Examination of witnesses (Questions 320
- 339)
THURSDAY 9 DECEMBER 1999
PROFESSOR JOHN
BRITTON, DR
JENNY MINDELL,
SIR ALEXANDER
MACARA and DR
BILL O'NEILL
Mr Austin
320. I was at a meeting a few nights ago where
one of the physicians was saying that the incidence of heart disease
was significantly increased by environmental tobacco smoke and
I see you left that off your list.
(Professor Britton) There is a long list of diseases
associated with that and I have mentioned some of them and heart
disease is another.
Audrey Wise
321. What do you think of the tobacco company's
approach to medical science both over the last few decades and
currently?
(Sir Alexander Macara) They have been very flattering,
have they not? All the evidence now is that they were at pains
to repeat the work which had been done by independent scientist;
in fact, they employed other independent scientists to research
the effects of tobacco. The evidence now is that their own research
has confirmed the evidence which had been produced and then they
appear to have been at pains, as we now know, to conceal this
confirmation. You may say that they were highly flattering in
that they recognised the need to repeat the work no doubt hoping
to be able to find loose threads that they can pull to unravel
the whole fabric of the argument against them. I am afraid in
historical terms they have shot themselves in the foot because
they have now been revealed to have been responsible for deliberate
suppression of the facts and misrepresentation about the facts
which had been produced.
322. I am interested in some of your phases
you have used, such as "as we now know" and "have
now been revealed" and that would not have happened to the
same extent by any means without people rooting about in dusty
archives. I wonder if you would care to comment a little bit more
on that because I have noticed in the BMA evidence you have a
list of tobacco company's failures, that is failure to inform
of the dangers of smoking and failure to reduce the harmfulness
and failure to disclose the contents and so on. Failure is an
interesting word in that context because failure suggests you
have tried to do something and you have not quite managed it.
I would rather say that they have tried to mislead rather than
failed to inform and I wonder if you would care to comment on
the thrust of your evidence there. Is your own evidence strong
enough? We hear that governments are weak.
(Sir Alexander Macara) We do not hesitate to use pretty
strong language on occasions because we feel it is our public
duty to promote public health and to protect our patients, but
sometimes we want to assume that there might just be some intention
of good faith on the part of the tobacco manufacturers. It may
be that they felt their responsibility was to protect their markets
and their shareholders and their employees, which is a very worthy
matter if you are an employer or a shareholder out with the responsibilities
to the public health. They might have thought that was your responsibility
as Parliamentarians and ours as medical scientists. We were restrained
in the use of that word(failure), but I certainly would not disagree
with the view that it is hardly strong enough.
323. You have mentioned your disappointment
at the failure of people to act on warnings about health damage.
It does seem rather remarkable that there has been quite a lot
of knowledge and suspicion about damage to health. I wonder if
you would care to reflect and discuss the issue of the public
mood in connection with this. We went to the USA last week and
I picked up a very strong feeling of anger which is missing here.
People are warned and there is a certain amount of anger on the
issue of the rights of the non-smoker, but because of the disclosure
of the tobacco companies misleading and manipulating people in
the USA and ripping off and denial and lying there is a considerable
mood of public anger. Do you not think that if people become angry
about being manipulated they may be more open to public health
messages?
(Dr O'Neill) The reality is that in this country it
is estimated that we have been spending about £10 million
per year getting across the health message as opposed to probably
ten times that amount of money being spent by the industry. There
is no doubt that in the United States the series of cases that
have gone to the courts has done an enormous amount to highlight
the dangers associated with smoking and, in particular, to highlight
the behaviour of the industry. The British Medical Association
publicly supported the group action that has been taken on behalf
of the 52 patients with lung cancer in this country through the
courts, not because of the probably relatively paltry sums of
money that patients were going to get at the end of the day, but
because of the information that would be disclosed in court, because
for the first time the truth would see the light of day and we
certainly regretted the collapse of that case.
