Thursday, December 30, 1999
Alan, you and I have known each another for 15 years, starting when you were editor of the New York State Journal of Medicine, where you published the first theme issues on tobacco of any medical journal in the united states (December 1983 and July 1985). You had also published a similar issue as editor of the Medical Journal of Australia (March 1983). But as I recall, your work in this regard was considered worrisome to some people not just in the tobacco industry but also in the health community.
It's ironic that my devotion to the idea of producing an annual comprehensive theme issue on smoking as a means of galvanizing greater attention on the part of the medical profession to tobacco problems led to my being fired as editor.
In my own case, it's also a fascinating story of interlocking connections among several industries and institutions. I was fired without warning just after Christmas 1985 by an interim director of the Medical Society of the State of New York. He came from the old school of medical politics, where deals were made in smoke-filled rooms, such as the longstanding alliance between the American Medical Association (AMA) and tobacco state Congressmen to protect doctors' economic interests in exchange for doing nothing against tobacco.
Health care industry lobbyists and tobacco industry lobbyists often have been one and the same. The headquarters of four major cigarette manufacturers have been located in New York, making it the international capital of the tobacco industry. New York is also the home of many of the tobacco industry's advertising and public relations agencies, as well as the major television networks, such as CBS, which was owned by Lorillard Tobacco.
The advertising and pr firms in turn also work for pharmaceutical companies.
I have no doubt whatsoever that my consistent editorial opposition to the promotion tobacco was a source of concern not just to tobacco companies but also to some within the health care field who depended on (and feared) the tobacco industry's political support, not to mention its research funding.
The New York State Journal of Medicine tobacco theme issues contained more than 100 articles from around the world and spared no one. I'm especially proud of having helped to expose the hypocrisy of the news media, particularly The New York Times, for its longstanding collaboration with the tobacco industry, which The Times has still not acknowledged. One article consisted of the unexpurgated decades-long correspondence between surgeon George Gitlitz and The Times in which the newspaper's editors refused either to publish his letters or to address the ethical conflict of accepting tobacco advertising while rejecting ads for a variety of other legal products.
In 1999, of course, The Times at long last announced that it would refuse to accept any more tobacco ads (a policy that still does not include most of its other newspaper and magazine holdings), sidestepping the question of just what makes cigarette ads in 1999 so much more of a danger than they were in 1959, 1969, 1979, or 1989. Could it be that the newspaper really wasn't really losing anything (and did in fact gain favorable publicity), since cigarette advertising had almost all disappeared from its pages in recent years-gone to the alternative weekly entertainment papers that young people read? (Don't be surprised if The Times and other big media corporations start buying up these weeklies, replete with cigarette advertising.)
I suffered a further rebuff in 1988 when after being selected over two dozen other candidates for the editorship of a leading journal of family medicine, the contract I was offered specifically precluded me from speaking on smoking in any public forum for a minimum period of one year. After discussing this with then-Surgeon General Koop, I turned down the job. Had I accepted the position, I would not have been permitted to participate in two extraordinary, substantive meetings convened by Dr. Koop and arranged by Ron Davis in the Office on Smoking and Health. These were the first-ever conferences on tobacco and minorities and tobacco and sports, under the auspices of the Inter-Agency Council on Smoking and Health. I take great consolation in Ron's having adapted the format and style of the New York State Journal of Medicine-combining scientific research, opinion, and images of tobacco promotion-for the journal Tobacco Control, and I'm honored to have served as one of its first deputy editors.
IN ADDITION TO HAVING BEEN AN EDITORIAL PIONEER IN TOBACCO CONTROL, YOU HAVE WORN SEVERAL OTHER HATS, INCLUDING ACTIVIST, TEACHER, AND FAMILY DOCTOR WORKING TO GET PATIENTS TO STOP SMOKING, AND MOST RECENTLY ARCHIVIST AND HISTORIAN. WHICH ONE HAS BEEN THE MOST GRATIFYING?
Grassroots activism, by far. At the World Conference on Tobacco and Health in Perth in 1990, I made a special plea to the members of the audience, most of whom were from rather well-funded governmental and private health agencies: "Take an activist to lunch today." Activists by my definition are the ones who either by choice or necessity have had to work to change the system from the outside. And they have never worried about the money, because they would do this work anyway. In the US, the driving force behind anti-smoking efforts for most of the past half-century has been the independent clean indoor air activist with scant institutional support. Dr. Alton Ochsner began being a rabble-rouser in the late 1930s. John Banzhaf created the first organization to focus on tobacco regulation in the 1960s.
