The Cigarette Century | Allan Brandt | Talks at Google

Hi, everyone, and welcome to today's Authors at Google event. Our guest today is Alan Brandt, who is professor of the history of medicine and history of science at Harvard, and the author, most recently of the Cigarette Century, which chronicles the history of the cigarette industry in America, where it's been, where it's going, why we expect to lose 1 billion lives over the next hundred years to cigarettes. And he wrote recently in the LA Times about why, if Barack Obama succeeds in his effort to quit smoking, it will actually be a victory for the cigarette industry. He'll be talking about those things and others today. And I was reading this book over the weekend on Saturday and I thought, wow, this is really great stuff. And I placed it in this recent history of books about these kind of inanimate objects. Mark Kurlansky's History of Salt specifically came to mind. And I remember thinking, oh, this is 100 times better than salt. It is interesting, engaging, and above all, scary without being moralizing or moralistic. I encourage you all to read it. We'll hopefully have books at the end of the event, which I know you're all wondering about, since we normally have them at the beginning. Without any further ado, I'd like to introduce Alan Brandt.

Thanks so much. It's great to be here. It must be like this for you all the time. Google has just become so much like a part of my life, and I've been getting like Google alerts on the book this morning, and so it's fantastic to actually be here and get to meet some of you. What I wanted to do this afternoon is just tell you a little bit about the book, sort of the key themes. And I have some slides, mostly of illustrations that are in the book that I'd like to show you. But my publicist keeps saying that the book took me 20 years. First he said 20 years to write, now he's saying 25 years to write. But the book actually begins when I'm 7 years old. And when I was 7 years old, my parents took me to New York City for the first time. And most of you are fortunately too young to remember this, but there was this incredible billboard in Times Square and it had a camel man. And the camel man actually blew smoke rings. And my parents had given me this book before we went to New York called this Is New York. And it actually had an illustration of the camelman blowing these smoke rings. That was the only place I wanted to go. And they took me to see this guy blow the smoke rings. It turns out there were 15 smoke rings blown per minute, all were perfect, and they drifted off into the sky. And I had already been told 1961, that there was quite a bit of evidence already about how dangerous cigarette smoking was. And I think I was perplexed. This seemed to me to be the single most fantastic thing in New York, or maybe ever. And yet at the time, I also knew smoking was bad. And I've thought back in terms of my own work as a historian and thinking about this problem. This was essentially the problem that perplexed me since that time that I tried to address in the book. How could something that in the middle of the 20th century seems so grand, was at the core of our film, at the core of our culture, actually, at the same time be so profoundly dangerous and destructive to human health? And so I started to try to work through what would be some questions that would get at that problem. And I really started the book by developing four essential questions. And I added a fifth. And I thought what I would do is just tell you what those questions are and then I'll show you some illustrations that I think represent to some degree how I've thought through those four problems. The first problem was how did cigarette smoking get to be so popular in the first place? And for a historian looking back just a century, the cigarette, for all intents and purposes, was just a marginal, highly stigmatized product as recently as 1900, and per capita consumption in the United states was about 50 per capita, it would go to over 4,000 cigarettes per person per year by 1970. So even as recently as just a century ago, the cigarette was really on the margins. How did it get to be so popular? And obviously we know a good deal about the answer to that. We knew before I wrote the book. Advertising, public relations, intensive promotion, as well as changes in American culture more generally. And I'll show you some slides that represent this in a second. The second question was, how do we know that it's dangerous? And in a way, it seems the most obvious thing that cigarette smoking is dangerous. You know, taking hot toxic air into your lungs couldn't be good for you. But on the other hand, being able to demonstrate scientifically that cigarette smoking caused lung cancer is really one of the watershed events in the history of medicine and science in the middle of the 20th century. So a lot of the book really focuses down on this question. How would you prove that smoking caused lung cancer? And the rise of modern epidemiology, the rise of modern statistical inference, in fact, so many things that today we would associate with evidence based medicine really have at the center this moment of demonstrating that smoking does cause lung cancer. And you can imagine it was one thing for a doctor to say, well, I think you should cut down on your smoking, or maybe in your instance, smoking has been bad for you. But how do you move from those kinds of clinical inferences to the actual medical, scientific knowledge this actually causes disease? That was a fundamental problem. And I can say more about it in the questions. The third question in my book is, once you know that something is harmful, and these early epidemiologists and scientists had demonstrated it by. I argue by the early 1950s that it was, what's the role of the state in moderating the risks that consumers face? So a lot of the book is about the politics of tobacco. And I argue that, in fact, the cigarette is probably the least regulated consumer product in the history of our consumer culture. And again, I could say more about it. We got labels in the 1960s, but the reality is that the tobacco industry invented special interest lobbying and were enormously effective in diverting any regulation. Today, if you ask the Federal Trade Commission, what are you doing about tobacco? Almost nothing. If you go to the Food and Drug Administration, say, what are you doing about tobacco? They say, we don't have authority to regulate tobacco. And there hasn't been a