual right to accurate health information. In this case, the communications represent what are clearly scientific misrepresentations of the truth. In other words, the communications are simply inaccurate. But even if the statements were merely deceptive, they would also represent unethical conduct on the part of the organizations delivering these messages to the public.
Even if someone were to argue, therefore, that by some technicality, the communications are not blatantly false (I think they are, but let's stipulate that someone could make an argument that they are not inaccurate by virtue of some technicality), they are still massively deceptive and therefore unethical.
Anti-smoking groups may provide a utilitarian-based argument that these inaccurate and/or misleading communications are doing more good than harm in the long run because they are helping to promote smoke-free policies which will protect the public's health and save lives. The problem is that even if this were true, the violation of these basic ethical principles is a core value of public health practice that cannot and should not be sacrificed. The ends do not justify the means, especially when those means are violating principles of autonomy and self-determination that form the essential bases for free societies.
Finally, while simply making mistakes in putting out a communication is excusable (we all do it), once the inaccuracy is called to the attention of the group and the group fails to correct it, then we are talking about a clear failure to exercise "care and consideration" in "the act of informing."
This appears to be the case with the 20 minute and 30 minute fiascos.
The rest of the story is that the dissemination of fallacious information by anti-smoking groups to the public in support of smoking bans is not only unfortunate because it is going to harm the tobacco control movement by undermining its credibility, reputation, and effectiveness, but because it is unethical and disrespectful of the basic principles of truthfulness and scientific accuracy in health communications, which are in turn founded on the principles of autonomy and self-determination, values which cannot and should not be trodden upon by public health organizations in free societies simply to promote a favored policy.
In this post, I will address the issue of why this is a big deal.
I have already discussed why I think this is a big deal in terms of its implications for the effectiveness of the tobacco control movement. I believe it will undermine the credibility and reputation of the movement and therefore make it increasingly more difficult to be taken seriously when we do make legitimate scientific claims.
Here, however, I argue that regardless of any effect on the movement's credibility, it is wrong simply because it is unethical.
For those who may not be regular readers of this blog:
ASH's fallacious claims are that 30 minutes of exposure to drifting tobacco smoke increases a nonsmoker's risk of a fatal heart attack and actually increases that risk to the level of a smoker.
SmokeFreeOhio's fallacious claims are that 20 minutes of exposure to secondhand smoke increases the risk of a heart attack in nonsmokers and reduces the ability of the heart to pump, and that 120 minutes of exposure increases the chances of suffering a fatal or catastrophic arrhythmia.
The Rest of the Story
It is important to recognize that the principle of providing accurate health information is a basic ethical principle of public health.
An editorial in the American Journal of Public Health, entitled "The Challenges and Opportunities of Ethics" (see: Dickens BM. Am J Public Health 2005; 95:1094), emphasizes "the responsibility of public health practitioners and scientists to conduct their practices ethically."
Specifically, the editorial suggests that the kind of ethical concerns that apply to individual research with human subjects should also apply at the collective level, and not only to research, but to the very practice of public health.
It is easy to see why it would be unethical to mislead an individual subject in a public health intervention about the reasons for such an intervention. But perhaps it is not as easy to see why it might also be considered unethical for a public health organization to mislead a community of individuals (e.g., the public) about the underlying facts regarding the scientific justification for a public health policy proposal.
But the principle of informed consent, if viewed to apply to communities as well as individuals, dictates that the same level of care and scrutiny that is given to communications to individual human subjects also be given to public communications that are attempting to influence the development and adoption of public policies, especially if those communications are designed to stir the public to political action.
The American Public Health Association's code of ethical practice specifies the "community-level" equivalent of the individual-level ethical principle of informed consent:
"Public health institutions should provide communities with the information they have that is needed for decisions on policies or programs and should obtain the community'’s consent for their implementation. ... there is a moral obligation in some instances to share what is known. For example, active and informed participation in policy-making processes requires access to relevant information. ...Such processes depend upon an informed community. The information obtained by public health institutions is to be considered public property and made available to the public."
Thus, just as public health organizations must provide individuals with full and accurate information before enrolling these individuals in research studies, public health organizations must also provide the public with full and accurate information that is necessary to make decisions on policies that affect them.
A second core ethical principle of public health practice is truthfulness itself. This was spelled out nicely in a Tobacco Control article (see Fox BJ. Framing tobacco control efforts within an ethical context. Tobacco Control 2005;14[Suppl II[:ii38-ii44).
While it may seem obvious, I think it is worth being explicit about the fact that truthfulness is an important aspect of ethical behavior, not only by individual practitioners but by public health organizations. As Brion Fox points out in his outstanding review of ethical principles in tobacco control practice, if organizations fail to be truthful, they will actually be doing a disservice to the public: "Hence the tobacco control community must hold this principle sacrosanct and strive for disclosing the whole truth, otherwise it may lose its credibility."
These two ethical principles (the community-level equivalent of informed consent and the principle of truthfulness itself) form the essential basic requirement for all public health communications, especially those designed to influence public policies.
One important aspect of these principles that needs to be emphasized is that they condemn not just the dissemination of scientifically false information, but also the publicizing of incomplete information that may distort or hide the whole truth.
Thus, it is not only unethical to provide false health information to the public, but it is also unethical to mislead the public by omitting certain essential information that may result in a distorted or incomplete view of the scientific facts.
An article in last year's Tobacco Control provides a very nice articulation of the basis of the public's right to accurate health information from public health organizations (see: Kozlowski LT, Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tobacco Control 2005; 14[Suppl II]:ii3=ii7).
Kozlowski and Edwards describe the public's right to accurate health information as deriving from the principles of autonomy and self-determination, and note that this right is supported by the Universal Declaration of Human Rights. The principles of autonomy and self-determination also are the basis of the doctrine of informed consent. As a result, "a right to be 'properly informed' suggests that the very act of informing must be undertaken with care and consideration."
According to Kozlowski and Edwards: "Individuals have a right to health relevant information; without it they cannot make meaningful health choices. Promoting and ensuring access to available knowledge is an obligation that follows from this right. ... Tobacco control information campaigns have sometimes fallen short of meeting the obligation of health relevant information. Failure can take many forms. Not informing that a product or activity involves health risks is one obvious example. Providing wrong or incomprehensible information would be another. Saying too little can also be deceptive and a violation of rights."
The authors of this paper specifically address the issue of web-based health communications: "Much of the health communication we discuss employs the internet, and ethical guidelines have been established specifically for the internet (as is discussed in the US Healthy People guidelines in health communication and health literacy). These guidelines are unambiguous on honesty: 'Be truthful and not deceptive.' They emphasize the importance of providing accurate and well supported information. There is no allowance for the use of deception in web based health communications."
Here, another important ethical concern deserves emphasis. It is not enough, according to these ethical guidelines, to simply provide information that is devoid of factual misrepresentations. Public communications must also be well supported by scientific evidence and should not be misleading, even if they are factually accurate.
Conclusion
It should be quite clear that the public communications presently being disseminated by Action on Smoking and Health and SmokeFreeOhio are disrespectful of the individual right to accurate health information. In this case, the communications represent what are clearly scientific misrepresentations of the truth. In other words, the communications are simply inaccurate. But even if the statements were merely deceptive, they would also represent unethical conduct on the part of the organizations delivering these messages to the public.
Even if someone were to argue, therefore, that by some technicality, the communications are not blatantly false (I think they are, but let's stipulate that someone could make an argument that they are not inaccurate by virtue of some technicality), they are still massively deceptive and therefore unethical.
Anti-smoking groups may provide a utilitarian-based argument that these inaccurate and/or misleading communications are doing more good than harm in the long run because they are helping to promote smoke-free policies which will protect the public's health and save lives. The problem is that even if this were true, the violation of these basic ethical principles is a core value of public health practice that cannot and should not be sacrificed. The ends do not justify the means, especially when those means are violating principles of autonomy and self-determination that form the essential bases for free societies.
Finally, while simply making mistakes in putting out a communication is excusable (we all do it), once the inaccuracy is called to the attention of the group and the group fails to correct it, then we are talking about a clear failure to exercise "care and consideration" in "the act of informing."
This appears to be the case with the 20 minute and 30 minute fiascos.
The rest of the story is that the dissemination of fallacious information by anti-smoking groups to the public in support of smoking bans is not only unfortunate because it is going to harm the tobacco control movement by undermining its credibility, reputation, and effectiveness, but because it is unethical and disrespectful of the basic principles of truthfulness and scientific accuracy in health communications, which are in turn founded on the principles of autonomy and self-determination, values which cannot and should not be trodden upon by public health organizations in free societies simply to promote a favored policy.
Thursday, March 16, 2006
Anti-Smoking Groups Refuse to Correct, Clarify, or Retract Fallacious Claims; Reward Being Offered
Although I have been quite critical of several anti-smoking groups - including Action on Smoking and Health (ASH) and SmokeFreeOhio - for making completely fallacious scientific claims, I recognize that sometimes organizations can make mistakes, especially in interpreting scientific studies and I acknowledge that I myself have from time to time made statements that needed to be clarified.
The important thing is being able to acknowledge the mistake, apologize, and correct it.
Unfortunately, weeks after first reporting ASH's fallacious claims and days after reporting SmokeFreeOhio's fallacious claims, as of the publishing of this post, those public statements (ASH; SmokeFreeOhio) remain unchanged.
As a reminder, ASH's fallacious claims are that 30 minutes of exposure to drifting tobacco smoke increases a nonsmoker's risk of a fatal heart attack and actually increases that risk to the level of a smoker. SmokeFreeOhio has a number of fallacious claims, but the main ones are that 20 minutes of exposure to secondhand smoke increases the risk of a heart attack in nonsmokers and reduces the ability of the heart to pump, and that 120 minutes of exposure increases the chances of suffering a fatal or catastrophic arrhythmia.
The Rest of the Story
I issue a challenge to ASH and SmokeFreeOhio to correct or retract their fallacious claims and apologize for misleading the public.
The first organization to do so will receive a prize: a $100 donation to their organization to help support their work and to acknowledge the character that it takes to admit and correct a mistake.
If both organizations correct their statements or retract them, and apologize for the misleading and inaccurate communications, then I will provide the prize to both organizations ($100 to each, not a shared prize).
It's worth $200 of my own money to help ensure that the scientific claims that we are making in tobacco control are accurate and to get these problems corrected so that they do not further threaten to undermine the credibility of the movement.
Good luck to both organizations. The world is watching; certainly the tobacco companies are - I'm sure they will be very curious to see what decisions these organizations make in terms of correcting or not correcting their fallacious scientific claims.
The important thing is being able to acknowledge the mistake, apologize, and correct it.
Unfortunately, weeks after first reporting ASH's fallacious claims and days after reporting SmokeFreeOhio's fallacious claims, as of the publishing of this post, those public statements (ASH; SmokeFreeOhio) remain unchanged.
As a reminder, ASH's fallacious claims are that 30 minutes of exposure to drifting tobacco smoke increases a nonsmoker's risk of a fatal heart attack and actually increases that risk to the level of a smoker. SmokeFreeOhio has a number of fallacious claims, but the main ones are that 20 minutes of exposure to secondhand smoke increases the risk of a heart attack in nonsmokers and reduces the ability of the heart to pump, and that 120 minutes of exposure increases the chances of suffering a fatal or catastrophic arrhythmia.
The Rest of the Story
I issue a challenge to ASH and SmokeFreeOhio to correct or retract their fallacious claims and apologize for misleading the public.
The first organization to do so will receive a prize: a $100 donation to their organization to help support their work and to acknowledge the character that it takes to admit and correct a mistake.
If both organizations correct their statements or retract them, and apologize for the misleading and inaccurate communications, then I will provide the prize to both organizations ($100 to each, not a shared prize).
It's worth $200 of my own money to help ensure that the scientific claims that we are making in tobacco control are accurate and to get these problems corrected so that they do not further threaten to undermine the credibility of the movement.
Good luck to both organizations. The world is watching; certainly the tobacco companies are - I'm sure they will be very curious to see what decisions these organizations make in terms of correcting or not correcting their fallacious scientific claims.
Calabasas Smoking Ban Goes Into Effect Tomorrow
A smoking ban in virtually all outdoor public places in Calabasas, including streets, sidewalks, and parking lots (but of course, not at the city's shopping malls) goes into effect tomorrow.
According to an article in the Los Angeles Daily News, the incoming Mayor of Calabasas defended the ordinance as follows: "We just don't want anyone blowing smoke in someone's face. Unfortunately, what smokers do is harmful to everybody else."
According to the article, a spokesperson for the American Cancer Society in Sacramento praised the ordinance, stating: "We salute Calabasas for raising the bar. Smoke regulations can play a very important role in reducing public exposure to harmful secondhand smoke."
Also according to an article, a security guard at the Calabasas Commons confirmed that he would not enforce the smoking ban.
The Rest of the Story
The comments of the public officials in Calabasas appear to me to confirm that the rationale behind the smoking ban leaves a lot to be desired.
If the city doesn't want people blowing smoke in other people's faces, then it should pass a law outlawing blowing smoke in other people's faces. I don't think any smokers would have a problem with such a law.
