publication date: Sep. 18, 2020
Seeing COVID-19 through a cloud of cigarette smoke
Alan Blum, MD
Professor and Endowed Chair in Family Medicine,
Director, The Center for the Study of Tobacco and Society,
University of Alabama School of Medicine, Tuscaloosa
Eric Solberg, MS
Vice president, academic & research affairs,
University of Texas Health Science Center at Houston;
Faculty associate, McGovern Center for Humanities and Ethics,
McGovern School of Medicine, Houston
This story is part of The Cancer Letter’s ongoing coverage of COVID-19’s impact on oncology. A full list of our coverage is available here.
The unprecedented COVID-19 pandemic makes it possible to compare and contrast the public health and political responses to previous health crises.
The most obvious comparison is to the influenza epidemic of 1918-19, which took the lives of 675,000 Americans in less than two years.
Yet a comparison with cigarette smoking, which has killed untold millions of Americans in the 20th century and continues to take the lives of 500,000 a year, is arguably more illuminating. At first glance, comparing COVID-19 to cigarettes seems illogical. Yes, people who take up smoking do so willingly, although most do so before they reach adulthood. And yes, those who contract COVID-19 do not willingly seek out the virus.
Disease and death from smoking take years, even decades to occur. Deaths from COVID-19 can occur within days or weeks, albeit in less than 2.9% of victims, most of whom have comorbid conditions such as hypertension, obesity, and emphysema.
As we assess the 50-year War on Cancer that was declared when President Richard M. Nixon signed the National Cancer Act of 1971, some parallels and lessons from the past that can be gleaned from anti-smoking campaigns and applied to the efforts against COVID-19.
As defiant and skeptical as President Trump may be of the preventive behavioral measures that all health agencies agree are the first step to contain the spread of the virus, his magical-thinking approach mirrors the playbook of previous presidents to ending the cigarette pandemic, even decades after it was recognized as the nation’s leading avoidable cause of death and disease.
Should anyone really be surprised that when it comes to public health and health care, money and politics take precedence over science?
In early April, no sooner had Anthony Fauci, of the White House COVID-19 Task Force, come to the conclusion that all Americans, not just front-line health workers and patients, needed to wear face masks, practice social distancing, and wash their hands to prevent the spread of COVID-19, President Trump began subverting this message by retweeting Fauci’s original assertion in March that mask-wearing by the general public was not yet necessary.
By mid-summer, Trump had rejected the recommendations by the Centers for Disease Control and Prevention on protecting meat processing plant workers, teachers, other school personnel, and children from COVID-19. Trump not only muted, muzzled, and marginalized the CDC, he had also become its de facto spokesperson.
Even as he has publicly played down the ease of spread and the adverse health consequences of COVID-19, last week we listened to the recording of his February interview by reporter Bob Woodward, in which Trump acknowledged the ferocity of the new virus.
This called to mind the response by another president to the efforts by the top health official in his administration to launch the federal government’s first anti-smoking campaign. In January 1978, U.S. Secretary of Health Education and Welfare Joseph A. Califano, Jr., announced that HEW would “place the weight of its scientific authority behind programs to inform the public—especially the young—about why they should not smoke and how they can quit if they wish. As the chief health officer of government, I have the duty to see that we do just that.”
Within weeks, Califano’s efforts were being undermined by President Jimmy Carter, who traveled to North Carolina to assure tobacco famers that the government would make cigarette smoking “even safer than it is today.” As Califano’s campaign continued to gain momentum, and after HEW published the most comprehensive indictment yet of cigarette smoking in its 1979 Surgeon General’s Report, Carter fired Califano. There was little doubt that the main reason was his fervent anti-smoking stance.
The present-day Republican-led opposition to state and local ordinances mandating the wearing of face masks in public places is akin to the vocal opposition in 1964 to federal legislation to require an understated warning on the side of cigarette packs (“Caution: Cigarette Smoking May Be Hazardous to Your Health”).
The staunchest opponents of the warning were not just the cigarette manufacturers and tobacco state congressmen, but also the American Medical Association, which claimed that the public was already well informed about the dangers of smoking.
In those days, Republican Sen. Jesse Helms were beating back anti-smoking bills introduced by Democratic Sens. Ted Kennedy and Dick Durbin and Reps. Henry Waxman and Ron Wyden. Today, we can take in the spectacle of Republican Sen. Rand Paul (a physician) and Republican House Members Matt Goetz, Luis Gohmert, and Mark Meadows deriding the recommendation to wear face masks.
All four contracted COVID-19, with Gohmert blaming his infection on having to wear a mask.
