Public Health Advocacy on Tobacco and Guns Down Under and Beyond – An Interview with Simon Chapman

Simon Chapman is Professor of Public Health at the University of Sydney in Australia. He has studied and participated in public health advocacy on tobacco, guns, and other issues. He is a sociologist who wrote his PhD dissertation on the semiotics of cigarette advertising, and has written 10 books and major government reports and published more than 160 papers in peer- reviewed journals. His main research interests are in tobacco control, media discourses on health and illness, and risk communication. He teaches courses in Public Health Advocacy and Tobacco Control in the University of Sydney’s MPH program. He also serves as editor of Tobacco Control and was a key member of the Coalition for Gun Control that won the 1996 Australian Human Rights and Equal Opportunity Commission’s community Human Rights award. His new book, Public Health Advocacy and Tobacco: Making Smoking History will be released this September by Blackwell Press. A few months ago, Corporations and Health Watch founder Nicholas Freudenberg interviewed Chapman in his Sydney office. We publish here excerpts of that interview.

CHW: Can you tell me your perspective on the similarities and differences in the tobacco control effort in Australia and the United States, and what’s special about how these conflicts have played out here in Australia?

Chapman: What is similar is that both Australia and the United States are very robust democracies where freedom of expression, criticism of the government, criticism of the corporate sector … all of those issues are not problematic. Whereas in places like China or Vietnam, talking about advocacy is like talking Esperanto because the notion that you could ever make an argument against government or even against corporations is pretty much unheard of. So that is the major similarity.

In Australia, in tobacco control, we have not had the problem that you’ve got in the States with the First Amendment and the issue of free speech being taken to include commercial free speech. Very early on in Australia, arguments were put forward about banning tobacco advertising and promotion, and there was never any serious impediment to that which was constitutionally based or, indeed, based in values that would suggest that corporations could somehow not be silenced in their exercise of free speech. The tobacco industry, of course, fought very hard against any restrictions, along the lines of trying to play games about getting us to reach an impossible level of evidence about cause and effect of advertising and smoking. But those arguments petered out and in the early 1990s we got rid of all tobacco advertisements in Australia. Today you can’t see any advertising anywhere except for very limited point of sale promotion inside tobacconists.

CHW: Are there other cultural or political differences that influence attitudes towards tobacco?

Chapman: Another difference between the States and Australia in terms of tobacco control is concern about what I would characterize as very trivial erosions of personal freedom like having to wear seat belts or a motorcycle crash helmet. Here in Australia, there has not been any significant civil libertarian resistance, whereas I’m very aware that in those two areas there has been conflict in the States. But we haven’t had anything like that, so arguments in Australia about, for example, rules about designating places where we couldn’t smoke were pretty well accepted by the population. The idea that it was fair and just that the government should intervene with laws when somebody was harming your health through second hand smoke was reasonable. So the problem always became the vested interest groups, mainly the tobacco industry, but more importantly, third parties acting on their behalf. This included principally the hospitality industry and the hotel industry, and what we call “clubs”, places where members can gamble, smoke and drink. Australia has successfully imposed restrictions on smoking in these places.

CHW: I know you have also worked on the issue of reducing gun violence in Australia. How does your experience here compare to the US?

Chapman: Well, again, we have nothing like the Second Amendment, or a right to bear arms. In 1996, we had a horrendous civilian massacre in Port Arthur, a historic tourist site in Tasmania, where a man ran amok with military style semi-automatic weapons and killed 35 people.

That was a tipping point for a lot of gun control advocacy that erupted in the decade leading up to that. I describe these experiences in my 1998 book Over our dead bodies: Port Arthur and Australia’s fight for gun control. ((Read the British Medical Journal review) In that book, I make the case that in health care we have disaster plans where every working hospital is prepared for a major industrial explosion or an aircraft crash or something like that. In public health we also ought to have disaster plans because sometimes big public health incidents, like a gun massacre, can trigger (sorry about the bad pun) major reconsiderations in public health law, and that was certainly what happened after Port Arthur.

CHW: By disaster plans, you mean a plan to move advocacy forward if there’s a window for policy change?

Chapman: That’s right. It opens a window of opportunity where a major disaster can suddenly concentrate decades of advocacy. All of a sudden, communities start using the arguments that you’ve been seeding for years and years, leading to a huge avalanche of public outrage that something should be done now. After the Port Arthur massacre, we found terms and phrases that we’d been using for years suddenly being repeated by politicians, police officers, and citizens in ways that showed the groundwork for advocacy comes home to roost when public concern is fired up by these incidents.

CHW: Have these same dynamics played out in tobacco control?

Chapman: With tobacco, the major challenge is that if you don’t do something about control today and you postpone it for weeks, months, or even years, there is not the obvious temporal association between something not having been done and the disease incidence down the road. It’s the old difference between statistical victims and what’s been referred to as the rule of rescue, where you’ve got identifiable, named individuals with acute health problems, saying the government should be providing this new cancer drug for me or reducing waiting lists in public hospitals. Whereas, with chronic disease, of which tobacco control is a great example, you can run the same arguments about harm reduction or controlling the tobacco industry for years and years. It’s really only when windows of opportunity open – and they include things like political charismatic leadership coming along where you start getting the substantive kind of gains. I’ve never seen really tobacco control events without a strong political advocate who comes along and decides to do something about it.

CHW: That’s an interesting observation. So you’re suggesting acute crises like gun massacres or a toxic release open their own windows of opportunity for policy change whereas chronic health problems related to tobacco, alcohol or food may depend more on charismatic leadership. Can we return for a moment to gun control? In the United States, as you know, one of the key obstacles to reducing gun violence is the National Rifle Association. Its well-funded and skilled lobbying operation has been remarkably successful in blocking public health measures, even when public support for such measures is strong. What’s the situation here in Australia?

Chapman: Well, gun ownership is pretty widespread in Australia but it’s not as common as in the U.S. Here, however, the organized gun lobby is fairly small. Since the Port Arthur massacre, people who want to have a gun are obliged to be a member of a sporting shooting club or show a history of hunting. The equivalent of the NRA in Australia is called the SSAA, Sporting Shooters Association of Australia. SSAA has become very well off because all shooters now have to undertake an approved safety instruction course, as if safety was the issue. Safety is really a trivial component of gun injuries and deaths. To own a gun here, individuals have to register their attendance at a shooting range a minimum of four times a year. And the criterion of ownership of a gun for self- defense was explicitly removed. You can’t just say, “I want a gun for self defense.” The only reasons you can have a gun are if you are a member of a sporting shooting club or you are a bona fide gun collector, and then you’ve got to show evidence you’ve been collecting for a long time. It’s very difficult to become a new collector. The third reason to have a gun is that you have explicit permission from a rural property owner to go on their property and shoot kangaroos and feral pigs, or whatever. But just the idea that you can have a gun if you want to is not allowed.

CHW: So the SSAA has developed a close interdependent relationship with the government?

Chapman: Yes, they get training course fees and club registration fees and so they become quite powerful. For example, we had a state election last week and I discovered that the SSAA had given $350,000 to a political party called the Shooters Party to try and get them elected. In Australia, that is a big political donation. So the question is where did they get the money? They get it from shooter’s licenses so the irony is that the government will be opposed by a funding stream its own laws created.

CHW: How did you become involved in public health advocacy? Do you think there’s a potential for bringing health advocates together across issues like tobacco, guns, alcohol and so on?

