Are public health advocates asking the federal government to overstep its bounds, or is it time for a national tobacco policy? David E. Bonfilio, an American Cancer Society volunteer, James W. Stratton, Deputy Director of Prevention Services, California State Department of Health Services, and Jacob Sullum, Senior Editor of Reason magazine and author of For Your Own Good: The Anti Smoking Crusade and the Tyranny of Public Health, discuss the war against tobacco.
ROBINSON Welcome to Uncommon Knowledge, I'm Peter Robinson. Our show today: The War Against Tobacco. To a generation of moviegoers, Humphrey Bogart was the ultimate tough guy. With a cigarette hanging from his lower lip, he dodged bullets and bad guys in dozens of films. Today, things have changed. The good guys still dodge bullets, but there are those who would say it's only the bad guys who still smoke cigarettes. As everyone now knows, cigarettes are dangerous to your health. In fact, it was years of smoking that killed Humphrey Bogart. The tobacco war rages on. Not too long ago, the big tobacco companies entered into an agreement with forty state attorneys general under which the tobacco companies would pay hundred of billions of dollars to the federal government and agree to live under a very strict regime of regulation.
With us today, three guests. James Stratton is the deputy director of the California State Department of Health, David Bonfilio who is a volunteer with the American Cancer Society, and Jacob Sullum is the auther of a book entitled For Your Own Good. James and David are against the tobacco companies. Jacob is against the government's efforts to regulate the tobacco companies. So the question is this: Is the federal government overstepping its bounds in its efforts to regulate tobacco, or do we need a national tobacco policy?
There is a famous anecdote: George Bernard Shaw sat next to a famous actress at dinner one evening and said, "Madam, would you sleep with me for some, for ten thousand pounds?" And she said, "I suppose I might. " Then he said, "Would you sleep with me five pounds?" And she said, "What do you take me for!" and Shaw answered, "We have already established that. Now we are trying to established the price."
ROBINSON So haven't the tobacco companies, in some sense, brought this on themselves? Now it's just a question of dickering over the price?
SULLUM Yes. I think they've sacrificed just about every principle that they've ever stood for. Now it used to be that they said smoking was a matter of individual choice, that if you choose to smoke, knowing the health consequences and you get sick, that's your responsibility. Now they had agreed to a pad all this money that would go to compensate smokers and trial lawyers among other people. They used to say that it should be up to individual property owners, business people, to decide what the smoking policy should be on their own property. Under the agreement they reached last year, they said that they would support a national legislation to restrict smoking on private property. They used to say that they have a right to free speech and that the right to commercial free speech is important in this country, it's protected by the first amendment. Under this deal, they would have voluntary censored themselves, so to speak, by agreeing to do away with just about all of the conspicuous forms of advertising and promotion that we see today. I think even though that was voluntary, with self-censorship in a sense, that inevitably will be used as precedent to apply to other industries that are unpopular and to argue that their advertising and promotion should be restricted.
ROBINSON So why are you sticking up for these guys, or is it not that you are sticking for them?
SULLUM I am not sticking up for the tobacco companies, per se. I think they do have a right to free to speech and I think they do have a right to sell cigarettes to willing buyers. I think smokers have a right to control their own bodies and to control what goes into them and they have a right to smoke if they choose. I think these are important rights that need to be respected. I also think that people who own bars or restaurants or other kinds of businesses have the right to determine whether people will be allowed to smoke on their own property.
ROBINSON I want to try to search out the first principles here, and first principle number one: What I am trying to reach for here is some reason why the government should have the right to treat the tobacco industry in a special way and in this case, an especially punitive way. Jim?
STRATTON Well, I would turn it around and say that what is happening, finally, it that the tobacco industry is starting to be treated like other industries. With four hundred thousand people dying every year from cigarette related disease is the equivalent of two jumbo jet liners crashing every day, like a Titanic full of smokers sinking every 36 hours. An airline that had that kind of track record with its customers would be out of business in a couple of days. If an automobile manufacturer made a vehicle that was killing four hundred thousand people a year, it would be taken off the market and shunned by consumers. What makes this different is that tobacco companies are selling a legal product that is highly addicting, and they use deceptive and manipulative marketing techniques aimed at children to get them hooked before they are old enough to know what is going on. And then they turn around and say that people have a freedom of choice. Well it is highly addicting and people can't easily choose to quit.
