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Tobacco Control 2000;9:351–354 351 Tob Control: first published as 10.1136/tc.9.3.352a on 1 September 2000. Downloaded from

animals. The methods used have been Dr P Bjucher (France), Professor I Plesko (Slovakia), described by HoVmann.56 Professor LJ Denis (Belgium), Professor H Senn (Switzerland), Professor H Zur Hausen (Germany), LETTERS TO The cigarettes were purchased in 29 coun- Professor H Hansen (Denmark), Professor U tries by volunteers (the International Veronesi (Italy), Dr K Bjartveit (Norway), THE EDITOR Cigarette Variation Group), who purchased Mr S Woodward (Australia), Dr V Tkeshelashvili (Georgia), Mr B De Blij (Netherlands), Professor M the premium example available, which were, Dicato (Luxembourg), Professor S Eckhardt in most cases, filtered. No “light”, “mild”, (Hungary), Mr T Hudson (Ireland), Dr J Mackay “menthol” or other variants were purchased. (Hong Kong), Professor Niu Shiuru (China), Dr I Letters intended for publication should be a Forty cigarettes of each brand were analysed Tannock (Canada), Dr H Vertio (Finland), Dr Zakelj maximum of 500 words, 10 references, and one (Slovenia), Professor W Zatonski (Poland), Ms M at the Institute of Carcinogenesis in Moscow. Ziv (Israel), Mr M Pertschuk (USA), Dr Estevez table or figure, and should be sent to the editor at Not all brands were available in each country (Argentina), Dr A Junquiera (Brazil), and Professor the address given on the inside front cover. Those and it is not known whether those purchased Abdrakhmanov (Kasakhstan).This work was con- responding to articles or correspondence published ducted within the framework of support from the were locally produced, imported or Italian Association for Cancer Research (Associazone in the journal should be received within six weeks smuggled, or how long they had been stored of publication. per la Ricerca sul Cancro). before sale. This is not a representative sample—the cigarettes were acquired as they NIGEL GRAY DAVID ZARIDZE* Variation within global cigarette brands would be by the person in the street. Our aim in tar, nicotine, and certain nitro- CHRIS ROBERTSON was to investigate international variation. L KRIVOSHEEVA* samines: analytic study The results of the tar and nicotine testing N SIGACHEVA* were unremarkable. Generally they con- PETER BOYLE EDITOR,—While the content of food, formed to the packet statement (where AND THE INTERNATIONAL CIGARETTE pharmaceutical products, drugs, and many present). Tar yield ranged from 10.6 mg/cig VARIATION GROUP other consumer goods are tightly regulated to 15.7 mg/cig for Camel, 11.8 mg/cig to Division of Epidemiology and Biostatistics, by governments, tobacco products, surpris- 20.4 mg/cig for Lucky Strike, and 8.4 mg/cig European Institute of Oncology, ingly, are not. to 15.9 mg/cig for Marlboro. Nicotine yield Via Ripamonti 435, 20141, Milan, Italy Tar and nicotine yields of cigarettes have ranged from 0.85 mg/cig to 1.3 mg/cig for *Institute of Carcinogenesis, progressively, but not universally, appeared on Camel and Lucky Strike, and 0.68 mg/cig to Cancer Research Centre, cigarette packets and advertising since 1967. Russian Academy of Medical Sciences, 1.25 mg/cig for Marlboro. Kashirskoye Sh. 24, Moscow 115478, Russian Federation These figures have been used to justify terms DiVerences in nitrosamine yields were such as “light” and “mild” in descriptive substantial. There is a threefold diVerence Correspondence to: Professor Boyle advertising. In 1981 a US public health report between the lowest and highest yields of [email protected] concluded: “the preponderance of scientific NNK for Camel, a fivefold diVerence for evidence strongly suggests that the lower the Lucky Strike, and ninefold for Marlboro (fig 1 US Department of Health and Human Serv- “tar” and nicotine content of the cigarette, the ices. The health consequences of smoking: the 1 1). NNK and NNN yields are highly less harmful would be the eVect.” correlated (correlation 0.88, 95% confidence changing cigarette. A report of the Surgeon Some