Sungkyu Lee seeking compensation against tobacco industry for financial losses due to smoking through litigation, is recommended. Facilitating tobacco

Special Article J Prev Med Public Health 2016;49:23-34 http://dx.doi.org/10.3961/jpmph.15.063 pissn 1975-8375 eissn 2233-4521 Journal of Preventive Medicine & Public Health The Tobacco Industry s Abuse of Scientific Evidence and Activities to Recruit Scientists During Tobacco Litigation Sungkyu Lee National Evidence-based Healthcare Collaborating Agency, Seoul, Korea South Korea s state health insurer, the National Health Insurance Service (NHIS), is in the process of a compensation suit against tobacco industry. The tobacco companies have habitually endeavored to ensure favorable outcomes in litigation by misusing scientific evidence or recruiting scientists to support its interests. This study analyzed strategies that tobacco companies have used during the NHIS litigation, which has been receiving world-wide attention. To understand the litigation strategies of tobacco companies, the present study reviewed the existing literature and carried out content analysis of petitions, preparatory documents, and supporting evidence submitted to the court by the NHIS and the tobacco companies during the suit. Tobacco companies misrepresented the World Health Organization (WHO) report s argument and misused scientific evidence, and removed the word deadly from the title of the citation. Tobacco companies submitted the research results of scientists who had worked as a consultant for the tobacco industry as evidence. Such litigation strategies employed by the tobacco companies internationally were applied similarly in Korean lawsuits. Results of tobacco litigation have a huge influence on tobacco control policies. For desirable outcomes of the suits, healthcare professionals need to pay a great deal of attention to the enormous volume of written opinions and supporting evidence that tobacco companies submit. They also need to face the fact that the companies engage in recruitment of scientists. Healthcare professionals should refuse to partner with tobacco industry, as recommended by Article 5.3 of the WHO Framework Convention on Tobacco Control. Key words: Tobacco, Tobacco industry, Tobacco litigation, Tobacco industry litigation tactics INTRODUCTION Litigation against tobacco companies plays an important role in reinforcing and advancing tobacco control policies. Through lawsuits, as hidden strategies of tobacco companies were revealed to the public, the truth about tobacco products, Received: November 12, 2015 Accepted: January 13, 2016 Corresponding author: Sungkyu Lee, PhD 173 Toegye-ro, Jung-gu, Seoul 04554, Korea Tel: +82-2-2174-2770, Fax: +82-2-747-4916 E-mail: wwwvince77@gmail.com This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. smoking behavior, and the industry was also exposed. In short, through this revelation, everyone can reach a consensus on the need to reinforce tobacco control policies. The history of US tobacco litigation shows that such lawsuits have been public teaching programs." Throughout the process, classified documents of tobacco companies have been disclosed to the public, and the immoral and unethical nature of the industry has become known to the world. This led the public to lose trust in the industry [1]. The importance of tobacco litigation has been emphasized in the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) as well. Article 19 of the FCTC recommends that all parties need to strengthen municipal law and build litigation support systems for facilitating tobacco lawsuits [2]. For example, establishing municipal law, which enables Copyright 2016 The Korean Society for Preventive Medicine 23

