Surgeon General’s Report 50 Years Ago Turned the Tide Against Smoking

Saturday marks the 50-year anniversary of perhaps the most important document in U.S. public-health history.

The 1964 report “Smoking and Health, Report of the Advisory Committee to the Surgeon General of the Public Health Service” had a profound impact that led to interventions that likely saved more lives than any other public-health effort in the second half of the last century, and the anti-tobacco fight continues unabated to this day.

The report called cigarette smoking the primary cause of lung and laryngeal cancer in men and chronic bronchitis in both sexes, and associated the behavior with coronary heart disease and emphysema.

“What probably seemed like a ground-breaking announcement a half-century ago is now accepted as common knowledge among most people, which is a big step in the right direction,” said Methodist Dallas Medical Center pulmonologist Arturo Aviles.

Prior to the report, per-capita U.S. adult cigarette smoking had increased annually for six decades. With the report’s release, smoking prevalence promptly did an about-face and has declined steadily since then. The adult smoking rate has been cut by more than half—from more than 42 percent to about 18 percent in 2012. Researchers have estimated that per-capita tobacco consumption would have been five times higher than it was in 2011 without tobacco-control efforts.

It is hard to believe a government report could have that kind of impact today. Americans’ trust in the federal government has plummeted from 68 percent during the Kennedy and Johnson administrations to 22 percent during President Obama’s first term.

Texas and Tarrant County match the 18 percent U.S. smoking rate. Only 12 percent of adults smoke in Collin and Denton counties, and 16 percent do so in Dallas County.

The 50-year effort added nearly 20 years of life to eight million Americans. U.S. death rates from all cancers combined decreased by 1.8 percent a year for men and 1.4 percent annually for women from 2001 to 2010, and researchers credited anti-smoking efforts for the progress.

Despite the success of anti-tobacco interventions, smoking persists especially among those with the least education. In 1966, more than 45 percent of high school dropouts smoked, compared with about 33 percent of college graduates. By 2011, less than 8 percent of college graduates smoked, compared with more than 36 percent of those without a high school diploma. Unfortunately, those smokers also generally occupy the lowest rung of the economic ladder and can least afford to support their habit.

Four proven strategies, if pursued aggressively, could nearly wipe out cigarette smoking. The policies with documented success are: increasing tobacco taxes; expansion of public smoking bans; anti-smoking advertising campaigns; and banning methods of cigarette marketing. The only barrier is the political will to stand up to strong tobacco lobbying efforts.

For example, New England Journal of Medicine researchers estimated tripling tobacco taxes worldwide would reduce the number of smokers by one-third and prevent 200 million premature deaths this century. Although smoking prevalence has decreased worldwide, the number of cigarette smokers has increased in the past 30 years because of population growth.

Smoking merely is considered a “bad habit,” said Tricia Nguyen, MD, Texas Health Resources executive vice president for population health, leading to limited coverage by insurance companies and making physicians less inclined to treat patients. She said tobacco “addiction,” which has a high relapse rate, should be treated as a life-long chronic disease, much like diabetes or hypertension.

David Balis, MD, director of the smoking cessation program at Parkland Health & Hospital System, added: “We know that smoking is the No. 1 preventable cause of death and illness, yet we don’t put the amount of resources and emphasis on smoking cessation or prevention that we should. The medical community needs to put even more effort into getting people to quit smoking. Tobacco is widely available, and even though most people know it’s bad for them, it’s a very, very strong addiction and it’s not simple to quit even when people want to do so.”

The nation’s bars, restaurants, and workplaces could be smoke-free by 2020, according to a Centers for Disease Control and Prevention official. About half of the 50 states have banned smoking in those venues since 2000, when none of the states had such bans.

“It is by no means a foregone conclusion that we’ll get there by 2020,” Dr. Tim McAfee, director of the CDC’s Office on Smoking and Health, said. “I’m relatively bullish we’ll at least get close to that number.”

