Fumo
Italy's Love Affair with the Cigarette
Carl Ipsen

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Appendix

2006 Expert Report

As described in the Introduction, this book derives from my employment as an expert witness for Shook, Hardy & Bacon in a tobacco case involving an Italian who migrated first to Canada and then the United States and died of lung cancer. Although I never testified in court, that work did lead to a report composed in consultation with the lawyers at that firm (and indeed in their Kansas City offices). This appendix presents that Expert Report (2004, with names, except my own, changed). The lawyers with whom I worked told me it was my material to do with as I pleased. In retrospect, it is an interesting document and bears comparison to the end result of my more involved historical research included in this book. If one restricts one’s research, as I was instructed to do, to “common knowledge of the health risks of cigarette smoking and the difficulty of quitting,” then it is not difficult to produce a document like this one that supports the argument that anyone who could read and paid some attention to the press ought to have known from the late 1950s that cigarettes caused lung cancer and that it was very difficult to quit smoking. What I hope I have done in the preceding chapters, among other things, is to ask other questions as well: Were there reasons for Italians to doubt the dire messages regarding smoking and health? Were there measures short of quitting, like switching to filtered or low-tar and nicotine cigarettes, that might significantly reduce the (possibly exaggerated) risks of smoking? The answer is of course that doubt and reassurance were part and parcel of the message promoted by tobacco multinationals and the Italian tobacco industry, and that message found a significant echo among important and influential Italian political and cultural figures. I suppose this document may also serve as something of a cautionary tale for other scholars attracted by the significant fees paid for work of this sort. I was told that the law firm received a summary judgment in its favor in the case.

Expert Report of Carl Ipsen, Ph.D. In Maria Rossi v. Lorillard Tobacco Company, et al.; United States District Court for the Northern District of Illinois

Qualifications

1. I am currently Associate Professor of History at Indiana University in Bloomington, Indiana. I received my Ph.D. in History from the University of California, Berkeley, in 1992. I have over fifteen years of teaching and research experience as a historian in the fields of European Studies and Modern Italian History. Prior to my tenure at Indiana University, I spent two years as a visiting professor at the Italian National Research Council’s Institute for Population Research in Rome. Since 1999, I have also consulted for the Psychoanalytic Institute for Social Research also in Rome. During my career, I have received a number of prestigious fellowships including a Fulbright Grant to study in Italy in 1990, an American Philosophical Society Grant in 1998 and a Mellon Prize to the American Academy in Rome in 1998–99. For the book I published in 1997, I received that year’s American Historical Association Marraro Prize for the best book on Italian history in any epoch. I have published a book and twenty journal articles, chapters, working papers and reviews on modern Italian history and serve on the editorial board of the Journal of Modern Italian Studies. My research has ranged from children in the 19th century to population policy under fascism to present day Italian society and immigration. I have translated several books from Italian to English. Since 1989, I have spent over six years in Italy, primarily conducting historical research. For additional information regarding my qualifications and a list of my publications, see the attached curriculum vitae [not included in this appendix].

Research

2. I have been asked to conduct historical research and analysis on the issue of common knowledge of the health risks of cigarette smoking and the difficulty of quitting in Italy focusing on the period from 1950–65. Further I have used sources of both national importance and of particular relevance to the environment in which Mr. Paolo Rossi lived. I have also been asked to evaluate the Italian newspaper and news magazine that Mr. Rossi read after moving to the United States. In researching this issue I have used the same historical methods that I have used in past projects, methods that are widely accepted in my field. Generally speaking it consists of formulating questions and then testing them against the historical evidence. In this case, for example, my first question consisted of: “Was there any discussion of cigarette smoking and associated health risks including the difficulty of quitting in the Italian sources I intended to consult?” I found that there was indeed an important discussion and so I explored further the nature of that discussion, what it revealed about contemporary scientific and popular opinion.

3. In doing this research, I examined a variety of materials consisting of both primary and secondary sources in Italian and English including items such as national and local newspapers and news magazines, government documents and legislation, literary and historic texts, proceedings of scientific and medical conferences, and scholarly works and articles. I have also reviewed fact depositions and interrogatory answers from this case in order to learn any details of Mr. Rossi’s life that might assist my research. The opinions that I give below are based on my education, training and experience as a professional historian as well as the research that I have conducted for this case. I may supplement this report with additional exhibits or demonstratives at a later date.