Chapman: I got into advocacy because I had a typical community health education job when I was a younger guy, and a few like-minded colleagues and I became frustrated with being obliged to work in downstream problem solution, educating school teachers, that sort of thing. We could see all of this corporate malfeasance and industry promotion of unhealthy behavior all around us. I was working in the drug and alcohol areas, so I thought, if we’re going to be serious about reducing drug and alcohol problems, we need to address the upstream stuff. So I got involved in forming a public interest group that was a typical, totally unfunded, flying by the seat-of-the-pants opportunistic pebble in the shoe of the tobacco companies. In the early 1980s, we had a major victory when we were able to engineer an end to the involvement in a leading cigarette advertising campaign of Paul Hogan, the actor, who was Crocodile Dundee. Hogan was on every advertisement for this particular brand, and he had major appeal to children. The tobacco industry had a self- regulatory rule that just didn’t work so we challenged that process and won. All of a sudden with no resources we made a difference by strategically using the media and creative research strategies. So I started getting interested in advocacy principally in tobacco control. Then in the early 1990s, I got involved in gun control.

CHW: So you have had a lot of experience on several different campaigns. As someone who is interested in the advocacy process, how do you decide which issues to work on, which to study?

Chapman: Well, you can’t do everything in advocacy, so I do the things I am interested in and feel are important and I try to do things that when windows of opportunity open I can jump in and do something. Being opportunistic is so vital for effective advocacy and if you can’t make room for those opportunities when they open you’re not going to be very effective.

CHW: Are you talking mainly about media advocacy here?

Chapman: Media advocacy is, of course, only one component of the overall public health advocacy enterprise, but to me it’s rare for an advocacy campaign to succeed if there is no media advocacy component. It’s usually the elephant in the living room that runs it.

CHW: You’ve written about the public discussion of tobacco. How do you think media advocacy has affected that dialogue?

Chapman: The tobacco industry in Australia has largely vanished from public discourse. In fact, I’ve got a graduate student of mine working on going back and looking when it was that the tobacco industry started disappearing from the press. It’s around about the late l990s when all those documents came out because, of course, it was then so easy just to contradict everything they said by showing them their own words. But they now operate almost entirely through elite-to-elite communication channels, you know through funding of political parties, through funding of free enterprise foundations, that sort of thing.

CHW: So in effect, you’re arguing that successful media advocacy by tobacco control activists re-framed the media discussion and drove the industry to find new channels of communication. How do you think this lesson applies to other industries, say alcohol or food?

Chapman: The alcohol industry is the one where I get the most requests from people who say, “Can you do for alcohol what you helped do for tobacco?” To me, there are enormous fundamental differences between the two. The main one is that there is no safe level of tobacco use, whereas there is a lot of very respectable epidemiology that suggests that low to moderate alcohol use is actually beneficial. So in alcohol there are not too many points of comparison with the core messages of tobacco control which are: “Get rid of all advertising and promotion”, “Put the price of tobacco products up significantly”, “Reduce opportunities to get hold of tobacco”, and “Limit sales outlets”. I haven’t heard a really compelling call for banning all alcohol advertising.

On the other hand, my alcohol advocacy colleagues tell me about issues that do call for advocacy. For example, you can buy bulk wine in Australia in these boxes with taps on the bottom. You can get four liters of this wine for under ten bucks, and it’s the favored drink of indigenous people who have extraordinary health problems from alcohol. It’s taxed at a much lower rate than table wine, quality wine. But there’s no rationale for different levels of taxes. There ought to be a standard way of taxing all beverages by alcohol content.

CHW: I’d like to switch gears here and talk about teaching about the impact of corporate practices on health and the role of public health advocacy. How do you approach this subject in your public health curriculum?

Chapman: The very first lecture I give in my Public Health Advocacy course is a description of the traditional host, environment, agent and vector model from infectious disease epidemiology. And I say, let’s apply this to chronic disease epidemiology and to the tobacco industry, tobacco control. What is the vector? The vector is the tobacco industry. I tell my students that any comprehensive approach to chronic disease control, injury prevention, whatever, if you don’t address the vectors who are profiting from the proliferation of abusive behaviors, or dangerous products, then you’re going to miss the boat. So vector control in chronic disease invariably takes you into consideration of industry groups who are out to profit.

CHW: And do you see this as a model for public health folks or do you think it has a potential for mobilizing more popular political support?

Chapman: I see it as both. When politicians favor downstream solutions, more education, more information, rather than upstream solutions, that’s because the comprehensive control model that they’re using does not embrace vector control, control of industry. At the same time, I also think that sometimes industry can be very much a part of the solution.

The food industry is a particularly complex area for public health advocacy. If I ask nutritionists and dieticians, “Exactly what is it that you want people to put in their mouths?” they give me laundry lists of a good diet. And if I ask, “And where do you get hold of that diet?” they say, “Oh, you can buy it at shops.” And I say, “Well, who puts it in shops?” The food industry puts it in shops.

Any view of the future of nutritional change which sees the food industry as being only part of the problem, rather than part of the solution, is myopic. They are certainly part of the problem, but I think that public health advocates also need to understand how coalitions and relationships and networks can be formed with the food industry to push it in the right direction.

Too often the public sector and the NGO sector people concerned about obesity just talk to each other. But where does the average person get nutrition information? They get it from food labeling and from advertising. They may get a bit from public sector, but the total budget of the average bread company is bigger than the government’s entire nutrition campaign budget. So sometimes the role of government can be to stimulate the market to do something differently. With the tobacco industry, people say it’s so easy, so black and white.

CHW: What do you see as the global dimensions of health advocacy to change corporate practices?

Chapman: Well, in tobacco, there has been an immense amount of global networking and information and strategy exchange going on. For example, 190 NGOs have been very instrumental in making sure that the Framework Convention of Tobacco Control just passed in 2003 is fully implemented.

And the Internet has absolutely revolutionized advocacy practice. Not a day goes by where somebody isn’t saying, “Do you know this organization?” “Do you know that individual?” “This has happened. What would you do?” “Is this guy an industry stooge?” So that has been immensely important. I’m not as well connected with gun control any longer, but a colleague of mine runs the major website for the world, gunpolicy.org , which reports on breaking news about guns and gun control from around the world.

CHW: So if I can come back to ask your opinion on the underlying question. What do you see as the potential for campaigns, advocacy networks or actual social movements that would bring greater attention and action on some of these issues, particularly in Australia?

Chapman: I think there’s a lot of potential. Public health has got many specializations within it. You walk around the corridors of this building, the public health building at the University of Sydney, there are statisticians, behavioral scientists, epidemiologists, and anthropologists, and you walk into major NGOs and there is a Director of Marketing, of Community Development, of Campaigns, but there is seldom an Advocacy Director. Advocacy is unfortunately something that people seem to do in their spare time almost. In University settings, there are not a lot of people around the world who are teaching courses on Public Health Advocacy in Masters of Public Health degree programs.

Now in the States I know you’ve got that Hatch Law that prevents government workers from engaging in certain kinds of political activities. . There’s not the problem with that here. Here in Australia, advocacy isn’t a dirty word nearly as much as it is in the States. Government officials, of course, can’t advocate but NGOs are expected to do that. Academic research in the advocacy process is an emerging specialization within public health. The course I teach here is problem based. I give students realistic scenarios and I say let’s analyze what’s going on here, and I ask a series of structured questions. What is the public health problem arising from this scenario? What are our public health objectives? What are our media advocacy objectives that would suit our public health objectives?

Is there opportunity that would short circuit the need for advocacy? How are our position and our opponent’s position being framed in public discourse? How is the debate running in the media? Is it about unnecessary debt or is it about commercial freedom? Then drilling down even further, say a reporter phones, you’ve got a chance to say something that’s going to heard by 20 million people, and you’ve got seven seconds to say it. What are you going to say? So actually bringing that analytical process to considering what your intervention is going to be in that seven seconds. And then, are there other strategies in which you would engage beyond the media advocacy? Are there influential people you can see? Can you discredit your opponents?

