On Jan. 11, 1964, Surgeon General Luther Terry dropped a bomb on the tobacco industry and the American public. He announced that smoking caused lung cancer. This marked the beginning of a crusade to reframe a national pastime that was deeply ingrained in the cultural fabric of the country, fueled by an unimaginably powerful industry and subsidized by the government. The battle that ensued contains the elements of a great novel: money, greed, manipulation, addiction, freedom, denial, social upheaval, disease and death, all in operatic proportions. It is a story of both the remarkable potential of public health policy and an unresolved problem.
On that day, a habit of 42.7 percent of Americans was identified as the single greatest preventable cause of disease and death. It is difficult to imagine the impact of this news half a century later. The United States Public Health Service chose a Saturday for the press conference in order to minimize the effect on financial markets and maximize coverage in the Sunday papers.
The impetus for the report was driven by a group of private health organizations. In 1961, the American Cancer Society, American Heart Association, National Tuberculosis Association, and American Public Health Association called for President Kennedy to form a national commission to address the issue of smoking and health. Studies linking smoking to premature death, heart disease and lung cancer had begun to appear in the medical literature in the 1920's.
By 1962 a committee including the above organizations and the Food and Drug Administration, Federal Trade Commission, American Medical Association and Tobacco Institute (lobby for tobacco industry) was assembled. After two years of scrutinizing the scientific literature, Terry issued his report. The description of deleterious effects of smoking on health included a 70 percent increase in the mortality rate of smokers over non-smokers, a 9- to 10-fold risk of developing lung cancer compared to non-smokers, and at least a 20 fold risk for heavy smokers. The report explained that this risk rose with the duration of smoking and diminished if one stopped. It also drew a causal connection between smoking and chronic bronchitis, emphysema and heart disease. Smoking during pregnancy was reported to lower the weight of newborns. Because the addictive properties of nicotine had not yet been appreciated, the "tobacco habit" was described as a habituation, not an addiction.
There is no question that Terry's report was heard. In 1958 a Gallup survey indicated that 44 percent of the population believed that smoking caused cancer. By 1968, that number had grown to 78 percent. One year after the Surgeon General's report, congress passed the Federal Cigarette Labeling and Advertising Act. This required all cigarette packs to carry the warning, "Caution: Cigarette Smoking May Be Hazardous to Your Health." This law was finally implemented in 1971 in addition to a ban on cigarette advertising on television and radio.
These early steps put an end to the consistent upward trend in American smoking that had started at the beginning of the 20th century. In 1986 the surgeon general's report documented the dangers of second hand smoke paving the way for a growing number of states to adopt clean indoor air legislation. In 1988, Surgeon General C. Everett Coop declared tobacco use an addiction, identifying nicotine as the primary addictive ingredient. This helped diminish the credibility of the tobacco companies' claim that smoking was a free choice rather than a drug dependency. Coop compared nicotine to heroin and cocaine. This rightsizing of tobacco was unimaginable just a decade or two earlier.
The tobacco industry countered with criticism of the science behind the health warnings and new advertising campaigns directed at the young, women and Blacks. Their persistence has not diminished. In 2011 tobacco companies spent $8.8 billion on cigarette and smokeless tobacco marketing in the U.S. alone, more than $24 million per day.
The success of these ad campaigns is not subtle. Each day, more than 3,000 people under the age of 18 smoke their first cigarette and another 2,100 young people move from occasional to daily smoking. Although there has been a dramatic decrease in the prevalence of adult smoking in the United States (from approximately 42 percent in 1965 to 18 percent in 2012) higher rates continue to plague the poor and least educated. 45.3 percent of adults with a GED diploma are smokers, compared to 9.3 percent of those with an undergraduate college degree. About 29 percent of people who live below the poverty level smoke.
Perhaps the most dangerous aspect of smoking in America is the perception that it is no longer a problem. The reality is that progress in decreasing the death toll caused by smoking has stalled. Smoking remains the most powerful preventable health risk. Some 70 percent of the 42 million American smokers want to quit. Tobacco-related deaths approach half a million per year in the United States. The economic costs of tobacco now exceed $289 billion annually.
While the use of military metaphors in healthcare often seems inappropriate, here it is particularly apt. The battle with tobacco has claimed 10 times the number of Americans killed in all our wars combined. If the current trends continue, 5.6 million children alive today will die prematurely due to smoking.
The recently released Surgeon General's report, "The Health Consequences of Smoking -- 50 Years of Progress," adds diabetes, rheumatiod arthritis and errectile dysfunction to list of diseases associated with smoking. It acknowledges how far we've come and how far we have to go. It is a call to arms and defines the specific goal of creating a society free of tobacco-related disease and death.
We have gotten wiser about what works. Increasing the cost of cigarettes, promoting smoke-free indoor policies, disseminating high impact media campaigns to counter the still formidable tobacco industry marketing, and facilitating access to smoking cessation programs have all proven effective. These efforts need to be reinvigorated.
The tobacco battlefield is complex and dynamic. The tobacco industry has proven remarkably adept at maintaining their markets. This has been accomplished in large part by attracting young people. Recent surveys indicate that more youth are using multiple tobacco products. The percentage of middle and high school students using electronic cigarettes more than doubled between 2011 and 2012.
If we are to win the tobacco battle the arbiters of social norms must come on board. Smoking in American movies has increased over the past two years. Research has indicated that youth who are exposed to smoking in movies are more likely to smoke. Those with the most exposure are about twice as likely to smoke.
So how are we doing 50 years down the road? As Phillip Morris said in their Virginia Slims ad, attempting to attract female smokers by tapping into the women's liberation movement, "You've come a long way, baby." But the truth is tobacco remains a formidable problem, baby.