Sources

4. The fact depositions and interrogatory answers in this case state that Mr. Paolo Rossi was born in Formia, Italy (south of Rome) in 1930. He attended school in Formia and started working as a baker in Rome at approximately 20 years of age. During the next fifteen years, he worked at three different bakeries in Rome, one owned by his brother Pietro. Mr. Rossi emigrated from Italy to Canada in 1965 when he was thirty-five years old and in 1967 he left Canada and moved to Chicago, Illinois. After moving to Chicago, Mr. Rossi continued to read Italian newspapers and magazines including Settimana enigmistica, La Gazzetta dello Sport¸ Corriere della Sera and OGGI. Mr. Rossi also made regular extended trips to visit family in Rome. While living in Italy, Mr. Rossi first started smoking at about the age of fifteen. He initially rolled his own cigarettes; some time after the war he quit rolling his own and smoked Italian brands, including Nazionali. Mr. Rossi was reported to have smoked from two to three packs per day while still in Italy. Mrs. Rossi stated that in the 1990s he smoked from four to four and a half packs per day. In response to urging from family members and friends to quit smoking, Mr. Rossi typically reacted with the cornuto gesture, also known as the horned hand, an Italian folk practice intended to ward off evil. Finally, Mr. Rossi was a Roman Catholic.

5. Using these facts, I identified the primary source material for my research. Since the goal was to evaluate the state of common knowledge in Italy on the health risks of cigarette smoking and the difficulty of quitting from 1950–65, I selected several daily newspapers from this period, both national as well as specific to Rome, and several large-circulation national weeklies that would reflect both the information available to the Italian public on smoking and health and the reaction to that information. Italy’s leading newspaper at the time (reaching 500,000 copies per day by 1965) was Corriere della Sera, published in Milan, considered to be the New York Times of Italy. This also seemed a good choice since it was a newspaper that Mr. Rossi read after moving to Chicago. Next, since Mr. Rossi grew up near Rome and spent fifteen years of his working life in that city, Il Messaggero, the principal daily newspaper in Rome, was an important source. I have also looked at Paese Sera, another Roman paper from the period that was especially successful among working-class readers. I have also looked at some articles from Il Mattino, a leading daily from Naples, near Mr. Rossi’s birthplace of Formia. The leading weeklies of the period (reaching as high as c. 500,000 circulation and akin to LIFE and LOOK in the United States) were OGGI and EPOCA and I have looked at these as well. Again OGGI was a publication that Mr. Rossi read while he was living in Chicago. I have also reviewed Domenica del Corriere, the Sunday magazine of Corriere della Sera. The largest circulation weekly of all at the time (reaching eventually 1 million copies) was Famiglia Cristiana, a Catholic publication distributed free of charge in Churches and parochial offices. To confirm the importance of these publications for the years in question I have consulted secondary sources on the Italian press.

6. I have also done general bibliographic searches for material available in US libraries that relate to smoking in Italy. I have as a result come across literary sources dating back to the nineteenth century, proceedings from scientific conferences, smoking statistics, multi-country sociological studies of smoking and the like. Another avenue of research I have followed is that of parliamentary debate and legislation in Italy. Italian law forbade the sale of tobacco to minors under the age of fourteen in 1931; in 1934 that age was raised to 16. In 1957 Senator Sturzo proposed a ban on tobacco advertising; that proposal became law in 1962. For the period after 1957 then I have consulted relevant parliamentary documents, legislative proposals and debates.

Scientific opinion

7. The scientific debate about cigarette smoking and the associated hazards receives increasing coverage throughout the period studied. The Italian press is especially sensitive to the studies carried out in the United States and United Kingdom and these are regularly reported. Throughout the central period studied (1950–65) references to the dangers of cigarette smoking appear regularly in the daily papers and over the years the weeklies carry a number of major multi-page features on smoking. Although opinions were initially divided, in particular with regard to the link between cigarette smoking and lung cancer, as we move through the period a consensus emerges, both in reaction to those foreign studies and as a result of work done and authoritative opinions expressed in Italy, that cigarette smoking is dangerous. Although news items can be found after 1954 either downplaying the seriousness of the risk or even rejecting the smoking-lung cancer link, they are by that date a distinct minority and virtually disappear after 1962. Throughout the period the overall message from the Italian press was that cigarette smoking, especially heavy smoking, posed serious risks to health; from 1954 the primary risk identified was lung cancer.

