Allan M. Brandt: Blaming the Victims - Lung Cancer and the Problem of "Responsibility"

Lung cancer claims some 160,000 American lives each year and more than 350,000 individuals are currently living with the disease, so I begin with an all too common scenario: “I have a friend in the hospital with lung cancer.” First question: “Did he smoke?” “Yes, he had tried to quit (repeatedly) but failed.” A shrug of the shoulders, “Well, that’s too bad, what did he expect?”

Unlike some cancers, which typically evoke sympathy and concern, lung cancer patients often experience stigma, isolation, and social judgment. In some instances, patients with lung cancer blame themselves and are filled with regret for having failed to take the advice (liberally meted out by doctors, family, friends, and strangers) to quit smoking. Patients who smoked (even those who had long ago quit) find themselves not only battling their disease, but also rebuke and self-recrimination.

What accounts for these beliefs, which so powerfully affect the experience of patients? Why do we blame lung cancer patients for their plight?

In American society, we have come to see smokers as weak, irrational, self-centered, and ignorant. As it turns out, this is precisely what the tobacco industry wants us to believe. After all, according to their pronouncements, smoking is a “voluntary risk”; anyone can quit, any time they really want to. In this way, the tobacco companies tap into a set of deep cultural values in American society. We must take responsibility for our behaviors and our health. Who could argue with that? It is an idea as American as apple pie and the 4th of July.

But this flies in the face of all we know about cigarette smoking and the complex, overdetermined process by which individuals (typically children and teenagers) come to be smokers in the first place. As a culture, we seek to insist—despite much powerful evidence to the contrary—that smoking remains a simple question of individual agency, personal fortitude, and the exercise of free will. Certainly, if it involves imposing risks on others, its public use should be legally curtailed. As a result, there has been much support for restrictions that prohibit smoking in public places. But at the same time there has been an ongoing insistence that smoking remains an aspect of personal agency, beyond the ken of regulatory interest. This widely-held view protects our larger sense of individual control and agency. Smokers, who are easy to stigmatize and condemn, assure our sense of a world in which individuals do in fact make decisions, exercise agency, and control their destinies. Keeping smoking essentially unregulated assists us in a larger cultural denial of forces over which we may have little control. In this sense, we need the cigarette and the smoker to make sense of our world. And the tobacco industry is willing and eager to assist in the assertion of the logic of individual responsibility, even as they have taken steps to make cigarettes even more highly addictive. Resistance to the blandishments of the companies and the addictiveness of nicotine is one cultural test of our discipline, independence, and individualism. This cultural idiom—central to the way we think about vulnerability, health and disease—continues to shape the history of the cigarette in our time.

Our insistence on personal responsibility may be a double-edged sword. It may encourage a heightened sense of individual control over health, but it also alienates and distances those who become ill. By doing so, we dissociate ourselves from the complex forces—economic, corporate, cultural, and biological—that have brought smokers to their plight. Shall we consider smokers ignorant and stupid for maintaining an “unnecessary behavior” that has clearly been defined as highly dangerous, or shall we recognize the power of corporate promotion, advertising and cultural conventions, as well as the biological and psychological qualities of addiction that constrain individual choice?

Calls for public responsibility to assist smokers who seek to quit need not erode our expectations of individual responsibility. It would be far easier and more appropriate to consider smoking truly an individual choice if, for example, cigarettes were subject to serious and effective regulations and the increasingly effective tools of cessation and prevention were fully accessible to all. Setting individual versus social responsibility creates a false dichotomy that has served the tobacco industry’s interests.

This is not to suggest that smokers are absolved of all accountability. To the contrary, most investigators of addictive behaviors confirm that individual motivation and acceptance of responsibility are critical to cessation and recovery. But we should not allow the industry to use calls for individual responsibility to secure a free ride at the expense of smokers and society. Indeed, the very notion that responsibility can be allocated either to smokers or to the industry misrepresents a deep historical reality about the relationship of culture, behavior, and commerce in the last century.

This essay is excerpted from: "The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America" (Basic Books, 2007).