At his nationally televised town meeting on Sept. 15, in which he claimed that “herd mentality” could make the virus “disappear,” Trump also claimed that the repeated putting on and taking off a mask could increase the chances of becoming infected with COVID-19.
The other two physicians in the Senate, Republicans John Barrasso and Bill Cassidy, have stood behind Trump every step of the pandemic. In May, Barrasso, an orthopedic surgeon until he was appointed to the Senate in 2007, cited his medical background to support Trump’s call to end COVID-19 containment shutdowns and echoed Trump’s comment that “we cannot allow the cure to be worse than the disease.”
Granted, oversimplifying the comparison between the response to COVID-19 and the fight against smoking risks reducing it to a body count competition. Yet, that is just what Stanford historian Robert Proctor did in a book review in the July 7 issue of JAMA:
“It all seems so February. Cigarettes remain the leading preventable cause of death, but that morbid fact is easily lost in more pressing pandemics. It is worth keeping in mind that even if the novel coronavirus 2019 (COVID-19) ends up killing 200,000 people in the U.S., that number will not be even half the annual toll from cigarettes, which still kill half a million Americans every year.”
Such a comment is as simplistic and cold-hearted as any of Trump’s unempathetic pronouncements downplaying the catastrophic impact of COVID-19. One hears echoes of the claim that the virus “will just disappear,” but smoking will remain.
The bigger killer
Sadly, this is the same narrative that all too many individuals who work in the field of “tobacco control” have used for other emerging health crises such as the rapid rise in obesity, namely that smoking is always the bigger killer.
They seem to see other health issues as a threat to their turf. Proctor calls the assertion that his smoking dog is bigger than your COVID dog an “enduring constancy” and insists that “scholars need to pay more attention to cigarettes, even in these distressing days of plague.
“Any focus on disease that ignores the cigarette or the cigarette industry is like pretending to have an interest in malaria while paying no attention to mosquitoes or swamps. Nicotine addiction is likely to outlive coronavirus, shackling millions in chains that lead to suffering and death. The havoc wreaked on human health is worse than any virus.”
Nathan Schachtman, an attorney and lecturer at Columbia Law School who has written on tobacco litigation, is appalled by Proctor’s claim. “This type of comparison between COVID-19 and smoking is inapposite,” he says. “COVID puts me at risk from even a brief encounter with an infected person. I have no control as an individual over the risk of this infectious disease; it absolutely requires coordinated action by government. We can all agree that both smoking and COVID are public health problems, while refraining from making inane comparisons. The thing about COVID-19 is that a pandemic ensures that there will be innocent victims—people who did not assume the risk, but had the risk of death and disability foisted upon them by fellow citizens.”
Two hundred thousand deaths—in addition to hundreds of thousands of potential “long-haulers” suffering from crushing fatigue, lung and heart damage, and other problems—caused by a single pathogen in just six months extrapolates to 300,000 deaths this year, plus a lingering morbidity comparable to that caused by cigarette smoking. And there is no cure in sight, but rather false promises by the president of a breakthrough vaccine “just around the corner” … before Election Day.
“Instead of trying to make the case that smoking is worse than COVID-19, we should instead be applying the lessons we’ve learned from anti-smoking efforts to reduce the toll of COVID-19,” argues Michael Siegel, professor of community health sciences at Boston University School of Public Health. “Most obviously, the chronic conditions of emphysema and cardiovascular disease that help COVID take hold are frequently due to smoking. The successes and failures of the past five decades of anti-smoking actions are playing out now in the daily COVID-19 death tallies.”
Writing in Financial Times on Aug. 4, Sir Richard Feachem, who served as under-secretary-general of the United Nations and founding executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, warns that counting on a COVID-19 vaccine to come to our rescue soon is “not only unlikely but is a dangerous assumption on which to plan the overall response to the pandemic.”
Politicians and vaccine developers have incentives to reinforce this assumption, he notes, in spite of the long odds against a vaccine with high efficacy, a protracted duration of protection, a convenient dosing schedule, and the ability to administer billions of doses.
Is this not reminiscent of the never-ending quest for the Holy Grail of the safe cigarette? Can anyone doubt that the biggest failure in the history of the National Cancer Institute is not to have dispelled the myth that filtered cigarettes can prevent lung cancer?
The tobacco industry’s view, as reflected in the Tobacco Observer, a publication of the Tobacco Institute, April 1982.
Following the release of the 1964 Surgeon General’s Report, there was a dramatic increase in advertising claims by the tobacco companies implying that filtered cigarettes were safer than non-filtered ones.
