Drug Abuse

Chapter 26. Cigarettes ––– and the 1964 Report of the Surgeon General's Advisory Committee

From 1492 to about 1910, tobacco was commonly smoked in cigars and pipes, inhaled as snuff, and chewed. Leaf-wrapped cigarettes––– miniature cigars––– were known to the American Indians before Columbus landed; and cigarettes with paper wrappers were available at least as early as the eighteenth century. But the cigarette as it is known today was first marketed in quantity toward the end of the nineteenth century. Not until the first quarter of the twentieth century did the cigarette become the most popular way of securing an hourly nicotine dose (see Figure 11).

Many factors contributed to this meteoric rise in popularity of the cigarette, including improved cigarette paper, automatic manufacturing machinery that lowered the price, and intensive nationwide advertising campaigns for the new cigarette brands. But the major factor was the appearance of a new type of tobacco––– known variously as "bright," "flue cured," or "Virginia"––– which made cigarette smoke more readily  inhalable. Cigarettes made of the new tobacco were called  mild ("not a cough in a carload") because the smoke could be drawn deep into the lungs. The size of the new cigarettes was also admirably adapted to the nicotine dose most people prefer. It was therefore easier for women and children to  learn to smoke cigarettes; the likelihood of nicotine overdose among novices, with such acute toxic side effects as pallor, sweating, nausea, vomiting, and even loss of consciousness (fainting), was minimized.

The explosive increase in cigarette smoking after 1910 can also be attributed in part to the public-health campaigns of that era against the  chewing of tobacco and its inevitable accompaniment, the cuspidor. The sputum of tobacco chewers, according to repeated public-health warnings, spreads tuberculosis and perhaps other diseases. Most of those who gave up tobacco chewing no doubt turned instead to cigarette smoking. The ashtray replaced the cuspidor, and lung cancer replaced tuberculosis as the major lung disease.

Perhaps because of their attractiveness to children and women, the new "mild" cigarettes aroused renewed hostility against nicotine. Beginning in the early 1900s, new anticigarette leagues, patterned on the politically potent antisaloon leagues, were founded and flourished both nationally and locally. Smoking by women and children was particularly assailed. This view was taken even by many confirmed pipe and cigar smokers––– including Thomas A. Edison, himself addicted to cigars. In 1914 Edison wrote a widely publicized letter to Henry Ford alleging that unlike cigar smoke, the smoke from a paper-wrapped cigarette "has a violent action in the nerve centers, producing degeneration of the cells of the brain, which is quite rapid among boys. Unlike most narcotics, this degeneration is permanent and uncontrollable. I employ no person who smokes cigarettes."

FIGURE 11. Production of Cigarettes, 1880 to 1968

Buttressed by such authoritative statements from respected public figures, the anticigarette campaigns were remarkably successful among lawmakers. By 1921––– the year after alcohol prohibition––– fourteen states had enacted cigarette prohibition, and ninety-two anticigarette bills were under consideration in twenty-eight state legislatures. The campaigns were not as effective, however, among cigarette smokers. Men, women, and children went right on smoking (as in the realms of the czar, the sultan, and the mikado centuries before), and in 1927 the last of the statewide cigarette prohibition laws was repealed. Only laws against sales to minors remained.

Examples of these laws are cited below. All of these laws were in effect in the early 1960s, and some may indeed remain in effect today.

A Florida law made it illegal for anyone under the age of twenty-one to smoke cigarettes. It was also illegal in Florida to provide anyone under twenty-one with a cigarette, a cigarette wrapper, or a substitute; a twenty-year-old caught in possession of a cigarette could be hauled into court and compelled to testify concerning its source.

In Georgia, Kansas, West Virginia, and perhaps other states, the legal age for smoking was also twenty-one. In Idaho, incredible as it may seem, the minimum cigarette age for men was twenty-one, but girls could smoke at eighteen.

In Maine an  offer to sell cigarettes to a minor was punishable. In Florida it was unlawful to advise or counsel anyone under twenty-one to smoke. In Massachusetts snuff and cigars were forbidden to young people under sixteen; the ban against cigarettes continued until eighteen. In North Dakota it was unlawful to permit minors to gather in a public place to use tobacco. In Pennsylvania, a minor who refused to divulge the source of cigarettes or cigarette paper could be fined, imprisoned, or certified to the juvenile court; refusal to serve as an informer against his cigarette supplier also made a child a criminal in South Carolina.

These laws led, of course, to ridicule and contempt on the part of law defying young people.

