SMOKE AND MIRRORS

 

Three hundred and seventy five years ago, the author and scholar Robert Burton wrote in his Anatomy of Melancholy:

 

Tobacco, divine, rare, superexcellent tobacco, which goes far beyond all the           panaceas, potable gold, and philosopher’s stones, a sovereign remedy to all diseases . . . but as it is commonly abused by most men, which take it as tinkers do ale, ‘tis a plague, a mischief, a violent purger of goods, lands, health, hellish devilish and damned tobacco, the ruin and overthrow of body and soul.

 

So it is today, an insidious scourge, as well as a source of pleasure, comfort and gratification.  While nearly fifty million Americans continue to puff away, over 400,000 deaths--premature deaths, to be exact--each year are attributed to the use of tobacco, more than from the use of all other consumer products combined.  According to the Surgeon General, cigarette smoking is the chief avoidable cause of premature death in this country.  One statistician has computed the comparative risk in terms of days off your life from these activities:

 

Toxic waste sites: 0-4 lost days,

Pesticide residues: 0-4 lost days,

Flying: 4 lost days,

House fires: 18 lost days,

Driving: 182 lost days,

30% overweight: 303 lost days,

Smoking: 2,580 lost days,

Poverty: 3,600 lost days.

 

The danger from using tobacco is indisputable and well known; surveys indicate that over 90 per cent, including 85 per cent of current smokers, believe that smoking causes lung cancer.  Yet more than twenty percent of Americans continue to smoke cigarettes, including ten percent of youngsters 17 years and younger, and nearly one third of those between 18 and 25. 

 


Tobacco is a unique phenomenon.  No other product sold to the public is harmful when used as intended.  It is not that tobacco use is high risk, such as use of guns, motor cycles, and hang gliders.  Those products are not inherently harmful, i.e. they are associated with danger but they can be used safely. Tobacco products are different--they cannot be used safely.  There is no safe level of use, no safe dose.  Every time one lights up, the heart, the lungs, and other parts of the body suffer injury. And yet, our society, while obsessed with the risks of exposure to carcinogenic substances in trace amounts and indignant over the deaths of 50 children a year from airbags that save thousands of lives, continues to accept the staggering health consequences of tobacco use.

 

This poses challenging issues of public policy and profound moral dilemmas.  The way in which we deal with them holds up a mirror to our society.  Let us look at how we got to where we are today and then where we might go from here.

 

While tobacco originated in America, smoking was first introduced to Europe and the Middle East and then brought back to America in the 1600s.  From the beginning, smoking was regarded as harmful, filthy and immoral, and authorities tried to prohibit it though with little success.   In the 1850s, Horace Greeley described a cigar as a fire at one end and a fool at the other.  Cigarettes, because they were difficult to manufacture, did not come into common use in the United States until the invention of the rolling machine in the 1880s which brought mass production of cigarettes.  But soon their particular appeal to young boys and the fear of all kinds of adverse health effects led to wide spread efforts  to outlaw them.  The Annapolis Evening Capital said in 1886: ”Something heroic must be done for the suppression of  this monstrous evil or the coming American man will be a pygmy and a disgrace to their race.  Let our Legislature come to their rescue.”  A headline in the Chicago Tribune proclaimed: “States Declare War on Cigaret.”  Sound familiar?

 

While a number of states adopted laws prohibiting the sale and even the use of cigarettes, the cigarette industry grew and prospered.  It was one of the early successes of free enterprise in the United States.  James Duke rode roughshod over his competitors to create the Tobacco Trust.  In 1911,  the Supreme Court struck the Trust down under the Sherman antitrust law, splitting it into three major companies, the American Tobacco Company, Liggett & Myers, and Lorillard.   This may have created the first truly national competitive market in a consumer product, and, equally important, it launched the American advertising business as we have come to know it.   What greater challenge than to sell a fungible product that is dirty, smelly, and harmful to the consumer and of no utility whatever.  The tobacco entrepreneurs rose to the challenge.  The first great milestone in tobacco advertising was George Hill’s slogan for Lucky Strike cigarettes: “It’s Toasted.”  Within a year, Luckies captured ten percent of the market.  Not to be outdone, a few years later Reynolds came back with the slogan, “I’d Walk a Mile for a Camel,” on the back of which it eventually gained 40 percent of the market.  Then Liggett & Myers designed an elegant package for its Chesterfield brand, featuring old English script and  the slogan “They Satisfy,” and gained 25 percent of the market.