Sungkyu Lee seeking compensation against tobacco industry for financial losses due to smoking through litigation, is recommended. Facilitating tobacco lawsuits is essential for strengthening and advancing tobacco control policies. In Korea, several lawsuits have also been filed against the tobacco industry. In September 1999, a patient with lung cancer who had a long history of smoking and his family filed a compensation suit against the Korean government and Korea Tobacco & Ginseng Corp. (currently KT&G). In December of the same year, six lung cancer victims and their families also filed a suit against the Korean government and Korea Tobacco & Ginseng Corp. Furthermore, although different from diseaserelated compensation claims caused by smoking, in January 2009, Gyeonggi province sued KT&G for compensation for damages caused by a fire started from a cigarette butt [3]. Against this backdrop, the Korea National Health Insurance Service (NHIS), a state health insurer, filed 53.7 billion Korean won worth of compensation suits against three tobacco companies KT&G, British American Tobacco Korea, and Philip Morris Korea Inc. on April 14, 2014. Unlike the previous cases where individuals sued tobacco companies, this time, the NHIS, a government organization, did, which is noteworthy and raises hopes for successful results. However, if the NHIS were to lose, the ramifications would include serious obstruction to the advancement of national tobacco control policies as well as fatal adverse effects to public health. That is why careful attention by the government, academia, and the public is much needed in the current suit brought by the NHIS. It is worth asking what kind of attention should be paid. According to the cases of other countries, tobacco companies steer litigation toward outcomes favorable to themselves by adopting various strategies during suits. A case in point is misuse of scientific evidence submitted as supporting evidence on the issues of the lawsuit. The companies also win over scientists who can provide evidence or testimonies favorable to them, so as to secure an advantage in the suits. In this present study, we aim to analyze strategies employed by tobacco companies during the NHIS s ongoing litigation and to identify what activities the companies are carrying out in implementing the key strategies misuse of scientific evidence and recruitment of scientists. METHODS In order to identify and analyze tobacco companies strategies in the litigation between the NHIS and three tobacco companies (2014 Gahap 525 054 Compensation claim), content analysis was performed on the petition submitted by the NHIS to the Seoul Central District Court and preparatory documents submitted by the three companies to the court against the petition. Documents submitted as supporting evidence by the Korea Tobacco & Ginseng Corp. to the court in the compensation claim lawsuit (99 Gahap 104 973 Compensation claim [miscellaneous]) brought by six lung cancer patients and their families against Korea Tobacco & Ginseng Corp. were also analyzed. Content analysis is a quantitative method of information communicated mainly via documents, TV, or radio [4]. In content analysis, words, topics, or sentences can be a unit of analysis, and the subjects of the analysis are classified by frequency or category. In this present study, content analysis was performed in an attempt to identify the claims and intentions of the tobacco companies of the case, focusing on the words and topics of the petition and preparatory documents. The petition and preparatory documents of the NHIS litigation were obtained by the author in the process of consulting for the current litigation as a member of the NHIS Normalization Promotion Committee. In addition, the list of the supporting evidence that the Korea Tobacco & Ginseng Corp. submitted to the court was obtained through the legal agent of the plaintiff of the case. Later, to access the original copies of the supporting evidence on the list, the Legacy Tobacco Documents Library (https://industrydocuments.library.ucsf.edu/tobacco/), where internal documents of multinational tobacco companies are kept, was searched. For research reports or academic papers among the supporting evidence submitted by the tobacco companies, the possibility of any conflicts of interest or connections among the authors, participating researchers, and the tobacco companies was investigated by checking Science-for-sale (www.sciencecorruption.com). MISUSE OF SCIENTIFIC EVIDENCE BY TOBACCO COMPANIES For the NHIS to win the current compensation claim suit, what is most needed is to prove that smoking causes diseases. The defendants, tobacco companies, are claiming that epidemiological approaches and results that the NHIS uses to prove the causality are far-fetched. Therefore, proving the causal link is the paramount issue in this case, as it has been in past cases. Besides demonstrating the causal relationship between 24

