Chapter 2
A Historical Review of Efforts to Reduce
Smoking in the United States

Introduction 29

Early Events 29

The Rise of the Cigarette  30

Popularity and Protest 30
The Attraction of Cigarettes  31
Women and Cigarettes 36
Winds of Change 37

Medical Warnings 38

Public Dissemination 38
Toward a Medical Consensus  39

Turning Point: The Surgeon General's Report  40

A Stubborn Norm 40
Economic and Social Impedance  41
Delayed Effects and Delayed Actions  47
From Disease Treatment to Risk Management  42

The Diverse Momentum of the Movement to Reduce Smoking  43

Support From Business 43
The Attack on Advertising  45
Toward a National Policy to Reduce Smoking  4.5

From Antismoking to Nonsmokers' Rights  46

Regulations, Legislation, and Lobbying for Nonsmokers  46
ETS: From Annoyance to Carcinogen  47

The Impact of the Movement to Reduce Smoking  48

Conclusions 51

References 52


Reducillg Tobacco Use

Introduction

  Like many other social phenomena, the use of
tobacco has created a tapestry of themes, motivations,
and social forces, woven together with a complexity
that has begun to capture the interest of social histori-
ans (Brandt 1990; Burnham 1993; Klein 1993; Tate
1999). Tobacco has economic, social, and political
reverberations and is intimately tied to collective im-
ages and attitudes. Nonetheless, some simplification
is possible: the history of tobacco use can be thought
of as the conflict between tobacco as an agent of eco-
nomic gain and tobacco as an agent of human harm.
An exhaustive history would not be content with such
a simple contrast, but it serves the purpose of this chap-
ter. The chief barrier to reducing tobacco use-the path
of most resistance-is a powerful industry whose
efforts to promote tobacco have continued to shape
public opinion and social norms. Against this back-
ground, the chapter considers the underlying forces

Early Events

that have motivated the movement to reduce smok-
ing. Many recent events that are of critical historical
importance for nonsmoking are considered in other
segments of the report (e.g., social advocacy actions
[Chapter 71; taxation-based initiatives in states [Chap-
ter 71; Food and Drug Administration regulations re-
garding minors as the target of tobacco advertising
{Chapter 51; and proposed national legislation, settle-
ment and attempted settlement of various lawsuits
against the tobacco companies, and criminal proceed-
ings against tobacco companies [Chapter 51). As noted
in Chapter 1, some of the most dynamic changes in the
history of smoking control efforts are currently taking
place, and we are not sufficiently distanced from these
events to evaluate them fully. This chapter will con-
sider, rather, the changing thematic content-religious,
hygienic, medical, and social-of the movement to
reduce smoking that has presaged the current events.

  In North America, the history of tobacco use pre-
cedes written records. After American Indians intro-
duced tobacco to the European colonists, tobacco was
transported from the colonies to Europe, where it
quickly became a widely used consumer item. Just as
quickly, however, the use of tobacco became contro-
versial. Critics of the day attacked tobacco use as
morally irresponsible, extravagant, and a habit of
people of base condition (Best 1979). In England, King
James I published an antitobacco tract in 1604 that,
among other things, offered an early critique of sec-
ondhand smoke: the royal author expressed his con-
cerns that a husband who smoked might "reduce
thereby his delicate, wholesome, and cleane complex-
ioned wife to that extremitie, that either shee must also
corrupt her sweete breath therewith, or else resolve to
live in a perpetual1 stinking torment" (quoted in
Apperson 1916, p. 206). In many countries of north-
ern Europe, tobacco use was criminalized (Best 1979).
Part of the objection in England and elsewhere was
that trading gold to Spain for tobacco-the best tobacco

came from Spain's colonies--was dangerous to the
state economy. But with the English colonization of
Virginia and the growing need in England, and else-
where in Europe, for more state revenue, governments
turned their policies around, despite continued moral
objections to tobacco use. King James I himself set
aside his previous objections and sought ways for the
crown to profit from the tobacco trade (Morgan 1975;
Best 1979).

  Of all the novel consumer goods the New World
made available to the Old World, "tobacco enjoyed the
most rapid diffusion" (Shammas 1990, p. 801 among
people of different income levels, who bought it on
a fairly regular basis.  Closer to the source, mass
consumption was even more pronounced: in the
American colonies during the 18th century, yearly con-
sumption averaged between 2 and 5 pounds per capita
(Shammas 1990). When used medicinally, tobacco was
favorably regarded; but in its widespread use for plea-
sure, "it was considered harmful and faintly immoral"
(Morgan 1975, p. 91; see also Stewart 1967).


Sw~eorz Gerzrral's Rqmrt

  Although that reputation for immorality never   one historian reports, "helped to buy American inde-
entirely vanished, by 1776, tobacco was not only a val-   pendence" (Morgan 1975, p. 6). Thomas Jefferson
ued consumer good but also the economic foundation   thought well enough of tobacco to propose that its
of the colonies' independence movement. "King   leaves be carved into the pillars in one of the Capitol
Tobacco Diplomacy" was a central element in gaining   rotundas in Washington (U.S. House of Representa-
French support for the struggling colonies; tobacco,    tives 1969).

The Rise of the Cigarette

  Before the 20th century, tobacco was used pre-
dominantly for chewing, pipe smoking, inhaling (as
snuff), and cigar smoking. The cigarette was an inno-
vation that appeared sometime early in the 19th cen-
tury. The term "cigarette" first made its appearance
in English in the 1840s (Apperson 1916). For reasons
including cost and ease of use (discussed later in this
chapter), the product quickly caught on among tobacco
users. In the United States, cigarette smoking increased
enough during the Civil War for cigarettes to become
subject to federal tax in 1864 (Tennant 1950). But it
was not until its manufacture was mechanized that the
cigarette became a major tobacco product.

  James Albert Bonsack patented a cigarette roll-
ing machine in 1881 that, by the late 188Os, produced
cigarettes at 40 times the rate of a skilled hand worker
(Tennant 1950; Chandler 1977). The mechanization of
cigarette manufacture, like that of a number of other
products in the late 19th century (such as prepared
cereals, photographic film, matches, flour, and canned
food products such as soup), precipitated a marketing
revolution. Industries that developed "continuous
process" production (Chandler 1977, p. 249) could
increase unit production without increasing produc-
tion costs-the main production problem of the day.
The cigarette industry, like these others, could now pro-
duce almost unlimited quantities of product at mini-
mal cost per additional unit. When James Buchanan
Duke installed two Bonsack machines in 1884 and
arranged the next year an advantageous leasing ar-
rangement with Bonsack, his cigarette output soared.
Within a decade, his unit cost of producing cigarettes
dropped to one-sixth of what it had been (Chandler
1977). In 1890, following a series of price wars made
feasible by these cost savings, Duke merged with
several competitors to form The American Tobacco
Company. With the production problem solved and
competition reduced, the focus of business thinking

shifted to marketing. At a time when national adver-
tising of many products was in its infancy, The Ameri-
can Tobacco Company was innovative and expansive
in its promotional efforts (U.S. Department of Health
and Human Services [USDHHSI 1994).

Popularity and Protest

  The growing popularity of cigarette smoking
coincided with the years of populist health reform in
the 19th century. Antitobaccoism was a standard fea-
ture of various writings on personal health, which held
that any "stimulant" was unhealthy (Nissenbaum
1980). Some of these health beliefs were tied to a reli-
gious orientation. Ellen Gould Harmon White, the
prophetess who founded the Seventh-day Adventists,
spoke out strongly against tobacco. In 1848, her first
vision concerning healthful living taught her the reli-
gious duty of abstaining from tobacco, tea, and coffee.
She attacked these products for the money squandered
on them and for their dangers to health. White may
have picked up these views from Captain Joseph Bates,
a Millerite (follower of William Miller, whose
millenarian group believed that the Second Coming
of Christ would occur in 1843). Not until 1855, how-
ever, did tobacco abstention become a larger theme
among the Adventists. In that year, the group's
Reuirzu a& Herald printed two lead articles attacking
"the filthy, health-destroying, God-dishonoring
practice of using tobacco" (quoted in Numbers 1976,
p. 40).

  This protest was an integral part of the complex
antitobacco crusading at the time. In addition to the
religious motif, there was the considerable influence
of the hygiene movement, which branded "tobacco-
ism" a disease, tobacco a poison (Burnham 1989, p. 6),
and dubbed cigarettes "coffin nails" (Tate 1999, p. 24).

30 Chapter 2


Reducing Tobacco Use

Spearheaded by the American Anti-Tobacco Society,
which was founded in 1849, antitobacco critics found
tobacco a cause of ailments ranging from insanity to
cancer. During this time, cigarettes were often con-
sidered narcotics because they seemed to have addict-
ing qualities (Tate 1999). This litany of physiological
ills ascribed to tobacco use did not prove to have the
social power of the announcement, a century later, that
numerous medical studies had found a direct link be-
tween smoking and specific diseases that, as was un-
derstood only in that later century, often took decades
to manifest themselves. Between 1857 and 1872, George
Trask published the Anti-Tobacco Jozmal in Fitchburg,
Massachusetts, attacking the filth (especially of chew-
ing tobacco), the dangers to health, and the costliness
of tobacco (Tennant 1971). Early 19th century popular
health movements tended to ally themselves with
"nature" and "natural" remedies in opposition to pro-
fessional medicine; by the late 19th century, health
movements were more likely to take medical profes-
sionals as their spokesmen (Burnham 1987).

  One such professional was Dr. John Harvey
Kellogg, Seventh-day Adventist and director of the
famous Adventist-founded Battle Creek (Michigan)
Sanitarium, whose main concern was improving diet.
Kellogg argued that tobacco was a principal cause of
heart disease and other illnesses and that it adversely
affected both judgment and morals (Schwarz 1970).
Along with Ellen Gould Harmon White and her hus-
band, a Millerite preacher, Kellogg organized the
American Health and Temperance Association in 1878,
which opposed the use of alcohol, tea, coffee, and
tobacco. Later, Kellogg served as president of the
Michigan Anti-Cigarette Society and, after World War I,
as a member of the Committee of Fifty to Study the
Tobacco Problem.

  Other organizational efforts directed specifically
at cigarettes began in the last two decades of the 19th
century. These efforts were generally directed at sav-
ing boys and young men from the dangers of cigarette
smoking. In New York City, the president of the board
of education, a smoker himself, set up the Consolidated
Anti-Cigarette League and won the pledges of 25,000
schoolboys not to smoke until they turned 21 (Troyer
and Markle 1983).

  The first to call for cigarette prohibition was the
National Woman's Christian Temperance Union
(WCTU) (Tate 1999). Led by Frances Willard, a friend
of Harvey Kellogg, who was further inspired by her
brother's death from smoking-related illnesses, the
WCTU as early as 1875 made plans to instruct mem-
bers of its youth affiliate, the Juvenile Work, about the
dangers of tobacco, as well as the hazards of alcohol.

In 1883, the WCTU established the Department for
Overthrow of Tobacco Habit, which was renamed the
Department of Narcotics in 1885 (Lander 1885; Tate
1999).

  The campaign against tobacco became a perma-
nent part of the WCTU. Reports from their annual
meetings documented the accomplishments of state
and local chapters in combating smoking. In 1884, the
superintendent of the Department for Overthrow of
Tobacco Habit acknowledged the difficulty of the task
before her: "With a spittoon in the pulpit and the vis-
ible trail of the vice in countless churches, with its
entrenchments bearing the seal of respectability, its for-
tifications so long impregnable will yield slowly and
unwillingly to the mightiest opposing forces" (WCTU
1884, p. v). She noted that tobacco was a habit costing
people "more than the support of all [their] ministers
of the gospel" or than the price of educating their chil-
dren; that it caused disease, "especially the loss of sight,
paralysis, prostration, and scores of ailments hitherto
credited to other sources"; and that it "lower[ed] the
standard of morality" (WCTU 1884, p. v).