 


Meanwhile two developments made cigarettes respectable and cemented their niche in American life.  First, World War I transformed cigarettes into morale builders for our soldiers.  General John Pershing, commander of the American Expeditionary Forces, said, “You ask me what we need to win this war.  I answer tobacco as much as bullets.” Second, smoking became emblematic of the emancipation of women, so long as they didn’t do it on the street.  Cigarette sales took off;  by 1922, cigarettes for the first time passed snuff and cigars to become the largest selling tobacco product, and per capita consumption in ten years had risen ten-fold, from 140 to 1,400 cigarettes per year.

 

Health concerns were still only a tiny black cloud on the horizon.  Henry Ford, for one, was convinced that cigarettes produced degeneration of the cells in the brain and would employ no persons who smoked.  A number of large companies actively discouraged smoking.  And in 1918, a prescient Mormon scientist published a study observing that cigarette smoke introduced carbon monoxide into the bloodstream, with consequences yet unknown.  Meanwhile the cigarette companies turned health concerns to their advantage.  Lorillard introduced a new brand, Old Gold, claiming “Not a Cough in a Carload,” and captured 7 percent of what by 1930 had become a huge market. Camels advertised that you could smoke as many Camels as you liked, that smoking them restored body energy, steadied the nerves, and didn’t get your wind, and soon Camels became the largest selling brand. 

 

On the raw product side of the industry, the power of the tobacco companies had enabled them to squeeze the tobacco farmers so that by the coming of the New Deal, farmers were in desperate straits.  The Roosevelt administration, sympathetic to the farmers’ plight, threatened to regulate cigarette prices and inspect the industry’s books unless the major companies committed to pay the farmers a specified minimum price for tobacco.  The companies, which were immensely profitable, could well afford to pay more. They accepted the federal tobacco price support system under the Agricultural Adjustment Act which has been with us ever since, giving growers acreage allotments and crop quotas and guarantying them an adequate price. The program has been paid for by the excise tax on tobacco, now 24 cents a pack.  That tax has been a small price for the tobacco companies to pay to preserve their prime political constituency,  the growers and all those economically tied to them.  The tobacco crop is valued at about $3 billion, only about 5 percent of the total value of agricultural crops, but it is concentrated in a few states which helps explain the vigorous political support from senior members of Congress from North Carolina, Virginia and Kentucky (a tobacco harvesting tool and framed tobacco leaves are prominently displayed in the office of Kentucky Senator Mitch McConnell).

 


The Readers’ Digest sought to keep the health issue alive in the 1930s by  launching a campaign against smoking, focusing on the dangers of nicotine and smoke.   But then came World War II and the public’s mind was on other things.  The war  probably did more for cigarette smoking than the tobacco companies could have hoped for in their wildest dreams.  Who can forget Bill Mauldin’s Willie and Joe, facing death in a foxhole with a cigarette dangling out of the corner of their mouths.  Or Paul Henreid, leaning on the rail of an ocean liner as he suavely lit two cigarettes, handing one to Bette Davis to seal their romance.  The socialization of cigarette smoking had reached its apex: a smoke meant an energizing break, a peaceful moment, glamor, companionship and  romance, whatever the smoker was up for at the moment.  Having successfully survived the war, Americans did not much worry about the health effects of cigarettes.  But the age of innocence was winding down.