major piece of federal tobacco control legislation in the United States since 1984. The four rotating labels, and I think if you asked any of us, well, what do the four rotating labels say? No one remembers, have been shown to be relatively innocuous or if not completely ineffective. So the third question was, how do we regulate risks in the culture? The fourth question then turned to law, and as you know, many individuals began to sue the companies. And I felt that pursuing the legal side of it was very important because this is how we adjudicate responsibility for risk. And a big part of the book is about the question, who's responsible when somebody smokes? And if a smoker gets sick, should he or she be held responsible? Or what level of responsibility should the corporations that produced cigarettes hold? This has been a very contentious issue in our law and our culture. Now, those were the first four questions that I started with. But as Rick mentioned when he was introducing me, there was this other thing that evolved during the course of this. Well, my publicist would say 25 years that I was working on the book, maybe it's 15 or 20. But something evolved that was of great concern to me, which was that the multinational tobacco industry that was producing cigarettes, principally in the US and in Western Europe, began To work aggressively to promote cigarette use around the world. And so I realized that the fundamental themes of globalization Were intricately linked to the history of the cigarette in the 20th and now in the 21st century. So it's really those five questions that were at the center of my research and my writing. This is a camel sign. I'm actually not in this photograph. When I found this photograph, I thought, how could I have been so impressed with this? But at the time, the idea that I could see this guy blowing smoke rings was unbelievable. One of the aspects of the book is that as a result of the litigation, Millions and millions of documents about the tobacco industry came to light. So I was actually able to go back into the tobacco archives, Find the original contracts for this sign, the designs of the steam machine that blew the smoke into the air. So now we have unbelievable access to internal tobacco industry documents As a result of the litigation. And they've mostly all been put up on the web. So if you go to the legacy documents, which are held at UCSF or tobaccodocuments.org, you can look at the actual internal documents of the company companies. We know more about the tobacco industry and its internal workings Than any industry in the history of the United States. Now, this is some of the data that I mentioned. The first part of the book is devoted to explaining this very steep rise in smoking. It occurred about 20 years later among women. And as you can see, the other thing that I wanted to explain was, how do we explain the decline in smoking, at least since the middle of the 1960s? Part of the argument was, if we could understand the dynamics of building a behavior like this, as well as the decline in the behavior, we might get more leverage From a public health point of view. These are the charts that are so dramatic. The radical decline in deaths from lung cancer during the course of the 20th century. And partly what I was saying about the epidemiologists Is that they were trying to figure this out in 1940 and 1945. So what seems so obvious to us late in the century Couldn't have been quite so obvious to them at the time. This is the same chart for women. And of course, as I mentioned, women started smoking later than did men. But this got a lot of attention in the mid-1980s, when the numbers of deaths from lung cancer Surpassed the number of deaths from breast cancer, which has gotten so much attention. There are more deaths today from tobacco related diseases Than all of these diseases on the left combined. And we could add illicit drugs. You see, I have homicide, hiv, Accidents, Alzheimer's, suicide and diabetes on the left. And it's just a little bit more than half or it's two thirds of the total deaths from tobacco related causes today. And this is after there's been really significant declines in smoking in the United States. This is James Buck Duke, who was the father of the modern industry. He never used cigarettes himself, but he had this idea that he could sell a lot of cigarettes, especially after he helped in the development of this bonsack machine, which could mass produce hundreds of thousands of cigarettes in a day. And partly what I'm suggesting in the book is that there's no element of American society over the last hundred years, from agriculture to technology to health and science, to film and popular culture, that's not in some ways fundamentally interconnected with the cigarette. These are collecting cards. My kids collected Pokemon cards. It was Duke who really invented this idea, especially of boys collecting cards. Very sophisticated. First you'd collect baseball players, but then if you lost interest in baseball, he would have actresses that you could collect. And the whole idea of collecting, which I think is so much a part of sort of, you know, early childhood development, in a way, he had really tapped into. By the 1880s, 1890s, the idea of national branding was really created by the tobacco industry. Camels and Lucky Strikes were two of the first national brands. The idea I'd walk a mile for a Camel was actually developed by an RJ Reynolds executive who was apparently on a golf course, ran out of cigarettes, and said to one of the other RJR executives, I'd walk a mile for a Camel as soon as up on every billboard in the United States. Just to reiterate a point I made A minute ago, only 2% of all tobacco being used in 1900 was for cigarettes. By 1952, of all the tobacco grown in the United States, 82% went into cigarettes. One of the big issues was, should women smoke? And there was a big gender disparity in men's and women's smoking in the 1920s. At first, it was considered inappropriate for the advertisers to advertise directly to women. So this Chesterfield ad, which is from 1926, shows a woman saying, blow some my way. But soon the industry actually was advertising aggressively to women directly. This is a Life magazine cover from the mid-1930s. By the early 1930s, this question, do you inhale Lucky Strikes claims that they were toasted cigarettes, removing the impurities. Of course, everyone inhales, and here you see a couple, it says, everybody's doing it. These were actually Drawn by a