Tobacco Documents Online

October 31, 1980 MINORITY ?,EPORT The majority report recommends a series of costly and wide-ranging measures designed to curtail the use of tobacco products in the State of Michigan. In view of the drastic -- indeed, sometimes punitive -- nature of the recommendations, the Governor and the citizens of Michigan were entitled to a searching analysis by the panel of the majority's factual assumptions and a careful weighing of the probable costs and benefits of the measures being considered. Regrettably, this did not occur. The result is a series of hastily conceived recommendations that would disserve the citizens of the State of Michigan. The majority report contains several statements as to the health consequences of smoking on smokers as well as nonsmokers. As demonstrated in Part II of this Report, these statements are not warranted by the available medical and scientific evidence. Indeed, the theory of "excess" deaths or disease relied upon by the majority has been criticized repeatedly. The majority's assessment of the "costs" of smoking stands on no firmer footing, as explained in Part III below. Finally, Part IV of this Report sum- marizes some of the more glaring problems and objections associated with the majority's major policy recommendations. I. The Majority Report Is the Product of Hasty and Uncritical Deliberations by the Panel The idea of creating a citizens' panel to consider a particular public policy issue has much to recommend it. Such a panel can be composed of people having diverse exper- tise and interests, and can take advantage of its members' sense of community service. But these benefits cannot be realized if the panel is unduly limited in focus, is denied sufficient time or resources to complete its work or is controlled by some preordained notion of what would be an "acceptable" result. In the latter circumstances, the citizens' panel is little more than a charade -- with the attendant danger that the panel's recommendations will be given more attention than they deserve. That is precisely the danger presented here. I

2 The ability of the present panel to contribute to the dialogue on smoking and health depended upon the panel's willingness to investigate, as comprehensively and objec- tively as possible, the available scientific evidence and then to recommend to the Governor any policy initiatives that seemed warranted by that evidence. But instead of proceeding in that manner, the panel engaged in a headlong rush to judgment. Prior to the first meeting of the panel, which took place on June 19, 1980, the Project Director, Dr. Kenneth E. Warner, sent to all panel members a memorandum that addressed in summary fashion a variety of smoking and health issues. The note that accompanied the memorandum pointed out that the memorandum was "a first draft" that had been prepared during the preceding "week and a half." The memorandum was entitled a "discussion paper," suggesting that the issues covered by Dr. Warner would be the subject of investigation and discussion by panel members. This suggestion was strengthened by the statement in Dr. Warner's covering note that "[t]he attached paper is intended to provide [panel members) with background information as a common starting point for the Panel's deliberations." Rather than providing a "starting point," the panel majority uncritically, and without the necessary examination, accepted the factual assertions in the Warner memorandum. In announcing the first meeting of the panel, Dr. Maurice S. Reizen, Director of the Department of Public Health, referred to the Warner memorandum and then informed panel members that "[d]ue to the limited amount of time to make recommendations to the Governor on a Statewide plan, we will begin with a discussion of policy options during the June 19th meeting." In fact, beginning with the June 19 meeting of the panel, and at all succeeding meetings, the panel majority simply ignored the acknowledged limitations of the Warner paper and, at the same time, refused to consider any opposing views. The panel majority seemed to view its responsibility solely in terms of identifying all conceivable means of curtailing the use of tobacco products in Michigan or pun- ishing the users of such products. At no time did the panel consider whether such goals were appropriate or feasible. After having challenged this restricted and mis- guided view of the panel's responsibility at the panel's July 17 and August 18 meetings, the minority summarized its

3 concerns in a letter to Dr. Warner dated August 26, 1980. That letter pointed out, among other things, that -- °Many of the statements in the Warner memorandum concerning smoking and health are highly question- able,*and are based upon unproven medical assump- tions, dubious social accounting techniques, and unbalanced economic rationales. °The panel's decision to restrict public comment to a total of 1-1/2 hours effectively prevented any constructive public dialogue on the funda- mental issues that should have been of concern to the panel. °The delegation of much of the panel's work to a small subcommittee, which was not representative .of the entire panel, and the failure of many panel members to attend scheduled meetings, robbed the panel of its proper deliberative character, making the panel little more than a rubber stamp for staff and subcommittee decisions. The letter ended by noting that "unless the nature and scope of the Panel's deliberations are altered significantly to include a comple'te airing of the smoking and health issue, the Panel's ultimate recommendations to the Governor will represent a disservice to the citizens of the State of Michigan." On September 2, 1980, Dr. Warner wrote to the minority to make clear that no questioning of the factual assumptions being relied upon by the staff and the panel majority would be permitted. According to Dr. Warner, "[w)ith a lot more time and a commitment of significant fiscal resources, I am sure that we could refine our under- standing of policy needs and alternatives, but not, I suggest, of the basic smoking and health facts." In the same letter, written almost a month before panel proceedings had concluded, Dr. Warner suggested that the minority consider f iling a "minority report" -- thus leaving no doubt that the panel would pursue but one course, the course charted by Dr. Warner. In keeping with this attitude, the panel discour- aged participation by representatives of the business cor,ununity in favor of participation by groups with views