 

The first comprehensive epidemiological studies demonstrating a link between smoking and lung cancer were published in 1950.  The public gradually awoke to the cancer risk although not everyone came on board.  The American Medical Association, for example, was reluctant to antagonize powerful Senators and Congressmen from tobacco states on whom it was counting for support in its fight against socialized medicine.  The American Cancer Society chose not to be persuaded to avoid offending many contributors who were enthusiastic smokers.  It was said that the ACS board was finally persuaded to take a stand when told the story of a Russian nobleman who suspected his wife of being unfaithful.  One night he told her he would be going out of town but instead secretly posted himself outside a nearby house. He saw his wife greet a handsome Guards officer at the door, saw them embrace at the window of the upstairs bedroom and saw the lights go out.  Asked why he didn’t act, the anguished count said: “Proof, proof, if I only had the proof.”

 

            Still the growing public awareness of the cancer risk confronted the tobacco companies with a dilemma.  Should they respond by offering a safer cigarette, which would amount to a damaging, perhaps fatal admission?  Or should they do nothing and risk the decline and ultimate demise of the business?  Lorillard, probably because it was so small that it could risk it, decided to capitalize on public fear and in 1952 came out with Kents, the first filter cigarette.  Kents’ micronite filter was promoted as “the greatest health protection in cigarette history.”  It reduced tar and nicotine by about half but, unfortunately, it was made of asbestos fiber.  Kents were enormously successful, forcing other brands to follow, always careful, however, to avoid reference to health concerns in promoting filter cigarettes.  Nevertheless, in only five years, by the end of the fifties, filter cigarettes held fifty percent of the market.  Polls showed that most smokers who switched to filters did so for health reasons, but many smoked more frequently, dragged more deeply and punctured the filter to compensate for the reduction in tar, nicotine and flavor in filter cigarettes, and there is no evidence that filters ever produced health benefits.  By the end of the 1950s, per capita consumption, which had slumped after the first revelations about cancer risk, had risen to 4,200, a three fold increase since the 1920s.

 

Then came the 1964 report of the Surgeon General, the watershed event in the history of smoking. The members of the advisory panel that produced the report argued long and bitterly before reaching the compromise the report reflected.  The report’s conclusion was narrow and cautious: that “cigarette smoking is a cause of lung cancer in men and a suspected cause in women, and increases the risk of dying from pulmonary emphysema.”  The 1967 report went further, stating that cigarette smoking was the principal cause of lung cancer and can cause death from coronary heart disease.  Reports in the years that followed presented more evidence to reinforce these conclusions.  Studies accumulated going beyond epidemiological evidence which merely proved association to demonstrate that cigarette smoke caused cell changes in the lungs leading to carcinoma and to heart disease through thickening of the walls of blood vessels which interfered with distribution of oxygen to the body.

 


The 1964 report and those that followed had a powerful effect on smoking in the United States.  It was fortuitous that they came at a time when the public had begun to focus on environment and personal health.  This was the time, for example, when Rachel Carson’s The Sea Around Us and Dr. Cooper’s Aerobics became best sellers.  Congress was persuaded to adopt the 1968 Labeling Act and in 1970 legislation that banned broadcast advertising of tobacco products.  Smoking started to decline.  In 1989 the Surgeon General reported that in the preceding twenty-five years, smoking among adults had decreased from 40 percent to 29 percent (it is now about 25 percent),  and that about half of all living adults who ever smoked have quit.  Prevalence of smoking varies greatly across states, however; for example, it’s 25 percent in California but 32 percent in Illinois and higher in Kentucky and North Carolina.   Annual per capita consumption has declined from over 4,000 to less than 3,000 cigarettes.

 

In response to the assault on smoking, the industry took a three pronged position:

 

1) That although there was a statistical association between smoking and cancer                and heart disease, the causal evidence was inconclusive and more studies were needed;

2) That those who smoked did so by free choice and with full knowledge of the                risks disclosed in the warnings that had since 1968 been printed on each cigarette package and advertisement;

and

3) That life was full of risks that people routinely assumed and this was just                       another risk.

 

Those arguments served the industry fairly well for a time--until last year, they could say that they had never been held liable and had never paid a judgment or settlement.  But the ground under them is starting to erode.  Clinical and other scientific evidence against smoking is now overwhelming and continues to accumulate. For example, scientists recently reported that benzo[a]pyrene, a chemical in cigarette smoke, causes genetic mutations in lung cells identical to those found in patients with lung cancer. In light of such evidence, the argument that life is risky is a bit lame since, as I have said, injury from smoking is not a risk, it is a certainty.

