Tobacco industry influence on the definition of tobacco related disorders by the American Psychiatric Association

Objective: The Diagnostic and statistical manual of mental disorders, third edition (DSM-III), published by the American Psychiatric Association (APA) in 1980, included the first official definitions by the APA of tobacco dependence and tobacco withdrawal. Tobacco industry efforts to influence the DSM-III were investigated. Method: Searches of previously secret tobacco industry documents, primarily the University of California San Francisco Legacy Tobacco Documents Library and British American Tobacco collections. Additional information was collected through discussions with editors of DSM-III, and library and general internet searches. Results: The tobacco companies regarded the inclusion of tobacco dependence as a diagnosis in DSM-III as an adverse event. It worked to influence the content of the DSM-III and its impact following publication. These efforts included public statements and private lobbying of DSM-III editors and high ranking APA officers by prominent US psychiatrists with undisclosed ties to the tobacco industry. Following publication of DSM-III, tobacco companies contracted with two US professors of psychiatry to organise a conference and publish a monograph detailing controversies surrounding DSM-III. Conclusions: The tobacco industry and its allies lobbied to narrow the definition of tobacco dependence in serial revisions of DSM-III. Following publication of DSM-III, the industry took steps to try to mitigate its impact. These actions mirror industry tactics to influence medical research and policy in various contexts worldwide. Such tactics slow the spread of a professional and public understanding of smoking and health that otherwise would reduce smoking, smoking induced disease, and tobacco company profits.     

Globalisation of tobacco industry influence and new global responses

The globalisation of tobacco marketing, trade, research, and industry influence represents a major threat to public health worldwide. Drawing upon tobacco industry strategy documents prepared over several decades, this paper will demonstrate how the tobacco industry operates as a global force, regarding the world as its operating market by planning, developing, and marketing its products on a global scale. The industry has used a wide range of methods to buy influence and power, and penetrate markets across the world. It has an annual turnover of almost US$400 billion. In contrast, until recently tobacco control lacked global leadership and strategic direction and had been severely underfunded. As part of moving towards a more sustainable form of globalisation, a global enabling environment linked to local actions should focus on the following strategies: global information management; development of nationally and locally grounded action; global regulation, legal instruments, and foreign policy; and establishment of strong partnerships with purpose. As the vector of the tobacco epidemic, the tobacco industry's actions fall far outside of the boundaries of global corporate responsibility. Therefore, global and local actions should not provide the tobacco industry with the two things that it needs to ensure its long term profitability: respectability and predictability.     

From strange bedfellows to natural allies: the shifting allegiance of fire service organisations in the push for federal fire-safe cigarette legislation

Background: Cigarettes are the leading cause of fatal fires in the USA and are associated with one in four fire deaths. Although the technology needed to make fire-safe cigarettes has been available for many years, progress has been slow on legislative and regulatory fronts to require the tobacco industry to manufacture fire-safe cigarettes. Method and results: We conducted a case study, drawing on data from tobacco industry documents, archives, and key informant interviews to investigate tobacco industry strategies for thwarting fire-safe cigarette legislation in the US Congress. We apply a theoretical framework that posits that policymaking is the product of three sets of forces: interests, institutions, and ideas, to examine tobacco industry behaviour, with a special focus on their and others'' attempts to court fire service organisations, including firefighters'' unions as allies. We discuss the implications of our findings for future policy efforts related to fire-safe cigarettes and other tobacco control issues. Conclusions: Tobacco control advocates ought to: continue efforts to align key interest groups, including the firefighters unions; contest tobacco industry "diversionary" science tactics; and pursue a state based legislative strategy for fire-safe cigarettes, building towards national legislation.     

Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill

Objectives: To describe the tobacco industry''s relationships with and influence on homeless and mentally ill smokers and organisations providing services to them. Methods: Analysis of internal tobacco industry documents and journal articles. Results: The tobacco industry has marketed cigarettes to the homeless and seriously mentally ill, part of its "downscale" market, and has developed relationships with homeless shelters and advocacy groups, gaining positive media coverage and political support. Discussion: Tobacco control advocates and public health organisations should consider how to target programmes to homeless and seriously mentally ill individuals. Education of service providers about tobacco industry efforts to cultivate this market may help in reducing smoking in these populations.     

Tobacco control implications of the first European product liability suit

Objective: To examine tobacco control implication of the first European product liability suit in Finland.

Methods: Systematic search of internal tobacco industry documents available on the internet and at the British American Tobacco Guildford Depository.

Results: Despite legal loss, the litigation contributed to subsequent tobacco control legislation in Finland. The proceedings revealed that the industry had concealed the health hazards of its products and, despite indisputable evidence, continued to deny them. The positions taken by the industry rocked its reliability as a social actor and thus weakened its chances of influencing tobacco policy. Despite fierce opposition from the tobacco industry, tobacco products were included in the product liability legislation, tobacco was entered on the Finnish list of carcinogens, and an extensive Tobacco Act was passed in Parliament.

Conclusions: Tobacco litigation might not stand alone as a tool for public health policymaking but it may well stimulate national debate over the role of smoking in society and influence the policy agenda.

     

Entering our 16th year

Background and objective

British American Tobacco (BAT) has historically enjoyed a monopoly position in Kenya. Analysis of recent tobacco control debates and a case study of BAT''s response to the emergence of competition in Kenya are used to explore the company''s ability to shape public policy and its treatment of tobacco farmers.

Design

Analysis of internal industry documents from BAT''s Guildford depository, other relevant data and interviews with key informants.

Results

BAT enjoys extensive high‐level political connections in Kenya, including close relationships with successive Kenyan presidents. Such links seems to have been used to influence public policy. Health legislation has been diluted and delayed, and when a competitor emerged in the market, BAT used its contacts to have the government pass legislation drafted by BAT that compelled farmers to sell tobacco to BAT rather than to its competitor. BAT was already paying farmers less than any other African leaf‐growing company, and the legislation entrenched poor pay and a quasi‐feudal relationship. BAT''s public relation''s response to the threat of competition and the ministers'' public statements extolling the economic importance of tobacco growing suggest that BAT has manipulated tobacco farming as a political issue.