4 identical to those of most panel members. Few business groups or emoloyer-related organizations even were apprised of the panel's meetings. Indeed, of a group of 28'organiza- tions that were notified of panel meetings, only four were business related; the rest were almost entirely health or health education groups.l/ The panel also refused to consider evidence, sub- mitted by the minority, that disputed the principal medical and economic assumptions contained in Dr. Warner's original "discussion paper."2/ The minority's complaints concerning the panel's failure to consider this evidence went largely unheeded, as did the frustration voiced by the minority over the panel's failure to consider fully the ramifications of the policy proposals advanced in the majority report. In sum, in their zeal to immose their views regarding smoking on all the people of Michigan, the major- ity failed to consider the propriety or wisdom of doing so. Because of the panel's failure to analyze the factual assump- tions underlying the majority recommendations, or to engage in a meaningful cost-benefit analysis of the proposals, the recommendations can only be viewed with substantial skepticism. II. The Medical Assumptions Relied Upon To Justify the blajority Recommendations Reauire Critical Evaluation The primary justification for the restrictive measures advanced by Dr. Warner in his original memorandum (and repeated without substantial change in the majority report) is the theory of "excess" deaths or disease due to 1/ The minority's request that business groups be notified of the panel's meetings or involved in the panel's delibera- tions was rebuffed by concerns about "time constraints," fears of "disrupting" the panel's schedule, and the sugges- tion that any response by the business community could be put off until the panel's reco:nmendations were submitted for legislative action. . 2/ Dr. George E. Schafer, "The Smoking and Health Contro- versy: Another Side," August 1980; Letter to Dr. Warner from Walter P. Maner III, dated October 1, 1980.

cigarette smoking.l/ The paper of Dr. George L. Schafer, submitted by the minority, amply demonstrated the highly questionable nature of that theory. . Although the majority report assumes a causal connection between cigarette smoking and death or disease, no such causal relationship ever has been established. Moreover, the Advisory Committee that prepared the 1964 United States Surgeon General's Report expressly rejected the theory of "excess" deaths or disease upon which the panel majority has relied.2/ The questionable validity of assuming that "excess" deaths or disease are caused by cigarette smoking is demon- strated by a few simple facts. For instance, if smoking causes lung cancer, it would be reasonable to expect higher rates of the disease in countries where more cigarettes are smoked per capita. But that is not always the case. Lung cancer mortality rates vary from country to country, and many countries with low tobacco consumption patterns have high lung cancer mortality rates. Moreover, the age of onset of lung cancer is independent of the age of initiation of smoking: In fact, on the average, smokers and nonsmokers get lung cancer at approximately the same age -- a fact that is curious if smoking indeed causes lung cancer. There are 1/ Warner, "Smoking and Health in Michigan," p. 1; Majority Report, p. 1. 2/ The Advisory Committee stated: "The total number of excess deaths causally related to cigarette smoking in the U.S. population cannot be accurately estimated." United States Public Health Service, Smoking and Health: Report of-the Advisory Committee to the Surgeon General of the Public Health Service, Dep't of Health, Educ. and Welfare, PHS Pub. No. 1103 (1964). In explaining the reason for its refusal to claim "excess deaths," the Advisory Committee stated: "The Commit~ee considered the possibility of trying to make suc'rh calculations, but it involves so many assumptions that the Committee felt that it should not attempt this ***." Hundly, J., Transcript, News Conference, Released by United States Public tieal:.h Service (January 11, 1964). i