  The WCTU was one group that pressed with
some success for legislation to prohibit the sale of
tobacco to minors.' By 1890, such laws had been passed
in 23 states. Connecticut and New York enacted pen-
alties for both the underaged smoker and the merchant
who sold to the minor (WCTU 1890). In New York,
the strengthened law arose out of WCTU lobbying.
"We found so many evasions of the law as it stood,"
the WCTU reported at its annual meeting in 1890, "that
we decided our only way to save the boys was to
amend the law, so as to punish the boy who was found
using tobacco in any public place, street or resort"
(WCTU 1890, p. 185). The Department of Narcotics
organized a letter-writing campaign that mobilized
women, educators, and ministers (p. 185). By 1897,
the Department of Narcotics report could proudly
claim, "everything points to the death of the little cof-
fin nail, if our women will only continue faithful"
(WCTLJ 1897, p. 343).

`The laws prohibiting sales to minors began in New Jersey
and Washington as early as 1883, Nebraska in 1885, and
Maryland in 1886. By 1940, all states except Texas had
laws of this sort on the books (Gottsegen 1940). By 1964,
Texas had joined the list, but Louisiana and Wisconsin had
repealed their laws as unenforceable (LJSDHHS 1989).
The legality of the laws was confirmed by the United
States Supreme Court (Austi~~ zl. Ennessre, 179 US. 343,21
S. Ct. 132 [19001), and a Federal Court of Appeals ruled in
1937 to uphold the authority of local jurisdictions to ban
vending machine sales of cigarettes in the effort to protect
minors (USDHHS 1989).

Historical Reuiezu 31


Surgeor Gcrwrd `s` Report

  Announcements of tobacco's death were prema-
ture, but cigarette sales declined in the last years of
the 19th century. Most likely, the decline was precipi-
tated by the "Plug War," in which The American
Tobacco Company bought several plug tobacco pro-
ducers and sharply cut prices, attracting cigarette us-
ers back to other tobacco products. Moreover, as the
country came out of the depression of the 189Os, cigar
smokers who had shifted to the cheaper cigarettes
moved back to their preferred smoke (Sobel1978). But
the campaign against the cigarette certainly had a leg-
islative impact. Cigarettes were prohibited for both
adults and minors by law-if only temporarily-in
North Dakota in 1895, Iowa in 1896, Tennessee in 1897,
and Oklahoma in 1901. Eleven states had some gen-
eral anticigarette legislation by 1901, and almost all
state legislatures had considered curbs on cigarette
sales (Outlook 1901).

  In 1899, Lucy Page Gaston, a WCTU activist, set
up the Chicago Anti-Cigarette League (changed to the
National Anti-Cigarette League in 1901 and to the Anti-
Cigarette League of America in 1911). The league
focused on the dangers of cigarettes to boys. Gaston
sponsored frequent rallies, at which a chorus of young
nonsmoking men provided the music (Duis 1983; Tate
1999). One of the innovations of Gaston's crusade was
the establishment of a smoking cessation clinic in Chi-
cago (Troyer and Markle 1983). Gaston, whose long
career against tobacco would culminate with her bid
for the Republican presidential nomination in 1920 on
an antitobacco platform (New York Times 1920), worked
tirelessly lobbying for antitobacco legislation.

  Such legislation continued to pass, particularly
in midwestern and some western states-Indiana,
Nebraska, and Wisconsin in 1905; Arkansas in 1907;
and Kansas, Minnesota, South Dakota, and Washing-
ton in 1909. But evasion of the laws was apparently
easy. Cigarette "makings" (e.g., cigarette papers and
cigarette tobacco) were sold even if cigarettes were not,
and some retailers sold matches for a higher-than-
usual price and gave away cigarettes with them
(Warfield 1930; Sobell978). Other retailers and smok-
ers evaded the law through a product wrapped in a
tobacco leaf rather than paper (New York Times 1905).

   The WCTU was not alone in its efforts. Several
businesses and prominent individuals were outspo-
ken in the crusade against tobacco use, some going so
far as to support Gaston's proposed (and defeated)
20th amendment to the Constitution that would have
outlawed the manufacture and shipment of tobacco
products (Junod 1997). Henry Ford attacked the habit
of cigarette smoking and enlisted Thomas Edison to
investigate its dangers (Brandt 1990). According to

Harper's Weekly (1910), many railroads and other firms
would not hire smokers. Sears, Roebuck and Com-
pany and Montgomery Ward Holding Corporation
refused to employ smokers (Porter 1947-48). The Non-
Smokers' Protective League of America was estab-
lished in 1911 with a distinguished board of directors,
including Harvey W. Wiley, chief chemist of the U.S.
Department of Agriculture and father of the (1906)
Pure Food and Drug Act; James Roscoe Day, chancel-
lor of Syracuse University; and David Starr Jordan,
president of Stanford University (New York Times
1911). Dr. Charles G. Pease, a physician and dentist,
was the leader of this group. "Almost single-handed,"
according to a New York Times report (1928, p. 71, Pease
won a 1909 prohibition against smoking in the sub-
ways. In 1917, he opposed sending tobacco to Ameri-
can soldiers in Europe.

  But the New York Times reported in 1928 that "little
has been heard from Dr. Pease since" (p. 7). Indeed,
the anticigarette movement by then was waning.
Cigarette prohibition was repealed in Indiana in
1909; Washington in 1911; Minnesota in 1913; Okla-
homa and Wisconsin in 1915; South Dakota in 1917;
Nebraska in 1919; Arkansas, Idaho, Iowa, and Tennes-
see in 1921; Utah in 1923; North Dakota in 1925; and
Kansas in 1927 (Gottsegen 1940). Legislatures in other
states-including Lucy Page Gaston's home state of
Illinois-considered but did not enact anticigarette bills
(Duis 1983). Even the WCTU, at the time judged "the
most powerful and the most formidable organization
which is actively opposing the use of tobacco" (Brown
1920, p. 4471, in 1919 voted against supporting tobacco
prohibition. The organization pledged to keep to an
educational rather than a legislative campaign (New
York Times 1919).

  A major weapon against the tobacco prohibition
movement was the American soldier. Cigarettes had
been popular among the armed forces since the Civil
War. By 1918, during World War I, cigarettes were part
of the army's daily ration (Dillow 1981); soldiers used
cigarettes for relief during the extremes of tedium and
tension characteristic of the profession. General John
Joseph Pershing himself is supposed to have said, "You
ask me what we need to win this war. I answer
tobacco, as much as bullets" (quoted in Sobel 1978,
p. 84).  "The soldiers, we are told, must have their
tobacco," a newspaper editorialized in 1915: "The ciga-
rette is the handiest form in which this can be sent"
(Lymr [Mass.] Ewr7iq News 1915, p. 4). Even the Young
Men's Christian Association altered its antitobacco
stance and, along with the International Red Cross and
other charitable and patriotic organizations, sent ciga-
rettes off to the soldiers in the field (Schudson 1984).


Reducing Tobacco Use

This outspoken, soldier-directed sentiment in favor
of the cigarette was thus a large-scale factor in the
reversal of anticigarette laws. A representative ques-
tion that fueled the repeal effort in Kansas in 1927 was,
"If cigaret[te]s were good enough for us while we were
fighting in France, why aren't they good enough for
us in our own homes?" (Literary Digest 1927, p. 12; see
also Smith 1973).

  Weakened but not vanquished by these legisla-
tive setbacks, the war on tobacco persevered. In 1921,
the Loyal Temperance Legion reported holding anti-
cigarette essay contests, distributing antitobacco blot-
ters in schools, and stubbing out 125,000 cigars and
cigarettes (WCTU 1921). The Department of Narcot-
ics held up its own end; in 1929, for instance, it held
poster contests, cooperated in antitobacco work with

other civic organizations, sponsored 214 debates on
tobacco, and ran essay contests producing more than
50,000 essays against tobacco use (WCTU 1929). Reli-
gious denominations, including the Presbyterians,
Methodists, and Baptists, also took a stand against
tobacco (Troyer and Markle 1983). The antitobacco
position was especially strong among the Mormons
(Latter-day Saints). A motto of the Mormon youth or-
ganization in 1920, "We stand for the non-use and non-
sale of tobacco" (quoted in Smith 1973, p. 3601, seems
to have presaged the current low prevalence of tobacco
use in Utah.

  Such dedicated opponents did not prevent the
popularity of the cigarette-an inexpensive, easy-to-
use form of tobacco product-from increasing in the
1920s (Figure 2.1; the demographic and epidemiologic

Figure 2.1. Adult per capita cigarette consumption and major smoking and health events, United States,
       1900-1999

1964 Surgeon
General's report
1 r Broadcast ad ban
                 Coalescence of

u.3. entry
into WWII

modern advocacy
  movement

First modern

Fairness Doctrine
messages on
broadcast media

Great Depression

1940    1950    1960    1970    1980    1990

  Year

Note: The 1999 data are preliminary.
Sources: Adapted from Warner 1985; U.S. Department of Health and Human Services 1989; Creek et al. 1994;
U.S. Department of Agriculture 2000.

Historical Rezkw 33


Surgeon Getzcrtll's Report

details of cigarette consumption have been docu-
mented in detail in prior reports [USDHHS 1989,1994]
and will not be repeated here). Men in substantial
numbers either switched from other tobacco forms or
took up smoking, and women in smaller but visible
numbers began taking up tobacco use-in the form of
cigarette smoking-for the first time, even as the fre-
quently women-led antitobacco efforts continued. By
the 193Os, cigarettes accounted for more than one-half
of all tobacco consumption (Schudson 1984).
  In response to these trends, the WCTU cam-
paigned for strict enforcement of laws forbidding the
sale of tobacco to minors, attacked advertising that
claimed or suggested health benefits, and criticized
smoking among women. In 1927, the Department of
Narcotics reported that chapters across the country had
sponsored thousands of antismoking events and strat-
egies. For example, the Portland, Oregon, chapter suc-
cessfully protested a leading department store's use
of a female mannequin holding a cigarette. Members
stubbed out 219,560 cigarettes and 39,713 cigars. The
WCTU also lobbied for laws prohibiting smoking in
places where food was displayed for sale and reported
that 21 states had enacted such laws (Schudson 1993).
  As the cigarette's popularity increased, so did
concerns about its health consequences. Serious rt'-
search of the day sought to link tobacco with a variety
of conditions (Burnham 1989), but uncovered little new
ground (Tate 1999), while sobering results were often
lost amid a welter of overblown charges. For example,
the common observation at the time that cigarette
smokers seemed more dependent on their habits than
other tobacco users, now explained by increased blood
nicotine levels (`rate 1999), led one writer in 1912 to
warn that users would naturally progress from tobacco
to alcohol to morphine (Sinclair 1962). Similar unsub-
stantiated charges have often made better headlines
than the results of serious scientific studies over the
years. In 1930, one doctor claimed that 60 percent of
all babies born to mothers who smoked died before
reaching the age of two (Sinclair 1962). Smoking was
said to depress intelligence and academic achievement
(Troyer and Markle 1983). One historian writing in
1931 recalled a widely distributed antismoking poster
that wordlessly voiced these concerns by showing a
woman who had a cigarette in her mouth and was
holding a baby; the poster bore "no words-the mere
presentment, it was hoped, would have a deterrent
effect" (Corti 1931, p. 266).

