On 8 September 1998, former United States Surgeon General C Everett Koop delivered the speech reproduced below to the National Press Club in Washington, DC. This text is based on a transcript prepared by the Federal News Service, a private firm located in Washington, DC. Dr Koop kindly consented to publication of his speech in “Tobacco Control”.—ED

I was invited to speak here today, and when I heard that Dr Kessler was also going to be present, I presumed the subject would be tobacco. But I am not going to give you a blow-by-blow description of the tobacco wars. I think you know that history probably as well as anyone, and several of you are probably already writing books on the subject. Instead, I would like you to consider the anatomy of a scandal, and I’m not talking about the scandal that springs most readily to people’s minds. I’m talking about a scandal that really involves the entire nation and especially Washington.

This is a scandal of some in Congress trading public health for PAC [Political Action Committee] money and believing the slick ads of the tobacco industry. This is a scandal of senators, well over half voting “yes” but still losing. This is a scandal of some hiding from the potential to save lives and choosing instead to posture. This is a scandal of politics for sale, and to my dismay, some Republicans are going to the highest bidder.

If outsiders were to visit this land, their conclusion would have to be that the enormity of the burden of tobacco, the metastasis of this malignancy in the tobacco industry, and of the failure of Congress to respond to it, all constitute a scandal that should have pushed Monica Lewinsky to page seven of the second section. (Laughter.) Instead, this is now mostly a silent scandal, press and public alike, sort of saying “Politics as usual”, and the politicians saw their duty and did not do it—so what else is new?

I, however, want you to consider anew the disgraces of the tobacco wars and ask you, where is the outrage? Let’s start with a factual description of the problem.

Based on the calculations of the finest statistical minds in the world and the World Health Organisation, they have predicted that by 2025, 27 years from now, 500 million people worldwide will die of tobacco-related disease. That’s a numbing figure. It is too large to take in, so let me put it in other terms for you. That’s a Vietnam war every day for 27 years. That’s a Bhopal every two hours for 27 years. That’s a Titanic every 43 minutes for 27 years.

If we were to build for those tobacco victims a memorial such as the Vietnam wall, it would stretch from here a thousand miles across seven states to Kansas City.

And, if you want to put it in terms per minute, there’s a death every 1.7 seconds, or about 250 to 300 people, since I began to speak to you this afternoon.

These unnecessary deaths are a disgrace—but where is the outrage? A Vietnam a day should produce more than a press conference from the House and a filibuster in the Senate. But let’s go from facts to behaviour. Bhopal and the Titanic were accidents. Tobacco deaths are not. They are the predictable result of a malignant industry that manipulates, packages, advertises, and sells its product at every corner of the globe. By any reasonable standard, tobacco executives understand and know the consequences of their acts—that is, they know that they will and are causing disease and death. But they stood in front of Congress and swore under oath that their products were not addictive or dangerous and that they had not marketed to children.

After the decades of the industry hiding its lies and its misdeeds, some brave and diligent people showed us the facts. Skip Humphrey, for example, the attorney general of Minnesota, and his colleagues really pursued the truth with admirable tenacity. They exposed some of the most incriminating evidence of lying, deceit, and suppression of science ever. And we learned that the industry was marketing to children as young as 13, that it was really spiking their product to achieve greater addictiveness, and that it was covering up the truth about a range of diseases from infant mortality to cancer.

We have also learned that the industry recently paid scientists thousands of dollars to write letters to the editors of prominent publications to question the link between environmental tobacco smoke and lung cancer and to undermine the 1993 Environmental Protection Agency findings.

This included one former NIH (National Institutes of Health) cancer researcher who was paid $20 000 over seven months to write to the lay and professional press. And when questioned he replied: “Are you getting paid for what you’re writing? We’re all out there working.”

Where is the outrage?

The Congress is threatening to bring down the government over testimony about a blue dress. And yet it seems that perjury about addicting children and tampering with evidence on airborne cancer is of no interest to them. And there’s not only the perjury of the tobacco industry that should be viewed as a scandal, there’s the question of tainting the entire legislative process.

Maybe my story should be called Dr Smith Goes to Washington. But I never really believed that politics are corrupt or that politicians are for sale. But when I look at the lobbying effort of the tobacco industry over the past year, I have to wonder if that’s still true in its entirety.

The industry hired one lobbyist for every two members of Congress. The major manufacturers spent over $30 million in lobbying fees last year alone, a number that does not include the millions in campaign contributions or the billions spent on advertising, grass roots (activities), and front organisations.

