Authors: Richard Kluger
The relative abundance of data reviewed in this Report, their cohesiveness, and their biological plausibility allow a judgment that involuntary
[i.e.
, secondhand] smoking can cause lung cancer in nonsmokers. Although the number of lung cancers due to involuntary smoking is smaller than that due to active smoking, it still represents a number sufficiently large to generate substantial public health concern.
It is certain that a substantial proportion of the lung cancers that occur in nonsmokers are due to ETS exposure; however, more complete data on the dose and variability of smoke exposure in the nonsmoking U.S. population will be needed before a quantitative estimate of the number of such cancers can be made.
In fact, the data were neither abundant nor cohesive—and certainly not conclusive. And to state that ETS could plausibly kill people did not advance the scientific dialogue or social debate over whether restrictive measures were called for to curb smoking in public, as spitting had been outlawed at the beginning of the century. It was misleading, if not disingenuous in the extreme, to note merely that the number of lung cancer deaths from secondhand smoke was “smaller” than from active smoking when the most latitudinarian reading
of the literature placed the annual toll for the disease attributable to ETS at one-twentieth as large. Nor was it “certain,” as Koop’s preface said, that a “substantial portion” of lung cancer deaths in nonsmokers was due to ETS; it was, no doubt, plausible and even likely, but in his own words, more data were needed before a “quantitative estimate” could be made authoritatively. The truth was that nobody yet knew the total human absorption of toxicity from ETS—there had been only calculated guesswork, a far cry from the overwhelming array of data, including quite precisely measurable dosages, on direct smoking.
At his press conference unveiling the report on ETS, Koop went a good deal further by stating that the health risk to nonsmokers from smoking colleagues in the workplace was so clear that everyone ought to be able to enjoy employment in a smoke-free environment. His new report, the Surgeon General added, would be “a turning point” comparable to the one marked by the original 1964 report. But a diligent reading of the 1986 text disclosed considerable equivocation in its findings, suggesting that Koop was indulging in hyperbole. The text noted, for example, that “healthy adults exposed to ETS may have small changes in pulmonary testing function but are unlikely to experience clinically significant deficits in pulmonary function as a result of ETS exposure alone … .” The spousal studies like Hirayama’s on lung cancer risk from ETS, the report commented, were shadowed by doubts because “misclassification of exposure to ETS is inherent” and some degree of exposure to ETS “has been almost inevitable” among nonsmoking spouses, especially in the U.S., where so many wives worked or were otherwise away from home much of their time. Using the smoking habits of a spouse as the index of involuntary smoking might be a “convenient” measure, the report went on, but it was also “simplistic,” and there was “no reason to believe that such exposure was limited to or governed by that source … . More accurate estimates for the assessment of exposure in the home, workplace and other environments are needed. Studies of sufficiently large populations should also be performed.”
Why, then, since the jury was clearly still out, was the Surgeon General so denunciatory about the ETS peril? In the retrospective view of chemist Frank Resnik, who was then president of Philip Morris USA, Koop was “bending the research to accomplish his objective,” which he had declared two years earlier to be a “smoke-free America by the year 2000.” One prominent investigator on the dangers of smoking asked Koop at the time why he appeared to be overstating the findings of his scientific advisors, who were far more cautious in the text they had prepared to go out under the Surgeon General’s imprimatur. Koop replied, according to this leading scientist, that as the nation’s ranking public-health advocate, he had to be forceful in warning of the ETS threat in order to win the public’s attention.
Without a doubt he succeeded, and without a doubt Koop was on the side of
the angels, but without much doubt, either, he was in this instance using dubious means—shaky science—to justify the worthy end of achieving a healthier society. That same year, the
American Review of Respiratory Diseases
summed up the evidence this way: “[T]he existing data on passive smoking and lung cancer do not meet the strict criteria for causality of this association,” adding that to reach that point “may be exceedingly difficult, if not impossible,” due to methodological problems like measuring dosages and determining who was truly a nonsmoker. Even one of the soundest and most astute of the public-health investigators with an antismoking bent, economist Kenneth E. Warner of the University of Michigan, noted in his 1986 booklet,
Selling Smoke: Cigarette Advertising and Public Health
, that although a majority of the twenty or so studies done since 1980 had found a statistically significant elevated risk of lung cancer from ETS, “the likelihood that a lifelong nonsmoker will contract lung cancer is so small that a doubling of that risk remains relatively small.” What made even that small risk significant, Warner did not fail to note, was that ETS exposure was so widespread, indeed nearly universal, that a substantial death toll “may be found in the aggregate.”