  That image of mother and child projected an anti-
smoking message that, typical of its time, contained
both a moral and a medical objection to smoking. His-
torian Allan M. Brandt has observed that antitobacco

crusaders early in the century "saw no tension in see-
ing the cigarette as ungodly and unhealthy; they
equated moral dangers and health risks" (Brandt 1990,
p. 159). A 1925 WCTU pamphlet held that because the
brain's higher functions develop last, youthful smok-
ers would have "impaired morals, weak will, lack of
religious and spiritual development, and a shocking
incapacity for unselfishness and consideration of the
rights of others" (p. 9). One of the moral dangers that
remained a theme in anticigarette propaganda was the
danger smoking posed to thrift, as cigarettes were a
needless expense, especially among the poor (Brown
1920).

  Although anticigarette crusaders had medical
objections to smoking, they did not have any medical
consensus behind them. Medical opinion was gener-
ally noncommittal. Most physicians counseled that
tobacco in moderation was not harmful (Hygeia 1928;
Tobey 1930; Johnson 1932). Media reports even located
medical research that suggested that smoking had
health benefits. During World War I, army surgeons
praised cigarettes for providing the wounded relax-
ation and relief from pain (Nez(~ York Times 1918); a Paris
physician claimed that tobacco use might prevent the
development of microbial infections (Nezc, York Times
1923); and a famous mountain climber said that smok-
ing helped breathing at high altitudes (NL>ZO York Times
1922).

  Without a strong medical component, the objec-
tion against tobacco use was scarcely distinguished
from any number of other protest targets of the reform
movement early in the century. Lacking as strong an
opponent as, for example, the alcohol temperance
movement, tobacco use continued unabated. In the
instance of cigarettes, use proliferated.

The Attraction of Cigarettes

  Throughout its boom period, from the 1920s un-
til the mid-1960s, cigarette smoking was generally
regarded as a consumer activity rather than as a medi-
cal problem. In its commercial essence, the cigarette
is simply a "package," as a Philip Morris Companies
Inc. memorandum has suggested, for a "product"
(Cipollone u. Liggett Group, Inc., 505 U.S. 504, 112 S. Ct.
2608 [1992], cited in Lynch and Bonnie 1994, p. 60). In
fact, the cigarette is by far the most commercially suc-
cessful package for the product-tobacco, itself a
delivery device for nicotine-yet devised. Such think-
ing fits well with the notion that consumption is an
act of imagination-that is, that one buys not the prod-
uct but rather the attributes for which the product is
merely the vehicle (Fox and Lears 1983).

34 Clraptrr 2


Reducing Tobacco Use

  Each vehicle for nicotine delivery has different
social propensities. The unique qualities of the cigarette
as a tobacco form were critical in its role as the agent
through which tobacco use was made both available
and acceptable to all social classes. Put simply, ciga-
rettes not only made tobacco cheaper (through auto-
mated production) but also easier to use. This utility
stemmed from several distinctive features that sepa-
rated cigarettes from other modes of tobacco use and
fueled the spread of the smoking habit.

  The first distinctive feature of the cigarette is its
mildness. This attribute, along with its inexpensive
unit cost, made the cigarette especially appealing to
boys. Before the cigarette became popular, adolescent
males were likely to first try smoking by using cigars,
a practice that required a degree of skill to draw in but
not inhale the strong smoke. The unpleasant side
effects resulting from failing this tobacco rite of pas-
sage were largely avoided when new smokers tried
cigarettes, which used a milder form of tobacco that
was meant to be inhaled. Many of the legislative ef-
forts during the 1890s and after were directed not at
tobacco use generally but at cigarettes exclusively be-
cause they were so accessible to boys and young men
and because they were inhaled (Ol~tlook 1901). A 1907
Wisconsin court decision used this issue of adolescent
accessibility to justify a regulatory distinction between
cigarettes and other forms of tobacco. The cigarette,
the decision stated, was able ". . . to remove the pro-
tection which nature placed in the way of acquiring
habits of use of the more vigorous tobacco commonly
used in cigars. Before the day of the cigarette, mas-
tery of the tobacco habit was obstructed by agonies of
nausea usually sufficient to postpone it to a period of
at least reasonable maturity" (State u. Goodrich, 113
N.W. 388, p. 390 [Wis. 19071).

  Mildness was especially characteristic of ciga-
rettes smoked after the 187Os, when cigarette tobacco
was made milder by being flue-cured rather than fire-
cured. Moreover, the stronger Turkish tobaccos that
were popular in the early 20th century became unavail-
able with the interruption of trade during World War I;
thus, blended American tobaccos came into wider use,
making the cigarette an even milder product than be-
fore (Tennant 1950).

  The inhalability of the milder tobaccos used in
cigarettes is the source of a second important distinc-
tion between cigarettes and other forms of tobacco.
Because the smoke of pipes, cigars, and dark tobacco
is relatively alkaline, its nicotine dose is absorbed
through the linings of the mouth and nose. Flue-cured
"blond" or light-colored tobacco, from which Ameri-
can cigarettes are normally blended, produces slightly

acidic tobacco smoke; the nicotine dose thus must be
inhaled to be absorbed. Drawn into the lungs through
cigarette smoking, nicotine is absorbed into the sys-
temic circulation more quickly than in other forms of
smoking-hence the greater potential for nicotine
addiction (Lynch and Bonnie 1994).

  A third distinctive feature of the cigarette is its
relative convenience and disposability. This mild and
quickly consumed tobacco product seemed to contem-
poraries "peculiarly adaptable to the temperament of
the American people in an age when things are done
hurriedly and yet with greater efficiency than at any
previous time" (Young 1916, p. 119). The New York
Tinles editorialized in 1925 that the cigarette was "short,
snappy, easily attempted, easily completed or just as
easily discarded before completion-the cigarette is the
symbol of a machine age in which the ultimate cogs
and wheels and levers are human nerves" (New York
Tir~rs 1925, p. 24). Facility of use was further aug-
mented by the introduction of the safety match just
before World War I (Burnham 1989).

  In short, cigarettes had a "natural adaptability"
to the rhythms of urban life (Tennant 1950, p. 142).
Cigarettes fit more easily than other forms of tobacco
into brief moments of relaxation, they were more
readily used while working, and they were more eas-
ily managed without the use of one's hands. Ciga-
rettes helped combat the tedium of industrial work.
Particularly before workplace smoking restrictions
were widespread, cigarettes could, in the words of one
commentator, "not only help pace out a day-on the
production line, in the typing pool, behind a lunch
counter or waiting on a welfare line-but they could
give you a steady flow of small rewards to keep on
trucking" (Blair 1979, p. 33). Cigarettes organized and
controlled the passage of time; a cigarette, writes Ri-
chard Klein, is "a clock" (Klein 1993, p. 24).

  After World War I, cigarettes, which were less
costly to use than cigars or pipe tobacco, became part
of a more general "throwaway ethic" reflected in other
consumer developments of the day (Busch 1983). The
disposable razor blade came into widespread use dur-
ing and after World War I (Schudson 1984); in 1927,
U.S. wristwatch production surpassed pocket watch
production, as the more conveniently consulted wrist-
watch had won favor among soldiers (Busch 1983).

  Changing attitudes about hygiene also stimu-
lated this predilection for convenience and disposa-
bility. Between 1909 and 193645 states banned the
common drinking cup used in public facilities such
as railroads; the railroads became the first principal
customers for the paper cup and paper cup dispens-
ers (Busch 1983). Disposable sanitary napkins and

Historical Reuieul 35


Kleenex tissues also became mass-market items for the
first time in the 1920s (Busch 1983). From a strictly
hygienic perspective, the cigarette appeared to give a
cleaner smoke than the cigar. A Lucky Strike adver-
tisement directly contrasted the neatness of cigarettes
to the messiness of cigars, which require more oral
manipulation: "Spit Is an Ugly Word, but It's Worse
on the End of Your Cigar" (Tennant 1950, p. 286). This
advertisement also played on an earlier scandal in
which cigar makers were purported to have used spit
to seal the cigar's leaf wrapper (John C. Burnham, tele-
phone conversation with Richard B. Rothenberg, May
25, 1995). For a generation working in offices and
riding to work in subways, streetcars, and automobiles,
milder smoke was less irritating to others. Both the
strong fumes of cigar and pipe smokers and the
unsightly by-products of snuff and chewing tobacco
users were generally more objectionable than the
smoke and ashes of cigarette smokers. Historian
Cassandra Tate has concluded that one of the lessons
of the first antismoking campaign is that "any success-
ful social reform movement carries within it the seeds
of a backlash" while "incessant warnings can fade into
the ozone of the commonplace" (Tate 1999, p. 155).
  An important part of the cigarette's convenience
was its readiness of use. Some smokers still rolled their
own cigarettes in the 1920s and 193Os, but these con-
sumers were a small segment of the market (Tennant
1950). By far, most smokers during these key decades
of rising cigarette popularity used cigarettes prerolled
by the manufacturer. (Cigars were also prerolled, but
by hand rather than by machine, and thus at consider-
able expense to the buyer.) The cigarette's ready-made
convenience was immediately apparent when com-
pared with, for example, the care required to load a
pipe so that it burned neither too quickly (thereby over-
heating the bowl) nor too slowly (thereby requiring
frequent relighting). The cigarette was far more easily
lit and drawn than other smoked tobacco products.
  One final distinctive feature of the cigarette is
its cultural connotation as a minor moral transgres-
sion. Smoking cigarettes is-and has always been-
considered slightly illicit. A practice that "looked so
strange, felt so pleasant, accomplished so little, and
cost so much [although less than cigar or pipe smok-
ing] could not be unopposed" (Tennant 1950, p. 115).
The pleasure it offers is culturally mediated-that is,
part of the pleasure of smoking is the guilt connected
with it. None of the marketing efforts of the tobacco
giants ever fully legitimized the image of smoking-
and there is some suspicion that they never meant to
(Burnham 1993). As one sympathetic cultural observer
has put it, part of the seductive quality of the cigarette

is "beauty [that] has never been understood or repre-
sented as unequivocally positive; the smoking of ciga-
rettes, from its inception in the nineteenth century, has
always been associated with distaste, transgression,
and death" (Klein 1993, p. xi). A modern parallel is
the recent cachet of smoking as a sexual fetish, with
images available on the Internet (Hwang 1996, p. 5).
Culturally, in fact, interviews have shown that ciga-
rettes became a generational marker for the transform-
ing generation that had come of age during World War I,
as well as for the reform-minded generation of the Viet-
nam War era (Tate 1999).

Women and Cigarettes

  Several features of the cigarette helped make it a
particularly suitable product for, and symbol of, the
liberation of women, who came to smoking in grow-
ing numbers beginning in the 1920s. Just as the ciga-
rette "fairly leaped" into its rightful position as "the
smoke of manly men" with the aid of stories and pic-
tures from the World War I front ([New York] Tobacco
Leaf 1914, p. 6, quoted in Young 1916, p. 228), so for
young women after the war smoking was "perhaps
the one most potent symbol" of the new sense of free-
dom and equality (Fass 1977, p. 292). For the growing
number of women who attended college in the 192Os,
smoking was "a welcome form of notoriety" (p. 293).
Objections to women's smoking betrayed a traditional
double standard, for such opposition arose from the
twin cultural perceptions that cigarettes were not moral
and were not feminine. Smoking "implied a promis-
cuous equality between men and women and was
an indication that women could enjoy the same vul-
gar habits and ultimately also the same vices as men"
(p. 294). But while they were tokens of equality with
men, cigarettes were also amorphic, making men ap-
pear more manly and women more womanly (Tate
1999).

  Aware of (and perhaps sharing) these objections,
cigarette manufacturers were initially cautious about
targeting this potential new market. As late as 1924,
the editor of a tobacco trade journal wrote that "all
responsible tobacco opinion [found the idea of women
smoking so] novel.. . that it would not be in good taste
for tobacco men as parties in interest to stir a particle
toward or against a condition with whose beginnings
they had nothing to do and whose end, if any, no one
can foresee" (Wessell924, p. 6). Even advertisements
with women in mind did not dare picture them actu-
ally smoking.

