The latest  US Surgeon General’s Report released in 2014 states: “today’s cigarette smokers – both men and women – have a much higher risk of lung cancer and chronic obstructive pulmonary disease (COPD) than smokers in 1964, despite smoking fewer cigarettes.”

The report further establishes that the increased risk of lung cancer is the result of tobacco industry changes to the design and composition of cigarettes.

The Surgeon General relied on evidence from large epidemiological studies which demonstrate that there has been a progressive increase in lung cancer and COPD among smokers in the United States between 1959 and 2010.

The Surgeon General found that, between 1959 and 2010, the risk of lung cancer to smokers increased tenfold for women and doubled for men. The risk increased despite the fact that the prevalence of smoking and the number of cigarettes consumed per smoker decreased over the same time period.

Moreover, the epidemiological evidence demonstrates that the increased rates of lung cancer have only occurred in smokers; there has been no comparable increase for non-smokers. This disparity leaves no doubt that the increase is directly linked to cigarette smoking and points to changes in the cigarette as the likely cause.

Tobacco specific nitrosamines (TSNA) are potent carcinogens. Changes in cigarette design over the last 50 years have dramatically increased TSNA levels in American cigarettes.

“The evidence indicates that changing cigarette designs over the last five decades, including filtered, low-tar, and “light” variations, have not reduced overall disease risk among smokers and may have hindered prevention and cessation efforts.” What is new is the emerging recognition that the very design change that lowered machine tar and nicotine ratings has in all likelihood increased the risk of smoking-related disease.

After an exhaustive trial and the presentation of a massive amount of evidence, US District Court Judge Gladys Kessler found, and the US Court of Appeals for the DC Circuit upheld, that the companies have known for decades that there is no health benefit from smoking low-tar or low nicotine cigarettes as opposed to conventional, full-flavored cigarettes; that the machine test method for measuring tar and nicotine was unreliable for measuring the amount of tar and nicotine a smoker would absorb in part because it did not take into account addiction and the phenomenon of smoker compensation; and that smokers were concerned and anxious about the health effects of smoking and chose light cigarettes because they relied on the health claims that the companies falsely made for light cigarettes as a reason for not quitting.

Despite this knowledge, the companies extensively − and successfully − marketed and promoted their low-tar and light cigarettes in ways that led consumers to believe they were less harmful alternatives to full-flavor cigarettes.

As a result of this evidence, the 2009 Tobacco Control Act prohibited the use of descriptors such as “light,” “smooth,” or “mild” for cigarettes sold in the United States beginning in 2010.
The same prohibition is included in the WHO Framework Convention on Tobacco Control, a global treaty that has been ratified by 178 nations. Despite this prohibition, cigarette manufacturers continue to market such cigarettes and communicate the same misleading messages by color-coding their packs. Thus, products incorporating the same cigarette design elements responsible for increasing the risk of lung cancer to smokers remain dominant in the marketplace.

The Surgeon General helps to answer a critical question:
Why does tobacco use remain such an enormous public health problem?

Prior reports have highlighted the role of tobacco marketing, especially in causing kids to start and continue using tobacco. The tobacco industry continues to spend huge sums – $8.8 billion a year, or $1 million every hour – to market its products, according to the latest data from the Federal Trade Commission.

What was not known until recently is the public health impact of design changes the tobacco industry has made to the cigarette itself.

The latest Surgeon General’s report concludes that over the past 50 years, tobacco manufacturers have designed and marketed ever more sophisticated products that are highly effective at creating and sustaining addiction to nicotine, more appealing to new youth smokers and more harmful. They took a deadly and addictive product and made it worse, putting smokers at even greater risk of addiction, disease and death.

This report describes the key ways in which tobacco companies design and manipulates their products to attract new youth smokers, create and sustain addiction, mislead consumers to think that they are reducing their risk of disease and make it more difficult for users to quit. It also found, the design changes during the past 50 years to make cigarettes even more dangerous.

This report is based on an extensive review of scientific studies and tobacco industry documents made public as a result of litigation against the industry. It also draws on the conclusions of Surgeon General’s reports and the 2006 Final Opinion of U.S.

District Court Judge Gladys Kessler, who in U.S. v. Philip Morris, Inc., found the major cigarette manufacturers had violated civil racketeering laws by deceiving the American people about the addictiveness and health risks of their products.

This evidence makes clear those tobacco products – and cigarettes in particular – are highly engineered to expand the appeal of these products and facilitate the consumption and addiction to nicotine, a highly addictive drug. Tobacco companies also know that almost all new smokers begin their addiction as children and that smoking is distasteful for new smokers, so they carefully design the product to appeal to this important market.

The companies have spent huge sums to research the design of their products and ensure they achieve these goals, even if the impact of these changes also makes the product more dangerous.

Addictiveness of cigarettes
Independent evidence and the tobacco industry’s own documents make clear that the tobacco companies have used design features and chemical additives in the manufacturing process in ways that increase the impact of nicotine, the addictive agent in tobacco products. Some of the ways the addictiveness of cigarettes has been increased include:
• Increasing nicotine levels
• Adding ammonia or ammonia compounds, which increase the speed at which nicotine is delivered to the brain
• Adding sugars, which increase the addictive effects of nicotine and make it easier to inhale tobacco smoke.
Judge Kessler concluded in her final opinion, “Defendants have designed their cigarettes to precisely control nicotine delivery levels and provide doses of nicotine sufficient to create and sustain addiction.”
“The and contents of tobacco products make them more attractive and addictive than ever before. Cigarettes today deliver nicotine more quickly from the lungs to the heart and
brain. While nicotine is the key chemical compound that causes and sustains the powerful addicting effects of cigarettes, other ingredients and design features make them even more attractive and more addictive.”

