Ashes to Ashes (144 page)

Even these increases, however, were dwarfed by the prospect that accompanied the arrival in the White House in 1993. of the first avowedly antismoking President. As governor of Arkansas, Bill Clinton had vetoed a smokers’ rights bill as trivializing authentic civil rights concerns. New First Lady Hillary Clinton, practically the moment she set foot in the nation’s executive mansion, declared it a smoke-free zone—an important symbolic breakthrough for the tobacco control movement. In making clear, furthermore, that health-care reform was the keystone of his legislative agenda, Clinton said that the goal could be achieved without resorting to any increase in taxes—except for one. “I think health-related taxes are different,” he explained. “I think cigarettes, for example, are different. We are spending a ton of money in private insurance and government tax payments to deal with the health-care problems occasioned by bad health habits—and particularly smoking.”

How high was the national medical bill for smoking-related diseases? In 1994, the Centers for Disease Control placed the figure at $50 billion annually, or twice the previous estimate for direct medical costs attributable to smoking; the new figure represented 7 percent of the entire U.S. health bill. But public-health and antismoking groups, in calculating the net dollar cost to society, never mentioned the $12 billion or so that smokers paid in the form of federal and state cigarette taxes; instead, they called for a two-dollar-a-pack increase in the federal excise levy to cover the alleged $50 billion smokers’ health-care cost. Tobacco-state congressmen made it clear to the White House that so huge
an increase, roughly doubling the price of a pack of cigarettes, would lose the President their support for any health-care reform bill he put forward, and the Clinton administration’s proposed figure was pared to seventy-five cents—still more than tripling the federal cigarette levy.

But the tobacco industry now drew attention to evidence gathered by econometricians, biostatisticians, and other analysts that the net figure for health costs attributable to smoking-caused diseases was being much exaggerated by tobacco control advocates. The most highly regarded work on the true health-cost burden smokers were imposing on the rest of society was a 1991 study sponsored by the Rand Corporation and published by Harvard University Press—
The Cost of Poor Health Habits by Willard G. Manning et al
. The Manning study added up the higher lifetime medical costs for smokers, the deficit in life insurance premiums they paid in as compared with the total payout to their beneficiaries, the property damage from cigarette-ignited fires, and the tax revenues that prematurely dying smokers did not pay to finance health and retirement programs—but out of fairness the study also calculated the
savings
that smokers provided by being fated to die younger than nonsmokers. Smokers received far less in retirement and health-care benefits from the government’s Social Security and Medicare programs, drew far less in payments from private pension funds, and made far less use of private nursing homes. When all of these factors were taken into account, the Manning study as updated to 1995 dollar values found the net cost to the rest of society due to smoking-related diseases to be thirty-three cents per pack, not the two dollars the government’s CDC claimed—and well under the fifty-two cents a pack in federal and state taxes which smokers were paying in 1994.

The Congressional Research Service, operated by the Library of Congress, examined the Manning study and several others on the same subject and found, in a 1994 report entitled “Cigarette Taxes to Fund Health Care Reform: An Economic Analysis” by Jane G. Gravelle and Dennis Zimmerman, that the Manning methodology was the most thorough and its “spillover” cost figure of thirty-three cents a pack was the median for all studies on the subject, thereby casting doubt on the fairness of a heavy additional tax on smokers alone to pay for the new Clinton health-care program. The Gravelle-Zimmerman report also remarked:

Some argue these estimates of net external costs [due to smoking-related illness and not borne by smokers themselves] are inaccurate because they do not account for the intangible costs of premature death
(e.g.
, the grief of family and friends). … Pleasure driving, many recreational activities, some dietary practices, and some occupations, to name just a few activities, involve the same actuarially-validated risks of premature death and grief. In fact, we do not impose taxes on these activities.