From the 1970s to the present, groups like GASP and Americans for Nonsmokers Rights and individuals like Ed Sweda in Massachusetts, Don Morris and Dr. Lee Fairbanks in Arizona, Jeannie Wigam in Minnesota, Gina Carlson in New Jersey, and Dr. Charles Tate in Florida, to name but a few, have been the heart and soul of efforts to reduce tobacco use. In the 1980s, BUGA-UP in Australia was the model for tackling tobacco advertising and increasing public disgust over smoking, and Gar Mahood's Non-Smokers' Rights Association in Canada was the model for creating first a local, then provincial, then national clean indoor air policy.
Meanwhile, the well-funded voluntary health agencies have lagged way behind, especially when one considers their enormous annual tax-deductable income.
Typical is the one-day-a-year smokeout in the US, which has long since lost its impact except as a pharmaceutical promotion. I've always felt we should give the tobacco industry one day a year to push smoking, and we'll take the other 364. US Government efforts for the most part have been disappointing and uninspired, with the rare exception of Surgeon General Koop and less successful attempts by surgeons-general Antonia Novello and Joycelyn Elders and Secretaries of Health Joseph Califano and Louis Sullivan.
SO HOW DID YOU BECOME INVOLVED IN THE TOBACCO ISSUE?
The inspiration came from my late father, also a family doctor. He was a great skeptic, and when I would watch Dodgers baseball games with him as a young boy in the 1950s, he was always upset at the fact that one of the sponsors was Lucky Strike cigarettes. One day soon, he predicted, no one would possibly believe that anyone ever associated tobacco and sports! He urged me to tape record the cigarette commercials and save the sports magazines for posterity, as well as to write about tobacco as editor of my high school newspaper in 1964 when the first Surgeon General's report came out. I know only a handful of individuals who have been continuously involved in the tobacco issue from that time, including Don Shopland, who has worked with several government health agencies and served as director of the Office on Smoking and Health, and Mike Pertschuk, who was a behind-the-scenes force in the prescient efforts of Senator Maurine Neuberger to scrutinize the tobacco industry.
By the time I entered Emory University School of Medicine in the early 1970s, I assumed that I would be in a health care environment in which everyone would be taking up the charge of the Surgeon General's report and actively fighting tobacco use and promotion in the clinic, classroom, and community.
Nothing could be further from the truth. Medical schools and schools of public health have done an appalling job of teaching about tobacco. I heard only one lecture in four years that dealt primarily with tobacco-a presentation by Dr. Brigitte Nahmias on pulmonary disability. But by including a slide of a colorful cigarette ad in her talk followed by a slide of a patient with emphysema, she gave me an idea to create an archive of tobacco advertising, out of which I could develop slide presentations juxtaposing tobacco advertising and tobacco-related diseases. By the end of medical school, I was giving presentations to my colleagues and in local schools, and in 1977 I started DOC (Doctors Ought to Care) in an effort to unite medical students and physicians in tackling the tobacco pandemic and other lethal lifestyles in the clinic, classroom, and community. (Earlier this year I gave my 1700th invited presentation since 1973.)
WHAT HAS MADE DOC SO DIFFERENT FROM OTHER HEALTH GROUPS?
We took an issue-smoking-that everyone had heard over and over again was "dangerous to your health" and got people to think about it in a different way. We moved beyond the pamphlets, preaching, and posters of other groups and kept challenging them to do more. From day one, our aim has always been to tap the highest possible commitment of every health professional, to inspire the highest possible creativity of every adolescent, to purchase counter-advertising space in the mass media, to use satire and pungent humor as our main weapon, and to undermine Marlboro and other major brand-names and their associated imagery.
I am proud of the fact that in 1977 DOC became the first organization anywhere to put its money where its mouth was to purchase counter-advertising space-in newspapers, on radio, on bus benches, and on billboards. The funding came from $10, $25, $50, and $100 membership donations, and we have been one of the few such self-sustaining organizations in the movement.
Virtually every physician in the US who has been actively involved in the tobacco issue can trace his or her involvement to DOC. We also convened the US' first youth conference on tobacco (SuperHealth 2000) in Miami in 1978 and led the first street protests (which we named "housecalls") to ridicule tobacco promotions such as the Virginia Slims Cigarettes Tennis Tournament (which we renamed the "Emphysema Slims"). To give you an idea of the kind of uphill battle we faced, when I founded DOC in 1977 in Miami, Florida, the local division of the American Cancer Society was still the beneficiary of the proceeds from the Virginia Slims Cigarettes Tennis Tournament. Over the years, we have established more than 150 chapters in the US and in 27 other countries.