6 many other factors linked with lung cancer such as occupa- tional exposures, viruses, diet, food additives, pollution, stress, aging, and impaired effectiveness of body defense' mechanisms.l/ Undue preoccupation with cigarette smoking can be counterproductive in searching for the causes of and cures for lung.cancer.2/ Likewise, it has not been established that ciga- rette smoking is Causally related to coronary heart disease. In addition, there is persuasive evidence, as reported by Dr. Carl Seltzer in "Smoking and Coronary Heart Disease:r What Are We To Believe?", American Heart Journal (September 1980), demonstrating the unreliability of the conventional view that cessation of smoking reduces the risk of death from heart disease. Dr. Seltzer also has pointed out that, despite many years of research and experimentation, a causal connection between smoking and coronary heart disease has not been established. In reality, cardiovascular disease is multifac- torial in origin. There are many suspects: high cholesterol, high blood pressure, diabetes, aging, being male, obesity, personality type, physical inactivity and stress. Dr. Ancel Keys, a noted scientist, emphasized in his recent book, Seven Countries Studv, that the relationship between smoking and heart disease is not as simple as first supposed. Others have found that the mortality rates for cardiovascular disease have declined markedly in the past decade. These declines are even more marked in women,than in men. Yet, during this same period, tobacco consumption by women was reportedly on the rise. These reports are difficult to reconcile with the causal hypothesis. Several national com- mittees have considered the decline in cardiovascular disease and have not been able to attribute the decline to any known factor or group of factors.3/ 1/ For example, the incidence of lung cancer at General riotors Corporation's Coldwater Road plant in Flint is more than double the national average. A signif icant number of lung cancer deaths at that plant occurred among people who worked in areas where chrome, nickel and,cadmium were used. The Tr:ashington Post, Sept. 23, 1980. 2/ Schafer paper, pp. 7-9. 3/ Schafer paper, pp. 10-13.

7 The second major flaw in the "excess" deaths and disease theory is the unreliability of the "extrapolations from national data" used by Dr. Warner to arrive at smoking and health statistics purportedly meaningful to the State of Michigan.l/ Many of the national figures themselves are questionacle because they are out of date2/ or were the result of studies that -- - "tended to investigate the rate of smoking independently of other behavioral variables, such as alcohol consumption and other lifestyle factors, occupational and environmental hazards, and certain psychological factors."3/ In view of the questionable nature of the national data, "extrapolations" from that data must be examined with particular care -- all the more so when such extrapolations fail to take into account factors unique to the State of Michigan. The majority did not examine Dr. Warner's tech- nique of extrapolation or data base with regard to smokers at all. The factual assumptions underlying the*majority's recommendations to "protect" nonsmokers from tobacco smoke suffer from a similar lack of critical examination. For years, evidence on the possible health effects of tobacco smoke on nonsmokers has been limited and mixed. In fact, the 1979 Surgeon General's Report concluded: "Healthy nonsmokers exposed to cigarette smoke have little or no physiologic response to the smoke, and what response does occur may be due to psychological factors."4/ Many inde- pendent scientists have reached similar conclusions.5/ 1/ Warner, "Smoking and Health in Michigan," pp. 17, 20; Majority Report, p. 1. 2/ Schafer paper, p. 4. 3/ Schafer paper, p. 5; quoting from United States Public Health Service, Smoking and Health: A Report of the Sur eon General, Dep't of Health, Educ. and Welfare, DHEW Pub. No.. 79-50066 (1979). 4/ United States Public Health Service, Smoking and Health: A Report of the Surgeon General, Dep't of riealth- auc. and Welfare, DHEW Pub. No. 79-50066 (1979), at p. 11-28. 5/ Schafer paper, pp. 14-16.

