Politics

Because the tobacco industry makes a product that is deadly and generates substantial controversy and opposition, its survival depends on being an active and effective political player at all levels of government. The industry fares better when there are low taxes on its products: little or no regulation on tobacco products and advertising; and few restrictions on its legal liability for the death and disease it causes, or where smoking is permitted. Conversely, enactment of public health policies to reduce the burden of disease and death that the tobacco industry causes involves political action on the part of public health advocates, which the industry works to block.

Since the tobacco industry is held in low esteem nearly everywhere in the world, it often exercises its political influence in the background, working through third parties (from the liberal American Civil Liberties Union to the conservative Cato Institute) and through front groups that it creates and secretly funds (such as "hospitality associations" that oppose clean indoor air laws) to press its agenda. It also exerts more direct influence on individual politicians and political parties through large and strategically placed campaign contributions.

Public health advocates have been most effective in countering the tobacco industry's influence when they can move the field of play from the national or state to the local level. There, the resources that public health advocates can muster are adequate to the task and the tobacco industry's superior resources and national political connections are less effective. The tobacco industry works to neutralize local political action with "preemption," whereby national or state government restricts the right of subordinate political bodies, which are closer to the public and more willing to implement the popular will for tobacco control, than units higher in the political system.

Early Battles on Smoking and Health

The tobacco industry's heavy involvement in politics began in the mid-1950s after the Reader's Digest published an article titled "Cancer by the Carton." As a result, the public began to embrace scientific research linking smoking to lung cancer. A wave of public concern led to debates by political units at all levels on restrictions on the sale of cigarettes and on cigarette advertising and promotion. The tobacco industry responded by creating the Tobacco Industry Research Committee (TICR, later renamed the Council for Tobacco Research), a nominally independent scientific body, to get to the bottom of the "smoking and health controversy," and the Tobacco Institute, a lobbying organization, based in Washington, D.C., that was created to allow the cigarette manufacturers to present a unified front to Congress and other political decision makers at all levels. Both organizations were tightly controlled by industry executives and lawyers.

Public awareness of the evidence that smoking was dangerous increased in 1964, when the U.S. Surgeon General, acting on behalf of the United States government, released a report concluding that tobacco use was linked to lung cancer, chronic bronchitis and emphysema, cardiovascular diseases, and other forms of cancer. Public interest in the report—and concerns by the industry that it would adversely affect them—was so strong that release was delayed until after business for that week when the New York Stock Exchange was closed. The industry also feared that public health groups, most notably the American Cancer Society, would use the publication of the report to severely restrict the industry.

The resulting wave of public concern led to several legislative proposals and in 1965 Congress passed the Cigarette Labeling and Advertising Act. While health forces were pleased that the act added warning labels to cigarettes, the combined political and economic power of the tobacco industry and the strength of the constituency of tobacco farmers kept the warning label small and weak. More important, the act prevented states (and localities) from taking any further action on cigarette labeling or advertising. While the labeling law marked a small step forward at the time, preemption prevented strong local and regional action against cigarettes permanently. Indeed, half a century later, in 2001 in the case of Lorillard Tobacco et al. v. Reilly, Attorney General of Massachusetts et. al., the Supreme Court cited the 1965 act in striking down strong advertising and labeling legislation enacted by Massachusetts that would have prohibited tobacco advertising within 1,000 feet of schools, including both outdoor advertising and advertising within retail stores that could be viewed from outside the store. The industry would use the strategy of giving a little, such as agreeing to a modest warning label, to get preemption and arrest future progress on tobacco control at both the national and state levels in the coming decades.

Most political battles during the late 1960s and early 1970s over tobacco control continued at the national level. Tobacco control forces won a substantial victory in 1967 when, in response to a lawsuit brought by a law professor at Georgetown University, the Federal Communications Commission (FCC) ruled that cigarette advertising was "controversial," requiring radio and television stations to give free time to broadcast antismoking advertisements. These advertisements, produced by health groups, ran at the rate of approximately one antismoking advertisement for every three protobacco advertisements. As shown in Figure 1, this counter-advertising campaign led to a 5 percent decline in cigarette consumption per person in the United States, in 1975, the first sustained drop in cigarette consumption.

