On January 11, 2014, the nation commemorated the 50th anniversary of a document that transformed our public health landscape and has saved millions of lives: Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. This groundbreaking report, which definitively established smoking as the primary cause of lung cancer, became a key publication for those committed to eradicating tobacco-related disease. Although challenged by Big Tobacco and social norms, the Surgeon General’s report fostered a tectonic shift in public health policy, resulting in a dramatic reduction in smoking.

Despite considerable success, smoking remains America’s number-one cause of preventable death. In that regard, the Surgeon General’s report is a living document that is still critical to ongoing tobacco cessation initiatives.

A Time of Change

Although the work of Ernst Wynder, MD, and others had brought public awareness to the negative health effects of smoking (see “Paving the Way for the Surgeon General’s Report,” on page 40), it was a 1962 report by the Royal College of Physicians in Britain that clearly showed cigarette smoking caused lung cancer. Shortly after that report’s release, Luther Leonidas Terry, MD, appointed by President John F. Kennedy as the country’s ninth Surgeon General, established and chaired the Surgeon General’s Advisory Committee on Smoking and Health.

Pouring over the biomedical literature, the committee analyzed more than 7,000 articles related to smoking and disease. On January 11, 1964, after exhaustive work, Dr. Terry released the Surgeon General’s report, concluding that cigarette smoking caused lung cancer and was therefore a serious health hazard that needed remedial action.

The reaction to Dr. Terry’s report was swift. For several days after its release, the report provided headlines for newspapers and lead stories on television news programs across the country. Moreover, the national attention helped galvanize the antismoking dialogue of policymakers on Capitol Hill.

Soon after, the U.S. Congress adopted the Federal Cigarette Labeling and Advertising Act of 1965 and the Public Health Cigarette Smoking Act of 1969. In short, these laws required health warnings on cigarette packages, banned cigarette advertising in broadcast media, and called for an annual report on the health consequences of smoking. For historical perspective, in the early 1960s, more than 50% of U.S. men smoked cigarettes, and of 535 members of Congress, 521 were men. Therefore, a large percentage of the legislators that initiated these antismoking acts were, in fact, smokers themselves.

The enormous publicity generated by the Surgeon General’s report had an unparalleled impact on public health, ending a 6-decade pattern of nearly uninterrupted U.S. cigarette consumption. Despite the addictive nature of tobacco and the formidable economic forces promoting its use, smoking rates have declined annually since 1964; adult smoking prevalence in the 1960s was about 46%, and has since fallen to about 18%. The success of the Surgeon General’s report earned the “recognition of tobacco use as a health hazard” a spot on the Centers for Disease Control and Prevention’s (CDC’s) list of 10 great public health achievements of the 20th century.

Trends in Smoking

The first major shifts in national smoking habits were instigated by two factors unrelated to industry’s intentions to influence tobacco use: World War I and the Great Depression. In pre-WWI America, smoking cigarettes was considered effeminate; most men opted for manlier cigars or pipes. However, cigars and pipes were unwieldy on the battlefields, so cigarettes were supplied in soldier’s rations. When the addicted men returned from the war, cigarette smoking rapidly escalated. Several years later, the Great Depression had a dampening effect on smoking prevalence. The reason was simple economics: jobless people couldn’t afford the habit. These two grand examples of behavior modification demonstrate how events can shape public health.

The Surgeon General’s report accelerated research into contemporary social behavior trends that affect smoking, which provides a powerful tool for creating targeted cessation programs. For instance, a 2008 National Cancer Institute report confirmed that exposure to actors smoking in the movies promotes adolescent smoking initiation; other studies found that viewing celebrities smoking is a catalyst for between one-third and one-half of adolescents starting to smoke.

Studies have also established a strong corollary in how education levels affect smoking trends. A 2012 Gallup poll found that 28% of adults with a high school education (or less) smoke, whereas only 8% of those with a postgraduate education light up, showing a much-needed cessation effort in our less educated populations.

