Tobacco

Myth Communication: Selling a Smoke-Free Society

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(Presented at the National Press Club, Ottawa, Canada, June 16, 1999)

Great causes have stirring slogans. The American Revolution had "Give me liberty, or give me death." The civil rights movement had "We shall overcome." The anti-smoking movement has "You shouldn't smoke because it's bad for you."

This injunction is direct and to the point. It tells you what to do, and it tells you why. On the other hand, it's a bit one-sided. Granted that smoking is bad for you in the sense that it raises the risk of certain diseases and tends to shorten your life. But might smoking also be good for you, in the sense that it provides pleasure, relieves stress, or offers some other benefit?

Many smokers seem to think so. The journalist Christopher Hitchens says "cigarettes improve my short-term concentration, aid my digestion, make me a finer writer and a better dinner companion." National Review columnist Florence King writes, "I believe life should be savored rather than lengthened, and I am ready to fight the misanthropes among us who are trying to make me switch."

Tobacco's opponents typically dismiss such statements out of hand. Scott Ballin, former chairman of the U.S. Coalition on Smoking or Health, once told me, "There is no positive aspect to [smoking]. The product has no potential benefits….It's addictive, so people don't have the choice to smoke or not to smoke."

Hence smokers who acknowledge the risks of their habit but cite countervailing rewards are dishonest or deluded, displaying the classic defense mechanisms of rationalization and denial. The sociologist Anne Wortham, herself a smoker, says tobacco's opponents believe that if you smoke, "you are in a state of false consciousness, because you are not aware of what is in your interests. It's the refusal to acknowledge people's capacity to make choices. You just define them out of the discourse. 'Addiction' says they can't even talk about their own likes and dislikes. We can decide for them."

The refusal to acknowledge the benefits of smoking–to admit the possibility that anyone could rationally choose to smoke–illustrates the arrogance of insisting, "You shouldn't smoke because it's bad for you." Who are you, a smoker might well ask, to say what is good for me?

That objection has especially strong force when tobacco's opponents seek the government's assistance in discouraging smoking. To gain public support for that effort, they need a stronger argument.

One you will often hear is that smoking threatens the public health. The phrase calls to mind the control of infectious diseases, which has long been considered a legitimate function of government. Tobacco's opponents emphasize that pedigree, calling smoking "Public Health Enemy Number One," "the greatest community health hazard," "the single most important preventable cause of death," "the manmade plague," "the global tobacco epidemic."

The problem is that smoking is a not a disease. It is a pattern of behavior, something that people choose to do. Unlike typhoid or cholera, it is not transmitted to other people against their will, which is the aspect of communicable diseases that justifies government intervention.

Treating risky behavior like a contagious illness has troubling implications. If the government is authorized to discourage personal decisions that might lead to disease or injury, there is no end to the interventions that could be justified–and no safe harbor for individual freedom.

Anyone who recognizes limits to government should be reluctant to join the march toward a smoke-free society under the banner of "public health," which turns out to be little more than a fig leaf for paternalism. Tobacco's opponents have therefore offered a series of arguments intended to overcome the suspicion that their movement is aimed at protecting people from themselves.

I'll discuss seven of these arguments. Five of them question the legitimacy of the decision to smoke because of the circumstances in which it is made. The other two arguments suggest that smokers do not harm only themselves, so the government should step in to protect innocent third parties.

If cigarettes have no benefits, as Scott Ballin says, it's a bit of a puzzle why so many people continue to smoke them. One answer is that people smoke because of advertising.

This argument relies on a perception of advertising as a mysterious force that seduces people into acting against their interests. That view, which was popularized by social critics such as Vance Packard and John Kenneth Galbraith, remains influential among intellectuals and the general public–though, tellingly, people rarely apply it to their own behavior.

For those who are convinced that companies routinely manufacture goods and then trick consumers into buying them, it's obvious that people buy cigarettes because of advertising. But anyone who requires proof for this proposition will have a hard time finding it.

Clearly, exposure to advertising is not a necessary condition for smoking. People throughout the world smoked for centuries before the emergence of the modern tobacco industry, with its slick magazine ads, eye-catching billboards, and nifty tote bags. During this century, they smoked up a storm in countries, such as China and Russia, where the Marlboro Man was rarely seen.

