Pisgah Forest in North Carolina’s transylvania County may seem like an odd place for human health fortunes to have pivoted, but there’s something to be said for it. Here in the fall of 1953 an experiment was conducted that would change how tobacco companies viewed the world, demonstrating to their apparent satisfaction that cigarettes can cause cancer. The setting was the Ecusta Paper Corporation, the nation’s leading supplier of rolling paper for the American tobacco industry. For more than ten years the company had been churning out the thin white papers that, when rolled into cylinders around chopped fermented tobacco leaf, got smoked in the form of cigarettes. Cigarette paper wasn’t their only product: the company also produced paper for Bibles and financial forms. Death and taxes in a Bible sandwich, good coverage, vertical integration.

 

Cigarette paper hasn’t gotten much attention in the recent tobacco wars, though it is worth recalling that you can’t smoke a cigarette without also inhaling the soot, tar, and gases released by burning paper. Unlike a pipe or a cigar. Today we know to blame the tobacco for the lion’s share of cancers—thanks in part to Ecusta’s experiments—but there was a time in the 1940s and early 1950s when some people blamed a pesticide (such as arsenic) sprayed on the leaf, or a chemical agent used in its manufacture, or the stems and ribs increasingly used from the leaf, or vapors released by lighters or safety matches, or outgassings from the burning paper. People didn’t seem to be falling ill so much from smoking pipes and cigars—and clearly there weren’t so many cancers of the lung in former years, when cigarettes had not yet come into fashion. What was causing this epidemic of malignancies? And if it was the tobacco, or its method of preparation, or even the paper, what could be done to stop it? Was there a poison that could be identified and eliminated, giving tobacco a clean bill of health? Could cigarettes be made safe?

A great deal of attention has been given to when the tobacco industry could have—or at least should have—known that smoking was killing people. The question has become of substantial legal interest, given the many recent lawsuits in which the timing of such events takes center stage. Historians are being asked to testify to whether the industry acted properly in the 1950s, 1960s, 1970s, 1980s, and 1990s, when the tobacco Institute, the Council for Tobacco Research, and other industry bodies routinely dismissed claims that cigarettes could cause cancer or any other malady. Historians are being asked to judge at what point it is reasonable to talk about a “consensus” or “state of the art” regarding knowledge of such hazards and by what time it was no longer legitimate to ignore or dismiss such hazards.

These are not trivial questions, and it is often not even possible to say when a particular body of evidence becomes convincing or “indisputable”without also asking, convincing for whom? And to what level of certainty? Our answers will depend on the community whose knowledge pulse we are taking, and we shouldn’t be surprised if discoveries are received differently in different parts of “the” scientific community—whose homogeneity is easy to exaggerate. Methods are not always uniformly appreciated, and different disciplinary communities can have very different prejudices or investments. Why should we expect new scientific findings to permeate every discipline at precisely the same rate? The presumption of a singular and well-defined state of the art is an ahistorical construct lawyers have to deal with, as part of their job of dividing the world into tidy packages of innocence and guilt. The law is more digital than analog, with nuance often the first casualty.

 

Judged from a historical distance, it makes sense that there must have been a time when the tobaccomen didn’t know (or believe) that cigarettes could cause cancer. There must also have been a point by which they had come to recognize this fact, by which time we are justified in characterizing their protestations of ignorance (as in “We need more research”) as negligent or even duplicitous. How and when did this change take place? When did the industry recognize the reality of tobacco hazards? When did they start lying?

One way to approach such questions is to distinguish between public claims and private communications, with the former represented by, say, press releases and the latter by the millions of internal industry documents divulged in the course of litigation, most ofwhich are nowavailable online at http://legacy.library.ucsf.edu. This is an unparalleled historical archive—indeed a treasure—that scholars have only just begun to explore and from which we get a good sense of the changing status of knowledge within the industry.