And if it is true that what smokers do is harmful to everybody else, then the city should just ban smoking altogether. After all, if it smoking is a serious hazard and it harms other people, then how can the city rationalize allowing it?
It's quite clear to me that what city officials are shying away from is confronting the lack of scientific evidence that outdoor smoke in places like streets, sidewalks, and parking lots is a serious health hazard that causes any significant damage to nonsmokers in Calabasas.
The city officials do everything except talk about the hazards of smoking in outdoor environments where nonsmokers can easily avoid exposure to the smoke.
And that's no surprise. Because the ordinance is extremely hypocritical. It bans smoking in places where very few nonsmokers have any significant exposure to smoke and where they can easily avoid the exposure, but it does not prohibit smoking (in outdoor smoking areas) at the city's crowded shopping malls, where exposure cannot easily be avoided.
Presumably, what smokers do is harmful to everybody else, unless they are spending money at the city's shopping malls and helping provide needed revenue and economic prosperity to the city. Then it's OK to overlook the harm that smokers are doing to "everybody else."
If this comes down to a debate over the scientific evidence of public health hazards and the seriousness of those hazards, the Calabasas City Council is going to lose the debate hands down. So they're avoiding it like the plague. They're offering all kinds of other justifications under the sun: this is to promote family values in Calabasas...this is to set a good example for our children...this is to protect children from seeing smokers...this is to prevent litter...this is to protect the city's creeks and streams, etc.
What it's really about, however, is disdain for smokers and an attempt to punish them.
Perhaps more disturbing to me that the city officials' defense of the ordinance is the praise for this ridiculous law that is coming from anti-smoking groups. The American Cancer Society praises the law for "raising the bar." As if this is some sort of game where the more draconian your anti-smoking proposals are, the better. The ACS spokesperson correctly notes that smoking bans reduce exposure to harmful secondhand smoke, but he fails to address the issue of what evidence there is that exposure to secondhand smoke in streets, sidewalks, and parking lots is a significant public health problem.
And is it not slightly ironic that the American Cancer Society, which has refused to link secondhand smoke with breast cancer because it doesn't want to harm its "scientific credibility," is supporting a law that threatens to erode the scientific credibility of the entire anti-smoking movement because it is so obvious to the public that smoking in wide-open outdoors places is not associated with any substantial public health problems?
I don't usually condone violating or overlooking the law, but in this case, I applaud the security guard at Calabasas Commons who apparently decided that protecting the security of shoppers and stores (which is his rightful job) is more important than tracking down people smoking outside and delivering them to city prosecutors for possible criminal punishment.
If I lived in Calabasas, I would certainly look the other way if I saw smokers lighting up in streets, sidewalks, and parking lots around me. And you know what? According to the Calabasas law, I would be guilty of a criminal offense - a misdemeanor - every time that I looked the other way. Because it is a crime under the law to conceal a violation of the ordinance.
In the ultimate of ironies, my reading of the law suggests that a smoker could actually sue a nonsmoker for not reporting him or her to authorities. Because aiding, abetting, or concealing a criminal offense under the law (i.e., smoking in public) is itself a criminal offense and under the law, any citizen can bring a lawsuit against any other citizen for violating the law.
Can you imagine that? Smokers could have a great time in Calabasas. They could go around lighting up around nonsmokers, and then if those nonsmokers do not report them, they could sue them for violating the law.
The situation in Calabasas is really a mess. In my opinion, it makes a mockery of the entire smoke-free movement, which I view as a serious, evidence-based, public health effort to protect workers from a bona fide occupational hazard.
It's just a shame that anti-smoking groups are contributing to and supporting this mess. And I don't think they're doing the tobacco control movement, or the public's health, any favors by doing so.
According to an article in the Los Angeles Daily News, the incoming Mayor of Calabasas defended the ordinance as follows: "We just don't want anyone blowing smoke in someone's face. Unfortunately, what smokers do is harmful to everybody else."
According to the article, a spokesperson for the American Cancer Society in Sacramento praised the ordinance, stating: "We salute Calabasas for raising the bar. Smoke regulations can play a very important role in reducing public exposure to harmful secondhand smoke."
Also according to an article, a security guard at the Calabasas Commons confirmed that he would not enforce the smoking ban.
The Rest of the Story
The comments of the public officials in Calabasas appear to me to confirm that the rationale behind the smoking ban leaves a lot to be desired.
If the city doesn't want people blowing smoke in other people's faces, then it should pass a law outlawing blowing smoke in other people's faces. I don't think any smokers would have a problem with such a law.
And if it is true that what smokers do is harmful to everybody else, then the city should just ban smoking altogether. After all, if it smoking is a serious hazard and it harms other people, then how can the city rationalize allowing it?
It's quite clear to me that what city officials are shying away from is confronting the lack of scientific evidence that outdoor smoke in places like streets, sidewalks, and parking lots is a serious health hazard that causes any significant damage to nonsmokers in Calabasas.
The city officials do everything except talk about the hazards of smoking in outdoor environments where nonsmokers can easily avoid exposure to the smoke.
And that's no surprise. Because the ordinance is extremely hypocritical. It bans smoking in places where very few nonsmokers have any significant exposure to smoke and where they can easily avoid the exposure, but it does not prohibit smoking (in outdoor smoking areas) at the city's crowded shopping malls, where exposure cannot easily be avoided.
Presumably, what smokers do is harmful to everybody else, unless they are spending money at the city's shopping malls and helping provide needed revenue and economic prosperity to the city. Then it's OK to overlook the harm that smokers are doing to "everybody else."
If this comes down to a debate over the scientific evidence of public health hazards and the seriousness of those hazards, the Calabasas City Council is going to lose the debate hands down. So they're avoiding it like the plague. They're offering all kinds of other justifications under the sun: this is to promote family values in Calabasas...this is to set a good example for our children...this is to protect children from seeing smokers...this is to prevent litter...this is to protect the city's creeks and streams, etc.
What it's really about, however, is disdain for smokers and an attempt to punish them.
Perhaps more disturbing to me that the city officials' defense of the ordinance is the praise for this ridiculous law that is coming from anti-smoking groups. The American Cancer Society praises the law for "raising the bar." As if this is some sort of game where the more draconian your anti-smoking proposals are, the better. The ACS spokesperson correctly notes that smoking bans reduce exposure to harmful secondhand smoke, but he fails to address the issue of what evidence there is that exposure to secondhand smoke in streets, sidewalks, and parking lots is a significant public health problem.
And is it not slightly ironic that the American Cancer Society, which has refused to link secondhand smoke with breast cancer because it doesn't want to harm its "scientific credibility," is supporting a law that threatens to erode the scientific credibility of the entire anti-smoking movement because it is so obvious to the public that smoking in wide-open outdoors places is not associated with any substantial public health problems?
I don't usually condone violating or overlooking the law, but in this case, I applaud the security guard at Calabasas Commons who apparently decided that protecting the security of shoppers and stores (which is his rightful job) is more important than tracking down people smoking outside and delivering them to city prosecutors for possible criminal punishment.
If I lived in Calabasas, I would certainly look the other way if I saw smokers lighting up in streets, sidewalks, and parking lots around me. And you know what? According to the Calabasas law, I would be guilty of a criminal offense - a misdemeanor - every time that I looked the other way. Because it is a crime under the law to conceal a violation of the ordinance.
In the ultimate of ironies, my reading of the law suggests that a smoker could actually sue a nonsmoker for not reporting him or her to authorities. Because aiding, abetting, or concealing a criminal offense under the law (i.e., smoking in public) is itself a criminal offense and under the law, any citizen can bring a lawsuit against any other citizen for violating the law.
Can you imagine that? Smokers could have a great time in Calabasas. They could go around lighting up around nonsmokers, and then if those nonsmokers do not report them, they could sue them for violating the law.
The situation in Calabasas is really a mess. In my opinion, it makes a mockery of the entire smoke-free movement, which I view as a serious, evidence-based, public health effort to protect workers from a bona fide occupational hazard.
It's just a shame that anti-smoking groups are contributing to and supporting this mess. And I don't think they're doing the tobacco control movement, or the public's health, any favors by doing so.
MSA-Induced Addiction to Tobacco Money Finally Being Recognized
An editorial in the today's Deseret News acknowledges that the Master Settlement Agreement (MSA) has resulted in the states becoming addicted to tobacco revenues and therefore in an inherent conflict in the state's motivations to protect the public's health by reducing tobacco use.
"The madness of the 1998 Master Settlement Agreement between the states and Big Tobacco was that payouts depended upon people continuing to smoke. Never mind that the states' lawsuit against tobacco companies sought to end deceitful advertising practices and the marketing of tobacco products to children. ... the states, Utah included, have grown accustomed to the settlement funds. ... It's a nasty addiction, considering that it's dirty money -— it depends on people continuing to smoke -— and there is now a question as to whether the full amount will be delivered to the states."
The Rest of the Story
I don't know what it is but the folks out in Utah are able to see things clearly. Perhaps it's the clear Rocky Mountain air. If so, then all of us should get ourselves out there to clear our thinking (and I know a few anti-smoking groups that could use a week or two in that air).
The Deseret News is precisely correct. The true legacy of the MSA is not any improvement in the public's health, but rather the creation of an addiction of the states to tobacco revenues. And it is a nasty addiction, because it does depend on "dirty" money - revenues derived largely from addicted smokers. The fact that smokers are now the chief, or only source of revenue for major state infrastructure and programs means that the states can no longer practice tobacco control effectively, because any interventions on their part which substantially reduce tobacco sales will also substantially reduce their MSA funding and threaten vital programs and services.
When it really comes down to it, the MSA can be viewed simply as a huge monetary transfer. Essentially, it transfers money from addicted smokers to state budgets and to wealthy lawyers. But it's not just a one-time transfer. It is a continuing system in which that money is constantly being transferred, and the system is dependent upon smokers continuing to smoke, or else it will collapse.
I was opposed to the MSA when it was first announced in 1998 and I predicted it would be devastating to the protection of the public's health. But I never thought it would work out this beautifully for the tobacco companies, Attorneys General, and plaintiffs lawyers, and this terribly for the nation's smokers and for the public.
"The madness of the 1998 Master Settlement Agreement between the states and Big Tobacco was that payouts depended upon people continuing to smoke. Never mind that the states' lawsuit against tobacco companies sought to end deceitful advertising practices and the marketing of tobacco products to children. ... the states, Utah included, have grown accustomed to the settlement funds. ... It's a nasty addiction, considering that it's dirty money -— it depends on people continuing to smoke -— and there is now a question as to whether the full amount will be delivered to the states."
The Rest of the Story
I don't know what it is but the folks out in Utah are able to see things clearly. Perhaps it's the clear Rocky Mountain air. If so, then all of us should get ourselves out there to clear our thinking (and I know a few anti-smoking groups that could use a week or two in that air).
The Deseret News is precisely correct. The true legacy of the MSA is not any improvement in the public's health, but rather the creation of an addiction of the states to tobacco revenues. And it is a nasty addiction, because it does depend on "dirty" money - revenues derived largely from addicted smokers. The fact that smokers are now the chief, or only source of revenue for major state infrastructure and programs means that the states can no longer practice tobacco control effectively, because any interventions on their part which substantially reduce tobacco sales will also substantially reduce their MSA funding and threaten vital programs and services.
When it really comes down to it, the MSA can be viewed simply as a huge monetary transfer. Essentially, it transfers money from addicted smokers to state budgets and to wealthy lawyers. But it's not just a one-time transfer. It is a continuing system in which that money is constantly being transferred, and the system is dependent upon smokers continuing to smoke, or else it will collapse.
I was opposed to the MSA when it was first announced in 1998 and I predicted it would be devastating to the protection of the public's health. But I never thought it would work out this beautifully for the tobacco companies, Attorneys General, and plaintiffs lawyers, and this terribly for the nation's smokers and for the public.
Wednesday, March 15, 2006
Attorneys General Have Provided Immunity to Tobacco Companies; MSA Ruled to Preclude Citizens' Rights to Seek Punitive Damages Related to Tobacco Use
The Attorneys General may have provided the tobacco companies with more than simply a partnership with the states when they signed the Master Settlement Agreement (MSA). Based on a Georgia Supreme Court decision released this week, they may have also provided the tobacco companies with immunity from litigation.
In the case (termed the Gault case), the Georgia Supreme Court ruled that Georgia's participation in the Master Settlement Agreement precluded state citizens from seeking punitive damages from the tobacco companies related to smoking.
The litigation involved a suit by the widower of a woman who died, allegedly from smoking Brown & Williamson cigarettes, against the manufacturer for compensatory and punitive damages. The question of whether the MSA precludes plaintiffs from seeking punitive damages for smoking-related injuries was brought forward to the Georgia Supreme Court, which answered in the affirmative. The suit is now being sent back to the district court for adjudication of the compensatory damage claims.
The basis of the Georgia Supreme Court decision was three-fold, as follows:
"Because punitive damages serve a public interest and are intended to protect the general public, as opposed to benefiting or rewarding particular private parties, we find the State, in seeking punitive damages in the suit against B&W, did so as parens patriae and in this capacity represented the interests of all Georgia citizens, including plaintiffs here. Accordingly, we conclude that the State and plaintiffs were privies in that action."
