Antismoking Movement From 1950

The modern-era antismoking movement (1950s to present) developed out of a direct link to earlier efforts to control tobacco use and prohibit cigarette sales. Specifically, the common links between the work of such organizations as the Anti-Cigarette League of America (1899—1930s) and later efforts beginning in the 1950s were the temperance movement and strategies developed out of Christian-based morality. While understanding the similarities to earlier crusades is an important part of the examination of the emergence of present-day antismoking activism, more important is an understanding of the differences—namely that the moral campaign (and campaigners) against smoking that emerged in the post-war era were now fueled with scientific evidence to back claims made about the association (and later causation) between tobacco use and adverse health effects.

Morality Meets Science

By 1950, the cigarette-smoking population in the United States (and most other developed countries) was well on its way to reaching its peak (more than 42% of the U.S. population smoked in 1964), despite the fact that the worldwide scientific community for nearly two full decades already had been asserting the link between cigarette smoking as a major cause of cancer (especially lung cancer) and other diseases. The scientific inquiry between 1910 and 1950 was largely a combination of retrospective epidemiological studies, clinical observation, and autopsy review. During this period, a few prominent researchers emerged as activists, most notably Dr. Alton Ochsner, a surgeon from New Orleans who provided one of the first scientific voices to the antismoking movement by campaigning publicly against cigarette smoking, basing his claims on his own and others' research findings.

The early 1950s was a pivotal period in the history of the antismoking movement in that important studies appearing in the medical literature resulted in widespread publicity through the media. Perhaps the best summary (for a lay audience) of the scientific literature at that time was written by Isroy (Roy) M. Norr, a former public relations consultant to the soap industry and to the Radio Corporation of America. In the October 1952 issue of the Christian Herald, Norr's article, "Smokers Are Getting Scared" became the basis for his own national campaign against smoking, after a condensed version of the article was published a few months later by Reader's Digest under the title "Cancer by the Carton" (Norr 1952). Norr went on to work closely with the American Temperance Society (supported by the Seventh Day Adventist Church) in developing educational films about the health hazards of smoking and launched his own national newsletter (published between 1955 and 1963), the Norr Newsletter about Smoking and Health, which was devoted to providing a layperson's review of the mounting scientific literature on smoking and health issues. The Norr Newsletter also covered legislative and congressional proceedings, excerpts from media coverage of smoking and health issues, and formal statements and announcements made by other organizations, such as the American Cancer Society. But the Norr Newsletter also focused on the need for challenging the tobacco industry and its hired allies. In nearly every issue, Roy Norr challenged cigarette manufacturers, or what he called "the cigarette cartel," "the cigarette pushers," and "tobacco propagandists."

As much as the 1950s was a decade of continued discovery and mounting scientific evidence against cigarette smoking, it was also a period of trial and error for an emerging antismoking movement. While the case against cigarettes was building, this scientific knowledge was not immediately translated into a coordinated, decisive plan of action by thepublic health community. It wasn't until October 1957 that the American Cancer Society (ACS) formally accepted the cause-and-effect relationship between smoking and lung cancer. The resolution adopted (unanimously) at the forty-fourth annual meeting of the ACS called on the Public Health Service (PHS) and other agencies to "proceed with such measures as present knowledge indicates are needed for the protection of the health of people in this respect." U.S. Surgeon General Leroy Burney also released a statement on 12 July 1957 declaring the official position of the Public Health Service to be that "the weight of the evidence is increasingly pointing in one direction: that excessive cigarette smoking is one of the causative factors in lung cancer." A copy of Burney's statement and supporting evidence was sent to state medical societies and all state superintendents of education. However, Burney maintained that the agency would limit its action to disseminating new scientific information to state health departments and would not initiate an antismoking campaign or national health education effort aimed at the general public.

Verdict: Guilty; A Call for Action

On 1 June 1961, the American Cancer Society, the American Heart Association, the National Tuberculosis Association, and the American Public Health Association sent a joint letter to President John Kennedy pressing for the appointment of a special commission to examine the responsibilities of government and business in relation to smoking and health. After much discussion, President Kennedy announced that he was assigning the responsibility of a study on smoking and health to then-Surgeon General Dr. Luther Terry, who established the Advisory Committee on Smoking and Health. The committee's report, Smoking and Health: A Report of the Surgeon General's Advisory Committee, was released on Saturday 11 January 1964 to substantial media attention. The report concluded that smoking caused lung cancer and chronic bronchitis and "is a health hazard of sufficient importance in the United States to warrant appropriate remedial action." The first major policy response to the 1964 surgeon general's report was the 1965 Cigarette Labeling and Advertising Act, which mandated warning labels on all cigarette packages.

