SAN DIEGO — Fifty years after the landmark report from the Surgeon General of the United States sounded the alarm over the health risks of smoking, half as many Americans are smoking, but far too many are still dying prematurely from avoidable smoking-related causes.
Experts commemorating the fiftieth anniversary of the report here at the American Association for Cancer Research (AACR) 2014 celebrated the progress that has been made, but emphasized that much remains to be done.
"Tobacco is the largest preventable cause of death," said Roy Herbst, MD, PhD, chief of medical oncology at the Yale Cancer Center in New Haven Connecticut. About 480,000 Americans die prematurely each year from tobacco use, he reported.
"Hit the Country Like a Bombshell"
The 1964 report heralded the beginning of a dramatic change in the United States — from smoking being accepted as a social norm to becoming a social stigma.
According to US Surgeon General Luther Terry, the physician responsible for the report, the news "hit the country like a bombshell. It was front-page news and the lead story on every radio and television station in the United States, and many abroad."
Dr. Herbst noted that even though smoking has declined in the United States by more than half since 1964, nearly 20% of Americans still smoke. And the cost to society is about $280 billion a year in healthcare and lost productivity.
According to the Centers for Disease Control and Prevention, about 20 million people have died from smoking-related illnesses since 1964, and the list of diseases associated with tobacco use continues to grow. In addition, 2.5 million nonsmokers have died from conditions caused by exposure to secondhand smoke.
Smoking Was Pervasive
This anniversary is an opportunity to reflect on the fact that smoking was pervasive in 1960s American society, said panelist Mitch Zeller, JD, director of the Center for Tobacco Products at the US Food and Drug Administration (FDA). "Growing up in Brooklyn, New York, in second and third grades, we made ashtrays for our parents in school as arts and crafts projects," he said. "At my parents' dinner parties, they put out a bowl of loose cigarettes as a welcoming gesture."
"We need to acknowledge all of the progress we have made, but also look at what we still have to do," said Zeller. "We are still finding new diseases that are caused by smoking, and we know that smoking harms nearly every organ in the body. Almost 18 million Americans will die of preventable or avoidable deaths by midcentury if we don't do anything to alter that trajectory."
Breaking the Habit
The landmark report did not just happen overnight; in fact, it was many years in the making. Smoking became increasingly common and fashionable in the early part of the twentieth century, and the tobacco industry grew rapidly as a result of aggressive and persuasive campaigns. Military personnel, for example, were targeted by tobacco companies, and cigarettes became part of daily rations for British, American, and German soldiers in World Wars I and II. Cigarettes continued to be included in rations for US military personnel until 1975.
Advertising also got a boost in the early twentieth century, when full-page color magazine and newspaper advertisements often featured endorsements from celebrities or physicians attesting to the benefits of a particular brand. In fact, in the 1940s, Ronald Reagan, future president of the United States, was featured in several ads for Chesterfield cigarettes.
After World War II, television became a popular media tool for the tobacco industry to hawk its wares, sponsoring many programs, coming up with catchy jingles (Winston tastes good like a cigarette should!), and amassing an ever increasing array of celebrities to extol the virtues of a selected brand. Even cartoon characters, such as Fred Flintstone, were used to advertise the merits of relaxing with a Winston cigarette.
But in this golden age of tobacco use, there was already mounting evidence that smoking was wreaking havoc on public health. Evidence had begun accumulating before and after World War II, as noted in the 1964 report, that tobacco use, especially cigarette smoking, was causally linked to several diseases, including lung cancer, coronary artery disease, chronic bronchitis, and emphysema.
In 1954, the tobacco industry released a Frank Statement to reassure the public that cigarette smoking was safe. Among the assertions made were: "We believe the products we make are not injurious to health" and "We always have and always will cooperate closely with those whose task it is to safeguard the public health."
Despite industry attempts to deflect any health risks associated with smoking and reassure the public, numerous studies suggested that tobacco use — not air pollution, asbestos contamination, or radioactive materials — was the primary cause of the increase in lung cancer cases in the twentieth century.
In 1957, Surgeon General Leroy Burney announced that it was the official position of the US Public Health Service that there was a causal relation between smoking and lung cancer.
Five years later, the newly appointed Dr. Terry convened an expert committee to conduct a comprehensive review of the scientific literature on smoking. The committee reviewed data from more than 7000 articles with the assistance of more than 150 consultants. The press conference to announce the release of the report was held on a Saturday in January 1964, in part to minimize the effect on the stock market and in part to maximize coverage in the Sunday papers.
