Dialogue, stakeholders and the future of tobacco control
In a Jan. 31 BMJ blog post, Dr. Ruth Malone, editor of Tobacco Control, excoriated the Food and Drug Administration for proposing “facilitated dialogue” with the “tobacco industry.” This assertion was based on her perception that such dialogue would lend the “tobacco industry” legitimacy that they do not deserve. She further denied that the “tobacco industry” should be referred to as “stakeholders,” and denied the possibility that they might have goals in common with the public health community.
While this statement of righteous indignation reflects a view held by many within the tobacco control community, it is both technically incorrect and dysfunctional from a number of perspectives.
In her ruling, U.S. District Court Judge Gladys Kessler, of the D.C. District, found seven major cigarette manufacturers guilty of racketeering. While these companies are the largest and most visible cigarette manufacturers, they do not represent the larger “tobacco industry.” The tobacco industry consists of hundreds of other companies manufacturing and selling a wide range of tobacco and tobacco-related products. Dr. Malone, in her stereotyping the entire industry on the basis of criminal activity by seven firms, showed a profound lack of understanding of the structure and dynamics of the larger tobacco industry.
Even worse, by painting the entire industry as guilty of racketeering, Dr. Malone strengthens the hand of the guilty cigarette companies by effectively silencing the many others within the tobacco industry who are ready and able to work with the public health community in pursuit of public health objectives.
In her post, Dr. Malone references action by tobacco companies as “creating divisions within the tobacco control community.” She seems unable to imagine the possibility that, by gaining a better understanding of the dynamics of the larger tobacco industry, that we, in public health, could exploit similar divisions within the industry in a manner supportive of public health objectives.
It is not the FDA who has given the seven cigarette companies the cloak of social responsibility. It is the larger tobacco control community, which has offered total and unquestioning support of the FDA Tobacco Control Act that provided this benefit to the racketeering companies. They knew, or should have known, at the time this bill was making its way through Congress, that Altria/Philip Morris helped draft major sections of the bill. In the name of protecting children from nicotine addiction, multiple provisions were written into the bill to protect both cigarette and pharmaceutical companies from competition from far less hazardous and likely less addictive tobacco/nicotine products.
Perhaps the greatest fault of Dr. Malone’s post was her failure to recognize the realpolitik and power dynamics of tobacco-related issues in the United States in this second decade of the 21st Century. For the past half century, the tobacco control community, both in the United States and internationally, yearned for a “tobacco-free society.”
During the 1990s, under the leadership of then-FDA Commissioner Richard Kessler, we attempted to secure federal legislation that would have empowered the FDA to ban at least some tobacco products. That was not to be. We only secured FDA authority to regulate tobacco when Congress and the president were presented with a bill that carried the strong support of the largest cigarette company. With passage of that bill, that question was put to rest. Our society will not be tobacco-free.
That being the case, the FDA is not “unwittingly acting as an agent for the tobacco industry…and undermining a strong tobacco control strategy.” The FDA is realistically taking the action needed to reduce tobacco-attributable illness and death and further our efforts to reduce teen initiation of tobacco/nicotine use.
Dr. Malone is not alone in her failure to recognize the manner in which the advent of the FDA tobacco law changes the American tobacco control landscape. If used wisely by the FDA and others in the tobacco control community, these changes can secure more rapid and more substantial reductions in tobacco-attributable illness and death than previously imagined, and most likely do so while further reducing teen initiation of tobacco products. If used unwisely, this law will do more harm than good, in terms of these public health objectives.
Wise use of the power given to the FDA under the new law will require facilitated dialogue between the public health community and all within the tobacco industries who care to engage in such dialogue. Central to this discussion will be consideration of tobacco harm reduction – the potential means by which relatively low risk, and possibly less addictive tobacco products could be used to displace cigarettes as the dominant means of nicotine delivery in the United States.
Wise use of this power will enable us to take advantage of natural market forces, in addition to strict regulation and frank health education, to pursue our public health objectives. How we collectively manage the skyrocketing popularity of e-cigarettes will be the first real test of our ability, as a tobacco control community, to adapt to a radically changed tobacco policy environment and use these changes to benefit the health of the public.