Maximizing appeal
In addition to controlling the addictive properties of their products, tobacco companies also manipulate their products in ways that attract new smokers and increase the likelihood that they will become regular smokers. By altering the taste, smell and other sensory attributes of their products, tobacco manufacturers make it easier for new users – the vast majority of whom are kids – to start and continue smoking.

Since the nicotine can make tobacco smoke harsh and difficult to smoke, manufacturers use chemical additives to alter the taste and smoothness of tobacco use in ways that make tobacco products more appealing to the young, novice smoker;
•    Levulinic acid reduces the harshness of nicotine and makes the smoke feel smoother and less irritating.
•    Flavorings, such as chocolate and liquorices, boost the sweetness of tobacco, mask the harshness of the smoke and make tobacco products more appealing to young people.
•    Bronchodilators expand the lungs’ airways, making it easier for tobacco smoke to pass into the lungs.
•    Menthol cools and numbs the throat to reduce throat irritation and makes the smoke feel smoother.
Design changes
The report identified two specific changes as the most likely reason for the increased risk of developing lung cancer:
•    An increase in the levels of highly carcinogenic tobacco-specific nitrosamines in US cigarettes – This report linked this increase to tobacco blends used in US cigarettes compared to cigarettes sold in Australia and Canada as well as the curing process now being used.
•    Introduction of ventilation holes in cigarette filters that caused smokers to inhale more frequently and vigorously which makes drawing of carcinogens in the smoke more deeply into the lungs.

Tobacco manufacturers have conducted extensive research on ammonia technology and its effect on nicotine. Through complex chemical reactions, ammonia compounds can produce smoothing effects that make the naturally harsh and burning smoke of the tobacco leaf more readily inhalable. But ammonia compounds do much more to help control the nicotine dosing and generate increased levels of freebase nicotine to cause addiction.

Philip Morris was the first tobacco manufacturer to discover that adding ammonia or ammonia-based compounds during the manufacturing process alters the chemical composition of nicotine and smoothes the smoke. Ammonia compounds increase the pH or the alkalinity of smoke and convert the nicotine molecules into a form often referred to as “freebase” nicotine.

Freebase nicotine is more readily absorbed by the smoker, offering a faster and more intense fix of nicotine, and the smoother smoke can be more easily inhaled deeply into the lung. It is more addictive and reaches the brain speedily.

“Freebase version of Marlboro cigarettes was one of the greatest triumphs in the history of modern drug design and one reason the brand became the world’s most popular cigarette.”

Ammonia compounds are among the most frequently used additives, by volume, in the tobacco industry. In her final opinion, Judge Kessler of the US found that the cigarette companies were “well aware of the particular chemical characteristics and effects of free nicotine, and undertook efforts to exploit these features.”

Ammonia technology, not just the Marlboro Man, played a pivotal role in turning Marlboro from a relatively marginal brand in the 1960s and early 1970s into the world’s best-selling cigarette.

After Marlboro was introduced with higher pH and increased levels of “free” nicotine, sales for the cigarette brand rose sharply and have remained at high levels for decades.

The tobacco industry devoted significant resources to reverse engineering the chemistry of Marlboro cigarettes to discover what was behind their popularity. Other tobacco manufacturers eventually discovered the role that ammonia played in catapulting Marlboro to the top. By the end of the 1980s, five of the six big tobacco companies were using ammonia technology.

Sugars like glucose, fructose and sucrose are naturally present in tobacco leaf, but tobacco companies have also added sugars to their products in substantial quantities. For some cigarettes, including Marlboro, sugar is the main constituent after tobacco.

When sugars are burned in cigarettes, they form the addiction-enhancing, cancer-causing chemical acetaldehyde. While only minor amounts of acetaldehyde are absorbed into the bloodstream, acetaldehyde is believed to interact with nicotine to enhance nicotine’s addictive effects by making receptors in the brain more receptive to nicotine. In fact, animal research conducted by Philip Morris demonstrated a synergistic interaction between nicotine and acetaldehyde – rats pressed the lever more for the combination of nicotine and acetaldehyde than for either substance by itself.

Tobacco companies also add sugars to their products to neutralize tobacco’s harsh taste and make the smoke seem milder and easier to inhale. By making cigarettes more palatable to first time users, sugars ultimately increase the risk for addiction because they encourage initiation.

Researchers have concluded that sugars and how they are manipulated in tobacco also significantly contribute to the adverse health effects of smoking.

Tobacco companies not only manipulate the addictive properties of their products, but also the product in ways that both attract starter smokers and enhance the likelihood that they will become regular smokers.

Many brands are designed to appeal to specific target groups, like youth, women and African Americans. By altering the taste, smell and other sensory attributes, tobacco manufacturers are able to make it easier to start smoking and create a better experience for the smoker.

Tobacco manufacturers have exploited the distinct sensory preferences among various demographic groups by tailoring products specifically to these preferences.

Decisions regarding product manufacture and design have been made following intensive research on how to make the product appealing to non-smokers, experimenters and specific subgroups. For example, research suggests that women are most attracted to flavors such as coconut and spearmint and products with a fresh aftertaste and pleasant aroma. As a result, companies have created products with these characteristics.

Tobacco industry documents indicate the companies are aware that attracting new young customers is the key to their survival, and they have designed products that appeal to this important market. Tobacco companies have admitted in their own internal documents that, if they don’t capture new users by the age of 21, it is very unlikely that they ever will. Indeed, 90 percent of adult smokers began smoking at or before the age of 18.