"We similarly find identity of the causes of action. In the prior action, the State sought compensatory damages to reimburse the treasury for funds spent by the State for tobacco attributable health care costs. In the subsequent proceeding, plaintiffs sought compensatory damages for Ms. Freeman'’s tobacco-related personal injuries. Insofar as the punitive damage claims are concerned, the matters put in issue in the State'’s action and in plaintiffs'’ proceeding are the same. In each case, punitive damages were sought in connection with tobacco industry product liability claims."
"Here, the State sought punitive damages in its action against B&W and the plain language of the agreement demonstrates that the parties in that action intended to compromise and settle the State'’s claim for punitive damages. To that end, the agreement specifically defined settled claims as '“liabilities of any nature including civil penalties and punitive damages'” and expressly included any claims the State asserted... .
The Rest of the Story
The rest of the story is that the Attorneys General appear to have signed away more than just the public's health when they agreed to the Master Settlement Agreement in November 1998. It turns out that they may have also signed away the legal rights of American citizens to pursue justice by disallowing them from suing tobacco companies to recover punitive damages.
This decision is a critical one, because it offers a very different view of the impact of the MSA than the one which the Attorneys General offered when they boasted about the Agreement after it was negotiated. It had been argued that the MSA only provided cigarette companies with immunity from lawsuits brought on behalf of the states. However, this decision makes it clear that the MSA is being interpreted in such a way that at least in Georgia, it also effectively precludes lawsuits against the companies brought by individual citizens or classes of citizens.
While citizens can still sue to recover compensatory damages, there will be little incentive for them to do so and even less incentive for attorneys to agree to take these cases if there is no possibility of obtaining punitive damages. So effectively, this decision does provide the tobacco companies with immunity in Georgia.
While this decision is binding only in Georgia, it certainly is going to lead the companies to pursue similar judgments in other states. And the decision does set a precedent (not a binding one) that could well be followed by courts in other states.
It also opens the door to the possibility of a definitive determination of this issue by the United States Supreme Court, which might just be interested in a question of this magnitude where there have been differing opinions offered by courts in the different states. Such a decision, if in the tobacco companies' favor, could decimate the entire future of tobacco litigation and perhaps even overturn a number of punitive damage awards that have already been made.
The Florida Supreme Court is prepared to release a decision any day now on an almost identical issue in the appeal of the Engle case, which had resulted in a jury verdict of $145 billion against the cigarette companies. Tobacco company defendants have argued that the state of Florida's settlement of its lawsuit against Big Tobacco precludes punitive damage claims in that case.
This story seems to confirm my prediction in a commentary of October 24 of last year that the "MSA may have provided immunity" for the tobacco companies.
In that piece, I argued that: "While the MSA was billed by the Attorneys General who signed it as precluding only state-based lawsuits against the tobacco companies and not providing protection from private class actions or large punitive damage awards, this very well may be the case. The Florida District Court of Appeals ruled that the MSA does in fact preclude punitive damage awards in private class action litigation where the major claims of the plaintiffs are similar to those of the states (e.g., fraud, conspiracy, and the sale of a defective and addictive product). ...
While it is not yet clear whether the Florida Supreme Court will agree with the appellate court's reasoning and it is not clear whether courts in other states would make similar findings, as of right now there is strong reason to believe that the MSA has indeed given the tobacco companies a large measure of immunity from private class action claims that are similar to those made by the states (which are, of course, similar to those being made in the majority of tobacco litigation throughout the country).
This provides more evidence to back up my earlier assertion that the Master Settlement Agreement was the worst public health blunder of my lifetime.
Now, not only have the state Attorneys General who signed the MSA released all state claims against the companies, but they have apparently also released, for all intents and purposes, many (perhaps most) private claims against the companies as well.
My first inclination is to close this post by chastising the AG signatories to the MSA for this public health blunder. Instead, I will close by congratulating the tobacco company attorneys who negotiated the MSA for their brilliance in taking advantage of the monetary and political greed of public officials who pretended to be primarily interested in the public's health. They knew that the billions of dollars would be too much to pass up, and they made them pay for every cent they received."
Just 5 days after the Attorneys General stood before the American people and boasted about the great accomplishments of the MSA and about how it was such a great public health victory, the truth has come out. The MSA was a complete public health and civil justice disaster. It has decimated tobacco litigation, and therefore a huge part of the tobacco control movement, in at least one state, and it threatens to devastate similar litigation (and thus, a key element of the tobacco control movement) in other states as well, and perhaps even in the nation as a whole.
Truly, the MSA was the worst possible thing that the Attorneys General could have done to advance the cause of tobacco control, public health, and social justice in the United States. The only thing worse is that this was all done because of the prospect of money and political gain.
What really happened is that the Attorneys General sold out the rights of American citizens to pursue justice and traded away the legal rights of American citizens without their consent, all in an effort to bring in lots of money to their states and political goodwill for themselves.
I can't think of a darker day in the history of tobacco control and public health than November 20, 1998.
In the case (termed the Gault case), the Georgia Supreme Court ruled that Georgia's participation in the Master Settlement Agreement precluded state citizens from seeking punitive damages from the tobacco companies related to smoking.
The litigation involved a suit by the widower of a woman who died, allegedly from smoking Brown & Williamson cigarettes, against the manufacturer for compensatory and punitive damages. The question of whether the MSA precludes plaintiffs from seeking punitive damages for smoking-related injuries was brought forward to the Georgia Supreme Court, which answered in the affirmative. The suit is now being sent back to the district court for adjudication of the compensatory damage claims.
The basis of the Georgia Supreme Court decision was three-fold, as follows:
"Because punitive damages serve a public interest and are intended to protect the general public, as opposed to benefiting or rewarding particular private parties, we find the State, in seeking punitive damages in the suit against B&W, did so as parens patriae and in this capacity represented the interests of all Georgia citizens, including plaintiffs here. Accordingly, we conclude that the State and plaintiffs were privies in that action."
"We similarly find identity of the causes of action. In the prior action, the State sought compensatory damages to reimburse the treasury for funds spent by the State for tobacco attributable health care costs. In the subsequent proceeding, plaintiffs sought compensatory damages for Ms. Freeman'’s tobacco-related personal injuries. Insofar as the punitive damage claims are concerned, the matters put in issue in the State'’s action and in plaintiffs'’ proceeding are the same. In each case, punitive damages were sought in connection with tobacco industry product liability claims."
"Here, the State sought punitive damages in its action against B&W and the plain language of the agreement demonstrates that the parties in that action intended to compromise and settle the State'’s claim for punitive damages. To that end, the agreement specifically defined settled claims as '“liabilities of any nature including civil penalties and punitive damages'” and expressly included any claims the State asserted... .
The Rest of the Story
The rest of the story is that the Attorneys General appear to have signed away more than just the public's health when they agreed to the Master Settlement Agreement in November 1998. It turns out that they may have also signed away the legal rights of American citizens to pursue justice by disallowing them from suing tobacco companies to recover punitive damages.
This decision is a critical one, because it offers a very different view of the impact of the MSA than the one which the Attorneys General offered when they boasted about the Agreement after it was negotiated. It had been argued that the MSA only provided cigarette companies with immunity from lawsuits brought on behalf of the states. However, this decision makes it clear that the MSA is being interpreted in such a way that at least in Georgia, it also effectively precludes lawsuits against the companies brought by individual citizens or classes of citizens.
While citizens can still sue to recover compensatory damages, there will be little incentive for them to do so and even less incentive for attorneys to agree to take these cases if there is no possibility of obtaining punitive damages. So effectively, this decision does provide the tobacco companies with immunity in Georgia.
While this decision is binding only in Georgia, it certainly is going to lead the companies to pursue similar judgments in other states. And the decision does set a precedent (not a binding one) that could well be followed by courts in other states.
It also opens the door to the possibility of a definitive determination of this issue by the United States Supreme Court, which might just be interested in a question of this magnitude where there have been differing opinions offered by courts in the different states. Such a decision, if in the tobacco companies' favor, could decimate the entire future of tobacco litigation and perhaps even overturn a number of punitive damage awards that have already been made.
The Florida Supreme Court is prepared to release a decision any day now on an almost identical issue in the appeal of the Engle case, which had resulted in a jury verdict of $145 billion against the cigarette companies. Tobacco company defendants have argued that the state of Florida's settlement of its lawsuit against Big Tobacco precludes punitive damage claims in that case.
This story seems to confirm my prediction in a commentary of October 24 of last year that the "MSA may have provided immunity" for the tobacco companies.
In that piece, I argued that: "While the MSA was billed by the Attorneys General who signed it as precluding only state-based lawsuits against the tobacco companies and not providing protection from private class actions or large punitive damage awards, this very well may be the case. The Florida District Court of Appeals ruled that the MSA does in fact preclude punitive damage awards in private class action litigation where the major claims of the plaintiffs are similar to those of the states (e.g., fraud, conspiracy, and the sale of a defective and addictive product). ...
While it is not yet clear whether the Florida Supreme Court will agree with the appellate court's reasoning and it is not clear whether courts in other states would make similar findings, as of right now there is strong reason to believe that the MSA has indeed given the tobacco companies a large measure of immunity from private class action claims that are similar to those made by the states (which are, of course, similar to those being made in the majority of tobacco litigation throughout the country).
This provides more evidence to back up my earlier assertion that the Master Settlement Agreement was the worst public health blunder of my lifetime.
Now, not only have the state Attorneys General who signed the MSA released all state claims against the companies, but they have apparently also released, for all intents and purposes, many (perhaps most) private claims against the companies as well.
My first inclination is to close this post by chastising the AG signatories to the MSA for this public health blunder. Instead, I will close by congratulating the tobacco company attorneys who negotiated the MSA for their brilliance in taking advantage of the monetary and political greed of public officials who pretended to be primarily interested in the public's health. They knew that the billions of dollars would be too much to pass up, and they made them pay for every cent they received."
Just 5 days after the Attorneys General stood before the American people and boasted about the great accomplishments of the MSA and about how it was such a great public health victory, the truth has come out. The MSA was a complete public health and civil justice disaster. It has decimated tobacco litigation, and therefore a huge part of the tobacco control movement, in at least one state, and it threatens to devastate similar litigation (and thus, a key element of the tobacco control movement) in other states as well, and perhaps even in the nation as a whole.
Truly, the MSA was the worst possible thing that the Attorneys General could have done to advance the cause of tobacco control, public health, and social justice in the United States. The only thing worse is that this was all done because of the prospect of money and political gain.
What really happened is that the Attorneys General sold out the rights of American citizens to pursue justice and traded away the legal rights of American citizens without their consent, all in an effort to bring in lots of money to their states and political goodwill for themselves.
I can't think of a darker day in the history of tobacco control and public health than November 20, 1998.
Monday, March 13, 2006
Forget 30 Minutes; Anti-Smoking Group Claims 20 Minutes of Secondhand Smoke Exposure Increases Heart Attack Risk
I may have been a bit misleading when I suggested that Action on Smoking and Health (ASH) went off the deep end by claiming that 30 minutes of exposure to drifting tobacco smoke increases a nonsmoker's risk of a fatal heart attack to that of a smoker's.
In fact, ASH appears to be somewhat conservative, if you can believe it.
It turns out that another anti-smoking group - SmokeFreeOhio - is claiming that just 20 minutes of exposure to secondhand smoke increases a nonsmoker's risk of suffering a heart attack.
According to a SmokeFreeOhio "fact" sheet entitled "The Dangers of Secondhand Smoke":
"After twenty minutes of exposure to secondhand smoke, a nonsmoker's blood platelets become as sticky as a smoker's, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."
Elsewhere in the "fact" sheet, SmokeFreeOhio claims that:
"Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries."
Elsewhere, SmokeFreeOhio claims that:
"In that same 30 minutes, changes to your blood boost your risk of building up fat deposits that could lead to heart attacks and strokes."
And still elsewhere, SmokeFreeOhio claims that:
"After 120 minutes of exposure, your heart rate variability is reduced, increasing the chance of an irregular heart beat that can itself be fatal or trigger a heart attack."
The Rest of the Story
I find each of these four claims to be scientifically inaccurate.
Let's take each of the claims, one by one:
1. "After twenty minutes of exposure to secondhand smoke, a nonsmoker's blood platelets become as sticky as a smoker's, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."
I agree that there is evidence that after 20 minutes of secondhand smoke exposure, platelet aggregation increases and that it may increase to the level of that seen in an active smoker. Thus, it is fine to say that a nonsmoker's platelets become as sticky as a smoker's after 20 minutes of secondhand smoke exposure.
However, how do you get from a little platelet stickiness to a reduced ability of the heart to pump and an elevated risk of heart attack?
You simply can't equate a transient increase in platelet stickiness with an elevated heart attack risk. And you certainly can't equate it with reducing the ability of the heart to pump.
If someone were exposed to secondhand smoke repeatedly for a long period of time, then the constant and prolonged effects of secondhand smoke on platelets, along with the effects on endothelial dysfunction, could initiate and maintain the process of atherosclerosis. But it cannot occur in just 20 minutes.
