The Cigarette Century
Page 35
These studies often took years, even decades, to complete. One of the first major studies to be reported came from a longitudinal investigation that had been underway in Japan since 1965 but was not reported until 1981. Epidemiologist Takeshi Hirayama of the Tokyo National Cancer Center Research Institute had been studying the impact of factors, such as alcohol use, occupation, and marital status on health in over 250,000 adults over forty years of age. Having already collected substantial data on smoking in this population, he now measured the rates of lung cancer among the nonsmoking wives of smoking husbands in his study. Hirayama found that wives of smokers and ex-smokers had a substantially increased risk of developing lung cancer and that these risks were significantly related to dose. The greater the consumption of cigarettes by the husband, the higher the wife’s risk. Women whose husbands smoked fourteen cigarettes a day had a 40 percent greater chance of developing cancer than those whose husbands did not smoke at all. If a husband smoked a pack or more a day, the difference rose to 90 percent.19
At the same time that Hirayama was exploring the impact of secondhand smoke among Japanese couples, epidemiologist Dimitrios Trichopoulos and colleagues were conducting a case control study in Athens. Trichopoulos identified fifty-one women with confirmed diagnoses of lung cancer admitted to Greek hospitals between September 1978 and June 1980. He then matched this group to a control of 163 women who did not have cancer. Eliminating the women who smoked from his analysis, he found significantly higher rates of lung cancer among nonsmoking wives of smoking husbands. It was not by chance that these two early and important studies of the risks of passive smoking were conducted in Japan and in Greece. Both were countries where very few women smoked, offering what Trichopoulos called an “unusual opportunity to investigate this issue.”20 He noted that high rates of smoking among both men and women in other populations would “confound and conceal the lesser effects of passive smoking.”21
In the United States, James Repace, a physicist, and Alfred H. Lowrey, a theoretical chemist, were employing a different approach. Drawing upon new technology as well as sophisticated new theoretical models, Repace and Lowrey conducted a study of the effects of tobacco smoke on indoor air quality. They developed a model for estimating the “respirable suspended particles” (RSPs) from cigarette smoke in enclosed environments and then measured actual levels of smoke in bars, restaurants, bowling alleys, and other sites using a small handheld device called a piezobalance. The resulting article, which appeared in Science in 1980 following that journal’s usual extensive peer review process, explicitly compared these familiar environments to the vicinities of coke ovens and other heavily polluted sites, noting that ETS exceeded legal levels for carcinogens by 250 to 1,000 times. “Under the practical range of ventilation conditions and building occupation densities,” Repace wrote, “the RSP levels generated by smokers overwhelm the effects of ventilation and inflict significant air pollution burdens on the public.” Better ventilation was unlikely to solve the problem, he contended, “Indoor air is a resource whose quality should be maintained at a high level. Smoking indoors may be incompatible with this goal.”22 Repace described “the RSP burdens from ambient tobacco smoke” as “so large that they must be incorporated explicitly in future epidemiological assessments of the relation between particulate levels and morbidity and mortality.” His conclusions underscored the risks to the nonsmokers:Clearly, indoor air pollution from tobacco smoke presents a serious risk to the health of nonsmokers. Since this risk is involuntary, it deserves as much attention as outdoor air pollution.
Repace’s research offered scientific confirmation of his personal experience as a sufferer of childhood asthma, exposed to smoke by his father, who died of lung cancer at fifty-nine.23 Soon employed at the EPA, he would help make indoor air quality a significant aspect of the agency’s regulatory efforts. These studies would mark the early recognition of the built environment as posing important health risks.
In 1981, a National Academy of Sciences committee on indoor air pollutants directed specific attention to the impact of tobacco smoke, urging that “public policy should clearly articulate that involuntary exposure to tobacco smoke ought to be minimal or avoided where possible.”24 By the late 1980s, many additional studies of the harms caused by secondhand smoke had cleared the bar of peer review in medical and scientific journals. 25 These studies would be subjected to intense scrutiny and attack by those representing the tobacco interests and from some independent scientists as well.
