Cigarettes Become a Dangerous Product: Tobacco in the Rearview Mirror, 1952–1965

摘要

Tobacco control’s unparalleled success comes partly from advocates broadening the focus of responsibility beyond the smoker to include industry and government. To learn how this might apply to other issues, we examined how early tobacco control events were framed in news, legislative testimony, and internal tobacco industry documents. Early debate about tobacco is stunning for its absence of the personal responsibility rhetoric prominent today, focused instead on the health harms from cigarettes. The accountability of government, rather than the industry or individual smokers, is mentioned often; solutions focused not on whether government had a responsibility to act, but on how to act. Tobacco lessons can guide advocates fighting the food and beverage industry, but must be reinterpreted in current political contexts. Tobacco control shines as a beacon of success in public health, having demonstrated unequivocally that policy interventions can improve environments and reduce morbidity and mortality at a population level. 1–3 Yet tobacco remains the leading cause of preventable death in the United States 4 and worldwide. 5 Indeed, the tobacco industry continues to resist a wide variety of tobacco control initiatives by insisting that there is no need for government intervention: smoking is a choice, and if smokers want to quit, they should take personal responsibility for their own health and just quit. For example, the Centers for Disease Control and Prevention’s Communities Putting Prevention to Work program, which emphasized tobacco control interventions, came under attack from tobacco industry representatives claiming that, All across the country, Americans are growing increasingly concerned about the role of government, and it’s believed by a substantial population in this country that the government is overreaching its bounds and getting too involved in our personal lives. 6 Indeed, beginning in the 1980s the tobacco industry was instrumental in fomenting conservative activism focused on concerns about the role of government. 7 Thus, it is no surprise that public health advocates working on other issues are subject to similar arguments. The food industry, for example, has responded to concerns about obesity with arguments that focus attention on personal responsibility and negate the role of government. 8 We were interested in better understanding how public health has weathered the drumbeat of personal responsibility rhetoric to inform ongoing tobacco control efforts and emerging public health interventions to address obesity. We know, for example, that successful tobacco control programs such as California’s 9 , 10 have sought to denormalize tobacco use and the tobacco industry by employing a spectrum of strategies from individually oriented cessation programs to tax policy and environmental changes to reduce exposure to secondhand smoke. 11 California’s famously effective media campaign illustrated that comprehensive approach with advertising that ranged from messages reminding smokers that “quitting takes practice” to warning that “the tobacco industry is not your friend.” One set of messages placed responsibility on individuals to quit smoking; the other set placed responsibility on the tobacco industry and government regulation. 12 Both discourses exist in tobacco control just as they coexist in society at large, though one or another may dominate the public discussion at any given time. Since the 1970s in the United States, personal responsibility rhetoric has increasingly dominated public policy debate. 13,14 President Clinton’s 1996 landmark welfare reform legislation, the Personal Responsibility and Work Opportunity Reconciliation Act, 15 and the rise of the Tea Party 16 in 2010 are 2 manifestations of this perspective. “Framing” refers to how an idea or issue is defined, portrayed, and understood. Frames operate at the cognitive level, consciously or unconsciously, to construct meaning 17 by promoting “a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described.” 18 (p52) One of the most enduring frames in American discourse is “rugged individualism,” 19 which presents problems as a matter of personal choice or accomplishment independent of—or despite—social, historical, or environmental forces. This frame presumes that individuals or the laissez-faire market, not government or other entities, are the genesis of and appropriate agent for remedy of problems. 20 Alternatively, American discourse at times includes frames suggesting collective responsibility in which government or institutions are the source of or solution to social problems. 21 The precursor to questions about individual responsibility or institutional accountability in tobacco control is this: does smoking harm health? Although for most people this question was definitively answered by the 1964 Surgeon General’s Report, it was doggedly