PUBLIC HEALTH THEN AND NOW

o Hoctars' Choice Is America's Choice''
The Physician in US Cigarette Advertisements, 1930-1953
Martha N, Gardner, PhD, and Allan M, Brandt, PhD

In the 1930s and 1940s, smoking became the norm for both men and women in the llnited States, and a majority of physicians smoked. At the same time, there wasrisingpublic anxiety about the healthrisksof cigarette smoking. One strategic response of tobacco companies was to devise advertising referring directly to physicians. As ad campaigns featuring physicians developed tfirough the early 1950s, tobacco executives used the doctor image to assure tiie consumer that their respective brands were safe. These advertisements also suggested that the individual physicians' clinical judgment should continue to be the arbiter of the harms of cigarette smoking even as systematic health evidence accumulated. However, by 1954, industry strategists deemed physician images in advertisements no longer credible in the face of growing public concern about tbe health evidence implicating cigarettes. {Rm J Public Health. 2006; 96:222-232. doi:10.2105/AJPH.2005. 066654}

IN 1946, THE RJ REYNOLDS

Tobacco Company initiated a major new advertising campaign for Camels, one of the most populai- brands in the United States, Working to establish dominance in a highly competitive market Reynolds centered their new campaign on the memorable slogan, "More doctors smoke Camels than any other cigarette," This phrase would be the mainstay of their advertising for the next 6 years. Touting surveys conducted by "three leading independent research orgajuzadons," one typical advertisement proclaimed that according to "nationwide" surveys of 113 597 doctors "from every branch of medicine." Camel was the brand smoked by most resprondents. It also asserted that this statistic was an "actual fact" not a "casual claim," In realit>', this "independent" surveying was conducted by RJ Reynoids's advertising agency, the William Esty Company, whose employees questioned physicians about their smoking habits at medical conferences and in their offices. It appears that most doctors were surveyed about their

cigarette brand of choice just after being provided complimentary cartons of Camels.' Even without the suspect nature of the data used in the "More Doctors" campaign, the frequent appearance of physicians in advertisements for cigarettes in this and many other ad campaigns is both striking a:id ironicfromthe vantage point of the early 21st century. Any association between physicians and cigarettes—the leading cause of death in the United States—is jarring given our cuirent scientific knowledge ahout the relationship of smoking to disease and the fact that fewer than 4% of physicians in the United States now smoke,^ In 1930s and 1940s, however, smoking had become the norm for botli men and women in the United States—and a majority of physicians smoked,'' At the same time, however, rising public and scientific anxiety existed about cigarettes' risks to health, creating concern among the tobacco companies. The physician constituted an evocative, reassuring figure to include in their advertisements.

In retrospect, these advertisements are a powerful reminder of the cultural authority physicians and medicine held in American society during the mid20th century, and the manner in which tobacco executives aligned their product with that authorily, Even before modem epidemioiogicaJ research would demonstrate the health risks of smoking at mid-century, there had already arisen considerable concem about the health impact of cigarette use,' Questions of the moral and health consequences of cigarette smoking that bad been prevalent at the beginning of the 20th century still lingered. Although many physicians were unconvinced by this older research, some had begun to recognize a disturbing increase in lung cancer, and some had also started to consider the respiratory and cardiovascular effects of smoking. A common theorj' held that cancer resulted ftxjm chronic irritation to the affected tissue, and many wondered whether cigarette smoke "irritated" lung tissue in this

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Well aware of these concerns— and their impact on cigarette sales—the tobacco companies devised advertising and marketing strategies to (1) reassure the public of the competitive health advantages of their brands, (2) recruit physicians as crucial allies in the ongoing process of marketing tobacco, and (3) maintain the salience of individual clinical judgments about the health effects of smoking in the face of categorical scientific findings. These elements would be of growing importance as the healtli effects of smoking came to be more fully elucidated. One aspect of these promotional strategies was to refer directly to physicians in botb images and words. We explored how physicians were depicted in these advertisements and how the ad campaigns developed as health evidence implicating cigarette .smoking accumulated by the early 1950s. EARLY MEDICAL CLAIMS American Tobacco, the leader in the splashy ad campaigns that had made its Lucky Strike brand dominant by the late 1920s, was the first to mention physicians in advertisements. The physician was just one piece of a much larger campaign on bebalf of American Tobacco. As cigarette sales grew exponentially in the United States in the early 20th century. Lucky Strikes had become the preeminent brand largely because of its massive promotional elTorts. Company president George Washington Hill worked with ad man Albert Lasker to develop a "reason why" consumers should purchase their brand. With no real scientific evidence to back their claims, American Tobacco insisted that the "toasting" process that Lucky

Strikes tobacco underwent decreased throat irritation.'' In fact, Lucky Strikes' curing process did not significantly differ from that of other brands. Related campaigns emphasized that "Luckies" would help consumers—especially women, their new market—to stay slim, since they could "Reach for a Lucky instead of a sweet." ;\long with these persistent health

American Tobacco, We leader in the splashy ad campaigns that had made its Lucky Strike brand dominant by the late 1920s, was the first to mention physicians in advertisements.

claims, a ^ i c a l advertisement from 1930 boldly stated that "20,679 Physicians say 'LUCKIES are less irritating'" and featured a white-haired, whitecoaled doctor with a reassuring smile (Figure 1).' In this manner, American Tobacco advertisements refiected an awareness of ongoing public concern about the potential health effects of cigarette smoking. Referring to a large number of physicians who they claimed backed up the superiority of Lucky Strikes, the ad text noted in small print that their account-

ing firm had "checked and certified" this number, independently validating the claim.** Their advertLsing agency. Lord, Thomas and Logan, had sent cartons of cigarettes to physicians in 1926, 1927, and 1928 and asked them to answer whether "Lucky Strike Cigarettes . . . are less irritating to sensitive and tender throats than other cigarettes." Ibuting the toasting process in the accompanjong cover letter, adveitising executive Thomas Logan pointed out the virtues of Lucky Strikes and claimed that

FIGURE 1—Advertisement: "20,679" physicians say 'LUCKIES are less irritating.'" Source. Magazine of Wall Street. July 26, 1930.

