Authors: Richard Kluger
Five years in preparation, the 232-page FTC report turned out to be largely devoid of concrete policy proposals to Congress. Still, its muted findings could not be ignored altogether. Chief among them was that the eleven-year-old warning label on cigarette packs and in ads, stating merely that smoking was dangerous, “does not communicate information on significant, specific risks that have recently been identified” and was too abstract, read by only 3 percent of smokers, according to surveys, and “simply worn out.” The cigarette makers’ ads, it was charged, “have continued to attempt to allay anxieties about the hazards of smoking” and in their graphic allure and seductive texts have served to “make it more difficult for the health warning to be effective and may further increase the possibility of deception … .” While voluntary restraint by the industry would be preferable to new government regulations, the report pointed out that the cigarette manufacturers had never acknowledged the
health hazards of their product, had instead aggressively attacked the validity of the scientific evidence against them, and had agreed to warn the public only when threatened by imminent government actions.
The only plausible proposal in the staff report was to increase the size and change the shape (to a circle with an imposed arrow) of the health warning and to replace the present caution with a series of short, rotating messages of the sort used in Sweden—the “fortune cookie” approach, as the FTC staff called it—to inform the public more fully. But the proposal, along with the rest of the staff report, generated little attention from an administration elected on the promise to get government off the people’s back. In such a climate, Matt Myers sought the united endorsement of the FTC report by the three big voluntary health societies as a means of attracting public notice and possibly stirring legislative action, but “I was told it was out of the question.” Nor was the newly throttled FTC itself pushing the report with Congress. Myers left the agency in August, seeing scant hope for any forward movement in regulating cigarette ads under Reagan.
Another spirited young figure in the capital’s tiny corps of antismoking political activists—John Pinney, director of the Office on Smoking and Health (OSH) at what was now called the Department of Health and Human Services (HHS)—came to the same conclusion. In Pinney’s case, the decision to leave was hurried along by his new superiors’ collective response to what he felt was “the best thing we had ever done” to educate the public on the perils of smoking. To reverse the uptrend in cigarette use by teenagers, especially among girls who were found to link smoking with slimness and sexiness, OSH accepted the offer of teenage film actress Brooke Shields for a series of short television messages on the theme that smoking was anything but sexy. It amounted to a million-dollar campaign all but donated to the government.
But when Pinney sent up the finished public service announcements for departmental review, he was advised that his HHS overseers found Shields to be an “inappropriate” role model for teenage Americans and her antismoking message thus valueless. Strongly suspecting that the HHS brass was fearful of upsetting the White House, where attitudinizing on “family values” was in vogue, if hardly honored in the practice, Pinney soon grew exasperated. He took the Shields messages to the American Heart Association, which found them too controversial to attach its hallowed name to, and the American Cancer Society said it would think it over. Frustrated after three spirited years revivifying OSH and instilling the Surgeon General’s reports with new authority and focus, Pinney left.
Still more depressing to the prospects of the antismoking cause was Reagan’s nominee for Surgeon General, a sixty-four-year-old evangelical Christian highly regarded as a pediatric surgeon in Philadelphia but a lightning rod for protest from the women’s liberation movement due to his anti-abortion
speeches—Dr. C. Everett Koop. So vehemently did this child-healer with the stentorian voice and full beard, which gave him the sound and look of an Old Testament prophet, deliver his “pro-life” message that congressional liberals were fearful that they might have a reactionary fanatic on their hands. The chief executive of the American Public Health Association pronounced Koop “almost uniquely unqualified to be Surgeon General,” and in the Senate, Ted Kennedy, a power on public-health issues, charged that the nominee was deluded by “cruel, outmoded, and patronizing stereotypes” of women. But Kennedy could muster only twenty-three colleagues against Koop, and after the liberals had stalled the confirmation process as long as possible, the new Surgeon General was confirmed. He was hardly expected to be a forceful anti-smoking advocate.
II
JAMES
L.
REPACE
, a round-faced, gently spoken physicist with an infectious enthusiasm, came naturally by his aversion to polluted air. Since childhood he had suffered from asthma, which was aggravated by exposure to the cigarette smoke frequently emanating from his father, who would die from lung cancer at fifty-nine. Working at places where he could avoid smoke, Repace had become a clean-air and antismoking activist in his spare time. He helped fight a District of Columbia plan to put up incinerators not far from where he worked and joined with a citizens’ group in Prince Georges County, Maryland, where he lived, and pushed for smoking restrictions in restaurants in Bowie, his hometown.
