By: U.S. Department of Health, Education, and Welfare
Source: U.S. Department of Health, Education, and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, D.C.: Government Printing Office, 1964, 7, 8, 25, 26–27, 28–30, 31.
About the Organization: Congress created the U.S. Department of Health, Education, and Welfare in 1953 upon the recommendation of President Dwight D. Eisenhower (served 1953–1961). The department consolidated several medical and health agencies under one umbrella. Among its agencies was the Public Health Service, which examined the link between smoking and illness.
The smoking of tobacco and its relation to health has a curious history. Virginia planters exported tobacco to England and continental Europe beginning in 1617, only ten years after the founding of the Jamestown colony. King James I of England declared smoking a filthy habit. He was Scottish by birth, leading many Englishmen to disdain him as a foreigner. In an era when no government tolerated criticism, Englishmen could, without fear of arrest, express their dislike of King James by smoking tobacco.
Eager to adopt the habits of fashionable Englishmen, Americans took up smoking in the seventeenth century. Few people at that time suspected tobacco of impairing health.
During the twentieth century, vaccines and antibiotics reduced the number of deaths from infectious diseases, leaving heart disease and cancer as the two leading causes of death in the United States. Deaths from heart disease declined for unknown reasons between 1900 and 1955, when they began a climb that continued into the early twenty-first century. Cancer deaths have risen steadily since 1900. Physicians and scientists studied these trends, coming to suspect by 1960 that smoking increased the risk of both diseases.
Such suspicion worried cigarette manufacturers and tobacco farmers, who pressured Congress not to fund the Public Health Service of the U.S. Department of Health, Education, and Welfare in a study of the link between smoking and heart disease and cancer. However, in 1962, President John F. Kennedy (served 1961–1963) commissioned Surgeon General Luther L. Terry to establish a committee to investigate the link between smoking and these diseases.
The department issued its report in 1964. The report chronicled the rise in the number of lung cancer deaths from less than 3,000 in 1930 to 41,000 in 1962. The report linked these deaths to smoking, demonstrating that tobacco smoke and tar caused cancer in laboratory animals, that autopsies of smokers revealed damage to organs including the lungs, and that smokers died more often than nonsmokers of lung cancer, bronchitis, emphysema, cancer of the larynx, oral cancer, cancer of the esophagus, ulcers, and heart disease.
The report also demonstrated that death rates increased with the number of cigarettes one smoked. The young were particularly vulnerable to the dangers of smoking, noted the report. Those who started smoking before age 20 died at younger ages than those who began after age 25.
Perhaps most important, the report identified smoking as a factor in making heart disease and cancer the leading causes of death among Americans. The report focused attention on smoking as a cause of lung cancer. Heavy smokers incur 20 times the risk of death from lung cancer than nonsmokers.
The report did little to deter smokers. Cigarette sales in 1964 fell only three percent below 1963 sales, and after an initial decline tobacco companies' stock rose.
Nor was government aggressive. Although Congress required cigarette packs to include a warning that "cigarette smoking may be hazardous to your health," President Lyndon Baines Johnson (served 1963–1969), who was so active in promoting the federal government's role in advancing health, did nothing to curb smoking.
Primary Source: Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service [excerpt]
SYNOPSIS: The U.S. Department of Health, Education, and Welfare reported in 1964 that cigarette smoking caused heart disease and cancer, the leading causes of death in the U.S. The report amassed evidence from animal experiments, autopsies of smokers, and comparisons of death rates for smokers and nonsmokers.
