Tobacco as a Social Justice Issue

Cheryl Healton
January 1, 2001

address to the National
Conference on Tobacco
or Health
n November 27, 2001, Dr. Cheryl Healton, president and CEO
of the American Legacy Foundation, addressed the National
Conference on Tobacco or Health on the subject, ?Tobacco as a Social Justice
Issue.? Dr. Healton described the excess burden that tobacco places on society?s
poor and underserved populations and recommended ways to expand
access to cessation services. She called upon the federal government to hold
the tobacco industry accountable for decades of deceptive business practices.
And she urged the states to fulfill their moral obligation to use Master
Settlement Agreement funds to protect their citizens from future harm from
tobacco. The full text of Dr. Healton?s remarks follows.
Public Health Thank you. Being here today makes
me feel like I?ve come full circle. My mother
died of smoking at age 62. I started smoking
as a girl. As a young woman, I waited
tables at the Howard Johnson?s in Times
Square in New York where I was constantly
exposed to not only my own smoke but to
secondhand smoke, as waitresses continue
to be in too many places. I finally quit for
good in 1992, and at this Thanksgiving
season, like all Thanksgiving seasons, I am
happy to just ?be? because I well know the
implications of my years of heavy smoking.
I am also thankful for the chance to work
with the American Legacy Foundation and
to be with all of you today.
As a woman and former smoker, I have a
personal understanding of tobacco as a
social justice issue, which is the subject
of my remarks. And as a public health
professional, I have a broader understanding
of health as a social justice
issue. But before I address these issues,
I want to briefly discuss a few recent
developments in our field.
First, I?m sure we were all excited to
learn that the folks at Philip Morris are
changing ? at least their name ? to
?Altria,? which is Latin for ?high.? While
they may think they?re ?high,? some of us
may wonder what they?ve been smoking.
The second recent development that I
want to mention is 9/11. Cigarette consumption
has been on the rise since the
attacks. The American Cancer Society
released a study on November 14 that
reported that approximately 30 percent of
smokers have increased their smoking
since 9/11, and that more than five percent
of former smokers have picked up
their cigarettes again.1 A Legacy study
found similar results in New York City.
Nearly 30 percent of smokers in New
York City reported smoking more since
9/11; within this population the average
increase was one-half a pack.2 This may
explain why the tobacco industry, which
was enjoying record profits even before
9/113, has been one of the best-performing
industries in the stock market in the
1 Smokers encouraged to join the American Cancer Society?s 25th annual Great American Smokeout. (2001).
PRNewswire. Retrieved January 30, 2001, from
2 Research Triangle Institute. (2001). [Analysis of American Legacy Foundation Media Tracking Survey IV].
Unpublished raw data.
3 Fonda, D. (2001). Why tobacco won?t quit. Time Magazine, 157(26), 38-39.
Social Justice weeks since the attacks. Compare that
with the tens of thousands of low-income
workers thrown out of their jobs in the
travel, hospitality, restaurant, and other
service industries as a result of the
attacks. Big Tobacco gets bigger while
the little guy gets littler.
Among the goals of pursuing justice are
to hold those who have done wrong
accountable, and, if necessary, to force
wrongdoers to change their bad
behavior. It would be difficult to find a
corporate wrongdoer more deserving
of justice than the tobacco industry.
Many of you are familiar with the federal
government?s lawsuit against the tobacco
industry, filed in September 1999 ?
United States v. Philip Morris, Inc.
The suit seeks to hold the tobacco
industry accountable for nearly 50 years
of what the government alleges are illegal
and harmful practices, such as deceiving
the public about the health risks of
smoking and the addictive nature of
nicotine, and marketing to children.
The lawsuit seeks:
The return of profits obtained through
illegal acts;
Disclosure of all relevant internal
cigarette company research on
smoking and health;
Payments to establish programs to
address the ongoing effects of the
companies? illegal conduct (such as
funds for cessation, research, public
education and counter-advertising);
Permanent injunctions against:
1) Making false, misleading, or
deceptive statements about
2) Engaging in public relations campaigns
that misrepresent or suppress
information about the harm
from smoking or its addictiveness,
including the low-tar farce; and
3) Marketing to kids.
