Allan Brandt, "The Case of the Framework Convention on Tobacco Control."

all right well thank you for coming tonight welcome to the the last lecture in this series this summer summer fever of the 2011 Hertog global strategy initiative so I’d like to thank as I always do Rodger Hertog and the Hertog foundation for making all this possible I want to also thank the mailman School of Public Health both the Center for the history and ethics of public health but also I want to thank the communications department for all their support I want to thank as well since this is the last lecture all of those who have been helping all along to make all this possible and that especially it’s a case with Sidney gross thank you so much to me so if you’ve been coming to these lectures you know that these lectures are a part of a larger program and includes a research program there’s a seminar at this there are elective courses there’s a lot that we’re trying to do to pack in every summer and so we’ve drawn on the talents of many others as well so I want to also thank will Leonard if he’s here thank you so much well I want to thank Lydia Walker it’s also played a key role Thank You Lydia and I also want to thank Andrew and Chang and Amina the the interns who’ve joined us later in the summer about but if volatility mand their talents and their intelligence and and and all these waves made this program better than it might have been so thank you again the idea behind this program is that we’re trying to take on problems that are transnational in nature and global and scope and we’re trying to see whether it’s possible to do a historical research on some of the most pressing problems in world politics and think too about how it is history might help us to plan for and prepare for these challenges so this is a program that while its historical in nature and in the sense of the kind of research we do the archives we go to the interviews we conduct the kinds of people who come to us and and tell us about what they’ve learned over the course of their careers and in the research that they’ve done it’s also one that tries to bring in people from different disciplines to help us as historians better understand the nature of these kinds of problems last year’s nuclear proliferation this summer it’s on pandemics in public health next summer we’ll be looking at religious violence and apocalyptic movements so we’re taking on some of the biggest problems in world politics we’re trying to do basic research and we’re trying to do it in a way that’s actually relevant and maybe even useful for thinking about these problems and trying to do something about them so in bringing people together we’re also bringing together undergraduates and graduate students undergraduates are doing very advanced research as I’ve been hearing and as others of you already know over the last three days and the presentations that they’ve done and graduate students as well who I think in part because it’s the summertime and all the adults are away including their advisers they’re able to ask questions that in some ways may be our bigger and bolder they’ve been they’ve been trained to to take on in the course of doing say a dissertation they’re doing all that in the course of the summer instead of in six years and I assure you the results is you’ll be seeing in the publications that they will produce I think have been quite exciting but let me welcome Allan Brant in particular and and thank him for coming because in many ways the work that he’s done has been a model for many of us in this program not only in the the path-breaking and incredibly important books that he’s written the cigarette century and also a no magic bullet but asking very basic questions about how we understand agenda-setting and in public health how it is that problems in public health help to create a prism by which we can better understand society but also because of the kind of the ways of its he’s used this research to inform public debates on the most important issues of life and death for millions of people for instance in the way that he testified for the US Department of Justice in the US vs Philip Morris and in many other ways that I won’t tell you about and he would be much too modest to tell you about but which you could read about if you just begin to research Alan Brown and then finally is the Dean of the Graduate School of Arts and Sciences at Harvard Allen as he’s been telling us has been doing really exciting things in graduate education and I want to thank him too for talking to our students about some of those things and helping them think critically as we all must

about the history and future of public education and higher education in the United States so in all these ways I want to thank Alan and I want to thank him too for preparing this exciting lecture on history health and global governance the case of the Framework Convention of tobacco on tobacco control so thank you again Ellen thank you very much Thank You professor Connelly and for such a great introduction and I want to thank you and professor Morse and especially Sidney grosse for inviting me and having me here today when I got the invitation from you in the spring I have to say as I’ve read about the program I got excited right away because these are the questions that have been so essential to me personally about how we find a usable past how to think about the history of contemporary problems how to try to do serious scholarship but scholarship that also is related to crucial questions of the present and the future and I just have to say getting to talk with the students who participated in the program this summer you know how excited I am for the kinds of work that you’re doing it’s really a remarkable program and it has all the right values because I’m somebody who believes in knowledge for knowledge sake but at the same time I’m also somebody who believes that the kind of work we can do in our scholarship can really be related to the most powerful moral and cultural political questions of our time and figure out how to do that in a way that really has rigor and is done in a systematic way something I’m still struggling with so what I thought I would do is is tell you about a problem that I struggled with in my recent work on tobacco and I think it will raise a lot of questions about things that you’ve been studying all summer and maybe we can have a broader conversation about some of those questions we just came from a smaller seminar and I was explaining when I came to Columbia to do my graduate work in 1975 I thought I would work on comparative questions across nations and I was immediately told either you’re an American is tour Europe you’re a Europeana stand a lot of American history has centered on the question of how is America so different and I have to say unfortunately that’s the tradition in which I was taught and Americanist really worked on America as if it was unconnected from the world and so many the questions at stake in thinking about global history I mean placing America within a broad global context in the kinds of transnational exchanges that Professor Connelly just mentioned and that’s really the theme that I want to take up today but I have to admit even when I started my book on cigarette smoking I really thought I was gonna write a history of cigarette smoking in American life and that I would trace a rather remarkable story of how cigarette smoking came to be so popular in the United States and then ultimately about its relative decline in the last two or three decades and I thought that was a great story for the most part smoking doesn’t exist as we know it as recently as 1900 there was this phenomenal rise of cigarette smoking during the course of the 20th century in the United States and then a very good story for public health that a behavior that’s highly addictive that’s intensely advertised and so on actually declines in number over a series of decades that that would be sort of beginning middle of an end and that’s really where I started I just thought I would briefly review some of the questions that were at stake in this this is just a chart that shows the rise of male smoking very intense in the first decade of the of the 20th century often associated with World War one the women’s Christian Temperance Union opposed smoking and said now that we’ve banned alcohol will ban smoking but by the end of the First World War the women’s Christian Temperance Union is distributing cigarettes to the troops so there’s a profound social and cultural change that takes place during the war tremendous rise in men’s smoking and then followed about a 20-year lag in women smoking almost getting to the rates in which men smoked and this was really the chart that I began my project with I wanted to explain this and I thought there are so many important questions to American social cultural historians historians of medicine and public health that that would be my project but it turned out not exactly to be the case but what I thought I would do is just quickly show you sort of some of the factors that led to that rise in cigarette smoking and just mention it