This campaign extended to Hollywood, where TV and movie heroes and heroines smoked filtered brands while the crooks and tramps smoked non-filters. Alas, the history of the filter is at the heart of why the reduction in smoking has been so slow.
Beginning in the early-1950s, when the devastating reports of the impact of smoking on health were making front-page news and beginning to drive down cigarette sales, the tobacco industry took the upper hand by proclaiming in full-page newspaper advertisements across the U.S. that it would fund research to identify and remove any harmful ingredients from cigarette smoke.
By the late 1960s and throughout the 1970s, the National Cancer Institute’s research efforts on smoking were almost entirely directed toward finding a safer cigarette. This dead-end research didn’t get the ax until 1980, when Vincent DeVita became director of NCI and began shifting the focus of smoking research to getting heavy smokers to quit.
Even then, a far more heavily funded NCI research project in the 1980s was “chemoprevention,” which aimed to reduce lung cancer in smokers with large doses of vitamin A. The highly promoted study was halted when it was found that this caused an increase in lung cancer.
The unequivocal conclusion of the landmark 1964 U.S. Surgeon General’s report on smoking and health that cigarettes cause lung cancer and other diseases was to have ended a debate that had raged for decades.
Instead, the tobacco industry made a preemptive strike by funneling a total of $18 million over 14 years to the American Medical Association—the only major health organization to withhold its endorsement of the report—in a research program to identify and remove any possible harmful components of cigarette smoke.
Why did the AMA choose not to campaign against smoking, but rather to conduct the same kind of research that the report had already found sufficient for its indictment of smoking?
It did so in order to remain in the good graces of tobacco state senators, whom it counted on to help prevent the creation of Medicare by Congress. This, in turn, leads to another villain that has gone unnoticed: the insurance industry, which never lifted a finger to fight smoking, even long after a small Massachusetts insurer, State Mutual Life Assurance Company, offered the first non-smoker discount after the SG report came out in 1964.
Because the anti-smoking narrative has been revised as a great victory instead of an abject failure, the rogues’ gallery is endless. One of the genuine leaders was the fearless Sen. Maureen Neuberger, who castigated not just the tobacco companies but also the see-no-evil, hear-no-evil, speak-no-evil AMA in her 1964 book Smoke Screen: Tobacco and the Public Welfare.
The AMA/tobacco industry collaboration distributed research funds to dozens of universities to keep scientists in their laboratories and not out testifying to the need to end smoking now. Columbia University, although not a participant as an institution with the AMA program, went so far as to market a patented “super-filter” that it claimed would remove the cancer-causing “tar” and prevent lung cancer. It didn’t.
The filter con endures to the present day. Ninety-nine percent of cigarettes sold are filtered brands, in spite of the fact that filters likely increase the risk of death and disease from smoking by virtue of the smoker needing to inhale more deeply—and by fostering complacency about the dangers of smoking.
Essentially the same kind of players that fought efforts to pass clean indoor air legislation or bills to ban or restrict cigarette advertising and promotion are at it again with COVID-19. The cigarette companies’ filter and low-tar hucksterism is not unlike the touting by Trump of oleander, hydroxychloroquine, zinc, bleach, Lysol, and UV light for the prevention of COVID infections.
Meanwhile, Trump’s COVID-19 advisers include individuals untrained in infectious disease, notably retired Stanford radiologist Scott Atlas. In a scathing op-ed in the Los Angeles Times on Sept. 10 by Stanford epidemiologists Steven Goodman and Melissa Bondy, co-signed by all of their epidemiology colleagues at the university, the authors castigate Atlas for recommending less COVID-19 testing and less mask-wearing in indoor public spaces, as well as for downplaying the nonfatal health risks of the virus and its transmissibility by children.
The Washington Post and The New York Times were criticized by an editorialist at The Wall Street Journal for questioning Atlas’ fitness and credentials, even though Atlas got the job after espousing his unconventional views on Fox News. Both the Journal and Fox News are controlled by the pro-Trump Murdoch family, whose patriarch Rupert Murdoch served on the board of Philip Morris from 1989 to 1998; Philip Morris executives in turn have served on the board of Murdoch’s News Corp.
To think that in 1854, fully 40 years before Robert Koch discovered the bacterium that causes cholera, a lone London obstetrician named John Snow identified the source of a cholera outbreak with pencil, paper, and shoe leather.
By interviewing surviving family members of many of the more than 500 victims, he realized that the fatalities were clustered around a single water pump in Broad Street, from which most of the victims had obtained their household supply.
Countless lives were saved when the pump was ordered shut, over the objections of the water companies, which blamed the cholera epidemic on “bad air,” or miasma. Religious zealots blamed divine intervention.
