It has been more than 26 years since the first surgeon general's report on smoking and health was released. The good news: The percentage of cigarette smokers in the United States has declined. The bad news: People are still smoking themselves to death at an alarming rate.
In 1985, the last year for which estimates are available, 390,000 people died from smoking-related diseases. Think of it this way: That's about 1,000 deaths every day. Or this way: One in every six deaths is due to smoking.During the past 26 years there have been gains in the campaign to control tobacco use. The body of scientific data on the health hazards of smoking has grown dramatically. People are more aware than ever of the health consequences of smoking, and policies are being adopted at all levels of government to discourage the use of tobacco.
Making further cuts in the use of tobacco nationwide will require greater effort and resources in the future, according to C. Everett Koop, the former U.S. surgeon general, who released the 20th report on the health consequences of smoking last year.
Why? Because those groups that continue to smoke the most - blue-collar workers, less-educated people, women, young people and minorities - are harder to reach with anti-smoking messages and smoking cessation programs.
A chemical delivery system
Cigarettes are the only product that, when used as intended, kill people, according to Dr. John H. Holbrook, a internal medicine specialist at the University of Utah Medical Center. Holbrook is also a professor of internal medicine at the university's School of Medicine and served two years in the National Clearinghouse on Smoking and Health (now called the Office on Smoking and Health) in Washington, D.C. While there, he helped prepare annual reports on tobacco and health for the U.S. surgeon general and has since continued as an editor of the reports.
"The cigarette is like a miniature chemical factory," Holbrook said. "The delivery system is extraordinarily effective.
"When somebody inhales smoke, billions of tiny particles are drawn into the terminal air sacs, cross a membrane and gain access to the bloodstream, and then they are disseminated widely throughout the body," Holbrook said.
"It is literally like putting a needle in your vein and injecting this mixture of substances . . . into your blood more than 70,000 times a year. If you project that over a lifetime, you can see why this one product can do so many bad things - because it isn't just one harmful substance, it's many harmful substances."
Health effects of smoking
The first reports scientifically linking smoking with adverse health effects began to appear in the 1920s. In 1954, researchers E. Cuyler Hammond and Daniel Horn published a paper in the Journal of the American Medical Association that concluded smoking caused lung cancer.
Ten years later, in 1964, an advisory committee on smoking and health reported to then-Surgeon General Luther L. Terry that cigarette smoking is a cause of lung cancer and other serious diseases.
The committee reported, in what became the first surgeon general's report on smoking and health, that studies showed significant associations between smoking and cancer of the esophagus and urinary bladder, coronary artery disease, emphysema, peptic ulcer disease and low-birthweight babies.
At least one thing hasn't changed in the 26 years since the first surgeon general's report on smoking and health was released: Cigarette smoking is still the main cause of lung cancer, which on average kills people within three years.
But some things have changed. Many of the health problems the first report listed as "associated with smoking" have since been shown to be caused by smoking. New relationships between smoking and certain health problems have also been demonstrated.
For example, studies have shown cigarette smoking is a major cause of strokes, the third leading cause of death in the United States. Studies have shown cigarette smoking is also the single most important factor in heart attacks in individuals under age 35, according to Holbrook.
A University of Utah study published in the Journal of the American Medical Association in 1989 found that women exposed to secondhand cigarette smoke for three hours or more per day were three times more likely to develop cervical cancer than women not steadily exposed to cigarette smoke. The risk of the cancer is even slightly higher for women who smoke.
"The majority of smokers eventually develop either lethal complications or significant disabling complications that may or may not be lethal," Holbrook said.
Holbrook says a "genetic factor" makes some individuals "uniquely susceptible to the adverse effects of smoking.
"It is not really predictable," Holbrook said. "If a patient comes to me, I can tell him smoking is definitely harmful. That I can safely say. But I can't really say to someone that `You're going to get lung cancer.' I can say, `Your risk of getting lung cancer is 20 times greater than a nonsmoker.' But that is the sort of information we give.
"We can say if you smoke two packs a day and you are a 25-year-old man, your risk of living a normal life is significantly shortened," Holbrook said. "In fact, you on an average will live eight to nine years less than somebody else who is your same age, sex, race and the other things that help determine how long we live."
Tobacco company response
The fact that doctors cannot say with certainty that any given individual smoker will develop a smoking-related disease provides tobacco companies with the argument that there is no proof smoking causes disease.
Tobacco companies are particularly incensed over the controversy about the health effects of secondhand smoke, saying there is no substantial evidence to support the view that exposure to environmental tobacco smoke is a significant health hazard to non-smokers.
Tobacco companies for decades have promoted their products' filtering systems and low tar and nicotine content - all the while maintaining cigarette smoking doesn't cause health problems.
"They get in a bind because they have never acknowledged that their product is harmful in any way," Holbrook said. "They can't very well say it is a safer cigarette because they have never admitted it was harmful in the first place."