And even chronic exposure to secondhand smoke does not reduce the ability of the heart to pump. What reduces the ability of the heart to pump is injury to the cardiac muscle, such as occurs in a heart attack, with cardiomyopathy, with certain arrhythmias, with myocardial disease, with cardiac tamponade, or with ventricular hypertrophy or valvular disease. But secondhand smoke exposure does not reduce the ability of the heart muscle to pump. Chronic exposure could lead to a heart attack, and that could certainly reduce the heart's ability to pump. But this claim that only 20 minutes of secondhand smoke exposure can reduce the heart's ability to pump is inaccurate.
The fact sheet backs up this claim by citing a study which shows that brief exposure to secondhand smoke decreases platelet sensitivity to prostacyclin.
But you can't go from a study that showed that brief exposure to secondhand smoke decreases platelet sensitivity to prostacyclin to a claim that it reduces the ability of the heart to pump and increases the risk of a heart attack.
In fact, what the study showed was that the effects of brief exposure to secondhand smoke on platelet sensitivity to prostacyclin are transient, such that in passive smokers, a measurable decline in this sensitivity can be detected. However, in chronic smokers, there is no observed decline in platelet sensitivity, because presumably, the chronic and repeated nature of the exposure creates a condition under which platelets are constantly activated (see: Burghuber OC, Punzengruber C, Sinzinger H, Haber P, Silberbauer K. Platelet sensitivity to prostacyclin in smokers and non-smokers. Chest 1986; 90:34-38).
As the study concluded: "This study indicates that platelets of chronic smokers are less sensitive to exogenous PGI2 than platelets of non-smokers. In addition, active as well as passive smoking decreases platelet sensitivity to PGI2 in non-smokers, whereas chronic smokers exhibit no further decline."
Thus, the study actually demonstrates just why it is that a brief exposure to secondhand smoke does not cause atherosclerosis, while a prolonged and chronic exposure may.
The study actually uses the sensitivity to prostacyclin of briefly exposed nonsmokers to provide support for the hypothesis that altered platelet function in smokers plays a role in the development of atherosclerosis in these individuals.
Rather than documenting SmokeFreeOhio's claim, this study actually shows why the claim is inaccurate.
2. "Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries."
This is completely inaccurate. You simply cannot develop atherosclerosis in 30 minutes. If that were the case, you would see lots of young people dying from smoking as well as from secondhand smoke.
Why is it that most smokers who develop coronary artery disease don't show evidence of this disease until they are at least 40 years old?
The answer is that it takes many years to develop atherosclerosis. It is not a process that happens overnight, and certainly not in 20 minutes!
In fact, it usually takes something on the order of a 90% stenosis (i.e., narrowing) of the coronary arteries before the blood flow is restricted enough to cause a heart attack. Obviously, that cannot happen in 20 minutes.
The fact sheet backs up this claim by citing a study which shows that 30 minutes of exposure to secondhand smoke can cause endothelial dysfunction, as measured by coronary flow velocity reserve (CFVR), in nonsmokers to the same degree as seen in smokers (see Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441).
But endothelial dysfunction is a far cry from narrowing of blood vessels, restricted blood flow, and hardening of the arteries (atherosclerosis).
In fact, what endothelial dysfunction measures is the early process of atherosclerosis. As the authors (Otsuka et al.) concluded: "The present findings suggest that reduction of CFVR after passive smoking may be caused by endothelial dysfunction of the coronary circulation, an early process of atherosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbidity and mortality in nonsmokers."
What this means is that acute exposure to secondhand smoke can result in endothelial dysfunction in nonsmokers that if prolonged and repeated over a long time, could eventually result in atherosclerosis and heart disease.
In other words, this study provides a potential mechanism for the observed increase in heart disease risk among passive smokers. It provides biologic plausibility for a causal relationship between exposure to secondhand smoke and heart disease. But it does not suggest that a nonsmoker could develop atherosclerosis as a result of a 30 minute exposure to secondhand smoke.
3. "In that same 30 minutes, changes to your blood boost your risk of building up fat deposits that could lead to heart attacks and strokes."
For the same reasons as above, this claim is also inaccurate. You simply cannot develop fat deposits that could lead to heart attacks and strokes from a 30 minute exposure.
The fact sheet backs up this claim by citing a study which shows that brief exposure to secondhand smoke causes cellular and biochemical changes that are seen in atherosclerosis. In other words, similar to the effect of passive smoking on endothelial dysfunction and platelet activation, the effects of passive smoking on low density lipoprotein (LDL) metabolism and cellular accumulation demonstrate a potential biologic mechanism by which chronic exposure to secondhand smoke could lead to atherosclerosis.
Far from concluding that 30 minutes of secondhand smoke exposure increases the build-up of fat deposits that could lead to heart attacks and strokes, what the study actually concluded was that: "Exposure of nonsmoking subjects to secondhand smoke breaks down the serum antioxidant defense, leading to accelerated lipid peroxidation, LDL modification, and accumulation of LDL cholesterol in human macrophages." (see Valkonen M, Kuusi T. Passive smoking induces atherogenic changes in low-density lipoprotein. Circulation 1998; 97:2012-2016).
4. "After 120 minutes of exposure, your heart rate variability is reduced, increasing the chance of an irregular heart beat that can itself be fatal or trigger a heart attack."
While the first part of this statement is accurate, as there is evidence that acute exposure to secondhand smoke does reduce heart rate variability, the second part of the statement is false. This short-term decrease in heart rate variability does not increase the risk of an arrhythmia (irregular heart beat) that could be fatal or trigger a heart attack.
Just think about it. If this were true, you would see nonsmokers dropping dead all the time after acute exposure to secondhand smoke. If this were true, you would see nonsmokers suffering fatal arrhythmias induced by brief exposure to secondhand smoke. But in the sum total of my years of clinical experience, I have never heard of a patient suffering a fatal or catastrophic arrhythmia from acute exposure to secondhand smoke.
Also, if this were true, it would be unethical to do this type of research without doing cardiac monitoring of human subjects and having resuscitation equipment available. You couldn't just walk into the Salt Lake City airport (as was done in the relevant study) and ask subjects to spend 2 hours in a smoking area, measure a decrease in heart rate variability that could cause a fatal arrhythmia and then discharge those subjects.
The fact sheet backs up this claim by citing a study of the effects of a 2 hour exposure in a smoking area at Salt Lake City Airport on heart rate variability and it does show that the exposure alters heart rate variability. However, the clinical significance of this finding with regards to an acute exposure is nil. The relevance is in terms of the effects of chronic exposure. Once again, this study provides a potential mechanism for the observed increase in heart disease risk among individuals chronically exposed to secondhand smoke (see Pope CA, Eatough DJ, Gold DR, et al. Acute exposure to environmental tobacco smoke and heart rate variability. Environmental Health Perspectives 2001; 109:711-716).
It is important to point out that air pollution also decreases heart rate variability, in a very similar way to the findings observed due to secondhand smoke. There are at least 3 studies which have documented that particulate air pollution changes heart rate variability, just like secondhand smoke; however, one wouldn't warn the public that exposure to air pollution may trigger a fatal or catastrophic arrhythmia. (see Liao D, et al. Environmental Health Perspectives 1999; 197:521-525; Gold DR et al. Circulation 2000; 101:1267-1273; Pope CA et al. American Heart Journal 1999; 138:890-899).
To be clear, I am not accusing SmokeFreeOhio of lying or intentionally deceiving the public. I don't know their beliefs or intentions. It is possible that they simply misinterpreted the results of these studies. What I am simply saying is that what they are disseminating is wrong. It is scientifically inaccurate.
Conclusion
The rest of the story is that another anti-smoking group is making an inaccurate scientific claim in order to support its policy agenda of promoting smoking bans. This one, more aggressive than the first (Action on Smoking and Health) is claiming that just 20 minutes of secondhand smoke exposure (rather than 30) increases the risk of a heart attack in nonsmokers.
In addition to being wrong because it is, I believe, unethical, inappropriate, and irresponsible to be disseminating scientifically invalid information, these actions are going to harm the credibility of the anti-smoking movement simply because they are so completely implausible and seemingly taken out of nowhere. The extrapolations being made are so extreme that they threaten to undermine the public's perception of the anti-smoking movement's ability to interpret and report the results of scientific studies at all, even when that reporting is appropriate.
The problem is - the public and policy makers will not necessarily know the difference. They will not be able to differentiate easily between when the claims we are making are legitimate and when they are extreme and errant extrapolations. They will just begin to question everything that we say.
So as we stand today, the claim that 30 minutes of secondhand smoke exposure increases heart attack risk among nonsmokers is a conservative one. Now we're down to 20 minutes. Does any anti-smoking group care to go for 10 minutes? Anybody? Anybody?
In fact, ASH appears to be somewhat conservative, if you can believe it.
It turns out that another anti-smoking group - SmokeFreeOhio - is claiming that just 20 minutes of exposure to secondhand smoke increases a nonsmoker's risk of suffering a heart attack.
According to a SmokeFreeOhio "fact" sheet entitled "The Dangers of Secondhand Smoke":
"After twenty minutes of exposure to secondhand smoke, a nonsmoker's blood platelets become as sticky as a smoker's, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."
Elsewhere in the "fact" sheet, SmokeFreeOhio claims that:
"Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries."
Elsewhere, SmokeFreeOhio claims that:
"In that same 30 minutes, changes to your blood boost your risk of building up fat deposits that could lead to heart attacks and strokes."
And still elsewhere, SmokeFreeOhio claims that:
"After 120 minutes of exposure, your heart rate variability is reduced, increasing the chance of an irregular heart beat that can itself be fatal or trigger a heart attack."
The Rest of the Story
I find each of these four claims to be scientifically inaccurate.
Let's take each of the claims, one by one:
1. "After twenty minutes of exposure to secondhand smoke, a nonsmoker's blood platelets become as sticky as a smoker's, reducing the ability of the heart to pump and putting a nonsmoker at an elevated risk of heart attack."
I agree that there is evidence that after 20 minutes of secondhand smoke exposure, platelet aggregation increases and that it may increase to the level of that seen in an active smoker. Thus, it is fine to say that a nonsmoker's platelets become as sticky as a smoker's after 20 minutes of secondhand smoke exposure.
However, how do you get from a little platelet stickiness to a reduced ability of the heart to pump and an elevated risk of heart attack?
You simply can't equate a transient increase in platelet stickiness with an elevated heart attack risk. And you certainly can't equate it with reducing the ability of the heart to pump.
If someone were exposed to secondhand smoke repeatedly for a long period of time, then the constant and prolonged effects of secondhand smoke on platelets, along with the effects on endothelial dysfunction, could initiate and maintain the process of atherosclerosis. But it cannot occur in just 20 minutes.
And even chronic exposure to secondhand smoke does not reduce the ability of the heart to pump. What reduces the ability of the heart to pump is injury to the cardiac muscle, such as occurs in a heart attack, with cardiomyopathy, with certain arrhythmias, with myocardial disease, with cardiac tamponade, or with ventricular hypertrophy or valvular disease. But secondhand smoke exposure does not reduce the ability of the heart muscle to pump. Chronic exposure could lead to a heart attack, and that could certainly reduce the heart's ability to pump. But this claim that only 20 minutes of secondhand smoke exposure can reduce the heart's ability to pump is inaccurate.
The fact sheet backs up this claim by citing a study which shows that brief exposure to secondhand smoke decreases platelet sensitivity to prostacyclin.
But you can't go from a study that showed that brief exposure to secondhand smoke decreases platelet sensitivity to prostacyclin to a claim that it reduces the ability of the heart to pump and increases the risk of a heart attack.
In fact, what the study showed was that the effects of brief exposure to secondhand smoke on platelet sensitivity to prostacyclin are transient, such that in passive smokers, a measurable decline in this sensitivity can be detected. However, in chronic smokers, there is no observed decline in platelet sensitivity, because presumably, the chronic and repeated nature of the exposure creates a condition under which platelets are constantly activated (see: Burghuber OC, Punzengruber C, Sinzinger H, Haber P, Silberbauer K. Platelet sensitivity to prostacyclin in smokers and non-smokers. Chest 1986; 90:34-38).
As the study concluded: "This study indicates that platelets of chronic smokers are less sensitive to exogenous PGI2 than platelets of non-smokers. In addition, active as well as passive smoking decreases platelet sensitivity to PGI2 in non-smokers, whereas chronic smokers exhibit no further decline."
Thus, the study actually demonstrates just why it is that a brief exposure to secondhand smoke does not cause atherosclerosis, while a prolonged and chronic exposure may.
The study actually uses the sensitivity to prostacyclin of briefly exposed nonsmokers to provide support for the hypothesis that altered platelet function in smokers plays a role in the development of atherosclerosis in these individuals.
Rather than documenting SmokeFreeOhio's claim, this study actually shows why the claim is inaccurate.
2. "Only 30 minutes of secondhand smoke exposure can cause narrowing of blood vessels, restricting the flow of blood and contributing to hardening of the arteries."
This is completely inaccurate. You simply cannot develop atherosclerosis in 30 minutes. If that were the case, you would see lots of young people dying from smoking as well as from secondhand smoke.
