By Liz Szabo
Health advocates are marking the 50th anniversary of the 1964 Surgeon General report on smoking with a call for more aggressive action to protect people from tobacco.
That landmark report, along with subsequent Surgeon General reports on the addictive power of nicotine and the dangers of secondhand smoke, led to a sea change in the country's attitude toward tobacco. Smoking rates have dropped by 59%, and many communities now ban smoking in public places.
No other single report has had this large of an effect on public health, says Thomas Frieden, director of the Centers for Disease Control and Prevention.
"I can't think of anything else that has come close," says Theodore Holford, a professor at the Yale University School of Public Health.
But with so much evidence of the harms of smoking - which causes cancer, heart attacks, strokes and a multitude of other illnesses - some advocates say the country needs to go much further.
"The 50th anniversary of the Surgeon General report should be a catalyst to say, 'We can't wait another 50 years to end death and disease caused by smoking,' " says Matthew Myers, president of the Campaign for Tobacco-Free Kids, an advocacy group.
Nearly 42 million Americans still smoke, according to the CDC. More than 5 million people around the world die each year of smoking-related illnesses, according to an editorial by physicians Steven Schroeder and Howard Koh in Tuesday's Journal of the American Medical Association.
Every day, more than 3,000 teens pick up their first cigarettes, says Robin Koval, president and CEO of Legacy, an anti-smoking advocacy group created by the 1998 Master Settlement Agreement between tobacco companies and state attorneys general.
In some ways, combating tobacco is even more challenging than fighting infectious diseases, Frieden said in an interview. Frieden noted that more people would have stopped smoking if not for aggressive efforts by the tobacco industry to keep people addicted.
"I spent over a decade working on tuberculosis control," Frieden said. "But tuberculosis doesn't have a lobby working against tuberculosis-control measures."
The tobacco industry continues to work hard to keep people using its products, spending more than $8 billion a year on marketing in the USA alone, according to Schroeder and Koh's editorial.
In a related editorial, Frieden notes that new products, such as electronic cigarettes, present both opportunities and risks. Some health leaders say electronic cigarettes - which contain nicotine but no tobacco - may help smokers quit. But Frieden says he's concerned that e-cigarettes could increase the number of people addicted to nicotine by attracting kids. Frieden is also concerned that e-cigarettes could lead some smokers to avoid quitting, by allowing them to feed their habits even in smoke-free areas.
Yet, health advocates also note that the cultural landscape around smoking has changed enormously since the 1960s.
Back then, passengers could smoke on any plane, and flight attendants distributed free cigarettes along with meals. School kids sculpted ash trays for Mother's Day presents.
Tobacco companies formed one of the most powerful industries in the world, employing stars such as Ronald Reagan, Humphrey Bogart and Louis Armstrong to sell their products.
Today, tobacco companies are "convicted racketeers," says Stanton Glantz, a professor at the University of California-San Francisco, referring to the 2006 ruling by U.S. District Judge Gladys Kessler, who found that tobacco companies defrauded the American people by lying about the health risks of smoking.
UCSF's archive includes 82 million pages of tobacco-industry documents, revealing cigarette makers' strategies for marketing to children and the fact that they knew that cigarettes caused cancer and nicotine was addictive.
The surgeon general in 1964, Luther Terry, described the report's effect as a "bombshell."
At the time, and for decades afterward, the tobacco industry tried to "poke holes" in research documenting the harms of smoking, Frieden says.
With the surgeon general's report, "this was the first time that the government was saying, 'No. There is no doubt that smoking causes cancer,' " Frieden says.
The report's conclusions - based on more than 7,000 documents - were almost immediately accepted by nearly everyone, except for the tobacco industry, Myers say.
American attitudes toward the safety of smoking changed quickly.
In 1958, only 44% of American believed smoking caused lung cancer, according to a Gallup survey. By 1968, that percentage had risen to 78%.
Congress acted, as well.
In 1965, Congress passed legislation requiring the now-familiar "Surgeon General's warning" on cigarette packages, although it took six years to implement. In 1971, cigarette makers stopped advertising on TV.
"The tobacco industry thought they were just going to be crushed," says Glantz, author of a history of the tobacco industry called The Cigarette Papers. "The government and others didn't have the nerve to do what the tobacco industry had feared, which is come up with major regulation. ... Politics has always saved the tobacco industry."
The tobacco industry also fought fiercely to protect its business, says Glantz, likening the battles over smoking to "trench warfare." For years, he notes, the tobacco industry funded bogus research suggesting that cigarettes and secondhand smoke were safe.
Smoking rates briefly rose in some of the first few years after the Surgeon General report's release, as the tobacco industry ramped up advertising to women and minorities, says Mark Pertschuk, a long-time anti-tobacco activist and director of the advocacy group Grassroots Change.
It was another surgeon general, C. Everett Koop, who "really got us where we are today," says Otis Brawley, chief medical officer of the American Cancer Society.
In 1986, Koop issued a Surgeon General report on "involuntary smoking," or secondhand smoke, that provided the scientific basis for protecting non-smokers from tobacco, Brawley says.
"When people realized that smoking hurts more than just the smoker, that's what led to change," Brawley says.
Flight attendants such as Kate Jewell - forced to breathe smoky, recirculated air during long plane trips - began to call for smoking bans on plane flights. Jewell recalls brown water dripping from the air vents. "It was so smoky, you couldn't see from one end of the cabin to another," Jewell says.
Long before the research was completed, Jewell says she and her fellow flight attendants knew that secondhand smoke was toxic. Jewell, whose career spanned 1970 to 2007, recalls keeping her airline uniform in the garage, because it smelled too awful to allow in her home.
"I would pull into the garage and strip down before I went into my house, because I didn't want to bring that into my house," says Jewell, 64, of Orcas Island, Wash.
In 1989, Congress banned smoking on domestic flights. Communities across the country began banning indoor smoking, as well.
As fewer Americans smoked, the tide began to turn toward cleaner air.
The tobacco industry's image took a beating in the 1990s, with the leak of industry documents showing that cigarette companies had hidden evidence that nicotine was addictive, Glantz says.
But the industry hasn't gone away.
Tobacco companies continue to oppose tobacco taxes and smoking bans. They're also still fighting implementation of the 2006 racketeering ruling, which required them to fund ad campaigns acknowledging that they lied about the addictiveness of nicotine, Glantz says.
"That is still being fought in the courts to this day," Glantz says. "The industry is still out there being as aggressive as (it) can be."
R.J. Reynolds, one of the leading tobacco companies, declined to comment.
David Sylvia, a spokesman for Altria, the parent company of tobacco giant Philip Morris, said his company welcomes regulation. Sylvia said Altria has no interest in marketing to kids, and simply hopes to sells its cigarettes to current smokers.
"The reason that tobacco remains such a problem isn't because the American public has failed to respond" to the surgeon general's warning, Myers says. "It's because the tobacco industry has used its economic, scientific and political might."
The tobacco industry has made technological improvements in cigarettes, for example, to make them less harsh, so that new smokers don't cough as much as in the past. That makes cigarettes more appealing to kids and first-time users, Myers says. The industry continues to sell menthol-flavored cigarettes, as well, which mask the harshness of tobacco with a minty flavor. "Fifty years later, cigarettes look sleeker, but they are no safer," Myers says.
Myers and others say they're disappointed that the Food and Drug Administration has not yet banned menthol cigarettes, although Congress has given it the power to regulate tobacco.