important health issues by
Cigarette smoking remains one of the most important preventable causes of death and disease. In recent years, SFMS has provided strong leadership in the efforts to curtail use of tobacco. As part of our historical perspective, we asked Dr. Tom Addison to provide us with a sweeping overview of tobacco issues, with a focus on California and San Francisco.
1492. After landing in the Caribbean, Columbus and his men notice the natives' fondness for chewing and smoking the dried leaves of an aromatic plant. The Indians inhale smoke through a Y-shaped pipe called a tobaga, thought by etymologists to be the origin of the name of the plant. While Columbus scolds his men for sinking to the level of the savages by mimicking their habit, he was reported to have said that, "it was not within their power to refrain."
1556. Tobacco use spreads to the old world through Spain and Portugal. Jean Nicot de Villemain, the French ambassador to Lisbon, sends seeds of the tobacco plant to Catherine de Medicis, then Queen of France. The plant that grew from these seeds is christened Nicotina tabacura by Linnaeus, thereby immortalizing Jean Nicot's name. Later the addictive alkaloid is called nicotine.
1761. Dr. John Hill, in his paper Cautions against the Immoderate Use of Snuff, describes what he believes to be two cases of malignancies of the respiratory tract thought to be caused by tobacco.
1881. James E. Bonsack invents the automated cigarette-making machine. It can produce 200 cigarettes per minute, a production rate which would have previously taken 50 workers, thereby markedly reducing the cost of production. Within one year the largest cigarette manufacturer sells more than a billion cigarettes annually.
1900. Smoking is primarily a male habit and most smokers choose cigars. Smoking cigarettes is considered pedestrian and unmanly.
1912. Hugh Morrison Davies performs the first successful lobectomy for lung cancer. Physicians did not know that the thorax should be drained postoperatively and the patient dies in eight days from an empyema.
1917. During World War I cigarettes become the smoke of choice as pipes and cigars prove unmanageable at the front. Between 1910 and 1919 cigarette production increases by 633% from under 10 billion/year to nearly 70 billion/year, and cigarette smoking begins to become fixed among American men. The American Red Cross and the Young Men's Christian Association, previously opposed to the propagation of cigarettes, actively supply them to the troops overseas.
1919. Alton Ochsner, a medical student at Washington University in St. Louis, attends a postmortem of a patient with a disease so rare the he was told he would never see another case...lung cancer.
1927. The American Tobacco Company begins a campaign claiming that 11,105 physicians endorse Lucky Strikes as "less irritating to sensitive or tender throats than any other cigarettes."
1929. Harold Brunn at Mt. Zion Hospital in San Francisco performs six successful lobectomies, draining the thorax with a red rubber catheter, and has only one mortality, thereby beginning the era of modern thoracic surgery.
1932. A paper in the American Journal of Cancer associates lung cancer with cigarettes.
1933. Evarts A. Graham performs the first successful pneumonectomy for lung cancer. Dr. Graham, a smoker, goes on to do pioneering research demonstrating the link between lung cancer and tobacco smoking. He succumbs from small cell lung cancer in 1957, and is survived for more than half a decade by the patient upon whom he performed the first pneumonectomy.
1934. The American Medical Association accepts tobacco advertising in their journals. These ads include statements like, "We advertise KOOL cigarettes simply as a pleasant combination of fine tobaccos made even more pleasant by the cooling sensation of menthol. They won't cure anything. They won't harm anybody. They will prove enjoyable."
1936. Alton Ochsner, who had not seen another case of lung cancer since 1919, sees nine patients in six months. All of the patients had begun smoking in World War One. He postulates that the cause of this epidemic was probably cigarette smoking.
1939. Franz H. Muller, a German epidemiologist, in a case-controlled study documents the association between lung cancer and cigarette smoking.
