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The history of smoking shows we have a choice in our collective health

Don’t let companies use the language of freedom and autonomy to hack your freedom and autonomy

It is a fundamental tenet of a free society that we as individuals have the freedom to make different choices in our lives, and that our society is strengthened when we do so. Yet in the quest to assert and exercise our personal autonomy, sadly it is often large, entrenched, and yes profit-minded interests on the other side of the equation that try to keep us from doing so. Those interests are constantly attempting to hack our autonomy while we’re not looking, to get us to make choices we otherwise wouldn’t make. Then, they try to convince us that we in fact have no choice at all, that our current path is just the way the world works.

We’ve seen this story before.

In the post-World War II boom of the 1950s and 1960s, smoking was on the rise and so too were deaths from lung cancer. Back then, tobacco companies actually advertised the health benefits of smoking, everything from helping with digestion to providing “throat protection” from the irritations of a cough:

Whenever I think of the decades-long public health campaign against cigarettes, a campaign which JAMA estimated saved 8 million Americans from premature death, I think of Mad Men, the show about a NYC advertising agency in the 1960s.

In the pilot episode, advertising executives Pete Campbell and Don Draper pitch a new advertising campaign to their largest client, Lucky Strike. The government has just prohibited tobacco companies from advertising about health benefits, and so it’s time to come up with a new strategy.

The campaign they settle on in the show is drawn from real life (the “It’s toasted” slogan from the ad above)—but it’s the one they reject that I actually think would have been more successful. We Americans don’t like being condescended to with paternalistic warnings, and it’s this fierce individualism and resistance to authority that Pete suggests the tobacco company use to its advantage:

As Pete tells it: “People get in their cars every day to go to work, and some of them die. Cars are dangerous. There’s nothing you can do about it. You still have to get where you’re going. Cigarettes are exactly the same. So why don’t we simply say, ‘So what if cigarettes are dangerous? You’re a man. The world is dangerous. Smoke your cigarette. You still have to get where you’re going.’’’

The older tobacco executive rejects the idea, mainly because it would entail admitting that cigarettes are dangerous in the first place, something real-life tobacco executives were lying about as recently as 1994. It was then, during a now infamous Congressional hearing, that executives from the seven-biggest tobacco companies all decided to simultaneously perjure themselves rather than acknowledge what had been patently obvious for more than two decades: that nicotine is addictive.

Yet Pete’s insight into human nature, especially in a country as individualistic as the U.S., remains to this day. People continue to smoke. No one deludes themself that smoking is healthy anymore, but they do it anyway. Why? Because life is full of risk, and—here’s where Pete’s logic breaks down—there’s nothing you can do about it.

In fact, there is much we can do about it. We made cars safer by requiring seat belts. And we made smoking less ubiquitous by implementing a range of regulatory changes, combined with public health messaging that transformed smoking from being cool and transgressive to something more likely regarded to be gross, unhealthy, and uncool.

But imagine if, instead of waging a massive public effort to change people’s behavior, we as a society had instead thrown up our collective hands and simply concluded as Pete does, that life is unsafe, the world is full of risks, so go ahead: smoke your cigarettes.

It’s remarkable how similar the debates are today over everything from vaccine uptake to sugar to social media. The difference today from the smoking campaigns of the past, if there is one, seems to be simply the noise of modern life, combined with our collective cynicism about authority in general, a cynicism widely shared on both the left and the right, a cynicism which only increased in the aftermath of botched public health messaging during the pandemic.

In 1964, the U.S. Surgeons General released a landmark report that linked cigarette smoking to lung cancer and heart disease. Before that report, cigarette sales had been on an endless upward trajectory. After that report, sales began to fall. There are few victories in public health as stunning as the one over cigarette smoking, and this chart shows that victory with stunning clarity:

And yet, if the U.S. Surgeons General were to release a report today about the dangers of highly refined sugar and its connection to diabetes, I doubt it would make much of a blip at all. And when big city mayors try to ban, for example, the sale of gigantic sugary drinks (the canonical example is Michael Bloomberg in NYC), the move is generally considered to be the height of condescending, paternalistic government overreach.

