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Chapter 1

We sit alone in her office. She leans back, crosses her legs, and puts me—the interviewer—at ease. A cigarette would look natural in her hand.

"Now, here's an interesting story," she starts. "I go through lots of guilt about this. Neither of my parents smoked. The only person I knew who smoked was my grandfather, and he smoked a pipe.

"When I was—oh, God, in the first grade?—we found out at school how bad smoking is, and all this stuff that somehow you end up not caring about in your teen years. I remember getting down on my knees, crying and begging my grandfather to quit smoking. I told him that it was killing him. Begging him to quit smoking!

"And he did. And here I am smoking, how many years?" She doesn't quite stop to count.

"I don't smoke around him. He probably knows I smoke, but he doesn't say anything, and I don't tell him. I don't smoke before I see him, and I don't smoke until after I finish seeing him. Christmas is really difficult, because I can't wait to go have a smoke.

"Smoking was a bad thing, a horrible thing. I do it! I'm a horrible person!" She punctuates her self-condemnation by flinging up well-manicured hands and laughing. She is not a horrible person. She is merely a woman who smokes.

A Drug for All Reasons

Tobacco is everywhere and nowhere. Tobacco is clamped in the mouth of the woman in the car ahead of yours. It dangles from the fingers of the teenager walking toward you. Its stubs pack the crevices of the sidewalk at your bus stop. As you walk down a street, an elderly man walking ahead of you flips away a cigarette with a motion he has probably performed longer than you've been alive. The backpack you buy for your daughter's schoolbooks comes with a zippered cigarette case sewn into the strap. And when you rent a movie you first saw several years ago, now you notice that the good guy is smoking a cigar. You rent another movie and see that this time it's the bad guy. The night you take the garbage out to the curb, you spot a pinprick of light hovering back and forth across the neighbors' porch and realize that the neighbor boy has taken up smoking. Tobacco is everywhere, even where you are so used to seeing it that you no longer notice it.

It is also nearly invisible. Most of us don't know that every hour, around the clock and around the world, 342 people die of tobacco-related disease. One of us dies every ten seconds. Perhaps these numbers go largely unnoticed because tobacco-related disease is a veneer spread across the world, touching every country and every continent, every day. Virtually everywhere, people use tobacco; not all of them die from it. The pandemic seems selective and whimsical. Some smokers consume a pack a day until they die of an unrelated cause in their 90s. Other smokers die unexpectedly of cardiovascular disease in their 30s. Then again, so do some nonsmokers. Scientists can predict that tobacco-related disease will strike a certain proportion of users, although they cannnot predict precisely who those users will be.

Even though about three million smokers die worldwide every year, obviously they don't all die on the same day. When the disease and death are spread out across the months and years, we become inured. Perhaps if it all occurred on one cataclysmic day, in one terrible afternoon, the news media would overflow with stories of grief and waste. Instead, the ultimate and untimely losses from tobacco occur in a hospital room here, a hospice there, a home somewhere else. Scattered tragedies form a picture only when we step back statistically.

Even as the death and disease continue, some pundit criticizes the news media for portraying smokers as victims of the tobacco industry and slams the scientific community for attempting to scare smokers into stopping. It echoes the rebuke from British philosopher Roger Scruton in the Wall Street Journal: "It says something about our times that one of the only moral crusade [sic] that has the consistent backing of modern governments is directed against a source of sensual pleasure that does not directly flow, as drugs and pornography do, into the swelling river of delinquency."

Such attacks and counterattacks have become commonplace. On the news, we see that Congress will be considering a hefty hike in tobacco taxes. An hour later, a fictional hero puffs on a cigar. As he contemplates how to save one beautiful woman from going to prison, another sits at his table and orders a drink ("Make it a double"). She ignores his cigar smog; many of us less-beautiful folks who are less used to cigars would be coughing, our eyes puddling, our stomachs churning. Meanwhile, a CNN Headline News segment features cigar paraphernalia. And the same day, the Internet's Businesswire tells us that 7-Eleven stores, "the first name in convenience," will now be the "first name in premium cigars." More than 3,000 7-Eleven stores in the United States will cater to cigar smokers (the typical one is a 33-year-old college-educated male) by offering high-quality premium cigars. The price will range from $1.50 to $18. That's per cigar. And to keep cigar smokers well equipped, the stores will carry cigar cutters and butane lighters. At Christmastime, the stores will also sell humidors, cigar ashtrays, leather carrying cases, and other gift items. No 33-year-old college-educated male should be without them.