Nor is exposure to advertising a sufficient condition for smoking: All of us see the ads, but only some of us smoke.

So the question is whether some smoking can be attributed to advertising, whether fewer people would be smokers if it weren't for all those images of sexy women and macho men with cigarettes. And the answer is: Maybe, but the effect has yet to be verified, let alone measured, in the real world.

It's important to remember that the issue is whether advertising encourages people to smoke, not whether it encourages them to smoke, say, Camels instead of Marlboros. And even while calling for limits on advertising and promotion, tobacco's opponents admit there is little evidence that such restrictions would substantially reduce the total number of smokers.

The settlement deal that the leading U.S. tobacco companies negotiated with the state attorneys general last year includes bans on cigarette billboards, cartoon figures, product placement in movies, promotional merchandise imprinted with brand logos, and all but a few event sponsorships. When he negotiated a separate deal with the industry earlier in the year, Minnesota Attorney General Hubert H. Humphrey III had insisted on similar restrictions. Yet in a New York Times op-ed piece published last November, Humphrey was not optimistic that such changes would have a noticeable impact. "Judging from the experience of those countries where all advertising is banned but teen-agers still light up in droves," he wrote, "limits on advertising may not make much difference." Now he tells us.

There are good reasons for such skepticism. The 1989 surgeon general's report conceded that "there is no scientifically rigorous study available to the public that provides a definitive answer to the basic question of whether advertising and promotion increase the level of tobacco consumption. Given the complexity of the issue, none is likely to be forthcoming in the foreseeable future." The 1994 surgeon general's report, which focused on underage smoking, also acknowledged the "lack of definitive literature."

None of the highly publicized studies that have appeared in recent years, including the much-hyped research on Joe Camel, actually measured the impact of advertising on an individual's propensity to smoke, which is the crux of the issue. Now, it's possible that tobacco advertising has an effect that simply cannot be measured. We can imagine a case–say, an ambivalent teenager whose parents and friends smoke–where the influence of advertising might be decisive.

The question is whether that possibility is enough to justify censorship. We shouldn't lose sight of the distinction between persuasion and coercion. If tobacco advertising is in fact a "bad influence," that is something to counter not with force but with information, exhortation, and satire. The rush to ban tobacco advertising because it might encourage people to smoke suggests a low regard for freedom of speech.

Quebec Superior Court Justice Jean-Jude Chabot framed the issue well in his 1991 decision overturning Canada's ban on cigarette advertising. "The question," he wrote, "is whether the State has the right, through the elimination of all competing messages, to impose on its citizens its view and only its view of what is right in an attempt to mould their thoughts and behavior." He concluded that "[t]his form of paternalism or totalitarianism is unacceptable in a free and democratic society."

For those who suspect that advertising is really not as powerful as some people suggest, tobacco's opponents have another argument: The tobacco companies concealed the hazards of smoking.

This is one of the main rationales for all those lawsuits, and it is potentially a very powerful argument. If cigarette makers hid the truth about their product, if they lied to their customers and led them to believe that smoking isn't dangerous, it would be a classic example of fraud, of selling something under false pretenses. And if smokers were misled by the tobacco industry, it's hard to argue that they made an informed decision to smoke, knowing the risks involved.

It cannot be denied that the tobacco companies for decades questioned the evidence about the health hazards of smoking, even while privately conceding those hazards. Indeed, that is the main reason they have become one of the most reviled and ridiculed industries in the world.

But that very reputation tends to undermine the charge that the tobacco companies fooled us into believing that cigarettes are safe. The truth is that warnings about the health risks of smoking go back hundreds of years. King James I, in his 1604 Counterblaste to Tobacco, called smoking "a custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stygian smoke of the pit that is bottomlesse." In every generation, tobacco's opponents have echoed him, attributing a long list of maladies to smoking. Persuasive scientific evidence of tobacco's hazards, which began to emerge in the early 1930s, has received wide attention since the '50s.