 

   The voluntary choice argument has until recently been an effective defense.  The companies could argue that at least since 1968, every smoker has been warned by the labels on cigarette packages and advertising.  But evidence is accumulating that casts doubt on the free choice argument.  The 1986 Surgeon General’s report, six hundred pages long, concluded that nicotine in cigarette tobacco makes smoking addictive. It described nicotine as a powerful pharmacologic agent that enters the brain through the blood stream, initiating metabolic and electrical activity as well as causing skeletal muscle relaxation and cardiovascular and hormonal effects.  Nicotine causes addiction or dependence--the report uses the terms interchangeably--which the report describes as “the behavior of repetitively ingesting mood-altering substances by individuals.”  It identified the scientifically accepted indicia of drug dependence as these:

 


1) highly controlled or compulsive use;

2) psychoactive effects;

3) drug-reinforced behavior;

4) continued use despite harmful effects; and

5) physical dependence, euphoric effects and tolerance.

 

The report asserts that “the processes that determine tobacco addiction are similar to those that determine addiction to other drugs, including illegal drugs” and that “cigarettes and other forms of tobacco are addicting in the same sense as are drugs such as heroin and cocaine.”  It does acknowledge that many smokers have quit and that some smoke only occasionally.  But this is true of illicit drugs as well, and the great majority of smokers admit that they would like to quit but have been unable to do so. 

 

The tobacco industry disputes that smoking is addictive, arguing that:

 

1) the Surgeon General’s definition of addiction is too broad and would include               such habit-forming activities as drinking coffee and jogging, and perhaps gambling;

2) smokers are able to give up smoking and have done so in large numbers;

3) true addictive drugs, unlike cigarette smoking, cause intoxication, interference              with rational thinking, and severe withdrawal symptoms;  and

4) addiction to illegal drugs usually leads to inability to maintain normal family                 lives and occupations--to equate it with habitual smoking trivializes drug addition.

 

So the argument is in part semantic, and this explains the tobacco industry executives’ denial in testimony before a Congressional committee last year that cigarettes are additive.

 

From a medical/biological perspective, whether smoking should be considered to be addictive is debatable. While it is certainly habit-forming, it is also true that the quit--ratio among smokers has climbed in the last twenty years from 25 to 45 per cent, but that still leaves the other 55 per cent who have not quit.  It is true that both nicotine and illicit drugs are psychoactive, but it does not follow that they are equivalent; after all, caffeine and jogging are also psychoactive.  Tobacco dependence is probably more easily dealt with than addiction to cocaine or heroin, partly although not entirely because the latter are criminalized, and therefore does not lead to a similar degradation of life style. At the same time, there is little question that tobacco is more deadly than illicit drugs; drug users die of overdoses and of gun shot wounds but not of cancer or heart disease, and in much smaller numbers.  So it is arguable that the immediate danger from smoking is greater than from other drugs.

 


But the main reason why the issue is important is legal.  If nicotine is addictive it is a drug and that gives the FDA regulatory jurisdiction over cigarettes as drug delivery devices.  Surprisingly, a federal district court recently ruled in favor of the FDA on that issue. The decision will be appealed but if it stands, and if Congress does not interfere, the FDA can be expected to impose substantial regulations on the industry.  It could control the amount of nicotine and require removal of certain additives such as ammonia that heighten its effect.  It would probably require larger and more frightening warning labels and prohibit certain advertising, such as billboards at sporting events and near schools, and mandate early retirement for Joe Camel and the Marlboro Man.  But attempts to impose comprehensive advertising restrictions would encounter First Amendment problems.

 

Numerous states, cities and counties, including San Francisco, have brought damage suits against tobacco companies to collect the additional costs of medical care the plaintiffs claim to have incurred because of the health effects of smoking on their citizens.  Establishing liability will be problematic, to say the least.  It will be even more problematic to prove damage caused to public agencies by smoking.  There is a pretty good argument that whatever additional health costs might have been incurred during smokers’ lifetimes are offset by the savings due their premature demise.  But settlement negotiations have been in progress for some time and reports suggest that the industry has become reconciled to some degree of regulation.

