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The cigarette catastrophe continues

2015; Elsevier BV; Volume: 385; Issue: 9972 Linguagem: Inglês

10.1016/s0140-6736(15)60519-0

1474-547X

Robert N. Proctor,

Global Public Health Policies and Epidemiology

There is a myth of sorts that cigarettes are a solved problem. This can be heard when the topic turns to sugar or obesity or the climate crisis, where hopes are raised that these problems, too, might be solved “the way we fixed tobacco”. Of course that is convenient for the makers of cigarettes, who want us to think of tobacco-related death as something from the distant past, a kind of archaism we don't really need to fret too much about. The fact is that cigarette use remains the world's leading preventable cause of death, killing roughly 6 million people every year. That number will stay high over the next couple of decades, as the toll of present habits is taken. Disease rates from smoking peak about 30 years after peak rates of consumption, which explains why most of the epidemic lies in the future. Global smoking has now reached an astonishing 6 trillion cigarettes per year, nearly double what it was only four decades ago. That is why most of the cigarette holocaust is yet to come: in 2001 I published a paper predicting that whereas about 100 million people died from smoking in the 20th century, we could expect up to a billion deaths in the present century—assuming that nothing is done to reverse the trend. If this catastrophe is regarded with lethargy in some quarters, that is partly because of how “news” is conceptualised. Ebola has rightly been an important story in the news of late, but even at the height of the epidemic about 1000 people were dying from cigarettes for every victim of the virus. In Africa, even with its low smoking rates, more people will die this year from cigarettes than from Ebola—by a couple orders of magnitude. Some 10 000 people have died from Ebola during the past couple of years; during that same period more than 10 million people perished from smoking. Josef Stalin is notorious for having mused that while one death is a tragedy, a million is a statistic. Indeed, it is the routine, everyday nature of tobacco death that makes it so easy to ignore. Death from smoking is difficult to turn into headlines, especially given the distraction of “electronic” devices purporting to emit only “digital” vapours. But Americans still smoke about 280 billion “analogue” cigarettes every year, and the British consume some 35 billion. Cigarettes still cause thousands of deaths worldwide from residential fires, not to mention erectile dysfunction, macular degeneration, spontaneous abortions, cancers in multiple organs, and gangrene of the feet. Amputees are a terrible symbol of war, but more soldiers actually lose their legs to cigarettes than to bombs from a hostile army. Progress against tobacco is certainly being made in richer parts of the globe, but the timing of that progress is often misunderstood. While per capita adult cigarette consumption peaked in the USA in 1964, for example, per capita consumption for all ages combined did not peak until 1976—because teenagers had begun smoking in unprecedented numbers. And total consumption did not peak until 1982—when 630 billion cigarettes were smoked in the USA. This number reveals the magnitude of the catastrophe. After all, when a plane crashes, we don't say that the annual rate of aviation death rose from 0·0045 to 0·0090 per 100 000 people. The cigarette toll is more like four fully loaded Boeing 747s crashing every day—and that's just in the USA. Consumption peaked in the USA in 1982, but production actually peaked in 1997—at 770 billion cigarettes. That is because an increasing proportion of the cigarettes made in the Americas are shipped overseas. The death once directed inward is now directed outward. Even in the USA, though, tobacco-related mortality is only now reaching its peak. The 2014 US Surgeon General's Report calculates more than 480 000 annual deaths from smoking, the highest ever recorded in such a report. As horrific as such numbers are, they disguise the fact that the cigarette is not inherently dangerous, but rather dangerous by design. The fundamental defect of cigarettes is sugar: cigarettes today are made from tobaccos containing high levels of sugar—typically about 15–20% by weight—which makes the resulting smoke inhalable. That explains why lung cancer was so rare prior to the 20th century: it was not until the 19th century that high-sugar tobaccos—notably flue-cured and Turkish—were used in cigarette manufacturing. Tobacco before this time had been air-cured, a process during which the sugars native to the leaf were destroyed, yielding leaf that was roughly 2% sugar. By contrast, the heat applied during flue and sun curing denatures the enzymes responsible for digesting sugars, which is why flue-cured and Turkish tobacco are both so sugary. Smoke from tobacco was rarely inhaled before the 20th century; the smoke was simply too harsh, too alkaline. High-sugar tobaccos exposed a far larger (and more vulnerable) bodily territory to cancer-causing smoke: recall that while the surface area of the mouth is roughly that of a tennis ball, the area of the lungs is more like a tennis court. There is a tragic irony here, since one of the main goals of cigarette manufacturers in the early decades of the 20th century was to