That attention has included thousands of scientific studies, the most important of which were covered in the general press; dozens of major government reports; countless newspaper and magazine stories; anti-smoking commercials, print ads, billboards, posters, pamphlets, buttons, bumper stickers, and school curricula; and cautionary labels on every package of cigarettes. In the face of all these warnings, it is hard to argue that the tobacco companies succeeded in pulling the wool over anyone's eyes.

In his introduction to The Cigarette Papers, a book that contrasts the industry's public positions with its behind-the-scenes concessions, former U.S. Surgeon General C. Everett Koop notes that "the public knows about the deleterious effects of smoking," and "even smokers do not believe what they hear from the industry." Nevertheless, he says, "smokers and nonsmokers alike should feel misled by the tobacco companies and their deceptive practices." Apparently, we should feel misled, even if we weren't.

If you don't buy that fraud theory, here's another one: The tobacco companies concealed the addictiveness of smoking.

This argument has the same advantage as the previous one: If smokers didn't know what they were getting into because the tobacco companies lied to them, the transaction is tainted by fraud. And again, it's easy to show that the tobacco companies have been less than candid on this topic.

But this argument also suffers from the same disadvantage as the other fraud theory, since the difficulty of giving up the tobacco habit has been common knowledge for centuries. James I's lord chancellor, Sir Francis Bacon, observed, "In our times the use of tobacco is growing greatly and conquers men with a certain secret pleasure, so that those who have once become accustomed thereto can later hardly be restrained therefrom."

Johann Michael Moscherosch, a 17th-century polemicist, called smokers "thralls to the tobacco fiend," while Cotton Mather dubbed them "Slave[s] to the Pipe." Louis XIV's court physician described the tobacco habit as "a fatal, insatiable necessity…a permanent epilepsy." Henry Ford's 1914 collection of anti-cigarette diatribes was entitled The Case Against the Little White Slaver.

In light of this history, it's hard to take seriously the idea that tobacco's addictiveness was discovered only recently, due to the hard work of people like C. Everett Koop.

But the issue of tobacco's addictiveness leads to another argument: Addiction prevents smokers from quitting. Even if smokers know about tobacco's addictiveness when they light up the first time, it hardly seems fair if they are then trapped in a potentially deadly habit, unable to escape when they think better of it.

Announcing his foray into tobacco regulation in 1994, David Kessler, commissioner of the U.S. Food and Drug Administration, asserted that "once they have started smoking regularly, most smokers are in effect deprived of the choice to stop smoking." He suggested that "it is a choice by cigarette companies to maintain addictive levels of nicotine in their cigarettes, rather than a choice by consumers to continue smoking, that in the end is driving the demand for cigarettes in this country."

This argument redefines what appears to be a voluntary transaction–the purchase of cigarettes–as a coercive relationship. If people smoke because they've been enthralled by the tobacco companies, perhaps the state has a duty to break the spell.

Such a view of smoking fits neatly with widely held beliefs about addiction, which attribute quasi-magical powers to psychoactive chemicals and depict people who use them as chemical zombies. It also offers a handy excuse to the smoker who is tired of being pestered to quit or who is ambivalent about a habit that offers short-term rewards at the price of long-term risks.

The problem is that the depiction of nicotine as irresistible and inescapable flies in the face of everyday experience: People who try cigarettes do not necessarily become regular smokers, and regular smokers quit all the time. Many former smokers say quitting was very hard, while others say it was no big deal.

Such impressions are confirmed by survey data. Nearly three-quarters of Americans have tried cigarettes at some point, but only a quarter are currently daily smokers. According to the U.S. Centers for Disease Control and Prevention, there are about as many former smokers in the United States as smokers, and 9 out of 10 gave up the habit without formal treatment, usually by quitting cold turkey.

The addiction argument is often paired with another: Smoking is a pediatric disease. This slogan, first used by Kessler, packs a big rhetorical wallop. It combines an appeal to protect children with the idea of addiction as a compulsive illness and the public health justification for government intervention, all in five words.

I've already addressed the disease model and the public health rationale, so let's focus on the "pediatric" part. It is true that most smokers start smoking daily before they turn 18–more than 70 percent, according to the 1994 surgeon general's report. Judging from recent survey data, the average age at which people become daily smokers is somewhere between 17 and 18.

