Since cigarette smoking is so deadly, and this is so well known, why do more than one in five American adults still do it? Why did my mother, a former editor of this magazine who died of lung cancer last year, do it? Why did I do it as a teenager?
In The Cigarette Century: The Rise, Fall and Deadly Persistence of the Product that Defined America, Allan Brandt, a medical historian at Harvard, reminds us of the answers to these questions. The common explanation is that people start smoking when they are young as a result of peer pressure, or curiosity, or a rebellious desire to seem mature and sophisticated. Repeated exposure to nicotine distorts the brain system responsible for cognition, awareness, and a sense of well-being, so that the smoker comes to crave the chemical.1 Once hooked, people naturally become fatalistic about the risks, or deny them. Smoking rates are especially high among the poor and the mentally ill, perhaps because they can afford few other consolations and because the mild antidepressant effects of smoking make quitting especially difficult.
But there is another reason why so many people smoke, and this is the central theme of Brandt’s detailed, illuminating book. For most of the twentieth century, few people were aware of how dangerous smoking really was; they were lulled into a false sense of security by a deliberate industry campaign to promote the falsehood that scientists had failed to prove that there was a strong, consistent link between smoking and cancer. For decades, the companies managed to fool not only the public but also the medical community, Congress, the courts, and the press.
Throughout the second half of the twentieth century, practically everyone knew that smoking was risky; what they didn’t know is that it is extremely risky. Smokers who consume more than twenty-five cigarettes a day are fifty times more likely to contract cancer than nonsmokers. According to the American Cancer Society, “about half of all Americans who continue to smoke will die because of the habit.” Diseases related to tobacco account for 20 percent of all deaths in the US each year, and they are now the second leading cause of death in the world.
We all willingly accept some risks, whether in skiing, skydiving, or other forms of recreation, or simply by driving in the rain. However, if half of all skiers died prematurely, losing roughly a third of their natural lifespanâ€”and if people knew itâ€”skiing would be much less popular than it is. Smoking really is that dangerous, and for decades the companies that sold cigarettes knew it. But most ordinary people did not.
Beginning in the 1980s, a number of former smokers suffering from cancer sued the cigarette companies for having misled them about just how dangerous smoking was. For a corporation to withhold accurate health information is not only against the law, it is also a violation of human rights, according to the 1948 Universal Declaration of Human Rights. In a world in which health and human rights really mattered, and were not so often secondary to economic and political concerns, the tobacco companies and their executives would have faced ruin. But the tobacco companies won many of their cases, and even when they lost, the resulting settlements forced them to change their message but not their devious tactics.
The industry’s main legal defense was based on an illogical set of assumptions: the risks of smoking were “unproven,” they claimed, but consumers had been sufficiently warned about whatever risks existed, and thus the companies were not responsible for them. Some juries were actually convinced by these arguments.
But if the companies sometimes seemed to be getting away with murder in the courts, they don’t get away with it in Brandt’s book, which painstakingly documents this depressing sideshow in American corporate history. The first mass-produced cigarettes appeared on the market in the 1880s, but cigarette smoking in America really took off after World War I. The nation was changing rapidly, from small enclaves of often ethnically concentrated communities with largely local economies to a mass consumer culture that was increasingly fed, clothed, transported, and entertained by national corporations. Assembly-line production enabled these companies to produce goods ever more cheaply, and brand advertising vastly expanded their markets.
At the same time, America’s moral climate was also changing. People were becoming increasingly secular and individualistic and Victorian moral attitudes were fading. Smoking, once considered a vulgar, degenerate habit, came to symbolize the new liberated, optimistic attitudes of the 1920s. In those days, the themes of cigarette advertising were gay, insouciant, spirited. The Chesterfield brand associated its product with sex, using ads depicting a couple languishing under a full moon. “Blow some my way,” the woman says to the man, who is smoking a cigarette. Philip Morris’s early brands “Oxford and Cambridge Blues” aimed for the sophisticated smoker while Lucky Strikes capitalized on the rise of feminist sentiment with playfully rebellious slogans such as “Women! Light another torch of freedom! Fight another sex taboo!”
But in the 1930s, as suspicions about the damaging health effects of cancer began to grow, many ads adopted a more sober, reassuring, and “scientific” tone in which doctors featured heavily. In one ad for Camels, reproduced in Brandt’s book, a handsome young physician wearing a head-mirror advises, “Give your throat a vacation.” In another, an older doctor with a warm smile and a pince-nez holds a pack of Lucky Strikes and informs us that exactly “20,679 Physicians say ‘Luckies are less irritating.’”