Tobacco Industry's Tactics During the Litigation smoking and disease, another key issue in this case is product liability: Tobacco industry is responsible for their products. If they deliberately manipulate the product and harm their consumers, they, as manufacturers, become liable for the damage caused to the consumers. With regard to product liability, the NHIS is aggressively making an issue of the tobacco companies use of various additives. The NHIS claims that additives included in tobacco reinforce the addictive nature of nicotine and encourage smoking behavior [5]. In other words, the NHIS points out that including additives itself generates new smokers and worsens nicotine s addiction. About this issue, the defendants argue that the additives to tobacco are harmless. To back up their claim, Philip Morris Korea cited reports of the WHO and American Cancer Society (ACS) in opposition to the argument of the NHIS. Below is how Kim & Chang, of the law firm representing Philip Morris Korea, cited the reports of the WHO and ACS (Figure 1). In citing or explaining the reports of the WHO and ACS, the tobacco companies misused scientific evidence. The reason why both reports compared the danger of tobacco with and without additives was that tobacco companies such as American Spirit were being irresponsibly promoted as additive-free tobacco at the time (Figure 2). Therefore, the two organizations wrote and published the reports to inform the public that the tobacco products labeled as additive-free were no different from common tobacco products with additives, in terms of danger. Nonetheless, tobacco companies misinterpreted the reports to be communicating exactly the opposite idea in order to dodge the criticism by the NHIS. In other words, the companies interpreted the reports warning of the danger of the tobacco advertised as additive-free in a way that tobacco products with additives were just as harmless as the ones without additives; thus, adding additives to tobacco is harmless. In fact, the WHO and ACS reports explained that tobacco products labeled as additive-free were also found to contain additives through component analysis. Therefore, tobacco products putatively with and without additives are both dangerous. For instance, the WHO stated that cigarettes claimed to be without additives and made of organic tobacco have never been demonstrated to be less dangerous or addictive than conventional cigarettes [Reference #13 of the preparatory document]. In addition, the ACS, on its website, stated that Smoke from all cigarettes, natural or otherwise, has many chemicals that can cause cancer (carcinogens) and toxins that come from burning the tobacco itself, including tar and carbon monoxide. [Reference #14 of the preparatory document]. The defendant has not used additives to increase the harmful or addictive nature of tobacco as the plaintiff argues [6]. Figure 1. Philip Morris s argument on tobacco additives. Philip Morris Korea cited the World Health Organization s report, entitled Tobacco: deadly in any form and the American Cancer Society s report (website), entitled Are any types of cigarettes safe to smoke? in order to argue against the National Health Insurance Service s argument that tobacco additives are harmful to tobacco users. Figure 2. Image of a tobacco brand named Natural American Spirit. Natural American Spirit has been widely advertised as 100% additive-free natural tobacco around the world. Source from: Clarey B. Cover story 200,000 cigarettes; 2014 [7]. 25