These goods ought to sell well. The chain's cigar market has grown at a rate of 47 percent per year recently.

Observers of popular culture chuckle and wave off concerns about the resurgence of tobacco's popularity. They say the cigar boom and the upsurge in youth smoking, if they are even real, are just fads, no more enduring than hula hoops. In a contrary spirit, those who follow tobacco trends see in the upswing a dangerous relaxation of the awareness of the risks of smoking; the anti-tobacco movement was slow to develop momentum and could fade quickly, they fear.

One tobacco researcher, former government scientist Jack Henningfield, expressed concern over tobacco's upsurge when he addressed a conference of psychologists in 1996. Never, he told the group, had he thought that in the mid-1990s he would be delivering the news he was about to give. Twenty years earlier, smoking was declining in the United States. Now the country's smoking decline had "basically flattened out," and, in fact, smoking appeared to be increasing for the first time in decades. Many of the scientists listening already knew it, but few had expected it. Even when tobacco use had leveled off in the mid-1990s, it was unclear at first whether that represented merely a blip in the overall downward trend, or whether it was the end of the trend.

"Four years in a row of increased [tobacco] use by young Americans," Henningfield announced, adding that the cheaper price of generic cigarettes had made them more accessible to youth. Canada's relaxation of cigarette taxation had increased rates of tobacco use there as well. On top of that, the use of smokeless tobacco, or snuff, had increased dramatically. "The demographics flipped," he explained. In the 1970s, most users of smokeless tobacco were men over 50. Now those men had died, and smokeless tobacco use had shifted to a younger population. The number of new cases and the total number of people affected were increasing.

That wasn't all of the bad news, either. Data from thousands of young smokers indicated that they wanted to quit but had little or no access to effective treatment. In two polls, about 40 percent of young smokers had expressed interest in seeking treatment to quit using tobacco, but treatment was unavailable to them. More than half of them had tried to quit but had failed.

Only a few years earlier, society and scientists alike had believed that tobacco's spell was broken. Few in the health professions would have expected tobacco use to increase following decades of public health campaigns about tobacco-related disease, after limitations on tobacco advertising, after warning labels appeared on cigarette packages, and after smoking was banned in many public places. Epidemiologists were optimistic. However, the decline in tobacco use was neither as permanent nor as pervasive as they had hoped.

In the 1960s and 1970s, smoking still embodied sophistication and finesse. Health professionals didn't treat smokers for nicotine addiction, because smoking wasn't considered an addiction. Even most scientists considered tobacco use a habit, albeit a more dangerous one than popping one's knuckles or chewing one's fingernails. A 1964 report of the U.S. Surgeon General did not apply the word addiction to tobacco use because scientific evidence was incomplete. It did, however, indicate that nicotine was the primary reinforcing pharmacologic agent in tobacco that led to continued use. Smoking was tolerated in most public and social settings. As science writer Mark Gold recalled, "A cigar after dinner and a cigarette after sex were culturally embedded in our behavior. Marlboro country was the state we all wanted to live in."

In that climate, a nonsmoker who didn't get a nonsmoking seat on an airplane could end up in the middle of the smoking section. Even though FAA regulations specified that the nonsmoking section should be expanded to meet the needs of nonsmokers, airline crews were reluctant to offend smoking passengers by moving the boundary. Similarly, people often smoked at work. Before the advent of workplace smoking bans, nonsmokers were expected to breathe secondhand smoke without complaint. When a nonsmoker forced to breathe environmental tobacco smoke developed smoke-related health problems, only the most enlightened managers created nonsmoking zones, and these were usually within a few feet of the smoking area.

Many institutions implemented nonsmoking policies in the 1980s and 1990s in response to hundreds of scientific studies exploring the health risks of environmental exposure to tobacco. The government limited tobacco advertising in broadcast media. Cigarette packaging carried health warnings. Municipalities controlled smoking in public places and on public transportation. For a time, tobacco use declined in almost every segment of the population.

Then, with the unpredictable changes of a tight election or a close ball game, tobacco use rose again. The smoking limitations remained, as if society were using them to prove it had paid its dues to health, but the culture began to turn back toward tobacco with the same winking indulgence that had allowed tobacco to become ingrained in society in the first place. This time, though, it was not in innocence or ignorance. This time, most people knew that cigarette filters didn't prevent cancer, and that menthol cigarettes weren't as safe as Ben-Gay. This time, the Surgeon General's warnings were already more prominent than the letters LS/MFT. And this time, the United States was helping spread tobacco leaves across the globe.