early reports concluded, plausibly, General, 1981. Rockville, Maryland: Public interval 0.83 to 0.93), so only NNK is shown Health Service, OYce of the Assistant Secre- that a decrease in lung cancer mortality could in the figure. tary for Health, OYce on Smoking and be ascribed to smoking reduced tar We have shown that a three- to ninefold Health, 1981. (DHHS Publication No (PHS) cigarettes, although more recent data2 suggest 81–50156.) variation in carcinogen dose can be given to 2 Thun MJ, Heath CW Jr. Changes in mortality that there is little if any diVerence in the long the smoker, without any warning, in products from smoking in two American Cancer term outcome of smoking “low tar” as that are trademarked and globally advertised. Society prospective studies since 1959. Prev 1997; :422–6. against “regular” cigarettes. Further there has In 19987 some of us proposed the setting of Med 26 been an increase in adenocarcinoma relative 3 Thun MJ, Lally CA, Flannery JT, Calle EE, http://tobaccocontrol.bmj.com/ upper limits on such carcinogens by Flanders WD, Heath CW Jr. Cigarette smok- to squamous carcinoma, more pronounced in establishing the market median as an initial ing and changes in the histopathology of lung women than men, and this may be caused by upper limit. Clearly lower nitrosamine cancer. J Natl Cancer Inst 1997;89:1580–6. the increases in tobacco specific nitrosamines 4 Levi F, Franceschi S, LaVecchia C, Randimbi- cigarettes can be, and are, produced, and son L, Te VC. Lung carcinoma trends by in cigarettes plus more intense (compensa- there is no excuse for the wide, within brand, histologic type in Vaud and Neuchatel, tory) smoking and deeper inhalation variations described here. Switzerland, 1974–1994. Cancer 1997; 34 :906–14. associated with modern cigarettes. We see these results as a compelling and 79 We decided to test three global brands 5 Brunnemann KD, Genoble L, HoVmann D. urgent argument for government regulation Identification and analysis of a new tobacco- (Camel, Lucky Strike, and Marlboro) for of carcinogen concentrations in cigarettes. specific N-nitrosamine - 4-(methylnitros- consistency of tar and nicotine yields and Obviously such regulation should go beyond amino)-1-(3-pyridyl)-1-butanone. Carcinogen- for two tobacco specific nitrosamines, esis 1987;8:465–9. carcinogens to other toxic, modifiable 6 Djordjevic MV, Brunnemann KD, HoVmann 4 - (methylnitrosamino)-1-(3-pyridyl)-1- substances, and to nicotine. D, Identification and analysis of a nicotine- butanone (NNK), and N-nitrosonornicotin derived N-nitrosamino acid and other nitro- (NNN). The former is a powerful lung samino acids in tobacco. Carcinogenesis 1989; adenocarcinogen, regardless of route of We thank the members of the International Cigarette 10:1725–31. on September 29, 2021 by guest. Protected copyright. Variation Group, who purchased and supplied the 7 Gray N, Boyle P, Zatonski W. Tar concentra- administration, and the latter is an cigarettes at their own expense. They are: Professor tions in cigarettes and carcinogen content. established oesophageal carcinogen in JG McVie (UK), Dr AK Kubik (Czech Republic), Lancet 1998;352:787–8.

Camel Lucky Strike Marlboro

300 300 300

250 250 250

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NNK (ng/cig) 100 NNK (ng/cig) 100 NNK (ng/cig) 100

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0 0 0 UK UK UK Italy Italy Italy Peru USA USA USA Israel Israel Israel Brazil China Russia Russia France France France Poland Ireland Ireland Mexico Mexico Finland Finland Finland China 2 China 1 Holland Norway Norway Norway Belgium Belgium Belgium Portugal Slovakia Slovakia Hungary Hungary Slovenia Slovenia Slovenia Australia Australia Australia Denmark Denmark Denmark Lithuania Germany Germany Germany Argentina Argentina Argentina Czech Rep. Czech Rep. Czech Rep. Kazakhztan Hong Kong Hong Kong Hong Kong Switzerland Switzerland Switzerland Netherlands Netherlands South Africa Luxembourg Luxembourg

Figure 1 Results of testing for NNK yields from three brands of cigarettes in various countries.