because I always had the notion that if we could understand why cigarette smoking got to be so popular in the United States you would recover some of the mechanisms for undoing that behavior that there was almost perhaps a form of reverse engineering in a historical project like this that to really understand what types of public health interventions might be most effective today around smoking you really had to understand how its appeal was built up in the early years of the 20th century there are many aspects of this changes in biz and business organization that I described in my book changes in technology and the mass production of cigarettes people went from rolling several hundred a day to machines that could roll hundreds of thousands in an hour and then how do you mass market a product that you can produce so easily and cheaply but branding was a critical aspect and the emergence of national brands is at the heart of consumer cultures and camels was one of the first major brands these ads are from right around the time of the first world war one of the big issues that the chart that I showed you already raises is men started smoking but there was a widespread perception in American culture in the first decades of the 20th century that it was not appropriate for women to smoke so the companies realized we’ve only got half the market and so how are we going to change cultural norms to think about getting women to smoke when there are serious moral social and cultural prescriptions about women smoking and especially women smoking in public the reason I want to raise this so so clearly now is that when we look at smoking globally today smoking is principally around the world a male behavior and I know what that means to the tobacco industry it means we’re missing major segments of the market and they had a specific strategy in the United States to getting women to smoke in these early decades of the 20th century that now we’re seeing deployed again in very culturally nationally and historically specific ways one of the ways they did it here is they said well we can’t really advertise directly to women so let’s have these ads that say have a woman saying blow some my way this is these ads are from 1928 and right away Chesterfield became the most popular cigarette among women’s smokers American tobacco hired this very brilliant public relations expert on your left Edward Bernays and he actually hired debutantes to smoke in the nineteen Easter Day Parade in New York and Bearnaise is really a fascinating figure in the history of consumer cultures and his papers are at the Library of Congress in Washington and so when I started this project I went down there and they said well his papers won’t become available until he dies and I said well how old is he and they said well he’s 98 so I waited and I waited and historians can be quite ghoulish in this way and Bearnaise died at a hundred and three and the next day I was at the National Archives and what I found was really curious is that he had collected scrapbooks with newspaper articles and I kept asking myself the question that a historian should about documents why is he collecting these scrapbooks of newspaper articles because he did not want to identify that he had been involved in the production of these news stories but what he wanted to do was to create news and then documented the way he could demonstrate this for his client in this instance American tobacco was by collecting all the news clippings and at the time there were news clippings services many of you have worked in archives have seen these kinds of collections he documented that when he got the debutantes to smoke Lucky Strikes on Fifth Avenue at the 1928 parade he made sure that there were news photographers there to do it and he said controversy this will create women smokers women smoking in public he associated it with feminism and women’s liberation at the moment and was all incredibly effective you see this ad on your right I really don’t know if I should smoke but my brothers and my sweetheart smoked and it does give me a lot of pleasure there’s a transformation at this moment in American culture about the idea that pleasure is indulgent and wrong to actually creating a pleasure oriented economy where it says indulge in a Lucky Strike the most pleasurable cigarette and I noticed this transformation in American culture around items like the cigarette at this

time these are ads that were Bernays ads do you inhale everybody’s doing seven out of ten smokers inhale knowingly the other five inhale unknowingly the the use of sexuality to sell products seems apparent here some of my students think that these are sexually suggestive I don’t see it myself these were actually drawn by a famous pinup artist of the 1930s but by by this time women and men are smoking equally it’s seen as a sign of relations between men and women smoking becomes very popular in American film one of the questions I got all the time as I was beginning this project was does the smoking you see in American film as a visual representation reflect changes in the culture don’t you see smoking in film because more people were smoking but when we get into the tobacco documents you see that Bernays was working with Hollywood directors and with major film companies to assure that they used cigarettes in their film so the relationship between film as a cultural idiom and force and industrial interests is much more complex than simply seeing it as a mirror of changing culture so the other thing that became so apparent during this period of the rise of cigarettes is that cigarettes turned out to be extremely dangerous and so one of the things that I have studied is the rise of the science of Epidemiology as it was reflected in the cigarette some of my friends have said you don’t need to be an epidemiologist to see the causal relationship here but what I want to suggest is as early as the 1930s and 40s when people became very concerned about cancers and tobacco this relationship would have been much more difficult to unpack and so the very early years of epidemiologists looking at this question looks like this and so one of the things we know about tobacco is that the knowledge in certain disciplines that were that evolve were crucial to the determination of evidence-based notions of causality and disease which is critical to so many material questions in global health and so I don’t have to to go into the detail now but the early evolution of retrospective and then prospective trials to unpack this particular question is a crucial element of mid twentieth century science and the development of Epidemiology as a field and I like showing this slide when I teach in schools of public health because it really puts you back in a moment where some of the tools that we use just normally now weren’t always available and how do you understand this question you see a small rise in disease but is it caused by the rise in automobiles the paving of roads which is highly toxic the development of cigarette smoking which is a major popular behavior or some other variable and understanding I think epidemiology at that level is crucial to thinking about the skill set that’s really needed to unpack very complicated problems of causality here’s how the tobacco industry responded to scientific knowledge more doctors smoke camels than any other brand when I testified against the tobacco industry in the case that Matt mentioned I had found out that actually what they were doing is they would go to medical meetings and put Camel cigarettes in the doctors rooms then they would have a pollster in the lobby and the poster would say doctor what cigarette brand are you carrying and then fish out this free pack of camels and then they said more doctors smoke camels than any other brand I was telling a story at the trial and like 30 tobacco lawyers got up all at one time and said we object we’re stipulating to this story we don’t want to hear a hit so I thought it’s a pretty good story the other types of responses were to say you know filter cigarettes or our cigarettes don’t really cause disease and a lot the reason I show these slides in this context is a lot of these issues are persistent safer brands ultralights a lot of issues that had that have been very difficult from a public health point of view really have their origins in the 50s around the definitive evidence that smoking causes lung cancer what the companies did they put out at this statement that again was planned by public relations people that said we’ve always been committed to public health we want to get to the bottom of this there’s a great deal of scientific uncertainty around the problem of cigarette smoking rely on us to get to the bottom of this and so this remains part of the strategic orientation that I’ll describe more about the tobacco industry in a in a global context finally the Surgeon General of the United States in 1964 came forward and

said cigarette smoking causes lung cancer and it really required the state and one of the questions that we want to ask I think when we’re thinking about global health is what is the appropriate role of the state in this instance the state adjudicated a controversy that had been invented by the industry and the state was recognized as a neutral player in the resolution of that dispute even though the industry would be deeply committed to undermining the findings of the first Surgeon General’s report often through political lobbying the first label on cigarettes after Surgeon General Terry makes his announcement that cigarette smoking causes lung cancer was a label that the industry wanted on cigarettes that said cigarette smoking may be hazardous to your health now why did the industry want that on the package it was viewed as a public health intervention because then they could say cigarettes are labeled you’re aware that they may be harmful and the decision is yours so you cannot hold our companies responsible so there’s a very ambiguous history to labeling in which we think of it as a public health intervention but in this instance it very much served the interests of the tobacco industry and I’ll say a bit more about that a little bit later on so here we have this chart and I have to say in my American Exceptionalist orientation I viewed this chart with some degree of gratification that cigarette smoking had grown tremendously I thought I had some explanations for why that was the that I understood it better as I conducted my study and I began to understand why cigarette smoking had declined modestly but significantly given its biologically and socially and culturally addictive qualities and I thought this is a good story for public health where you identify health risks even in the face of powerful industrial interests and yet you create a society that begins to modify it and we went from as you see almost 60% of men I recently saw a data point that in medical schools in the mid-1960s nearly 80% of all medical students were regular smokers imagine that today and yet today we see these dramatic declines in medical schools you know you would have fewer than 1% of medical students are smokers today so it was a good story but here’s my point in the context of thinking about global health this good story of American public health and the nature of what we understand about tobacco has had dramatic implications for global health and so we need to think about this story in a much more complicated way because one of the things I think it will teach us is that an intervention that may be successful in one nation-state has all kinds of very serious implications for other nations and for indices of global health and that’s really where I want to take off today so one of the questions that I think we really need to ask when we tell a story of success in public health is what were its ramifications in terms of some of the transnational and relational issues that are really at the core of how to think about global health and one of the big problems that we have right now is how are we going to define global health is it just everything that happens relating to health on the globe or can we be somewhat more specific about the kinds of human and disease interactions and movement that actually crosses societies and States in ways that might be informed by different types of public policies and that’s at the heart of what I really wanted is that’s what the companies realized and they realized it early on was that what was happening in the United States and the growing awareness of tobacco as the principle public health risk that Americans were experience experiencing made them think about other markets and I have to think that that the tobacco industry has been remarkably intelligent and sophisticated about the overall decline in American smoking that they anticipated as early as the 1970s and they began to aggressively think about where are other markets that will create what they refer to in their own documents as replacement smokers they said American smokers are quitting or they’re dying and if we are going to sustain our industry we need new smokers and where will new smokers come from they’ll either come from kids today in the United States and other Western developed countries who don’t smoke but given the levels of affluence and education and the public health

