The 1964 Surgeon General's report and Americans' beliefs about smoking.

The 1964 Surgeon General’s Report and Americans’ Beliefs about Smoking THOMAS R. MARSHALL

ABSTRACT. Half a century ago, on January 11, 1964, the U.S. Surgeon General’s office released a landmark report on the health consequences of smoking. That report received massive media attention and triggered a steadily growing number of federal, state, and local restrictions on the advertising, sale, and use of cigarettes. Little is known about the report’s impact on American public opinion because all the timely public opinion polls that measured the report’s impact were privately commissioned by the tobacco industry and were not made publicly available. A review of these polls shows that the 1964 Surgeon General’s report had a large and immediate effect on Americans’ beliefs that cigarettes were a cause of lung cancer and of heart disease. However, the report had less impact on public preferences for government action or on smoking rates. KEYWORDS: Surgeon General, public opinion, polls, smoking, cigarettes, lung cancer, heart disease.

landmark 1964 Surgeon General’s report on cigarette smoking has now reached its fiftieth anniversary and enjoys a well-deserved place in medical history.1 That report is best known for tying cigarette smoking to lung cancer and to a variety of other diseases. The report called for “appropriate remedial action” on cigarette smoking, albeit only in general terms,2 and led to an

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1. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service (Washington, DC: U.S. Department of Health, Education, and Welfare, 1964). Hereafter cited as Surgeon General, Smoking and Health. 2. Ibid., 33. JOURNAL OF THE HISTORY OF MEDICINE AND ALLIED SCIENCES,

Volume 70, Number 2 # The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected] Advance Access publication on February 6, 2014 doi:10.1093/jhmas/jrt057

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Department of Political Science, University of Texas at Arlington, 601 S. Nedderman Dr., Arlington, Texas 76019-0539. Email: [email protected]

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3. For the importance of the 1964 report, see Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America (New York: Basic Books, 2007), 211 –39; A. Lee Fritschler, Smoking and Politics: Policymaking and the Federal Bureaucracy, 3rd ed. (Englewood Cliffs, New Jersey: Prentice-Hall, 1969), 39 –49; Richard Kluger, Ashes to Ashes: America’s Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris (New York: Vintage, 1997), 221 –62; Surgeon General, Smoking and Health, 19–21, 179 –89; Mark Parascandola, “Skepticism, Statistical Methods, and the Cigarette,” Persp. Biol. Med., 2004, 47, 244 –61. 4. Kenneth E. Warner, “Tobacco Policy Research: Insights and Contributions to Public Health Policy,” in Tobacco Control Policy, ed. Kenneth E. Warner (San Francisco: Jossey-Bass, 2006), 21. 5. The iPOLL archive at http://www.ropercenter.uconn.edu is a searchable database of poll questions from major polling companies. For summaries of poll questions on cigarette smoking, see Hazel Gaudet Erskine, “The Polls: Smoking,” Public Opin. Q., 1966, 30, 140– 52 and “The Polls: Cancer,” Public Opin. Q., 1966, 30, 308 –14; Julianna Pacheco, “Trends—Public Opinion on Smoking and Anti-Smoking Policies,” Public Opin. Q., 2011, 75, 576 –92; Lydia Saad, “A Half-Century of Polling on Tobacco: Most Don’t Like Smoking but Tolerate It,” The Public Perspective, 1998, August/September, 1–4.


increasing number of regulations on cigarette smoking, sales, and advertising. The report was important in two other ways: it received enormous media attention and it acknowledged the emerging standards for studying chronic diseases.3 Less well understood is what impact the 1964 Surgeon General’s report had on Americans’ beliefs about the health risks of cigarette smoking or on Americans’ attitudes toward government regulations on smoking.4 This lack of understanding occurs because many important public opinion polls were not at that time publicly available, and even for polls that were available, the results have been only cursorily examined. Examining these poll questions shows that the 1964 report was not simply a highly visible media event. The report was also critical in changing Americans’ health beliefs on the health risks of smoking, although the report had far less impact on Americans’ attitudes about what government measures should be undertaken to cope with the menace of smoking or on smoking rates in the short term. Public opinion polls are conducted under two very different circumstances. Some pollsters conduct public opinion polls either for their organization’s public release or on behalf of their news media or government clients. The results of these poll questions are typically promptly released and are thereafter accessible to the public, now often in the University of Connecticut’s online iPOLL archive of poll questions or in other publicly available archives.5 For example, Gallup Poll’s well-known and often-cited series of poll questions on the

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6. After 1999 Gallup’s poll questions were significantly differently worded than the poll questions discussed herein, and the results cannot be directly compared; see the iPOLL archives or Gallup’s web site at http://www.gallup.org. 7. Unless otherwise noted, the poll reports cited herein may be accessed through the Legacy Tobacco Documents Library at http://legacy.library.ucsf; see also E. Balbach, R. Gasior, and E. Barbeau, “Tobacco Industry Documents: Comparing the Minnesota Depository and Internet Access,” Tob. Control, 2002, 11, 68–72; R. E. Malone, “Tobacco Industry Documents: Comparing the Minnesota Depository and Internet Access,” Tob. Control, 2002, 11, 285; Ruth E. Malone and Edith D. Balbach, “Tobacco Industry Documents: Treasure Trove or Quagmire?” Tob. Control, 2000, 9, 334 –38. All survey results reported herein are based on representative surveys of U.S. adults nationwide unless otherwise noted.


perceived linkage between smoking and lung cancer or heart disease was made publicly available soon after the polls were conducted, and the results are accessible in the iPOLL archive. Gallup’s important series of poll questions, described further below, begins in January 1954 (for lung cancer) or in June 1957 (for heart disease); these questions were asked several more times until 1960, but were not then again asked in publicly available polls until 1969 and intermittently thereafter through 1999.6 As a result, accounts that rely on publicly available poll questions cannot fully explain the large shifts in Americans’ attitudes about the health risks of cigarette smoking during the 1960s. This nine-year gap is unfortunate since several landmark events in the fight against cigarette smoking occurred between 1960 and 1969, including the 1962 British report on smoking, the 1964 U.S. Surgeon General’s report, the cigarette package warning label requirement enacted by Congress in 1965, and the Federal Communication Commission’s 1967 “fairness doctrine” ruling requiring television and radio stations to air unpaid antismoking ads if the station aired paid advertising for cigarettes. Publicly available polls are not the only types of polls conducted either in the United States or elsewhere. Most polls are conducted for private clients, such as corporations, labor unions, trade associations, political candidates, or interest groups to guide their marketing and public relations efforts. Typically, the results of privately conducted polls are not publicly released. Beginning in the 1950s, individual cigarette companies; the industry’s lobbying association, the Tobacco Institute; and the industry’s leading public relations firm, Hill & Knowlton, all commissioned numerous polls and from several different polling organizations.7 Although much of this polling focused on individual companies’ marketing efforts, many poll questions tapped public perceptions of the health risks of smoking and attitudes toward


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Cigarette smoking became increasingly popular in the United States during the 1890s and early 1900s and many conflicting claims about health risks of smoking soon arose.9 A vigorous grass-roots anticigarette movement charged cigarettes with a wide variety of dangers, some moral and some medical, and among the latter: nervousness, cancer of the mouth or throat, digestive and stomach disorders, and stillbirths among pregnant women. During the early 1900s, fifteen states enacted a ban on the sale, manufacture, or giving away of cigarettes to adults, and nearly all states banned the sale of cigarettes to minors. By the mid-1920s, however, the anticigarette movement faded away and in 1927, the last state law (in Kansas) banning the sale of cigarettes to adults was repealed. All the while, cigarette companies’ advertising stressed mildness and presented images of young, attractive, and healthy smokers.10 Scientific journals and a few popular magazines printed occasional stories on the health risks of 8. Brandt, Cigarette Century, 416 –23. 9. Ruth Clifford Engs, Clean Living Movements: American Cycles of Health Reform (Westport, Connecticut: Praeger, 2000); John P. Pierce and Elizabeth A. Gilpin, “A Historical Analysis of Tobacco Marketing and the Uptake of Smoking by Youth in the United States: 1890–1977,” Health Psychol., 1995, 14, 500 –8; D. J. Ringold and J. E. Calfee, “The Informational Content of Cigarette Advertising: 1926–1986,” J. Public Pol. Manag., 1990, 9, 30–41; Kerry Segrave, Women and Smoking in America, 1880 –1950 (Jefferson, North Carolina: McFarland & Company, 2005); Cassandra Tate, Cigarette Wars (New York: Oxford University Press, 1999). 10. Segrave, Women and Smoking, 162 –78; Robert Sobel, They Satisfy: The Cigarette in American Life (New York: Anchor Books, 1978); Brandt, Cigarette Century, 200 –1; Gerard S. Petrone, Tobacco Advertising: The Great Seduction (Atglen, Pennsylvania: Schiffer, 1996);


possible government regulations. Some privately sponsored poll questions used the same wording as did publicly available poll questions and were, indeed, asked by the same pollsters who at other times conducted and released publicly available polls on smoking and health. Until the 1990s, these privately conducted polls remained out of the public eye, when the reports became publicly available under federal court order and are now a part of the online tobacco archives.8 The cigarette industry’s private polling reveals a much more complete story about how Americans’ attitudes changed on the health risks of smoking, and points to the critical importance of the 1964 Surgeon General’s report.