Ironically, it was a minister, Rev. Henry Whitehead, who at first contended that the outbreak was not caused by tainted water but by God’s will, who surprised himself to discover that the cause was a soiled diaper emptied into a leaky cesspool near the pump.
More than half a century after the causes of the epidemic of lung cancer and emphysema became known through epidemiologic studies, the tobacco industry, like the water companies of Snow’s London, insisted that their product was not to blame. They were backed up by administration after administration as the cigarette—and its tax revenues—became a mainstay of the economy.
Arguably the best single summary of government policy on smoking came from the United Kingdom’s Royal College of Physicians in the 1971 sequel Smoking and Health Now to its pioneering report on smoking and health in 1962: Castigating the government for spending little to educate the public about the dangers of smoking—a tenth of the amount spent on traffic safety.
The report dryly observes, “It seems that Ministers, while accepting the evidence that cigarette smoking is dangerous to health, are guided in their actions by the view that the risks are regrettable but inevitable consequences of a habit which they believe to be an essential source of revenue.”
The economy-over-lives approach to COVID-19 by the current president is reminiscent of other administrations’ approach to curbing smoking.
“College football, get out there and play football,” Trump said on Aug. 11, when the only major universities left whose officials had given the season a green light—in the Atlantic Coast and Southeastern conferences—are located in the very region with the least adherence to personal COVID-19 health precautions and a steady rise in the number of cases.
By his masks-be-damned rallies and his tweets to “Liberate Michigan!” and other battleground states with Democratic governors from the inconvenience of wearing a mask and washing hands, Trump has become a 21st century Typhoid Mary, a super-spreader of COVID-19 through his crowded campaign rallies.
By stoking the embers of anti-scientific thinking for years in regard to the safest and most effective vaccines, by mocking the wearing of masks and social distancing, and by claiming that there is a COVID-19 vaccine just around the corner, Trump has undermined confidence in the safety and efficacy of any such rushed-out vaccine by those who would normally support vaccination.
In addition, HHS and FDA have been corrupted by political pressure to approve hydroxychloroquine and convalescent plasma as treatments for COVID-19 in spite of the absence of safety data. Fauci has been told to refrain from stating that children can transmit COVID-19. And CDC has been forced to walk back recommendations on school reopening and contact tracing, and its venerable publication, MMWR has been censored by the administration.
On June 23, Financial Times published the marvelously understated headline, “Resistance is low at U.S. disease-control body.” This week we finally learned that the source of this chaos and the sharp decline in the public’s and health professionals’ confidence in the CDC has been a troubled Trump appointee, Michael Caputo, a far-right conspiracy-monger and protégé of convicted felon Roger Stone.
It is déjà vu all over again. In 1987, one of us (AB) would be told upon assuming a faculty position at Baylor College of Medicine that he could not use his academic affiliation when speaking publicly on smoking and that he should “consider getting into something more socially acceptable, like cocaine.”
This meant, of course, that studying illicit drugs—not cigarettes—was where the grant funding was—and don’t you keep messing with the folks at the tobacco companies who have influence over Capitol Hill and the NIH!
One year later, he would be offered the editorship of the journal of the American Academy of Family Physicians, American Family Physician—contingent on his not speaking publicly on the subject of smoking.
The AAFP was a recipient of advertising revenue from food subsidiaries of RJ Reynolds and Philip Morris. AB turned down the job.
Politics, money—and COVID-19
What is the fairest way to compare strategies to contain the virus with the efforts to reduce cigarette smoking? Why not begin with those who are made ill by a known agent through no fault of their own, as well as through willfully misleading directives by elected officials?
The turning point in the effort to reduce cigarette smoking came in the early 1980s, when studies in Japan and Greece found that long-term exposure to cigarette smoke could cause lung cancer in a person who did not smoke.
Certainly, those individuals who were involuntarily exposed to cigarette smoke over many years at the workplace and who developed terminal lung cancer or emphysema would be unequivocal innocent victims of smoking.
What about those who contract COVID-19?
The only ones in this population who aren’t unequivocally innocent victims are those who refuse to wear masks, practice physical distancing, wash hands frequently, and refrain from participating in social gatherings, political rallies, or protest demonstrations.
Another way to look at smoking-related deaths is through the number of those who had chosen to continue to smoke in spite of knowing that it could kill them.
One could argue that nicotine addiction is too powerful to overcome, and that, therefore, all of the blame must be laid at the feet of tobacco industry executives and the leaders of allied businesses that have engaged in the promotion of cigarettes in spite of the dangers.