Publicly, the industry is notorious for having refused, time and again, to admit the health hazards of cigarettes—until the final years of the twentieth century. As late as 1994 the CEOs of the nation’s seven leading manufacturers—the “Seven Dwarfs”—all stood up before theU.S. Congress and swore they did not believe that cigarettes caused cancer or were addictive. Then again, in 1998, PhilipMorris CEO Geoffrey Bible testified under oath, “I do not believe that cigarette smoking causes cancer.” Bible conceded a “possible risk” but not a “proven cause,” the distinction lying in a kind of legal having-it-both-ways: an admission strong enough to ward off accusations of having failed to warn, yet weak enough to exculpate from charges of having marketed a deadly product.

Privately, however, the companies were already discussing tobacco as a potential carcinogen by the 1940s. Industry scientists were keenly interested in the evidence starting to show that smoking could cause cancer and took limited steps to identify and remove whatever offending agents could be found in cigarettes. The goal for a time (beginning already in the 1930s) was to create a “safe” or at least a “safer” cigarette—though this was rarely expressed in public, given the reluctance to admit that tobacco was at all unsafe. And once the decision had beenmade to deny all evidence of harms—in 1953—it was difficult (for legal reasons) to stray very far from this path. Management must have known that the sordid admissions would eventually have to bemade, but the hope was that this could be delayed into the indefinite future, into someone else’s watch. It’s as if they were operating a gigantic—and deadly—oncologic Ponzi scheme.

So when did the industry realize it was killing people? That turns out to depend on what you mean by “the industry.” Even if we restrict our attention to manufacturers in the United States, it is difficult to establish a uniform time scale for the acceptance or recognition of hazards, since we are talking about large and complex organizations with tens of thousands of employees. Did tobacco growers know as early as the chemists employed in the industry’s research laboratories? (Surely not.) What about theworkers mixing the flavorants, or the lawyers guarding against lawsuits, or the CEOs running the show?

The tobaccomen eventually came to speak with a single voice, but this required painstaking planning by some of the best brains of American hucksterism. Coordination was not without certain risks, of course, since the industry had been reeling from charges of collusion since 1911, when “Buck” Duke’s American tobacco empire was broken up through exercise of the Sherman Anti-trust Act. Even after dismemberment the companies had to ward off charges of illegitimate consort—there are examples from the 1930s and 1940s—and the perennial threat of regulation. This was a clear and present danger into the 1950s, and the stakes must have been high for the companies to risk yet another charge of collusion, as they did on December 14, 1953, when CEOs from the nation’s leading tobacco makers met at the Plaza Hotel in Manhattan to plan a response to escalating publicity of a cigarette–cancer link. Paul M.Hahn, president of the American Tobacco Company, had organized the meeting, knowing that the industry could well be fighting for its life. And it was here, with the aid of the public relations firm Hill & Knowlton, that the industry decided to launch its infamous “Not Yet Proven” campaign of distraction, false reassurance, and manufactured ignorance.

We also have to recognize, though, that smoking causes myriad different kinds of disease and that evidence for these various links comes at different points in time. Attention is often focused on cancer, but that is partly for legal reasons, having to do with the fact that it is easier to litigate a relatively monocausal disease (like lung cancer) than a malady with varied and diverse causes (such as heart disease). Tobacco kills more people via cardiac arrest, but since a higher fraction of all lung cancers are traceable to smoking, it is easier to win a legal case on the cancer front than on the (messier) field of the cardiovascular. Ninety percent of all lung cancers are caused by smoking, compared with only about a third of all heart attacks. This also seems to have influenced tobacco historiography; there is much more written about tobacco cancer than tobacco heart disease. Or emphysema or chronic bronchitis.

The lung cancer focus, though, is not unjustified. Smoking causes many other kinds of tumors—lip, throat, esophagus, tongue, gums, jaw, even bladder and female breast—but pulmonary malignancies are the quintessential calling card of smokers, killing about 160,000 Americans every year and more than ten times this globally.

So when was it realized that smoking causes lung cancer? The question is deceptively complex, and our answer will depend on what stage in the process of medical discovery we want to highlight.

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Excerpted from Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition Copyright © 2012 by Robert N. Proctor.  Excerpted with permission by University of California Press.
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