If the anticigarette laws had been effective, one might view them from a different perspective. But here are the cigarette production figures during the decades when anticigarette campaigns were at their height and anticigarette laws were mushrooming in the state legislatures:

Years	Cigarettes per Year (Billions) a
1900-1909	4.2
1910-1919	24.3
1920-1929	80.0

^a The comparable 1970 figure was 583 billion.

As we shall show in Parts VII and VIII, the laws and campaigns of the 1960s against LSD and marijuana helped to popularize those drugs. In retrospect, it seems reasonable to conclude that the anticigarette laws and campaigns earlier in the century were similarly among the significant factors popularizing the cigarette. The prohibition served as a lure.

Thomas Edison was no doubt wrong in alleging that cigarettes permanently damage the cells of the brain––– but he was right in his view that cigarettes are more damaging than pipes or cigars. In part at least, this is because cigarette smoke is usually inhaled deep into the lungs. Some cigarette smokers do not inhale the smoke, while some cigar and pipe smokers do inhale. In general, however, the conversion to cigarette smoking meant a phenomenal increase in smoke inhalation.

Evidence of the added hazard this introduced was soon forthcoming. In 1921, for example, Dr. Moses Barron reported that there had been only four cases of death from lung cancer found among 3,399 autopsies performed at the University of Minnesota from 1899 through 1918. Between 1919 and July 1921, in contrast, there were nine lung-cancer deaths in 1,033 autopsies––– an 800 percent increase. * In 1927, Dr. F. E. Tylecote reported in the British medical journal  Lancet that almost every patient with lung cancer he had seen was a regular smoker, usually of cigarettes. Thereafter confirmatory evidence accumulated rapidly, and lung cancer among smokers reached epidemic proportions.

* By 1952, the rate at the University of Minnesota had risen to 264 lung-cancer deaths in 8,332 autopsies––– almost a 3,600 percent increase over the pre-1919 rate.

Conclusive evidence that cigarette-smoking is by far the most important cause of lung cancer, and is also a major factor in deaths from coronary heart disease, chronic bronchitis, emphysema, and other diseases, was collected during the 1950s and 1960s in a brilliant series of large-scale studies conducted by Dr. E. Cuyler Hammond and his associates of the American Cancer Society. The ACS studies also revealed greatly increased illness rates among smokers and a notable shortening of life expectancy; cigarettes were more damaging in many of these respects than cigars or pipes. Finally, and of the utmost importance, the ACS studies established the fact that ex-smokers live longer than smokers, and that the longer they go without smoking, the closer their life expectancy approaches the life expectancy of those who have never smoked.

Recent studies have also shown that cigarette smoking during pregnancy adds to the hazards of the unborn baby. An English and in American researcher, C. M. Fletcher and Daniel Horn, summarized the evidence in a 1970 World Health Organization publication, "Smoking and Health":

There is now clear evidence from seven large independent surveys that the babies born to women who smoke during pregnancy are, on the average, 150-240 grams lighter than those of non-smokers and that smokers have two or three times as many premature babies [defined as babies weighing less than 2,500 grams]. By their first birthday, these small babies have caught up with and are as heavy as those of nonsmoking mothers.

Recent studies of over 8,000 pregnancies have, however, shown that the risk to the fetus from a mother's smoking may be more serious than this, for the babies of mothers who smoked during pregnancy were about twice as likely to be aborted, to be stillborn, or to die soon after birth as the babies of nonsmoking mothers. The risk to babies of mothers with pre-eclamptic toxemia was increased if the mother smoked. In one study it was calculated that one in five of babies lost would have been saved if their mothers had not smoked.

The data incriminating cigarette smoking as a health hazard were reviewed in a report of the Royal College of Physicians of London in 1962, and in the Consumers Union Report on Smoking and the Public Interest in 1963. These reports, however, reached only hundreds of thousands of people; publicity was relatively limited in the mass media.

On January 11, 1964, a turning point was reached. The Report of the Surgeon General's Advisory Committee on Smoking and Health, published amid unprecedented worldwide fanfare in the mass media, convinced even most smokers that cigarette smoking shortens human life, causes lung cancer and other forms of cancer, and exacerbates heart disease, emphysema, bronchitis, and a number of other illnesses––– gravely increasing the risk of dying of them.

For a brief few weeks, this report had a major nationwide impact. Within a few days after its publication, some chain supermarkets announced that cigarette sales had fallen 20 to 25 percent. In Iowa, where the impact of the report was most noticeable, tax officials reported that the number of taxed packages fell 31.7 percent in February 1964, the month after the report was issued. Nationally, the drop in taxed packages was between 15 and 20 percent. The true impact of the report was much greater than even these figures suggest. For casual smokers (of less than a pack a day) were more likely to stop smoking than heavy smokers (two packs or more a day). Thus a 20 percent decline in number of cigarettes smoked may have represented a 25 or even 30 percent decline in number of smokers still smoking.