Sungkyu Lee What is more interesting in Philip Morris Korea s citation of the reports from the WHO and ACS can be found in the reference of the preparatory documents, marked in the footnotes. While the other international references are all in English, the report from the WHO was translated into Korean, although it was originally written in English. In other words, the ACS report was presented in English in the footnote, and the WHO report was presented in Korean in the footnote. The original title of the WHO report is Tobacco: deadly in any form or disguise. (Figure 3). However, in order to hide the word deadly, which means fatal, or leading to death, they translated the title into Korean and footnoted the reference as Tobacco, harmful in any form. TOBACCO COMPANIES RECRUITMENT OF SCIENTISTS The author reviewed the supporting evidence submitted by KT&G (the defendant of the current litigation and of other in- dividual lawsuits that have been ongoing for more than ten years) to the court responsible for the individual lawsuits then, claiming that tobacco additives were harmless: Eulna Exhibit No.188, entitled A safety assessment of ingredients added to tobacco in the manufacture of cigarettes (March 1994), a research paper written by John Doull, John P. Frawley, William George, Ted Loomis, Robert A. Squire, and Stephen L. Taylor. The key message of the paper was that the ingredients of tobacco additives were not dangerous. John Doull was a long-term consultant (mainly in the dangers of flavours) to tobacco companies. Dr. John Doull, professor at the University of Kansas Medical School, was appointed by Senate Minority Leader Robert Dole (RKansas). Both Dole and Doull were long-term friends of the tobacco industry [8]. To examine how those researchers conducting such studies were linked with tobacco companies, the author performed investigations by accessing the Science-for-sale website (www. sciencecorruption.com) and investigating John Doull, the lead author of the paper. The results revealed that he had worked as a consultant of tobacco companies for a long time. In short, a person who had long consulted for the tobacco industry published a research paper, and tobacco companies used it as evidence to support their claim that tobacco additives were safe. Science-for-sale introduces John Doull as follows: John Doull was a long-term consultant (mainly in the dangers of flavours) to tobacco companies. Dr. John Doull, professor at the University of Kansas Medical School, who was appointed by Senate Minority Leader Robert Dole (R-Kansas). Both Dole and Doull were long-term friends of the tobacco industry [8]. DISCUSSION AND CONCLUSIONS Figure 3. The cover page of the World Health Organization s report, entitled Tobacco: deadly in any form or disguise. Philip Morris Korea had translated the title of this report into Korean and had replaced the word deadly with harmful in their citation of the report. 26 Tobacco industry has responded to the claims of plaintiffs, using various strategies during litigation. A key tactic is to provide scientific evidence to support their positions and to recruit scientists who can endorse the tobacco industry, by giving testimonies favorable to themselves in court. In addition, targeting the lack of expertise of the Department of Justice, they have sometimes submitted a vast number of expert research reports. In the process, the researchers selectively submitted the research reports that could be advantageous to tobacco

Tobacco Industry's Tactics During the Litigation companies or they sometimes misused scientific evidence. It is likely that the tobacco companies have been using or will use these two strategies in response to the current litigation that the NHIS has filed. The misuse of scientific evidence has already been attempted as we have reviewed in this study. The recruitment of scientists although it was revealed through the analysis of the materials used in the prior individual lawsuits is highly likely to be done in the present case. When it comes to tobacco litigation, tobacco companies worldwide have allied among themselves as partners, not rivals. A prior study analyzing the internal documents of tobacco companies introduced a letter that Korea Tobacco & Ginseng Corp. sent to its rival Philip Morris Korea, asking for support for litigation at the point when a tobacco lawsuit was first filed [3]. This means that it is highly possible that materials or evidence to be used in litigation are shared inside the tobacco industry. To address such an issue, thorough examination of all supporting evidence submitted by tobacco companies in the current lawsuit brought by the NHIS is imperative: Experts on tobacco control should actively participate in reviewing the supporting evidence. For research reports or academic papers, in particular, investigations need to be performed on