Arlington and Fort Worth are among 20 of the 50 largest U.S. cities that do not have comprehensive smoking bans. Smoking is banned in Arlington’s restaurants, Cowboys Stadium, the University of Texas at Arlington, and many businesses. However, there are no comprehensive prohibitions for the city’s workplaces and bars. Smoking is prohibited in Fort Worth’s workplaces and restaurants, but not in bars. Dallas has a comprehensive smoke-free prohibition.

Texas has resisted a statewide smoking ban. State Rep. Myra Crownover (R-Denton) and state Sen. Rodney Ellis (D-Houston) have introduced smoke-free legislation for the past four legislative sessions. The House passed the legislation in 2007 and 2011 but the measures never gained traction in the Senate.

November also marked another important milestone: the 1998 tobacco settlement between the four largest tobacco manufacturers and the attorneys general of 46 states. The companies agreed to halt some tobacco marketing activities and pay the states at least $206 billion over 25 years to offset Medicaid healthcare costs in exchange for private tort liability.

Texas was among the first states to file suit against Big Tobacco. The state’s cut of the agreement was $15 billion over 25 years and $2.3 billion through 2003 to Texas counties and hospital districts.

The states collectively are expected to receive $25 billion in fiscal year 2014. According to Campaign for Tobacco-Free Kids, states are spending less than two cents of every dollar in tobacco revenue to fight tobacco use.

“I remember thinking early in my career that if people would just stop smoking, then most of the diseases I treat would be cured,” said Michael Mack, MD, chief of cardiovascular services at Baylor Health Care System. “To a large degree that has come true due in large part to the public health campaign against cigarette smoking. Unfortunately, this public health hazard has largely been supplanted by another one: morbid obesity with the high blood pressure, diabetes and sleep apnea that is caused by it. It is long past time for a new campaign against obesity to match the success of the one against cigarette smoking 50 years ago.”

Steve Jacob is editor-at-large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at steve.jacob@dmagazine.com.

One comment on “Surgeon General’s Report 50 Years Ago Turned the Tide Against Smoking

  1. Leave smokers alone

    The real tragedy here is smokers that have been beaten down for the sole reason of being smokers, thanks to a top-down campaign to cast them aside for the crime of enjoying something some people object to

    by Richard White on 8 January 2014 06:54

    When George Godber spoke at the 3rd World Conference on Smoking and Health in 1975, he gave his vision of the future: “our target must be, in the long-term, the elimination of cigarette smoking…”, he said.

    “We may not have eliminated cigarette smoking completely by the end of this century, but we ought to have reached a position where a relatively few addicts still use cigarettes, but only in private at most in the company of consenting adults… The practice ought to be an enclosed one, not to be endured by the non-smoker in ordinary social intercourse; and no one should be allowed to use advertisement or any indirect means to suggest otherwise.”

    In 1975, the general public would have scoffed at such a notion, but it was the apparent threat of secondhand smoke to non-smokers that gave anti-smokers the golden key to legislation restricting smoking from any indoor area.

    It didn’t matter that the 1992 EPA report first demonstrating harm only managed to do so by cherry-picking studies and lowering the confidence interval – and even then, finding that for every 40,000 worker-years of exposure to omnipresent smoke as in the 1960s, there would be approximately one extra instance of lung cancer – nor that only 15 percent of the studies done on secondhand smoke and lung cancer managed to find any scientifically significant result at all – and even then the results were less “deadly” than wearing a bra.

    With the 2007 blanket smoking ban in the UK, anti-smokers have become ever bolder – pushing for smoking bans in cars, hospital grounds, care homes, even talking about private homes.

    All of this is based on the harm posed from passive smoking, despite the statistically insignificant relative risk only existing for those living or working with smokers for hours on end, day after day, for decades.

    The mantra that secondhand smoke kills thousands a year has continued even though the large prospective studies show otherwise – Enstrom and Kabat found no risk, the WHO found no risk, and now, a new study examined in the Journal of the National Cancer Institute has found no risk, despite the researchers expecting to find one.

