The Medical State of the Art: Tobacco and Asbestos. A Comparison of Industry and Public Knowledge and Responses to Knowledge with Respect to the Health Effects of Tobacco Smoke and Asbestos............... 5 1. Demonstrative Exhibits that may be used include: ......................................................................................... 6 2. Background and Qualifications .......................................................................................................................... 7 3. Introduction............................................................................................................................................................ 8 4. Methodology........................................................................................................................................................ 10 A. Review of medical literature........................................................................................................................ 10 B. Review of corporate documents.................................................................................................................. 10 C. Review of depositions................................................................................................................................... 10 D. Principles of general causation.................................................................................................................... 10 E. Probabilistic causal analysis......................................................................................................................... 10 F. Importance of clinical experience ............................................................................................................... 11 G. Examples from medical practice ................................................................................................................. 12 1. Injuries........................................................................................................................................................ 12 2. Diseases...................................................................................................................................................... 12 3. Proposed Treatments................................................................................................................................ 13 4. Examples from medical literature .......................................................................................................... 13 5. Hill’s Criteria for determining causality............................................................................................... 16 5. Medical Knowledge of Health Risks ............................................................................................................... 19 A. Tobacco........................................................................................................................................................... 19 1. Lung Cancer .............................................................................................................................................. 19 a) Pathologic Studies............................................................................................................................... 19 b) Epidemiological Studies .................................................................................................................... 20 c) Animal Studies .................................................................................................................................... 21 d) Identification of Carcinogens............................................................................................................ 23 2. Other Tobacco-Related Diseases........................................................................................................... 26 3. German Literature .................................................................................................................................... 27 B. Asbestos........................................................................................................................................................... 29 1. Asbestos Company’s Knowledge and Conduct.................................................................................. 29 C. Comparison of Asbestos Company and Tobacco Company Conduct.................................................. 31 1. Education of users:................................................................................................................................... 31 2. Government influence:............................................................................................................................ 31 3. Product usefulness:................................................................................................................................... 32 4. Marketing and Design: ............................................................................................................................ 32 5. Addiction:.................................................................................................................................................. 33 6. Public Health Obligations: The tobacco industry’s public health obligations to safeguard the health of consumers and the public ............................................................................................................................................. 34 A. Public Health Obligations ............................................................................................................................ 34 1. The strength of the association between the product and certain health effects............................ 34 2. The severity of the health effects........................................................................................................... 34 3. The importance of the product or ingredient to commerce. .............................................................. 34 4. Use by children ......................................................................................................................................... 34 5. Effects on bystanders especially children and the unborn................................................................. 35 B. Historical recognition of manufacturer’s public health obligations to test their products and take appropriate public health actions........................................................................................................................... 35 C. Contemporaneous corporate view of their public health responsibilities ............................................ 36 D. Health education through sales people....................................................................................................... 37 E. Obligations and Promises: In Their Own Words ..................................................................................... 38 F. Additional obligations incumbent upon manufacturers due to the nature of the product, children’s use, and previous misleading health representations.......................................................................................... 39 1. Marketing to children. ............................................................................................................................. 39 a) Tobacco Companies’ Marketing to Children: In Their Own Words.......................................... 41 2. The addictive nature of the product....................................................................................................... 43 3. Misleading Statements............................................................................................................................. 46 (a) Semantic arguments............................................................................................................................ 46 i. Associations, Risk Factors and causes....................................................................................... 46 ii. Necessary and sufficient causes .................................................................................................. 46 iii. Habituation versus Addiction...................................................................................................... 47 4. Design issues ............................................................................................................................................. 49 a) Intentional Control of Nicotine Levels ............................................................................................ 49 b) Toxic constituents of Tobacco Smoke ............................................................................................. 50 i. Particulates ...................................................................................................................................... 50 ii. Asbestos in Cigarettes................................................................................................................... 50 c) Toxic constituents of Tobacco Smoke that Mask Its Warning Properties Blocking the Smoker’s Natural Senses.............................................................................................................................. 51 i. Additives ......................................................................................................................................... 51 a) Sweets........................................................................................................................................