Conclusions

The extent of BAT''s influence over public policy is consistent with the observations that, despite ratifying the Framework Convention on Tobacco Control, progress in implementing tobacco control measures in Kenya has been limited. The benefits of tobacco farming seem to be deliberately exaggerated, and an analysis of its true cost benefits is urgently needed. Tobacco farmers must be protected against BAT''s predatory practices and fully informed about its activities to help them have an informed role in policy debates. As image, particularly around the importance of tobacco farming, seems key to BAT''s ability to influence policy, the truth about its treatment of farmers must be publicised.Driven by the recent expansion of transnational tobacco corporations (TTCs) across many low‐ and middle‐income countries, the burden of tobacco''s health effect is shifting. It is predicted that, by 2030, 70% of the estimated 10 million global deaths from tobacco will occur in developing countries.¹ In this context, sub‐Saharan Africa (SSA) offers an opportunity for global health, being the only region in the world where primary prevention of the tobacco epidemic remains possible.² However, with TTCs investing heavily in the region during the last decade and with evidence of rapidly rising consumption, particularly among youth,³ this window of opportunity is closing rapidly.Implementation of comprehensive regulatory measures is required to prevent further escalation of the epidemic in SSA, and the World Health Organisation''s Framework Convention on Tobacco Control (FCTC) provides excellent opportunities in this regard. The African nations recognised this in pressing unanimously for a comprehensive treaty while simultaneously acknowledging the need to find an alternative income for countries dependent on tobacco farming, notably Zimbabwe and Malawi.^2,3 Tobacco farming represents a unique dimension to the tobacco control debate in SSA, and previous analyses of tobacco industry documents suggest that the tobacco industry has attempted to hijack such debates by presenting tobacco control as a “first world” concern that would lead to economic destabilisation and exacerbate poverty and malnutrition among tobacco‐growing countries.⁴ By contrast, a growing body of evidence suggests that tobacco farmers face considerable financial and health risks from growing tobacco.^{5,6,7,8,9,10,11,12}As African nations seek to implement the provisions of the FCTC, tobacco control legislation will have to be developed and enacted, providing opportunities for the tobacco industry to influence policy. The fact that Kenya has signed and ratified the FCTC¹³ while (as detailed below) efforts to implement legislation consistent with the treaty have been unsuccessful amid persistent reports of BAT influence¹⁴ highlights the possible barriers. Hence, there is an urgent need to understand the tobacco control policy environment in Africa, including the relationships between tobacco farmers and TTCs, which are clearly integral to this. However, there remains a dearth of research in this area. This paper seeks to address this gap by examining British American Tobacco''s (BAT) policy influence in Kenya.BAT merits particular attention as it is the dominant player in SSA, with a market share of over 90% in 11 countries.³ The selection of Kenya reflects its significance to BAT''s operations in Africa, the role it seems to have in BAT''s efforts to influence policy regionally¹⁵ and the nature of Kenyan tobacco politics.After an introduction to the origins and character of BAT''s political influence in Kenya and an overview of recent tobacco control debates in the country, this paper uses a case study of the company''s response to an emergent competitor, Mastermind Tobacco Kenya (referred to in the documents as MTK or MTCo), to examine BAT''s influence on policymaking. The paper therefore aims to shed important light on issues critical to the development of tobacco control across SSA.     

International trade agreements: a threat to tobacco control policy

International covenants establish a role for governments in ensuring the conditions for human health and wellbeing, which has been recognised as a central human right. International trade agreements, conversely, prioritize the rights of corporations over health and human rights. International trade agreements are threatening existing tobacco control policies and restrict the possibility of implementing new controls. This situation is unrecognised by many tobacco control advocates in signatory nations, especially those in developing countries. Recent agreements on eliminating various trade restrictions, including those on tobacco, have expanded far beyond simply international movement of goods to include internal tobacco distribution regulations and intellectual property rules regulating advertising and labelling. Our analysis shows that to the extent trade agreements protect the tobacco industry, in itself a deadly enterprise, they erode human rights principles and contribute to ill health. The tobacco industry has used trade policy to undermine effective barriers to tobacco importation. Trade negotiations provide an unwarranted opportunity for the tobacco industry to assert its interests without public scrutiny. Trade agreements provide the industry with additional tools to obstruct control policies in both developed and developing countries and at every level. The health community should become involved in reversing these trends, and help promote additional measures to protect public health.     

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND: Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda. OBJECTIVE: To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures. DESIGN: This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports. RESULTS: In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states. CONCLUSIONS: The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.     

What the public thinks about the tobacco industry and its products

Objectives: To assess public attitudes toward the tobacco industry and its products, and to identify predictors of attitudes supportive of tobacco industry denormalisation.

Design: Population based, cross sectional survey.

Setting: Ontario, Canada.

Subjects: Adult population (n = 1607).

Main outcome measures: Eight different facets of tobacco industry denormalisation were assessed. A denormalisation scale was developed to examine predictors of attitudes supportive of tobacco industry denormalisation, using bivariate and multivariate analyses.

Results: Attitudes to the eight facets of tobacco industry denormalisation varied widely. More than half of the respondents supported regulating tobacco as a hazardous product, fining the tobacco industry for earnings from underage smoking, and suing tobacco companies for health care costs caused by tobacco. Majorities also thought that the tobacco industry is dishonest and that cigarettes are too dangerous to be sold at all. Fewer than half of the respondents thought that the tobacco industry is mostly or completely responsible for the health problems smokers have because of smoking and that tobacco companies should be sued for taxes lost from smuggling. In particular, less than a quarter thought that the tobacco industry is most responsible for young people starting to smoke. Non-smoking, knowledge about health effects caused by tobacco, and support for the role of government in health promotion were independent predictors of support for tobacco industry denormalisation.