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they had heard from "a good many people" that they could smoke Lucky Strikes "with perfeet comfort to their throats." American Tobacco used the physicians' responses to this survey to validate their claim that Lucky Strikes were "less irritating," claiming it confirmed their enduring assertion that their "toasting" process made cigarettes less irritating. Toasting, the advertisement went on to explain, was "your throat protection against irritation— against cough."^ Although there was no substantive evidence that this process of curing tobacco was superior to the methods tised by other companies, American Tobacco made the bold claim and tied it to physicians. By the mid-1930s. Philip Morris, a newcomer to the market took the use of health claims a step ftirther, designing a campaign that used a new strategy of

referring directly to research conducted by physicians. Both in magazines targeted to the general public and in medical journals, Philip Morris claimed tbat their cigarettes were proven to be "less irritating." For example, in a 1937 Saturday Evening Post advertisement, Philip Morris's ballmark spokesman, bellhop Johnny Roventini, announced that according to "a report on the findings of a group of doctors . . . when smokers changed to Philip Morris, every case of irritation cleared completely and definitely improved" (Figure 2). The text referred specifically to faithfijl doctors "day after day... [keeping] a record" to "prove conclusively" the decrease in irritation."^ These "findings" resulted from an aggressive pursuit of physicians and focused on the concept that adding a chemical to their cigarettes, diethylene-glycol. made them moister and less irritating than other brands. As Alan Blum,
editor of the New York State Journal of Medicine, explained in bis 1983 assessment of cigarette advertisements that had appeared in the journal from 1927 to 1953, Philip Morris—armed with papers written hy researchers that the company bad sponsored— attempted to use "clinical proof to establish the superiority of their brand." Specifically, Columbia University pharmacologist Michael Mulinos and physiologist Frederick Flinn produced findings (on the basis of tbe injection of diethylene-glycol into the eyes of rabbits) that became the centerpiece of the Philip Morris claim that diethylene-glycol was less irritating, although other researchers not spoasored by Philip Morris disputed these findings. ^ Thi.s highly successful campaign made Philip Morris into a major brand for tbe first time.'"* As a

1943 advertisement in the Saturday Evening Post proclaimed, Philip Morris provided "[fjull reports in medical journals by men, higb in their profession—regularly offered to physidans on request."' These advertisements used physicians and science to make their particular brand appeal to the broader public while at the same time they curried favor with physicians. Company operatives appeared at medical conventions and in physidans' private offices, providing pbysidans with free dgarettes and reprints of sdentific articles on the subject. As a 1936 Portune Magazine profile of Pbilip Morris & Company made clear:

HGURE 2—Advertisement: "A report on the findings of a group of doctors.*" Source. Saturday Evening Post.

October 16,1937.

REPORT ON THE FINDINGS )F A GROUP OF DOCTORS*

TTie object of all this pmpaganda is not only to make doctors smoke Philip Morris dgarettcs. thus setting an example for impressionable patients, but also tn implant tbe findings of Mtilmos so strongly in tlie medical mind tbat tbe doctors will actually advise their coughing, rtieumy, and fur-ttingut'd patienLs to switcli to Pbilip Morris on the ground that Ihey are less irritating."

tiocror kcpr a r«wd .f ..,,,

With careful, deferentiiil appeals to physicians, Philip Morris aimed to gain tbeir approval. The spedfic positive references to clinical evidence tbat had appeared in medical journals helped to establish and maintain this connection between physicians and tobacco companies, and between health and dgarettes. TOBACCO INDUSTRY COURTS DOCTORS According to a number of accounts, medical professionalshaving themselves joined the ranks of inveterate smokersdoubted the connection between smoking and disease after 1930."' Although hygienic and physiological concerns continued

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to be voiced, clinical medidne claimed that individual assessment and judgment was required.'^ During this era, there was a strong tendency to avoid altogether causal hypotheses in matters so clearly complex. There was—and would remain— a powerful notion that risk is largely variable and thus, most appropriately evaluated and monitored at the individual, clinical level."* According to this logic, some people could smoke without risk to health, whereas others apparently suffered untoward and sometimes serious consequences. As cigarette smokiiig became increasingly popular in the early decades of the 20th century, medicine offered no new insight into how best to evaluate such vaiiabiiity other than on an individual post hoc basis. If, and when, an individual developed symptoms, a physician might appropriately advise restricting or eliminating tobacco. As a restilt, rather than being located within the sphere of public health, cigarette use remained within the domain of clinical assessment and prescription. The tobacco industry would actively seek to keep cigarettes within this clinical domain. For the tobacco companies, physicians' approval of their product could prove to be essential, especially since patients often brought smoking-related symptoms and health concerns to the attention of their doctors. Through advertisements appearing in the p ^ s of medical journals for the first time in the 1930s, tobacco companies worked to develop close, mutually benefidai relationships with physicians and their professional organizations. These advertisements became a ready source of income for numerous

medical organizations and journals, including the New England Journal of Medidne and the Journal of the American Medical Association (JAMA), as well as many branches and bulletins of local medical associations.''' Coming during the Great Depression, the placement of advertisements in medical journals helped to keep medical organizations financially solvent when resources were scarce. Philip Morris praised physidans in these advertisements with taglines like "Every doctor is a doubter" and "Doctor as judge" as they appealed to physicians' expert ability to evaluate the evidence, referring them to scientific articles that they daimed illtistrated the superiority of their brand. As one sudi advertisement explained in its entirety in 1939, "If you advise patients on smoking—and what doctor does not—you will find highly important data in the studies listed below. May we send you a set of reprints?""'^ Not only, then, did physidans' findings help to make the Philip Morris brand appear superior in the eyes of the public, but the company also turned to physidans with great effect Physicians became, through this process, an increasingly important conduit in the marketing process. RJ REYNOLDS'S MEDICAL RELATIONS DIVISION Althou^ Philip Morris may have created this strategy—and gained a leg up in tbe competitive cigarette mai'ket-Rj Reynolds became the leading force in soliciting physidans. Reynolds created a Medical Relations Di\Tsion (MRD) in the early 1940s that became the base of their aggressive physician/health claims promotional sti-ategy. They directly solicited

