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Big Tobacco says that smoking is about freedom and choices. But a battalion of experts at Emory is showing that better choices can be made—and that not much about tobacco is free...

Tobacco-related illnesses kill more than 430,000 Americans a year—more than AIDS, car accidents, and illegal drugs combined—and cost the nation about $90 billion in health care annually.

His father smoked Marlboros, two or three packs a day, starting at 13 as a farm kid in Nebraska and quitting when he died of lung cancer at 49. But Dearell Niemeyer’s battle against smoking is much more than a personal vendetta.

For nearly two decades, Niemeyer has challenged the conventional wisdom that tobacco use is an individual problem that can be remedied with smoking cessation classes and warning labels. Niemeyer, executive director of the newly formed Tobacco Technical Assistance Consortium (TTAC) at the Rollins School of Public Health, sees tobacco as a societal health problem—and he places much of the blame squarely in the pockets of Big Tobacco. “Nobody realizes how insidious they’ve been,’’ he says. “The government was very slow to come to the forefront and hold the tobacco industry responsible.’’

Beginning with Mississippi in 1994, states started filing individual lawsuits on the premise that they should be able to recover the costs of treating diseases caused by tobacco use. This led to the Master Settlement Agreement, signed in November 1998 by the attorneys general of 46 states and five US territories and the top four tobacco companies. “...States realized they were picking up the bill for citizens dying from tobacco use,” Niemeyer says. “They asked, ‘Why shouldn’t the tobacco companies share in that cost?’”

Facing decades of litigation, R.J. Reynolds, Brown & Williamson, Lorillard, and Philip Morris agreed to pay the states $206 billion over 25 years. Florida, Minnesota, Mississippi, and Texas, which had previously settled lawsuits, received a total of $40 billion.

The settlement was a crucial turning point for the anti-tobacco movement, providing not only funds for tobacco control programs but sweeping new restrictions on the sale and promotion of tobacco products: More than 14,000 tobacco billboards nationwide were torn down or replaced with anti-smoking messages. Outdoor advertising on public transit systems and in stadiums and shopping malls has been removed. Banned were cartoon characters advertising tobacco products, trinkets emblazoned with pro-tobacco messages, and paid product placements in movies and television. Tobacco industry trade secrets and internal memos were made public.

“When you look at some of the disclosed documents and see how they were so callous about targeting 13-year-olds, it makes you angry,” Niemeyer says. “I think we need to do a better job of letting the public feel some of this outrage.”

But three years after the first settlement payments were distributed, anti-smoking advocates are expressing dismay over how the funds have been spent. The report Show Us the Money: An An Update on the States’ Allocation of the Tobacco Settlement Dollars, released in January by a coalition of public health organizations, found that just five states —Arizona, Maine, Massachusetts, Mississippi, and Minnesota—are using 20% to 25% of their settlement funds for tobacco prevention programs as the Centers for Disease Control and Prevention recommends. The majority of states spend less than half that amount.

“We have conclusive evidence that tobacco prevention works,” said William V. Corr, executive vice president of the Campaign for Tobacco-Free Kids, citing dramatic cuts in smoking rates among children and adults, reduced incidence of lung cancer and heart disease, and millions of dollars in reduced health care costs in California and Massachusetts—the two states with the most comprehensive tobacco prevention programs. “All of these benefits will be lost if the states do not live up to their promises.”

Indeed, tobacco bestows a lingering legacy: Even if current use stopped completely, tobacco’s residual effects on past users would cause disease and premature death for decades to come. “I keep telling the state legislators and governors: ‘You’re not going to get a chance to sue these guys again,’” Niemeyer says. “‘Don’t you want to invest in reducing future tobacco-related costs?’’’

As chief of tobacco control in California from 1989 to 1991, Niemeyer oversaw one of the first experiments focusing on smoking prevention rather than cessation and treatment for tobacco-related diseases. The state funded these efforts with Proposition 99, which added a 25-cent tax onto every pack of cigarettes sold. “The tobacco tax hadn’t gone up since 1966, which shows how powerful Big Tobacco was,’’ he says.

“When you see some of the disclosed documents and how they were so callous about targeting 13-year-olds, it makes you angry,” Niemeyer says. “I think we need to do a better job of letting the public feel some of this outrage.”

But Niemeyer found he was battling a mindset even more firmly entrenched than the tobacco lobby. From the time of the Surgeon General’s first report on the health consequences of smoking in 1964, health workers had concentrated on convincing individual users to “kick the habit.” Parents tended to view smoking as a rite of passage, grateful that it was “only tobacco.” Politicians and physicians alike asked, “What more can be done? People know cigarettes are bad for you. If they still want to smoke, it’s their choice.’’

“As a society, we were really blaming the victim,” says Niemeyer. He and other anti-smoking advocates began to fight back on the tobacco industry’s own turf—with money, legislation, and counter-advertising campaigns. “The drumbeat started getting louder,’’ Niemeyer says. “We stopped focusing programs on the individual smoker and started looking at laws, marketing, pricing, private policies, schools, and the workplace. We started focusing on the social environment and how it promoted or didn’t promote tobacco use.”

For the anti-tobacco movement, this was a paradigm shift akin to John Snow breaking the handle off the water pump. A full-fledged concentration on prevention tactics and community change spread across the country as other states picked up the banner. Workplaces and public spaces enacted Clean Indoor Air rules. Smokers found themselves ostracized, herded into small, smoky rooms in airports or huddled on outside patios. Counter-advertising campaigns put faces to the issue.

“People, money, and resources converged with the understanding of the need for major, wholesale change,” Niemeyer said. “Social change is often like an earthquake: the pressure builds up to the point where plates slip. It doesn't happen out of the blue.’’

