Ashes to Ashes (23 page)

The arrival of radiology and the X ray near the end of the nineteenth century improved cancer diagnosis, but chemotherapy was as yet unknown. Surgery was the only treatment, and often the size of the tumor was so massive that its attempted removal was almost always fatal. In lung cancer, before the development of the artificial respirator, surgery was complicated by the need to avoid collapsing the lung on incision and shutting down much or all of the body’s breathing apparatus. By 1926, there were 800 clinics for venereal disease in the U.S., 600 tuberculosis sanitoria, and 100 heart clinics, but hardly a single institution devoted solely to cancer care. To bring the disease out of the closet, the American Society for Control of Cancer—later called the American Cancer Society, the nation’s largest voluntary health organization—was formed in 1913 and devoted itself primarily to educating the public on the need for early detection of the condition. But only when the cancer society began enlisting women from the Social Register to spread the word about this disease that did not distinguish among the socioeconomic classes in settling on its victims did public awareness of it intensify. In 1937, the federal government established the National Cancer Institute at Bethesda, Maryland, but it was a shoestring operation.

Still, researchers were coming to understand how normal cells turned malignant
by stages—in a protracted metamorphosis of unknown cause or causes. The initial phase, hyperplasia, was commonly attributed to chronic irritation either chemical or mechanical
(e.g.
, by rubbing or some other form of abrasion) in nature which caused the cells to divide in a defensive reaction, so that the one or two layers of cells lining, say, the breathing passages would become aggravated by cigarette smoke and grow protectively to five or six layers. Hyperplasia in itself was a benign enough process, a toughening of tissue like the formation of a callus where a part of the foot or hand was constantly rubbed. The second phase of the cancer cycle—metaplasia—was more menacing. Cells became altered in their structure as they proliferated; their nuclei typically enlarged while the life-sustaining cellular fluid, or cytoplasm, was diminished. The reasons for this basic alteration remained obscure. The third and critical phase of cancer—neoplasia, meaning a new growth—generally referred to the development of a tumor. But there were tumors of varying degrees of virulence. Some grew and stopped; some enlarged continually but remained in their original organ or tissue site; some burst through the body’s retaining structures, began devouring anything in their path, and spread their deadly reach via the body’s circulatory systems. Learning why tumors behaved in their differing ways and whether medical science could do anything about them had to await the arrival of better tools and more knowledgeable investigators.

Laboratory experiments were under way in earnest by the early ’Thirties, and a few scientists were beginning to conclude that whatever other effects nicotine triggered in the body, cancer was not among them. The far more likely agent was one or possibly several of the chemical compounds in the tobacco that underwent changes during the combustion process and, upon inhalation, blanketed the bronchial system. Most prominent among these investigators was an Argentinian, A. H. Roffo, director of the new cancer institute in Buenos Aires, who pioneered in distilling from tobacco smoke the tarry residue—with the nicotine removed—of the burning process and applying it to the ear linings of rabbits. The resulting tumors were produced by the tar distilled from tobacco burned at high temperatures. And the most carcinogenic, or cancer-causing, compounds, Roffo’s laboratory learned through chemical analysis by use of the new spectroscope, were a category known as hydrocarbons, of which the coal-tars were typical. Just how these compounds grew unstable in their internal atomic configuration when heated and turned into marauding irritants of peril to human cells could hardly be guessed at. But by the late 1930s, Roffo had come to believe that the menace of lung cancer from tobacco was so serious that antismoking measures ought to be undertaken by government. But some believed his dosages of tobacco tar distillate for animals was too large and hardly comparable to human exposure to cigarette smoke.