Why is it that most smokers who develop coronary artery disease don't show evidence of this disease until they are at least 40 years old?
The answer is that it takes many years to develop atherosclerosis. It is not a process that happens overnight, and certainly not in 20 minutes!
In fact, it usually takes something on the order of a 90% stenosis (i.e., narrowing) of the coronary arteries before the blood flow is restricted enough to cause a heart attack. Obviously, that cannot happen in 20 minutes.
The fact sheet backs up this claim by citing a study which shows that 30 minutes of exposure to secondhand smoke can cause endothelial dysfunction, as measured by coronary flow velocity reserve (CFVR), in nonsmokers to the same degree as seen in smokers (see Otsuka R, Watanabe H, Hirata K, et al. Acute effects of passive smoking on the coronary circulation in healthy young adults. JAMA 2001; 286:436-441).
But endothelial dysfunction is a far cry from narrowing of blood vessels, restricted blood flow, and hardening of the arteries (atherosclerosis).
In fact, what endothelial dysfunction measures is the early process of atherosclerosis. As the authors (Otsuka et al.) concluded: "The present findings suggest that reduction of CFVR after passive smoking may be caused by endothelial dysfunction of the coronary circulation, an early process of atherosclerosis, and that this change may be one reason why passive smoking is a risk factor for cardiac disease morbidity and mortality in nonsmokers."
What this means is that acute exposure to secondhand smoke can result in endothelial dysfunction in nonsmokers that if prolonged and repeated over a long time, could eventually result in atherosclerosis and heart disease.
In other words, this study provides a potential mechanism for the observed increase in heart disease risk among passive smokers. It provides biologic plausibility for a causal relationship between exposure to secondhand smoke and heart disease. But it does not suggest that a nonsmoker could develop atherosclerosis as a result of a 30 minute exposure to secondhand smoke.
3. "In that same 30 minutes, changes to your blood boost your risk of building up fat deposits that could lead to heart attacks and strokes."
For the same reasons as above, this claim is also inaccurate. You simply cannot develop fat deposits that could lead to heart attacks and strokes from a 30 minute exposure.
The fact sheet backs up this claim by citing a study which shows that brief exposure to secondhand smoke causes cellular and biochemical changes that are seen in atherosclerosis. In other words, similar to the effect of passive smoking on endothelial dysfunction and platelet activation, the effects of passive smoking on low density lipoprotein (LDL) metabolism and cellular accumulation demonstrate a potential biologic mechanism by which chronic exposure to secondhand smoke could lead to atherosclerosis.
Far from concluding that 30 minutes of secondhand smoke exposure increases the build-up of fat deposits that could lead to heart attacks and strokes, what the study actually concluded was that: "Exposure of nonsmoking subjects to secondhand smoke breaks down the serum antioxidant defense, leading to accelerated lipid peroxidation, LDL modification, and accumulation of LDL cholesterol in human macrophages." (see Valkonen M, Kuusi T. Passive smoking induces atherogenic changes in low-density lipoprotein. Circulation 1998; 97:2012-2016).
4. "After 120 minutes of exposure, your heart rate variability is reduced, increasing the chance of an irregular heart beat that can itself be fatal or trigger a heart attack."
While the first part of this statement is accurate, as there is evidence that acute exposure to secondhand smoke does reduce heart rate variability, the second part of the statement is false. This short-term decrease in heart rate variability does not increase the risk of an arrhythmia (irregular heart beat) that could be fatal or trigger a heart attack.
Just think about it. If this were true, you would see nonsmokers dropping dead all the time after acute exposure to secondhand smoke. If this were true, you would see nonsmokers suffering fatal arrhythmias induced by brief exposure to secondhand smoke. But in the sum total of my years of clinical experience, I have never heard of a patient suffering a fatal or catastrophic arrhythmia from acute exposure to secondhand smoke.
Also, if this were true, it would be unethical to do this type of research without doing cardiac monitoring of human subjects and having resuscitation equipment available. You couldn't just walk into the Salt Lake City airport (as was done in the relevant study) and ask subjects to spend 2 hours in a smoking area, measure a decrease in heart rate variability that could cause a fatal arrhythmia and then discharge those subjects.
The fact sheet backs up this claim by citing a study of the effects of a 2 hour exposure in a smoking area at Salt Lake City Airport on heart rate variability and it does show that the exposure alters heart rate variability. However, the clinical significance of this finding with regards to an acute exposure is nil. The relevance is in terms of the effects of chronic exposure. Once again, this study provides a potential mechanism for the observed increase in heart disease risk among individuals chronically exposed to secondhand smoke (see Pope CA, Eatough DJ, Gold DR, et al. Acute exposure to environmental tobacco smoke and heart rate variability. Environmental Health Perspectives 2001; 109:711-716).
It is important to point out that air pollution also decreases heart rate variability, in a very similar way to the findings observed due to secondhand smoke. There are at least 3 studies which have documented that particulate air pollution changes heart rate variability, just like secondhand smoke; however, one wouldn't warn the public that exposure to air pollution may trigger a fatal or catastrophic arrhythmia. (see Liao D, et al. Environmental Health Perspectives 1999; 197:521-525; Gold DR et al. Circulation 2000; 101:1267-1273; Pope CA et al. American Heart Journal 1999; 138:890-899).
To be clear, I am not accusing SmokeFreeOhio of lying or intentionally deceiving the public. I don't know their beliefs or intentions. It is possible that they simply misinterpreted the results of these studies. What I am simply saying is that what they are disseminating is wrong. It is scientifically inaccurate.
Conclusion
The rest of the story is that another anti-smoking group is making an inaccurate scientific claim in order to support its policy agenda of promoting smoking bans. This one, more aggressive than the first (Action on Smoking and Health) is claiming that just 20 minutes of secondhand smoke exposure (rather than 30) increases the risk of a heart attack in nonsmokers.
In addition to being wrong because it is, I believe, unethical, inappropriate, and irresponsible to be disseminating scientifically invalid information, these actions are going to harm the credibility of the anti-smoking movement simply because they are so completely implausible and seemingly taken out of nowhere. The extrapolations being made are so extreme that they threaten to undermine the public's perception of the anti-smoking movement's ability to interpret and report the results of scientific studies at all, even when that reporting is appropriate.
The problem is - the public and policy makers will not necessarily know the difference. They will not be able to differentiate easily between when the claims we are making are legitimate and when they are extreme and errant extrapolations. They will just begin to question everything that we say.
So as we stand today, the claim that 30 minutes of secondhand smoke exposure increases heart attack risk among nonsmokers is a conservative one. Now we're down to 20 minutes. Does any anti-smoking group care to go for 10 minutes? Anybody? Anybody?
Utah's Budget Director Admits States are Addicted to Tobacco Money Due to Master Settlement Agreement
In a rare display of telling it like it is, the budget director for the state of Utah admitted that the states are addicted to tobacco money because of the Master Settlement Agreement (MSA), which is providing states with payments based on the volume of tobacco sales, and therefore provides an incentive for them not to reduce cigarette consumption too much. The statement was made in the context of discussion over the threatened loss of tobacco company payments to the states under the MSA because of the non-participating manufacturer adjustment provision.
According to an article in the Deseret News: "Record-low cigarette sales in the United States could mean less money coming to the states through payments from big tobacco manufacturers, although how much and when the states would take the hit remains uncertain. ... The states' lawsuit against tobacco makers originally sought to stop deceitful advertising practices and the marketing of tobacco products to children. And while many Americans may have kicked the tobacco habit, Ellis [Utah's budget director] said, many states have not. 'We've become addicted to the tobacco money,' he said."
The Rest of the Story
For the first time in a long time, there is no rest of the story. The Utah budget director has told it like it is and called a spade a spade. It is refreshing to see a government official tell it like it is. The truth is that the states have become addicted to tobacco money, through the ingenious scheme that is the MSA. And that addiction is going to be harder to break than quitting smoking itself.
According to an article in the Deseret News: "Record-low cigarette sales in the United States could mean less money coming to the states through payments from big tobacco manufacturers, although how much and when the states would take the hit remains uncertain. ... The states' lawsuit against tobacco makers originally sought to stop deceitful advertising practices and the marketing of tobacco products to children. And while many Americans may have kicked the tobacco habit, Ellis [Utah's budget director] said, many states have not. 'We've become addicted to the tobacco money,' he said."
The Rest of the Story
For the first time in a long time, there is no rest of the story. The Utah budget director has told it like it is and called a spade a spade. It is refreshing to see a government official tell it like it is. The truth is that the states have become addicted to tobacco money, through the ingenious scheme that is the MSA. And that addiction is going to be harder to break than quitting smoking itself.
What Are They Waiting For? Tobacco Companies Should Claim that Smoking Presents No More Risk of Heart Attacks than Brief Secondhand Smoke Exposure
If I were working for a tobacco company, I would recommend to the public relations department that they immediately put out some sort of communication to smokers and to the public indicating that smoking poses no more serious risk of a heart attack than a transient (30 minute) exposure to drifting tobacco smoke (secondhand smoke).
You may ask the question - how could I recommend putting out such an obviously false health claim?
Well I wouldn't exactly put it out in a way that implies that my company were making such a claim. What I would say is that "according to" a prominent anti-smoking group, smoking poses no more risk of a heart attack than 30 minutes of secondhand smoke.
After all, that's exactly what Action on Smoking and Health (ASH) claims in a statement on its website, a re-emphasized statement on its web site, and in a communication sent to all members of the New Hampshire House of Representatives: "breathing drifting tobacco smoke for as little as 30 minutes ( less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker’s risk of suffering a fatal heart attack to that of a smoker."
And another anti-smoking group - SmokeFreeOhio - actually tops ASH. They claim that not 30, but just 20 minutes of secondhand smoke exposure in a nonsmoker reduces "the ability of the heart to pump" and increases the "risk of a heart attack." So if anything, the 30 minutes is a conservative estimate.
So as a tobacco company, you don't even have to go out on a limb in proclaiming that a smoker's risk of a heart attack is no more than that of a nonsmoker's. You simply have to cite the health claims that the anti-smoking movement is making.
What a tremendous public relations coup this would be. Imagine if you could convince smokers and the general public that smoking was not a serious cardiovascular risk after all. Imagine if you could convince the public that smoking actually puts people at no more risk of a heart attack than breathing in drifting tobacco smoke or 20 or 30 minutes.
You would be able to completely undermine the public's appreciation of the severe hazards of smoking, to be taken seriously in doing so, and to reverse the effects of years of public education about the health hazards of smoking.
It seems like a dream come true.
The Rest of the Story
I think it may be interesting and perhaps informative to consider the question of why the tobacco companies have not jumped on this amazing opportunity. They have nothing to lose because they wouldn't be making any health claim themselves. They would simply be pointing the public to claims that "anti-smoking authorities" have made. This is completely in line with what the companies presently do on their web sites.
They could even just provide direct quotes from Action on Smoking and Health and SmokeFreeOhio, without adding any editorial comment that might be construed as the company itself making a claim of any kind. But the damage would be done. It would help to completely undermine the public's understanding of the cardiovascular health risks of smoking.
This is an incredible public relations opportunity that has kindly been provided by the anti-smoking movement.
To make it even more appealing, not only have these public statements been made by several anti-smoking groups, but they have not been contested by a single anti-smoking group or advocate, other than myself (and I'm just a tobacco stooge anyway). In fact, they have been publicly defended by a number of advocates and groups. Thus, the companies can argue that they had no reason to believe that there was any doubt about the claims that these anti-smoking groups made.
It may seem strange, but the reason I think the tobacco companies will not use such a tactic is that they know the claim would be completely fallacious.
While the companies have, in the past, used deceptive and misleading statements, they generally have not made direct factual misrepresentations. And more recently, it appears to me that they have become more careful about even possibly misleading the public in terms of making deceptive health claims. This is in fact the reason why I believe that Philip Morris and perhaps other companies are reticent to market reduced exposure products without an FDA stamp of approval for these products.
So the fact is that tobacco companies will not take advantage of this opportunity simply because they themselves view the claim as being completely fallacious. They know that it is completely fallacious.
Which puts us in the all too ironic situation (a little too ironic), with respect to this particular matter, of the tobacco companies being more concerned about scientific integrity than the tobacco control movement.
Because that's what it really comes down to. The tobacco companies are not making and will not make a claim that smokers' risk of a heart attack is equivalent to that of a nonsmoker exposed to drifting tobacco smoke. But anti-smoking groups are making and apparently will continue to make the claim that a smokers' risk of a heart attack is the same as that of a nonsmoker exposed to 30 minutes of drifting tobacco smoke.
So the anti-smoking movement is willing to make a completely fallacious claim to advance its agenda, while the tobacco industry is not willing to make the same fallacious claim to advance its agenda.
I never thought it would come to this, but the rest of the story is difficult to deny. It's happening before my eyes. I'm just glad that my eyes are open, and that I'm able to write about what I'm seeing. Because maybe this harsh truth will finally hit the anti-smoking groups over the head hard enough to make them see what is going on. And to realize that they are on the verge of completely losing all semblance of public credibility.