well known 1930s pinup artist named John Legotta. One of the big campaigns for Lucky's in the 30s were when tempted, reach for Lucky instead of a sweet. And the American confectioners threatened to sue American Tobacco. And so they changed the ads to just when tempted, reach for Lucky instead. It's a very controversial campaign. The industry understood that controversy often drove sales. And so this was a very popular campaign very early on. The association of smoking with dieting and weight loss was already part of the advertising campaign. There were always concerns about smoking and health going all the way back. These two ads are from 1930 and 1932. Some of my students think this guy looks a little bit like Franklin Roosevelt, 1930, but I don't know. But the idea. One of the principal theories of cancer causality in the 1930s was irritation. So there was this argument, our cigarette is less irritating. This ad on your right, lucky's a light smoke. Ask your doctor about a light smoke. And they really tried to bring the medical profession into the consideration of the health issues associated with smoking. This is a very popular campaign. It's fun to be fooled. For R.J. reynolds, lots of ideas that smoking was actually good for you were promoted in these ads. So here you have sports champions, famous baseball players say, camels, don't get your wind. Dizzy Dean, Lou Gehrig. And Here you have Mrs. Williams Hollingsworth in Beverly Hills saying, for digestion's sake, smoke Camels. These are very characteristic ads of the 1930s. Very busy, lots of copy. Later you would see no copy in cigarette ads in film. Here are Bogart and Marlene Dietrich, absolutely ingrained in mid 20th century film. These are from very well known films. Trade Winds with Frederick March, Now Voyager with Paul Heinrich and Bette Davis. This one where he keeps lighting two and passing her one of the cigarettes. It's a great film. Now, Voyager, here's Dana Andrews and Joan Fontaine and Warren Beatty and Faye Dunaway and Bonnie and Clyde. You just can see from their lighting the cigarettes all the sexual content, the issues of gender and attraction that were part and parcel of smoking in the mid 20th century. One of the things that companies did is they would advertise directly to doctors. So they would say, if you're going to tell a patient who's having trouble, or what was often called smoker's heart or high blood pressure to stop smoking, no, tell them to smoke our brand instead. And I found these ads in medical journals from the 1930s and 1940s. Think about what they're doing, though. Eyewitness reports, it says it is one thing to read results in a published research, quite another to see them with your own eyes. So they're subverting statistical inference. They're saying make your own judgment, do your own test. And of course what we know is we could never know that smoking was harmful so long as every facility physician exercised independent clinical judgment about tobacco and its harms. By the mid-1940s, rising concern about these death rates and the beginning of intensive investigation into the hypothesis that smoking causes lung cancer. So how did the companies respond? More doctors smoke Camels than any other brand. And actually when I was doing my research, I found some documents associated with this campaign. Very clever. What they would do is go to medical meetings, hand out free packages of Camel cigarettes. Then a so called independent polling agency would come meet doctors, for example, on the boardwalk in Atlantic City and say, doctor, what brand of cigarettes are you carrying? They'd fish the Camels out of their pockets and then they would get marked down. More doctors smoke Camels than any other brand. I like these because I'm going to grow 100 years old. And possibly she may for the amazing strides of medical science have added years to life expectancy. So they're engaging modern medical science at the same time that they were undermining it. Very positive images of the doctors who were at the time fighting national health insurance. RJR Philip Morris the company's make major contributions to the AMA in their fight against compulsory health insurance in the 40s and the 50s as a means of trying to get physicians to be their allies. This is an ad from the early 1950s and look at what she says. I made my own personal 30 day test. Now I know Camels are the mildest, best tasting cigarette I ever smoked. And mildness became a euphemism for safer. That was critical during this early phase of scientific evidence about the harms of smoking. To see a physician holding a cigarette like that now is almost like an oxymoron, but very part of the visual culture of the moment. These are two of the epidemiologists who did path breaking work to figure out that smoking does cause lung cancer. Richard Dahl on your right. Ernst Winder on your left. Winder actually did this work as a medical student and I always tell my medical students at the medical school how important the work of medical students could be. It was really a path breaking study. Dahl was one of the great epidemiologists of the 20th century and I was very hopeful that he would win the Nobel Prize prize and it would recognize the importance of epidemiology for both clinical medicine and public health. But he died just two years ago. This is how the industry responded. A frank statement to cigarette smokers. This is January 1954, saying, we will always cooperate with public health authorities. We will do anything we can to find out the truth about the responsibility relationship of smoking and health. What we now know is that they knew a ton about the carcinogens in their cigarettes as early as the early 1950s, but put out a massive publicity campaign to disparage the scientific evidence. The tobacco industry really invented scientific disinformation campaigns in the 1950s. This is their Tobacco Industry Research Council. I like this photo because these are the guys who. The scientists, they signed up to really sponsor their research campaigns, which were completely diversionary. And you see one of the scientists there is actually holding a cigarette in the photograph. This is the first Surgeon General's Commission, which in 1964 put forth a major report demonstrating once and for all that smoking caused lung cancer. They were forced to do it, really, by the publicity campaign of the tobacco industry. But it represents a sort of new kind of consensual science in which scientists would come together and come to conclusions about