 

Even if the industry enters into an agreement with the states and perhaps the FDA, it is not likely that there can be a global settlement of the innumerable individual personal injury and death suits that have been or can be expected to be filed.  Litigation is fueled by the revelations about what tobacco companies have known and done over the years. Recently disclosed internal documents disclose not only that the companies’ own research led them to acknowledge the harm from cigarette smoking but also that they thought the problem sufficiently serious to try to develop a safe cigarette.  That project was abandoned for fear that it would be a damaging admission;  and extreme measures were taken to prevent public knowledge of the internal documents. The most damning evidence against cigarette smoking then comes not so much from the Surgeon General’s report as from the cigarette companies’ own lack of candor.  But even with this evidence plaintiffs have great difficulty, first, overcoming the fact of thirty years of warning labels and, second,  proving that more probably than not it was smoking that caused a smoker’s lung cancer and not asbestos or natural causes.

 

Though smoking has become much less prevalent, it still remains perhaps our most serious public health problem.  The principal concern is teen-age (and younger) smoking.  The vast majority of smokers take it up as teen-agers and the internal documents of the tobacco industry strongly suggest (in spite of denials) that they were looking to that market to replenish their customer base as other smokers quit or died. Still there have been encouraging statistical data: the percentage of current smokers in the 12-17 bracket declined from 25 percent in 1974 to 10 per cent in 1993; the percentage of kids in that bracket who ever smoked dropped from 52 to 35 percent.  In the 18 to 25 year bracket, current smokers declined from 50 per cent to 30 per cent.  Regrettably, and inexplicably, recent data show a reversal of the downward trend of teen-age smoking.

 


What can be done?  Our experience with enforcing the laws against drugs argues strongly against criminalizing cigarettes, even if it were feasible which it is not. We could hardly outlaw what is claimed to be a $50 billion industry responsible for some 2.3 per cent of United States employment making a product regularly used by 40 million people, some of whom are heavily dependent.

 

More stringent labeling requirements by the FDA will help though they may encounter opposition in Congress.   Although Congress in the 1970s did require rotating health warnings on all cigarette packages and advertising that state categorically that cigarette smoking causes lung cancer, heart disease and emphysema, it has refused to mandate a warning of addiction and remains generally protective of the cigarette industry.  Government-prescribed labels could also be counter-productive.  Currently the Federal Trade Commission requires disclosure of tar and nicotine content only on advertising for fear that placing it on packages would somehow lead the public to think that the government was regulating cigarettes and had approved the yields as safe.  More effective than labeling of packages would be negative advertising. This has produced good results, particularly among young people, in California and Massachusetts where it is financed by tobacco taxes.

 

           Taxes are the most powerful deterrent to smoking, particularly among teen agers.  In addition to the federal excise tax of 24 cents, state taxes range from 2 cents in Virginia to 81 cents in Washington state, averaging about 25 cents a pack.  Cigarette taxes are higher than for any product relative to its selling price and three times as high as the tax on gasoline. Still United States taxes are the lowest in the industrial world; in Canada and Great Britain the tax is over $3 and in Germany over $2 a pack.  Economists say that for every ten per cent increase in the price of cigarettes, 12 per cent fewer teen-agers will start smoking. An internal Philip Morris memo states, “It is clear that price has a pronounced effect on the smoking prevalence of teen-agers.”    The economic benefits of reducing smoking are undeniable; the Congressional Office of Technology Assessment, for example, estimated the annual cost of health care for smoking related diseases at $22 billion and the loss of wages due to smokers missing work at $43 billion, about $2 per pack.  Yet, in the present anti-tax climate, even a tax increase with the potential of generating such large public benefits faces insuperable obstacles.  Witness the defeat of the Hatch-Kennedy amendment that would have increased the federal tax by 43 cents to help pay for health insurance for children; even President Clinton, who wants to be considered the anti-smoking president, opposed it.  Senators opposed it variously because it would be unfair to teen-agers and because it would reduce cigarette purchases so much that the states would suffer revenue losses.