There is very little evidence that low-tar, low-nicotine cigarettes are in fact safer, Holbrook said.
Most people inhale more frequently and more deeply to get more smoke, thus counteracting any benefits, he said.
Cigarette advertisements routinely link cigarettes with health and success by picturing smokers in healthful, green lush vacation spots and in groups of laughing young, healthy people. Mediums of choice: billboards, magazines and then news-papers.
Cigarette companies have concentrated their advertising dollars in sponsorship of sporting events and giving away free samples and coupons ever since television stations were forced by the Federal Communications Commission to kick the cigarette ad habit in 1970.
In 1985, cigarette advertising and promotion totaled $2.5 billion.
Whom tobacco companies aim for
There are 56 million smokers in America between the ages of 15 and 84. To meet the demand of these smokers, tobacco companies shipped 524 billion cigarettes to wholesalers in 1989.
Who have the cigarette companies set their sights on? The young, the uneducated, women, minorities and blue-collar workers.
"The number of individuals smoking and the per capita consumption continues to go down," Holbrook said. "So the (tobacco companies') strategy is to try to attract certain segments of the market. It is really, in my view, an obscene kind of corporate policy, where they target, for example, young women that are poorly educated.
"I consider these companies from a moral point of view to be bankrupt," Holbrook said. "They know they have a harmful product, they know it is an addicting product, and they know they are basically attracting teenagers or (children), and in spite of that they persist because of the huge profits involved. I find that incredible."
Tobacco companies maintain smoking is an adult habit and say they aim their advertising efforts only at adults, Holbrook said.
"What they say in public flies in the face of their own research data that show the majority of their consumers became smokers in the teenage years," Holbrook said. "They know that very well. They won't say that in public, but their own research and research of others show that."
Declining cigarette consumption in the United States combined with difficulties in introducing new brands here has forced tobacco companies to look elsewhere for new recruits. They have found them in Third World countries such as those in Africa, where smoking increased 77 percent between 1971 and 1981, Asia and Latin America, according to the World Health Organization.
Other countries, like Japan, "send us cars, we send them cancer," Holbrook said.
Toward a smoke-free society
Koop, as surgeon general, dared to envision a smoke-free society. "In the 1940s and 1950s, smoking was chic; now, increasingly, it is shunned," Koop wrote in the introduction to the 1989 smoking report. "Movie stars, sports heroes and other celebrities used to appear in cigarette advertisements. Today, actors, athletes, public figures and political candidates are rarely seen smoking. The ashtray is following the spittoon into oblivion."
An increasing proportion of adults - 69 percent in a 1986 survey - said cigarette smoking is annoying, according to the surgeon general's 1989 report. Ninety-two percent say they believe cigarettes cause lung cancer; in the 1950s only 40 percent to 50 percent of adults held that belief, indicating increased awareness today of the health hazards of smoking.
Forty-three states have laws restricting the sale of cigarettes to minors.
More than 320 local communities had adopted laws or regulations restricting smoking in public places by mid-1988, a threefold increase in three years. Forty-two states now ban smoking in public places, as do approximately half of all large businesses.
"We've come a long way," Holbrook said. "When I was back in Washington, the things that are happening now would have been unheard of - to ban smoking on our airlines. The transcontinental bus companies recently came to the federal government and said they - the companies - wanted to ban smoking on the buses. Imagine that! The companies coming to the federal government."
SMOKE - WHAT'S IN IT?
There are more than 4,000 known chemical substances - 43 of which are known carcinogens - in tobacco smoke. Nicotine, carbon monoxide, phenol, indole, cresol, benzopyrene, nitrosamines. Sound like a toxic mix? It is, according to researchers. Yet the average pack-a-day smoker inhales all of these substances and more about 200 times a day.
Utah has the lowest incidence of lung cancer in the country: 26.9 cases per 100,000 people per year compared to a national rate of 54.5. While Utah may have the lowest tobacco consumption in the country, it does not get off scot-free when it comes to health-care expenses and productivity losses associated with smoking-related diseases. The U.S. Department of Health and Human Services estimates the annual expense of such diseases is $56 for each man, woman and child in the state.
Smoking's growing toll among U.S. women
Smoking's toll is predicted to wreak havoc on women in the coming decade. Over the past 26 years, the decline in smoking has been slower among women than men. In fact, when it comes to smoking, women have gained equality with men: There are 26.4 million male smokers and 24.5 million female smokers.
California takes lead
California has taken the lead in striking out against tobacco use. Voters there approved Proposition 99, the Tobacco Tax Initiative, in November 1988. The state estimates 24 percent of its population of 29 million smokes and that more than 30,000 Californians die from smoking-related diseases annually. Carol Russell of the state health department estimates Californians spend more than $5.6 billion a year for health-related costs due to tobacco use. The initiative added a 25-cent tax to each pack of cigarettes and other tobacco products sold in the state. The tax is expected to generate $650 million a year for tobacco-related research, education, intervention and health care.