Surgeon General's Advisory Committee Research Articles

MEANINGS & MOTIVES Experts Debating Tobacco Addiction

Over the last 50 years, tobacco has been excluded from and then included in the category of addictive substances. We investigated influences on these opposing definitions and their application in expert witness testimony in litigation in the 1990s and 2000s. A scientist with ties to the tobacco industry influenced the selection of a definition of addiction that led to the classification of tobacco as a "habituation" in the 1964 Surgeon General's Advisory Committee report. Tobacco was later defined as addictive in the 1988 surgeon general's report. Expert witnesses for tobacco companies used the 1964 report's definition until Philip Morris Tobacco Company publicly changed its position in 1997 to agree that nicotine was addictive. Expert witnesses for plaintiffs suing the tobacco industry used the 1988 report's definition, arguing that new definitions were superior because of scientific advance. Both sides viewed addiction as an objective entity that could be defined more or less accurately.

Cigarettes and the US Public Health Service in the 1950s.

The conclusion of the United States Surgeon General's Advisory Committee on Smoking and Health in 1964 that excessive cigarette smoking causes lung cancer is cited as the major turning point for public health action against cigarettes. But the surgeon general and US Public Health Service (PHS) scientists had concluded as early as 1957 that smoking was a cause of lung cancer, indeed, "the principal etiologic factor in the increased incidence of lung cancer." Throughout the 1950s, however, the PHS rejected further tobacco-related public health actions, such as placing warning labels on cigarettes or creating educational programs for schools. Instead, the agency continued to gather information and provided occasional assessments of the evidence as it came available. It was not until pressure mounted from outside the PHS in the early 1960s that more substantive action was taken. Earlier action was not taken because of the way in which PHS scientists (particularly those within the National Institutes of Health) and administrators viewed their roles in relation to science and public health.

The Silver Anniversary

On Wednesday, Jan 11, 1989, I will release the next Surgeon General's report on the health consequences of smoking. That date is the 25th anniversary of the day on which the historic report of the Surgeon General's Advisory Committee on Smoking and Health was released to Surgeon General Luther L. Terry, MD. This anniversary report will review and analyze the major developments related to smoking and health that have occurred in the United States during the past quarter century. Tremendous gains have been made. The prevalence of cigarette smoking among adults has fallen steadily since 1964. Per capita cigarette sales have declined each year since 1973. Even total cigarette sales have decreased about 2% each year during the past six years, despite growth in population.1Smoking is no longer socially acceptable, and is prohibited in more public places than ever before. Physicians and other health care providers, medical organizations,

Smokeless tobacco and cancer: the epidemiologic evidence.

In summary, evidence from human populations has shown that smokeless tobacco users have risks of cancer several times higher than that of nonsmokers. Smokeless tobacco is very strongly related to cancers of the cheek and gums, locations typically in direct contact with the tobacco. The association is evident in studies in the US and Scandinavia and also in Asia, where the chewing of quids containing tobacco and other ingredients is strongly related to the region's high rates of oral cancer. Reports on health effects date back to the 18th century and the evidence is consistent, with most investigators reporting positive findings. Dose-response relationships--increasing risk with increasing use--are also evident in several studies. Finally, preliminary work on cancers in other anatomic sites suggests that smokeless tobacco may also be related to other upper digestive tract cancers. With the exception of one group of medical scientists who described the relationship as only an "association," expert consensus conferences and committees in both the US and France have agreed that the evidence from clinical, epidemiologic, and carcinogenesis studies supports a causal relationship between the use of smokeless tobacco and oral cancer in humans. These expert groups include the International Agency for Research on Cancer (1984), the National Institutes of Health Consensus Conference on the Health Implications of Smokeless Tobacco Use (1986), and the Surgeon General's Advisory Committee on the Health Consequences of Using Smokeless Tobacco (1986).(ABSTRACT TRUNCATED AT 250 WORDS)

In smoke's way: Socioemotional reactions to another's smoking.