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http://tobacco.stanford.edu/tobacco_main/index.php. All web address cited herein were last accessed September 3, 2013. 11. Frederick Hoffman, “Cancer and Smoking Habits,” Ann. Surg., 1931, 93, 50 –67; Herbert L. Lombard and Carl R. Doering, “Cancer Studies in Massachusetts,” N. Engl. J. Med., 1928, 18, 481 –87; Raymond Pearl, “Tobacco Smoking and Longevity,” Science, March 4, 1938, 216– 17; and James J. Short, Harry J. Johnson, and Harold A. Ley, Jr., “The Effects of Tobacco Smoking on Health,” J. Lab. Clin. Med., 1938, 1938, 586 –89; see also Robert N. Proctor, The Nazi War on Cancer (Princeton: Princeton University Press, 1999) and “The Nazi War on Tobacco: Ideology, Evidence, and Possible Cancer Consequences,” Bull. Hist. Med., 1997, 71, 435 –88. 12. The Gallup results combine responses to two questions, “Do you smoke?” and “What do you prefer to smoke—cigarettes, cigars, or a pipe?” Both the Fortune and Gallup figures are in iPOLL. 13. Jean M. Converse, Survey Research in the United States: Roots and Emergence, 1890–1960 (Berkeley: University of California Press, 1987). 14. Prior to 1946, Gallup and Roper polls occasionally asked about the honesty of cigarette advertising or familiarity with recent media reports on the harmfulness of cigarettes, but not whether respondents believed that smoking was harmful.


smoking,11 but these accounts did not lead major newspapers to give much news coverage to the issue of smoking and health. Throughout all this time, the rates of cigarette smoking steadily rose. A 1939 Roper survey for Fortune magazine reported that 41 percent of Americans smoked cigarettes—a figure similar to Gallup Poll’s report of 43 percent that year.12 What ordinary Americans made of the conflicting claims about the health risks of smoking is unclear. Modern public opinion polling did not emerge until the mid-1930s, when pollsters such as George Gallup and Elmo Roper showed that accurate readings of Americans’ attitudes could be obtained by interviewing only one thousand or one thousand five hundred representative adults nationwide.13 Perhaps because the anticigarette movement had largely faded away by the 1930s, not until the late 1940s did pollsters ask any poll questions tapping Americans’ beliefs about the health risks of smoking.14 In 1946, Gallup Poll asked cigarette smokers (only) the first healthrelated question: “Do you think smoking is harmful to you?” Two-fifths (42 percent) of smokers said yes, 54 percent of smokers said no, and 4 percent of smokers offered no opinion. In November 1949, Gallup asked both smokers and nonsmokers a slightly different question: “Do you think cigarette smoking is harmful or not?” Among all respondents, 60 percent said yes, 33 percent said no, and 7 percent volunteered no opinion. More cigarette smokers (52 percent) said yes than no (45 percent), with 3 percent of smokers offering no opinion.


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15. Colin Talley, Howard Kushner, and Claire Sterk, “Lung Cancer, Chronic Disease, Epidemiology, and Medicine 1948–1964,” J. Hist. Med. Allied Sci., 2004, 59, 329 –74. 16. Karen S. Miller, The Voice of Business: Hill & Knowlton and Postwar Public Relations (Chapel Hill: University of North Carolina Press, 1999) and “Smoking up a Storm: Public Relations and Advertising in the Construction of the Cigarette Problem,” Journal. Monogr., 1992, 136, 1–35; David T. Courtwright, “Public Relations and Advertising Strategies of American and British Tobacco Companies since 1950,” Bus. Hist., 2005, 47, 421– 32. 17. The 71 percent figure results from combining from the original data file in iPOLL all respondents whose answers refer to a specific medical condition (such as “causes lung cancer”


Two-thirds (66 percent) of nonsmokers said yes, 24 percent said no, with 10 percent of nonsmokers offering no opinion. Soon after Gallup’s November 1949 survey, a growing number of important scientific journals published articles pointing to the health risks of smoking. In 1950, the Journal of the American Medical Association, the British Medical Journal, and Cancer Research published five major studies tying cigarette smoking to cancer of the lung or the respiratory tract.15 All five studies were retrospective studies of hospital patients based on interviews or medical records, and all used some type of a control group. In December 1953, executives in the cigarette industry reacted to the rising number of adverse scientific findings, unfavorable media coverage, and slumping cigarette sales by hiring a prominent New York public relations firm, Hill & Knowlton; soon thereafter, on January 4, 1954, the so-called Frank Statement was published in hundreds of American newspapers.16 The Frank Statement typically appeared as full-page ads, discounted the health risks of smoking, and promised an industry-funded research effort. A few days thereafter, Gallup again polled its 1949 “harmful” question, this time reporting that among all Americans, the percentage who said that smoking was “harmful” rose from 60 percent in November 1949 to 70 percent in January 1954. Among smokers, that figure rose from 52 to 62 percent, and among nonsmokers, the figure rose from 66 to 78 percent. In short, comparing Gallup’s November 1949 and its January 1954 “harmful” questions suggests that the scientific studies of the early 1950s, rising media attention and, ironically, perhaps even the Frank Statement itself, raised public awareness of the health risks of cigarette smoking. In the January 1954 survey, Gallup also asked respondents to describe in their own words exactly how smoking was harmful; most (71 percent) respondents cited one or more serious bodily health problems, such as lung cancer, diseases of the lungs or bronchial tubes, or more general descriptions.17

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or “bad for the lungs, bronchial tubes”) or to more general terms describing bodily harm (“poison, irritant, doctors say so, dope”). Respondents who gave only responses that did not indicate a bodily harm (such as “impolite, stinks the house”) are not included in the 71 percent figure. 18. The 1987 results from a Gallup survey conducted for the American Lung Association are included in the iPOLL archive. 19. Talley, Kushner, and Sterk, “Lung Cancer.”


In that same January 1954 survey, Gallup asked an important poll question that would later be repeated in identical or closely similar wording seventeen more times until 1999: “What is your own opinion—do you think cigarette smoking is one of the causes of lung cancer, or not?” Beginning in June 1957, Gallup asked a similar question about heart disease. Gallup Poll repeated and made publicly available the lung disease question in June 1954, twice in 1957, and once each in 1958, 1960, 1969, 1971, 1972, 1977, 1981, 1987, 1990, and 1999.18 Gallup asked the heart disease question and made the results publicly available once more in 1957, and once each in 1958, 1960, 1977, 1981, 1990, and 1999. In some years, however, including 1959, 1961, 1962, 1963, and 1964, the Gallup Organization asked these poll questions for its clients in the cigarette industry and the results were not made publicly available, a not uncommon practice within the polling industry. Unfortunately, these important but privately commissioned poll questions remained unavailable until the poll reports were released under a federal court order during the mid-1990s. Reconsidering both the (originally) public and the (originally) private poll questions together offers new evidence on Americans’ changing attitudes toward the health risks of cigarette smoking and points to the 1964 Surgeon General report’s critical importance. Figure 1 depicts the percentage of Americans who said that cigarette smoking is a cause of lung cancer or heart disease between 1954 and 1999. The debate over cigarette smoking’s effect on health continued unabated throughout the 1950s and early 1960s. Soon after Gallup Poll’s January 1954 survey, two separate prospective studies were released, one conducted by the American Cancer Society and the other by British scientists.19 Both studies reported that smokers suffered much higher death rates from lung cancer or heart disease than did nonsmokers. During the next few years, numerous scientific studies reported similar results based either on retrospective or prospective studies. In 1957 and 1959, then-U.S. Surgeon General Leroy


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Burney issued statements linking “excessive” cigarette smoking to lung cancer.20 Press coverage of the issue rose steadily in popular magazines and newspapers, although the level of coverage still remained modest compared to that of later years. In the New York Times, the number of news stories, letters to the editor, or editorials published annually on the health dangers of smoking rose from an average of only eight stories a year between 1940 and 1953 to fortynine stories a year during the “cancer scare” in 1953 and 1954, and then averaged thirty-three stories a year between 1955 and 1961.21 Figure 2 depicts the New York Times figures from 1940 to 2005. 20. Leroy E. Burney, “Statement, July 12, 1957,” Bull. Cancer Prog., 1958, 8, 44 and “Smoking and Lung Cancer: A Statement of the Public Health Service,” JAMA, November 28, 1959, 171, 1829–36; Jon M. Harkness, “The US. Public Health Service and Smoking in the 1950s: The Tale of Two More Statements,” J. Hist. Med. Allied Sci., 2007, 62, 171 –212; J. Mark Parascandola, “Cigarettes and the US Public Health Service in the 1950s,” Am. J. Public Health, 2001, 91, 196 –205. 21. The average annual number rose to 94 (1962 –93) and to 245 (1994– 2005). These estimates were compiled by the author from the New York Times’ published annual indexes. For similar estimates based on the Reader’s Guide to Periodical Literature, see Frank R. Baumgartner and Bryan D. Jones, Agendas and Instability in American Politics (Chicago: University of Chicago, 2009), 90 –93, 114 – 17, 257 –59; Ronald J. Troyer and Gerald E. Markle, Cigarettes: The Battle over Smoking (New Brunswick, New Jersey: Rutgers University Press, 1983), 57 –59; Gary T. Ford, Debra J. Ringold, and Martha Rogers, “Cigarettes in the Popular Press, 1930 –1960: Preliminary Research,” Adv. Consum. Res., 1990, 17, 467 –73.