important public health and medical information. This is, again, is the way the industry responded. Play safe. Smoke Chesterfield. Arthur Godfrey. A proven record with smokers. It says again and again, over a full year and a half, a group of Chesterfield smokers have been given thorough medical examinations. The doctor's reports are a matter of record. No adverse effects to the nose, throat and sinuses from smoking Chesterfields. Arthur Godfrey later died of lung cancer. Here's Frederick March, who you saw in one of the films, and Marlene Dietrich. This is it, Just what the doctor ordered. And I looked up this doctor whose letter is quoted here, Dr. Darcus, and he was a chemist for a private research firm. But here it's presented as if it's medical advice about smoking. This famous tagline on Lucky Strikes. So round, so firm, so fully packed, so free and easy on the draw. The Marlboro campaign shifted radically in the 1950s from being a woman's cigarette to being a filtered cigarette. And what Marlboro was trying to do was to create a filtered cigarette that men would smoke. They knew they had to enter that market. And one of the things I argue in the book is that the Marlboro man really represented a notion of independence. Don't believe what you read, don't believe what you see, don't believe what you hear. You can be independent. And the Marlborough man's independent, born around 1955, 1956. Just as the evidence was becoming absolutely definitive that smoking was harmful, but with a filter. This was really the crucial campaign that launched the nation's most popular cigarette. These are ads that were directed at women. I study in the book A Major suit by woman Rose Cipollone. And these were all brands that she smoked. She tried to quit repeatedly but couldn't. And so I looked at these campaigns in particular and they really appealed to Mrs. Cipollone, who died of lung cancer in 1983. I thought about all I'd read and said to myself, either quit or smoke. True, I smoke. True. These are the relatively recent campaigns. I did a lot of research into the Joe Camel campaign and it's a really fascinating campaign. It took a lot of heat in the media. And some of you may remember when these ads were on in magazines and very prominently portrayed in magazines like Rolling Stone and others. And RJR was taking hit after hit and, and people were saying, you're pitching this cigarette towards kids and you should withdraw the campaign. Even the national association of Advertisers begged RJR to get this campaign off because they felt it was damaging the entire profession of modern advertising. Now we know a lot about this campaign and RJR was in really big trouble. Kids weren't smoking any RJR brand. The principal brands for RRJR in the 70s and 80s were Winston and Salem's. Mostly smoked by people in their 50s and 60s who were either quitting or dying. And it says right in the documents we needed replacement smokers. And we have to get into the youth market. We have to compete with Marlboroughs. So you get a sense of the risk reward structure within the tobacco industry in the 70s and 80s where a campaign like this would take a lot of heat, but they had to get active in recruiting young smokers. And the campaign was incredibly successful. A professor at the Medical College of Georgia decided to do a study comparing whether kids recognized the Joe Camel logo versus Mickey Mouse and other kids oriented logos. And he found that as many as as many 3 to 6 year olds recognized Joe Camel as recognized Mickey Mouse. The article appeared in the Journal of the American Medical Association. But even then RJR wouldn't pull the campaign. These are ads that were very effective for the rise of an anti smoking campaign in the 1970s and 80s. The idea that doctors quit, I think was incredibly, incredibly influential on the American public. These are the kinds of pictorial labels that appear in other countries now. And I was actually in Montreal two summers ago and I was in a pharmacy and I wanted to bring back a pack of cigarettes like this to show some of my students and colleagues. So I was at the pharmacy and I said, I want a pack of Dunhills. And the pharmacist gave me a different pack. I said, no, I want the ones with the mouth disease on them. He looked at me like I was crazy because people had actually been giving those back to ask for different labels that they found less offensive. The tobacco industry continues to spend, now this chart's out of date, $15 billion last year on tobacco promotion in the United States alone. But here's really the problem, and here's where I'll end. In 2000, 4 million people died of tobacco related diseases around the world. By 2030, it will be 10 million. But look at how the breakdown changes. It will go from 2 to 3 million in developed countries like the U.S. western Europe, Australia, Canada, but it will go from 2 million to 7 million in the developing world. And many of those countries are having simultaneous epidemics of infectious diseases, but will also be facing the systemic chronic diseases of later life that are most typically associated with tobacco use. This is Philip Morris. Philip Morris is now making four to five times as much money selling cigarettes abroad as it's making selling cigarettes in the United States. The business has really shifted radically to the developing world. And here's the problem. In the 20th century, about 100 million people died of tobacco related diseases, all told, around the world. But even if we could cut cigarette smoking in half, by 2020, the numbers would jump to over 400 million. And if smoking continues at its current rates, by the end of the 21st century, 1 billion people will have died of smoking related diseases. And I think this is really the question for us. And it's sort of the question I think I was asking when I was seven. How can we know so much about a risk and a harmful product and yet not have the capacity to alter the character of this pandemic? And I think it's a question of public health, it's a question of infrastructure, it's a question of politics. And ultimately it's a question of morality. These are street scenes. On the left are Cambodian monks in Pun Phnom Penh. On the right is an Indonesian tobacco vendor. And this is the future of the epidemic. On the right are street children in Shanghai. On the left is an eight year old boy, eight years in 1995, named Sergey Miroff in St. Petersburg, who insists on only smoking Marlboros. So let me stop there. And I'll take any questions. Yeah.