1940. Hitler calls tobacco the "wrath of the red man against the white man for having been given hard liquor" and begins the world's first national anti-tobacco movement. He raises taxes on tobacco to 90% of the retail price, limits cigarette rations to the Wehrmacht, and bans smoking during pregnancy, in air raid shelters, on streets and on city trains and buses. German cigarette consumption drops by half between 1940 and 1950. During this time American consumption doubles.
1945. Smoking is now socially acceptable for women. Another generation of Americans is now habituated to tobacco as a result of free cigarettes distributed by the Red Cross and other organizations to our fighting men and women.
1946. The golden age of tobacco advertising is upon us. R.J. Reynolds claims that "more doctors smoke Camels than any other cigarettes." A 1949 Camel ad includes a picture of "noted throat specialists" who had found "not one case of throat irritation due to smoking Camels." Aurthur Godfrey would sign off his Chesterfield-sponsored variety show, saying, "This is Arthur 'Buy-em-by-the-carton' Godfrey." He and Edward R Murrow, who is never seen on the air without a cigarette, would both develop lung cancer.
1950. Lung cancer deaths quintuple in the United States from 5/100,00 in 1930 to 20/100,00 in 1950 (17,500/yr). JAMA publishes a landmark article by Graham and Wynder showing that almost all patients with lung cancer have been long-time cigarette smokers.
1953. Ernst Wynder publishes the results of a study in Cancer Research, demonstrating that carcinoma could be induced in a mouse skin model by distillates of tobacco smoke. Cigarette sales decline by three percent. The cigarette companies take out a full page ad in 448 papers across the United States claiming that although research had shown that there were many likely causes of lung cancer, there was no proof that smoking was one of them. They finish the ad by stating that for more than 300 years tobacco "has given solace, relaxation and enjoyment to mankind." At the same time it is being held responsible "for practically every disease of the human body. One by one these charges have been abandoned for lack of evidence." This pattern of obfuscation and outright lying is to be repeated on many occasions over the next 45 years.
1954. Marlboro Man is introduced by Phillip Morris and its virile image takes the market by storm. Twenty-two years later the documentary "Death in the West," which juxtaposed years of Marlboro Man commercials with interviews of real cowboys dying of lung disease, is suppressed by a British court. This same year the AMA Board of Trustees votes to discontinue accepting advertisements for tobacco and alcohol-related products.
1958. JAMA publishes a landmark article by Horn and Hammond tying tobacco smoking to lung cancer and many related diseases. A Gallup poll reveals that 44 percent of Americans believe that smoking causes lung cancer. The Tobacco Institute opens in Washington, funded by the tobacco industry in proportion to each tobacco company's market share. They publish Tobacco and Health Research, which is distributed free to 200,000 doctors and medical personnel. They publicize any studies which relate to anything but smoking and lung cancer.
1959. Surgeon General Leroy E. Burney publishes the United States Public Health Services position that cigarette smoking causes cancer. Two weeks later an editorial in the JAMA states that there were not yet enough facts to warrant "an all or none authoritative position" about the relationship between smoking and cancer. Some feel that the need to avoid angering legislators from the tobacco states, who were needed as allies in upcoming congressional battles, helped to form the conservative AMA position.
1962. President Kennedy, when pressured to give his opinion about smoking and health, indicates that he would not give an opinion because, "the matter is sensitive enough and the stock market is in sufficient difficulty without my giving you an answer which is not based on complete information, which I don't have..." Shortly thereafter he assigns Luther Terry, MD, the United States Surgeon General, to study the issue of smoking and health.
1964. Ten scientists work for 14 months to review the world scientific literature at the time and conclude in the Surgeon General's Report on Smoking and Health that "cigarette smoking is a health hazard of sufficient import in the United States to warrant appropriate remedial action." AMA accepts a $10 million no-strings-attached grant from the tobacco industry to do a five-year study of smoking. This serves to suggest that organized medicine was not ready to accept the surgeon general's findings. The AMA executive vice president, F.J.L. Blassingame, testifies against cautionary labeling on cigarettes. Per capita consumption of cigarettes drops by two percent. Mild warning labels are required on tobacco products.