Fig. 1. Percentage of Americans who believed that cigarette smoking is a cause of lung cancer or heart disease, 1954 – 99.

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By the late 1950s, alarmed by mounting evidence about the health dangers of cigarette smoking and frustrated by the federal government’s continued inaction, public health advocates turned to American schools to warn young people about the dangers of smoking. Their efforts were on a massive scale. The American Cancer Society alone sent materials to over half of American schools.22 By 1968, over two-thirds of teenagers reported that their schools offered anticigarette presentations.23 Perhaps surprisingly, notwithstanding all this rising publicity and grass-roots activism, Gallup’s polling between 1954 and 1962 show very little change in the public’s belief that cigarette smoking was a cause of either lung cancer or heart disease. Between January 1954 and May 1962, the percentage of Americans who said that smoking is a cause of lung cancer rose only from 42 to 47 percent, an annual rate of increase of less than 1 percent. Between July 1958 and May 1962, the percentage of Americans who said that smoking is a cause of heart disease actually dropped slightly, from 33 22. Constance A. Nathanson, “The Contingent Power of Experts: Public Health Policy in the United States, Britain, and France,” J. Policy Hist., 2007, 19, 71–94; Talley, Kushner, and Sterk, “Lung Cancer,” 370 – 71. For a comparison to earlier efforts to discourage spitting; see Jeanne E. Abrams, “‘Spitting Is Dangerous, Indecent, and against the Law!’ Legislating Health Behavior during the American Tuberculosis Crusade,” J. Hist. Med. Allied Sci., 2012, 67, 29 –31. 23. Lieberman Research, The Teenager Looks at Cigarette Smoking (New York: American Cancer Society, 1969), 64– 67.


Fig. 2. Number of New York Times stories, editorials, and letters on the health risks of smoking, 1940 – 2005.


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24. The question “Have you heard or read anything recently that cigarette smoking may be a cause of cancer of the lung?” was asked January 9–14, 1954, with 83 percent yes and 18 percent no, and again June 12– 17, 1954 with 90 percent yes and 10 percent no. 25. Gallup Poll, conducted June 27 to July 2, 1957: “Did you happen to read or hear about the recent report of the American Cancer Society reporting the results of a study on the effects of cigarette smoking?”—78 percent yes, 23 percent no. 26. Between 1953 and 1958, an average of 84 percent Americans said that they had “heard or read something” about recent news stories on cigarette smoking and health-related issues. For all other health-related stories, the average was 77 percent; for foreign and international events, 61 percent; for domestic events, 59 percent; and for politicians and celebrities, 57 percent. Figures were compiled by the author based on all “heard or read” Gallup Poll questions in iPOLL.


to 32 percent. In short, despite growing scientific evidence tying cigarette smoking to serious health risks, rising media coverage, and widespread grass-roots activism in American schools, adult Americans’ beliefs on the health risks of cigarette smoking barely changed—at least until the Surgeon General’s advisory committee was authorized and began its work. Why Americans’ beliefs changed so little during this time period is puzzling. On several grounds, a greater rate of change might have been expected. As discussed above, the percentage of Americans who believed that smoking was “harmful” rose from 60 to 70 percent between November 1949 and January 1954. Most Americans also knew of reports linking cigarette smoking to illness. In Gallup’s January and June 1954 polling, most (90 percent and 83 percent, respectively) Americans said that they had heard or read something recently that cigarette smoking may be a cause of lung cancer.24 In June 1957, three-quarters (78 percent) of Americans said that they had read or heard something about the American Cancer Society’s study on the effects of cigarette smoking.25 In Gallup’s frequent polling on whether respondents had heard or read different types of recent news stories, familiarity with stories on cigarette smoking was greater than stories on politicians, celebrities, foreign events, or other health stories.26 Further, the cigarette industry’s credibility ratings were already very low, compared to the credibility ratings of scientists and health advocates. In a 1958 Roper survey, when asked who they were most likely to believe if an organization said that there was no connection between lung cancer and cigarette smoking, respondents ranked the American Cancer Society as first (at 39 percent from a list of seven

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27. Elmo Roper and Associates. A Study of Attitudes toward Cigarette Smoking and Different Types of Cigarettes. January 1959. Philip Morris. http://legacy.library.ucsf.edu/tid/ jco76b00/pdf. 28. Timothy Dewhirst, “Public Relations,” in Tobacco in History and Culture: An Encyclopedia, ed. Jordan Goodman, vol. 2 (Detroit: Charles Scribner’s Sons, 2005), 473– 79; Robert N. Proctor, “Agnotology,” in Agnotology: The Making & Unmaking of Ignorance, ed. Robert N. Proctor and Londa Schiebinger (Palo Alto: Stanford University Press, 2008), 1 –33; Jon Christensen, “Smoking Out Objectivity: Journalistic Gears in the Agnogenesis Machine,” in Agnotology, 266 – 82; Mark Parascandola, “Skepticism, Statistical Methods, and the Cigarette,” Persp. Biol. Med., 2004, 47, 244 –61. 29. “U.S. Acts to Curb Cigarette Claims,” New York Times, September 16, 1954, 33;“‘Guide’ Published on Cigarette Ads,” New York Times, September 23, 1955, 44; Debra Jones Ringold and John E. Calfee, “The Informational Content of Cigarette Advertising: 1926–1986,” J. Public Pol. Mark., 1989, 8, 1–23; John E. Calfee, Cigarette Advertising, Health Information and Regulation before 1970 (Washington, DC: Federal Trade Commission, 1985).


groups), while the Tobacco Industry Research Committee (or TIRC) tied at fifth (at 3 percent).27 Why, then, did Americans’ attitudes about the health risks of smoking change so little before mid-1962 when the Surgeon General’s report was authorized? The most common explanation is that the tobacco industry successfully “created controversy” about the link between cigarette smoking and diseases such as lung cancer or heart disease. In this view, the industry’s vigorous, far-reaching, and wellfunded public relations efforts through Hill & Knowlton, TIRC (later renamed the Council for Tobacco Research), and the Tobacco Institute successfully sustained public doubts about the health risks of smoking despite mounting scientific evidence to the contrary.28 Examining Gallup’s privately conducted polls together with its publicly available polls suggests a second explanation for the almost nonexistent level of change in Americans’ beliefs about cigarette smoking and health from 1954 until 1962. In this view, a share of the responsibility lies with the Federal Trade Commission’s on-and-offagain approach to cigarette advertising during the 1950s and the 1960s.29 Responding to mounting evidence that cigarette smoking was hazardous, the FTC in 1955 negotiated a voluntary agreement with the cigarette industry banning several then-common advertising claims. No longer could cigarette ads claim medical approval for smoking in general or for any particular brand; nor make claims that a brand was low in nicotine, tars, or another substance unless the claims were established by competent scientific proof (at that time, not available); nor make reference to the effect of smoking on the nose, throat, larynx, respiratory track, digestive system, nerves,


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30. Ringold and Calfee, “Cigarette Advertising,” 9–18; Debra Jones Ringold and John E. Calfee, “What Can We Learn from the Informational Content of Cigarette Advertising: A Reply and Further Analysis?” J. Public Pol. Mark., 1990, 9, 30 –41; “Embattled Tobacco’s New Strategy,” Fortune, January 1963, pp. 100 following. 31. Ringold and Calfee, “Informational Content.”


another body part, or energy levels; nor compare sales of competing brands unless the sales figures were accurate at the time; nor rely on testimonials by celebrities unless the celebrity himself or herself currently smoked the brand; nor otherwise falsely or misleadingly disparage other brands. As the FTC’s many critics noted, nothing in the 1955 voluntary agreement reduced the number of cigarette ads; nor prohibited cigarette giveaways or promotions; nor banned ads depicting young and healthy smokers; nor barred advertising that reached teenagers, or children; nor required warning labels on cigarette packages or in radio, television, print, or outdoor advertising. To the FTC’s critics, the agreement, in effect, eliminated most of the publicity on the health risks of smoking, since cigarette ads often made implicit or explicit claims that their brand was less hazardous than were other brands.30 Comparing Gallup’s June 1954 and July 1958 polls suggests that the FTC’s critics were correct. During the time of the FTC’s voluntary agreement with the cigarette industry, the percentage of Americans who said that cigarette smoking was a cause of lung cancer rose only from 42 to 44 percent, an annual rate of less than 1 percent. During the late 1950s, the FTC changed its policy to allow mentions of tar and nicotine, setting off a three-year so-called tar derby during which cigarette advertising made frequent claims of lower tar and nicotine content.31 Between Gallup’s July 1958 and its May 1960 surveys, when the tar derby occurred, the percentage of Americans who said that cigarette smoking was a cause of lung cancer rose sharply from 44 to 50 percent, an annual rate of about 3 percent. Between Gallup’s May 1960 and its May 1962 surveys, the FTC once again reversed course and banned tar and nicotine claims; during this time period, the percentage of Americans who said that cigarette smoking was a cause of lung cancer dropped slightly from 50 to 47 percent. By the polling evidence, the FTC’s critics, including the American Cancer Society, the Consumers’ Union, and Reader’s Digest, were correct: the FTC’s policies were misguided and the cigarette industry’s own health-oriented advertising claims better served

