Book Review

The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America

N Engl J Med 2007; 356:2115-2116May 17, 2007

Article

The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America
By Allan M. Brandt. 600 pp., illustrated. New York, Basic Books, 2007. $36. ISBN: 978-0-465-07047-3

As a child, Allan Brandt recalls at the start of this superb book, he was fascinated by the billboard in Times Square that featured the fabled Camel Man, blowing “endless perfect smoke rings into the neon-lit night sky.” For Brandt, who teaches the history of medicine and science at Harvard University, that childhood fascination led to a punishing ambition: to write the definitive history of the cigarette as a cultural icon and a public health nightmare. He began the project in the late 1980s, but new sources and developments kept changing its contours. Rather than rushing to publish, Brandt took his time to get it right, and the end result is a masterful account of what he calls the cigarette century.

Given its status as the single biggest preventable cause of death and illness in modern times, the cigarette is an important topic in its own right. But there is more to this book than the title suggests. For in telling the story of cigarettes, Brandt illuminates a veritable scientific revolution in the way people think about disease. Proving the connection between smoking and disease, he explains, “required a fundamental transformation in medical ways of knowing in the mid-twentieth century.” Unlike the development of the scientific method, which arose from the bacteriologic revolution and was famously codified in the Koch–Henle postulates, establishing the link between smoking and disease required a new kind of investigation, one that was “collaborative and iterative, rarely the work of a single scientist experimenting in isolation and rarely yielding definitive answers in a single stroke.” It required “the integration of methods and approaches across the biomedical sciences.”

This type of scientific work was also particularly vulnerable to industry efforts to unsettle it. Brandt details at length the tobacco industry's long, determined campaign to create uncertainty about the health effects of smoking. “Just as the tobacco industry in the late nineteenth century had developed the technology for mass production of cigarettes, so now it had developed techniques for the mass production of controversy and doubt,” Brandt writes of the late 1950s. Faced with powerful commercial interests that were determined to promote smoking, public health authorities responded with a new kind of procedural science, exemplified by the celebrated Surgeon General's report of 1964, in which not only the collection of data but also the process of its interpretation became subject to new rules of analysis. As Brandt shows, the cigarette also forged a new kind of politics, forcing regulators to navigate between the competing ideals of free commerce and public health. Compromises between the extremes of no regulation (as desired by the tobacco industry) and total prohibition (as desired by antismoking advocates) created a legal terrain that was ripe for litigation. Thus the cigarette helped transform product liability law in the 1980s and public interest law in the 1990s.

The last two chapters focus on the globalization of the tobacco controversy. Faced with declining numbers of American smokers, tobacco companies have moved swiftly and surely to find replacement smokers in developing nations. Philip Morris International now sells more than four times as many cigarettes as its American counterpart. Using arguments reminiscent of those used in the 1960s, global tobacco interests now oppose World Health Organization efforts at tobacco control as “paternalistic and intrusive.” Brandt concludes: “We stand on the threshold of a global pandemic of tobacco-related diseases that is nothing short of colossal.”

In telling this complex story, Brandt proves equally adept at treating the cultural, scientific, legal, and political aspects of his material. Although he is tough on tobacco companies (and historians who testify on their behalf), his judgments are neither simplistic nor shrill. As he puts it, “We must confront a well-known, but often avoided, reality: that public health must engage economy and politics at the same time it deploys science and medicine.” To that end, The Cigarette Century should be required reading for every medical and public health student in the United States.

Nancy J. Tomes, Ph.D.
State University of New York at Stony Brook, Stony Brook, NY 11794
nancy.tomes@sunysb.edu