According to antismoking organizations such as ASH (Action on Smoking and Health), not only does cigarette smoke pose a potential health hazard to those exposed to it (Doyle, 1974), but its smell may cause discomfort as well. Compared to the large volume of medically related research (Surgeon General's Advisory Committee, 1964), few studies have sought to assess the impact of another's smoking on reactions toward the smoker and one's own emotional state. In view of this, the present work examined the immediate consequences of exposure to second-hand cigarette smoke on a variety of socioemotional responses including interpersonal attraction and personal feelings.

The Audience for National TV News Programs

Despite the vast amounts of data collected by TV ratings services, surprisingly little information about the composition of the audience for the evening newscasts of Huntley-Brinkley, Reynolds-Smith, or Walter Cronkite has come to light. The questions addressed in this article are rather mundane in nature, since there are more important questions about the impact of such programs in informing the public, increasing public concern about social issues, altering audience perceptions, and changing audience attitudes.' Nevertheless, consideration of these questions does bear on the likely effects of news programs and leads us to challenge certain other findings regarding the audience for television news. The data reported here come from television viewing diaries collected by the W. R. Simmons organization from a national probability sample of persons 18 years and older. The diaries were kept by 6,834 viewers for various two-week periods between October i2 and November 1i, 1969. These data offer unique advantages over alternative sources. First of all, the sample has a national probability base, but is over three times as large as those few previous studies of news viewing that were nationwide in scope. Second, considerable experience and care in collecting valid data on highly specific aspects of mass media use are built into the Simmons data gathering operation. Third, Simmons collects data on three media simultaneously; few organizations engaged in media research collect detailed data on more than one medium at a time. Finally, the data are collected by a commercial organization, a factor minimizing the likelihood that respondents would overreport their news behavior because it might be expected of them (as is to be feared when the focus of the survey is news and the respondent knows it). * The data reported here were analyzed for the Surgeon General's Advisory Committee on Television and Social Behavior, under the auspices of the National Institute of Mental Health. Further details will be contained in the final report of this committee. The author wishes to acknowledge the skillful guidance of Harold Israel of the Simmons organization in analysis of these data. tJohn P. Robinson is a Study Director at the Survey Research Center, University of Michigan.

Influenza in Los Angeles County, 1968-69

T HE LAST SIGNIFICANT epidemic of A2 influenza in Los Angeles County had occurred in early 1966, with its estimated peak around February 20. Although the remainder of the nation experienced epidemic influenza in the 1967-68 winter season, California, including Los Angeles, did not (1) . In July 1968 the World Health Organization received reports of an influenza epidemic in Ho,ng Kong. The agent isolated from patients in this outbreak was found to differ antigenically from recent A2 strains, and it was labeled influenza A2/Hong Kong/68 (2). Because of the magnitude of the antigenic drift, the Surgeon General's Advisory Committee revised its statement of June 1968 (3). Their original forecast had mentioned little or no influenza activity for most of the nation in the 1968-69 season. The revised statement and recommendatio,ns proved to be correct, as the entire country experienced epidemic activity by January 1969. This report describes the epidemic in Los Angeles County and the surveillance methods used to monitor it. Surveillance Methods Daily reporting of absenteeism from city schools. Beginning in September 1968, all Los Angeles city schools with more than 10 percent absenteeism reported by telephone to a central administrative office that in turn informed the health department on a daily basis. This surveillance included 576 public schools-130 senior and junior high schools and 446 elementary schools. Weekly reporting of school absenteeism. A sample of approximately 30 city, county, and parochial schools reported absenteeism by mail on a weekly The authors are with the County of Los Angeles Health Department. Dr. Matlof is an epidemic intelligence service officer from the Public Health Service's Center for Disease Control, Atlanta, Ga., and he is assigned to the county health department's Acute Communicable Disease Control Division. Mr. Murray is epidemiology analyst, and Dr. Kamei is chief of the division. Dr. Heidbreder is the county health officer. Tearsheet requests to Harvey Matlof, M.D., 220 North Broadway, Los Angeles, Calif. 90012.