But what about the accountability of public health agencies, which are tasked both with curbing infectious outbreaks and improving the health of the entire population? If a commissioner of health were found to have failed to allocate funds to mosquito control after an outbreak of West Nile, dengue, St. Louis encephalitis, or zika, then that individual would be held partially responsible for the cases that resulted—and criminally negligent if the funds were deliberately withheld because the commissioner didn’t believe that mosquitoes were the vector, or if he or she pocketed the money.
Analogously, why shouldn’t a health commissioner or health agency that chooses not to allocate funding to discourage smoking be held accountable for a failure to reduce tobacco-related deaths and diseases and/or cigarette consumption? Fanciful? But if the number one avoidable cause of death and disease in the health district doesn’t receive sufficient funding, then why shouldn’t there be accountability?
Although Surgeon General Luther Terry called for appropriate remedial action on smoking in 1964, it would be fully 25 years before every state had even a single individual assigned to reduce smoking.
Nor were health department commissioners permitted to endorse efforts to pass clean indoor air regulations to protect nonsmokers.
And what about academia, organized medicine, and the voluntary health organizations, such as the American Cancer Society? What did they do as the battles over restrictions on cigarette advertising heated up in the 1980s? Most were nowhere to be found.
“We were duped”
Individual tobacco product liability lawsuits brought against the tobacco industry beginning in 1983 by New Jersey attorney Mark Edell (Cipollone v Liggett Tobacco Group Inc.), followed by class action suits brought by several state attorneys general in the mid-1990s, began to expose the myth of organized medicine as an enemy of Big Tobacco.
In a TV interview in 1996, the president of the American Medical Association, Lonnie Bristow, famously claimed, “We were duped.”
This is in spite of the AMA having accepted cigarette ads in its journal from the early-1930s to the mid-1950s, the same time period when the epidemiological and pathological research showing the association between smoking and disease was being published.
This was also in spite of the publication of the Surgeon General’s Report in 1964, following which the AMA, as noted here, spent 14 years conducting research funded by the tobacco industry in lieu of taking action or even calling for action against smoking, apart from advising the public not to smoke in bed.
Since the 1980s, product liability litigation brought against the tobacco industry has been based on when the industry first knew that cigarettes were harmful and what it then did to deceive the public.
Even though everyone and his uncle is now aware of the lethal dangers of smoking and its toll on society, the question that is not taught in public health schools or acknowledged by public health organizations, is, “When did the medical and public health communities learn about the harmfulness of cigarettes and what did they do about it?”
The much-avoided answer is that the public health community knew no later than the 1930s through the epidemiologic work of Raymond Pearl at Johns Hopkins and the clinical reports of Alton Ochner at Tulane.
Beginning in 1942, the Federal Trade Commission even held hearings on deceptive health claims in cigarette advertising.
But did the American Medical Association, the American Public Health Association, medical schools, schools of public health, the American Cancer Society, or federal public health agencies launch anti-smoking efforts? An emphatic no.
This failure to own up to the health community’s failure in the mid-20th century has been willfully ignored by the professional field known as “tobacco control” that emerged in the 1990s.
Tobacco control devotes most of its efforts to research, the bulk of which is aimed at providing the basis for regulatory or legislative approaches to reduce tobacco use and exposure to tobacco smoke, something called “tobacco regulatory science” by inside-the-Beltway bureaucrats.
Touting the public health achievement of reducing the prevalence of cigarette smoking among adults from 42.7% in 1964 to 18.1% 50 years later, the authors of an editorial in JAMA on Jan. 8, 2014, claim that “much of the progress stems from the rigorous development of evidence-based tobacco control policies that now serve as a robust foundation for public health action.” Come again?
In fact, much of the progress in tobacco control, most notably in protecting the public from exposure to others’ smoke by the passage of clean indoor air laws, occurred in the 1970s, 1980s, and 1990s—long before the creation in 2014 of 14 mostly university-based “centers of excellence in tobacco regulatory science,” each given $20 million by the FDA.
It is anathema, we realize, to suggest that allocating more money to attack a health problem is not the answer, but when it comes to ending the smoking pandemic the overwhelming preponderance of funds has gone into research, not action.
The public health community, including schools of public health, government health agencies, and organizations of state and territorial health officials only joined the efforts against smoking in the mid-1990s, as public opinion of the tobacco industry became increasingly unfavorable.
Yet these groups have perpetuated a false narrative wherein giant-killing heroes in public health triumphed over a rogue industry, which for most of the 20th century kept the truth about the addictive, debilitating, and lethal consequences of cigarettes away from the public.