Even before scientific evidence of the harms of secondhand smoke emerged, tobacco-control advocacy groups and grassroots organizations began calling for restrictions on smoking in public places. In the early 1970s, John Banzhaf III and his small public interest group, ASH, which had so effectively challenged tobacco ads on the airwaves, turned their attention to the impact of smoking on nonsmokers. Banzhaf urged nonsmokers to stand up for their rights and to tell smokers, “Please put your cigarette out; the smoke is killing me.”26 He noted ominously (if speculatively) that “a non-smoker may actually be forced against his will to breathe almost as much carbon monoxide, tar, and nicotine as the active smoker sitting next to him.”27 Implicit in this tactic was a new line of attack on smokers themselves, whom antitobacco advocates would portray as selfishly disregarding the health and well-being of nonsmokers. “It’s time we made them stop taking such liberties with our health and comfort,” 28 Banzhaf argued. He began petitioning the federal government to establish nonsmoking sections on planes and public transport, and in the workplace.
Such campaigns offered new opportunities for public health activists who had been stymied in their attempts to secure effective federal regulation in Congress, where the tobacco lobby held sway.29 New grassroots organizations, typically modeled on environmental groups, began to solicit activist volunteers to advocate for the rights of nonsmokers. They were influenced as well by the examples of the civil rights and antiwar movements. Organizations like Group Against Smoking and Pollution (GASP), founded in 1971 by Clara Gouin, developed small groups of volunteers committed to local action. Their constituents generally had two things in common. Many, including Gouin, had lost family members and loved ones to lung cancer and other diseases. Gouin’s father had died of lung cancer at fifty-seven, and she attributed his death to smoking. Others joined the group primarily because of their own sensitivities to smoke from allergies, asthma, and other respiratory diseases. Soon, Gouin’s small cohort was printing flyers and buttons, sending out a newsletter—the Ventilator—to local lung associations, and offering advice to new local chapters. By 1974, the newsletter claimed fifty-six local chapters, each pushing forward the agenda that “non-smokers have rights, too.”30 Framing the question as a rights issue drew on the powerful antecedents of the civil rights movement and offered an important justification for state action in response to the libertarian perspectives that had traditionally dominated the politics of smoking. GASP’s local chapters quickly moved from seeking to define the problem of secondhand exposures to aggressively seeking local and state ordinances regulating smoking in offices, public buildings, and restaurants. 31 They successfully called for special sections for nonsmokers in restaurants and other public spaces. Some restaurants were easily persuaded, before any legislation was passed, to set up small nonsmoking sections, which expanded as they proved popular with patrons.
The fight for tobacco control ordinances demonstrated the possibilities of grassroots public health advocacy. Single-issue advocacy groups were in a far better position to take up the fight than the traditional voluntary health organizations like the American Cancer Society and the American Heart Association. The latter had complex constituencies and philanthropic and educational missions that led to an inherent conservatism; they sought to avoid political controversy that could alienate not only smokers, but donors from tobacco-growing states.32 The new organizations reveled in controversy, deliberately seeking media attention to sustain their cause.
The pr
incipal message of these local efforts appealed to the public’s disdain for involuntary exposures to tobacco smoke. In 1966, Betty Carnes, an ornithologist whose son had died of lung cancer, had founded Arizonans Concerned About Smoking, one of the first nonsmokers’ rights groups established in the United States. She and her colleagues sent off thousands of “Thank you for not smoking” signs and lobbied state legislatures for new regulations. Carnes was quick to point out that a majority of the state population did not smoke; in lobbying for the bill, she surveyed legislators to find who might be nonsmoking supporters. Arizona, with a large number of individuals with respiratory ailments, proved to be a strong base to generate popular support for the legislation. In 1973, after two years of intensive campaigning by Carnes and her group, Arizona became the first state in the nation to pass a law restricting smoking in public places—banning it in elevators, theaters, museums, libraries, and buses, and establishing assigned smoking areas in government buildings, health care facilities, and other public spaces. The law was soon amended to include restrooms, doctors’ offices, and school buildings. Skeletal in its approach, it provided no funding to the Health Department to oversee compliance.33 Even without a commitment of funds, such legislation demonstrated the political feasibility and popularity of antismoking measures. Activists and legislators soon found that even unenforced regulations had high levels of compliance. The fact that such legislation typically required no new funds gave it a significant political advantage over costly public health initiatives.
