The Lancet: "The Harvard historian of medicine Allan Brandt begins his book with a bit of childhood nostalgia about his first trip to New York City, in 1961, and his fascination with Douglas Leigh's spectacular Camel billboard that blew smoke rings in Times Square. Everyone of a certain generation who arrived at this Centre of the World, stood in awe at the perfect smoke rings emanating from the smiling figure overhead. The 7-year-old Brandt stood, stared, and was, as all of us were, impressed. It was the perfect moment: the drama of the Great White Way, the erotic figures on the stage and on the billboard enjoying their Camels, the small boy overwhelmed by the very notion of becoming a grown-up by smoking a cigarette. As Brandt shows us this was a moment that was the culmination of the American century of the cigarette. Thereafter the glamour began to become dissipated; the erotic aspect gave way to greater and greater claims about the dangers of smoking."
In many ways the cigarette is the perfect model for understanding the 20th century. It was the product of industrialisation. James Bonsack's cigarette-rolling machines made it possible to mass produce something that had been, up to the late 19th century, the product of hand workers. The cigarette was also one of the first mass-produced products to be the subject of modern advertising, psychological testing, and marketing. The approach, advocated by American Tobacco's George Washington Hill, formulated by the advertising genius Albert Lasker, and made acceptable by Sigmund Freud's nephew, Edward Bernays, the first modern “counsel on public relations”, sold the cigarette as the symbol of the modern age. It was the pioneer in the creation of brand loyalty, with smokers purchasing status and image even more than the actual object. The Coca-Cola-isation of the marketplace was simultaneously its Camel-isation. This is also the moment of globalisation: the working relationship between American and British tobacco companies set a model for today's economy without borders.
The dangers of cigarettes were, however, also recognised early on: they were banned from sale in the state of Washington in 1893. Indeed, state condemnation of smoking had been a theme of government from the 17th century, but “luxury” taxes and state tobacco monopolies placed tobacco, and especially cigarettes, in the privileged position of being one of the most lucrative income sources for those very governments. Yet in many ways the public debates about cigarettes has had a legacy much greater than the “problem” of smoking itself. For as Brandt's extraordinary history of smoking illustrates, its primary legacy is to be found in the mantra of advertising guru John W Hill: if you don't like the science (that explains the dangers and horrors of smoking or anything else) then create the science that you need.
Brandt shows how as long as you can claim something is “unproven” you can postpone any action. It was cigarette manufacturers who pioneered the very notion of “junk science”, that is, the science that you don't like. The long, and often comic, account of the tobacco companies' struggle against the evidence of the pernicious health effects of smoking has parallels most recently in the doubters' view of phenomena as diverse as global warming and the fossil record. The argument rarely stated that there were no health risks, but rather that the health risks were “unproven” and more research (some of it good, some of it bad), paid for by special interests, was necessary. It was research done for tobacco interests that identified the carcinogens in cigarette smoke: it, of course, went unpublished and was only “discovered” (an amusing legal fiction) when the companies' records were opened during law suits against tobacco interests.
The parallel rates of increase in cigarette sales and lung cancer during the 20th century did not seem to be a compelling enough argument against the charge that the danger was “unproven”. More science was always needed; statistical proof was not “real” proof. There was a gold standard set by the bench scientists, who did the “real” science that had to be answered before “proof” was present. Brandt subtly shows how all of these claims were constructed by the tobacco industry itself. The claims for what was, and was not, “real” science in the age of statistical reasoning and bacteriology was an artifact of tobacco's interest in making every possible argument seem “unproven” and, therefore, impossible to take seriously before more work was undertaken. As Brandt notes, it was as if one should have asked John Snow to leave the handle on the Broad Street pump in 1854 until we really knew what caused the cholera, since one could not rely on mere statistics. Luckily, Snow simply took the handle with him and it was only in 1883 that the agent that caused cholera was identified and even longer before the biochemical processes of infection were adequately described.
By the mid-20th century the “little cigar” became the symbol of everything good, erotic, attractive. Nothing was left to chance in the expansion of the market to include, first women, and then, minorities. And as the market expanded the number of cases of lung cancer and various forms of lung disease expanded exponentially. But, the argument went, could there have not been another cause: more cars on the road, longer lifespan, genetic predisposition, chance. More research was always necessary.
Many serious researchers in the first half of the 20th century saw the correlation clearly. Alton Ochsner, a great American diagnostician, campaigned against smoking because there could be no other explanation for the rise in deaths from lung cancer among his patients. And the tobacco companies, as Brandt documents, fought back by arguing—well, we still need more research. By the end of the 20th century, the battle was lost: what had been erotic became disfiguring, what had been attractive had become dangerous. The western smoker had been transformed from the idealised modern citizen to the addicted, social outcast. Well, at least in general: youth rates of smoking, after decades of reduction, have started to slowly spiral upwards in the USA, perhaps because the dangers of smoking now make it even more attractive to those looking at risk as a means of confronting societal norms. Look at the newest films made in Hollywood (and indeed Bollywood): who smokes there now? The “bad” boys and girls, not the love interests—as John Milton found out Satan is always the most interesting character in the book.
Brandt ends The Cigarette Century at another point in his life. His book was a long time in its making. It was clear that a professor at Harvard University would be a great, or a devastating, witness in the many trials in the 1990s pinpointing the tobacco companies' culpability. He was approached repeatedly, but agreed to testify only when it was clear that other historians of medicine had signed on to the bandwagon. Brandt's account of his conversion from observer to activist in the light of the perversion of the “science” of history is an education in itself. For it was not only the scientists who were corrupted by their own ideological stance, or tobacco money, or the illusion of a perfect science, but this spread to those who were to somewhat objectively document these confrontations. Brandt's account reflects back on his own book and the process by which his solidly documented account evolved. The Cigarette Century is a model for the writing of engaged history: should others follow it, it would not be the worst thing for medical history.