What do we make of the fact that most smokers start as teenagers? Well, you could say that only an adolescent is stupid or reckless enough to start smoking. That is the conclusion tobacco's opponents tend to draw.

According to a recent article in The Journal of the American Medical Association, "Once people are old enough to rationally evaluate the well-known health risks of smoking, they choose not to start." In his book Smokescreen, the journalist Philip Hilts flatly asserts that "adults do not start smoking."

But that is not the case even now, since a minority of smokers do start as adults, and the number of people in that group is likely to expand if efforts to discourage underage smoking are successful. While it may be true that the young are especially attracted to smoking, it is probably also true that individuals who are especially attracted to smoking tend to start young. In many cases, keeping people away from cigarettes until they're adults may simply delay smoking rather than prevent it.

That is not to say that we shouldn't make a more serious effort to enforce laws against the sale of cigarettes to minors. But we should also keep in mind that policies supposedly aimed at protecting minors, such as banning advertising or dramatically increasing the price of cigarettes, affect mainly adults, who represent more than 90 percent of smokers.

For those callous few who don't much care what happens to smokers, no matter when they pick up the habit, tobacco's opponents insist that nonsmokers must be protected from secondhand smoke. In terms of broadening support for the anti-smoking movement beyond activists and public health specialists, this has probably been the most effective argument of all.

For centuries nonsmokers have been annoyed by secondhand smoke. In his Counterblaste to Tobacco, James I showed much concern for the bystanders who had to endure "the black stinking fume" from pipes. He reported that many men had reluctantly taken up the habit "to be as one that was content to eat Garlicke (which hee did not love) that he might not be troubled by the smell of it, in the breath of his fellowes." And he called it "a great iniquitie…against all humanitie" that a smoker "shall not bee ashamed, to reduce thereby his delicate, wholesome, and cleane complexioned wife, to that extremitie, that either shee must also corrupt her sweete breath therewith, or else resolve to live in perpetuall stinking torment."

Such complaints have been strengthened and legitimized by two ideas: first, that secondhand smoke is a health hazard as well as a nuisance; and second, that people have a right to a "smoke-free environment." Armed with these two claims, tobacco's opponents are gradually eliminating the locations outside of the home where people are allowed to smoke. In places like California and Toronto, it is illegal to smoke even in bars.

Bans on smoking in businesses operate at a practical level, making smoking less convenient, and at a symbolic level, helping to transform what was once a perfectly respectable habit into a shameful vice. They push smokers out into the cold both literally and figuratively.

The thrust of this campaign is illustrated by a billboard from the California Department of Health Services. It shows a suave, nattily dressed man–the sort of smoker you might see in an old movie–asking the elegant woman beside him, "Mind if I smoke?" She replies, "Care if I die?" Smoking near someone is thus depicted as a kind of homicidal negligence.

That portrayal exaggerates both the strength of the evidence against secondhand smoke and the level of risk involved. Consider the claim that secondhand smoke causes lung cancer, which is the one that has received the most attention, largely because it was endorsed by the U.S. Environmental Protection Agency.

The EPA's report on secondhand smoke has been criticized as a rush to judgment not only by the tobacco industry but by independent scientists, government analysts, and journalists. Last July, U.S. District Judge William Osteen agreed with the gist of that criticism when he invalidated the EPA's classification of secondhand smoke as a known human carcinogen. Among other things, he found that the EPA "publicly committed to a conclusion before research had begun" and "adjusted established procedure and scientific norms to validate the Agency's public conclusion."

Osteen also touched upon the most important flaw in the evidence, which has to do with the limitations of epidemiology in dealing with low levels of exposure. The association between secondhand smoke and lung cancer is so weak that it may be impossible to rule out alternative explanations, such as diet or unreported smoking.

Even if we accept the EPA's findings, there's no reason to panic about exposure to secondhand smoke. According to an estimate based on the EPA's report, living with a smoker raises a woman's lifetime risk of lung cancer from about 0.34 percent to about 0.41 percent. That risk applies to someone who lives with a smoker for decades. There is no evidence that casual exposure to secondhand smoke–say, sitting next to a smoker in a restaurant or on a plane–has any impact on your life expectancy.