Within days of the release of the 1964 surgeon general's report, the American Medical Association (AMA) struck a deal with six of the nation's leading tobacco manufacturers and formed its own committee to conduct research. Three of the members of the AMA's committee also had served on the surgeon general's advisory committee, while two others also served on the industry's Council for Tobacco Research. The AMA had rebuffed previous requests to get involved in the issue. It would be fully 14 years (and nearly $18 million from the tobacco industry) later before the AMA, the leading medical professional society in the country, would finally endorse the 1964 report of the surgeon general.

One of the first major nongovernmental antismoking initiatives was launched in 1967 by John Banzhaf, at the time a young attorney who successfully petitioned the Federal Communication Commission (FCC) to apply the Fairness Doctrine (an FCC regulation that required broadcasters to allot time to contrasting points of view on controversial topics) to cigarette advertising, thus requiring broadcasters to air antismoking commercials. The effect (an initial, significant reduction in cigarette consumption) was short-lived. In response, tobacco companies removed their advertisements from the airwaves (thereby removing the antismoking commercials at the same time as the fairness doctrine would no longer apply), a policy that was made law by the 1969 Public Health Cigarette Smoking Act. However, a limited form of cigarette advertising on television continued indirectly through the sponsorship of televised sport and sporting events. In 1968, Banzhaf founded the organization Action on Smoking and Health (ASH), which has remained a force in the antismoking movement, especially in the area of clean indoor air legislation.

Emerging Activism

Beginning in the 1960s and into the 1970s and 1980s, antismoking efforts in the U.S. began to develop into a more diverse movement, with a broad constituency consisting of traditional public health organizations (i.e., governmental, voluntary and professional health, medical and scientific agencies) and the formation of collaborative efforts. This trend included the priority of advocating for new policy and regulation at all levels, such as cigarette advertising restrictions, warning labels on cigarette packs and in cigarette advertising, increases in cigarette excise taxes, and clean indoor air legislation.

This was also a period where activism emerged in the form of independent organizations and individuals with a focus on restricting and eliminating smoking in public places. Local and statewide grassroots organizations, such as GASP (Group Against Smoking Pollution), were formed in the early 1970s in order to address both the nuisance and public health threats posed by the inhalation of secondhand smoke. Such grassroots efforts had begun in the 1960s by individuals, most notably flight attendants who fought to ban smoking on U.S. commercial airlines (something that would not happen until the 1990s). In 1971, in conjunction with the release of an updated report on smoking and health, U.S. Surgeon General Dr. Jesse Steinfeld called for a nonsmokers' rights movement, citing the accumulating evidence of adverse health effects caused by secondhand smoke. Dr. Steinfeld called for a ban on smoking in all confined public places including restaurants, theaters, airplanes, trains, and buses. This call was later echoed by succeeding Surgeons General Drs. Julius Richmond (1977–1981) and C. Everett Koop (1981–1990), which helped to fuel the already-growing public sentiment for smoke-free public places.

Shifting the Focus: Tobacco Industry Becomes Target

During the 1970s, however, the action by government agencies did not match the priorities advocated by outspoken public health individuals and grassroots organizations. The National Cancer Institute (NCI), the federal government's leading cancer research arm, focused its research efforts primarily on studying potentially "less hazardous cigarettes" rather than studying methods for preventing youth smoking or helping adult smokers to quit. It was not until 1978, after lawyer Joseph Califano became Secretary of the Department of Health, Education, and Welfare under the incoming Carter Administration, that a strong antismoking campaign became a priority for the federal government. In January 1978 Califano outlined his battle plan in a public speech in which he called cigarette smoking "Public Health Enemy Number One" and "slow motion suicide." However, Califano was fired by President Carter the following year, allegedly because of his outspoken stand against tobacco.

During the late 1970s and throughout the 1980s, the antismoking movement realized a primary shift of focus—away from the behavior of people who smoke and toward the behavior of the tobacco industry. In 1977, a family physician, Dr. Alan Blum, founded DOC (Doctors Ought to Care). Drawing from the grassroots successes of GASP organizations, DOC organized physicians and other health professionals to take action on smoking in the clinic, classroom, and community. In the late 1970s and early 1980s, DOC became best known for its "housecalls" made at tobacco-sponsored sports and cultural events. These orchestrated protests were designed to call public attention to and ridicule such events as the nationwide circuit of Virginia Slims Tennis Tournaments, the Benson and Hedges Film Festival, and the KOOL Jazz Festival. The organization used humor and satire in its efforts and pioneered the strategy of paid counteradvertising in the mass media. Many of DOC's concepts and strategies were born from the frustration of failed government and voluntary health agency efforts, and the feeling that such organizations were simply providing lip service to tobacco problems (i.e., the benefactor of the 1976 Virginia Slims Tennis Tournament in Miami was the local division of the American Cancer Society).