But the curtailment was short-lived; what has been called "the Great Forswearing" of January and February 1964 was followed by the "Great Relapse" of March––– further evidence that in the twentieth century, as in the sixteenth, nicotine remained an addicting drug. Within a few months cigarette consumption was back almost to pre-1964 levels.

The failure of the Report of the Surgeon General's Advisory Committee to curtail cigarette smoking more than briefly was naturally a disappointment, but health agencies did not despair. The United States Public Health Service, the American Cancer Society, and countless other national and local agencies launched campaigns with three major and related goals: to inform people that cigarette smoking is dangerous, to persuade people to stop smoking, and to help those who were having trouble in stopping. The possibility that nicotine, for a large percentage of users, might be an addicting drug––– the possibility that many people might not be able to stop, even though they wanted to, decided to, and tried to was not given serious consideration. It was during the same years 19641970, it will be recalled, that the public was similarly being assured that heroin addiction is curable.

Judged by their effect on  attitudes, the antismoking campaigns launched following the 1964  Report of the Surgeon General's Advisory Committee were notably successful. A survey conducted by the United States Public Health Service in 1966 revealed the following attitudes among a nationwide cross section of males  who were current cigarette smokers:

71.3 percent agreed that smoking is harmful to health.

67.3 percent disagreed with the statement that cigarettes do more good to a person than harm.

59.5 percent hoped that their children would never smoke.

57.7 percent agreed that cigarette smoking is a cause of lung cancer.

56.3 percent disagreed with the statement: "The chances of getting lung cancer from smoking cigarettes are so small that it's foolish to worry about it."

54.6 percent agreed that smoking is a dirty habit.

44.9 percent agreed that there is something morally wrong with smoking cigarettes.

43.1 percent agreed that cigarette smoking is a cause of emphysema and chronic bronchitis.

33.4 percent agreed that cigarette smoking is a cause of coronary heart disease.

Among women who were currently smoking cigarettes, and among nonsmokers, the percentages decrying cigarettes were even higher on every one of those questions. *

* Also noteworthy was an increase in support for cigarette prohibition. In 1964 and again in 1966, only 23 percent of respondents in a National Clearinghouse for Smoking and Health survey agreed with the statement, "The selling of cigarettes should be stopped completely." In a 1970 survey, 38 percent of respondents agreed with this prohibitionist position.

These figures, clearly, are a tribute to the effectiveness of the antismoking campaigns. Even many confirmed cigarette smokers were persuaded by the campaigns that smoking is a dirty habit, harmful to health and morally reprehensible. But the prevalence of negative attitudes toward smoking among smokers, unfortunately, had little effect on their actual smoking. Here are the cigarette consumption figures.

Year	Number of cigarettes smoked (in billions)	Daily per capita consumption (aged 18 and over)
1958	449.8	10.8 cigarettes
1959	467.4	11.2 cigarettes
1960	484.4	11.4 cigarettes
1961	502.7	11.7 cigarettes
1962	508.4	11.7 cigarettes
1963	523.9	11.9 cigarettes
1964	511.2	11.5 cigarettes
1965	528.7	11.7 cigarettes
1966	541.2	11.8 cigarettes
1967	549.2	11.7 cigarettes
1968	545.6	11.5 cigarettes
1969	528.9	10.8 cigarettes
1970	542.0	11.0 cigarettes

In short, the number of cigarettes consumed in 1970 was up 3.4 percent since 1963, while per capita consumption was down 7.6 percent.

The increase in cigarette consumption, moreover, occurred despite an increase of more than 40 percent in retail cigarette prices between 1964 and 1970. Retail expenditures for cigarettes increased from an estimated $7.2 billion in 1964 to an estimated $10.5 billion in 1970. Thus despite the anticigarette campaigns and despite the increased awareness of smoking hazards, Americans were spending 45 percent more for cigarettes in 1970 than in 1964.

The  Report of the Surgeon General's Advisory Committee and the subsequent anticigarette campaigns did have one major effect, however. Vast numbers of smokers turned from plain to filter-tip cigarettes and from high-tar-high-nicotine to low-tar-low-nicotine brands. While the data are not conclusive, it seems probable that the increase in number of cigarettes smoked  per smoker was related to this switch; some smokers no doubt increased their daily cigarette quota to compensate for the smaller amount of nicotine in each cigarette. Other smokers no doubt compensated by taking more puffs on each cigarette and leaving shorter butts.