On September 28, 2000, Judge Gladys
Kessler canceled two of the government?s
claims (those brought under the
Public Health Medical Care Recovery Act and the
Medicare Secondary Payer Act), but
ruled that the case could go forward,
and that the government?s claims under
the Racketeer and Corrupt
Organizations (RICO) Act were valid.
Judge Kessler stated, ?while the government?s
theories of liability have been
limited, the extent of Defendants? potential
liability remains, in the estimation of
both parties, in the billions of dollars.?4
No one should be surprised that
?killing? the federal lawsuit remains one
of the top priorities of the tobacco industry
and that the current Administration
appears ready to do their bidding. This
spring, while Attorney General John
Ashcroft announced he would seek to
settle the case, anonymous
Administration officials told the press
they believed the case was ?weak.?5 In
addition, the Attorney General has, for
months, refused to provide adequate
funding for his own department?s litigation
effort. The Administration?s actions
have been heavily criticized by public
health and tobacco control organizations.
Fortunately, settlement talks with
the tobacco industry are said to have
foundered and the Administration now
appears to be moving forward with the
case, set for trial in June 2003.
Just two weeks ago, on November 15,
2001, the Department of Justice filed
hundreds of pages of expert reports
documenting the tobacco industry?s
pattern of fraudulent behavior dating
back to the 1954 ?frank statement.?
In a nutshell, the federal lawsuit is
about whether or not the most powerful
government in the world can force what
is arguably the most powerful industry
in the world to change the practices that
have brought so much harm to so many.
If the case is allowed to go to trial, we
may find out the answer! And if it?s the
right one, we might be on the road to
social justice.
We usually think of ourselves as being in
the better health business, and we don?t
usually see ourselves as being crusaders
for social justice. But we are,
because smoking is not ? as Hollywood
would like us to believe ? a lifestyle
choice of the rich and famous. In the
real world, smoking is an affliction of
the young, the poor, the depressed, the
stressed out, the uninsured, the less
4 Stout, D. (2000). Judge dismisses part of U.S. tobacco suit. The New York Times. p. A22.
5 Campaign for Tobacco Free Kids. (2001). Introducing Philip Morris?s latest cost-saving device. Retrieved
January 31, 2001, from
Social Justice educated, the blue-collar worker, the
minority group member, the ill-at-ease
college freshman, and the young gay
man making the urban bar scene
seeking social entree with a cigarette
in hand.
The tobacco industry has succeeded in
addicting those who have the least information
about the health risks of
smoking, the fewest resources, the
fewest social supports, and the least
access to cessation services. The link
between smoking and low income and
lower levels of education cannot be
overemphasized. Tobacco is not an
equal-opportunity killer.
Americans below the poverty line are
over 40 percent more likely to smoke
than those at or above the poverty line.6
A study done by the World Bank
concluded that tobacco may be responsible
for more than half the difference in
adult male mortality between those of
highest and lowest socioeconomic
status.7 The poor are not only more likely
to smoke, they are less likely to quit.8
Education is another key indicator.
Nearly 38 percent of all Americans with
only 9 to 11 years of education smoke,
compared to just 13 percent of those
with an undergraduate college degree.9
Girls and women with only 9 to 11 years
of education are nearly 15 times more
likely to smoke during pregnancy than
women with four years of college.10
Secondhand smoke is also a major
social justice issue. Over half of all
white-collar workers are covered by
smoke-free policies in their work
places, compared to only about a third of
6 U.S. Centers for Disease Control and Prevention. (2001). Cigarette smoking among adults ? United States,
1999. Morbidity and Mortality Weekly Report, 50(40), 869-873.
7 The World Bank. (1999). Health consequences of smoking. Curbing the epidemic: Governments and the economics of
tobacco control. Retrieved January 30, 2001, from
8 Flint, A.J., & Novotny, E.T. (1997). Poverty status and cigarette smoking prevalence and cessation in the
United States, 1983-1993: The independent risk of being poor. Tobacco Control, 6(1), 14-18.
