La Traviata: “Libiamo, ne’ lieti calici”

In 954 the tobacco industry paid to publish the “Frank Statement to Cigarette Smokers” in hundreds of U.S. newspapers. It stated that the public's health was the industry's concern above all others and promised a variety of good-faith changes. What followed were decades of deceit and actions that cost millions of lives. In the hope that the food history will be written differently, this article both highlights important lessons that can be learned from the tobacco experience and recommends actions for the food industry. Methods: A review and analysis of empirical and historical evidence pertaining to tobacco and food industry practices, messages, and strategies to influence public opinion, legislation and regulation, litigation, and the conduct of science. Findings: The tobacco industry had a playbook, a script, that emphasized personal responsibility, paying scientists who delivered research that instilled doubt, criticizing the “junk” science that found harms associated with smoking, making self-regulatory pledges, lobbying with massive resources to stifle government action, introducing “safer” products, and simultaneously manipulating and denying both the addictive nature of their products and their marketing to children. The script of the food industry is both similar to and different from the tobacco industry script. Conclusions: Food is obviously different from tobacco, and the food industry differs from tobacco companies in important ways, but there also are significant similarities in the actions that these industries have taken in response to concern that their products cause harm. Because obesity is now a major global problem, the world cannot afford a repeat of the tobacco history, in which industry talks about the moral high ground but does not occupy it. Keywords: Food, obesity, tobacco, industry, ethics, politics, public policy In December 1953, the CEOs of the major tobacco companies met secretly in New York City. Their purpose was to counter the damage from studies linking smoking to lung cancer. A year earlier Reader's Digest—then the public's leading source of medical information—had printed an article entitled “Cancer by the Carton” (Norr 1952). After it appeared, cigarette sales plummeted for two years, the first such decline of the century except during the Great Depression. Working closely with John Hill, the founder of the public relations giant Hill & Knowlton, the industry created “A Frank Statement to Cigarette Smokers” and paid to have it published in 448 newspapers on January 4, 1954. To give the industry a human face, the statement included the signatures of the nation's top tobacco executives and assured Americans that “we accept an interest in people's health as a basic responsibility, paramount to every other consideration in our business.” Furthermore, they promised that “we always have and always will cooperate closely with those whose task it is to safeguard the public's health” (Tobacco Industry Research Committee 1954). The “Frank Statement” was a charade, the first step in a concerted, half-century-long campaign to mislead Americans about the catastrophic effects of smoking and to avoid public policy that might damage sales. Unearthed later, industry documents showed the repeated duplicity of its executives. Everything was at stake. The industry wanted desperately to prevent, or at least delay, shifts in public opinion that would permit a barrage of legislative, regulatory, and legal actions that would erode sales and profits. Today another industry is under attack for marketing products perceived by some to damage health, and it also faces legislative, regulatory, and legal threats that could fundamentally alter how it does business. Schools are banning soft drinks and snack foods; legislation requiring calorie labels on restaurant menus has been passed at state and local levels and is being considered nationally; restrictions in food marketing practices have been proposed around the world; and even radical measures such as taxing snack foods are part of the national debate. Such actions invite comparison of the food and tobacco industries, exemplified by a Fortune magazine cover story in 2003 entitled “Is Fat the Next Tobacco?” The cover depicted a French fry lying in an ash tray as if it were a cigarette. The article did what is now common—debate the parallels between tobacco and food in the context of culpability for health damage and ask whether Big Food should be sued for the same reasons that Big Tobacco was. There are, of course, differences between food and tobacco as substances. The most obvious is that humans must eat to maintain health and life, whereas the unnecessary activity of smoking is, in the words of former Secretary of Health, Education and Welfare Joseph Califano, “slow-motion suicide.” Moreover, selling tobacco to children is illegal, but there currently are no restrictions on food sales. Tobacco has a well-chronicled addictive process, whereas research on food and