The Emperor of All Maladies: A Biography of Cancer (47 page)

*
It was Ford’s student Henry B. D. Kettlewell who used this moth-labeling technique to show that dark-colored moths—better camouflaged on pollution-darkened trees—tended to be spared by predatory birds, thus demonstrating “natural selection” in action.

By the way
, [
my cancer
]
is a squamous cell cancer apparently like all the other smokers’ lung cancers. I don’t think anyone can bring up a very forcible argument against the idea of a causal connection with smoking because after all I had smoked for about 50 years before stopping.

—Evarts Graham to Ernst Wynder, 1957

We believe the products that we make
are not injurious to health. We always have and always will cooperate closely with those whose task it is to safeguard public health.

—“A Frank Statement to Cigarette Smokers,”
a full-page advertisement produced
by the tobacco industry in 1954

Richard Doll and Bradford Hill published their prospective study on lung cancer in 1956—the very year that the fraction of smokers in the adult American population reached its all-time peak at 45 percent. It had been an epochal decade for cancer epidemiology, but equally, an epochal decade for tobacco. Wars generally stimulate two industries, ammunition and cigarettes, and indeed both the World Wars had potently stimulated the already bloated tobacco industry.
Cigarette sales had climbed
to stratospheric heights in the mid-1940s and continued to climb in the ’50s. In a gargantuan replay of 1864, as tobacco-addicted soldiers returned to civilian life, they brought even more public visibility to their addiction.

To stoke its explosive growth in the postwar period, the
cigarette industry poured tens, then hundreds
, of millions of dollars into advertising. And if advertising had transformed the tobacco industry in the past, the tobacco industry now transformed advertising. The most strik
ing innovation of this era was the targeting of cigarette advertising to highly stratified consumers, as if to achieve exquisite specificity. In the past, cigarettes had been advertised quite generally to all consumers. By the early 1950s, though, cigarette ads, and cigarette brands, were being “designed” for segmented groups: urban workers, housewives, women, immigrants, African-Americans—and, to preemptively bell the medical cat—doctors themselves. “More doctors smoke Camels,” one advertisement reminded consumers, thus reassuring patients of the safety of
their
smoking. Medical journals routinely carried cigarette advertisements.
At the annual conferences of the American Medical Association
in the early 1950s, cigarettes were distributed free of charge to doctors, who lined up outside the tobacco booths.
In 1955, when Philip Morris
introduced the Marlboro Man, its most successful smoking icon to date, sales of the brand shot up by a dazzling 5,000 percent over eight months. Marlboro promised a nearly erotic celebration of tobacco and machismo rolled into a single, seductive pack: “
Man-sized taste of honest tobacco
comes full through. Smooth-drawing filter feels right in your mouth. Works fine but doesn’t get in the way.”
By the early 1960s, the gross annual sale
of cigarettes in America peaked at nearly $5 billion, a number unparalleled in the history of tobacco. On average, Americans were consuming nearly four thousand cigarettes per year or about eleven cigarettes per day—nearly one for every waking hour.

Public health organizations in America in the mid-1950s were largely unperturbed by the link between tobacco and cancer delineated by the Doll and Hill studies. Initially, few, if any, organizations highlighted the study as an integral part of an anticancer campaign (although this would soon change). But the tobacco industry was far from complacent. Concerned that the ever-tightening link between tar, tobacco, and cancer would eventually begin to frighten consumers away, cigarette makers began to proactively tout the benefits of filters added to the tips of their cigarettes as a “safety” measure. (The iconic Marlboro Man, with his hypermasculine getup of lassos and tattoos, was an elaborate decoy set up to prove that there was nothing effeminate or sissy about smoking filter-tipped cigarettes.)

On December 28, 1953, three years before
Doll’s prospective study had been released to the public, the heads of several tobacco companies met
preemptively at the Plaza Hotel in New York. Bad publicity was clearly looming on the horizon. To counteract the scientific attack, an equal and opposite counterattack was needed.

The centerpiece of that counterattack
was an advertisement titled “A Frank Statement,” which saturated the news media in 1954, appearing simultaneously in more than four hundred newspapers over a few weeks. Written as an open letter from tobacco makers to the public, the statement’s purpose was to address the fears and rumors about the possible link between lung cancer and tobacco. In about six hundred words, it would nearly rewrite the research on tobacco and cancer.

“A Frank Statement” was anything but frank. The speciousness began right from its opening lines: “Recent reports on experiments with mice have given wide publicity to a theory that cigarette smoking is in some way linked with lung cancer in human beings.” Nothing, in fact, could have been further from the truth. The most damaging of the “recent experiments” (and certainly the ones that had received the “widest publicity”) were the Doll/Hill and Wynder/Graham retrospective studies—both of which had been performed not on mice, but on humans. By making the science seem obscure and arcane, those sentences sought to render its results equally arcane. Evolutionary distance would force emotional distance: after all, who could possibly care about lung cancer in mice? (The epic perversity of all this was only to be revealed a decade later when, confronted with a growing number of superlative
human
studies, the tobacco lobby would counter that smoking had never been effectively shown to cause lung cancer in, of all things, mice.)

