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The Very Deadliest Habit

WHEN I FIRST picked up Robert Proctor’s history of cigarettes and the industrial giants that relentlessly purvey them, two things struck me. The first was the stunning cover jacket, which features a wonderful Van Gogh painting of a skeleton with a flaming cigarette in his mouth. The second was the book’s title. Surely another designation could have been chosen. Such a choice of words was all the more puzzling given that Proctor is an accomplished historian of Nazi medical practices and the author of two excellent books on the subject.

Moral outrage over the tobacco industry’s century-long (and counting) merchandising of death colors every word of this book, from the title page to the final entry in the index. When you finish reading this superbly contextualized and harrowing work, I predict you will not only share Proctor’s ire, you will even agree with his titular word choice. (Well, almost; and I hope not.)

Much of this story will be familiar to those who have read Richard Kluger’s Ashes to Ashes, Stanton Glantz’s The Cigarette Papers, and Allan Brandt’s The Cigarette Century. But what makes Golden Holocaust so valuable is that in the years since those fine books appeared, advances in computing and optical scanning have made the tobacco industry’s once-secret archives of memoranda, scientific studies, and outright chicanery freely available. One can now type in any search term into this massive database, and so Proctor has been able to drill this quarry deeper and wider. The result, in Proctor’s hands, is a forcefully written and genuinely alarming tour de force of history, public health, and muckraking.

It is best to begin by reviewing a few statistics, so as to better understand the global reach of such companies as Philip Morris/Altria, R.J. Reynolds, Lorillard, American Tobacco Company/Fortune Brands, and several others. Six trillion—6,000,000,000,000—cigarettes are smoked every year. That means if you placed one year’s cigarette sales end to end, you would create a chain long enough to travel from the earth to the sun and back with a couple of extra round-trips to Mars when the red planet is in near-earth orbit. But that is only a measure of volume. Without question, tobacco consumption comprises the single largest preventable cause of death. And because there is such a long tail between the point at which a smoker first picks up a pack to the point at which he develops a fatal case of emphysema, heart disease, or cancer, many of the deaths predicted today will not occur for decades.

As Proctor cogently explains, while tobacco killed “only about a hundred million people in the twentieth century,” we can anticipate a billion more deaths in the twenty-first century if trends continue as they have in the past. At present, tobacco kills some 6 million people a year, more than AIDS, malaria, and traffic accidents combined. Half of all life-long smokers will die from their habit. Every cigarette deletes seven minutes from a smoker’s life.

Cigarettes did not become a staple of daily life until the early decades of the twentieth century. Before that could happen, the industry had to make a number of “improvements” to their product. The first step was a process called “flue curing,” in which tobacco leaves were cured in low brick chimneys with closed iron pipes or flues. There were two valued results of this process when compared to the older method of simply exposing the leaves to a wood-burning fire: the risk of burning down the barn in which they were cured was reduced to a minimum, and the resultant tobacco not only turned a bright golden color but was also much milder to smoke and, hence, could be deeply inhaled. The last factor enhanced the smoker’s enjoyment of nicotine; it also made each cigarette far more deadly than pipes, cigars, or chewing tobacco.

There were other technological and merchandising advances required to create this juggernaut of disease. For a start, there was the invention of matches, which allowed for a portable, convenient, and ubiquitous source of fire; the mechanization of machines to roll and mass-produce cigarettes in a fast and inexpensive fashion; government taxation, which produced a second form of addiction in that states and the federal government grew reliant upon the taxable revenues the tobacco companies produced; the wide distribution of cigarettes to soldiers during World Wars I and II, causing millions of soldiers on both sides of these conflicts to become addicted to the product; and cutting edge mass-marketing techniques that spread sales around the world.

