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Public-Private Partnerships in Chronic Disease Prevention-Part 6

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[Elizabeth Majestic] My name is Elizabeth Majestic and I'm the Associate Director for Program Development for the National Center for Chronic Disease Prevention and Health Promotion at CDC. I'm serving as the guest editor for this special edition of Preventing Chronic Disease, which is focused on public/private partnerships. Here with me today is Dr. Michael Eriksen. Dr. Eriksen is the director of the Institute of Public Health at Georgia State University. Prior to serving in this position he was the director of the Office on Smoking and Health at the Centers for Disease Control and Prevention for eight years. And we are going to be discussing whether or not public health should explore public-private partnerships with the tobacco industry. Welcome Dr. Eriksen. Are public-private partnerships with the tobacco industry possible?

[Michael Eriksen] Well the short answer is no. The tobacco industry has had half a decade, excuse me, half a century to try to establish the basis for public-private partnerships and they really have forfeited that, based on their behavior and the harm that they’ve caused. The history of this goes back to the 1950s. And at that time the data started to become known about smoking being harmful, and some of the original clinical work was finding that cigarette smoke was causing cancer in laboratory animals. Some of the hospital studies were showing that it was causing cancer in men because that's primarily who smoked. The tobacco industry knew this better than anyone and they had a meeting at The Plaza Hotel in New York in 1955 and they had a decision to make as to whether to try to make smoking safer...to try to reduce the harm caused by smoking or to obfuscate the issue, to withhold the information and to launch a public relations campaign to make smokers believe that smoking is safe and not harmful. Unfortunately, they chose the path of obfuscation and deceit and, as a result of that, tens of millions of Americans have died as a result of that decision in New York over 50 years ago. And when you have a legacy like that it's hard to partner in the same way that you would partner with almost any other type of private entity.

[Elizabeth Majestic] Dr. Eriksen, has the tobacco industry forfeited its opportunity to participate in public-private partnerships?

[Michael Eriksen] Well I think different people would say different things. I think, as of today, they have forfeited the right to participate in a partnership or to collaborate with public health agencies and state and local entities...anyone who really cares about the public good. But it's conceivable that that could change in the future. And I think there are certain criteria that would need to be met for that to happen. The first is that there would need to be a common agenda that the tobacco industry and the public health community would come to an agreement that the goal is to reduce dramatically, if not completely, the harm caused by tobacco use. Only up until the last few years has the tobacco industry even admitted that smoking is harmful. Now, as we all know that smoking is the leading preventable cause of death in the nation, soon to be in the world, just in America, over 400,000 people die each year from smoking, and it's hard to imagine a scenario where that would continue and the public health groups would partner with tobacco companies.

[Elizabeth Majestic] But doesn't public health have a monitoring function of some type that we need to fulfill in relation to the tobacco industry?

[Michael Eriksen] Yes, and we have done that. When I was at CDC in the Office on Smoking and Health we did an excellent job of counting the bodies, of monitoring the economic loss caused by tobacco use, of looking at how young kids became addicted. So we would monitor the tobacco company independent of the tobacco company. They were not a partner. We would just be…really, people would joke about the term ‘surveillance’ but that's exactly what we were doing. We were doing surveillance of the tobacco industry and the harm that they caused. That's truly not a partnership. The partnership possibility is if there was this "common ground." If there was the agreement that we can't go on the way we are, that we need to reduce the burden, and we need to do it dramatically. And it's conceivable that the tobacco companies, going forward, and the public health community, could work together on that but there would need to be these ground rules and they would include things like admitting the full harm that's been caused, being accountable for the harm that wascaused, which could include compensating individuals who have been harmed by tobacco use. And it would ultimately, in my mind, include the phasing out of combusted tobacco products. As you know, the harm from smoking is from the smoke. If you were to smoke marijuana as much as people smoke cigarettes you would also have lung cancer from smoking marijuana. The fact that people are habitually smoking 20 cigarettes a day, 365 days a year, for 20, 30, 40, 50 years, is the accumulated exposure to smoke, to combusted vegetable products, is what's causing the adverse health effects. And there're signs that the tobacco industry is trying to phase that out. And to the extent that they do phase out combusted tobacco products and look at more innovative ways of providing nicotine, which is why people smoke in the first place, there's certainly the possibility that there could be a partnership between public health and tobacco companies, or public health and pharmaceutical companies, or some blend of them, that would try to provide nicotine when necessary but not the smoke.

[Elizabeth Majestic] So if I understand you correctly, what you're suggesting is that there needs to be some evidence that in fact the tobacco industry has changed in order to be eligible to partner with public health. Perhaps not in the traditional way that we think of public-private partnerships, but certainly would have more significant interactions than what we've had in the past.

[Michael Eriksen] I think it would have to go beyond evidence. I think that they have had plenty of opportunity to provide evidence. I think the only way a partnership could really occur is if there was a regulatory framework in which it operated. I think the tobacco industry has proven that they can't be trusted. And that everything that they do, whether it's supporting warning labels on cigarettes or taking advertisements off of television, have all been concerted efforts to protect themselves and to further advance their own profit gains. For a partnership to exist, it would need to be very tightly regulated with a common agenda of saving lives. And that they would not simply be put in a position where we would have to trust them or rely on the evidence they provided, but we would need to have some type of accountability and oversight that would assure that we’re not, once again, being taken advantage of by the tobacco companies as they have a, you know, a half a century of...we have a half a century of experience of them having done that.