So with all the bad press based on christinogens and things like that, do you think that manufacturers will shift more towards additive free brands? And if that's going to actually, you know, stem the wave of attacks against the tobacco industry and they're going to have to come up with a whole new ground of evidence to show that additive free tobacco is bad, just as bad for you as also bad do when compared to other tobacco.

Yeah, it's a very good question. The question I don't know if everybody could hear was, will there be no new cigarettes that make claims to be less dangerous? Right, exactly. What we know about the history of light and low tar cigarettes, the history of filters, is that they have been ineffective in reducing the harms of cigarettes for a number of reasons. One is people who, when filters really got to be effective, people smoked them much harder and in different ways to get the same dose essentially out of a cigarette. And it's a process called compensation. The industry right now, and Philip Morris is probably ahead of some of its competitors, is working very hard to develop what they're going to market as harm reduced products. But what we don't know is, first of all, how could we really study clearly to know when a claim is made that this is a harm reduced product, that it really is, what if you could reduce the harms of the product by 20%, what would the impact be? And would smokers want it? Would it discourage people who are prepared to quit from actually quitting? Would some kids who might not take up smoking or say, well, you know, now there are harm reduced products. So it's very hard, I think, to get a handle on what harm reduced products will really mean. What we do know though is that there's no such thing as a harm reduced product now. And there's, and it's virtually impossible to assume that there will be a safe cigarette. All cigarettes are incredibly harmful. But this could be part of an overall industry strategy which I've been trying to document a bit where they say, look, we're responsible corporate citizens, we know we make a dangerous product, we're working hard to make it safer. If we possibly can and would like to market safer cigarettes. And we don't want kids to smoke, we don't advertise or promote cigarettes to kids. And if you are a smoker and you want to quit, we would like to see you quit. And this was what I wrote about Barack Obama, was I think that if he does quit successfully, Philip Marshall would say, good for you. Barack Obama, because you have proven what we always have claimed. Anyone can quit if they really want to, and they persevere. And that's really where the industry is now. They're in a very shrewd. They're in a very shrewd space because they're saying, we know it's dangerous, something they denied for 50 years. We don't market to children, something that they continue to do, but it's hard to document, and anyone can quit anytime they want. And we'll help you. We'll refer you to the Surgeon General. So this whole issue of harm reduction, which your question raises and where the industry is right now is, I think, a really critical question. Yeah. The three ways that you typically see.