Still more doubt was cast on the equity of a massive jump in the tobacco excise by a paper prepared for a November 1994 conference of the National Bureau of Economic Research by Duke economist W. Keith Viscusi. In “Cigarette Taxation and the Social Consequences of Smoking,” Viscusi argued that although the tar and nicotine yields of cigarettes had dropped to about 25 percent of the levels of a half-century earlier, most of the mortality calculations still in use were drawn from epidemiological studies dating back to the 1950s and 1960s, based on lifetime smoking experiences with brands probably far more toxic than those in current use. Even granting that some smokers of low-tar brands compensated and extracted more hazardous yields than the machine-tested ratings for their brands, Viscusi concluded that smokers on balance were actually
saving
twenty-three cents a pack more than they were costing the rest of society because they had the misfortune to die younger. Strictly as sound fiscal policy, he jocularly added, “cigarette smoking should be subsidized rather than taxed.” If the escalating mortality figures for secondhand smoke being put forward lately by smoking control advocates were taken at face value—and Viscusi made his doubts about them plain—he found the net health costs of smoking to be a break-even proposition, even before taking into account the excise taxes that smokers were paying.

IV

IN
the first week of 1993, within days of the end of the Bush administration, which had guarded and indeed advanced the interests of the tobacco industry, and months after a panel of outside scientific advisors had signed off on it for a second time, EPA administrator William Reilly finally released his agency’s risk assessment on secondhand smoke—more than five years after it was begun. Whether he was at last approving findings that the lame-duck White House had long pressured him to delay for political reasons or he was overcoming doubts he himself had about the verdict was unclear. The fact, though, was that Reilly released the report at the last possible moment of his tenure.

For all the objections that had been raised by the cigarette makers, there was little equivocation in the final version of the risk assessment. The Group A classification of ETS as lethal to man was the least of it. Airborne cigarette smoke was labeled “a serious and substantial public health risk,” responsible for approximately 52,000 deaths a year—15,000 due to various kinds of cancer and the rest from heart disease (not addressed by the EPA review)—as well as being implicated in from 150,000 to 300,000 cases of pneumonia and bronchitis in infants up to eighteen months old and a complicating factor for between 200,000 and 1 million youngsters afflicted with asthma.

The EPA’s judgment did not go entirely unchallenged. The presumably nonpartisan Congressional Research Service advised the Senate that “statistical evidence does not appear to support a conclusion that there are substantial health effects from passive smoking.” Such a caveat, of course, was precisely why the EPA assessment so infuriated the tobacco industry, which had long and speciously argued that there was
nothing but
statistical evidence to support the health charges against direct smoking. The industry’s case against the EPA findings was most expansively and persuasively argued on the pages of the March 1994 issue of
Forbes MediaCritic
by Jacob Sullum, managing editor of the conservative magazine
Reason
, who contended that the press had uncritically accepted the EPA indictment of ETS and had promoted it into an essential prop for the smoking control movement by inviting the public to infer that the data against secondhand smoke was just as incriminating as the case against direct smoking. Sullum’s analysis, marred by too much reliance on quoted authorities who had long taken the tobacco industry’s money, nevertheless drew attention as few other commentators had to the obvious limitations behind the scientific charges against ETS, starting with the weakness of the association by epidemiological standards and the fact that in only six of the thirty lung cancer studies had the reported risk differential risen to the level of statistical significance (meaning that the odds were at least twenty to one against the results being a chance occurrence).

After Philip Morris showcased the Sullum article in a five-day series of full-page advertisements in several leading newspapers, the Clinton-backed EPA strongly defended its ETS stand. The EPA’s June 1994 counterattack, “Setting the Record Straight,” called it “an indisputable fact” that ETS was “a real and preventable health risk.” Few objective observers questioned that view; the issue was how severe the risk was and whether the EPA had rushed to judgment in endorsing the high death toll attributed to ETS by the Centers for Disease Control and other public-health investigators, especially since the bulk of the total was blamed on multicausal heart disease through plausible but still speculative pathological agents and processes. That the EPA was not above playing the propagandist in its own defense was suggested by its broadside when it spoke of “the remarkable consistency” of the results of the studies on ETS. If there was any characteristic that marked the findings, particularly in the larger studies on lung cancer risk due to ETS exposure, it was the inconsistency of the results—except the weakness of the associations, where they were found to exist at all. The frequent absence of dose-relatedness, which had been the key to the findings against direct smoking, served only to strengthen the suspicion that the EPA was exaggerating its case.