The Economic Costs of Cigarette Smoking

THE HEALTH HAZARDS of cigarette smoking are well established, as evidenced by the 1964 report of the Surgeon General's Advisory Committee and the 1967, 1968, and 1969 reports to Congress by the Public Health Service (1-4). An iinportant part of this evidence is represented by several major prospective studies of large population segments. These studies have revealed a far greater incidence of early death among smokers than among their nonsmoking counterparts. The evidence is consistent for major groups and for both sexes, and the health hazard increases with greater exposure to smoking. No attempt has yet been made in the United States to use data from these studies to assess another important part of the smoking problem-the magnitude of economic losses which smoking engenders. The incidence of sickness and death caused by or contributed to by cigarette smoking obviously drains our economy heavily by diverting scarce health resources from other needs and by reducing national economic production through early death and excess morbidity.

Smoking and the Coronary Arteries

To the Editor:— Dr. Seltzer's thoughtful and well-documented review of and Coronary Heart Disease ( 203 :193, 1968) makes no reference to personality factors. Perhaps there are no research data about personality differences of the cigarette smoker in contrast to the pipe or cigar smoker, but popular attitudes generally suggest that the pipe or cigar smoker is more phlegmatic and less likely to suffer from tension states. A striking difference in the incidence of coronary disease is found between the two groups. Apparently the Surgeon General's Advisory Committee on Smoking and Health (quoted by Dr. Seltzer) in its list of predisposing factors mentioned only occupations involving—stress and ignored individual personality factors basic to psychomatic disturbances, which may predispose to coronary heart disease.

An Evaluation of the Effect of Smoking on Coronary Heart Disease

In January 1964, the Surgeon General's Advisory Committee on Smoking and Health 1 in considering the available information on smoking and coronary heart disease (CHD) (International Statistical Classification [ISC] 420) reported that male cigarette smokers have a higher death rate from coronary artery disease than nonsmoking males, but it is not clear that the association has casual significance. Three points should be noted. First, the committee left no doubt that there was a consistent statistically significant association among cigarette smokers of increased mortality and morbidity from CHD in men, particularly during middle life. Seven large completed or current prospective studies of smoking and death rate gave a CHD median mortality ratio (current cigarette smokers to nonsmokers) of 1.7, with no significant excess deaths among cigar and pipe smokers. Second, the committee recognized that certain factors other than smoking were known or thought to predispose to the condition or to be

The cigarette war--who is winning?

ON JAN 11, 1964 the Surgeon General's Advisory Committee on Smoking and Health published its report documenting the serious and increasing health menace of cigarette smoking. On July 27, 1965 the Congress of the United States enacted the Cigarette Labeling and Advertising Act, that became effective Jan 1, 1966. As part of the act the Federal Trade Commission was instructed to report to Congress 18 months after the effective date, and annually thereafter, concerning the effectiveness of cigarette labeling, current methods of cigarette promotion, and recommendations for further legislation. On June 30,1967 the Federal Trade Commission published its first report to Congress. 1 The contents will be of great interest to all physicians including otolaryngologists. In 1964, following the Surgeon General's report, cigarette sales declined about 2%, most of this occurring in January and February immediately following publication of this report. In the next two years cigarette sales

Lung Cancer and Bronchitis in Relation to Cigarette Smoking and Fuel Consumption in Twenty Countries