The tobacco industry responded by going back to Congress and supporting legislation to eliminate cigarette advertising on radio and television. While ending broadcast cigarette advertising was viewed as a public health positive, the fact that the cigarette advertisements were off the air meant that the antismoking advertisements also disappeared as of 2 January 1970. Unlike the health groups, however, the tobacco industry had the resources to continue to expand its advertising efforts in magazines, billboards, and other media.

The Rise of Nonsmokers' Rights

The focus of tobacco politics shifted away from the national level to the states in the mid-1970s. The tobacco industry had effectively contained legislation on cigarette advertising at the national level, but there was growing awareness that secondhand smoke was dangerous to nonsmokers. In 1975, after some limited legislation in Arizona restricting smoking in most public places such as government buildings and health facilities, freshman Minnesota Representative Phyllis Kahn introduced the first comprehensive state clean indoor air law. This legislation, which passed with relatively little opposition, prohibited smoking in public places except in smoking-designated areas, and required barriers and ventilation for smoking areas. While modest by twenty-first-century standards, the Minnesota Clean Indoor Air Act represented a real step forward and stimulated efforts to enact similar legislation elsewhere, particularly in California and Florida.

In California, a small group of local activists worked to pass local legislation modeled after the Minnesota Clean Indoor Air Act, and passed the first such law in April 1977 in Berkeley. Following this success, they worked for several years to enact a state law through both the legislature and the initiative process, through a law is enacted by a direct vote of the people. Between 1977 and 1980 the tobacco industry spent more than $10 million opposing these efforts. Recognizing that they could not win in the state legislature or in an expensive state initiative campaign, which, in a large state like California, is essentially an advertising contest, Californians shifted their efforts to enacting local ordinances. The organization they created, which later became known as Americans for Nonsmokers' Rights (ANR), took the lead in grass roots organizing against the tobacco industry.

Across the country in Florida, local advocates were also passing local clean indoor air ordinances. In 1985 in Florida, in contrast to California, the tobacco industry, with the naive support of some health advocates, was able to pass a weak statewide law. This law appeared to address the problem of secondhand smoke but included preemption, which overturned the then-existing local tobacco control laws, effectively stopping local restrictions in Florida until 2002, when health advocates overturned the 1985 law with a voter-enacted initiative after a major state political campaign.

In the mid-1980s, as the local clean indoor air movement was gaining momentum, the tobacco industry responded with a national effort to pass weak state laws that preempted local tobacco control activity. The industry was successful in passing some form of preemption in 22 states. At the same time, however, local tobacco control advocates prevented preemption in the remaining 28 states. Despite increasingly sophisticated and aggressive use of third parties and front groups, initially in the hospitality industry, then expanding to gambling interests to fight local tobacco control laws, the tobacco industry often lost efforts to enact these laws. Between the early 1980s and 2004, the nonsmokers' rights movement has helped to pass clean indoor air ordinances in 1,675 municipalities across the United States (see Figure 2).

However, the tobacco industry did not limit its pursuit of preemption to clean indoor air ordinances. The tobacco industry co-opted a federal effort designed to make it more difficult for children to purchase tobacco, so-called youth access, as another vehicle to preempt local tobacco control efforts. In 1992, Congress passed the Synar Amendment requiring states to reduce the illegal sale rate of tobacco to minors to less than 20 percent of attempted sales or risk losing federal substance abuse block grants. In 1996, when the implementing regulations were issued, the tobacco industry pushed "compliance bills" that included preemption of more aggressive local youth access laws in many states. In some cases, the industry managed to use the debate over youth access to pass broad preemption that also preempted local clean indoor air ordinances.

National Politics

While most of the successes in tobacco control during the 1980s and 1990s were at the local or state level, there were still several important debates at the national level, where the tobacco industry continued to dominate the process through a combination of campaign contributions and well-connected lobbyists and allies. As of 2004, tobacco remained the only substance ingested by humans that was exempt from any federal regulation as a food, drug, or consumer product.

Contributions from tobacco interests (including contributions to federal candidates, political parties and noncandidate committees) increased from $7.8 million in 1997–1998 to $8.7 million in 1999–2000 to $9.4 million in 2001–2002, the most recent complete election cycle for which data are available. Tobacco companies spent an additional $91.1 million on lobbying between 1999 and 2003.

