Surgeon General's 'Smoking and Health' Turns 50

Peter Page

The word “landmark’’ is not in the title, and strictly speaking it is not the Surgeon General’s report but that of an advisory committee to US Surgeon General Luther Terry. Yet “the landmark 1964 Surgeon General’s report’’ is shorthand for the document that would change America’s mind about cigarettes, and, in time, the habit of smoking.

“It was a big deal,” Tom Glynn, 66, senior director of cancer science and trends for the American Cancer Society, said of the report, which is approaching the 50-year anniversary of its release on January 11, 1964.1 Glynn grew up in a New York City apartment where both parents smoked and his grandfather puffed a pipe. His father died of lung cancer.

“I remember clearly it got a lot of news ... 1964 was the highpoint, depending on your point of view, for smoking in the United States. Most people don’t remember, but if you sat in a movie theater, people smoked next to you. People smoked on airplanes; homes were filled with smoke.’’

As the advisory committee worked feverishly for most of 1963 to prepare the report, the nation’s cigarette consumption per capita peaked at 4345, having risen steadily for decades from just 54 in 1900.2 What Terry referred to in his foreword as the “tobacco-health controversy,’’ the decades-long lockstep increase in cigarette consumption and lung cancer, was officially unresolved in the view of the US Public Health Service, but Terry was determined that it would be. “The subject does not lend itself to easy answers. Nonetheless, is has been increasingly apparent that answers must be found,’’ he wrote.

Terry released Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service, 1 on a Saturday, timed to roil the Sunday newspapers but not the stock market. The committee’s conclusion, that cigarette smoking causes lung cancer in men and probably women, and is among the causes of chronic bronchitis, resounded like a voice from
the sky. As Terry expected, headlines with the report’s findings blared across the Sunday papers, with The New York Times front page referring to the cigarette “peril” and “cancer link cited.”3
“I remember debating the news with a group of teenagers the day it came out,’’ recalled Gregory N. Connolly, 64, director for the Center for Global Tobacco Control and professor at the Harvard School of Public Health. “My father eventually quit smoking. The report was a transfer of science to the public that touched every individual.’’

While the report was a thunderous end to the official uncertainty about whether smoking is unhealthy, its conclusions were not an abrupt departure from medical opinion. In the neutral language of a government report, the committee outlined an unfolding shift in global public health opinion about smoking from studied to alarmed. The committee noted the 1962 report of the Royal College of Physicians in England, which stated, “Cigarette smoking is a cause of lung cancer and bronchitis and probably contributes to coronary heart disease and various other less common diseases.’’4

By the time Terry appointed his advisory committee, the committee noted, the nations of Denmark, Italy, and Great Britain had banned or limited tobacco advertising. Those reports and actions abroad, along with a request from the Federal Trade Commission (FTC) on whether the science required that cigarettes carry a health warning, were among the reasons Terry listed for appointing the advisory committee. Beginning in the 1930s but accelerating through the 1950s, a mountainous body of research had accumulated correlating lung cancer with smoking cigarettes.

In 1956, then–surgeon general Leroy E. Burney appointed a scientific study group on smoking and health, drawing from the National Cancer Institute, the National Heart Institute and the American Heart Association, marking the Public Health Service’s first involvement in the question. Guided by the study group’s conclusion, Burney in 1957 published a statement declaring, “It is clear that there is an increasing and consistent body of evidence that excessive cigarette smoking is one of the causative factors in lung cancer.”5

What constituted “excessive’’ Burney did not say, and he dropped the adjective in a second official statement in 1959, writing “the weight of evidence at present implicates smoking as the principal factor in the increased incidence of lung cancer.’’6


A New Approach to Showing “Cause”

In June 1961, a reevaluation of smoking and health was suggested by the American Cancer Society, the American Heart Association, The National Tuberculosis Association (later the American Lung Association) and the American Public Health Association in a letter to President John F. Kennedy.

The letter suggested that Kennedy appoint a committee to find “a solution to this public health problem that would interfere least with the freedom of industry or the happiness of individuals.’’7 Terry invited representatives of those same organizations in June 19627 to a meeting for “objective assessment of the nature and magnitude of the health hazards’’ of smoking after President Kennedy responded to their request for a committee.