Conclusions: Although Ontarians are ambivalent toward tobacco industry denormalisation, they are supportive of some measures. Mass media programmes aimed at increasing support for tobacco industry denormalisation and continued monitoring of public attitudes toward this strategy are needed.

     

African American leadership groups: smoking with the enemy

BACKGROUND: Among all racial and ethnic groups in the USA, African Americans bear the greatest burden from tobacco related disease. The tobacco industry has been highly influential in the African American community for decades, providing funding and other resources to community leaders and emphasising publicly its support for civil rights causes and groups, while ignoring the negative health effects of its products on those it claims to support. However, the industry's private business reasons for providing such support were unknown. OBJECTIVE: To understand how and for what purposes the tobacco industry sought to establish and maintain relationships with African American leaders. METHODS: Review and analysis of over 700 previously secret internal tobacco industry documents available on the internet. RESULTS: The tobacco industry established relationships with virtually every African American leadership organisation and built longstanding social connections with the community, for three specific business reasons: to increase African American tobacco use, to use African Americans as a frontline force to defend industry policy positions, and to defuse tobacco control efforts. CONCLUSION: As the tobacco industry expands its global reach, public health advocates should anticipate similar industry efforts to exploit the vulnerabilities of marginalised groups. The apparent generosity, inclusion, and friendship proffered by the industry extract a price from groups in the health of their members. Helping groups anticipate such efforts, confront industry co-optation, and understand the hidden costs of accepting tobacco industry largesse should be part of worldwide tobacco control efforts.     

Public health foundations and the tobacco industry: lessons from Minnesota

Objective: To investigate whether private foundations can be created in a way that will insulate them from attacks by the tobacco industry, using the Minnesota Partnership for Action Against Tobacco (MPAAT) as a case study.

Design: Information was collected from internal tobacco industry documents, court documents, newspapers, and interviews with health advocates and elected officials.

Results: The creation of MPAAT as an independent foundation did not insulate it from attacks by tobacco industry allies. During 2001–2002, MPAAT was repeatedly attacked by Attorney General Mike Hatch and major media, using standard tobacco industry rhetoric. This strategy of attack and demands for information were reminiscent of previous attacks on Minnesota's Plan for Nonsmoking and Health and the American Stop Smoking Intervention Study (ASSIST). MPAAT was ultimately forced to restructure its programme to abandon effective community norm change interventions around smoke-free policies and replace them with less effective individual cessation interventions. Neither MPAAT nor other health advocates mounted an effective public response to these attacks, instead relying on the insider strategy of responding in court.

Conclusion: It is not possible to avoid attacks by the tobacco industry or its political allies. Like programmes administered by government agencies, tobacco control foundations must be prepared for these attacks, including a proactive plan to educate the public about the principles of community based tobacco control. Public health advocates also need to be willing to take prompt action to defend these programmes and hold public officials who attack tobacco control programmes accountable for their actions.

     

Fiscal versus social responsibility: how Philip Morris shaped the public funds divestment debate