CHW: Tell me about your new book, Public Health Advocacy and Tobacco: Making Smoking History. Ken Warner, the Dean of the University of Michigan School of Public Health and a long-time tobacco researcher wrote about your book, “ I was fascinated, educated, and occasionally entertained by this broad and deep “manual” of how to do tobacco control in the 21st century.” What’s the aim of your book?

Chapman: Well, I think the goal of tobacco control is to make smoking history. In the book, I describe effective and ineffective approaches, condemn overly enthusiastic policies that ignore important ethical principles, and offer readers a cookbook of strategies and tactics for denormalising smoking and the industry that promotes it. I hope readers will find it useful.

CHW: Thanks very much.

Free trade, the food industry and obesity: How changes in US – Mexico food trade contributed to an epidemic

Like other countries, Mexico has seen a dramatic increase in obesity and diabetes in the last decade. While obesity has many causes that operate at multiple levels, this report examines how new trade agreements can lead to changes in the practices of multinational companies that can then contribute to health problems. It also illustrates how these global changes interact with national and local trends to influence health.

At the global level, the food market integration between Mexico and the United States that began in the 1980s accelerated after the two countries signed the North American Free Trade Agreement (NAFTA) in 1994 (1). NAFTA removed trade barriers between the US, Canada and Mexico, making it easier for Mexico to export flowers and tropical fruits, for example, and for US companies to sell Mexicans low-cost corn, processed food and other goods and to invest US dollars in the Mexican food industry. Between 1988 and 1997, U.S. foreign direct investment in the Mexican food processing industry increased from US $ 210 million to US $ 5.3 billion, a 25-fold increase (1). This increase had a major impact on the types of food available in Mexico.

Most NAFTA-inspired US foreign direct investment in the Mexican food industry supported production of processed food. Between 1995 and 2003, sales of processed food increased by 5 to 10% annually (1). In the same period, the Mexican diet changed considerably. Between 1992 and 2000, for example, calories from carbonated soft drinks increased by almost 40%, from 44 to 61 Kcal per capita per day. By 2002, the average Mexican was drinking more Coca Cola servings per year, 487, than US residents, who drank 436 8- ounce serving (1).

Increased globalization and consolidation of the Mexican retail food sector and the growing consolidation of supermarkets affected others sectors of society, including agriculture, where small farmers had trouble selling to large supermarkets (2). As a result, many left their farms and moved to the city, leading to more urbanization, decreased access to fresh foods and loss in family and community food self-sufficiency.

How did these changes influence food intake? Between 1988 and 1999, the total energy intake from fat in Mexico increased from 23.5% to 30.3 % (1,3). The increase in urban Mexico City was 32%, compared to the poorer more rural South, where it was only 22 % (3). In this same period, the national prevalence of overweight/obesity increased from 33% to 59%, a 78% increase (4). The overall prevalence of diabetes in Mexico increased from 8.8% in 1993 to 11.4% in 1999, a 30% increase.

In Mexico and other developing nations, urbanization can contribute to higher prevalence of obesity by increasing access to energy-dense fatty foods, especially for low socioeconomic populations groups moving from rural areas (5). Between 1970 and 2000, the proportion of the Mexican population living in urban areas increased from 58% to 75%, the highest rate in Central America. By 2000, Mexico City, the capital, was the second largest city in the world. Furthermore, longitudinal studies suggest that the rapid transition from rural to urban and from high rates of early malnutrition to later childhood overnutrition serve as independent risk factors for obesity, diabetes and cardiovascular disease in adulthood (6). Thus, the particular pattern of economic development that Mexico pursued facilitated gains in weight, especially in the growing urban low income population. When food markets then made high calorie low nutrient foods readily available to newly urbanized, mostly sedentary people, the stage was set for rapid weight gain.

Impact on Health

Growing rates of diabetes, fueled by the epidemic of obesity, consumed larger portions of the nation’s health care budget, depriving resources from other health problems. In 2000, the annual cost of diabetes care per person per year in Mexico was US $607 and one study estimated that total diabetes costs in Mexico in 2000 were US $15.1 billion (7).

At the municipal level, changes in the economy and food availability led to price increases. Between 1992 and 2000, in part as a result of economic changes precipitated by NAFTA, the cost in pesos per megacalorie of food tripled in both urban and rural areas but remained twice as high in urban than rural areas – making low-cost low-nutrient foods more attractive (8). Aggressive marketing of soft drinks and other high calorie, low nutrient snack foods by global and national beverage makers, especially to urban children and young adults, the fastest growing segment of the population and industry’s best hope for increased market share, further encouraged consumption (1). Cities, with dense populations, established media markets and numerous retail outlets, made particularly suitable venues for advertising. Often ad campaigns were planned by increasingly globalized advertising companies (1). In Mexico City, the first McDonald’s restaurant opened in the early 1980s; twenty years later there were 200 Golden Arches in the city (9).

At the neighborhood level, rapid urbanization, loss of green space, the decline in physical labor and high crime rates combined to discourage physical activity, further contributing to obesity. This social environment where diets included more high calorie low nutrient foods and less fresh produce as well as reduced opportunities for physical activity led to weight gain.

Genetic characteristics of the Mexican population also contributed to rates of obesity but it was environmental exposure to a rapidly escalating obesogenic environment that precipitated the phenotypic expression of genotypic vulnerability (10). Moreover, those with Indian ancestry, at higher risk of a genetic predisposition to diabetes, were often concentrated in the low-income urban and rural areas as a result of socioeconomic and ethnic segregation, precisely those areas where food availability was changing most rapidly. For example, a study of diabetes prevalence in a low-income barrio in Mexico City found that 59% of the population had some Native American ancestry (9). Thus, global, national and municipal factors intersected to create a new environment for a specific population with a higher genetic risk for obesity and diabetes.

This case also shows how changes in the practices of global food companies – e.g., increased exports to developing nations; aggressive marketing of high calorie, low nutrient foods and beverages; and expansion of retail outlets to reach diverse sectors of the population– created an obesogenic environment that contributed to the explosive growth of the epidemics of obesity and diabetes in a genetically vulnerable population. Rising rates of obesity and diabetes affected both urban and rural Mexico, but as a result of dense urban markets that facilitated aggressive food advertising, a growing urban middle class that could afford more processed food and a working class population whose food choices became more constrained and less healthy and the declines in physical activity, these epidemics left a distinct footprint in Mexico’s cities. Reversing these trends will require intervention at the multiple levels that have triggered the changes.

Popular mobilization is one potential source of change. In Mexico last year, corn tortillas, a crucial source of calories for 50 million poor people, doubled in price, precipitating protests, demonstrations and eventually government price controls. Whether similar global food changes will lead to a Mexican food justice movement that takes on hunger, obesity and the growing corporate control of food remains to be seen.

By Nicholas Freudenberg, Hunter College, City University of New York.