324. I think some of us individually might agree
with you on that. Does that not make it even more important to
ensure that the truth sees the light of day?
(Dr O'Neill) We believe that until the industry are
put in the dock in this country, whether it be in front of a Committee
such as this or some other forum, we will not have the full truth,
and nor will the public, of what has actually gone on over the
last 20 to 40 years.
325. The Chairman asked you whether you had
attempted to access the Guildford depository. Are you aware that
if you did try tomorrow you would almost certainly be told, "I
am sorry, nobody can get in for at least the next four months
because we are booked up"?
(Dr O'Neill) We are absolutely aware of that.
326. Perhaps there is some merit in looking
in dusty archives. If they are so keen on keeping it secret, should
not all of us be rather keen on getting it revealed?
(Professor Britton) I would not wish to be misinterpreted—
Chairman
327. I think you might have been, Professor.
(Professor Britton) On the one hand it is important
to establish the truth of events that have gone by if that influences
public mood in terms of engendering a sense which I, too, have
detected in the United States of betrayal by an industry, but
the facts of the health arguments have been with us for nearly
40 years and perhaps it is appropriate to look to the future rather
than the past in terms of resolving this problem.
Audrey Wise
328. But that implies, does it not, that they
have all changed their spots?
(Professor Britton) Who has?
329. The tobacco companies.
(Professor Britton) Effective public health measures
to do with smoking will come from legislation.
330. Are you conscious of the scientific and
technological precision and power which we and health authorities
in general are facing? We were told, for example, by the US Food
and Drug Administration that the scientific knowledge and technological
power of the tobacco companies enables them to ensure a nicotine
dosage of such precision in every cigarette packet that outweighs
the capacity of the pharmaceutical companies to ensure the dosage
they want in nicotine replacement therapy. That is the level of
scientific and technological power that we are facing. Does that
suggest that this is all to do with past attitudes of the tobacco
companies?
(Professor Britton) Tobacco companies produce very
sophisticated products, I do not think anybody here would argue
against that. Cigarettes are nicotine delivery devices, that is
what they are created to be. Salbutamol inhalers are broncho-dilatory
devices used by people with asthma to treat their asthma. They
are also very sophisticated devices. The asthma device is legislated
to very tight standards of safety and disclosure and cigarettes
are not. That is a failure of legislation, not of technological
advance.
(Sir Alexander Macara) It is even worse than that
because we have evidence of the manufacturers deliberately putting
additives about which we simply do not know enough into tobacco
in order to increase the absorption of nicotine from the bronchi.
They even use chocolate for this purpose. I have no doubt if they
put on the packet that their product contained chocolate it might
be a very clever marketing device. I think they ought to have
me as a consultant. They put it there in order to increase the
absorption of the nicotine in the cigarettes. That is absolutely
right, they are using the results of their own research to potentiate
the addictive part of their product.
331. That does suggest that when we talk about
manipulation by the tobacco companies it is current as well as
past.
(Sir Alexander Macara) There is no question about
that. I do not know whether my colleagues would like to add anything.
(Dr Mindell) I think what Professor Britton was saying
is that if governments want to act to introduce comprehensive
legislation to control tobacco they can do that on the basis of
what is already known without necessarily having additional information
from the archives. However, the archive material is important
partly because of increasing the public's awareness and acceptance
and demand for such legislation but also to avoid the tobacco
industry knowing things that Government does not when the legislation
is worded and that is why I think that continuing exposure of
current research and other internal memos would be important as
well.
332. I am very anxious that Professor Britton
should not be misinterpreted by anybody else.
(Sir Alexander Macara) So are we.
333. We had an exchange with the Department
of Health on this when they came to give evidence and some of
us were surprised to find that there is no assessment of the real
public health consequences made about additives, additives just
get approved. We were told, "Well, we don't look at whether
they are dangerous because they are used in such small quantities".
