On January 11, 1964, at a packed press conference at the State Department in Washington, DC, US Surgeon General Luther L. Terry released what would become one of the most important and most widely quoted documents in the annals of medicine: Smoking and Health—Report of the Advisory Committee of the Surgeon General of the Public Health Service.
“Few medical questions have stirred such public interest or created more scientific debate than the tobacco–health controversy,” noted Dr. Terry. But the findings of the year-long study by the 10-member committee were blunt and unequivocal. Principal among the conclusions was that “cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking far outweighs all other factors.” Moreover, the report emphasized that smoking “is a health hazard of sufficient importance to warrant appropriate remedial action.”
Fifty years after the Surgeon General’s landmark report, the health and economic toll taken by smoking remains devastating. Dr. Terry’s 1964 indictment of cigarettes as the principal cause of lung cancer should have marked the beginning of the end of the Marlboro Man. But far from riding off into the sunset, the tobacco industry has more than met the challenge of maintaining the nicotine addiction of nearly 50 million Americans. The tragic result is that cigarette smoking is still the nation’s number one avoidable health problem, accounting for 440,000 deaths a year. Although adult cigarette smoking prevalence in the United States has been cut in half since 1964, to 20% of the population, approximately the same number of Americans smoke, and the cohort of smokers is younger.
Those with the lowest income and least education are most likely to light up. Approximately 40% of individuals who lack a high school diploma smoke, compared to 10% of those with a college degree. It is abhorrent that Philip Morris (now called Altria), the manufacturer of Marlboro, the nation’s and the world’s leading cigarette brand, continues to be welcomed with open arms by career centers at dozens of US universities, where the company recruits students at campus job fairs for positions as Territory Sales Managers to stock Marlboro cigarettes in convenience stores, supermarkets, and drugstores. These include CVS, Walgreens, and Rite-Aid, which claim to be partners in healthcare. Two-thirds of the nation’s 56,000 pharmacies are now owned by such drugstore chains, nearly all of which still sell cigarettes.
Health organizations praised CVS effusively for its surprise announcement in February that it would phase out cigarette sales within the year in its 7,600 drugstores. The Campaign for Tobacco-Free Kids, a Washington, DC, anti-smoking lobbying group, even called the move “courageous.” What nonsense! Over the past three decades, CVS and its rivals have swallowed up thousands of locally owned, independent, community pharmacies, most of which had long ago stopped selling cigarettes or had never sold them to begin with because tobacco products are antithetical to the healthcare role of the pharmacist. Meanwhile, these chains had rebuffed repeated calls over the years from medical activists to remove tobacco products from their shelves. The real reason CVS will stop selling cigarettes is the company’s rapid expansion into a broad range of health services, notably walk-in clinics staffed by nurses and physicians. To continue to sell cigarettes in this setting is hypocrisy that even hard-boiled smokers would not fail to notice.
Contrary to popular belief, the 1964 Surgeon General’s Report did not mark the beginning of our knowledge about the devastating impact of cigarette smoking on health, but rather the moment when the government put an end to all doubt about the cause of the rising epidemic of lung cancer. It should also have marked the beginning of vigorous government action against smoking, but this did not occur.
In fact, robust research warning against the dangers of smoking had been available 25 years earlier. In 1939, a review of the relationship between smoking and lung cancer—a comprehensive study with more than 400 references—was published by Ochsner and DeBakey. They had observed for several years that their patients with this once-rare condition had all started smoking as soldiers during World War I, when they had been given cartons of cigarettes by the Red Cross and other health organizations. Yet Dr. Ochsner’s vocal anti-smoking advocacy in the 1940s was met with indifference or derision by fellow physicians, more than two-thirds of whom smoked. His 1954 book, Smoking and Cancer: A Doctor’s Report (Figure 1), was negatively described in the March 1955 issue of the American Journal of Public Health, with the reviewer opining that, while “written...by an outstanding surgeon,” the causal relationship between cigarettes and cancer “is not proved,” adding, “This reviewer plans to place this book in the nonscience section of his library.”
Epidemiologic studies by Hill and Doll in the United Kingdom and Wynder and Graham, Levin, and Hammond and Horn in the United States in the late 1940s and early 1950s elucidated the causal role of cigarette smoking in lung cancer. Dancing around this evidence, tobacco companies competed to promote the “safest” cigarette brands. R.J. Reynolds claimed in certain advertisements that “more doctors smoked camels” (Figure 2). P. Lorillard created the Micronite filter for Kent that was made of an unnamed substance “so safe, so pure, it’s used to filter the air in many hospitals.” That substance was asbestos.
The Journal of the American Medical Association (JAMA) accepted such cigarette advertisements until 1954, and tobacco companies remained sponsors of some state medical association meetings—where they gave out cartons of cigarettes and other gifts to doctors—until the mid-1980s (Figure 3). (With few exceptions, hospitals did not prohibit smoking until the 1990s, and then only because the Joint Commission for the Accreditation of Hospitals [JCAH] finally mandated this policy; the American Hospital Association had simply turned a blind eye to the issue until the JCAH policy became effective.)
In the 1960s and 1970s, when smoking was implicated as the major avoidable cause of emphysema and heart disease, cigarette manufacturers invented “low-tar” and “light” cigarettes. Yet filtered, low-tar, light, and ultra-light cigarettes, or those infused with menthol (an anesthetic), are not safer in any way. At the same time, beginning in 1968, Philip Morris co-opted women’s liberation slogans to run successful marketing campaigns promoting Virginia Slims (Figure 4).
The implied health claims of all cigarette brands were found to be fraudulent in August 2006 by federal judge Gladys Kessler, who ruled that Philip Morris, R.J. Reynolds, Brown & Williamson, and other tobacco companies had engaged in racketeering—and decades of deceiving the American public. Yet even today no major health organization has made it clear to the public that the filter is a fraud. Filtered brands, the choice of more than 95% of cigarette smokers, not only fail to confer a scintilla of reduced harm but also actually increase the risks of heart disease and emphysema because smokers tend to compensate for the presence of a filter by inhaling more deeply to get the desired nicotine effect.
Upon publication of the Surgeon General’s Report, Senator Maurene Neuberger (D–Ore.) urged the American Medical Association (AMA) to join with other health organizations such as the American Cancer Society (ACS) in taking a strong stance against cigarette smoking. But rather than assuming a leadership role in such a campaign, the AMA entered into a $10 million contract with six cigarette manufacturers to conduct more research on smoking—with the aim of creating a safer cigarette. Such acquiescence enabled the tobacco industry to perpetuate the myth that there was still doubt about smoking as a major cause of death and disease. Meanwhile, from the 1950s through the 1990s, while tobacco industry scientists and executives were testifying before Congress and issuing reports claiming that the association between cigarette smoking and lung cancer was merely statistical, the industry’s own researchers and officials were acknowledging in internal memoranda that smoking caused cancer.
In 1978 the AMA published Tobacco and Health, a summary of its research projects funded by the tobacco industry, which confirmed the findings of the 1964 Surgeon General’s Report on smoking and lung cancer and cemented the association between smoking and heart disease. However, the tobacco industry had succeeded in stifling any AMA action on smoking for 14 years. Well into the 1980s, the AMA was known more for its silence on smoking than for courage in confronting the tobacco industry. In a 1982 memo, the then-editor of JAMA cautioned the journal’s editorial staff to “exercise appropriate caution in our JAMA publications on tobacco and control of tobacco use, nuclear war, and abortion.” In providing this “preventive advice,” he noted that “sensitivities are particularly high prior to the meetings of the Board of Trustees and the Annual and Interim Meetings of the House of Delegates.”