Calls for institutional investors to divest (sell off) tobacco stocks threaten the industry's share values, publicise its bad behaviour, and label it as a politically unacceptable ally. US tobacco control advocates began urging government investment and pension funds to divest as a matter of responsible social policy in 1990. Following the initiation of Medicaid recovery lawsuits in 1994, advocates highlighted the contradictions between state justice departments suing the industry, and state health departments expanding tobacco control programmes, while state treasurers invested in tobacco companies. Philip Morris (PM), the most exposed US company, led the divestment opposition, consistently framing the issue as one of responsible fiscal policy. It insisted that funds had to be managed for the exclusive interest of beneficiaries, not the public at large, and for high share returns above all. This paper uses tobacco industry documents to show how PM sought to frame both the rhetorical contents and the legal contexts of the divestment debate. While tobacco stock divestment was eventually limited to only seven (but highly visible) states, US advocates focused public attention on the issue in at least 18 others plus various local jurisdictions. This added to ongoing, effective campaigns to denormalise and delegitimise the tobacco industry, dividing it from key allies. Divestment as a delegitimisation tool could have both advantages and disadvantages as a tobacco control strategy in other countries.     

Tobacco interests or the public interest: 20 years of industry strategies to undermine airline smoking restrictions

Objectives

To understand the evolution of 20 years of tobacco industry strategies to undermine federal restrictions of smoking on aircraft in the United States.

Design

We searched and analysed internal tobacco industry records, public documents, and other related research.

Results

The industry viewed these restrictions as a serious threat to the social acceptability of smoking. Its initial efforts included covert letter‐writing campaigns and lobbying of the airline industry, but with the emergence of proposals to ban smoking, the tobacco companies engaged in ever increasing efforts to forestall further restrictions. Tactics to dominate the public record became especially rigorous. The industry launched an aggressive public relations campaign that began with the promotion of industry sponsored petition drives and public opinion surveys. Results from polling research that produced findings contrary to the industry''s position were suppressed. In order to demonstrate smoker outrage against a ban, later efforts included the sponsorship of smokers'' rights and other front groups. Congressional allies and industry consultants sought to discredit the science underlying proposals to ban smoking and individual tobacco companies conducted their own cabin air quality research. Faced with the potential of a ban on all domestic flights, the industry sought to intimidate an air carrier and a prominent policymaker. Despite the intensification of tactics over time, including mobilisation of an army of lobbyists and Congressional allies, the tobacco industry was ultimately defeated.

Conclusions

Our longitudinal analysis provides insights into how and when the industry changed its plans and provides public health advocates with potential counterstrategies.     

Tobacco industry strategy to undermine tobacco control in Finland

Objective: To identify and explain tobacco industry strategy in undermining tobacco control measures in Finland and results of these interferences in tobacco policy development during the 1980s and early 1990s.

Methods: Tobacco industry documents, which have been publicly available on the internet as a result of litigation in the USA, were analysed. Documents were sought by Finland and by names of organisations and tobacco control activists. Documents were accessed and assessed between September 2000 and November 2002. Tactics of the tobacco industry activities were categorised as presented by Saloojee and Dagli.

Results: The international tobacco companies utilised similar strategies in Finland as in other industrial markets to fight tobacco control and legislation, the health advocacy movement, and litigation. These activities slowed down the development and implementation of the Tobacco Act in Finland. However, despite the extensive pressure, the industry was not able to prevent the most progressive tobacco legislation in Europe from being passed and coming into force in Finland in 1977 and in 1995.

Conclusion: Denying the health hazards caused by tobacco—despite indisputable scientific evidence—decreased the credibility of the tobacco industry. Strategy of denial was falsely chosen, as health advocacy groups were active both in society and the parliamentary system. The strong influence of the tobacco industry may have in fact increased the visibility of tobacco control in Finland as the litigation process was also drawing attention to negative health effects of tobacco. Therefore the tobacco industry did not manage to convince public opinion. However, the tobacco industry did obtain experience in Finland in how to object to tobacco control measures.