addiction is just now maturing. And although the fight against tobacco coalesced around a single product made by a few companies, food and its industries are far more complex. The more important issue is whether tobacco history is instructive in addressing the problems created by unhealthy diets. A half century of tobacco industry deception has had tragic consequences: Since the “Frank Statement,” approximately 16 million Americans have died from smoking, and millions more have suffered from debilitating diseases ranging from emphysema to heart disease. Had the industry come clean in 1954—matching deeds with promises—many of these deaths would almost certainly have been prevented. No one knows how many. Perhaps 3 million. Maybe 5 million. Maybe 7 million—just in the United States. An honest approach by industry might have saved more lives than any public health measure taken during the past fifty years. Furthermore, if industry had made good faith efforts globally, rather than exploit and addict the developing world, the benefits could have been stunning. Food, physical inactivity, and obesity may be in the same league. An astonishing two-thirds of the U.S. adult population is overweight or obese (Ogden et al. 2007). As with smoking, social justice issues are prominent, given that obesity rates are highest in the poorest segments of the population (Kumanyika 2006). But weight issues are hardly unique to the United States. The World Health Organization has declared obesity a global epidemic, now surpassing hunger as the chief nutrition problem, even in some developing countries (WHO 2004). Obesity rates are especially troubling in children, rising at three times the rate of increase in adults (Ogden, Carroll, and Flegal 2008). Indeed, the term adult onset diabetes has now been scrapped and replaced with Type 2 diabetes because children as young as eight are developing the disease. Canadian researchers conducted a fifteen-year follow-up of children diagnosed with Type 2 diabetes and found an alarming rate in young adults of blindness, amputation, kidney failure requiring dialysis, pregnancy loss, and death (Dean and Flett 2002). Health experts now are asking whether America's children will be the first in the nation's history to live shorter lives than their parents (Olshansky et al. 2005). Such statistics worry people, leading the press, parent groups, school officials, nutrition experts, health care providers, and government leaders to conclude that something must be done. Caught in the crosshairs, the food industry is reacting, sometimes with heavy ammunition. As an example, in response to menu-labeling initiatives, the restaurant industry has sued New York City, used its political might to weaken legislation in California, and successfully encouraged federal legislators to introduce weak national legislation that would preempt states and cities from acting more aggressively. There are striking similarities, and some differences, in the way the food and tobacco industries have responded to public mistrust, damning scientific evidence, and calls for legal and legislative actions. As an important example of the similarities, food companies have issued their own versions of frank statements, stating their concern with the public's well-being and pledging to make changes to benefit public health. In this article we discuss what can be learned from tobacco and propose what might be done to avoid the repetition of a deadly history. Go to: A Crossroads for Food The food industry is on the defensive, hit hard by nutrition groups and public health professionals, the press, parent groups, child advocacy organizations, and state and national legislators sponsoring bills that could have a powerful impact on business. Popular books like Fast Food Nation (Schlosser 2001) and movies like Supersize Me have sensitized the public to industry practices. In turn, the industry has had to react to claims that it seduces children into a lifestyle of unhealthy eating, infiltrates schools, buys loyalty from scientists, and pressures administration officials into accepting weak and ineffective nutrition policies (Brownell and Horgen 2004; Nestle 2002). To the extent that these charges are fair, the analogy with the tobacco experience is inescapable. Seducing children? There is no better example than Joe Camel. Buying the loyalty of scientists? It happened time and again with tobacco. Using pressure to stall or prevent needed policy change? Few industries have been more effective than tobacco (Advocacy Institute 1998). A first step is to understand the industry players. Unlike tobacco, with one major product and a handful of companies producing it, food involves an immense array of products made by thousands of companies worldwide. The industry is diverse and fragmented in some ways, counting as its players a local baker making bread for a few stores; a family running a convenience store; an organic farmer; mega companies like Kraft, McDonalds, and Coca-Cola; and even Girl Scouts selling