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From the time when the native peoples of the Americas introduced Europeans to tobacco until the second decade of the twentieth century smoking and other forms of tobacco use focused on questions of production, commerce, and morality rather than on questions of medicine (U.S. Department of Health and Human Services, 1992). The first public policy issues concerning tobacco centered on its role as an important cash crop and a potential source of tax revenue. Medical questions about tobacco use did not materialize because until the 1920s there were no scientific grounds for supposing that smoking endangers the health of smokers. Half a century passed before epidemiologists began to make a case for the dangers of environmental tobacco smoke (ETS) to nonsmokers. Smoking and other forms of tobacco use provide a vivid illustration of how ethical considerations can change over time as scientific evidence and the social, political, and economic dimensions of an issue change.
Scientists began to build the case for the dangers of smoking when A. C. Broders (1920) published an article correlating tobacco use with lip cancer. Subsequent studies repeatedly linked tobacco use, in particular smoking, with a variety of diseases, primarily lung cancer and respiratory diseases. Evidence was derived from epidemiological studies, typically retrospective laboratory studies, and findings at autopsy. In 1957 based on the findings of a federally sponsored study group on smoking and health the U.S. Public Health Service (USPHS) concluded that there was a causal link between smoking and lung cancer (U.S. Department of Health, Education, and Welfare). The USPHS also affirmed a causal link between smoking and numerous other cancers, as well as other diseases in 1964, when Surgeon General Luther Terry issued an advisory report titled Smoking and Health (U.S. Department of Health, Education and Welfare).
Since 1964 a wealth of research has demonstrated the deleterious effects of tobacco use on health. Both government and private agencies have been instrumental in publicizing and documenting research findings and their implications, most efficiently through their websites. For example, the Centers for Disease Control and Prevention (CDC) lists all the surgeon general’s reports on tobacco and health from 1964 to 2001. These reports summarize the state of research and education on tobacco use at the time of each report. Research articles, tobacco industry documents, tobacco control guideline programs, and educational materials can be accessed through the CDC’s site. Other websites—the Agency for Healthcare Research and Quality (AHRQ), the U.S. Department of Health and Human Services (USDHHS), the National Library of Medicine, and the National Institutes of Health (including the National Cancer Institute), as well as private foundations such as the American Cancer Society and the American Lung Association—all provide access to research and educational materials for laypersons and professionals. The importance of tobacco use and exposure as a health risk is demonstrated further in the USDHHS document Healthy People 2010 (2000a), which cites morbidity and mortality related to tobacco use and ETS as one of the leading indicators of the health of the American people for the next ten years.
Reflection on some of the facts gives one a sense of the ethical and policy problems posed by smoking. Approximately 440,000 deaths in the United States are due to smoking and diseases related to tobacco use (American Lung Association, 2002). Exposure to ETS (also known as passive smoking) increases the risk of cancer in people who have never smoked (Hackshaw et al.). Tobacco use has become a serious pediatric health issue, but in spite of regulation, children and adolescents continue to be able to obtain tobacco products (U.S. Department of Health and Human Services, 2000b). Control of the risks and diseases related to tobacco use has been hampered by continuing efforts by the tobacco industry to promote and market its products without constraints (U.S. Department of Health and Human Services, 2000b; Ong and Glatz).
The negative health effects of tobacco use are widely known and may be widely acknowledged even though individuals may not change their behavior on the basis of that knowledge. The reasons for the lack of behavioral change are many and complex (U.S. Department of Health and Human Services, 2000b). The ethical issues are also complex and have evolved over time and as a result of political and legal factors. Major ethical issues related to smoking and other tobacco use are: (1) the protection of nonsmokers from the effects of ETS; (2) the protection of children from an addictive product; (3) the scientific integrity of tobacco industry research; and (4) corporate integrity in marketing tobacco products.
In the past ethical arguments about smoking focused on issues of autonomy, paternalism, and societal harm. Smoking as an individual choice was juxtaposed against the restriction of individual smoking behavior as a consideration in protecting the individual from himself or herself and protecting society from smokers. Today the moral issues associated with tobacco use have moved away from individual autonomy and individual values because of the recognition of the significant public health implications of smoking. However, the earlier ethical arguments regarding smoking and tobacco use will be reviewed here to gain a historical perspective.