A balanced appraisal, then, would have held that to try to calibrate the ETS hazard by linking it to the toll from active smoking was like comparing apples and oranges—or, to invoke a more apt metaphor, to try to quantify the peril of death by ranking the lethal power of a conventional bomb alongside that of a nuclear device. It was the wrong frame and scale of reference. More to the point was that the best or median guesses of the ETS lung cancer toll—the NRC study had put the figure at 2,400, or about half of Repace and Lowrey’s outside number—were higher than the entire toll attributed to all other airborne pollutants regulated by the EPA. Donald Shopland, the longtime OSH technical information specialist and later acting director of the antismoking agency, conceded that the data indicting ETS were “much thinner,” but also pointed out, “Everything is a small risk compared with direct smoking.” ETS posed a much greater danger, for example, than asbestos exposure, believed to cause about thirty deaths a year across the U.S. and then costing almost a billion dollars annually to combat.
In short, the precise magnitude of the danger posed by other people’s cigarette smoke was both uncertain and beside the point by the mid-1980s, so far as most in the public-health community were concerned. Their watchwords were preventive medicine, and linking ETS with direct smoking in order to alarm and mobilize the public against the still widely practiced habit served to counter the unstinting drumbeat of denial, distortion, and disinformation sounded by the tobacco industry in order to stay in business. As epidemiologist Lester Breslow, former dean of the UCLA School of Public Health, remarked, it is hard to awaken the people to a public-health peril, but once the arousal has begun, “it builds to a mighty wave, gathering force from almost any supporting
evidence.” Koop had won the people’s attention on the smoking menace as no individual before him had, but “the turning point” he had spoken of was not to be found in the scientific evidence about ETS but in the public perception of what by any rigorous standard was a complex risk measurement. To Congressman Charles Whitley, retiring that year after five terms in the House representing North Carolina’s tobacco-rich Third District, the 1986 Surgeon General’s report and Koop’s dissemination of it were “a very deliberate attempt to turn nonsmokers into antismokers” and thus the document was “a political, not a health, report.” In truth, it was both, as purveyed by America’s foremost public-health protector—and some felt that it was about time to put aside the velvet gloves in battling the tobacco interests.
IV
THE
emergence of scientific evidence, however murky, on the dangers of ETS allowed the public-health and antismoking forces to open a second front that would prove far more difficult for the tobacco industry to withstand.
The cigarette makers had held off serious government restrictions by firming up their political alliances, challenging the scientific case, confusing the public, reassuring their customers—and no doubt salving their consciences by lowering the tar and nicotine yields of their product. As an antismoking movement began to coalesce during the ’Seventies and the public increasingly accepted the scientific consensus, the industry had taken to painting its foes as killjoys who would deny to millions worldwide a cheap and simple pleasure.
This defensive strategy worked so long as smoking was generally perceived as a self-indulgent, if perverse and self-destructive, practice that was indeed the smokers’ business—and their right. If smoking killed them, it did so by inches, and the number of premature deaths, to go by the U.S. Public Health Service reports, had by now cumulatively amounted to so many millions that there was little sense of urgency in the popular mind about the nagging problem. Like the weather, people talked about it, and the habit similarly seemed almost a force of nature. In addition, an economic dependency on cigarettes affected so many—in the form of tobacco growers’ livelihoods, manufacturers’ salaries and wages, vendors’ markups, governments’ tax revenues, and stockholders’ dividends—that the industry had essentially won the argument about whether money or health mattered more. Smoking and health remained a low-priority issue on most congressmen’s agenda; a great many of their constituents still smoked, including any number of powerful people who did not relish being thought of or called weak-willed, possibly deviant, or even moronic addicts. Officeholders had discovered that it was much easier to lose votes by opposing something of paramount importance to a minority of voters
than to gain votes by advocating a position—in this case, the regulation of smoking—of scant or no concern to the majority. In the words of ex-Congressman Charles Whitley, who went to work as a Tobacco Institute lobbyist and spokesman after leaving office, “Those hurt will know about it and will let you know.”