In 1950, the link between smoking and lung cancer was confirmed by epidemiological studies led by Richard Doll and Austen Bradford Hill in England and Ernst Wynder and Evarts Graham in the US. By then, the incidence of lung cancer in the US had tripled in just thirty years and the new studies were widely publicized, particularly by an article in Reader’s Digest called “Cancer by the Carton.”
Nevertheless, smoking rates rose 20 percent during the 1950s, and rose further still in the following decade. How did this happen? The question bears on one of the great mysteries of public health. Why don’t people listen to health warnings? What are the obstacles to changing behavior? What goes on in the mind of a smoker or a teenager picking up the habit for the first time? Volumes of research on how to promote health and change behavior have been devoted to this issue and the answers are much debated; but in the case of smoking, it seems that the cigarette manufacturers colluded in a highly successful campaign of half-truths and outright falsehoods intended to cast doubt on the lung cancer studies and other research findings. This gave many people the impression that the habit could not be all that dangerous if there was so much “controversy” about it. But the risks associated with smoking were not small. They were huge, and there should have been no controversy.
In response to the studies of Doll and Hill and Wynder and Graham, the tobacco companies issued in 1953 a “Frank Statement to Cigarette Smokers” which was published in newspapers across the country. The statement claimed that cigarettes were “not injurious to health,” but that more research into the question was needed. At the same time, the industry endowed a new Tobacco Industry Research Committee (TIRC) whose purpose was to create the impression that the industry took the health issues seriously. In fact, the TIRC was mainly a public relations outfit. It funded scientists willing to question the evidence linking smoking and cancer and publicized their “findings.” The scientists used their grants to search for causes of cancer other than cigarettes, such as genetics and the environment, and they searched for beneficial effects of smoking. When some industry-funded scientists found evidence that cigarette smoke was loaded with carcinogens, their results were suppressed. None of these scientists complained, and it was only in the 1980s that a small number of tobacco industry “whistle-blowers” came forward. Meanwhile, for decades, the TIRC continued to issue such statements as: “There is no conclusive scientific proof of a link between smoking and cancer.”
In 1957, seven years after the publication of Doll and Hill’s and Wynder and Graham’s studies, the scientific director of the TIRC wrote,
The problem of causation of any type of cancer is complex and difficult to analyze…. Despite all the attention given to smoking as an accused factor in human lung cancer, no one has established that cigarette smoke, or any one of its known constituents, is cancer-causing to man.
What the scientific director neglected to mention was that the constituents of cigarette smoke had been shown to be highly carcinogenic in mice, and that conducting a similar experiment on human beings, by, for example, applying cigarette tar directly to a person’s lungs would be unethical and impossible.
Brandt cites numerous internal industry documents showing that its executives knew exactly what they were doing. The companies benefited from a general skepticism on the part of the public concerning statistics and from the antipathy of doctors toward the science of epidemiology, a relatively new discipline. At the time, few doctors were trained in either subject, and some may have sensed that the epidemiologists posed a threat to their position as the premier authorities on human health. In the 1960s, the American Medical Association, which at one time accepted a $15 million research grant from the TIRC, maintained that the links between smoking and cancer were “unproven.” The US Public Health Service, staffed by many doctors, took a similar position. Even the editors of the New England Journal of Medicine and the Journal of the American Medical Association were persuaded that there was a “controversy.” And, always on the lookout for a “balanced” story, journalists and editors, including Edward R. Murrow, a chain-smoker who died of lung cancer at fifty-seven, also collaborated in the farce that the “controversy” about smoking and cancer was real.
In 1964, the US surgeon general issued a report confirming the links between smoking and disease. This finding should have led to government regulation of the industry. The following year, Congress passed the Cigarette Labeling Act which mandated warning labels on cigarette packages. When the tobacco companies lobbied to have the label watered down to read “Caution: Cigarette Smoking May Be Hazardous to Your Health” (emphasis added), Congress, many of whose members received generous donations from tobacco companies, agreed. The warnings had little effect on consumption, perhaps partly because the phrasing helped keep alive the canard that there was some serious question about the health risks of smoking.
A growing number of brands now came in filtered versions. Filters are largely cosmetic and don’t reduce the risks of smoking, but Brandt tells us that roughly half of all smokers believed they did. “Light” cigarettes began to appear on the market somewhat later, and were promoted as a “milder” alternative to ordinary cigarettes. While the industry itself never claimed that they were “safer,” an industry-funded scientist writing in the Journal of the American Medical Association stated that some low-tar brands were “below the critical threshold of risk of disease.” There was scant evidence for this claim at the time, and we now know it’s not true.
See Jean-Pierre Changeux and Stuart J. Edelstein, Nicotinic Acetylcholine Receptors (Odile Jacob, 2005).↩
See Jean-Pierre Changeux and Stuart J. Edelstein, Nicotinic Acetylcholine Receptors (Odile Jacob, 2005).↩