The Cigarette Century

by Allan Brandt

  In another instance, British American Tobacco based its opposition to the FCTC on its “respect for cultural diversity”:Our perspective on doing business throughout the world is based on long held respect for cultural diversity. . . . We do not believe in “one size fits all.” In business operations, and in issues surrounding foreign investment, development, the environment, labour standards or appropriate regulation, we believe that local self-determination is vital. National governments and citizens are best placed to define national priorities, and the actions that will work in their societies. . . . Calls for global regulations and standards, however reasonable they may seem to western eyes, can risk alienating emerging nations and damaging their competitiveness. If globalization is to bring widespread benefits, the views of the few should not be imposed on the majority.123

  The tobacco industry had now honed its new arguments for the defense of the realm. After nearly half a century, the tobacco industry had finally abandoned its traditional justification of “no proof.” To maintain a protected social space for an increasingly stigmatized product and behavior, the companies now justified the continued unfettered promotion of tobacco products throughout the world by affecting a posture of democratically minded concern for individual autonomy:• We have no interest in recruiting new smokers; only in getting current smokers to switch brands;

  • Smoking is for adults only; we have no interest in underage smoking. To the contrary, we will work diligently to restrict smoking to adults. When children do become smokers, it is generally a result of peer pressure;

  • Advertising and marketing of tobacco products is exclusively for encouraging adult smokers to switch brands;

  • We know that smoking is a “risk behavior,” and that in some instances may lead to disease;

  • There is a significant, if not overwhelming, uncertainty about the risks of smoking to nonsmokers;

  • Smoking is a voluntary behavior; anyone can quit, although for some it may be difficult.

  These universal half-truths—refined over decades—form the basis for the aggressive marketing of tobacco across the globe. The future of the industry today is based on the effective assertion of this new theme: “responsibly marketing a dangerous product.”

  Recent studies have shown that historians and astrologers are about equally successful in predicting the future. It is difficult to assess what impact the Framework Convention for Tobacco Control is likely to have. But it has already cleared some important obstacles, and it at least offers the potential for the nations of the world to consolidate a range of antitobacco policies, and so advance the cause of reducing tobacco-related sickness and death in the years ahead. It marks a growing recognition that in many crucial instances public health must take on powerful transnational corporate interests. The ultimate test of the framework convention will be in the negotiation of binding protocols following the treaty’s entry into force, which occurred in 2005.124 The first meeting of the Conference of Parties, which took place in February 2006, initiated this process. As of this writing, 140 countries have become party to the convention. In this respect, the U.S. failure to ratify the FCTC is consistent with the failure to ratify other important conventions and the emerging ethos of American unilateralism. President Bush—Secretary Thompson’s effusive public endorsement notwithstanding—has not forwarded the treaty to the Senate for consideration.

  The framework convention has the capacity to expose the hypocrisy and exploitation associated with tobacco promotion around the world. The industry’s assertion that harms deemed unacceptable in the affluent West are tolerated in the developing world smacks of a dubious moral calculus. It implies that people in India or Egypt really don’t object to dying of cancer as long as they were spared from TB or cholera. Common sense suggests the fundamental flaw in this logic. The FCTC also reveals long-standing tensions at WHO—and indeed at the heart of modern public health—between biological and technical approaches to disease and the sociopolitical interventions often required for prevention and health promotion. This is another false dichotomy: all public health engages both the technical and the political. One of the great appeals of biotechnology is that it appeared to free public health from the most difficult sociopolitical questions. Global tobacco control, however, makes gene modification seem simple. And the tobacco wars are a persistent reminder of the powerful economic and political forces arrayed near the trenches. The problems of reducing tobacco-related diseases are radically different from those associated with assuring the provision of vaccines and medication, and they force the public health community to confront its critical limitations in strategy, capacity, and resources.

  Is tobacco control merely a luxury for affluent nations that have brought acute infectious diseases under control? The notion that national and international public health programs must address communicable diseases before tackling noncommunicable diseases is highly suspect. It is typically based on the misconception that wealthy nations are affected by systemic, chronic diseases whereas poorer nations remain exclusively under the burden of infectious disease. Today, in the developing world, noncommunicable diseases have become the leading cause of morbidity and mortality. If the global burden of disease is to be reduced, public health strategists will need to resist the traditional division of communicable and noncommunicable diseases, partly because they share many risk factors in common. The risks of tobacco exacerbate the risks of infection and poverty, and vice versa.125

  The long latency of tobacco-related diseases remains a major obstacle to regulation and behavior change. Moreover, the slow development of symptoms and health effects has the effect of blocking political initiatives for tobacco control. Politicians and public health officials typically need to demonstrate short-range returns to secure investment or popular support. In the case of tobacco regulation, the health benefits are often two or three decades in the future. Yet the costs in lost agricultural, manufacturing, and tax revenues are quickly and concretely apparent.126