The early achievement of DOC was to shift the focus away from nicotine, the smoker, and lung cancer, and instead onto the source of the problem: the tobacco industry. I was fortunate to work for over a decade with Dr. Rick Richards and Dr. Tom Houston, as we fought to jump-start the involvement of organized medicine in truly attacking the tobacco industry. And for several years of the pre-Globalink era, Drs. Greg Connolly and John Slade and I would spend countless stimulating hours brainstorming by telephone or letter on new strategies for taking on tobacco.
DO YOU THINK THAT PERHAPS IF YOU HAD BEEN LESS CRITICAL OF OTHER HEALTH GROUPS OVER THE YEARS, THEN DOC WOULD HAVE RISEN TO THE FOREFRONT OF THE ANTI-SMOKING MOVEMENT?
That may be true, and it certainly would have been a lot safer to pretend that the health community is one big happy family. But when you consider that, at least in the US, virtually every major health group and government agency from the American Cancer Society (ACS) and the AMA in the private sector to the National Cancer Institute (NCI) and the Food and Drug Administration (FDA) in the public sector has had to be shamed into taking a stronger position against tobacco use and promotion, then I don't regret a thing. I took my inspiration from labor organizer Saul Alinsky, self-taught media guru Tony Schwartz, and Mad Magazine. The fact is, we don't need more epidemiologists, nicotine addictionologists, smoking cessation specialists, and professional grant writers. We do need more creative, unconventional, innovative people-artists, comedians, historians, film-makers" and trouble-makers.
In Miami in 1978, the ACS and the American Heart Association gave virtually no financial or other support to the nation's first county-wide referendum on a clean indoor air measure, which lost by only a few hundred votes out of more than 200,000. GASP had to go it alone and still almost beat Goliath.
It was not until 1983 that the ACS even began to address the subject of cigarette advertising and not until 1985 that the AMA proposed a cigarette advertising ban. Until the 1980s, the major effort by the NCI on smoking was to find a safer cigarette! In the early 1990s the head of the NCI called us to ask if he would be sued by RJ Reynolds if he were to publish a picture of Joe Camel in an NCI report. He thought it was an act of courage to mention a brand name! The FDA had flunked every test on tackling tobacco and was about to be castigated in an ABC-TV news report for having done nothing when Dr. Kessler, who had been commissioner for several years, suddenly announced he would be looking more closely into nicotine.
In the mid-1990s, the release of tobacco industry documents, many of which were actually available a decade or more earler in the Cippolone trial and other litigation, seems to have provided the perfect excuse for health groups to explain away their minimal activity against tobacco for more than 40 years. For people in some major health organizations to suggest that for decades their leadership had been duped by the industry, unaware of the addictiveness of nicotine, or ignorant of the attempts to attract a youthful market is contemptible. The question I think should be asked is why are the organizations that not too long ago were content to sit on the sidelines and look down their noses at the activists literally marching in the streets against the tobacco industry now talking so tough about "Big Tobacco"? And how is it that these folks got control of the pursestrings?
I'm afraid the grand tobacco settlement (which has taught me that lawyers go for settlements, seldom for victories) has in some ways spoiled and corrupted us. Almost all the news we read is about chasing the settlement dollars.
It's no longer about people who have died from tobacco-related diseases or the taxpayers who helped pay the bills. It's not even about fighting tobacco.
Rather, it's about fighting over the money to fight tobacco, like the same old Beltway Bandit institutes who keep hauling down the grants to write policy papers that are carbon copies of what the activists were calling for 20 years ago. And while some revile Philip Morris for its youth anti-smoking campaign, I fail to see anything much more creative on our side of the fence.
I think the paid counter-advertisements that DOC did 20 and 10 years ago on a shoe-string budget, with true brand-name ridicule (including Barfboro, Fartboro, Emphysema Slims, and "Dakota, Dacough, Dacancer, Dacoffin" and our radio ads with Tony Schwartz) are still far better than most of the slick "award-winning" multi-million dollar ad agency stuff today. However self-serving that sounds, I'll still match our ads any day with any others on cost-effectiveness and popularity among the target audience.
