In discussing responsibility as an ethical framework for public health (AJPH, July 2009), Turoldo¹ suggests that the warning “Smoking kills” on cigarette packs represents an example of exaggerating negative consequences or the magnitude of problems. He argues that the label should more accurately say, “according to statistics, there is a certain probability of developing lung cancer through smoking, above all in people with a genetic predisposition. But nevertheless, there are cases … of hardened smokers who have not developed lung cancer.”^1(p1198) Such a statement ignores the evidence that about half of lifelong smokers will die prematurely from tobacco-caused diseases,² and that tobacco-caused heart disease kills far more people than does lung cancer, the most common among the many tobacco-caused cancers.³ What role genetics plays is unknown, but it is clearly insufficient to independently cause lung cancer in any appreciable numbers. Claiming that some smokers do not develop lung cancer is arguing from exception, minimizing the likelihood of only one type of tobacco-caused death, and distracting readers from the more critical point. In debate, the name usually given to that device is smokescreen.

Turoldo also asserts that, to help “individuals make informed decisions rather than limiting choices… . The effects of smoking tobacco products are listed on cigarette packets.”^1(p1199) Actually, in most countries very few of the diseases tobacco causes are listed on packs.

Turoldo claims that tobacco is “subject to heavy taxation in almost all countries worldwide.”^1(p1200) While “heavy” is subject to interpretation, the World Health Organization regards tobacco taxes as “low in the overwhelming majority of countries.”^4(p54) In more than 30 countries, the real price of local cigarettes decreased between 2002 and 2007.⁵ In one quarter of World Health Organization–surveyed countries, tobacco taxes accounted for less than 25% of the pack price, and only 4 countries, representing 2% of the world's people, have rates more than 75% of the price, as recommended. Among low and middle- income countries, major targets of the multinational tobacco industry, less than one quarter tax tobacco at 50% or more of retail price.⁵

Finally, Turoldo asserts that the tobacco industry is among those with an important role in delivering public health. The “important role” tobacco companies play in the delivery of public health is that of the vector of diseases public health seeks to prevent. Do mosquitoes have an important role in delivering public health? Internationally, the Parties to the Framework Convention on Tobacco Control have affirmed as a guiding principle that “there is a fundamental and irreconcilable conflict between the tobacco industry's interests and public health interests.”⁶ Unfortunately, the tobacco industry has worked hard to portray itself as “part of the solution.” Papers legitimizing this position can be used to undermine public health.

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