Public Opinion, Public Policy, and Smoking: The Transformation of American Attitudes and Cigarette Use, 1890–2016 by Thomas R. Marshall (review)

The rise and subsequent fall of tobacco use in the United States ranks among both history’s greatest public health disasters and its greatest victories. But how informed were Americans about the health risks of cigarette smoking? How have their awareness and attitudes changed over this time period? And how much have these attitudes been reflected in public policies to control tobacco use?

In Public Opinion, Public Policy, and Smoking, Thomas R. Marshall, professor of political science at the University of Texas–Arlington, draws on over half a century of public opinion polling to understand the evolution of Americans’ attitudes toward tobacco. Changing public opinion, he argues, was a key driving force in decreasing tobacco use and advancing tobacco control policies.

Mass public opinion polling emerged just in time to capture the publicity over cigarette smoking and cancer in the mid-twentieth century. Since the late 1940s, American pollsters have asked over five thousand poll questions on smoking and health. The shift was gradual but persistent. The proportion of Americans who believed that smoking was a cause of lung cancer increased steadily, from 43 percent in 1954 to 62 percent in 1964, 70 percent in 1972, and 91 percent in 2013 (p. 51). “In magnitude,” Marshall suggests, “these belief changes are among the largest ever reported in modern survey research” (p. 51), comparable to changes in attitudes around racial segregation or same-sex marriage.

The one event that did have an immediate, measurable impact on Americans’ beliefs (if not on their tobacco use habits) was the release of the 1964 report of the Surgeon General on “Smoking and Health.” The proportion of Americans believing smoking to be a cause of lung cancer jumped from 47 percent in 1962 to 62 percent in 1964 (p. 59).

Meanwhile, the tobacco industry pursued an organized public relations campaign to sow doubt around the science of smoking and health. Marshall concludes that industry efforts appear to have had a limited impact on public opinion. For example, the industry’s 1954 “Frank Statement” questioning the link between cigarette smoking and cancer was not followed by a measurable change in beliefs. However, Marshall does not address the possibility that the industry campaign may have slowed what would have otherwise been a more rapid recognition of the health hazards of smoking.

Changes in public awareness of health risks did not immediately translate into support for government intervention around tobacco use. It was not until the 1970s that grassroots efforts pushed for separate smoking sections and restrictions on smoking in public places, such as airplanes, buses, restaurants, and theaters. By 1986, 83 percent of never smokers and 73 percent of current smokers agreed that smoke from someone else’s cigarette was annoying (p. 85). Attitudes toward the tobacco industry also shifted, as Americans became more distrustful of the industry.

Marshall also describes an innovative analysis to match fifty-nine federal tobacco control policy proposals with nationwide polls from the 1960s to the 2000s to assess the degree of consistency between policy and public opinion. Overall, American public opinion was out in front of federal policy making—while fewer than half of the proposals reviewed were adopted, 70 percent had majority public support. Marshall notes this is consistent with other areas of public policy, but it is more remarkable here given the well-organized and well-funded opposition from the tobacco industry to many tobacco control proposals.

Marshall’s book is especially innovative in focusing on what the public knew or believed and how public opinion shifted over time. Other recent historical accounts of this period have focused largely on scientific knowledge and on what scientists, health officials, and the tobacco industry knew or believed. Nevertheless, Marshall’s analysis would be strengthened by further historical context in some sections. In particular, Marshall neglects to...