Once the EPA had finally spoken on ETS, however, it was not about to retreat, and the rest of government and most of the public-health community now took the scientific case against secondhand smoke to be a given. The
CDC, for example, issued a slick pamphlet on the subject in which it asserted that “secondhand tobacco smoke causes thirty times as many lung cancer deaths as all other cancer-causing air pollutants regulated by the EPA.” It failed to note that the latter figure was estimated to be about one hundred deaths annually. That is not an inconsiderable number of human lives, certainly, nor could any conscientious investigator outside the tobacco industry’s pay dismiss the likely pathological potency of ETS. Still, the government agencies seemed nearly as capable in this instance of blowing smoke at the public to cloud the scarcity of cold, clinical science in support of the indictment of ETS as a substantial public-health risk as the cigarette companies had habitually been in denying and distorting the overwhelming scientific case against direct use of their product.

As predicted, the EPA branding of ETS set off a chain reaction of governmental and private measures to discourage smoking, starting with the proposed huge increase in the cigarette excise tax to help pay for the Clinton health-care reform program. It was followed by the Waxman House health subcommittee’s approval of the sweeping Smoke-Free Environment Act, which would have virtually banned smoking in all nonresidential sites in the nation, including every office entered by ten or more people per week. But the measure got sat on when it reached the full House Commerce Committee, where tobacco-state congressmen among others held it hostage against the pending healthcare reform program. Meanwhile, the Clinton administration indicated its readiness to act against smoking by administrative edict. The Labor Department, through OSHA, proposed a ban on smoking, except in set-aside and properly ventilated rooms, at some 6 million work sites across America and scheduled a series of public hearings on its proposed new rule that drew a loud and sustained protest by the tobacco industry, bent on indefinitely delaying implementation of the step. Congress, however, actually passed a requirement, more symbolic than substantive, that any school district receiving federal funds had to ban smoking in its buildings. The Department of Defense banned smoking in all military workplaces, starting with the inside of tanks. More tellingly, U.S. Trade Representative Mickey Kantor, who had once worked for the tobacco industry in fighting a ban on smoking in Beverly Hills restaurants while a Los Angeles lawyer, held a series of meetings with top HHS Department officials and then announced an about-face in the government’s trade policy on cigarettes. The USTR would no longer aggressively try to force open foreign markets for U.S. tobacco companies, Kantor said, adding, “We will not challenge the health-based regulations of other countries as [they] were challenged in the past concerning tobacco products,” especially their advertising restrictions so long as they were applied to domestic as well as imported brands. But Bill Clinton refrained from the one act he could have accomplished with a stroke of the pen early in his term of office: order smoking
banned in all federal office buildings—a proposal that HHS had urged George Bush to institute, without success.

V

NOTHING
better illustrated the power of an antismoking president to energize the tobacco control movement than the action taken early in 1994 by the one person in the federal government with the statutory authority to end the long-standing travesty that had allowed society’s most dangerous consumer product to escape serious regulation.

The federal Food and Drug Act of 1906 and its later amended versions had handed oversight powers to the Food and Drug Administration with regard to the licensing, manufacturing, labeling, selling, and advertising of thousands of everyday consumer goods, but it was never established that tobacco products qualified as a food or a drug. The definition of a drug eligible for FDA governance was expanded by Congress under the Food, Drug, and Cosmetic Act as amended in 1938 to refer to a substance or device that was, according to the language in a Senate committee report accompanying the passage of the amendment, “intended for use in the cure, mitigation, treatment or prevention of disease” and included non-food products and cosmetics that were “intended to affect the structure and function of the body.”