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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 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

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