www.tobaccocontrol.com 352 Letters, Books Tob Control: first published as 10.1136/tc.9.3.352a on 1 September 2000. Downloaded from

Carbon monoxide in the expired air of Light cigarettes smokers who smoke so-called “light” Usual cigarettes brands of cigarettes 50 BOOKS 45 40 EDITOR,—Tobacco smoke is an important 35 source of carbon monoxide (CO). Smokers Book reviews and books of interest to with expired CO values of 11–21 parts per 30 million (ppm) are defined as mild smokers, % 25 “Tobacco Control” should be sent to the 20 whereas those with expired CO values of editor at the address given on the inside 15 more than 21 ppm are defined as heavy front cover. 10 smokers.1 We report on the expired CO read- 5 ings of smokers who smoke “light” brands 0 Tobacco war compared to those who smoke regular 0–10 11–20 21–30 31–40 41–50 > 50 brands. The approach chosen was designed Mean CO value (ppm) Tobacco war: inside the California to reflect real smoking habits, and was not battles. Stanton A Glantz, Edith D Figure 1 Distribution of carbon monoxide laboratory based. Many health agencies Balbach. Berkeley, California, measure tar and CO values using smoking (CO) readings of “light” cigarette smokers and regular cigarette smokers. University of California Press, 2000. machines under standardised laboratory conditions.2 However, cigarettes are not ISBN 0-520-22285-7. 469 pages. smoked by machines, and smokers may The method used in this study was very For a decade, since voters there approved a titrate their nicotine intake by varying their much related to the situation in real life, referendum question raising the state’s smoke inhalation and cigarette where consumers might be attracted by cigarette excise tax and assigning a portion of consumption.34 Here we show that there is “light” cigarettes because they assume these the revenue to a campaign to reduce tobacco no diVerence in CO concentrations in the will reduce their health risk.9 Other variables use, California has been a cockpit of conflict expired air of smokers who smoke “light” may aVect the present results, but it is likely between public health forces and the tobacco brands versus smokers who smoke regular that further studies will confirm the present industry. For most of that time, Stanton brands. assumption that tobacco consumers are mis- Glantz, Professor of Medicine at the Univer- The study assessed 178 smokers (83 led by the information on the packages. If sity of California, San Francisco, has been an males, 95 females; mean age 49.05 years), expired CO values are indicative of the intake important figure in the struggle. This is his whose cigarette consumption was diagnosed of harmful substances, this might indicate history of it, written with Edith Balbach, according to the Vienna Standard Protocol.5 some limitations in the CO haemoglobin Director of the Community Health Program (This protocol includes the measurement of saturation curve. (From the machine at Tufts University in Boston. CO in expired air). The sample consisted of measurement of these values there is a corre- For readers of this journal, Tobacco war is first visit clients attending publicised lation between tar and expired CO—letter most useful not for its accounts of tobacco information meetings held by the Nicotine from laboratory government chemist, industry perfidy, but for describing the evolu- Institute, Vienna during a three week London). DiVerent tobacco markets may also tion of tactics used by health advocates to sampling period. The smokers were divided diVer in the labelling of cigarette brands, but counter the industry’s political strategy. In into two groups: those who smoked a brand as the smokers in this study were all exposed California, the war has been fought at the of cigarette with the word “light” indicated to the same information about cigarettes (in local and state levels, and in the electoral, leg- on the packaging (n = 63), and those who Austria), these findings are at least reliable for islative, and administrative arenas. smoked a brand that did not carry this this market. These results support the The authors’ main theme is that tobacco message (n = 115). This information was suggestion that smokers titrate their nicotine control advocates most eVectively influence http://tobaccocontrol.bmj.com/ gained by asking smokers whether they intake by varying their inhalation habits. public policy by mobilising public opinion, smoked “light” cigarettes, and by checking rather than employing traditional lobbying ERNEST GROMAN techniques. Glantz and Balbach repeatedly their cigarette packs. There was no diVerence DORIS BLAUENSTEINER in sex distribution between the two groups. URSULA KUNZE demonstrate that the conventional insider Tobacco dependence was measured by the RUDOLF SCHOBERBERGER tactics of influence, persuasion, and compro- Fagerström test for nicotine dependence Institute of Social Medicine, mise result in setbacks for tobacco control, (FTND).6 The two groups (“light” and regu- University of Vienna, while an aggressive public posture that lar smokers) did not diVer in this respect. Alserstr. 