1968. Gallup poll reveals that 71 percent of the country believes that smoking causes cancer.
1970. Department of Health, Education and Welfare finds that the warning statement on cigarette packs has little effect on cigarette consumption and pressures the Federal Trade Commission to eliminate tobacco advertising in broadcast media. The ban takes effect after midnight on January 1, 1971, to allow tobacco advertisers one final fling during the college bowl games.
1978. AMA Education and Research Fund releases Tobacco and Health, a compilation of 844 investigations begun after the 1964 Surgeon General's Report and fully funded by the tobacco industry, most of which were only tangentially related to the smoking and health issue. There are no studies related to smoking and lung cancer.
1980. In a poll on health and safety priorities, Americans rank smoking 10th in order of importance behind such priorities as having smoke detectors in the home.
1983. With concerns about environmental tobacco smoke's effect on others, the San Francisco City Council passes the nation's first smoke-free workplace initiative. It withstands a referendum placed on the ballot by smoking interests and within two years there are 89 cities and counties with tough workplace restrictions.
1983. Cigarettes are the most heavily advertised consumer product in America. One and a half billion dollars are devoted to their promotion. In a Newsweek supplement devoted to "Personal Health Care" prepared by the AMA, with financial support from the magazine, 16 pages of text are devoted to advice about diet, weight control and exercise but only four sentences mention cigarettes. Not one mention specifically states that smoking is a health hazard. The same issue has 12 pages of cigarette advertisements. The AMA, at its House of Delegates, votes to "work toward promoting a smoke-free society by the year 2000."
1984. A similar supplement of Time devoted to health and produced in cooperation with the American Academy of Family Physicians, contains no references to cigarette smoking. This issue contains eight pages of cigarette advertising. Tobacco advertising increases approximately seven-fold between 1974 and 1984, targeting women, blacks, Hispanics, blue collar workers, children and adolescents. During this time, most magazines that accept tobacco advertising fail to report on the issue of tobacco and health.
1985. The Office of Technology Assessment places the cost of health care for smoking-related disease at $22 billion annually. Lung cancer now kills more men that the other three leading malignant causes of death combined. More women will die of lung cancer than of any other malignancy. Environmental tobacco smoke becomes a major issue.
1987. The California Tort Reform Act giving malpractice relief is passed in California. Unfortunately, in order to get sufficient support to pass the bill, CMA must agree to exempt tobacco companies from product liability in California.
1988. Congress bans smoking on flights of two hours or shorter. The
ban is extended to all domestic flights in 1990.
Proposition 99, a proposal to increase the California tobacco tax by 25 cents, passes in California in spite of a $21 million campaign against it by tobacco interests. Twenty percent of the revenue is to be for health education and five percent for tobacco-related research. SFMS is represented on the city-wide committee overseeing these funds.
1990. Prop 99 is an outstanding success. $150 million is raised for education, and local tobacco control programs are set up in 1,000 school districts and 58 counties. A hard-hitting 14-month advertising campaign is supervised by the Department of Health Services. The program is enormously successful, with the percentage of Californians who smoke dropping from 26% to 16%. Proposition 99 was called "one of the most important public health measures of the latter part of the 20th century" by Dr. Kenneth Kizer former director of the California Department of Health Services. The tobacco industry spends $5 million in campaign contributions, trying to gain support to undermine the public health aspects of Prop 99. The public health provisions of the tax are relentlessly attacked by the tobacco lobby, and for the next five years, funds will be removed from the main anti-tobacco accounts and diverted to pay for direct health care services. The CMA supports the goals of the tobacco lobby, the governor and the legislature in this endeavor.