References

1. Hawkes C. Uneven dietary development: linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases. Global Health. 2006; 28;2:4. 
2. Schwentesius R, Angel Gomez M: Supermarkets in Mexico: impacts on horticulture systems. Development Policy Review 2002, 20:487-502.
3. Rivera JA, Barquera S, Gonzalez-Cossyo T, Olaiz G, Sepulveda J: Nutrition Transition in Mexico and in Other Latin American Countries. Nutrition Reviews 2004, 62:S149-S157.
4. Rivera JA, Barquera S, Campirano F, Campos I, Safdie M, Tovar V: Epidemiologial and nutritional transition in Mexico: rapid increase of non-communicable chronic diseases and obesity. Public Health Nutrition 2002, 5:113-122.
5. Jimenez-Cruz A, Bacardi Gascon M, Jones E: Fruit, vegetable, soft drink, and high-fat containing snack consumption among Mexican children. Arch Med Res 2002, 33:74-80.
6. Jimenez-Cruz A, Bacardi Gascon M,: The Fattening Burden of Type 2 Diabetes on Mexicans.Diabetes Care 2004, 27:1213-1215. 
7. Barcelo A, Aedo C, Rajpathak S, Robles S: The cost of diabetes in Latin America and the Caribbean. Bulletin of the WHO 2003, 81:27. 8. Arroyo P, Loria A, Mendez O: Changes in the household calorie supply during the 1994 economic crisis in Mexico and its implications for the obesity epidemic. Nutrition Reviews 2004, 62:S163-S168.
9. Williams K, Stern MP, Gonzalez-Villalpando C. Secular trends in obesity in Mexico City and in San Antonio.Nutr Rev. 2004;62(7 Pt 2):S158-62.
10. Gonzalez-Villalpando C, Stern MP,Gonzalez ME, Rivera MD, Simon J,Andrade IS, Haffner SM. The Mexico City Diabetes Study: a population-based approach study of genetic and environmental interactions in the pathogenesis of obesity and diabetes. Nutr Rev 1999;5:S72 – S77 

 

Spotlight on the Food Industry: Coke, PepsiCo, and McDonald’s Pledge Healthier Ads for Kids; Critics question impact

In April 2007, 15 food companies, including McDonald’s, Coca-Cola, and PepsiCo, announced that beginning in 2008, they will devote at least half of their ads directed to children under 12 toward promoting “healthy dietary choices” and/or physical activity. Does this new pledge represent a change in direction or is it simply an effort to avoid stronger public oversight?

At least some companies worry about the growing public focus on obesity. In a recent talk at the Venice Festival of Media, Coca-Cola Company Chief Creative Officer, Esther Lee admitted, “Our achilles heel is the discussion about obesity. It’s gone from a small, manageable U.S. issue to a huge global issue. It dilutes our marketing and works against it. It’s a huge, huge issue.”

A recent study of television advertising for children conducted by the Kaiser Family Foundation found that for children under the age of eight , only one ad out of 26 promotes fitness or a healthy diet and for children 8 to 12, it’s even worse, one ad out of 48. Furthermore, the food and beverage ads directed towards children overwhelmingly promote high fat and sugary snacks or fast food. The study looked at 8,854 commercials aimed at children, none of which promoted fruits or vegetables.

Do these ads affect eating behavior? A recent study at the University of Liverpool found that children who had been exposed to food advertisements on television were more likely to overeat than children who had not been so exposed. In the study, 59 nine to eleven year old children of varying weights were exposed to 10 food or 10 toy ads. The children were then allowed to eat a range of snacks at will – from fruit to potato chips and candy. Results showed that total calorie intake was significantly higher after the children were exposed to the food ads. Children of normal weight increased consumption by 84 percent, overweight children by 101 percent, and obese children by 134 percent even though the foods that the children were allowed to eat were not the ones that were advertised.

According to Dr. Jason Halford, Director of the University of Liverpool’s Kissileff Human Ingestive Behavior Laboratory and an investigator in this study, “That’s important because what we’re showing goes beyond branding effects. Advertisers have always argued that food ads do nothing but get kids to change from one brand to another for the same thing – the same argument tobacco companies used. This study shows that that’s completely incorrect. It doesn’t matter if the ad is for a specific product. It produces consumption. Kids consume after they see them.”

These studies suggest that to reduce over consumption and obesity, children may need to see fewer ads, not different ones. According to Marion Nestle, Professor at the Department of Nutrition and Food Studies at New York University, the main nutrition message Americans need to hear is “Eat less” yet the food industry consistently encourages Americans to eat more, the necessary message for healthy profits if not healthy children.

Several recent and current government investigations have scrutinized food advertising to children. For example, this summer, the Federal Trade Commission will be issuing compulsory requests for information from 44 food, beverage, and quick-service restaurant chains. The FTC is especially interested in marketing practices of in-store promotions, events, packaging, internet marketing and product placement in video games, movies, and TV programs. According to the Institute of Medicine, annual sales of food and beverages to American children was more that $27 billion in 2002. Some researchers have calculated that children are exposed to 27 food ads a day and that most promote foods high in fat, sugar, and calories. As a result, children begin to make their first request for a product by two years of age, and 75 percent of those requests are for sugary cereals.

School foods have also become a new battleground. In an effort to lower the rates of childhood obesity, in April, the Institute of Medicine (IOM) recommended strict standards to cut calories, fat, and sugar in all snacks and beverages sold in school vending machines, at fundraisers, and as a la carte items in school cafeterias. In school systems around the country, parents, teachers and food activists are struggling to clear schools of unhealthy food.

Many food industry executives resent government involvement and dread the close attention. One executive told Advertising Age, “It’s clearly a witch hunt.” He said if anyone is to be picked as the scapegoat it’s likely to be the fast food outlets that buy as much media for the 6-to-11-year-old set as other marketers spend on their entire annual budget.

The April announcement is in part a response to this growing government attention. Food industry leaders hope that their voluntary measures will stave off further oversight. Yet, research evidence suggests that voluntary guidelines developed by industry often fail to achieve their objectives. Recently two nutritionists reviewed changes in portion sizes of sodas, hamburgers and French fries at McDonald’s, Burger King and Wendy’s and found few changes despite pledges by these companies to improve their offerings. The authors concluded that “voluntary efforts by fast-food companies to reduce portion sizes are unlikely to be effective, and that policy approaches are needed to reduce energy intake from fast food.”1

Historically the food and beverage industry have shown their capacity to respond quickly to public concerns about health. In 1991 the industry was called to introduce 5,000 new reduced fat food products by the year 2000 to support the Healthy People 2000 initiative – a goal they met by 1995. Yet as these new products came on the shelf, obesity rates continued to grow.

The Coca-Cola Company has been particularly adept in responding to new market forces. The Company’s global beverage portfolio now includes 400 brands that include soft drinks, diet soft drinks, juices, juice drinks, sports beverages, waters, teas, coffees, milk-based drinks and fortified beverages. However, no advertiser has yet promoted reduced consumption of such beverages or encouraged use of tap water, two messages that nutritionists support.

In fact, soft drink companies have been especially eager to promote physical activity, another avenue to weight reduction, rather than reduced consumption. For example, in its Get Active/Stay Active program, Pepsi Cola encourages young people to engage in sports and other physical activities while it still signs pouring rights contracts that require high schools to serve only Pepsi. The effort to divert blame for obesity to physical inactivity is reminiscent of the tobacco industry’s attempt to point the finger at air pollution as the main cause of lung cancer. Both air pollution and physical inactivity warrant attention but the self-serving goal of the focus makes the message suspect.

Some countries have chosen alternatives to voluntary guidelines. In November 2006, the British food regulator agency banned advertising of high fat, salt and sugar foods in television programs made for children or of particular appeal to children under age 16. In announcing the new regulations, outgoing Prime Minister Tony Blair said, “Particularly where children are concerned, I have come to the conclusion we need to be tougher, more active in setting standards and enforcing them.” The British regulatory agency also decided to prohibit the use of licensed characters, celebrities, promotional offers and health claims in food advertising to children. Whether the United States is ready for such a step could make an important issue for the 2008 election.

 

1 Young LR, Nestle M. Portion sizes and obesity: responses of fast-food companies. J Public Health Policy. 2007;28(2):238-48.

Towards a Global Tobacco Control Agenda: The WHO’s Framework Convention for Tobacco Control

Each month Corporations and Health Watch examines global perspectives on corporations and health. We post coverage of campaigns to change corporate practices in other developed and developing countries; present news and analysis on new global trade and other agreements among corporations and their supporters and among international alliances of advocacy groups working to modify health-damaging practices. We invite readers to send us suggestions for campaigns, reports and issues to analyze for our Global Perspectives section. Send suggestions to us.

