The Emperor of All Maladies: A Biography of Cancer (49 page)

Hesitantly at first, but with growing confidence—“
a reluctant dragon
,” as Kenneth Endicott, the NCI director, would characterize him—Terry chose the third path. Crafting a strategy that seemed almost reactionary at first glance,
he announced that he would appoint an advisory committee
to summarize the evidence on the links between smoking and lung cancer. The committee’s report, he knew, would be scientifically redundant: nearly fifteen years had passed since the Doll and Wynder studies, and scores of studies had validated, confirmed, and reconfirmed their results. In medical circles, the link between tobacco and cancer was such stale news that most investigators had begun to focus on
secondhand
smoke as a risk factor for cancer. But by “revisiting” the evidence, Terry’s commission would vivify it. It would intentionally create a show trial out of real trials, thus bringing the tragedy of tobacco back into the public eye.

Terry appointed ten members to his committee. Charles LeMaistre, from the University of Texas, was selected as an authority on lung physiology. Stanhope Bayne-Jones, the senior-most member of the committee, was a bearded, white-haired bacteriologist who had moderated several prior committees for the NIH. Louis Fieser, an organic chemist from Harvard, was an expert on chemical carcinogenesis. Jacob Furth
from Columbia, a pathologist, was an authority on cancer genetics; John Hickam was a clinical specialist with a particular interest in heart and lung physiology; Walter Burdette, a Utah surgeon; Leonard Schuman, a widely respected epidemiologist; Maurice Seevers, a pharmacologist; William Cochran, a Harvard statistician; Emmanuel Farber, a pathologist who specialized in cell proliferation.

For nine sessions spanning thirteen months, the team met in a sparsely furnished, neon-lit room of the National Library of Medicine, a modern concrete building on the campus of the NIH. Ashtrays filled with cigarette butts littered the tables. (The committee was split exactly five to five among nonsmokers and smokers—men whose addiction was so deep that it could not be shaken even when deliberating the carcinogenesis of smoke.) The committee visited dozens of labs.
Data, interviews, opinions, and testimonies
were drawn from some 6,000 articles, 1,200 journals, and 155 biologists, chemists, physicians, mathematicians, and epidemiologists. In total, the trials used for the report encompassed studies on about 1,123,000 men and women—one of the largest cohorts ever analyzed in an epidemiological report.

Each member of the committee
brought insight to a unique dimension of the puzzle. The precise and meticulous Cochran devised a new mathematical insight to judge the trials. Rather than privilege any particular study, he reasoned, perhaps one could use a method to estimate the relative risk as a composite number through
all
trials in the aggregate. (This method, termed meta-analysis, would deeply influence academic epidemiology in the future.) The organic chemist in Fieser was similarly roused: his discussion of chemicals in smoke remains one of the most authoritative texts on the subject. Evidence was culled from animal experiments, from autopsy series, from thirty-six clinical studies, and, crucially, from seven independent prospective trials.

Piece by piece, a highly incontrovertible and consistent picture emerged. The relationship between smoking and lung cancer, the committee found, was one of the strongest in the history of cancer epidemiology—remarkably significant, remarkably conserved between diverse populations, remarkably durable over time, and remarkably reproducible in trial after trial. Animal experiments demonstrating a causal link between smoking and lung cancer were inconclusive at best. But an experiment was not needed—at least not a laboratory experiment in the traditional sense of that word. “
The word ‘cause,’” the report read
, leaning heavily on Hill’s prior work,
“is capable of conveying the notion of a significant, effectual relationship between an agent and an associated disorder or disease in the host. . . . Granted that these complexities were recognized, it is to be noted clearly that the Committee’s considered decision [was] to use the words ‘a cause,’ or ‘a major cause,’ . . . in certain conclusions about smoking and health.”

In that single, unequivocal sentence, the report laid three centuries of doubt and debate to rest.

Luther Terry’s report, a leatherbound, 387-page
“bombshell” (as he called it), was released on January 11, 1964, to a room packed with journalists. It was a cool Saturday morning in Washington, deliberately chosen so that the stock market would be closed (and thus bolstered against the financial pandemonium expected to accompany the report). To contain the bomb, the doors to the State Department auditorium were locked once the reporters filed in. Terry took the podium. The members of the advisory committee sat behind him in dark suits with name tags. As Terry spoke, in cautious, measured sentences, the only sound in the room was the dull scratch of journalists furiously scribbling notes. By the next morning, as Terry recalled, the report “was front-page news and a lead story on every radio and television station in the United States and many abroad.”

In a nation obsessed with cancer, the attribution of a vast preponderance of a major cancer to a single, preventable cause might have been expected to provoke a powerful and immediate response. But front-page coverage notwithstanding, the reaction in Washington was extraordinarily anergic. “
While the propaganda blast was tremendous
,” George Weissman, a public relations executive, wrote smugly to Joseph Cullman, the president of Philip Morris, “. . . I have a feeling that the public
reaction
was not as severe nor did it have the emotional depth I might have feared. Certainly, it is not of a nature that caused prohibitionists to go out with axes and smash saloons.”

Even if the report had temporarily sharpened the scientific debate, the prohibitionists’ legislative “axes” had long been dulled. Ever since the spectacularly flawed attempts to regulate alcohol during Prohibition, Congress had conspicuously disabled the capacity of any federal agency to regulate an industry. Few agencies wielded direct control over any industry. (The Food and Drug Administration was the most significant exception to this rule. Drugs were strictly regulated by the FDA, but the cigarette had nar
rowly escaped being defined as a “drug.”) Thus, even if the surgeon general’s report provided a perfect rationale to control the tobacco industry, there was little that Washington would do—or, importantly,
could
do—to achieve that goal.

