Tobacco Industry Use of Personal Responsibility Rhetoric in Public Relations and Litigation: Disguising Freedom to Blame as Freedom of Choice

We examined the tobacco industry’s rhetoric to frame personal responsibility arguments. The industry rarely uses the phrase “personal responsibility” explicitly, but rather “freedom of choice.” When freedom of choice is used in the context of litigation, the industry means that those who choose to smoke are solely to blame for their injuries. When used in the industry’s public relations messages, it grounds its meaning in the concept of liberty and the right to smoke. The courtroom “blame rhetoric” has influenced the industry’s larger public relations message to shift responsibility away from the tobacco companies and onto their customers. Understanding the rhetoric and framing that the industry employs is essential to combating this tactic, and we apply this comprehension to other industries that act as disease vectors.Throughout the history of tobacco control, as concerns over health have prompted public calls for reform, the tobacco industry has attempted to combat criticism and influence public health debates through the use of rhetorical techniques that deflect attention from corporate responsibility.1,2 The tobacco industry’s use of personal responsibility frames, or arguments, to protect its business interests against litigation3^{(p870–873),}4^(p820),5–8 and regulation and tobacco control measures9,10^{(p197–198),}11–14^(p406) has been widely recognized. Although previous studies have enumerated and described many of the key frames employed by the tobacco industry and its allies, there is still important work to be done in more rigorously analyzing the relationships between the content of this rhetoric and its origin in either the legal or public relations (PR) context. Such an analysis helps illuminate the importance of subtle variations in the deployment of similar language to convey diverse meanings that can sway public opinion and regulators’ actions.15 This study also can inform efforts aimed at other industries that produce products that have a negative impact on public health, such as sugar-sweetened beverages (SSBs) and junk food, all of which employ techniques the tobacco industry originated and perfected.16Framing refers to the use of key concepts familiar to the listener that help guide the understanding of an issue.17 In particular, frames structure for the audience the cause of social problems and prescribe which actors should and should not act to address them.18 Powerful default frames such as personal responsibility indicate that those who suffer the consequences of consuming certain risky products, such as smokers, are to blame for their injuries and that it is not the role of social institutions such as the government to intervene and protect them.19 Analyzing which frames are present—and absent—in public discourse such as the news is especially valuable as these frames influence policymakers by helping set the agenda for public debates, and signaling which issues are salient and which others are less urgent.20,21The trajectory of the tobacco industry’s use of personal responsibility framing and argumentation began in 1954, when the major US tobacco companies reacted to the release of scientific studies linking smoking and cancer by hiring a PR firm to craft an advertisement called “A Frank Statement to Cigarette Smokers,” which claimed the industry “accept[ed] an interest in people’s health as a basic responsibility, paramount to every other consideration in our business.”9 The industry’s purposely ineffectual efforts to address the dangers of smoking amounted to little more than whitewash and PR rhetoric, with a major emphasis on obfuscation and delay in verifying whether its products were deadly, along with an effort to maintain this as an “open scientific controversy.”In 1964, US Surgeon General Luther Terry released a landmark report that analyzed and evaluated the existing scientific research, concluding that smoking causes disease and death.22 Closely following was the passage of the Federal Cigarette Labeling and Advertising Act (FCLAA) in 1965, which required warning labels on cigarette packages (mandatory warnings for cigarette advertising were later added in 1969) with the tepid and equivocal verbiage “Caution: Cigarette Smoking May Be Hazardous To Your Health.”2,23 At that time the emphasis by the public and regulators was largely on governmental accountability for addressing the problems cigarette smoking caused, while the tobacco industry escaped most culpability and accountability, even weathering the imposition of mandatory warning labels by turning it to its advantage as another way of assigning blame to smokers for their illnesses.24 In 1986, Congress passed the Comprehensive Smoking Education Act, which required rotating warning labels that were phrased unequivocally linking smoking with particular diseases.25In the 1970s, after warning labels were imposed and both governmental agencies and voluntary health organizations had committed massive resources to educating the public about the dangers of smoking, responsibility for avoiding smoking-related illness was generally viewed as a matter of individual responsibility.12 Tipping the scales further in that direction was a growing sentiment in US society that escalating health care costs could only be contained if individuals changed their unhealthy behavior.26 Pushing back against these forces was the effort by public health advocates to highlight the dangers of secondhand smoke, with the result that “the hazards of smoking were relocated from the individual’s risky behavior to that of his or her smoking neighbor, [and] exposure was no longer a matter of choice but was involuntary victimization.”12^(p339) Thus, the onus shifted once more toward government regulation to ban public smoking, with a concomitant call for businesses to ban smoking in their premises in the absence of governmental action. Up to this point, the tobacco industry had largely escaped accountability by either the public or government despite wide recognition and acceptance of cigarettes’ causal responsibility for disease and death.24The tobacco industry’s use of explicit personal responsibility rhetoric reached its height in the 1980s, during a wave of consumer litigation in which the tobacco defendants countered injured smokers’ lawsuits with claims that ultimately the responsibility for the consequences of smoking cigarettes belonged to the smoker who voluntarily consumed them.27 As the 1990s began, particularly negative pressure was brought to bear on the industry when whistleblowers began leaking internal corporate documents that showed a clear conspiracy to produce an addictive product while ignoring the health hazards of which the tobacco companies were well aware, thus confirming corporate responsibility for the harm the industry’s products caused.9,28,29 As a result of the document leaks and in the face of increasing public demand for industry accountability, many of the industry’s usual allies in business and government began to abandon its cause.This led to a flood of litigation against the industry. Cases brought by state attorneys general seeking Medicaid reimbursement for smoking-related illnesses culminated in the 1998 Master Settlement Agreement.29,30 In the late 1990s and into the 2000s, several juries found in favor of injured smokers in private litigation, with damages being awarded in the millions and even billions of dollars.31 These types of cases continue to be litigated, primarily in Florida, where a jury in a class action found the tobacco industry liable, setting the stage for thousands of individual claims.32,33 Despite continuing to use personal responsibility arguments in smokers’ litigation,34 currently the tobacco defendants are losing about two thirds of the Florida cases, with the juries apportioning responsibility between the plaintiff and the defendant in each case.35Adding to existing scholarship, we sought a deeper understanding of the tobacco industry’s framing, rhetoric, and tactics, and their application, based on both content and legal analyses. Our first study examined the early debate about tobacco and the initial scientific revelations that it was harmful (from 1952 to 1965) and found an unexpected lack of personal responsibility rhetoric by any of the speakers but rather an emphasis on the government’s responsibility to address the issue, which culminated in the passage of the FCLAA.24 Our next study focused on determining when the debate shifted and the tobacco industry began explicitly referring to smokers’ individual personal responsibility, which we found began in the 1970s and gained prominence in the late 1980s, during what has been called the “second wave” of tobacco litigation.27In our study, we examined the specific rhetoric used by the tobacco industry to frame personal responsibility arguments in both the media and the courtroom, and analyzed how the 2 influenced each other. This study’s findings have application not only for tobacco control advocates, but also for others focusing on public health issues arising from the consumption of numerous other products that cause avoidable noncommunicable disease and death, such as obesogenic food and beverages,16,36 alcohol,37 electronic gambling machines,38 and firearms,39 because those industries are now replicating and refining successful tobacco industry tactics and rhetoric. Comprehension of the evolution and cross-pollination of corporate litigation and communications strategy and a focus on corporate malfeasance and deceit will furnish public health advocates with ammunition for developing countermarketing strategies to denormalize health-compromising products and the industries that produce them.40–42     