  It has been conservatively estimated that 100 million people around the world died from tobacco-related diseases in the twentieth century. Through the first half of that century, the health risks of smoking had yet to be scientifically demonstrated. In this century, in which we have known tobacco’s health effects from the first day, the death toll is predicted to be one billion.127

  This is a pandemic. But it is different from pandemics that most historians, public health officials, and physicians are familiar with. It is unlike the plague that swept medieval Europe, the flu of 1918, or the HIV disease currently devastating sub-Saharan Africa. The difference is that the agent—the cause of disease—is a popular and aggressively marketed legal product, the lifeline of one of the most successful multinational industries of the last hundred years, and a source of revenues to farmers, workers, and governments throughout the world. Not only individual smokers, but nation states too, suffer from tobacco dependence. For such an epidemic, there will be no magic bullets.

  Never in human history has a product been so popular, so profitable, and so deadly. In the twentieth century, we came to understand—in ways both rational and scientific—tobacco’s character. But we are only now learning how difficult and complex it will be to mitigate its harms in the face of powerful corporate interests deeply committed to the diffusion of their product and the profits it secures. We must confront a well-known, but often avoided, reality: that public health must engage economy and politics at the same time it deploys science and medicine. The FCTC marks a contemporary approach—modest and limited, but an approach nonetheless—to public health innovation in the face of an unprecedented, commodity-driven pandemic.

  CHART 9 Projected total global deaths from cigarettes

  If we are to ultimately develop effective programs to address the epidemiological rise of noncommunicable diseases, we must first understand the social nature of risks and their movement across the globe. Just like infectious pathogens, risk factors for noncommunicable dise
ases move across the planet in ways that are neither random nor idiosyncratic. Like infectious diseases in the past, they follow the routes of trade and commerce. They move from less vulnerable populations to those more vulnerable, from more highly-regulated polities to less-regulated ones, from more affluent regions to those less well-off, from the literate to the non-literate, and from nations where cultural cues constrict the risk, to those whose cultures tend to expand it. In the case of tobacco, the movement of risk has been carefully orchestrated, and it is profoundly affecting the global burden of disease; new regions continue to be invaded by this ongoing plague of cigarettes—the result of calculated and documented corporate practices, often supported by national governments.

  It is, of course, the long-standing position of the tobacco industry that smoking is a voluntary behavior, engaged in by consenting adults who now are well aware of—and assume—what risks are attributed to the industry’s product. So long as we accept the premise that the risks of smoking are assumed by individuals who are exercising their rights, there is indeed no case for an international tobacco control regime. These classic notions of individual responsibility and freedom are central to the multinationals’ ability to promote tobacco use throughout the world. Such arguments, as we have seen, were employed repeatedly in the United States as the risks of tobacco use became known; as long as tobacco was viewed as a risk of individuals, rather than populations and societies, it would remain weakly regulated. We want to believe (and the industry wants us to believe) that smoking is a voluntary behavior and that citizens with fortitude can simply quit. And this view is reinforced because people do quit all the time.

  But we cannot let the fact that some are able to quit blind us to a more complex reality about risk behaviors and their promotion. The tobacco industry’s position belies the history of the movement of tobacco’s harms around the world. Tobacco use is aggressively promoted and marketed; a vast majority of smokers throughout the world begin as children; smokers become addicted to nicotine, a powerful drug; this addiction is reinforced by marketing, promotion, and powerful cultural symbols; and nonsmokers (again, especially children) are harmed by the tobacco smoke of adults (who became addicted as children). There is a deep cultural and psychological pressure, sustained by the multinational industry, to reject this view of the tobacco trade.

  Today, it is commonly understood that cigarette smoking constitutes an important risk to health, that smokers are vulnerable to many significant diseases and death. But the processes by which we determine, measure, and assess risks like smoking are complex and subject to culture, psychology, and politics. Most of these methods offer a uniform and objectified evaluation of risks as a determinant object. There are real advantages in this approach in that it permits us to enumerate and compare disparate risks (e.g., the risk of dying in a traffic accident versus an airplane crash). But risks also have social and cultural attributes that may subvert any single metric.

  Risk culture is often shaped by powerful externalities. In the rise of the cigarette, we see the powerful role played by the world wars of the twentieth century. In both wars, the prospect of immediate and violent death overwhelmed any concerns about the health risks of smoking—or worries about its propriety. It took an era of sustained good health in the West to fully expose the cigarette’s most serious, long-term harms. By the same token, the risks of smoking may be portrayed as relatively small in societies (or communities) where infectious disease and violent trauma remain significant killers. Much of this book, then, is about the historical process of determining what kind of a risk it is to smoke cigarettes. This is not a simple matter of calculation but a question that draws on a range of disciplines, methods, and theories in historically and culturally specific ways.

  What is the risk?

  How is it known? And by what methods?

  How can it be modified, reduced, or eliminated?

  Can it be tolerated? And under what conditions?

  Who bears the responsibility for the risks we face?

