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 lifespan—and if people knew it—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.
While such bogus “debates” continued in medical and policy circles, the tone of cigarette advertising, as Brandt shows, changed once again. In 1953, tobacco executives met privately in New York’s Plaza Hotel and collectively decided to stop claiming that one brand was healthier than another, since this would likely generate discussion of the risks of smoking in general. Instead, the companies changed the subject from health back to fun. The doctors were phased out and the ads returned to the earlier themes of fantasy, rebellion, and freedom. One frank advertising executive, whom Brandt quotes, put it this way: “We’re not trying to sell cigarettes, we’re selling a way of life, an exclusive club which has its own song, its own passwords, and a membership of millions.” The advertiser’s task was to “create an image of the swinging people who smoke your brand. We’re saying, ‘Look attractive, feel at ease, smoke Burpos with that filter of straw or that carcinogenic taste, and you’ll never again be lonely.'”
As a child in the 1960s, I too dreamed of going to “Marlboro Country” and this was the brand I started smoking when I was twelve. The glamorous “You’ve come a long way, baby” Virginia Slims women undoubtedly had a similar effect on others. So did the cheerful “Alive with pleasure” couples in the ads for Salem. When the cartoon character Joe Camel made his debut in the late 1980s, teen smoking rates, which had been falling for years, rose.
Today, across the industrialized world, cigarette advertising is increasingly restricted and bans on smoking in public places are now in force in several US states and in Great Britain and Ireland. As a result, smoking rates are declining rapidly. But how many lives would have been saved had the government stood up to the industry’s manipulative tactics and issued a loud and clear warning about smoking fifty-seven years ago, when the definitive epidemiological studies were first published? This can never be known, but we do know that some antismoking campaigns work. For four years in the late 1960s, the Federal Trade Commission required that antismoking ads be run on television at regular intervals in order to counterbalance cigarette ads. During this period the population increased by 6.6 percent, but cigarette sales did not increase and even declined slightly. Recognizing this trend, the cigarette companies volunteered to take their ads off the air. The FCC mandate had been established under the “fairness” doctrine, requiring broadcasters to give equal time to both sides of controversial issues. So when the cigarette ads stopped, the antismoking ads ceased as well, as did the decline in smoking rates. Members of Congress, beholden to their tobacco industry benefactors, had no incentive to order the antismoking ads to continue and broadcasters were thrilled to be released from the obligation to give free airtime to the cause.
In 1990, the General Agreement on Tariffs and Trade forced Thailand to allow imports of American cigarette brands. The Thai government, concerned that a flood of these “glamorous” imports would lead to an increase in cigarette consumption, launched a vigorous antismoking campaign which resulted in a 20 percent decline in the smoking rate. In just two years between 2000 and 2002, “Truth,” a Florida antismoking campaign that accused the tobacco companies of manipulating the young, resulted in a 38 percent drop in the teen smoking rate. In one “Truth” campaign television ad, a tobacco executive, confronted by a group of teenagers, sings the following song:
Just stay focused on the positive!
Every eight seconds a smoker dies—it’s becoming routine.
But let’s stay focused on the positive!
Those seven seconds in between.
When we consider how addictive cigarettes are, these successes are remarkable. Today, smoking rates are down by 50 percent from the 1960s and some 40 million people have quit since 1964. Most importantly, lung cancer death rates have finally peaked as well. It seems clear that changes in behavior are possible when people have the right warnings and information. The horror is that until recently most Americans had neither; nor do billions of people in the rest of the world where smoking rates continue to rise and where large American tobacco companies continue to do a brisk business.
By the 1980s, cigarettes were killing some 400,000 Americans a year, and it was becoming evident that the tobacco industry had something to answer for. A series of court battles followed. Brandt himself eventually agreed to testify as an expert witness against the tobacco companies and his account of the back-and-forth arguments is dynamic and revealing.
The industry’s principal defense was that because of the warning labels—limp as they were—and the general awareness that smoking could be dangerous, the plaintiffs must have been well informed about the risks, and thus the companies could not be held responsible for someone’s individual choice. In any case, they argued, rare cases of lung cancer occur in non-smokers, so it was impossible to prove that a particular case was necessarily caused by smoking and would not have occurred anyway.
During a series of major tobacco trials in the 1980s, a number of interesting findings came to light. In 1985 a New Jersey judge ruled that the public has a “right to know what the tobacco companies knew and know about the risks of cigarette smoking and what it did or did not do with regard to that knowledge.” The industry, it turned out, had for years suppressed its own research linking cigarettes and cancer; in the 1970s, industry-funded researchers had developed a form of tobacco that was in fact safer, but it was never marketed because industry lawyers apparently feared that doing so would amount to admitting guilt for marketing ordinary tobacco in the past. Some of the cigarette companies, moreover, aware that low-tar cigarettes contained less nicotine and were thus less addictive, deliberately added extra nicotine to their “Light” brands.
