Interview Summary

Access the PLOS article “Dynamics of combatting market-driven epidemics: Insights from U.S. reduction of cigarette, sugar, and prescription opioid consumption.”

So, Jono, let’s start with you. Tell us what you mean by market driven epidemics.

The pattern is familiar to people. There is a product that that humans like and the business community says we can make a lot of money on this unmet need. And so they do that and they start selling a lot of it. And then people start noticing that this thing that the humans like is killing some of them. And so, the scientists do the public health. And then the business community says these scientists are going to kill the golden goose. They buy up other scientists and try to defend themselves. And then it goes on and on before we really bend the epidemic curves. This pattern of consumer products that have harmful effects, those products are major contributors to the root causes of at least a million deaths a year in the US, and over 20 million deaths worldwide.

So, to try to look at this from an epidemic point of view, we first established a case definition. Our definition of market driven epidemic is a significant increase in death, disability and other harmful effects on humans and human health and wellbeing. It’s arising from a consumer product whose use has been accelerated by aggressive marketing. Whose harmful effects have been denied or otherwise minimized by producers. And for which effective mitigation is possible but actively opposed by producers.

So, we looked at the natural history of this, and we found five phases through which these epidemics pass. There’s market development, either inventing a new product, developing a product like prescription opioids, or transforming an existing product like tobacco. Phase two is evidence of harm. First, there’s suspicion, astute clinicians, whistleblowers, and then eventually proof of harm. Phase three is corporate resistance. Companies deny harm, seek to discredit accusers, commission counter science, manufacture doubt, mount legal challenges. All the while deaths and social upheaval and economic costs are mounting. And finally, our next phase four is mitigation. We get some regulatory efforts going, and there’s a tipping point for the consumption and resulting deaths. And then finally, phase five of this is market adaptation. In a response to decreasing or threatened consumption, companies and consumers typically seek alternatives. Adaptations can be positive or negative. Some are healthier, some are equally or more harmful.

Thanks very much for that description. It really helps explain what the concept is all about. You chose three areas of focus. You could have chosen others, but you chose cigarettes, sugar, and prescription opioid use. Why those in particular?

We wanted to identify differences in these market driven epidemics in a few product categories. We wanted to look at distinctly different consumer experiences so we could see what worked and what didn’t in terms of bending the epidemic curve. We picked nicotine delivery, food, and prescription medicine. And to choose within those categories we established five inclusion criteria. So, number one, the product had to have proven adverse health effects. Number two, there needed to be well documented histories of product development, marketing, mitigation efforts, and so forth. Number three, the product needed to meet the overall case definition. That is, companies knew they were doing harm, continued to do harm, and fought that harm. Number four, there needed to be long term data available for product consumption and associated impact. And number five, most important, we chose products for which mitigation efforts had already resulted in significant sustained reduction in product consumption. Based on these three criteria, cigarettes, sugar, and prescription opioids came out as the ones that we studied.

Thanks. I really appreciate that description. And when we get to the punchline in a minute, it’s going to be interesting to see whether the behavior of the industry in this natural history that you talked about is similar, given that the substances are so different. We’ll get to that in a minute. So Eszter, I’d like to turn to you. What kind of information did you pull together to write this paper?

I think I looked at over a thousand different documents. But there were two clear types that I interrogated to pull together all of our background data. The first category was publicly available data, so that could have been a clinical study, epidemiological study, advertisement by the company, CDC or other government reports, mortality data, etc. But then there was also a distinct different type of data that we really looked at and that was really useful for putting together these pictures of the natural history, which was internal documents. In some cases, these could have been leaked by an internal employee, which was the case with the so called ‘brown documents’ with tobacco. But it also came from sometimes court hearings or as a result of lawsuits that the companies had to release internal data. It was really interesting to compile together the different sides, of the outside look from CDC reports, and then the insider scoop from Purdue Pharma. So, it’s a very well rounded, interesting way to find all this data.

I admire your effort. It’s a big job to do a normal scientific review where you might have 50 papers and you were looking at things that were much harder to obtain and a vast number of things that are really quite different in character. Boy, congratulations for just reading all those things. Tell us what you found.

Gosh, so even though there’s so many distinct differences between a lot of these epidemics, what we actually found was that there was a lot of narrative similarities. And because of that, we could really create this holistic, but also really well-fitting idea of market driven epidemics. A lot of the corporate strategies were either mirrored, imitated, or in some cases quite literally lifted over because of overlapping ownership between the companies.

