The Cigarette Century

by Allan Brandt

  According to Wakeham, this inconsistency cost the industry credibility in all its public pronouncements. “I am, therefore, advocating emphasis on the positive aspects of smoking both in research and in public relations,” he explained.

  Nobody believes we are interested in the truth on this subject; and the fact that a multibillion dollar industry has put up 30 million dollars for this over a ten-year period cannot be impressive to a public which at the same time is told we spend upwards of 300 million dollars in one year on advertising.78

  In December 1970, Wakeham wrote to Philip Morris President Joseph Cullman III, suggesting that the industry change its tack. “It might be appropriate to comment on the question: what kind of CTR program is best for the industry?” Wakeham noted.

  It has been stated that CTR is a program to find out the “truth about smoking and health.” What is true to one is false to another. CTR and the Industry have frequently denied what others find as “truth.” Let’s face it. We are interested in evidence which we believe denies the allegation that cigarette smoking causes disease.

  Wakeham suggested what he called “Option B”:Use the CTR program as a means of establishing expert scientific witnesses who will testify on behalf of the Industry in legislative halls, in litigations, at scientific meetings, and before the press and public.79

  This is precisely what the CTR was already doing under the Special Projects programs that began in 1966.80

  Under the rubric of special projects, the CTR could exert greater influence and control over research than was the case with research selected for funding under the grants program of the SAB. Perhaps the most notorious known case was that of pathologist Freddy Homburger, whose Cambridge-based Microbiological Associates had been retained to conduct experiments on hamsters exposed to smoke. Homburger and his colleagues found precancerous lesions similar to earlier research conducted by pathologist Oscar Auerbach on beagles. But when he submitted the draft paper to CTR, Hockett raised a series of objections, requesting that he substitute medical euphemisms to describe the characteristic malignant lesions; Hockett advised that he use the term pseudoepithieliomatous hyperplasia. When Homburger refused, he was notified that CTR would no longer fund his work. Further, they enlisted publicist Leonard Zahn (formerly of Hill & Knowlton) to attempt to discredit him. Such cases were in all likelihood unusual; researchers doing contract work for CTR, as well as those funded through the SAB, understood that the future of their support depended on not rocking the boat of Big Tobacco. For the most part, CTR research steered clear of experiments and studies that might elucidate the relationship of cigarettes and disease.81

  A number of other observers also noted that the industry would require fundamentally new strategies to sustain the cigarette business. George Weissman of Philip Morris concluded that “at some point, reflecting the same seriousness with which we met the Report, we must in the near future provide some answers which will give smokers a psychological crutch and a self-rationale to continue smoking.”82

  Despite internal debate, the cigarette manufacturers continued to collude in a PR approach that claimed that the evidence against their product was wholly inadequate and that attempts to regulate their product were unnecessary and inappropriate given the “continuing controversy.” Executives insisted publicly that there remained an “open question” and “ongoing controversy” about the harms attributed to their product. In a 1968 memo on industry communications with doctors and dentists, sent to William Kloepfer of the Tobacco Institute, Carl Thompson, who had worked on the tobacco account at Hill & Knowlton since 1953, underscored the industry’s commitment to denial:The most important type of story is that which casts doubt on the cause and effect theory of disease and smoking. . . . Thus, the headline should strongly call out the point—Controversy! Other factors! Unknowns!83

  As many company executives anticipated, the surgeon general’s report greatly weakened this defense strategy. While the industry refused to abandon its commitment to “uncertainty,” its focus would shift. It would now contend that the (alleged) risks of smoking must be borne exclusively by the smoker. Even as it insisted that the harms of smoking were unproven, the industry would argue that those same harms were well-known to smokers, who accepted them rationally and knowingly. This new strategy would prove essential to the marketing, promotion, and especially the defense of tobacco in the decades ahead.

  Following the release of the report in January 1964 and the resulting banner headlines throughout the country, it was widely assumed that Americans would give up tobacco. After a fine year in 1963, cigarette sales fell some 15 to 20 percent in the first half of 1964. By 1965, however, the industry had rebounded, reporting record sales, per capita consumption of 4,318 cigarettes, and the highest profits in its history. By 1973, tobacco consumption had not declined appreciably from 1964 levels.84 Reports of the demise of Big Tobacco had been premature.

  Nonetheless, the surgeon general’s report was a pivotal document in the history of public health. In making such a powerful and definitive statement, the report created a new realm of action for public health officials. As political scientist A. Lee Fritschler pointed out in his analysis of smoking and federal policy making, the surgeon general’s office provided the “combination of legitimacy and exposure” necessary to making smoking’s harms an unquestioned fact. The PHS distributed 350,000 copies of the report within a year after its release, including one to every medical student in the country. It also planned to post a brief summary of the report in 50,000 pharmacies by January 1965.85 But the surgeon general’s office possessed few resources to mount any significant public health programs. Nonetheless, the report did create an authority that surgeons general have been eager to use ever since. The report became the model for thirty subsequent reports on smoking and its harms, which have been influential in shaping the policy of tobacco regulation.86 The report’s format became a model for reports on numerous other health concerns as well.

