By Richard C. Wender, MD
Fifty years ago, on January 11, 1964, Luther Terry held a press conference to announce the results of the first Surgeon General's report on smoking and health, the most impactful public health document in history. The report laid to rest over a decade of debate about the health risks of smoking by definitively stating that smoking causes lung and laryngeal cancer in men, chronic bronchitis, and other diseases.
Research conducted by the American Cancer Society and other groups had already demonstrated the adverse health effects of smoking, but, until the Surgeon General's report, the tobacco industry had been successful in hiding the truth. The extraordinary methods used by the Surgeon General to ensure that the report was completely unbiased -- including allowing the tobacco industry to veto nominees to serve on the panel -- the thoroughness of the research, and the clarity of the conclusions, all led to one outcome: the end of the debate about the health risks of smoking and the launch of the true fight to end the use of tobacco products. The progress in the tobacco fight over the past 50 years represents one of the most successful, life-saving public health campaigns in our nation's history.
The public health victories, and the challenges
Forty-three percent of Americans smoked prior to the Surgeon General's report; 18% smoke today. Smoking in airplanes, restaurants, and places of employment has largely disappeared. We're now fully aware of the addictive nature of the nicotine in tobacco products, and the importance of preventing and treating that addiction. Tobacco executives were eventually forced to admit, before Congress and the country, that they were long aware of the addictive nature of their products as well as the harmful health effects.
We've learned that raising the cost of a pack of cigarettes is the single most effective way to reduce the number of people who start using tobacco products and the most effective way to promote quitting. Tobacco tax increases have been implemented in many states. As of 2009, the FDA was granted the authority to regulate tobacco products, although the tobacco industry has placed substantial roadblocks in the path of effective FDA action. The United States is not alone. Smoking rates in most high-resource ("Western") nations like England, Canada, and Australia have substantially declined, comparable to the progress that we've seen. We've witnessed 50 years of amazing progress; we truly do have much to celebrate.
And much to lament. Since January 11, 1964, we have seen dramatic shifts in the pattern of tobacco use. Prior to the report, smoking was a common practice among men in every walk of life, in every income bracket and profession. About half of physicians were smokers, as were about half the members of Luther Terry's panel. Following release of the report, smoking rates in college graduates began to fall to the relatively low rate of 7.5% we see today. A very different story emerges in looking at individuals with lower income and education. While the smoking rate 50 years ago in non-high school graduates was 45.5%, this rate has barely dropped; 36.7% of non-high school graduates still use tobacco, 29% more than the rate seen in college graduates. While smoking rates in men started to go down after the release of the report, smoking rates in women did not decline substantially until aggressive counter measures catalyzed a more rapid decline in smoking in women. Low-income populations have been specifically targeted by tobacco advertising, and smoking is more common in lower income communities.
Important shifts have occurred in tobacco use in various cultures. While about 19% of Caucasian and African Americans smoke, and few Hispanic women smoke, smoking rates in American Indians and Alaskan Natives are disturbingly high, at 31.5%. Lesbians, gay men, and bisexuals are much more likely to smoke than heterosexuals. And more than 35% of individuals who suffer from chronic mental illness use tobacco. This disenfranchised group is often overlooked when we define public health policy and interventions.
Fifty years after the Surgeon General's report, more than 440,000 tobacco-related deaths still occur in the United States every year. But that's not the whole story. While higher-resource nations have made substantial progress, the tobacco industry has increasingly recognized the opportunity to reap substantial profits by marketing tobacco use in middle- and low-income nations. Projections of the number of tobacco-related deaths that might occur in Africa over the next 15 years if we don't curb the growth of the tobacco industry there are staggering. Should the tobacco use epidemic continue at its current pace, the World Health Organization estimates that, by 2030, 80% of the 8,000,000 annual tobacco related deaths will occur in low- and middle-income nations. The battle to control tobacco must now be fought on many fronts, all around the world.
The danger of resting on one's laurels
In my view, the single greatest threat to the future control of tobacco is complacency. Despite great progress, the tobacco fight has not been won in this, or any country. The fact that populations with less political clout in our own country are now bearing a disproportionate share of suffering has contributed to a slowing of political action and blunting of our sense of urgency in the United States.
As chief cancer control officer at the American Cancer Society, I can assure you that we have not and will not succumb to complacency. In fact, we are going to celebrate the 50th anniversary of the Surgeon General's report the right way, by renewing our commitment to defeating the tobacco industry here and around the world. We are dedicating ourselves to bringing tobacco use rates to less than 10% as quickly as possible in the U.S., and partnering with our international partners to block what now appears to be inevitable tobacco use in lower-resource nations.
Fifty years later, Luther Terry's Surgeon General's report is a living, dynamic document, a continuous driver for change. We are going to build on our remarkable track record as leaders in the anti-tobacco fight to consolidate efforts within the American Cancer Society and American Cancer Society Cancer Action Network (ACSCAN), our non-profit, non-partisan advocacy agency, to become a center of anti-tobacco activism. Hand in hand with our many public health partners here and around the globe, on this 50th anniversary of the most influential public health report in history, we pledge a redoubling of our efforts to once and for all strive for the tobacco endgame to finish the fight against tobacco.
Dr. Wender is chief cancer control officer for the American Cancer Society.
Dr. Wender wants to acknowledge the following source: Warner KE. 50 years since the first surgeon general's report on smoking and health: A happy anniversary? Am J of Pub Health. Jan 2014;104(1):5-8