One of the things that we really wanted to hammer into our article was that producers not only created their product, but they also manufactured doubt. Which means that they created, on purpose, public hesitancy around their product even when they internally knew that it was harmful to health. They wanted the public to be on the fence about what the health impact of their product was. There was a lot of different ways that they achieved that goal. Sometimes it was through showing propaganda films in high schools. Which I still can’t believe that happened and then that was legal. But also in different ways, like co-opting science, paying scientists to publish articles in their favor. I know a really famous example of this that has now been public is that two Harvard researchers in cardiovascular disease published saying that sugar was not harmful to health. So, there’s a lot of different ways that they achieved it, but the goals overall were very similar by all the companies.

You know, you mentioned overlapping ownership. And so, you might have been referring specifically to the ownership of the food companies by the tobacco companies.

Correct.

Because it happened a while ago, that’s not something that was well known. But there’s a fascinating history there about how the tobacco industry used its technology to maximize addiction and used that to develop food products and to change the DNA of the food companies in ways that still exist today, even though that ownership ended many years ago. I’m really glad you pointed that out.

Yeah, exactly. I think there’s this shared idea that there’s a turning point for companies. Where they know internally that their product is causing harm. And what really tips them over into becoming market driven epidemics is not actually coming out and saying that there’s an issue with their product or not improving it. But you know really digging that information into the dirt and saying no we’re going to protect our product and keep giving this out to the public despite the harms.

You know, maybe we can come back to this, but the fact that you’re finding similarities between these areas suggests that there are contingencies that act on corporate executives that are similar no matter what they’re selling. And that’s helpful to know because in the future, you can predict what these companies will be doing because there are many more similarities than differences. Jono let me ask you this. You’ve talked about this appalling period of time between when there are known health consequences of use of some of these things and the time when meaningful action occurs to curb their consumption and to rein in the behavior of the companies. How long is this gap, and what explains it?

Kelly, this is one of the most fascinating things about this study. And it really highlights the importance of taking an epidemiologic approach. This is a behavioral epidemic, not a viral one. But it has so many characteristics. One of the key points is that is how important time is. And we see that in any epidemic curve when things start going exponential. If we take cigarettes, okay, the harms of cigarettes had long been suspected. But the first credible scientific publication was by a US physician, Isaac Adler, in a 400-page 1912 book where he first associated cigarettes with cancers. Fast forward over 40 years to British scientists Doll and Hill, and they did the epidemiology which definitively and convincingly links cigarette cancer with smoking deaths. So that gap was incredible and so that’s one of the first examples. Once those articles were published, others followed the initial one. It took about a decade until the 1964 Surgeon General’s report on smoking and health. And that was quickly followed by a series of federal actions. So, 1964, ’63, ’64 was the tipping point. Five decades after the initial suspicion.

For sugar, the journey from suspicion to compelling evidence was more complex. There was a big debate between researchers, clinicians, scientific journalists, that began in the ’50s. A diabetologist from Britain John Yudkin, argued in the 1957 Lancet piece, it’s sugar that’s equal or larger than fats. An American physiologist, Enzo Keyes, says au contraire. He said it on the cover of Time Magazine. From 1950 to 2000, there was this debate back and forth. Finally, sugar consumption in the US peaked in ’99 when a sugar wary group of researchers, journalists, and advocacy groups began becoming really vocal. And that was the tipping point. The actual compelling science, it came a few years after the preponderance of folks engaged said, no, it’s sugar. You got to do something.

And finally, with prescription opioids: 1997, rural doctors Art Van Zee and another fellow, alerted Purdue Pharma, the producer of OxyContin, about rising overdoses. A year later, there was a publication that said the sustained release version of OxyContin, which was a hydrocodone that was sustained release, that they first tried it with morphine, and they had evidence from there that the sustained release drugs were a problem. And again, it was over a decade later that mounting prescription opioid deaths in the US convinced CDC to declare an epidemic of [00:14:00] opioid prescribing. This gap, if you look at it, to summarize, for cigarettes, the journey from credible suspicion of harm to consumption tipping point, five decades. Sugar, four decades. Prescription opioids, fourteen years. But the key thing is that the power of collective action, because today, only one in eight Americans smoke, and it was nearly 50 percent at the peak. The US consumption of sugar, which increased by 30 pounds between the year 1950 and the year 2000, when all this debate was going on. We picked up an extra 30 pounds of sugar consumption per person per year, but within two decades, that was cut back. We gave back 15 pounds of that. And now prescription opioids have gone back to a medically defendable level, having risen to 8 to 10 times that in the peak of the prescription opioid epidemic.