Ethics and Restrictive Policies: Autonomy, Paternalism, and Societal Harm
Before the harmful effects of ETS were demonstrated, the health risks of smoking suggested that at least some restrictive policies designed to protect smokers from themselves could be ethically justified. Knowledge of the risks that smokers impose on nonsmokers could support public policies designed to keep smokers from exposing nonsmokers to ETS or imposing on nonsmokers the medical costs of smoking. In addition to these two considerations the promotion of health has served as a third impetus for a restrictive policy. For example, in 1992 the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), the chief hospital accreditation agency in the United States, required hospitals to forbid smoking within their premises by 1994 as a condition of accreditation (Center for Disease Control Chronology of Significant Developments). Robert Goodin (1989) used these considerations to develop a vigorous case for a public policy aimed at a total ban on smoking. Today bans on smoking in public places are common and often complement state tobacco control programs that have been shown to be effective, at least in one instance, in reducing the mortality from heart disease attributed to smoking (Fichtenberg and Glantz).
Restrictive social policies that attempt to protect an individual from harming himself or herself have been viewed as paternalistic. At least since John Stuart Mill’s (1859) On Liberty antipaternalistic sentiment has been widespread in the English-speaking philosophical community, with Joel Feinberg being one of its leading contemporary voices. Feinberg has emphatically rejected legal paternalism, the doctrine that “[i]t is always a good reason in support of a prohibition that it is necessary to prevent harm (physical, psychological, or economic) to the actor himself ” (Feinberg, p. xvii). Despite an absence of consensus on what constitutes a competent choice, factors such as coercion, ignorance, mental impairment, and addiction serve as grounds for challenging the competence of a choice. The rejection of restrictive smoking policies on the basis of their paternalistic nature and curtailment of individual autonomy thus was considered a viable moral argument until the addictive properties of nicotine and the extent of children’s tobacco use became known. The case for smoking as simply another autonomous value choice became difficult to make for an addictive substance whose use often began in childhood or adolescence.
Ethics and the Public’s Health: Protecting Children and Nonsmokers
Although a moral argument based on the freedom to exercise individual autonomy could be made for not restricting competent adults from engaging in tobacco-related behaviors that are detrimental to their health, that argument fails because of the propensity of adult smokers to begin smoking in childhood or adolescence and the known effects of active and passive smoke on nonsmokers, children, and fetuses. According to a 1994 surgeon general’s report, most first-time smoking occurs before graduation from high school, and the younger a child is when he or she begins smoking, the greater are the negative health effects (U.S. Department of Health and Human Services, 1994). Smoking and ETS are associated with decreased fetal growth during pregnancy and respiratory problems in school-age children who were exposed to smoke during early development (American Academy of Pediatrics). Children exposed to passive smoke are more likely to develop respiratory and middle-ear problems (Cook and Strachan).
Maternal smoking has been associated with sudden infant death syndrome, and passive smoke has been associated with an increase in hospital admissions among children with cystic fibrosis (Cook and Strachan). Because of these and other significant health risks to children and adolescents, the American Academy of Pediatrics has identified the reduction of children’s exposure to both active and passive smoke as a primary goal of preventive health (American Academy of Pediatrics Committee on Substance Abuse).
The moral obligation to protect a vulnerable population is heightened by the dangers of tobacco to children in all stages of development and the fact that those risks are preventable. Although children potentially may be harmed by actively smoking or by their parents’ smoking, children are also at risk from ETS outside the home.
The harm from ETS in all age groups is well established. The increased risks of respiratory and heart diseases and the role of passive smoke as an irritant were summarized in a 1986 surgeon general’s report (U.S. Department of Health and Human Services, 1986). More recent meta-analyses of epidemiological studies have continued to affirm ETS as a cause of lung cancer (Hackshaw et al.) and have provided further evidence of the negative cardiac effects associated with ETS (He et al.). The continuing confirmation through scientific evidence of the detrimental health effects of passive smoking and the recognition of nicotine as addicting have moved smoking from the realm of personal value choice to the realm of public health.
The ethics involved in public health issues may differ in some respects from those involved in clinical medicine in that obligations to society as a whole may be different from or conflict with obligations to an individual patient. Although some conflicts between the rights of society and the rights of individuals may entail controversy, the overwhelming scientific evidence for the detrimental effects of tobacco has effectively eliminated controversy and promoted consensus among health professionals. The evidence justifies the imposition of restrictions such as workplace bans and restrictions on smoking in public places, whereas the lack of a total ban allows adult individuals to make the choice to smoke. Rather than being viewed as restrictions on personal liberty or intolerance of diverse values, those restrictions can be seen as analogous to the imposition of speed limits to protect the public’s safety on highways. Occasional challenges to the scientific evidence still appear, but it is recognized increasingly that one reason for the public’s (and some health professionals’) delay in accepting the scientific evidence regarding the negative effects of smoking was an active campaign by the tobacco industry to market tobacco use aggressively and discredit scientific evidence about its negative health effects (Ong and Glantz).
