werner@aecom.UUCP (10/27/86)
<>
[Edited version]
Editorial JAMA May 24, 1985; 253:3001-3.
In the AMA, Policy Follows Science:
A Case History of Tobacco
[Pro-cigarette text] -- ADVERTISEMENT, JAMA, Nov. 4, 1939; 113:37.
[Summary of decision making theory]
[Summary of AMA decision making]
[Notes on Scientific Journals
[Notes on Tobacco Use]
Thus, decades elapsed from
the first explosion of tobacco cigarette use around the time of World
War I before data appeared calling clear attention to the correlation
between tobacco use and diseases. Not until 1950 did Wynder and Graham
publish in JAMA a major article from a study of 684 proved cases strongly
implicating tobacco smoking as a possible etiologic factor in lung
cancer.
Beginning in 1934, the AMA accepted tobacco advertising in its
journals. In 1952, Ochsner and colleagues drove the nail in the coffin
(so to speak) with their article on bronchogenic carcinoma. Shortly
thereafter, the Board of Trustees of the AMA voted to discontinue
advertisements for tobacco and its allied products and also not to accept
liquor advertising, both to be effective Jan. 1, 1954. In 1958, JAMA
published the pivotal article by Hammond and Horn tying tobacco smoking
with many additional diseases.
Additional evidence mounted and in a policy enacted in June 1963,
the AMA House of Delegates recognized the deleterious effect of tobacco
as well as other toxic substances on human health. It suggested that
further research by done, at the same time urging physicians "to engage
more actively in intensive educational programs regarding smoking and
health, directed to the public in general and to youth in particular."
In June 1964, the House of Delegates removed all doubt and went on record
as recognizing " a significant relationship between cigarette smoking and
the incidence of lung cancer and certain other diseases, and that
cigarette smoking is a serious health hazard."(8)
From that time until today, 21 years later, the Public Health
Service, the AMA, and many other other individuals and groups have
labored long and hard to get people who currently smoke to stop and have
tried to prevent people who don't smoke from starting.
Actions of the House of Delegates in those 21 years have been
many, culminating in the June 1983 Annual Meeting, when Minnesota
Delegation Resolution 121 was adopted:
"Resolved, That the American Medical Association urge the medical
community, related groups, educational institutions, and
government agencies more effectively to demonstrate the
health hazards inherent in the use of tobacco products and
work towards promoting a smoke free society by the year 2000."
You can't be much stronger than that.
[Summary]
[Notes on addiction]
Tobacco kills every day in virtually all major cities in our
society, almost always legally. The only serious challenger to tobacco
as a premier destructive substance in ethyl alcohol. Who then is
responsible for the epidemic of bronchial carcinoma, pulmonary emphysema,
coronary artery disease, etc, tied to tobacco cigarette smoking?
Answering this question is easy becuase so many people share the blame.
Everyone from tobacco farmers, cigarette company stockholders, and
ashtray manufacturers to the publishers of newspapers and magazines that
carry tobacco advertising, the tennis players who play under the tobacco
banner, and everyone in between is culpable.
[Conclusion]
[References]
-- George D. Lundberg, MD
--
Craig Werner (MD/PhD '91)
!philabs!aecom!werner
(1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517)
"If you've heard this story before, don't stop me. I want to hear it again."werner@aecom.UUCP (10/27/86)
<>
[Generally, I don't read the JAMA editorials, but occasionally I do cut
them out. What follows is one that I did cut out, retrieved from the black
hole and typed in -- CW]
<>
Editorial JAMA May 24, 1985; 253:3001-3.
In the AMA, Policy Follows Science:
A Case History of Tobacco
"... cigarettes simply as a pleasant combination of fine tobaccos
made even more pleasant by the cooling sensation of menthol. They
won't cure anything. They won't harm anybody. They will prove
enjoyable."
-- ADVERTISEMENT, JAMA, Nov. 4, 1939; 113:37.
In the evolution of health policy we can trace a cycle beginning
with need, followed by a perception of that need, leading to questions.