On May 31, 2007 tobacco control advocates and activists around the world recognized World No Tobacco Day. Through their actions, they drew attention to the fact that globally, tobacco products claim nearly 5 million lives per year and secondhand smoke has been proven to cause death and disease, and they challenged Big Tobacco’s continuing attempts to weaken national and international tobacco control measures.

Tobacco control is a global issue for several reasons. First, as Western nations implement stricter laws curbing secondhand smoke and tobacco industry practices, Big Tobacco increasingly looks to the global south – where there are often weaker tobacco control laws in place – to market its products. Second, in an era of globalized media, Big Tobacco’s marketing efforts reach beyond their country of origin and influence individuals, particularly youth, worldwide. Third, if current trends continue, by 2030 tobacco products will cause more than 10 million deaths per year with 70% of such deaths taking place in the global south. Thus, controlling tobacco has the potential to improve population health around the world. Finally, smuggling of tobacco products is an international issue and this practice is often coordinated by the tobacco industry itself.

As part of a global effort to fight Big Tobacco, 168 countries have signed the Framework Convention for Tobacco Control (FCTC) created by the World Health Organization. Of these, 147 have become Parties – members of the regulating body of the FCTC. More than 250 organizations from 90 countries have also joined the Framework Convention Alliance for Tobacco Control – an international group created to support the FCTC.

The FCTC is considered the world’s first public health treaty. The treaty is designed to address the growing crisis of tobacco-related death and disease and to reduce the health, social, environmental and economic impact of tobacco and secondhand smoke. It was adopted unanimously by the World Health Assembly (the governing body of the World Health Organization) in May 2003. In November 2004, Peru became the 40th country to ratify the treaty, thus meeting the minimum number of ratifications needed to enter the FCTC into force, an event that took place in February 2005. The FCTC is legally binding for those countries that ratify it. However, it is up to national governments to implement the agreement.

The main provisions of the FCTC require signatories to: 1) Ban the use of misleading tobacco advertising; 2) Enact and enforce comprehensive bans on tobacco marketing and sponsorship within five years of ratifying the treaty; 3) Increase tobacco taxes; 4) Require health warnings on tobacco packaging that cover a minimum of 30% of the display area but ideally cover 50% and 5) Implement comprehensive measures to protect citizens from the health hazards of secondhand smoke.

The FCTC also promotes research and the sharing of such research internationally, encourages legal action against the tobacco industry, suggests signatories support cessation services, and requires action against tobacco smuggling and for regulation and labeling of all ingredients in tobacco products. Countries that sign and ratify the FCTC are encouraged to look to these provisions as minimum measures and are encouraged to take a stronger stand against the tobacco industry practices that harm health.

The United States has been an international leader in tobacco control, particularly since the 1998 1998 Master Settlement Agreement, the provisions of which helped reduced already declining smoking rates in the United States. However, the Bush Administration has not been supportive of the FCTC. For more than a year the U.S. refused to sign the treaty and attempted to undermine it. In particular, the Bush Administration fought the provision which mandated a comprehensive ban on tobacco advertising, sponsorship and promotion, claiming that this would be unconstitutional in the United States as corporations are granted First Amendment rights to freedom of speech, which protects their right to advertise. The Bush Administration continued to fight this provision even when language was proposed that would have called for a ban of advertising “within constitutional limits.” The U.S. also fought the funding provisions within the treaty. Finally, in May 2004 the United States signed the FCTC but as of yet it has neither been ratified by Congress nor have its legislative mandates been passed . “Unfortunately,” Kathryn Mulvey of the advocacy group Infact told The Washington Post, “our government has a history of signing treaties, leveraging its power to weaken the treaties, and then never ratifying them. This is a stunning PR maneuver. We are not holding our breath for the U.S. to ratify the treaty.”

By July 2006, 131 countries representing more than 75% of the world’s population had ratified the FCTC. Thus, as other countries sign, ratify and implements its mandates, the United States is falling behind.

From June 30 to July 6, 2007, the Framework Convention for Tobacco Control’s “Conference of the Parties”, a group of countries that lead the effort to monitor implementation, will meet in Bangkok, Thailand. Their agenda is to develop guidelines to:

  • provide protection from exposure to tobacco smoke in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.
  • eliminate of illicit trade in tobacco products.
  • move towards a comprehensive ban on tobacco advertising, promotion and sponsorship, covering both its within-country and cross-border elements.
  • establish standards for packaging and labeling of tobacco products.

The Framework Convention and its nongovernmental partners have the potential to match the global tobacco industry in advancing an international agenda on tobacco, an agenda that protects rather than harms health. Whether the decisions made in Bangkok can realize this potential remains to be seen.

Campaign Profile: Licensed to Kill

Last month youth activists from around the world working with Essential Action’s Global Partnerships for Tobacco Control held a rally in front of the Altria/Philip Morris’ New York City headquarters one day after the company’s 2007 shareholder meeting. The youth staged an action Altria and handing out information to passersby. While youth activists have been taking on Big Tobacco internationally for some time, what made this action particularly interesting was that the activists were joined by rival tobacco company Licensed to Kill (LTK). At the rally, LTK representatives attempted to deliver the “Profiting off of Poison Award–Golden Coffin Award 2007″ to Altria representatives who declined to receive it.

Lest you think that tobacco industry representatives have finally come clean about the fact that their product, when used as directed, causes cancer, emphysema, heart disease and death, it is important to know that LTK is the creation of former corporate lawyer and now activist Robert Hinkley of Essential Action. However LTK is more than just a spoof; it is an actual tobacco company incorporated in the state of Virginia with the stated purpose of engaging in the “manufacture and marketing of tobacco products in a way that each year kills over 400,000 Americans and 4.5 million other persons worldwide.” Hinkley formed the company in order to make a point about both the tobacco industry and the protected status of corporations in American society, particularly those that operate at the expense of public health and safety. While LTK’s application raised eyebrows at the State Corporation Commission, as long as the name isn’t already registered and the applicant pays the filing fee, the application meets basic requirements, and the state has little choice but to grant a corporate charter. Thus, on March 19, 2003, Licensed to Kill was born.

One month later, anti-tobacco activists, including 200 youth, staged a protest at the Virginia State Capital to condemn the company, to call for stricter tobacco control and to stand in solidarity with tobacco control activists around the world. The activists were not alone. Licensed to Kill CEO “Rich Fromdeth” and other Senior VPs were at the state capital celebrating the founding of their new company. Company director Gray Vastone stated, “If a person was to ask the state for authorization to go on a serial killing rampage, he would surely be locked up in jail or a mental institution. Luckily, such moral standards do not apply to corporations.” As LTK executives attempted to introduce their new cigarette brands “Serial Killer,” “Genocide,” and “Global Massacre,” the youth activists booed and attempted to drown out their speeches. In an imaginative alliance, LTK and Essential Action work together to educate the media and the general public about the health hazards of tobacco, the tobacco industry, and the nature of corporations that profit at the expense of human health. In these staged confrontations, LTK “representatives” spoof Big Tobacco and Essential Action youth protest them and the tobacco industry at large.

Licensed to Kill’s website is a humorous critique of Big Tobacco. In the “about our company” section, LTK defines the five attributes that define their business as “a strong commitment to profits over people; excellence in marketing death; financial pay-offs; innovation in public relation spin, and an undying dedication to making a killing.” Their motto is “We’re Rich. You’re Dead!” Licensed to Kill separates itself out from other Big Tobacco companies through their dedication to transparency. They openly admit their products cause death and disease (and that they don’t care); they don’t attempt to improve their public image through a company name change, and they don’t state one thing publicly and another privately. Instead, LTK admits that they market to young people (“Duh! It’s plain common business sense!”) through brands like “Chain™”, a chocolate flavored cigarette. The company also admits it markets to African Americans and specifically designed the product “Slave” to celebrate the historical linkages between Africans and the tobacco industry.