Scientific Integrity and Corporate Morality
Since the 1990s confidential tobacco industry documents have become public as a result of litigation and increased public knowledge about the health effects of active tobacco use and ETS. Those documents demonstrate the efforts of the tobacco industry to publicly deny its own research results confirming the dangers of ETS, alter data to support its desired conclusions, and discredit legitimate scientists whose work demonstrated negative effects of ETS (Barnes et al.). Elisa K. Ong and Stanton A. Glantz describe how between 1993 and 1998 lawyers and marketing firms employed by Philip Morris directed a campaign to distort epidemiological standards with contrived concepts of sound science in order to attack legitimate scientific evidence on the negative health effects of tobacco use. Because further regulation of the tobacco industry appeared inevitable, the industry’s goal was to raise the standards for scientific proof of harm so that legitimate studies demonstrating harm could never reach those standards and thus could be dismissed as junk science (Ong and Glantz).
The campaign was insidious but lost its force when epidemiological organizations refused to agree to some of the statistical standards being pushed by the tobacco industry (Ong and Glantz). This example of the tobacco industry’s unethical attempts to manipulate public opinion is only one of many. Policies related to the sale of tobacco to foreign countries also raise difficult issues, including the promotion of cigarettes to children or to people who lack adequate information about the risks of smoking. Vigorous opposition by tobacco companies to efforts to inform Third World consumers about the effects of smoking and attempts to manipulate those efforts have exacerbated the problem (Emri, Bagci, Karakoca, Baris). Corporate morality leading to conflicts of interest and potential harm to individuals remains an unresolved problem.
Legal Regulation of the Tobacco Industry
All defensible theories of just laws recognize the harmfulness of a conduct to others as a good reason for regulating that conduct (Feinberg). In the environment of recognized health risks and the deceptive marketing practices of the tobacco industry lawsuits and regulations have become increasingly common.
Historically, legal decisions and regulations have been decided for and against both the tobacco industry and consumers. For example, the Federal Cigarette Labeling and Advertising Act of 1965 required the warning label that is familiar today but at the same time prohibited warning labels on cigarette advertisements for a period of three years (Center for Disease Control). The Controlled Substance Act of 1970, regulating addictive substances; the Consumer Product Safety Act of 1972, regulating hazardous substances; and the Toxic Substances Control Act of 1976, regulating injurious chemicals, specifically excluded tobacco from their lists of hazardous or addictive substances (Center for Disease Control). Other notable regulations include policies and laws in 1973, 1987, and 1989 to segregate and then ban smoking on domestic airline flights and bans on smoking in government workplaces in 1987, 1994, and 1997 (Center for Disease Control). The CDC website provides a summary of the numerous government regulations pertaining to tobacco since the early twentieth century (Center for Disease Control).
Over the years legal battles by individuals against the tobacco industry were fought with varying degrees of success, but eventually more consumers began to prevail in the courts. Although most disputes were heard in lower courts, two cases involving state laws, cigarette advertising, and injury or potential injury reached the U.S. Supreme Court and resulted in rulings that were partially favorable to each side (Thomas Cipollone; Lorillard Tobacco Company). In a third case, a victory for the tobacco industry, the U.S. Supreme Court ruled that the U.S. Food and Drug Administration did not have the authority to regulate tobacco products as it did other drugs.
By the mid-1990s four individual states had sued the tobacco industry to obtain reimbursement for healthcare costs related to tobacco use. In an effort to avoid more lawsuits the six major tobacco companies entered into an agreement with the attorney generals and representatives of the remaining forty-six states, along with U.S. territories and the District of Columbia. This so-called Master Settlement provides billions of dollars in payments to states from the tobacco industry beginning in June 2000 and extending over the following twenty-five years (Wilson). In addition to settlement payments, provisions of the Master Settlement include the prevention of industry targeting of children and adolescents in advertising, the regulation of tobacco industry lobbying, and public access to industry records and research (Wilson).
Since the last two decades of the twentieth century the changes in the ways in which the public thinks about and uses tobacco have been sweeping. The moral considerations of individual personal choice and freedom in smoking have become issues of public health, the protection of children, the integrity of science and scientists, and the morality of corporations. On January 27, 2003, Philip Morris changed its name to Altria Group, Inc., to demonstrate, it claimed, “To better clarify its identity as the owner of both food and tobacco companies that manage some of the world’s most successful brands.” However, the moral tensions between the industry and the public continue. What the industry changes will mean in the long term remains to be seen.
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