campaigns and especially the campaigns about sidestream smoke that became so important by the 70s and 80s the United States market the Western European market the Australian and Canadian markets for example are all going to be compromised so where is the future of our product and it was really in the developing world and so this in a way is the problem in the year 2000 approximately four million people died of tobacco-related diseases worldwide and half of them were in the developed world and half of them were in the developing world low income in some middle-income countries and by the year 2030 now only less than two decades from now the number of total deaths will go from four million to 10 million it will more than double but those desk will occur predominantly very significantly 70% of those deaths will now occur in the developing world and this is the material representation of a tobacco industry strategy that was really hatched in the 60s and 70s in terms of finding new smokers and aggressively promoting smoking in places that had lower levels of literacy and education which had weaker state governments which had no regulatory regimes and I’ll say a bit more about that I don’t know if if you’ve used these maps in the course have used some of these these are really fascinating maps and I I highly recommend that you go on this website it’s called world mapper org and these come from the University of Sheffield in England but a cartographer they’re working with a physicist from the United States worked out a distortion map in which you could enter a single variable and distort landmass by that variable and so they have literally hundreds of these maps on the website maternal mortality education a lot of health outcomes a lot of social indicators and they put in one variable and then the map distorts and what this does is it really tells you where where that variable is most active at any one time I have to say this was surprising to me and I’ve been studying tobacco for a long time to realize that there’s so much smoking going on in Russia and the former Soviet Union in India and Southeast Asia and just how how reduced smoking is in North America how it has not been so predominant in Latin America and you know I feel in my work I’ve gotten inside the head of the tobacco industry and as I say they’re very sophisticated they see this map and they say what are some of the opportunities on this map and a giant opportunity is Africa and Latin America where individuals tend to be less well educated and in which you can create a new market given you know consumer economies so it’s it’s pretty impressive here it is for women and so you can see there are many places that for men have tremendous numbers of smokers but look at the difference between India or the Russian states on this and you and you and you see that is an opportunity and what I learned in my study is if you’re a tobacco executive and you’re thinking where’s our weakness it’s on women smokers in India then they become very sophisticated and they know a lot about this and they actually did this in the United States in the 1920s and what are the associations of getting women to smoke there around equality under equality women in the workplace women as attractive and glamorous so a lot of the building blocks for addressing this from if you will the dark side are really expressed in these material maps and you can learn a lot from these maps very quickly here’s what’s been happening smoking is on the decline in the US and the UK it’s been on a very steep incline on in China the Great British epidemiologist Richard Peto did a major study of the epidemiology of smoking and smoking harms in China he said if the if the Chinese smoke like the American and the British they’ll die like the American and the British and this is an enormous problem for the health care system in China but it’s also indicative of some of the questions that I want to raise about markets and commerce from a global perspective here’s he’d tobacco related deaths per year and China by 2040 will eclipse all

of the developed nations in terms of numbers of deaths that’s an evolving healthcare system how will putting this number of chronic related diseases that we associate with smoking into that system impact the emerging Chinese economy in the middle of the 21st century I think this is a very clever illustration so I wanted to share it with you this is from Alan Lopez and what he’s done is he has put various areas of the world into different stages of what he would call tobacco epidemics or the tobacco pandemics and so you see Western Europe the United Kingdom the US Canada in Australia having declining smoking rates and they’re in the fourth stage after very significant rises in the middle of this chart Eastern Europe and southern Europe have plateaued Latin America but sub-saharan Africa China Japan South East Asia are really steeply rising and so you can in a way develop some periods of this epidemic but one of the things this raises for us is is there something that we could learn from what the Western European or American history of the epidemic that we could guide back into stage 1 and stage 2 countries so that they would have stronger tools to resist this rise of smoking and so these are some of the questions of governance that I think we get into in policy is what do we know from our experience in the West that might be utilized effectively in other places of the world at this time and it’s that transfer of knowledge that’s a critical aspect of globalization as well this has tremendous implications for the overall burden of disease and I don’t know how much some of you have spent on overall concepts of the burden of disease and how its measured but it’s a critical element and we’ve actually made a lot of progress in coming to more consensual measures about the burden of disease in societies in the last 20 years but what I wanted to suggest by this complicated slide which I’ll try to explain is that in developing countries the predominant aspect of the burden of disease have become non communicable diseases and so we’re dealing in the West with systemic chronic diseases heart disease the diseases associated with obesity the cancers that are a very significant component of our burden of disease with a minority of disease outcomes impacted by infection in the developing world they’re still dealing with fundamental epidemics of infectious diseases tuberculosis and malaria tend to be highly prevalent what this will do in those countries is that rather than having what we call a traditional Health transition which we saw in most Western countries from periods of epidemic infectious diseases to systemic chronic diseases they will have a simultaneous burden of infectious disease and systemic chronic diseases for those who survive infectious disease and this double burden is double jeopardy will have a tremendous impact on the health systems of developing countries that are often resourced poor when it comes to developing access to health services so the changes in the use of tobacco will severely impact developed countries here’s what’s going on now as many of you know Altria or Philip Morris USA was split from Philip Morris International and Philip Morris Altria sales even though its profits are increasing but sales are essentially flat in the West but this is the numbers of cigarettes that Philip Morris International is manufacturing and selling now so the entire shift of this industry has gone from the west to the developing countries in the most dramatic ways in a relatively brief period of time so there is a tremendous potential for the a colossal epidemic of tobacco-related diseases one things we know about tobacco is unlike so many other risky harmful substances it causes so many different diseases and so much more bida t so it is just a highly toxic that has so many negative health outcomes and no no benefit on the other side there are some there are some risks that at least have some potential benefits on the other side this is what the global market share of tobacco looks

like now obviously the China tobacco monopoly continues to produce a tremendous number of cigarettes and sell them but here you see British American Tobacco and Philip Morris are together much more significant than even the China National tobacco monopoly what the tobacco companies have been doing in places like this ad in Nigeria are finding ways to aggressively promote cigarettes in countries that are highly vulnerable to initial sales and initiation of tobacco and you see here one of the things they did at this event is they lit cigarettes and gave them to people coming to the movies one of the things have done at a lot of discotheques in Southeast Asia is you need to return empty packages in order to get access to the discotheque so these are practices that obviously you know if people tried them in New York City now would be illegal but there’s a there’s a regulatory map you might say that the industry has and they’re looking for countries where regulatory processes are at there are at their very most limited these are ads let me tell you where these come from one second sorry these are from Senegal Kenya and Nigeria these are all either British American or or Philip Morris products this is the kind of advertising you see in Ukraine on the upper left Pakistan China Senegal and Cambodia now this is very interesting these are these are photographs from Thailand and Thailand bans cigarette advertising in 1988 and it’s still banned there so what do they do they do what is often called brand stretching and these brands are well known internationally there on the internet they’ve been on the web and so while they’re not selling cigarettes they promote the brand through other logos on t-shirts sports paraphernalia water bottles canteens and for a while I was collecting this stuff like I had hats from racecars and was afraid somebody would come to my house and think I worked for the tobacco industry but this was a very interesting thing the Thais actually developed a very robust anti tobacco policy and they had very high tariffs on Western tobacco products as did Japan South Korea and Taiwan in the 1980s and so there was this question you know were these in restraint of trade did they vote did they violate World Trade Organization at that time known as GATT the general agreement on tariffs and trade and the ties were very aggressive about it and the American tobacco industry went to the US Trade Representative’s this was in the late Reagan administration the first Bush one administration and they said these countries have illegal tariffs that are restricting the sale of our products and this was also the time that Surgeon General coop was mounting the most aggressive effort in the United States history against big tobacco so here you have the American government on the one hand getting really behind sidestream smoke restricting smoking in public places one of coops major Surgeon General’s report was on smoke as addiction in a press conference he said smoking is more addictive than heroin and cocaine and so it’s a major critic of the tobacco industry much feared by big tobacco at the same time the US Trade Representative for the united states are going to Japan Thailand Korea and Taiwan and saying you must open your market to American tobacco products and so what happened the Japanese the Taiwanese and the South Koreans were forced by threats of American trade boycotts to open their markets to American products and what happens when you open your your trade to American products you increase competition you increase advertising in Japan cigarettes before this tariff change were the 40th most advertised

