The public's opinion of tobacco use has dramatically changed over time. Gone are the days when cigarette companies advertise using slogans like "fresh as mountain air" or "more doctors smoke Camels than any other cigarette." We now know that cigarettes cause blindness and tuberculosis, among many other conditions, and are highly addictive.
But in the era of nicotine e-cigarettes that are touted as cool and harmless, have we really changed our ways? I spoke with Robert Proctor, PhD, a professor of history at Stanford, to learn more about his work.
What inspired you to research the history of cigarette design?
Cigarettes are the world's leading preventable cause of death, killing about 6 million people worldwide every year. A physician might hope to heal a thousand or perhaps ten thousand people over a career, but what if we could save these 6 million people annually? It was this hope of saving lives that led to my exploring how cigarettes have been designed, and how they might be stopped.
Where do you find your research materials?
The Legacy Tobacco Documents Library is a real treasure. I use it to explore the industry's myriad secret projects -- like Project Subculture Urban Marketing, a secret Reynolds campaign from the 1990s to target gays and the homeless in San Francisco. I also use it to find out what they've been adding to cigarettes -- like diammonium phosphate, a free-basing agent used to boost the potency of the nicotine molecule. I also use it to find out who has been working for the industry, as grantees or expert witnesses. Historically, that included dozens of Stanford professors, but I don't know any still working in that capacity today.
What do you think about the FDA's plan to reduce nicotine in cigarettes?
As I explained in a recent op-ed for the New York Times, the Food and Drug Administration will try to mandate the reduction of nicotine in cigarettes to a sub-addictive level. However, they will encounter ferocious resistance from the industry, which sees nicotine as the indispensable ingredient of their business. For beginning smokers, nicotine is actually a negative in the smoking experience. Once addicted, most smokers regret having started. It will be crucial for the FDA to reduce nicotine sufficiently to make sure these new users don't become addicted. De-nicotinization is easy. Multiple techniques are available to achieve this, including genetic technologies and some of the same techniques used to de-caffeinate coffee.
Have you also studied e-cigarettes?
I have studied e-cigarettes but not as intensively. Many of the same techniques once used to market traditional cigarettes have been revived for e-cigarettes and other vaping devices, as Robert Jackler, MD, and his colleagues have shown so beautifully. E-cigarettes may help some smokers quit, but they are more likely to renormalize smoking and act as gateways to regular cigarettes. They also serve as bridge products to keep smokers from quitting nicotine entirely, which is why the big cigarette makers have all launched new vaping devices.
What more can be done?
Physicians often know the right thing to do, but may not have the power to make that happen -- that is medical impotence. A third of all cancer deaths, for example, are caused by cigarettes. Just knowing that, though, isn't enough to do any good, since there are powerful forces dedicated to making sure we keep pulling smoke into our lungs. Much more could be done to solve such problems -- the new age minimum for purchasing cigarettes should help. I also believe we need to explore what I call 'the causes of causes.' Cigarette smoking causes disease, but what causes cigarette smoking? Too often we end with the individual, rather than going upstream to the source of the problem in the first place. Stop the manufacture of cigarettes, for example, and you stop having to yank out tumors from lungs or putting people on oxygen. We need more upstream thinking in the practice of medicine.
We also need to think more about health in our own community. For instance, Stanford got a failing grade from the Santa Clara County Public Health Department in 2011 as the most cigarette-friendly campus in the Bay Area -- for allowing the sale and use of cigarettes on campus. We did finally manage to get the sale of cigarettes in the student union stopped, after years of painful protest.
Editor's note: Stanford has a smoke-free environment policy that prohibits smoking in all buildings, facilities, vehicles, covered walkways and during indoor or outdoor athletic events. Smoking has been banned on the School of Medicine campus for a decade.
Previously: Exploring the addictive nature of cigarettes, Bringing an end to smoking, Stanford tobacco expert discusses the FDA's new tobacco and nicotine regulation plan and What you need to know about e-cigarettes
Photo courtesy of Robert Proctor