Philippe Boucher's Rendez Vous: C. Everett Koop
Rendez-vous with C. Everett Koop, M.D., SC.D.
Former Surgeon General of the United States
By Philippe Boucher
RENDEZ-VOUS 70 Wednesday, July 12 2000
PB : Thank you Dr Koop for accepting our rendez-vous.
May I ask you to introduce yourself?
Dr Everett Koop : I am C. Everett Koop, medical doctor with a degree of doctoral science in medicine as well and I had a 40-year career as a pediatric surgeon before being called by Ronald Reagan to be Surgeon General of the United States. I served two four year terms and after that remained in Washington for an additional eleven years where in some senses I had more access to government being out of office than I did when I was in it. Smoking control has been one of my passions and the questions I have been asked were directed largely toward either my role as Surgeon General or in my capacity as an anti-smoking advocate.
Q1. First question : the surgeon generals have played a very important role promoting tobacco control especially when they were coming back year after year with an annual report on tobacco and health that was extensively covered by the media. Before Dr Satcher was nominated in 1998 there has been a 4-year hiatus with nobody holding this position and the annual reports have disappeared. Don't you regret this opportunity used by the surgeon generals to raise the tobacco issue each year in a prominent way ? I personally wish the surgeon general'report would return because -contrary to what a few claimed- there are still many issues that are disputed and a lot to monitor. Do you think the annual report should/could come back?
EK : The Surgeon General's reports have been reinstituted. There have been other times when there was no Surgeon General in office, but the Surgeon General's reports were still cranked out. I think things worked better when the Office of Smoking Health was in the office of the Surgeon General rather than being in the Center for Disease Control as it is in the present time. I think the annual report to Congress by the Surgeon General on Smoking and Health is the backbone of the armamentarium that the public uses in its fight against tobacco. For example, the semi-annual reports that I did on the effects of environmental tobacco smoke and on addiction have been very strong weapons for the public to use in the fight against tobacco and the addiction report has helped to support this creation of spread of health and scientific societies devoted to studying the addiction process. Remember that the Surgeon General's reports are put together by maybe eighty to a hundred people who are qualified to do the specific things that they do and they represent the backbone of unsung heroes in the war against tobacco.
Q2. The second items one links with the Surgeon General are the health warnings. In Canada the Health Minister is now proposing new health warnings on (and inside) cigarette packs that go way beyond the US model and the European Union is discussing similar changes.
In the first settlement the tobacco companies had agreed (if I recall correctly) to warnings the way they are now in Canada (25% of the surface, front and back, black and white).
In this context, don't you think it would be appropriate to push for a bold revision of the health warnings on tobacco products in the US ? including new tools like a toll-free number to help people quit as well as a website (since the tobacco companies do use those tools on their packs to promote their products) ? What about inserting -like the Canadians propose- a surgeon general's message within the pack ?
EK : I'm not sure how effective Surgeon General's warnings on tobacco cartons and advertising are in the long run but I think that two or three things are to be said. One is that repetition is a good way to teach but eventually over-repetition makes the message stale and people pay no attention to it. Therefore, I think the label should be rotated, not just rotated periodically, but they should be restated in different language so that people know they're different and read them and sometimes it will strike a responsive note in someone that it never did before. I have always been in favor of Canadian style large type warnings and I think they should be as bold and as blunt and as eye catching and as provocative as they can possibly be. The idea of the toll free number is excellent but as far as the United States is concerned it's going to have to take a greater commitment on the part of government against tobacco than just funding the meager budget for the annual Surgeon General's Report. I think that within a year you will see a major effort on the part of Internet sites to deliver the smoking cessation message to the public and to do it in such way that there will be very high success rates at the end of the year.
Q3. Many countries have been adopting advertising and promotion bans. When one looks at the situation in the US there is already a partial ban since there are no ads on TV, on the radio, the billboards are gone, many newspapers now refuse tobacco ads. But there is still a significant and often shocking presence in magazines even if Philip Morris just announced -under pressure from the Ags- they would drop part of their printed ads and plenty of promotions.
What regulation would be appropriate?
EK : In reference to advertising, everything you stated in your question is correct and the United States has done a lot to get rid of ads largely by public pressure and by private effort rather than through the government. Don't be fooled by Phillip Morris's grand stand play of taking tobacco ads out of magazines that are aimed at children. If you follow the advertising reports closely you will find that they have actually increased their advertising but they're moving just a little bit higher to an age at which they still can addict youngsters and appeal to them about the "Coolness" of smoking. Remember, you can not believe what the tobacco companies say and even if they say we are conducting a campaign to cut down smoking, that means that they have found a way to use a smoking reduction campaign to increase smoking in other ways for themselves.
Q4. Dr Satcher holds at the same time the office of Surgeon General as well as the position of Assistant Secretary for Health. Since he is more part of the government's team isn't there a risk that he lose part of the independence that made the Surgeon General's office so special and so precious ?
EK : Dr. Satcher is the second person who has held both the offices of Assistant Secretary for Health and the Surgeon General. I begged President Clinton not to give him both jobs and I begged David Satcher not to accept both jobs. The temptation was too great however, and now Satcher is in two jobs, neither of which he can do as well as if he did one of them alone. The Assistant Secretary's job is a political job and it takes precedence in the eyes of the Secretary of HHS. The Assistant Secretary reports on health matters to political scientists. That doesn't leave much time to be the Surgeon General and in addition to that the combined efforts of the Government both in the Executive Branch and in Congress have reduced the infrastructure that made it possible for me to accomplish a lot of the things that I did as Surgeon General. Usually the Executive Branch and the Congress balance each other out but in reference to tobacco the country was caught in a pincers movement. The President's "downsizing" was disguised under the term "reinvention" of government. When the House of Representatives became Republican, the sad tenor was the same because their contract with the people was also an effort to reduce the size of government and the infrastructure that took so long to build and hone the Public Health Service was sadly skeletonized. I don't think the two jobs belong together and I think the Surgeon General's job should be one of independence -- nobody, including the President, telling him what he can or cannot say. The Surgeon General's job has been weakened because the Surgeon General has two jobs. If the Surgeon General is known as a no-nonsense, straight from the shoulder occupant of the bully pulpit where he tells the American people how to prevent disease and promote good health, the people will listen to him.
Q5. The American Legacy Foundation with a yearly budget of $ 300 millions is a powerful new player in the tobacco control field. How do you feel about their strategy and their achievements so far?
EK : We can only welcome the American Legacy Foundation to the tobacco wars. Their national activities which will be in the form of public service announcements, advertising, and public relations can only aid the anti-smoking cause.
When it comes to grants to groups working within individual states, there is the pre-requisite that American Legacy Foundation dollars have to be matched by state dollars. This is a reasonable request, but unfortunately it will deprive the organizations in states that don't have a good sense of stewardship with the money that they have already received in reference to treating addiction and keeping kids from smoking and therefore, will not benefit from the matching grant process.
However, in the long run those who run the American Legacy Foundation know exactly what the problems are and I think we can look forward to things being only better now that they are on the scene.
Thank you Dr Koop for taking the time to be with us today.
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