36 Chnpter 2


Reducing Tobacco Use

  This initial caution was dictated by canny atten-
tion to the political environment. Cigarette manufac-
turers feared a backlash in legislation or public
opinion if they too aggressively sought female
consumers (Tennant 1950). In light of anticigarette leg-
islation arising during the 192Os, and particularly in
light of the ongoing experiment in alcohol prohibition,
this anxiety was reasonable.

  The cigarette industry's caution was short-lived.
As the 1920s advanced, appeals to women through
tobacco marketing were increasingly direct. In 1926,
the Chesterfield brand ran a then-controversial
advertisement wherein a woman urged a male com-
panion to "Blow Some My Way" (Ernster 1985, p. 336).
In 1927, Lucky Strike advertisements showed a famous
female opera star recommending Luckies as soothing
to the throat and a famous actress assuring readers that
Luckies did not irritate the throat (Schudson 1984).
And in 1928, Luckies were advertised with the diet-
conscious slogan, "Reach for a Lucky Instead of a
Sweet" (Ernster 1985, p. 336).

Winds of Change

  The industry's direct appeal to the new market
of female smokers likely reflected less boldness than
it did a recognition of a prevailing wind of cultural
change, of which the women's movement was only a
single component. In the 192Os, on the heels of the
19th Amendment, women's growing assertion of their
equality with men was part of a larger shift in Ameri-
car. culture, the move to a more modern culture from
the somewhat puritanical milieu that supported the
populist reform movement. In the language of one
observer, the change was from a culture of middle-class
respectability to one of "lower-order parochialism"
sponsored and encouraged by industries that catered
to the minor vices (Burnham 1993, p. 16). The 1920s
saw the triumph of "a new behavioral ethic" (Brandt
1990, p. 157), one of consumerism and self-indulgence
rather than the self-denial that had been, for example,
the traditional lot of women. Through the marketing
of cigarettes, the tobacco companies strategically ex-
ploited this development among the less puritanical
and self-recriminating members of both sexes.

  Even at the time, opinion was divided on whether
the massive marketing efforts of the cigarette giants
motivated the change toward a society of smokers
or only took advantage of a cultural and behavioral
shift already under way. In 1940, by which time the

cigarette had clearly triumphed over other forms of
tobacco, one study of the tobacco industry concluded,
"how much of increased cigarette consumption is due
to advertising and how much to fashion is impossible
to determine. The latter influence is still imponder-
able" (Gottsegen 1940, p. 204).

  Fashion and advertising were not the only two
factors. Three other matters were potentially impor-
tant: (1) the physical product itself was not a constant,
(2) the price was variable, and (3) society changed in
ways that influenced consumption. For example,
before the explosion of cigarette marketing in 1914
(Burnham 1989), men smoked more than women, the
rich smoked more than the poor, and urban dwellers
smoked more than rural inhabitants. (For a more com-
prehensive account of the demographic dynamics, see
USDHHS 1989.) With growth in the movement for
women's equality, a rising per capita income in real
dollars, and the long-term trend toward urbanization,
there would likely have been an increase in cigarette
sales even if tobacco companies had not marketed the
product aggressively.

  Regardless of what directed the impetus, per
capita consumption of all forms of tobacco was remark-
ably steady from 1913 to 1945 (Figure 2.11, rising when
real income per capita rose, falling when real income
fell (Tennant 1950). The spectacular growth in ciga-
rette consumption reflected not only the introduction
into the tobacco market of new consumer groups (such
as women) but also, as was previously noted, a major
shift among existing male smokers from other forms
of tobacco use to the cigarette. Annual per capita con-
sumption of tobacco hovered at 7 pounds from 1915
through the late 193Os, except for a transient decline
in the early 1930s that was coincident with a drop in
per capita income in the early years of the Great De-
pression (Tennant 1950). It is possible, however, that
actual consumption of tobacco per unit of weight in-
creased because of less work in both the manufactur-
ing and the use of the increasingly popular cigarette.
World War II, like World War I, served to increase and
promote cigarette smoking, to which numerous war
novels, movies, and other public images testify (Klein
1993). A 1943 treatise observed that the cigarette
achieved a heroic standing from its association with
soldiers during World War II (Gehman 1943). In short,
between about 1920 and 1950, "cigarettes became an
acceptable and noncontroversial part of U.S. life"
(Troyer and Markle 1983, p. 124).

Historical Review 37


Surgeorl Grrwal's Report

Medical Warnings

  Medical opinion at first took little heed of the
growing popularity of cigarettes. Physicians tended
to take an ambivalent or qualified position on the ciga-
rette phenomenon. For instance, although Dr. James
J. Walsh wrote in 1937, "We physicians of the older
generation who have seen the smoking of cigarettes
grow from what seemed scarcely more than a toy into
what is now one of the most significant of social insti-
tutions are under an obligation to the rising genera-
tion to warn them of the serious dangers associated
with the abuse of cigarettes in our day" (Walsh 1937,
p. 665), even Walsh admitted to smoking an occasional
cigarette himself. He further attested that many doc-
tors he knew smoked 20 or 30 cigarettes a day and yet
were "as healthy as the proverbial trout" (p. 665). He
held that "not the cigarette smoke so much as the ex-
cess of it" (p. 665) brought about serious conditions
like Buerger's disease.

  The Puritan temperament that had fueled anticiga-
rette activity early in the century was on the defensive.
Antipathy to Puritan moralism was strong enough to
weaken faith in any research tainted by it. For example,
Alton Ochsner's suggestions in the 1930s and 1940s of
a connection between cigarette smoking and lung can-
cer were discounted by his colleagues because he was
known to be "an anti-smoking enthusiast" (Burnham
1989, p. 18). During these crucial times when cigarette
smoking became widespread, "physicians tended to
absorb the common sense of the general population"
(p. 11). By the 193Os, common sense, in some measure
influenced by the advertising claims of the era, held that
smoking in moderation was not a health hazard
(Burnham 1993).

  In 1938, Raymond Pearl published one of the first
significant epidemiologic studies that indicated smok-
ing to be "statistically associated with an impairment
of life duration" (Pearl 1938, p. 217, quoted in Breslow
1982, p. 134; see also Brandt 1990). But only in the late
1940s and early 1950s did definitive evidence begin to
accumulate from various sources and studies show-
ing the association between cigarette smoking and
overall mortality. First retrospective and then large-
scale prospective studies confirmed that smoking was
associated with higher death rates; excess mortality
was especially pronounced for coronary artery disease
and lung cancer.

  In the late 1940s and early 195Os, research linked
lung cancer to smoking. The initial report by Wynder

and Graham (1950) just preceded an article by Doll
and Hill (1950). Subsequent articles by Doll and Hill
(19521, Levin (19531, and others confirmed the asso-
ciation. Levin's contribution was of particular inter-
est, because he derived the formula for attributable risk
in a footnote to the article-an overt demonstration of
the link between the smoking etiology and the emerg-
ing methodology of epidemiologic analysis.

Public Dissemination

  The findings from these and other studies of the
era were publicized in a 1952 Christian Herald article.
In December 1952, that article was reprinted in the
widely circulated magazine Reader`s Digest as "Can-
cer by the Carton" (Norr 1952). Popular concerns
aroused by this publicity apparently led to an almost
immediate decline in cigarette consumption (Tennant
1971). The decline was temporary but severe enough
to lead the tobacco companies to step up their market
promotion of the relatively new filter-tip cigarette.
Originally intended to attract new smokers by offer-
ing a milder smoking experience, the filtered cigarette
assumed a marketing prominence that was seen as a
tacit acknowledgment that there might be a health risk
in smoking (Fortune 1953). Whether for smoking com-
fort or for supposed health advantage, the market
share of filter brands increased from less than 1 per-
cent in 1952 to 73 percent in 1968 (Tennant 1971).

  The nonprofit consumer advocacy organization
Consumers Union paid attention to smoking through-
out the 1950s. Early mentions in the organization's
monthly magazine Comurner Reports, like so much
commentary elsewhere, warned only against excessive
smoking. In 1953, Consumer Reports found the evidence
connecting smoking to lung cancer "suggestive" and
recommended that until further research results were
available, "those who can" should reduce smoking to
a "moderate" level, which was defined as not more
than one pack a day (p. 74). In the same issue, how-
ever, the magazine reminded readers that smoking had
health benefits; specifically, smoking reduced "the
inner nervous tensions and strains resulting from
man's exposure to the stresses and responsibilities
imposed by society" (p. 74). Smoking, the magazine
further observed, relieved such pressure in a way less
harmful than alcohol or overeating (Consumer Reports
1953).

38 Chapter 2


Reducing Tobacco Use

  In 1954, medical advisers for Consumers Union
spoke more strongly about the research link between
smoking and lung cancer, but the organization
remained vague in its advice to smokers (Consumer
Xeports 1954). In the absence of further scientific sup-
port, this tentativeness was not surprising. It was hard
to imagine that a habit so widespread, so apparently
normal, so integrated into American culture, and so
ennobled by its wartime use could turn out to be fun-
damentally destructive. In 1954, the American Can-
cer Society's (ACS) Tobacco and Cancer Committee
adopted a resolution recognizing an association be-
tween cigarette smoking and lung cancer (Breslow
19821, but the board of directors did not consider the
possibility of a causal association. Efforts of the phy-
sician members of the board were blocked by lay mem-
bers in meetings that were themselves "filled with
smoke" (Breslow 1977, p. 849).

  By 1958, Consumers Union agreed that the medi-
cal research provided nearly definitive evidence on
the risk of lung cancer posed by smoking. The organi-
zation further argued that smokers should not try to
allay their concerns by switching to filter cigarettes, as
no evidence indicated that filters reduced the risk of
cancer. Smokers were thus advised "to cut out or cut
down" on cigarettes (Consunler Reports 1958, p. 636).

Toward a Medical Consensus

  With growing sentiment, in and beyond the
medical community, that there were serious risks to
tobacco use, government agencies became more con-
cerned about tobacco advertising that stated or implied
health benefits to the cigarette. Several times during
the 195Os, the Federal Trade Commission (FTC) issued
orders against cigarette advertising that made health
claims. Congress also took an interest in tobacco
advertising; in 1957, Representative John A. Blatnik
(D-MN) held hearings on deceptive filter-tip cigarette
advertising (Neuberger 1963). The Surgeon General
first brought the Public Health Service into the scene
by establishing a scientific study group in 1956 to ap-
praise the effects of smoking on health. The study
group determined that there was a causal relationship
between excessive smoking of cigarettes and lung
cancer. Surgeon General Leroy E. Burney issued a
statement in 1957 that "the weight of the evidence is
increasingly pointing in one direction: that excessive
smoking is one of the causative factors in lung can-
cer" (Burney 1958, p. 44). In an article he subsequently
published in the Journal of the American Medical Asso-
ciation, Burney reiterated this view and went even

further: "The weight of evidence at present implicates
smoking as the principal etiological factor in the
increased incidence of lung cancer" (Burney 1959,
p. 18351.

  Much of the medical profession, however,
remained ambivalent on the issue. In an editorial sev-
eral weeks after Burney's article, the journal itself ar-
gued against taking the Surgeon General too seriously:
"Neither the proponents nor the opponents of the
smoking theory [that cigarette smoking causes cancer]
have sufficient evidence to warrant the assumption of
an all-or-none authoritative position" (Talbott 1959,
p. 2104).