 


The question remains: why should the state interfere with personal freedom to smoke.  Why not let smokers kill themselves if they wish?  The strongest case for restricting individual freedom to smoke would be proof that it  also harms nonsmokers, the innocent bystanders.  The 1986 Surgeon General’s report concluded that involuntary smoking, i.e. environmental tobacco smoke (ETS) or sidestream smoke,  is a cause of disease including lung cancer in healthy nonsmokers.  It suggested that because of the magnitude of the disease risk from high dose exposure by direct smoke, i.e. the risk to the smoker, lower dose exposure by involuntary smokers may also have risks.  A 1993 EPA study concluded that ETS was a serious and substantial public health risk responsible for 52,000 deaths per year from cancer and heart disease as well as contributing substantially to the incidence of respiratory diseases.  The data underlying these studies were shaky and their conclusions were only an educated guess.  Recently, however, the results of a ten-year Harvard study tracking more than 32,000 healthy women were released, showing that women who did not smoke but were exposed regularly to cigarette smoke at home or at work had a 91 percent higher risk of heart attack than those without exposure.  Second-hand smoke damages the arteries, lowers levels of HDL cholesterol, and increases blood clotting tendencies.  The study estimates 50,000 annual deaths from heart attacks attributable to passive smoking, but only 3,000 deaths from cancer.

 

While ETS obviously is harmful, its effect depends on the facts and circumstances of each particular case, such as the degree of dilution and the frequency of exposure; it is therefore impossible at this point to make dose-based risk assessments that would permit calculating reliable cost-benefit ratios.  And control of ETS carries heavy economic and therefore political costs; consider, for example, that the Las Vegas casino industry estimates losses of from $5 to $10 billion if smoking were outlawed or severely restricted.

 

This still leaves the question whether, apart from the ETS issue, the right of individuals to smoke should be restricted.  It brings to mind Samuel Butler’s satirical 19th century novel Erehwon.  Butler created an imaginary society in which illness and disease were crimes punishable by imprisonment.  Erehwonians were held both legally and morally responsible for their physical well-being.  How far are we prepared to move in that direction--how much freedom are we prepared to sacrifice?

 

To some smoking has become a moral issue.  They see the tobacco industry as merchants of death who must be destroyed.  That is an extreme position but consider whether it is right to share in the profits of Philip Morris by owning its stock, or to accept its largesse by enjoying, say, an exhibition of the Vatican Treasures, one of the innumerable cultural events it has underwritten.  When a top officer of a leading New York museum was questioned about accepting tobacco money, his answer was, “Grow up!”  Still the line between legitimate moral concern and self-righteousness is difficult to draw.

 

As a democracy, perhaps we should be content to follow a course of moderation. 

The public is becoming aware of the health consequences as well as the social costs to smoking;  we know that people who smoke are less productive due to more frequent illness and incur higher medical costs during their life time and that their lifetime may also be shorter.  There is wide agreement that smoking is a nasty habit--most smokers will probably agree.   Smokefree buildings and public places are becoming common; San Francisco adopted the first ordinance restricting smoking in the work place in 1985.  Our culture has changed profoundly.  While in the Reagan White House, cigarettes were offered after dinner,  in the Bush White House this practice was stopped, and the Clinton White House is smoke free.  If present trends continue, the percentage of the population that smokes will shrink, though there may be an irreducible minimum given that some will always derive pleasure and satisfaction from smoking.


To what lengths should we go to make life miserable for those who continue to smoke, to deny them jobs, housing and insurance, and to penalize or stigmatize them in other ways?  The tobacco industry has a point when it equates intolerance of smokers with discrimination against other groups, a contention that resonates among minority groups.  But at what point does tolerance become reckless indifference to social harm?

 

Cigarette smoking confronts us with dilemmas.  Only time will resolve them, yet we also do not have the luxury to stand by and do nothing.

 

 

 

 

 

 

William W Schwarzer

May 1997