21/12, confronts not only the tobacco industry but Expired CO measurements were obtained 1080 Vienna, Austria also its political allies leads to victory. with the Bedfont EC-50-Micro Carbon Correspondence to: Dr Groman Their argument is that public health agen- Monoxide Monitor. The smokers were not [email protected] cies, which do not make political campaign informed of the test before the measurement, contributions or employ influential lobbyists, which was performed at 5 pm. None of the smokers refused this measurement, and none 1 Groman E, Bernhard G, Blauensteiner D, on September 29, 2021 by guest. Protected copyright. Kunze U. A harmful aid to stopping smoking. were excluded from the analysis. None of Lancet 1999;353:466–7. them had changed their cigarette brand dur- 2 Federal Trade Commission. Tar, nicotine, and ing the previous three months. carbon monoxide of the smoke of 993 varieties of Analysis of the data focused on the relation domestic cigarettes. Washington DC: Federal between the “light” claim and the expired Trade Commission, 1994. 3 White C. Smokers are misled about low tar CO measurement, intentionally not taking cigarettes. BMJ 1997;314:845. into account the (relatively unreliable) infor- 4 Kozlowski LT, Frecker RC, Khouw V, Pope M. mation on cigarette consumption reported by The misuse of ‘less-hazardous’ cigarettes and the smokers. Reported cigarette consump- its detection: hole-blocking of ventilated fil- ters. 1980; :1202–3. tion is not very reliable compared to objective Am J Public Health 70 5 Schoberberger R, Kunze U, Schmeiser-Rieder measurements of CO concentrations, A, Groman E, Kunze M. Vienna standard in because these concentrations depend on the diagnosis of nicotine dependence: Vienna puV rate and inhalation habits of the Standard Smoking Inventory. Wien Med Wo- individual. No significant diVerence chenschr 1998;148:52–9. 6 Heatherton TF, Kozlowski LT, Frecker RC, (p > 0.55) was found in the distribution of Fagerström KO. The Fagerström test for nico- CO readings of the “light” cigarette smokers tine dependence: a revision of the Fagerström compared to regular cigarette smokers (fig tolerance questionnaire. Br J Addict 1991; 1). The mean CO value achieved by the 56:1119–27. 7 Kozlowski L. Tar and nicotine delivery of regular cigarette smokers was 27.85 ppm cigarettes: what a diVerence a puV makes. (SD 12.34, SE 1.15), and the mean value of JAMA 1981;245:158–9. the “light” cigarette smokers was 29.63 ppm 8 Kozlowski L. Smokers are unaware of the filter (SD 10.90, SE 1.37). These results support vents now on most cigarettes: results of a national survey. Tobacco Control 1996;5:265– the findings of other studies that questioned 70. the possible advantage of cigarette brands 9 White P. Consumers and the changing cigarette. claiming to be “light”.78 London: Health Education Authority, 1999.

www.tobaccocontrol.com Letters, Books 353 Tob Control: first published as 10.1136/tc.9.3.352a on 1 September 2000. Downloaded from cannot compete at the insider game with the reports, and internal company documents lever from behind the scenes. Charles cigarette manufacturers, which do both to an uncovered through state lawsuits against the Fletcher and Robert Platt set the first Royal almost unparalleled extent. But, “[t]he agen- cigarette manufacturers. These last help elu- College of Physicians report in train. But cies . . . enjoy high name recognition and cidate the industry’s strategy and its analysis heroes such as these are few and far between. credibility with the public. By contrast, the of the health advocates’ activities. Even some of the heroes were naive: they tobacco industry has very low public This reader would have appreciated a brief did little lobbying, and made the mistake of credibility. This diVerence in public standing description of the research methodology, par- thinking that the industry’s leaders were hon- means that outside strategies are likely to be ticularly the interview procedures. Not every- ourable. So the manufacturers received the public health community’s best means to one’s viewpoint is adequately represented, advance copies of Royal College of achieve good tobacco policy, because the and there are occasions when the actions of Physicians (RCP) and other reports, enabling skills and resources of the voluntary health tobacco control advocates are questioned by their supporters and scientific lackeys to agencies tend to be amplified in public arenas the authors or by other participants, without minimise any political damage. while those of the tobacco industry are any response from the accused. This is jarring Some of the early politicians did their best. muted. But outsider strategies require a com- in view of how much of the text consists of They may