various aspects, including their research design, analysis methods, results, conflicts of interest among the researchers, and research funding sources. The experts also need to be well aware of the litigation strategies that the tobacco industry has adopted and is likely to adopt in the future, such as asking researchers to conduct studies to gain supporting evidence or recruiting scientists across diverse disciplines to request testimonies in the suits [9-12]. Article 5.3 of the WHO FCTC has set various recommendations to protect tobacco control policies from the vested interests of the tobacco industry [13]. Among them, the recommendation to refuse to partner with tobacco companies is particularly noteworthy for healthcare professionals, a likely target of such recruitment. Acknowledging that working with the tobacco industry undermines tobacco control polices and negatively affects public health policies, health professionals and researchers should adamantly reject offers made by tobacco companies. The current NHIS litigation is gaining worldwide attention. As the number of cases in which tobacco companies lose increases, more tobacco lawsuits will be filed globally. Furthermore, such a spread of tobacco lawsuits may lead to reinforcement of tobacco control policies, and ultimately, even the end of the tobacco industry. The NHIS s position and strategies for preparing for the current tobacco lawsuit will be the key to determining the outcome of the suit. The key message of the present study to the NHIS is that the organization should make every effort to thoroughly review the supporting evidence that tobacco companies submit during the case, regardless of the time and budget required. The history of tobacco lawsuits in the US dates back nearly 60 years. Even though the plaintiff lost in the first case, the experience provided the groundwork for developing strategies for the next cases. With more litigation experience, the chances of winning later cases grew gradually [14]. Korea should benchmark the progress of litigation in the US. The plaintiffs have lost in individual lawsuits. However, the NHIS and experts in tobacco control policy should be more proactive in informing the public of the hidden truth the misuse of scientific evidence and recruitment of scientists by the tobacco industry which was not carefully examined in prior lawsuits and yet was identified in the present study. If the NHIS wins the current case, it would have a positive impact on not only the tobacco control policies in Korea, but also similar tobacco litigation in other parts of the world. Considering the implications of the suit, the NHIS and related experts should prepare for the case meticulously with a great sense of responsibility. Finally, the scope of this study was limited to the analysis of only a portion of the materials from all ongoing tobacco litigation. Therefore, further analysis of the documents that remain to be submitted by tobacco companies should also be performed promptly and comprehensively. CONFLICT OF INTEREST The author served as a member of the National Health Insurance Service s Committee for Restoration of National Health Insurance. He has carried out consulting activities specifically on tobacco litigation. SUPPLEMENTAL MATERIAL Supplemental material (Korean version) is available at http://www.jpmph.org/. ORCID Sungkyu Lee http://orcid.org/0000-0002-6419-2086 27

Sungkyu Lee REFERENCES 1. Richard AD, Eric L. Product liability. Tob Control 2012;21(2): 227-228. 2. World Health Organization. WHO Framework Convention on Tobacco Control [cited 2015 Oct 10]. Available from: http:// www.who.int/fctc/text_download/en/. 3. Lee S, Kim JH, Kim IS. Tobacco litigation and transnational tobacco companies' componential analysis of South Korea's tobacco brands. Health Soc Welf Rev 2012;32(3):461-484 (Korean). 4. Mayring P. Qualitative content analysis. Forum Qual Soc Res 2000;1(2):Art. 20. 5. Gu KY. Tobacco litigation, intensive battle. News1; 2014 Sep 12 [cited 2015 Oct 30]. Available from: http://news1.kr/articles/?1854787 (Korean). 6. Kim & Chang. 2014 Gahap 525054 Damage claim. Briefs. Seoul Central District Court 22 Department of Civil case. 2014 Jul 15 (Korean). 