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32. Gideon Doron, The Smoking Paradox: Public Regulation in the Cigarette Industry (Cambridge, Massachusetts: Abt, 1979), 131 –34; Kenneth Friedman, Public Policy and the Smoking-Health Controversy (Lexington, Massachusetts: D.C. Heath and Company, 1975). 33. Representative John A. Blatnick, “Report of the Hearings: False and Misleading Advertising (Filter-Tip Cigarettes)” (Washington, DC: U.S. Congress, 1958), 25. 34. Elmo Roper and Associates. A Study of Attitudes toward Cigarette Smoking and Different Types of Cigarettes, Vol. II. January 1959. Philip Morris. http://legacy.library.ucsf. edu/tid/nnc04e00.pdf. 35. The Gallup Organization. Trends in Public Attitudes on the Possibility of a Health Hazard in Cigarette Smoking. June 1959. American Tobacco. http://legacy.library.ucsf.edu/ tid/gma15f00/pdf. 36. Elmo Roper and Associates. A Study of Cigarette Smokers’ Habits and Attitudes in 1960, Vol. I. April 1960. Philip Morris. http://legacy.library.ucsf.edu/tid/lht28e00/pdf.


to alert Americans to the health risks of smoking than did the FTC-imposed blackout on such claims. Examining the tobacco industry’s private polling archive also suggests a third explanation for why American public opinion on the health risks of smoking changed so little during the 1950s and 1960s. Between 1954 and 1975, the six major cigarette manufacturers (R. J. Reynolds, Philip Morris, American, Liggett & Myers, Lorillard, and Brown & Williamson) brought out at least seventy-two new brands, including many new brands of filter cigarettes.32 Between 1952 and 1962, filters rose from 1 to 43 percent of all sales. Critics charged that the rise of filter cigarettes led to a popular belief that cigarette smoking was becoming less risky. A 1957 Congressional subcommittee report, for example, argued that “ . . . the connection between filter-tip cigarettes and ‘protection’ has become deeply embedded in the public mind.”33 The industry’s private polling supports this view. In a 1958 Roper poll conducted for the industry, about half (48 percent) of cigarette smokers agreed that “filter-tip cigarettes are no safer than non-filters,” but nearly as many (41 percent) smokers disagreed, with 11 percent replying do not know or no answer.34 A 1959 Gallup poll conducted for the industry asked cigarette smokers: “Regardless of what you, yourself, smoke, what one brand of cigarettes do you think is the safest to smoke from the standpoint of health?” One-fifth (21 percent) of smokers said none, and another 16 percent of smokers said that they could not say, but 61 percent of smokers named a particular brand as the safest to smoke.35 In a 1960 Roper poll conducted for the industry, half (48 percent) of smokers said that all filters give protection, and another 7 percent of smokers said that only high filtration filters do so.36 Even after the 1964 Surgeon


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37. The Gallup Organization. Trends in Public Attitudes on the Possibility of a Health Hazard in Cigarette Smoking. March 1964. R. J. Reynolds. http://legacy.library.ucsf.edu/ tid/zni99d00/pdf. 38. Pollsters typically follow the voting-age definition of an adult and began to include eighteen, nineteen, and twenty-year-olds as adults about 1971 when the Twenty-sixth Amendment to the U.S. Constitution was ratified. 39. Figures are recomputed from Eva Salber, R. B. Reed, and S. V. Harrison, “Smoking Behavior, Recreational Activities, and Attitudes toward Smoking among Newton Secondary School Children,” Pediatrics, 1963, 32, 911 – 18. 40. “Students See Link between Smoking and Cancer,” Sr. Scholast, February 17, 1960, 27.


General’s report, most smokers continued to name some particular brand as the safest to smoke. In a February/March 1964 Gallup poll conducted for the industry, two-thirds (69 percent) of smokers named some brand as the safest to smoke.37 From this perspective, an important part of “creating controversy” was in introducing a growing number of well-advertised filter brands which many smokers believed were safer to smoke than were unfiltered brands. Another important explanation as to why Americans’ attitudes on the health risks of smoking changed so little prior to the authorization of the 1964 Surgeon General’s report lies in pollsters’ then-common practice of defining adults as those who were twenty-one years of age or older.38 As a result, polls did not capture rapidly changing attitudes among teenagers and young adults who were eighteen, nineteen, or twenty years old. Further, the unusually low birth rates during the Great Depression in the 1930s and during World War II in early and mid-1940s meant that attitude change among young adults little affected nationwide poll results until the late 1960s. Because health advocates concentrated their efforts on American schools beginning in the mid-1950s, teenagers and the youngest adults became the groups most likely to recognize the health risks of smoking. In a 1959 survey from Newton, Massachusetts, for example, 90 percent of junior high school students and 95 percent of senior high school students said that they had heard that lung cancer may be caused by smoking, and 82 percent of students said that cigarette smoking was bad for health.39 In a 1960 nationwide survey for Senior Scholastic magazine, two-thirds of American teenagers said that smoking was a risk factor for lung cancer.40 In a 1961 survey, three-quarters of high school sophomores, two-thirds of high school seniors and

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T H E S U R G E O N G E N E R A L’ S R E PO RT A N D B E L I E F S A B O U T T H E H E A LT H R I S K S O F S M O K I N G

Despite rising scientific evidence, grassroots activism, and media attention, the White House, Congress, and the federal courts largely ignored the smoking and health issue—at least until a May 23, 1962, news conference when a reporter asked President John F. Kennedy whether he and his medical advisors agreed with studies linking cigarette smoking with cancer and heart disease. President Kennedy did not immediately answer the reporter’s question, but promised an answer.44 Two weeks later, on June 7, 1962, the Surgeon General’s office announced that an advisory committee would review evidence on smoking and health. Then-Surgeon General Luther Terry named ten prominent scientists and physicians to the committee who spent 41. Attitudes of Young American Adults—A Survey Conducted for the Saturday Evening Post (Princeton, New Jersey: Public Opinion Surveys, August 1961). 42. In Gallup’s January 1954 survey, only 36 percent of those aged twenty-one to twentyfive said that cigarette smoking was a cause of lung cancer, a figure 5 percent lower than among older adults; by 1960, that figure was 60 percent, a figure 10 percent higher than among older adults. These figures are recomputed from Gallup’s original data files in iPOLL. 43. During the 1950s and early 1960s, the belief that smoking was a cause of lung cancer increased rapidly among doctors and cancer researchers, although their numbers were too small to affect poll results among the adult public; M. Powell Lawton and Alfred E. Goldman, “Cigarette Smoking and Attitude toward the Etiology of Lung Cancer,” J. Soc. Psych., 1961, 54, 235 –48; Julian Simon, “Doctors, Smoking, and Reference Groups,” Pub. Opin. Q., 1967–68, 31, 646 –47; “Doctors Have Changed Their Smoking Habits,” Resid. Physic., 1957, 3, 50 –63. 44. “Kennedy Promises Reply on Smoking,” New York Times, May 24, 1962, 26. This press conference occurred after Gallup completed interviewing for its May 1962 survey and so did not affect those results.


college juniors and seniors, and just over half of nonschool young adults agreed that cigarette smoking is a cause of lung cancer.41 All these figures are higher than those found at the time among adults. Although the youngest adults (those who were twenty-one to twenty-five years old) were in Gallup’s January 1954 polling the least well informed age cohort on the health risks of smoking, by 1960, young adults twenty-one to twenty-five years old were the age group most likely to link cigarette smoking to lung cancer.42 In short, attitude change was already occurring by the late 1950s among younger Americans, as it was within the medical community,43 but polls that reported results only among all adults aged twenty-one years or older poorly captured the early signs of that change.


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45. 46. 47. 48.