Honestly, that’s my initial, gut reaction as well. I generally think government should be making the trains run on time, keeping people safe, and picking up the trash, not regulating the size of the drink I’m allowed to buy at McDonald’s (or Whole Foods, if that’s more your thing).

And yet… even I must acknowledge that if there’s a big, sugary cake sitting on my kitchen counter, I’m pretty likely to eat a piece—many pieces. I do have a sweet tooth. But I also know I don’t really want to be eating that much sugar, so I don’t buy or make big sugary cakes, so they’re never in my house to tempt me. Some people have more discipline than me, others less, but we can all understand that our discipline only goes so far.

As the saying goes: “Genes load the gun, environment pulls the trigger.” In other words, we all have genetic predispositions to like or dislike certain things, which may or may not be bad for us. But then our environment plays a huge role in determining whether those predilections are indulged or impeded. Self-knowledge about one’s own tendencies, toward addiction, for example, is fundamental to maintaining our personal autonomy.

But sometimes a regulatory nudge can make a big difference, as it did for smoking. As is evidenced by the chart above, our society threw every tool in our toolkit at the problem of smoking. We made it more expensive to smoke by taxing cigarettes. As mentioned above, we banned certain kinds of advertising, even going so far as to say there would be no advertising allowed on either television or radio. And, we systematically shrank the public places where one was allowed to smoke, starting with planes and moving to inside and immediately surrounding most workplaces.

Again, imagine the counterfactual for a moment—a world in which our collective reaction to the harms of smoking was to throw up our hands, and simply say, “Hey, the world is a dangerous place! Smoke your cigarettes.”

What is the point of remembering all this history? I think it is to shed light on the current debates about nature vs. nurture, genetics vs. environment. As Dr. Falcone wrote last month, there is currently a large push within the healthcare profession and in public health in general, to declare that environmental factors (the so-called Social Determinants of Health) are a kind of trump card, eclipsing all other causes of our nation’s chronic health crisis.

“However, one thing that has fallen almost completely out of the discussion? Talk of personal responsibility,” wrote Dr. Falcone. “And that’s too bad because, depending on the context, understanding the extent of one’s own autonomy in decision-making can have a hugely positive effect on their health.”

In this, I completely agree. Declaring a meaningful role for personal responsibility is an essential tool of public health. We must understand how much discipline we each have, and in what circumstances, so we can protect our autonomy from those interests which are daily, actively trying to subvert it, whether that’s a tobacco company trying to get us to smoke, a beverage company trying to convince us to “taste the feeling” of high-fructose corn syrup, or a social media company that designs its endless scroll the same way a casino designs its slot machines: to keep us pulling the refresh.

The smoking history is instructive; it was the combination of public health messaging and regulatory changes that made it easier for people to change their own behavior. You can call it paternalistic or big government overreach, but the fact remains that it’s easier to make healthy choices if the unhealthy ones are too expensive, or socially isolating.

This is why I (and Dr. Falcone as well) tend to react with innate caution to pharmaceutical solutions for chronic health problems, whether that’s the new weight loss drugs for obesity or SSRIs for depression. By emphasizing pharmaceutical solutions, we ignore that totally interesting combination of genetic, environmental, and personal factors that can usually prevent or reverse those diseases.

As Hippocrates said, “If you are in a bad mood go for a walk. If you are still in a bad mood go for another walk.” The only thing Hippocrates was missing in that analysis is that sometimes the street is itself dangerous, or maybe there are no sidewalks, or the smog outside is so bad that the risks outweigh the benefits. Environment does matter, but if we stop there, we miss the most important part: that we have many tools, both individually and collectively, to influence and change our environment. Or to put it more simply, as Jack Nicholson’s character said in The Departed: “I don’t want to be a product of my environment; I want my environment to be a product of me.”

We used many tools at our disposal to reduce smoking. We can use them again for other problems. For me, it’s not just about influencing public health, saving money on healthcare, or fixing our long-term problems with chronic disease—it’s about protecting my personal autonomy and decision-making from forces trying to hack it for their own profit-minded ends.

What a tragedy that would be, if the Pete Campbells of the world tricked us, using the language of our own stated values, into making decisions to serve their own interests, rather than our own.

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