In the eighteenth century, Charles Lamb described his own addiction to nicotine in striking language:

For thy sake, tobacco, I
Would do anything but die.

The current evidence indicates that Lamb seriously understated the case.

Meanwhile, what of the effects of current public health anticigarette campaigns on children and young people? A 1970 survey made for the American Cancer Society by Lieberman Research, Inc., shows that, as in the case of adults, the campaigns––– including the anticigarette TV commercials of 1968-1970––– were enormously effective in molding the attitudes of young people toward cigarettes.

The Lieberman study covered a nationwide cross section of young people aged thirteen through eighteen, both smokers and nonsmokers. More than two-thirds of these teenagers (70 percent of the nonsmokers and 66 percent of the smokers) recalled anticigarette presentations to which they had been exposed in school. More than half had seen anticigarette educational films and posters. Almost all of them had seen the powerful anticigarette messages then being aired on television; indeed, the teenagers in the sample reported having seen an average of 8.9 anticigarette television spots during the previous four weeks.

The vast majority of these teenagers, moreover, were convinced by what they had seen and heard. When asked whether cigarette smoking causes cancer, for example, 86 percent of the teen-age nonsmokers and 65 percent of the teen-age smokers agreed that it did. Similarly, 71 percent of the teen-age nonsmokers and 66 percent of the smokers agreed it was "definitely or probably true" that cigarette smoking triples the likelihood of a heart attack.

As in the case of adults, however, a firm conviction that smoking causes cancer and heart attacks had very little effect on teen-age smoking habits. "When children enter their teen-age years," the 1970 survey noted, "the rate of cigarette smoking is relatively low. By the time they reach the end of their teen-age years, the rate of cigarette smoking is not far from the rate for the general adult population."

Two surveys made for the National Clearinghouse for Smoking and Health, a unit of the United States Public Health Service, suggest that during the years from 1968 to 1970, the proportion of teenagers recruited to cigarette smoking was actually increasing* Here are the figures.

* The 1970 Lieberman Report also revealed that more than half of all teenagers who smoke had their first cigarettes by the age of twelve and 85 percent had smoked before the age of fifteen.

Age at First Cigarette	Percentage of Total Who Ever Had Smoked
8 years or under	14
9-10 years	14
11-12 years	27
13-14 years	30
15-16 years	12
17-18 years	2
Don't know or no answer	1
	100

PERCENTAGE SMOKING
Year	Boys	Girls
1968	14.7	8.4
1970	18.5	11.9

Why do boys and girls convinced that cigarette smoking causes cancer and heart attacks nevertheless start smoking cigarettes? One answer fairly leaps from the pages of the Lieberman survey. The single most important fact about smoking has been kept a secret from them.  They have not been told that nicotine is an addicting drug. As a result, most of them think that they will smoke for a while and then stop. Indeed, among the teen-age smokers in the Lieberman survey, only 21 percent thought it "very likely" that they would still be smoking five years hence; and an additional 27 percent thought it only "fairly likely." The majority confidently expected to stop in five years or less.

The thought that many smokers  can't stop seems not to have occurred to these teenagers. They believed not only the campaigns stressing smoking as a cause of cancer and heart attacks, but also the campaigns insisting that it is possible to stop smoking if you "make up your mind" to stop. So why not smoke for a few years and then swear off? That in effect was the majority view among the teenagers in the Lieberman sample.

The campaigns do not, of course, tell children that it is  easy to stop smoking. They suggest that it requires considerable effort of will and perhaps some suffering. As noted in Part I, this is precisely the kind of challenge that attracts voting people. A majority of the teen-age smokers in the Lieberman sample envisioned themselves as confronting that challenge a few years hence, and winning.

The role of cigarette advertising in exacerbating the problem of nicotine addiction is difficult to evaluate. Smoking does not depend on advertising. In Italy, where all cigarette advertising has been banned, there has been little change in cigarette consumption. People who already smoke go right on smoking, largely because they are addicted to nicotine.

But why do young people start smoking? Here the answer is more complex. Fifteen-year-olds start in part because their elders smoke and in part because other teenagers smoke. But it seems highly likely that cigarette advertising––– which associates smoking with youth and music and joy and sex––– is an auxiliary factor, perhaps a quite potent one.

For almost all of these children, of course, smoking was illegal; for many of them, smoking a cigarette was their first experience with an illicit drug.

