Confronting America’s Smoking Pandemic, Part 2: 1967–1985

In Washington, DC, recent law school graduate John F. Banzhaf, III, files a petition with the Federal Communications Commission (FCC) to apply the Fairness Doctrine to broadcast cigarette commercials (such as the televised Marlboro advertisement shown in this slide) and thus grant equal time for anti-smoking advertisements. The FCC agrees, and its ruling is upheld by the US Court of Appeals. Anti-smoking ads, such as those developed by the American Cancer Society, appear more frequently on TV and radio. In 1969, the tobacco companies announce they will end TV cigarette ads if Congress gives them an anti-trust exemption so they will not be accused of collusion.

Keynote speaker Senator Robert F. Kennedy (D–NY) calls on TV networks to broadcast more anti-smoking advertisements, urges government and private employers to ban smoking in the workplace, and warns that cigarettes with lower tar and nicotine may not be safer.[1] He notes, “At present rates, one seventh of all Americans now alive-about 28 million people-will die prematurely of diseases associated with cigarette smoking...Each year cigarettes kill five times more Americans than do traffic accidents...The cigarette industry is...dealing in people’s lives for financial gain...The industry we seek to regulate is powerful and resourceful. Each new effort to regulate will bring new ways to evade...Still, we must be equal to the task. For the stakes involved are nothing less than the lives and health of millions all over the world.”

The Great American Smokeout becomes a nationwide program in 1977 and remains an annual event held on the third Thursday in November, promoted by the ACS and city government anti-smoking groups, as shown on this recent cover of the free tabloid newspaper am New York.[2]

Speaking at a convention in Los Angeles a few weeks after President Nixon had announced a “war on drugs,” Dr. Steinfeld says, “Smokers have to their so-called right to smoke, which I would redefine as a ‘right to pollute.’ It is high time to ban smoking from all confined public places such as restaurants, theaters, airplanes, trains, and buses. It is time that we interpret the Bill of Rights for the nonsmoker as well as the smoker.”[3]

The Minnesota Clean Indoor Air Act, introduced by Representative Phyllis Kahn, is the first statewide law in the US requiring separate smoking areas in public places. The Association for Nonsmokers–Minnesota (ANSR), founded by Jeanne Weigum, MSW, mobilizes public support for the law, and continues to be at the forefront of creating tobacco-free environments.

In the mid 1970s, Donna Shimp, of Salem, NJ, sues her employer, New Jersey Bell Telephone Company, for the right to be free from exposure to secondhand smoke in her workplace. The company had banned smoking around sensitive telephone equipment but not around fellow employees. The ruling in her favor by the New Jersey Superior Court leads to the prohibition of smoking in the company’s offices and customer service areas.[4] In other efforts to protect the rights of nonsmokers, California Group Against Smoking Pollution is founded as a nonprofit corporation. The organization becomes a national resource for clean indoor air legislation (and in 1988 becomes Americans for Nonsmokers’ Rights).[5] Pioneering GASP groups established in the 1970s include those in Maryland, Massachusetts, New Jersey, and Colorado, as well as similar grassroots organizations such as Seattle’s FANS (Fresh Air for Nonsmokers).

DOC, Doctors Ought to Care, pioneers in the purchase of counter-advertisements in the mass media-including billboards, bus benches (see ‘Country Fresh Arsenic’), radio, TV, newspapers, magazines, and posters for schools and physicians’ offices (for example, the ‘I smoke for smell’ satire on ‘I smoke for taste,’ an ad for Winston cigarettes)-to parody brand names and cigarette ads and to mock tobacco companies. The group leads the first protest demonstrations against tobacco sponsorships of sports and the arts, and over the next 20 years makes satirical street theater “house calls” at dozens of cigarette company–sponsored events and institutions, including the Virginia Slims tennis tournament (renamed “The Emphysema Slims” by DOC), the Benson & Hedges 101 Film Series (renamed “Benson and Heart Attacks”), the Marlboro Country Music Festival (renamed “Barfboro”), the Miami Herald, the Metropolitan Museum of Art, the Houston Museum of Fine Arts, the California State Fair, and numerous Major League Baseball stadiums with cigarette billboards. On its 25th anniversary in 2002, DOC’s national office closes. However, local chapters of DOC remain active at several medical schools, and an offshoot of DOC, “Tar Wars,” is adopted by the American Academy of Family Physicians as its national anti-smoking education program for elementary schools.[6]

Califano points out that in the previous year, smoking was a major factor in 220,000 deaths from heart disease, 78,000 from lung cancer, and 22,000 from other cancers. “Smoking adds between $5 and $7 billion to health-care costs,” and costs between $12 and $18 billion in lost productivity, lost wages, and absenteeism. The Tobacco Institute rebuffs the Secretary in newspaper ads and distributes bumper stickers that say, “Califano is dangerous to your health.” In August of 1978, in an effort to mitigate falling support of the administration in tobacco-growing states (and the impact of a tobacco­-industry funded 14-year research program by the American Medical Association that confirmed the conclusions of the 1964 Surgeon General’s Report), President Carter visits North Carolina and pledges to have “an accurate and an enlightened education program to make the smoking of tobacco even more safe than it is today...” President Carter asks for Califano’s resignation in July 1979.