make cigarettes ever “milder”, meaning easier to inhale. This made sense in an era when “irritation” was the dominant theory of cancer causation (versus the mutation theory postdating the work of James Watson and Francis Crick): if irritation was responsible for cancer, then what possible harm could there be in making cigarettes milder? When combined with innovative marketing—cigarettes for decades were the most heavily advertised product on radio, television, and billboards—cigarettes became the preferred form of tobacco use for millions. By the 1950s, 60% of all American physicians were smoking cigarettes. And four of the seven astronauts training for NASA's Mercury mission were smokers. What changed in the 1950s was not so much the make-up of cigarettes, but rather the lengths to which manufacturers would go to reassure smokers, including the all-important youth market (aka “replacement smokers”). In the mid-1950s, a scientific consensus arose that cigarettes were the leading cause of lung cancer, based on a confluence of evidence from epidemiology, animal experiments, clinical pathology, and chemical analytics. The industry responded by launching a massive campaign of denial. Hundreds of scientists were paid to research “alternative causation”, especially maladies caused by constitutional predispositions, viral agents, psychological stress, air pollution, occupational poisons, or anything else that might distract from “the cigarette hypothesis”. From 1964 into the 1970s, cigarette manufacturers paid the American Medical Association (AMA) some US$20 million, in exchange for which the AMA refused to endorse the landmark 1964 Surgeon General's Report indicting cigarettes as a cause of cancer, or the warnings placed on cigarette packs, or the broadcast ban on advertising from 1971. Documents from this period in the industry's archives reveal the industry characterising its chief sponsored research arm—the Council for Tobacco Research—as “a successful defensive operation”. What is astonishing is how effectively Big Tobacco managed to harness, influence, and sometimes even corrupt large segments of the scientific community. At least 26 Nobel Laureates are known to have taken money from the cigarette industry for research, honoraria, or consulting. In the USA, the industry wielded influence over Congress and the Presidency: Joseph Califano in 1965 urged President Lyndon Johnson to endorse the Surgeon General's Report, for example, but the President refused, explaining that a confrontation with Tobacco could result in the Democrats losing the Presidency to the Republicans. There was a level even of corporate bullying, as in the early 1980s, when Philip Morris pressured Merrell Dow Pharmaceuticals to delay its rollout of Nicorette gum. Merrell Dow's Smoking Cessation Newsletter, planned to advise physicians on how to help their patients quit smoking, was suppressed after publishing only one issue. Throughout this time there is also evidence of the tobacco industry disrespecting its customers. R J Reynolds Tobacco Company in the 1990s, for example, launched Project SCUM—for Subculture Urban Marketing—with the goal of marketing cigarettes to homosexuals and the homeless in San Francisco. 3 years before this, the industry's powerful Committee of Counsel, its supreme authority on all matters of smoking and health, had met to elect a new Chairman. Minutes from the meeting talk about the coronation of a new “God King” to lead the enterprise, showing that while disrespecting its customers, the industry deified its leaders. For decades there have been calls to abolish the cigarette; the BMJ issued such a call as early as 1953. The difficulty has always been the immense financial—and therefore political—power of this industry. Credit Suisse recently compared a broad range of industries to see how well these had performed as investments. What they found was that, over the past century or so, tobacco stocks have performed better than any other single investment—by far. According to their analysis, a dollar invested in tobacco stocks in 1900 was worth $6·28 million in 2010. And most cigarette stocks have continued on the rise ever since. It is also crucial to realise, however, that the industry's power has limits. 2014 was probably the absolute peak year for global cigarette consumption, and we are likely soon to see a fall in global cigarette use, in consequence of governments realising how costly this epidemic has been for their citizens. One often hears that by ignoring history, one is doomed to repeat it. The more grim truth is that ignoring history can actually make things worse. History helps us understand what is possible, and how things can and have gone wrong. And perhaps even how we might make them go right. I have served as an expert witness in litigation against the tobacco industry. What will it take to create a tobacco-free world?Last month, British American Tobacco released their preliminary results for 2014. “I am delighted with the excellent progress we have made”, said chief executive, Nicandro Durante. It has been “another strong performance in 2014”, he added. The Group's revenue continued to grow by 2·8% and its adjusted profit from operations increased by 4·4%. Of the 667 billion cigarettes sold in 2014, 197 billion were sold in the Asia-Pacific and 227 billion were sold in Europe, the Middle East, and Africa—regions known as “high-growth markets”. Full-Text PDF