Book Review

The Cigarette Business

Ashes to Ashes: America's hundred-year cigarette war, the public health, and the unabashed triumph of Philip Morris

N Engl J Med 1996; 335:981September 26, 1996

Article

Ashes to Ashes: America's hundred-year cigarette war, the public health, and the unabashed triumph of Philip Morris
By Richard Kluger. 807 pp. New York, Alfred A. Knopf, 1996. $35. ISBN: 0-394-57076-6

Kluger's newest work, about Camel, Chesterfield, Lucky Strike, Old Gold, Pall Mall, and Marlboro cigarettes, is the definitive history of the cigarette in this country. It tells how Buck Duke and Dick Reynolds created the foundations of empires with classic all-American, rags-to-riches grit and determination. Throughout the saga of advertising wars and titanic battles for market share, we glimpse figures dodging through the trees, guerrilla fighters issuing irritating and unpatriotic reports of the dangers being foisted on the populace in the name of free enterprise. The book is exhaustively researched but reads like a finely plotted novel, intertwining the doings of larger-than-life industry bosses with their dogged counterparts in public health and politics, a tortoise-and-hare race that has yet to reach the finish line. It is a history full of sad ironies, from the early discovery of a milder tobacco that would eventually make cigarettes possible (and much more addictive than the pipe or cigar) to the development of one of the first cigarette filters that incorporated asbestos as a filtering agent, from warning labels that have been a godsend to the industry to adolescents who are attracted to the product precisely because of its forbidden nature.

The tobacco plant, Kluger tells us, originally required 400 hours of painstaking cultivation to prepare a single acre for market, and even today, with modern equipment, it requires over 200 hours of cultivation per acre. How did this incredibly labor-intensive crop, which must be chopped, mixed, and rolled into thin, white cylinders — each virtually indistinguishable from the next — become one of the most lucrative legal products in the nation? The answer: almost entirely through the miracle of modern advertising.

The book draws the reader into the saga of brilliant and callous industry barons, ambitious advertising executives and image makers, stoic and unyielding industry lawyers, and those persistent voices in the wilderness crying out a warning that refuses to be heard. Even the chapter titles sound more like a list of some newly discovered short stories by Flannery O'Connor than a scholarly recounting of one of the most complex health issues of our time: “Of Dragon Slayers and Pond Scum,” “Stroking the Sow's Ear,” and “Melancholy Rose,” to name a few.

The book delves into the international impact of American cigarette companies — most notably, Philip Morris and R.J. Reynolds — and sets the stage for a tragedy. We read about free-trade agreements opening up immense markets and a global community too preoccupied with day-to-day survival to worry about a habit that takes its toll over decades of use. We learn how tobacco use abroad presents new opportunities for the cigarette industry and new challenges to the international medical community. In contrast, the American public has become increasingly educated about and hostile to the industry and adamant in its opposition even to secondhand smoke. Although cigarettes are peddled with impunity abroad, the industry has learned to tread lightly at home. As an example, the author tells of an ennobling “voluntary” recall by Philip Morris in the spring of 1995, which was attributed to a contaminant in the filter, prompting one observer to comment, “They've taken a product that kills you and have recalled it because it makes you dizzy.”

Ashes to Ashes is accessible to laypeople and, the sign of an excellent work, its interest increases in direct proportion to the reader's previous knowledge of the topic. The book is a short history of the science of epidemiology and a discouraging lesson in how knowledge is used, ignored, and “spun” in a struggle with high stakes. It is a book about power and impotence, about human suffering and human ambition. The author makes no bones about his own stance on the issue, but I find his account well balanced and thought-provoking. The book elicits indignation at an industry that has exploited free choice in total disregard of the mortal costs of that choice. But even more deeply, the book causes us to examine our own ethical standards in a time of increasingly intricate health issues at home and abroad. If the world's problems cannot be ours to solve, they must at the very least not be ours to export.

Luis G. Escobedo, M.D., M.P.H.
U.S. Public Health Service, El Paso, TX 79925