Impressed by the report of the Study Committee and by other new evidence, Surgeon General Leroy E. Burney issued a statement on July 12, 1957, reviewing the matter and declaring that: "The Public Health Service feels the weight of the evidence is increasingly pointing in one direction; that excessive smoking is one of the causative factors in lung cancer." Again, in a special article entitled "Smoking and Lung Cancer—A Statement of the Public Health Service," published in the Journal of the American Medical Association on November 28, 1959, Surgeon General Burney referred to his statement issued in 1957 and reiterated the belief of the Public Health Service that: "The weight of evidence at present implicates smoking as the principal factor in the increased incidence of lung cancer," and that: "Cigarette smoking particularly is associated with an increased chance of developing lung cancer." These quotations state the position of the Public Health Service taken in 1957 and 1959 on the question of smoking and health. That position has not changed in the succeeding years, during which several units of the Service conducted extensive investigations on smoking and air pollution, and the Service maintained a constant scrutiny of reports and publications in this field.
Establishment of the Committee
The immediate antecedents of the establishment of the Surgeon General's Advisory Committee on Smoking and Health began in mid-1961. On June 1 of that year, a letter was sent to the President of the United States, signed by the presidents of the American Cancer Society, the American Public Health Association, the American Heart Association, and the National Tuberculosis Association. It urged the formation of a Presidential commission to study the "widespread implications of the tobacco problem."
On January 4, 1962, representatives of the various organizations met with Surgeon General Luther L. Terry, who shortly thereafter proposed to the Secretary of Health, Education, and Welfare the formation of an advisory committee composed of "outstanding experts who would assess available knowledge in this area [smoking vs. health] and make appropriate recommendations …" …
On July 24, 1962, the Surgeon General met with representatives of the American Cancer Society, the American College of Chest Physicians, the American Heart Association, the American Medical Association, the Tobacco Institute, Inc., the Food and Drug Administration, the National Tuberculosis Association, the Federal Trade Commission, and the President's Office of Science and Technology. At this meeting, it was agreed that the proposed work should be undertaken in two consecutive phases, as follows:
Phase I—An objective assessment of the nature and magnitude of the health hazard, to be made by an expert scientific advisory committee which would review critically all available data but would not conduct new research. This committee would produce and submit to the Surgeon General a technical report containing evaluations and conclusions.…
Another cause for concern is that deaths from some of these diseases have been increasing with great rapidity over the past few decades.
Lung cancer deaths, less than 3,000 in 1930, increased to 18,000 in 1950. In the short period since 1955, deaths from lung cancer rose from less than 27,000 to the 1962 total of 41,000. This extraordinary rise has not been recorded for cancer of any other site. While part of the rising trend for lung cancer is attributable to improvements in diagnosis and the changing age-composition and size of the population, the evidence leaves little doubt that a true increase in lung cancer has taken place.…
Kinds of Evidence
1. Animal experiments
In numerous studies, animals have been exposed to tobacco smoke and tars, and to the variouschemical compounds they contain. Seven of these compounds (polycyclic aromatic compounds) have been established as cancer-producing (carginogenic). Other substances in tobacco and smoke, though not carcinogenic themselves, promote cancer production or lower the threshold to a known carcinogen. Several toxic or irritant gases contained in tobacco smoke produce experimentally the kinds of non-cancerous damage seen in the tissues and cells of heavy smokers. This includes suppression of ciliary action that normally cleanses the trachea and bronchi, damage to the lung air sacs, and to mucous glands and goblet cells which produce mucus.
2. Clinical and autopsy studies
Observations of thousands of patients and autopsy studies of smokers and non-smokers show that many kinds of damage to body functions and to organs, cells, and tissues occur more frequently and severely in smokers. Three kinds of cellular changes—loss of ciliated cells, thickening (more than two layers of basal cells), and presence of atypical cells—are much more common in the lining layer (epithelium) of the trachea and bronchi of cigarette smokers than of non-smokers. Some of the advanced lesions seen in the bronchi of cigarette smokers are probably premalignant. Cellular changes regularly found at autopsy in patients with chronic bronchitis are more often present in the bronchi of smokers than non-smokers. Pathological changes in the air sacs and other functional tissue of the lung (parenchyma) have a remarkably close association with past history of cigarette smoking.