Hearing you talk about that, it’s nice that there’s sometimes light at the end of the tunnel. But boy, it’s a long tunnel. And that you can count the, the number of deaths during that tunnel period of time in the millions. It’s just unspeakable how much damage, preventable damage gets caused. Now, and I’d like to, when I come back to wind up this podcast, I’d like to ask each of you, what do you think might be done to help narrow that or shrink that time gap and to prevent these long delays and to help address these corporate determinants of health. But before I get there, Eszter, you know, I’d like to follow up on the conversation we had earlier. You know where it’s clear that sugar and tobacco and opioids are all quite different substances, but the companies, the natural history of these things looks quite similar. And you mentioned in particular the industry attempt to plant doubt. To create doubt in the minds of people about the stories they were hearing of the dangers of these things, whether they were true or not. And were there other things that the industry was doing during that time that you noticed might have similarities across these areas?

Oh my gosh, so many. I have to go through all the examples in my head and make sure that I have a very crisp message out of all of them One of the ones that is interestingly being employed today in a very different epidemic with firearms and guns, is this idea of whose choice is the consumer product in its use. And today there’s a lot of ideas that were initially created by tobacco, and then used by food, that are currently being used by gun lobbyists talking about individual freedoms. So with some of the previous market driven epidemics, like tobacco and prescription opioids, it’s a way easier argument to make that the individual at some level does not choose to use the product. Maybe in the beginning, the first couple uses were their individual choice, but then there’s on purpose, a really strong withdrawal response in the body and socially. The individual kind of had to continue using the product. But some of those ideas are being used today with firearms. The idea that somebody has the liberty to use this product or to purchase this product, which undoubtedly causes harm. You know, it’s probably not really good for public health if this argument exists. And, in the cases with firearms, which I think is a little bit ironic and sad, a lot of the people that buy guns for their own self-defense actually experience those guns turned around and used on them, usually by the perpetrators of aggression. These ideas of individual freedoms usually backfire to the people that are consuming the products. It’s interesting to me that a lot of these ideas were initially created for very different products, but are being used in the current day.

So interesting to hear you say that because here we have yet another area where there are similarities with the firearms. And the companion argument to that idea that it’s your personal liberty to use these things is the argument that there’s overreach by government, big brother, things like that. When government wants to, you know.

Yeah.

It’s so interesting.

So one point on that. The market economy was never meant to be a free for all. Because the reality is that the market economy has brought billions of people out of poverty and saved more lives than most health interventions. But the problem is, as I said, it wasn’t meant to be a free for all. And it depends on having good consumer information and when companies are distorting it, they’re basically taking away the informed choice, which is critical. The other part of it is, when they are purposely engineering their products for maximal addictiveness, which is done with clicks and social media, and was done purposefully with the nicotine content in cigarettes, then you don’t have a real informed choice. The freedom of choice. You’ve had your brain pleasure center hijacked by, by purposely addictive products.

Right, and you didn’t mention food, but there’s another example of substances that are created to hijack the reward pathway in the brain.

Absolutely.

I’d like to ask each of you, what in the heck can we do about this? I mean, you’ve pointed out a massive problem. Where the number of lives that are sacrificed because of corporate behavior, just enormous numbers. What can we do about it? Jono, I will start with you. And, you know, you’ve written this very highly regarded book called The End of Epidemics. And you’ve talked about things like bending epidemic curves and accelerating shifts. But tell us more. What do you think can be done in the case of these market driven epidemics like we’re talking about?

Well, I think it’s important to realize that both kinds of epidemics, viral and behavioral, are communicable. Both involve a lot of rumor, blame, uncertainty. And as we’ve talked about both cause deaths in the thousands or millions. And we haven’t talked so much about the significant social disruption, and the cost. Trillions of dollars in economic losses and additional health burdens. So let me focus on four kinds of key actors because when it comes down to it, it’s groups that that really start acting against these things. The first is the research community and its funders. You won’t be surprised given the time it takes to get the evidence because what’s clear is without clear evidence of product associated harm, we’re not going to move the political agendas. We’re not going to get public support for epidemic curves. So, we have really good researchers working in these areas. They need to guard against groupthink. That’s what happened with our salt sugar 50 years of chaos discussion. And conflict of interest because companies do try to undermine the database.

