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Leone, F.T. (2002). A Question of Intent: A Great American Battle with a Deadly Industry. By David Kessler, MD. New York: Public Affairs, 2001.. J. Appl. Psychoanal. Stud., 4(4):451-453.

(2002). Journal of Applied Psychoanalytic Studies, 4(4):451-453

A Question of Intent: A Great American Battle with a Deadly Industry. By David Kessler, MD. New York: Public Affairs, 2001.

Review by:
Frank T. Leone, M.D., M.S.

Think about the words “Policy Thriller.” Certainly an oxymoron in any context. Well, David Kessler, the former head of the United States Food and Drug Administration, has been able to achieve the seemingly impossible. His story of the battle to regulate the sale of tobacco products in the U.S. is simultaneously a primer on the democratic process of creating policy, as well as a first rate thriller, complete with shady informants with nicknames like “Deep Cough,” anonymous phone tips from people with voices disguised, and an antagonist embroiled in a massive conspiracy to hide the truth in favor of enormous profits. The reader is compelled to turn the page by the obvious relevance to our daily lives.

In the United States alone, there are over 440,000 deaths attributable to tobacco each year. This astonishing number is the equivalent of over 1200 deaths per day, 50 per hour, or nearly one per minute every minute. Unfortunately, the scope of the problem is not limited to the number of attributable deaths. Early deaths and disability, $50 billion dollars per year in direct healthcare expenditures, another $60 billion in lost productivity and absenteeism; these are the hidden, onerous costs that we are all forced to bear. No other public health risk exacts such a gruesome toll on the well being of our Nation.

Most people think of tobacco as a legal product, the decision to use it a very personal one. Politically, it has been difficult to exert control over a transaction that is both legal and an expression of self-determination. The concept of smoking as an adult choice has undermined not only efforts to regulate its production, but to some degree, has also diluted our healthcare system's response to it. Fewer than 70% of smokers are identified as such during visits to their physician, less than 30% are advised to quit, and only a hand full are offered pharmacologic intervention.

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