1991. Prop 99 re-authorization bill diverts money from the health education account to medical services.
1992. Governor Wilson decides not to sign the contract to continue the anti-smoking media campaign.
1993. The 1994-95 budget continues to divert money from health education to medical care, citing deficiencies in the general fund as the primary reason for the diversion. Declining tobacco use in the state levels off and begins to rise in some populations. Governor Wilson signs an executive order making all state buildings smoke free. Phillip Morris sponsors the California Uniform Tobacco Control Act, a euphemism for snuffing out local tobacco control laws. The initiative fails with a 71% vote against, keeping California in the forefront of discouraging smoking. The Environmental Protection Agency, after five years of study, determines that environmental tobacco smoke (second-hand smoke) is a class A carcinogen. San Francisco Board of Supervisors bans smoking in restaurants, jumping ahead of a coming statewide ban. The SFMS joins in the heated debate in favor of this proposal and joins the city-wide tobacco-free coalition with other health organizations and advocates.
1994. California's Governor and legislature are sued by the American Lung Association and American Cancer Society for diverting Prop 99 money intended for health education and research to health care services. The CMA board of trustees is divided but votes to support the diversions. AB 13 is passed in the legislature making all California workplaces smoke free.
1995. AB 13 goes into force except in bars. It is surprisingly well accepted. Nonsmoking becomes more the norm. AMA House of Delegates votes to oppose any sort of tort reform that would benefit the tobacco industry. President Clinton endorses David Kessler's proposal that the Food and Drug Administration regulate the tobacco industry's production of cigarettes as drug delivery devices.
1996. After much debate, CMA house of delegates votes to require the CMA to support full funding of the Prop 99 health, education and research accounts. The SFMS supports this return to the original priorities of Prop 99 funds. Suits proliferate in Minnesota, Mississippi, West Virginia and Florida for reimbursement of costs for smoking-caused illnesses. California is prohibited from joining those suits because of the statute, passed as a part of malpractice reform in 1987, exempting the tobacco companies from product liability suits in California. This statute is subsequently overturned by the legislature. The "cigarette papers," a massive amount of extremely damaging internal tobacco industry documents, are leaked to UCSF Professor Stanton Glantz and published both online and in book form.
1997. Cigarette manufacturers and congressional negotiators negotiate relief for the tobacco industry from threats of litigation in exchange for increased tobacco taxes to pay for medical care caused by tobacco-related disease, and intense regulation of tobacco manufacture and distribution. Anti-smoking advocates state that the agreement is inadequate and not likely to serve the nonsmoking citizens. One tobacco company, Liggett, breaks ranks with the industry and provides damaging evidence to investigators; their CEO admits that "it was about time someone stood up and told the truth." The SFMS joins in presenting a "global summit" on international tobacco issues.
1998. Nonsmoking bars become the norm in California. An Oakland
biotechnology firm admits to conspiring to manipulate nicotine levels in tobacco
with an unnamed tobacco company. Internal R.J. Reynolds documents surface
showing that Joe Camel was a marketing effort intentionally targeted to teens.
San Francisco's supervisors, prodded by health groups including the SFMS, ban
most outdoor advertising of tobacco. Documents reveal that Brown &
Williamson in the 1970s considered sweetening tobacco with honey to make it more
attractive to children. Other documents reveal that Marlboro cigarettes were
altered with ammonia to keep them addictive even if made lower in tar and
nicotine. The AMA's House of Delegates overides AMA leadership and rejects any
"deal" to limit the tobacco industry's legal liabilities
Two hundred thousand Americans will develop lung cancer this year; 180,000 of them will die. This is more American deaths than in World War One, Korea and Viet Nam combined. By the year 2000 more women than men will die of lung cancer. The cure rate is similar to that which was true in 1964 at the time of the first Surgeon General's report. Eighty-five percent of these cases could have been prevented, as many began habitual tobacco use after the Surgeon General's report in 1964. Although many individual physicians stand out in this public health struggle, the organized profession as a whole has been less than exemplary in the past. There are signs, though, that things may be improving.
Dr. Addison is a clinical professor of medicine at UCSF and the director of Pulmonary and Critical Care at UCSF Mt. Zion. He is a member of the SFMS board of directors. Dr. Addison is past president of the California Thoracic Society and has been interested in tobacco issues since 1974.