ROBINSON How would you answer that?
SULLUM Well I'd say first of all, what we are talking about is a voluntarily assumed risk. That's the way which in this way this hazardous product is different from a hazardous product that's dangerous and people don't know about danger. People have known about the hazards and the addictiveness of smoking. It has been a part of common knowledge of decades, if not centuries, as I show in my book. So while it is true that the tobacco companies have been saying all kinds of disingenuous things about the health hazards of smoking and the --
ROBINSON You grant that these guys are liars.
SULLUM Yes. But the point is, who was fool? That's the question. To make out a case for fraud, you have to show that people were actually misled and made a decision, on the basis of what the tobacco companies were saying, to smoke; because they were convinced that actually, it was safe. Documents, documents that were released as a result of the Minnesota trial,
ROBINSON And these documents are available on the Internet now?
ROBINSON Twenty thousand pages of documents?
SULLUM Yes, yes. It shows that the tobacco industry was targeting kids, by their own admission, as young as 14 years old.
ROBINSON Tobacco companies may have been lying for years, but was anybody really deceived? People know perfectly well that cigarettes are unhealthy, but they chose to smoke anyway. So what about personal responsibility?
I walk in to buy a pack of cigarettes. Not I, I hasten to add, for my life insurance company, I checked the box "I don't smoke," but if I were to walk in and buy a box of cigarettes at Seven Eleven, there's that warning right on the side of the box. It tells me, as I pay my money, I pick it up, and here is the warning, and it says "cigarettes may harm; do damage to fetuses if you are pregnant; one warning after another. Now, I take the risk, right?
BONFILIO As an adult, you're taking a risk. I am talking about the fact that most smokers start before they are adults, most smokers start as teenagers, and I don't think you'll disagree with me.
SULLUM No I don't.
BONFILIO You even say that in your book. And they are hooked before they become adults. So, the choice, especially when we see the tobacco industry has targeted these kids, the tobacco industry makes it glamorous. You look at the ads, you look at the images they put around smoking, it's sexy, it's cool, it's glamorous, you're going to get a man, you're going to get a woman, your going to have a nice life. That's what the kids want. The kids are very much today, they're not looking at what is going to happen to them 20, 25 years down the road.
ROBINSON Every statistic I've seen suggests that there are huge numbers of former smokers.
ROBINSON And a very common statistic, I am slightly tentative about this because I know there are half a dozen statistics out there on any single point, but the statistic I've seen most often is that are about as many former smokers in the United States as there are present smokers, which suggest that millions of people have been able to quit smoking.
ROBINSON You grant that.
ROBINSON So is it all that addictive?
SULLUM Well, what typically happens is, in young people, they will try a cigarette here, a cigarette there. But our research is showing, in California, if a young person tries as many as 100 cigarettes in the course of several years, that they find themselves habituated and addicted to nicotine.
SULLUM Could I just make this point about addiction? I mean, I think there is a fundamental misunderstanding about what addiction means. Addiction is not inescapable. Addiction is a habit that is hard to break, not impossible to break. And the fact that tens of millions of Americans have quit smoking shows that. According to the CDC, ninety percent of those people quit smoking without any kind of formal treatment. Typically they quit by going cold turkey. Now, even though it is matter of a concern, I'll grant both of you, that most smokers start as teenagers before are adults, it's not as if you start smoking at sixteen and get lung cancer at eighteen. You have to smoke many years before you develop the diseases associated with smoking, assuming that you do, and you have plenty of time to think better of the habit and to quit. As to the second point about advertising, we have to keep in mind that what we're talking is speech, persuasion. There's nothing about advertising that compels anybody to do anything or that casts a magical spell on them that makes them into smokers. And in fact, if you look at the research on this, there's very little evidence that advertising plays an important role in getting people to smoke, as opposed to getting them to smoke a particular brand.
ROBINSON But doesn't it just seem intuitively the case, that with cigarette packs designed to be attractive with the advertisements in magazines, designed to convey, just as Dave said, just as we all know, every American who reads a magazine sees fun, glamour, a little sexual titillation, all of these things are associated with cigarettes. Doesn't that just intuitively seem like the wrong thing to make available to kids?