The current generation of workers in tobacco control, predominantly those with master’s degrees in public health who work for health departments, has been led to believe that anti-smoking efforts began with the creation of The Truth campaign in the late-1990s as the result of the Master Settlement Agreement (MSA) between the state attorneys general and the tobacco industry that gives money to the states each year to fight smoking.
In reality, the $256 billion-MSA was a pennies-on-the-dollar back tax. More tragically, today just 1.9% of MSA funds go to address tobacco problems, and much of that is for salaries. Ominously, the MSA actually assures a dependence by the states on tobacco industry money in perpetuity, and only an infinitesimally small amount of it has gone to fight smoking.
There is scant paid mass media advertising against smoking or vaping. Only a few states have passed legislation that dedicates a portion of cigarette taxes to reduce cigarette smoking and other forms of nicotine addiction.
“A Frank Statement”
It is this background that one needs to keep in mind to understand the public health efforts to counter cigarette smoking and its promotion today, as well as how it has begun to tackle COVID-19.
Finding the solution to ending either the smoking pandemic or the COVID-19 pandemic is not a moonshot for which one simply pours money into academic research and health department data collection.
The smoking and health issue has been settled for nearly 60 years, yet 37 million Americans still smoke and they’re younger on average than ever. That’s partly because funding media messages to enhance knowledge and change attitudes that lead to improvements in health behaviors isn’t happening.
The government itself only began running paid mass media messages in 2012 for its TIPS for Smokers quit-smoking campaign—by all accounts a successful one—with a budget that only permits a few months of TV messages per year.
One gets the sense that those in public health don’t trust any information on the history of the smoking pandemic that does not come from the tobacco industry documents, as if the very same public exposés of the tobacco industry’s disingenuous denial of smoking’s dangers—by muckraking journalist George Seldes in the 1940s; writer Roy Norr in The Christian Herald and The Reader’s Digest and Harvard University Medical School’s Daniel Rutstein in The Atlantic Monthly in the 1950s; and Sen. Maurine Neuberger on the floor of the U.S. Senate and New Yorker writer Thomas Whiteside in the 1960s—were chopped liver.
A mystery of science? Tobacco Observer questions the link between smoking and lung cancer, April 1982.
So, it has always been in getting to the bottom of the tobacco tragedy. By 1963, when the Surgeon General’s advisory committee was reviewing the world’s literature on smoking, there were 7,000 articles in scientific journals.
But Luther Terry’s call upon the release of the Surgeon General’s report smoking and health on Jan. 11, 1964 for “appropriate remedial action” to begin reducing smoking in the U.S. went largely unheeded by the federal government until Surgeon General Jesse Steinfeld issued a Non-Smokers Bill of Rights in 1971 (after HEW Secretary Elliott Richardson had tried to block him from doing so), and then not until 1978, when Califano launched his crusade.
Meanwhile, the NCI’s safer cigarette research program fit the tobacco industry’s agenda, first described and disseminated in a full-page advertisement in newspapers across the country in 1954 after cigarette sales flattened on the heels of growing evidence that smoking caused lung cancer.
Headlined “A Frank Statement,” the ad from the newly formed Tobacco Industry Research Committee downplayed the experiments on mice that “have given wide publicity to a theory that cigarette smoking is in some way linked with lung cancer in human beings.”
The committee wrote that “we feel it in the public interest to call attention to the fact that eminent doctors and research scientists have publicly questioned the significance of these experiments.
“Distinguished authorities point out:
“That medical research of recent years indicates many possible causes of cancer.
“That there is no agreement among the authorities regarding what the cause is.
“That there is no proof that cigarette smoking is one of the causes.”
Asserting, “We accept an interest in people’s health as a basic responsibility, paramount to every other consideration in our business,” the committee pledged “aid and assistance to the research effort into all phases of tobacco use and health.”
In addition, the industry lured cancer researcher Clarence Cook Little, a longtime managing director of the American Cancer Society, to become the committee’s director and the industry’s scientific face.
The industry’s stated aim for the next half century would be to eliminate any possible harmful ingredients in tobacco smoke.
Meanwhile, as millions would die from cigarette smoking, the industry introduced a plethora of filters, low “tar” products, “reduced emission” cigarettes, and “mild,” “light,” and “ultra-light” brands, none of which made smoking safer.
Indeed, on Aug. 17, 2006, Federal Judge Gladys Kessler found the cigarette companies had violated civil racketeering laws over a 50-year period by deceiving the public about the dangers of smoking by manipulating the design of cigarettes and suppressing research.
The more visible and vocal face of the tobacco industry throughout that time was the Washington, D.C. public relations and lobbying operation The Tobacco Institute (TI), the two longest-serving heads of which were a former four-term House Member from North Carolina and a former governor of Kentucky.