Parascandola, “Skepticism”; Talley, Kushner, and Sterk, “Lung Cancer.” Surgeon General, Smoking and Health, 19– 21. Ibid., 37. Ibid., 25.


over a year reviewing thousands of published articles and other research on smoking and health, making site visits to review records of important research, and consulting with a wide variety of experts, all with a degree of secrecy almost unprecedented for the federal government. At a press conference on Saturday morning, January 11, 1964, the report was released to a full contingent of well over one hundred reporters. The 1964 report was important on two fronts. First, the report acknowledged an important shift in recent scientific thinking about the study of chronic diseases. Instead of relying solely on the so-called germ theory standard or on controlled experiments,45 the report endorsed five standards for evaluating the cause-and-effect relationship between smoking and illness: the consistency of the association between smoking and health, the strength of the association, the specificity of the evidence, whether the evidence fit a cause-and-effect temporal relationship, and whether the evidence was coherent in terms of smoking habits and related diseases.46 Second, the report unambiguously tied cigarette smoking to several diseases, most notably to lung cancer: “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, points in the same direction.”47 Smoking was tagged with causing roughly 90 percent of all lung cancer deaths, and, as the report noted, the number of lung cancer deaths rose from fewer than three thousand in 1930 to forty-one thousand in 1962.48 The report further called cigarette smoking “the most important” cause of chronic bronchitis and as causative of larynx cancer. The report linked emphysema to smoking, but did not call the relationship causal. For coronary artery disease, the report did not call the relationship causal, but warned that “it (is) more prudent from the public health viewpoint to assume that the established association has causative meaning than to suspend judgment until no uncertainty remains.” The report causally linked pipe smoking to lip cancer. For cancers of the esophagus, urinary bladder (in men), and the stomach,

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49. Ibid., 31 –40. 50. Ibid., 32, 349 –50. 51. Ibid., 355. 52. Ibid., 34, 350 –56. 53. Ibid., 33. 54. Brandt, The Cigarette Century, 218 –30; Kluger, Ashes to Ashes, 242 –48. Nearly, all (96 percent) major newspapers attributed the findings to medical scientists and to the Surgeon General’s office (100 percent did). Most papers quoted at length from the report (83 percent did), described the panel of experts as prestigious (96 percent did), and described the report as unanimous (100 percent did). 55. These results are based on a stratified sample, by region and circulation, of forty-nine of the largest one hundred American newspapers from Friday, January 10, through Tuesday, January 14, 1964. Although no television archives exist for this time period, newspaper accounts and the Hill & Knowlton surveys indicate that televised news reports and special programs aired after the report. 56. Four major newspapers, the Atlanta Constitution, the Los Angeles Times, the Chicago Tribune, and the New York Times, published an average of twelve smoking-related news stories, including two front-page stories, per paper, from January 15 through 31, 1964.


peptic ulcers, tobacco amblyopia, cirrhosis of the liver, low-weight newborns, and traffic accidents, an association with smoking was described but was not termed causal. The report described several carcinogens in cigarette tars. Cigarette smoking was tied to a 70 percent increase in age-specific death rates among males.49 Even so, the report carefully qualified several conclusions. Except for its addictive qualities, nicotine was largely exonerated as a health hazard.50 The report described but termed as “comparatively inconsequential” several benefits of smoking, such as contentment, mental health, good intestinal tone and bowel habits, and fighting obesity.51 The report described smoking as a habit, rather than as an addiction.52 The report called for “appropriate remedial action,” but only so in general terms.53 Many of these findings had been previously reported, but never before after so far-reaching a review of existing research and by so high profile and prestigious a group of American scientists.54 American newspapers covered the story prominently and in depth. On Sunday, nearly all (98 percent) major American newspapers gave the story front-page coverage.55 Typically, the Surgeon General’s report was the largest front-page story (63 percent of the time) and often carried a bigger headline than any other story (48 percent of the time). Nearly all (94 percent) major newspapers printed the story “above the fold” where readers were more likely to see it. Nearly all (95 percent) newspapers continued the story on one or more inside pages. Nor did newspaper coverage cease on Sunday.56 On Monday, 98 percent of major newspapers published one or more additional


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57. “Smoking—The Government Report,” Time, January 17, 1964, 42; “Verdict on Cigarets: Guilty as Charged,” Life, January 26, 1964, 56A–64A; “Cigarette Smoking Is a Health Hazard,” Newsweek, January 13, 1964, 48 –50. 58. The tobacco industry’s low-key response reflected disagreements on how to handle the report; Kluger, Ashes to Ashes, 260 –61; Brandt, The Cigarette Century, 30 –237. In Hill & Knowlton’s January postreport survey, only 22 percent of respondents said that they had “heard or read anything of the tobacco industry’s reaction to the report.” 59. Compared to poll shifts after other highly visible crisis events, the shifts that followed the 1964 report were unusually large and rapid; William G. Mayer, The Changing American Mind (Ann Arbor: University of Michigan, 1992), 131 – 32, 229– 75, 310 –11; Jon D. Miller, “The Challenger Accident and Public Opinion,” Space Policy, 1987, 3, 122 –40; Benjamin Page and Robert Shapiro, “Changes in Americans’ Policy Preferences, 1935– 1979,” Public Opin. Q., 1982, 46, 24–42; Benjamin Page, Robert Shapiro, and Glenn Dempsey, “What Moves Public Opinion?,” Am. Polit. Sci. Rev., 1987, 81, 23–43; Theresa Rogers, Eleanor Singer, and Jennifer Imperio, “Poll Trends: AIDS—an Update,” Public Opin. Q., 1993, 57, 92–114.


stories, and most (66 percent) newspapers again gave the story frontpage coverage. On Tuesday, nearly all (96 percent) major newspapers wrote one or more stories, with many (40 percent) papers again covering the story on the front page. Popular magazines such as Time, Life, and Newsweek also provided in-depth coverage.57 As Figure 2 indicates, the 1964 report sparked far more news coverage on smoking than did the “cancer scare” of the early 1950s, the 1957 or 1959 statements of Surgeon General Burney, the 1962 British report, or other earlier stories. Newspaper coverage focused most heavily on lung cancer. Nearly all (98 percent) Sunday newspapers specifically described the lung cancer danger. One-third (35 percent) of newspapers headlined the cancer danger. The Washington Post’s Sunday headline read: “Cigarette Smoking Cited as Main Cause of Deadly Lung Cancer.” The Chicago Tribune’s full-page-wide Sunday headline read more simply: “Tie Cancer to Cigarets.” Although cancer was most prominently featured, most (94 percent) newspapers also described other health risks such as heart disease, bronchitis, and emphysema. Nearly all newspapers described these health risks as proven or conclusive, and nearly all (94 percent) newspapers described the call for remedial action. Nearly all (91 percent) newspapers described the tobacco industry’s response, but usually only in a brief mention that did not directly contradict the panel’s findings and that only called for more research.58 Given such widespread news coverage, a large and rapid shift in public opinion might well be expected.59 That is exactly what happened, at least on attitudes about the link between cigarette smoking

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60. Opinion Research Corporation. The Impact on Public Attitudes of the Surgeon General’s Report. March 1964. American Tobacco. http://legacy.library.ucsf.edu/tid/ mup60a00/pdf. 61. Elmo Roper and Associates. A Study of Reactions to the Surgeon General’s Report on Cigarette Smoking. February 1964. Philip Morris. http://legacy.library.ucsf.edu/tid/ jro53e00/pdf.


and lung cancer or heart disease. At the time these attitude changes went largely unnoticed because all the timely polls were privately conducted for the tobacco industry. With the release of tobacco industry documents, the industry’s once-private polls clearly point to a large and rapid shift in Americans’ beliefs about the dangers of smoking. The best evidence on the report’s immediate impact on American public opinion comes from three surveys conducted for Hill & Knowlton, a public relations firm then closely tied to the tobacco industry.60 These three surveys were conducted, by telephone, on Friday, January 10 (the day before the report’s release); Monday, January 13 (two days after the report); and on February 24 and 25 (about six weeks later). On lung cancer, attitudes changed quickly. The percentage of Americans who agreed that smoking is “a major cause” of lung cancer rose from 34 percent on the day before the report to 52 percent two days after the report, and then to 48 percent six weeks later. The 14 percent rise on the lung cancer question was greater than the equivalent 4 percent rise on a question about heart disease. On whether smoking is “a major cause” of heart disease, the percentage agreeing rose from 22 to 25 to 26 percent across the three surveys. By Monday, January 13, Hill & Knowlton’s polling also showed that the report was already widely known; three-quarters (78 percent) of respondents knew of a recent report on smoking and health, typically through television or newspapers. Three weeks after the report was issued, a Roper survey conducted for Philip Morris also showed near-universal awareness of the report; nearly all (95 percent) respondents had heard about the report, with only slight differences in awareness by education, geography, age, or gender.61 For Hill & Knowlton’s clients in the cigarette industry, these findings were doubtlessly not welcome, but another finding was more reassuring: Americans’ changing health beliefs did not lead to increased demands for government action. Between Friday’s prereport survey, Monday’s postreport survey, and the final survey six weeks later, the percentage of Americans who supported “drastic


