Inaugural address of the 162nd president of the American Medical Association.

On June 26, 2007, Ronald M. Davis, MD, was inaugurated as the 162nd president of the American Medical Association at an ornate ceremony in the Grand Ballroom of the Hilton Chicago Hotel. He is the first AMA president to be board-certified in preventive medicine. After Dr. Davis completed the Epidemic Intelligence Service program and the preventive medicine residency program at the U.S. Centers for Disease Control and Prevention, he served as director of CDC's Office on Smoking and Health and then as medical director of the Michigan Department of Public Health. Since 1995, he has served as director of the Center for Health Promotion and Disease Prevention at the Henry Ford Health System in Detroit. By tradition, the presidents of state medical societies and the leaders of a few other medical organizations sit on the dais during the AMA president's inaugural speech. Reflecting Dr. Davis's interest in strengthening the partnership between clinical medicine and public health, he invited leaders of seven preventive medicine and public health organizations to join him on the dais during his address: the Aerospace Medical Association, the American Association of Public Health Physicians, the American College of Occupational and Environmental Medicine, the American College of Preventive Medicine, the American Public Health Association, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials. Dr. Davis's inaugural address appears below, except for a portion at the beginning in which he gave tribute to many family members, friends, and colleagues for their support through the years. This portion of his speech can be found on the Journal's website at www.ajpm-online.net.

The Tobacco Deposition and Trial Testimony Archive (DATTA) project: origins, aims, and methods.

Research on previously secret tobacco industry documents has grown substantially during the past decade, since these documents first became available as the result of private and governmental litigation and investigations by the US Congress and the US Food and Drug Administration. Complementary research on tobacco litigation testimony is now being conducted through the Tobacco Deposition and Trial Testimony Archive (DATTA) project. We obtained transcripts of depositions and trial testimony, deposition and trial exhibits, expert reports, and other litigation documents from law firms, court reporter firms, individual lawyers and witnesses, tobacco company websites, and other sources. As of 3 March 2006, the publicly available collection of DATTA (http://tobaccodocuments.org/datta) contained 4850 transcripts of depositions and trial testimony, including a total of about 820,000 transcript pages. Transcripts covered testimony from 1957 to 2005 (85% were for testimony from 1990 to 2005) given by more than 1500 witnesses in a total of 232 lawsuits. Twelve research teams were established to study the transcripts, with each team covering a particular topic (for example, the health consequences of tobacco use, addiction and pharmacology, tobacco advertising and promotion, tobacco-product design and manufacture, economic impact of tobacco use, youth initiation of tobacco use, and public understanding of the risks of tobacco use and exposure to second-hand smoke). The teams used qualitative research methods to analyse the documents, and their initial findings are published throughout this journal supplement.

Epidemiology of the third wave of tobacco litigation in the United States, 1994-2005.

OBJECTIVE: To describe the epidemiology of litigation against the tobacco industry in the United States during the years 1994-2005 (described as the "third wave" of tobacco litigation). "Epidemiology" refers to the study of the distribution and determinants of disease in populations. We apply the term "epidemiology" to the litigation context for purposes of characterising qualitatively and, to the extent possible, quantitatively the variety of cases litigated against tobacco manufacturers and allied tobacco interests during the third wave and their impact on the tobacco industry. METHODS: The data for this paper come from legal cases identified in the Tobacco Deposition and Trial Testimony Archive (DATTA) collection (http://tobaccodocuments.org/datta), transcripts of testimony and related documents found in DATTA, government-mandated reports filed by tobacco manufacturers with the US Securities and Exchange Commission, investment company reports, reports and analyses published by the news media, a variety of informational documents produced by the Tobacco Control Resource Center at the Northeastern University School of Law, and legal settlement documents provided by the National Association of Attorneys General. RESULTS: The US tobacco industry faced a far greater number of lawsuits, and a greater variety of types of lawsuit, between 1994 and 2005 than it had in previous years. Plaintiffs won 31 (41%) of the 75 cases that were tried to verdict during the years 1995-2005. Seven plaintiffs have been paid awards totalling US$115 million, including interest, following the exhaustion of appeals. Based on an evaluation of litigation brought against US industry leader Philip Morris, the total number of cases pending peaked in 2000, dropping off modestly since then. For example, 36 class actions were pending in 2000, while 33 were pending in 2005. In the same time period, individual actions fell from a total of 3385 to 2863. While the playing field has been levelled to some degree in the tobacco litigation arena with respect to the resources brought to bear by plaintiffs and defendants, tobacco industry defendants continue to employ far greater financial and human resources than their adversaries. CONCLUSIONS: The third wave of tobacco litigation has represented a sea change in efforts to hold the tobacco industry in the United States accountable in American courtrooms. While tobacco manufacturers continue to do their utmost to make these cases difficult to pursue, many of the cases that have gone to trial have met with success in recent years, which suggests that plaintiffs' lawyers are now better equipped to persuade juries of the defendants' culpability.

