Harvard Public Health Review
Winter 2005




Where There's Smoke

After 20-plus years of battling the hydra of Big Tobacco, which now takes in $85 billion in sales a year in the U.S. alone, former Massachusetts Tobacco Control Director Dr. Greg Connolly was pleased when workplaces throughout the state went smoke-free last July. But having seen Massachusetts' model anti-smoking programs reduced to ashes by budget cuts in 2003, Connolly, now at HSPH, doesn't spend much time celebrating small victories. When you cut one head off the tobacco monster, another one grows back.

Anti-tobacco warriors' optimism hit an all-time high back in 1998, the year of the historic Master Settlement Agreement (MSA). Through the MSA, a deal forged by 46 state attorneys general, the four biggest tobacco companies in America agreed to reimburse states in perpetuity for Medicaid expenses incurred in the treatment of tobacco-related illnesses--$245 billion within the first 25 years. They also agreed to stop advertising, directly or indirectly, to America's youth.

Today, six years later, "The companies haven't changed," Connolly says. "They've only gotten smarter."

As proof, he points to a host of new brands targeted to women, minorities, nicotine addicts looking for a "safer" cigarette, and the next generation of smokers--teenagers. Logging onto R.J. Reynolds' "adults only" website with a password from his 14-year-old son, Connolly clicks through promotions for Camels "Exotic Twist" brands: Twista Lime, Bayou Blast Mardi Gras Berry Blend, Kauai Kolada. Sweet, spicy, fruity flavors appeal to young people, Connolly says, by masking tobacco's harshness.

"It's guerilla marketing," he says of R.J. Reynolds' (RJR) viral marketing schemes, which link hip cigarette packaging to a website touting games and contests with a speakeasy theme. He squeezes the filter on a berry cigarette. "Feel anything in there? That's a flavor-injection device," he says of a tiny plastic reservoir discovered by a staff member while sifting through millions of industry documents made public by the MSA.

"In the early 1900s, the Food and Drug Administration (FDA) banned additives that masked the toxicity of rancid meat. But today the FDA can't stop the sugar-coating of Camels," Connolly says, talking fast, as if time were running out. "Tobacco companies have all the ads they need, from the pack to the web, to recruit new smokers."


Once compared by a tobacco insider to Torquemada, the ruthless leader of the Spanish Inquisition, Connolly is known for his bold, in-your-face attacks on an industry whose products kill an estimated 5 million people worldwide each year. From the bully pulpit of the Massachusetts Department of Public Health from 1986 until the fall of 2003, he led a campaign to "Make Smoking History," overseeing the fastest decline in smoking in any state: adult cigarette consumption dropped 4 percent per year, while most states saw a 1 percent annual decline. He also appeared on national television, testified before Congress, addressed trade conferences in foreign countries, took his cause to the Clinton White House, and helped wage eight lawsuits, one of which made its way to the U.S. Supreme Court.

More than a gadfly, colleagues say Connolly is that rare public health leader who can do research, then use his findings to educate the public, transform social norms, and shape public policy. His ability to translate science into practice is why Howard Koh, former Commissioner of Public Health for Massachusetts, recruited Connolly to HSPH in January of 2004. (Or rather, brought him back to the School. Connolly, who earned an MPH from the School in 1978, created the first course in the country on tobacco control at HSPH while teaching part-time in 1990. On a field trip, he took five students to the annual meeting of the American Brands Tobacco Company in New York, where each lectured 1,000 shareholders on the health dangers of smoking.)

Koh, a physician who began waging his own high- profile crusade against tobacco after seeing too many smokers die, was Connolly's boss for five-and-a-half years, and has worked with him in the trenches. "Greg has been way out front on this issue for decades," says Koh, who left the Department of Public Health in 2002 to lead the School's Division of Public Health Practice. "Greg is absolutely tireless, absolutely fearless. He's testified, been cross-examined, sued by the industry. He's been through the ups and downs of public health practice. And he's persevered."

Currently an instructor in the Division, Connolly thinks he can make a difference by passing on all he's learned. The key, he tells students, is what he calls "barefoot research"--scientific studies done quickly in response to salient issues of the moment, such as flavored cigarettes or a report of rising illegal tobacco sales to minors. Hard data is the best weapon for challenging Big Tobacco, whether in front of the public or a court of law.

"In public health practice, I've always contended that you need public debate, you need a policy on the table to resolve that, and you need good science to validate it," says Connolly. "What I learned was, anything you do with the tobacco industry, you were inches away from the courtroom. So if you make a move, your science has to be better than what might be in the New England Journal of Medicine (NEJM) when it gets before a federal judge." To date, Connolly has published three papers in the NEJM and approximately 60 others in leading journals, including the Lancet and the Journal of the American Medical Association.

With $4 million in research grants over the next three-and-a-half years, Connolly and his five-member staff aim to ratchet up tobacco control efforts at HSPH. Connolly recently received one of only two Distinguished William Cahan Professorship awarded this year by the Flight Attendants Medical Research Institute to support his studies at HSPH of the impact of state smoking bans on the hospitality industries, as well as on the health of restaurant and bar workers. With support from the National Cancer Institute, his research team is combing through tobacco industry documents to examine how companies have designed cigarettes to appeal to the very young and maintain addiction among adult smokers. And with funds from the Legacy Foundation, Connolly has set up a surveillance system to monitor companies' new products and advertising strategies, to see whether they are in compliance with the MSA.