9 U.S. Centers for Disease Control and Prevention. (2001). Cigarette smoking among adults ? United States,
1999. Morbidity and Mortality Weekly Report, 50(40), 869-873.
10 Matthews, T.J. (2001). Smoking during pregnancy in the 1990s. National Vital Statistics Report, 49(7).
Hyattsville, MD: National Center for Health Statistics.
Public Health all service workers and only a little more
than a quarter of blue-collar workers.11
One study found that food service workers
exposed to secondhand smoke have
a 50 percent excess risk of lung cancer.12
Being a waitress isn?t a crime, and it
shouldn?t carry the death penalty.
The link between smoking and heart
disease and cancers has serious
health implications for the poor,
women, and minorities. Multiple
researchers have found that women,
minorities, and those of lower income
are diagnosed later for heart disease
and cancer than well-off white men
and receive fewer interventions.13-17 The
pattern is clear: more likely to start to
smoke; more likely to continue; less
likely to receive timely intervention;
more likely to die younger.
Flint and Novotny18 examined poverty
and smoking prevalence and cessation,
and reported that ?poverty may be an
indicator of underparticipation in the
11 Gerlach, K.K., Shopland, D.R., Hartman, A.M., Gibson, J.T., & Pechacek, T.F. (1997). Workplace smoking
policies in the United States: Results of a national survey of more than 100,000 workers. Tobacco Control, 6(3),
12 Siegel, M. (1993). Involuntary smoking in the restaurant workplace: A review of employee exposure and
health effects. Journal of the American Medical Association, 270(4), 490-493.
13 Fiscella, K., Franks, P., Gold, M.R., & Clancy, C.M. (2000). Inequality in quality: Addressing
socio-economic, racial and ethnic disparities in health care. Journal of the American Medical Association,
283(19), 2579-2584.
14 Schnieder, E.C., Zaslavsky, A.M., & Epstein, A.M. (2002). Racial disparities in the quality of care for enrollees
in Medicare managed care. Journal of the American Medical Association, 287(10), 1288-1294.
15 Bradley, C.J., Given, C.W., & Roberts, C. (2001). Disparities in cancer diagnosis and survival. Cancer,
91(1), 178-188.
16 Hiatt, R.A., Pasick, R.J., Stewart, S., Bloom, J., Davis, P., Gardiner, P., Johnston, M., Luce, J., Schorr, K.,
Brunner, W., & Stroud F. (2001). Community-based cancer screening for underserved women: Design
and baseline findings from the Breast and Cervical Cancer Intervention Study. Preventive Medicine, 33(3),
17 Shavers, V.L., & Brown, M.L. (2002). Racial and ethnic disparities in the receipt of cancer treatment.
Journal of the National Cancer Institute, 94(5), 334-357.
18 Flint, A.J., & Novotny, E.T. (1997). Poverty status and cigarette smoking prevalence and cessation in the
United States, 1983-1993: The independent risk of being poor. Tobacco Control, 6(1), 14-18.
Social Justice changing social norms regarding
smoking behavior in recent years,? and
?further research may be needed to
understand why poverty is a persistent
independent marker? of smoking.
We know that some smokers who are
poor turn to tobacco because they feel it
is a source of pleasure in a cruel world.
I can also tell you that in some poor
communities, buying your own cigarettes
is a status symbol ? it shows that you have
disposable income. Bringing social justice
to these communities will take a lot more
than tobacco control. It will require our
entire society to deal more effectively with
broader issues such as racism in all its
manifestations. It is safe to say that
tobacco is just barely on the radar screen
of leaders in poor communities, despite
the fact that it is the single greatest preventable
cause of death. It must compete
with other pressing problems.
