ELLEN R GRITZ: What I would like to ask you to address is the political and economic realities behind your charge to this audience, given the tremendous power that the tobacco industry continues to wield?

JOSEPH A CALIF ANO : There are political realities. The industry has more money than we will ever have. But I think we have tremendous opportunities with the media, particularly with respect to television, both local and national, bolstered by the fact that the industry cannot advertise cigarettes on television. It is a key reason why television reporters are so good at covering this subject, and we ought to try and get them to cover it more.

We do two things at the Center on Addiction and Substance Abuse at Columbia University (CASA). We run demonstration programmes, and we do studies designed to illuminate these problems and help inform our people. We are going system by system. We have almost finished an analysis of the cost of substance abuse to the health care system. We have done inpatient Medicaid hospital costs, some of which I mentioned. We have done inpatient Medicare hospital costs. By the middle of this year, we shall be releasing a report on the cost of tobacco, drugs, and alcohol to the health care system.

We have begun an analysis of the costs to the legal system, and we have just developed a protocol for the costs to business, and after that we will go after education. We have to demonstrate these relationships.

JOHN R HUGHES: CASA has done an excellent job of taking scientific information to raise consciousness and awareness about drug abuse problems, but I would suggest that we, in this audience, face the same problem with our friends working on substance abuse problems.

We know that tobacco accounts for 60-80 % of substance abuse problems. I would be satisfied when CASA and the National Institute on Drug Abuse (NIDA) spend 80% of their time on tobacco-related illnesses. So the same sort of problems that you face with the general public, making them aware of substance abuse, we face with the substance abuse community, trying to make them aware that tobacco accounts for 80% of the substance abuse problems.

JOSEPH A CALIF ANO: I agree with your assessment of the challenge, and I think you will see a focus on tobacco use in our Medicare study and in our health care study. Our recent commission on substance abuse in colleges and universities ended up focusing primarily on alcohol because that is where they saw the large problem. We have just established a commission to look at substance abuse among high school students, and I am sure tobacco will play a major role in their report.

DAVID B ABRAMS: Despite the failure of the Clinton health care reform package, I think we were already seeing at the tail end of it that the fuller prevention packages were probably not going to make it into the final managed care priorities.

I wonder if there are any lessons and insights to be learned from that, because managed care is clearly here to stay, and is going ahead despite government intervention. How can we raise the sort of level or the incentives to get for health promotion and prevention more than a window dressing place in managed care?

JOSEPH A CALIF ANO: This is not particularly popular in this day and age, but I think with the reality of the pressures on managed care organisations to produce health care treatment at the lowest possible cost, the only way in the next few years we are going to deal with that is to have legislation that requires managed care organisations to commit some amount of their resources to prevention, and certainly to provide substance abuse treatment.

It is also important to emphasise health promotion. We have a lot of incentives we can put in the system. Health insurance should cost more for smokers than non-smokers, for example. I think there is a variety of things we can do, but we need a legal requirement to make it happen, given the pressure on managed care organisations.

RONALD M DAVIS: Mr Califano, when you were Secretary of Health, Education, and Welfare (HEW) and were launching your antitobacco campaign, many people in the White House were concerned about the impact on President Carter’s political future.

It seems that right now we have a similar situation, with the FDA and the Occupational Health and Safety Administration (OSHA) poised to announce very aggressive antitobacco regulations. We probably have people in the White House who would just as soon have the executive branch back off on tobacco, and perhaps not cost President Clinton support in the southeastern part of the country for the next presidential campaign. Based on your own personal experience, how do we combat this political problem?

JOSEPH A CALIFANO: I think the problem is probably more of money than of votes. It would be extraordinary for President Clinton to carry any southern states besides Arkansas, so he is not going to lose something he otherwise might have had.

But money is very, very important. I think the politics of tobacco at the national level are driven by money. You remind me of an experience in the early 1980s. Mayor Ed Koch asked me if I would chair a commission on smoke-free space and draft a law for New York City. We drafted a law, which is the same law that has been toughened recently, and the tobacco industry indicated they were going to spend $5 million to kill the law in the city council. I was speaking to Mayor Koch about this, and I said, “All this work is really for naught, we are dead, I have been through this before.” But he replied, “You don’t understand, this is New York.” I asked what he meant, and he explained that the city council will take the $5 million, then they will vote for the law, which they did. Unfortunately, the national legislature does not operate in that way.