In 1975, Minnesota became the first state in the nation to pass a comprehensive Clean Indoor Air Act, banning smoking in most public offices, stores, and banks. A former state senator, Edward Brandt, had helped to found the local chapter of the Association for Non-Smokers’ Rights (ANR) in early 1973.34 ANR surveyed restaurants in the Twin Cities to see how many offered nonsmoking areas. Although many of the restaurants expressed interest in providing such accommodations, few were doing so. In 1974, after much grassroots campaigning and rising public interest, Representative Phyllis Kahn introduced the bill, designed to “protect the public health, comfort and environment by prohibiting smoking in public places and at public meetings except in designated smoking areas.”35 Smoking in all public places was forbidden unless specifically allowed, and restaurants had to set aside at least 30 percent of their seats for nonsmokers. Penalties for violating the act ranged from warning citations to $100 fines.36
With the tobacco industry’s lobbying being focused in Washington, these early bills came in under its radar. But as the industry geared up to resist state and local legislation, it became increasingly difficult to move smoking regulation bills through legislatures. In 1978, for example, some fifty-four bills were proposed, but only six resulted in legislation, and none contained major limits on public smoking like those in the Minnesota Act.37 A decade later, when the Minnesota legislature sought to create a major campaign to reduce smoking, the industry was well prepared to dismantle the proposed bill through aggressive lobbying and opposition.
In 1978, a referendum in California, Proposition 5, which would have led to statewide restrictions on smoking, went down in defeat after the tobacco industry spent some $6.5 million to kill it. This loss, however, helped to galvanize the state’s emerging nonsmokers’ rights movement. After a second statewide campaign failed in 1980, activists shifted their focus to local municipalities, where the tobacco industry had considerably more difficulty in exercising political clout. In 1983, for example, San Francisco enacted broad restrictions on public smoking. Even against the industry’s significant efforts to prevent such regulations, by 1981 thirty-six states had some form of restriction on smoking versus just five a decade earlier. Further, 20 percent of firms had issued workplace rules restricting smoking, and litigation often supported protections for nonsmokers in the workplace.38
Increasingly, employers realized the potential liabilities of not providing smoke-free workplaces. A report prepared by a consultant to Fortune 500 companies explained:There is a growing body of court cases and legal opinions that indicate (1) employees have a right under federal law to sue for a smoke-free work environment, (2) employers must be prepared to bear some responsibility for the discomfort, pain, and illness caused to employees by smoke in the workplace, and (3) employers are within their rights in banning smoking in the workplace or in hiring only non-smokers.39
By the mid-1980s, most large corporations—and many smaller businesses—had developed explicit smoking policies with no prompting from the government. Boeing Company, with some 90,000 employees, announced a total ban and sponsored free smoking-cessation programs for its workers.40 The elimination of smoking in the workplace offered several advantages: lower health care costs, fewer absences, and reduced cleaning services. What had been unimaginable ten years earlier now became commonplace as offices mandated their own “local” rules. Surveys of smoke-free companies demonstrated that overall tobacco consumption decreased even outside the workplace.41 But perhaps most significantly, the very notion of smoking as a normative behavior was now in decline.