doctors in a 1942 advertisement that appeared in medical journals describing the MHD. Declaring that "[tlhe most significant medical data is derived from the every-day records of practising [sicj physicians," the text asserted "your office record reports in stich cases should prove interesting to study."^' The MRD, induding its longtime director. A. Grant Clarke, was in fact a part of RJ Reynolds's advertising firm, rather than any kind of professional scientific division of the company. The MRD's mailing addmss was tbe side door of tbe William Hsty Advertising Company.^' The work of the MRD focused on promoting Camels mainly through finding and courting researchers to belp suKstantiate the health claims RJ Reynolds made in theiiadvertisements. In the late 1930s and early 1940s, Clarke—wbo had no medical or scientific trainingcorresponded with many researchers who were pursuing questions relating to smoking and health. The MRD financed research tbat Reynolds then referred to in advertisements. Rather than emphasizing claims of moistness as Philip Morris had done, RJ Reynolds foctised on nicotine absorption, insisting that Camels were the slowest burning of all cigai-ettes. The safety of nicotine—like the issue of chronic irritation—was a source of ongoing concern; Reynolds maintained that nicotine was "the chief component of pharmacologic and physiological significance." Camels' slow burning rate, their advertisements now asserted, decreased nicotine absorption; as a result, Camels offered smokers an advantage over other, fasterburning ^^

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their products and brands. Tobacco companies' participation in medical conventions provided a deal- example of their efforts to appeal to physidans. For example, sodal commentator Bernard Devoto described tbe exbibit hall of the 1947 American Medical Assodadon (AMA) convention in Atlantic City, where doctors "lined up by the hundred" to receive iree cigarettes.^^ At the 1942 AMA annual convention, Philip Morris provided a lounge in which doctors could relax and sodalize. The lounge, an advertisement explained, was "designed for your conifort. Drop in. Rest... read ... smoke ... or jtist chat"^^ (Figure 3). Besides welcoming physidans to the convention, Reynolds touted their scientific research into dgarcttes. In an advertisement that appeared in medical journals across the country in the weeks before tbe 1942 AMA meeting, Reynolds reiterated their claim tliat 'Tt]he .smoke of slowburnmg CAMELS contained less nicotine than that of die 4 other largest-selling brands tested," and condnued to direct its health theme at doctors. The advertisement also referred to "the interesting features of the Camel cigarette exhibit," including "the dramatic visualization of nicotine absorpdon from dgarette smoke in the human respiratory tract" and "giant photo-murals of Camel laboratory research experiments." At a dme when laboratory sdence had garnered espedal admiration, the advertisement linked clinical medicine to the authority of invesdgadve science. ' Along with directly solidting physidans, the tobacco advertisements portrayed a glowing image of physicians in both medical journals and popular magazines. In advertisements that were

precursors to the "More Doctors" slogan, Rj Reynolds spedfically featured dedicated physidans serving their country and its soldiers during World Wai' 11. As a 1944 advertisement that appeared in Life Magazine entitled "Doctor of Medicine . . . and Morale" illustrated, doctors on the front received hero status:
He wears the same uniform.... He shares the same risks as Ihe man with (he giin, , , , Yes, the medical man in the service today is a figlitiiig man ihroiigh and through, exeept he fights without a gun. . . . [Hit's a trusted fnend to every fighting man,. . IHjc well knows the comfort and eheer Ihnre Ls in a few moments' relaxation with a goixl cigarelle , , . like Camel . . . the Favorite dgarette with men in atl the serviecs.""

Philip Morris

FIGURE 3—Advertisement: "Philip Morris invites you to t h e . . . Doctor's ^ ^

As they made this claim, RJ Reynolds also asked physicians to use the infomialion when advising their patients. They referred to "a number of reports from physicians who recommend Camels" and called on those reading the advertisement to send in their own ctimcal experiences and to request copies of medical journal articles from the MRD that proved their assertions, llse ofler served to legitimate R] Reynolds's claims. The main article dted diti not in fact address Camels specifically, although it did make the claim that slow-burning cigarettes were superior.^"* With no deaiknowledge about whether nicotine absorption was even an area that should concern smokers, and with very little data showing Camels' slower absorption, the scientific basis for Reynolds's claim remained obsnire. Nonetheless, such health claims would become the basis for tbe aggressive recruitment of physician.s as allies in the promotion of

With this and similar advertisements, the positive place that physicians held in American culture was both exploited and underlined by RJ Reynolds's advertising scribes. Linking physicians to wartime patriotism further elevated their status and, with it, Camel dgarettes. THE "MORE DOCTORSCAMPAIGN When the "More Doctors" campaign began in January 1946, it also focused on die respected and romandc image the medical profession had achieved in American sodety.^" Featuring 6 illustrations of physidans with patients— in the laboratory or sitting back with dgarette in hand—this first advertisement personalized the physidan for the readers of such popular magazines as Ladies'
Home journal-And 7ime.'"'Pref-

aced with the bold statement that "Every dodor in private pracdce was asked:—family physidans, surgeons, spedalists . . . doctors in eveiy branch of medicine," the

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advertisement touted the thoroughness of their survey and insisted that "yes, your doctor was asked . . . along with thousands and thousands of other doctors from Maine to California." By linking their depiction of physicians to the consumer's own physician. Reynolds brought immediacy to their claims. Any fears that smoking might be harmful were also easily contradicted by the physician's being a smoker himself. Admirable, forthright physicians—including the consumer's own—had "named their choice," and that choice, the advertisement insisted, was Camels, hands down. Even though a few of these advertisements did appear in print, the Reynolds advertising department soon realized that they might have overstepped their evidence. With the Federal Trade Commission already challenging suspected health claims in cigarette advertisements, RJ Reynolds toned down their copy, quickly shifting their claim to "113,597 physicians" surveyed rather than fl//physidans.'" At least some individual physicians questioned the original claim. In a letter to Howard T Behrman, a physidan who had requested "more specific Intbrmation concerning the survey of physidans' smoking preference," RJ Reynolds advertising executive W T. Smither assured liim that the surveying had heen thorough and sdentific. Explaining that the question about brand preference had been embedded in a survey that included less relevant topicssuch as medical journals, medical conventions, and ntimerous consumer products—Smither emphasized how 3 independent surveys had garnered "similar findings, and in doing so, sei"ved to conlirm the acctiracy of each ^^