  In June 1961, the presidents of the ACS, the
American Public Health Association, the American
Heart Association (AHA), and the National Tubercu-
losis Association (later the American Lung Association
[ALA]) urged President John F. Kennedy to establish
a commission to study the health consequences of
smoking (U.S. Department of Health, Education, and
Welfare [USDHEW] 1964). Early in 1962, representa-
tives of these organizations met with Surgeon General
Luther L. Terry, who then proposed establishing an
advisory committee to assess available knowledge and
make recommendations concerning smoking and
health. In April, Terry provided the Secretary of
Health, Education, and Welfare a fuller proposal ask-
ing to reevaluate the Public Health Service's position
on smoking. Among the factors prompting his call for
action, Terry cited new studies on the adverse conse-
quences of smoking, the 1962 Royal College of Physi-
cians report (which had been summarized that year in
Reader's Digest [Miller 1962]), and other evidence of a
shift in medical opinion against smoking as well as
similar views among the national voluntary organiza-
tions. Terry also pointed to efforts to reduce tobacco
use in Britain, Denmark, and Italy; to Senator Maurine
(Brown) Neuberger's (D-OR) proposal that Congress
create a commission on smoking; and to a request from
the FTC for guidance on the labeling and advertising
of tobacco products.

  In the summer, Terry announced the appoint-
ment of a committee to review all of the data on the
medical effects of smoking. The committee was es-
tablished after consultation with representatives of
relevant government agencies, the voluntary health or-
ganizations, the American Medical Association (AMA),
the American College of Chest Physicians, and the
Tobacco Institute. Each organization was empowered
to veto any names proposed for the committee; people
who had taken public positions on the questions at
issue were eliminated from consideration.

Historical Review 39


Surgeon Ger7eral's Report

  While the committee reviewed the data, actions
were being urged or taken in response to the evidence
that had emerged. Leroy Collins, former governor of
Florida and president of the National Association of
Broadcasters, urged broadcasters in 1962 to "make
corrective moves" on their own to limit or regulate
tobacco advertising to which children might be ex-
posed. "We cannot ignore the mounting evidence that
tobacco provides a serious hazard to health," he as-
serted (Nezo York Ti777es 1962, p. 71). Also in 1962-a
busy year for efforts to reduce smoking-Air Force

Surgeon General Major General Oliver K. Niess
ordered an end to the distribution of free cigarettes in
Air Force hospitals and flight lunches (Neuberger
1963). Smoking education was a growing phenom-
enon in public schools, where materials were provided
by the ACS and other voluntary organizations. Church
groups (particularly the Seventh-day Adventists) and
temperance organizations continued their campaign
against smoking. And although the AMA remained
silent on the issue, at least eight state medical societies
had adopted resolutions on smoking and health.

Turning Point: The Surgeon General's Report

  Social movements may be precipitated or
strengthened by events that "dramatize a glaring con-
tradiction between a highly resonant cultural value
[such as health] and conventional social practices [such
as smoking]" (McAdam 1994, p. 40). Rarely in social
history, however, can a single such event be identified
as a key source of social change. The publication of
the 1964 Surgeon General's report on smoking and
health might qualify as such a rarity. The Surgeon
General's report consolidated and legitimized I5 years
of growing evidence of the dangers of smoking to
health (USDHEW 19641. Its publication "marked the
beginning of a revolution in attitudes and behaviors
relating to cigarettes" (Brandt 1990, p. 156). "Begin-
ning" should be stressed, because abandonment of
cigarettes was not precipitous. Smoking prevalence
did begin a persistent but hardly precipitate decline
in 1965 of 0.5 percent per year (USDHHS 1989).
Cigarette sales kept increasing and would not peak
until the late 1970s. Although per capita cigarette con-
sumption reached its highest level in 1963, the year
before the report's publication, it did not begin a steady
year-to-year decline until 1973 (USDHHS 1994).

  Thus, the Surgeon General's report was certainly
a pivotal event, but it did not change smoking pat-
terns overnight. Why this was so-why people did
not, upon learning of the report's findings, immedi-
ately cease either beginning or continuing to smoke-
is a complex phenomenon, even if one disregards the
major role of nicotine addiction. On the one hand,
a change in behavioral norms can be precipitated by
a change in what people generally believe. On the
other hand, people do not always act in their own

best interests, even in response to clearly stated facts
(Schudson 1984; USDHHS 19891. The outcome in a
conflict between cultural mores (in this instance, be-
liefs instilled through the social, behavioral, and physi-
ological habit of smoking; reinforced by marketing)
and scientific fact (as represented in the widely publi-
cized findings of the Surgeon General's report) often
depends on how the -latter is diffused-that is, on
whether new information can become so broadly and
effectively. transmitted and received that it .becomes
accepted knowledge that then supplants habit. As one
sociologist has observed, "The diffusion of new knowl-
edge is a major cause of collective searches for new
norms in the modern world" (Davis 1975, p. 53).

A Stubborn Norm

  In the case represented by the Surgeon General's
report, the diffusion of new knowledge was impeded
by the entrenched norm of smoking, a widespread
practice fueled by the persistent and pervasive mar-
keting of cigarettes (see "Advertising and Promotion"
in Chapter 5). During the decade preceding the
report, many social norms were established or
strengthened through the dominant new. mass
medium, television. Whatever effect television adver-
tising had on cigarette sales, the constant presence of
cigarettes both in advertisements and in the real and
imaginary lives of the medium's "stars" was a strong
force in reinforcing smoking as a norm. Furthermore,
TV-related marketing coincided with, and helped bring
to the public's attention, the availability of the filter-
tipped cigarette-thereby not only reinforcing the

40 Chapter 2


Reducing Tobacco Use

smoking norm but also helping screen the imputed
health hazards of smoking (USDHHS 1994).

  The smoking norm could be found in the most
unlikely settings and thus gave rise to considerable
cognitive dissonance. The first significant government
response to the report was the FTC's 1964 ruling that
warning labels be required on cigarette packs and that
tobacco advertising be strictly regulated (see "Attempts
to Regulate Tobacco Advertising and Packaging" in
Chapter 5). The resulting legislation that was passed,
however (the Federal Cigarette Labeling and Adver-
tising Act of 1965 [Public Law 89-9211, undermined
much of the original proposal's strength by requiring
a more weakly worded warning label than the FTC had
proposed (USDHHS 1994). Furthermore, the act not
only preempted the FTC's ruling but also prohibited
the FTC or any other federal, state, or city authority
from further restricting cigarette advertising until
after the expiration of the law on June 30,1969. In 1969,
former Surgeon General Terry would refer to the 1965
act as a "hoax on the American people" (U.S. House of
Representatives 1969, p. 267, citing Dr. Terry).

  This dissonance between legislative intent and
legislative action was detectable, in more than one
sense, in the smoke-filled congressional hearings at the
time. In 1967, for example, when Dr. Paul Kotin,
director of the Division of Environmental Health Sci-
ences, National Institutes of Health, came to testify
about the health hazards of cigarette smoking, Sena-
tor Norris Cotton (R-NH) asked, "Is it going to preju-
dice anybody if I smoke my pipe?" Dr. Kotin replied,
"I trust it won't prejudice anybody any more than my
smoking my pipe will" (U.S. Senate 1968, p. 14). Dr.
Kotin's smoking was a topic of conversation again in
congressional hearings in 1969. Dr. Kotin along with
Surgeon General William H. Stewart, Dr. Kenneth Milo
Endicott (director of the National Cancer Institute), and
Dr. Daniel Horn (director of the National Clearing-
house on Smoking and Health) came together to tes-
tify in favor of stronger health warnings on cigarette
packages and legislation requiring similar warnings
in all cigarette advertising. At one point, Representa-
tive Dan H. Kuykendall (R-TN) asked Surgeon
General Stewart, "Isn't [Dr. Kotin] one of the most
knowledgeable men in this field?" When the Surgeon
General replied affirmatively, Kuykendall returned,
"Why doesn't he quit smoking?" Kuykendall then
directly asked Kotin whether he was sure that smok-
ing a pipe did not cause lip cancer; Kotin responded,
"A risk I am willing to take, sir" (U.S. House of Repre-
sentatives 1969, p. 167). The next day, Representative
Tim Lee Carter (R-KY) observed that, in fact, all four
of the men in the delegation, including the Surgeon

General, were smokers (U.S. House of Representatives
1969). Actions undermine words, and scenes such as
these were symbolic of a strong wish not to believe in
the health consequences of smoking. Given that the
nation's chief health policymakers did not, or were not
able to, apply to their own behaviors the very evidence
they had gathered, the strength with which the smok-
ing norm persisted among the general population is
more easily comprehended.

Economic and Social Impedance

  General economic conditions also supported the
continuation of smoking. The 1960s and early 1970s
was a time of general prosperity. Real cigarette prices
rose in the 1960s but declined in the 1970s (USDHHS
1994). The affordability of cigarettes increased from
1965 to 1980 and served as an economic counterweight
to the growing awareness of tobacco's ill effects (Lynch
and Bonnie 1994) (see also "Effect of Price on Demand
for Tobacco Products" and "Taxation of Tobacco Prod-
ucts" in Chapter 6).

  Another compelling social condition may have
further limited the initial impact of the Surgeon
General's report. From the early 1960s to 1973, Ameri-
can military personnel were engaged in Vietnam.
During this period, 8.7 million Americans served in
the military, including 2.7 million in Vietnam (Moss
1990). Whether the Vietnam War encouraged smok-
ing has not been a topic of speculation, probably
because of that war's more publicized role in suppos-
edly encouraging the use of marijuana and other drugs
(Klein 1993). But the norm of smoking would only
have been strengthened by the mobilization of a large
military force bringing several million young men and
women into a setting where smoking was tradition-
ally held to offer relief from both stress and boredom,
and where it was part of a lingering cultural image of
the heroic soldier. Moreover, the prevalence of ciga-
rette smoking was and has remained higher in the
military than in the population at large (in 1992,35 vs.
26 percent) (Lynch and Bonnie 1994).

Delayed Effects and Delayed Actions

  A significant biologic explanation for the delayed
effect of the 1964 report can be found in the delayed
progression of smoking-related diseases, which
generally take substantial time to fully manifest
themselves in chronic illness and death. The cigarette's
tremendous growth in popularity during the decades
preceding the Surgeon General's report would thus

Historical Rezlieup 41


Srrrgeo77 Gcrreral's Report

have only begun to show its vast health consequences.
In 1965, an estimated 180,000 persons died from
smoking-related diseases (USDHHS 1989); over the
next two decades, that yearly estimate increased to
337,000, even though smoking prevalence had been
steadily declining since the early 1970s (USDHHS
1989). First-time or long-time smokers in the mid-1960s
to mid-1970s thus had far less opportunity than the
next generation to personally witness the tragic but
convincing demonstration of the health consequences
of smoking. It might be hypothesized that this som-
ber proof of the Surgeon General's report at last evoked
a meaningful response among the surviving relatives
and friends of the deceased.

From Disease Treatment to Risk
Management

  Another possible reason for the delayed response
to the Surgeon General's report was its less-than-
traditional medical perspective. The report's medical
researchers were reporting not the kind of traditional
clinical data that physicians were used to encounter-
ing in their literature but rather data from epidemio-
logic studies that indicated the risks of smoking.
Eventually, such data would be persuasive enough to
mark a perceptual shift to "a new kind of numeracy
among medical researchers and clinicians alike"
(Burnham 1989, p. 19). But in 1964, most physicians
were not prepared to understand-much less be per-
suaded by-the epidemiologic data represented in the
report, nor to incorporate a public health model into
their medical practice.

