MEMORANDUM BY THE BRITISH MEDICAL ASSOCIATION
THE TOBACCO INDUSTRY (TB 25)
THE BRITISH
MEDICAL ASSOCIATION—THE
VOICE OF
BRITAIN'S
DOCTORS
1. The British Medical Association is the
voice of the medical profession in the UK. With a membership of
more than 115,000, the BMA represents more than 80 per cent of
British doctors. Every day, Britain's doctors come face to face
with the suffering and death caused by smoking. In the UK, smoking
accounts for more han 120,000 deaths each year—about one
in every five deaths. In England alone, it has been estimated
that annually, around 284,000 admissions to NHS hospitals, 8 million
GP consultations and 7 million prescriptions are the result of
a smoking-related illness[3].
The evidence of the BMA to the Committee reflects its members'
concern for their patients, their responsibilities to the health
of the nation, and their duties as public servants.
SCIENTIFIC KNOWLEDGE
OF THE
HARMFUL HEALTH
EFFECTS OF
SMOKING AND
OF THE
NATURE OF
NICOTINE
2. More than 70,000 scientific papers and
reports have been published on the adverse health effects of smoking[4].
Landmarks in the evolution of early scientific knowledge of the
health effects of smoking are outlined in Appendix 1.
3. Beginning in the 1960s, a series of authoritative
reports have assessed and evaluated the scientific evidence that
smoking causes disease, notably:
— 1962—Royal College of Physicians
of London concludes that smoking causes lung cancer and bronchitis
and probably contributes to coronary heart disease[5].
— 1964—US Surgeon General's Report
concludes that smoking causes lung and laryngeal cancer and chronic
bronchitis[6].
— 1971—Royal College of Physicians
of London concludes that "if women . . . smoke the way men
do, their death rate is likely to become the same[7].
— 1977—Royal College of Physicians
of London concludes that tobacco smoking is a form of drug dependence
and that nicotine is probably the addictive substance involved[8].
— 1983—UK Independent Scientific
Committee on Smoking and Health concludes that smoking during
pregnancy retards foetal growth[9].
— 1986—US Surgeon General's Report
concludes that nicotine addiction plays a central physiological
role in smoking[10].
— 1988—UK Independent Scientific
Committee on Smoking and Health concludes that passive smoking
causes lung cancer[11].
— 1992—US Environment Protection
Agency Report concludes that passive smoking causes cancer and
heart disease[12].
— 1998—UK SCOTH Report concludes
that smoking is the most important cause of premature death in
developed countries and accounts for one fifth of all deaths in
the UK[13].
— 1999—WHO expert consultation
concludes that passive smoking causes respiratory disease and
middle-ear infection, and reduces lung growth and function in
children[14].
Appendix 2 summarises selected recommendations
by UK expert committees from 1962 to 1998.
4. Active smoking is the major cause of
lung cancer, chronic bronchitis and emphysema and a major cause
of heart disease and stroke. It is also causes or contributes
to a plethora of other illnesses[15].
A breakdown of the death toll from smoking-induced disease in
the UK is given in Appendix 3.
5. Passive smoking has been established
as a cause of heart disease[16]
and of lung cancer[17]
in adults. In children, passive smoking is known to cause lower
respiratory illness, reduced lung growth and middle ear disease.
In addition, second-hand smoke can cause asthma, and increases
the severity of the condition in children who are already affected.
[18]
6. Nicotine is a psychoactive substance
that occurs naturally in tobacco. Nicotine affects the brain,
heart and endocrine system, quickening the heart rate, increasing
blood pressure, and narrowing blood vessels.
7. Nicotine is highly addictive. Tobacco
dependency is recognised as a behavioural disorder in the World
Health Organisation International Classification of Diseases.
[19]Habitual
use of nicotine through smoking meets the key medical criteria
for drug dependence, including psychoactive effects, compulsive
use and self-reinforcing behaviour. Smokers experience a withdrawal
syndrome when they abstain from tobacco. [20]
8. Nicotine addiction can rapidly become
established after initiation of tobacco use. [21]As
the SCOTH report concluded: "addiction to nicotine sustains
cigarette smoking and is responsible for the remarkable intractability
of smoking behaviour." [22]Addiction
to nicotine therefore increases the smoker's vulnerability to
the harm caused by long-term exposure to tobacco smoke.
TOBACCO INDUSTRY
RESPONSE
9. The results of the body of independent
scientific work on the adverse health effects of tobacco are in
the public domain. They have been, and continue to be, available
to the tobacco industry. In addition, the industry has had privileged
access to the results of its own research programmes and of certain
other research studies it has funded.
