Simplistic explanations of health, wellbeing, and disease in complex environments often result when analysts retreat into theoretical and methodological certainties embedded within their own, specific disciplines. Such explanations provide partial, and in some cases naïve understandings of how disease is manifest in groups of people across time, place, and space. Mac Marshall's Drinking Smoke is not one of these simplistic explanations—he embraces complexity. He systematically describes historical, political, environmental, socio-cultural, and economic aspects of how tobacco has become rooted in new ways in which people live in the contemporary Pacific. He also describes new ways in which they die as a result. This complexity is analyzed through the relatively new concept of “syndemic”: how two or more “parts” of a complex population health problem are intertwined, and through different combinations that emerge over time, manifest in greater disease. In the case of tobacco, the author clearly articulates how it connects various biological diseases across Oceania, and describes the assorted historical, political, and sociocultural factors which introduced and then embedded tobacco there. Marshall describes “a complex, interrelated, multivariate phenomenon made up of both biological and sociocultural parts” (p. 191). Drinking Smoke in this way provides an in-depth, multi-disciplinary analysis of tobacco's negative impacts in Oceania, but also how it has been perceived as a commodity of desire, exchange, and progress.
Drinking Smoke is the first book to examine the tobacco syndemic across the breadth of Oceania. The seven chapters of Part One provide detailed overviews of the history, economy, and ethnography of tobacco in the region. Examples and case studies are drawn from across Micronesia, Melanesia, and Polynesia. This part describes tobacco's introduction within the endeavors of traders, colonial enterprises, and missionary expansions. It explores how tobacco soon became entrenched in local mechanisms of trade and exchange between Pacific Islanders in ways that have produced complex social, cultural, and interpersonal meanings. The title Drinking Smoke expresses how tobacco became akin to a food or beverage in Oceania's collective societies, and thus deep cultural meanings and obligations attached to food and drink were extended to this introduced plant/drug. Part One concludes with chapters on how tobacco use has changed, particularly during and since World War II as the Pacific has become increasingly entangled with the globalized economy. During this period consumption began to shift from homegrown tobacco—smoked in pipes, wrapped in leaf, or chewed—to industrially manufactured cigarettes. With the latter came “death, taxes, and tobacco control” and more direct engagement with government and nation-state structures.
Part Two focuses on three case studies of disease concentration and disease interactions in Aotearoa/New Zealand, U.S. Associated Micronesia, and among Native Hawaiians. It draws on data and literature from medicine, epidemiology, environmental health, health policy, public health, and medical anthropology to describe the implications of tobacco—particularly industrially manufactured cigarettes—for cancer, cardiovascular disease, stroke, chronic obstructive pulmonary disease, diabetes, and maternal smoking. Through the processes of invasion, colonization, and globalization, tobacco consumption interacted with changes in physiology that accompanied dramatic changes in what people eat, away from taro, yams, sweet potato, bananas, coconuts and locally caught fish and toward white rice, refined flour, noodles, and canned processed meats. Marshall clearly explains how ethnicity and deeply rooted inequalities perpetuate disease in each of the three cases. Part Two concludes with the chapter “Tobaccosis: The Tobacco Syndemic,” in which the book's multiple threads are brought together in a clear and concise synthesis, and Marshall presents suggestions for addressing tobacco's devastating effects in the region.
Marshall in this book deftly brings together an extensive literature in a way that is accessible to readers across disciplines. A particularly engaging aspect of Part One is his use of contributions from subscribers to the Association for Social Anthropology in Oceania (ASAO) email network. Marshall invited answers to questions he posed there about interactions ASAO members have had with tobacco across the Pacific. This provided a wealth of information about tobacco's histories, usage, and meanings, and also how anthropologists themselves have variously used tobacco across time and place in Oceania; it also brought insights into the changing ethic of tobacco use as a research enabler in the past half-century, as disastrous health consequences become better understood.
In the attempt to be comprehensive in the broad description of tobacco in Oceania, some parts, particularly in the first chapters, present excessive detail; multiple examples demonstrate the same issue and reinforce the same point. (Of course, those interested in the specific issues or locations may welcome this.) Another drawback is that the detailed description of the history, economy, and ethnography of tobacco in Melanesia in Part One is not paired with a case study from Melanesia in Part Two. This is not a deliberate omission, however, but rather a consequence of the lack of comprehensive epidemiological, health service, and disease data from Melanesian countries.
In the concluding chapter, measures to reduce tobacco consumption are proposed using the structures of the “tobacco syndemic” framework. Perhaps because these structures were so explicitly and skillfully explained throughout the book, there is brevity to this section that left this reader seeking a little more. An example is that despite an excellent section on the influence of Christian missionaries and churches in both actively spreading and resisting tobacco use, there is no discussion in how contemporary Church structures/institutions at the family, village, and societal levels can be employed to reduce tobacco consumption and address the ill-health that results (across denominations, regardless of specific past theological/church tobacco policies). Community-level church organizational structures such as women's, men's, or youth groups—so central and valued among so many Pacific peoples—offer enabling structures for locally led “tobacco control” measures informed by indigenous social, cultural, political, and spiritual specificities.
Drinking Smoke is a must-read for scholars and students of Pacific history, anthropology, public health, and globalization. Those studying the political economy of health will find it of particular interest. The book directly challenges the notion of “lifestyle diseases” that blames ailments on the failure of those who sufferer them to follow a “healthy lifestyle.” Such individualizing biomedical models can blame the victim for health disparities that are in fact consequences of deeply embedded social, historical, political, and economic structures. Marshall adeptly disputes this perspective in an accessible and absorbing manner. He challenges readers to consider the tobacco syndemic in other regions and to “think syndemically” about other complex health issues.