When the tobacco companies are a bit more concerned about scientific integrity than you are, it should be a wake-up call telling you that something needs to change. And this isn't just a wake-up call, it's a thunderous, shrieking, earsplitting alarm.
You may ask the question - how could I recommend putting out such an obviously false health claim?
Well I wouldn't exactly put it out in a way that implies that my company were making such a claim. What I would say is that "according to" a prominent anti-smoking group, smoking poses no more risk of a heart attack than 30 minutes of secondhand smoke.
After all, that's exactly what Action on Smoking and Health (ASH) claims in a statement on its website, a re-emphasized statement on its web site, and in a communication sent to all members of the New Hampshire House of Representatives: "breathing drifting tobacco smoke for as little as 30 minutes ( less than the time one might be exposed outdoors on a beach, sitting on a park bench, listening to a concert in a park, etc.) can raise a nonsmoker’s risk of suffering a fatal heart attack to that of a smoker."
And another anti-smoking group - SmokeFreeOhio - actually tops ASH. They claim that not 30, but just 20 minutes of secondhand smoke exposure in a nonsmoker reduces "the ability of the heart to pump" and increases the "risk of a heart attack." So if anything, the 30 minutes is a conservative estimate.
So as a tobacco company, you don't even have to go out on a limb in proclaiming that a smoker's risk of a heart attack is no more than that of a nonsmoker's. You simply have to cite the health claims that the anti-smoking movement is making.
What a tremendous public relations coup this would be. Imagine if you could convince smokers and the general public that smoking was not a serious cardiovascular risk after all. Imagine if you could convince the public that smoking actually puts people at no more risk of a heart attack than breathing in drifting tobacco smoke or 20 or 30 minutes.
You would be able to completely undermine the public's appreciation of the severe hazards of smoking, to be taken seriously in doing so, and to reverse the effects of years of public education about the health hazards of smoking.
It seems like a dream come true.
The Rest of the Story
I think it may be interesting and perhaps informative to consider the question of why the tobacco companies have not jumped on this amazing opportunity. They have nothing to lose because they wouldn't be making any health claim themselves. They would simply be pointing the public to claims that "anti-smoking authorities" have made. This is completely in line with what the companies presently do on their web sites.
They could even just provide direct quotes from Action on Smoking and Health and SmokeFreeOhio, without adding any editorial comment that might be construed as the company itself making a claim of any kind. But the damage would be done. It would help to completely undermine the public's understanding of the cardiovascular health risks of smoking.
This is an incredible public relations opportunity that has kindly been provided by the anti-smoking movement.
To make it even more appealing, not only have these public statements been made by several anti-smoking groups, but they have not been contested by a single anti-smoking group or advocate, other than myself (and I'm just a tobacco stooge anyway). In fact, they have been publicly defended by a number of advocates and groups. Thus, the companies can argue that they had no reason to believe that there was any doubt about the claims that these anti-smoking groups made.
It may seem strange, but the reason I think the tobacco companies will not use such a tactic is that they know the claim would be completely fallacious.
While the companies have, in the past, used deceptive and misleading statements, they generally have not made direct factual misrepresentations. And more recently, it appears to me that they have become more careful about even possibly misleading the public in terms of making deceptive health claims. This is in fact the reason why I believe that Philip Morris and perhaps other companies are reticent to market reduced exposure products without an FDA stamp of approval for these products.
So the fact is that tobacco companies will not take advantage of this opportunity simply because they themselves view the claim as being completely fallacious. They know that it is completely fallacious.
Which puts us in the all too ironic situation (a little too ironic), with respect to this particular matter, of the tobacco companies being more concerned about scientific integrity than the tobacco control movement.
Because that's what it really comes down to. The tobacco companies are not making and will not make a claim that smokers' risk of a heart attack is equivalent to that of a nonsmoker exposed to drifting tobacco smoke. But anti-smoking groups are making and apparently will continue to make the claim that a smokers' risk of a heart attack is the same as that of a nonsmoker exposed to 30 minutes of drifting tobacco smoke.
So the anti-smoking movement is willing to make a completely fallacious claim to advance its agenda, while the tobacco industry is not willing to make the same fallacious claim to advance its agenda.
I never thought it would come to this, but the rest of the story is difficult to deny. It's happening before my eyes. I'm just glad that my eyes are open, and that I'm able to write about what I'm seeing. Because maybe this harsh truth will finally hit the anti-smoking groups over the head hard enough to make them see what is going on. And to realize that they are on the verge of completely losing all semblance of public credibility.
When the tobacco companies are a bit more concerned about scientific integrity than you are, it should be a wake-up call telling you that something needs to change. And this isn't just a wake-up call, it's a thunderous, shrieking, earsplitting alarm.
Friday, March 10, 2006
Anti-Smoking Group Uses False Information to Support New Hampshire Smoking Ban
Action on Smoking and Health (ASH) - a Washington, D.C.-based anti-smoking group - has sent a message to each member of the New Hampshire House of Representatives supporting a bill, under consideration now, that would ban smoking in restaurants. The communication sent to each House member indicated that breathing secondhand smoke for even brief periods can be deadly to people who don't have asthma and that breathing secondhand smoke for as little as 30 minutes raises the risk of a fatal heart attack in a nonsmoker to the same level as in a smoker.
A major justification in support of a smoking ban that ASH provides is the following scientific claim about the health effects of secondhand smoke:
"Even for some people without respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Controls [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes can raise a nonsmokers risk of suffering a fatal heart attack to that of a smoker."
The Rest of the Story
The rest of the story is that ASH's claims (both of them) are false and there is absolutely no documentation that supports either claim.
There is simply no solid evidence that breathing secondhand smoke for brief periods can be deadly to nonsmokers. The only exception to this would be severe asthmatics, for whom a brief exposure could trigger an asthmatic attack, which could potentially be fatal. But this claim excludes asthmatics. What it is clearly referring to is death from a fatal heart attack. But there is no credible evidence that I have seen that is sufficient to document a claim that a person is at risk of a heart attack from breathing secondhand smoke briefly.
The second claim is completely fallacious. It is simply not true that breathing in drifting tobacco smoke for 30 minutes raises the risk of a fatal heart attack in a nonsmoker to the same level as in a smoker. And there is absolutely no evidence to support such a claim.
Moreover, I can find not a shred of evidence that CDC made any such claim. What CDC said was that 30 minutes of exposure could cause endothelial dysfunction equivalent to that seen in a smoker. But nowhere did CDC state that 30 minutes of exposure could raise the fatal heart attack risk to that of a smoker.
In fact, you cannot get a heart attack from breathing in secondhand smoke for just 30 minutes if you are otherwise healthy. It just can't happen. You cannot develop atherosclerosis in 30 minutes!
I'm not going to repeat the reasons why these claims are fallacious here. Interested readers can find my attempts at a detailed explanation elsewhere (post#1; post#2; post #3; post #4; post#5).
Suffice it to say that for the first claim, there is simply not sufficient evidence to support it.
And the second claim is simply a bunch of crap.
Now let me make it clear that I am arguing that these claims are fallacious and false. I'm not arguing that ASH is lying. In other words, it is possible that ASH actually believes the crap they are stating. I'm not claiming they are deliberately trying to deceive people. It is quite possible that they actually believe the ridiculous, implausible, and impossible claim that they are making. Although if that's true, you would think it would help them to get some sort of physician or scientist on board as quickly as possible to help prevent them from spreading such false information.
Regardless of the reasons or intentions, the bottom line is that a prominent anti-smoking group is spreading complete misinformation in an attempt to promote a public policy. And I find that wrong and irresponsible. And I think it severely harms the credibility of the entire anti-smoking movement.
For the movement to save itself and preserve any semblance of scientific integrity and credibility, I think anti-smoking groups and advocates need to clearly and publicly reject ASH's misinformation, and explain to the public that these claims are untrue and do not represent the thinking of the entire movement, but simply of one fanatical organization that is going far beyond the realm of science to support its agenda.
A major justification in support of a smoking ban that ASH provides is the following scientific claim about the health effects of secondhand smoke:
"Even for some people without respiratory conditions, breathing drifting tobacco smoke for even brief periods can be deadly. For example, the Centers for Disease Controls [CDC] has warned that breathing drifting tobacco smoke for as little as 30 minutes can raise a nonsmokers risk of suffering a fatal heart attack to that of a smoker."
The Rest of the Story
The rest of the story is that ASH's claims (both of them) are false and there is absolutely no documentation that supports either claim.
There is simply no solid evidence that breathing secondhand smoke for brief periods can be deadly to nonsmokers. The only exception to this would be severe asthmatics, for whom a brief exposure could trigger an asthmatic attack, which could potentially be fatal. But this claim excludes asthmatics. What it is clearly referring to is death from a fatal heart attack. But there is no credible evidence that I have seen that is sufficient to document a claim that a person is at risk of a heart attack from breathing secondhand smoke briefly.
The second claim is completely fallacious. It is simply not true that breathing in drifting tobacco smoke for 30 minutes raises the risk of a fatal heart attack in a nonsmoker to the same level as in a smoker. And there is absolutely no evidence to support such a claim.
Moreover, I can find not a shred of evidence that CDC made any such claim. What CDC said was that 30 minutes of exposure could cause endothelial dysfunction equivalent to that seen in a smoker. But nowhere did CDC state that 30 minutes of exposure could raise the fatal heart attack risk to that of a smoker.
In fact, you cannot get a heart attack from breathing in secondhand smoke for just 30 minutes if you are otherwise healthy. It just can't happen. You cannot develop atherosclerosis in 30 minutes!
I'm not going to repeat the reasons why these claims are fallacious here. Interested readers can find my attempts at a detailed explanation elsewhere (post#1; post#2; post #3; post #4; post#5).
Suffice it to say that for the first claim, there is simply not sufficient evidence to support it.
And the second claim is simply a bunch of crap.
Now let me make it clear that I am arguing that these claims are fallacious and false. I'm not arguing that ASH is lying. In other words, it is possible that ASH actually believes the crap they are stating. I'm not claiming they are deliberately trying to deceive people. It is quite possible that they actually believe the ridiculous, implausible, and impossible claim that they are making. Although if that's true, you would think it would help them to get some sort of physician or scientist on board as quickly as possible to help prevent them from spreading such false information.
Regardless of the reasons or intentions, the bottom line is that a prominent anti-smoking group is spreading complete misinformation in an attempt to promote a public policy. And I find that wrong and irresponsible. And I think it severely harms the credibility of the entire anti-smoking movement.
For the movement to save itself and preserve any semblance of scientific integrity and credibility, I think anti-smoking groups and advocates need to clearly and publicly reject ASH's misinformation, and explain to the public that these claims are untrue and do not represent the thinking of the entire movement, but simply of one fanatical organization that is going far beyond the realm of science to support its agenda.
Campaign for Tobacco-Free Kids Criticizes Tobacco Companies for Attempting to Enforce Master Settlement Agreement
In a press release issued this past Tuesday, the Campaign for Tobacco-Free Kids attacked the tobacco companies for pursuing or supporting litigation against the American Legacy Foundation which claims that some of its "truth" campaign advertisements have violated the terms of the Master Settlement Agreement (MSA) by "vilifying" the tobacco companies, something that is prohibited by the agreement.
Lorillard Tobacco Company earlier filed suit to shut down the "truth" campaign because of what it alleges is a violation of the "vilification" clause in the MSA. On March 3, Philip Morris and R.J. Reynolds sought to be recognized in the lawsuit for the purpose of filing amici curiae briefs in support of Lorillard's appeal to the Delaware Supreme Court (the Delaware Chancery Court has rejected Lorillard's claim).
According to the Campaign for Tobacco-Free Kids' press release, this action by the tobacco companies "show they haven't changed and still want kids to smoke."
The release states: "The tobacco companies claim that they have changed their ways and do not want kids to smoke, but their actions continue to tell a different story. ... their effort to shut down the truth® campaign shows again that they remain the main cause of the problem and diehard opponents of policies and programs that actually reduce tobacco use. ... It is critical that the American Legacy Foundation prevail in the Delaware Supreme Court so that it can maintain its independence and continue to run hard-hitting advertising proven effective at preventing kids from smoking. The fact that Philip Morris, RJR, and Lorillard are all seeking to stop Legacy's successful efforts to reduce youth smoking is further proof that Big Tobacco has not changed."
The Rest of the Story
While I support the "truth" campaign and agree that anti-smoking media campaigns are critical in the effort to prevent smoking, and while I agree that the tobacco companies have largely not changed and still do want kids to smoke, I do not find this particular action by the tobacco companies to be evidence that they haven't changed and still want kids to smoke.
After all, the states signed a contract agreeing not to vilify the tobacco companies in the Legacy advertisements and the tobacco companies have every right to attempt to enforce that contract. If the complaint were completely frivolous, then I might agree that it was merely a thinly-veiled attempt to try to shut down the operation. But the complaint is not at all frivolous; I think it is a legitimate question of interpretation that deserves to be resolved. I think that the tobacco companies have a right to make sure that the states are living up to their part of the contract.