8. As early as 1949–50 Italian physicians are reported in the press asserting the link between smoking and cancer. For example, in July 1949 Italy’s leading cancer expert, Pietro Rondoni, stated that “smoking has definite carcinogenic properties” [OGGI 7/14/49; 12/7/50]. More influential still than the work done in Italy are the studies carried out in the US and UK and regularly reported on in the press. Starting in 1951, for example, studies of Doll and Hill and studies published in JAMA about the links between lung cancer and smoking are reported in various Italian publications [OGGI 1/17/51; 12/20/51; EPOCA 12/5/51; Paese Sera 3/12/53]. Moreover, the importance of the issue is demonstrated by a cover story appearing in OGGI of that year with the following lines on the cover: “The nicotine of 40 cigarettes is enough to kill a person. The use of tobacco in Italy continues to increase and the harm inflicted on the human organism by smoking is a pressing issue (di urgente attualita) . . .” [OGGI 9/6/51]. In 1953 we find statements like that of an Italian physician who states that smoking is an important factor in the production of cancer and that for those over 45 the risk is 50 times greater for those who smoke 25 cigarettes per day as compared to non-smokers [OGGI 6/11/53]. At the same time a few authors and physicians argue that tobacco does not cause lung cancer and that there are other explanations for the statistical correlations discovered by that time; still others identify tobacco smoking as only a minor cause [OGGI 12/20/51; 1/15/53; Famiglia Cristiana 3/24/53].

9. While prior to 1954 the debate over the smoking-lung cancer link is fairly balanced, news coverage in that year (more precisely beginning in December 1953) signals a turning point as extensive reports on the studies of, among others, Wynder and Graham in the United States, reveal a growing consensus regarding the role of cigarette smoking in causing lung cancer [Corriere della Sera 12/14/53, 12/16/53, 2/13/54; Il Messaggero 2/13/54; Famiglia Cristiana 1/10/54; OGGI 8/12/54; Paese Sera 8/12/54, 10/13/54]. In Famiglia Cristiana Graham is quoted as saying: “there is something in cigarettes that causes cancer. We are no longer at the hypothesis phase; our experiments have demonstrated that the doubts have been overcome” [Famiglia Cristiana 1/10/54]. In another example, one journalist writes: “it is well known (risaputo) that smoking 10–15 cigarettes per day for 15–20 years is enough to cause, in one smoker in four, disturbances that will require hospitalization. The problem is serious, more serious than one would like to believe” [EPOCA 2/21/54]. Articles also appear with titles like “The danger starts at five cigarettes” [Famiglia Cristiana 3/7/54], “Tobacco and Cancer” [Famiglia Cristiana 3/21/54], or “Tobacco and Cigarettes Condemned” [Famiglia Cristiana 5/30/54]. Another piece refers to the “thunderbolt created by American scientists this past winter, repeated also by English physicians, who declared smoking the cause of lung cancer. It seems to us that we are being objective in stating that a link between smoking and lung cancer is undeniable” [OGGI 6/17/54].

10. One finds similar statements in 1955–56, and then another qualitative change in 1957 [see Paese Sera 5/18-19/56]. EPOCA in 1957, for example, publishes a two-part multi-page spread by an Italian physician on smoking and health which in its section on cancer states: “while it is true that one cannot with complete scientific rigor assert that smoking tobacco, and especially cigarettes, is the lone determinant cause of the increase in lung cancer over the past 20–30 years, nonetheless one cannot deny the existence of a link between cigarette smoking and cancer that is proportional to the total consumption of tobacco” (emphasis in original). The second part of the article includes interviews with 13 physicians, nearly all of whom are of the opinion that smoking was either a cause or the leading cause of lung cancer [EPOCA 3/3/57, 3/10/57]. That year also saw reporting of both the American Cancer Society Hammond and Horn study and the British Medical Research Council report, both confirming the link between smoking and lung cancer [Il Messaggero 6/28/57, 6/29/57; Corriere della Sera 6/5/57, 6/29/57; Paese Sera 3/26/57, 5/11/57].

11. In 1959 the Italian National Research Council itself initiated a study on the relationship between smoking and lung cancer [Corriere della Sera 1/25/59]. Nonetheless, reports from the US and UK continued to dominate coverage of the issue. On the occasion of another American Cancer Society study, one journalist remarks on the finding that 80% of lung cancer sufferers are smokers: “If the correlation does not conclusively demonstrate causality, it nonetheless makes it highly probable and no counter-proof has been offered” [Corriere della Sera 5/8/59]. An article reporting on the 18th International Congress of Pharmaceutical Sciences opens with the observation: “The link between smoking and lung tumors has been the object of numberless studies in the past ten years so it is not a new problem. Nor can we claim that the results of scientific research are unknown to the public” [Il Messaggero 8/22/59].

