Book Review

The Cigarette Business

The Cigarette Papers

N Engl J Med 1996; 335:981-982September 26, 1996

Article

The Cigarette Papers
By Stanton A. Glantz, John Slade, Lisa A. Bero, Peter Hanauer, and Deborah E. Barnes. 539 pp. Berkeley, Calif., University of California Press, 1996. $29.95. ISBN: 0-520-20572-3

Extensive research links tobacco use with addiction, lung cancer, and heart disease. Yet, among recent lawsuits against tobacco companies brought by families of persons who died from lung cancer, only two have demonstrated liability. Why is the tobacco industry able to fend off legal attacks and maintain, if not increase, its profitability? The Cigarette Papers addresses this question by tracking how the Brown and Williamson Tobacco Corporation and its parent company, BAT Industries (formerly British–American Tobacco), expanded their market while stifling information about the risks of cigarette smoking for over 30 years. Extending the information published in several key articles in the Journal of the American Medical Association in 1995, Glantz and his coauthors provide a compendium and interpretation of several thousand pages of internal Brown and Williamson documents, congressional reports, and private papers.

Their analysis of these documents reveals that BAT used three arguments repeatedly to counter claims of a link between tobacco and disease: there is no conclusive proof that tobacco causes disease; since smoking or quitting is a free choice, the industry should not be liable for diseases contracted by using tobacco; and the industry has shown its commitment to protecting smokers by supporting internal and external research on the effects of smoking on health. The authors demonstrate that the industry used the natural hesitancy of researchers to equate statistical data with causality as a mark of the inconclusive evidence that tobacco use is dangerous. Through internal advertising memorandums and conference presentations, the issue of free choice was addressed by identifying as the “enemies” those who object to a smoker's right to smoke, arguing that regulation of smoking is an infringement on freedom of choice, and encouraging smokers and nonsmokers alike to “read the fine print” and decide for themselves whether the claim that tobacco causes disease is credible. The authors provide a list of funded research and consultants and legal memorandums that suggest the industry's increasing control over the conduct and reporting of scientific research and, even more sobering, the industry's increasing legal control over advertising and research management.

The documentation of the tobacco industry's attempts to deny, then reverse, then mask the dangers of tobacco use is exhaustive. In 11 chapters covering the 1960s through the 1980s, the authors present evidence suggesting that there were attempts to modify an early surgeon general's report to refer to smoking as habitual rather than addictive and to fund research on nicotine delivery as a means to reduce stress. Once internal research studies suggested links between cancer and nicotine, tar, and cigarette additives, BAT documents reveal the competition among tobacco companies to reverse the adverse effects by developing low-tar, safe cigarettes — without success. The management of research and the editing of results by BAT's legal department, including attempts to block research on addiction and ignore, then edit out data on the negative environmental effects of tobacco smoke, give new meaning to the term “spin doctor.”

An account of the progressive evidence linking tobacco use with disease and the tobacco industry's escalating tactics to counteract this evidence could have become a legal or business treatise too technical for many audiences. Instead, the evidence and its counteraction are clearly outlined and discussed by a team of authors who collectively represent expertise in research on tobacco control, tobacco policy, law, and information science. The Cigarette Papers should appeal to a wide audience, including physicians, public health workers, scientists, lawyers, policy makers, and the general public.

The book has few limitations. The authors acknowledge their reliance on selected information from one tobacco company as the basis for their arguments. The last chapter could have presented more information about litigation and policy changes in the 1990s. Specific brief suggestions for prevention, cessation, and other antitobacco efforts could have been added. The potential relation of changes in marketing strategies to emerging trends in tobacco-related products and their impact on the public could have been addressed, including the increased availability of nicotine gum and patches and of cigars in cigar shops and nightclubs. Perhaps such issues will be discussed in a future book.

Mary Ann Pentz, Ph.D.
University of Southern California School of Medicine, Los Angeles, CA 90032