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Evidence-Based Oncology November/December 2013

Surgeon General's 'Smoking and Health' Turns 50

Peter Page
Smoking and Health: A Public Health Milestone
The Public Health Cigarette Smoking Act of 1969 banned cigarette advertising on television and radio, and the package label changed to the sterner “Warning: The Surgeon General Has Determined that Cigarette Smoking Is Dangerous to Your Health,’’ but precluded states and localities from regulating other forms of advertising such as billboards and promotions.11 The industry remained largely unregulated by the federal government12 until 2009, when President Barack Obama signed the Family Smoking Prevention and Tobacco Control Act that brought cigarettes under purview of the US Food and Drug Administration (FDA), although this groundwork was laid in 1996 by former FDA commissioner David Kessler, MD, a pediatrician.13

“After the 1964 report Terry called for remedial action. What happened was Congress exempted tobacco from every health and safety law,’’ said Connolly of the Harvard School of Public Health.

AMA and Big Tobacco: It’s Complicated

One of the first studies to link cigarette smoking and cancer was coauthored in 1939 by Alton Ochsner, MD, founder of the famed Ochsner Clinic in New Orleans, Louisiana. Early on, Ochsner was ridiculed for his aggressive promotion of his findings, but he became one of the nation’s earliest advocates against cigarette smoking.14 Most in the medical profession did not see much harm in moderate cigarette use, and many doctors smoked themselves, a fact that the tobacco companies would use to their advantage as health concerns about cigarettes grew.15

Tobacco companies courted physicians as soon as health concerns arose. One way was placing advertising in the Journal of the American Medical Association (JAMA), which accepted tobacco ads for 20 years starting in 1933.16 Eventually, tobacco companies used depictions of physicians in the ads themselves; “More doctors smoke Camels” became a classic. When research by Ochsner and others led to a December 1952 Reader’s Digest article, “Cancer by the Carton,”17 it caused a temporary dip in cigarette sales and an immediate response from both JAMA and the tobacco companies.

JAMA stopped accepting tobacco ads. But the industry formed the Tobacco Industry Research Committee (TIRC) to both award research grants and advance the industry’s position.18 Advertising strategy shifted from overt representation of doctors to the promotion of filtered or “safer” cigarettes, which were buoyed by their “studies” and Hollywood actresses who crowed that these new models were “just what the doctor ordered.”19

The connections among Big Tobacco, the advertising industry, and physicians did not ebb overnight. Pushed by Ochsner, in 1952 the American Cancer Society began a long-term study to prove cigarettes caused cancer.20 JAMA published Ochsner’s findings and Burney’s 1959 statement on tobacco, but when necessary the industry simply bypassed this outlet and sent favorable study results directly to physicians. Big Tobacco was so entrenched in American culture that Ochsner was warned before an appearance on Meet the Press not to state that there was a causal link between cigarettes and lung cancer.20

By 1964, as Smoking and Health rocked the country, the AMA seemed poised to issue a report on cigarette smoking and cancer. For 2 years, however, the physicians’ group had been fighting another battle: President Kennedy’s proposal to create Medicare. Although the AMA denied the charge, US Rep. Frank Thompson (D-NJ) and others accused the group of striking a deal with lawmakers from the tobacco states: if the AMA held its tongue on cigarettes, the legislators would fight Medicare.19

On February 7, 1964, less than a month after the Surgeon General’s report was unveiled, the AMA accepted $10 million A Permanently Altered Landscape Knowledge of the dangers of cigarette smoking have seeped into the public consciousness to a degree unthinkable in 1964. This has allowed research priorities to shift as well, as studies turn to issues surrounding public education and health disparities; it is well documented that the effects of smoking hit hardest on low-income groups and the developing world.25 In fact, in October 2013, the American Thoracic Society and the European Respiratory Society published a statement in The American Journal of Respiratory Critical Care Medicine announcing the creation of a committee to address the fact that lower-level socioeconomic groups are 14 times more likely than higher-level groups to suffer from respiratory ailments, with cigarette smoking being a major reason.25

In recent decades, the AMA has joined with other medical groups to combat cigarette smoking, especially among the young. In September 2009, the AMA praised the FDA for a ban on flavored cigarettes, after numerous studies in which “the evidence shows that young smokers are the primary users of flavored tobacco products.”26

Much of today’s policy focus is on stopping young people from picking up the habit; last month, the New York City Council raised to 21 the age at which it is legal to buy cigarettes.27

Clinically, smoking still kills. The most recent data sheet from the Centers for Disease Control and Prevention (CDC), published August 1, 2013, states that 440,000 deaths, or 1 in 5 in the United States, are caused by smoking.28 This includes 90% of all deaths from COPD.28 Many were already smokers in their twenties when the 1964 report came out, who have been unable to quit, and now suffer its health effects in their old age.29

The 1964 report was the first big step in a very long trek to a smoke-free society, said Glynn of the American Cancer Society, who is working on commemorating the 50th anniversary.