12. The years 1962–64 saw the publication of major governmental reports in both the US and the UK, laying to rest remaining doubts about the links between cigarette smoking and lung cancer. Already in 1961 Nobel-laureate Linus Pauling’s statements about the dangers of smoking were reported in Italy, namely his statement that smoking one pack of cigarettes a day probably shortens one’s life by 8 years, and two packs by 18 years [Corriere della Sera 3/22/61; Famiglia Cristiana 4/30/61]. The March 1962 British Royal College of Physicians report was described in these terms: “The conclusions can be summed up in a few words: tobacco smoking is harmful to health. It promotes the following diseases: lung cancer, tuberculosis, chronic bronchitis and coronary thrombosis. It has been noted that the frequency of these diseases is greater in smokers and that the frequency increases with the increasing number of cigarettes smoked” [Corriere della Sera 3/8/62; Il Messaggero 3/30/62]. According to another journalist at the time: “In other words . . . the link to the abuse of cigarettes . . . is no longer merely statistical but one of interdependence: cause and effect” [Corriere della Sera 3/15/62]. Other pieces identify nicotine as more dangerous than atomic radiation [Famiglia Cristiana 6/2/62] and include statements like “the link between smoking and lung cancer is now proven beyond a shadow of a doubt by the vast and well-documented statistical studies carried out in the United States and Great Britain” [Il Messaggero 6/11/62] and “There is no doubt that smoking is one of the major causes of lung cancer” [Famiglia Cristiana 6/24/62].

13. Smoking and Health, the 1964 report of the US Surgeon General, Luther Terry, which would frequently be referred to in Italy as the “famous” Terry Report, received broad coverage. The day after the report’s publication Corriere della Sera ran a piece entitled “There is a causal effect between cigarettes and tumors” and returned to the topic a few days later in another entitled “The American report against the insidiousness of cigarettes” [Corriere della Sera 1/16/64]. EPOCA devoted four and a half pages to the report in its January 26 issue. The physician writing that article recites the mortality findings from Smoking and Health including that the level of lung cancer for smokers is 10 times that of non-smokers and that the risk increases as a function of the number of cigarettes smoked and number of years as a smoker. He describes the conclusions from the first part of the study as “dramatic”: “Smoking increases general mortality and in particular for specific diseases. Far and away the most important of these is lung cancer” [EPOCA 1/26/64]. Referring to the report the next month Corriere della Sera wrote: “Following the famous ‘Report’ that arrived from the US with so much clamor, fear of the terrible consequences of smoking for the human body—a fear supported by authoritative declarations from practitioners of the medical sciences and statisticians—gripped everyone (ha preso un po’ tutti)” [Corriere della Sera 2/10/64]. In 1965 Terry issued a second report which was covered in the Italian press, including the observation that 18 million Americans had quit smoking since 1962 [Corriere della Sera 1/13/65; Il Messaggero 1/13/65]. Results of the Italian National Research Council study begun in 1959 are reported in March of 1965. The results are not so dramatic as the U.S. reports but nonetheless reveal a prevalence of smokers among lung cancer patients especially heavy smokers of 20, 40 or more cigarettes [Paese Sera 3/7/65].

Heavy Smoking

14. One risk factor that was consistently recognized from the beginning of the period studied was heavy smoking or the “abuse” of smoking. Generally speaking heavy smoking was described as more than 20–25 cigarettes per day (and very heavy as over 40). One also finds reference to the risks run by “inveterate” smokers, often understood to be those who have smoked more than 20 cigarettes per day for more than 20 years. As early as 1950, one journalist reports on an American study that found 98% of lung cancer patients to be smokers and notes that the hardest-hit group consists of heavy (“forti”) smokers (defined as more than 20 cigarettes per day for more than 20 years) [Corriere della Sera 7/9/50]; similar figures are reported in other articles in this period [Corriere della Sera 2/7/52; OGGI 9/4/52]. A 1953 article in OGGI reports that for those over 45 the risk of lung cancer is 50 times greater for those who smoke 25 cigarettes per day [OGGI 6/11/53]. Quantitative statements from 1954, an important year for smoking studies, include comments like the following: “Moreover, it is well known (risaputo) that smoking 10–15 cigarettes per day for 15–20 years is enough to cause, in one smoker in four, disturbances that will require hospitalization. The problem is serious, more serious than one would like to believe . . .” [EPOCA 2/21/54]; and a Famiglia Cristiana article from that year is entitled “The danger starts at 5 cigarettes” [Famiglia Cristiana 3/7/54]. In a full-page article entitled “Smoking and Cancer” on the work of the British researchers Doll and Hill, Famiglia Cristiana further reports that the risk is proportional to the amount smoked and that there is no indication of a threshold below which there is no risk [Famiglia Cristiana 6/17/56; see also Il Messaggero 8/6/63]. In an article from EPOCA in 1957 a physician offers this assessment of the risk of heavy smoking: “It is certain however that over 20 cigarettes per day (not to mention 50, 60 or even 120 in rare cases) lead to harm and danger (un danno si ordisce e un pericolo si prepara)” [EPOCA 3/10/57]. Paese Sera observes that one person in ten of those who smoke two packs or more a day will die of lung cancer as compared to one in 275 for non-smokers [Paese Sera 3/26/57]. Similarly, Il Messaggero writes “Must one stop smoking? Many doctors say that it is enough to not exaggerate. The danger may lie in the excessive abuse of what is a difficult habit to abandon” [Il Messaggero 2/19/57].