I did point out that the purpose of some of them was to make the
tobacco more palatable and more attractive. You could use an analogy
with cocaine: you use spices and salt in very small quantities,
but it has a very big effect on whether you want to eat it or
not and the same thing could apply to cigarettes. It may be that
this message goes into the Department of Health. Would you like
to add your comments on this particular aspect?
(Sir Alexander Macara) Dr O'Neill certainly will.
I would just add that strychnine is very effective even in the
very smallest possible doses.
Dr Brand
334. Are you suggesting that we add that to
tobacco and shorten the course of events?
(Sir Alexander Macara) I can think of some people
who might think of it as an advantage.
(Dr O'Neill) The reality is that we regulate our food,
we regulate our drugs and tobacco does not fall into either category.
The majority of additives in food are regulated. There is absolutely
no reason why additives in tobacco and other constituents in tobacco
should not be regulated and until we have effective regulation
we are unlikely to see any real change.
335. Can I pick up that point on regulation,
Mr Chairman, because we put the same point to the Department of
Health, which is that there does not seem to be any consumer protection
for people that smoke. The feedback I think we had was, "Well,
why should there be since it is such a nasty habit anyway which
kills half its consumers", and I think there has been an
absolutist attitude towards smokers which is beginning to shift
a little. I recognise in the evidence we have received from ASH
and in the written evidence from the Royal College of Physicians
that people are now talking about safer cigarettes and the regulation
of products. I do not want to be too historical, but have we not
been at fault in saying that we really cannot cope with anyone
that smokes at any time?
(Dr Mindell) I will make two points in response to
that. Firstly, as regards regulation, we have the bizarre situation
at the moment that nicotine delivery devices that deliver only
nicotine are highly regulated, but if they deliver thousands of
other toxic chemicals as well then they are not regulated. You
should remember that almost all smokers start smoking when they
are children, when they are far too young to be concerned with
dying when they are 40 or 50 rather than when they are 60 or 80.
Most smokers want to give up but they are addicted. When you interview
teenagers you find that most of them say, "Yes, I smoke now
but I'm going to stop", and they find it very difficult to
do so. Some find it extremely difficult. Some have managed to
stop. We know that there are still a very large number of people
who would like to stop smoking. There are a lot of inequalities
in this country, not so much in who starts smoking and not so
much in who wants to stop, but particularly in those who succeed
in stopping smoking and that is where the biggest divide is.
Chairman
336. So it is a social class divide, the implication
being it is middle class people who can stop and working class
people who cannot, is it?
(Dr Mindell) Those in the poorest circumstances may
not be able to afford the additional benefit of nicotine replacement
or they may have so many other stresses in their life that the
difficulties of stopping smoking are more than they feel they
can cope with. The two most important things in stopping smoking
are the desire to want to stop and to believe that you can stop
and that you can exist without cigarettes and this is why all
these other things that we have also been touching on, whether
it is price rises or smoke free areas, are also important for
smoking cessation because it can encourage people to exist as
a non-smoker.
Dr Brand
337. Is it not very important that we have access
to the information that clearly the tobacco companies have to
their knowledge that allows them to produce products that encourage
people to continue?
(Professor Britton) It is clearly important to know
what is in cigarettes. The gains in public health that are to
be realised have to do with legislating against what is there
and what is likely to be produced in response to legislation.
A point one of my colleagues made was that having a fuller awareness
of what is known about tobacco technology is crucial to the phrasing
of such legislation and the formulation of legislation, but the
public health gains can be made without getting too obsessed with
what is actually in the cigarette.
Mr Austin
338. Can I deal with what is in the cigarette.
In a previous session, we had evidence that suggested that a large
number of smokers actually believe that smoking low-tar cigarettes
or lights or milds or ultra-lights are less harmful, but we have
had evidence that because they need to get their fix, they engage
in compensatory smoking, so that more virulent forms of cancer
and adenocarcinomas have been increasing as well, which brings
me on to whether there is such a thing as a safer or a less deadly
cigarette. Obviously the Government's health campaign is that
obviously, we all agree, the best thing is not to start and if
you do start, to stop, but even if the Government meets its targets
of getting people to quit smoking, in ten years' time a quarter
of all adults will still be smoking and overwhelmingly in the
poorest groups in society. Is it possible to reduce that health
impact on those who continue to smoke by requiring, by legislation,
changes to the content of cigarettes, to remove selectively or
reduce chemicals which we know contribute to cancer and lung and
heart disease?