The questions result in the challenge of thinking and research,
generating data, which becomes information and are distributed. Over
time, new knowledge may lead to changed attitudes. As some individuals
change, they work to change the policies and practices of their
institutions so they will reflect the new knowledge. Those who attitudes
have not changed will resist policy changes, and a struggle follows. If
the force of the new knowledge and attitudes is strong enough, new
policies will result. These will be followed by the implementation of
new procedures, their subsequent evaluation, and further questions. The
process cycles endlessly as humans and systems cycle. Subsequently,
changing human behavior on a large scale is perhaps the most difficult
change, and it may happen slowly or not at all.
Since it was founded in 1847, the American Medical Association
is an illustration of all aspects of this cycle. Through its councils,
committees, task forces, the Board of Trustees, and the House of
Delegates, the AMA establishes policy.(1) Policies are implemented by
educating physicians and other science and health workers, patients,
legislators, and the public at large. Ultimate change is accomplished
by changing public knowledge, attitudes, and behavior, by direct
representative political actions, by working to elect individuals
supportive of AMA policies, by persuasion of government regulators, and,
as a last resort, by actions in the courts. A great deal of this process
is accomplished through the medical literature, one reason why the AMA
has become the world's largest medical publisher.
This sequence of events explains why scientific journals,
regardless of ownership, are editorially independent. Through these
journals every stop described above is presented, debated, validated, or
invalidated, and ultimately acted upon. Scientific journals often
publish information at variance with both public and organizational
policy since health policy results from science rather than vice versa
and since the two are often out of synchrony with each other.
The issue fo tobacco use is an excellent example of how this
process works. First came the discovery of tobacco, then its use and the
proliferation of that use, followed by the need to assess health effects.
Any drug, even one tested extensively in advance in experimental anumals,
must be used by many humans over long periods of time under normal
circumstances to determine adverse effects. Thus, decades elapsed from
the first explosion of tobacco cigarette use around the time of World
War I before data appeared calling clear attention to the correlation
between tobacco use and diseases. Not until 1950 did Wynder and Graham(2)
publish in JAMA a major article from a study of 684 proved cases strongly
implicating tobacco smoking as a possible etiologic factor in lung
cancer. This paper is reprinted in today's JAMA as a landmark article
with an accompanying perspective by Jesse Steinfeld.(3)
Beginning in 1934, the AMA accepted tobacco advertising in its
journals. In 1952, Ochsner and colleagues(4) drove the nail in the coffin
(so to speak) with their article on bronchogenic carcinoma. Shortly
thereafter, the Board of Trustees of the AMA voted to discontinue
advertisements for tobacco and its allied products and also not to accept
liquor advertising, both to be effective Jan. 1, 1954. In 1958, JAMA
published the pivotal article by Hammond and Horn(5) tying tobacco smoking
with many additional diseases. This too became a landmark article and was
republished in 1984 with a perspective by Sir Richard Doll.(6)
Additional evidence mounted and in a policy enacted in June 1963,
the AMA House of Delegates(7) recognized the deleterious effect of tobacco
as well as other toxic substances on human health. It suggested that
further research by done, at the same time urging physicians "to engage
more actively in intensive educational programs regarding smoking and
health, directed to the public in general and to youth in particular."
In June 1964, the House of Delegates removed all doubt and went on record
as recognizing " a significant relationship between cigarette smoking and
the incidence of lung cancer and certain other diseases, and that
cigarette smoking is a serious health hazard."(8)
From that time until today, 21 years later, the Public Health
Service, the AMA, and many other other individuals and groups have
labored long and hard to get people who currently smoke to stop and have
tried to prevent people who don't smoke from starting. Results have been
slow but the trend is encouraging.
Actions of the House of Delegates in those 21 years have been
many, culminating in the June 1983 Annual Meeting, when Minnesota
Delegation Resolution 121 was adopted:
"Resolved, That the American Medical Association urge the medical
community, related groups, educational institutions, and
government agencies more effectively to demonstrate the
health hazards inherent in the use of tobacco products and
work towards promoting a smoke free society by the year 2000."
You can't be much stronger than that.
In a recent comprehensive literature search of publications in
JAMA and the AMA specialty journals regarding tobacco and its health
effects, we found 321 related references in JAMA since 1958 and more than
300 references in the ten specialty journals since 1966. Obviously the
AMA has been very active in publishing scientific information and
commentary on this important topic in public health and preventive
medicine. Today's JAMA is our second tobacco theme issue in two years.
The first issue, Nov 23/30, 1984, attracted major scientific clinical
attention and was widely reported by the media to the public.(9).