SULLUM Well, I mean, there's obviously a surface plausibility with this, which is why this notion is so widely accepted, that people smoke because of advertising. And it may very well be the case, that there are teenagers out there who are ambivalent, whose parents smoke, whose friends smoke, and maybe advertising, combined with other kinds of cultural messages, sort of tips them over the edge. But the point is, whatever the effect is, it's so subtle that it has never been measured in any kind of study.
STRATTON I'd like to respond to that. The tobacco companies had a full court press on with tobacco promotional items, such as leather jackets, hats, shirts, T-shirts, sandals, back-packs, other things, all of them with tobacco logos, so-called tobacco paraphernalia. Studies in California show that by the eighth grade, one-third of all students have at least one tobacco- related item in their possession.
ROBINSON By the eighth grade.
STRATTON By the eighth grade, and more than half of all teenagers can name a "favorite cigarette ad."
SULLUM All that you've described is consistent with the idea that tobacco companies are competing for the business of underage smokers, which I will grant you. But, it does not show that the advertising promotion actually makes people into smokers.
BONFILIO Why then do many industries, not just the tobacco industry, spend the billions of dollars that they do in this country and countries all over the world to get us to try their products? The tobacco industry has the science down pat. How to get to these kids, the way to get to these kids, the place to get to these kids, how to, with this paraphernalia, to have that message in front of these kids all the time.
ROBINSON All right, but adults know the risks they take when they smoke. Why should the government interfere?
There are warnings on the pack, there are warning all over the culture, so if an adult wants to smoke why not let him?
BONFILIO This is not a habit that exposes just the smoker. It exposes their family, it exposes the people around them. I mean, how many of us now, including smokers, like the fact that you can get on an airplane, and there's no smoking on the air plane? It becomes pleasurable. You go to San Francisco Airport today, they have got designated smoking areas where you can't even see in the room.
ROBINSON I just want to dig out your position here, or at least sort of delineate the position. Second hand smoke is another--we're working our way through here, peeling the onion, so to speak, kids is one argument. Second hand smoke is another argument. Let me pause it to you purely for the sake of argument, that second hand smoke does no harm at all. Purely for the sake of argument, and I will let you pounce on that assertion in a moment. If that were the case, would you care if adults smoked? If the damage they did were only to themselves, would you still want the government involved in exercising punitive measures on the tobacco companies?
BONFILIO I probably could not go that far and I will say, and the reason I will say this is because there is still a social cost. We still have to care for these people when they get sick, either through Medicare, Medicaid or our own health insurance rates.
ROBINSON Isn't it the case though that, well, I've seen studies that because smokers die earlier and because they pay taxes on every pack of cigarettes, for those two effects, they die sooner so they don't collect Social Security, they pay taxes through the government, as a matter of fact, they are something of a bargain to the rest of the public?
BONFILIO Well, so you're trading off the fact that it is all right for somebody to die early and the impact that may have on their family and their environment, but you also said they pay taxes on tobacco. Yes they do pay taxes on tobacco, which only covers a fraction of the cost related to smoking or tobacco related disease.
ROBINSON Is it your view that freedom ought to extend, in the United States, to doing things that are stupid and harmful so long as they harm only one's self?
BONFILIO I would agree with that.
ROBINSON You'd grant that. You'd grant that as well?
ROBINSON Okay. So, if you argue, that because of social effects second hand smoke, let's call them second hand effects, generally, why do you stop with tobacco industry? Don't those arguments militate in the direction of regulating and engaging in punitive measures against the alcohol industry as well? Or so far as that goes, against McDonald's for producing fatty foods or Coca-Cola for producing... this may sound absurd but I am trying to follow the line of your argument and find out where it stops, how far it goes.
STRATTON That absurd argument is often raised, but the facts are,
ROBINSON Tell me why it's absurd.
STRATTON It is fundamentally different because cigarettes and tobacco products are inheritably hazardous when used as intended by the manufacturers. Alcohol in moderation is not necessarily harmful and it may actually help with heart disease, the occasional hamburger, not eaten to excess is also not harmful to health.
ROBINSON So tobacco is additive. They use manipulative advertising to targets kids and it's worse.
STRATTON And it's the leading preventable cause of death in the United States and the world.