American clinicians, building on their direct experience and intuition, were
coming to be persuaded in small but growing numbers of a causal link between smoking and lung cancer. One of them was Boston thoracic surgeon Richard H. Overholt, who, faced with the reality that removing the visible portion of a lung tumor often left intact its microscopic outcroppings and the promise of a fresh malignancy, took out his first whole lung in 1933. Lungs ravaged by cigarette smoke, he found, were not as black, certainly, as those of afflicted coal miners, but they were heavily pigmented and felt heavier and stiffer than normal ones. They behaved differently as well during surgery, taking longer to collapse—the standard procedure, surgeons had learned, before attacking the tumor—and longer to reinflate afterward, a plain indication of loss of the elastic, bellows-like function of the organ and its efficiency as the body’s prime oxygenating agent. Firsthand knowledge of this condition, along with a keener awareness that cigarette smoke somehow overstimulated the mucus-producing cells of the bronchial system and generated congestive phlegm inviting to infectious microorganisms, helped Overholt understand why smokers fared so much more poorly postoperatively than nonsmokers. He began to refuse accepting patients for surgery unless they stopped smoking; in time he became a vigorous opponent of smoking and lost friends over it in the medical profession, too many of whom, Overholt was convinced, let their own smoking addiction warp their judgment about the true pathological nature of the habit.

Perhaps the best known of the outspoken medical critics of cigarette smoking at this time was New Orleans surgeon Alton Ochsner, who as a third-year student at Washington University’s medical school in 1919 was summoned to observe a lung cancer surgery then considered so rare that he was told he might never see another in his career. And indeed, seventeen years passed before he confronted his second lung cancer patient—and then, as a professor of surgery at Tulane, he saw eight cases within six months, all smokers who had contracted the habit during the world war. This pattern struck Ochsner as far more than coincidence and suggested that the incubation or latency period of the wasting process might well be twenty or more years. By 1939, Ochsner was reporting in the journal
Surgery, Gynecology, and Obstetrics
on seventy-nine cases of pulmonary malignancy he had treated which left him in little doubt that the inhalation of smoke was a prime factor because of the chronic irritation it caused throughout the bronchial tract.

Probably the best-informed and most persuasive scientific paper of the decade on the smoking and health question was “Tobacco Misuse and Lung Carcinoma,” written in 1939 by Franz Hermann Muller of the University of Cologne’s Pathological Institute. He observed that the great increase in the consumption of tobacco starting before the First World War and accelerating since “runs parallel with the increase in primary lung cancer”
(i.e.
, cancer originating in the lung) and, given the smoking habits of the sexes, explained why
the disease was six times more prevalent among men. Muller added that the incursion of the disease was probably linked to the breakdown of “the physiological defense mechanisms of the lung, particularly the action of the ciliated epithelium,” a reference to the concerted sweeping action of the cilia, tiny hairlike projections lining the bronchial tubes and pushing along the protective film of mucus that trapped waste and abrasive foreign matter. In a defective body or one malfunctioning “due to continuous excessive strain (smoker’s catarrh), the accumulation of carcinogenic substances which enter into the lungs from the outside occurs much more readily … .”

Müller had conducted the first careful study of its kind on the clinically observed relationship of smoking to lung cancer. Comparing the case histories of eighty-six men so afflicted with another eighty-six men of comparable backgrounds who were healthy, he found that only three of the lung cancer victims were nonsmokers—a correlation so high that in and of itself it was suggestive of a close link. Yet all but fourteen of the healthy cases were also smokers, so that the habit could hardly be said to constitute a sufficient cause of the disease. When the
amount
of smoking, rather than the mere fact of it, was taken into consideration, however, half of the lung cancer victims turned out to have smoked twenty-five or more cigarettes a day, while only about 10 percent of those unaffected by the disease smoked that heavily, suggesting a clear dose-response relationship.