In their report on Smoking and Health, the Royal College of Physicians (1962) concluded that cigarette smoking was a cause of lung cancer but that smoking was not the only cause of this disease. The report on the same subject by the Surgeon General's Advisory Committee of the United States Public Health Service (1964) concluded that: Cigarette smoking is causally related to lung cancer in men; the magnitude of the effect of cigar ette smoking all other factors. The phrase far outweighs has been wrongly taken by some to imply that the other factors are of little consequence in their total effect but, when dealing with a disease responsible for some 30,000 deaths a year in the United Kingdom, a fraction of only one-fifth due to other factors would account for 6,000 deaths and such a number could hardly be regarded as unimportant. The first tentative esti mates of one-fifth were derived from very small numbers of non-smokers, and studies of more adequate data have shown that in some large urban areas the contribution of other causes to the total deaths must be a good deal higher. For example, it was estimated in 1955 that about half the deaths of men from lung cancer in Liverpool arose from cigarette smoking and about three-eighths must have been due to factors only slightly present in neighbouring rural areas (Stocks and Campbell, 1955). In classical studies of lung cancer mortality related to histories of past residence and smoking of men and women in the United States, Haenszel and his co-workers (Haenszel, Loveland, and Sirken, 1962; Haenszel and Taeuber, 1964) have analysed in great detail the periods of life-time spent, by those who died of the disease, in towns of different population size and in rural and farm areas. Standardized mortality ratios based on 100 for all white males, and adjusted both for their age and smoking history, were, for all durations of residence combined, 65 in farm areas increasing by stages according to the size of town lived in to 123 in cities of half a million population or over; and for white females the mortality ratios increased from 69 in the farm areas to 132 in the large cities. When durations of residence between 10 and 40 years only were considered, the corresponding mortalities were 77 and 122 for males, 70 and 149 for females. This disposes of the idea that the urban excess of lung cancer could be explained away by more cigarette smoking in town than country. Another study of male mortality in Canada according to smoking history, comparing those who had lived for 5 years or more in cities with those who had not, showed an overall ratio of 1-50 for lung cancer contrasted with 1 12 for all causes of death (Department of Health and Welfare, Canada, 1966). A recent evaluation of the urban excess for lung and stomach cancer and bronchitis in English conurba tions compared with surrounding areas, during periods from 1921-30 to 1951-60, has shown that the excess, which continues to be large, cannot be explained either by smoking differences or by the social factors affecting the three diseases, and must be attributed to air pollution in the case of lung cancer and bronchitis for lack of any other conceiv able explanation (Stocks, 1966). Comparisons between lung cancer death rates in whole countries with good standards of diagnosis and cause certification have become possible in recent years, and Nielsen and Clemmesen (1954) demonstrated a rough correspondence between the crude rates in eight countries about the year 1950 and the annual consumption of tobacco per inhabitant 20 years previously. Improvement in reliability of death rates and in availability of trade figures of cigarette consumption made possible a study of death rates at different ages in 1958-9 in 181

MORTALITY FROM DISEASES ASSOCIATED WITH SMOKING: UNITED STATES, 1950–64

Extensive studies using epidemiological, experimental, and clinical methods have been made on the effects of tobacco on health. In 1962, the Advisory Committee on Smoking and Health appointed by the Surgeon General of the Public Health Service reviewed and evaluated the studies available at that time and presented the results in the report Smoking and Health, issued in 1964. In their report the Advisory Committee weighed the evidence of the relationship of smoking, particularly of cigarettes, to Malignant neoplasm of trachea, bronchus, and lung and to a number of other diseases. As a result of various activities that were undertaken following the publication of Smoking and Health and the interest in measuring the long-range effects of programs to stop the rise in mortality during the productive years of life from Malignant neoplasm of trachea, bronchus, and lung and from other diseases linked with cigarette smoking, it was considered desirable to pay special attention to current and future mortality trends from these diseases. In 1966, the National Center for Health Statistics published a reports on mortality associated with smoking, which was designed to lay the foundation for the long-range observation of these trends. This report was divided into two major sections: (1) the trends of mortality from diseases that the Surgeon General's Advisory Committee considered to be causally related to smoking, and (2) the trends of mortality from diseases that the Advisory Committee considered to be associated with but not clearly causally related to smoking. It covered the 1950-64 period.

REPORT ON ORAL POLIO VACCINES.