Beyond the questionable methods used to gather data. Reynolds was also careful how they described the surveyfindingsin advertising copy, making sure to avoid conflating doctors' choice of a dgarette with any belief on their part that Camels were healthier. In theii- advertisements, Ihey asserted, "Doctors smoke for pleasure just like the rest of us."''^ Internally, Reynoids's advertising executives cautioned William Esty. their advertising company, to be careful of what they claimed, insisting that "in no way [shotiid] the copy.., intimate that doctors recommended smoking of CAMELS, [or] that CAMELS are good for health." '"* This cautionary approach reflected the growing industry concern about potential regulation and litigation."^^ Even so, the "More Doctors" campaign resonated effectively with American cultural values about contemporary medidne. Throughout 1946. the slogan flooded print, radio, and television media. Doctors were often idealized, as in the 1946 advertisement "I'll be right over!" Here, a middle-aged physidan, in bed in his pajamas, telephone in hand, is about to grab the black bag lying ready on his bedside table and make a middle-of-the-night visit to a patient in need:
24 hours a day your doctor is "on duty."... [l]n his daily routine he lives more drama, and display.s more devotion to the oath he has taken, than the most imagijiative mind could ever invent. And hf asks no speciai credit. When there's a job to do, he dops it. A few winks of sleep. , a few puffs of a eigaretle. . . and he's back at the job again.^''

"an honored profession . . . his professional reputation and his record of service are his most chenshed possessions,"'*' The importance of professional autonomy loomed large, and tlie industry was eager to sustain this view. As physidans geared up tofight(he Truman administration s national health insurance proposals, their image as loyal and deserving of respect was especially important"^ Along with providing images of professional trustworthiness and dedication, the "More Doctors" ad campaign also exploited the popular faith and admiration of medical science and technology. In one such "More Doctors" ad. a 5-year-old girl sits next to her mother in a doctor's office and proclaims, "I'm going to grow a hundred years old" to the kindly man in white (Figtire 4).

FIGURE 4—Advertisemerrt from the Camels "More Doctors" series: "I'm going to grow a hundred years oM!" Source. Good Housekeeping. July 1946.

More Doctors smoke (>amcls
N

This neighbortiood family physidan is saintly and deserving of trust, r'eprescntiiig (as another 1946 advertisement explained)

CAMI:I.S
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Referring to the "amazing strides in medical science [that] have added years to life expectancy," the advertisement goes on to "thank medical science for that. Thank your doctor and tliousands like him.. . toiling ceaselessly. .. that you and yours may enjoy a longer, better life."''* With medical advances having

and 1948 continued to remind readers about the survey as the focus of the adverdsements shifted. Tbe main slogan of one sucb campaign was "Experience is tlie best teacher." In this series of adverdsements, Rj Reynolds explained that the cigarette shortage created by the war had forced many to smoke whatever brands were available, and this experience, they claimed, had made the superiority of Camels' quality dearly evident. The smoker was able to tell the diflerence between brands, and such "experience" translated to other areas where someone might have know how. When the slogan appeared in magazines like Life and
Saturday Evening Post, the "expe-

answering this quesdon, the adverdscment juxtaposed a "doctors report"—illustrated with a physician, cigaiette in hand and head mirror sd'apped ai'ound his brow—with a "smokers report"— illustrated with a smiling "Sylvia MacNeill, secretary." Physidans, the adverdsement explained, had concluded after scientific invesdgadon that there was "not one single case of throat initadon" from smoking Camel dgarettes. In fact, "noted throat specialists" had conducted "weekly examinadons" of padents in making this determinadon. Reynolds used this depicdon of careful, clinical observation to substandate their health claim (Figure 5).^^ The adverdsement went beyond medical authority, however, asserdng that smokers didn't even have to take their pbysidans' word for it Instead, they could take their "own personal 30-day test," as Sylvia MacNeill had done. She concluded that she "knew" that "Camels are the mildest besttasdng dgarette I ever smoked." Advertisements in popular magazines took smokers' ability to judge for themselves even further, with Elana O'Brian, real estate broker, declaring in a typical example, "I don't need my doctor's report to know Camels are mild" 'Yhe adverdsement underlined her asserdon with photos of 6 other smokers from various walks of life under the heading "Thousands more agreel"^' In another example, Anne Jeffreys, a stage and screen star, insisted, "The test was fijn and it was sensible'." Parallel to earlier solidtadon of physidans' opinions, in this series of adverdsements RJ Reynolds requested that smokers determine the safety of Camels on their own and praised their acumen. With some advertisements calling on

rience" dted might be that of a talented celebrity athlete able to discern quality in his or her sport. In medical journals, the references were to famous scientific researchers. These advertisements championed physicians and medicine and reminded their audience again that "More doctors smoked Camels" as they also continued to praise science,"" But the idea of "experience" also figured into another prevalent theme communicated in RJ Reynolds's adverdsing—that of individual authority, both the physician's and the individual consumer's. The quesdon of throat irritation so central to many 1920s and 1930s ad campaigns again emerged here as RJ Reynolds introduced a "mildness" theme. With the central claim that Camels did not irritate the throat, Reynolds featured both the physician-researcher and the everyday smoker to convince readers of Camels' mildness. In July 1949 issues of both local and nadonal medical journals, Rj Reynolds asked, "How mild can a dgarette be?" In

Figure 5—Advertisement: "How mild can a cigarette be?" Source. OMo State Journal of Medicine, iuly 1949:45:670.

captured popular imaginadon, connecdons drawn between sdendfic discovery and Camelsmoking doctors added to the appeal of their cigarette of choice.""' MEDICAL AUTHORITY AND TOBACCO After the inidal onslaught of heroic physidans and medical miracles in 1946. the "More Doctors" advertisements in 1947