A year after a translation of Müller’s seminal study was published in the
Journal of the American Medical Association
(
JAMA
), that journal carried a report by three investigators at the Mayo Clinic entitled “Tobacco and Coronary Disease.” It was largely statistical and did not speculate on the possible agents or mechanics of the disease, but the data were the first to suggest with authority a systemic pathological impact of cigarette smoke beyond the lungs. A cohort of 187 men between forty and forty-nine with coronary heart disease (CHD) included 80 percent who smoked; in a comparable group of 307 free of the disease, 62 percent were smokers—meaning that smokers in the study were about one-third likelier to contract the disease. In larger samples of 1,000 in each category, the Mayo investigators found that 5.4 percent of smokers in the forty-to-forty-nine age category suffered from heart disease compared with 1 percent for nonsmokers; in the fifty-to-fifty-nine age bracket, 6.2 percent of smokers had CHD vs. 2.6 percent of nonsmokers.

The public, unaware for the most part of these technical reports and serenaded by manufacturers about how benign their brands were, was taking to smoking as never before. By 1940, Americans eighteen and over were annually smoking 2,558 cigarettes per capita, nearly twice the 1930 level of consumption, even during the nation’s worst economic catastrophe. The industry as a whole was earning 17 percent on its invested capital in 1940, or nearly twice the overall rate for publicly held American corporations.

The tobacco companies, therefore, had no need now to compete in pricing or leaf purchasing; only disastrous internecine warfare would ensue. Tobacco, no longer a monolithic trust, had become a classic cartel, prompting the U.S. Department of Justice to undertake a two-year investigation that culminated in a mid-1940 antitrust suit against the industry. But in the course of a twenty-week trial in a Kentucky federal court the following year, the government failed to produce any explicit evidence of collusion and proved only that it was in the companies’ joint interest to act identically, except for their advertising, in what they paid to make, and charged for, their product. A jury found the industry guilty of unfair competition, even though during the immediately preceding years two companies had emerged as profitable new competitors to the established entries and a whole new tier of economy brands had come into existence beneath the leaders’ price level. The fact was that the cigarette business, like most American industries now, was ruled by major players whose economies of scale were lifting the nation’s standard of living. And nobody thought of the lords of tobacco as deadly predators.

“Shall We Just Have a Cigarette on It?”

THE
December 1941 issue of
Reader’s Digest
, the only mainstream periodical of the time to crusade against the alleged perils of tobacco, carried an article entitled “Nicotine Knockout” and attributed to Gene Tunney, in which the retired, undefeated heavyweight boxing champion, then running the U.S. Navy’s physical fitness program, noted three likely consequences of serious smoking: “[Y]ou smell so strong and dogs will never bite you,” you will cough in your sleep and so robbers “will not try to steal your belongings,” and “you will have many diseases … and die young.”

Within days of the article’s appearance, many would be dying young from more acute causes than smoking as the world plunged into its first truly global bloodletting. In light of the imminent carnage, any risk attached to consuming cigarettes seemed irrelevant, and they became as never before the drug of choice to allay the chronic stresses of wartime. The U.S. military machine would eventually require 12 million bodies to operate it, and they smoked an average of thirty cigarettes a day, or about 30 percent of the total output, which soared to half again as much as its prewar level during the almost four years of American involvement. The classic renderings of weary, dirt-caked G.I.’s by cartoonist Bill Mauldin invariably showed young soldiers with butts dangling from their grimly wisecracking lips. The leaders of the Big Three nations in the antifascist coalition were heavy smokers, and the supreme commander of the Allied military effort in the Pacific theater, a corncob pipe clenched with resolve in his firm jaw, replied to home-front aeronautical workers who had wired him asking how best to spend the $10 million they had raised to help the
fighting forces: “The entire amount should be used to purchase American cigarettes which, of all personal comforts, are the most difficult to obtain here.” Earlier, President Roosevelt had ennobled smoking by declaring tobacco an essential wartime material and granting military exemptions to those who grew it. And women, supplementing the depleted civilian labor pool, took up heavy manufacturing jobs with their attendant pressures and smoked’as never before, if not quite as heavily as men. The forced separations and other emotional exigencies of wartime added further to the perceived usefulness of the cigarette as a sublimating device to soothe the nation’s arrested sex drive and promote fidelity until the troops came marching home. Could any product, lethal or otherwise, be more patriotic?