BRUCE K LIESE: In some ways I am disappointed that you are not going to speak later, because I am curious about your thoughts on harm reduction. I was in agreement with your book regarding not legalising illicit drugs, and was interested in what your thoughts are about needle exchange programmes and other harm reduction methods.

JOSEPH A CALIFANO: I think legalisation of drugs would be a terrible mistake for a variety of reasons. It has not worked wherever it has been tried, to the extent it has been tried. I do not know if any of you saw the ABC special on addiction last Thursday night, but I was personally appalled by that. They presented smoking pot in The Netherlands where anybody over 16 can buy pot freely, and they put a couple of people on to rhapsodise about legalised marijuana. They never mentioned that the number of young marijuana users in The Netherlands has gone up 250 % over the last decade, that the rate of crime, particularly property crimes, has soared in The Netherlands, and that Amsterdam has twice as many police officers relative to its population as the average American city. They have a number of serious problems there. In England, they presented a doctor who said that there were 400 individuals on heroin maintenance, and then produced anecdotal studies indicating that the drug dealers were leaving the streets. They never mentioned that there are 150000 heroin addicts in England, and I hardly think having 400 on heroin maintenance has put any drug dealer out of business.

And they never cited the other experiences in Europe. Italy has decriminalised heroin since 1975 and has 300000 heroin addicts, the highest proportionate number in Europe. Sweden tried prescribing drugs in 1965; they then stopped because of what happened. In 1980, Sweden moved to policies just like ours, declaring the objective of a drugfree country, and they have had a sharp fall in the number of military conscripts using drugs (75 %), and in the number of ninth graders-a reduction of 66% since they moved to that policy. They didn’t mention Needle Park in Zurich. It was started for a few hundred addicts. Within a few years, there were 20000 heroin addicts in and around Needle Park. The Swiss cleaned it out. They moved it to an abandoned railway yard, and in February of this year, they had to clean that out too. They have now adopted fairly tough policies.

I shall make one other point about legalisation. We have had no success in keeping cigarettes or alcohol out of the hands of children. If there is an indictment against the cigarette industry in this country, it is that they probably do more damage to America’s children than anyone else. They are murderers’ row for our children in this country, and it is a disgrace. We have three million children in this country who smoke under age, and we have millions of underage children who drink. I do not see any reason for greater success with drugs if they became legal.

On needle exchanges, I think we do not know yet how well they work. Some people say they work, some people say they don’t. In the context of HIV, we ought to be looking at exchanges and systematically analysing, but I think the jury is out.

STEPHEN I RENNARD: Addiction as a whole seems to be increasing as a problem for America. While our goals have not been met with smoking, there certainly has been some success in reducing the number of smokers. Can you explain the apparent decrease in smoking prevalence while there is an increase in other kinds of addictive behaviour?

JOSEPH A CALIFANO: Let me make something clear. We have had remarkable success in this country in reducing the use of experimental drugs, and it is by experimentation that you ultimately become hooked. Nobody who snorts their first cocaine or smokes their first joint thinks they are going to get hooked.

We have had a 50 % reduction in drug use in this country. On the “Nightline” programme recently, Ted Koppel pointed out the sharp reductions in cocaine use among the general population and in marijuana use among young people. There has been a small increase in the last year or two, but I think this is because the consistent messages of recent years have become mixed, partly by the Surgeon General, partly by the revival of pot as a big part of our popular music and in the movies. We have had some increase in smoking as well, I think partly because there is so much smoking in movies and because of the contemporary culture among our young people.

The two things I wish I had known in my years at HEW in the way that I know them now are first the relation between weight and quitting smoking as far as young women are concerned, and what a tremendous motivation that was to keep women smoking; and second, I did not really appreciate how critical those years from 10 to 20 were for every aspect of what the government does in terms of research and prevention. If we get people through those teenage years without smoking or without using drugs, they are home and dry.