At one hearing, a local councilman asked Repace for hard data on the extent of pollution exposure from environmental tobacco smoke (ETS), and when he researched the question, he found little beyond anecdotal complaints. Because the Environmental Protection Agency (EPA) was empowered to deal only with outdoor pollutants, there were no accepted standards for indoor airborne breathable particles. This struck Repace as a serious lacuna in the scientific literature, since Americans spend an average of 85 to 90 percent of their lives indoors. And in the wake of the Mideast oil crisis of the early ’Seventies, national energy and fuel conservation measures had resulted in far more tightly sealed homes, with a substantial drop in ventilation rates, and many workplaces with permanently sealed windows and air-conditioning systems using recycled, stale air. Among indoor contaminants, colorless, odorless carbon monoxide was the most common and cigarette smoke the most readily detectable—and thus the most annoying to nonsmokers.
To measure the amount of cigarette smoke in confined areas, Repace undertook some basic and somewhat crude field research that no one else with his
technical training had bothered to attempt. Using a piezobalance, a lightweight, noiseless device about the size of a woman’s handbag, Repace counted the level of tiny air impurities known as respirable particulate (RSP) per cubic centimeter in real-world settings, starting with thirty-three indoor smoke-free sites to provide a basis for comparison; these included homes without smokers, nonsmoking sections of restaurants, public libraries, churches, and a bagel factory. The average of these RSP background levels was then subtracted from the RSP count he recorded in twenty-three smoky public places, among them eight restaurants, three cocktail lounges, two lodge halls during bingo games, a club during a dinner-dance, a bowling alley, a sports arena, and a hospital emergency room. While Repace could not take an accurate reading of the ventilation systems without the use of trace gases to measure how readily they were dissipated—impracticable under the circumstances without disclosing his mission and possibly affecting the random nature of his selection process—he nevertheless made every effort to place his gauge at tabletop level as close to the center of every room or hall he visited.
But what portion of the RSP measured could Repace reasonably attribute to cigarette smoking? The answer would surely have varied, depending upon how many smokers were in the room, how heavily they smoked, what the toxic yields of their cigarettes were, how large the room was, how well it was ventilated, its temperature and humidity, and other factors that were impossible for him to measure, given the time, money, and personnel constraints of the study. Instead Repace simplified the process by adopting the reasonable premise that smoking was a random process when it occurred among large groups of people, so he could rely on “equilibrium values,” average figures based on known national data and standards. Thus, once he knew how many people were present at any of his sites, he could reasonably assume that one out of three was a smoker, that each of those smoked for about ten minutes and waited twenty minutes before lighting his or her next cigarette (assuring a more or less constant level of ETS), that each cigarette had an inhaled yield of 17.6 milligrams of tar (from which, based on the known level of mainstream smoke retained in the lungs and the emission rate of side-stream smoke, the quantity of ETS could be extrapolated), and that the known standards for ventilation systems as set down by the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) could be applied, neutralizing actual on-site differences for the purpose of his study. Taking all of this into account, Repace calculated that ETS, cigarette smoke in the air, was overwhelmingly the largest contributor to his RSP readings, provided that he avoided industrial neighborhoods and cooking facilities, from which combustible emissions could seriously skew his figures.
Conducted over a ten-week period in 1978, Repace’s fieldwork disclosed
that the pollution level was forty times higher inside a bowling alley than in the air outside, that the air in a bingo hall was fourteen times dirtier than that in the nonsmoking section of a restaurant, and that even in a heavily ventilated sports arena the air was four times more impure than either the air outside or in the smoke-free part of a selected restaurant. Plainly, then, a double standard was being employed by federal environmental air protectors. For if ETS, which contained four of the five pollutants held hazardous by the EPA—benzene, arsenic, coke oven emissions, and radionuclides (but not asbestos)—was coming out of smokestacks, it would have been held illegal. Repace computed the risk of exposure to lung cancer from the ETS levels he obtained to be 250 to 1,000 times above the acceptable level as set down by federal guidelines for carcinogens in air, water, and food.