While other tobacco industry representatives try to downplay the health hazards of smoking and secondhand smoke, (“The solution is really quite simple: just don’t breathe!”), LTK boasts that the death and disease caused by smoking is good for the economy: “When our customers eventually succumb to emphysema and cancer, they spend billions of dollars on oxygen tanks, chemotherapy, and medical operations. Every cigarette smoked represents money earned and a stronger American economy.” Big Tobacco is also good for the global economy, states LTK, and applauds weaker tobacco control regulations in countries around the world which allow them to market their products to larger numbers of youth and adults. Finally, Licensed to Kill representatives also laud the U.S. government for its granting corporations Bill of Rights protections such as the right to advertise a deadly product is protected under the guise of “free speech.”

Through mock documents on their website, press releases, and events staged throughout the world, LTK specifically critiques Philip Morris/Altria. For example, shortly after LTK’s incorporation, former Virginia Governor Mark Warner announced that Philip Morris would create 450 jobs in the Richmond area in return for a $25 million performance-based grant from the Virginia Investment Program. LTK responded that it would also seek a relocation incentive package from the state of Virginia. In order to increase its chances, company executives announced that they would invest $1 million in local Richmond area charities: “It’s a tried and true way of showing that, despite our company’s intent to kill 4.9 million people annually, we’re really a good corporation citizen – every dollar we donate buys us the freedom to continue business as usual,” stated Senior VP Corrie Prutspin.

In 2004 the company issued a press release stating LTK executives were in Thailand to attend the ASEAN Art Awards and to “lend Philip Morris support in defending their industry’s right to use art to cover up the 5 million lives it kills worldwide and every year – including more than 40,000 in Thailand alone.” Company spokesperson Virginia Slime also announced LTK’s support for efforts to prevent the ratification and implementation of the Framework Convention on Tobacco Control. The company had previously praised the Bush Administration for its efforts to gut the treaty. Rich Fromdeth declared, “A ban on tobacco advertising, promotion and sponsorship would eliminate one of our industry’s most effective avenues for hooking kids and young adults to our addictive product line. It’s heartening to have a president who stands up for the Big Guys, however unpopular or detrimental to public health it may be.”

In June of 2005, LTK issued a press release announcing that executives would be in Washington, DC to lobby DC city council member Jim Graham against supporting smokefree workplace legislation. CEO Rich Fromdeth argued, “If he cares at all about the health of the tobacco industry, he will take a stand for maintaining the smoky status quo.” Senior VP Virginia Slime continued, “Unlike our industry rival, Altria, which gave the Metropolitan Restaurant Association of Washington $10,000 for its awards ceremony last week, Licensed to Kill believes in direct lobbying.”

Essential Action’s humorous and over-the-top approach both provides information about Big Tobacco and also generates media and public interest in tobacco control, especially among young people. It demonstrates that small organizations can contribute to the changes in public consciousness that will be needed to reduce the harm from tobacco and other lethal but legal products.

Scientists, the Food Industry, and Heart Health: An Interview with Dr. Jeremiah Stamler

Dr. Jeremiah Stamler is one of the founders of preventive cardiology, a speciality that focuses on preventing heart disease.. He is now professor emeritus and was founding chairman of the department of preventive medicine at Northwestern University’s medical school in Chicago. He has published more than a thousand articles, monographs and reports and now in his mid-80s, he continues to write, publish, and advise younger researchers around the world. During his career, he has had numerous encounters with the food industry and government agencies concerning the policy implications of his research. In Fall 2006, Corporation and Health Watch founder Nicholas Freudenberg interviewed Stamler in New York City and Sag Harbor, New York. Here we present excerpts of Dr. Stamler’s descriptions of some of his interactions with the food industry and government as well as his advice for young scientists.

CHW: Dr. Stamler, tell me how your research on heart disease first brought you into contact with industry groups.

STAMLER: As you know, I am a cardiovascular researcher primarily focused on atherosclerotic disease as it affected the coronary arteries. I began as an animal experimentalist, got interested in that in medical school, and spent my first ten years focused on animal experimental work, although I soon branched out into clinical trials and epidemiological issues. Early on I became convinced that the animal experimental knowledge was applicable not just to individual men and women, but to whole populations. It became clear to me that the growing epidemic of cardiovascular and, particularly, coronary heart disease, including sudden death, was related to lifestyle.

From the start, we found ourselves involved in hassles with industry. I had one limited personal encounter — an interesting experience. I got a grant from the National Dairy Council, a one year grant, for experiments on feeding cholesterol to chickens. A knowledgeable and decent colleague was the Scientific Director of the Dairy Council, and we dealt with her. We got that grant with the usual rules, which I had learned from my chief, Louis Katz, the Director of Cardiovascular Research at Michael Reese Hospital in Chicago. Dr Katz taught me that if you take money from an industry or an agency related to an industry, the ground rules have got to be very clear.

CHW: And what were Dr. Katz’s rules?

STAMLER: Rule Number 1. The protocol is our responsibility. We’re pleased to show it to you (the funder), but we will not modify it at your request unless we agree the modifications are useful.

Rule Number 2. We make the decision as to the duration of the study. There are no restrictions on the duration of the study. If we think at the end of a given period, spelled out in the protocol, we need to do further work, repeating or modifying or extending the given study, we extend it. You can give us money, enough to support six months, or a year, or whatever; but if we find that we are not well off at that point and we think more work should be done, it’s our right to continue to do so.

Rule Number 3. With regard to publication, we elect to publish or not to publish. If we do not publish, we will give the data to you for your confidential information. It can not be used in the public arena. If we do publish, we will show you copies of the manuscript, but we have complete control of the manuscript.

And Rule 4. Any money you give us is an unrestricted gift. There are no strings whatsoever, even if it may be for a very specific piece of research. It comes as a check for all, so to speak, a deposit in the bank, and that’s it. We use it as we wish. No strings attached. Those are very good rules. Many young people don’t even know about such rules, when they get involved with drug companies.

CHW: Tell me more about what happened with the Dairy Council.

STAMLER: Well, The Dairy Council agreed to these terms and we got a grant. It was a modest sum, $10,000 for one year. In the middle of the grant year, I got a call from the Scientific Director at the Council.

”Jerry, I’d like you to help us with something,” she said.

“Anything, I can do to help. Tell me what you want.” I replied.

“We’d like you to testify.”

“Where would you like me to testify?”

“State Legislature.”

I said “Well, what would you like me to testify about?”

“Margarine.”

“What about margarine?”

“Coloring of margarine.”

I said, “Oh, you’re in favor of it.” (Which I knew, of course, was not the case.) [The Dairy

Council opposed coloring of margarine that made it look more like butter.]

There was a pause on the other end, and she said “No, we’re against it.”

I said to her, “Look, they say every man has his price. Far be it for me to be Jesus, Moses,

Mohammed, Sir Gallahad, Sir Lancelot — maybe I’ve got a price, too. Maybe if you said a one million dollar deposit in a numbered account in Switzerland, I might think twice. But for one miserable $10,000 grant for which I get nothing in my personal pocket, no way.” The next year I didn’t get renewed.

CHW: Tell me about some of your interactions with government agencies on these questions.

STAMLER: Norman Jolliffe was a distinguished national and international nutritionist who was the Director of the Nutrition Bureau at the New York City Department of Health from 1949 to 1961. As a good public health officer, Norman wrote letters to the Food and Drug Administration, which a number of us co-signed, expressing profound concern with the failure of the FDA to do anything about what came to be known as the diet-heart question. He requested that the FDA go officially on record supporting diets lower in saturated fats and cholesterol, as part of healthy nutrition. You have to understand that prior to the USDA/DHHS dietary guidelines there were only nutritional recommendations for health, focusing mainly on undernutrition. Also, one of the problems was that the dairy industry had a — what is the wrestling term? — a grip lock on nutritional recommendations. The dairy industry, through the National Dairy Council, was the dominant source of nutrition information in elementary schools, high schools, colleges, and rural areas.