These expenditures have been effective investments for the tobacco industry because the industry has continued to prevent any meaningful action at the federal level. Bills were introduced in 2001 and debated during the 107th Congress to give the U.S. Food and Drug Administration the authority to regulate tobacco products. A weak proposal supported by Philip Morris was sponsored by Senate Majority Leader Bill Frist (R-Tenn.) and Representative Tom Davis (R-Va.). Frist accepted more than $2.2 million from the tobacco industry between 1999 and 2002 in his capacity as chair of the National Republican Senatorial Committee, and Davis accepted more than $2.5 million between 1999 and 2002 in his capacity as chair of the National Republican Congressional Committee, in addition to $14,000 in contributions for his personal reelection campaign. At the same time, Representatives Greg Ganske (R-Iowa), John Dingell (D-Mich.), and Henry Waxman (D-Calif.) supported a stronger bill that granted substantial authority to the FDA to regulate tobacco. The 127 supporters of this bill accepted an average of $613 in tobacco industry campaign contributions compared with an average of $12,707 in tobacco industry contributions among the 17 supporters of the Frist/Davis bill. Neither bill passed.

In June 2000, tobacco industry dollars once again secured political allies during debate on funding for a U.S. Department of Justice lawsuit against the tobacco companies. The intent of the lawsuit was to recover tobacco-related health care costs paid for by the federal government, similar to the successful state lawsuits that recovered tobacco-related healthcare costs incurred by state Medicaid programs. On 19 June 2000 during the first vote to provide funding for the lawsuit, 207 members of the House of Representatives who voted against the funding had accepted an average of $9,712 in tobacco industry contributions. In contrast, the 197 representatives who voted to approve funding for the lawsuit accepted an average of $1,750 in contributions since January 1997. This proposal also did not move forward, but the lawsuit continued.

State Politics

The states, sandwiched between the federal level where the tobacco industry dominated the political process and the local level where health advocates often prevailed, were battlegrounds in three areas: preemption, taxation, and, beginning in the mid-1980s, large scale tobacco control programs.

In 2002, Delaware became the first state to overturn preemption of local tobacco control laws after a long campaign by public health advocates. Voters in Florida enacted a state clean indoor air law through direct voter initiative that made all workplaces and public places (except bars) smoke-free, and other states began enacting state clean indoor air laws. As is true at the national level, the tobacco industry fought back using well-connected lobbyists and campaign contributions. Occasionally the tobacco industry's largesse backfired on them. For example, in 2003 in Connecticut, public health advocates successfully brought public attention to financial ties between the tobacco industry and the Speaker of the House who was blocking a bill to repeal preemption in that state. The result of the controversy was that the Speaker of the House introduced and championed a statewide clean indoor air law, thereby skirting the issue of preemption, which passed and went into effect in the fall of 2003 for restaurants and April 2004 for bars and cafes.

Similar to preemption, tobacco taxation is another area where the tobacco industry works at multiple levels. Federal tax increases on cigarettes, although beneficial in financial and health terms, rarely occur; the last increase in the federal cigarette tax was in 2001 when it only increased from 34 cents per pack to 39 cents per pack. However, after many years of relatively small tobacco tax increases, the fiscal difficulties that engulfed much of the United States in the early twenty-first century forced states to substantially increase the cigarette tax. Between 2001 and 2003, 33 states increased their cigarette tax; five states made two increases during that time period. One such state, New Jersey, had the highest tax rate at $2.05 per pack. The tobacco industry was unable to stop these taxes, but, despite the proven effectiveness of large-scale tobacco control programs, little of the money the taxes raised was devoted to helping smokers to quit or to prevent young people from starting. While the industry fights these tax increases, it also often uses them to mask price increases that exceed the tax, ensuring continued revenue growth for the companies.