not have got it all right (and who mitment of resources to a continuous public verbatim quotes from participants. can blame them, given the paucity of information eVort. Equally important, they But, all in all, this is an important book for information at the time) but some credit require a willingness to anger powerful politi- the tobacco control movement. It is an inter- surely belongs to health ministers such as Iain cians and interest groups by publicizing their esting, at times compelling, narrative, Macleod and Enoch Powell, who refused to misdeeds.” containing many object lessons that anyone prevaricate and pressed for immediate action. Glantz and Balbach understate the impor- engaged in tobacco control policy advocacy And as science minister, Lord Hailsham tance and necessity of eVectively playing the will benefit from. reluctantly agreed to meet the industry, but inside game. EVective legislative advocacy RUSSELL SCIANDRA told his oYce to “give me some nasty things helps assure that public opinion is translated to say . . .”. Center for a Tobacco Free New York, into eVective, not cosmetic, policy. And they For the rest, there are villains and prevari- may overestimate the depth and durability of 1450 Western Avenue, Suite 303, Albany, New York 12203 USA, cators. Prime ministers, cabinets, and the public’s goodwill, once health agencies [email protected] ministers found every possible reason to begin to use it. But the point is well taken. avoid doing anything, from worrying that Their halo of disinterested concern for public Political history of telling the public about the dangers of smok- health is the best weapon voluntary agencies ing might generate “cancer phobia” to have in fighting the tobacco industry, and its smoking and health concern for the Rhodesian economy. Even in judicious use, combined with eVective lobby- 1962, the chancellor of the exchequer, ing, is the surest path to success. Denial and Delay—The Political History Selwyn Lloyd, persuaded his colleagues that The recent infusion of tobacco settlement of Smoking and Health, 1951-64; “it would be preferable that the government money into the US states has changed the Scientists, Governments and Industry should not at this stage appear to be political dynamics of tobacco control as seen in the papers at the Public assuming a responsibility for ‘discouraging’ advocacy. Voluntary agencies, which only Records OYce. David Pollock. London: adults from smoking”. Civil servants were recently adopted an aggressive stance Action on Smoking and Health, 1999. ISBN generally cautious: some simply didn’t like towards Big Tobacco, are now learning that 1 872428 444. doctors (“by habit and training inclined to they must confront both the industry’s allies the pontifical in expressing their views”, in public o ce and other interests, some of Y The British Civil Service documents according to Miss Boyes of the Board of them quite worthy, competing for the funds. everything, and eventually makes its papers Trade), while a Mr Selby-Boothroyd felt that The California experience is sure to be http://tobaccocontrol.bmj.com/ available to researchers. David Pollock has the first RCP report could be dismissed on repeated, and careful attention to the history used some of the papers provided in the Pub- the basis that people were divided into “soft recounted in will help others Tobacco war lic Records OYce at Kew in London to tell shells”, who were vulnerable to lung cancer, avoid some of the mistakes made there. the story of how action on smoking was and “hard shells”. A most depressing element of the delayed between 1951 and 1964, coinciden- The tobacco manufacturers, of course California story is the role played by tally a period of Conservative government. used every possible device to question, deny, organised medicine. The California Medical Little did we know at the time how true the undermine, and oppose both the evidence Association (CMA) paid lip service to the 1964 Labour election slogan “Thirteen and any worthwhile action. Mr (later Sir 1988 Proposition eVort while working Wasted Years” would prove to be. John) Partridge of Imperial Tobacco would behind the scenes to undermine it because Pollock’s story is limited, for as he points not now be allowed by his company to the CMA wanted to avoid alienating the out he has essentially investigated only one of concede, as he did in 1962, that the industry tobacco industry, with which it had made the various sets of documents available, and advertised “to young people”—but he and common cause in weakening medical and his book is less a “political history” than an his colleagues used all the same techniques product liability laws. When the Proposition illustrated journey through oYcial docu- their successors use today: deny the evidence; won, the CMA embarked on a years long ments. But it is riveting reading and provides on September 29, 2021 by guest. Protected copyright. eVort