product and after the fall in the tariff and the introduction of American brands in Japan they became the second most advertised product in Japan and what happens when you have that kind of intensive advertising and competition tobacco consumption went up and Japan went up by 10 percent within a year especially went up among women smokers in Japan very few women were smoking in the mid to late 1980s well what did the tides do this is a really fascinating story the in Thailand where there had been a local indigenous tobacco control movement they said we’re not raising our calf we refuse to do it and so what happens in these kinds of trade disputes it goes to a court in Geneva where it’s adjudicated by the general agreement on tariffs or trades or the World Trade Organization and so the Thai said we have this tariff on Western products because it’s a public health carrot and there’s less smoking in Thailand because we restrict trade in American tobacco products and they got the World Health Organization to come and testify on their behalf and there’s actually a there’s a codicil in the general agreement on tariffs and trade known as 20b which says that you can restrict trade by tariffs for public health reasons so they cited this 20 B rule in their presentation before the trade Court in Geneva but the American representative said this is straight out a restraint on American trade they can have Public Health processes if they want but they should appeal equally to American and Thai produced tobacco products and what did the court decide the court decided that they must open their trade to American tobacco products and it’s very interesting the 20 B rule has three three levels one is that it must be necessary for Public Health if you did it so you might satisfy that when you say it’s a public health mechanism and the World Health Organization got behind the ties then you have to you have to identify that it’s the least restrictive possible measure for accomplishing that goal harder to demonstrate and then the third thing is you have to say if you do have a tariff on tobacco you must be able to show that it’s an effective public health policy also very difficult so those three rules are in the interest of trade over public health but so the ties were actually forced to open their markets they were permitted by the decision of the trade Court to continue to ban advertising which was in a way a victory for public health but this has been the strategy for the companies to undermine the ban on tobacco advertising but this is what this is my key point here is that if we’re going to understand health risks in a global context they must be understood in the context of our trade agreements and trade issues and I don’t know if anybody here has been studying generic drugs and HIV but the very same rules that in a way have been significant in restricting public health interventions for tobacco have also been utilized to restrict access to essential medical so the relationship of Public Health to trade in a global context is going to be one of the critical areas of investigation as we move forward here’s what surgeongeneral coupe said about this he wasn’t allowed to come to any of the meetings with the US Trade Representative and he was pretty outraged he said I feel the most shameful thing that this country did was to export disease disability and death by selling our cigarettes to the world what the companies did was shocking but even more appalling was the fact that our own government helped make it possible and here you have like the government acting in completely distinct ways domestically and in terms of global interactions here’s what here’s what Philip Morris said in any event despite the lingering tobacco liability cases and the drop in cigarette consumption in the United States the tobacco companies themselves have never been healthier in part because of the lift of these tariffs first foreign consumption of American cigarettes continues to grow dramatically because of the falling value of the dollar a reduction in tariff and non-tariff barriers to cigarettes and the image of American cigarettes as the best in terms of quality and character Japan is now important u.s. cigarettes and China shows great potential I did a little math just to figure out about American tobacco consumption had fallen from 60 percent or 50 percent to about 20 percent which is about where it stands

today and I asked myself what percentage of the Chinese market would you need to replace all the American smokers who had died or quit and it was about 2 to 3% of the Chinese market so you can see just a foothold in the Chinese market completely puts the companies back beyond where they were when they were principally selling tobacco domestically here’s another Philip Morris quote demographically the population explosion many underdeveloped countries insures a large potential market for cigarettes culturally demand will increase with the continuing emancipation of women and the linkage in the minds of many consumers of smoke looking manufactured cigarettes with modernization sophistication wealth and success a connection encouraged by much of the advertising for cigarettes throughout the world so you could rely on the historical meanings that had been invented for domestic American tobacco throughout the world politically increased cigarette sales can bring benefits to the government of an underdeveloped country that are hard to resist and one of the things we find about this period of the last 20 years of the 20th century is that health ministers would go to cabinet meetings and say we must control the the introduction of Western tobacco into our countries and the economic ministers would say we need these funds now for the good of our population in terms of their immediate health care infrastructure all needs and so on so you see enormous tensions within developing world governments about the role and character of tobacco profits this a model that a colleague of mine develop Julius Richmond – a Surgeon General during the Carter Administration very brilliant sort of theorist of public health and he said to develop strong public health policies you need to have a strong stroke social strategy a political will and a strong knowledge base and I thought it would introduce this here because I think it gets at three of the critical components that any historical or sociological public health analysis would need to make of the introduction of effective public health policies nothing would have happened in the u.s. in terms of reducing smoking if there hadn’t been this excellent scientific knowledge base about the harms of smoking and yet if you only had the knowledge base and you didn’t have a social strategy for its deployment or the political will for its application you still don’t get where you need to go so what Richmond was very interested in was what’s the relationship of these three components I think it’s been very interesting to watch this in the United States people said in the 1960s and 70s smoking is your own fault if you do it so essentially the company said we’re free and clear we’ve told everybody we’ve put it on the label and so if somebody smokes now when they get sick it’s their responsibility so some of the social strategist in the public health campaign against tobacco in the United States said but what if we could show that your smoke is harmful to me then we would change the calculus of Public Health regulation in a fairly radical way so what did that social strategy require that social strategy required more science about the harms of secondhand smoke which then created political will to regulate public spaces so I think that it you can try this around different types of issues but you begin to see the relationship of these components in thinking about public health interventions and possibly Public Health governance so the question might be what’s the use of law in global Public Health what’s the quality of the knowledge base overall is there political will to modify the trade in tobacco which has been such a dominant aspect of tobacco Commerce and its implications for the burden of disease and this is what began to happen in the early 21st century and a group of lawyers had the idea that we’re reviewing the World Health Organization Charter and one of the things in the Charter it said is the World Health Organization has the authority to make treaties and it was now 2003 2004 the World Health Organization had never developed a treaty for public health but treaties were becoming important in certain kinds of transnational exchange and in which there were perceived to be very significant supranational interests that could not be moderated or affected by a single nation-state and so there was a model of protocols what were called Framework conventions treaties around certain kinds of environmental