The number of tobacco lobbyists on the Hill was obscene. But it was not the quantity, it was the quality of such lobbyists that was a stroke of genius on the part of the tobacco industry. As one anti-tobacco, Republican senator confided to me: “Do you have any idea how difficult it is to be faced by a former colleague now lobbying for tobacco? I try not to take all his calls but I do have to take some of them.”

Moreover, it is not just influence-peddling at work here, there are also donations to think about, donations that abounded to those who confirmed and contributed to the demise of tobacco legislation. Even if the donations are not in the form of cash, the Congress can also look forward to some other types of in-kind donations and help from the tobacco industry in the form of advertising.

Let me ask you, when the McCain bill is long dead, why does the tobacco industry keep running the ads against it?

Is it to pay back loyal supporters? Senator McConnell, the chief opponent of campaign finance reform, said that the ads would be generally helpful to the people who decided to kill this bill as a big tax increase on working Americans.

Or is it, as Kathleen Hall Jamieson of the Annenberg Public Policy Center says, to provide political protection to those in Congress who decide to stick with the industry?

Or is it to keep the Democrats at bay, defending themselves during the upcoming campaign? Or is to help the Republicans who are in power?

And the answer, I think, is all of the above. And my thanks go to Dick Polman of the Philadelphia Inquirer, who put that together so nicely.

But don’t think it stops there. In addition to the Congress, the tobacco industry wines and dines state legislatures, giving them everything from lavish dinners to trips to the Kentucky Derby and NASCAR races. Since many states have even looser restrictions on campaign donations than does the Congress, as hard as that may be to believe, the industry is also undoubtedly helping them out with elections as well.

But where is the outrage about that?

This Congress is holding the attorney general in contempt over memos about the building from which a fundraising call came. But no one seems to be troubled by lobbying federal and state officials, the number of lobbyists, stacks of campaign cash, ongoing targeted ads and dirty tactics. That, I suppose, is “business as usual” in defending the right to sell cancer to unknowing and immature minors.

When I came to Washington as the surgeon general-designate, I thought that health should be non-partisan and that I would maintain that position. I’m proud to say that I did. I was appointed to my post by a Republican president and I served him for seven years and then his successor for one year more; that’s two full four-year terms. I’m still a registered Republican, but I have to admit a certain shame when I say that because of some Republican behaviour on tobacco legislation.

Let me quickly say that I do not mean this as a blanket statement about all Republicans because there are people like senators McCain, Chafee, Specter, Gregg, Frist, and so on, and congressman Hansen and a dozen of his colleagues—all have been strong Republican leaders in the fight against tobacco, as have a handful of others in this Congress; and to them we owe a great debt.

But we have to admit that it was the Republican party that defeated the McCain tobacco bill in the Senate and that prevented the Hansen bill from even being discussed in the House.

As a Republican, I find it hard to understand why the Republican party has been so opposed to comprehensive tobacco legislation.

They say that they are against drugs, but tobacco contains a dangerous addictive drug, perhaps the most addictive of them all, and one that is also a gateway drug to the others that give them so much concern.

They claim to be pro-life. Tobacco causes spontaneous abortion, prematurity, and low birth weight. In addition to the 430 700 tobacco-related deaths last year, we know that that year also probably saw between tens of thousands and 100 000 newborn babies die before birth. New data also show that permanent fetal brain damage and disabilities are caused by tobacco, including problems such as attention deficit hyperactivity disorder.

The GOP [Grand Old Party, an appellation of the Republican Party for a hundred years] says it is for protecting children. But they must not think that preventing the addiction of children to a life of bondage to tobacco and premature death comes under the category of child protection.

And finally, Republicans are, of course, pro-family. And yet nearly half a million families are disrupted every year by a tobacco-related death alone. And moreover, many times that number are disrupted by tobacco-related illness and disabilities.

But where is the outrage?

My party splits bitterly over who is sufficiently pro-life, pro-child, pro-family. But the leadership of the Republican party avoids all mention of its links with the tobacco industry and tobacco money.

I am not proud of that and I think many other Republicans, like me, who are truly anti-drug, pro-life, pro-child, and pro-family, would not be proud of it either.

During this battle of the tobacco wars, no sustained outrage ever developed. There were early victories such as overturning the middle-of-the-night $50 billion theft in the balanced budget bill and reversing the cut in FDA (Food and Drug Administration) enforcement funding. But confusion, distractions, resignation to politics as usual, and plain old apathy took over. And instead of a public that demanded contrition, an apology from the tobacco industry, regulation of corporate misdeeds, and jail terms for some, there has been a resurgence of arrogant dishonesty on the part of the tobacco industry.