     

The tobacco settlement: an analysis of newspaper coverage of a national policy debate, 1997-98

OBJECTIVE: To examine the framing of tobacco policy issues in the news media during the national tobacco settlement debate of 1997-98. The major aims were (1) to describe the extent of newspaper coverage of each of the specific components of the proposed tobacco settlement; (2) to identify the tobacco control frames, and the dominant frame, appearing in each newspaper article; and (3) to examine trends in tobacco control frames over time. DESIGN: A content analysis was performed on 117 articles related to national tobacco legislation appearing in the Washington Post from 1 January 1997 through 18 June 1998. MAIN OUTCOME MEASURES: (1) Major policy themes of the settlement referred to or implied in each article; (2) major frames used to discuss the problem of tobacco in each article. RESULTS: The generation of new revenue was the dominant theme of the articles, appearing as a major focus in 44% (52) of the articles. Other than the issues of Food and Drug Administration regulation of tobacco and restrictions on cigarette advertising, the public health policy aspects of the tobacco settlement received little attention. The problem of tobacco was portrayed as one of youth smoking in 55% (64) of the articles, but as one of a deadly product in none of the articles. CONCLUSIONS: Future discussions of comprehensive tobacco policy should be driven by a more specific discussion of the precise programme and policy mechanisms by which tobacco use can be most effectively prevented and controlled. The public health community must find ways to frame the tobacco issue more broadly than simply as one of youth smoking.     

Understanding Philip Morris's pursuit of US government regulation of tobacco

Objective: To investigate Philip Morris's support of US Food and Drug Administration (FDA) regulation of tobacco products and analyse its relationship to the company's image enhancement strategies.

Data sources: Internal Philip Morris documents released as part of the Master Settlement Agreement.

Methods: Searches of the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) beginning with such terms as "FDA" and "regulatory strategy" and expanding to include relevant new terms.

Results: Philip Morris's support for government regulation of tobacco is part of a broader effort to address its negative public image, which has a damaging impact on the company's stock price, political influence, and employee morale. Through regulation, the company seeks to enhance its legitimacy, redefine itself as socially responsible, and alter the litigation environment. Whereas health advocates frame tobacco use as a public health policy issue, Philip Morris's regulatory efforts focus on framing tobacco use as an individual choice by informed adults to use a risky product. This framing allows Philip Morris to portray itself as a reasonable and responsible manufacturer and marketer of risky products.

Conclusions: Philip Morris's ability to improve its image through support of FDA regulation may undermine tobacco control efforts aimed at delegitimising the tobacco industry. It may also create the impression that Philip Morris's products are being made safer and ultimately protect the company from litigation. While strong regulation of tobacco products and promotion remain critical public health goals, previous experiences with tobacco regulation show that caution may be warranted.

     

Tobacco industry success in preventing regulation of secondhand smoke in Latin America: the "Latin Project"

OBJECTIVE: To examine the tobacco industry's strategy to avoid regulations on secondhand smoke exposure in Latin America. METHODS: Systematic search of tobacco industry documents available through the internet. All available materials, including confidential reports regarding research, lobbying, and internal memoranda exchanged between the tobacco industry representatives, tobacco industry lawyers, and key players in Latin America. RESULTS: In Latin America, Philip Morris International and British American Tobacco, working through the law firm Covington & Burling, developed a network of well placed physicians and scientists through their "Latin Project" to generate scientific arguments minimising secondhand smoke as a health hazard, produce low estimates of exposure, and to lobby against smoke-free workplaces and public places. The tobacco industry's role was not disclosed. CONCLUSIONS: The strategies used by the industry have been successful in hindering development of public health programmes on secondhand smoke. Latin American health professionals need to be aware of this industry involvement and must take steps to counter it to halt the tobacco epidemic in Latin America.     

Tobacco industry strategies to undermine the 8th World Conference on Tobacco or Health

Objective: To demonstrate that Philip Morris and British American Tobacco Company attempted to initiate a wide ranging campaign to undermine the success of the 8th World Conference on Tobacco or Health held in Buenos Aires, Argentina, in 1992.

Data sources: Publicly available tobacco industry documents housed in Minneapolis, Minnesota, USA; Guilford, UK; on-line document websites; and telephone interviews with informed parties.

Study selection: Those documents determined to be relevant to the companies' campaigns against the 8th World Conference on Tobacco or Health.