Suicide screening scales may not adequately predict disposition of suicidal patients from the emergency department

Background

Suicide screening scales have been advocated for use in the ED setting. However, it is currently unknown whether patients classified as low-risk on these scales can be safely discharged from the emergency department. This study evaluated the utility of three commonly-used suicide screening tools in the emergency department to predict ED disposition, with special interest in discharge among low-risk patients.

Dietary Salt Intake and Discretionary Salt Use in Two General Population Samples in Australia: 2011 and 2014

The limited Australian measures to reduce population sodium intake through national initiatives targeting sodium in the food supply have not been evaluated. The aim was, thus, to assess if there has been a change in salt intake and discretionary salt use between 2011 and 2014 in the state of Victoria, Australia. Adults drawn from a population sample provided 24 h urine collections and reported discretionary salt use in 2011 and 2014. The final sample included 307 subjects who participated in both surveys, 291 who participated in 2011 only, and 135 subjects who participated in 2014 only. Analysis included adjustment for age, gender, metropolitan area, weekend collection and participation in both surveys, where appropriate. In 2011, 598 participants: 53% female, age 57.1(12.0)(SD) years and in 2014, 442 participants: 53% female, age 61.2(10.7) years provided valid urine collections, with no difference in the mean urinary salt excretion between 2011: 7.9 (7.6, 8.2) (95% CI) g/salt/day and 2014: 7.8 (7.5, 8.1) g/salt/day (p = 0.589), and no difference in discretionary salt use: 35% (2011) and 36% (2014) reported adding salt sometimes or often/always at the table (p = 0.76). Those that sometimes or often/always added salt at the table and when cooking had 0.7 (0.7, 0.8) g/salt/day (p = 0.0016) higher salt excretion. There is no indication over this 3-year period that national salt reduction initiatives targeting the food supply have resulted in a population reduction in salt intake. More concerted efforts are required to reduce the salt content of manufactured foods, together with a consumer education campaign targeting the use of discretionary salt.     