  Accordingly, the medical profession did not
quickly jump on the smoking reduction bandwagon
that began rolling with the Surgeon General's report.
The American Medical Association Alliance House of
Delegates, in fact, refused to endorse the report when
it appeared in 1964 (Burnham 1989). Medical person-
nel increasingly warned people against smoking, but
this precept did not carry over into practice. In 1964,
smoking remained as acceptable in medical settings
as it was elsewhere. Moreover, although 95 percent of
physicians in that year saw smoking as hazardous, 25
percent continued to smoke (Burnham 1989); even by
the mid-1970s, nearly one in five physicians was a
smoker (Nelson et al. 1994). The AMA was criticized
by other health organizations for not taking a more
aggressive stance to reduce tobacco use. As late as
1982, for example, the association was faulted for help-
ing prepare for Newszueek a 16-page "personal health
care" supplement, in which the only advice provided

on smoking was that a smoker should discuss the risks
with a personal physician and should refrain from
smoking in bed (Iglehart 1984). Soon thereafter, the
AMA had become an active advocate (see "Toward a
National Policy to Reduce Smoking," later in this chap-
ter). By 1990-1991, only 3.3 percent of physicians
smoked, although smoking rates among nurses were
significantly higher (Nelson et al. 1994).
  Some social critics of the time tacitly welcomed
what they saw as a rare reluctance by the establish-
ment to embrace a social movement. Sociologists and
other outside observers of American medicine had
noted a previous tendency of the establishment to
"medicalize" social problems, such as tobacco use and
alcohol abuse. From this perspective, medicine was
viewed askance as an "institution of social control,"
as a "new repository of truth, the place where abso-
lute and often final judgments are made by suppos-
edly morally neutral and objective experts" (Zola 1972,
p. 487). Implicit in this criticism was the fear that the
medical establishment was using its considerable
clout-its professional domination of the world of
facts-to translate all social ills into clinical terms that
could be treated in a clinical setting. One such critic,
medical sociologist Eliot Freidson, wrote that the phy-
sician who calls alcoholism a disease "is as much a
moral entrepreneur as a fundamentalist who claims it
is a sin" (Freidson 1974, p. 253).

  But the medical establishment's initial hesitancy
to join the movement to reduce smoking likely had
little to do with scruples about overstepping its pur-
view. There is no dispute that cancer is a disease and
little dispute that the medical profession is the expert
social authority for defining and treating it. The "moral
entrepreneurship" of the Surgeon General's 1964 re-
port was not to declare cancer a medical problem but
rather to declare smoking a health risk-hence the cen-
tral position of epidemiologic data in the report.

  Thus, while organized medicine followed slowly
and sometimes reluctantly in the wake, and while so-
cial skeptics worried about the Orwellian implications,
a battery of public health officials, politicians, and con-
sumer advocates, armed with the findings of the Sur-
geon General's report, moved against the persisting
social and medical problem of smoking. Ultimately,
the broad cultural current that distrusted medical moral
entrepreneurship embraced these efforts. The "de-
medicalizing" movement, which sought to make health
care both a personal matter and a political matter rather
than one wholly under the guardianship of physicians
(Starr 1982), supported a practice of medicine that took
a preventive stance instead of an exclusively therapeu-
tic one. Preventive action-to prevent smoking, and

42 Chapter 2


thereby to prevent unnecessary illness and death from   called for in the epidemiologically based recommen-
smoking-related illnesses-was precisely the solution   dations of the 1964 Surgeon General's report.

The Diverse Momentum of the Movement to Reduce Smoking

  Another reason for the languid pace of change
in smoking prevalence after 1964 is that it took time to
assemble an active dissemination and lobbying force
around the Surgeon General's report. In the present
period, so many different groups are active in anti-
smoking activity, and so many different strategies are
operating, that sorting them becomes difficult. Since
1964, the campaign to reduce smoking refers to "the
entirety of changes in the social environment spawned
by scientific and social interest in the hazards of smok-
ing" (Warner 1989, p. 144); this movement covers not
only specific activities but also "the changing social
norms that have accompanied them" (p. 144). The span
of activities involves persons, private organizations,
and government agencies, all with different motiva-
tions: those ideologically committed to a movement
to reduce smoking, those who operate profit-making
businesses, those seeking public office, and those in
public office who mandate laws and regulations.
Important actors have included national health orga-
nizations, medical researchers, organized medicine,
government regulatory agencies and health depart-
ments, school officials, voluntary organizations in
health, lobbying groups for reducing smoking, private
firms dealing with the health or insurance needs of
employees, smoking cessation clinics, and individual
medical practitioners.

  The industry-funded Tobacco Institute began
distributing smoking education materials in 1984
KJSDHHS 19941, although with a different agenda. For
example, the institute's "It's the Law" program pur-
ports to discourage minors from purchasing cigarettes
(Tobacco Institute 19901, but the program focuses on
the legal responsibilities of the purchaser rather than
the vendor, characterizes smoking as an "adult behav-
ior" (which may make it more attractive to adoles-
cents), does not address the dangers of smoking, and,
in one assessment, was ineffective in preventing ille-
gal sales (DiFranza et al. 1996).

  The work of the Tobacco Institute highlights what
may be the foremost obstacle to changing the social
norm of smoking: the multifaceted actions of the

industry in preventing prevention. In an analysis of
tobacco industry tactics, the Advocacy Institute (1995)
has defined nine areas of activity: intimidation, alli-
ances, front groups, campaign funding, lobbying,
legislative action, buying expertise, philanthropy, and
advertising and public relations (see the text box). In
its discussion of well over 100 instances in these areas,
documented largely from media reports, the Advocacy
Institute does not accuse the tobacco industry of ille-
gal activity but rather of a far-ranging and systematic
effort to ensure the continued use of tobacco. Taken
together, and backed by the enormous resources of the
industry, these efforts have considerable impact in pro-
moting tobacco use and retarding efforts to reduce or
prevent it. Because of the considerable litigation now
directed at the industry, however (see Chapter 51, the
public is more aware of these efforts and may prove
more resistant than previously to this powerful com-
mercial s:lbterfuge.

Support From Business

  The supportive role of businesses in the move-
ment to reduce smoking probably did not arise from a
spontaneous realization that preventive measures
could improve employee health. Already shoulder-
ing new costs from complying with health-related (but
non-tobacco-related) new federal legislation, such as
the Occupational Safety and Health Act of 1970 (Pub-
lic Law 91-596) and the Toxic Substances Control Act
(1976) (Public Law 94-4691, many companies in the
1970s sought ways to control the rapidly rising costs
of health care (Iglehart 1982). Supporting or enacting
policies to curb a proven health risk (such as smok-
ing) that had expensive consequences simply made
good business sense.

  A special case is insurance. Beginning with State
Mutual Life Assurance Company of America in 1964,
life insurance companies began offering discounted
policies for nonsmokers (Cowell 1985). By 1987,
approximately 80 percent of life insurance companies
offered discounts to nonsmokers (Schauffler 1993).


Framework of Tobacco Industry Tactics

T he Advocacy Institute has developed an overview of tobacco industry strategy, with extensive docu-
mentation taken from current media reporting. The documentation provides examples of each of the

strategies listed below.

I. Intimidation

A. Legal (harassing suits, subpoenas, in-
junctions, outspending plaintiffs)
B. Economic (withdrawal of advertising,
withdrawal of business operations)
C. Political (retribution directed at elected
  and other officials)

D. Personal (harassing researchers, advo-
cates, and reporters)

II. Alliances

A. Strong allies (subsidiaries, trade asso-
ciations, advertising industry, tobacco
  farmers)
B.  Weak allies (labor unions, lawyers' asso-
  ciations, doctors' associations)

III. Front Groups

A. Political groups (Michigan Citizens for
  Fair Taxes, Californians for Statewide
Smoking Restrictions)
B. Scientific groups (Council for Tobacco
Research U.S.A. Inc., Healthy Buildings
  International)
C. Smokers' rights groups (National Smok-
  ers Alliance)

IV. Campaign Funding
A. Candidate funding
  B.  Continued contributions after election
C. Direct funding of interest groups and
      caucuses

D. Political party funding
E.  Funding state ballot initiatives, or fund-
ing opposition to initiatives

V. Lobbying
  A. Support of lobbyists at state and national
    levels

B. Seeking alliances with other lobbying
groups on specific issues
C. Gifts and contributions to specific causes
D. Generating grassroots activity

Source: Advocacy Institute 1995

VI.

Legislative Action
A. Preemption

B. Weakening or diluting legislation, or
making it unenforceable
C. Adding unrelated clauses to, or chang-
ing, the contents of legislative bills
D. Shifting debate (stressing personal free-
dom rather than health; promoting smok-
ers' rights)

VII. Buying Expertise
  A. Enlisting outside experts (economists,
    epidemiologists, medical researchers,
    statisticians, legal counsel)
  B. Creating the Council for Tobacco Re-
     search U.S.A. Inc.

VIII. Philanthropy
   A. Buying innocence by association (finan-
    cial support to wide range of organiza-
     tions)
   B.  Funding (women's groups, racial and eth-
    nic minority groups, homeless shelters,
    acquired immunodeficiency syndrome
    [AIDS] groups, arts groups, educational
    initiatives, community-based nonprofit
    organizations, sporting events)

IX. Advertising and Public Relations
A. Issue framing (choice, civil rights, per-
    sonal freedom)
  B.  Advertising to promote corporate char-
     acter
  C.  Disinformation (health effects, economic
   importance of tobacco)

44 Chapter 2


Health insurance rates, in contrast, have not typically
distinguished between smokers and nonsmokers.
Acceptable actuarial data on additional medical ex-
penses incurred by smokers did not exist until the early
1980s; at present, discounts for nonsmokers or sur-
charges for smokers have not been widely adopted by
health insurance companies (Schauffler 1993). None-
theless, both the health insurance and the life insur-
ance industries have become active in smoking-related
public policy. In 1977, the trade associations of the
two industries formed the Center for Corporate Pub-
lic Involvement to take up public policy issues that
affected them. By 1980, the organization was urging
its members to adopt workplace nonsmoking policies,
and by 1984, it had become an active lobbyist support-
ing legislation to reduce tobacco use (Schauffler 1993).

The Attack on Advertising

  In the 1970s and 198Os, the movement to reduce
smoking was in part the work of grassroots activity, in
part the work of professional consumer advocates, and
in part the work of the public health bureaucracy. In
1966, a complaint filed with the Federal Communica-
tions Commission (FCC) by John F. Banzhaf III called
for the application of the Fairness Doctrine to man-
date repIy time to cigarette advertising on television
and radio broadcasts (see also "Attempts to Regulate
Tobacco Advertising and Packaging" in Chapter 5).
The FCC agreed with Banzhaf's complaint and on June
2,1967, ordered broadcasters to provide "significant"
air time for antismoking messages. Banzhaf, antici-
pating and forestalling an almost certain appeal from
the tobacco industry, appealed his own victory
(Whiteside 1971). Under the guise of seeking equal
rather than significant broadcast time, Banzhaf
succeeded in having his original ruling upheld and
in having its application specified: television and
radio stations were required to run one counter-
advertisement, free of charge, for every three cigarette
commercials. This policy lasted until 1971, when a ban
on cigarette broadcast advertising went into effect.

  The campaign to ban or regulate cigarette adver-
tising has been one of the most visible and emotion-
ally compelling of all the subthemes in the campaign
to reduce smoking. (Highlighted in this section, this
theme is discussed in greater detail in "Attempts to
Regulate Tobacco Advertising and Packaging" in
Chapter 5.) All along, opponents have apparently "re-
sented most of all the ubiquity and presumed power
of cigarette advertising" (Patterson 1987, p. 224). These
critics have argued that advertising is a powerful force
blinding Americans to the health consequences of

smoking, but the tobacco industry has maintained a
vigorous defense of its right to advertise (Patterson
1987).

  In 1969, congressional hearings considered ban-
ning cigarette advertising on television and radio;
strengthening health warnings on packages; extend-
ing the warnings to all cigarette advertising; and
ending the preemptive ban on FTC, state, and local
regulatory activity. This time, the tobacco industry did
not benefit, as they had during hearings in previous
years, from the hesitancy of those conducting the hear-
ings. Since 1964, public concern about the health haz-
.ards of smoking had been growing, and although the
tobacco industry had powerful supporters in the U.S.
House of Representatives, in the Senate, Warren Grant
Magnuson (D-WA) and Frank E. Moss (D-UT) were
canny and committed antagonists. Recognizing it
would have to make some concessions, the industry
agreed to a television and radio advertising ban.