The role of tobacco advertising and promotion: themes employed in litigation by tobacco industry witnesses.

OBJECTIVES: To identify key themes related to tobacco advertising and promotion in testimony provided by tobacco industry-affiliated witnesses in tobacco litigation, and to present countervailing evidence and arguments. METHODS: Themes in industry testimony were identified by review of transcripts of testimony in the Tobacco Deposition and Trial Testimony Archive (http://tobaccodocuments.org/datta) from a sample of defence witnesses, including three academic expert witnesses, six senior executives of tobacco companies, and one industry advertising consultant. Counterarguments to the themes embodied in defence testimony were based on information from peer-reviewed literature, advertising trade publications, government reports, tobacco industry documents, and testimony provided by expert witnesses testifying for plaintiffs. RESULTS: Five major themes employed by defence witnesses were identified: (1) tobacco advertising has a relatively weak "share of voice" in the marketing environment and is a weak force in affecting smoking behaviour; (2) tobacco advertising and promotion do not create new smokers, expand markets, or increase total tobacco consumption; (3) the tobacco industry does not target, study, or track youth smoking; (4) tobacco advertising and promotion do not cause smoking initiation by youth; and (5) tobacco companies and the industry adhere closely to relevant laws, regulations, and industry voluntary codes. Substantial evidence exists in rebuttal to these arguments. CONCLUSIONS: Tobacco industry-affiliated witnesses have marshalled many arguments to deny the adverse effects of tobacco marketing activities and to portray tobacco companies as responsible corporate citizens. Effective rebuttals to these arguments exist, and plaintiffs' attorneys have, with varying degrees of success, presented them to judges and juries.

Tobacco manufacturers' defence against plaintiffs' claims of cancer causation: throwing mud at the wall and hoping some of it will stick.

BACKGROUND: In the late 1990s and the early part of this decade, the major US cigarette manufacturers admitted, to varying degrees, that smoking causes cancer and other diseases. OBJECTIVE: To examine how tobacco manufacturers have defended themselves against charges that their products caused cancer in plaintiffs in 34 personal injury lawsuits, all but one of which were litigated between the years 1986 and 2003. METHODS: Defence opening and closing statements, trial testimony, and depositions for these cases were obtained from the Tobacco Deposition and Trial Testimony Archive (http://tobaccodocuments.org/datta/). All available defence-related transcripts from these cases were reviewed and a content analysis was conducted to identify common themes in the defendants' arguments. RESULTS: After review of the transcripts, defendants' arguments were grouped into seven categories: (1) there is no scientific proof that cigarette smoking causes lung cancer; (2) the plaintiff did not have lung cancer as claimed; (3) the plaintiff had a type of lung cancer not associated with cigarette smoking; (4) the plaintiff had cancer that may have been associated with cigarette smoking or smokeless tobacco use, but tobacco products were not to blame in this particular case; (5) the plaintiff had cancer that may have been associated with cigarette smoking, but the defendant's cigarette brands were not to blame; (6) the defendant's cigarettes (or smokeless tobacco) may have played a role in the plaintiff's illness/death, but other risk factors were present that negate or mitigate the defendant's responsibility; and (7) the defendant's cigarettes may have been a factor in the plaintiff's illness/death, but the plaintiff knew of the health risks and exercised free will in choosing to smoke and declining to quit. Use of the argument that smoking is not a proven cause of lung cancer declined in frequency during and after the period when tobacco companies began to publicly admit that smoking causes disease. Corresponding increases occurred over time in the use of other arguments (namely, presence of other risk factors and "free will"). CONCLUSIONS: Despite the vast body of literature showing that cigarette smoking causes cancer, and despite tobacco companies' recent admissions that smoking causes cancer, defendants used numerous arguments in these cases to deny that their products had caused cancer in plaintiffs. The cigarette companies, through their public admissions and courtroom arguments, seem to be saying, "Yes, smoking causes lung cancer, but not in people who sue us".