SULLUM Every study, that I've seen, that takes into account long term savings as well short term costs, including studies that have been published in the Journal of the American Medical Association, New England Journal of Medicine, by Congressional Research Service, have found it is not the case that tax payers are footing a bill unfairly as a result of smoking.
ROBINSON The American Cancer Society, the American Lung Association, lots of public health groups are working hard to persuade people to lead healthier lives. What's Jacob doing?
These guys strike me as good people. They want fellow Americans to be healthy, to lead rich fulfilling lives, and to behave in a sensible way, and they are willing to use the government, elected democratically, whose activities are open to a free press, to that end. Now I am sure this isn't quite the case, but the way your argument is marching along, it's almost as though, "let them cough and hack themselves to death, it's their own damn fault." That is to say, I don't see any willingness on your part to try to exhort your fellow human beings to lead good lives.
SULLUM Well, I don't think it's the government's business to do that. The principle that is being established in the area of tobacco policy, is that the government has the authority to promote the public health, in the sense of trying to reduce overall levels of morbidity and mortality. Now the problem is that people die, a lot of the time, because of things they voluntarily choose to do, risky things like smoking, like overeating, liking failing to exercise, like riding motorcycles, like skiing. All kinds of things that people do that carry risk. And if you're going to say that the government may intervene in our lives to discourage us from doing risky or unhealthy things that might lead to disease or injury, there really is no end to the kind of intervention that could be justified. That's one of the fundamental messages of my book.
ROBINSON The argument that Jacob makes is an argument that has persuaded juries for forty years. In case after case after case, throughout forty years of tobacco lawsuits, the tobacco industry has always won precisely on these grounds. Their lawyers go to the jury and they say: individual responsibility. People know what they're doing. If they want toquit, they can. Millions have done so.
BONFILIO There is personal responsibility. I don't back away from that part, but I also think, based upon what tobacc,o the harm tobacco has done, in this country and country after country in the world, is something that needs to be taken care of.
ROBINSON Why don't you just make smoking illegal, follow up the logic of your argument?
BONFILIO We have had experience with prohibition in this country. It doesn't work.
ROBINSON You'd like to ban it, but it won't work. Would you like creeping legislation that progressively works toward the goal of making tobacco illegal? Would you like that in your heart of hearts?
STRATTON Tobacco can remain a legal product. The issue really is the nicotine content and the other things, and that's at the heart of the discussion now about the degree to which the federal Food and Drug Administration can regulate nicotine and regulate cigarettes as a drug delivery device.
ROBINSON While I am teasing out principles, Jacob, are you in favor, then, of legalizing all drugs?
ROBINSON You are?
SULLUM And in fact I'm sort of tickled when anti-smoking people say "well we couldn't ban tobacco, because that would create a big black market." Well we have a big black market now, we've had it since 1914. And it has a tremendous negative effects in terms of corruption, and violence, and unnecessary deaths, and the spread of disease, and disrespect for the law and on and on, not to mention the routine injustice that is practiced when you punish people for ingesting certain substances that are deemed to be politically incorrect. And yet the tax payers support it. It has overwhelming support. So it is not at all implausible to me that at some point when the level of smoking is reduced enough, that it will seem practical and politically doable to add tobacco to the list of the enemies in the war on drugs. That's one of the things I'm concerned about.
ROBINSON Today public health advocates are after tobacco. What might they be after tomorrow?
Jacob's position has the virtue of intellectual consistency. That is to say, he says the government should not tell us how to behave and, as a matter of fact, not only is it okay with him if you smoke cigarettes, it's okay with him if you smoke crack cocaine, right?
SULLUM That's right.
ROBINSON Okay. I have to say that it strikes me that there's some inconsistency in your position. We can pound tobacco with a sledgehammer, with a legislative sledgehammer, but hands off alcohol. We can pound tobacco, but hands off fatty food. Isn't it a reasonable supposition that if the two of you carry the day and are able to put a check mark against tobacco, the next thing you'll do is go to item number two?
BONFILIO In our education programs, we talk to people about eating a balance diet, watching the amount of red meat they eat, exercising regularly, and moderate alcohol use. That has been consistent. It is consistent with the American Cancer Society, it's consistent with the American Heart Association, it's consistent with the American Lung Association, it's consistent with CDC, with DHS. Most medical people say, if you do, if you do these things, you will be okay. It's moderation. When your talking about--
ROBINSON Moderation doesn't apply at all to cigarettes? If you have one cigarette a day?