Eleven years later, the Surgeon General’s 1988 report, The Health Consequences of Smoking: Nicotine Addiction, describes the pharmacologic basis of tobacco addiction and arrives at three major conclusions: (1) Cigarettes and other forms of tobacco are addicting; (2) nicotine is the drug in tobacco that causes addiction; and (3) the pharmacologic and behavioral processes determining tobacco addiction are similar to those determining addiction to heroin and cocaine.[7] The addictive nature of tobacco use and nicotine is subsequently discussed in the Diagnostic and Statistical Manual of Mental Disorders, beginning in 1994.

The same year as US Surgeon General Dr. Julius Richmond's report,[8] the American College of Chest Physicians adopts the following pledge for all of its members: “As a fellow of the American College of Chest Physicians and a leader in the most important struggle faced by healthcare professionals, the prevention and control of our major health problems of lung cancer and cardiovascular and chronic pulmonary disease, I shall make a special personal effort to control tobacco use and to eliminate this hazard from my office, clinic, and hospital. I shall ask all my patients about their use of tobacco, and I shall assist the tobacco user in eliminating this deadly habit. I make this pledge to my patients and to society.”[9]

The tobacco industry spends more than $1.1 million in mass media advertising (a national record for a county referendum), compared with the proponents’ mostly $5,000 bumper-sticker effort. The American Lung Association, the American Heart Association, and American Cancer Society provide virtually no assistance. On May 9, the ordinance is defeated by 820 votes out of more than 192,000. On November 8, 1983, voters in San Francisco pass Proposition P, a referendum on the city’s workplace smoking ordinance, then the strongest such law in the nation. The final tally is 80,740 to 79,481-a remarkable victory in light of the $1.25 million spent by the tobacco industry, compared with $3,300 by proponents, led by Californians for Nonsmokers’ Rights.

Twenty-five years later, in 2005, Neuman, Bitton, and Glantz reveal extensive efforts by the tobacco industry to prevent DSM-III committee chair Robert L. Spitzer, MD, from including tobacco dependence.[10]

In 2005, Westin Hotels & Resorts becomes the first major American hotel chain to go smoke-free when it bans smoking at all 77 of its properties and adds a $200 cleaning fee to the bill of anyone who violates the policy. By 2013, the American Hotel & Lodging Association reports that two-thirds of hotels are smoke-free, although only 39% of economy hotels have banned smoking.

Subsequent reports issued by Dr. Koop include those showing that smoking causes even more deaths from heart disease than from cancer (1983) and that cigarette smoking accounts for most deaths from chronic obstructive pulmonary disease (1984). The tobacco industry contests these findings. [11]

In 1988, Dr. Cullen launches the Community Intervention Trial for Smoking Cessation (COMMIT), a 4-year community-based intervention in 11 matched cities to help heavy smokers (those consuming more than 25 cigarettes per day) aged 25 to 64 to stop smoking. The intervention, from January 1989 to December 1992, does not have a significant impact on smoking prevalence compared with non-intervention cities, although smoking does decline by 3% in both, in keeping with the national trend.[12]

The image shows the cover of a school curriculum that Dr. Glantz and colleagues developed to accompany showings of the film to an estimated 1 million school children.[13]

The lawsuit, Cipollone v. Liggett Group, Inc., accuses the tobacco companies of having misrepresented the risks of smoking in their advertisements. Judge Lee Sarokin rules in favor of the plaintiff as reported in a June 1983 front-page article in this Greenville, SC, newspaper, but the verdict is overturned on appeal. In 1988 a second trial, before a jury, results in a $400,000 award to plaintiff Cipollone’s family, but it is nullified by an appeals court. Nearly a decade later, in 1992, the US Supreme Court holds that the Surgeon General’s warning does not preclude lawsuits against tobacco companies.

The journals’ mix of original research, economic and legislative analyses, investigative reporting, and illustrated articles on tobacco marketing and anti-smoking activism inspires the creation in 1992 of a new journal Tobacco Control, published by the British Medical Journal, edited by Ronald Davis, MD, (former director of the CDC’s Office on Smoking and Health) and deputy editors Simon Chapman, PhD, and Dr. Blum. Chapman becomes editor in 1998, and Ruth Malone, PhD, RN, takes over the position in 2009.

In 1992, the nicotine patch (Nicoderm, among others) is approved by the FDA. Both the gum and the patch, now known as nicotine replacement therapy, are approved for over-the-counter sale in 1996, and by 1998 the nicotine patch accounts for half of the pharmacologically assisted quit attempts.[14] Two oral pharmacologic medications, bupropion (Zyban) and varenicline (Chantix), are approved by the FDA for smoking cessation in 1997 and 2006, respectively.[15] In 2009 the FDA requires a black-box warning in the prescribing information for these two medications, to highlight the risk of serious mental health events associated with use of the drugs, including changes in behavior, depressed mood, hostility, and suicidal thoughts.[16]