For too long, government and voluntary health agency tobacco control functionaries have measured progress in terms of the establishment of coalitions and the publication of policy papers to promulgate such unrealistic goals as the reduction of smoking by "50% by the year 2000" or the creation of a "smoke-free generation" by that time. And there has been an unfortunate presumption in some circles that successful action in reducing tobacco use cannot occur without enormous amounts of money. I disagree.
Accountability for how funds are spent would be the obvious way to judge the biggest bang for the buck. Ironically, although the jobs of tobacco industry personnel depend on increased sales, I have yet to meet anyone in tobacco control whose job depends on there being a decline in tobacco consumption.
YOU'RE NOT REALLY SUGGESTING THAT THE TOBACCO SETTLEMENT OR TOBACCO LITIGATION IN GENERAL IS A BAD THING?
Tobacco litigation is a bad thing only when the truth has been distorted or when used for personal financial gain. Unfortunately, as evil as the tobacco industry was and is, some people on our side have simply climbed on the litgation bandwagon. Although I haven't been invited back to speak at a Tobacco Product Liability Project (TPLP) meeting in several years (after having spoken at the first nine) after I challenged the commitment of one of the newly arrived Rolls-Royce-driving plaintiffs attorneys to put HIS money where his mouth was by supporting the anti-smoking activists in exchange for the support he was seeking to oppose tort reform legislation, I credit Professor Dick Daynard with convincing people on the need for tobacco litigation. In this vein, I would say that among the handful of people who really changed the world of tobacco litigation the key individuals are attorney Marc Edell, who won the initial round of the Cippolone case against the tobacco industry, and attorneys Stanley and Susan Rosenblatt, who took on the seemingly impossible odds of bringing a class action suit against the industry in Florida. These lawyers were willing to search out the truth and tell the whole story, including naming the collaborators in the media, politics, and the health community that helped the industry get away with their deceptive practices for so long.
The downside of the litigation, in my opinion, are cases brought by the Blue Cross health insurors or the US Justice Department. Blue Cross did nothing whatsoever to discourage smoking for decades in spite of knowing about its terrible health and economic costs. And the US government was, by virtue of its tobacco support programs and weak educational efforts, a veritable accomplice of the tobacco industry. Somehow the victims are no longer the people who have become sick from tobacco products, but rather governments and private agencies that are basing claims on economics---essentially asking for reimbursement for their own mistakes in not accounting properly for the enormous health and economic toll taken by tobacco, which has been well known for the past half-century. (In refusing to endorse the concept of warning lables on cigarette packages in 1964, the AMA testified in Congress that the public had been well-informed for at least a decade on the hazards of smoking!)
WHAT DO YOU SEE AS THE BIGGEST STRENGTH AND THE BIGGEST WEAKNESS OF TOBACCO CONTROL?
Our strength is that working to reduce demand for tobacco products is based on arguably the most extensive body of scientific evidence of any health problem of the twentieth century. For that matter, we really didn't need the tobacco industry's documents to tell us what for the most part we already knew. Another strength is the integrity, decency, and longterm commitment of so many individuals working on this problem.
Our weakness has been too often confusing our own press clips with progress.
There is a definite danger, especially among those who have little knowledge of or interest in the history of the anti-smoking movement, of a herd mentality regarding tobacco control policy, such as the assumption that nicotine regulation by the FDA or any law regulating tobacco use, purchase, promotion, or price, is, per se, a good thing. Nor am I comfortable with the trend toward creating a kind of smoke police to enforce the many laws. We sometimes can't decide whether to demonize the tobacco industry or the person who smokes. Is everyone who uses any form of tobacco in any form truly a hopeless, helpless addict? Can we admit that anyone could possibly enjoy tobacco? We are oblivious to the backlash that comes with prohibition. We have not forged strong alliances with health advocates in other issues, such as those working to curb alcohol use and promotion.
My research colleague for the past decade, Eric Solberg, and I presented a paper at the World Conference in Paris in 1994 entitled, "Revisionism, Magical Thinking, and Hokey-Pokey Objectives in the Anti-Smoking Movement,"
which was probably the first critique of tobacco control from within. We called for 1. a setting of priorities (as opposed to the politically correct practice of equating in importance every single aspect of tobacco control
[eg, occasional cigar smoking, candy cigarettes, clove cigarettes, and the notion that some cigarette ads are worse than others]), 2. for a division of responsibilities to avoid the inordinate duplication of activity and squandering of resources, and, above all, 3. for accountability to gauge the success or failure of our efforts. Eric and I knew we would ruffle some feathers within the establishment health agencies, and were not surprised by the hostility from a handful of bureaucrats, perennial grant-recipients, and other insiders. But we were gratified by the positive comments we received from many individuals in developing nations who felt that what activist groups like DOC had set in motion and accomplished on a shoestring budget is a more realistic model than a set of lofty policy goals handed down by a global health agency or an industrialized country.