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smokers to "Prove it yourself!' and even guaranteeing a money-back guarantee for dissatisfied customers, Reynolds insisted on the superiority of their product. '•* These advertisements worked to subvert the emerging populationbased epidemiological findings by emphasizing the primacy of "individual" judgment. By 1952, advertising copy went beyond the typical individual smoker to emphasize the sheer volume of people who chose Camels as their cigarette. Highlighting that Camel was "America's most popular cigarette by billions." the ad copy mentioned that "long before Camel reached those heights, repeated surveys showed that more doctors smoke Camels than any olher cigarette.""* The cigarette's popularity in itself became a selling point; how could so many people be wrong? And physicians' cigarette choice served to contirm this popularity. As the heading of a similar advertisement explained, "The doctors' choice is America's choice.'"*^ THE DISAPPEARING DOCTOR Ultimately, however, the use of physicians in Camel advertisements could not be sustained as the health evidence against cigarettes accumulated. When disturbing scientific results connecting lung cajicer and cigarettes began to emerge, Camel advertisements shifted away from physicians' judgment and authority. In 1950, the publication of the now-famous work of Evarts Graham and Kmst Wynder in the United States—as well as that of A. Bradford Hill and Richard Doll in the United Kingdomshowed that there was cause for alarm.'*'' The reporting of their

findings connecting lung cancer to cigarette smoking in national magazines like Time and Reader's Digest—and the corresponding declines in sales and stock prices—forced tobacco executives to assess strategies for responding to growing medical and public concerns about their product.*"^ By 1953. when Wynder, Graham, and their colleague Adele Croninger published laboratory fmdings confirming that cigarettes were carcinogenic, scientific fijidings constituted a critical threat to the industry."''* Tobacco executives were well aware both of these findings and of the public attention they were receiving, and their statements and actions reflected an understanding that this new scientific evidence constituted a full-scale crisis for their corporations. Most notably, company executives realized that they would have to work together in the face of the scientific evidence. Although each company still sought an advantage over its competitors, the new healtli evidence threatened the hilvre of the entire industiy. In December 1953, the tobacco executives met to devise a joint strategy. They hired prominent public relations firm Hill & Knowlton to aid in this effort. As a planning memo makes deay, health claims were considered to be no longer viable. According to Edward Dakin, a Hill & Knowlton executive, it would be critical to
Develop some understanding with companies that, on this problem, none is going to seek a competitive advantage by inferring to its public that its product is less risky than othere. (No claims that special fillers or toasting, or expert selection of tobacco, 01' extra leii(rth in the butt, or anything else, makes a given brand less likely (o cause you-know-what. No

"PIay-Safe-with-Luckies" idea— or with Caniels or with ajiything else.)^"

Hill & Knowlton's advice was that the industry as a whole must desist from health claims that had been a centerpiece of the advertising that featured physicians. Such claims, the agency now contended, would now draw attention to the "health scare." as they professed to call it.^'

Tobacco executives were well aware both of these findings and of the public attention they were receiving, and their statements and actions reflected an understanding that this new scientific evidence constituted a full-scale crisis for their corporations.
In popular magazines, the last notable reference to doctors in an advertisement came in 1954, After the other tobacco companies had left such marketing techniques behind, Liggett and Myers {which had declined participation in the joint industry program directed by Hill & Knowlton) made the claim that their L&M filter cigarette was "Just what the doctor ordered!" In a typical advertisement that appeared in a February issue of Life magazine, Hollywood star Fredric March made this assertion after having i-L'ad the letter written hy a "Dr Darkis" that was inset into the advertisement Darkis explained in this letter that L&M filters used a "highly purified eilpha cellulose" that was "entirety harmless" and "effectively filtered the smoke" (Figure 6), Dr Darkis was in fact not a medical doctor at all but a re.search chemist, yet another example of misrepresentation in a tobacco ad.^^ More significantly,

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this use of implicit doctor endorsement of cigarettes would not occur again in American advertising after this campaign. Much in the way that the industry had used doctors to reassure smokers in the 1940s, filter cigarettes were heconiing the industry's new strategy for appealing to consumers, whose concerns about the health risks of smoking would be repeatedly confirmed by new research studies. In 1950, filter dgarettes were 2'Vii of the US dgarette market; by 1960, they were 50"/[j.^-' In medical journals, the lastgasp attempt by a tobacco company to ally itself with physicians came in 1953, when the Lorillard Company appealed to physicians as they promoted their new filter dgarette, Kent. These advertisements queried, "Have you tried this experiment, doctor?"

FIGURE G—Actor Fredric March in an advertisement for L&M RHers: "This ts K." Source. Life Magazine. February 22, 1954.

and "Why is it, doctor, that one filter cigarette gives so much more protection than any other?" One advertisement mentioned how "thousands" of physicians at a recent AMA convention witnessed "a convincing demonstration. . . [of] the effectiveness of the MICRONITE FILTER" and included photos of the experiment demonstrated there. In their marketing of Kent, Loriltard had created a campaign reminiscent of those designed by Philip Morris and RJ Reynolds in the 1930s and early 1940s.^*' Just as in those earlier advertisements, Lorillard called on physicians to interpret scientific results using their individual, clinical judgment But tbe swift and vehement reaction to these advertisements clearly illustrated bow the social and scientific climate had shifted, A 1954 JAMA editorial labeled the reference to physicians and the MIA convention an "unauthorized and medically unethical use of the prestige and reputation of the American Medical Assodation. "^^ No longer could tobacco companies count on physicians to serve as public advocates of their product. In fact, in \953JAMA had decided to stop accepting cigarette advertisements in its publications and banned cigarette companies from exhibiting their products at AMA conventions.^'* After conducting its own survey of physicians, the AMA explained in a letter to tobacco companies that "a large percentage of physicians interviewed expressed their disapproval" of dgarette advertisements m medical journals. Other JAMA advertisers had come to dislike having their products appear next to cigarette advertisements as well.'^ With tbe AMA publidy condemning the Kent ad campaign In 1954 as

"hucksterism," it became even more clear to tobacco companies that the purported allegiance with physidans was no longer feasible or effective. One additional indicator of the growing medical disdain for cigarettes was the very fact that many physidans who followed tbe emerging health evidence began the [irocess of giving up smoking. According to one study of physicians' smoking practices in Massachusetts, nearly 52% had reported being regular smokers in 1954 (over 30% reported smoking at least a pack per day); just 5 years later, only 39% were regular smokers. Additionally, only 18% now reported consumption of a pack or more per day.^" Although the industry would continue to solicit physicians witb materials disputing the relationship between smoking and disease and would also seek out physicians who doubted the harmfulness of cigarettes in order to imdermine emerging scientific findings, such efforts would be gi^eeted with rising skepticism.'''^ The era of explicit use of pbysicitins and health claims to promote smoking had ended even though the AMA would not publicly acknowledge the harms of cigarette smoking until 1978."" The smoking physician had become a visual oxymoron. The industry would turn to new images and more sophisticated strategies to hawk their dangerous product. •

About the Airtlior
Martha N. Gardner is with the Depurtment of Arts and Sciences, Massachusetts College of Pharmacy and Health Sciences, Boston. Mass. Allan M. Brandt is with the Department of Social Mediane. Hurvard Medical School and the History of Science Department. Harvard University. Cambridge, Mass.