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62. The absence of a large poll shift about a government response may result from the lack of specifics in the call for “appropriate remedial action” and the lesser amount of press coverage on this issue. Few newspaper accounts described any specific remedies except for scattered mentions of a possible health warning in advertising or on cigarette packages. 63. Elmo Roper and Associates. A Study of Reactions to the Surgeon General’s Report on Cigarette Smoking. February 1964.Philip Morris. http://legacy.library.ucsf.edu/tid/ jro53e00/pdf. 64. For the Centers for Disease Control and Prevention figures, see http://www.cdc. gov/tobacco/data_statistics/tables/economics/consumption/. The drop in per-capita cigarette consumption in 1964 was smaller than the 8.9 percent two-year drop during the 1953– 54 “cancer scare”—an earlier and short-lived drop in consumption. For mixed evidence on the report’s impact on cigarette consumption or mortality, see J. L. Hamilton, “The Demand


government action to discourage the use of cigarettes” rose slightly, but soon fell back to prereport levels—at 37, 42, and 36 percent, respectively. The percentage of respondents who favored “special labeling of cigarettes to warn people about health problems” showed the same pattern: 65, 72, and 64 percent, respectively. Perhaps most critically, two-thirds or more (66, 72, and 73 percent, respectively) of Americans pinned the primary responsibility for doing something about smoking and health problems on the individual himself or herself, rather than on the tobacco industry (only 13, 13, and 14 percent) or on government (only 8, 9, and 8 percent). On the question “What do you think the government should do about the possible connection between smoking and health?,” more modest approaches such as educating the public (26, 23, and 22 percent) or doing nothing (29, 28, and 33 percent) were the most commonly given answers; few Americans advocated tougher measures such as restrictive regulations (only 8, 9, and 11 percent) or prohibiting cigarettes (only 8, 6, and 7 percent).62 A Roper survey conducted three weeks after the report gave its cigarette industry clients yet another reassuring finding: actual smoking behavior had changed only modestly and perhaps only temporarily. Ten percent of prior smokers quit smoking after the report, but of those who quit, half were already smoking again. Of those who cut down on smoking, one-fifth said it was only temporary. Three-quarters of smokers said that they had not changed their smoking behavior.63 These poll findings captured a short-term, modest drop in per-capita smoking. The number of cigarettes smoked, per capita, dropped 3.5 percent (from 4,345 to 4,194) between 1963 and 1964, then rose slightly in 1965 and 1966 before beginning a sustained long-term decline, a trend that slightly lagged the decline in smoking prevalence.64 The Roper

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for Cigarettes: Advertising, The Health Scare, and the Cigarette Advertising Ban,” Rev. Econ. Stat., 1972, 54, 401 –11; Kenneth Warner, “The Effects of the Anti-Smoking Campaign on Cigarette Consumption,” Am. J. Public Health, 1977, 67, 645 –40 and “Effects of the Antismoking Campaign: An Update,” Am. J. Public Health, 1989, 79, 144 –51; cf., Richard Ippolito, Dennis Murphy, and Donald Sant, Staff Report on Consumer Responses to Cigarette Health Information (Washington, DC: Federal Trade Commission, Bureau of Economics, 1979), 3– 8; Youth and Tobacco—Preventing Tobacco Use among Young People (Washington, DC: U.S. Department of Health & Human Services, 1992), 163 –69. Smoking prevalence, then measured as the percentage of adults who had smoked one hundred cigarettes or more during their lifetime and who also currently smoked, began to drop steadily by 1965 among men, but not until the mid-1970s among women; Warner, Tobacco Control Policy, 22–24. 65. Hans Toch, Terrence Allen, and William Lazer, “Effects of the Cancer Scares: The Residue of News Impact, Journal. Mass Comm. Q., 1961, 38, 25 –34, 126; Hans Toch and William Lazer, “The Public Image of Cancer Etiology,” Public Opin. Q., 1961, 25, 411 –14; Edward J. Robinson, “Analyzing the Impact of Science Reporting,” Journal. Q., 1960, 37, 306– 14; Charles Cannell and James MacDonald, “The Impact of Health News on Attitudes and Behavior,” Journal. Q., 1956, 33, 315 –23. 66. Models of health psychology, cognition, and risk analysis now treat health information as an important, but not wholly sufficient precondition to behavioral change. These models now typically also consider respondents’ smoking habits and addiction, emotional states, and (typically overly optimistic) assessment of their own perceived health status or risk; the often-inefficient or idiosyncratic heuristics used in processing health information; and social context, including peer and family support, cigarette price increases, and restrictions on cigarette advertising, sales, and public smoking. For reviews of this extensive literature, see Laura Bogart and Douglas Delahanty, “Psychosocial Models,” in Handbook of Clinical Health Psychology, ed. Thomas Boll, vol. 3 (Washington, DC: American Psychological Association, 2004), 214 – 28; Edwin Fisher, Ross Brownson, Andrew Heath, Douglas Luke, and Walton Sumner II, “Cigarette Smoking,” in Handbook of Clinical Health Psychology, ed. Thomas Boll, vol. 2 (Washington, DC: American Psychological Association, 2002), 75 –120; Neil D. Weinstein, “What Does It Mean to Understand a Risk? Evaluating Risk Comprehension,” J. Natl. Cancer Inst. Monog., 1999, 25, 15 –20 and “Accuracy of Smokers’ Risk Perceptions,” Ann. Behav. Med., 1998, 20, 135 –40. 67. Gallup’s February/March 1964 survey also reported a slight drop (of 4 percent from 51 to 47 percent) in current adult smoking rates, compared to June 1963, but no drop in the average cigarettes smoked per day by current smokers.


results reflected earlier findings that science news did not necessarily lead to widespread, immediate changes in behavior because many adults doubted or were hard-pressed to understand science news, because many adults (such as smokers) either discounted or were fatalistic about health risks, and because less-educated adults were typically less aware and less accepting of science news.65 From a modern viewpoint, the lack of a large, immediate drop in smoking might not be surprising,66 but in 1964, this was less well understood and the cigarette industry’s polling closely explored this issue.67 The longest-running series of poll questions on Americans’ beliefs about the health dangers of smoking comes from the Gallup


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68. The Gallup Organization’s 1959, 1960, 1961, 1962, 1963, and 1964 reports may be found under the titles “Trends in Public Attitudes on the Possibility of a Health Hazard in Cigarette Smoking” as follows: http://legacy.library.ucsf.edu/tid/gma15f00/pdf, http:// legacy.library.ucsf.edu/tid/bkn04d00/pdf, http://legacy.library.ucsf.edu/tid/inb99d00/pdf, http://legacy.library.ucsf.edu/tid/ckn04d00/pdf, http://legacy.library.ucsf.edu/tid/dkn04d00/ pdf, and http://legacy.library.ucsf.edu/tid/zni99d00/pdf. 69. Between Gallup’s mid-1962 and early 1964 surveys, beliefs that cigarette smoking was a cause of lung cancer rose 15 percent among all adults, with a larger increase (of 22 percent) among the college-educated than among those with a high school education (16 percent) or those with less than a high school education (8 percent). Larger increases occurred among those thirty-five to forty-nine years old (21 percent) or those twenty-one to thirty-four years old (14 percent) than those fifty or older (11 percent). Larger gains occurred among younger and better-educated adults despite those two groups already being the most likely to link smoking to lung cancer. Among men, the increase was 18 percent, among women 11 percent, among cigarette smokers 15 percent, and among nonsmokers 13 percent. On the heart disease question, the increase was 18 percent overall, but 30 percent among the college-educated, 20 percent among the high school educated, and only 10 percent among those with less than a high school education. By age group, the increase was 25 percent among those twenty-one to thirty-four years old, 19 percent among those thirty-five to forty-nine, and 13 percent among those over fifty. For both the lung cancer and heart disease questions, the change in beliefs for cigarette smokers versus nonsmokers, or for men versus women, was less consistent than were differences by education or age.


Organization, including its 1959, 1961, 1962, 1963, and 1964 surveys for the cigarette industry.68 As described above, until May 1962 Americans’ beliefs that cigarette smoking was a cause of either lung cancer or heart disease changed only slowly. Once the Surgeon General’s report was underway, attitudes changed much more rapidly. Between May 1962 and June 1963, beliefs that cigarette smoking was “one of the causes” of lung cancer rose by 6 percent (from 47 to 53 percent). Beliefs that cigarette smoking was “one of the causes” of heart disease rose even more—by 11 percent over the same time (from 32 to 43 percent). Attitude changes during these thirteen months alone were greater than the changes over the entire prior (1954–62) eight-year period for lung cancer or over the entire prior five-year (1957–62) period for heart disease. Once the report was released, Gallup’s polling reported yet more attitude changes. Between the June 1963 and the February/March 1964 surveys, beliefs that cigarette smoking was a cause of lung cancer rose by another 9 percent (from 53 to 62 percent). Beliefs that cigarette smoking was a cause of heart disease rose by another 7 percent (from 43 to 50 percent). Changes occurred among all groups of adults with the largest changes among college-educated and younger Americans.69 On a question that asked respondents “When you think of cigarettes, what comes to mind?,” the percent who mentioned “cancer” rose from 15 percent in May 1962 to 25 percent in June 1963 and then to