People combating cigarette smoking are taxing, you know, making an economic disincentive, education and regulation. How do they compare in terms of their effectiveness?

What we do know, the question had to do with taxation, education, and regulation as three very important approaches to tobacco control. We know that taxation is effective. It's very effective, and it's especially effective with younger smokers. So some people have pointed to taxation as being regressive, but there have been some studies by some of the new behavioral economists, an economist I know at mit, John Gruber, for example, and what he shows is that if people could predict how difficult it would be to quit, their willingness to pay index goes way up on tobacco. So he doesn't think tobacco taxes are really that regressive, and they're shown to reduce smoking. So as taxation's gone up, that's been one of the spurs to the declines here. Education's obviously crucial, and it probably is something that needs to be, you know, gone over again, because even though probably your generation learned well, if you let up on education, you make people vulnerable, especially to new products. One of the things I claim in the book is that the cigarette is the most unregulated product in our economy. And it escaped FDA regulation, it escaped Federal Trade Commission regulation, and it's kind of been grandfathered from what is a fairly significant regulatory state. And we just don't really know, I think, whether in many instances, the industry used regulation to its own ends. They first thought, well, we'll oppose putting labels on cigarettes. And they said, oh, well, put them on. And then they realized having the label, and they didn't realize it late, their lawyers predicted it, having the label on cigarettes will protect us from liability, and in large measure, it has. So with regulation, one needs to always tread care carefully, because a lot of regulatory efforts end up being to the benefit. For example, there's FDA regulation that's been proposed now and you may have been reading about it in the papers and people are calling it the Philip Morris Monopoly Protection act because Philip Morris is now the industry leader and regulation might really be to their benefit at this particular moment, especially if it's not effective, if it doesn't have strong teeth and and so on. But I think all three elements are crucial elements about thinking about strategies for tobacco control. Yeah.

Professor, thank you for the unbiased research.

Thanks.

So I just wanted to know if this agree with the statement. So it seems like here in the US we've reached a point where most people know that it's harcourt to smoke in a lot of the Olympic countries. It seems like that's not always the case.

Right.

Almost seems like they have bigger problems to worry about. And so a lot of people, all the other problems.

Right.

Talk to us a little bit more about that. Like how the cigarette companies are marketing.

Yeah, I mean, exactly what you said that in developing countries it's often thought, well, you know, we have more immediate problems to worry about than smoking. And the companies often articulate that argument. Exactly. They say, you know, aren't we being paternalistic when countries are fighting the AIDS epidemic and now you want to have a no smoking campaign. And I think it's incredibly shortsighted. First of all, it has the implication, well, you can only do one thing at a time and no developing country can afford to only do one thing thing in its health interest at one time. But the industry has really played into that and they've hired people who take that position and then apparently take it independently. So there was a well known British philosopher named Roger Scruton. He was writing this argument all the time in the Financial Times, in the Wall Street Journal. Why are people going after tobacco when there are such important problems? And then it turned out he was actually getting paid by the time tobacco companies and he lost his gig with the Financial Times and the Wall Street Journal. So that argument's out there, but it's really interesting. A lot of times when an argument like that is available, the industry seizes upon it and goes with it. And what I'm really seeing in terms of the epidemiology I'm reading in the developing world is that the developing world has a giant problem with non communicable diseases. And I didn't show this slide but. But their relative burden of disease in terms of infectious and non communicable diseases is looking more and more like ours. Where Infectious diseases play a smaller role, and non communicable diseases like cancer, stroke, cardiovascular disease are going to be an enormous weight. The Chinese government, for example, knows this, and they know that they're in this difficult bind between getting a lot of, of tobacco revenues and knowing that it's going to be incredibly Costly as the 21st century goes on in terms of the diseases associated with it. So I think that the traditional dichotomy between infectious diseases, we have to do something right away. Behaviorally related diseases that everyone knows about really breaks down when you really think about public health. The other thing about the everyone knows argument, I'm quite familiar with this. I think in the United States everybody feels like, well, you have to be an idiot to smoke because of all that we know and the cultural change. But one of the things we know about smoking is most people start when they're kids. And in fact, what we know now is most kids are starting younger and younger, and most people don't begin to smoke as adults. You know, like, I'm 22 and I just graduated from college and now I think I'll try cigarettes. You know, it's just not, it's not how smoking works. The industry knows it's not how smoking works. So when they say we're not interested in kids, if you really took them at their word, there would be no smokers. If they really were not interested in kids, they have to get kids because that's the only way you get smokers. And then the other thing we know is that it's incredibly hard to stop. And the industry knows this. In the last 10 years, the percentage of nicotine yield in an average pack of American cigarettes has increased by 10%. Now, this is based on industry data, but the industry has no comment on that. So it's a very tough. It's a very tough business.