The U.S.S. Nicotiana

An episode of the fictional Star Trek: The Next Generation had the starship Enterprise crew encountering two symbiotic human-like groups of beings in an alien planetary system. One group, the Brekkans, produced a substance called felicium that they traded with beings on a neighboring planet. Their interplanetary neighbors, the Ornarans, were survivors of a plague that was cured with felicium. The Ornarans believed that they needed felicium to control their illness, since they sickened whenever they went without felicium.

The two groups' means of transporting goods and medicine between planets had broken down, and the Ornarans, having run out of felicium, begged the Enterprise crew to fix the broken transport. The Enterprise medical staff discovered that felicium was not treating a continuing plague but was actually an addictive drug, which the Brekkans were using to keep the Ornarans locked in a perpetual trade relationship. If the Ornarans ceased trading with the Brekkans, they would not receive their felicium and would experience withdrawal, which they had mistaken for an illness. This is exactly what the Enterprise captain then allowed to happen. He decided that he must follow his fleet's "prime directive" of noninterference and must let the consequences follow a natural outcome. The Ornarans would be forced to break their addiction to felicium. (This, predictably, made them Ornary.)

The episode probably wasn't written specifically to be about the drug nicotine, but it could have been. As with many substances that can lead to addiction or to physical dependence, nicotine is the trap or the hook in tobacco. It is believed to be the primary addictive agent among the thousands of identified compounds in tobacco. It is a major part of what keeps most smokers smoking.

Nicotine is a remarkable drug. Depending on the rapidity and the route of its delivery, it can be a stimulant or it can reduce feelings of anxiety. In high-stress times, it can calm; in down times, it can provide a mild mood elevation. It can enhance thinking and sharpen mental focus. It can help the user relax. Once a person develops physical tolerance to nicotine and overcomes an initial nausea, nicotine becomes a drug for all reasons.

Several recently published scholarly histories of tobacco trace its early use among native tribes in the Americas. The wild form of the tobacco plant Nicotiana was spread by natural events over millennia. Cultivated Nicotiana, on the other hand, appears to have been profoundly relevant to the horticultural people who cultivated and dispersed it. Only some of the species of Nicotiana produce enough nicotine for use in chewed, sucked, or smoked tobacco.

Old World Europeans, first encountering tobacco in the Americas, were unfamiliar with its use, although many plants other than tobacco had been used for chewing and inhaling throughout the world. In 1492, men from Christopher Columbus' crew visiting the northern coast of Cuba were the first Europeans to witness tobacco smoking. Various explorers recorded that natives used tobacco ceremonially by smoking a type of cigar and blowing tobacco smoke through a long pipe. Amerigo Vespucci may have seen native people chewing tobacco, but the account is unclear as to where Vespucci encountered them or what the native people were chewing. Tobacco was indeed well known to many native peoples along the northern coast of South America. In fact, a form of rolled tobacco served as money. However, more people chewed it or used it as snuff.

Europeans observing and copying the many means of taking tobacco into the body learned all too soon of tobacco's addictive properties. Unlike the native peoples who used it for sacred purposes such as enhancing fertility, predicting weather, conducting war councils, and enabling vision quests, the Europeans used it mainly because they liked using it. It also served as an analgesic for the pain associated with syphilis.

Smoking eventually came to be viewed as sinful, as its use spread throughout Europe and Asia. In some countries, smoking was punishable by mutilation or death. In other countries, tobacco quickly became a valuable crop. Despite prohibitions and condemnations, tobacco use spread rapidly. Tobacco was believed to have medicinal properties and thus was prescribed by physicians for a variety of ailments.

Tobacco was so integral to early colonial culture in North America that the first slaves purchased from Dutch slave traders were bought with tobacco. An early colonist could pay a fine, finance a marriage, or bury a deceased relative by paying in tobacco tender. Historians speculate that tobacco taxes and tobacco debts to England contributed to the unrest that led to the Revolutionary War. Tobacco also helped the colonies win that war.