As a result of these and other revelations, a few plaintiffs actually won their cases, although the awards they received were small. For example, the estate of the plaintiff in the New Jersey case, a woman named Rose Cipollone who died of lung cancer, was awarded $400,000 in damages—an amount that would have had little impact on the billion-dollar industry. Meanwhile, many states, faced with the skyrocketing Medicare costs of dealing with smoking-related diseases, also sued the companies. Wishing to staunch the flow of lawsuits, the industry scrambled to negotiate a settlement with the states that would limit both their costs and further suits. The task of working out the details of the settlement fell to Congress, and in the Master Settlement Agreement of 1998, the industry agreed to pay $246 billion to state governments and accept stronger regulations on advertising in exchange for immunity from most future lawsuits.
An earlier version of the tobacco settlement bill, sponsored by Senator John McCain, would have required an increase in tobacco taxes, FDA regulation of nicotine, and penalties to the industry if teen smoking rates did not fall by a certain percentage in the coming years. At first Newt Gingrich, then House speaker, supported the bill, but when the tobacco companies reminded him that they contributed three times more to the Republicans than to the Democrats, he changed his position and helped negotiate the much-watered-down bill that eventually passed. The companies ensured that in the final agreement, states were not required to spend their tobacco windfall on either medical care for tobacco victims or antismoking campaigns. Thus the states came to rely on the money for ordinary budgetary expenditures, giving the tobacco industry influence over future tobacco-related legislation, including taxes, and funding for cessation programs among them. The bill also contained only the weakest provisions to limit marketing to children and teenagers, such as bans on large billboards but not small ones. Since it came into force, the companies have invested more heavily than ever in advertising that targets young people, and have even developed chocolate- and raspberry-flavored brands.
Even so, during the Clinton years, the national teen smoking rate dropped by 30 percent, perhaps as a result of publicity from the trials and rising cigarette prices. Teen marijuana use doubled during this period, so this was not part of a general trend away from rebellious adolescent behavior.
What are the companies up to now? In his passionate new book High Society: How Substance Abuse Ravages America and What to Do About It,2 former secretary of health and human services Joseph Califano brings us up to date. Califano’s book is mainly about the dangers that illegal drugs pose to the nation, but he is also a longstanding foe of the tobacco companies and his account of their recent activities suggests that little has changed.
According to Califano, cigarette taxes are among the most powerful weapons against the industry. When New York’s Mayor Michael Bloomberg increased cigarette taxes in 2002, the smoking rate fell by 11 percent, and by 36 percent among teens. Cigarette companies now spend billions fighting tax increases by providing discounts, free samples, and coupons, all meant to attract teenagers and the poor, the two groups of consumers who care most about prices. The companies also continue to contribute to the political campaigns of candidates willing to vote down new cigarette taxes3 ; according to Califano, they have even fostered cross-border smuggling rackets in Canada and Europe, in order to persuade governments to reduce cigarette taxes, which they claim provide opportunities for “organized crime.” The irony of this does not escape Califano.
The industry is particularly eager to attract “replacement smokers,” a euphemism for teenagers, who are meant to “replace” dead smokers or those who quit. In the future, most of these teenagers will come from developing countries, where some 82 percent of all smokers already live, and where regulations on advertising and promotion are generally weak. Across much of Asia, the logos of American cigarette companies can be seen on clothing, rucksacks, and other accessories, and at sports events, night clubs, and discos and on television. As always, the companies go after those most vulnerable to manipulation by associating their products with a glamorous Western lifestyle and women’s emancipation.
The genius of the tobacco companies has been to exploit not just the purchasing habits of the young and the addictive centers of their brains, but their dreams for a better life and their constant search through fantasy for meaning and identity. When my mother was fourteen, she and her friend Naomi would buy cigarettes from a local shop in Boston, pretending they were for Naomi’s aunt. Then they’d go up to Naomi’s attic and play “movie star.”
One of the many cruelties of smoking-related diseases is the sense of shame that some victims feel, as if they deserved their fate. Few realize just how heartlessly they have been lied to. When my mother got sick, she said to one of her doctors, “I wish I hadn’t smoked.” The doctor, who had long experience with lung cancer, replied, “Well, that’s who you were.”
July 19, 2007
See Jean-Pierre Changeux and Stuart J. Edelstein, Nicotinic Acetylcholine Receptors (Odile Jacob, 2005). ↩
Public Affairs, 2007. ↩
A list of past and present members of Congress and state government officials who have received tobacco industry money can be found at: tobaccofreeaction.org/contributions. ↩