15. In August 1959 Il Messaggero reports on the 18th International Congress of Pharmaceutical Sciences that addressed current statistical research on the risk of lung cancer and found that the risk was a function of the number of cigarettes smoked: over 10 per day and the risk of lung cancer becomes statistically significant; the research further found that even 4–5 per day doubles the risk when compared to non-smokers [Il Messaggero 8/22/59]. Subsequently Linus Pauling’s estimate of the life shortening effects of cigarette smoking being tied to the number of packs smoked is also reported in Italy, namely that smoking a pack a day probably shortens one’s life by 8 years; two packs by 18 years [Corriere della Sera 3/22/61; Famiglia Cristiana 4/30/61].

16. By the 1960s some commentators are recommending very low levels of consumption in order to reduce or avoid the risks associated with smoking, 6–8 cigarettes per day for example [EPOCA 4/24/60]; Il Messaggero recommends no more than three cigarettes per day in 1962 [Il Messaggero 6/11/62], and OGGI suggests only one cigarette after each meal [OGGI 7/12/62].

17. Following the Surgeon General’s or “Terry” Report in 1964, Corriere della Sera reports that heavy smokers have mortality levels that are 90–120% greater than those of non-smokers, and similar statistics can also be found in earlier publications [Corriere della Sera 1/12/64; see also OGGI 12/23/54; OGGI 12/27/56].

18. Taken as a whole, throughout the period studied heavy smoking is identified as posing a serious danger to health.

Popular opinion

19. Prior to 1950 there is evidence of an accepted wisdom regarding the dangers of smoking. Going back to the 19th century one encounters statements like “All smokers know that smoking is bad for us” [Svevo 1890] and even poetic references like that of Roman poet G. G. Belli in the 1830s to the “death one pays to the tobacconist” [Belli 1975, p. 384, also cited on Famiglia Cristiana 7/13/58; see also Belli 1962, p. 129; Belli 1975, p. 356]. And according to an Italian proverb life can be shortened by three fundamental vices: smoking, alcohol, and women [Famiglia Cristiana 12/30/62]. Smoking in Italy has also long been referred to as a vice and a destroyer of health, something that is “bad for you.” [Svevo 1892–98; Famiglia Cristiana 3/1/64]. Beginning in the 1950s, popular opinion about the dangers of smoking came to be more and more influenced by scientific opinions as published in the popular press.

20. Evaluation of popular opinion necessarily entails the use of both direct and indirect evidence. Throughout the period studied we find references to what people knew about the dangers of smoking (e.g., from journalists, government officials, physicians, and scientists), market indicators of consumer concern about the dangers of smoking (including increased use of filters and smoking cures), as well as statements from the public revealing popular perceptions (e.g., letters to the editor). That evidence confirms earlier beliefs about the dangers of smoking and a growing widespread awareness about the specific risks of lung cancer, despite the rare reference to folk beliefs about the antiseptic properties of tobacco.

21. As early as 1953 lung cancer is being referred to as “smokers’ cancer” [OGGI 6/11/53; EPOCA 7/22/62]. In 1954 an important spread in EPOCA includes comments like the following: “Everyone knows that nicotine is a poison that attacks the cells in general . . .” and “The smoker knows perfectly well that smoking is unhealthy . . .” [EPOCA 1/21/54]. And in 1957 a Corriere della Sera journalist comments: “All cigarettes, as all smokers know deep in their heart, are harmful” [7/1–2/57]. That year saw initiation of the parliamentary debate over the law to ban tobacco advertising. In that context, the government’s High Commissioner for Health (Senator Mott) referred to “public opinion, which however is fully aware of the dangers associated with the abuse of tobacco” [Il Messaggero 10/3/57]. Several years later another minister commenting on a price increase on cigarettes noted: “If some decide to smoke less, all the better since the dangers of tobacco are known to all” [Il Messaggero 11/28/62].