We Are the World

30% adults worldwide who are regular smokers
1.1 billion number of smokers worldwide
14% fifth-grade boys in Moscow, Russia, who smoke
53% tenth-grade boys in Moscow, Russia, who smoke
28% tenth-grade girls in Moscow, Russia, who smoke
37% Caribbean men who smoke
60% men in Spain who smoke
24% women in Spain who smoke
53% women physicians in Spain who smoke
73% Vietnamese men who smoke
24.6 number of cigarettes that one can buy for the price of one McDonald's Big Mac in the U.S.
76.7 number of cigarettes that one can buy for the price of one McDonald's Big Mac in South Korea

Tobacco use continued to spread throughout the next century and a half, but the virtual explosion in smoking came after the development of machine-rolled cigarettes in the early 1880s. Automated cigarette manufacturing meant that one machine could produce thousands of cigarettes per hour, continuously. As the population of the United States swelled with immigrants, smoking expanded among the poorer classes. Tobacco taxes came and went with successive wars, but the ranks of smokers steadily increased. Many factors fanned the flames—soldiers given free cigarettes during wartime, children exposed to advertising in print and broadcast media, women assuming the male role of smoker as they assumed jobs previously held only by men. Some 4 percent of Americans' income was spent on tobacco products by the late 1920s. Tobacco seemed to ease the stresses of difficult times; even during the Great Depression, Americans who could afford few other pleasures spent nearly 7 percent of their income on tobacco. Per capita consumption of cigarettes in the United States peaked in 1960 at more than 4,000 cigarettes per person per year. U.S. consumption declined over the next several decades in the face of repeated reports of tobacco's health risks. It has now reached the pre-1950 per capita level of more than 2,500 cigarettes per capita per year—nearly 7 cigarettes per day for every person age 18 and older.

No U.S. state, even among the tobacco states, has ever approached the smoking rates of some countries outside the United States. Although tobacco has been used in many countries for centuries, the development of the machine-manufactured cigarette made cigarettes relatively inexpensive and available. Even in areas of the world where tobacco use can be traced to religious practices several hundred years old, the most widespread form of tobacco in use is the modern cigarette.

Also, cigarettes marketed outside the United States can differ considerably from their American counterparts. Cigarettes sold in the United States have lower levels of tar, as determined by machine testing, but the overall mortality risk from smoking is the same for the United States and for other countries, and has not changed in the last 30 years. Tobacco use has become widespread in countries that are ill equipped to handle extant health care problems, much less the future health needs of a nation of smokers.

The statistics worldwide are astounding. On planet Earth, some 1.1 billion people smoke. Just less than one-third of all adults in the world smoke regularly. To cite some examples:

The World Health Organization reported: "If current trends continue, the chief uncertainty about this alarming prediction is not whether there will be 10 million deaths a year from tobacco, but precisely when, during the early part of the next century." Those deaths will not only occur in old age, but will start when smokers are about age 35. Half of those who die from smoking-related causes will die in middle age, each one losing about 25 years of life expectancy.

The rise and fall of smoking rates has intertwined with public sentiment in the United States. An anti-tobacco crusade in the late 19th century brought about a ban on cigarette sales in 15 states. One of the legislative measures designed to counteract the anti-cigarette movement was the exclusion of tobacco from federal regulation under the Pure Food and Drug Act of 1906. With this precedent, the regulation of nicotine in tobacco remained outside Food and Drug Administration (FDA) regulation until the FDA recently asserted jurisdiction over tobacco.

Not So Fine, China

65% - 68% men in Hunan, Helongjiang, and Jiangsu (China) who smoke
up to 21% women in Hunan, Helongjiang, and Jiangsu (China) who smoke
one-half approximate amount of the world's tobacco that is produced in China
one-third approximate amount of the world's cigarettes that are manufactured in China
one-half proportion of the world's 1976-1986 increase in tobacco use that occurred in China
Chinese government manufacturer and seller of the majority of cigarettes in China

As tobacco has circled the world, the smoking and anti-smoking groups have circled the wagons. At the center of the antagonism is an ongoing debate about the health risks associated with tobacco use. As smokers have sued tobacco companies and state and national officials have tried to maneuver manufacturers into vast payment agreements and marketing restrictions, the public war over tobacco has made headlines. In the meantime, each smoker's private war has continued unabated.

If tobacco killed everyone who used it, or if the disease process were shorter, the debate might not be so polarized. Instead, half of the people who smoke or otherwise use tobacco do eventually die from other causes. Even so, half of all tobacco users and a proportion of those involuntarily exposed to tobacco smoke eventually suffer disease and death as a direct result of tobacco use.

A series of publications from the office of the U.S. Surgeon General entitled The Health Consequences of Smoking chronicled the risks. The subtitles tell the story:

None of these had the societal impact of the 1964 report Smoking and Health, an advisory committee report to the Surgeon General that marked the government's first substantive public stance on the health consequences of tobacco use. The 1964 publication concluded that several forms of cancer were caused by cigarette smoking, among them lung cancer and laryngeal cancer in men, and probably lung cancer in women. The report proposed that the risks for emphysema and cardiovascular disease were augmented by cigarette smoking, although the evidence for a cause-and-effect relationship wasn't yet clear.