[Elizabeth Majestic] Now you mentioned that the tobacco industry would have to demonstrate that they have changed. I would think they would argue that, in fact, they have acknowledged that using tobacco does cause harm. And they do make recommendations that the public should seek out, in fact, resources, some of those that the Centers for Disease Control and Prevention, the American Cancer Society and the like, to help them quit smoking if they want to. So how, and, and in fact some of them, I think Philip Morris, in fact, is supportive of FDA regulation. Is that the kind of evidence that you'd be looking for or does it kind of move beyond that into the more FDA regulation framework that you would want to see before we would fully engage into this kind of partnership?

[Michael Eriksen] Yes, I think we would actually have to move beyond the FDA regulation that’s currently being debated. As I indicated, I think the tobacco industry has proven that they can't be trusted without some type of oversight. They have forfeited the right for a collaboration of the type that public health is seeking with other private-sector partners. They've done it repeatedly. Even today, they say, "Believe public health experts when it comes to smoking and health." They really don't admit themselves that smoking causes disease. They continue to advertise deadly and addicting tobacco products in this country and associating it with glamour and sex and sophistication and having fun, when the product is inherently...kills 1 out of every 2 of its users. Overseas it's even worse. They are virtually unfettered around the world and they continue to operate around the world in the ways that they operated in this country, you know, just a very short number of years ago.

[Elizabeth Majestic] And so do you think public health in this country should set a standard for the behavior of the tobacco industry abroad? In other words, should we not partner with them if their behavior abroad is inconsistent with the behavior that we want to see them engage in in this country?

[Michael Eriksen] I think that would be an exciting opportunity to make up for some of the leadership shortcomings that have occurred in the recent past. Many of us feel that the U.S. has been at the forefront of tobacco control from a research standpoint and a surveillance standpoint, and many of us are disappointed that the Framework Convention on Tobacco Control has not been ratified by the U.S. That many of the major tobacco companies around the world are headquartered in the U.S. So if we were able to exert some leverage on the tobacco companies to behave better globally, it would begin to make up for some of the lost opportunities that we haven't followed up on over the last few years when we should have.

Let me give you an example of this. In the current Department of Justice litigation against the tobacco industry for racketeering, I was an expert witness in this litigation and spent a good amount of time being deposed and testifying for the government against the tobacco companies. The judge, Gladys Kessler, ruled that the tobacco companies were guilty of racketeering and that they were found guilty of defrauding the American public for their own profit. The remedies that she ordered were, I think, very minor, but they included not using the terms "Low Tar" or "Light Cigarettes" in the future. So the tobacco industry's response to this was twofold. One is that they appealed the verdict and that case is now in the U.S. Federal District Court of Appeals in Washington. But they also went to Judge Kessler and said, "OK, you say we can't use the terms ‘Light’ and ‘Low Tar’ in the United States, but we'd like to use them globally." And the judge debated their appeal and basically said, "How dare you?!" "How dare you try to do something overseas that you weren't allowed to do in this country?! You're an American company, you can't do it." And so she was quite firm about that decision, but it was just indicative of the fact that they are going to go kicking and screaming to do the right thing unless there is very strong regulation that guides any type of collaboration. And that collaboration really should be focused on killing as few number of people as possible. When your leading preventable cause of death in the country...if you can reduce it by 90 percent you'll make a huge public health statement but at the same time you'll still kill more people than are killed in car crashes. So we have a long way to go but I don't think that we can trust the tobacco companies to do that independently.

[Elizabeth Majestic] Dr. Eriksen, is this a recent concern about the tobacco industry's behavior or has this been an ongoing issue?

[Michael Eriksen] Well it certainly has been an ongoing issue. I remember when I first came to CDC in 1992, there was one of the most heated discussions about partnering with the tobacco industry and CDC convened a group of nonprofits, all the volunteer agencies, to discuss what potential is there to partner with the tobacco industry and out of that process there was a clear "No, there is no possibility of partnering." But it even goes back further than that. As I mentioned, in 1955 the tobacco companies made their decision to go on a public relations campaign to really obscure the fact that smoking was harmful. And a few years after that, at the first meeting of the World Conference on Smoking and Health, Bobby Kennedy addressed the crowd, and this was unfortunately just a few months before he was assassinated, but he said at that time, "The cigarette industry is peddling a deadly weapon. It is dealing in people's lives for financial gain. The industry we seek to regulate is powerful and resourceful. Each new effort to regulate will bring new ways to evade." And you can see him on this video saying how that should inspire us to make a difference.

Robert Kennedy: Dr. Terry, Dr. Baker, and ladies and gentlemen. I am very pleased to be here with you today. I am honored to address such a distinguished group and I believe your conference is really one of the most important meetings ever held to discuss a health problem. Your presence indicates your agreement with that statement, for this is truly a world conference, a conference of the highest order. Still, we must be equal to the task, for the stakes involved are nothing less than the lives and the health of millions of people around the world. But this is a battle that can be won and with the commitment that is demonstrated by this conference, with the commitment that all of you show in being here, and in your work at home, I know that it is a battle that will be won. Thank you very much. (Applause.)

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