Data extraction: Revision of chapter VIII of the July 2000 WHO report by a committee of experts, entitled: Tobacco company strategies to undermine tobacco control activities at the World Health Organization: report of the committee of experts on tobacco industry documents.

Data synthesis: Internal documents describe proposed media and science orientated campaigns developed by BAT, Philip Morris, and their consultants to divert attention away from the conference.

Results and conclusion: This work shows that the tobacco industry has the resources and vested interest to combat perceived threats in its regional operating markets, in this case its Latin American market. It is important for the worldwide public heath community to become aware of the numerous ways in which the tobacco industry and its front groups can work against international tobacco control meetings, even including the manipulation of or working with other public health groups to oppose tobacco control efforts. Future world conference planners and participants should be aware that the tobacco industry is likely to continue to employ such methodology. There is no reason to think that the industry is paying less attention to such conferences in the present or future. Rather, it is likely the industry will adopt and expand strategies that were successful while abandoning those that were not effective. Required disclosure of financial support by all participants at all tobacco scientific conferences is recommended. For the tobacco control community, we also recommend careful coalition building and networking with other public health groups on the ways tobacco is implicated in other public health issues.

     

A comparison of US and Norwegian regulation of coumarin in tobacco products

Objective: This paper examines policy processes regarding why the USA and Norway have not regulated coumarin in tobacco.

Design: A qualitative analysis of all tobacco industry documents regarding coumarin since the 1950s from the 1998 US Master Settlement Agreement and subsequent legal settlements. Additional data were collected from newspaper reports, general internet search engines, journal articles, scholarly reports, court cases, statutes, regulations, and informal correspondence with tobacco control experts in Norway.

Main outcome measure: An overview, summary, and analysis of all documents related to coumarin.

Results: In the USA from 1954 until 1985 when coumarin was reportedly removed from domestic cigarettes, but not from pipe tobacco until 1996, and not at all from imported Indian bidi cigarettes, regulatory efforts were stymied. In Norway, from 1973 to the present, the tobacco industry has never disclosed whether its tobacco products contain coumarin. In both the USA and Norway, the extreme delay and lack of vigorous evidence gathering and significant remedies were caused by tobacco industry assertions that revealing tobacco additives was a violation of trade secrets, and by weak regulatory authority and efforts to regulate coumarin.

Conclusion: Vigorous and expeditious regulatory investigations and remedies for harmful additives in tobacco, such as coumarin, can protect the public health. Astute insider and outsider political advocacy by health advocates is required to hold elected officials and civil servants publicly accountable for failing to enact disclosure laws and to engage in effective regulatory efforts.

     

Push or be punished: tobacco industry documents reveal aggression against businesses that discourage tobacco use

OBJECTIVE: To learn how the tobacco industry reacted to businesses' voluntarily enacting policies to discourage tobacco use and minimise exposure of employees and patrons to secondhand smoke. DATA SOURCES: Internal tobacco industry documents discovered among those posted on the internet. Approximately 24 million documents have been posted as of this writing. Information in this article was culled from among these documents, which have been made public as a unique requirement of the state of Minnesota's settlement with the industry. STUDY SELECTION: Those documents were used that offered insight into, and which gave a perspective on, the industry's attitudes and reactions toward other businesses as they adopted tobacco-free policies. CONCLUSIONS: In the wake of widespread acceptance that tobacco use causes illness and death, many individual businesses (and even entire industries) took positive steps to eliminate employees', customers', and facilities' exposure to tobacco smoke. Steps were also taken to discourage tobacco use among employees. Internal tobacco industry documents show that the industry reacted with aggression, and in some cases with retribution, against businesses that voluntarily adopted policies to discourage tobacco use. The intent of these actions appears to be to reverse these policies, with a broader goal of neutralising large scale public and private trends that reflect the decreasing social acceptability of tobacco use.