Another kind of evidence regarding an association between smoking and disease comes from epidemiological studies.…
In the combined results from the seven studies, the mortality ratio of cigarette smokers over non-smokers was particularly high for a number of diseases: cancer of the lung (10.8), bronchitis and emphysema (6.1), cancer of the larynx (5.4), oral cancer (4.1), cancer of the esophagus (3.4), peptic ulcer (2.8), and the group of other circulatory diseases (2.6). For coronary artery disease the mortality ratio was 1.7.
Expressed in percentage-form, this is equivalent to a statement that for coronary artery disease, the leading cause of death in this country, the death rate is 70 percent higher for cigarette smokers. For chronic bronchitis and emphysema, which are among the leading causes of severe disability, the death rate for cigarette smokers is 500 percent higher than for non-smokers. For lung cancer, the most frequent site of cancer in men, the death rate is nearly 1,000 percent higher.
Other Findings of the Prospective Studies
In general, the greater the number of cigarettes smoked daily, the higher the death rate. For men who smoke fewer than 10 cigarettes a day, according to the seven prospective studies, the death rate from all causes is about 40 percent higher than for non-smokers. For those who smoke from 10 to 19 cigarettes a day, it is about 70 percent higher than for non-smokers; for those who smoke 20 to 39 a day, 90 percent higher; and for those who smoke 40 or more, it is 120 percent higher.
Cigarette smokers who stopped smoking before enrolling in the seven studies have a death rate about 40 percent higher than non-smokers, as against 70 percent higher for current cigarette smokers. Men who began smoking before age 20 have a substantially higher death rate than those who began after age 25. Compared with non-smokers, the mortality risk of cigarette smokers, after adjustments for differences in age, increases with duration of smoking (number of years), and is higher in those who stopped after age 55 than for those who stopped at an earlier age.
In two studies which recorded the degree of inhalation, the mortality ratio for a given amount of smoking was greater for inhalers than for noninhalers.
The ratio of the death rates of smokers to that of non-smokers is highest at the earlier ages (40–50)… and declines with increasing age.
Possible relationships of death rates and other forms of tobacco use were also investigated in the seven studies. The death rates for men smoking less than 5 cigars a day are about the same as for non-smokers. For men smoking more than 5 cigars daily, death rates are slightly higher. There is some indication that these higher death rates occur primarily in men who have been smoking more than 30 years and who inhale the smoke to some degree. The death rates for pipe smokers are little if at all higher than for non-smokers, even for men who smoke 10 or more pipefuls a day and for men who have smoked pipes more than 30 years.
Several of the reports previously published on the prospective studies included a table showing the distribution of the excess number of deaths of cigarette smokers among the principal causes of death. The hazard must be measured not only by the mortality ratio of deaths in smokers and non-smokers, but also by the importance of a particular disease as a cause of death.
In all seven studies, coronary artery disease is the chief contributor to the excess number of deaths of cigarette smokers over non-smokers, with lung cancer uniformly in second place. For all seven studies combined, coronary artery disease (with a mortality ratio of 1.7) accounts for 45 percent of the excess deaths among cigarette smokers, whereas lung cancer (with a ratio of 10.8) accounts for 16 percent.
Some of the other categories of diseases that contribute to the higher death rates for cigarette smokers over non-smokers are diseases of the heart and blood vessels, other than coronary artery disease, 14 percent; cancer sites other than lung, 8 percent; and chronic bronchitis and emphysema, 4 percent.
Since these diseases as a group are responsible for more than 85 percent of the higher death rate among cigarette smokers, they are of particular interest to public health authorities and the medical profession.…
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.
The risk of developing lung cancer increases with duration of smoking and the number of cigarettes smoked per day, and is diminished by discontinuing smoking. In comparison with non-smokers, average male smokers of cigarettes have approximately a 9- to 10-fold risk of developing lung cancer and heavy smokers at least a 20-fold risk.
The risk of developing cancer of the lung for the combined group of pipe smokers, cigar smokers, and pipe and cigar smokers is greater than for non-smokers, but much less than for cigarette smokers.
Cigarette smoking is much more important than occupational exposures in the causation of lung cancer in the general population.
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