to shift money from the tobacco much splendid material to demonstrate the denigrate the researchers; oVer funding for control programme into medical care caution of civil servants, the short sightedness irrelevant research; defend all forms of accounts (and, incidentally, doctor’s pock- of politicians, and—as ever—the iniquities of promotion; accept no restrictions; assert that ets). the tobacco industry. the only worthwhile approach is (carefully One hopes that most physicians would not The story has plenty of gems but few stars. limited) school based education. There is endorse this kind of political deal making at In 1947, when “a large scale statistical study” nothing new about the arguments they use the expense of public health. But the people on smoking and lung cancer was under con- today or their lobbying techniques. they hire through their associations to repre- sideration, Austin Bradford Hill recom- What are the lessons? Perhaps above all, it sent them, committed to playing the inside mended “ . . .a very good worker to whom it is distressing to see how little has changed: game, will continue to sell out tobacco is well worth giving a wider experience in only a few doctors and health professionals control over pocketbook issues until the medical statistical work with an eye to the campaign for action on tobacco; most membership tells them to do otherwise. Pro- future . . .”: a judgement about Richard Doll bureaucrats remain cautious; health generally viders concerned about tobacco control need with which none would now argue. A few loses out when it comes into conflict with to do more to hold their professional organi- researchers such as Doll, Hill, Wynder, and more important government departments; sations accountable for tobacco control Graham recognised the importance of politicians with the determination to act on advocacy. tobacco. A desperately limited number of tobacco are rare and are soon moved; and the Despite Glantz’s involvement in many of medical administrators and civil servants tobacco manufacturers and their agents are if the events described, Tobacco war is a largely (especially in Scotland) sought early action. anything tougher and nastier than ever. even-handed account of the major issues Horace Joules, a distinguished chest And in the UK, 50 years after Doll and confronted by California’s tobacco control physician, led the early medical campaigners, Hill’s first published reports and nearly 30 movement, particularly during the 1990s. In but his views were often discounted because years after the first RCP report, just under writing Tobacco war, the authors drew on of his perceived “left wing bias”. Among the 30% of adults still smoke, and literally interviews with many of the players bureaucrats, Sir George Godber characteris- millions have died because they smoked. (including some from the other side), tically became involved long before he was Denial and delay shows that much of the contemporaneous memoranda and news entitled to do so, and pressed every available responsibility for these deaths rests not only

www.tobaccocontrol.com 354 Letters, Books Tob Control: first published as 10.1136/tc.9.3.352a on 1 September 2000. Downloaded from with the tobacco industry, but also with its because of its distaste for “cooked development is quite strong. As one reviewer many active and passive allies in government. meat”—allows him to flee into the corridor. on amazon.com commented, “this is bloody The matches and the fire, ironically, save him good stu ”. My main interest in the stories, MIKE DAUBE V from an “unspeakable end”. Another hotel though, was in their portrayal of smoking. Cancer Foundation of Western Australia, guest, returning from the ice machine, puts And King’s treatment of the subject is 334 Rokeby Road, out Enslin’s flames. However, Enslin is left unmistakably pro-health. Listeners are left Subiaco, WA 6008, Australia with severe emotional and physical scars, and with the clear message that smoking is harm- [email protected] can no longer write—another in the long list ful and addictive. A particularly compelling of victims of room 1408. example is this excerpt from Lunch at the The horrors of In the Deathroom features Mr Fletcher, a Gotham Café: New York Times reporter being interrogated “There are two phases of withdrawal from smoking in a Central American stronghold. Authori- tobacco, and I’m convinced that it’s the Blood and smoke. Stephen King. New ties are using electric shock to extract second that causes most cases of recidivism. information from him about an upcoming The physical withdrawal lasts 10 days to two York: Simon & Schuster Audio, 1999, Communist coup against the country’s weeks, and then most of the symptoms— $23.50 (audiocassette), $27.50 (CD), 3.5 fascist dictatorship. Escobar, his chief sweats, headaches, muscle twitches, pound- hours. ISBN 0671046160 (cassette)/ interrogator, oVers Fletcher a Marlboro— ing eyes, insomnia, irritability—disappear. 