7. Clarey B. Cover story 200,000 cigarettes; 2014 [cited 2016 Jan 20]. Available from: http://triad-city-beat.com/in-printcover-story-200000-cigarettes/. 8. Science-for-sale. Risk assessment and management commission [cited 2015 Nov 1]. Available from http://sciencecorruption.com/atn182/00534.html. 9. Park S, Choi K, Cho H. Analysis of Korean scientists in internal tobacco company documents. J Korean Soc Res Nicotine Tob 2014;5(1):1-9 (Korean). 10. Gruning T, Gilmore AB, Martin M. Tobacco industry influence on science and scientists in Germany. Am J Public Health 2006; 96(1):20-32. 11. Tong E, Glantz S. ARTIST (Asian regional tobacco industry scientist team): Philip Morris' attempt to exert a scientific and regulatory agenda on Asia. Tob Control 2004;13(Suppl 2):ii118-ii124. 12. Muggli ME, Hurt RD, Becker LB. Turning free speech into corporate speech: Philip Morris' efforts to influence U.S. and European journalists regarding the U.S. EPA report on secondhand smoke. Prev Med 2004;39(3):568-580. 13. Lee S, Jee S, Kim HJ, Oh Y, Kim HJ, Mok YJ, et al. Finding an effective strategy to implement the WHO FCTC Article 5.3. Seoul; Yonsei University; 2012 (Korean). 14. Miura M, Daynard RA, Samet JM. The role of litigation in tobacco control. Salud Publica Mex 2006;48(Suppl 1):S121-S136. 28

Tobacco Industry's Tactics During the Litigation Tobacco Industry s Abuse of Scientific Evidence and Activities to Recruit Scientists During Tobacco Litigation Sungkyu Lee National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea 담배소송중담배회사의과학적근거오용과과학자포섭활동 이성규 한국보건의료연구원 국민건강보험공단이담배회사를상대로손해배상청구소송을진행중에있다. 담배회사는전통적으로소송진행과정에서과학적근거를오용하거나과학자를포섭하여소송을유리한방향으로이끌어가기위한노력을해왔다. 본연구는전세계적으로주목받고있는국민건강보험공단의소송과정중담배회사의전략을분석하였다. 선행연구를통해이미밝혀진담배회사의담배소송전략을이해한다. 국민건강보험공단소송중법원에제출된소장, 준비서면, 증거자료등에대한내용분석을통해담배회사의소송전략을파악한다. 국민건강보험공단의소장내용중첨가물사용과관련된쟁점에대해담배회사는세계보건기구의 Tobacco: deadly in any form or disguise(2006) 보고서중 American spirit 과같은천연담배로광고하는담배제품에대한의견을마치첨가물이들어간제품과천연담뱃잎을사용하는담배제품간위험성이나중독성에차이가없다는내용으로준비서면을작성하였다. 하지만원래보고서내용은첨가제가들어가지않았다고광고하는천연담배의위험성을경고하는내용이었다. 즉, 보고서의작성의도를무시하고정반대의해석으로과학적근거를오용하였다. 또한준비서면내다른해외자료들은영문그자체로참고문헌에수록하였지만세계보건기구보고서는한글로번역하였고, 그이유는아마도보고서제목의 deadly 가부담스러웠던것으로해석된다. 또한국민건강보험공단소송이전에제기되었던개인소송중담배회사가법원에제출한증거자료의일부를분석한결과담배회사의컨설턴트로활동한과학자의연구결과를증거자료로제출한것도확인할수있었다. 국내담배소송에서도해외사례와마찬가지로담배회사의소송전략은유사했다. 담배소송결과는담배규제정책에막대한영향을미친다. 성공적인소송을위해보건의료분야전문가들은담배회사가제출하는방대한분량의의견서와증거자료에대한적극적인관심을가져야한다. 또한담배회사의과학자포섭활동을인지하고세계보건기구담배규제기본협약 (Framework Convention on Tobacco Control) 제5조3항의권고사항처럼담배업계와의협력을거절해야할것이다. 핵심어 : 담배, 담배업계, 담배소송, 담배소송전략 연구배경 담배회사를상대로한소송 (litigation) 은담배규제정책강화및발전에중요한역할을한다. 소송을통해담배회사의감춰진전략들이세상에공개될때담배제품, 흡연행위, 그리고담배회사에대한진실이대중에공개되고이를통해담배규제 정책강화의필요성을모두가공유할수있게되는것이다. 미국의담배소송역사를보면담배소송은그야말로 대국민교육프로그램 (public teaching program) 이었음을확인할수있다. 담배소송과정에서담배회사의내부기밀문건이대중에공개되고, 담배회사의부도덕성과비윤리성이알려지면서담배회사에대한신뢰가바닥으로떨어지는계기가되었던것 29

Sungkyu Lee 이다 [1]. 담배소송의중요성은세계보건기구 (World Health Organization, WHO) 담배규제기본협약 (Framework Convention on Tobacco Control, FCTC) 에서도강조하고있다. 협약제 19 조에서는모든협약당사국들이담배소송을추진하기위하여국내법을강화할필요가있고, 소송을위한지원체계를구축할것을권고하고있다 [2]. 예컨대흡연으로인한국가재정손실에대해서담배회사로하여금소송을통해손해배상을청구할수있는국내법을제정하라는것이다. 담배소송을추진하는것은담배규제정책강화및발전을위하여꼭필요한전략이라고할수있다. 국내에서도이미여러차례담배회사를상대로한소송들이제기되었다. 1999 년 9 월장기흡연후폐암에걸린환자, 그리고그의가족들이국가와한국담배인삼공사 ( 현 KT&G) 를상대로손해배상청구소송을제기하였고, 같은해 12 월에는 6 명의폐암환자와가족들이국가와한국담배인삼공사를상대로손해배상청구소송을제기하였다. 흡연으로인한질병발생관련손해배상청구와달리 2009 년 1 월에는경기도가 KT&G 를상대로담배꽁초로인한화재피해보상소송을제기하기도하였다 [3]. 이러한상황에서국민건강보험공단 ( 이하건보공단 ) 은지난 2014 년 4 월 14 일담배회사 3 곳, KT&G, British American Tobacco Korea, Philip Morris Korea 에대해 537 억원규모의손해배상청구소송을제기하였다. 그동안개인차원에서담배회사를상대로소송을진행하였던것과는달리이번에는공공기관이담배회사를상대로소송을제기한것이기때문에건보공단의소송은특별한의미를가진다고할수있고기대심을불러일으킬수있는것이다. 하지만, 만에하나건보공단이이번소송에서패소하게된다면그결과는국가담배규제정책발전을심각하게방해할뿐아니라국민보건에치명적인악영향을미치게될것임이틀림없다. 그렇기때문에건보공단의담배소송에정부, 학계, 대중의특별한관심이필요하다고할수있다. 그렇다면과연어떤관심을가져야하는가? 다른나라의사례를살펴보면담배소송진행중담배회사는다양한전략을통해소송을유리한쪽으로이끌어간다고한다. 대표적인전략이소송쟁점에대한증거자료제출시과학적근거를오용하는사례가있을수있고, 또한소송중유리한위치를확보하기위해유리한증거혹은증언을지원해줄수있는과학자를포섭하는활동들이있다. 본연구는현재진행중인건보공단담배소송과정중담배회사의전략을분석하여담배소송중담배회사가채택하는대표적인전략, 과학적근거오용및과학자포섭과관련해어떠한활동을펼치고있는지확인하고자한다. 연구방법 이번건보공단과 3 개담배회사간의소송 (2014 가합 525 054 손해배상청구 ) 중담배회사의전략을확인하고분석하기위하여건보공단이서울중앙지방법원에제출한소장, 그리고이소장에대응하여 3 개담배회사가법원에제출한준비서면에대한내용분석을실시하였다. 또한과거 6 명의폐암환자와가족들이국가와한국담배인삼공사를상대로제기한손해배상청구소송 (99 가합 104 973 손해배상 ( 기 )) 당시한국담배인삼공사가법원에증거자료로제출한문건들에대한내용분석도실시하였다. 내용분석 (content analysis) 은주로문서, TV, 라디오등을이용한의사소통내용을양적으로조사하는방법이다 [4]. 단어, 주제, 문장등이분석단위가될수있고빈도, 범주등을분류하여조사대상을관찰하는방법이다. 