Connolly is also using Legacy funds to continue challenging the safety claims of so-called "reduced harm" products--cigarettes like Advance, Omni, and Eclipse. When RJR's Eclipse debuted in 2001 with ads proclaiming that there was no cigarette like it and that the brand "may pose a reduced risk of lung cancer," Connolly grabbed two "ultralight" brands, Now and Carlton, and sent them to a laboratory in Canada. "We found their smoke chemistry had lower carcinogen levels than Eclipse," he says. He took his data to the Wall Street Journal, which ran a story, as did the news networks that night. Next, he filed complaints with the Federal Trade Commission and the FDA. A group of attorneys general are currently investigating RJR's claims.

The trip from lab to courtroom takes two steps forward, one step back, Connolly says. For example, the tobacco industry fought a Massachusetts law based on his research that required full disclosure of ingredients in all products. Part of the statute was struck down in federal appellate court in 2003, but one key provision survived. Today, companies must report nicotine yields for all brands based on new, more rigorous testing criteria, which now suggest that all "light" and "ultralight" descriptors are deceptive.

"Our research is laying a foundation for the regulation of tobacco products as drug delivery devices by the FDA," Connolly explains. Given the dismal failure of Prohibition, he says, Congress won't ban tobacco outright, no matter what some public health advocates might be hoping for. "But with FDA oversight, you might one day take out candy-like additives, get rid of misleading descriptors like ultra-light, remove toxins, reduce nicotine." He smiles. "It could be very difficult for tobacco companies to make cigarettes that are safe and taste good."


Connolly's goal at HSPH is to teach students practical skills--"how to operate in the real world." Currently he is teaching a course on international tobacco control. This winter, he'll teach one on running a health education campaign. "How do you hire an ad firm, place an ad, evaluate your outcome? Produce a documentary? How do you develop your media contacts? For every dollar you spend on paid media, you should get $3 in free news coverage," asserts Connolly, who enlisted the creative talents of filmmaker Michael Moore and "Doonesbury" cartoonist Garry Trudeau, among others, to help develop anti-smoking messages for Massachusetts.

Another idea: A course on navigating the legislative and legal systems. "How do you wrestle with a big industry and win? Be an expert witness? Get to litigation and trial? How do you testify before a Congressional committee? Write a bill or regulation that can survive legal challenge by the industry?" Connolly will bring in people outside of the public health arena, he says, including experts on tobacco product liability law and shareholders who have filed resolutions against the tobacco industry.

Asked for his secret for transforming the social norm, Connolly says there's no silver bullet. It's a combination of forces: price increases, public education through the mass media, treatment for people trying to quit, laws and policies that make it less socially acceptable, and more difficult, for people to smoke in public--all were critical to the success of Massachusetts. The closest thing Connolly has to a formula is an acronym: "KILLS. Keep it loud and local, stupid." Behavioral changes take root in the community, he says; you can't impose them through legislation unless the people are willing.

Here's how it works: In 1995, towns from Attleboro to Wilbraham passed clean-air ordinances that prohibit smoking in restaurants and bars. By 2002, scores of others, including Boston, had followed suit. Finally, in July 2004, Massachusetts declared virtually all workplaces smoke-free, the sixth state to do so. Through a process Connolly calls "diffusion," a profound change in the social norm gathered momentum.


Diffusion can also happen on an international scale. On the strength of Massachusetts' programs, Connolly, an advisor to the World Health Organization, has helped persuade countries from Australia to Poland to put the lid on tobacco, and recently met on the issue with members of Armenia's parliament. Following his work with the Ministry of Health, Ireland in 2004 banned smokeless tobacco, advertising, and smoking in public places, including pubs. Among developing countries, "Thailand's done everything right," Connolly says. There, sparked by a student- and physician-led movement that quickly gathered steam, the government banned advertising, got ingredient disclosures, and raised prices sky high. The Royal Decoration from Thailand's king on Connolly's office wall proclaims his contributions to the health of that nation. Taiwan, South Korea, Vietnam, the Phillipines, Malaysia--these nations will follow, he predicts.

To aspiring tobacco fighters, Connolly sounds this cautionary note: "No one wins." Instead, as in most other areas of public health, one must measure progress in increments. "Twenty years ago we were trying to get Boston's mass-transit system to stop advertising cigarettes … trying to get restaurants to ban smoking...trying to get rid of billboards in South Boston," he points out.

Fall 2004 was yet another season of ups and downs. The latest of many bills to require FDA supervision of Big Tobacco died in the waning days of this Congressional session, a victim of corporate lobbying--"the Don Quixote quest at its absolute worst," Connolly quips. Meanwhile, the U.S. Department of Justice launched a mega-trial against Big Tobacco, seeking to recover $280 billion in alleged illegal profits from a "massive 50-year scheme to defraud the public," in violation of the federal Racketeer Influenced Corrupt Organizations (RICO) Act.

"You make a little bit of progress every day. We're on a roll," Connolly says with a grin. "But it's a roller coaster."

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