Another problem we have to acknowledge is our penchant for trying to fit our findings to our predetermined biases. As one who has tracked tobacco advertising daily for more than 20 years with the initial hope of getting rid of it entirely, I've come to the conclusion that a goal of a total advertising ban is an illusion. The creativity of the industry and the expanding global electronic media means it is likely we will continue to chase our own tail as we keep spending enormous time and effort on incremental advertising restrictions. Ubiquitous counter-advertising is a far better use of resources than paying people to count the number of Marlboro signs on storefronts. And having been sued (unsuccessfully) by Philip Morris for spoofing one of its ad campaigns, I've come to appreciate all the more the protection the First Amendment of the US Constitution offers those of us who choose to buy ads to make fun of drug pushers. Believe me, the tobacco industry hates counter-advertising far more than it hates laws that purport to ban ads or regulate nicotine.
WHAT ARE YOUR PLANS FOR ALL OF THE ADVERTISEMENTS, BOOKS, DOCUMENTS, AND OTHER MATERIALS YOU HAVE COLLECTED? ARE THESE BEING INCORPORATED IN THE UNIVERSITY OF ALABAMA CENTER FOR THE STUDY OF TOBACCO AND SOCIETY?
Although several universities over the years have asked to host the collection, the University of Alabama was the first to offer a no-strings opportunity to establish a center to explore the tobacco issue from all vantage points. In other words, this is a sociocultural resource that will document and analyze the evolving worldwide story of tobacco not only from the health advocacy viewpoint but also from the historical, agricultural, anthropological, archeological, and economic perspectives, among others. I call it scholarly activism. The Center will become, in effect, the first true international tobacco museum. It's a nice fit for a university that already operates several museums and is one of the few to offer courses in museum studies. Incidentally, Dr. Luther Terry, who as Surgeon General in 1964 published the original report on smoking and health, was from Alabama, as was Congressman Claude Pepper, who along with Senator Dick Durbin was the mastermind behind the ban on smoking on airlines.
We have a space for exhibitions, such as "When More Doctors Smoked Camels: A Century of Health Claims in Tobacco Advertising," which I originally created for the first US conference on tobacco in Houston in 1988 and which has been displayed in various medical schools in the US. Another major exhibition will be a history of tobacco in the 20th century as seen through the eyes of political cartoonists. With the assistance of the Departments of Computer Science and the School of Library and Information Studies, we'll be developing a website to provide access to our more than 30,000 slides of tobacco advertising and promotion. We are cataloguing hundreds of antiquarian tobacco books and hundreds of thousands of advertisements, original newsprint reports, and tobacco industry publications. Many of these have been contributed by colleagues from around the world. Among our special collections are Dr. Koop's original memoranda and notebooks on tobacco when he was Surgeon General. He has been our leading supporter for the concept of a museum and center on tobacco and society.
We have thousands of videotapes and audiotapes, as well as an ongoing oral history project. And we plan to publish periodic monographs on tobacco history, as well as to invite guest speakers and sponsor debates. Numerous colleagues from around the world will be contributing in a variety of other ways. Lastly, we are looking to hire at least one full time creative scholarly activist, probably from outside the field of public health, and we welcome the inquiries of others who might wish to collaborate on research projects utilizing our material.
So, after being a full-time tobacco activist and reading at least six newspapers a day for the past 25 years-performing in essence a daily biopsy on tobacco and studying Philip Morris like a parasitic disease, I hope to provide a fuller context through The University of Alabama Center for the Study of Tobacco and Society for the proper consideration of scientific research on the one hand and tobacco industry documents on the other.
Perhaps we can turn this century's greatest public health failure into a triumph in the next one.
THANK YOU, ALAN. AND "BONNE CHANCE" WITH THE CENTER.
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to all of the globalink members our best wishes for a happy new year!
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P.S: THE UNIVERSITY OF ALABAMA CENTER FOR THE STUDY OF TOBACCO AND SOCIETY, 26 PINEHURST DRIVE, TUSCALOOSA, ALABAMA 35401.
TEL: 205-348-1372.
EMAIL: [email protected]
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