22. As knowledge and concern about smoking and lung cancer grew, the period after 1957 saw increased interest in both the use of cigarette filters and ways to quit smoking. In a 1959 health quiz, for example, in Famiglia Cristiana, one question asks: “Have you stopped smoking/cut down/continued since there has been so much talk about lung cancer?” [9/27/59]. And in a piece on a therapy to quit smoking the author comments: “With regard to tobacco-related illnesses public opinion focuses primarily on (si appassiona soprattutto di) the link between lung cancer and smoking that most researchers today take to be certain” (EPOCA 10/18/59). Both comments are signs that the lung cancer debate has penetrated public opinion. In addition to ads for cigarette holders with filters and methods to quit, we also see new advertising for and discussion of health exams specifically for smokers and the creation of clinics to aid in quitting, other indices of heightened concern [EPOCA 2/6/60, 10/30/60; Corriere della Sera 3/2/64]. Also in 1962 it is reported that filter use has increased by over 50% in the past year [Paese Sera 3/7/62; see also OGGI 7/27/61]. Moreover advertisements for filter cigarette holders become ever more dramatic by 1963 making statements such as: “Especially over age 40 every cigarette you smoke is an attempt on your life” [Corriere della Sera 7/14/63].

23. Public concern about cigarette smoking also led to the creation of a National Anti-Smoking League that advocated the ban on tobacco advertising and to that end met with the Italian Health Minister in 1960 [Corriere della Sera 1/23/60]. The year 1961 saw a National Convention for the Battle Against Smoking that sought to prevent sales of cigarettes to persons under the age of 16 and enforce a ban against smoking in movie theaters [OGGI 5/4/61; see also Il Messaggero 3/27/64].

24. Smoking concerns found their way into popular culture. One piece on smoking opens with a reference to a comic who remarked: “All the statistics and studies on cigarettes are so frightening that I have decided not to read them any more” [Famiglia Cristiana 4/1/62]. Quitting smoking is also the topic of a humorous fictional piece written in Roman dialect and appearing in Il Messaggero in 1962. It depicts an argument between office workers, one who has quit and one who continues to smoke. In response to repeated exhortations to quit (as the non-smoker has done), the smoker responds: “You quit two years ago and since that moment you haven’t let me smoke a cigarette in peace! Every time you tell me that my lungs will become black and I think of cancer! And you tell me that cigarettes are expensive and I think of my debts! And you tell me that you feel good and I feel worse than I normally would! May you die murdered, for that, now I’ve reached the point where I smoke out of stubbornness [“E va a mori’ ammazzato, a co’, mo’ so’ arivato a fuma’ pe’ tigna,”], since if I were to stop smoking that would give you satisfaction and that I don’t want to give you!” [4/20/62]. In order to be effective, these pieces require that the reader be knowledgeable about the dangers of smoking.

25. Further evidence that the dangers of smoking were known at a popular level is found in letters to the editor. For example, one writer notes in Famiglia Cristiana in 1962: “Everyone in fact is worried about the pitiful end that awaits many obstinate smokers who don’t know how to say no to the notorious cigarette, cause of so much harm” [Famiglia Cristiana 7/15/62]. Another letter to that same publication observes: “No-one can ignore that while it has always been the case that smoking ‘is never good for one (non fa mai bene),’ today we have the added knowledge that it has serious connections with illnesses like cancer” [Famiglia Cristiana 3/1/64].

26. Following the “famous” Terry Report, a Corriere della Sera journalist notes that fear has gripped everyone (ha preso un po’ tutti) and that more and more smokers are resolving to quit [Corriere della Sera 2/10/64]. A Domenica del Corriere article on the Terry Report carried the headline: “We Will Help You Escape from the Prison of Smoking—the 150,000 Most Terrible Words of the Century: Terror in America” [1/26/64]. Il Messaggero reports that cigarette sales have fallen in some areas of Italy by as much as 20% [Il Messaggero 3/27/64; see also Paese Sera 1/17/64]. These articles reflect the considerable impact of the U.S. Surgeon General’s Report on Italian popular opinion.

Difficulty of Quitting

27. Perceptions about how difficult it is to quit cigarette smoking change little throughout the period studied. What one does find is increased interest in methods for quitting and analyses of why it is that people smoke in spite of knowledge about the associated health risks. Occasionally smoking is compared to addictive substances like alcohol and hard drugs (stupefacenti). More often researchers focus on the psychological satisfaction derived from smoking. All agree that it is difficult to quit [Il Messaggero 6/14/53; OGGI 3/8/62, 3/22/62; EPOCA 10/9/55, 5/17/64].