  Ultimately, the Surgeon General’s Advisory Committee and its report opened a new era of what might be called procedural science. The substantive authority and impact of the report rested fundamentally on the integrity and independence of the process of reaching its conclusions. Resolving controversies in science, medicine, and public health—especially in areas where there were powerful vested interests—would increasingly require the integration of scientific data from a wide range of experiments, studies, and clinical observations. This would, in turn, require a collaborative process of critical evaluation to reach a state-of-the-art conclusion and recommendation for action. These recommendations could range from clinical interventions to policy innovations in public health to the assertion of regulatory authority.

  The production of the report created the essential protocol for procedural science. The participants must be deemed free of conflicts of interest, the process had to be essentially transparent, and the conclusion, to be received as authoritative, must ultimately rest on the collective expertise, status, and independence of those reviewing and negotiating over the available data. This is why, in subsequent decades, conflict of interest emerged as such a critical element in medical and public health science. Unannounced and undisclosed conflicts threaten the legitimate basis of procedural science and its impact on the integrity of clinical medicine and public health policy. Policies regarding conflict of interest came to be more sharply articulated and mandated.87 This approach stood in sharp contrast to the explicit conflicts of interest in industry-sponsored research.

  Procedural science calls for reaching consensus across diverse disciplines and perspectives, using multiple scientific methodologies. The search for agreement and consensus is crucial to this process. Participants are not required to relinquish disciplinary claims or approaches but to reach agreement within a diversity of methods and a priori claims. Finally, procedural science requires wide dissemination of clinically and socially important knowledge.

  The Surgeon General’s Advisory Commi
ttee created the operational model for procedural science in adjudicating conflicts in which powerful economic and political interests might unduly influence medical practice and public policy. Given the resources which the industry had brought to bear to sustain the notion of a scientific controversy, it was crucial for the government to develop a process to evaluate carefully and critically the available evidence and seek a consensual conclusion. Only with this type of unassailable evaluation could the government adequately inform the public and legislate programs for health promotion and disease prevention.

  To a reader of the report many decades later, the depth of the review, the importance of the analysis of causality, and the momentous conclusions are reflected on every page. In the dry prose of federal bureaucracy and modern science, the report succeeded—by its application of the principles of procedural science—in settling for good the question of the lethal harms of cigarette smoking. In an age in which powerful corporate interests threaten to overwhelm the integrity of science, procedural science offers a powerful counterweight.

  Following the release of the report, the surgeon general’s office and the federal government would assert new authority and responsibility for the most important health issues of our time. In this sense, the report can be seen as yet another example of the expansion of the federal government’s regulatory powers during the Kennedy and Johnson administrations.88 By setting out to determine the true relationship between cigarettes and disease, the government accepted new authority for science and health in the consumer culture. Inherent in the report, therefore, were powerful notions of the possibility of the liberal state. In the future, from tobacco to HIV, the American public and even the international community would look to the surgeon general for scientifically validated public health policies. The 1964 report remains a signal contribution not only to the history of the cigarette but to the history of public health.

  The Surgeon General is entitled to draw his own conclusions. He is treading on questionable ground, however, when he begins to impose these opinions on the public, without acknowledging the fact that this matter is in controversy among sci enti sts.1

  SENATOR SAM J. ERVIN, JR., 1965

  In the six years that have elapsed since the Surgeon

  General’s massive report on Smoking and Health, the

  total number of Americans who have died of cigarette-induced

  lung cancer is approximately ten times the

  number of deaths caused in August, 1945, by the dropping

  of the atomic bomb on Hiroshima.

  Can it possibly be true that the lethal effects of even

  ten Hiroshimas, in the form of these then silent holocausts

  in our very midst cannot move the Food and Drug

  Administration to act to warn and protect the American

  people against the perpetuation of this horror?2

  THOMAS WHITESIDE, 1971

  CHAPTER 8

  Congress: The Best Filter Yet

  AMONG THE CONCLUSIONS of the 1964 surgeon general’s report was that smoking constituted a hazard requiring “remedial action.” Although Luther Terry had proposed a “second phase” of investigation by the Public Health Service into what that action should be, it was already clear when the report was released that this assessment would take place in other venues. As Stanhope Bayne-Jones, the most politically seasoned member of the committee, later explained:Phase II led, of course, into economic and legal considerations of great magnitude. What would be done would affect the industries, affect part of the national economy, affect international relationships, possibly disturb labor relationships as well as laboring individuals. It was so important from a governmental standpoint that I doubt whether any clear notion of ever undertaking phase II through this mechanism was envisioned under the Public Health Service.3

  The very success of the advisory committee had depended on its isolation from such questions. Terry astutely recognized that the committee could only speak with authority about the scientific and medical nature of the health risks of smoking; the policy questions would be decided by a process far different from the procedural science conducted by his committee. Its main purpose was to provide scientific and medical authority to generate new public policies on tobacco. The committee sat at the boundary between knowledge and politics but derived its legitimacy and influence by not treading across it.