Yeah, well, I'm kind of interested in the addiction component of this whole story, which you were just mentioning. I guess I have two questions. One, is the tobacco industry. Is there anything preventing the tobacco industry from getting into the nicotine replacement therapy industry? And I can't help thinking about this whole issue when I see lines coming out of Starbucks. I mean, do you see any kind of correlation between the new coffee. Not that I know of. Anything that's proven that it's even close to is harmful. But, you know, there seems to be a correlation between these two.

Yeah, well, I mean, a lot of people feel, well, we gave up cigarettes and we took up caffeine and cell phones and there's Some people who are concerned about the impact of cell phones on health as we really begin to understand the metema. I don't know anything about that evidence, obviously. I think caffeine, you know, can be addicted. Speaking from personal experience. That said, you know, we really. There are just unique features to tobacco, and there are a lot of things in life that are addictive. And we manage, you know, both interpersonally, things that we become, you know, ritualized and, you know, compulsed behaviors. So I don't find that that unusual. What's really unusual in this case is you have this highly addictive, incredibly dangerous product aggressively marketed by a giant industry. So it really puts it, I think, you know, across some line that, for me, dissociates it from Starbucks and other things that clearly people, you know, may have, you know, strong compulsions to continue to use. So. Yeah. What do you think is more effective.

In preventing children from smoking, either legislation or parenting?

Well, I think parenting is crucial, but kids learn a lot in school and the relative accessibility of cigarettes is a big issue. And, you know, in terms of point of sale, there's a lot of people talking about legislation that would make it so that you can't see cigarettes in pharmacies or drug stores when you go to buy them, and they would really be put away. There's a lot of things about the packaging of cigarettes that's known to be especially appealing to kids. So there's a lot of regulatory opportunity to reduce smoking among kids. One thing that was found is when the state spent money on, or had money to spend on youth smoking prevention campaigns, they actually were incredibly successful. And the American Legacy foundation, you probably saw some of their ads on the Super Bowl. Like, they had one that was ice pops with glass shards. You'll love them. And they had this industry guy selling them. And they spoofed the tobacco industry, but very effectively with kids. And these campaigns were shown to reduce smoking, but they're underfunded. So I think parenting is obviously, you know, elemental. But one of the things I can say as a parent is you begin to see your authority receding quickly in the rear view mirror as your kids get a little older, and you begin to see the culture working on your kids in very powerful ways. And I would say that even where parenting and parent education about something like tobacco has been good, the social, peer and industrial designs on your kids, you know, have been intense. And so it's always a balance, I think I would say.

Yeah, I was wondering. So after studying cigarettes for the last century, like, are you cynical or optimistic about where things are going to go?

I'm not really cynical. I think I'm. The question was, what's my perspective after having studied this? And I'm not really cynical. I'm somewhat sober. I'm a kind of pragmatic and realistic person in general. And so I don't think we're going to be done with cigarettes tomorrow, but I think there are a lot of things we could do now. So that makes me somewhat hopeful, I would say. One other thing that I write about in the book, but I didn't have a chance to mention is that it did lead me to think about the relationship of academic work or objective historical work and issues of advocacy. And I think that's always been, you know, a more porous boundary than some historians like myself would want to admit. But I ended up testifying for the federal government in. In their big racketeering and fraud suit against the companies. It turned out that the suit turned on historical issues. What did the companies know? When did they know it? Things that I had been studying. So I spent two days being cross examined by tobacco industry lawyers. And I have to say, like, you know, I think that it forced me to ask, was there something. Was there some way for me to use what I had come to understand beyond just writing the book? And I felt that I could. And that was, you know. And so at one time I'd been worried. Well, I don't want to testify and I don't want to become an advocate. And in the end I said, you know, look, I've learned a lot. And if I can use it in some socially productive way, then I might have responsibilities really to do that. So, yeah, yeah.

One thing I've noticed is I've grown up in a community where we were pushed, you know, don't smoke throughout our childhood. And I always had communicated that most smokers start when they're kids thing. And I don't know if it's because my social circle has always been people planning on going to college, upper crust. So it's very select sample size. But all of the smokers I know are all the people who tried smoking. It was always in college, which to me was never what I was educated on as a kid. And I'm wondering, it seems to me that it gets lumped in as not as bad because it's part of that experimentation that goes to college. But I'm wondering if you've observed anything as far as marketing and things like that in that community. Because for me, I've Noticed that everybody I know, if they are a smoker now started in college. And there seems to be absolutely no stigma against smoking in the social setting, even though there is very much one other than that.