“We are very proud, as an organization, that we were at the table at that meeting when it was agreed to make an objective assessment of the health effects of tobacco,’’ said Erika Sward,  assistant vice president of National Advocacy for the American Lung Association. “The 1964 Surgeon General report states very clearly that cigarette smoking is causally linked to lung cance in men, and they established it as the most important cause of chronic bronchitis and emphysema, which is now known as COPD (chronic obstructive pumonary disease). It was a landmark report, the first time there was a massive declaration by the federal government that tobacco use was becoming an epidemic.”

Terry appointed a committee of 10 eminent specialists, none with expertise in smoking, to work with a small staff and a wide range of consultants to evaluate the available research, draw conclusions, and make recommendations. “The committee’s assignment has been most difficult,’’ the Surgeon General wrote in his foreword, a statement bordering on understatement. Between November 1962 and publication in January 1964, the committee reviewed 7000 studies and consulted with more than 150 experts. The list of acknowledgments covers 9 pages of names.1

The committee’s primary job was to determine if the enormous amount of evidence associating cigarette smoking with disease, particularly but not exclusively lung cancer, supported the conclusion that smoking “caused’’ the disease. The committee accepted the challenge, stating “statistical methods cannot establish proof of a causal relationship in an association. The causal significance of an association is a matter of judgment which goes beyond any statement of statistical probability.’’

The committee established 5 criteria for building a bridge from association to causation: (1) the consistency of the association; (2) the strength of the association; (3) the specificity of the association (4) the temporal relationship of the association; and (5) the coherence of the association. “Science at the time was looking at the mechanistic link,’’ said Connolly, of the Harvard School of Public Health.

“We wanted to know what in smoking triggered what cell in the lung so we could show cause. It was a very clinical perspective. This report really invented modern epidemiology, determining cause by looking at large population data.’’

Taking on Big Tobacco

The economic significance of the tobacco industry and the ubiquitous nature of smoking caused the committee to shroud its deliberations in secrecy. Most of its work was down deep in the National Library of Medicine (NLM). The import of the committee’s work soon became apparent to Don Shopland, who in the spring of 1962 was newly graduated from high school and beginning his first adult job at the NLM.

“There were locked files, administrative confidential files, that sort of thing,’’ said Shopland, who only months before had begun working at the library. Soon, he was working full time for the committee. In 1966, he joined the National Clearinghouse on Smoking and Health, and he later became director of the Office of Smoking and Health (OSH), where he helped write 20 more reports on smoking to Congress.

“There was constant tension around the work,’’ Shopland said. “We worked 7 days a week from August or September when I stared, for the rest of the year, often until midnight. I recall having off Christmas Day, Thanksgiving, and a half-day the day of Kennedy’s funeral. It was a very intense time.’’

The legendary investigative journalist, Drew Pearson, outlined in an October 1963 column the pressure on the committee, and the federal government’s lack of enthusiasm for regulating tobacco and smoking. Pearson correctly reported the committee would link smoking and cancer. He quoted US Secretary of Health, Education, and Welfare (HEW) Anthony Celebrezze, a pack-a-day smoker, who didn’t “consider it the proper role of the federal government to tell people to stop smoking.’’ Pearson cited concerns of the US Department of Agriculture on tobacco crop prices, as well as the FTC’s need for guidance on the need for warning labels and other regulatory issues.8

“When we submitted the report to the government printing office, it was the only non-military report that was printed ‘Top Secret,’ ’’ Shopland said. “The tobacco companies were major industries, almost like General Motors. (The committee) took great pains to make sure nothing leaked out that would affect the stock market. They were afraid what would happen to the tobacco industry and related industries for paper, packaging, Wall Street. Tobacco reached deep into society.’’

As it turned out, the regulatory fallout from the 1964 report had little immediate effect on most smokers, with the per capita consumption remaining around 4000 cigarettes for another decade,9 or on the industry, which remained profitable and politically potent. In June 1964, the FTC relied upon the surgeon general’s report to require health warnings on cigarettes while it considered restrictions on cigarette advertising.10 In 1965, Congress passed the Federal Cigarette Labeling and Advertising Act (which precluded any package warning except “Caution: Cigarette Smoking May Be Hazardous to Your Health.”) The law required the FTC to report annually on the effectiveness of the warning, and for HEW, of which the surgeon general was a part, to report annually to the Congress on the health consequences of smoking.11

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

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.’’
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