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Requests for reprints should be sent to Martha N. Gardner. PhD. Department of Arts and Sciences. Ma'isachuseits College of Pharmacy and Heatth Sciences, 179 I.ongWDod Ave, Boston. MA 02115 (e-muil: martha.gardner@bos.mcphsedu). 77iis (irtide uxis acceptedfune 20, 2005.

1987), See Ochsner and DeBakey, "Symposium on Cancer," for a din;(-t reference to "chronic irritation" and cancer (p. 446), 6. See "Good laste in Advertising." Fortune 1 (1930): 60-61, aaid T h e American Tobacco Co.," Fortune 14 (1936): 96-102, 154-160, 7. R. Marchand, Advertising the American Dream: Making Way for Modernity (Berkeley: University of California Press. 1985). 21-22; R. Sobel, They Satisfy: The Cigarette in American Life (Garden City. [S[Y: Anchor Books; 1978), 101; G. H. Allen. "Alhert Davis Lasker," Advertising and Selling 19 (1932): 21-22, 16-37. 8. In a report to the Federal Trade Commission, Amencan Ibbacco Company detailed this survey. See American Tobacco Company, "United States of America, Federal 'Trade Commission: Memorandum Submitted by the American Ibbacco Company." pp. 18-22, 80-89, 1976, Bates No. 980306396/ 6603. available at http;//legacy,libraiy, ucsfedu/tid/rum85!00. 9. Lucky Strike advertisement frotn Golden Book 12 (70) (1930), available at http: // tobaccodocuments.org/pollay _ads/ Luckn.07,html. 10. Philip Morris, "Report on the Findings of a Group of Doctors Call for Philip Morris," October 16, 1937. Bates N(j. 2061014890, available at htl4]://tobaccodocuments. org/ads_pm / 20610I4890,litml. 11. A. Blum. "When 'More Doctors Smoked Camels': Cigarette Advertising in the Journal," New York State foumal of Mediane 83 (1983): 1347-1352. 12. M. G. Mulinos and R. L. Osbf>me. "Irritating Properties of Cigarette Smoke as Influenced by 1 lygroscopic Agents," ;Veui York State fourruil of Medicine 35 (1935): 1-3. and "Pharmacology of Inflammation, III: Influence of Hygroscopic Agenis on Irritation I'rom Cigarette Smoke," Proceedings of the Sodety for Experimental Biology and Medidne 32 (1934): 241-245. For disjiute on their findings, see internal memas from ll.H. Hanmer, research director at American Tobacco, to C. F, Nailey (August 29. 1935, Bates No. 90516197711978, available at http://legacy.lihrary.ucsf.edu/ tid/Tioj54n30) and to E. Bogen (l^ecember 27, 1935, Bates No. 950143321/ 3,328. available at http://!egacy.library. ucsfedu/tid/pko54fOO). Howaid C. Ballenger had findings tbat contrailirted Mulinos in "Irritation of the Throat ["rom Cigaret Smoke: A Study of Hygroscopic Agents," .Archives of Otolaryngohgy 29 (1939): 115-123. 13. "Philip Morris & Co.," Fortune. Manh 1936. ip. 106-112.114.116, 119.

14. Philip Morris advertisement, from Saturday Evening Post. September 25, 1943, available at http:// tobaccodocuments,org/pollay_ads/ PbilO3.O4.html, 15. "Pliilip Morris & Co.," 116.

at http://iegacy, library, ucsf.edu/tid/ cst78dOO. 28. RJ Reynolds, "Camels Costlier Tobaccos," advertisement, available at bttp://tobaccodocuments .org/po II ay _ads /Camel4.17.html. This ad appeared in Saturday Evening Post. Life, and Colliers in May 1944, and similar ones appeared in the New England Journal of Medicine and the Journal of the American Medical Association. 29. J.C. Bumham, "American Medicine's Golden Age: What Happened to It?" Science 215 (1982): 1474-1479, 30. R] Reynolds, '"Every Doctor in Private IVactice Was Asked. According to a Recent Nationwide Survey: More Doctors Smoke Camels 'ITian Any Other Cigarette!" March 1946, available at http: //www. trinketsandtraih. org/results.asp. The Trinkets and 'Trash Web site notes that the ad appeared in the March 1946 Ladies Home Journal 31. See letters from Helen Tiemann. secretary to William Hsty, to the RJR Advertising Department dated Januaiy 9, 1946 (Bates No. 502597537, available at http://legacy,library.ucsfedu/ tid/ijs78d00) and December 26, 1945 (Bates No. 502597519, available at http [//legacy.library,ucsf.edu/ tid/qis78dOO). 32. Letter from W.T.Smither.RJ Reynolds Tobacco Company, to Dr Howard T. Behrman, February 22, 1946, Bates No. 2022238658/8660. available at http://legacy.library.ucsf.edu/ tid/rtx74e00. 33. RJ Reynolds, "liveiy Doctor in Private Practice Was Asked." 34. W. T. Smither, "Memorandum of Visit to William F:sty," June 10, 1946, Bates No. 501689543, available at http://legacy.lihraiy.iicsf,edu/tid/ guv29dOO. 35. See also James T. Weldi to A. G. Clarke, February 4, 1952. Bates No, 502400834. available at http://legacy. library.ucsf.edu/tid/blc 19d00. 36. RJ Reynolds. "More Doctors Smoke Camels." advertisement available at bttp: //tobaccod ocuments.org/ pollay^ads/Camel8.]7,htnil. Internal RJ Reynolds records note that this advertisement appeared in Life. Limk, Ladies Home Journal. Colliers, and Country Gentleman tinder the heading "I'll Be Right Over!" RJ Reynolds, "According to a Recent Nationwide Survey: More Doctors Smoke Camels 'Than Any Other Cigarette!" May and June 1946, advertisement Bates No. 502470699. available at http://legacy.lihrary.ucsf.edii/tid/ jyi88d00. 37 RJ Reynolds, "l"he Doctor Makes His Rounds: According to a Recent

Contribiftors
Both authors lieveioped, researched, aiid wrote the artide. M. N. Gardner is prttidpa] aulhnr and A, M. Brandt is coauthor.