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70. Smoking and Health: A Report of the Royal College of Physicians of London on Smoking in relation to Cancer of the Lung and Other Diseases (London: Pittman, 1962); Virginia Berridge, “Medicine and the Public: The 1962 Report of the Royal College of Physicians and the New Public Health,” Bull. Hist. Med., 2007, 81, 286– 311. 71. Surgeon General Burney’s 1957 and 1959 statements and the 1962 British report received only an average of two to three stories apiece in major newspapers including the New York Times, the Dallas Morning News, the Los Angeles Times, and the Chicago Tribune. 72. By Gallup’s figures, the percentage of Americans who believed that cigarette smoking was a cause of lung cancer or of heart disease either dropped slightly or was unchanged after


33 percent in February/March 1964. As did the Hill & Knowlton surveys, described above, Gallup’s results indicated that some troubling trends for the cigarette industry were offset by more reassuring findings. The percentage of respondents who were aware of suggestions that there be government action on the link between cigarette smoking and lung cancer rose from 23 percent in May 1962 to 39 percent in June 1963 to 63 percent in February/March 1964. Yet the percentage who themselves favored “the government taking any action at this time” changed much less dramatically (36, 44, and 41 percent, respectively). These privately conducted polls well informed the cigarette industry that an unusually large and rapid change in health beliefs was underway, but not an equivalent change in preferences for some sort of government action. Large and rapid changes in Americans’ health beliefs on this scale are unusual, even unique. No other events either before or after the 1964 report so greatly impacted Americans’ beliefs about the linkage between cigarette smoking and lung cancer or heart disease. An earlier British report, issued on March 7, 1962, had explicitly described cigarette smoking as a cause of lung cancer and bronchitis, as a probable contributor to coronary heart disease and tuberculosis morbidity and mortality among elderly men, and as an adverse influence on the healing of ulcers.70 The British report, however, received only limited coverage in major American newspapers71 and had no apparent effect on Americans’ health beliefs. Between Gallup’s May/June 1961 polling (nearly a year prior to the British report) and its May 1962 polling (shortly after the British report was issued), the percentage of Americans who believed that cigarette smoking was a lung cancer risk dropped slightly, from 50 to 47 percent, and from 36 to 32 percent for heart disease. Nor did U.S. Surgeon General Leroy Burney’s 1957 and 1959 statements lead to increasing public awareness that cigarette smoking was a risk for lung cancer or heart disease.72


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both Surgeon General Burney’s 1957 and 1959 statements—for lung cancer, a drop of 3 percent in 1957 and a drop of 5 percent in 1959, and for heart disease, a drop of 2 percent in 1957 and no change in 1959. 73. A federal government survey also shows little change in health beliefs between fall 1964 and spring 1966. The percentage of respondents who said that smokers were more likely to get lung cancer than were nonsmokers rose only from 68 percent in fall 1964 to 69 percent in spring 1966; for coronary heart disease from 42 to 44 percent; and for emphysema and chronic bronchitis from 51 to 52 percent. U.S. Department of Health, Education, and Welfare, Uses of Tobacco—Practices, Attitudes, Knowledge, and Beliefs—United States—Fall 1964 and Spring 1966 (Washington, DC: Public Health Service, 1969), 103 –26. A 1970 federal survey also showed only modest changes occurred between fall 1964, spring 1966, and spring 1970 on whether smoking cigarettes is “harmful to health” (81, 82, and 87 percent) and on whether cigarette smoking “frequently causes disease and death” (66, 66, and 76 percent). U.S. Department of Health, Education, and Welfare, Adult Use of Tobacco 1970 (Washington, DC: Public Health Service, 1973), 11. 74. Gallup’s May 1971 and April 1972 surveys did not include a question on heart disease. The broadcast ban also benefited the cigarette industry by greatly reducing the industry’s advertising expenses and by virtually ensuring that no major new cigarette brands would ever emerge; Kluger, Ashes to Ashes, 325 – 35; Brandt, The Cigarette Century, 270 –73.


The impact of the 1964 report was also greater than that of two soon-to-follow events: the cigarette package warning labels and the so-called fairness doctrine. Between Gallup’s February/March 1964 survey and its next survey in July 1969, two high-profile policy changes occurred. First, Congress in 1965 mandated that a warning label be printed on all cigarette packages—at that time: “Caution: Cigarette Smoking May Be Hazardous to Your Health.” Second, the Federal Communications Commission in 1967 required that television stations that aired paid cigarette advertisements must also air unpaid antismoking commercials. These two new policies had far less impact on Americans’ health beliefs than did the 1964 Surgeon General’s report. Over the five years between 1964 and 1969, the percentage of Americans who believed that cigarette smoking is a cause of lung cancer or of heart disease rose by 8 percent (from 62 to 70 percent) and by 10 percent (from 50 to 60 percent), respectively. The average annual rate of change of about 1.5 percent (for lung cancer) or 2 percent (for heart disease) is far smaller than that which occurred during the 1962– 64 period.73 As of January 2, 1971, Congress banned cigarette commercials on television—the so-called broadcast ban that also eliminated the requirement for unpaid antismoking ads.74 The broadcast ban also little affected Americans’ health beliefs, and by eliminating the required antismoking ads may even have slowed the rise in public

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75. Figure 1 depicts these changes. The heart disease question was not asked in all years, as indicated by the gaps in that line. 76. Admittedly, large increases in the belief that cigarette smoking was a cause of lung cancer or of heart disease became less likely as the percentage of Americans who already believed that it was steadily rose, and as public debate focused on other issues. Between Gallup’s June 1981 and June 1987 surveys, when growing attention led by a December 1986 Surgeon General’s report focused on second-hand smoke the belief that smoking was a cause of lung cancer grew from 83 to 87 percent, an annual rate of less than 1 percent. For the 1979 reports on fetal harm and the 1988 report on addiction, the annual lung cancer poll shifts are about one half of a percent and 1 percent, respectively. 77. These conclusions are based on the author’s comparison of responses from Gallup’s lung cancer and heart disease questions, broken down and tracked over time by age cohort, based on the original data files available in iPOLL. 78. The percentage of each new adult cohort (aged twenty-one to twenty-five) who believed that cigarette smoking was a cause of lung cancer was 36 percent in January 1954, 60 percent in 1960, 81 percent in 1969, 82 percent in 1977, and 96 percent in 1999. Each


awareness about the health risks of smoking. In Gallup’s July 1969 polling, conducted before the broadcast ban went into effect, 70 percent of Americans said that cigarette smoking is a cause of lung cancer; twenty-two months later, in May 1971, about four months after the broadcast ban, that figure was 71 percent; by April 1972, the figure was 70 percent. By September 1999, 92 percent of Americans said that smoking is a cause of lung cancer and 80 percent said that smoking is a cause of heart disease. Over the 28 years from May 1971 to September 1999, the 21 percent increase in the percentage of Americans who believed that cigarette smoking was a cause of lung cancer reflects a fairly steady pattern of average annual rises of a little less than 1 percent.75 No single event during these decades greatly affected the steady rise in beliefs tying cigarette smoking to lung cancer or heart disease.76 Instead, rising public awareness about the lung cancer and heart disease risks of smoking is about equally well explained by two causes: first, by the steady replacement of less-well-informed older cohorts by better-informed younger cohorts, and, second, by belief changes among adults.77 During these decades, each new cohort of young adults was better informed about the health risks of smoking than had been the prior new cohort of young adults a few years earlier. The addition of better-informed young adults, together with the dying-off of older and less well-informed cohorts, is an important reason for the risking awareness of the health risks of smoking, and suggests that health reformers’ efforts in American schools had an important, albeit long-term and gradual impact.78 Learning about


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new adult cohort was also more aware of the health risks of smoking than were the remaining (and older) adults at the time. 79. This pattern consistently appears over time. For example, 36 percent of the youngest age cohort (aged twenty-one to twenty-five) in 1954 believed that cigarette smoking was a cause of lung cancer, but among this group, that figure rose to 58 percent in 1960, 67 percent in 1969, 79 percent in 1977, and 92 percent in 1999. 80. American National Election Study, “Trust the Federal Government 1958–2008,” www.electionstudies.org/nesguide/toptable/tab5a_1.htm. 81. Connie DeBoer and Ineke Catsburg, “The Impact of Nuclear Accidents on Attitudes toward Nuclear Energy,” Public Opin. Q., 1988, 52, 254 –61; Allan Mazur, “Media Coverage and Public Opinion on Scientific Controversies,” J. Commun., 1981, 31, 106 –15.


the lung cancer and heart disease health risks of smoking also continued throughout the adult years, with larger gains in adult learning during a person’s twenties.79 All this suggests several reasons why the 1964 Surgeon General’s report had so large an impact on Americans’ health beliefs. First, the report’s panel of scientists was prominent and prestigious, and its conclusions were unequivocal and unanimous. Where the report was less clear and specific, as it was on an appropriate government response, far less attitude change occurred. Second, the news media gave the report very heavy coverage from a health-oriented framework. Third, the tobacco industry, internally divided, offered only a low-key and littleremembered response. Fourth, in 1964, the federal government itself enjoyed high levels of trust and confidence, adding to the report’s source credibility. In a 1964 nationwide survey, three-quarters (76 percent) of Americans said that “you can trust the government in Washington to do what is right” either “just about always” or “most of the time.”80 Public trust and confidence in the federal government thereafter sharply declined and never again reached such high levels. Fifth, prior to 1964, the percentage of Americans who already believed that cigarette smoking was a cause of lung cancer or heart disease was still relatively small and large attitude changes were more easily possible; prior to the 1964 report, nearly half (47 percent) of Americans either disagreed that cigarette smoking caused lung cancer or did not know; for heart disease that figure was 57 percent. Sixth, the poll questions on lung cancer and heart disease, described above, measure very general beliefs that can change more quickly than do assessments of personal smoking risks or actual smoking behavior. Finally, the 1964 report was the Surgeon General’s first official report and early events typically have a greater impact on public opinion than do later events.81

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82. Brandt, The Cigarette Century, 159 – 277; Fritschler, Smoking and Politics, 19 –50; Kluger, Ashes to Ashes, 141 –291. 83. Talley, Kushner, and Sterk, “Lung Cancer,” 371.


