The first witness to take the stand in the high-profile U.S. Department of Justice lawsuit against the tobacco industry was former FDA Commissioner David Kessler. The second witness was a Harvard history professor largely unknown to the tobacco control community at the time—Allan Brandt. After all, the factual issues in the case were largely historical, centering on whether the tobacco companies deceived consumers about the health effects of smoking and nicotine addiction. Thus, questions about what tobacco industry executives knew, and what the scientific community knew, about smoking and health and nicotine addiction at a given time were extremely important. Brandt’s testimony was cited over 100 times in Judge Gladys Kessler’s decision in the case.

It is difficult to overestimate the impact of the cigarette on 20th century American society. The prototypical “product of the century,” the cigarette became an ever-present part of American culture and played a central role in a range of major twentieth century developments, including changes in gender roles, social activities, manufacturing and production practices, and growing consumerism, not to mention public health. The cigarette was at the forefront of a new form of national marketing and advertising campaigns built around brand identity. Cigarette manufacturers used advertising to link their product to social issues and values of the time, such as American patriotism and women’s equality. Indeed, Brandt claims in The Cigarette Century, “There are few, if any, central aspects of American society that are truly smoke-free in the last century.” (p.3)

A running theme throughout the book is the resilience and adaptability of the cigarette, and the tobacco industry, throughout the century. Starting in the early days of the mass-produced cigarette, tobacco manufacturers faced substantial challenges from reformers and regulators. Between 1890 and 1930, fifteen states enacted laws to ban the sale, manufacture, and/or use of cigarettes. While these laws were short-lived, they reflected the concerns of temperance reformers who saw tobacco, along with alcohol, as part of a larger pattern of unhealthy and immoral behavior.

Additionally, in 1911, the U.S. Supreme Court found the American Tobacco Company to be in violation of the Sherman Antitrust Act and split the company into five pieces—the American Tobacco Company, Liggett and Myers, RJ Reynolds, and P Lorillard. While the ruling was intended to restore competition by dividing factories and brands, critics argued that it simply reinforced the dominance of a few leading players. Philip Morris would be the only company over the next century to break into this exclusive group. Brandt suggests that this episode foreshadowed the future efforts of the leading tobacco companies to band together to protect their interests.

The second section of the book focuses on science and the “causal conundrum” regarding smoking and health, material that was at the heart of Brandt’s courtroom testimony. Brandt describes the transition from early medical critiques of the cigarette, based more on morality than science, to the development of a substantial and rigorous evidence base during the 1950s, primarily through the science of epidemiology. However, the book gets some of the methodology wrong. Brandt suggests that a very low p value in Doll and Hill’s first lung cancer case control study showed that “the possibility that [the association with smoking] was a ‘chance’ finding was less than one in a million,” (p.138) which is a common misinterpretation of the p value. He also states that the concept of a ‘control group’ was introduced to eliminate bias on the part of the researcher. In fact, the need for the control group is even more fundamental than that, as without it there cannot be any valid comparison, much less an unbiased one.

Brandt is dismissive of those who doubted the emerging evidence on smoking and lung cancer in the 1950s. “There is no question that there was a real controversy about tobacco,” he acknowledges (p.183). The real question, Brandt suggests instead, is what the extent of that controversy was and what the interests were behind it. In the absence of the tobacco industry’s public relations efforts, debates about the limits of epidemiologic methods likely would have remained largely academic, rather than becoming the focus of popular magazine articles. However, while Brandt cites the skepticism of scientists like Joseph Berkson and R.A. Fisher, he does not explain why they took the position they did. While their arguments served the interests of the tobacco companies, they were initially motivated by scientific concerns. What drove them to adhere to the positions they took so vehemently?

Parts 3 and 4 of the book shift the focus to law and politics. While significant federal tobacco control legislation was passed following the 1964 Surgeon General’s report, these measures typically fell far short of what public health and tobacco control advocates sought. In fact, some commentators have argued that the addition of a weak cigarette warning label did more to protect the interests of the tobacco industry than to control them, by allowing manufacturers to claim in court that consumers were aware of the health effects of smoking when they chose to smoke. As long as smoking was viewed simply as a matter of informed, individual choice, Brandt suggests, interventions to regulate the product or human behavior were bound to be limited.

A dramatic shift in public attitudes towards smoking followed developments in two areas that challenged the portrayal of smoking as an individual choice—the effects of secondhand smoke and understanding of nicotine addiction. Grassroots activism to restrict smoking in public places began during the 1970s and early 1980s while the evidence of health effects was still emerging. During the same time period, a scientific understanding of nicotine addiction began to develop, leading up to the 1988 Surgeon General’s report focusing on nicotine addiction. But crucial breakthroughs also came from investigative journalism and litigation, which revealed the tobacco industry’s manipulation of nicotine in cigarettes and efforts to target children. The release of internal industry documents had an enormous impact here, without which Brandt clearly could not have written the book he did.

The Cigarette Century is a broad, sweeping history. Inevitably readers will wish that more or less attention had been devoted to a particular episode or issue. But this should serve as a reminder of how complex the topic is. This book will serve as an excellent reference for researchers, both new and experienced, in the field of nicotine and tobacco research, and it provides essential context for understanding current scientific and policy challenges in tobacco control.

While the past five decades have seen substantial reductions in smoking prevalence, dramatic developments in science, and social changes around the public acceptance of cigarette smoking, the product itself remains essentially unregulated. The problem, Brandt suggests, is that tobacco is fundamentally different from other public health threats. Cigarettes are a familiar product, still part of our culture, and with effects that take decades to emerge; the tobacco epidemic lacks the urgency and heightened fear of AIDS or bioterrorism. At the same time, the book’s closing chapter highlights the growing “global pandemic” which Brandt calls “nothing short of colossal.” And unlike previous pandemics, the cause is a legal product which is sustained by a complex international web of social and economic dependence. “For such an epidemic, there will be no magic bullets,” Brandt warns.

However, Brandt stops disappointingly short of offering explicit historical lessons to guide future tobacco control efforts. “[H]istorians and astrologers are about equally successful in prediction the future,” Brandt offers apologetically. Yet while the role of historians may not include predicting the future, it can and should include communicating lessons from the past to scientists and public health leaders of today and tomorrow. In the story of The Cigarette Century, there are many lessons to be learned and the astute reader will find them. As the cigarette becomes an increasingly global public health threat, many countries are now in the early stages of a tobacco epidemic. Here is where history may have the greatest impact, in counseling those who still have time to change the course of history so that they are not doomed to repeat it.

About the Author: Mark Parascandola, Ph.D. is an Epidemiologist in the Tobacco Control Research Branch at the National Cancer Institute. He has published several articles on the history of research and public health policy around smoking and health.