BONFILIO Tobacco is dangerous.
ROBINSON Full stop, even a cigarette a day is dangerous?
STRATTON The danger is --- but as I indicated, it's very difficult to smoke, if you smoke one a day, inside of three months, you're going to be hooked on nicotine.
SULLUM Well actually, I mean there's no epidemiological evidence that smoking as little as a cigarette or two a day raises your risk of lung cancer, for example, or other tobacco related illnesses, which one of the reasons to be skeptical about these arguments concerning second hand smoke.
ROBINSON But your view is that even if did, the hell with it.
SULLUM Oh sure, let them smoke.
But in terms of the obesity argument, I think that it's important to note that while you may be quiet sincere and you may be quiet sincere in saying, "we're just interested in going after tobacco," there are other people who are interested in obesity and exercise. The Journal of the National Cancer Institute is explicitly talking about applying the lessons from the anti-smoking movement to the whole area of diet and exercise, and if you want to talk about addiction, people have a great deal of difficulty losing weight and keeping it off, in the same way that people can have a great deal of difficulty quitting smoking. And they go back to it later. So, you can make the same kind of argument about compromise volition, the seductive images from McDonald's and others companies that are foisting unhealthy foods, fatty foods on us, all of these kinds of arguments, and the social costs, tax payers have to pick up the tab for all these obesity related illnesses and so on. So why not have a tax on food based on its content? Why not censor McDonald's commercials? Why not tax people for every pound above their ideal weight? All of these policies are permissible and may be demanded under current public health principle.
ROBINSON The argument is the puritans are coming and they won't stop at tobacco. Can you briefly reassure me or do your best to reassure me that that's not the case. I have to say, I still don't quite see the grounds on which tobacco is just plain different from all of these others.
BONFILIO Okay well, first I'm going to go back to something that Jim said earlier about tobacco. Tobacco, if used properly, causes serious health problems and death. That is a known fact.
ROBINSON And that's different from any other product.
BONFILIO That is different than any other product.
ROBINSON Jim, the puritans are coming. You take your shot on reassuring me on that point.
STRATTON You characterize it as the government telling people what to do. I would characterize it as a State and Federal Health, public health people, providing people with information about how to lead healthier lives, about how to enjoy life to the fullest, about how to age gracefully, and to be able to still run and play with your children when you're in your 50's and 60's, rather than wheeling around with emphezma and an oxygen tank.
ROBINSON Okay, so what do they think will actually happen?
Today, 1998, about a quarter of Americans smoke. What I want to know is, we've got a little bit of legislation, things play out over the next decade, does that number go up or does it go down ten years from now?
STRATTON It will go down if we have the same type of comprehensive tobacco control program that we have here in California. We've proved it with Prop. 99. They're proving it in Massachusetts with their legislation. If it's a comprehensive program, the rates of smoking will go down.
ROBINSON So although individual smokers can't quit, their addicted society can kick the habit.
SULLUM Well, I just want to point out that the assumption that all of these policies will work to reduce smoking, shows people can quit smoking. The whole assumption behind raising the tax and getting people to quit smoking, or educating them and getting them to quit smoking, or restricting the places where they can smoke so it's more inconvenient and less socially acceptable and therefore they will quit, it shows that people can control this behavior, and once the costs rise high enough, they choose to quit. So yes, I think, probably, given the way that the political and cultural climate is moving, the percentage of people who smoke will continue to decline and may be somewhere around 20 percent by the time your talking.
ROBINSON Small percentage.
SULLUM And look, marijuana is completely illegal, and yet millions of Americans smoke marijuana. So we have to be realistic about what can be accomplished in terms of both children and adults. You can't stop teenagers from smoking marijuana, so how are you going to stop them from smoking tobacco?
ROBINSON Ten years from now? What proportion of Americans will be smoking?
STRATTON We have achieved a forty percent reduction in the last ten years from investing a nickel a pack into our anti-smoking in California, the rest of the country can do it too.
ROBINSON Jacob, David, Jim thank you very much.
Fewer and fewer smokers. That's going to mean some changes for us tough guys. I'm Peter Robinson. Thanks for joining us.