With Rob Waters
Fifty years ago this week, Surgeon General Luther Terry released perhaps the most important public health document in U.S. history, the now-famous first Surgeon General's Report on Smoking and Health. It made explicit and public what virtually every scientist not on the payroll of the tobacco companies knew and acknowledged: that smoking cigarettes was deadly.
At the time, cigarettes cost about 35 cents a pack, 42 percent of American adults smoked and people lit up just about everywhere -- on airplanes, in restaurants and bars, even in doctor's waiting rooms. And more than 300,000 Americans were dying of lung cancer and other tobacco-related causes each year.
Flash forward 50 years and the landscape has changed dramatically. The percentage of adults who smoke has dropped by more than half, to 19 percent. The average cost of a pack of cigarettes is more than $5.60. And the rate of deaths has dropped dramatically.
New research just released in the Journal of the American Medical Association finds that tobacco-control efforts since 1964 kept 8 million people from dying prematurely. The decline in smoking has added 2.3 years to the average lifespan of American men and 1.6 years to the lifespan of American women. If those number sound modest, consider this: Each of the 8 million people spared a premature death because they never smoked, or quit smoking early, gained, on average, almost 20 years of life.
The anniversary of the Surgeon General's report is generating lots of media coverage tracking these changes, trends that are worth celebrating and understanding more deeply. But it's also important to note that these changes didn't happen solely as a result of the report itself, or the education efforts that came in its wake. It took policy changes, first small ones in a few places, then bigger ones in more places, to finally produce a groundswell.
In the early 1980s, I worked on the first multi-city no-smoking laws in the U.S., as director of prevention for the health department of Contra Costa, a politically moderate county east of San Francisco. We knew tobacco was a major cause of chronic disease and formed a local coalition that included the American Cancer Society, American Heart Association and American Lung Association, highly credible organizations whose boards included influential doctors and donors. This was lesson one -- the importance of building coalitions.
When we launched our efforts to ban smoking, many people said it would be impossible. Smoking was the norm, both acceptable and unrestricted. Many considered the tobacco industry too big to fight. Yet we were determined to influence smoking habits and believed that altering policy was the key.
Our initial goal was modest: to ban smoking in 40 percent of the seating in restaurants. By itself, of course, that wouldn't end lung cancer, heart disease, or emphysema. Yet it had a huge impact because each modest victory changed the status quo and spurred efforts for more sweeping change. Soon, communities across the country were passing laws that banned smoking in 50 percent of each restaurant, then 80 percent, then 100 percent. Next, we were regulating smoking on airplanes, in public buildings, and eventually in bars and on beaches. This is lesson two -- the importance of policy change.
These local smoking-control ordinances were combined with state and federal efforts to increase tobacco taxes. The taxes not only made cigarettes more expensive, dampening demand, they helped fund advertising campaigns warning people of the dangers of cigarettes and supported smoking quitlines. Together, this multipronged effort to change policy, backed by a powerful communications and educational strategy, created a snowball of change that transformed norms and expectations around smoking. Lesson three -- create campaigns that are multifaceted.
At every step, we faced the determined and deep-pocketed resistance of Big Tobacco -- just as advocates working today to pass taxes or marketing restrictions on soda and junk food face powerful, high-budget opposition from the food and beverage industries. Of course, one tactic always used by industry in opposing policy change is to coopt its leaders. In my case, that moment came at a lunch meeting I cautiously accepted with the state's top tobacco lobbyist, who offered to supply our county with all the child-safety car seats we wanted if we dropped our tobacco policy work. Lesson four -- expect and beware of efforts to coopt.
As we consider and celebrate these victories, we must also remember how far we have to go. Today, while the rate of smoking has dropped, it remains the leading cause of preventable death, claiming the lives of 440,000 Americans each year. Eight million Americans live with at least one serious chronic disease from smoking, and people of color and with lower incomes remain at higher risk. The cost to the U.S economy is $193 billion a year, half of it in direct medical costs. Tobacco companies continue to market their deadly products, focusing on the most vulnerable by pitching menthol cigarettes to African Americans, using flavored e-cigarettes to hook young people, and unconscionably trying to hold back attempts at regulation in the countries of the developing world. And that leads to lesson five -- keep up the fight (and we've only just begun).
Image credit: Anti-smoking ad, Wikipedia.