cookies. The same company making fried foods laden with saturated fat might also sell whole-grain cereal. In other ways, the industry is organized and politically powerful. It consists of massive agribusiness companies like Cargill, Archer Daniels Midland, Bunge, and Monsanto; food sellers as large as Kraft (so big as to own Nabisco) and Pepsi-Co (owner of Frito Lay); and restaurant companies as large as McDonald's and Yum! Brands (owner of Pizza Hut, Taco Bell, KFC, and more). These are represented by lobbyists, lawyers, and trade organizations that in turn represent a type of food (e.g., Snack Food Association, American Beverage Association), a segment of the industry (e.g., National Restaurant Association), a constituent of food (e.g., Sugar Association, Corn Refiners Association), or the entire industry (e.g., Grocery Manufacturers of America). Common to all these players is an arresting logic: to successfully address the obesity epidemic, the nation must consume fewer calories, which means eating less food. Marion Nestle (2002) estimates that the number of daily calories created for the American food supply rose from 3,300 per person in 1970 to 3,800 in the late 1990s, far in excess of what the average person needs to maintain a healthy weight. If consumers’ demand for food were to reflect what they needed to maintain a healthy weight, the market would contract. A shrinking market for all those calories would mean less money—a lot less. Of course there will always be a need for food—people cannot stop eating. But the types and amounts of food people eat must change dramatically if there is to be any hope of curbing obesity and other problems associated with unhealthy eating. The foods most at risk happen to be those most processed, dense in calories, highest in profit margin, and sold mainly by the major industry players. Industry stands at a crossroads where one turn would mean fighting change, defending practices like targeting children, forestalling policy changes, and selling as much product as possible no matter the consequences, and the other would require retooling, working with the public health community, selling far fewer harmful products, and promoting healthier options with much greater urgency. Adopting the first option while laying claim to the second was the path taken by the tobacco industry. Is the food industry different, or is history repeating itself, this time with another substance? In the remainder of this article we discuss the similarities to and differences from the general playbook/script adopted by the tobacco and food industries. Next we describe four areas in which the two industries share distinct similarities and make recommendations for constructive action by the food industry. These areas pertain to public relations and framing; influencing government and key organizations; disputing science, planting doubt, and creating conflicts of interest; and marketing products. Whether, and how much, the industry chooses to respond in a responsible manner will determine whether, and how much, formal governmental regulation of industry behavior will be required to redress challenges to the public's health posed by industry products and marketing behaviors. Go to: The Playbook The tobacco team had a playbook—a master plan and script that directed the behavior of industry executives, lobbyists, lawyers, scientists, and government officials friendly to the industry. In A Question of Intent, a former FDA commissioner, David Kessler (2001, p. xiii), wrote: Devised in the 1950s and ’60s, the tobacco industry's strategy was embodied in a script written by the lawyers. Every tobacco company executive in the public eye was told to learn the script backwards and forwards, no deviation was allowed. The basic premise was simple—smoking had not been proved to cause cancer. Not proven, not proven, not proven—this would be stated insistently and repeatedly. Inject a thin wedge of doubt, create controversy, never deviate from the prepared line. It was a simple plan and it worked. The food industry appears to have a strategy as well, repeatedly carried to the public by spokespersons from food companies, trade associations, and their political allies. As noted by Brownell and Horgen (2004) and Nestle (2002) regarding the food industry specifically and by Mooney (2006) and Michaels (2008) about industries in general, its main features are the following: Focus on personal responsibility as the cause of the nation's unhealthy diet. Raise fears that government action usurps personal freedom. Vilify critics with totalitarian language, characterizing them as the food police, leaders of a nanny state, and even “food fascists,” and accuse them of desiring to strip people of their civil liberties. Criticize studies that hurt industry as “junk science.” Emphasize physical activity over diet. State there are no good or bad foods; hence no food or food type (soft drinks, fast foods, etc.) should be targeted for change. Plant doubt when concerns are raised about the industry.