Book Review

Drug Policy and Substance Abuse

Smoking Policy: Law, Politics, and Culture

N Engl J Med 1994; 331:750-751September 15, 1994

Article

Smoking Policy: Law, Politics, and Culture
Edited by Robert L. Rabin and Stephen D. Sugarman. 243 pp. New York, Oxford University Press, 1993. $35. ISBN: 0-19-507231-6

Professors Rabin and Sugarman have edited a timely book on smoking policy. It is fitting that the funding for the research and writing of the book grew out of one of the most important events in the history of tobacco control -- the passage in 1988 of Proposition 99, which raised California's cigarette tax from 10 cents to 35 cents per pack and earmarked the new revenues (more than $500 million annually) for medical care, health education, and research on tobacco.

The book has chapters on clean-indoor-air policies, health insurance policies on smoking, tobacco-related litigation, and tobacco advertising. Other chapters examine smoking from a historical, sociological, and international perspective. The purpose of these chapters, according to the editors, is to “describe and analyze several important policy choices . . . to help decision makers fashion policy that is sensitive to the many competing perspectives in this critical area of social concern.”

The authors are a diverse group of professors of law, sociology, business, public policy, political science, and communications from the University of California and Stanford University. This diversity, a major strength of the book, brings experts from a variety of non-health-related disciplines -- with new and unique insights -- into a field of study that has been dominated by health professionals.

Several chapters are particularly valuable. Chapter 2 attempts to explain differences in tobacco-control policies in Canada, France, and the United States by comparing their governmental systems and political cultures. The authors believe that the United States is falling behind Canada, France, and other industrialized countries in tobacco-control policies because of the fragmentation of our political authority (which creates many pressure points where pro-tobacco interests can influence policy) and because our political culture eschews government paternalism and embraces free choice and free speech.

Chapter 9 reviews the policies of health insurance companies on smoking, focusing on the risk-rating of premiums on the basis of smoking status and on coverage of smoking-cessation programs. Along with coverage of this issue in the 1989 Surgeon General's report on smoking and health, this chapter is one of the few comprehensive analyses of an important and complex subject.

Two chapters provide a useful historical review and analysis of litigation related to tobacco-product liability, although the authors could have done a better job of defining the legal jargon they use. The first two waves of tobacco litigation -- in the 1960s and in the 1980s -- did not produce a clear victory for the plaintiffs in any of the cases. But in a prescient statement in chapter 6, Rabin predicts a third wave of tobacco litigation, in which “some venturesome personal injury lawyers will test the [tobacco] industry's resolve under the revised ground rules . . . focusing on the industry's conduct after the enactment of the [cigarette-package] warning legislation.”

In fact, the third wave began just a few months ago. Fifty law firms have promised an initial investment of $100,000 each to finance a class-action suit against tobacco companies on behalf of all people addicted to nicotine. This lawsuit, like others filed recently, is based on the results of investigations by the Food and Drug Administration and internal industry documents indicating that tobacco companies have intentionally manipulated nicotine levels in cigarettes, presumably to create and sustain addiction to nicotine, and that they have acknowledged in private, as far back as the early 1960s, the health effects of smoking and the addictiveness of nicotine.

Much of the writing is, in the editors' words, a “litany of caution,” which can go overboard in questioning matters about which consensus has been reached by the key parties (except the tobacco industry). The editors state that “it is possible to raise an objection” to the Surgeon General's 1988 report on nicotine addiction, and they ask whether tobacco use is any different from the “many passionate `habits' that provide sustenance to an individual's basic psychic needs,” such as daily running. But these “habits” would not satisfy the conventional definition of addiction, which includes the intake of a psychoactive drug.

Along the same lines, Sugarman states in chapter 8 that whether cigarettes are addictive “is obviously a controversial issue that has not been laid to rest by the Surgeon General's recent report.” This statement appeared in a chapter entitled “Disparate Treatment of Smokers in Employment and Insurance,” in which 2 pages were spent on “the case for disparate treatment” and 16 pages on “qualms about disparate treatment.” One “qualm” was concern about the familiar “slippery slope”; in this context the author cited (without disapproval) the absurd scenario of employers or insurers who would “next disfavor those who spend their time at home watching too much (or too little) TV.”

In addition to my concern about the “litany of caution,” there are occasional errors or oversights. For example, in chapter 10 Schudson suggests that “efforts at state and local advertising restrictions might make more strategic sense” than a federal ban on tobacco advertising, but he neglects to mention the federal preemption of state and local restrictions on cigarette advertising, which is an important obstacle to the passage of such restrictions. Kagan and Skolnick, the authors of chapter 4, acknowledge the health risks of exposure to environmental tobacco smoke in the home, but they state that “the published scientific studies provide no compelling evidence of comparable danger to fellow diners intermittently exposed in restaurants, to fellow workers in reasonably well-ventilated buildings, or to fellow patrons at baseball games.” This assertion ignores the fact that the risk of cancer depends on total cumulative exposure to the carcinogen in question, regardless of where the person happens to be when the exposure occurs.

Despite these problems, Smoking Policy is a valuable addition to the small library of work in this area. It is important reading for students and practitioners of tobacco control and, more generally, for people interested or involved in health policy.

Ronald M. Davis, M.D.
Michigan Department of Public Health, Lansing, MI 48909