Proctor notes how several scientists during the 1930s, such as the Argentine pathologist Angel H. Roffo, were demonstrating that the tars extracted from tobacco caused malignant tumors in experimental animals. Although this work was convincing enough for the public health officials in Hitler’s Germany to execute a war against tobacco consumption, such experiments failed to influence more than a handful of American physicians. The tobacco companies seized upon the medical profession’s disunity on this issue as a means to exonerate the cigarette. If doctors themselves could not agree on the true causes of cancer, how could anyone blame their delightfully packaged cartons of so-called coffin nails?  

But the years after World War II were a time of major breakthroughs in epidemiological thought. In 1950, Richard Doll and A. Bradford Hill of the British Medical Research Council created a sophisticated statistical technique to document the association between rising rates of lung cancer and increasing numbers of smokers. That same year, the prominent surgeon Evarts A. Graham and a medical student, Ernst L. Wynder, published a landmark article comparing the incidence of lung cancer in their non-smoking and smoking patients. They concluded that the long-term consumption of cigarettes was an important factor in the rising numbers of lung cancer cases.

Predictably, the tobacco companies—and their expert surrogates—derided these and other studies as mere statistical arguments or anecdotes rather than definitions of causality, a ploy they continued to use well after the famed Surgeon General’s Report on the dangers of smoking in 1964. At the same time, Proctor shows, the reams of Big Tobacco’s memorandums and research materials definitively demonstrate that the industry knew all too well how dangerous their product was. In the pursuit of profits, the tobacco companies preferred to bury such information and continued to hook more potential consumers into a smoky, tarry death march.

Even when the individual state attorneys general began the series of lawsuits against the tobacco industry in the 1990s, which resulted in the Tobacco Master Settlement Agreement of 1998, these companies continued to challenge solid scientific evidence linking smoking to cancer. Initially, tobacco executives mounted a mealy-mouthed defense that since everyone by now knew cigarettes were dangerous at some level, smoking was essentially an issue of personal choice and responsibility rather than a corporate one. More famously, they testified before Congress in 1994 and denied any knowledge of the dangers of smoking. In all of the Big Tobacco lawsuits, scientists and historians of medicine were recruited to testify on behalf of Big Tobacco. These extremely well paid and ethically challenged scholars never consulted the industry’s internal research or communications. Instead they focused primarily on a small group of skeptics writing about the dangers of cigarettes during the 1950s, many of which had or would eventually have ties to the tobacco industry. These witness-scholars often denied culpability for tobacco deaths but, as Proctor rightly observes, they certainly contributed indirectly to this public health nightmare by helping tobacco lawyers to win cases, avoid expensive settlements, and thus help keep the price of a pack of cigarettes down so more people could consume them.

In the 1980s, scientists confirmed the once revolutionary concept that nicotine is extremely addictive. The tobacco companies publicly rejected such claims, even as they clandestinely took advantage of cigarettes’ addictive potential by routinely spiking them with extra nicotine to make it harder to quit. Indeed, their marketing memorandums document advertising campaigns aimed at youngsters to hook whole new generations of smokers. Sadly, that is just the tip of the filter when it comes to what is added to or included in every puff of a cigarette. From arsenic, lead, and pesticides to artificial flavorings, moisturizers, and even radioactive isotopes, Proctor paints a disgusting picture that would have sickened Upton Sinclair.

Perhaps the only optimistic portion of Proctor’s powerful account is the closing chapter on how to prevent tobacco-related deaths in the future. Given that 99 percent of such fatalities are entirely preventable, his preferred line of attack is a complete ban on the manufacture and sale of cigarettes. Proctor understands the immense political and economic obstacles facing this noble goal, but he counters potential nay-sayers with several “obvious solutions” including banning smoking in all places where people congregate, banning all cigarette marketing and advertising techniques, increasing cigarette taxes to make them less affordable, ending all tobacco subsidies, and increasing the funding and execution of tobacco prevention and cessation programs that are commensurate with the harm such products cause.

Howard Markel, the author of An Anatomy of Addiction, is the George E. Wantz Distinguished Professor of the History of Medicine at the University of Michigan.