It fell upon an altogether odd backwater agency of Washington to cobble together the challenge to cigarettes. The Federal Trade Commission (FTC) was originally conceived to regulate advertisements and claims made by various products: whether Charlie’s liver pills truly contained liver, or whether a product advertised for balding truly grew new hair. For the large part, the FTC was considered a moribund, torpid entity, thinning in authority and long in the tooth. In 1950, for instance, the year that the Doll/Hill and Wynder/Graham reports had sent shock waves through academic medicine,
the commission’s shining piece of lawmaking
involved policing the proper use of the various words to describe health tonics, or (perhaps more urgently) the appropriate use of the terms “slip-proof” and “slip-resistant” versus “slip-retardant” to describe floor wax.

The FTC’s destiny changed in the summer of 1957. By the mid-1950s, the link between smoking and cancer had sufficiently alarmed cigarette makers that many had begun to advertise new filter tips on cigarettes—to supposedly filter away carcinogens and make cigarettes “safe.”
In 1957, John Blatnik, a Minnesota chemistry teacher
turned congressman, hauled up the FTC for neglecting to investigate the veracity of this claim. Federal agencies could not directly regulate tobacco, Blatnik acknowledged. But since the FTC’s role was to regulate tobacco
advertisements
, it could certainly investigate whether “filtered” cigarettes were truly as safe as advertised. It was a brave, innovative attempt to bell the cat, but as with so much of tobacco regulation, the actual hearings that ensued were like a semiotic circus. Clarence Little was asked to testify, and with typically luminous audacity, he argued that the question of testing the efficacy of filters was immaterial because, after all, there was nothing harmful to be filtered anyway.

The Blatnik hearings thus produced few immediate results in the late 1950s. But, having been incubated over six years, they produced a powerful effect. The publication of the surgeon general’s report in 1964 revived Blatnik’s argument.
The FTC had been revamped
into a younger, streamlined agency, and within days of the report’s release, a team of youthful lawmakers began to assemble in Washington to revisit the notion of regulating tobacco advertising.
A week later, in January 1964
, the FTC
announced that it would pursue the lead. Given the link between cigarettes and cancer—a causal link, as recently acknowledged by the surgeon general’s report—cigarette makers would need to acknowledge this risk directly in advertising for their products. The most effective method to alert consumers about this risk, the commission felt, was to imprint the message onto the product itself. Cigarette packages were thus to be labeled with
Caution: Cigarette Smoking Is Dangerous to Health. It May Cause Death from Cancer and Other Diseases
. The same warning label was to be attached to all advertisements in the print media.

As news of the proposed FTC action moved through Washington, panic spread through the tobacco industry. Lobbying and canvassing by cigarette manufacturers to prevent any such warning label reached a febrile pitch. Desperate to halt the FTC’s juggernaut, the tobacco industry leaned on Abe Fortas, President Johnson’s friend and legal adviser (and soon to be Supreme Court justice), and Earle Clements, the former governor of Kentucky who had become Little’s replacement at the TIRC in 1959. Led by Clements and Fortas, tobacco makers crafted a strategy that, at first glance, seemed counterintuitive: rather than being regulated by the FTC, they voluntarily requested regulation by Congress.

The gambit had a deeply calculated logic. Congress, it was well-known, would inherently be more sympathetic to the interests of tobacco makers. Tobacco was the economic lifeblood of Southern states, and the industry had bribed politicians and funded campaigns so extensively over the years that negative political action was inconceivable. Conversely, the FTC’s unilateral activism on tobacco had turned out to be such a vexing embarrassment to politicians that Congress was expected to at least symbolically rap the wrist of the vigilante commission—in part, by lightening its blow to tobacco. The effect would be a double boon. By voluntarily pushing for congressional control, the tobacco industry would perform a feat of political acrobatics—a leap from the commission’s hostile fire to the much milder frying pan of Congress.

So it proved to be. In Congress, the FTC’s recommendation was diluted and rediluted as it changed hands from hearing to hearing and committee to subcommittee, leading to a denervated and attenuated shadow of the bill’s former self.
Entitled the Federal Cigarette Labeling and Advertising Act
(FCLAA) of 1965, it changed the FTC’s warning label to
Caution: Cigarette smoking may be hazardous to your health
. The dire, potent language of the original label—most notably the words
cancer
,
cause
, and
death
—was expunged. To ensure uniformity, state laws were also enfolded into the FCLAA—in effect, ensuring that no stronger warning label could exist in any state in America. The result, as the journalist Elizabeth Drew noted in the
Atlantic Monthly
, was “an unabashed act to protect private industry from government regulation.” Politicians were far more protective of the narrow interests of tobacco than of the broad interest of public health. Tobacco makers need not have bothered inventing protective filters, Drew wrote drily: Congress had turned out to be “the best filter yet.”

The FCLAA bill was a disappointment, but it galvanized antitobacco forces. The twisting of an unknown piece of trade law into a regulatory noose for tobacco was both symbolic and strategic: an unregulatable industry had been brought to heel—even if partially so. In 1966, a young attorney barely out of law school, John Banzhaf, pushed that strategy even further. Brash, self-confident, and iconoclastic, Banzhaf was lounging at home during the Thanksgiving holiday of 1966 (watching the omnipresent cigarette ads) when his mind raced to an obscure legal clause. In 1949, Congress had issued the “fairness doctrine,” which held that public broadcast media had to allow “fair” airtime to opposing viewpoints on controversial issues. (Congress had reasoned that since the broadcast media used a public resource—airwaves—they should reciprocate by performing a public function, by providing balanced information on controversial issues.) The doctrine was little known and little used. But Banzhaf began to wonder whether it could be applied to cigarette advertising. The FTC had attacked the disingenuousness of the tobacco industry’s advertising efforts. Could a parallel strategy be used to attack the disproportionality of its media presence?