Visiting multiple sites for immunization and vaccine coverage levels of preschool children in 3 urban clinics: potential indicator of record scatter?

Record scatter is a clinic-level impediment to accurately reporting immunization coverage levels but may be attributed to certain patient characteristics. We determine the association between visiting multiple sites for immunization and underimmunization among urban clinic patients. After collecting immunization histories for patients aged 3-35 months, caregivers were surveyed by telephone. 159/483 caregivers (32.9%) were interviewed. Visiting > 2 sites for immunizations was associated with underimmunization, adjusted Odds Ratio (95% Confidence Interval)=2.7 (1.2-6.5). An interruption in health insurance showed a trend toward association with visiting > or = 2 sites. Our results support the need for working registries, clinic outreach, and continued evaluation of both.

Secondhand smoke as a potential cause of chronic rhinosinusitis: a case-control study.

OBJECTIVE: To assess the role of secondhand smoke (SHS) in the etiology of chronic rhinosinusitis (CRS). DESIGN: Matched case-control study. Associations between SHS and CRS were evaluated by conditional logistic regression odds ratios. SETTING: Henry Ford Health System, Detroit, Michigan. PARTICIPANTS: A total of 306 nonsmoking patients diagnosed as having an incident case of CRS and 306 age-matched, sex-matched, and race/ethnicity-matched nonsmoking control patients. MAIN OUTCOME MEASURES: Exposure to SHS for the 5 years before diagnosis of CRS (case patients) and before study entry (controls) for 4 primary sources: home, work, public places, and private social functions outside the home, such as parties, dinners, and weddings. RESULTS: Of controls and case patients, respectively, 28 (9.1%) and 41 (13.4%) had SHS exposure at home, 21 (6.9%) and 57 (18.6%) at work, 258 (84.3%) and 276 (90.2%) in public places, and 85 (27.8%) and 157 (51.3%) at private social functions. Adjusted for potential confounders (socioeconomic status and exposures to air pollution and chemicals or respiratory irritants from hobbies, work, or elsewhere), the odds ratios for CRS were 1.69 (95% confidence interval, 0.92-3.10) for SHS exposure at home, 2.81 (1.42-5.57) for exposure at work, 1.48 (0.88-2.49) for exposure in public places, and 2.60 (1.74-3.89) for exposure at private functions. A strong, independent dose-response relationship existed between CRS and the number of venues where SHS exposure occurred (odds ratio per 1 of 4 levels, 2.03; 95% confidence interval, 1.55-2.66). Approximately 40.0% of CRS appeared to be attributable to SHS. CONCLUSIONS: Exposure to SHS is common and significantly independently associated with CRS. These findings have important clinical and public health implications.

The Hitchhiker's Guide to Tobacco Control: a global assessment of harms, remedies, and controversies.