28. From as early as the nineteenth century, one can find discussions of the difficulty of quitting cigarette smoking. Early in the period studied here one encounters statements like the following: “In the life of many of us there is an adorable, intoxicating, and subtly poisonous nemesis that dominates us inexorably . . . the insidious enemy, the cigarette . . . more than 16 million feeble individuals who, faced with the temptation of that ardent seducer that is tobacco, cannot find the force to resist” [Il Messaggero 8/2/50], or: “For the smoker, smoking is not so much a pleasure as a necessity . . . a necessity . . . of a psychological order” [OGGI 9/20/51]. And in an Il Messaggero medical column on the “slaves of alcohol and drugs,” tobacco is identified as “another toxin that generates irresistible need” [Il Messaggero 6/27/52]. Various statements in advertisements attest to the fact that people were trying to quit smoking and having a hard time doing it. A 1952 mineral water ad, for example, states: “Many times you have tried to quit cigarettes . . . and yet you feel you can’t do without them” [Corriere della Sera 6/9–10/52].

29. As early as 1959 one finds ads for methods to quit smoking and articles about the development in Italy and abroad of medical and clinical treatments for quitting carrying titles like “Ten days are enough to quit smoking” [Famiglia Cristiana 5/3/59; EPOCA 6/7/59; 9/27/59; 10/18/59]. The next year Famiglia Cristiana ran a full-page article entitled “How to quit smoking” that opens: “Who can say that they haven’t tried at least once in their life to free themselves from the vice of smoking. Calling up all your willpower, you probably endured the deprivation for only a few days . . . And yes, your doctor even told you that it was important for your health to quit” [Famiglia Cristiana 5/8/60].

30. One method for quitting involved the use of a nicotine substitute called lobelina. According to a physician writing in Famiglia Cristiana, simple persuasion was unlikely to be successful and so there was a need for another approach “keeping in mind that a large proportion of smokers would like at some point to quit the use or abuse of cigarettes.” Attempts to quit, he claims, usually fail because willpower is insufficient [Famiglia Cristiana 6/24/62; see also Il Messaggero 30.vi.62]. In an article reporting on a conference held at the Centro Studi Biologici del Sovrano Ordine di Malta (Rome) in 1962 on “Cancer and Smoking,” Dr. Giorgio Alberto Chiurco described lobelina as a withdrawal treatment (trattamento divezzante) from the addiction (disassuefazione) of smoking. Lobelina, he described, in contrast to nicotine, does not create addiction (assuefazione) and so can be used by smokers to wean themselves (divezzare) from smoking [Il Messaggero 6/30/62]. Elsewhere one finds reference to a one-month lobelina treatment for quitting [OGGI 7/12/62].

Cultural Aspects

31. Throughout the period studied one encounters evidence of a degree of resistance on the part of Italian smokers to the increasingly alarming revelations about the health dangers of smoking. As noted above, Famiglia Cristiana reported on the comment of a comic: “all the statistics and studies about cigarettes are so frightening that I have decided not to read them any more” [Famiglia Cristiana 4/1/62]. Other comments reinforce the impression that a segment of the Italian smoking population preferred to ignore the risks [Famiglia Cristiana 4/1/62]. In a 1954 piece on “Tobacco and Cancer” that same publication remarked that “certainly the best advice to give would be to quit smoking, but that advice is sure to fall on deaf ears because we know that when it comes to vices people prefer to ignore the possible consequences rather than to abandon those vices” [Famiglia Cristiana 3/21/54]. In 1957 a journalist for Il Messaggero introduced an article on smoking with the following: “In the interest of improving the health of humanity we are obliged to discuss a topic that will be uncongenial to many inveterate smokers who would rather not hear about dangerous and sometimes lethal diseases in order that they not have to give up smoking an exaggerated and unrestrained number of cigarettes; cigarettes that have been an object of study by famous scientists now for more than 20 years” [Il Messaggero 2/19/57]. In that same year Senator Mott, the High Commissioner for Health, in Parliament described public opinion as being “fully aware of the dangers associated with the abuse of tobacco.” Nonetheless, he continued, “the behavior of many smokers does not reflect that awareness as they seem to be indifferent to any type of intervention or coercion” [Il Messaggero 10/3/57].

32. In 1964, following the Terry Report, Paese Sera carried out an informal survey of Roman tobacconists, the majority of whom concluded “smokers will not quit smoking even when faced with the threat of serious illness” [Paese Sera 1/17/64]. Similarly a journalist in Milan wrote that “those who worry least about the terrible report . . . are the smokers themselves: very few have given up the ‘vice’” [Corriere della Sera 9/24/64].