Age is another factor in smoking habits. The same poll found that smoking among young adults is far more prevalent than in older people, with 25% of 18- to 29-year olds smoking, compared with less than 12% of adults older than 65. While epidemiologic studies have multiple factors that affect their results, they give a broad understanding of the socioeconomic elements driving increased smoking in certain populations, which is key to creating effective antismoking programs.

Economics of Tobacco

The CDC estimates that since 1964, tobacco use in the United States is responsible for more than 20 million deaths.  It impossible to separate economics from the devastating health consequences of tobacco use illustrated by CDC’s shocking mortality data.

In a statement commemorating the 50th anniversary of the Surgeon General’s report, ASCO President Clifford Hudis, MD, said, “Unfortunately, tobacco still kills more than 440,000 Americans each year and costs our economy close to $193 billion annually. We must continue to be vigilant in our fight against this deadly addiction. Our efforts to fight the largest preventable cause of death and disability cannot cease or diminish.” The effort to thwart the tobacco addiction that Dr. Hudis and ASCO call for would not only save hundreds of thousands of American lives each year, it would reallocate billions of dollars toward valuable research and drug development.

One stark example of the economics of tobacco is taxation. For example, New York has the nation’s highest per-pack tax of $4.35. The Empire State has seen its smoking rates drop to 16%. By contrast, Missouri has the lowest per-pack tax of $0.17—and 24% of Missourians smoke. Other factors besides cost contribute to the difference in smoking prevalence between states. However, studies show that higher per-pack costs reduces cigarette consumption in two of the heaviest smoking groups: low income and youth.

But efforts to thwart tobacco addiction also have had a long-standing economic nemesis: Big Tobacco. Well before the Surgeon General’s report in 1964, the tobacco industry waged an unending lobbying and public relations campaign to simultaneously promote cigarettes and block any potentially effective antismoking initiative. The most well known of the industry’s efforts was the infamous 1954 “Frank Statement to Cigarette Smokers” published in more than 400 national newspapers, in which Big Tobacco used phony science to purposely deceive the public about the health risks of smoking.

Years later, the release of millions of pages of secret documents exposed Big Tobacco’s big lie, laying the groundwork for class actions such as the landmark 1998 Master Settlement Agreement between the states and the tobacco industry. The monies from the class-action settlements were earmarked for tobacco prevention.

Politics of Tobacco

The tobacco industry has always been a major player in congressional races, especially in Southern tobacco-growing states. Moreover, the industry is notoriously bipartisan in their political donations, and members of both parties have returned the favor by voting for tobacco interests.

“The 2014 Surgeon General’s report provides irrefutable evidence that elected officials hold the key to ending death and disease caused by tobacco use,” Harold P. Wimmer, American Lung Association National President and CEO, stressed in a public statement.

However, former ASCO President Paul Bunn, MD, gave this sobering assessment to The ASCO Post: “It is likely that the authors of the original Surgeon General’s report would not have foreseen the ability of tobacco companies to hinder efforts to eliminate tobacco smoking in the United States and Big Tobacco’s huge success in promoting smoking in underdeveloped nations. The American public can only view this as additional evidence that the Congress can be easily bought by private monies, and that these monies are more important to them than the public health of our citizens or the millions of citizens around the world who will die 10 to 20 years earlier due to their tobacco addiction.”

Speaking with The ASCO Post, Dr. Hudis also commented that American Big Tobacco has had great success at exporting this problem globally. “They successfully challenge labeling and restrictions around the world, sometimes under the guise of the free trade agreements our country signs with others,” he noted.

Although the changing tides of culture, politics, and economics have challenged our efforts to curb smoking, the Surgeon General’s report demonstrated that well directed antismoking programs do reduce the rate of smoking. A recent report in JAMA concluded that between 1964 and 2012, tobacco control was estimated to have saved 8 million premature tobacco-related deaths.¹

Despite vast progress, lung cancer remains America’s number-one cause of preventable death. Therefore, the unequivocal call for action generated by the Surgeon General’s report in 1964 is as powerful today as it was 50 years ago. ■

Disclosure: Drs. Hudis and Bunn reported no potential conflicts of interest.

Reference

1. Holford TR, Meza R, Warner KE, et al: Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964-2012. JAMA 311:164-171, 2014.