harms and there was this idea in countries what if we decided we would have great environmental policy but the country next door or didn’t do it then what would be the advantage of investing in environmental or ecological change if we didn’t have a partner nearby there pollution would simply be ours and so people began to think about this notion of global that’s different than some others in which what are those levels of risk and exchange that cannot be moderated by a single nation-state but can only be done collaboratively through shared assumptions and values and exchange and so the idea got proposed well what about doing this for tobacco and this tobacco appropriately fit the criteria of something in which there are those kinds of exchange or if you’re a tobacco industry executive you say it’s really up to every nation to decide how it wants to regulate tobacco there’s no there’s no characteristic exchange but one of the things we found was if one country’s advertising and the next one’s not that advertising bleeds immediately to nearby neighbors and even more so in an age of the internet and digital communications if one country raises its taxes but nearby countries don’t then there are black markets where they’re smuggling of tobacco and one of the things we know is that the tobacco industry has been deeply implicated in smuggling tobacco from high tax to low tax areas so there were some strong arguments for thinking about the movement of the risk of tobacco in a in a analogous way to thinking about changes in the environment and that became the underpinnings of developing this Framework Convention on tobacco control this slides too dense but let me just tell you what some of the key aspects of the Framework Convention which the World Health Organization approved in 2005-2006 there would be controls on lobbying they would s countries participating to raise their taxes to minimal levels on tobacco they would have rules about secondhand smoke and the control of smoking in public places they would force companies to be transparent about the ingredients in tobacco across nationally that there would be higher expectations about labeling that there would be programs for cessation programs to control sales to minors and so they took what were the key building blocks of all national tobacco control policies but said we’ll share these at a floor level and urge all countries to come up to these minimal levels and then increase them as we go and this is the way framework conventions work they have the series of protocols the protocols are discussed by the parties they’re commonly agreed to and then the idea is that they continue to change with time as these policies develop in specific national contexts so the World Health Organization approved at its General Assembly this Framework Convention on tobacco control it was developed by two very brilliant theorists in public health law Alan Taylor and Ruth Romer who’s a kind of heroic figure in the history of American public health law and it was developed with the support of Gro Brundtland who was the director-general of the World Health Organization and a kind of crack team of creative analysts and public health policy people at the World Health Organization one of them was Derek yok who was a young physician who had developed a fabulous tobacco control program in South Africa South African and had gone to the world World Health Organization and worked on developing and promulgating the Framework Convention on tobacco control and yock I think is a particularly important figure because he and some other people were theorists about the use of law about the nature of civil societies about rethinking global governance and what kinds of structures might go across nations as of thinking about as opposed to thinking about national regulatory or governance structure so I always have felt that yok was a pivotal figure in selling this to Brundtland and moving it through the World Health Assembly today nearly 170 countries have signed and ratified the Framework Convention on tobacco control the only major developed power that has not ratified the treaty is the United States and one of the questions that I

think should be put it was put to George Bush – and now should be put to the Obama administration is why have you not advanced the tobacco control protocols and Framework Convention to the US Senate for ratification and I think we know the reasons because the tobacco companies remain enormous ly strong these are some of the health warnings that were on cigarette packages and what what I’m partially arguing is they develop strong consensual notions that push one country and then pushed another country so these were in Brazil the United States had very weak labeling the Canadians developed very strong labeling and this has promoted Latin American countries and others to develop strong labeling this was sort of interesting I was in Montreal two summers ago and I was in a pharmacy and I said I’d like a pack of cigarettes with the cigarettes cause mouth diseases label and the pharmacist thought I was a nut because people have been trading that back for less offensive label when these first went into effect and as you may know the United States labels have not changed since 1986 there’s been no major piece of US tobacco legislation until two years ago the new FDA regulations of tobacco and these are the new labels that will begin to appear on American – cigarette packages beginning next year and I’d like to think I think there are some things in a merit in the American tobacco control arsenal that should be applied at the same time this is an instance where some of the things that we’ve learned from developing countries and other countries with much more aggressive labeling could have a very salutary impact on smoking rates in the US and you can see there about eleven of these they’re all pretty dramatic they’re gonna cover a major part of the tobacco package next year one things we know about labeling is they it wears out so by not changing the label since 1986 it’s been definitely demonstrated by public health experts it has no impact in the United States right now so most people don’t see the labels they don’t know what they say and these will these will have an impact now I want to take up just briefly the tobacco industry’s position on the Framework Convention on tobacco control I’m sorry to give you such a pros heavy slide but this is what an advisor to the – I’m Philip Morris had to say Philip Mars should be unapologetic about its advertising and promotion activity in the third world there’s something patronizing about the World Health Organization approach to smoking and health in the third world waho assumes that people must be saved from Diamond tobacco by their governments that they can’t be trusted to make personal decisions about whether or not to smoke people in the West despite increased government interventions make these decisions all the time and third world leaders generally resent the implication that they and their people must be protected and this has been a crucial trope in tobacco industry ideology going well back that people should make their own decisions and why should governments intercede in a individual decision about risk-taking and that really that’s what makes markets great there are a lot of risks out there and individuals should make up their own mind and this was seen as do-gooding the terminology for example that many of you have heard about health Nazis that’s just not a term that was made up that was a term invented in tobacco industry boardrooms and then they have public relations experts that help promote that kind of view of public regulatory interventions this is a philosopher who is writing in the Wall Street Journal in Europe a well-known British philosopher of public intellectual this is not to say that tobacco is harmless or that the trade and it is a good thing it is to say rather that where the risk of a product Falls entirely on consumers and is fully explained to them it cannot be the business of unelected bureaucrats to forbid or control it if we lose sight of this principle then we lose sight of the truth on which all free societies depend namely the freedom and risk are inextricable and whoever assumes the right to save me from risks is also assuming the right to limit my freedom this is a very powerful view very sharply articulated in the in the context of the Framework Convention here’s Scruton again by a semantic trick therefore missus Brundtland and her team have been able to classify as a dangerous disease what is in fact a voluntary activity and a source of pleasure the risk of which falls entirely on the smoker actually that’s not true it’s been shown by the World Health

Organization that 60% of all children in the developing world live in a house with a regular smoker and we now know that those are additional aspects of the burden of disease by the same reasoning we could link deaths from driving drinking and junk food to epidemics and this is one of the things that we think about when we defined what an epidemic is and put cars alcohol and McDonald’s on the WHI agenda and I can assure your cars alcohol and McDonald’s are on the wahi agenda but this was very interesting it came to light by an email from scrutinies wife that actually Scruton was in the employ of Japan tobacco one of the major producers of global tobacco and she wrote in light of this we were wondering whether you would consider putting up the fee from 4,500 pounds monthly to five thousand five hundred pounds on the assumption that we try our hardest to justify this amount and that you have the right to revise it downwards if dissatisfied we think we give good value for money in a business largely conducted by shysters and shark but you may not agree with this so this is a really important kind of document because in a way you could say there’s a big philosophical debate about smoking is it an individual behavior or should it be publicly regulated in some governance structures but part of this argument that’s so powerful and broadcast so effectively has actually been broadcast by the industry itself so in one sense you think well those are philosophical or ethical arguments about the character of tobacco but really it’s it’s an argument that has been articulated and broadcast by the actual industrial interests that it supports and there are many instances of this and partly what I want to suggest is this is Bernays to the industry became very acutely aware that it had a public relations issues that it could deal with very effectively behind the scenes and by sponsoring articles in prominent magazines like the Wall Street Journal Europe it gets its views out there into the political sphere in ways that will affect policy outcomes they hire firms like this montgo bin Bisco and Duchenne and they were advising philip morris about how to undermine the Framework Convention so here it says examination of the draft text will help Philip Mars anticipate the potential protocols that the Framework Convention will create the history of Framework Convention shows that successful weakening of the language of an article in a Framework Convention can be easily undermined in the protocol process the potential protocols are more important to the company in the long term than the Framework Convention itself so what does Philip marseilles oh we support the Framework Convention we think that’s a great idea because they know that the best place to intervene now how do they intervene they want they want there to be citizens that get to participate in the protocol making party arguing process and very often those are people who have had ties to the tobacco industry they’re very some strategic approaches to undermining these protocols aside from delaying the adoption of the Convention the company is best served by participating in the development of the agreement which is what they did it would be in the country in the company’s best interest have the treaty focus entirely on protecting children and leaving adult choice protected so this is you know this is the activity of global health and sometimes it’s most nefarious way here’s the chairman of British American Tobacco the Framework Convention is a developed world obsession being foisted on the developing world and on and on I don’t want to take too much time with this one of the strategies they had was spend more time talking about AIDS develop AIDS media which will distract from tobacco as a as a public health problem here’s British American Tobacco again a clumsy pursuit of global standards can become a form of moral and cultural imperialism based on assumptions that West is best imposing Western priorities are global solutions of course the values and priorities of any one country on another can become a new form of colonialism so here you have companies that are imposing tremendous burden of disease then defining the regulatory processes but a new form of colonialism and I think you know what’s concerning about this is how powerful and potentially effective these kinds of arguments can be to countries without strong state orientations or regulatory regimes these are kinds of things that Philip Morris is doing now in the US and I explained that I consider the u.s