  While the industry is eager to depict the FCTC as an act of Western paternalism toward the developing world, one may as easily read the framework as an attempt to use moral suasion in the service of preventing disease and to construct a world order that reduces the toll a rogue industry takes on human health. Ultimately, international health is based on assumptions of equity and justice: the right to a life free of preventable and treatable disease; the essential injustice that those less well-off and less well educated do not gain the opportunities provided by attainable levels of good health.128 “There is,” noted Brundtland, “an increasing consensus for ethical norms, standards, and codes of rules common to all regions and cultures of the world.”129 If we permit the shift of the burden of tobacco-related disease to continue unchecked, we violate this basic standard of equality.

  A century from now, historians will no doubt chronicle the history of the FCTC and assess its impact. Perhaps they will see it as a feeble and belated gesture at averting one of the worst epidemics in human history, exacerbated by the liberalization of trade in dangerous products. Yet if globalization facilitates the mass marketing of tobacco products throughout the world and a rise in overall consumption, perhaps it also holds the possibility of new and innovative arrangements in public health. Perhaps the next century’s historians will look back at the FCTC as a breakthrough for public health and the collective action of enlightened states: the beginning of new forms of global governance in an age of civil societies committed to health, equity, and social justice. As historians know too well, only time will tell.

  There is no reason for complacency about the dangers . . . of acquiring and propagating bacteria and viruses for biological weapons. But the dangers should be seen in the perspective of other threats to human life. In 1995, the last year for which official statistics are available, the number of people killed by tobacco in the United States was 502,000, of whom 214,000 were aged between thirty-five and sixty-nine. On average, each of these could have expected to live twenty-three years longer. In view of these alarming numbers, it seems to me that the still-prospering tobacco industry poses a proven threat to health and life that is many thousand times greater than the potential of bio-terrorism.1

  M . F . PERUTZ, 200

  Epilogue

  The Crime of the Century

  SORTLY AFTER I had begun work on this book, I got a call from an attorney at Shook, Hardy & Bacon, stalwart defender of the tobacco industry, asking if he could pay me a brief visit. I had already grown suspicious of the industry’s lawyers and their arguments, but they were eager to hear what I was up to, and I was equally eager to hear about their cases. The fellow soon appeared at my medical school office with four or five other attorneys in tow, all from elite firms like Arnold & Porter and Jones Day.

  They wanted to know whether there had been a controversy about smoking and health in the 1950s. Were any scientists and physicians genuinely skeptical of the epidemiological studies linking smoking to lung cancer? My answer was that of course there was a controversy, and of course there were skeptics. It would be difficult to identify a significant finding in medicine and science that did not attract some degree of skepticism. The lawyers seemed quite pleased with this response.

  But I went on to explain two additional facts. First, although there truly were skeptics, even a handful who were not associated with the industry, they were a rare breed, and very few had done any original research on smoking and health. Second, the industry had worked diligently to foment the controversy. Without these efforts, the harms of smoking would have been uniformly accepted by medical science long before the 1964 surgeon general’s report—which, I pointed out, the industry had also sought to trash. The perception of ongoing, heated debate about the relationship of cigarettes and disease had largely been a product of the industry’s intensive public relations efforts in the 1950s and after. Any professional historian, I said, who had thoroughly pursued the relevant published and unpublished
sources would place the “debates” about the harms of smoking into this context. Suddenly my visitors were not so happy with me. I never saw them again.

  I also heard from plaintiffs’ lawyers, including the redoubtable Richard Daynard, who was always anxious to hear what I’d dug up from the archives. The eternal activist-optimist, Daynard would explain to me that the plaintiff attorneys he was advising were about to break through and finally expose the Big Lie, inflicting untold damage on Big Tobacco. I would often reply that in American health culture, where there was such a strong emphasis on individual responsibility and agency, such a victory would be difficult if not impossible. Nonetheless, my sympathies, and my research, began increasingly to sustain Daynard’s hopes. Research on nicotine addiction, secondhand smoke, and the Joe Camel campaign all eroded the industry claim—central to its litigation strategy—that the harms of smoking were self-inflicted by choice. Even more importantly, industry documents now offered a paper trail of industry intent and deceit leading right into the CEOs’ offices. Perhaps Daynard would turn out to be right.

  Daynard would send plaintiffs lawyers to see me, and we would pick each others’ brains about the history of the industry and the rise of scientific knowledge. Don Davis, who worked with Don Barrett on Horton, visited several times, and Woody Wilner, who represented Grady Carter and several other smokers in successful individual suits, came by to trade footnotes. There was also always a question about my possible availability to testify in a trial on behalf of a plaintiff. Each time I respectfully declined. Certainly, my research confirmed that the industry had conspired over many decades to deny and obscure the deadly risks of its product. The archival record was replete with evidence of corporate malfeasance and deceit that I believed would disrupt the industry’s traditional blame-the-victim defense.