Among the TI’s most infamous claims in its pamphlets published in the 1970s and 1980s came in response to the growing evidence that mothers who smoked during pregnancy were twice as likely to have low-birthweight babies. The Institute insisted that many women preferred to give birth to lighter babies because they were easier to deliver.
“We need more research”
By the late-1970s, the Tobacco Institute had a team of spokespersons who fanned out across the country seeking debates on TV and radio stations with local physicians about the validity of claims about the dangers of smoking.
One such spokesperson was Charles Waite, a former assistant surgeon general of the U.S. Navy.
On May 12, 1977, in a three-hour match-up with one of us (AB) on a Miami radio show hosted by chain-smoking Larry King, Waite kept repeating variations of the same mantra, “We just don’t know that cigarette smoking causes lung cancer and other diseases. We wish we did know. We need more research.”
King agreed with him.
By the early-1980s, the industry was at it again, having invented an array of “smokers’ rights” groups, which in effect spoke for the last rites of the very people the industry’s products were killing.
Not long after C. Everett Koop became Surgeon General in 1982, he felt it necessary to point to the body of irrefutable evidence that smoking caused death and disease—compelled, because of the Tobacco Institute’s never-ending theme song, “we need more research.”
“When you survey the biomedical literature of the past 30 years, you have to be impressed with the extraordinary amount of evidence that has been generated to prove the causal relationship between cigarette smoking and some two dozen disease conditions,” Koop said, “The medical literature holds an inventory of more than 50,000 studies regarding smoking and health. The overwhelming majority of them clearly implicates cigarette smoking either as a contributing cause or the primary cause of illness and death.
“Now these are facts. They are part of the case built by medical researchers here and the world over for the past three decades, a case that is scientifically conclusive, and the verdict is clear: Smoking is the leading preventable cause of disease and death in this country.”
But by the late-1980s, the facts were still not enough to deter a new breed of abrasive radio and TV talk show hosts from stoking resentment over the abrogation of Americans’ freedom to smoke. Even as the airline smoking ban of 1988 became one of the most popular pieces of legislation ever passed by Congress, shock jocks Morton Downey, Jr. and Rush Limbaugh mocked “anti-smokers” and boasted about their love of smoking. Both men were later diagnosed with lung cancer.
Fox News, Sinclair and the anti-mask movement
Listening today to Fox News’ downplaying of the severity of the COVID-19 pandemic and the criticism of face mask mandates and other measures we know can help prevent infections is akin to reliving that era of cowardice.
The even more ardent Trump-supporting Sinclair Broadcast Group of 191 TV stations across the U.S. has one-upped Fox by promoting a documentary that claims that Anthony Fauci helped manufacture and spread COVID-19.
The political system has made it impossible to put the very obvious and simple preventive measures as the first priority.
Yes, research is good, even essential, but it’s not a substitute for wearing masks.
In his July 2 column in The New York Times, Nicholas Kristof wrote that in the face of coronavirus “Americans are acting curiously helpless… We don’t seem willing to assert independence from a virus that in four months has killed more Americans than the Korean, Vietnam, Gulf, Afghanistan and Iraq wars did over 70 years.”
The cost of distribution of free masks, he added, would be negligible, compared to the cost of hospitalizations. Repudiating Trump’s assertion that mask-wearing is simply a “personal choice,” Kristof warns that “in a time of plague, shunning a face mask is, like driving drunk, putting everyone in your path in danger.”
The U.S. has failed with the least educated portion of the population on both smoking and COVID-19. By virtue of its high COVID-19 rate of infection and the virus’ high death toll, has the U.S. become a shithole country?
It would appear that the number of studies it would take to change the minds of “anti-anti-smokers” or anti-maskers verges on infinity. But just how many studies on smoking have been published?
No one knows for certain, though a PubMed search of the terms “smoking,” “cigarettes,” “tobacco,” and “vaping” yields 349,592 references. (A Google Scholar search yields more than 3 million.)
To what extent have the 300,000 additional papers published in the past 40 years—and the enormous amount of funding to conduct them—led to improved health?
It has taken more than 50 years to flatten the mortality curve of lung cancer, in spite of having known all along the best single evidence-based action for entirely preventing lung cancer and other tobaccogenic diseases.
Research by one of us (ES) in the early-1990s found numerous cross-connections among the members of the Surgeon General’s advisory committee for the 1964 report, the AMA’s Education and Research Fund to administer grants from the tobacco industry, and the Tobacco Industry Research Committee (renamed the Council for Tobacco Research in 1964).