Human chemical dependence (addiction) is a biological phenomenon
thousands of years old against wich society has long sought
unsuccessfully for answers. As we have commented much earlier(10) there
are no simple answers and there may not even be any complicated answers
for society at large when dealing with chemical dependence. But there
are many excellent answers for individuals from the standpoint of
prevention, diagnosis, and treatment.
Tobacco kills every day in virtually all major cities in our
society, almost always legally. The only serious challenger to tobacco
as a premier destructive substance in ethyl alcohol. Who then is
responsible for the epidemic of bronchial carcinoma, pulmonary emphysema,
coronary artery disease, etc, tied to tobacco cigarette smoking?
Answering this question is easy becuase so many people share the blame.
Everyone from tobacco farmers, cigarette company stockholders, and
ashtray manufacturers to the publishers of newspapers and magazines that
carry tobacco advertising, the tennis players who play under the tobacco
banner, and everyone in between is culpable.
In short, a gigantic industry pervades society, but at its heart
is the frail human user who becomes the addict. In the addictive drug
field, the innumerable laws change constantly because no one has ever
figured out the right ones and because laws are not adequate to change
human behavior in the addictive disorders. Prohibiting tobacco obviously
would not work because there are too many addicts and growing and
bootlegging tobacco is easy. Ancient control methods up to and including
the death penalty apparently did not work either. The problem is truly a
very difficult one.
In 1983 and 1984, among the many resolutions that were presented
to the House of Delegates regarding tobacco, six were referred for
further study. Five resolutions that were adopted directed effort of the
AMA or recommended efforts by physicians to reduce the disease burden
imposed upon the American population by cigarette smoking. In response
to the referred resolutions, the Board of Trustees ask the Council on
Scientific Affairs to develop a report that would provide a unifying
theme for AMA policy on tobacco and health over the next decade for
consideration at the June 1985 Annual Meeting.
We hope that the data, information and commentary provided in
this JAMA tobacco theme issue will assist the House of Delegates in
taking the next significant stop toward the "smoke-free" society.
George D. Lundberg, MD
1 Stacey J: How the AMA develops policy. JAMA 1983;250:1426-7.
2 Wynder EL, Graham EA: Tobacco smoking as a possible etiologic factor in
bronchogenic carcinoma: Study of 684 proved cases. JAMA 1950;143:329-36.
3 Steinfeld JL: Smoking and Lung Cancer: A Milestone in awareness.
JAMA 1985;253:2995-97.
4 Ochsner A. DeCamp PT, DeBakey ME, Ray CJ: Bronchogenic carcinoma:
It's frequency, diagnosis, and early treatment. JAMA 1952;148:691-7.
5 Hammond EC, Hom D: Smoking and Death Rates: Reports on 44 months of
follow up on 187,783 men. JAMA 1958;166:1294-1308.
6 Doll R: Smoking and death rates. JAMA 1984;251:2854-7.
7 Proc. House of Delegates, 112th Annual Meeting, June 19, 1963.
8 Proc. House of Delegates, 113th Annual Meeting, June 24, 1964.
9 Pollin W: The role of the addictive process as a key step in causations
of all tobacco related diseases. JAMA 1984;252:2874.
10 Lundberg, GD: Drug Abuse in the western world. JAMA 1970;213:2082.
--
Craig Werner (MD/PhD '91)
!philabs!aecom!werner
(1935-14E Eastchester Rd., Bronx NY 10461, 212-931-2517)
"Morphology is part science and part 'Ipse Dixit.' "mcewan@uiucdcs.cs.uiuc.edu (10/29/86)
> [Craig Werner types in an article giving the history of the AMA's > anti-smoking campaign.] The conclusion is obvious: the tobacco companies are right and smoking is good for you. As soon as the AMA realized this they immediately started trying to stamp out this life-sustaining substance, in order to insure continued high profits for their members. Thank you, Craig, for again confirming that conventional physicians are only interested in money, not the health of their patients. Do I really need to add: :-):-):-):-):-):-):-):-):-):-):-):-):-):-):-) ? Scott McEwan {ihnp4,pur-ee}!uiucdcs!mcewan "I hope you can help me... I've just been accosted by a group of space aliens wearing Elvis wigs and tennis shoes."