While Repace’s methods may have seemed primitive and his assumptions oversimplified, they were scientifically plausible, and by the time he and a friend, Alfred Lowrey, a theoretical chemist, finished refining the raw data, they felt they had an article worthy of submission to
Science
. In the interim between his fieldwork and the article’s submission, Repace had gone to work in the EPA’s air policy office and, mindful of the political sensitivity of government bureaus over anything to do with the tobacco industry, he cleared his study with agency lawyers and appended a disclaimer stating that the article did not reflect EPA’s views. Nevertheless, his employment at EPA added to Repace’s credentials, which no doubt helped steel the editors of
Science
against criticism of the Repace-Lowrey study, some unsolicited from scientists who had been shown the article by the journal’s peer-reviewers. Chief among these was Professor Theodor Sterling of Simon Fraser University in British Columbia, who at that time was the recipient of grants totaling more than $400,000 for “special projects” approved by the industry lawyers overseeing the Council for Tobacco Research. Sterling wrote to
Science
that the Repace-Lowrey study suffered from poor methodology and mathematics, faulty equipment, and conclusions flawed by their failure to obtain background RSP and ventilation rates specific for every field location tested; that other variables were not accounted for; that the ETS. level at any given site could not possibly be determined without taking into account the “aging” rate at which the smoke was diluted; and that other pollutants besides ETS were impossible to separate from the RSP readings.
Repace persuasively answered these charges, contending that they were largely beside the point—that the “aging” rate of ETS, for instance, could be calculated as a constant value since it took about three hours to clear 95 percent of the ETS from a room, during which time the smokers in it collectively lighted, smoked, and discarded cigarettes in a more or less continuous process. To the claim that the ETS level could not be inferred from RSP readings because
other airborne pollutants were also present, he responded that the indoor pollution level is ten to one hundred times higher when people are smoking, by far the most significant source of respirable indoor air pollution.
Published in
Science
in May 1980, Repace’s article—his first in a major journal—asserted that the RSP levels generated by smokers overwhelmed the effects of existing ventilation systems and that ETS “presents a serious risk to the health of nonsmokers. Since this risk is involuntary, it deserves as much attention as outdoor air pollution.” The authors received 200 reprint requests almost at once, signaling that a new era of findings on smoking and health had opened.
But how could Repace state with such certainty that the ETS constituted a “serious risk” to society? The toxic ingredients may have been virtually identical to those that smokers drew into their lungs, but the dosage was obviously diluted, and who could say for sure if such a thinned dose was truly hazardous? Repace and Lowrey spent the next several years addressing that question, trying to link exposure rates of ETS to risk levels for contracting disease, in particular lung cancer. In its annual mortality toll, the U.S. Public Health Service put lung cancer deaths in 1982 at about 116,000, 85 percent attributed to the victims’ active smoking habit. What portion of the more than 17,000 non-smokers who died that year from lung cancer might have succumbed to the toxic intake from other people’s smoke?
Repace attacked the question the only way he could as a practical matter—mathematically, using hypothetical constructs based on straightforward national tables and standards, rather than by costly epidemiological studies tracking specific population groups and their real-life exposure to ETS. Basic to his calculations was a 1980 study of disease and death rates among a group of Seventh-Day Adventists (SDA), the least smoke-exposed cohort Repace could find. Not only were there serious SDA strictures against smoking, but adherents of that faith socialized heavily among themselves, and an unusually large proportion of them worked for the church. The death rate from lung cancer among SDA wives was found in the study to be about 5.3 per 100,000, compared with about 12.7 among nonsmoking wives of smoking husbands in the non-SDA cohort chosen for comparison; Repace attributed the differential of 7.4 deaths per 100,000 entirely to the non-SDA wives’ exposure to their husbands’ smoking, even though the authors of the study had not, suggesting that factors such as diets low in meat among the SDA cohort might somehow have been involved. By multiplying the 7.4 differential figure by the exposed nonsmoking population over age thirty-five, Repace came out with an annual lung cancer death toll attributable to ETS of about 5,000 Americans. He then checked this against figures he derived from models or averages he used in determining the total national exposure to ETS. He assumed, by way of examples, that a third of adult Americans were smokers; that they smoked two
cigarettes an hour in the course of a sixteen-hour waking day; that adults spent 90 percent of their time inside their homes or offices; that the average home (according to the National Association of Home Builders) contained 1,500 square feet with a height of 8 feet and that the average work site accommodated seven people per 1,000 square feet with a height of 10 feet; and that the U.S. workforce was divided about equally between white-collar workers, 80 percent of whom were exposed to ETS, and blue-collar workers, of whom only 50 percent were smoke-exposed due to safety or sanitary regulations. Further assuming that the RSP intake consisted largely of ETS, Repace concluded that the average nonsmoking American adult environmentally absorbed 1.43 milligrams of tar daily, or about the equivalent of one or two ultra-low-tar cigarettes smoked directly. He then divided the SDA-derived differential figure of 7.4 lung cancer deaths per 100,000 that he attributed to ETS by that 1.43-milligram exposure level and emerged with a risk exposure level of five deaths per 100,000 per milligram of tar absorbed per day per smoker—and that worked out to between 500 and 5,000 annual deaths, apparently corroborating the SDA-based calculations.