To the Editor:— In your issue of Oct 5, 1964 (Vol 190), you published a report of the Surgeon General's Special Advisory Committee on Poliomyelitis Vaccines together with a commentary by Dr. Albert Sabin. While both of these are valuable documents, both contain statements and points of view that should not go unchallenged. The Committee report, based in large part on an accompanying communication on Paralytic Disease Associated with Oral Polio Vaccines, makes reference to eight cases of paralysis in Nebraska, the occurrence of which was compatible with prior ingestion of Type III vaccine. Aside from the fact that many of the diagnoses were highly questionable, as pointed out by Dr. Sabin both currently and in a previous communication ( JAMA 183 : 268-71 [Jan 26] 1963), the Committee completely ignores the fact that the lot of vaccine used in Nebraska was used just as extensively in Minnesota, where no cases

Miscellanea Medica

<h3>Appointments</h3> Recently appointed to the Board of Regents of the National Library of Medicine are<b>Walsh McDermott</b>, MD, professor and chairman of the Department of Public Health and Preventive Medicine, Cornell University, Ithaca, NY;<b>Morris Tager</b>, MD, professor and chairman of the Department of Bacteriology and Immunology, Emory University, Atlanta, Ga.; and<b>Barnes Woodhall</b>, MD, vice provost of the Duke University Medical Center, Durham, NC. The board serves as an advisory body to the Library in its programs of acquiring and disseminating information in medicine and biology. It is the world's largest medical library. <b>Carroll L. Witten</b>, MD, an instructor in medicine at the University of Louisville, has been named to the Surgeon General's Advisory Committee on Indian Health for a four-year term ending in 1968. <b>Stanley P. Davies</b>, PhD, has received a one-year appointment as deputy director of planning (mental retardation) in the Division of Mental Health Resources and

WASHINGTON NEWS

<h3>Government Studies Tobacco Program.—</h3> US Surgeon General Luther Terry has ordered the Public Health Service to start work immediately on "appropriate remedial action" as a result of the findings of the Surgeon General's Advisory Committee that cigaret smoking is a health hazard. Terry indicated the major efforts would center around education campaigns aimed at the public and at stepped-up research into smoking's effect on health. He estimated the government is now spending several million dollars a year on research in this field. The American Medical Association's recentlyannounced long-range program of basic research on smoking is "meritorious," the Surgeon General told a news conference on the advisory committee's report. He said he did not believe the report should hamper future research in any way, and added that the AMA's program should increase over-all research. Edward R. Annis, MD, president of the AMA made the following comment on the report of the

WASHINGTON NEWS

<h3>Oral Polio Vaccine Green Light.</h3> —The US Public Health Service cleared all three strains of the Sabin oral polio vaccine for use in community vaccination programs. At the same time, PHS said "because potential risks of vaccine are believed by some to exist in adults, especially above the age of 30, vaccination should be used for adults, only with the full recognition of its very small risk." US Surgeon General Luther L. Terry said this was the recommendation of the Surgeon General's Special Advisory Committee on Oral Poliomyelitis Vaccine which held a 2-day meeting in Washington, D.C., in mid-December, and that he accepted the group's recommendation. Earlier, the committee, acting after reports of polio occurring in some individuals after taking the oral vaccine, had recommended that adults not take the Type III oral vaccine, but that all three types could be used for children and Types I and II for

PHS Replies to Critic of Flu Vaccine Safety During Pregnancy

A consultant to the U.S. Public Health Service disputed published warnings that commercial flu vaccines should not be administered to pregnant women or prospective blood donors with Type O blood. In a statement released by the PHS Communicable Disease Center in Atlanta, Dr. Fred M. Davenport, vicechairman of the Surgeon General's Advisory Committee on Influenza, disagreed with the conclusions of Dr. Georg F. Springer (<i>JAMA</i>, Nov. 3, 1962, advertising page 52). "My considered opinion," Davenport said, "is that it would not be in the public interest to discontinue vaccination of pregnant women or of blood group O potential donors." Here is the complete PSH statement: Rather extensive publicity has been given recently to the findings of Dr. Georg F. Springer and Mr. Harvey Tritel (Immunochemistry Section, William Pepper Laboratory and Department of Medical Microbiology, University of Pennsylvania) indicating that blood group A-like substances could be found in commercially available influenza

Geriatric Practice: Excerpts from Recommendations for Vaccination Against Influenza in Civilian Population Surgeon General's Advisory Committee on Influenza

Geriatric Practice: Excerpts from Recommendations for Vaccination Against Influenza in Civilian Population Surgeon General's Advisory Committee on Influenza