This report considers the biological and behavioral mechanisms that may underlie the pathogenicity of tobacco smoke. Many Surgeon General's reports have considered research findings on mechanisms in assessing the biological plausibility of associations observed in epidemiologic studies. Mechanisms of disease are important because they may provide plausibility, which is one of the guideline criteria for assessing evidence on causation. This report specifically reviews the evidence on the potential mechanisms by which smoking causes diseases and considers whether a mechanism is likely to be operative in the production of human disease by tobacco smoke. This evidence is relevant to understanding how smoking causes disease, to identifying those who may be particularly susceptible, and to assessing the potential risks of tobacco products.

The invention of mass marketing led to cigarettes being emblazoned in advertising and film, deeply tied to modern notions of glamour and sex appeal. It is hard to find a photo of Humphrey Bogart or Lauren Bacall without a cigarette. No product has been so heavily promoted or has become so deeply entrenched in American consciousness. And no product has received such sustained scientific scrutiny. The development of new medical knowledge demonstrating the dire harms of smoking ultimately shaped the evolution of evidence-based medicine. In response, the tobacco industry engineered a campaign of scientific disinformation seeking to delay, disrupt, and suppress these studies. Using a massive archive of previously secret documents, historian Allan Brandt shows how the industry pioneered these campaigns, particularly using special interest lobbying and largesse to elude regulation. But even as the cultural dominance of the cigarette has waned and consumption has fallen dramatically in the U.S., Big Tobacco remains securely positioned to expand into new global markets. The implications for the future are vast: 100 million people died of smoking-related diseases in the 20th century; in the next 100 years, we expect 1 billion deaths worldwide.

The cigarette is the deadliest artifact in the history of human civilization. It is also one of the most beguiling, thanks to more than a century of manipulation at the hands of tobacco industry chemists. In Golden Holocaust, Robert N. Proctor draws on reams of formerly-secret industry documents to explore how the cigarette came to be the most widely-used drug on the planet, with six trillion sticks sold per year. He paints a harrowing picture of tobacco manufacturers conspiring to block the recognition of tobacco-cancer hazards, even as they ensnare legions of scientists and politicians in a web of denial. Proctor tells heretofore untold stories of fraud and subterfuge, and he makes the strongest case to date for a simple yet ambitious remedy: a ban on the manufacture and sale of cigarettes.

This Surgeon General's report returns to the topic of the health effects of involuntary exposure to tobacco smoke. The last comprehensive review of this evidence by the Department of Health and Human Services (DHHS) was in the 1986 Surgeon General's report, The Health Consequences of Involuntary Smoking, published 20 years ago this year. This new report updates the evidence of the harmful effects of involuntary exposure to tobacco smoke. This large body of research findings is captured in an accompanying dynamic database that profiles key epidemiologic findings, and allows the evidence on health effects of exposure to tobacco smoke to be synthesized and updated (following the format of the 2004 report, The Health Consequences of Smoking). The database enables users to explore the data and studies supporting the conclusions in the report. The database is available on the Web site of the Centers for Disease Control and Prevention (CDC) at http://www.cdc.gov/tobacco.

The story of tobacco’s fortunes seems simple: science triumphed over addiction and profit. Yet the reality is more complicated—and more political. Historically it was not just bad habits but also the state that lifted the tobacco industry. What brought about change was not medical advice but organized pressure: a movement for nonsmoker’s rights.

Spanning a century, Pushing Cool reveals how the twin deceptions of health and Black affinity for menthol were crafted—and how the industry’s disturbingly powerful narrative has endured to this day. Police put Eric Garner in a fatal chokehold for selling cigarettes on a New York City street corner. George Floyd was killed by police outside a store in Minneapolis known as “the best place to buy menthols.” Black smokers overwhelmingly prefer menthol brands such as Kool, Salem, and Newport. All of this is no coincidence. The disproportionate Black deaths and cries of “I can’t breathe” that ring out in our era—because of police violence, COVID-19, or menthol smoking—are intimately connected to a post-1960s history of race and exploitation. In Pushing Cool, Keith Wailoo tells the intricate and poignant story of menthol cigarettes for the first time. He pulls back the curtain to reveal the hidden persuaders who shaped menthol buying habits and racial markets across America: the world of tobacco marketers, consultants, psychologists, and social scientists, as well as Black lawmakers and civic groups including the NAACP. Today most Black smokers buy menthols, and calls to prohibit their circulation hinge on a history of the industry’s targeted racial marketing. In 2009, when Congress banned flavored cigarettes as criminal enticements to encourage youth smoking, menthol cigarettes were also slated to be banned. Through a detailed study of internal tobacco industry documents, Wailoo exposes why they weren’t and how they remain so popular with Black smokers.

Millions of Americans use e-cigarettes. Despite their popularity, little is known about their health effects. Some suggest that e-cigarettes likely confer lower risk compared to combustible tobacco cigarettes, because they do not expose users to toxicants produced through combustion. Proponents of e-cigarette use also tout the potential benefits of e-cigarettes as devices that could help combustible tobacco cigarette smokers to quit and thereby reduce tobacco-related health risks. Others are concerned about the exposure to potentially toxic substances contained in e-cigarette emissions, especially in individuals who have never used tobacco products such as youth and young adults. Given their relatively recent introduction, there has been little time for a scientific body of evidence to develop on the health effects of e-cigarettes. Public Health Consequences of E-Cigarettes reviews and critically assesses the state of the emerging evidence about e-cigarettes and health. This report makes recommendations for the improvement of this research and highlights gaps that are a priority for future research.