Having used their money and lying advertising campaign to defeat the best tobacco legislation in the history of this country, the industry can now sit back and watch its profits grow, as Medicare, Medicaid, Veterans Affairs, private health insurance, and public hospitals pay the real price of their products.

Outrage is an endangered quality in America, not only about tobacco but also about a variety of other issues that even just a few decades ago would have produced moral indignation.

But outrage about tobacco need not become extinct. I believe that the press was quite effective in its reporting on the tobacco wars. Ironically, the paid ads in print, on radio, and on television undermined much of what the message was that you were reporting, but the reporting was generally comprehensive and very thoughtful.

So, if you don’t mind my saying so, it is up to you—the press—to keep outrage from becoming extinct. The United States and the public health community in particular need you now as never before. Please continue to be advocates for the public health. The public health folks do not have the resources to counter the sheer volume of industry propaganda, and we must rely on you, from the so-called free media, to make the system honest.

Let me make a few requests of you.

First, keep up a steady reminder on the effects of tobacco. Do not be numbed by the numbers. Remind everyone that one in every five deaths in the United States is tobacco-related, that nicotine is a very addictive drug, and that no form of tobacco is safe.

Remember, too, that the real issue is the addiction of children. Do not be sidetracked into meaningless discussions about the free choice of adults, when 90% of smokers start before they are 18. And do not make criminals of kids; punish the seller and not the buyer.

And don’t forget that most smoking adults really want to quit. Push for more scientifically sound programmes to help them and for more research to understand why they became addicted.

Remind the public that no amount of money is worth giving away the basic rights of citizens and states. Other companies have to pay the cost for their dangerous products and they include it as part of the prices that they charge. The tobacco industry has so much money because it avoids paying for the damage its products cause.

And never underestimate the tobacco industry. It is a social disease as dangerous as any malignancy and it metastasises more rapidly.

As I close, forgive me if I, as a physician, have been using the analogy of the attack of a malignancy on its victim. In medicine when we say “malignancy” we usually mean a tumour. And when we say “victim”, we are talking about the patient. In my analogy, the patient is society and the tumour is the malignant industry of tobacco.

Let me tell you some of the characteristics of a malignancy. It is unbridled in its growth. It uses great energy at the expense of its victim. It grows rapidly in secret before a sign or symptom makes it evident. When it has done its damage locally, it metastasises and spreads to distant sites. It can be controlled by surgery, my favourite method of treatment, because that means the malignancy is disposed of. But it also responds to other therapy such as radiation and chemotherapy.

But the good news is that progress is being made in understanding malignancy and there is hope for successful new prevention and new treatment.

This analogy comes to life with a few examples. Tobacco has grown without control in this country because of a network of special legislative exceptions and protections. The tobacco industry draws on the energy of society, forcing taxpayers to pay for its medical and social costs. The tobacco industry has acted in secrecy, corrupting the normal ways of doing business. After many years of deception, it has finally been recognised by the illnesses that it causes. And the tobacco industry has metastasised to every corner of the globe, using practices even more reprehensible than those that are used in America.

The tobacco industry perhaps could once have been controlled by surgery. But after waiting 200 years, such therapy is out of the question for now. It might gradually respond to such other therapies such as radiating light on its misdeeds and holding the industry responsible for its actions.

Finally, there is hope that, based on the experience we’ve had in fighting this battle of the tobacco wars, we can move forward in the next Congress to make progress in the prevention and treatment of this social cancer.

Ladies and gentlemen of the press, if this sounds to you like a plea, it is. We have tried lots of approaches and they have not worked. And now I think it might be up to you.

In my contacts with some of you, the press, I occasionally get notes that I cherish. One recently came from a reporter whose name I will not mention. As you folks say, I have to protect my sources. He said, “I can only share your outrage with the outcome of the proposed tobacco legislation in Congress. It was emblematic of a degree of Capitol Hill corruption and of disdain for health, safety and life itself. It beats anything I have known in my entire career as a Washington reporter.”

I hope that some of you here today feel the same way that that gentleman does and act accordingly. Please go out there and create some outrage.

Thank you. (Applause.)

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Drawing by Tom Funk, an artist who formerly worked for “The New Yorker” magazine. The idea for the drawing came from Dr William G Cahan, a senior attending surgeon at Memorial Sloan-Kettering Cancer Center in New York. Sitting between the Marlboro Man and Joe Camel is Senate Majority Leader Trent Lott (Republican from Mississippi). “GOP” refers to “Grand Old Party”, a common designation for the Republican Party.