Acknowledgments
A. M. Bi-ajidt is the recipient of the William Calian Distinguished Professor Award, granted by the Flight Attendants Medica] Research Institute. This award provides finandal support for research. A.M. Brandt served as a consultant and expert witness on behalf of the Department of Justice in USA v Philip Morris el al. M. N. Gardner also served as a consultant in the case.

16. C. A. Wemer, "The Triumph of the Cigarette." American Mercury 6 (1925): 419-420; W, M. Johnson, "The EU'ecLs of Ibbacco Smoking," American Mercury 25 (1932): 451-454; A. G. Ingalls. "If' You Smoke," Scientific American 154 (1936): 310-313,354-355. 17. J. C. Bumham, "American Physicians and Tohacco Use: Two Surgeons General. 1929 and 1964," Bulletin of the History of Medicine 63 (Spring 1989): 1-31. 18. See R. A, Aronowitz, Making Sense ofniness: Science, Society and Disease (New York: Cambridge UnivereiQ' Press, 1998), 111-144. 19. H. Wolinsky and T. Brune. The Serpent on the Staff: The Unhealthy Politics of the American Medial Association (New Yoi-k: Jeremy P. TaiT:hor/Putnam, 1994), 145-147; ''When 'More Doctors Smoked Camels,'" 1347. 20. Philip Morris, "If You ,Advise Patients on Smoking," August 1939, advertisement. Bates No. 2061011925, availahle at http://tobaccodocuments.org/ ads4)m/2O6IO11925.html. 21. RJ Reynolds, "The Medical Relatioas Division of Came! Cigarettes Believes That," September 1942. advertisement available at http://tobaccodocuments.org/ po llay_ads/CameO 2.16 .html. 22. Crist et al. "re. Jones/Day Liability Summary." 379-381. 23. RJ Reynolds, "When You Record tbe Effectiveness of Nicotine ControlLess Nicotine in the Smoke. CamelThe Cigarette Of Costlier Tobaccos," July 1942, advertisement, available al http://legacy.library.ucsf.edu/tid/ sgt78dOO. 24. C. W. Crampton, "The Cigarette, the Soldier, and the Physidan." Tlie Military Surgeon 89 (1941): 1-13. 25. B. DeVoto. "Doctors Along the Boardwalk." m Harper's magazine (1947), repnnted in DeVoto. The Easy C/iuiV (Boston: Houghton Mifilin Company, 1955), 91. 26. Philip Morris, "At the AMA. Convention," June 6, 1942, Bates No. 1003071327, available at http://legary. libraiy. ucsf.edu/tid/ fvmO 2 aOO. 27 RJ Reynolds, "Camel Invites You to Enjoy the Interesting Features of the Camel Cigarette Exhibit at the .\MA. Convention—June 8 to 12," June 1942, Bates No. 502596871/6871. available

Endnotes
!, See P. Crist, W.K.Marple.S.J, Kaczynski, and T. [„ Abrams, "re. Jones/Day Liability Summary ('Corporate Activity Project")," pp. 379-381, t986. Bates No. 681879254/9715, available at tobaccodocu ments.el's/ ness/37 37 5.html (acces.sed November 12. 2005, as were all Internet dtations); "[Memo to John \V, Hill] Re. RJR Claim of Doctor's Use of Camels." J. J. D. to John W. Hill, December 14, 1953. Wisconsin Historical Society, John W. Hill Papers, Box 110. Folder 10. 2, D. E. Nelson, G. A, Giovino, S. L. Emont, et al,. "Trends in Cigarette Smoking Among US Physicians and Uurses," Journal of the American Medical Association271 (19941: 1273-1275. 3[„ S. Snegireff and O. M. Lomhaitl, "Survey of Smoking Habits of Massachusetts Physidans." New England fimmal of Medidneim (24) (1954); 1042-1045; "The Physidan and Tobacco." Southwestem Medicine 36 (1955): 589-390. 4, H. L, Lombard and C. R. Doering. "Cancer Studies in Massachusetts. 11: Habits. Characteristics and Fnvironinent of Individuals With and Without Cancer." New England foumal of Medicine 196 (10) (1928): 481-487; FL.HofTman. "Cancer and Smoking Habits," Annals ofSurjieri/ 93 (1931); 50-67; A, Ochsner and M. DeBakey, "Symposium on Cancer: Primary Pulmonary Malignancy. Treatment by Total Pneumonectomy. Analysis of 79 Collected Cases and Presentation of 7 Personal Cases." Surgery, Gt/necology and Ohstetrits 68 (1939): 435-451. 5, J. Patterson, The Dread DiseaseCancer and American Culture (Cambridge. Mass: Harvard Universi^ Press,