The background to the lawsuit is as follows: Lorillard (maker of Newport, among other cigarette brands), has sued the American Legacy Foundation for violating the terms of the Master Settlement Agreement through its "truth" anti-smoking campaign. Specifically, Lorillard contends that the "truth" campaign ads violate the anti-vilification clause of the settlement agreement (section VI[h]), which states that: "The National Public Education Fund shall be used only for public education and advertising regarding the addictiveness, health effects, and social costs related to the use of tobacco products and shall not be used for any personal attack on, or vilification of, any person (whether by name or business affiliation), company, or governmental agency, whether individually or collectively."
The Campaign for Tobacco-Free Kids would have us believe that Lorillard's invocation of the anti-vilification clause (and the support of Lorillard's claim by Philip Morris and R.J. Reynolds) is simply an attempt to intimidate Legacy under the guise of anti-vilification provisions. But is that the case? Or is there a legitimate argument that could be made that the anti-vilification clause raises a legitimate legal question that warrants a judicial interpretation?
Here, a careful reading of the anti-vilification provision is critical. The clause states that the Foundation's ads must not make "any personal attack on, or vilification of, any person (whether by name or business affiliation), company, or governmental agency, whether individually or collectively." To vilify is defined as either "to lower in estimation or importance" or "to utter slanderous and abusive statements against."
While I personally would not interpret the anti-vilification clause in such a way that it would lead to a conclusion that some of the "truth" campaign ads have violated the provision, I do have to admit that it does not seem unreasonable to argue that some of the ads do attempt to lower the public's estimation of the tobacco companies. So I think the significant legal question for a court to determine is whether the definition of "vilify" would fall under the first (more general) or second (more specific) definition above. Under the first definition, it may not be unreasonable to interpret the MSA in such a way that the "truth" campaign ads represent a violation of the clause. Under the second definition, the "truth" campaign is home-free.
The problem is that it is not up to me to decide how to interpret the MSA. The relevant question is really whether there is a legitimate potential legal argument that the ads could violate the MSA, such that a court's hearing of the issue becomes essential for the tobacco company's interest in pursuing legal enforcement of the binding contract that both parties are subject to. And I think because there is at least the possibility of a more general interpretation of the anti-vilification clause, a lawsuit on this basis is not frivolous, but is within the realm of reason.
I therefore am not persuaded by the Campaign's press release. If anything, I think that it is in the best interests of the public's health in the long run to defend the legal system and the opportunity for parties to pursue justice under the laws of our nation. To cut off or restrain the legal ability of the tobacco companies to seek justice under a contract that is legally binding, just because the companies are very bad and we are very good, does not advance the overall interests of public health in the long run. And, frankly, I think it may violate legitimate legal rights of the tobacco companies. Yes, I do think that all entities in our society do have certain legal rights that cannot be stripped away simply on the basis of their being faulty in intention or action.
Thus, while I disagree with much of what the tobacco companies are doing, I think here they are exercising a legitimate right to seek a judicial interpretation of the binding contract they the states have signed, in which they may have agreed not to put out ads that lower in estimation or importance the tobacco companies (which the "truth" ads are certainly, and appropriately, doing).
The blame here lies not with the tobacco companies, but with the Attorneys General who signed this damaging contract in the first place. They were not required to include an anti-vilification clause in the contract. They had the option of telling the tobacco companies: "either you allow us to run the campaign how we think it should be run or forget the deal - we'll continue to fight you in the courtroom."
But they chose not to. They chose, instead, to compromise the potential effectiveness of what is arguably the key element of the Master Settlement Agreement by giving the tobacco companies a huge legal avenue to pursue exactly what they are exercising their rights to pursue. This all could have been foreseen (and was in fact foreseen) in November 1998.
There is no mystery here. No one who read the contract had any doubt that the tobacco companies were going to invoke the anti-vilification clause. And there was no doubt that the purpose of the anti-vilification clause was to give the tobacco companies an opportunity to try to prevent the hard-hitting ads that the "truth" campaign has put out.
The Tobacco Control Resource Center, in its March 1999 analysis of the MSA, concluded that the anti-vilification clause "appears to encompass 'personal' attacks or vilification of the tobacco industry (by virtue of the words 'company' and 'collectively') [and] could censor the most effective of state and local advertising and education campaigns."
And in answer to its question of "Will this 'no tobacco industry attacks' provision inhibit the development of and funding of effective counter advertising campaigns?" the analysis concluded: "Yes, to the extent states and localities depend on NPEF funds from the MSA to mount such campaigns. Counter-advertising campaigns that expose tobacco industry manipulation are among the most effective strategies for reaching target audiences and reducing tobacco consumption."
So it was clearly the expert opinion of top attorneys from within the tobacco control movement that the anti-vilification clause might reasonably be interpreted by the courts as precluding the very type of advertisements (exposing tobacco industry manipulation of youths) that the "truth" campaign has been running.
I'm not arguing here that the Tobacco Control Resource Center provided any definitive answer as to whether the "truth" ads violate the anti-vilification clause; I'm simply making the point that the tobacco companies' claim is a legitimate, rather than a frivolous one.
Perhaps what bothers me most about the Campaign's press release is that I feel it again (the Campaign's arguments in support of monetary remedies in the DOJ case being the first example) demonstrates a lack of regard for the rule of law.
Yes - it is in the best interests of the public's health to allow Legacy to run these ads. Yes - the tobacco industry should, if its primary concern were the public's health, abdicate its legal right to challenge the ads.
But should we not have some respect for the law? The states signed a contract and they are obligated to live by that contract. In fact, it was the Attorneys General - the chief law enforcement officers of the states - that signed the contract. They, if anyone, should have an overriding concern for following the rule of law.
It's clear to me that many anti-smoking groups are refusing to acknowledge that the MSA is a legal contract. They seem to be treating it as if it is some public health resolution by which the tobacco companies agreed to work to protect the public's health. Let's make no mistake about it. The MSA is not a public health resolution. It is a legal contract entered into voluntarily by the parties. And just as it is reasonable for the states to file suit against the companies for violating provisions of the MSA, it is also reasonable for the companies to file suit against the states for violating provisions of the MSA, as long as the legal claims are not frivolous.
Don't get me wrong. I am in no way arguing that the "truth" campaign ads violate the anti-vilification clause of the MSA. I think it is very possible that the more specific interpretation of the provision may carry the day. But I see nothing wrong with the tobacco companies exercising their right to enforce the provisions of the contract, especially since their claim is certainly not a frivolous one.
As a movement that relies upon the force of law to achieve perhaps the majority of objectives in promoting the public's health, I think it is time to demonstrate a little more respect for the law. And to hold ourselves a little more accountable for legally binding agreements that we make.
Yes - let's defend Legacy vigorously in the courtroom. Let's convince the judge that a more specific interpretation of the word "vilify" is what the signatories to the MSA had in mind. But let's not pretend that the contract is a one-way agreement whose provisions only we, as the good guys, can enforce.
In the long run, I think this approach is degrading to the integrity of our legal system - let's show the utmost respect for the opportunity for parties to seek justice under our legal system. After all, we have $145 billion resting on that principle.
Lorillard Tobacco Company earlier filed suit to shut down the "truth" campaign because of what it alleges is a violation of the "vilification" clause in the MSA. On March 3, Philip Morris and R.J. Reynolds sought to be recognized in the lawsuit for the purpose of filing amici curiae briefs in support of Lorillard's appeal to the Delaware Supreme Court (the Delaware Chancery Court has rejected Lorillard's claim).
According to the Campaign for Tobacco-Free Kids' press release, this action by the tobacco companies "show they haven't changed and still want kids to smoke."
The release states: "The tobacco companies claim that they have changed their ways and do not want kids to smoke, but their actions continue to tell a different story. ... their effort to shut down the truth® campaign shows again that they remain the main cause of the problem and diehard opponents of policies and programs that actually reduce tobacco use. ... It is critical that the American Legacy Foundation prevail in the Delaware Supreme Court so that it can maintain its independence and continue to run hard-hitting advertising proven effective at preventing kids from smoking. The fact that Philip Morris, RJR, and Lorillard are all seeking to stop Legacy's successful efforts to reduce youth smoking is further proof that Big Tobacco has not changed."
The Rest of the Story
While I support the "truth" campaign and agree that anti-smoking media campaigns are critical in the effort to prevent smoking, and while I agree that the tobacco companies have largely not changed and still do want kids to smoke, I do not find this particular action by the tobacco companies to be evidence that they haven't changed and still want kids to smoke.
After all, the states signed a contract agreeing not to vilify the tobacco companies in the Legacy advertisements and the tobacco companies have every right to attempt to enforce that contract. If the complaint were completely frivolous, then I might agree that it was merely a thinly-veiled attempt to try to shut down the operation. But the complaint is not at all frivolous; I think it is a legitimate question of interpretation that deserves to be resolved. I think that the tobacco companies have a right to make sure that the states are living up to their part of the contract.
The background to the lawsuit is as follows: Lorillard (maker of Newport, among other cigarette brands), has sued the American Legacy Foundation for violating the terms of the Master Settlement Agreement through its "truth" anti-smoking campaign. Specifically, Lorillard contends that the "truth" campaign ads violate the anti-vilification clause of the settlement agreement (section VI[h]), which states that: "The National Public Education Fund shall be used only for public education and advertising regarding the addictiveness, health effects, and social costs related to the use of tobacco products and shall not be used for any personal attack on, or vilification of, any person (whether by name or business affiliation), company, or governmental agency, whether individually or collectively."
The Campaign for Tobacco-Free Kids would have us believe that Lorillard's invocation of the anti-vilification clause (and the support of Lorillard's claim by Philip Morris and R.J. Reynolds) is simply an attempt to intimidate Legacy under the guise of anti-vilification provisions. But is that the case? Or is there a legitimate argument that could be made that the anti-vilification clause raises a legitimate legal question that warrants a judicial interpretation?
Here, a careful reading of the anti-vilification provision is critical. The clause states that the Foundation's ads must not make "any personal attack on, or vilification of, any person (whether by name or business affiliation), company, or governmental agency, whether individually or collectively." To vilify is defined as either "to lower in estimation or importance" or "to utter slanderous and abusive statements against."
While I personally would not interpret the anti-vilification clause in such a way that it would lead to a conclusion that some of the "truth" campaign ads have violated the provision, I do have to admit that it does not seem unreasonable to argue that some of the ads do attempt to lower the public's estimation of the tobacco companies. So I think the significant legal question for a court to determine is whether the definition of "vilify" would fall under the first (more general) or second (more specific) definition above. Under the first definition, it may not be unreasonable to interpret the MSA in such a way that the "truth" campaign ads represent a violation of the clause. Under the second definition, the "truth" campaign is home-free.
The problem is that it is not up to me to decide how to interpret the MSA. The relevant question is really whether there is a legitimate potential legal argument that the ads could violate the MSA, such that a court's hearing of the issue becomes essential for the tobacco company's interest in pursuing legal enforcement of the binding contract that both parties are subject to. And I think because there is at least the possibility of a more general interpretation of the anti-vilification clause, a lawsuit on this basis is not frivolous, but is within the realm of reason.
I therefore am not persuaded by the Campaign's press release. If anything, I think that it is in the best interests of the public's health in the long run to defend the legal system and the opportunity for parties to pursue justice under the laws of our nation. To cut off or restrain the legal ability of the tobacco companies to seek justice under a contract that is legally binding, just because the companies are very bad and we are very good, does not advance the overall interests of public health in the long run. And, frankly, I think it may violate legitimate legal rights of the tobacco companies. Yes, I do think that all entities in our society do have certain legal rights that cannot be stripped away simply on the basis of their being faulty in intention or action.
Thus, while I disagree with much of what the tobacco companies are doing, I think here they are exercising a legitimate right to seek a judicial interpretation of the binding contract they the states have signed, in which they may have agreed not to put out ads that lower in estimation or importance the tobacco companies (which the "truth" ads are certainly, and appropriately, doing).
The blame here lies not with the tobacco companies, but with the Attorneys General who signed this damaging contract in the first place. They were not required to include an anti-vilification clause in the contract. They had the option of telling the tobacco companies: "either you allow us to run the campaign how we think it should be run or forget the deal - we'll continue to fight you in the courtroom."
But they chose not to. They chose, instead, to compromise the potential effectiveness of what is arguably the key element of the Master Settlement Agreement by giving the tobacco companies a huge legal avenue to pursue exactly what they are exercising their rights to pursue. This all could have been foreseen (and was in fact foreseen) in November 1998.
There is no mystery here. No one who read the contract had any doubt that the tobacco companies were going to invoke the anti-vilification clause. And there was no doubt that the purpose of the anti-vilification clause was to give the tobacco companies an opportunity to try to prevent the hard-hitting ads that the "truth" campaign has put out.
The Tobacco Control Resource Center, in its March 1999 analysis of the MSA, concluded that the anti-vilification clause "appears to encompass 'personal' attacks or vilification of the tobacco industry (by virtue of the words 'company' and 'collectively') [and] could censor the most effective of state and local advertising and education campaigns."