It may be, of course, that a ban on all cigarette advertising would have little or no immediate effect on the recruiting of youthful new smokers; the other factors may be sufficient to maintain recruiting at present levels even in the absence of advertising. But no other methods of discouraging young people from beginning to smoke offer any likelihood of success so long as cigarette advertising remains licit.

The view here presented––– that cigarette smoking is an addiction to the drug nicotine, that the overwhelming majority of those who smoke more than a few cigarettes become addicted, and that relatively few addicts quit permanently––– seems to fly in the face of common sense. Some readers of this Report, for example, have no doubt quit smoking themselves perhaps with relatively little difficulty. Most readers no doubt know personally quite a few individuals who have quit. And most people, especially in 1970 and 1971, read repeated newspaper stories announcing that millions of cigarette smokers had quit smoking––– stories emanating in large part from the National Clearinghouse for Smoking and Health. Surely, some readers may feel, the case for the addicting nature of cigarette smoking is being exaggerated in this Consumers Union Report.

Since United States statistics concerning ex-smokers are currently in dispute, let us start with a British view.

"In the 10-year period 1958-68," Dr. Hamilton Russell of the Addiction Research Unit notes,

there was little change in smoking prevalence among men in the United Kingdom––– about 69 percent were smokers, 15 percent ex-smokers, and 16 percent had never smoked. In such a sample the ex-smokers form 18 percent of the smokers and ex-smokers combined. . . . Using the 1968 statistics for women, a similar figure is obtained. Thus some 18 percent of smokers have stopped smoking and become ex-smokers. This so-called natural discontinuance of smoking tends to occur after the age of 30 and rises further with increasing age. The average daily cigarette consumption also tends to drop quite sharply after the age of sixty. The ex-smoker status, however, is not a stable one and many relapse to regular smoking. This relapse rate is related to the duration of the ex-smoker status. Among ex-smokers [who have abstained for less than one year] 37 percent relapse within two years compared with 19 percent of those [who have abstained for one to two years] and 5 percent of those [who have abstained for more than two years]. There is therefore a sizeable turnover, with regular smokers discontinuing only to relapse later. The evidence suggests that in the present social climate of this country [Britain] it is unlikely that more than 15 percent of people who smoke regularly undergo natural discontinuance to permit non-smoking status before the age of 60. Furthermore, this situation has not changed appreciably over the past ten years.

This analysis of ex-smoker statistics should serve to warn against excessive optimism when superficially impressive figures are publicized. A headline announcing that a substantial percentage of all smokers have quit, for example, must be viewed with extreme caution. If the same percentage of all smokers had also quit ten years ago, the progress made against smoking is clearly  nil.

Dr. Hamilton Russell's analysis also explains the instinctive commonsense error in judgment people make when they decide that the war against cigarettes must be going well because they see around them so many former smokers who have quit. If they had looked around them a decade ago, they would also have noted many ex-smokers.

Data concerning current smokers, nonsmokers, and ex-smokers in the United States are available from the National Center for Health Statistics, a unit in the United States Public Health Service.

	Percentage	Percentage	Percentage
	1955 *	1966 *	1968
Current smokers	41.8	40.6	38.5
Never smoked	50.9	47.6	48.0
Ex-smokers	7.3	11.8	13.5 26

* There were minor changes in data-gathering methods between 1955 and 1966, but not enough to impair the comparability of the figures.

The above figures do not suggest a major victory over nicotine between 1955 and 1968. They are subject, however, to an important qualification. The surveys on which they are based asked each respondent to reply not only for himself but also for other members of the same household. It is easy for a respondent to report accurately who in his household smokes and who does not smoke; but in such a survey ex-smokers are sometimes reported as having "never smoked." Two 1970 surveys, one by the National Clearinghouse for Smoking and Health and the other by the Social Research Group of George Washington University, asked each respondent to report only for himself. As a result, the number of exsmokers is larger than in the statistics cited above, while the number of current smokers remains about the same.

	Percentage	Percentage
	National Clearinghouse for Smoking and Health, 1970	Social Research Group, 1970
Current smokers	36.2	38
Never smoked	40.3	39
Ex-smokers	23.5	22

The "ex-smoker" figures in these two studies seem to offer a ray of hope. But this apparent increase in ex-smokers since 1955 is not balanced by a decrease in current smokers; the ex-smokers in the 1970 surveys seem to come mostly from the "never smoked" category in the earlier surveys. Little comfort can be drawn from the fact that the proportion of current smokers in the country has declined from 41 to 42 percent in 1955 to 36 or 38 percent in 1970.

Footnotes
Chapter 26

		Next >