Well, the FDA never replied to any of Jolliffe’s letters. No replies at all. None. But finally one day Norman was at FDA headquarters, and he saw the Commissioner of the FDA and said, “Look, what’s going on? We write you letters. You don’t reply. You don’t say no, you don’t say yes, you don’t say anything. You file it, get rid of it. What’s the problem?”

The guy says, “Look, Jolliffe, you get meat, egg, and dairy off my back and I’ll reply.” Just that simple. And for years, the National Heart, Lung, and Blood Institute also avoided making a statement on diet and heart disease for similar reasons. In 1960, the American Heart Association issued its first statement on diet. I was a co-author. We went through seven revisions of a very careful statement on the possibility of preventing coronary disease. It was the first American Heart statement. A year or two before, there was a statement on risk factors for heart disease that Mary Lasker helped to publish through the National Health Education Committee, a private group. But the NIH Heart Institute was silent. The Public Health Service, FDA — for years — silent. Bob Levy, then Director of the National Heart, Lung, and Blood Institute, once had a Congressional staff person say to him, “You organize the Heart Institute to go on record on the diet-heart question, and we’ll cut the balls off your budget.” Simple.

CHW: Let’s turn to salt. The American Medical Association estimates that 150,000 lives could be saved annually if sodium levels in packaged and restaurant foods were cut in half. I understand you spent many decades studying the impact of salt on cardiovascular health. Tell me something about your interactions with Campbell’s Soups and with the Salt Institute, the industry trade group, on this issue.

STAMLER: Well, in the late 1980s, Campbell’s presented soups on the shelves called “Heart Healthy” on the basis that they were low in fat. But as you know by looking at any label of usual Campbell soups, they were then and they are today (except for a few “salt-modified” or “lowsalt” products), very high in salt. So people who were concerned with salt and heart health said “How can you make a claim for heart healthiness when you have a soup that’s so loaded with salt?”

So several advocacy groups went to the Federal Trade Commission and said that this was false and misleading advertising and should be stopped. In January 1989, the Federal Trade Commission cited Campbell’s for making misleading health claims and temporarily enjoined Campbell’s from making such claims, pending a hearing.

CHW: How did the Federal Trade Commission get to you?

STAMLER: A young FTC lawyer came to me and said the Commissioners are saying, “What are the data that refute the argument that salt sensitivity is a minority phenomenon prevalent only among some hypertensives, not a population wide phenomena? Will you come and talk to the Commissioners?” she asked. Before the FTC lawyers could go into the courtroom to get an injunction, they needed approval from the Commissioners. And I went and delivered a talk and then the lawyers got permission to go ahead.

In the court proceeding, I was asked to be an expert witness for the Federal Trade Commission on the question, “Is salt really a public health concern?” The argument repeatedly used by food processors whose products have a lot of salt and the salt industry is “No. If salt relates at all to blood pressure, first of all it’s one of many variables; second, it relates only to people who have high blood pressure, and, third, it relates only to a proportion of them who are ‘salt-sensitive’. Therefore, it is a clinical issue, not a public health issue. There is no reason to say that a soup that claims heart healthiness because of its low fat content can’t make that claim because of public health concern with salt.” By the way, these same syllogisms were used in the past by the food industry special interests that defended high fat food, until they finally more or less gave up on the fat question.

CHW: So what happened at the FTC hearing?

STAMLER: FTC proceedings allow a period of discovery so I was deposed by a distinguished, able, straightforward, calm, businesslike Washington attorney. In a day and a half or two of detailed depositions, his main objective was to try to undermine my scientific foundation for the statement that the problem with the so called salt sensitivity response of the blood pressure to dietary salt is not idiosyncratic, not only a clinical problem ; and does not affect only a small percent of population. Rather, we argued it’s fundamentally a population-wide issue.

Our Intersalt Study has shown that it is a problem throughout the population with, at most, only a small percent of people escaping the consequences with no rise in blood pressure with age. In that study, we found a consistent relationship between salt and blood pressure and concluded that high salt intake is a major preventable risk factor for epidemic cardiovascular disease.

CHW: When you were being questioned by this lawyer, did he know the science? Was he up on the science?

STAMLER: Oh, yes, he was very well prepared to represent his client. But I and my colleagues who were expert witnesses for the Government held our own. It wasn’t readily possible to shake the foundation of our conclusions. This, of course, is supported by the fact that such conclusions have been stated, and restated time and again by independent research groups.

CHW: So what happened next?

STAMLER: Soon after the depositions, Campbell’s Soups threw in the towel and dropped their objection to the FTC finding. I’m sure one of the reasons was that the legal action was costing a fortune. You can imagine what a good Washington law firm was costing them. Even for a relatively rich corporation, they are in the food industry where profit margins are not like in the drug industry.

CHW: Did Campbell’s change their products?

STAMLER: Well, they began to put out more soups that were modified salt, but most of these are still too high. There are three levels with Campbell’s Soup and salt. The first is the usual, which is almost like drinking sea water. The second is a modified version, which is somewhat lower but still too high in salt content. And then there are a few low salt, or really low salt soups. Their problem is that many people are attuned to soups that are high in salt, and there is no good salt substitute that gives the equivalent flavor. They’ve been wrestling with trying to get a substitute; they used potassium, they used other things, but it has been very hard. There are ways you can make soup that’s very tasty without salt. We know a wonderful cook who makes lentil soup for us, and we make tomato soups. Tomato’s a good way to go for taste without salt.

CHW: So what’s happening now on salt?

STAMLER: A new committee created through the Department of Agriculture and the Department of Health and Human Services is reviewing the dietary guidelines for Americans, one of the seven being on salt. The Salt Institute launches a big campaign to get rid of that one, and intensified its harassments and its objections and its criticisms of the latest scientific work on salt. But nonetheless, repeatedly that body has reiterated the salt recommendation. Recently, the World Health Organization had a huge conference in Paris reviewing the whole situation, it’s purpose being not to review the facts but, taking the facts as given, what can be done to reduce the population’s intake in salt. In addition, the American Medical Association joined the effort to reduce salt in processed food and the new USDA/DHHS guidelines reiterated the importance of reducing salt.

CHW: Even though you are a prominent scientist with a long track record of scientific publications, you have never hesitated to step into the policy arena or to take on the special interests that defend health damaging policies. What kind of advice can you give young researchers who want to look at the relationship between the food industry and patterns of illness? What advice would you give for how to study those things or for how to frame the questions in the context of the current biomedical framework?

STAMLER: Well, first of all, unfortunately, too few people have an interest of that kind. There is still prevalent in the scientific community a rejection of what I call the classic Baconian creed on what science is all about. You know, Bacon helped to create the foundations of modern scientific approaches, and struggled against scholasticism — medieval, church-based scholasticism of the kind of “How many angels are dancing on the head of the pin?” His idea was that the task of scientists is to collect information for human welfare, to improve the lot of mankind. And that became the creed of science. To this day there are big hassles in our country on the conflict between basic and applied research. Influenced by Bacon, Pasteur formulated the simple concept “There is no such thing as basic and applied science. There is only science and its application.” Very simple. Very clear. But to this day, throughout the scientific community in America, the good science, the real science, the quality science is still considered basic science.

But how do you define basic science? Do you mean you work at a bench? Do you mean you work on the sub cellular level, the cellular level, the tissue level, the organ level? Is it a level? Is it a place of work? Is it a scientific tool? What’s basic research? When Einstein formulated his famous equation, that was pretty basic research, and when it was made into a bomb, that was a pretty definitive application. Similarly with Fleming and penicillin. So what’s the dialectic there?