This account expands on existing research in several ways. First, these results clarify the landmark 1964 Surgeon General report’s enormous impact on Americans’ beliefs about the lung cancer and heart disease dangers of smoking, and its more limited impact on public preferences for government action. Existing accounts capably describe this time period in terms of elite-level conflicts among health reformers, elected officials, government agencies, and the tobacco industry, but give less attention to ordinary Americans’ beliefs and preferences.82 This article expands on prior research by focusing on American public opinion. To summarize: the January 1964 Surgeon General’s report more greatly raised public awareness of the lung cancer and heart disease risks of cigarette smoking than did any other event either before or after the report, but only modestly affected attitudes toward government regulation of cigarettes. This account also addresses several other long-standing questions in medical history. The Federal Trade Commission’s on-and-offagain regulations of cigarette advertising during the 1950s and early 1960s slowed the rise in public beliefs that cigarettes were a serious health risk. Further, while the polling evidence is limited, the “cancer scare” of the early 1950s and perhaps even the 1954 Frank Statement itself greatly increased beliefs that cigarette smoking was “harmful.” Neither U.S. Surgeon General Burney’s 1957 and 1959 statements nor the 1962 British report on the health dangers of smoking had any apparent impact on Americans’ beliefs that smoking was a lung cancer or heart disease risk. Further, health reformers’ efforts in American schools beginning in the late 1950s did affect public opinion, but in a way that was more specific than general and more gradual than immediate.83 Among adult Americans, there occurred very little increase in awareness of the lung cancer and heart disease risks of smoking, at least not until 1962 when the Surgeon General’s report was underway. Health reformers more successfully raised awareness about the health dangers of smoking among teenagers and young adults, and by the 1960s, this led to a steadily growing number of young adults who were better aware of the health risks of smoking


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84. Roper Research Associates. A Study of Public Attitudes toward Cigarette Smoking and the Tobacco Industry in 1968. July 1970. R. J. Reynolds. Page 5. http://legacy.library. ucsf.edu/tid/irk15d00/pdf.


than were previous generations. This research also clarifies the time lag between changing public opinion on the health risks of smoking and changes in actual smoking behavior, as measured by per-capita cigarette consumption. Whether measured by the “harmful” question or by more direct poll questions on lung cancer or heart disease, public awareness of the health dangers of smoking changed well before a sustained drop in cigarette consumption occurred. By the evidence here, the cigarette industry’s efforts to create and sustain controversy about the risks of smoking should be reevaluated. The industry’s greatest success at creating controversy was between 1954 and 1962 when its public relations efforts benefited from the Federal Trade Commission’s ill-advised regulatory policies and by the rise of filter cigarettes. Once the Surgeon General’s report was authorized in 1962 and then released in January 1964, the cigarette industry’s success at creating controversy dwindled very quickly. The percentage of Americans who believed that cigarette smoking was a cause of lung cancer rose from 47 percent in mid-1962 to 62 percent in early 1964, and for heart disease from 32 to 50 percent. Nor did the cigarette industry’s public relations efforts thereafter regain any lost ground. By 1968, a Roper report for the industry conceded that “there is little in this study that can be termed encouraging to the tobacco industry” and that “turning the tide of public opinion from the growing anti-cigarette position will be a large task.”84 As the strategy of creating controversy became an increasingly obvious failure, the industry searched for more persuasive messages—among its poll-tested messages, whether smokers believed that they were being treated unfairly; whether respondents believed that the tobacco industry offered significant economic benefits; whether the risks of smoking were perceived to be a personal, rather than a government responsibility; whether cigarette smoking was perceived to be only slightly harmful or whether only “excessive” smoking was perceived to be harmful; and even if Americans agreed with the so-called constitutional theory that those prone to illness are also more likely to smoke, and that the link between cigarette smoking and illness is only

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FUNDING

None.

85. In addition to the surveys cited herein, see, Political Surveys and Analyses. A Study of Cigarette Smokers’ Attitudes toward Smoking and Related Issues. April 1969. R. J. Reynolds. Vol. 2. http://legacy.library.ucsf.edu/tid/wll44d00/pdf; The Roper Organization. A Study of Smokers’ Habits and Attitudes with Special Emphasis on Low Tar Cigarettes. May 1976. Philip Morris. http://legacy.library.ucsf.edu/tid/wwm10j00/pdf; C. E. Hooper, Inc. Smoking Attitude Study—Marketing Research Report. October 1967. R. J. Reynolds. http ://legacy.library.ucsf.edu/tid/ygo78d00/pdf. 86. “Liggett Pact: Harbinger of Legal Battles to Come,” New York Times, March 21, 1997, A18; “Chief of R.J. Reynolds Says Smoking Has Role in Cancer,” New York Times, August 23, 1997, A7. 87. Brandt, The Cigarette Century; Martha A. Derthick, Up in Smoke: From Legislation to Litigation in Tobacco Politics, 2nd ed. (Washington, DC: CQ Press, 2005); A. Lee Fritschler and Catherine E. Rudder, Smoking and Politics: Bureaucracy Centered Policymaking (Upper Saddle River, New Jersey: Pearson Prentice Hall, 2007); Kluger, Ashes to Ashes.


a spurious correlation.85 Not until the late 1990s did the industry’s top leaders publicly concede that cigarettes were addictive and cancer-causing,86 but by then 92 percent of Americans believed that cigarettes were a cause of lung cancer and 80 percent of Americans believed that cigarettes were a cause of heart disease. Although this account has focused on events from the late 1940s to the early 1970s, the usefulness of including public opinion in medical historiography need not end at that point. Many struggles to limit the harmfulness of cigarette smoking were at that time barely underway. Important arguments in the medical history of smoking, such as addiction, second-hand smoke, and fetal harm, had yet to fully emerge. Nor had efforts to limit the harm of smoking yet reached approaches such as steep tax hikes; bans on billboards, product placement in films, or event sponsorships; large-scale class action lawsuits; bans on smoking in public places; state lawsuits to recover smoking-related Medicaid costs; or efforts to regulate nicotine as a drug.87 A careful attention to public opinion may also usefully inform medical historiography on these points.

The Surgeon Generals' reports and respiratory diseases. From 1964 to 2014.

Korean Americans' beliefs about colorectal cancer screening.

Tobacco control 50 years after the 1964 surgeon general's report.

Smoking, seat-belts, and beliefs about health.

Beliefs and behaviour about smoking among inflammatory bowel disease patients.

The 2014 Surgeon General's report: commemorating the 50th Anniversary of the 1964 Report of the Advisory Committee to the US Surgeon General and updating the evidence on the health consequences of cigarette smoking.

Surgeon General's report on the health benefits of smoking cessation.

Clinical implications of Surgeon General's Report on Smoking and Health.

Demographic and socioeconomic differences in beliefs about the health effects of smoking.

Family Beliefs and Behaviors About Smoking and Young Children's Secondhand Smoke Exposure.

Smokers' beliefs about the tobacco control potential of "a gene for smoking": a focus group study.

Meta-analysis and the Surgeon General's report on smoking and health.

A historic moment: The 50th anniversary of the first Surgeon General's Report on Smoking and Health.

Are young people's beliefs about menthol cigarettes associated with smoking-related intentions and behaviors?

50 years since the first Surgeon General's report on smoking and health: a happy anniversary?

The 1990 Report of the Surgeon General: The Health Benefits of Smoking Cessation.

Korean-Americans' Knowledge about Depression and Attitudes about Treatment Options.

Prevention of orofacial clefts caused by smoking: implications of the Surgeon General's report.

Beliefs and Preferences for Medical Research Among African-Americans.

Measurement of beliefs about consciousness and reality.

Controversial beliefs about diabetes and its care.

Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership.

Multidimensional assessment of beliefs about emotion: development and validation of the emotion and regulation beliefs scale.

[Tobacco control and the reduccion in smoking-related premature deaths in the United States, 1964-2012].