33. The thrust of these observations is that some Italian smokers chose to ignore the information available on the health risks of cigarette smoking. It is also clear that contemporary observers thought that they were informed of these risks. Some attempted to explain this behavior. In one example the Corriere della Sera journalist who wrote most about smoking equated smoking to a game and suggested that one of the attractions of smoking was the risk associated with it.

34. Use of the cornuto gesture can be understood as an expression of the sorts of attitudes described above; it is an Italian folk practice used to ward off evil. In this case the use of that gesture by Mr. Rossi in the context of information on smoking and health can fairly be construed as intended to ward off a known evil.

Opinions

35. I expect to offer the following opinions at the trial of this case. They are based on my education, training and experience as a professional historian, including over fifteen years devoted to the study of 19th and 20th century Italian society, culture and politics, as well as on the research carried out on this specific issue, some of which is summarized above.

(a) Since at least the 19th century a body of information from a variety of sources was available to the Italian public about the health risks of tobacco use, including the difficulty of quitting. Popular wisdom and folk sayings indicate an early awareness of the dangers of tobacco. More specifically, during the period 1950–65, the issue of the health risks of cigarette smoking, including the risk of lung cancer and the difficulty of quitting, received considerable coverage in national, regional, and local newspapers and magazines, including those in the city of Rome where Mr. Paolo Rossi lived at that time. As early as 1953, one can find lung cancer described as “smokers’ cancer.” Other references from popular culture and to the state of public knowledge show that coverage on smoking and health had reached the public. Indeed, awareness of the health risks of cigarette smoking, including the risk of lung cancer and the difficulty of quitting, was sufficiently widespread and prevalent as to be considered part of the common knowledge of Italian society at the time.

(b) During the period 1950–65, the ordinary consumer living in Italy, including the city of Rome where Mr. Paolo Rossi lived at that time, having the knowledge available to all Italian consumers, would have been aware of the health risks of cigarette smoking, including the risk of lung cancer and the difficulty of quitting.

(c) Information on the health risks of cigarette smoking in Corriere della Sera and OGGI (an Italian language newspaper and magazine that Mr. Paolo Rossi read while living in Chicago, Illinois, after 1967) would have served to remind and reinforce awareness of the health risks of cigarette smoking, including the risk of lung cancer and the difficulty of quitting.

(d) Information on the greatly increased risk of lung cancer from heavy smoking (defined as consuming over a pack of cigarettes per day) was repeatedly mentioned in multiple sources of the print media available to the ordinary consumer living in Italy, including Rome, from as early as 1953.

(e) Public awareness in Italy of cigarette smoking as a vizio or bad habit that is difficult to quit was reinforced in the media by articles and advertisements promoting smoking cessation programs, clinics, medications or products to aid quitting.

(f) Laws such as those prohibiting the sale of cigarettes to minors, the 1962 cigarette advertising ban and other government sanctions against smoking, served to remind and reinforce Italian public awareness of the health risks of cigarette smoking, including the risk of lung cancer.

(g) The attitude of the Roman Catholic Church and Roman Catholic publications would have served to remind and reinforce public awareness of the health risks of cigarette smoking, including the risk of lung cancer and the difficulty of quitting, for a Roman Catholic living in Italy from 1950–65.

(h) Examples from sworn testimony taken in this case demonstrate that Mr. Paolo Rossi had general knowledge of the health risks of cigarette smoking, including the risk of lung cancer and the difficulty of quitting.

(i) As necessary, I may express opinions based on my expertise as to statements of experts offered by plaintiff in this case.

(j) I hold these opinions with a reasonable degree of professional and historical certainty based on my experience, education, training and research.

36. My research on this matter is ongoing. A list of materials that I have considered and/or relied on for my opinions in this case is attached and is incorporated into this expert report [not included in this appendix]. My expert report gives some representative examples of materials found on my reliance list. Any of my reliance materials or reliance documents produced by plaintiff’s experts may be used as exhibits. I may use demonstrative exhibits that may consist of full or partial blow ups or summaries of individual documents or groups of documents, summaries of key points I may provide on direct examination, and/or summaries of key points, documents or groups of documents used to rebut testimony from plaintiff’s witnesses.

37. I am compensated at the rate of $200 per hour for consulting services and for testimony at deposition or trial. I have not previously provided expert testimony regarding this issue at deposition or trial.

I declare under penalty of perjury that the foregoing is true and correct.

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Carl Ipsen, Ph.D.Date