본연구에서는소장과준비서면속단어와주제에초점을맞추어문건속담배회사의주장과의도를파악하고자내용분석을수행하였다. 건보공단소송관련소장과준비서면은저자가국민건강보험정상화추진위원단위원으로이번건보공단소송의자문역할을수행하는과정에서취득하였다. 그리고과거소송중한국담배인삼공사가법원에제출한증거자료목록은해당사건의원고측법적대리인을통해취득할수있었다. 그후목록에기재된증거자료의원문을확보하기위해서다국적담배회사들의내부문건이보관된 Legacy Tobacco Documents Library (https://industrydocuments.library.ucsf.edu/tobacco/) 를검색하였다. 담배회사가제출한증거자료가연구보고서혹은학술논문인경우저자및참여연구원과담배회사간에어떤이해관계가있는지확인하기위해서 Science-for-sale (www.sciencecorruption.com) 을조사하였다. 담배회사의과학적근거오용 건보공단이이번손해배상청구소송에서승소하기위해서는가장먼저흡연이질병을유발한다는인과관계를입증하는것이중요하다. 피고인담배회사들은건보공단이인과관계입증을위하여사용한역학적접근과결과물을흡연자개개인에게적용하는것은무리가있다고주장하고있기때문에과거소송에서도, 그리고이번건보공단소송에서도인과관계를입증하는것이중요한쟁점이될것이다. 흡연과질병간의인과관계입증과함께건보공단소송에핵심쟁점으로다루어지고있는것은제조물책임 (Product Liability) 에관한내용이다. 담배회사는담배가흡연자건강에해를끼치지않는제품으로만들어야할책임이있는데, 만약담배회사가인위적으로담배를조작해사용자가해를입게되었다면사용자가입은피해에대하여제조사가책임을져야하 30

Tobacco Industry's Tactics During the Litigation 는개념이다. 제조물책임과관련해서건보공단은피고측담배회사들의각종첨가물사용에대해강력하게문제제기를하고있는상황이다. 건보공단은담배에들어가는첨가물은니코틴의중독성을강화하고흡연행위를용이하게하는작용을한다고주장한다 [5]. 첨가물을추가하는것자체가신규흡연자를양성하고, 니코틴중독을가중시킬수있다는의미다. 이에대해피고인담배회사들은담배첨가제에대해 무해하다 는주장을펼치고있다. 이러한주장을뒷받침하기위해 Philip Morris Korea 측은 WHO 와미국암학회 (American Cancer Society) 보고서를인용하여건보공단의주장에반박하였다. Philip Morris Korea 의소송대리인김 & 장법률사무소는아래와같이 WHO 와미국암학회보고서를인용하였다 (Figure 1). 나위험성에서는차이가없을것이라고설명했던것이다. Philip Morris Korea 의 WHO 와미국암학회보고서인용과정에서더흥미로운점은준비서면각주로표시된참고문헌에서찾아볼수있었다. 다른해외문헌의경우영어로참고문헌을표시한것과달리 WHO 의보고서는영문으로작성된보고서임에도불구하고한글로참고문헌을표기한것이다. 다시말 예컨대, 세계보건기구 (WHO) 는 첨가제가없는담배와 천연 (organic) 담배가 ( 기존의첨가제가있는 ) 궐련에비하여덜위험하거나중독성이덜하다고밝혀진바없다 고입장을밝혔습니다 [ 준비서면참고문헌 13번 ]. 미국암협회 (The American Cancer Society) 역시그웹사이트에서 담배의모든연기에는, 그것이자연적인것이든아니든, 타르와일산화탄소를포함하여담배를태우는그자체에서암 ( 발암물질 ) 을유발하는많은물질들과독소가함유되어있다 고밝히고있습니다.[ 준비서면참고문헌 14번 ] 피고회사는원고주장하는바와같이담배의위해성이나중독성을높이기위하여첨가제를사용한바없습니다 [6]. WHO 보고서와미국암학회보고서인용및설명에서담배회사는과학적근거를오용하였다. WHO 보고서나미국암학회보고서모두첨가제가포함된담배, 그리고첨가제가포함되지않은담배의위험성을비교했던이유는당시 첨가물이들어가지않는담배 (additives free tobacco) 라고광고하던 America Spirit 와같은담배들이무분별하게홍보되고있었기때문이다 (Figure 2). 그래서두가지보고서모두첨가물이들어가지않았다고광고하는담배제품역시첨가제가들어간일반담배제품과위험성측면에서차이가없다는것을알리기위해서해당보고서를작성해서발표했던것이다. 그럼에도불구하고담배회사는이내용을정반대로해석해건보공단의공격을피해가려한것이다. 첨가물이들어가지않은담배의위험성을경고하는보고서를거꾸로첨가물이들어가도첨가물이들어가지않은담배와위험성에차이가없으니첨가물을담배에추가하는것은아무런문제가없다고주장한것이다. 실제로 WHO 와미국암학회보고서에서는첨가물이들어가지않은담배역시성분분석을통해첨가물이여전히들어가있음을확인했기때문에첨가물이들어간담배제품이나그렇지않은담배제품이 Figure 1. Philip Morris s argument on tobacco additives. Philip Morris Korea cited the World Health Organization s report, entitled Tobacco: deadly in any form and the American Cancer Society s report (website), entitled Are any types of cigarettes safe to smoke? in order to argue against the National Health Insurance Service s argument that tobacco additives are harmful to tobacco users. Figure 2. Image of a tobacco brand named Natural American Spirit. Natural American Spirit has been widely advertised as 100% additive-free natural tobacco around the world. Source from: Clarey B. Cover story 200,000 cigarettes; 2014 [7]. 31

Sungkyu Lee 해 미국암학회에 보고서는 각주에 영어로 표기했고, WHO 보 고서는 한글로 번역을 해 각주로 표시한 것이다. WHO 보고서 원문 제목은 Tobacco: deadly in any form of disguise 으로 표기 되어 있었으나 (Figure 3) 담배가 사망을 이르게 하는, 치명적 (deadly) 제품이라는 WHO의 보고서를 제목을 숨기기 위해서 영문 제목 중 deadly 라는 단어 대신 한글로 번역해 해당 문헌 을 각주에 담배, 어떤 형태로든 유해 라고 표기했던 것이다. 담배회사의 과학자 포섭활동 현재 건보공단 소송의 피고이자 과거 10년 이상 진행되었던 개인소송에서의 피고인 KT&G가 담배 첨가물이 위해 하지 않 다는 주장을 내세우며 당시 개인소송을 담당했던 재판부에 제 출했던 증거자료를 검토하였다. 을나 제188호증, A safety assessment of ingredients added to tobacco in the manufacture of cigarette (March 1994) 라는 제목의 증거자료는 John Doull, John P. Frawley, William George, Ted Loomis, Robert A. Squire, Stephen L. Taylor가 작성한 연구보고서였다. 주요 내용은 담배에 첨가되 는 성분은 안전상에 문제가 되지 않는다는 내용이다. 과연 이 Figure 3. The cover page of the World Health Organization s report, entitled Tobacco: deadly in any form or disguise. Philip Morris Korea had translated the title of this report into Korean and had replaced the word deadly with harmful in their citation of the report. 32 러한 연구를 진행하는 학자들은 담배회사와 어떤 관계가 있을 지 확인해보고자 미국에서 운영되고 있는 Science-for-sale (www.sciencecorruption.com) 에 접속해 1저자인 John Doull에 대해 조사를 수행하였다. 그 결과 John Doull은 담배회사의 오 랜 컨설턴트였음을 확인할 수 있었다. 즉, 담배회사의 컨설턴 트로 오랜 기간 활동하였던 사람이 연구보고서를 작성하고 담 배회사는 이러한 보고서를 담배 첨가물이 안전하다는 주장을 뒷받침하기 위한 증거자료로 법원에 제출하였던 것이다. Science-for-sale은 John Doull에 대해 아래와 같이 소개하고 있다. John Doull was a long-term consultant (mainly in the dangers of flavours) to tobacco companies. Dr John Doull, professor at the Universityof Kansas Medical School, who was appointed by Senate Minority Leader Robert Dole (R-Kansas). Both Dole and Doull were long-term friends of the tobacco industry [7]. 