The Pump Handle is launching a new “Public Health Classics” series exploring some of the classic studies and reports that have shaped the field of public health. If you have a favorite Public Health Classic to recommend, let us know in the comments. And if you’re interested in contributing a post to the series, email us at thepumphandle@gmail.com (send us a link to the report or study along with a sentence or two about what you find most interesting or important about it). As we add more posts to the series, they’ll all be available in the “Public Health Classics” category.

A headline from the Washington Post’s January 1, 1964 edition read: “Cigarette Smoking in U.S. Hits Record.”  The story reported the year-end data from the U.S. Department of Agriculture on tobacco consumption.  The lead sentence read:

“Despite higher prices and the so-called ‘cancer scare,’ Americans smoked more cigarettes in 1963 than ever before in history—523 billion of them.”

Just two weeks later, the phrase ‘cancer scare’ would be replaced with the cancer facts.  On Saturday, January 11, 1964, the landmark “Smoking and Health: a report of the advisory committee to the Surgeon General of the Public Health Services” was released by U.S. Surgeon General Luther Terry.  The 387-page report reflected 14 months of work by an expert committee of 10 physicians and scientists, with assistance provided by a technical staff of two dozen and 150 consultants.

The Advisory Committee’s conclusion “hit the country like a bombshell,” said Dr. Terry.

“Cigarette smoking contributes substantially to mortality from certain specific diseases and to the overall death rate.”

“Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigarette smoking far outweighs all other factors.  The data for women, though less extensive, point in the same direction.”

“Cigarette smoking is the most important of the causes of chronic bronchitis in the United States, and increases the risk of dying from chronic bronchitis and emphysema.”

“Male cigarette smokers have a higher death rate from coronary artery disease than non-smoking males.  Although the causative role of cigarette smoking in deaths from coronary disease is not proven, the Committee considers it more prudent from the public health viewpoint to assume that the established association has causative meaning than to suspend judgment until no uncertainty remains.”

The findings attracted public attention much more than previous expert reports on the health perils of smoking.  Those earlier efforts included the call in 1956 by Surgeon General Leroy Edgar Burney to the National Cancer Institute, the National Health Institute, the American Cancer Society, and the American Heart Association to convene a study group to evaluate the relationship between cigarette smoking and lung cancer.  That study group examined 16 studies from five countries covering 18 years, and concluded “there is a causal relationship between excessive smoking of cigarettes and lung cancer.”  Dr. Burney amplified those findings by issuing a statement in 1957 reiterating that group’s conclusions.  He later authored a paper entitled “Smoking and lung cancer: a statement of the Public Health Service” which was published in the November 28, 1959 edition of the Journal of the American Medical Association.   Surgeon General Burney’s pronouncements were consistent with those made by other expert panels, such as the British Medical Research Council, the cancer societies of Denmark, Norway, Sweden, Finland and the Netherlands, and the Canadian National Department of Health and Welfare.  Despite these efforts, or maybe with them in the background, the 1964 Report to the Surgeon General on Smoking and Health took on a life of its own.

Surgeon General Luther Terry gave partial credit for the Advisory Committee’s birth and influence to a letter sent to President John F. Kennedy.  After six months in office, the President received a letter from the American Cancer Society, the American Heart Association, the National Tuberculosis Association, and the American Public Health Association calling for a presidential commission on smoking.  The leaders of the organizations wrote:

“On the basis of the weight of scientific evidence on the relationship of cigarette smoking to cancer, especially cancer of the lung, to cardiovascular diseases and to other debilitating and fatal diseases, we believe that such a Commission should examine the social responsibilities of business, of voluntary agencies, and of government in the education of the youth of America; and should recommend various ways to protect the public, weighing the costs against the benefits to be achieved and seeking a solution of this health problem that would interfere least with the freedom of industry or the happiness of individuals.”

By January 1962, Dr. Terry had begun the steps to establish the advisory committee, and their work concluded in January 1964 when their report was released.

The Advisory Committee did not undertake new research—one of the many criticisms launched by the tobacco industry against the report—but assembled and evaluated the best available evidence at the time to draw its conclusions.  This evidence included studies on laboratory animals, clinical and autopsy studies, and retrospective and prospective epidemiological studies.  The prospective studies consisted of seven papers, including:

• Doll R and Hill AB. Lung cancer and other causes of death in relation to smoking (Brit Med J. 1956; 2:1071-1081) a mortality analysis commencing in 1951 of 34,000 British physicians.
• Hammond EC and Horn D. Smoking and death rates—reported on forty-four months of follow-up on 187,783 men. (JAMA. 1958; 166:1159-1172, 1294-1308), a mortality analysis of 188,000 white males in nine U.S. States.
• Dunn JE Jr., Linden G, and Breslow L. Lung cancer mortality experience of men in certain occupations in California. (Am J Pub Health. 1960; 50:1475-1487), a mortality analysis of 67,000 male subjects.
• Best EWR, Josie GH, and Walker CB. A Canadian study of mortality in relation to smoking habits, a preliminary report. (Canad J Pub Health. 1961;52:99-106), a mortality analysis of 78,000 Canadian pensioners.

To the extent possible, the Advisory Committee pooled the data from the seven prospective studies and calculated mortality ratios by different causes of death for the smokers.   There were 26,233 deaths from all causes among the smokers, when the age-adjusted population data expected only 15,654 death.   That “all cause” mortality ratio was 1.68, or 68% more deaths from any cause than would be expected in that population.   Especially striking was the data for deaths from cancer.  For example, smokers experienced four times more deaths from oral cancers and nearly eleven times more deaths from lung cancer.

A year after the report’s release, Congress passed the Federal Cigarette Labeling and Advertising Act of 1965 (P.L. 89-92) which required warning labels on cigarette packs.  Similar warnings on print advertising for cigarettes was required by the Public Health Cigarette Smoking Act of 1969.

A Sunday, January 12, 1964 New York Times‘ editorial said this about the Surgeon General’s report:

“It is now official; it could hardly have been otherwise in view of findings by many physicians and health organizations in the United States and Europe.  The Surgeon General’s Advisory Committee on Smoking and Health has declared that there is a definite causative link between lung cancer and other major diseases and the continued use of tobacco.  To put it bluntly, smoking is harmful to health—and remedial action must be taken.   …The Surgeon General’s evaluation report is bold and devastating.  The findings cannot be ignored by cigarette, pipe and cigar smokers, young or old, or blown away by the tobacco industry’s spokesman.”

But blowing smoke on these findings—and the mountains of evidence that came after it—-is exactly what the tobacco industry spokesmen did for decades.  The 1996 publication The Cigarette Papers offers us hundreds of examples, like this one from 1971:

“…We believe there is sound evidence to conclude that the statement ‘cigarettes cause cancer’ is not a statement of fact but merely an hypothesis.” [emphasis in original]

and this from 1983:

“Cigarette smoking has not been scientifically established to be a cause of chronic diseases, such as cancer, cardiovascular disease, or emphysema.

Cigarette consumption in the U.S. has declined significantly since the 1964 Surgeon General’s report was issued.  At the time, per capita consumption of cigarettes was nearly 4,200 annually compared to about 1,600 today.  Global consumption of cigarettes, however, has skyrocketed to an annual estimate of 5,884 cigarettes per person.  from 3,262 billion cigarettes in 1970 to 5,884 in 2009—the equivalent of 43 packs per person.   In contrast to a time when public health officials sought tobacco control measures that “would interfere least with the freedom of industry or the happiness of individuals,” today the World Health Organization aim is to protect all people from the harms of tobacco.