Besides stigmatizing smokers, the ETS issue brought with it a fresh rationale for interventionist measures. If smokers were now viewed as violators of the social contract by imposing the unhealthful consequences of their pleasure-taking on others, then it might be quite acceptable to quarantine or even punish them as part of the broader social movement to cleanse the environment. Smoking near someone else was no more excusable than poisoning streams with industrial runoff or fouling the air with toxic smokestack emissions.
Even with this powerful added weapon, antismoking activists had to be organized and led, and nobody was as yet really doing that. The closest thing to a charismatic leader before Dr. Koop came to Washington was George Washington University law professor John Banzhaf, who ran his Action on Smoking and Health (ASH) effort as an adjunct to his teaching career and an extension of a not inconsiderable ego. By 1979, Banzhaf claimed a nationwide membership of some 60,000, who contributed an average of just six dollars apiece, so even ASH was no lavishly funded effort; it was a vehicle, rather, for its director to testify before congressional committees, appear on television, and exert what legal leverage he could against the cigarette companies, mostly by petitioning federal regulatory agencies to restrict smoking in public. Outside Washington, the grassroots GASPs (Groups Against Smoking Pollution), tiny, volunteer cells that generally depended for their survival on one or two deeply concerned individuals, pressed for local antismoking measures and tried, on shoestring budgets, to educate the public to the possible hazards of ETS.
The key to leadership if a national smoking control movement was to emerge resided not with these small, financially precarious units, but with the big voluntary health organizations, of which the American Cancer Society was by far the largest and best financed. The ACS, along with the American Heart Association (AHA) and the American Lung Association (ALA), had size, organization, and a universally acknowledged mission to educate the public. What they had no experience at, and little stomach for, was political crusading; what they shared was a determination to avoid controversy—and smoking remained an emotional, divisive issue. The Big Three’s tax-exempt status, furthermore, might have been imperiled if they had overtly lobbied Congress on the smoking issue (or any other); the health voluntaries could have brought legal action against the cigarette companies or testified against them, but such measures were seen as antithetical to the voluntaries’ basic task and might have cost them dearly.
Because the early epidemiological studies had disclosed so close and persuasive
a link between smoking and lung cancer, the ACS with its 2 million members was the first to become involved in the issue among the Big Three. Even with a tightly hedged commitment, it had carried on the cause practically alone for two decades during which the scientific studies on smoking proliferated. The AHA, the most conservative of the three health voluntaries, was dominated by the wealthiest of medical practitioners—cardiac specialists—who viewed diet as the prime health risk for heart disease and generally were far more concerned with the latest techniques in valve replacement and other technological marvels than in advancing preventive medicine by aggressively discouraging smoking. The ALA, the smallest of the Big Three, was the most militant on the smoking issue, partly because it was most in need of a medical issue to perpetuate its existence after tuberculosis had been brought largely under control. But the three voluntaries rarely worked jointly on anything.
The prime policymaker at the ACS was Lane Adams, the suave ex-banker from Utah who served as its executive director for twenty-four years, beginning in 1959. A Republican and a Mormon, Adams exercised skillful, top-down control over his monolithic organization, with its fifty-six branches, and closely husbanded its power, which was unique. The ACS, when compared with any other health voluntary or even professional society, had huge numbers, organizational cohesion, continuity of leadership, discipline in policy-framing and execution, and a nearly sanctified standing in the public mind. Adams held the ACS aloof from compromising alliances or activities, took it out of the United Way fund-raising mechanism for many years, and insisted that the cancer society’s mailing lists be jealously guarded. Perhaps because he was fiercely protective of the ACS’s standing, Adams was no antismoking zealot.