As a result of this report and the publication of hundreds of scientific studies, the general public learned of the increased risk for lung cancer and emphysema among smokers. The succeeding volumes in the series offered thousands of pages of technical reviews of a sizable body of research literature outlining the multifaceted risks of tobacco exposure.

Big Problems in a Small World

17 million annual worldwide death rate from infectious disease
19 million annual worldwide death rate from noncommunicable disease
3 million annual worldwide death rate from tobacco-related health problems
10 million estimated annual death rate from tobacco-related health problems by years 2020 to 2030
2 million estimated annual death rate of Chinese men from tobacco-related disease by the year 2025
600 — 700 million estimated number of children who will become regular smokers, of those now living in less developed countries
200 — 300 million estimated number of children who will die someday from smoking, of those now living in less developed countries

The studies documented in these reports were conducted with considerable scientific rigor. For example, to study the benefits of quitting smoking, a researcher must first document the smoker's actual smoking status. This could be determined by biologically measuring the levels of carbon monoxide in the lungs and the amount of nicotine and its metabolites (substances resulting from nicotine metabolism) in body fluids such as saliva, urine, or blood. The extent of a smoker's tobacco use would be measured not only with questionnaires, but also by biological verification from body fluids, and, in some circumstances, even by counting, weighing, and measuring a smoker's cigarette butts. Such verification is vital in tobacco research, since the risk of tobacco-related disease is directly related to the amount of tobacco exposure.

Not Only That, But the Surfing's Great

one-fourth proportion of U.S. adults who smoke
20 average number of cigarettes smoked per day by a typical U.S. smoker
20 number of cigarettes per typical pack
more than 95% tobacco consumed as cigarettes
Kentucky state with highest rate of adult smokers (28%)
Indiana state with second highest rate of adult smokers (27%)
Utah state with lowest rate of adult smokers (13%)
California state with second lowest rate of adult smokers (16%)
Hawaii state with highest overall health rating, third lowest in smoking (18%)

Despite the rigor and the quantity of the research, some effects of exposure to tobacco remain obscure except to health professionals. For example, many people are unaware that heart attacks rival lung cancer as a leading cause of premature death in smokers. Although the overall effect is somewhat diminished in those who absorb nicotine without smoking it, as would be the case with smokeless tobacco, it is possible that the cardiovascular system is still stressed by nicotine even in those instances.

Many of the adverse health outcomes of smoking are irreversible. Even so, the title of the 1990 Surgeon General's report on tobacco use assumed an optimistic tone: The Health Benefits of Smoking Cessation. This volume documented the ways in which quitting can help most smokers, particularly those who have had cardiovascular damage. We now know that quitting smoking at any age, after any period of tobacco use, substantially reduces the risk of premature death. Quitting reduces the likelihood of disease, reduces symptoms from existing disease, and improves the prognosis for some diseases that may have already developed.

A dramatic decline in tobacco use followed the publication of the Surgeon General's series of reports. Many public and private institutions instituted smoking policies as states and municipalities adopted measures to limit involuntary exposure to tobacco smoke. For instance, a cruise line designated one of its liners to be smoke-free. Most hospitals became smoke-free even before regulations forced them to do so. By presidential decree, many federal workplaces became smoke-free. Many restaurants went smoke-free, and those that didn't often faced stiff regulations regarding ventilation of smoking areas. Before the relatively recent smoking restrictions on domestic United States air travel, passengers on commercial airplanes could never completely escape the cigarette smoke circulating throughout the plane. Even many major airports went largely smoke-free, confining the smoking public to semi-enclosed cells with separate ventilation systems, or allowing smoking only in bars.

Ads and Fads

No amount of separate ventilation, no isolation of smokers from nonsmokers, could have isolated a prospective smoker from tobacco advertising prior to the partial bans that followed the Surgeon General's reports. Tobacco advertising was so common that we all could hum the advertising jingles. Long before Joe Camel came and went, the Marlboro man was an international icon. We knew that "Winston tastes good," and that a dedicated Camel man would walk a mile for a smoke. Then those images disappeared from television and radio, and cigarette promotions no longer cluttered such unlikely places as the covers of new high school textbooks.