0671046179 (CD) “the preferred cigarette of third world “What follows is a much longer period of I have never read a book by Stephen King. peoples everywhere”. At first Fletcher, having mental withdrawal. These symptoms might quit smoking three years previously, declines. include mild to moderate depression, mourn- But I couldn’t resist buying Blood and smoke, available only as an audiobook and read But at the moment of greatest peril, he ing, some degree of anhedonia (emotional engagingly by King himself. It comes in a flip accepts Escobar’s oVer. In launching his dra- flatness, in other words), forgetfulness, even a top box resembling a pack of Marlboros, and matic escape, he thrusts his lit Marlboro into species of transient dyslexia....Themost contains a CD or three audiocassette tapes, the eye of one of his captors, grabs his gun, common symptom of phase two withdrawal shoots three of his captors, and kills the is a feeling of mild unreality. Nicotine depending on the version you buy. The fourth with his own electric shock machine. improves synaptic transferral and improves “book” is actually a series of three short sto- One month later, back home in New York concentration—widens the brain’s informa- ries, which, according to the packaging, take City, Fletcher lives out a vision he had during tion highway, in other words. It’s not a big the listener “inside the world of yearning and his captivity. He buys a pack of Marlboro boost and not really necessary to successful paranoia, isolation and addiction ...the from a newsstand kiosk, smokes a cigarette, thinking, although most confirmed cigarette world of the smoker”. “The now politically and then discards the rest of the pack. In a junkies believe diVerently. But when you take incorrect habit plays a key role in the fates of brief exchange, Fletcher and the vendor agree it away, you’re left with a feeling—a pervasive three diVerent men in three unabridged that smoking is a “very bad habit” and that feeling in my case—that the world has taken stories of unfiltered suspense.” “We’re lucky to be alive”. on a decidedly dreamy cast.” In , Steve Davis is Lunch at the Gotham Café Each of these stories is creative, Why has King focused on the evils of distraught after his wife leaves him. Two days suspenseful, and well narrated. Character tobacco in Blood and smoke? The most likely later he quits smoking, after a 20 year history reason is the trauma he suVered when he was of smoking 20–40 cigarettes a day. For the hit by a Dodge van in June 1999, while walk- next two weeks he suVers intense withdrawal ing alongside a country road in his hometown from nicotine and his wife, until he meets her of Bangor, Maine. He was hospitalised for and her divorce lawyer for lunch at a three weeks, underwent at least six operations Manhattan restaurant. While arguing at the to repair broken bones in his right leg and http://tobaccocontrol.bmj.com/ table, they are attacked suddenly by a hip, and suVered broken ribs, a punctured psychotic, knife-wielding maïtre d’. Davis lung, and a laceration of the scalp. He told fights him oV bravely, saving his own life and the Bangor Daily News in August that he that of his ungrateful wife. Afterwards he hadn’t had a cigarette since the night before buys a pack of Marlboros and lights one up, the crash. “I took the Dodge van cure,” he but then tosses the cigarette in the gutter and quipped (www.bangornews.com/cgi-bin/ stamps the pack with his foot. “I hadn’t gone article.cfm?storynumber=10392). through this day just to start killing myself Two months later King told the Associated with tobacco again,” he explains. Press: “to be able to walk and talk and occa- 1408 is about Mike Enslin, a bestselling sionally crawl on my belly like a reptile has author of “true” ghost stories. While made me intensely grateful to be alive.” No researching his book about haunted hotels, doubt he recognises that smoking is he stays in New York City’s most haunted incompatible with the joy of being alive. Now, hotel room. Enslin quit smoking nine years with his message about tobacco in Blood and ago after his brother died of lung cancer— smoke, King aims to preach that gift of life to on September 29, 2021 by guest. Protected copyright. “another fallen soldier in the tobacco wars”. millions of others. But the writer always carries a cigarette RONALD M DAVIS behind his ear, replacing it each day with a Center for Health Promotion and Disease Prevention, fresh one, explained as “part aVectation, part Henry Ford Health System, superstition”. In his 70 minutes in room One Ford Place, 5C, 1408, Enslin experiences horrifying distor- Detroit, Michigan 48202-3450, USA tions of reality, and finds himself vanquished [email protected] by “the room”. He ignites his shirt with a A shorter version of this book review was published in hotel matchbook, and the room—perhaps the August 5th issue of the BMJ.