part of this global mix they say we’re supporting you know youth smoking restrictions here’s what you do if your child is smoking it’s become very clear in public health that the biggest single risk for kids are there if their parents smoke but there’s nothing in these pamphlets about that relationship and the idea that parents might quit if you decide to quit smoking so these are very effective they use these in the types of trials that I testified in they say no one’s more committed if somebody wants to quit then Philip Mars to helping them get what they need to quit so these become very effective public relations tools even though they’re shown from the kinds of science of public health assessment that they don’t actually assist people in quitting if philip morris is helping you quit cigarettes you’re in very big trouble when the government if Joe Camel they started camel number nine with these pink packages obviously with the idea that they would especially appeal to women these are being sold globally now here was one thing I would just wanted to mention you know I told you Derek yok was kind of a hero of mine and I think he’s one of the great thinkers I asked the class to read two of his papers that were very influential to me so Derek watt left World Health Organization went to Yale School of Public Health where he taught and had a decadal role and then he left yell School of Public Health and I started looking where’s Derek yeah today and some of you may know he went to PepsiCo where he became their principal vice president for global relations and here he is pictured in the center as senior vice president for global health policy at PepsiCo and I sort of invite you to go on the PepsiCo website because PepsiCo in the beverage industry has learned a lot from the tobacco industry about how to promote products that are very high in sugars around the world and so what they’ve done is introduced a range of products knowing that their sugared products are their most popular and most aggressively advertised and most highly sold but by introducing a range of safer and less risky products they then say don’t regulate sugared sodas because we are leaving this up to consumer choice and we’re providing much less risky products in the marketplace and that’s exactly what PepsiCo has done and I have to say I don’t blame this on Derek yok but it was real disappointment to lose his intelligence from public health to now really advising PepsiCo about how to orient themselves in a global market so this is from the PepsiCo website just pulled this off the day today whether it’s Quaker Oatmeal or Lay’s potato chips consumers around the world can choose products that are right for them and good for their families choices like these along with active lifestyles make it easier for consumers to enjoy the foods they like and achieve the energy bounds they need to lead active lifestyles and so I have to say I don’t think I would have noticed this reading this but having spent so much time following the logic of the tobacco industry argument I think you can see there’s a very powerful set of relationships and thinking about the global market the idea of freedom of choice the idea of opening trade the idea that risk is really can only be assessed by individual consumers and should not be regulated by governments so here are people smoking around the world this is really the problem and I’ll end here is that if consumption just remains constant as to what it is today 1 billion people will dive tobacco related diseases worldwide in the 21st century a hundred million died worldwide in the 20th century so we will increase tobacco deaths even if consumption only stayed right where it is by a factor of 10 in the 21st century a billion people and if you could moderate tobacco even somewhat you could reduce these figures but it’s very hard given the long time lags tobacco and the difficulties of cessation to really reduce this market so it will involve much more creative strategies about governance and regulation than we currently have if we want to impact a problem as insidious in which are such powerful industrial interests continuing to promote the product as there are in tobacco this is a child in Serbia on your left are monks in Cambodia a tobacco salesman in Jakarta Indonesia on your right are street children in Shanghai on your left is little boy and actually there’s a story about this name Sergey Myra and this was taken by Pulitzer Prize winning photographer in st. Petersburg in 1993 and the little boy was just eight years old at the time

and he told John Kaplan the photographer I only smoke Marlboro cigarettes so what this what what does this mean to me it means that given the dimensions of the problem we need to have far more creative and robust strategies of global governance and we have I actually find myself quite hopeful about a phenomena like the Framework Convention on tobacco control even though I’m prepared to recognize how weak it is in relationships the resources that will be brought to bear by the industry but if nations can participate as civil societies collaborating and recognizing the threat that’s posed by certain kinds of trade Commerce and industrial interests then at least we have the beginnings of some strategies that we need to think much more about I actually think that historians anthropologists sociologists epidemiologists there’s many fields represented here we’ll really need to collaborate much more consistently than we have in the past if we’re going to come up with the kinds of things that really contribute to change around issues like tobacco so thank you very much yes thank you again Alan and if you have questions I’m sure you will please come up to the microphone and I have to say that was really you know amazing demonstration of how you can use this tree to look ahead and see it differently and and at the same time you know weave in this this common concern of ours about the the idea of global governance and you know one of the critiques for those who speak about global governance is this question of accountability and it does seem that the tobacco industry is is playing on that idea who elected Gro Brundtland right and you know who is it it’s really behind these these advocacy networks and and so on so you know what do you say to this idea that those who are purporting to serve you know people in in poor countries by protecting them from the export of American cigarettes you know who do they answer to and why is it that we should allow them to set the agenda for all of us right you know the thing about complex governance structures like Framework conventions is that in the end it has to be consistent with national political democratic processes so even though the protocols can in a sense require countries to come up to these standards it’s really a consensual standard that then has to be it has to be supported through the internal state regulatory processes so it’s not as if the Framework Convention can decide everybody’s gonna label cigarettes in this way and then that actually puts the labels on the cigarettes what the framework does is it sets a standard that then the political processes will be held accountable to so in a sense that’s the weakness of the Framework Convention is that it invents standards that will not necessarily be fulfilled through all parties to the convention and I think that’s acceptable you know the question is it seems so ironic for the industry to say but who’s accountable to tobacco activists because we actually understand the accountability of industrial interests very well industries are accountable exclusively to their shareholders so to say that shareholders have a greater stake in public health processes than these other forms of formal and informal governance mechanisms seems to me to be somewhat hypocritical so you know it’s one thing to voice the argument that choice is very important but when you see the industry doing it as an industry that’s one thing when you see the industry supporting those arguments as if they are independent then I think it really undermines their authority to question accountability so I think the industry just incredibly sophisticated and that’s the that’s the question away what are the countervailing governance structures in the face of certain kinds of capital interests that can be very detrimental to the public good okay thank you I wanted to know since the tobacco industry has been proved guilty so to speak in the u.s. why isn’t it a slam dunk for other countries to sue them and