Obfuscation of facts, though, was only the first line of defense. The more ingenious form of manipulation was to gnaw at science’s own self-doubt: “The statistics purporting to link cigarette smoking with the disease could apply with equal force to any one of many other aspects of modern life. Indeed the validity of the statistics themselves is questioned by numerous scientists.” By half revealing and half concealing the actual disagreements among scientists, the advertisement performed a complex dance of veils. What, precisely, was being “questioned by numerous scientists” (or what link was being claimed between lung cancer and other features of “modern life”) was left entirely to the reader’s imagination.

Obfuscation of facts and the reflection of self-doubt—the proverbial
combination of smoke and mirrors—might have sufficed for any ordinary public relations campaign. But the final ploy was unrivaled in its genius. Rather than discourage further research into the link between tobacco and cancer, tobacco companies proposed letting scientists have more of it: “We are pledging aid and assistance to the research effort into all phases of tobacco use and health . . . in addition to what is already being contributed by individual companies.” The implication was that if more research was needed, then the issue was still mired in doubt—and thus unresolved. Let the public have its addiction, and let the researchers have theirs.

To bring this three-pronged strategy to fruition, the tobacco lobby had already formed a “research committee,” which it called the Tobacco Industry Research Committee, or the TIRC. Ostensibly, the TIRC would act as an intermediary between an increasingly hostile academy, an increasingly embattled tobacco industry, and an increasingly confused public.
In January 1954, after a protracted search
, the TIRC announced that it had finally chosen a director, who had—as the institute never failed to remind the public—been ushered in from the deepest realms of science. Their choice, as if to close the circle of ironies, was Clarence Cook Little, the ambitious contrarian that the Laskerites had once deposed as president of the American Society for the Control of Cancer (ASCC).

If Clarence Little had not been discovered by the tobacco lobbyists in 1954, then they might have needed to invent him: he came preformed to their precise specifications. Opinionated, forceful, and voluble, Little was a geneticist by training. He had set up a vast animal research laboratory at Bar Harbor in Maine, which served as a repository for purebred strains of mice for medical experiments. Purity and genetics were Little’s preoccupations. He was a strong proponent of the theory that all diseases, including cancer, were essentially hereditary, and that these illnesses, in a form of medical ethnic-cleansing, would eventually carry away those with such predispositions, leaving a genetically enriched population resistant to diseases. This notion—call it eugenics lite—was equally applied to lung cancer, which he also considered principally the product of a genetic aberration. Smoking, Little argued, merely unveiled that inherent aberration, causing that bad germ to emerge and unfold in a human body. Blaming
cigarettes for lung cancer, then, was like blaming umbrellas for bringing on the rain. The TIRC and the tobacco lobby vociferously embraced that view. Doll and Hill, and Wynder and Graham, had certainly correlated smoking and lung cancer. But correlation, Little insisted, could not be equated with cause.
In a guest editorial written for the journal
Cancer Research
in 1956, Little argued that if the tobacco industry was being blamed for scientific dishonesty, then antitobacco activists bore the blame for scientific disingenuousness. How could scientists so easily conflate a mere confluence of two events—smoking and lung cancer—with a causal relationship?

Graham, who knew Little from his days at the ASCC, was livid.
In a stinging rebuttal written to the editor
, he complained, “A causal relationship between heavy cigarette smoking and cancer of the lung is stronger than for the efficacy of vaccination against smallpox, which is only statistical.”

Indeed, like many of his epidemiologist peers, Graham was becoming exasperated with the exaggerated scrutiny of the word
cause.
That word, he believed, had outlived its original utility and turned into a liability. In 1884, the microbiologist Robert Koch had stipulated that for an agent to be defined as the “cause” of a disease, it would need to fulfill at least three criteria. The causal agent had to be present in diseased animals; it had to be isolated from diseased animals; and it had to be capable of transmitting the disease when introduced into a secondary host. But Koch’s postulates had arisen, crucially, from the study of infectious diseases and infectious agents; they could not simply be “repurposed” for many noninfectious diseases. In lung cancer, for instance, it would be absurd to imagine a carcinogen being isolated from a cancerous lung after months, or years, of the original exposure. Transmission studies in mice were bound to be equally frustrating. As Bradford Hill argued, “
We may subject mice, or other laboratory animals
, to such an atmosphere of tobacco smoke that they can—like the old man in the fairy story—neither sleep nor slumber; they can neither breed nor eat. And lung cancers may or may not develop to a significant degree. What then?”

Indeed, what then? With Wynder and other coworkers, Graham
had
tried to expose mice to a toxic “atmosphere of tobacco smoke”—or at least its closest conceivable equivalent. Persuading mice to chain-smoke was obviously unlikely to succeed. So, in an inspired experiment performed in his lab in St. Louis,
Graham had invented a “smoking machine
,” a contrap
tion that would puff the equivalent of hundreds of cigarettes all day (Lucky Strikes were chosen) and deposit the tarry black residue, through a maze of suction chambers, into a distilling flask of acetone. By serially painting the tar on the skins of mice, Graham and Wynder had found that they could create tumors on the backs of mice. But these studies had, if anything, fanned up even more controversy.
Forbes
magazine had famously spoofed the research
by asking Graham, “How many men distill their tar from their tobacco and paint it on their backs?” And critics such as Little might well have complained that this experiment was akin to distilling an orange to a millionth of a million parts and then inferring, madly, that the original fruit was too poisonous to eat.