In the meantime, many low-income men
and women addicted to nicotine must
choose between buying cigarettes or
purchasing family necessities. Their
children, in turn, are more likely to grow
up to be smokers because they see their
parents smoke.19 A smoking parent is a
walking billboard for the tobacco industry.
And if the children of the poor turn out
to be sensation-seeking teenagers, they
will be more likely to become lifelong
smokers than their sensation-seeking
peers who come from more affluent backgrounds
and have greater educational
opportunities. Teens who smoke in high
school but who go to good schools and
grow up to be lawyers are far less likely to
smoke in adulthood than teens who are
trapped in failing schools, who are told
they?re not good enough to go to college,
and who end up flipping burgers.
The quest for social justice must begin
with the states. Blessed with billions of
Master Settlement Agreement dollars,
the states have an historic opportunity to
launch proven programs to prevent and
reduce smoking.
But the states are letting this crucial
opportunity slip away. So far, they?ve
received about $20 billion in MSA
payments, but have devoted only five
percent to tobacco control.20 This is
happening in spite of the fact that the
19 U.S. Department of Health and Human Services. (2001). Women and Smoking: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon
General. p. 468.
20 Dixon, L. (2001). State Management and Allocation of Tobacco Settlement Revenue, 1999 to 2001. Washington,
DC: National Conference of State Legislatures. p.16.
Public Health money in the agreement ? approximately
$206 billion ? is supposed to compensate
the states for the costs they
incurred providing treatment to members
of the Medicaid population suffering
smoking-related illnesses.
In simple terms, Settlement dollars are
the blood money of the poor, and yet the
states ? with some notable exceptions ?
have made little effort to provide even
the minimal amount of dollars
recommended by the CDC to advance
tobacco control.
We must say to the states: Why did you
move against the tobacco industry?
Was it to protect your citizens from
smoking, the No. 1 cause of death
and disease? Or was it just a game of
pork-barrel politics?
We should not, of course, be too surprised
by all of this. When it comes to tobacco,
public health policy in our country is for
sale, and it has been bought by the
tobacco industry. This is not generally
the case with other major public health
problems, and we should resist its
continuing to be the case with tobacco.
On the federal level, the four largest
cigarette manufacturers spend over
$106,000 lobbying Congress for each
day that Congress meets.21 Half of our
federal elected officials have accepted
tobacco donations.22
We must also say to the states that
raising taxes on tobacco products is
right because it reduces consumption.
But higher taxes take a much bigger
bite out of the budget of the poor smoker
than the well-off smoker. Higher taxes
on cigarettes should not be a form of
social injustice. States that raise taxes
have a moral obligation to use these
funds to expand prevention and
cessation programs.
As important as government is, public
and private health care systems must
also play a much larger role. We have
effective treatments that can dramatically
increase the likelihood of longterm
cessation.23 These include the
21 Action on Smoking and Health. (2001). Tobacco spends over $100,000 daily for lobbying in DC. Retrieved
February 10, 2002, from
22 Campaign for Tobacco-Free Kids. (2002). Buying influence, selling death: Campaign contributions by tobacco
interests. Retrieved February 10, 2002, from
23 Fiore, M.C. (2000). Treating tobacco use and dependence: Quick reference guide for clinicians. Rockville, MD: U.S.
Department of Health and Human Services, Public Health Service.
Social Justice intensive treatments that low-income
smokers often require. But our health
care system is simply not set up to
deliver these interventions in a regular
and efficient way. A number of steps
must be taken.
Health care providers need more training
in how to deliver these interventions.
Every clinic should have a tobacco-user
identification system, plus dedicated
staff to provide treatments. Every HMO
and other private insurers should
include tobacco dependence treatments
as paid or covered services. And they
should reimburse clinicians and specialists
for delivery of treatments and
include interventions among the defined
duties of clinicians.