8 The panel majority, following Dr. Warner's lead, choose to ignore this.evidence 4nd to rely instead on a single, widely-criticized study by White and Froeb reported in the New Enaland Journal of Medicine.l/ Although the report of the stuay asserz.ed that ciiror.ic exposure to tobacco smoke affects the small airways of nonsmokers' lungs, many scientists have criticized the study for flaws in design, methodology and techniques -- and also for the conclusions drawn. Dr. Claude Le_zfant and Ms. Barbara Liu of the Heart, Lung and Blood Institute of the National Institutes of Health cautioned in an editorial in the same issue of the New England Journal of Medicine that contained the White-Froeb report: "The question must be asked whether White and Froeb's new evidence is sufficient to initiate new legislative actions that would further restrict smoking in public places. This is, of course, a difficult and delicate question. * * * [T]here is no proof as yet that the reported reduction in airways function has any physiological or clinical consecuences. The study is confined to only one aspect of an issue too complex to be resolved on such a limited basis."2/ In sum, there is substantial reason to doubt the factual assumptions underlying the recommendations in the majority•report as to both smokers and nonsmokers. In recent years, smoking has become an easy target for people anxious to solve our nation's health problems. But these problems will not be solved by ignoring the scientific complexities surrounding the smoking and health issue. But that is precisely what the panel majority has done. 1/ White and Froeb, "Snall-Airc•;ays Dysfunction in Non- smokers Chronically Exposed To Tobacco Smoke," New England , Journal of Medicine 720-723 (March 27, 1980). 2/ New England Journal of Medicine, pp. 742-743. For a representative listing of other critical discussion of the White-Froeb study, see Schafer paper, pp. 17-18.

9 III. The Asserted Economic Justifications for the Majority's Recommendations Also Are Flawed The panel majority also accepted without critical scrutiny the assertions contained in Dr. Warner's original "discussion paper" as to the social "costs" of smoking. These assertions are made suspect,-of course, by the unreli- ability of the medical assumptions upon which they are based. But even if the problems with Dr. Warner's medical data and conclusions are put to one side, Dr. Warner's economic assessments cannot withstand analysis. Dr. Warner failed consistently in his discussion paper to distinguish between private costs, which accrue to individuals as a result of their own personal choices, and external or social costs, which fall upon others. As a result, there is extensive double-counting of costs through- out Dr. Warner's discussion paper. Absenteeism and medical costs, to take an example, are fundamentally private, rather than social costs. That some part of certain medical bills often are paid out of common funds does not change the aggregate wealth of society. These transfers are merely from one sector of society to another. Furthermore, it is clearly inappropriate to speak of "the net cost of smoking" because cost, in economics, is an opportunity concept. It requires that we compare one state of affairs with another. When it is said that the cost of smoking is x dollars per year, what is the alter- native against which this cost is measured? If the answer is "no smoking," it must be recognized that we know little about the costs that would then arise. The only natural use of such comparative costs is to evaluate a proposed policy: Will the policy's benefits exceed its-costs? That is the ~ central question to which the Governor and the people of Michigan need a realistic answer. But the majority did not even conside!r the question. Indeed, the panel proceeded no further in its analysis than Dr. Ularner's initial discussion paper. And even Dr. Warner conceded in that paper (p. 50) the need to study the cost-effectiveness of any proposals that might be made. On the other side of the cost-benefit equation, ~ ~ Dr. Warner's discussion paper unduly minimized the tobacco 9 C rA ~ ~ m

industry's economic contribution to Michiga.n.l/ On Septem- ber 15, 1980, the Wharton Applied Research Center of the University of Pennsylvania released a study of the United States tobacco industry's economic contribution to the nation in 1979.2/ This study shows that in Michigan, in 1979, the direct and indirect contributions of the tobacco industry accounted for 76,410 full-time equivalent employees who earned over 1.2 billion dollars. Just under 10,000 of these employees were at work in 1979 because of the direct contributions of the core sectors of the tobacco industry in Michigan. These core sectors included intermediate dis- tribution, retailing and vending, and support industries such as media and promotion. Personal compensation in the support industries alone amounted to 11.5 million dollars. Gross sales exceeded 925 million dollars in the retailing and vending sectors, and approached 666 million dollars for the intermediate distribution sector. The direct contribu- tion to state taxes in Michigan in 1979 totaled 164.7 million dollars. Additionally, within the state, the tobacco industry's contribution to federal taxes totaled 171 million dollars (excise, FICA, personal income and corporate income). Thus, the policy recommendations of the panel majority, in addition to resting on highly questionable medical assumptions, arq the product of an economic analysis designed to inflate significantly the so-called "social" costs of smoking. This problem is compounded significantly by the fact that the panel majority chose to ignore entirely the substantial economic contributions of the tobacco industry to the State of Michigan and its citizens. 1/ Warner paper, pp. 27, 30. 2/ Wharton Applied Research Center and Wharton Econometric forecasting Associates, Inc., Report Summary, A Study of the U.S. Tobacco Industry's Economic Contribution to the Nation, Its Fifty States and The District of Columbia, (August 1980).