get a lot of money it’s a it’s a really good question and unfortunately even despite the success of the American tobacco suits most of the funds that were collected for example by the state attorneys generals in their cases when the company settled went to other things so rather than their some of that money being dedicated to tobacco control it went to pay debt in North Carolina paid for some tobacco warehouses it paid for the maintenance of golf courses in some states and so it turned out to be incredibly unfortunate two hundred and forty billion dollars collected by the collective’s state Attorneys General that now you know merely funds you know day-to-day operations in the state and you see the companies really understood that and they said we can get rid of these suits the monies won’t go to tobacco control so is again very sophisticated but the question is what where does liability fit in a global strategy and there are some countries where it will actually be quite viable there’s some Latin American countries where there are some very promising litigations against the tobacco industry but it really has to do with individual judicial structures and in the United States we’ve always had a relatively low threshold for civil litigation which is one of the really great Democratic aspects of the American court system is that if you had a legitimate complaint you could bring it against a company at relatively low cost and get into the courts there are other places like the United Kingdom where it’s almost impossible to enter the courts on a tort so there are these individual structures and I think when we’re doing comparative global work you would really want to understand better you know where are the places where there are opportunities for tobacco liability litigation to succeed where is that likely to be secondary what kinds of legal remedies could you pursue in the face of a failure of torts and other things so it’s a very good question because how can the courts be used more effectively with there’s a lot of people who sort of think that the in the u.s. the liability phase is over I’m less clear about that I think there are some very creative strategies and we may see some of these strategies move to other other products everyone left when some kids sued McDonald’s on issues of the health of their foods how transparent the calories and fat content were but what you did see is McDonald’s you know in their corporate structure responding to that very quickly in some positive ways by developing changes in their menu greater transparency in their nutritional identification so litigation I think sometimes forces better public practice and it’s one of those threats how could we use it more effectively even if you’re gonna fail i watch the tobacco litigation fail and fail but it’s having a tremendous impact in getting the documents out so the history that I was able to write was dependent on litigation that had failed and that irony really it told a story that has been used now I think by myself but many others to effectively galvanize public health interest in regulating tobacco that wouldn’t have been available without the suits and the companies kept saying we’re winning but as those documents began to come out they were in some aspects that we’re losing yes thank you very much some years ago C everett Koop said that as soon as americans found out that the tobacco companies had lied to them about the addictive qualities of cigarettes they would throw their cigarette packs away and be done with the whole thing and he he said it was one of the big disappointments of his life but that’s not what happened and that the problem of cessation was one that was actually stronger the addictive qualities were actually stronger than he had anticipated I’m wondering if you could tell us just a little bit about the history of tobacco cessation and how successful it is at this point yes it’s a great question and you know tobacco is one of those problems that is so dynamic and multiple that the only types of policies that really will work will be across a gradient from individual patient oriented services to you know strategic public communications and other regulatory interventions and cessations really important and we know that some people can quit and do quit but we also know now that for some individuals it is

enormous ly difficult to quit so a quit is not a constant phenomenon and we now understand that better for example people with a code we’re bid psychiatric condition have much more difficulty quitting people who are not in strong social networks have a much greater difficulty quitting so how could we address those that particular population this last 15 to 20 percent of Americans who are smokers that is a residual very difficult addicted population that will require stronger biomechanical and social interventions and we have available for them now but there have been other issues for example we haven’t third-party funded a lot of cessation services we know that some of the medications that are helpful are not helpful without therapy or counseling so there’s a lot that we could do to really address these needs I was I was doing a little research on smoking in mental health hospitals it’s really interesting in the 50s and 60s if you behave well they would give you cigarettes in these hospitals so one of the rewards was actually tobacco and there was a lot of concern what would happen if if certain mental health institutions went smoke free and they actually have and I think it’s a great thing because you really don’t want people exposed to you know who are suffering to be exposed to additional risks and people can quit under the right conditions with the right support and some of that is pharmacologic some of it is social and cultural so it really means putting those things together and we could do much better and we can and a lot of those things will be tremendously beneficial in the developing world as their health infrastructures become stronger thanks again for coming to speak one of the things we have talked about this summer in the class that’s associated with this lecture series is thinking critically about historical analogies and I was wondering if you could elaborate on how we might think critically about using the tobacco case and applied to fast food as well as the example you mentioned with PepsiCo and I was wondering what your thoughts were as well on the possibility that this might actually be to some advantage to company’s going forward in that they can point to litigation on fast food as something that is sort of similar to what they make their opponents out to be as somebody whose response is you know not merited as something that perhaps trivializes the public health threat of cigarettes yes it’s a really good point because you know when people sued McDonald’s the industry the tobacco industry right away said this is what happens when you get into a litigious society where there’s always someone else to blame where no one’s really accountable for their own individual decision making and I get asked that question a lot like well am i saying that people who smoke have no responsibility and they’re out of control and I actually think the goal of health in a way is giving people as much autonomy as possible over the control of their health but that would mean that you’d have to moderate some of these industrial interests so it’s a little bit of a misconception the best thing is is if people can quit but what’s the context in which they can quit it’s a regulatory context that’s the context in which the risks of the product are very clearly identified and which is educational and communications ideas I’ve been concerned about the story of tobacco in this way like on the one hand I wanted to tell it and I thought if I told it clearly people would see these strategies more clearly when they were applied by other industries I think one of the things we’re finding right now is a lot of industries are studying very closely what the tobacco industry did and how they’ve been so successful and they’re studying in many ways you know we should be looking for developing world global markets in places where the regulatory regimes are becoming more overt and aggressive in terms of sugared beverages for example which are not sold in many elementary schools anymore and it’s been shown that they have an impact on child and teen obesity we should be looking to develop worlds where there are less regulatory regimes and we see the movement of risk globally from more highly regulated to less well regulated places so that’s one thing the arguments about choice and freedom of individuals to make those determinations the arguments about individual Nations should make those decisions instead of doing it consensually across nations these are all things that were very clearly articulated in the tobacco industry documents which became widely available and unfortunately I wasn’t the only one using them I think the industrial interests of

similar products that have risk have been using them also so there’s been an emerging literature on sort of the tobacco PlayBook as it gets called and I think many people admire how effectively the tobacco industry responded to what was perceived in the 50s as a potential knockout blow to the industry and how they were able to sustain themselves and be enormous ly profitable throughout the second half of the 20th century into the 21st century despite marketing a product that is uniformly harmful to human beings it’s it is you know I mean I have to I have to say it’s a remarkable if you know terribly sobering story and I think that other industries will learn from it so you know those of us who are advocates for public health have to be more aggressive creative we have to rethink policies and and strategies and I think historians among other fields will have a lot to say about understanding how these how these structures got to be and how important they are for the overall burden of disease so I know that doesn’t completely answer your question but please hey thank you for your speech and I’m actually not sure whether you are the right person for me to ask this question but I just wanted to have a try I was thinking maybe it would be effective policy for Chinese government to tie up cigarette smoking with deduction in their medical bills so if they smoke they will not get government subsidy on the medical bill so my question is I wanted to know whether the current medicine would take technology is a very sensitive to early stage smoking because yeah I see those pictures away it’s very serious you can you can see the lawns okay but I wonder whether they can detect the wound needs about in an earlier stage yes it’s getting easier and better to detect lung cancer for example sooner there are biochemical assays that can show who’s smoking and who’s not but I have to say my own perspective has been not to restrict health services for smokers and that’s been a prominent argument in the United States it sort of says because it buys into the idea that this was an individual risk and therefore the smoker should be responsible for what he or she did in terms of smoking and the way I see smoking is that it’s a behavior that’s been motivated by the companies and the best way of demotivating it is regulating the industry as opposed to potentially punishing smokers and the reason I say that is that some people and I’m sure this is true in China are much more vulnerable to become smokers than other people they tend to be less well educated they tend to be of lower socioeconomic status and the companies know that their advertising is most likely to appeal to these target groups they tend to be young people and so what happens with most smokers is in the United States for example is most people most people who become smokers today start it when they were 14 or 15 years old sometimes younger and then by the time they get to be 30 they’re gonna be have a lot of trouble quitting and if they’re not in a good social network that has promoted quitting it’ll be even harder and then they’ll get sick and they’ll say well we don’t give health services to people who smoked even though the industry knew that the only place it was going to get smokers was in children who couldn’t make you know deeply informed educated decisions so I think the best policies are the ones that focus on striction zuv the product as opposed to sort of saying we won’t provide health services because by then it’s too late and what you really want to do is is have interventions that break the chain of tobacco commerce at an earlier point in time taxes are very effective so high taxes on tobacco have been shown to radically decrease tobacco consumption well I agree with you that dealing with the providing of tobacco is a a good strategy however since those developing world had already collapsed in terms of tariffs against American tobacco products I think if China right now to increase the tariffs against American tobacco products I think it might be difficult it probably would be although in China you know most of the tobacco