  This concession may not have been unwilling.
There is some indication that since the Fairness Doc-
trine was invoked in 1966, the resulting counter-
advertisements were hurting cigarette sales more than
the cigarette commercials were helping (Hamilton
1972). With the.passage in 1969 of the Public HeaIth
Cigarette Smoking Act (Public Law 91-222), which con-
tained the ban on cigarette advertising on television
and radio, the counteradvertisements vanished.. The
tobacco industry shifted its advertising to print and,
perhaps even more notable, shifted its marketing bud-
get from advertising toward promotion. The latter
move exposed vast audiences to cigarette brands
through techniques such as sponsoring sports events
and, later, merchandising brand-touting items such as
T-shirts and caps. Nonetheless, the elimination of ciga-
rette advertising from the nation's most powerful
medium was at the very least a stunning symbolic
defeat for the tobacco industry. At the same time, the
presence of cigarettes was gradually fading in televi-
sion programming; by 1982, fictional television char-
acters smoked nine times fewer cigarettes than they
had before 1964 (Signorielli 1993).

Toward a National Policy
to Reduce Smoking

  Victories through federal administrative agencies
or through direct assault on Congress were rare. The
first chairman of the new (1973) Consumer Product
Safety Commission claimed authority to set standards
for cigarettes or even to ban them, but Congress in
1976 passed legislation to deny the commission that


authority (Walsh and Gordon 1986). In 1972, the Civil
Aeronautics Board required a nonsmoking section on
commercial air flights, in part because of some volun-
tary action already taken; in 1983, responding to a
Court of Appeals ruling that nonsmokers were inad-
equately protected, the board banned smoking alto-
gether on flight segments up to two hours-but almost
at once Congress passed legislation to reverse this
move (Walsh and Gordon 1986).

  In the executive branch, several voices spoke out
against smoking. During his tenure as Surgeon Gen-
eral and thereafter, Dr. Jesse L. Steinfeld was an active
participant in the national and international movement
to reduce smoking (Steinfeld et al. 1976). Joseph A.
Califano, President Jimmy Carter's Secretary of
Health, Education, and Welfare, declared in 1978 that
smoking was "Public Health Enemy Number One."
When Califano was designated Secretary, he had no
notion that reducing smoking should be a significant
effort of the Secretary's department, but experts he

From Antismoking to Nonsmokers' Rights

consulted invariably urged that his public health efforts
include a major campaign on that topic (Califano 1981).

  Over the years, the main voluntary organizations
increased their aggressive posture against smoking. In
1982, the ACS, the ALA, and the AHA established the
jointly sponsored Coalition on Smoking OR Health as
a Washington-based lobbying organization. The coa-
lition represented some 5 million volunteers across the
country, at least some of whom were physicians and
other civic leaders who could influence particular leg-
islators (Pertschuk 1986). In 1985, the AMA called for
a complete ban on tobacco advertising and promotion
(Troyer 1989). Also that year, a rotating series of four
more specific, more severe, and larger print warning
labels replaced the traditional warning that "The Sur-
geon General has determined that cigarette smoking
is dangerous to your health" (Waxman 1985; see
"Attempts to Regulate Tobacco Advertising and Pack-
aging" in Chapter 5 for discussion of this regulatory
process).

  The rhetoric of the smoking controversy in the
1950s and 1960s focused on the scientific evidence link-
ing smoking and disease. In the wake of the 1964 Sur-
geon General's report and subsequent research and
reports, the battle over the credibility of the scientific
evidence was essentially over. In what has been called
"a remarkable demonstration of creative lobbying"
(Jacobson et al. 1992, p. 391, the tobacco industry
sought to shift the debate from the medical conse-
quences of smoking to the legal implications of
impeding the personal freedom of smokers to smoke
and of tobacco companies to advertise their wares
under the protection of the First Amendment. The
tactic appeared to work. By the late 197Os, the effort
to reduce smoking was foundering "on a traditional
American libertarian ethic: `It's my body and I'll do
with it as I please"' (Brandt 1990, p. 167). Serious dis-
cussion on the ethics of legislation to reduce smoking
emerged (Goodin 1989). To bring a public health per-
spective back into the center of the debate, a
countershift to nonsmokers' rights seemed strategi-
cally sound (Jacobson et al. 1992). During the 198Os,
this strategy acquired a conceptual foundation that
was framed in a persuasive vocabulary when the

terms (and the concerns they aroused) "passive smok-
ing, " "ambient smoke, " "secondhand smoke," and
most commonly, "environmental tobacco smoke"
(ETS) increasingly appeared in research reports and
public debate.

Regulations, Legislation, and Lobbying
for Nonsmokers

  Evidence mounted in the 1970s and 1980s that
smoking was not only an annoyance but also a health
hazard to nonsmokers. The 1972 Surgeon General's
report on smoking and health became the first of the
series to include a review of the effects of ETS. A year
earlier, Surgeon General Steinfeld had called for a na-
tional "Bill of Rights for the Non-Smoker." The call
was answered when the National Interagency Coun-
cil on Smoking and Health developed a Non-Smoker's
Bill of Rights and promoted the nonsmokers' rights
theme among its 34 member agencies (Schmidt 1975).
At the same time, the first successful efforts were
made to segregate smokers and nonsmokers in public
places. In 1971, United Air Lines became the first

46 Chnpfer 2


Redlicing Tobacco Use

major carrier to institute separated "smoking" and
"nonsmoking" sections on its airplanes.

  Analogous to private citizens who were active
in the antismoking movement early on, some private
businesses took the initiative to introduce worksite
regulations for reducing smoking. Typically, the pri-
vate firms would begin with a mild antismoking policy
that was made stricter over time. A life insurance com-
pany in Connecticut, for instance, in 1976 restricted
smoking in parts of the employee cafeteria. In 1983,
smoking was prohibited throughout the cafeteria and
was also banned from all conference rooms. In 1986,
all smoking at the workplace was prohibited except in
designated restrooms and lounges. Moreover, the com-
pany instituted an educational campaign about smok-
ing hazards and provided subsidies for employees who
attended smoking cessation clinics (Petersen et al.
1988). Other firms have also turned to carrots as well
as sticks, paying employees bonuses if they stop smok-
ing for a given length of time (Fielding 1984).

  States began advancing legislation against ET'S
in the early 1970s. In 1973, Arizona passed the first
statewide ban on smoking in public places. This im-
portant step for nonsmokers' rights, which was initi-
ated by a private citizen, Betty Carnes, was defeated
in a vote in 1972 but passed on its second try and a
year later was further strengthened (Schmidt 1975).
Two years later, Minnesota passed the first statewide
act to keep indoor air smoke free; the legislation re-
quired no-smoking areas in all buildings open to the
public unless a posted sign explicitly permitted smok-
ing. By 1975, legislation had passed in 10 states to regu-
late smoking in public places (Schmidt 1975); more
than 30 states and hundreds of local jurisdictions had
done so by 1985 (Koop 1985). By 1990, smoking was
restricted to some extent in public places or worksites
in 44 states, and hundreds of cities and towns had
passed their own, often more rigorous ordinances
(Rigotti and Pashos 1991). In cities with populations
of 25,000 or more, local smoking restrictions reached
more than two-thirds of citizens in various public and
private settings, and one-half of these restrictions could
be judged comprehensive.

  The courts supported these public and private
efforts to protect nonsmokers' rights. In 1976, a Supe-
rior Court of New Jersey ruled that an office worker
with an allergy to tobacco smoke had the right to a
smoke-free office. New Jersey was also the site of a
comprehensive ruling in 1978 that restricted smoking
in restaurants and other public places; this was the first
such regulation to be enacted by administrative rule
(through the State of New Jersey Department of
Health) rather than by new legislation, though the rule

was never actually implemented (Regina Carlson,
memorandum to John Slade, September 30,1996).

  At the federal level, government acted not only
legislatively to regulate public behavior in the states
but also administratively to regulate domains the
government itself directly controlled. For instance, ciga-
rettes were removed from military C rations and K ra-
tions in 1975, and smoking was restricted in all federal
government buildings in 1979. Smoking was banned in
the White House in 1993 (Stephanopoulos 1993).

  Behind many of these reforms in industry and
government were the unified efforts of private citizens.
How these grassroot activists could band together to
form powerful lobbying groups for nonsmokers' rights
was shown in the transformation of a segment of the
Group Against Smokers' Pollution (GASP), Inc., a na-
tional organization founded in 1971. In 1976, local
California chapters of GASP banded together and tried
but failed to effect statewide ordinances to protect
nonsmokers. In 1981, the chapters became Californians
for Nonsmokers' Rights and began focusing on local
legislative activity. Five years later, the group became
a national organization that took its successful local-
level approach to sites throughout the country. By
1986, more than 75 ordinances had been enacted in
California alone; nationwide, more than 400 had been
enacted by 1990 (Samuels and Glantz 1991). In 1985,
Los Angeles banned smoking in most public places
and in businesses employing four or more persons if
nonsmokers requested it (Fritschler 1989). California
has now banned smoking in practically all public
places (Tobacco Education and Research Oversight
Committee 1995).

  By the 198Os, the movement to reduce smoking
proceeded along many avenues and through a wide
set of loosely coordinated organizations. This lack of
systematic action has concerned activists in the move-
ment, who bemoan duplication of effort, lack of com-
munication, organizational rivalries, and the lack of a
federal effort and policy. At the same time, the move-
ment has clearly benefited from its multiple locations;
the movement is represented by active legislative ef-
forts in hundreds of small communities as well as by a
strong presence in Washington, DC, and in state capi-
tals (see also "Direct Advocacy" in Chapter 7 for a dis-
cussion of the influences of these advocacy activities).

ETS: From Annoyance to Carcinogen

  The powerful call for nonsmokers' rights added
considerable momentum to the campaign to reduce
smoking. The Surgeon General's report in 1979


reviewed further research on ETS. Considerable pub-
lic interest was aroused by a Japanese study, published
early in 1981, that found a high incidence of lung can-
cer among nonsmoking women married to smoking
men (Hirayama 1981; Nezc~smerk 1981). While local-
level smoking restrictions began to gather force, often
proving more comprehensive than statewide legisla-
tion, the evidence on passive smoking accumulated.
On releasing his 1982 report on smoking and health,
Surgeon General C. Everett Koop observed that ETS
might be a serious public health problem (Troyer 1989);
two years later, he spoke of solid evidence on this point
(quoted in Molotsky 1984, p. 1).

  The growing urgency of a public health focus
on ETS set the stage for two authoritative messages
that ETS posed a definite danger to all. In 1986, the
National Research Council report Elrvirorzmer7tal To-
bacco Smoke: Menslrrirrg &!~os~~i'es arm' hxessirlg Health
Effects found that ETS exposure increased the risk for
lung cancer by 30 percent in nonsmokers and had del-
eterious effects on the respiratory health of children
(National Research Council 1986). The same year, the
Surgeon General released Tile Health Cor~sequcnces of
Inoo~z~~~fauJ/ Smoki~J~, which concluded that "involun-
tary smoking is a cause of disease, including lung can-
cer, in healthy nonsmokers" (USDHHS 1986, p. 13).
That report also found that children of smoking par-
ents have an increased incidence of respiratory infec-
tions and that separating smokers and nonsmokers

within the same air space "may reduce, but does not
eliminate" exposure of nonsmokers to tobacco smoke
(p. 13).

  Critics charged that the evidence on passive
smoking was weak, but the evidence and the authori-
tative conclusions of the Surgeon General and the
National Academy of Sciences added support for
stronger acts to limit or prohibit smoking indoors. In
1987, Congress banned smoking on domestic air trips
shorter than two hours; in 1990, the ban was effectively
extended to all domestic commercial air travel.