고찰 및 결론 담배회사는 담배소송 중 다양한 전략을 활용해 원고들의 주 장에 대응하였다. 그중 가장 대표적인 것이 담배회사의 입장 을 지원해 줄 수 있는 과학적 근거를 제공하고 법원에서 담배 회사에 유리한 증언을 해줄 수 있는 과학자를 포섭하는 일이 다. 또한 재판부의 비전문성을 파고들어, 많은 분량의 전문적 인 연구보고서를 재판부에 제출하기도 하였다. 이 과정에서 담배회사에 유리한 연구보고서만을 선별해서 제출하거나 때 로는 과학적 근거를 오용하는 전략을 사용하였다. 건보공단이 진행하고 있는 이번 소송에서도 이들 두 가지 전략은 이미 사용되었거나 앞으로 사용될 가능성이 높다. 본 연구의 결과를 토대로 과학적 근거를 오용하는 것은 이미 시 도가 되고 있고, 과학자를 포섭하려는 활동은 이번 건보공단 소송이 아닌 이전 개인소송 과정에서 찾아낸 자료를 분석한 것이지만 앞으로 건보공단 소송에서도 동일한 전략이 사용될 가능성이 높다. 이미 전 세계 담배회사들은 담배소송에서만큼은 경쟁을 잊 고 서로가 협력하는 형태를 취하고 있다. 담배회사 내부 문건 을 분석한 선행연구에서, 국내 담배소송이 처음으로 제기된 시점에 한국담배인삼공사가 경쟁사인 Philip Morris에 소송지 원을 요청하는 편지가 소개되기도 하였다[3]. 즉, 담배회사 간 에 소송에 사용할 자료나 증거물이 서로 공유되고 있을 가능 성이 있다는 것이다. 이러한 문제를 극복하기 위해서는 현재 진행 중인 건보공단 소송에서 담배회사들이 제출하는 모든 증거자료에 대해 철저한 검증과정이 필요하다는 것이다. 담 배규제분야 전문가들의 적극적인 참여와 개입으로 증거자료,

Tobacco Industry's Tactics During the Litigation 특별히연구보고서혹은학술논문에대해서는연구설계, 분석방법, 결과해석, 저자들의이해상충관계, 연구비지원등에대한내용을검토할필요가있다. 또한담배회사들이증거자료확보를위해연구를요청하거나혹은소송증언을요청하기위하여각계각층의전문가들을포섭하는노력을기울여왔고 [8-11], 향후에도이러한활동이계속될수있는만큼전문가들은이러한담배회사의소송전략을잘이해하고있어야할것이다. WHO FCTC 제 5 조 3 항은담배업계의기득권으로부터담배규제정책을보호하기위한여러가지권고사항을정하고있다.[12] 이중 담배업계와의협력을거절할것 이라는권고는담배회사로부터포섭대상이될가능성이높은보건의료분야등전문가집단에서그의미를다시새길필요가있다. 전문가들의담배회사와의협력은담배규제정책을약화시키고, 공중보건정책에악영향을끼친다는것을인식하고, 담배회사의접촉시도를단호하게거절할수있어야할것이다. 전세계가우리나라에서진행되고있는건보공단소송에관심을기울이고있다. 담배소송에서담배회사가패소하는판례들이많이생길수록담배소송은일파만파다른국가들로번져나갈것이다. 또한이러한담배소송의확산은국제담배규제정책강화, 더나아가담배종말 (Tobacco endgame) 이라는결과를불러일으킬수도있을것이다. 건보공단의담배소송에임하는자세와전략은이번소송의승패를좌우하는중요한요소가될것이다. 본연구의결과가건보공단에던지는메시지는소송진행중담배회사가제출하는증거자료에대해시간과예산이들어갈지라도면밀히검토하는노력을보여야한다는것이다. 미국의담배소송역사는 60 년에이른다. 비록첫번째소송이패소했어도, 그첫번째소송이다음새로운소송에서사용할수있는전략을고양시키는밑바탕이되었다. 소송경험이늘어날수록다음소송에서의승소가능성은점차커져온것이다 [13]. 우리나라역시담배소송에있어미국의소송발전과정을따를필요가있다. 비록개인소송에서는패소하였지만과거소송에서철저하지못하였던, 그리고본연구에서확인한담배회사의과학적근거오용, 그리고담배회사의과학자포섭활동등에대해서는소송과정에서숨겨진진실이재판부와대중에알려질수있도록건보공단과전문가들은적극적으로노력해야할것이다. 이번담배소송에서승소한다면이는향후우리나라의담배규제정책뿐만아니라, 전세계에서벌어지고있는담배관련소송에도긍정적인영향을끼칠것이다. 건보공단과관련전문가들은이같은소송결과의엄중성을고려하여보다큰책임감을가지고철저히소송을준비할필요가있다. 끝으로본연구는현재진행되고있는소송중일부소송관련자료를분석한연구로향후담배회사측에서제출할문건에대한신속하고포괄적인분석이추가적 으로이루어질필요가있다. CONFLICT OF INTEREST 본연구자는국민건강보험공단국민건강보험정상화추진위원단위원으로활동하였고, 특별히담배소송에대한자문활동을수행하였음을밝힙니다. REFERENCES 1. Richard AD, Eric L. Product liability. Tob Control 2012;21(2): 227-228. 2. World Health Organization. WHO Framework Convention on Tobacco Control [cited 2015 Oct 10]. Available from: http:// www.who.int/fctc/text_download/en/. 3. Lee S, Kim JH, Kim IS. Tobacco litigation and transnational tobacco companies' componential analysis of South Korea's tobacco brands. Health Soc Welf Rev 2012;32(3):461-484 (Korean). 4. Mayring P. Qualitative content analysis. Forum: Qual Soc Res 2000;1(2):Art. 20. 5. Gu KY. Tobacco litigation, intensive battle. News1 2014 Sep 12 [cited 2015 Oct 30]. Available from: http://news1.kr/articles/?1854787 (Korean). 6. Kim & Chang. 2014 Gahap 525054 Damage claim. Briefs. Seoul Central District Court 22 Department of Civil case. 2014 Jul 15 (Korean). 7. Clarey B. Cover story 200,000 cigarettes; 2014 [cited 2016 Jan 20]. Available from: http://triad-city-beat.com/in-printcover-story-200000-cigarettes/. 8. Science-for-sale. Risk assessment and management commission [cited 2015 Nov 1]. Available from http://sciencecorruption.com/atn182/00534.html. 9. Park S, Choi K, Cho H. Analysis of Korean scientists in internal tobacco company documents. J Korean Soc Res Nicotine Tob 2014;5(1):1-9 (Korean). 10. Gruning T, Gilmore AB, Martin M. Tobacco industry influence on science and scientists in Germany. Am J Public Health 2006; 96(1):20-32. 11. Tong E, Glantz S. ARTIST (Asian regional tobacco industry scientist team): Philip Morris' attempt to exert a scientific and regulatory agenda on Asia. Tob Control 2004;13(Suppl 2):ii118-ii124. 12. Muggli ME, Hurt RD, Becker LB. Turning free speech into corporate speech: Philip Morris' efforts to influence U.S. and European journalists regarding the U.S. EPA report on secondhand smoke. Prev Med 2004;39(3):568-580. 33

Sungkyu Lee 13. Lee S, Jee S, Kim HJ, Oh Y, Kim HJ, Mok YJ, et al. Finding an effective strategy to implement the WHO FCTC Article 5.3. Seoul; Yonsei University; 2012 (Korean). 14. Miura M, Daynard RA, Samet JM. The role of litigation in tobacco control. Salud Publica Mex 2006;48(Suppl 1):S121-S136. 34