The second is the funders of research, foundations and all, and national health services need to have an early warning system and an annual research roadmap in this area. I think Eszter will probably talk about the importance of public health leaders, because she’s looked a lot at that. Another community though is the different civil society groups that are active. Because there’s Mothers Against Drunk Driving, there’s the Sandy Hook group on gun shooting, and there are a variety of interest groups. But what we realize is that there are lots of different strategies for how you move decision makers and all. So, more information sharing from those groups, civil society groups and all across. And finally, companies. It’s actually in their interest to be more forthcoming earlier on. With tobacco, with prescription opioids, and now with baby powder, with talc, what we’re seeing is companies at risk of bankruptcy paying billions of dollars. And if their CEOs aren’t looking at that, then their board needs to be.

Can I ask you a quick question about that? When the chickens come home to roost, and those bad things befall a company, you know, really seriously damaging lawsuits, or the possibility that perhaps sometime the executives will go to jail for corporate malfeasance. You know, the behavior that caused all the millions of deaths occurred 15 CEOs before them. So, if you’re a CEO and you know you have a certain shelf life as CEO, you want to maximize profit during that time. And by the time anything happens negatively to the company, you’re on vacation, you’re retired, or you’re gone. So how do you deal with that?

Here’s the thing, it’s having criminal and civil liability that can go back to the individuals involved. From a different sector, an example. The German executive who was head of Volkswagen over a decade ago when they cheated on their environmental issues. He’s been criminally charged today, a decade later. And I think that sort of personal accountability, it’ll be hard to get, but that’s the kind of thing that will make CEOs and their boards, if their boards also become responsible for hiding information in a way that it resulted in deaths. I think that, unfortunately, that kind of hammer, although it’s going to be hard to get, that’s probably what’s needed.

Okay, that makes good sense to me, and I’m glad I asked you that question. And I appreciate the answer. Eszter, anything you’d like to add to what Jono said about what could be done.

Yes. One of the amazing things about market driven epidemics was when we were creating the paper, we created a table of all the different types of actors that could have very successful mitigation. And that table actually ended up being cut from the paper because it was so long that the editor said that it might distract from the rest of the paper. But that’s actually a very positive message because there are so many actors that can have positive change, I’m going to highlight a couple of them because I think there’s a few things here that are fairly good core messages that we can take away.

One of the ones is the need for a trusted public health authoritative voice. I think nowadays there’s a lot of commotion over how much we trust the government. And how much we trust, for example, the head of the CDC and the types of data they’re talking about in terms of public health. But in the past, when we had a very trusted public health voice, that was really crucial in getting consumers to change their behavior. For example, in the 1964 Surgeon General’s report, seemingly overnight changed people’s behavior. Before then, smoking was a common, everyday social event. And after that, people started viewing it as a deadly, bad habit that some people had. And that type of change was really hard to get in the modern day. When we were talking about public health crises that were viral. So, I think one of the things that we really need to get again in the modern day is this trust between the people and public health voices so that when we have such good forthcoming information those statements actually mean something. So much so that the consumers change their behavior.

Another thing is with us individuals who maybe aren’t part of public health, we actually play a pretty big role in how much other people consume these different products. I remember when I was researching cigarettes in particular and the intersection with social media. I think if somebody under 18 saw a peer smoking and posted that to Instagram, that doubled their likelihood of trying out smoking for the first time. You have to be really careful with how you show yourself in the presence of others, and online too with a new digital age. Because you might tip the scale in somebody trying out a product for the first time. Which then if it has a very strong withdrawal effect, you know that person might have to might feel that they have to continue using that product to avoid withdrawal. I think as an individual, you can be more mindful about if you have a certain product use that you don’t want others to also pick up, to maybe not do it or not show it as much so that other people aren’t interested in doing that.

Okay, the last really positive message I have is that I think as my generation gets into higher positions of power, even within corporations, I think Gen Z and Gen Alpha and other young people have the sense of responsibility for others and for the planet. And I think if there was a young person in power in a corporation and saw that oh no this product that we’ve had is now there’s evidence that’s harmful. I think there would be more accountability and more of a want to do something that’s good for the planet and for people. I’m hopeful that, maybe 50, 60 years ago, if people were more in favor of kind of brushing things under the rug, then maybe the young generation won’t be as into those ideas. And we’ll actually want to be accountable and do what’s right.