Last week marked the fiftieth anniversary of the landmark 1964 publication of the U.S. Surgeon General’s report on smoking and health. The 386-page document detailed the link between cigarette smoking and a number of diseases, including emphysema, chronic bronchitis, and coronary heart disease. Crucially, it stated in unambiguous, unadorned language the causal link between cigarette smoking and lung cancer. The average smoker was nine to ten times more likely than a non-smoker to develop lung cancer; for a heavy smoker, the risk rose to twentyfold. Smoking, moreover, hastened death. “Cigarette smoking,” the report read, “is associated with a 70 percent increase in the age-specific death rates of males, and to a lesser extent with increased death rates of females.” The greater the number of cigarettes smoked, the higher the death rate.
I grew up in a time when smoking was both accepted and widespread. I remember pulling on the glass knobs of cigarette vending machines in restaurants, coughing my way through smoke-filled transatlantic flights, and catching a hazy glimpse of my junior high school English instructor taking a smoke break in the teachers’ lounge between classes. I surveyed the cigarette advertisements that filled the pages of magazines delivered to our house, pondering the rugged masculinity of the Marlboro Man and the self-conscious, flapper-era feminism of the Virginia Slims women. In the 1970s, my parents, both nonsmokers by that point, kept an ashtray in the living room for the convenience of any guests who wished to light up.
The 1964 Surgeon General’s report was the work of a ten-member advisory committee made up of men from various medical fields. It included a surgeon, a pulmonary specialist, a bacteriologist, and a toxicologist. Appointed by Surgeon General Luther Terry, the group met at the National Institutes of Health in Bethesda, Maryland for over a year to review more than 7,000 articles on tobacco and disease. At the time, 42 percent of Americans smoked. Terry was so worried about the potential repercussions to the economy, given the report's negative findings, that he scheduled his press conference on a Saturday morning to minimize the effect on the stock market.
The association between smoking and disease documented in the report was not new. Epidemiologists had been exploring the link since the 1930s; their work established causal inference as an acceptable standard of proof and transformed what constitutes adequate knowledge in medicine and public health. In 1957, the previous Surgeon General, Leroy Burney, had noted the increasing implication of excessive cigarette smoking in the causation of lung cancer. But the comprehensiveness of the 1964 study and the overwhelming weight of the evidence were so convincing that Terry, a smoker himself, switched from cigarettes to a pipe in the months before the report was released, believing the latter to be less harmful. Another member of the committee quit altogether. A third, the heaviest smoker of the group, was diagnosed with lung cancer less than a year later and underwent surgery to remove a lung.
It was less the findings of the 1964 report than the publicity surrounding its release that catapulted the issue of tobacco use to the forefront of American public health. In the months following, smoking rates plummeted immediately—and temporarily—by 15 percent, a measure of the gravity with which the news was received. It raised the specter of lung cancer in the public consciousness, laying the groundwork for decades of legislation restricting the use, sale, and advertising of tobacco products. From the placement of warning labels on cigarette packages and constraints on television advertising to curbs on indoor smoking and limitations on sales to minors, it changed public opinion about smoking and generated pressure for politicians to act. It also strengthened the resolve of tobacco companies to create doubt about the link between smoking and serious disease. Until its dissolution under the terms of the Tobacco Master Settlement Agreement in 1998, the tobacco industry continued to dispute the scientific evidence by funding its own studies through its research arm, the Tobacco Industry Research Committee.
In my lifetime, I have seen the ways in which cultural attitudes toward smokers have shifted. No longer viewed as rebellious or sophisticated, the act of smoking has increasingly been vilified as smokers have been exiled from bars and shunted from entire offices to single rooms to the outdoors, where they huddle in doorways as they maintain their addiction. But while the luster and influence of the tobacco companies have dimmed, they have not disappeared. Today, 19 percent of Americans continue to smoke, or about 43 million people. Smoking remains the leading preventable cause of death and disease in the U.S., and rates are increasing in China and other parts of Asia as corporations search for new markets, preferably ones with fewer restrictions on the sale and advertising of their products.
Perhaps the most significant legacy of the 1964 report, in addition to the lives saved through anti-smoking measures, has been the promotion of an ideology of individual liberty regarding public health. After the U.S. began to require warning labels on cigarette packages, tobacco companies sought to portray smokers as adults whose freedom to indulge in the habit was being unfairly infringed upon. According to this line of thinking, the decision to smoke was a matter of personal choice, and the government shouldn’t be allowed to restrict someone’s ability to engage willingly in unhealthy behavior. If an individual knew the risks of smoking and still wanted to light up, then he should have the right to do so and bear whatever consequences might befall him. As public health agencies today struggle to enact laws limiting the size of sugary beverages and requiring calorie counts on restaurant menus, we can look to the previous fifty years of tobacco control for antecedents both to these attempts to regulate our behavior and to our understanding of their cultural meaning.
Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: U.S. Department of Health, Education, and Welfare, 1964. Full text at http://profiles.nlm.nih.gov/ps/access/NNBBMQ.pdf.
Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America. New York: Basic Books, 2007.
Background on the 1964 report from the National Library of Medicine at http://profiles.nlm.nih.gov/ps/retrieve/Narrative/NN/p-nid/60.
Current statistics and other data on smoking from the Centers for Disease Control at http://www.cdc.gov/tobacco/data_statistics/index.htm.