In addition, every state must offer comprehensive
Medicaid coverage to make
smoking cessation affordable for the
poor. Currently, 17 states offer no coverage
at all, and only one state ? Oregon ?
provides coverage for all the appropriate
pharmacotherapies and counseling
services.24 And most important, America
must get on with the task of insuring the
tens of millions of people who have no
health insurance at all, a group that
probably includes a large proportion of
smokers. Secondhand smoke can be
markedly reduced by passing clean air
laws and resisting preemption efforts
by the industry. These laws lower
population-based smoking rates by
making smoking less socially acceptable
and increasing quit attempts.25
For our part, the American Legacy
Foundation is working to meet our
commitments to assist vulnerable
populations. Our multi-cultural truthsm
campaign is the largest countermarketing
campaign ever conducted to
prevent youth smoking. This year,
Legacy is investing over $100 million in
the campaign and its evaluation ? more
than any national social marketing effort
in the history of public health. The
tobacco industry is annoyed that we are
telling the ?truthsm? to youth, and I?ve
gotten some pretty harsh letters and
other feedback from tobacco companies
complaining about it.
A few days from now you will also hear
some exciting news about Legacy?s
plans to help pregnant women quit
24 Schauffler, H.H., Barker, D.C., & Orleans, C.T. (2001). Medicaid coverage for tobacco-dependence treatments.
Health Affairs, 20(1), 298-303.
25 Bitton, A., Fichtenberg, C., & Glantz, S. (2001). Reducing smoking prevalence to 10% in five years. Journal
of the American Medical Association, 286(21), 2733-2734.
Public Health smoking. Each year, nearly one-half
million women smoke during pregnancy.
If efforts to assist women to quit during
this time succeeded, we could substantially
reduce the 25 million women who
smoke early on ? before most of the
damage is done to them and their young
children. We could also take a big bite
out of health care costs.
This is part of our overarching Women
and Smoking Initiative, which will be the
centerpiece of our activities aimed at
helping women smokers during the
coming year. On your chair is a certificate
to receive a Sunburst pin designed
by world renowned Angela Cummings.
This pin ? which signifies hope for a
smoke-free society ? is our symbol to
raise awareness about the toll tobacco
takes on women and families.
And on November 5, Legacy announced
$8.5 million in grants to 32 organizations
in 18 states to help reduce tobacco
use among priority populations. Another
round of funding next year will bring our
total commitment to $21 million.
These grants fund innovative programs
to serve low-socioeconomic groups,
African Americans, Hispanics, Native
Americans, gays and lesbians, Asian
Americans, and Alaska Natives. Let me
give you a few examples:
One project will establish female
support groups for African-American
women trying to quit in major cities,
including right here in New Orleans;
In the tobacco-growing eastern
Tennessee region, a county antitobacco
coalition will partner with
community groups to serve lowincome
The Lesbian and Gay Community
Services Center in New York will offer
tobacco prevention, intervention, and
advocacy services to lesbian, gay,
bisexual, and transgender youth.
These young people are at substantially
greater risk of smoking ? many
are ?throwaway? youth having been
rejected by their families because of
their sexual orientation; and
The Albuquerque, New Mexico, Area
Indian Health Board will create community-
based tribal tobacco councils
to develop tobacco reduction initiatives
consistent with community values.
Social Justice In all of our efforts, Legacy stands on the
shoulders of some giants who came
before us. These include the leaders of
state public health programs like Dileep
Bal and Greg Connolly; private sector
leaders like Steven Schroeder, Nancy
Kaufman, Karen Gerlach, Tracy Orleans,
and Matt Myers; and association leaders
like John Seffrin, John Garrison, and Cass
Wheeler. And there is one new giant ?
filling the big shoes of Michael Erikson ?
Rosemarie Henson, who will join us for
the closing when she returns from
Geneva. Rosemarie is a public health
trooper who has fought in the women?s
health trenches for years addressing
AIDS, breast cancer, cervical cancer, and
environmental justice. She will bring a
fresh perspective to the work of the CDC
in a complex time when great political
skill is needed to keep tobacco control on
the national agenda.