Whatever the risk, of course, many people would like to avoid it. And even if secondhand smoke doesn't kill people, it certainly makes them uncomfortable. Isn't that enough of a justification for restrictions on smoking?

The real question is not whether there should be restrictions but who should impose them. In a system based on property rights and freedom of contract, a business's smoking policy is one of many factors that people consider when deciding where to shop, dine, or work. Those decisions, in turn, help shape the policy. Given a diversity of tastes and preferences, this process tends to produce a diversity of choices: Some businesses ban smoking; some segregate; some cater especially to smokers.

To justify government interference with this process, anti-smokers often compare secondhand smoke to assault. But secondhand smoke is really more like loud music than a punch in the face. When it disturbs the neighbors, loud music is a public nuisance. But when it's confined to a bar, dance club, or concert hall, it's just a feature of the establishment, one that some people will like and others will find annoying. No one proposes to ban loud music everywhere to accommodate those who prefer quiet.

By stepping in and imposing the same smoking policy on everyone, the government not only violates property rights, it destroys diversity–the potential to satisfy a wide variety of tastes and preferences.

You can try to avoid secondhand smoke, but you can't avoid taxes without risking fines and imprisonment. Recognizing that fact, tobacco's opponents argue that smoking imposes costs on society.

This argument appeals to fairness and individual responsibility, implying that smokers are making us pick up the tab for their recklessness. The social cost argument underlies not only calls for higher cigarette taxes but also the claim that tobacco companies should reimburse governments for the cost of treating smoking-related illness under taxpayer-funded health coverage. Payments to governments, of course, lead to higher cigarette prices, so such lawsuits are an indirect way of raising taxes.

In calculating the social cost of smoking, tobacco's opponents routinely fail to distinguish between costs imposed on others and costs paid by smokers themselves. For example, they count medical care that smokers pay for directly or through health insurance premiums, and they count forgone wages, as if everyone owes "society" a full lifetime of income.

Properly speaking, we should be looking at external costs–the ones other people are forced to bear. These are almost entirely expenses that the government makes taxpayers cover through programs such as Medicaid and Medicare in the United States or here. So the problem is not smoking so much as subsidized health care, which inevitably means that taxpayers will pick up the tab for other people's risky habits, including not just smoking but drinking, overeating, and dangerous recreational activities.

Even if we accept the premise that subsidized health care gives the government a license to meddle in activities that might lead to injury or disease, the social cost argument does not fly. Because smokers tend to die earlier than nonsmokers, they do not impose a net cost on taxpayers. In fact, they probably save us money.

As the U.S. Office of Technology Assessment noted in 1993, "Reduction or elimination of smoking would improve health and extend longevity, but may not lead to savings in health care costs. In fact, significant reductions in smoking prevalence and the attendant increase in life expectancy could lead to future increases in total medical spending, in Medicare program outlays, and in the budgets of Social Security and other government programs." A study published last year by The New England Journal of Medicine reinforced this point, finding that total medical costs would actually rise if everyone stopped smoking.

In his 1994 analysis of the issue, the economist W. Kip Viscusi found that "on balance there is a net cost savings to society even excluding consideration of the current cigarette taxes paid by smokers." Based on these calculations, he noted, one could argue that "cigarette smoking should be subsidized rather than taxed."

Strictly speaking, that tongue-in-cheek suggestion is no more absurd than the argument that cigarettes should be taxed because they drain the public treasury. This kind of analysis–which anti-smokers are quite fond of until it turns against them–is disturbing because it seems to treat individuals as a cost to be minimized or a resource to be exploited by the state. It's of a piece with the "public health" calculus that judges people by their contribution to collective measures of morbidity and mortality.

In his catalog of complaints about tobacco, James I said "the greatest sinne of all" was "that you the people of all sortes of this Kingdome, who are created and ordeined by God to bestowe…your persons and goods for the maintenance…of the honour and safetie of your King and Commonwealth, should disable your selves in both."

Thus, he forthrightly asserted that the function of the individual is to serve the state–i.e., him–and that the worth of anyone's actions hinges on how they affect what contemporary paternalists like to call "society as a whole." Nowadays, tobacco's opponents are a bit embarrassed to state this premise explicitly. As they should be.