And in answer to its question of "Will this 'no tobacco industry attacks' provision inhibit the development of and funding of effective counter advertising campaigns?" the analysis concluded: "Yes, to the extent states and localities depend on NPEF funds from the MSA to mount such campaigns. Counter-advertising campaigns that expose tobacco industry manipulation are among the most effective strategies for reaching target audiences and reducing tobacco consumption."
So it was clearly the expert opinion of top attorneys from within the tobacco control movement that the anti-vilification clause might reasonably be interpreted by the courts as precluding the very type of advertisements (exposing tobacco industry manipulation of youths) that the "truth" campaign has been running.
I'm not arguing here that the Tobacco Control Resource Center provided any definitive answer as to whether the "truth" ads violate the anti-vilification clause; I'm simply making the point that the tobacco companies' claim is a legitimate, rather than a frivolous one.
Perhaps what bothers me most about the Campaign's press release is that I feel it again (the Campaign's arguments in support of monetary remedies in the DOJ case being the first example) demonstrates a lack of regard for the rule of law.
Yes - it is in the best interests of the public's health to allow Legacy to run these ads. Yes - the tobacco industry should, if its primary concern were the public's health, abdicate its legal right to challenge the ads.
But should we not have some respect for the law? The states signed a contract and they are obligated to live by that contract. In fact, it was the Attorneys General - the chief law enforcement officers of the states - that signed the contract. They, if anyone, should have an overriding concern for following the rule of law.
It's clear to me that many anti-smoking groups are refusing to acknowledge that the MSA is a legal contract. They seem to be treating it as if it is some public health resolution by which the tobacco companies agreed to work to protect the public's health. Let's make no mistake about it. The MSA is not a public health resolution. It is a legal contract entered into voluntarily by the parties. And just as it is reasonable for the states to file suit against the companies for violating provisions of the MSA, it is also reasonable for the companies to file suit against the states for violating provisions of the MSA, as long as the legal claims are not frivolous.
Don't get me wrong. I am in no way arguing that the "truth" campaign ads violate the anti-vilification clause of the MSA. I think it is very possible that the more specific interpretation of the provision may carry the day. But I see nothing wrong with the tobacco companies exercising their right to enforce the provisions of the contract, especially since their claim is certainly not a frivolous one.
As a movement that relies upon the force of law to achieve perhaps the majority of objectives in promoting the public's health, I think it is time to demonstrate a little more respect for the law. And to hold ourselves a little more accountable for legally binding agreements that we make.
Yes - let's defend Legacy vigorously in the courtroom. Let's convince the judge that a more specific interpretation of the word "vilify" is what the signatories to the MSA had in mind. But let's not pretend that the contract is a one-way agreement whose provisions only we, as the good guys, can enforce.
In the long run, I think this approach is degrading to the integrity of our legal system - let's show the utmost respect for the opportunity for parties to seek justice under our legal system. After all, we have $145 billion resting on that principle.
Thursday, March 09, 2006
Jacob Sullum on Calabasas: Right on the Mark
In an article published yesterday on Reason Online, Jacob Sullum takes the Calabasas City Council to task for enacting an ordinance that goes far beyond the realm of public health and science-based tobacco control by banning smoking vitually everywhere in the city, including in every street, sidewalk, and parking lot, and does it partly in the name of protecting kids from seeing smokers in public.
The Calabasas City Council went so far as to prohibit smoking outside in the presence of a nonsmoker, even if the nonsmoker does not mind. So as Sullum points out, a smoker and a nonsmoking family member or friend can be walking along a deserted street at midnight and if the smoker lights up, he or she is automatically guilty of a crime. It is also a misdemeanor if the friend or relative is a smoker who just happens not to be smoking at the time.
And to add injury to insult, the friend or family member could actually be prosecuted under the law as being an accomplice to the crime if they did not protest. They could be prosecuted under the ordinance's allowing, aiding and abetting clause, which forbids them from knowingly permitting someone to smoke in an area that is under their de facto control.
Furthermore, their friend or relative could sue them for compensatory damages, or simply for statutory damages, court costs, and attorney fees.
Sullum calls the ordinance "moralistic intolerance masquerading as 'public health.'"
He points out that there is no scientific evidence backing up the need for the law's extreme provisions and that the supporters of the law aren't basing their support for it on health of nonsmokers in the first place:
The Rest of the Story
Yeah - what he said.
That's about all I can say about Sullum's article. His comments closely mirror those I have been making over the past few weeks since this law was initially considered and then approved (post #1; post #2; post #3; post #4; post #5).
Here's perhaps the most ridiculous fact about the law. If you are walking down a street and you see a smoker (within 20 feet), it is your legal obligation to report that smoker to authorities. If you conceal the fact that the individual broke the law, guess what? You yourself have just broken the law and committed a crime - a misdemeanor, punishable by a fine of up to $1,000 and a jail sentence of up to six months. You have allowed, aided, and abetted a crime.
This is pure lunacy!
Why else would the Calabasas City Council have included these provisions, which treat smoking outdoors as a misdemeanor - a crime - rather than simply as a civil violation, punishable simply by a fine? Why would Calabasas have included provisions that allow nonsmokers (or smokers for that matter) to sue a smoker for lighting up on an otherwise deserted street corner? Why would Calabasas want to include provisions that can throw a smoker in jail for smoking in a parking lot?
I think the answer is precisely what Sullum suggests: this is moralistic intolerance masquerading as public health.
It has no place in tobacco control, and anti-smoking groups should immediately and publicly speak out against this insanity.
The Calabasas City Council went so far as to prohibit smoking outside in the presence of a nonsmoker, even if the nonsmoker does not mind. So as Sullum points out, a smoker and a nonsmoking family member or friend can be walking along a deserted street at midnight and if the smoker lights up, he or she is automatically guilty of a crime. It is also a misdemeanor if the friend or relative is a smoker who just happens not to be smoking at the time.
And to add injury to insult, the friend or family member could actually be prosecuted under the law as being an accomplice to the crime if they did not protest. They could be prosecuted under the ordinance's allowing, aiding and abetting clause, which forbids them from knowingly permitting someone to smoke in an area that is under their de facto control.
Furthermore, their friend or relative could sue them for compensatory damages, or simply for statutory damages, court costs, and attorney fees.
Sullum calls the ordinance "moralistic intolerance masquerading as 'public health.'"
He points out that there is no scientific evidence backing up the need for the law's extreme provisions and that the supporters of the law aren't basing their support for it on health of nonsmokers in the first place:
"All this may seem a little extreme when you consider there's no evidence that outdoor smoking jeopardizes the health of bystanders. But that is not really what the ban's supporters have in mind when they talk about protecting 'public health.' Their aim is not just to eliminate secondhand smoke but to eliminate smoking. That's why the ordinance cites the health effects of smoking on smokers as a justification for the ban. And that's why the ban's official goals include 'reducing the potential for children to associate smoking and tobacco with a healthy lifestyle' and 'affirming and promoting the family-friendly atmosphere of the City's public places.'
The ban's backers see smoking as a shameful vice that must be kept out of sight, an indecent activity from which adults must shield children's eyes as well as their noses. The logic of forcing people to set a good example for the kids—which also would justify banning fat people and motorcyclists from public places—reduces adults to the level of children whenever they venture out of their homes."
The Rest of the StoryYeah - what he said.
That's about all I can say about Sullum's article. His comments closely mirror those I have been making over the past few weeks since this law was initially considered and then approved (post #1; post #2; post #3; post #4; post #5).
Here's perhaps the most ridiculous fact about the law. If you are walking down a street and you see a smoker (within 20 feet), it is your legal obligation to report that smoker to authorities. If you conceal the fact that the individual broke the law, guess what? You yourself have just broken the law and committed a crime - a misdemeanor, punishable by a fine of up to $1,000 and a jail sentence of up to six months. You have allowed, aided, and abetted a crime.
This is pure lunacy!
Why else would the Calabasas City Council have included these provisions, which treat smoking outdoors as a misdemeanor - a crime - rather than simply as a civil violation, punishable simply by a fine? Why would Calabasas have included provisions that allow nonsmokers (or smokers for that matter) to sue a smoker for lighting up on an otherwise deserted street corner? Why would Calabasas want to include provisions that can throw a smoker in jail for smoking in a parking lot?
I think the answer is precisely what Sullum suggests: this is moralistic intolerance masquerading as public health.
It has no place in tobacco control, and anti-smoking groups should immediately and publicly speak out against this insanity.
National Anti-Smoking Group Claims to be Only National Anti-Smoking Group
According to a prominent anti-smoking researcher and advocate, the Campaign for Tobacco-Free Kids - a national anti-smoking advocacy organization - has sent out a communication to its constituents claiming to be the only national purely anti-smoking organization.
The communication reportedly stated: "As the only national advocacy organization that works just on tobacco issues, it's critical that we team up with other organizations and individuals to be successful." [emphasis mine]
The Rest of the Story
The rest of the story is quite simple. The Campaign for Tobacco-Free Kids is not the only national anti-smoking advocacy organization that works just on tobacco issues.
Americans for Nonsmokers' Rights (ANR), without question, is a national anti-smoking advocacy organization. And from what I can tell, they work only on tobacco issues. I was on the Executive Board of this organization for several years, and I can vouch for the fact that we never dealt with any non-tobacco issues.
Action on Smoking and Health (ASH) is clearly a national anti-smoking advocacy organization. And ASH also works only on tobacco issues.
And the American Legacy Foundation is another national anti-smoking advocacy organization. By charter, it only works on tobacco issues.
So it certainly appears to me that the Campaign for Tobacco-Free Kids' statement is false, or at very least, terribly misleading.
I guess we can add this to the list of inaccurate and misleading statements made by anti-smoking groups to try to raise money and advance their cause.
This time, what troubles me is not only the lack of accuracy in public communication, but also the lack of humility and the disregard for the other work being done by other anti-smoking groups (as much as I disapprove of much of what these other groups are doing - it's hard to deny that they are indeed national anti-smoking advocacy organizations).
I remember a time when the tobacco control movement did not have a lot of money, and we consisted mainly of grassroots local advocates - largely volunteers or very low-paid workers - who were involved in the field simply because we cared about the issues. Achieving national recognition and taking credit for victories was not part of our plan. It just wasn't of interest to us.
But now, with the infusion of huge amounts of money into the movement, the true grassroots social movement that was, and should still be, tobacco control, has been overtaken and co-opted, I believe, by a few large national organizations. And I think their desire for money and recognition is practically destroying the tobacco control movement.
Today alone, we see self-congratulatory, boastful, yet inaccurate hot air emanating from two of the largest anti-smoking groups (see my earlier post today about the National Association of Attorneys General and American Legacy Foundation taking credit for a reduction in cigarette consumption that likely would have occurred anyway [in the absence of the MSA] and in my opinion, would have been greater had the MSA not been signed).
Where has honesty and humility, accuracy and scientific integrity gone in the tobacco control movement?
It seems to have been sucked into the black hole of money, desire for recognition, and fanaticism.
The communication reportedly stated: "As the only national advocacy organization that works just on tobacco issues, it's critical that we team up with other organizations and individuals to be successful." [emphasis mine]
The Rest of the Story
The rest of the story is quite simple. The Campaign for Tobacco-Free Kids is not the only national anti-smoking advocacy organization that works just on tobacco issues.
Americans for Nonsmokers' Rights (ANR), without question, is a national anti-smoking advocacy organization. And from what I can tell, they work only on tobacco issues. I was on the Executive Board of this organization for several years, and I can vouch for the fact that we never dealt with any non-tobacco issues.
Action on Smoking and Health (ASH) is clearly a national anti-smoking advocacy organization. And ASH also works only on tobacco issues.
And the American Legacy Foundation is another national anti-smoking advocacy organization. By charter, it only works on tobacco issues.
So it certainly appears to me that the Campaign for Tobacco-Free Kids' statement is false, or at very least, terribly misleading.
I guess we can add this to the list of inaccurate and misleading statements made by anti-smoking groups to try to raise money and advance their cause.
This time, what troubles me is not only the lack of accuracy in public communication, but also the lack of humility and the disregard for the other work being done by other anti-smoking groups (as much as I disapprove of much of what these other groups are doing - it's hard to deny that they are indeed national anti-smoking advocacy organizations).
I remember a time when the tobacco control movement did not have a lot of money, and we consisted mainly of grassroots local advocates - largely volunteers or very low-paid workers - who were involved in the field simply because we cared about the issues. Achieving national recognition and taking credit for victories was not part of our plan. It just wasn't of interest to us.
But now, with the infusion of huge amounts of money into the movement, the true grassroots social movement that was, and should still be, tobacco control, has been overtaken and co-opted, I believe, by a few large national organizations. And I think their desire for money and recognition is practically destroying the tobacco control movement.
Today alone, we see self-congratulatory, boastful, yet inaccurate hot air emanating from two of the largest anti-smoking groups (see my earlier post today about the National Association of Attorneys General and American Legacy Foundation taking credit for a reduction in cigarette consumption that likely would have occurred anyway [in the absence of the MSA] and in my opinion, would have been greater had the MSA not been signed).
Where has honesty and humility, accuracy and scientific integrity gone in the tobacco control movement?
It seems to have been sucked into the black hole of money, desire for recognition, and fanaticism.
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