Right. I think, you know, for many people college is a very vulnerable time for initiation to cigarettes. And what I've noticed, and I've talked to a lot of my students about this, is that there will be the idea that I'm just a social smoker, like a sort of social drinker. It's an analogy again, the tobacco industry really understands knows there's the term called chipping where you only smoke three or four cigarettes a day. And the idea that everybody's addicted isn't really, you know, there's this idea you can smoke the way people might drink a glass of wine four or five times a week. What's really not true about that is those are people who then become highly vulnerable to becoming regular pack a day smokers. So it's a transitional phase in what we might call the natural history of nicotine addiction to smoke. Sort of in the way that you're describing. There's also this idea that's very powerful. I can quit anytime I want. And there probably are a small number of smokers who actually can smoke at those levels. But they often become the attraction for other smokers who won't smoke in those ways. And then you add in college stress exams, I broke up with my partner. And right away you've created a very, you know, good environment for the initiation of smokers. So I think you're quite right. There is, you mentioned earlier, there's a very significant socioeconomic gradient to smoking. And if you just observe in your own sort of environment, you'll see that, you know, in lower to working class populations, a much higher incidence of smoking. And you're twice as likely to be a smoker if you haven't finished high school than if you finished high school. You're twice as likely again to be a smoker if you went to high school but not to college. And so there's this very powerful gradient. And so smoking contributes a lot to the health disparities we see more generally across American society, but now really across the globe. Yeah.

One of the tobacco industry arguments, correct.

Me if I'm wrong, is that people.

Know the risks of smoking and are.

Making an informed decision. Is there any important each event? Well, I mean, I think this is a crucial thing. Like they say we only want informed smokers. Philip Morris is saying this. If you go to the Altria website, you Know, it's all about, we're a responsible corporate citizen. People should choose to smoke. Smoking is a choice. People who want to quit can quit. And this is part of the whole ideology that the industry is really built on. And they really do believe, you know, people hear the evidence, and if they want to quit, they can. And they. They shouldn't start if they don't want to. And building that notion of individual responsibility has been a key element of the industry, especially since the 1950s. But it goes back even earlier. And the early advertisers said, what we're doing is they use the term engineering consent. And what they wanted to do is motivate behavior, but create the impression that somebody had made a choice. And this is a key element in our consumer culture. And the tobacco industry really honed it. So, yeah, yeah, those films in the 30s and stuff, where the smoking is.

Such powerful image, was that just absorbed.

From the culture or was there a real push by the industry to get. To get the cigarettes? Yeah, it's a really interesting question. It's about film and how smoking got into film, and some of both. I mean, the industry also invented product placement. And one of the most notorious stories was one of the early Superman movies with Christopher Reeve, where he flies across a big Marlboro sign in Times Square. They paid a lot for that. Sylvester Stallone took a lot of money for his movies to have product placement. At the same time, smoking was really in the culture and it meant things. And so I wouldn't want to presume that every time you saw people smoking in film, it was a result of an explicit product placement. But the industry hired publicists who would write an article, I cite one in the book that sort of says, no matter what you're trying to demonstrate theatrically, anger, rage, pensiveness, reflection, anxiety, the cigarette is exactly the implement that you want to use to do that. And then this would appear in Atlantic Monthly. It was really written by a tobacco person.

So, yeah, I wanted to ask, what.

Has been the moral knowledge of non US Companies? I mean, has been the development of cigarettes and smoking, like American in its essence and for non US Companies aware of the health effects? I think that non US Companies have been aware of the health effects for a long time. But there is this association in the developing world with smoking, with modernity, with America, with American values and culture. So I read a lot of things that say, you know, kids want to wear Nikes, drink Coca Cola and smoke Marlboros. So there has been that element. Now, a lot of the developing countries had very inefficient monopolies, but now that they're competing with the multinational companies, they have upgraded their equipment, their factories, they're advertising more. So one of the things that happened in the 80s and 90s is that as some of these markets were open to American tobacco, the developing countries that had state run inefficient monopolies actually improve their tobacco industry to compete more effectively. And the bottom line was that there were more smokers than ever before. So how are we doing for time? We should probably quit. Anyway. Listen, thanks a lot for having me. Really enjoyed it.