  If Terry’s committee had been distinguished by its disinterested adherence to facts as determined by scientific research, the next phase would be remarkable for aggressive political combat. The need to decide what should be done about the risks of smoking—now that they had been so clearly determined—created a radical new era in the history of the cigarette and, for that matter, the history of regulatory politics. Although the tobacco industry would maintain its ten-year-old strategy of scientific denial and rhetorical skepticism, the battle turned sharply away from science and into the domain of public policy. What should the state do when a popular product is demonstrated to cause such significant harm to health?

  The historical evolution of the cigarette offered few precedents for regulatory intervention. The “fiasco” of Prohibition would be repeatedly cited—especially by the tobacco industry—as supporting a hands-off approach. The industry argued that the government had no regulatory burden: since “everyone” was now aware of the “controversy” over the “alleged” harms of smoking, it would be paternalistic and counterproductive to regulate the promotion and sale of cigarettes.4 But there were many available options between the extremes of no action and outright prohibition, ranging from education to radical restrictions on the marketing and public use of cigarettes.

  Tobacco products were still virtually unregulated, an increasingly exceptional status at mid-century. Throughout the economy, the regulation of new products for safety had become a prominent feature of the emerging consumer culture. But the cigarette had fallen through this tightening net. As food and drug regulation was created in 1906 and stiffened in 1938, tobacco products were viewed within the Food and Drug Administration as neither food nor drug and, thus, outside the agency’s mandate.5 The industry successfully avoided any requirements for reporting ingredients or evaluating the safety of the product. There was virtually no governmental oversight of the manufacturing process. Given the overwhelming task of assuring the safety of food and drugs, it was small wonder that the FDA avoided adding tobacco to its mandate, even as concerns about the health impact of smoking were rising.

  The first regulatory proposals following the 1964 surgeon general’s report centered on advertising and packaging. The growing public recognition of the harms of smoking had brought cigarette promotion under close scrutiny. In a time when many saw advertising’s purpose as mainly informational—educating consumers to make rational choices among competing products—cigarette ads were widely viewed as motivational and perhaps too persuasive.6 They had so stretched the notion of “information” that they were frequently offered as key examples of excess in modern consumer marketing. 7 Now that the product was deemed harmful—even deadly—the manipulation of consumer desire could no longer be ignored. Should tobacco advertisements and packaging be required to apprise consumers of the risks the surgeon general’s committee had now so explicitly specified?

  Unsure that either the industry or consumers were to be trusted, advocates of tobacco regulation looked to the federal government to adjudicate these tensions at the intersection of culture and public health. The Federal Trade Commission, the agency charged with maintaining standards of truth in advertising, was the governmental branch to address this task. The FTC had investigated tobacco ad campaigns as early as the 1930s, focusing mainly on ads that promised particular health benefits of smoking. These ads had often been found by the federal agency to be misleading, prompting officials to issue orders for the companies to “cease and desist” from such claims. This process was both time-consuming and costly. Certainly, the industry considered such interventions a nuisan
ce, but the very purpose of these campaigns was to test the boundaries of what was permissible in a fluid market.8 If an ad campaign came under FTC scrutiny, it could be modified or abandoned for an even bolder alternative.9

  Throughout the 1950s, tobacco companies continued to circumvent advertising regulation, presenting a variety of claims about the salutary health effects of particular brands, downplaying health concerns, and attempting to reassure consumers with images of healthy, attractive smokers. As we have seen, several prominent campaigns—most notably, R.J. Reynolds’s “More Doctors Smoke Camels”—prominently featured doctors in an effort to reassure smokers about rising medical concerns.

  In 1955, in the face of the emerging epidemiological findings, the FTC issued voluntary guidelines that urged cigarette makers to avoid unsubstantiated or ambiguous claims about the tar and nicotine content of particular brands.10 Such claims were all but meaningless because there was no uniform technique for measuring this content and no approach to assessing how cigarettes were smoked in practice. Yet they could have a powerful influence over smokers worried about their health.

  Beyond listing tar and nicotine content, tobacco companies had been altering their product in response to public concerns about the cigarette’s health effects. The most durable and popular of these changes was the introduction of new filter cigarettes. Even as manufacturers—at John Hill’s insistence—abandoned the use of doctors and other health claims in their advertising, they began to market filters and promote apparent reductions in tar and nicotine with bold fanfare. Kent’s “Micronite” filter, which in its original form contained asbestos, assured consumers that “your voice of wisdom says SMOKE KENT.” Liggett & Myers proclaimed that its new filter was “just what the doctor ordered.” Viceroys promised “Double-Barreled Health Protection.” Menthol cigarettes were also promoted aggressively during this period, drawing upon traditional therapeutic associations with cough and cold remedies.11 Salem, combining both innovations, announced that its mentholated filter cigarette marked the “First Truly New Smoking Advance in over 40 Years!”