The primary focus of the report was the deleterious effect that tobacco use had on the incidence of lung cancer, but it also addressed the association between tobacco use and other diseases and the elevated mortality rates in smokers.
Deaths related to lung cancer rose from less than 3000 in 1930 to 18,000 in 1950. In the even shorter period from 1955 to 1962, lung cancer deaths jumped from less than 27,000 to 41,000. This "extraordinary rise has not been recorded for cancer of any other site," the report notes. Although part of the growing trend could be attributed to improvements in diagnosis and the changing demographics of the population at large, the "evidence leaves little doubt that a true increase in lung cancer has taken place," it continues.
Mortality related to arteriosclerotic, coronary, and degenerative heart disease increased from 273,000 in 1940 to 578,000 in 1962. And deaths related to chronic bronchitis and emphysema rose from 2300 in 1945 to 15,000 in 1962.
Overall, cigarette smoking was considered to be responsible for a 70% increase in the mortality rate of smokers, compared with nonsmokers. The report estimated that average smokers had a 9- to 10-fold risk for lung cancer, compared with nonsmokers. For heavy smokers, the risk was at least a 20-fold. The report also pointed to smoking as the most important cause of chronic bronchitis, suggested a correlation between smoking and emphysema and coronary heart disease, and noted that smoking during pregnancy was associated with reduced weight in newborns.
At the European Lung Cancer Conference earlier this year, epidemiologist and cancer prevention advocate Peter Boyle, Dsc(Med), PhD, who is president of the International Prevention Research Institute in Lyon, France, echoed these statistics on lung cancer. He pointed out that in 1912, lung cancer was described as one of the rarest tumor types. Within the space of a century, it had become the most common cancer.
"As the twentieth century drew to a close, the world was coming to terms with a product, which when used as the manufacturer intended, leads directly to immense and immeasurable pain and suffering and premature death among its consumers," said Dr. Boyle at that meeting.
Beginning of Long Confrontation With Industry
Although the report publicly shone light on the profound health risks of smoking, it was only the beginning of a long confrontation with a powerful industry. "The methodology was important because it set up a standard of a complete and comprehensive review and evaluation of the evidence," Jonathan Samet, MD, MS, director of the University of Southern California Institute for Global Health in Los Angeles, said during a special symposium at the AACR meeting.
"But there are things that the report did not say, like what should be done about the smoking problem," he noted. In essence, it was left to the lawmakers to initiate binding changes.
This was instituted almost immediately, when Congress required all cigarette packages distributed in the United States to carry a health warning. A few years later, effective September 1970, all cigarette advertising on television and radio was banned.
Over the past 50 years, 31 reports from the Surgeon General have confirmed the initial findings and touched on a variety of smoking-related topics, said Dr. Samet. Among the highlights were "the first mention of indoor smoking and air pollution, and the possible health consequences," in the 1979 report.
"In 1986, Surgeon General Koop released a report on involuntary smoking, which reached several powerful conclusions," he added. It decisively portrayed secondhand smoke not just as an annoyance, but as a quantifiable health risk.
The 1988 report concluded that nicotine was addictive, and the 2004 report emphasized active smoking and the litany of diseases associated with the habit. In 2006, the report noted that there was consensus on passive smoking, and that the "debate was over." More recent reports have focused on the effects of media and advertising on rates of tobacco use by youth.
Much of the 2014 report focuses on policy, "on what still needs to be done," Dr. Samet explained. "Smoking-attributable morbidity and death have not declined, although there is progress for some diseases. We have many tools that we can use, but we need to use them better and faster if we are going to drive down the rate of smoking to as low as we'd like it to be."
FDA Steps In
In 2009, the Family Smoking Prevention and Tobacco Control Act (also known as the Tobacco Control Act) granted the FDA authority to regulate tobacco products.
"For the first time, the federal government was able to regulate the manufacturing, marketing, and distribution of tobacco products," said Zeller.
This year, the FDA announced a number of new actions, and one of their priorities is to reduce youth smoking rates. "If current trends persist, 5 to 6 million kids today will die prematurely later in life of smoking-related diseases," he said. "If we can break through — reach these kids with a compelling message of the health consequences of what they're doing — we can make a profound difference and have a positive impact."
The FDA has a unique opportunity to build on the vital progress that has been made since the 1964 report, Zeller continued. "We expect that with the addition of tobacco product regulation to the arsenal of tobacco control strategies, there will be an important story to tell when we mark the 75th anniversary of the Surgeon General's report."
American Association for Cancer Research (AACR) 2014. Presented April 7, 2014
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