Smoking, however, was still visible. Not only was smoking common in television and films, but it actually became overrepresented. A disproportionately large percentage of characters in television and films were depicted as smoking, compared to the actual rates of smoking in the United States. At the same time, news media accounts of smoking underrepresented the health risks of smoking, overplaying instead the prevalence of illness and death from less common causes such as drug overdoses.

On television and in movies, tobacco still is presented as a normative behavior. Researchers Anna Hazan and Stanton Glantz at the University of California at San Francisco sampled three weeks of prime-time television programming on the major networks in fall 1992. They coded all "tobacco events," including anti-smoking messages, as they analyzed 157 programs. One-fourth of the programs contained at least one tobacco event. Overall, about one tobacco event occurred per hour of television. Dramas contained more tobacco events than comedies. The researchers determined that more than 90 percent of the depicted tobacco events were pro-tobacco. Men performed three times as many smoking acts as did women. Whites engaged in nearly 80 percent of the events. Most smokers were shown as middle class or rich, with two-thirds working in professional or technical occupations. More good guys than bad guys smoked. Little of this smoke-filled fictional universe matched the actual smoking demographics for the groups portrayed.

Hazan and Glantz also compared the television findings with a previous study they had published about tobacco use in popular films. An analysis of 62 randomly selected films from 1960 through 1990 revealed that more than one-third of the film intervals studied contained a reference to tobacco. Over the 30 years of film, the presence of tobacco was depicted with little change. The depiction of the motivation of the smokers did, however, shift with time, with relaxation a more prominent motive in the 1960s and 1980s. Major characters in the films were depicted less and less as smokers. Although most smoking was done by white characters, a small but increasing amount was done by African-American characters. Female smoking increased as well. The most dramatic increase, however, was among young smokers: Tobacco events involving characters ages 18-29 more than doubled, while smoking in the 30-45 age group was almost halved. Even though smoking among elite characters declined over the three decades studied, it remained nearly three times as prevalent as it was in the actual population.

The Smoky Screen

10 — 15 minutes time between film depictions of tobacco use, 1970s
3 — 5 minutes time between film depictions of tobacco use, 1990s
1.20 smoking depictions per hour of prime-time TV drama
92% proportion of those depictions deemed pro-tobacco
55% tobacco-using TV characters depicted as "good guys"
42% middle-class TV characters depicted as smokers
65% male movie characters depicted as smokers
relaxation movie characters' apparent motivation for smoking
doubled depiction of movie tobacco events involving relatively young characters, from 1960s to 1980s
halved depiction of movie tobacco events involving older characters, from 1960s to 1980s
business activity most popular movie smoking context
nearly three times extent to which smoking among elite movie characters exceeds its actual prevalence in the population
90% proportion of movies depicting tobacco use, 1960-1991
rarely how often moviemakers disclose what tobacco companies pay for product placement
(Hazan and Glantz, 1995; Hazan, Lipton, and Glantz, 1994;
Stockwell and Glantz, 1998.)

As the prevalence of smoking has been overrepresented in fiction, so its risks have been underrepresented in the various public media. Using a process called content analysis, researcher Karen Frost and colleagues examined such news and general readership staples as Time, Family Circle, Reader's Digest, and USA Today. They reported in 1997 that "substantial disparities" existed between actual causes of death and the amount of coverage given to those causes by print media. The most underrepresented causes were tobacco use, cerebrovascular disease, and heart disease. Overrepresented causes of death included illicit use of drugs, which received more than 17 times the news coverage that would have been proportional to its actual occurrence; motor vehicles, nearly 13 times; toxic agents, nearly 11 times; and homicide, more than 7 times.

Tobacco received only 23 percent of the expected copy. Nor was it alone in inaccurate representation: The number two health risk factor, relating to diet and physical activity, got the same amount of coverage as illicit drug use, which was the lowest ranking risk factor among causes of mortality. The authors termed these statistics "impressively disproportionate."

Why would this occur? The authors attributed it to competition for viewers and for advertising. They cited the tobacco companies' sizable advertising budgets as influencing news coverage. As they noted, "News reporting is also driven by rarity, novelty, commercial vitality, and drama." Their findings were consistent with a 1992 New England Journal of Medicine article by Ken Warner and colleagues of the University of Michigan, revealing that magazines carrying cigarette advertising were less likely to publish information about the hazards of smoking than were publications that restricted tobacco advertising.