Identification of modifiable work-related factors that influence the risk of work disability in rheumatoid arthritis

OBJECTIVE: To define work-related factors associated with increased risk of work disability (WD) in people with rheumatoid arthritis (RA). METHODS: Questionnaires were mailed to all RA patients who used a province-wide arthritis treatment program between 1991 and 1998 (n = 1,824). The association between risk factors and WD (defined as no paid work due to RA for at least 6 months) was assessed using multiple logistic regression analysis, controlling for significant sociodemographic and disease-related variables. RESULTS: Of the original 1,824 patients, 581 were eligible and responded to the questionnaire. Work survival analysis revealed a steady rate of WD starting early, with 7.5%, 18%, and 27% work disabled at 1, 5, and 10 years, respectively. Significant determinants in multiple logistic regression were physical function (Health Assessment Questionnaire), pain (visual analog scale), and 6 work-related factors: self employment, workstation modification, work importance, family support toward employment, commuting difficulty, and comfort telling coworkers about RA. CONCLUSION: Work disability occurs early in RA. Novel work-related factors were identified, which are potentially modifiable, to help RA patients stay employed.     

Solid‐phase extraction–liquid chromatography–tandem mass spectrometry method for the qualitative analysis of 61 synthetic cannabinoid metabolites in urine

This article comprises the development and validation of a protocol for the qualitative analysis of 61 phase I synthetic cannabinoid metabolites in urine originating from 29 synthetic cannabinoids, combining solid‐phase extraction (SPE) utilizing a reversed phase silica‐based sorbent (phenyl) with liquid chromatography–tandem mass spectrometry (LC?MS/MS). Validation was performed according to the guidelines of the German Society of Toxicological and Forensic Chemistry. Sufficient chromatographic separation was achieved within a total runtime of 12.3 minutes. Validation included specificity and selectivity, limit of detection (LOD), recovery and matrix effects, as well as auto‐sampler stability of processed urine samples. LOD ranged between 0.025 ng/mL and 0.5 ng/mL in urine. Recovery ranged between 43% and 97%, with only two analytes exhibiting recoveries below 50%. However, for those two analytes, the LODs were 0.05 ng/mL in urine. In addition, matrix effects between 81% and 185% were determined, whereby matrix effects over 125% were observed for 10 non‐first‐generation synthetic cannabinoid metabolites. The developed method enables the rapid and sensitive detection of synthetic cannabinoid metabolites in urine, complementing the spectrum of existing analytical tools in forensic case work. Finally, application to 61 urine samples from both routine and autopsy case work yielded one urine sample that tested positive for ADB‐PINACA N‐pentanoic acid.     

An evaluation of clinical stability criteria to predict hospital course in community-acquired pneumonia

A number of different methods exist to assess clinical stability, a key component of pneumonia management. We compared the prognostic value of different stability criteria through a secondary analysis of the Edinburgh pneumonia study database. We studied four clinical stability criteria (Halm's criteria, the ATS criteria, CURB and 50% or more decrease in C-reactive protein from baseline). Outcomes included 30-day mortality, need for mechanical ventilation or vasopressor support (MV/VS), development of a complicated pneumonia, and a combined outcome of the above. A total of 1079 patients (49.8% male), with a median age of 68 years (IQR 53–80), were included. Ninety-three patients (8.6%) died by day 30, 91 patients (8.4%) required MV/VS and 99 patients (9.2%) developed a complicated pneumonia. Patients with increasing severity of pneumonia on admission, assessed by both CURB-65 and PSI, took a progressively longer time to achieve clinical stability assessed by any method (p < 0.001 for all criteria). Halm's criteria had the highest area under the curve (AUC) for prediction of 30-day mortality (AUC 0.95 (0.94–0.96)), need for MV/VS (AUC 0.96 (0.95–0.97)) and combined adverse outcome (AUC 0.96 (0.95–0.97)). C-reactive protein had the highest area under the curve for complicated pneumonia (AUC 0.96 (0.95–0.97)). Adding C-reactive protein to Halm's criteria increased the area under the curve, but the difference was only statistically significant for complicated pneumonia. All of the criteria performed well in predicting adverse outcomes in patients with pneumonia. Halm's criteria performed best when identifying patients at low risk of complications.     