10. Internal documents released during legal
action in the United States of America reveal that an industry-wide
effort sought to create and maintain doubts about the harmful
effects of tobacco. Misinformation campaigns were conducted with
a view to protecting against liability actions brought by customers
whose health had been damaged by smoking, avoiding government
regulation, and maximizing profits by maintaining product sales.
[23]
11. The industry conducted extensive internal
research into the health effects of smoking, including analysis
of cigarette smoke, identification and characterisation of cancer-inducing
and tumour-promoting components, and the elucidation of the effects
of smoking in animal models and in human subjects. For the most
part, the results of these studies remained secret. Moreover,
while publicly criticising the scientific tests being used by
independent scientists in studies demonstrating the link between
smoking and cancer, the industry was using these same tests to
assess the mutagenic and carcinogenic effects of cigarettes. Despite
the high quality of much of this research, very few of these studies
were published in the scientific literature. [24]
12. The early response of the industry included
a private research programme to investigate the possibility of
producing a "safe" cigarette. [25]A
certain degree of progress appears to have been made in identifying
additives that might reduce the carcinogenicity of cigarettes.
[26]Ultimately,
however, concerns that marketing a "safe" cigarette
would amount to an admission of the dangers of the existing product
came to dominate, and research in this area was all but abandoned.
[27]
13. Through front groups such as the Tobacco
Industry Research Council, the industry sponsored studies by external
scientists. In public, the industry maintained that the primary
aim of this research was to help resolve the "controversy"
surrounding tobacco and health. In private, however, the industry-sponsored
research was directed with an eye to reducing the likelihood of
future liability actions. Company lawyers were intimately involved
in controlling industry-sponsored studies, vetoing the research
agenda, drafting and approving study reports, and deciding which
projects would be funded or discontinued[28].
14. An extensive industry research programme
investigated the effects of nicotine in animals and in humans.
Industry scientists and executives understood the essentially
addictive nature of their product, and emphasised the key importance
of nicotine in selling tobacco[29].
15. The tobacco industry developed technologies
to allow it to control the level of nicotine in tobacco and to
modify the amount of nicotine absorbed by the smoker. Patents
filed in the USA document processes by which nicotine can be removed
from tobacco or added to cigarettes, by spraying on tobacco, on
filters or on cigarette paper[30].
CONSUMER PROTECTION
16. Given the weight of the scientific evidence
and the scale of the suffering caused by smoking, a responsible
industry would be expected to act to protect the health of its
consumers. However, with regard to consumer protection, the response
of the tobacco industry has been singularly inadequate. Throughout
the course of the tobacco epidemic, the industry has failed in
its responsibilities on numerous counts.
Failure to fully inform of the dangers of smoking
17. Active smoking. The record shows that
while publicly denying the harmful effects of its product, the
tobacco industry has been well aware of its hazards. Only recently
has the tobacco industry admitted the fact that active smoking
harms health. However, these admissions continue to be couched
in terms that owe more to concerns of liability then to consumer
welfare, and fail to address the true nature and magnitude of
the health effects of smoking.
18. Passive smoking. The tobacco industry
has yet to admit that passive smoking causes illness. Industry-wide
studies on the health effects of passive smoking have been underway
since the 1960s, and privately, the industry has accepted the
validity of independent studies on the harmful effects of passive
smoking[31].
Publicly, the same tatics used in creating a false controversy
around the harmful effects of active smoking are now being used
to attempt to discredit scientific knowledge of the harms caused
by passive smoking.
19. Nicotine addiction. The tobacco industry
has not accepted that nicotine is addictive. Rather, setting aside
the compelling evidence that the effects of nicotine on the brain
are similar to those of drugs such as heroin and cocaine[32],
the industry trivialises the central physiological role of nicotine
addiction in motivating smoking by comparing tobacco dependency
to habits such as eating chocolate. The tobacco industry has consistently
maintained that smoking is entirely a matter of "free choice".
Failure to reduce the harmfulness of their product
20. A less harmful cigarette? The
record shows that industry research carried out into a "safe"
cigarette was not implemented because of fears of product liability
actions. Instead, the industry has produced "light"
cigarettes, described as low in tar and nicotine. These products
were developed in an effort to alleviate smoker's health concerns
and marketed accordingly. However, it is clear that the stated
yields of tar and nicotine on the packet bear little resemblance
to those absorbed by the smoker[33].
The industry was well aware both that these cigarettes offered
no real health benefits, and that marketing of "light"
cigarettes would "actually retain some potential quitters
in the cigarette market"[34].
Not only does the tobacco industry knowingly continue to market
a product that seriously harms health, it exploits smokers' health
concerns to protect company profits.