Edith Balbach, working with Glantz at UCSF, found that money also apparently talks in unlikely places. They compared tobacco-related articles from two widely distributed elementary-school publications, Weekly Reader and Scholastic News. An event prompting their inquiry was the publication in 1994 of a fifth-grade edition Weekly Reader cover story titled "Do Cigarettes Have a Future?" Surprisingly, the article promoted smokers' rights. Controversy centered not only on the article itself, but also on the fact that the company that purchased Weekly Reader in 1991 had been the majority owner of RJR Nabisco, the second largest manufacturer of cigarettes in the U.S.

The UCSF researchers tested this question: Was Weekly Reader less likely than Scholastic News, which was family owned and not connected to tobacco interests, to mention the consequences of smoking, or to discourage tobacco use? The answer, based on the evaluation of six years of both publications, was a definite yes. Weekly Reader was more than twice as likely to give a tobacco industry position. Scholastic News was significantly more likely to include a clear no-use message. The authors recommended that health professionals monitor the information carried in both publications, which reach a combined 1 to 2 million students per grade level every week.

None other than Joe Camel appeared in full color on the cover of the February 12, 1992, sixth-grade edition of Weekly Reader. Joe showed up in Weekly Reader eight times, including once as a centerfold, in the publication's issues evaluated by the research team. Joe's presence there reflected the 1991 findings of Paul M. Fisher and colleagues that some 30 percent of three-year-olds and 91 percent of six-year-olds could identify Joe Camel as a symbol of smoking. It may be no accident that the three brands of cigarettes most smoked by young smokers are also the three most heavily advertised brands. Adults, in contrast, are more likely to choose a generic brand that is advertised less and costs less.

But advertising is not the entire story. It is not even the major part of the story. Over the last several years, tobacco companies in the U.S. have spent far more on what are called "promotions" than they have spent on conventional advertising such as magazine ads and billboards. Promotional items include sporting goods, accessories, caps, and even a wardrobe. Half of adolescents who smoke own at least one promotional item. Many are acquired through attendance at a tobacco-sponsored sporting event. (See table, p. 45.)

Light My Ire: Tobacco Titles

"All Fired Up over Smoking" (Time, 18 April 1988)
"Butt of Course: In Amtrak's Smoking Lounge, Fresh Air" (Washington Post, 6 July 1997)
"C'mon Baby, Light My Fire" (Time, 27 January 1997)
"Cigar's Glow Lighting Up Retail Scene" (The New York Times, 23 June 1997)
Cigarette Confidential: The Unfiltered Truth about the Ultimate Addiction (1996 book)
Drag (vocal album, k.d. lang, released 1997)
"First Lady Has a Nicotine Fit" (Toronto Sun, 31 August 1997)
"Git Along, Little Stogie" (Business Week, 22 December 1997)
"Hard Times at the Hard-Sell Café" (Houston Business Journal, 7 July 1997)
"Holy Smokes" (Time, 20 January 1997)
"Listening to Nicotine" (Psychological Science, May 1997)
Smokescreen (1996 book)
"Smoking Gun: A Cigarette Maker Finally Admits" (Time, 31 March 1997)
"State's Harsh Tobacco 'Fix'" (Associated Press, 5 July 1997)
The Cigarette Papers (1996 book)
"The Cigarette Papers: How the Industry is Trying to Smoke Us All" (The Nation, 1 January 1996)
"The Noxious Weed That Built a Nation" (Washington Post, 14 May 1997)
Dying to Quit (1998 book you are reading)

In some cases, the promotion is not just an item, but an ambience. A recent promotional approach geared toward young adults has aggressively and successfully pursued the young adult market. In one midwestern city, Camel (owned by RJR Nabisco Holdings, Inc.) has invested money in about two dozen bars popular among young adults. In exchange for exclusively promoting Camel cigarettes, the bars receive Camel napkins, matches, ashtrays, T-shirts, lighters, and display cases. Employees get free Camel cigarettes. Display cases, which hold only varieties of Camels, sit prominently behind the bar. Camel representatives swap a full pack of Camels with customers smoking non-Camel brands.

Camel runs full-page ads in newsweeklies to advertise the bars it has signed onto this promotional program. An ad is called a "Camel Page." Highlighting more than a dozen bars a week, it lists themes, specials, and schedules for Camel nights. Camel pays for the ads, saving each participating bar owner perhaps thousands of dollars a year. In return, Camel has an exclusive association with bars where young adults congregate to drink and smoke. The bars sell only Camels, from a veneer-and-glass display case with a backlit "Kamel" sign on top. Since vending machines could be outlawed in pending tobacco negotiations and legislation, this arrangement positions itself on the side of future legality by selling Camels from behind the bar. Eventually, that might be the only place cigarettes can be sold in bars. Some experts say that this is the tobacco industry's smartest marketing strategy yet, and perhaps the only type of promotion that would not be affected by legislation or industry settlements.