We live in a nation that values human
life. We demanded the recall of
Bridgestone/Firestone tires when they
were connected to 271 deaths.26 I wonder
if it wouldn?t be a good idea to demand
the recall of tobacco products that kill
about 271 Americans every 5 1/2 hours27?
that leave 12,000 children motherless
each year in the U.S. alone28? and that
take an average 14 years of life from each
smoking woman who dies of tobaccorelated
That might bring us the social justice
we seek, at long last. Thank you all
very much.
? Cheryl Healton, Dr.P.H.
26 National Highway Traffic Safety Administration. (2001). Firestone tire recall. Retrieved November 15, 2001,
27 Calculation based on a figure of 430,000 smoking-related deaths per year from Smoking-attributable
Mortality, Morbidity and Economic Costs (SAMMEC) version 3.0, cited in: Centers for Disease Control and
Prevention. (1999). Investment in tobacco control: State highlights ? 1999. Atlanta, GA: U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health.
28 Leistikow, B.N., Martin, D.C., & Milano, C.E. (2000). Estimates of smoking-attributable deaths at ages
15-54, motherless or fatherless youths, and resulting Social Security costs in the United States in 1994.
Preventive Medicine, 30(5), 353-360.
29 U.S. Department of Health and Human Services. (2001). Women and smoking: A report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon
General. p.193.
Dr. Healton Dr. Cheryl Healton is a researcher, professor, and public health administrator
with more than 20 years experience. She has been at the forefront of some of the
most important efforts to improve public health in America. She has been one of the
leading voices in the development of policies and programs to prevent and treat
HIV/AIDS, substance abuse, and violence, and to promote women?s health.
Before joining Legacy, Dr. Healton served as head of the Division of Sociomedical
Sciences and as Associate Dean for Program Development at the Columbia
University School of Public Health. She founded and directed the school?s Center
for Applied Public Health, conceptualizing and implementing applied research in
emerging issues in public health, including AIDS care for women and children,
staffing and burnout at AIDS care organizations, training and development for
AIDS care professionals, and the computer networking of medical records.
Dr. Healton has extensive experience in tobacco control issues. She developed a
program to study the effects of tobacco marketing and counter-marketing on
youth tobacco use for the Centers for Disease Control and Prevention. She also
developed a series of prevention partnerships linking public health researchers
with New York State tobacco health policymakers, and she has evaluated intervention
programs for the state?s largest youth tobacco prevention program.
Working at Columbia to bring an interdisciplinary approach to tobacco control and
prevention, Dr. Healton developed innovative grants linking academic researchers
to public health practitioners in the field. She wrote a chapter on cessation and
smoking policy in the recently published Treatment of the Hard Core Smoker,
edited by Yino Covey and Dan Seidman.
Dr. Healton continues to serve as a professor of Clinical Public Health at
Columbia, where she is instrumental in developing course offerings for public health
professionals on topics such as tobacco policy, tobacco interventions, and tobacco
control through distance learning and the Internet.
Dr. Healton has won three public health awards. The New York Public Health
Association cited her award-winning radio campaign to improve public health. The
U.S. Department of Health and Human Services recognized her leadership in developing
the National Pediatric AIDS prevention marketing campaign. And the New York
Department of Health cited her ?years of outstanding contributions to public
health? in 2000.
Dr. Healton holds a doctorate from the Columbia University School of Public
Health and a master?s degree in Public Administration (Health Policy and
Planning) from New York University.
The American Legacy Foundation is a national, independent,
public health foundation located in Washington, DC, dedicated to
fighting for the health and well-being of all generations of Americans.
Legacy collaborates with organizations interested in
decreasing tobacco consumption to achieve the goals of
reducing youth tobacco use, decreasing exposure to secondhand
smoke, increasing successful quit rates, and improving access
to tobacco prevention and cessation services for all populations.
1001 G Street, NW, Suite 800
Washington, DC 20001
Ph: 202-454-5555
Fax: 202-454-5599