CHW: So bring this back to your advice to young scientists.

STAMLER: Yes, let me go back to your question — that was a long diversion. My fundamental viewpoint is that everything having to do with medicine, at every level has to do with a practical, applied branch of human life. Therefore, everybody working in medicine must ask himself/herself the question: “What are the possible applications?” And in fact, when you write a research grant you have to put it in. That’s kind of ironic. There’s no such thing as a research grant — at least not for the National Institutes of Health — where the researcher can say, “I’m doing basic research. I don’t have even a remote idea—a hypothesis– about the application.” By the way, the only real definition of basic research is, research whose application is not currently apparent.

So every scientist working in medical research, wherever, has to be conscious of possible applications. Any scientist who has any application that is in the public health arena at all, and nowadays that covers anything related to treatment because all treatment relates to pharmaceutical and other industries. So as soon as you get to treatment, you’re up to your eyeballs in commercial interests. Therefore, you have to be aware that what you are working on not only may have applications, but may relate to special interests that have an axe to grind in relation to those applications. Sometimes a very nasty axe of downright vicious opposition. C. E. Winslow, the great public health leader the of the early twentieth century, said all progress in public health in the United States is going to be very difficult from now on because every step proposed will be in conflict with special interests. So every scientist must be aware of this. And every scientist who is worth his weight in anything should be prepared to struggle for the integrity of the application, of the sound knowledge that he collects. He or she cannot be indifferent.

Now, this business of indifference is a whole ideology: “ I’m a scientist. I collect the data. I make them available to the policy makers to do with it what they see fit. What is done with these data is not my responsibility.” That’s a whole ideology. Some researchers say “Well, I’ve got to remain objective. If I espouse a cause, I become committed and, therefore, biased.” That’s not true. To espouse the truth is not biased. To fail to espouse the truth is to betray the Baconian tradition.

CHW: So what are the implications for training scientists?

STAMLER: Well, I have certain ideas. If you’re going to espouse the proper application of your findings and other findings, then you have to do it skillfully, carefully, not just a gesture. And that means first and foremost, you have to work with organizations. So if you’re in the cardiovascular field you have to be active in the Heart Association, if you’re concerned with public health, the American Public Health Association. You may even be active in electoral politics at one level or another, you have to respond with articles on policy, not just articles on your scientific findings, etc. Do it well. Do it well. Don’t just give it a lick, a promise, a gesture.

And the final thing is, of course, you cannot allow yourself to be intimidated by special interests who deliberately try to intimidate you. I’ve had my experience with the salt industry and others as well. I received a letter from The Salt Institute’s lawyers challenging our data and demanding the whole data file so that further and “proper” analyses could be done. That could be very intimidating, you know.

In fact, many people prefer not to get involved in the public arena because they don’t want all those hassles, including the time it consumes. It consumes a lot of time. So I think good preceptors need to make all young scientists aware of this set of issues. What is the right tradition of science? Does advocacy mean loss of objectivity? Advocacy for valid, true, clearly established, sound data –so defined by the scientific community? What does that signify? Is such advocacy bias that reflects loss of objectivity? Is commitment biased? Is that a valid line of thinking? Unfortunately, many young scientists are never confronted with these issues.

Spotlight on the Alcohol Industry: Anheuser-Busch Pulls “Spykes” Amid Criticism

Anheuser-Busch, the manufacturer of Spykes, a two-ounce flavored malt beverage, decided to pull the product from the market after receiving a written warning on May 10th from 27 state Attorneys General accusing the company of violating the Beer Institute Advertising and Marketing Code. According to the Attorneys General, Spykes the drink, as well as its promotions and advertising, appeared to be especially designed to attract youth, particularly young girls.

Spykes was a two-ounce flavored malt beverage containing caffeine, ginger, guarana –and 12% alcohol. The product was available in such flavors as chocolate, mango, watermelon, and lime and was marketed as a flavor additive to beer. According to Anheuser Busch, Spykes was created for adults as a lower alcohol alternative to hard liquors. They pointed out that the market contains more than 50 products in this category in all colors and flavors, most of which are hard-liquor beverages that have a greater concentration of alcohol by volume than Spykes. However, according to one critic, Bruce Livingston, the Executive Director of The Marin Institute, “Spykes was a 12 percent alcohol depth charge – clearly designed to appeal to teenage girls in brightly colored 2 ounce containers that look like nail polish.” Richard L. Keller, MD, a coroner from Chicago added that “my concern is that they fit easily into a tuxedo jacket pocket, or purse for prom night ‘fun’.”

The Attorneys General pointed out that the product was marketed primarily on the Internet with no effective means of preventing underage visitors from entering the site. In addition, they noted that the product website included wallpapers, screensavers, instant messaging icons and ringtones that were highly attractive to teenagers. Finally, they stated that Spykes Internet ads offered “vivid” descriptions of the flavors available, but no mention that the product contained alcohol. They concluded that “The labeling for Spykes is inadequate and the content of its advertising is irresponsible, reflecting a basic disregard for consumer safety and welfare.”

In defense, Francine Katz, a spokesperson for Anheuser-Busch stated, “Those who criticize Spykes fundamentally misunderstand the behavior of many illegal underage drinkers. They drink for instant impact. The fact that Spykes are sold in two-ounce bottles and have a total alcohol content equivalent to only one-third of glass of wine makes it much less likely that illegal underage drinkers will choose Spykes as opposed to similarly-colored and similarly-flavored products that are 70 to 80 proof hard liquor.”

However, according to a statement from the Connecticut Attorney General, Richard Blumenthal, “Spykes is double trouble – alcohol and caffeine combined in large doses to create a high energy rush with the illusion of alertness when drinkers are impaired. With Spykes marketing and promotion, Anheuser-Busch belies the fight against underage drinking and its own public pitch to ‘drink responsibly.’”

The May 10th letter was signed by Attorneys General from Alaska, Arizona, California, Connecticut, Colorado, Florida, Illinois, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Nevada, New Mexico, New York, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Utah, Vermont, West Virginia, and Wyoming.

Alcohol Producer Voluntarily Adopts Stricter Rules in an Effort to Reduce Underage Drinking

While state attorneys general mount a high-profile campaign to curb under-age drinking, Beam Global Spirits and Wine, manufacturers of such brands as Jim Beam, Maker’s Mark bourbon and Canadian Club whiskey, announced earlier this month that they would voluntarily adopt stricter rules to keep messages away from young people.

Beam elaborated that it would purchase print and broadcast advertisements only in outlets where at least 75 percent of the audience is above the legal drinking age. This is a more stringent standard than the current, self-imposed industry standard of 70 percent.

However, the move may be largely symbolic. Beam Global Spirits and Wine does not produce beer or flavored malt liquors – the target of most of the objections to alcohol advertising. Critics argue that beer and flavored malt beverages – often referred to as alcopops – appeal to under-age drinkers, particularly young girls, while Beam’s products appeal to primarily an older, adult audience. According to George Hacker, Director of the Alcohol Policies Project at the Center for Science in the Public Interest, “If Beam takes a good look at their target audience, they are not sacrificing a lot.” Mr. Hacker added that he would prefer to see Anheuser-Busch and Diageo, maker of Smirnoff-Ice, adopt the higher standard. “Their products are more deliberately targeted to young people.”

While Beam Global Spirits and Wine is volunteering to curb its advertising, it maintains that advertising does not contribute to under-age drinking. But Steven Rowe, the attorney general of Maine argued, “To say there’s no causal connection is to have your head in the sand. It’s to not recognize reality.” He told The New York Times that he and other attorneys general were “calling on industry members to follow Beam’s lead and join the effort to reduce under-age drinking.”

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