  Two further developments raised public (and
public policy) awareness of ETS to a level that posi-
tioned it in the front ranks of the campaign to reduce
smoking. In 1991, the National Institute for Occupa-
tional Safety and Health, Centers for Disease Control,
issued the report Environmental Tobacco Smoke in the
Workplace, which concluded that ETS can cause lung
cancer and other health problems (National Institute
for Occupational Safety and Health 1991). More
important, in December 1992, the Environmental Pro-
tection Agency (EPA) classified ETS as a "Class A"
carcinogen, the most dangerous class of carcinogens.
The agency's final report, Respirntor!y Health Effects of
hsivc Smoking: LJfJlg Cancer nrld Otkr Disorders, con-
cluded that ETS is a human lung carcinogen respon-
sible for some 3,000 deaths annually from lung cancer
among nonsmokers (EPA 1992).

The Impact of the Movement to Reduce Smoking

  The campaign against tobacco promotion is, in a
sense, a public health hybrid. It is in part a public
health movement, like those oriented to ensure that
food and drugs are pure and that water supplies and
air quality are clean-movements that look to improve
upon the collective provision of healthful environ-
ments. But because the campaign to reduce smoking
necessarily seeks to alter personal behavior, it is per-
ceived or cast by some as a moral reform movement.
"We are in the midst of one of those periodic moments
of repression," writes one observer, "when the culture,
descended from Puritans, imposes its hysterical visions
and enforces its guilty constraints on society, legislat-
ing 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" (Klein 1993, p. 3). Such critics worry about
possible erosions of civil liberties and express irrita-
tion with the puritanical cast of the movement to re-
duce smoking (Berger 1986; Hitchens 1994; Leonard
1994; Laqueur 1995). One recent historian refers to
health reform movements of this and the past century
as "hygienic ideologies, " because the movements have
sometimes reached levels of "devotion, asceticism, and
zeal" that virtually mark them as "hygienic religion"
(Whorton 1982, p. 4). In sum, the arguments have pit-
ted this moralism against the freedom to choose
(Sullum 1996). In doing so, issues of addiction and
corporate responsibility are sidestepped (Hilts and
Collins 1995).


Reducing Tobacco Use

  It would be hard to deny that moral zealotry has
entered into the contemporary movement to reduce
smoking. But it would be equally hard to argue that
zealotry is the dominant element in the movement.
The contemporary campaign to reduce smoking, like
some elements of the early 20th-century efforts, has
been fueled by medical research and, more recently,
by revelations about the additional but secret medical
research carried on by tobacco companies themselves
on nicotine and other addictive substances (Kluger
1996). But leadership has been both medical and non-
medical and has been oriented to conventional public
policy mechanisms rather than to moral reformation.
Where the broad contemporary health movement has
"an ambivalent orientation toward science and technol-
ogy" and "draws upon Americans' significant and
growing distrust of physicians" (Goldstein 1992, pp.
30-l), the movement to reduce smoking firmly em-
braces establishment medical research. Its sometimes
inventive and ingenious strategies notwithstanding, the
movement has typically avoided ideological ends and
has instead worked toward concrete, public policy ob-
jectives. In this respect, it is self-consciously political,
adopting a style found now in many health movements
(e.g., AIDS, breast cancer, and even advocates of spe-
cific health care reforms).

   Whether or :lc)t the movement to reduce smok-
ing has avoided the finger-pointing associated with
many ideological movements is debatable. On the one
hand, the movement has tended to demonize the to-
bacco companies rather than the smokers who use their
products. This distinction may arise partly because,
some cultural icons aside, smoking has rarely been
perceived as a feature of personal behavior that is cen-
tral to someone's identity. Placing the burden else-
where than on the smoker has been amply reinforced
by the research-steered perceptual transition of smok-
ing as "habit" to smoking as "addiction." As codified
by the 1988 Surgeon General's report (USDHHS 1988)
and reiterated more recently (Lynch and Bonnie 19941,
smoking is now medically viewed as nicotine addic-
tion, and as the title for Chapter 4 states, smoking ces-
sation is now the management of such addiction. This
transition has had considerable impact on overall strat-
egy for reducing smoking, especially in litigation ap-
proaches (see "Litigation Approaches" in Chapter 5).

  On the other hand, as regulations against smok-
ing become more widespread, the tendency to stigma-
tize smokers may increase (Troyer 1989). Moreover,
some critics ha;e complained of an ideology that
smacks of political conservatism, in that the focus for
the problem is turned away from the product source

(the manufacturer) and to the user-victim (the smoker);
this blame-the-victim perspective also characterizes
sociopolitical movements that divert public attention
to personal behaviors and away from larger, corporate
sources of environmental health risks, such as indus-
trial pollution and workplace hazards (Crawford 1979).

   In at least one sense-that of social values-
efforts to reduce smoking have been moralistic. The
contemporary reform movement can fairly be charac-
terized as middle-class-that is, its values are those
connected with traditional values such as deferred
gratification, self-control, and personal responsibility
(Goldstein 1992). Nonsmokers may feel morally su-
perior to smokers, and former smokers may pride
themselves on their personal accomplishment and self-
denial. As one cultural observer has pointed out,
former smokers especially may be "tediously zealous
about the addiction they have left behind" (Styron
1987, p. 284).

  The net result, whatever the role of moral issues,
is the main emphasis the movement places on chang-
ing the social conditions that enable, and the cultural
conditions that legitimatize or romanticize, smoking.
In this sense, the movement to reduce smoking is an
old-fashioned populist movement that seeks to defend
the "public interest" against the moneyed corpora-
tions, the purveyors of death and disease. It is now
less an "anti-smoking" political movement and more
a campaign against tobacco promotion.

  A reflection of this broadly populist attitude has
been the movement's lack of any real links to partisan
politics. Senators Wallace F. Bennett (R-UT) and Rich-
ard L. Neuberger (D-OR) were among the first to seek
curbs on the tobacco industry (Fritschler 1989). In the
early 198Os, Republican Senators Robert W. Packwood
(R-OR) and Orrin G. Hatch (R-UT) introduced legisla-
tion to require more explicit warning labels on ciga-
rette packages (Troyer 1989). House Democrats have
been both key defenders and key critics of the tobacco
industry. In the White House, Democratic President
Lyndon 8. Johnson remained silent on the preemptive
Federal Cigarette Labeling and Advertising Act of
1965, but White House pressure helped support the
Tobacco Institute's efforts to pass the bill (Pertschuk
1986); the President signed the act into law privately
in his office, without guests or comment (Fritschler
1989). Similarly, Democratic President Jimmy Carter
refused to take a position on tobacco (Fritschler 19891,
but he regarded USDHEW Secretary Joseph Califano's
crusade against tobacco as "an enormous political
liability" (Califano 1985, p. 360). The absence of po-
litical affiliation for the antitobacco movement may be


altered, however, by recent changes in the party com-
position of elected officials from tobacco-producing
states.

  The efficacy of efforts to reduce smoking, inde-
pendent of other social changes beginning early in the
20th century, is hard to determine. Students of 19th-
century temperance, for example, have concluded that
although the temperance efforts likely accelerated the
antebellum decline in alcohol consumption, the decline
may have been more deeply tied to independent
changes in styles of liquor consumption (Aaron and
Musto 1981). The antismoking movement of the early
20th century, despite temporary gains, had little long-
term effect on stopping the rapid growth of smoking;
though noteworthy, the emergence of antismoking
legislation in some midwestern and western `states
was brief and showed little convincing evidence of
enforcement.

  But neither the temperance movement of the 19th
century nor the antismoking movement early in the 20th
century commanded the significant allies and the range
of weapons of the contemporary effort to reduce
smoking. The critical factor has been definitive medi-
cal research linking smoking to cancer, heart disease,
chronic obstructive pulmonary disease, and adverse
outcomes of pregnancy (USDHHS 1989). Beginning in
1964, the imprimatur of the Surgeon General of the
United States provided a symbolic centerpiece that has
given inestimable momentum to the campaign. The
all-but-unanimous and compelling character of the
epidemiologic research in that first report and its suc-
cessors is the chief factor that leads to the-conclusion,
"As a target of opportunity for public health action,
smoking stands alone" (Walsh and Gordon 1986, p. 127).
  Measuring the overall impact of the rich and
multifaceted effort to reduce smoking is difficult, in
part because current prevalence should not be judged
against an arbitrary historical benchmark (for instance,
against prevalence at the time of the 1964 Surgeon
General's report) but against an estimate of what
prevalence would have been in the absence of such
efforts. The events of the past decades that coincided
with these efforts are clear: cigarette consumption rose
steadily from the 1930s until 1963, fluctuated, then
fell from 1973 tq the present. But such broad-brush
observations provide little insight into cause and ef-
fect, especially given the multiplier effect of certain
social actions, the differential changes in demographic
and social subgroups, and the influence of forces ex-
traneous to smoking (Warner 1989).

  It is problematic, for example, to try to assess the
relative impact of, on the one hand, government edu-
cational actions and government regulatory actions
and, on the other hand, changing social norms-two
factors that are clearly interrelated. The impact of gov-
ernment curbs on smoking in public places (see "Clean
Indoor Air Regulation" in Chapter 5) may actually be
bound up with "voluntary adjustments to new infor-
mation" (Zimring 1993, p. 97). Similarly, doubts have
been raised as to the influence of curbs on tobacco
advertising (Schudson 1993; see "Advertising and Pro-
motion" in Chapter 51, because such restrictions have
occurred in conjunction with a growing stigmatization
of smoking. Once nonsmoking is established as a
norm, the minority status of smokers makes them
"more vulnerable to negative social evaluations. .
As smokers, the group most interested in defending
the moral position of the cigarette smoker, become both
less numerous and less influential, smoking behavior
and the people who engage in it become more vulner-
able to social reinterpretation" (Zimring 1993, p. 106).
Such a reinforcing chain of events may permit curbs
on advertising, rather than the reverse.
  It is equally difficult to gauge or predict the in-
fluence of government restrictions. On the one hand,
a regulation may be an educative force-for example,
by reminding people to take their Surgeon General
seriously. In some instances (such as indoor prohibi-
tions and access restrictions), government actions in-
terpose a physical barrier. On the other hand, legal or
otherwise formal barriers could have an unintended
effect on individual predisposition, as the abiding aura
of antisocial behavior can be at least as great a stimu-
lus for some as it is a deterrent for others. Finally, the
psychological and social pathways by which economic
actions of government affect smoking are complex.
  Sorting through this complexity is critical to
understanding appropriate policy and action for re-
ducing smoking. The ensuing chapters assess the
available evidence to judge the efficacy of educational
efforts (Chapter 3), the management of nicotine
addiction (Chapter 4), regulatory efforts (Chapter 51,
economic approaches (Chapter 61, and comprehensive
programs (Chapter 7). This brief history of the anti-
smoking movement provides a backdrop to such as-
sessment and may furnish some perspective on future
directions.

50 Clq't'r 2


Reducing Tobacco Use

Conclusions

1.  In the years preceding the development of the    3.  Despite the growing scientific evidence for ad-
  modern cigarette, and for some time thereafter,     verse health effects, smoking norms and habits
  antismoking activity was largely motivated by     have yielded slowly and incompletely. The rea-
  moralistic and hygienic concerns. Health con-     sons are complex but attributable in part to the
  terns played a lesser role.               industry's continuing stimulus to consumption.

2.   In contrast, in the second half of the 20th cen-
  tury, the impetus for reducing tobacco use was
  largely medical and social. The resulting plat-
   form has been a more secure one for efforts to
  reduce smoking.

Historical Review 51


Surgeon General's Report

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52 Chapter 2