Large-Scale State Tobacco Control Programs

Perhaps the most important innovation in tobacco control at the state level has been the emergence of large-scale tobacco control programs. Such programs represent the first real challenge to the tobacco industry's monopoly of the advertising medium since 1970 when the industry effectively removed antismoking advertising from television and radio when it had Congress enact the broadcast advertising ban that went in to effect. Minnesota developed the first state-funded antsmoking campaign in the United States in 1983 and implemented the program in 1985. The tobacco industry worked from the early stages of conception of the program to defeat it through campaign contributions and lobbying efforts and portraying the program as ineffective. It even developed its own "youth smoking prevention program," "Helping Youth Decide," that carefully avoided talking about the health dangers of smoking or the fact that nicotine was an addictive drug. In Minnesota, as elsewhere in the world, the industry presented its own ineffective programs as an alternative to meaningful tobacco control measures run by public health professionals. In addition, third party allies, such as the Teamsters Union, were recruited to defeat the tobacco control campaign. The tobacco industry also created a lobbying team made up of former state legislators and state employees with access to the legislative decision-making process, which allowed the industry to stay a step ahead of all plans for implementation of the program. While the industry did not prevent the program from beginning in 1985, its efforts to chip away at the program began to succeed in 1990 when the state legislature cut the program's budget from $1.5 million to $1 million. The election of Republican Governor Arne Carlson, whose ties with the tobacco industry included campaign contributions from industry lobbyists, and a 1996 outing in Australia financed by Philip Morris during Minnesota's case against the tobacco industry, led to the fall of the program in 1993. Carlson used inflated claims of a fiscal crisis, saying that the state was running out of money even as he was cutting taxes on the grounds that the state had more money than it needed; then he used the money "saved" by eliminating the tobacco control program for tax rebates.

The largest and longest surviving state program was created in California in 1988. After a hard-fought election campaign between health advocates and the tobacco industry, voters enacted an initiative known as Proposition 99, that increased the state tobacco tax by 25 cents per pack and allocated some of the revenues to fund tobacco education and prevention programs. The state Department of Health mounted an aggressive campaign that combined tough antismoking ads, many of which confronted the tobacco industry's decades of manipulation of the public and built a statewide infrastructure to support local tobacco control activities, particularly clean indoor air and encouraging organizations to refuse tobacco industry money. The program reduced cigarette consumption so rapidly that it produced a corresponding drop in smoking-induced heart attacks.

Encouraged by California's success, public health activists used the initiative process in several other states—Massachusetts, Arizona, and Oregon—to enact programs modeled on California.

The tobacco industry, however, did not accept these developments. In addition to fighting these initiatives at the polls, the industry used its considerable political muscle in state legislatures to hobble these programs by forbidding them from attacking the industry or working on policy change. In California the industry increased its campaign contributions dramatically and, working through allies in the California Medical Association (the political deal was that the tobacco industry would help the Medical Association enact favorable legislation on malpractice in exchange for its help in shutting down the tobacco control program), nearly destroyed the program. Only an aggressive attack on the California Medical Association and the governor led by the American Heart Association and Americans for Nonsmokers' Rights, combined with several lawsuits defending the program, saved it. Other states did not fare so well; despite the fact that the tobacco control programs were enacted by the voters and had demonstrated effectiveness, the tobacco industry lobbying efforts led to state budget cuts that virtually shut down the Massachusetts program in 2002 and the Oregon and Florida programs in 2003.

The federal government recognized that public policy interventions at the state and local level were the most promising way to lower the burden of disease and death cased by the tobacco industry. Between 1991 and 1999, the National Cancer Institute carried out a large-scale trial of this proposition through the American Stop Smoking Intervention Study (ASSIST) program. ASSIST provided funding to 17 states, awarded after a national competition, to build a local infrastructure to enact policy changes, including increased tobacco taxes and local clean indoor air laws. ASSIST represented the first large scale (although at a state level not as large as the large-scale tobacco control programs the states mounted themselves later), and represented a serious threat to the tobacco industry. Secret tobacco industry documents acknowledged that "ASSIST will hit us in our most vulnerable areas—in the localities and in the private workplace. It has the potential to peel away from the industry many of its historic allies" (<http://www.gaspforair.org/2000>) and "the antitobacco forces have developed a more sophisticated and well-funded structure to address local government affairs. . . . [ASSIST] guarantees that local matters will take increasing portions of our time and effort. . . . Thus our local plan is crucial" (<http://www.tobaccodocuments.org/1998>).

The industry mobilized aggressively against ASSIST by organizing tobacco vendors, company sales people, restaurateurs, grocers, convenience store owners, and other business organizations. These organizations were used to create accusations and divert attention from reducing tobacco use in the population to claims of "illegal lobbying" and used massive and targeted requests made under the Freedom of Information Act (FOIA) to burden tobacco control advocates with the task of copying documents rather than pursuing tobacco control. The results were also used in attempts to smear the work of ASSIST and other tobacco control organizations by claiming that these parties were using funds for "illegal lobbying." The industry also used its allies in Congress to put restrictions into law that restricted ASSIST's activities designed to promote public policy change to promote the public health.

