Book Review

ISCUSI may be the most prominent academic critic of current public health approaches to smoking, often serving as an expert witness for cigarette companies. He is perhaps best known for his conclusion that smokers provide governments with net economic benefits because they pay more in taxes than do nonsmokers and, thanks to their smoking-shortened lives, consume fewer government benefits. Viscusi’s new book, Smoke-Filled Rooms, presents itself as a critical analysis of the states’ settlements of their lawsuits against the cigarette companies. This framework serves Viscusi well, because it supports the narrow, dollars-and-cents approach he favors and excludes important public health considerations. As he writes, “the focus of the litigation is solely on whether the government incurred financial costs as a result of the cigarettes.” Not only are private costs ignored, but so are the suffering and loss caused by smoking and other undesirable effects that are not reflected in government expenditures. “Framing the question in this manner may seem narrow, which it is,” he writes, and he blames the “anti-smoking forces and the governmental lawsuits” for creating such a framework. But Viscusi does not go beyond this kind of sterile and limited economic view. This narrow approach might make sense if Viscusi’s book discussed only the state tobacco settlements, but it clearly does much more. Besides criticizing all other litigation against the tobacco companies (and similar litigation against other businesses), Viscusi evaluates current government and public health initiatives for reducing tobacco use, finds them lacking, and offers a controversial alternative approach. Viscusi’s analysis is often superficial and incomplete, even within the narrow framework he has chosen. In his accounting of smoking-related costs and savings, for example, Viscusi states that “this comprehensive review reflects all cost components that have been recognized in the professional economics literature.” But he later, without explanation, indicates that he “will omit influences such as costs associated with low-birthweight babies” — despite estimates that the costs resulting from smoking-affected pregnancies are as high as $2 billion per year. Other overlooked costs include Social Security survivors’ insurance payments to spouses and children of adults who die early because of smoking, cleaning and maintenance costs related to smoking, and costs related to secondhand smoke. Although Viscusi considers the costs of secondhand smoke in a separate chapter, he does not provide any estimate or substantial discussion of the costs of treating ailments caused or exacerbated by secondhand smoke, nor does he cite the published research that does so. It is also impossible to evaluate the subtotals of costs and savings that Viscusi does present, because he reveals very little about his underlying calculations, data, and assumptions. V Viscusi’s conclusion that smoking has a net positive effect on government budgets might still be valid, but he does not show why that finding would be relevant to the public health goal of minimizing the harm caused by tobacco. Indeed, Viscusi appears to reject that goal, stating that government policy should, instead, respect individual choice and promote informed risk taking by consumers. But he also argues that adopting this new goal would reduce the harm caused by smoking more effectively than current public health approaches do, by exploiting the power of competitive markets to foster the development and use of safer cigarettes. In support of this argument, Viscusi claims that the increasing use of filters and decreasing tar levels in the cigarettes consumed in the United States since the 1950s have reduced the health risks of smoking and the overall harm caused by it. He acknowledges that some smokers “may” override the benefits of filters and compensate for lower tar and nicotine levels (for example, by plugging up the vent holes in filters, inhaling more deeply, or smoking more cigarettes). But he concludes — offering very little supporting research, data, or analysis — that such behavior has not substantially reduced the health benefits from this shift to “safer” cigarettes. In contrast, the recent monograph on low-tar cigarettes published by the National Cancer Institute states that “there is no convincing evidence that changes in cigarette design between 1950 and the mid-1980s have resulted in an important decrease in the disease burden caused by cigarette use either for smokers as a group or for the whole population.” More important, Viscusi fails to account for the fact that offering “safe” cigarettes actually increases smoking rates by providing smokers with a welcome alternative to cutting back or quitting altogether. Although he acknowledges this possibility, he makes no attempt to estimate the extent to which “safe” cigarettes have increased the costs and harms of smoking or to predict how more aggressive marketing of these cigarettes might increase smoking and its related costs and harms. Other parts of the book also present a somewhat naive view of the cigarette companies. For example, Viscusi states as a fact that the tobacco industry does not support smoking by persons under 18 years of age, and he ignores the major part the companies play in impeding effective antismoking laws and regulations. Despite these problems, the book remains a useful resource for careful readers who wish to understand the chief theoretical attacks against antismoking efforts. The book also reveals numerous points of agreement between Viscusi and the public health community, such as support for eliminating smoking by young persons, for comprehensive oversight of “safer” tobacco products by the Food and Drug Administration, and for providing consumers with accurate and more refined information about the hazards of smoking. But here, as in the rest of the book, the devil is in the details — or their absence.