Closely monitoring these new restrictions, the tobacco industry regarded the debate about public smoking as a powerful threat to its future. In many ways, the issue had taken tobacco executives by surprise. But in tracking the changing social attitudes toward cigarette smoking in public, they soon came to appreciate the role that secondhand smoke would play in their future. Notably, the Roper Organization, which conducted a survey for the Tobacco Institute in 1978, warned that “once smoking becomes widely thought of as a public health hazard . . . the justification for legal measures against cigarette sales and use has been established. . . . What the smoker does to himself may be his business, but what the smoker does to the nonsmoker is quite a different matter.”42 Roper’s assessment emphasized that “more people say they would vote for than against a political candidate who takes a position favoring a ban on smoking in public places.”43
Nearly six out of ten believe that smoking is hazardous to the nonsmoker’s health, up sharply over the last four years. More than two-thirds of non-smokers believe it and nearly one-half of all smokers believe it. This we see as the most dangerous development to the viability of the tobacco industry that has yet occurred.44
Given the industry’s recent history, this was no small judgment, but it was not an overstatement. This movement in public opinion, resting on a changing knowledge base regarding smoking and its perils, now radically reoriented the personal and public meanings of tobacco—and with it, the image of the industry.
Roper presented the industry with a “balance sheet” of assets and liabilities in public attitudes toward smoking. The liabilities were serious and mounting. Of particular concern, the report noted, was the fact that a majority now believed that it was “probably hazardous to be around people who smoke even if they are not smoking themselves.” There was growing interest in segregating smokers from nonsmokers in public spaces. This loss of confidence in the cigarette and its social legitimacy would compromise the companies’ ability to respond to regulatory and other challenges. Even smokers were ambivalent about cigarettes, with two-thirds expressing a desire to quit. Finally, the Roper survey indicated that the tobacco companies’ credibility had significantly deteriorated and that “favorable attitudes toward the industry are at their lowest ebb.” According to the report, “a steadily increasing majority of Americans” now believed that the companies knew smoking was harmful despite their ongoing denials.45 The survey ominously predicted:As the anti-smoking forces succeed in their efforts to convince nonsmokers that their health is at stake too, the pressure for segregated facilities will change from a ripple to a tide.46
And the threat did not stop there:If segregated facilities do not accomplish the anti-smoking forces’ desire of making segregated smoking so untenable that smokers will give it up, the next step could be an outright ban.47
Roper, ever helpful, offered some scientific advice:The strategic and long ru
n antidote to the passive smoking issue is, as we see it, developing and widely publicizing clear-cut, credible medical evidence that passive smoking is not harmful to the non-smoker’s health.48
This approach was in the grand Hill & Knowlton tradition. It both denied the current state of science and suggested that the industry could simply obtain—at will—the desired findings. Roper’s suggestion closely mirrored John Hill’s counsel in 1953: if you don’t like the prevailing science, get your own.
As the industry renewed its strategy of attacking the developing science on passive smoking, the federal government sought to evaluate the emerging data. As early as 1971, Surgeon General Jesse Steinfeld had directed attention to the impact of smoke on nonsmokers, telling the Interagency Committee on Smoking and Health, “Nonsmokers have as much right to clean air and wholesome air as smokers have to their so-called right to smoke, which I would redefine as a ‘right to pollute.’ It is high time to ban smoking from all confined public places such as restaurants, theaters, airplanes, trains and buses. It is time that we interpret the Bill of Rights for the Nonsmoker as well as the smoker.”49 But Steinfeld offered no new data to back this proposal. The first surgeon general’s report to explicitly raise the possibility of harm from passive smoke appeared in 1972.50 Subsequent reports—focusing on cancer in 1979 and chronic obstructive lung disease in 1984—devoted somewhat more attention to the risk of harm to nonsmokers but generally noted a lack of conclusive data. In 1986, two major reports on the issue appeared, one from Surgeon General Koop, the other from the independent National Academy of Sciences (NAS).51 The NAS report, comprehensively reviewing the scientific studies, found that children of smokers were twice as likely to suffer from respiratory infections, bronchitis, and pneumonia than children whose parents did not smoke. Though vigorously contested by the tobacco industry, these reports, utilizing the strategies of procedural science, tipped the balance in the debate. The effect of cigarette smoke on nonsmokers was transformed from an annoyance into a verifiable, quantifiable health risk.