Effects of blood pressure lowering with perindopril and indapamide therapy on dementia and cognitive decline in patients with cerebrovascular disease

BACKGROUND: High blood pressure and stroke are associated with increased risks of dementia and cognitive impairment. This study aimed to determine whether blood pressure lowering would reduce the risks of dementia and cognitive decline among individuals with cerebrovascular disease. METHODS: The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was a randomized, double-blind, placebo-controlled trial conducted among 6105 people with prior stroke or transient ischemic attack. Participants were assigned to either active treatment (perindopril for all participants and indapamide for those with neither an indication for nor a contraindication to a diuretic) or matching placebo(s). The primary outcomes for these analyses were dementia (using DSM-IV criteria) and cognitive decline (a decline of 3 or more points in the Mini-Mental State Examination score). RESULTS: During a mean follow-up of 3.9 years, dementia was documented in 193 (6.3%) of the 3051 randomized participants in the actively treated group and 217 (7.1%) of the 3054 randomized participants in the placebo group (relative risk reduction, 12% [95% confidence interval, -8% to 28%]; P =.2). Cognitive decline occurred in 9.1% of the actively treated group and 11.0% of the placebo group (risk reduction, 19% [95% confidence interval, 4% to 32%]; P =.01). The risks of the composite outcomes of dementia with recurrent stroke and of cognitive decline with recurrent stroke were reduced by 34% (95% confidence interval, 3% to 55%) (P =.03) and 45% (95% confidence interval, 21% to 61%) (P<.001), respectively, with no clear effect on either dementia or cognitive decline in the absence of recurrent stroke. CONCLUSIONS: Active treatment was associated with reduced risks of dementia and cognitive decline associated with recurrent stroke. These findings further support the recommendation that blood pressure lowering with perindopril and indapamide therapy be considered for all patients with cerebrovascular disease.     

Interventions in labour and birth and satisfaction with care: The Canadian Maternity Experiences Survey Findings

Objective: To examine whether interventions in labour and birth contributed to ratings of satisfaction with these experiences, in women giving birth vaginally or attempting a vaginal birth prior to giving birth by caesarean section. Background: Ratings of satisfaction with women’s overall experience of labour and birth have long been encouraged, yet remain challenging to assess or to interpret. Methods: Data from the Canadian Maternity Experiences Survey (MES) – a nationally representative sample of women who had a singleton live birth in 2005–2006 – were analysed. Associations between the number of and type of labour and birth interventions, and women’s satisfaction with the overall labour and birth experience and six aspects of caregiver interactions, were assessed. Results: Among women having vaginal births, fewer interventions during labour was significantly associated with higher overall satisfaction with the labour and birth experience (ranging from 75% of women having no interventions to 46.4% having eight or more interventions rating their experiences as ‘very postive’). The same pattern was observed for satisfaction with women’s perceptions of caregiver’s respect, concern for dignity, compassion shown to them, the information given to them, their involvement in decision making, and caregiver’s competence. Among women having unplanned caesarean sections following attempted vaginal birth, the number of interventions was not associated with satisfaction ratings; however, satisfaction ratings were consistently lower than among women giving birth vaginally. Conclusion: These findings provide support for demedicalising vaginal labour and birth as well as for optimising the potential for a vaginal birth rather than caesarean section.     

Optimizing the management of patients with spinal myeloma disease

Myeloma is one of the most common malignancies that results in osteolytic lesions of the spine. Complications, including pathological fractures of the vertebrae and spinal cord compression, may cause severe pain, deformity and neurological sequelae. They may also have significant consequences for quality of life and prognosis for patients. For patients with known or newly diagnosed myeloma presenting with persistent back or radicular pain/weakness, early diagnosis of spinal myeloma disease is therefore essential to treat and prevent further deterioration. Magnetic resonance imaging is the initial imaging modality of choice for the evaluation of spinal disease. Treatment of the underlying malignancy with systemic chemotherapy together with supportive bisphosphonate treatment reduces further vertebral damage. Additional interventions such as cement augmentation, radiotherapy, or surgery are often necessary to prevent, treat and control spinal complications. However, optimal management is dependent on the individual nature of the spinal involvement and requires careful assessment and appropriate intervention throughout. This article reviews the treatment and management options for spinal myeloma disease and highlights the value of defined pathways to enable the proper management of patients affected by it.