    Within the study article, though, comes the admission of its roots in Godber’s 1975 comments – Jyoti Patel, MD, explained that there is only a borderline risk of lung cancer from secondhand smoke, but that “[t]he strongest reason to avoid passive cigarette smoke is to change societal behavior: to not live in a society where smoking is a norm”.

    And therein lies a chilling message: puritans, with the full backing of the medical establishment, will fabricate health risks to make sure we aren’t doing what they don’t think we should be doing – regardless of the consequences for families and businesses.

    It was a given that smoking bans would not pass on that basis, though – health needed to be put at risk to get people to listen. The fabrication is based on distorting science and using weak study models that produce biased results.

    Case-control studies depend on people’s recall of smoking exposure 30 or 40 years in the past and are so unreliable they were rejected in the original 1964 Surgeon General’s Report. To lift an excerpt from my own book: “remembering how many cigarettes someone smoked thirty years ago is not an easy task and there is no way the response can be accurate.

    In fact, in the 1964 Surgeon General’s Report the authors rejected the retrospective studies and focused on the remaining studies; it speaks volumes that forty years on the medical establishment now accepts flawed methodologies that were rejected in the past for being unreliable.”

    Knowing that the real purpose of showing harm from secondhand smoke was to push forward an agenda to marginalise smoking, it stands to reason that retrospective studies were so fervently conducted – while prospective studies take many years to do, retrospective studies can be conducted quickly, frequently and show anything the researchers want them to.

    In no time at all, then, a large body of so-called evidence can be amassed, before the first prospective study comes in – so by the time the first, second and third turn up to show the risk of harm has been blown up out of all proportion, anti-smokers are popping the corks in their (presumably non-alcoholic) champagne in celebration of the bans they’ve succeeded in passing.

    Yet amidst all this, no one bothered to ask what secondhand smoke actually is. Sure, the smoke on one end is the same as the smoke on the other, but dilution was never considered.

    We know that ‘the poison makes the dose’ and that’s why there are safe limits to anything (including water, as anyone who has observed the amusing Dihydrogen Monoxide satire can attest, as even something as necessary as water can be painted to be a societal burden and mass killer), but few cared about the effects of dilution on smoke.

    It’s a crucial point though, not least because a non-smoker with long-term exposure to a smoker’s passive smoke will consume only in the region of five cigarettes per year.

    Michael McFadden devoted his attention to the properties of secondhand smoke in his book Dissecting Antismokers’ Brains: “about 90 percent of secondary smoke is composed of water and ordinary air with a slight excess of carbon dioxide.

    Another 4 perecent is carbon monoxide, a gas that can act as a poison when in sufficient quantity by reducing the amount of oxygen your red blood cells can carry. The last 6 percent contains the rest of the 4,000 or so chemicals supposedly to be found in smoke… but found, obviously, in very small quantities.

    “Most of these chemicals can only be found in quantities measured in nanograms, picograms and femtograms. Many cannot even be detected in these amounts: their presence is simply theorized rather than measured. To bring those quantities into a real world perspective, take a saltshaker and shake out a few grains of salt. A single grain of that salt will weigh in the ballpark of 100 million picograms!”

    Had the public (or politicians, perhaps) known such information it is doubtful that smoking bans would have passed on the basis of risk to health – after all, if a spouse living with a smoker is consuming five cigarettes in an entire year, how many are (or in the British case, were) being consumed by a person sitting in a bar for a few hours?

    It’s the families that have suffered huge rifts through fear, the businesses that have shut down, the elderly and terminally ill pushed outside in the depth of winter.

    All of which happened while we were watching X-Factor and celebrating what a civilised country we live in.
    Maybe – just maybe – this study, combined with those before it, and the justified attention on the issue, can mark the start of the tide turning to an inclusive society, where we don’t bully and ostracise people for not behaving exactly how we want them to.

    The real tragedy here is smokers that have been beaten down for the sole reason of being smokers, thanks to a top-down campaign to cast them aside for the crime of enjoying something some people object to.

    Richard White is the author of Smoke Screens: The Truth About Tobacco and owner of Word Edit: Professional Literary Services

    Reply

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