Strategic marketing success is not new to tobacco. Auburn University marketing professor Herb Rotfeld lamented such success in a 1996 commentary for the American Marketing Association's Marketing News. Rotfeld criticized the "misplaced marketing" through which public information might be distorted to the detriment of society. Firms should be allowed to sell their products, he wrote, but marketing raises the question of whether firms should be able to maximize their profits with products that negatively impact public health. "Tobacco firms are efficient marketers," his headline read, adding the provocative question, "Should they be?"

Whatever ground tobacco interests lost in the public arena because of public concern over health risks, they have regained in many private lives. The United States and some other countries take smoking seriously enough to ban it on airplanes, in restaurants, at workplaces, and in public buildings, yet many people are unwilling or unable to ban it in their own homes and vehicles. Like cultures before ours that accepted death from infectious disease as part of the human condition, we have come to accept the risk of death and disease from tobacco use as the consequence of our free agency.

Those who would be the Pasteurs, van Leeuwenhoeks, and Clara Bartons of this preventable cause of human death sometimes find themselves labeled as tyrants trying to abridge human freedom. An examination of the smokers'-rights literature shows that the sides have become deeply polarized. A 1995 report by Teresa Cardador, Hazan, and Glantz analyzed the thematic content of smokers' rights publications. The team found that the literature reflected the tobacco-control stance as a threat to individual rights and free choice. The publications sought to undermine the opposition by refuting scientific evidence related to the health hazards of secondhand (environmental) tobacco smoke. By creating legitimacy for the tobacco industry's position, the literature encouraged readers to perceive the pro-smoking side as "targets of unfair discrimination." Readers learned of political and social action movements that purportedly threatened or supported smokers' rights.

Curiously, the authors then matched the tobacco publications' themes to what is known as the "stages of change" theory, a model of the process of changes in human behavior that has been applied to smoking cessation by Prochaska and DiClementi. The four prevalent themes matched four stages of change, ranging from the pre-contemplation phase in which one is on the verge of considering a behavior change, to the stage termed action. The authors counted mentions of items in the four themes across a six-year span (1987-1992) and discovered a dramatic increase in mention of social action and efforts to undermine the opposition in the more recent years. The tobacco-control movement was characterized with what the authors termed "contemptuous language," with words such as hysteria, extremist, smoker-bashing, class hatred, victimization, alarmist, zealous, and warfare. Agencies and individuals involved in tobacco control were portrayed as "liars who ignore the truth and manipulate the public to impose their lifestyle choices on others."

Is the polarization itself changing how we perceive tobacco? As smoking disappears from public view, does its appeal increase? Author Richard Klein considered the relationship: "We are in the midst of one of those periodic moments of repression, when the culture, descended from Puritans, imposes its hysterical visions and enforces its guilty constraints on society, legislating moral judgments under the guise of public health, all the while enlarging the power of surveillance and the reach of censorship to achieve a general restriction of freedom."

As a national climate suppresses public display of tobacco use, does a smoldering cigarette take on an enticing aroma? If smoking were banal, like taking an aspirin or yawning, would famous people bother to be on the cover of Cigar Aficionado magazine, or would the magazine even exist? Does our determination to create a healthy culture make unhealthful behaviors appealing?

Answers to such questions do not come quickly or cheaply. The use of tobacco (or any other addictive substance, for that matter) is bewilderingly complex, stretching the definitions and boundaries of both psychopharmacology and behavioral science. It refuses to fit tidily in any one field, demanding instead that addiction scientists also become sociologists, anthropologists, and perhaps even publicists.

Tobacco was once used in sacred ceremonies. When tobacco left the realm of the shaman, as anthropologist Joseph Winter of the University of New Mexico believes, its powers overtook a naïve world unprepared for its hold. Each smoker struggling repeatedly to quit, each grade school child smoking a first cigarette, each of us touched by the life of someone who cannot stop using tobacco—in other words, all of us—lives with the consequence of the widespread profaning of a sacred substance.

Whatever the source of tobacco's control, it affects all who use it. For each of us who uses tobacco, the experience is unique. The sensations are as individual as a voice-print, as stylized as the tilt of an eyebrow, and as irreproducible as a kiss. To use tobacco is to use a drug, to make a statement, to march through a rite of passage, to satisfy a craving. And more.

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Copyright 1998 National Academy Press