Health Affairs, 27, no. 1 (2008): 296-297 doi: 10.1377/hlthaff.27.1.296 © 2008 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Book Reviews

In The Land Of The Smoke Drinkers

When European explorers set foot on the shores of the "new world" in the fifteenth century, they took great fascination in observing the natives igniting rolled-up dried leaves and then "drinking" the smoke.¹ The explorers returned to Europe with tobacco plants, and the odd behavior rapidly took hold throughout the continent, although not without opposition or controversy.² Indeed, with the exception of its origins in the Americas, controversy has always accompanied the use of tobacco. For example, in 1633, Turkish Sultan Murad IV implemented what is likely the world’s most draconian tobacco control policy, one that demonstrated conclusively that smoking was a health hazard: He declared the use of tobacco punishable by death and reportedly executed smokers daily.³ The fact that smoking persisted, and indeed flourished, in spite of such policies speaks volumes about the seductiveness and tenacity of the behavior.

All species, save one, instinctively flee from smoke. Humans choose to suck it into their lungs, at the peril of death. Over the past century, the U.S. citizenry has done so with particular zeal. As Allan Brandt demonstrates, Americans have been aided and abetted by an equally zealous tobacco industry.

Brandt, a professor of the history of medicine and science at Harvard University, devoted a fifth of the cigarette century to the evolution of this book. Although the book’s focus never wanders from the tobacco story per se, Brandt effectively guides the reader through the multiple impacts that this story has had on America writ large. For example, he explains how research on smoking and lung cancer helped define the field of epidemiology and, more broadly, redefine the nature of medical evidence. He elucidates the central role of tobacco in the development of the modern advertising and public relations industries and in the process shows us the myriad techniques an industry uses to manipulate the nation’s cultural life. He demonstrates the grip of special interests on Congress through the lens of one of the most powerful of those groups. And he critiques the use and intentional distortion of science to serve the ends of a greed-infested corporate interest.

Brandt divides his thirteen chapters into five sections: culture, science, politics, law, and globalization. Each theme is covered in detail, and each is graced with a mellifluous writing style that makes the detail that much more accessible. The political story is perhaps too big to be relegated to a mere three chapters; fortunately, the interested reader can consult a wealth of writings on the subject, many referenced in the book. (The book’s prodigious referencing is itself a contribution, with seventy-two pages of small-font sources for the hopelessly addicted.) Brandt does justice to the still-emerging story on the globalization of the tobacco pandemic, but we will have to await future historians’ assessment of what is undoubtedly one of the most important public health stories of the twenty-first century.

Ironically, while The Cigarette Century covers most of the major players in the tobacco story, it largely omits a critically important category: smokers. In the book, smokers are passive actors, seemingly controlled entirely by the tobacco industry. Indeed, one might conclude that were it not for the aggressive advertising, prevarications, and other nefarious tactics of the industry, smoking would simply disappear. This is a popular myth among tobacco control advocates. Yet the myth denies 2,000 years of tobacco use. It ignores the high smoking rates among Eastern European countries prior to the dissolution of the Soviet Union and in China prior to the opening to the West, when in both cases cigarette advertising was almost nonexistent. It fails to explain the widespread use in India of bidis, small hand-rolled cigarettes produced by a nearly advertising-free cottage industry. It disregards the widespread popularity of illicit drugs such as marijuana. Notably, it omits consideration of the powerful addictiveness of nicotine. And it is oblivious to the pervasive use of nicotine and smoking as a form of self-medication for the millions of smokers—approaching half of all U.S. smokers—who suffer from psychiatric comorbidities.⁴ To be sure, rates of smoking would be much lower, and disease burdens much smaller, in the absence of a powerful tobacco industry. But both would remain substantial.

Brandt lets another group off the hook: we the people. Why have we tolerated our legislators’ cozying up to an industry that knowingly commits mass murder? Why do we accept the fact that the Consumer Product Safety Commission has prohibited lawn darts, but when it considered investigating the safety of tobacco products, Congress amended its charter to remove tobacco from its purview?⁵

At its core, The Cigarette Century is a pessimistic book. Yes, tobacco remains our nation’s leading cause of death—a cause that is 100 percent preventable, at least in concept. But the successes of the nation’s antismoking campaign, and those of many countries, represent the single greatest source of lifesaving in the developed world in the past half-century.⁶ I must admit to disappointment in Brandt’s failure to devote sufficient attention to the many successes in the battle against "Big Tobacco"—the policies and practices that have turned the epidemic around in the world’s affluent nations. What are they? What have they achieved? What can we learn from them to control the tobacco epidemic in the developing world?

Curiously, the book concludes with an epilogue that recounts Brandt’s struggle with his own role in the tobacco story: whether he should risk his academic purity, and hence perceived objectivity, by serving as an expert witness in the courtroom battle against the tobacco industry. For years he refused to do so. Then in 2002, he succumbed to the need to balance what he perceived as highly biased and inaccurate expert statements by historians in the Department of Justice (DOJ) lawsuit against the industry. While the epilogue recounts important aspects of the DOJ case, Brandt’s personal story is not a major part of the cigarette century. Thus, his apologia seems an unfortunate way to end an otherwise brilliant history of a powerful industry’s role in one of the epic public health stories of our time.

Kenneth E. Warner

Editor's Notes

 
Kenneth Warner (kwarner{at}umich.edu) is the dean and the Avedis Donabedian Distinguished University Professor of Public Health at the University of Michigan School of Public Health in Ann Arbor. An economist, he has been engaged in tobacco policy research for the past thirty years.

NOTES

1. E.M. Brecher and the Editors of Consumer Reports Magazine, "Tobacco," chap. 23 in The Consumers Union Reporton LicitandIllicitDrugs, 1972, http://www.druglibrary.org/schaffer/library/studies/cu/cu23.html (accessed 21 September 2007).
2. J. Goodman, Tobacco in History: The Cultures of Dependence (New York: Routledge, 1993).
3. Ibid.
4. K. Lasser et al., "Smoking and Mental Illness: A Population-Based Prevalence Study," Journal of the American Medical Association 284, no. 20 (2000): 2606–2610.[Abstract/Free Full Text]
5. U.S. Department of Health and Human Services, Reducing the Health Consequences of Smoking: Twenty-five Years of Progress, Report of the Surgeon General, Pub. no. (CDC) 89-8411 (Rockville, Md.: U.S. Public Health Service, 1989).
6. K.E. Warner, "Tobacco Policy Research: Insights and Contributions to Public Health Policy," in Tobacco Control Policy, ed. K.E. Warner (San Francisco: Jossey-Bass, 2006), 3–86.

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