A seismic shift in the public perception of the tobacco industry was occurring as well: More and more, the industry was viewed as profiting handsomely from the deceitful peddling of death and disease to teen-agers and adults, both domestically and abroad.

Smoke and Mirrors
Through the 1990s, tobacco companies suffered public relations blows from nearly every quarter. R.J. Reynold’s grandson, Patrick, became the spokesman for a smoke-free America after the family’s cigarette brands, Camel and Winston, killed his father and eldest brother. Brown & Williams executive Jeffrey Wigand, the highest ranking tobacco company executive to go public with what he knew, was held up as an Orwellian hero in the movie The Insider. Ben and Jerry’s dropped Oreo cookies, manufactured by RJR/Nabisco, from its ice cream selection. Universities sold off their tobacco stocks. McDonald’s banned smoking in all of its restaurants. And Marlboro Man David McLean died of lung cancer at age 73.

But in a country where states have tobacco leaves and flowers as ornamental carvings in their capitol buildings and tobacco companies have brazenly wielded money, power, and political influence for hundreds of years, Big Tobacco wasn’t going to tuck tail and skulk away.

The tobacco industry had long framed its fight with anti-smoking advocates as “big government versus individual freedoms,’’ while targeting underage smokers with kid-friendly ad campaigns like Joe Camel and spiking nicotine levels to maximize their product’s addictive qualities. Anti-smoking advocates were labeled “health Nazis,” who were trying to legislate a tobacco “prohibition.”

The companies had the easy confidence of multi-billion dollar, name-brand conglomerates with high consumer loyalty. After all, Philip Morris isn’t just the largest cigarette manufacturer in the world. It also makes Kool-Aid, Kraft Macaroni & Cheese, Grape-Nuts, Oscar Meyer Hot Dogs, and Jell-O.

Tobacco-related illnesses, including cancers and chronic diseases, kill 430,000 people each year.
“ Tobacco companies thought they were covered legally because they had placed warning lables on their products since the late 1960s. Indeed, despite multiple lawsuits from individual smokers and their families from the mid-1950s to the mid-1990s, the tobacco industry had never lost a case. The juries adopted the theory of assumption of risk: that the consumers knew the risk and voluntarily began to smoke and voluntarily continued to smoke,” wrote Emory law professor Frank Vandall in a 1998 article in the Southwestern University Law Review. Also, individuals had to prove that their illnesses had definitively been caused by the company’s product.

The attorney general of Mississippi decided to file suit against the tobacco manufacturers in 1994 but wanted to find a way around the industry’s usual defenses. This was supplied by a group of visionary thinkers including Ray Gangarosa, now a research fellow at the Ethics Center at Emory, who blended his background in medicine, engineering, and epidemiology to help invent a new legal strategy. Gangarosa believed states could bring their own suit for injuries to recover the costs of treating disease stemming from tobacco use, without having to combat the argument of assumption of risk or proving the cause of illness.

Industries like gambling, alcohol, and tobacco are “societal cancers,” says Gangarosa, that cause “exceptional social harm, including death, disability, addiction, and secondhand injury, on the scale of a commercial holocaust . . . (and have) escaped society’s usual controls by shifting blame for harmful commerce to their consumers, and then shifting associated downstream costs onto society. We must hold these harmful industries accountable for their costs.”

Gangarosa, who is working toward a PhD in epidemiology at RSPH, was disappointed in the Master Settlement Agreement, in which he feels “some terrible compromises were made.” But he acknowledges the complexity of the issue. “The tobacco industry doesn’t make enough money to pay for the social harm that they do. We would bankrupt them,” says Gangarosa. “But if we don’t ask them to pay the social cost, then they are effectively being subsidized.”

"As a head and neck cancer surgeon, I am painfully aware that tobacco contributes to cancers of the oral cavity, pharynx, and larynx, as well as the esophagus and bladder. If TTAC is able in any way to reduce smoking and other tobacco use, especially by children and teens, it will make an important contribution to the fundamental mission of the Woodruff Health Sciences Center, which is, quite simply, to make people healthy."

— Michael M. E. Johns, executive vice president for health affairs

Other public health experts are skeptical that tobacco companies will end up bearing the costs at all. “These settlements came about without thought for the rest of the world,” says Bill Foege, presidential distinguished professor of international health. “The fines could be increased tenfold, and the tobacco companies could still pay them on the backs of the rest of the world.”

Still pending is a federal lawsuit against tobacco companies filed by the US Government in 1999, accusing the industry of a “coordinated campaign of fraud and deceit.” True to form, the tobacco industry is trying to pass on as much of its litigation and settlement burden as possible. Niemeyer cites a USDA report stating that cigarette prices surged 45 cents per pack on November 16, 1998, the day the Master Settlement Agreement was signed. “Who’s really paying for this?” Niemeyer asks. “Smokers. First they hook you, then they charge you to pay for their harm to society. This isn’t going to put the tobacco industry out of business. It is still too profitable.”

Nevertheless, Niemeyer was gratified to see a strong turnout at the National Conference on Tobacco this past November. “There were 2,750 people there—more than double the number from two years ago,” he says. “Public health jobs follow the resources. Just because we were saying tobacco was unhealthy in the past doesn’t mean we were doing anything about it. Never before have we had such an opportunity to make a difference.”

Mary Loftus, a former Knight Journalism Fellow at CDC and reporter for the New York Times Co., is associate editor of Emory Magazine.

Related article in this issue:

Tobacco and Technical Assistance Consortium
From their new offices on the eighth floor of the Rollins School of Public Health, TTAC will provide blueprints for community tobacco control and prevention programs, train staff, and evaluate existing services.

Spring 2002 Issue | Dean's Message | In Brief | Innocence Lost |
Making Smoking History | Alumni News | Rollins School of Public Health

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