smoked in China continues to be produced by the Chinese government and this has been one of the problems in a lot of developing world countries I didn’t have enough chance to say about it is that these tobacco monopolies sold a lot of tobacco especially the Chinese monopolies which was actually started by the British American Tobacco Company talked about colonialism in the 1880s and 1890s and then Mao seized the British American Tobacco factories and made them the Chinese national tobacco monopoly during the Chinese Revolution but those companies get a lot of revenue for other functions of the government so there are strategies within those governments of sort of saying and I think this is happening in the Chinese government right now is sort of saying you know we’re creating a lot of disability that we will have health responsibilities for so maybe we have to rethink the balance between promoting tobacco which has been a revenue producer for the government and beginning to restrict it but one of the things that happens is when you when the tariffs are lower when there is competition from abroad the monopolies become much more effective so they begin to modernize their machine they begin to advertise more so one of the things it’s like the World Bank was against monopolies because they found them economically inefficient in a global trade but tobacco monopolies actually restricted the the profusion of tobacco in important ways but I’m much more for acting on that production side than on the side of the individual smoker Scott yeah sorry I have to cut off discussion but it’s just said we were around for a bit so we can we can take it okay go ahead thank you very much those fantastic talk my work my PhD work is actually in Indonesia and I I see a huge number of primarily males smoking in Indonesia I find it fascinating is I think some surveys have put it upwards of 70 or 80 percent of males it’s deeply ingrained within you know it’s intergenerational as you have pictures of children are smoking primarily boys and it goes into teenagers some of the groups that I work with if you don’t smoke as a male you’re called ilaria which is a transgender individual illness it’s a stigmatizing term of course in many cultures in many parts of Indonesia now I’m wondering if any public health interventions have aimed at breaking down and and uprooting those those norms as the sense of masculinity and femininity and I’m wondering if there’s anything outside of litigation or financial incentives pressures taxes is there any way in which those can be uprooted and is there any examples in the US or anywhere else of those programs yeah this is a really great question because you know partly what I’ve been talking about is is global and it’s it’s complicated for us because on the one hand I think what I’m arguments we need to take a global perspective on problems like this and yet at the same time I think you I think we really need to understand these very intricate local meanings of cigarettes if you were to develop a whole tobacco control program and there certainly are you know I spoke to a group of teenagers in New York City about eight or nine years ago and one of the students came up to me afterwards and he sort of said I didn’t have any friends he was 15 he said I didn’t have any until I started smoking now I have so many friends and I know I should stop but you know I built my I built my friends you know around beginning to smoke and that’s what we do we smoke and I know it’s not good for me and I it gave me some notion that that it’s very easy for us to see this as a bad behavior without any social rewards but in certain cultures in certain subcultures there can be very significant benefits to this and to not understand that preclude some of the interventions that might help us undo it I mean one of the things I’ve noticed in American tobacco control initiatives is among adolescents making the industry the villain is much more effective than sort of saying you’re doing something bad and so there’s been some very effective local teen and kid campaigns that really emphasize they’re manipulating us and so I think you know those psychologies are not universal so you really need to understand in a cultures you know such as Indonesia how is this working and is there some way of uncoupling the cultural connections that it currently makes and the meanings that it has and I watched the meaning of cigarette smoking change in the United States from you know from everyone doing it in film to people apologising for doing it for people feeling ashamed about doing it I don’t see those as bad things but if we understood those processes are there ways to engineer

them in some ways and I think that you know that’s why we really needs very creative ethnographic and culturally specific work to understand how smoking functions in a different culture even though the product seems universal and and globally branded as it’s put now so I think that was a great question I really appreciate that answer as well fantastic talk I kind of went to a Probie war on the issue of stigmatization of the smoker versus stigmatization of the industry and you know there is a exchange that you had mentioned between scott burress and ron bear in terms of whether we should use thigma at all as a tool against individual smokers when it is an addictive problem and the industry is so involved with promoting this unhealthy activity so I’m wondering just if you could kind of expound upon your I think will be used in terms of ways what is appropriate and given given the history of the role of industry yeah I mean I think that there’s a progression to these things so for example we could take outdoor bands as just one example like I would have started without to our bands or bands on Jones Beach or something like that but I’m not adverse to that now and you know I was walking through the Columbia campus you know which I walk through thousands of times as a student you know what if smoking was banned in the main quadrangle of the Columbia campus here on 116th Street what would be the implications of that it’s a very interesting kind of thought experiment what if there were just signs as you enter those gates that say you know smoking is not allowed you know within the gated historic part of the Columbia campus it wouldn’t say you couldn’t smoke on Amsterdam at but you know just in that space and I actually think that’s a pretty good public health intervention now is it stigmatizing a lot of people visit Columbia from all over the world it says Columbia cares about health that within this enclosed out outside space we don’t permit smoking and there would be you know places where you could put a cigarette out as you enter that space now is it like that yes you can’t smoke there that’s great yeah the the I mean I’ve seen some very effective anti-smoking bands are they stigmatizing I think at one time like the bands were stigmatizing I noticed for example that nurses hadn’t quit in many health care institutions but the doctors had and the doctor would come out a lot of nurses would be smoking by the doorways and they’d say you know you really need to quit and you know I didn’t think that was such a great thing but I wonder you know like spitting on New York City subways was hot you know was prominent became you know illegal became stigmatized is that necessarily you know a bad thing and is that only about health in part it is but in part it’s about other things but I think things have put out powerful public signals that this is a at the very least a contested and dangerous behavior you know for individuals is the state acting in a you know in a public good way so you know this was the one thing that drove the company is crazy they knew that their their public choice arguments were very powerful and they said we’re really in danger on the side stream smoke because it unseats all of our public choice it’s only happens to the smoker himself and it really undid them and so I think where you can spread the notion that smoking is harmful to others even if it has an edge of stigma it’s something smokers should understand and it’s something that you know the public should have signals about so I’m not that sensitive I think certain things should be stigmatized they’re harmful harmful to self or others I’m sorry I’m gonna have to make this the last question or speakers been speaking now for almost four hours and I’d like to give my all right first of all I just really wanted to thank you for the very wonderful talk on but you’ve told us how throughout the years these tobacco companies have evolved in an almost Darwin esque fashion to the changing factors within the environment by developing such products as light cigarettes or something like that and recent years some things like the electronic cigarettes have merged as wondering what’s your opinion on the strength of the existing framework to prevent I guess the spread of these products yeah it’s a it’s a very good and kind of sad question because I think well part of what I’m suggesting is that we’ve really made some substantial public health progress and we’ve seen you know in a relatively well educated and affluent societies the ability to significantly reduce smoking and I see that as the positive side and then I think the negative side is very significant that the companies have understood that those markets remain

significant if compromised and that they can move to other more vulnerable markets very successfully and it will involve strategies that we just haven’t imagined yet and it it really comes into question you know the character of markets and health and trade and those are very difficult issues and I was thinking about my talk today and sort of how aggressive it is about industry interests that spread risks but that is going to be the contested territory of public health and population health in the 21st century it’s around generic drugs and the pharmaceutical industries it’s about essential medications it’s about risks like sugared beverages or alcoholic beverages it’s about many things and so we’re going to need more robust governance and regulatory structures if we really want to support health through societies and I think we’re at a relatively there’s a lot that we’ve learned but we’re at a relatively preliminary stage in building those kinds of structures and that’s part of the message I think okay thank you again Alan Thanks so so together with my partner in this program Steve Morse who you’ve seen many times here up at the podium I want to thank you all again for coming and I hope some of you will come back again next summer for another year at the Hertog global strategy initiative so thank you thank you Steve for being my partner and and thank you all