(Sir Alexander Macara) It would be one contributory
factor, but on its own it would be of limited value.
(Professor Britton) I think there are at least two
issues raised by that. One is genuine harm reduction in smokers
who cannot give up and that is obviously as desirable as any other
harm reduction intervention. One of the problems, as I see it,
with the whole low tar strategy is that what it may well do is
encourage people to continue smoking, believing that they are
smoking a safer product, when in fact they are not. I think it
is a very difficult judgment to make between something that genuinely
reduces harm for those people addicted to the products and who
cannot give up from that product which actually increases harm
by extending the market for the product.
(Sir Alexander Macara) There is no such thing as a
safer cigarette; there are only less dangerous cigarettes.
(Dr O'Neill) I think we need to be very careful with
the terminology because there is no doubt about it, that the industry
has scored an enormous goal with the concept of low-tar and light
cigarettes. I think we need to make sure that that does not happen
again. Having said that, I think we do need to acknowledge the
fact that even if we meet the targets which are set, 24 per cent
of the population will still be smoking in ten years' time, and
whatever can be done to lessen the burden of disease in that group
of people clearly is very important, but absolutely accepting
the point that Professor Britton made, that we need to be careful
that that then does not fudge the whole issue, that we do not
find we are actually discouraging people from giving up cigarettes
by implying that there actually is a safe product. It is quite
clear that there cannot be a safe product in the way in which
we understand this product. There are clearly opportunities for
looking both at additives, for looking at other constituents in
cigarettes, and you have already had evidence about the possibility
of lowering nitrosamines in cigarettes and lowering carbon monoxide
levels in cigarettes which would respectively have an effect on
the burden of cancer and indeed heart disease. I think those avenues
should be pursued, but I think we need to make sure that we are
actually getting at the truth we have all of the information and
that we do not allow the industry further opportunities to score
points on this issue.
(Sir Alexander Macara) And we do not allow the industry
to try to paint those of us who are anxious to help the victims
of their successful marketing, that we do not allow them to paint
us as nannies or as health fascists because this is the obvious
ploy now which I think in part answers Dr Brand's question as
to why are we not doing enough to protect smokers. I sense, Chairman,
and I am sad to say this, but I sense with your colleagues, within
government generally, within the Department of Health a terror
about being accused of being nannies or health fascists when all
we are trying to do is the job you have been elected to do and
we have a moral duty to do which is to stop these people from
killing people to the extent that we possibly can.
Chairman: I think I will bring Simon Burns in
and he is not called "Burns" for nothing!
Mr Burns
339. If there is no such thing as a safer cigarette,
but there are only less dangerous cigarettes, then how much do
you think that nitrosamine-free cigarettes are less dangerous
than conventional cigarettes?
(Professor Britton) In theory, nitrosamine-free or
nitrosamine-reduced cigarettes should be safer than conventional
cigarettes, but I think that there is a risk with initiatives
such as that, as with the low tar initiative which dates back
30 years, to assume that because it seems logical that something
will generate a health gain, it actually will. What we have seen
with low-tar cigarettes is a change in the way that people smoke,
the products that they smoke and a change in the disease profile
that emerges from it, so the assumption that reducing tar will
produce a health benefit may have actually backfired by just changing
the profiles of cancers caused and by people compensating and
finding a way around the measures that have been made to reduce
the toxicity of the cigarette, so, in theory, yes, reducing nitrosamines,
reducing tar in general should help, but, in practice, you do
not know it does until you have introduced it and tried it, and
if that perpetuates smoking in society for another 30 years while
you decide whether it has worked or not, you have lost.
|
