Profit Before People: The commercial determinants of health and lessons from the tobacco epidemic (2023)
How tobacco became a commercial determinant of health (CDoH)
That a single apparently harmless plant can, through a series of human controlled steps, become one of the most profitable, yet immoral and deadly products ever known, is a story worth thinking about. That this happened in plain sight and without control or regulation for so long tells us a lot about the power of private enterprise, the harm this can cause, and what the public will tolerate.
Tobacco originated in South America and has been used for thousands of years by indigenous cultures for spiritual and cultural purposes. Early European colonists of the Americas noted the physiological effects of tobacco, whether smoked, chewed or inhaled as snuff and immediately set about commanding its growth and sale. Now a European commodity, profit became a priority, and, within a few years, tobacco was being grown in Africa, India, and the Far East, as well as in the American colonies.
However, as early as 1604, the health effects of tobacco were debated and King James I described its use as:
"loathsome to the eye, hateful to the nose, harmful to the brain, and dangerous to the lungs".
Yet these views did not stand in the way of profit, and by 1670, it is estimated that 50% of the male population of England were using tobacco for 'medicinal' purposes3. As a non-nutritional crop which provided large profits, tobacco displaced more beneficial crops and presented landowners with 'get rich quick' opportunities. As supply increased, prices fell and competition increased, making the labour and time intensive nature of growing and production less profitable. This had an impact on another evil but profitable trade - slavery. By the start of the eighteenth century, the mainly white tobacco growing and manufacturing workforce were replaced by slaves.
During the second half of the nineteenth century, various innovations such as sweeteners drove popularity further, particularly in the form of the cigarette, which while thought of as a lesser form of tobacco than the cigar, was cheaper, even if production was labour intensive. It took an hour to roll 200 cigarettes by hand, but with the introduction of a rolling machine, the output increased to around 200 cigarettes per minute. This period of industrialisation, innovation and aggressive empire building led some major tobacco producers to merge, forming the American Tobacco Company. This monopoly allowed competition, pricing, and profits to be controlled, and soon cheap cigarettes flooded western countries, increasing smoking prevalence with aggressive, targeted and very effective marketing practices developed to ensure a steady stream of new users.
Those with concerns about the health and 'moral' dangers of smoking soon found themselves outnumbered as the public turned to cigarette smoking, and the World Wars produced opportunities for the TI. The horrors of war put health concerns into perspective and soon cigarettes were being donated and distributed as part of support efforts on the home fronts. Soon governments were supplying this newfound 'comfort' to their servicemen, and cigarettes became a staple of military rations. This created a literal army of addicted smokers, each with their favoured 'brand.'
Meanwhile the TI continued using clever marketing and branding campaigns to compete for market share, while also conspiring to keep prices consistent, and the brand became a central attraction for smokers - Marlboro, Camel, Capstan, Embassy, and many, many more became household names all over the world. They all 'sold' an image, creating an identity for the smoker and a feeling of belonging to an exclusive club. By the end of the Second World War in 1945, cigarette smoking was universally accepted and promoted by ever more creative means that appealed to all - male and female, child, and adult. Iconic characters and brands were everywhere - on billboards and newspapers, in the hands of Hollywood A-list stars and cartoon characters - creating a society saturated by tobacco.
By the 1940s, enough people had been smoking for long enough that links between smoking and disease started to appear, and the TI started to take notice and prepare. Most notable was that cases of lung cancer had tripled in the previous three decades. However, the length of time between uptake of smoking and signs of disease made it difficult to prove a 'causal' relationship. Of course, this lack of 'proof' suited the TI, which recruited doctors into their advertisements to reassure smokers, launching efforts to dispute and deny evidence harmful to their profits.
Research continued of course, but there was always just enough room for uncertainty, a space into which the TI stepped enthusiastically to sow doubt and confusion. It was not until 1962 that a ground-breaking Royal College of Physicians report put the issue of tobacco harms beyond doubt. The TI response to this was telling - continued forceful and assuring marketing campaigns, while ignoring the accumulating evidence.
In 1963, the Philip Morris Tobacco Co. stated that: 'We believe there is no connection (between smoking and ill health) or we wouldn't be in the business'
Then came serious public relations exercises with the goal of producing and sustaining scepticism towards the scientific findings and creating controversy that would allow them to consistently suggest that the evidence was not strong enough. This in turn sowed doubt in the mind of the smoker (and non-smoker) creating a 'rationale' to continue, or to begin, smoking.
Doubt is our product, since it is the best means of competing with the 'body of fact' that exists in the mind of the general public - Brown and Williamson Tobacco Co. 1969
Political lobbying was another tactic, as was TI funded research which yielded favourable results, litigation against those who spoke out, and so-called 'scientific' breakthroughs such as low tar cigarettes and improved filters. In short, the TI, when faced with the horrifying truth, chose not to tell that truth or to save lives, but rather set out to maintain shareholders profits and to actively obscure and deny the damning truth.
It was not until the mid-1990s that leaked documents from Brown and Williamson Tobacco were published and the public became aware that for more than 30 years the company's public statements were completely different to their internal knowledge and activities - the cat was out of the bag. But as late as late as 1994, TI executives swore under oath in the US Congress that nicotine was not addictive. However, pressure continued to grow on them until in 1994, the State of Mississippi began litigation to seek financial damages for the harm caused. By 1998, 46 US States were involved, and the TI settled these claims to the tune of $206 billion. As part of the settlement agreement, thousands of pages of internal documents became available and laid bare the appalling record of activities that global corporations were willing to perform in the pursuit of profit.
References
3. Brandt, A.M. (2009). The Cigarette Century. Basic Books, Philadelphia