“I grew up in a small New York City apartment with 2 cigarette smokers and my grandfather smoking a pipe. No one thought a thing about it,’’ Glynn said. “We went from 42% of the population then (smoking) to 19% now. That is a huge public health success. Probably between 8 and 12 million lives have been saved since the publication of that report, but we still have 44 million people smoking, even though 70% of them say they want to stop. Our work remains to get people to stop smoking, period. I know that sounds obvious, but that’s the work, still.’’

from tobacco companies, which it would combine with $500,000 of its own funds for research grants. Ochsner publicly called the AMA “derelict.”20 A decade would pass before the AMA would issue an official statement on smoking and health, and the group opposed early efforts to regulate cigarette advertising.19

Secondhand Smoke Dangers

While the 1964 report told smokers the dangers of cigarettes, in the 1970s the Surgeon General began warning America’s nonsmokers about the dangers of  smoke-filled rooms. Shopland recalled Surgeon General Jesse Steinfeld mentioning the health effects on nonsmokers when presenting the 1971 report to the National Interagency Council on Smoking and Health.

“The entire report was about smokers, but at the end of his presentation he said it was his opinion nonsmokers needed a bill of rights, that nonsmokers had the right to clean air instead of smokers having the right to pollute the air,’’ Shopland recalled. “We started getting mail from around the country supporting him. That first raised the idea that being around smoking was not a good idea.’’

The 1972 report21 contained 3 chapters on “environmental tobacco smoke,’’ giving momentum to the nascent movement to restrict indoor smoking. By the end of the 1970s, 18 municipalities around the nation had passed indoor smoking ordinances.

The 1986 report was entirely about secondhand smoke,22 accelerating the momentum of nonsmokers pressing for clean indoor air. In 1995, California became the first state to pass a law regulating indoor smoking. Currently, 81.5 percent of the US population lives in a locality where indoor smoking is restricted; in many places, outdoor smoking is restricted as well.23

“You saw America acting as it usually does on social change,’’ said Connolly.  “At the community level people said they’d had enough; they deserved clean indoor air, they wanted an end to marketing to children. They combined the science from the Surgeon General with moral virtue. Smoking rates plummeted in America because of what common citizens did, not what Washington did. It’s the best public health story of the last century.’’

The single greatest blow against cigarette sales in the United States was landed in 1998 when the nation’s 4 largest manufacturers—Phillip Morris USA, R.J. Reynolds Tobacco Company, Brown & Williamson, and the Liggett Group—signed the “master settlement agreement’’ with 46 states. The agreement guarantees billions of dollars in annual payments to offset Medicaid costs for smoking-related disease. The agreement limits tobacco advertising, with particular restrictions on the use of cartoon characters and other devices for marketing to children. And, it forced the permanent dismantling of the Council for Tobacco Research, the successor to the TIRC. 24

A Permanently Altered Landscape

Knowledge of the dangers of cigarette smoking have seeped into the public consciousness to a degree unthinkable in 1964. This has allowed research priorities to shift as well, as studies turn to issues surrounding public education and health disparities; it is well documented that the effects of smoking hit hardest on low-income groups and the developing world.25 In fact, in

October 2013, the American Thoracic Society and the European Respiratory Society published a statement in The American Journal of Respiratory Critical Care Medicine announcing the creation of a committee to address the fact that lower-level socioeconomic groups are 14 times more likely than higher-level groups to suffer from respiratory ailments, with cigarette smoking being a major reason.25

In recent decades, the AMA has joined with other medical groups to combat cigarette smoking, especially among the young. In September 2009, the AMA praised the FDA for a ban on flavored cigarettes, after numerous studies in which “the evidence shows that young smokers are the primary users of flavored tobacco products.”26

Much of today’s policy focus is on stopping young people from picking up the habit; last month, the New York City Council raised to 21 the age at which it is legal to buy cigarettes.27

Clinically, smoking still kills. The most recent data sheet from the Centers for Disease Control and Prevention (CDC), published August 1, 2013, states that 440,000 deaths, or 1 in 5 in the United States, are caused by smoking.28 This includes 90% of all deaths from COPD.28 Many were already smokers in their twenties when the 1964 report came out, who have been unable to quit, and now suffer its health effects in their old age.29

 
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