21. Nicotine and addiction. While
the technology is available to reduce the nicotine content of
cigarettes, an analysis by the USA FDA found that the levels of
nicotine in cigarettes has increased rather than decreased. There
is evidence that this has been made possible through the introduction
of additives that increase the effective dose of nicotine delivered
to the smoker, while having no effect on testing systems used
by most regulatory authorities for ascertaining the levels of
tar and nicotine displayed on cigarette packs[35].
The industry has failed to act to protect its customers' health
by removing nicotine from its product; rather, it has used the
knowledge and technology available to enhance delivery of nicotine
in its products.
Failure to disclose the content of their product
22. Cigarette smoke contains more than 4,000
components, including many toxins, mutagens and carcinogens. The
industry carried out extensive analyses of both mainstream (inhaled)
and sidestream (second-hand) smoke; however, the results of this
research were not made public. In addition, more than 600 substances
are authorized for use in tobacco products[36].
Additives can be used to modify cigarette smoke to make it more
palatable and to increase the dose of nicotine that the smoker
receives. The substances added may dilate the airways, increasing
exposure to the harmful effects of tobacco smoke inhalation, and
may numb the throat, making it easier for novice smokers to persist
with experimentation. They may also reduce the visibility and
smell of second-hand smoke. The tobacco industry has failed to
disclose the additives used in particular products, as well as
information on their toxicity and biological effects.
Failure to compensate for damage caused to consumer
23. It has been estimated that during the
past 50 years, almost 6 million Britons have been killed by smoking.
In developed countries, the death toll is around 60 million[37].
Behind these statistics lie the enormous human suffering and distress
caused by smoking-related illnesses, both fatal and non-fatal.
Industry documents reveal that a central motivating factor in
the response of the tobacco industry to scientific knowledge on
the harmful effects of smoking has been the desire to evade product
liability claims from individual consumers, health insurance companies
and governments. While failing to fully inform the consumer of
the true nature and risks of smoking, the tobacco industry has
also failed to compensate those who suffer from smoking-induced
illnesses as the result of using its product as intended.
Avoidance of regulation
24. The legitimate role of government in
protecting the consumer and the public health includes effective
regulation. Measures that have been proven to be effective in
reducing the burden of avoidable disease and death from smoking
and in protecting the individual from the harmful effects of smoking
include effective taxation policies, bans on advertising and promotion
of tobacco, and measures of the protection of non-smokers[38].
While failing to publicly accept that these measures are effective
in reducing tobacco consumption, the tobacco industry has consistently
resisted and campaigned against their implementation.
25. Regulation of the tobacco industry in
the UK has often been attempted through voluntary agreements with
the industry. Adherence has been assessed by the Committee for
Monitoring Agreements on Tobacco Advertising and Health, composed
in equal part of representatives from the tobacco industry and
independent assessors. Experience shows that the effectiveness
of this mechanism is limited. The procedure relies on public complaints
and allows infringements of the agreements to continue while a
ruling is made. Moreover, no meaningful penalty is imposed on
the industry when a complaint is upheld. The introduction of a
legislative ban on tobacco promotion and advertising is welcome,
placing as it does the burden on the tobacco industry to comply
with measures to protect the public health. Future regulatory
measures to prevent tobacco-induced illness and death should be
framed with this experience in mind.
Failures of global responsibility
26. The British-based tobacco industry operates
in a global market, and is among the largest transnational cigarette
manufacturers. As tobacco consumption in the UK falls, British
tobacco companies are increasingly looking to market opportunities
elsewhere.
27. If current trends continue, the global
death toll from tobacco will rise from about 4 million per year
in 1998 to about 10 million per year in 2030. Over 70 per cent
of these deaths will occur in the developing world[39].
In 1990, smoking accounted for one in six adult deaths; in 2020,
it will account for one in three[40].
28. While scientific knowledge on the harmful
effects of smoking is accepted internationally, public knowledge
of the health risks of smoking varies worldwide. In 1991, health
warnings were required by 70 countries[41].
In the absence of warnings imposed by government, the tobacco
industry fails to disclose even the most basic information on
the health risks of smoking.
29. A recent report by the World Bank highlighted
the economic losses associated with tobacco and concluded that
an integrated strategy to address the global tobacco epidemic
would mean increasing taxes, adding prominent warning labels to cigarettes,
adopting comprehensive bans on advertising and promotion, and
restricting smoking in workplaces and public places[42].
30. Internatinal action is urgently needed
to curb the global tobacco epidemic. The International Convention
for Tobacco Control being developed by the World Health Organisation
is an international legal instrument designed to protect the public
health against the global spread of tobacco. We commend the support
for the Convention expressed in the recent White Paper on Tobacco[43],
and urge the Government to facilitate its development and implementation.
October 1999
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