The result was to pad the nests of pet institutions and delay any meaningful action for another 14 years while such important-sounding research was going on.
We knew what we needed to do in 1964, and we didn’t do it. Now, incredibly, with COVID-19 we are witnessing the same foot-dragging of politicians, the same payouts to vested interests, and the same fear on the part of academia and organized medicine in speaking truth to power.
The case can be made that most of the legislation to protect public health on smoking, notably clean indoor air laws, had been passed by the 1990s. Where, then, were the public health funding resources for reducing smoking directed through the years? Invariably they were put into more research, and, with the exceptions of California and Massachusetts, not into the purchase of mass media space to promote not smoking.
Signed by President Obama in 2009, the Family Smoking Prevention and Tobacco Control Act gave the FDA regulatory authority over tobacco products—the first federal legislation on tobacco since the 1988 airline smoking ban.
But far from standing up to Big Tobacco, Congress was doing the bidding of Philip Morris, the biggest champions of the bill.
The measure mainly regulates new and potentially less hazardous tobacco products, but does not apply these same regulatory standards to the most irredeemably harmful form of tobacco, existing cigarettes, which take the lives of upwards of half a million Americans a year.
In other words, Marlboro was grandfathered in. Thus, FDA devotes more effort to attacking e-cigarettes than cigarettes. Incredibly, this agency which regulates cancer drugs and can remove them from the market, now is charged with approving for market the latest variations of cigarettes by Philip Morris and other cigarette manufacturers.
As for other funding to reduce smoking, Bloomberg Philanthropies awarded Johns Hopkins over $300 million to do more research and to support anti-smoking legislation around the world, as well as more than $100 million to the D.C.-based Campaign for Tobacco Free Kids for its anti-smoking lobbying and public education efforts.
As with the government, engaging mass media education takes a back seat to the safe sinecure of research.
The MSA-funded Truth campaign (formerly the American Legacy Foundation, established with $2.5 billion in settlement funds) also spends most of its budget on research, with a modest amount going for paid mass media, but with restrictions on the mention of tobacco company names and cigarette brand names.
Sorely needed: political resolve
We propose a new concept for evaluating the impact of public health interventions. The calculation would include the length of time between when the public health community had sufficient evidence for a specific intervention, the degree of commitment and proportionate allocation of resources for implementing the intervention [as opposed to solely writing policy papers and getting more research grants]; the manpower involved, the buy-in and coordination among health, business, media, academic, and political entities; the proportion of the population that learned about the intervention; the proportion of this group that ignored it; and so forth.
By our estimate, this would put the reduction of smoking as one of the worst failures in public health.
This sad state of affairs is bemoaned by Ed Anselm, an assistant professor of medicine and public health at Icahn Mount Sinai School of Medicine who teaches medical students about smoking.
“Tobacco control advocates often proclaim that the 50% recent reduction in smoking since the first Surgeon General’s Report on Smoking and Health in 1964—from over 40% of the population then to less than 20% today—was a success,” he notes. “Given that over 50 years later the excess deaths attributed to tobacco in the United States still exceeds 500,000 per year, it would be more appropriate to call this a continuing disaster. The various books in recent years about the history of cigarette smoking and efforts to end it may make interesting reading, but they certainly do not offer anything actionable for students new to this troubling story.”
Every single president, Democrat or Republican—Johnson, Nixon, Carter, Reagan, Bush, Clinton, Bush, and Obama—passed the buck on the tobacco pandemic. In stark contrast to the $2 trillion CARES Act and other allocations to address COVID-19, Congress has never approved any significant funding to fight smoking.
Historians, including Robert Proctor, claim that we need know more about the dirty doings of Big Tobacco, but Anselm suggests instead that “what we really need to know is how to obtain the social and political resolve to change things. At a time when people are proclaiming that ‘Black Lives Matter,’ the truth is that very few lives matter when balanced against profit.”
The cigarette—and COVID-19—is too important, here and now, to be left to historians to write the same old narrative.
And make no mistake, the similarity between Trump’s CDC and the CDC in the 1970s, when Big Tobacco was king of the hill, is chilling. In 1977, the federal government’s information resource on smoking for the public and physicians alike, the National Clearinghouse on Smoking and Health, was located in the basement of a small house near CDC in Atlanta.
When one of us (AB) visited that year with its director, Dan Horn, an epidemiologist who had co-authored landmark studies on smoking and lung cancer in the 1950s, he explained the balancing act he had to perform:
“If we only produce pamphlets and posters, then people will be suspicious. But if we become too visible in raising the alarm about smoking, we’d be shut down in a minute.”
His words were prophetic, but for a different pandemic and a different president.