One in three adults worldwide (>1.1 billion people) smokes; 80% live in low- and middle-income countries. Tobacco use causes five million deaths each year and, if current smoking patterns continue, will kill 10 million persons annually by 2020. From 1970 to 2000, tobacco leaf production decreased by 36% in developed countries but more than doubled in developing countries. China is the world's leading producer and consumer of tobacco. Seven multinational tobacco companies dominate the world cigarette market, led by Altria, British American Tobacco, and Japan Tobacco, which collectively manufacture more than 2 trillion cigarettes per year. Extensive knowledge exists about effective tobacco control interventions. However, dissemination of best practices and adoption and implementation of recommended policies are fragmentary. The Framework Convention on Tobacco Control (ratified by 140 countries as of October 1, 2006) provides a template outlining the ingredients for a comprehensive tobacco control campaign.

Editorial independence at medical journals owned by professional associations: a survey of editors.

The purpose of this study was to assess the degree of editorial independence at a sample of medical journals and the relationship between the journals and their owners. We surveyed the editors of 33 medical journals owned by not-for-profit organizations ("associations"), including 10 journals represented on the International Committee of Medical Journal Editors (nine of which are general medical journals) and a random sample of 23 specialist journals with high impact factors that are indexed by the Institute for Scientific Information. The main outcome measures were the authority to hire, fire, and oversee the work of the editor; the editor's tenure and financial compensation; control of the journal's budget; publication of material about the association; and the editor's perceptions about editorial independence and pressure over editorial content. Of the 33 editors, 23 (70%) reported having complete editorial freedom, and the remainder reported a high level of freedom (a score of > or = 8, where 10 equals complete editorial freedom and 1 equals no editorial freedom). Nevertheless, a substantial minority of editors reported having received at least some pressure in recent years over editorial content from the association's leadership (42%), senior staff (30%), or rank-and-file members (39%). The association's board of directors has the authority to hire (48%) or fire (55%) the editor for about half of the journals, and the editor reports to the board for 10 journals (30%). Twenty-three editors (70%) are appointed for a specific term (median term = 5 years). Three-fifths of the journals have no control over their profit, and the majority of journals use the association's legal counsel and/or media relations staff. Stronger safeguards are needed to give editors protection against pressure over editorial content, including written guarantees of editorial freedom and governance structures that support those guarantees. Strong safeguards are also needed because editors may have less freedom than they believe (especially if they have not yet tested their freedom in an area of controversy).

Medical journals' conflicts of interest in the publication of book reviews.

The purpose of the study was to assess medical journals' conflicts of interest in the publication of book reviews. We examined book reviews published in 1999, 2000, and 2001 (N = 1,876) in five leading medical journals: Annals of Internal Medicine, British Medical Journal (BMJ), Journal of the American Medical Association (JAMA), Lancet, and New England Journal of Medicine. The main outcome measure was journal publication of reviews of books that had been published by the journal's own publisher, that had been edited or authored by a lead editor of the journal, or that posed another conflict of interest. We also surveyed the editors-in-chief of the five journals about their policies on these conflicts of interests. During the study period, four of the five journals published 30 book reviews presenting a conflict of interest: nineteen by the BMJ, five by the Annals, four by JAMA, and two by the Lancet. These reviews represent 5.8%, 2.7%, 0.7%, and 0.7%, respectively, of all book reviews published by the journals. These four journals, respectively, published reviews of 11.9%, 25.0%, 0.9%, and 1.0% of all medical books published by the journals' publishers. Only one of the 30 book reviews included a disclosure statement addressing the conflict of interest. None of the journals had a written policy pertaining to the conflicts of interest assessed in this study, although four reported having unwritten policies. We recommend that scientific journals and associations representing journal editors develop policies on conflicts of interest pertaining to book reviews.

Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for tobacco cessation.

In August 2002, the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH) was charged with developing recommendations to substantially increase rates of tobacco cessation in the United States. The subcommittee's report, A National Action Plan for Tobacco Cessation, outlines 10 recommendations for reducing premature morbidity and mortality by helping millions of Americans stop using tobacco. The plan includes both evidence-based, population-wide strategies designed to promote cessation (e.g., a national quitline network) and a Smokers' Health Fund to finance the programs (through a 2 US dollar per pack excise tax increase). The subcommittee report was presented to the ICSH (February 11, 2003), which unanimously endorsed sending it to Secretary Thompson for his consideration. In this article, we summarize the national action plan.