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Nationwide Survey More Doctors Smoke Camels Than Ajiy Other Cigarette!" August and September 1946. Bates No. 50247074:*, available at http://le8acy .library.ucsf edu/Eid/ 38. Compulsonf Health Insurance: The Continuing American Debate, ed. R. L. Numbers (Westport, Conn: Greenwood Press. 1982). 39. RJ Reynolds internal doaiment. Bates No. 502470717, available at bttp;//legacy.librdry.ucsf.edii/tid/ bwj88dOO. 40. See [' Ue Kniif, Micrvbe Hunters (New York: Blue Ribbon BtHjks, 1926), and B. SokolofT, The Miracle Drugs (Clucago: Ziif-Davls Pub Co. 1949). 41. RJ Reynolds, "E-^xperience Is the Best Teacher Sir Cbarles Bell." Maj-cb 1947, Bates No, 502470841. available al btlp[//legacy.library iicsf.edu/tJd/ moj88d00, and RJ Reynolds, "Experience Is tbe Best Tcacber. Mildi-ed ODonnell," May and June 1947, Bates No. 502470864, available at ht^: //I egacy. library ,u csf.edu/tid/ jp]88d00. 42. RJ Reynold.s. "How Mild Can a Cigarette Be''" July 1949. Bates No. 502471375, available a! bttp:// legacy.libiary.ucsf.edu/tid/nii8BdOO; RJ Reynolds. "Mow Miid Can a Cigarette Be?" July 1949, Bates No. 502598073. available at bttp:// legacy.library.ucsf.edu/tid/ztr78dOO. RJ Reynold.s bad also bad a related long term campaign in tbeir ads, asking consumers to take a "30-day test" of their "T-iione" so tbat tbey cnuld decide for themselves abnut tbe effect of Camels on tbeir tbroat. 43. HJ Reynolds, "Not One Single Case of Tbroat Irritation Because of Smoking Camels! Noted Tbiijat Spedalists Report on 30-Day Test of Camel Smokers," January 1949. Bates No. 502598158, available at http^/legaty.library.ucsf edu/tid/ flr78dOO. 44. RJ Reynolds, "SO-Day Smoking Test Proves Camels Mildness!" November 20. December 4, 6, 7. 1948, January 1949, Bates No. 502597957, available at bttp [//legacy .library.ucsf edu/ tid/obs78dOO. 45. Display ad. New York Times. August 25, 1952, p. 6. 46. Display ad. New York Times, June 16, 1952, p. 10. 47. K, L. Wynder and 1:;. A. Grabam, "Tobacco Smoking as a Possible Etiologic I'actor in Bronchiogenic Carcinoma: A Study of 684 Proved Case.s," Journal of the American Medical .-Issoaiition 143 (1950): 3 2 0 - 3 3 6 : R. Doll and A. B. Hill, "Smoking and Carcinoma of

the I.ung; Preliminary Report," British Medical Journal 2 (1950): 739-748. For a discussion of the significance of these ajticles. see Ernst L. Wynder, "Ibbacco as a Cause of Lung Cancer: Some Reflections," American Journal o/F.pidemiologif 14(i (9) (1997): 687-694, and Allan M. Brandt, "line Cigarette, Risk, and American Culture," Daedalus 119 14) (19901: 155-176. 48. For examples of coverage in the pojjutar press, see R. Norr, "Cancer by tlie Carton," Reader's Digest. December 1952, pp. 7—8: "Smoking & Cancer." rime, July 5, 1952, ji. 34; "Beyond Any Doubt," Time. November 30, 1953, pp. 60-Hl: L. M. Miller and J. Monaban, "Tbe Facts Behind the Cigarette Controversy," Reader's Digest, July 1954, pp, 1-6; "Smoke Gets in tbe News," Life. December 21, 1953. pp, 20-21. See also Hans 11. Tocb, Terrence M. Allen, and William Lazer, "Efiec-ts of the Cancer ScaiTs: Tbe Residue of News Impact," you r««/is"i Quarterly 33 (1961): 25-34. 49. Enist L. Wynder, FIvarts A. Graham, and Adele B. Croninger, "Experimental Pnxluction of Cai-cinoma With Cigarette Tar," Cancer Research 13 (1953): 855-864. 50. Edwin Dakin and Hill & Kiiowlton, "Forwarding Memorajidum: To Members of tbe Planning Committee," December 15, 1953, Trial Exbibit 18,904. available at bttp://tobaccodocumenLs.f)rg/ ness/3793.html; also available at Wisconsin Historical Society, Jobn W. Hil! F^pet^, Box 110, Folder 2, pp. 8-9. 51. See K.M. Cummings, C. P. Morley, ajid A. Hyiand, "Failed Promises of the Cigarette IndiLstry and Its EHett on Consumer Misperceptions About the llealtb Risks of Smoking," Tobacco Controt 11 (SuppI 1) (2002): 1110-1117, and R. W. Pollay, "Propagajida, Piiftirig and the Public Interest: Cigarette Publicity lactics. Strategies and Effects," Public Relations Review 16 (1990): 27-42. 52. Liggett and Myers,"[ redric March Says-Tbis Is It: 'L&M Filtere Are Just Wbat ibe Doctor Ordered,"" February 22, 1954, Bates No. 2021368933, available at http://tobaccodoaiments.org/pm/ 2O21368933.btml. 53. See R.W. Pollay, 'Tbe Dark Side of Marketing Seemingly 'Light' Cigarettes: Successful Images anti Failed Fact," Tobacco Control 11 (Supjil 1) (2002): 118-130. 54. l.orillard, "Have You Heand the Stoiy of New Kent Cigarettes, Doctor?" 1953, Bates No, 92373155, available at bttp://Iegacy.library.ucsf edu/tid/ eej54aOO: l.oi-illard, "Wby Is It, Doctor, "ITiat One I iltcr Gives So Mucb More Protection TTian Any Otber? Kent. Tbe

Only Cigarette With the Micronite Filter for the Greatest Protection in Cigarette History," 1953, Bates No. 92373147, available at http://legacy.library.ucsf, cdu/tid/mej54a00; Lorillard, "Have You Tried Tbis Fxperiment. Dactnr?" 1953. Bates No. 92373153, available at bttp://Iegacj.libriiry.ucsf edu/tid/ gej54a00; Lorillard, "Some Questions About Filter Cigarettes That May Have Occurred to You, Doctor and llieir Answers by tbe Makers of Kent," August 22. 1953, Bates No. 89749655, available at http://legacy.librarj.ucsf edu/tid/dnml3cOO. 55. "Cigarette Hucksterism and tbe AMA." Journal oj the American Medical Association. April 3,1954, p. 1180. 56. Serpent on the Staff. 152-154.

57 " 'AMA Journal' Stops Taking Cigaret Ads," Adifertising Age 1 (1953): 93. 58. L.S. Snegireif and O.M. Lombard, "Smokuig HabiLs of Massachusetts Physicians: Five-Year Fotlow-Up Study {\954-1959): New England Journal of Medicine2bl (1959): 603-604. 59. For a discussion of a newsletter distributed across the counti^' in doctors' and dentLsLs' offices, see Hill & Knowiton, "i. Tobacco ajid Health— 1962," (November 15, 1961, Bates No. 966046705/6719, available at bttp://legacy.library.ucsfedu/tid/ zgo21aOO. 60. Serpent on the Stajf. 155.

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