determined that lung cancer had vastly increased in accordance with the number of smokers. Using epidemiological studies, they began to establish a clear link between smoking and cancer, but it was difficult to prove the connection using laboratory techniques since such techniques would entail keeping humans in controlled conditions for much of their lives. Scientists also found increased cancer rates for mice exposed to smoke. When the scientific studies were translated to aReader’s Digest article entitled “Cancer by the Carton,” the tobacco industry had to react, and it did so by engineering a brilliant public relations campaign. The industry allayed public anxieties about smoking hazards by including many doctors in advertisements. Also, by employing the public relations firm of Hill and Knowlton, tobacco executives started a “collaborative research entity,” the Tobacco Industry Research Committee (TIRC), which would sponsor its own scientific research in order to give the appearance of responding responsibly to the health threat that their product imposed. By hiring noted biologist Clarence Cook Little to head the TIRC, the tobacco industry found a public spokesman-scientist who would spend much of the rest of his career casting doubt on the supposed health risks of cigarettes. Little believed that the major cause of cancer was genetic, and because of the limitations of epidemiological research techniques, he could legitimately cast doubt on these studies, although naturally his credibility diminished over time as other medical studies found further links to lung cancer. Thus, while the industry could not exactly deny the scientific research, it could manufacture scientific controversy, creating enough doubt in the smokers’ minds to keep them smoking, an activity helped along by addiction to nicotine.

By the early 1960’s, Surgeon General Luther Terry set up an Advisory Committee with the express purpose of releasing a consensus report establishing a definitive causal link between cigarettes and lung disease. When the report came out in 1964, the tobacco companies responded by promoting new filtered cigarettes, giving the illusion of cleaner smoke. When the U.S. Congress started looking into some sort of regulatory control over the cigarette industry, the tobacco lobbyists proved very effective in watering down any legislation. Thanks to their influence, the warning on cigarette packaging became “Caution: Cigarette Smoking May Be Hazardous to Your Health.” Since the use of the word “may” cast any health concerns in doubt, the warning was not so effective, and the industry ultimately benefited later when the warnings helped with their defense in court. By 1966, as Brandt says, “cigarette sales had reached all time highs,” and smoking would decline in the United States from that point on, although predictions that the industry would fold under scientific or government pressure proved premature.

In fact, tobacco companies frequently found ways to turn legislation to their advantage. When people called for the end of television advertising for cigarettes in 1969, the companies complied when they realized that the antismoking public service messages would stop as well. Companies could continue to advertise in magazines and other media. Finally, by the 1970’s, anticigarette forces found some traction in persuading people to prevent passive smoke from harming nonsmokers. When scientific studies found that flight attendants, for instance, could get lung disease from secondhand smoke, the American public started supporting smoke-free public spaces. As the proportion of smokers dropped below 50 percent, Brandt says, “the very notion of smoking as a normative behavior was now in decline.” Smoking was increasingly eliminated from restaurants, theaters, and major forms of public transportation. While the industry’s public relations managed to keep smoking largely a matter of individual responsibility and risk, the rights of nonsmokers became increasingly important to the public. As a result of new antismoking legislation, the meaning of cigarettes became more negative.

Toward the end of the century, the tobacco industry still prided itself on not giving away a penny in any court cases, but several dramatic developments eventually changed that. One lawyer, Marc Edell, tried at length to win a product liability suit for Rose Cipollone, a victim of lung disease whose history of smoking showed that she switched brands depending on the health claims of the brands of the time. Edell was not successful, but his attempt paved the way for future legal victories. Moreover, legal challenges to the tobacco industry brought to light secret cigarette company memorandums and other files that showed the extent to which the industry knew about the health concerns of its product and its strategies to circumvent any attempts to block the industry. Simply by walking out of his workplace with papers stashed on his person, Merrell Williams stole a massive cache of secret files from a law firm working for the industry. When the cigarette companies attempted to have him arrested for theft, the judge agreed that the information was too important and should be disclosed. This information hurt the companies’ defense, in which they claimed that they lacked information about the harmfulness or addictiveness of their product. As a result of these findings, people started to win claims against the tobacco industry in the 1990’s.

While Brandt does include interesting stories about people standing up to the combined legal might of the industry, he could have done more to detail their heroism. For instance, Jeffrey Wigand, a biochemist, was fired by Brown and Williamson’s research division of the tobacco industry. When he sought to go public with what he knew about industry manipulation of nicotine levels in cigarettes, the tobacco companies sent him death threats. His dramatic story eventually was turned into a popular movie called The Insider (1999), even though both the American Broadcasting Company (ABC) and the Columbia Broadcasting System (CBS) refused at first to release the news stories because of the financial risk of the tobacco industry’s reprisals.

Brandt neatly itemizes how cigarette advertising has changed now that the hazards are better known. For one thing, marketing copy has largely disappeared, and images predominate, especially in the case of the cartoon Camel campaign and the Marlboro cowboy. By associating cigarettes with autonomy and the Wild West, the Marlboro brand has endured without making any verbal claims at all. In the case of the Camel campaign, while the industry denied it, the urbane Joe Camel was clearly oriented toward children to help offset the disadvantages of an aging clientele. When surveys showed that children knew Joe Camel almost as well as Mickey Mouse, public outcries finally obliged R. J. Reynolds to shut down the campaign.

By 1994, seven tobacco executives testified before a Congress subcommittee that, in Brandt’s words, “tobacco was not addictive and that their companies had taken no action to manipulate the levels of nicotine in cigarettes.” A public relations disaster, the testimony exposed how much the industry was still relying on outdated defensive tactics. Within a year, all of the chief executive officers had been replaced, but the industry still enjoyed robust sales well into the twenty-first century. As U.S. smoking consumption declined, the industry turned its marketing attention to exporting the cigarettes to Third World markets. In the early twenty-first century, there are more cigarettes sold across the world than ever, which Brandt finds will lead to a massive international pandemic. Conveniently for the advertisers, developing countries can respond to various advertising tactics used in the United States long ago. Moreover, the U.S. government often defends the industry’s interest in free trade.

While Brandt thoroughly maps out the history of the cigarette industry, more remains to be written about the personal battles with the industry. As a history of medicine professor at Harvard University, Brandt tends to look at the larger forces at work, but often the smaller, more individual acts of resistance betray the ferocity with which the industry will protect its interests. For instance, in his epilogue, Brandt mentions how he testified in a trial against the tobacco conglomerate. When he spoke to the main attorney for the tobacco litigation team, she asked him if he knew what he was getting himself involved in. He told her that he “realized that the industry lawyers would try to make [him] look as bad as possible.” She replied, “That’s not it. They want to destroy you and leave you in a pool of blood.” With many such examples, Brandt paints a compelling portrait of an industry that still fiercely wants to protect its profits regardless of the many people who have or will die from tobacco-related illnesses.