Despite these attacks—and the corresponding reduction in effectiveness of ASSIST because it reduced its policy-related activities—ASSIST was successful in reducing tobacco use. ASSIST was associated with a decline in prevalence that could have resulted in 278,700 fewer smokers between 1991 and 1999 across the United States if ASSIST had been implemented nationwide.

Lawsuits Against the Tobacco Industry

A new front opened in the political battles between public officials and the tobacco industry in 1994 when the Attorneys General of Mississippi, Minnesota, and other states sued the tobacco industry to recover the costs of smoking paid by taxpayers and to stop other industry practices, particular predatory marketing against children. (These lawsuits were separate from private suits that had been in litigation with little success for years.) The industry opposed these suits not only in court, but also through the political process. In many states, the industry succeeded in preventing the attorneys general from spending state funds on the litigation (that led to the cases being pursued in cooperation with and financed by private lawyers). In Mississippi, the pro-tobacco governor even sued the attorney general in an unsuccessful effort to stop the suit, claiming that the suit was illegal since he never consulted with the governor.

None of these cases went all the way to a court verdict. Instead, all the cases were settled out of court, the first four states (Mississippi, Florida, Texas, and Minnesota) individually, and the remaining 46 states in the jointly negotiated Master Settlement Agreement (MSA) in 1998. These settlements imposed some restrictions on cigarette advertising (most notably, ending large billboards), established state antismoking programs in the states that settled individually, required the release of about 40 million pages of previously secret internal tobacco industry documents, and, most important, provided hundreds of billions of dollars to states into the indefinite future to partially reimburse the states for the costs of smoking through a complex formula based on cigarette sales.

The MSA and other settlements created the opportunity for every state to build a successful large-scale tobacco control program based on the successes of California, Massachusetts, ASSIST, and others. It remained up to the state legislatures—where the tobacco industry still wielded substantial political clout—to allocate some of the MSA money for tobacco control programs. In the early years after the settlements, some states did use the settlement dollars for tobacco control, but as of 2002, states were using less than 25 percent of the MSA payments for tobacco prevention and an even smaller portion of the state's total tobacco-related revenues. Most of the money went to anything but tobacco control, including capital projects, public works, and health services. By 2004, however, the threat of even these modest programs to the tobacco industry had greatly diminished. Programs in Florida and Minnesota established by their individual state settlements were eliminated (in large part because of the failure of health advocates in those states to mount the kind of aggressive defense that had rescued the California program a decade before), and funding in many other states had been cut.

Even worse from a public health perspective, the MSA created an unexpected alliance between the tobacco industry and some of the states that were more interested in protecting the cash flow of the MSA than reducing tobacco use. In the spring of 2003, 37 attorneys general (many of whom had been directly involved in negotiating the MSA) filed a brief of amici curiae in support of Philip Morris, which was attempting to avoid posting a $12 billion appeal bond after losing a private class action lawsuit in Illinois, claiming that its marketing of "light" and "mild" cigarettes defrauded the public. The attorneys general accepted the claim that posting a bond of this magnitude would jeopardize Philip Morris' ability to make its annual MSA payments to the states.

Beyond general support from the attorneys general due to financial interests, the tobacco industry built a solid alliance with members of the Republican Attorneys General Association (RAGA). RAGA was conceived by Alabama Attorney General Bill Pryor in 1999 (Pryor was named a federal judge by President George W. Bush in 2004), as a means of defending against the alliances that some attorneys general had formed with private lawyers to sue the tobacco industry, providing an unfair advantage against the tobacco industry and threatening the entire business community. The links between the tobacco industry and RAGA were well hidden because RAGA was not required to report campaign contributions.

In many ways, the politics of the post-MSA era have marked a return to those of the late 1980s and early 1990s, with a resurgence of local tobacco control activities concentrated on clean indoor air. Probably the most important legacy of the litigation against the tobacco industry is the fact that more than 40 million pages of previously secret tobacco industry documents are now available to the public on the Internet. During its lawsuit against the industry, Minnesota Attorney General Hubert Humphrey III doggedly pursued release of the tobacco industry's secret internal correspondence. He forced this material to be made public as part of the Minnesota settlement. Later, the MSA required that this material be placed on the Internet (<http://legacy.library.ucsf.edu>). These documents give an unprecedented view into the inner workings of the tobacco industry and its involvement in politics at the local, state, national, and international levels. While the practices of the tobacco industry have not drastically changed over time, access to the tobacco industry's internal documents has allowed the public to see how the tobacco industry does business and allowed health advocates to do a better job of countering the industry's activities.

International Politics

Three multinational corporations operating worldwide—Altria (Philip Morris), British American, and Japan Tobacco—dominate the tobacco industry. The combined opportunities created for these multinational corporations through globalization and through the reduction of smoking in the United States and other developed countries by tobacco control advocates have led the tobacco industry to increasingly focus its efforts on the developing world. As in the United States, these tobacco companies, and their smaller cousins, aggressively use politics to protect and promote their interests, using the same techniques as in the United States: well-connected lobbyists, political money, and third party front groups and allies.

For example, in the mid-1980s, the tobacco industry faced a significant challenge in the European community, which was proposing legislation to end tobacco advertising and promotions. The tobacco industry recognized the economic consequences of such an action and began to forge alliances with third parties, including the International Chamber of Commerce, the Union of Industrial and Employers' Confederations of Europe, and several members of the communications and business communities, as well as friendly governments, most notably Germany, against the legislation. While these strategies were not successful in preventing the passage of the ban on advertising and promotion, a case brought by Germany led the European Court of Justice to strike the legislation in 2000.

Similar to the tactics of the tobacco industry in the United States, Philip Morris and Brown & Williamson developed an international network of scientists secretly funded by the tobacco industry and managed by Covington and Burling, the law firm that handles much of the tobacco industry's political work in the United States, to conduct research to refute the dangers of secondhand smoke in the mid-1990s. This network successfully delayed the spread of clean indoor legislation to Latin America and other parts of the world.

The industry faced its strongest international challenge in the late 1990s, when the World Health Organization began using its treaty-making powers for the first time to create the first international public health treaty, the Framework Convention on Tobacco Control (FCTC). The goal of the FCTC is to create a framework to be implemented at all levels of government to reduce the prevalence of tobacco use and exposure to secondhand smoke, thereby decreasing the health, social, environmental, and economic consequences. To accomplish this goal the FCTC envisions bans on tobacco advertising, promotion, and sponsorship, including requiring the placement of prominent and strong health warnings on all tobacco packages, banning the use of deceptive terms such as "light" and "mild," protecting the public from exposure to secondhand smoke in all public places, increasing tobacco taxes, and working to prevent cigarette smuggling, which is often organized with the active participation of the multinational cigarette companies as a way to penetrate new markets and bypass national tobacco control laws.

The tobacco industry actively monitored the treaty development and worked through national governments in sympathetic countries, most notably the United States (particularly after the pro-tobacco George W. Bush administration took power), Germany, and Japan. The industry also applied standard tactics such as working through third parties and front groups to lobby for weakening the treaty by eliminating key provisions. In the end, a concerted effort led by countries in the developing world and nongovernmental organizations in the United States, Europe, and elsewhere forced the United States, Germany, and Japan to back down, and the treaty was approved by the World Health Assembly in 2003. However, the treaty must be ratified by the participating countries for it to go into effect, and this process will take substantial time and will face opposition in many countries orchestrated by the tobacco industry (often acting through other third parties), including the United States.

Conclusion

The politics surrounding tobacco are often characterized as a tug-of-war between the tobacco industry and the public health community. The tobacco industry works to pull the issue up the hierarchy of the political system, knowing that its greatest chance for victory is at the federal level since it is the most concentrated area of government, furthest from the people, and most susceptible to tobacco industry lobbyists and campaign contributions. Working down the political system to state and local governments, health advocates increase their chances of making progress in tobacco control as the tobacco industry cannot be in all places at all times and because, in a highly visible public political fight, local politicians are more sensitive to the public's desire to be protected from the tobacco industry than to tobacco industry money. The industry has responded by increasing its efforts to stay in the background and work through other organizations such as "hospitality associations." Local tobacco control advocates tend to be successful when they can expose these connections and frame the issue as local citizens against Big Tobacco.

See Also Doctors; Insurance; Toxins.

? JENNIFER K. IBRAHIM
? STANTON A. GLANTZ

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