The efforts of DOC sparked a nationwide effort to reform the antismoking movement (at its peak in the late 1980s DOC had established more than 150 local chapters in nearly every state). Other grassroots organizations were formed with a focus on developing new viewpoints and strategies to counteract tobacco use and promotion. In 1985, STAT (Stop Teenage Addiction to Tobacco) was formed by Joe Tye, a hospital administrator, to draw attention to cigarette manufacturers' targeting of children with advertising and promotion, and to advocate for policies restricting the sale of cigarettes to children. Several organizations, with missions similar to the GASP groups formed in the 1970s, began popping up around the country. One of the earlier groups, Arizonans Concerned About Smoking (ACAS), and its director Don Morris relied on the leadership and support from former Public Health Service leaders, including Dr. and Mrs. Luther Terry and Dr. Leland Fairbanks. In the late-1980s, the organization SmokeFree Educational Services was founded by Joe Cherner in New York to work for clean indoor air legislation, as was SmokeFree Pennsylvania established by Bill Godshall. While many of these organizations were originally formed to strengthen clean indoor air laws at the local and state levels, most evolved into multi-focus groups, developing collaborative strategies with other activist organizations.

Meanwhile, during this period, the voluntary health organizations were working to develop federal policy initiatives (including, among others, to increase the federal excise tax, ban cigarette advertising, and improve the language of mandated health warnings on cigarette packs and in advertisements). The Coalition on Smoking OR Health, initially established by the American Cancer Society, American Lung Association, and American Heart Association (other organizations would join as sponsors later), set out to serve as a national leader for advocating policies to govern and regulate the tobacco industry at the federal level. For much of the 1980s and into the 1990s, this was the major national antismoking initiative of these organizations. The demise of the Coalition on Smoking OR Health in the mid-1990s came after the announcement of the formation of the Campaign for Tobacco-Free Kids, a new national organization based in Washington, D.C., and funded by the Robert Wood Johnson Foundation, the nation's largest health foundation and a newcomer to the tobacco issue.

The 1990s also witnessed a dramatic expansion in litigation as a major antitobacco strategy involving major political players—state attorneys general, well-financed plaintiffs lawyers, former tobacco company employees testifying for plaintiffs (so-called whistle-blowers), class action status among some suits, and the efforts on behalf of a host of third-party plaintiffs (the states, health insurance companies, pension funds). The State of Mississippi and its Attorney General Mike Moore are credited with the first major success in tobacco litigation, having brought suit against the major U.S. cigarette manufacturers in 1994 (stating claims for reimbursements the state made for Medicare costs due to smoking-related illnesses) and settling before trial for nearly $4 billion in 1997—to be paid out to the state over 25 years. It was the first suit of its kind, and other states began to follow this legal model shortly after Mississippi filed its claim. The end result (but not the end of tobacco litigation) was the development and ratification of a Master Settlement Agreement in 1998 between six major U.S. cigarette manufacturers (other, smaller tobacco companies have joined the settlement) and 46 states in the U.S. (the tobacco industry had settled separately with Mississippi, Florida, Texas, and Minnesota). The total sum to be paid by the tobacco industry to the states over 25 years was $206 billion (the total, including the four states that settled separately, was $246 billion).

Success or Failure?

During the 1990s, the National Cancer Institute conducted a large nationwide intervention study—the American Stop Smoking Intervention Study, known as Project ASSIST. With a budget of approximately $120 million over seven years (two years for planning and five years for the actual intervention), the overall goal of Project ASSIST was to reduce smoking in the U.S. by 50% by the year 2000. This reduction was to be accomplished through the implementation of a public health model for what was by 1991 being called "tobacco control." Specifically, Project ASSIST provided funding to seventeen states for the development and support of coalitions at the state and local levels to plan a multi-layered approach for implementing antismoking messages in an effort to change social norms. The goal of ASSIST was to change the social, cultural, economic, and environmental factors that promote smoking by utilizing four policy strategies: promoting smoke-free environments; countering tobacco advertising and promotion; limiting youths' access to tobacco products; and raising excise taxes to increase the price of tobacco products. The interventions were developed and implemented by networks of state and local tobacco control coalitions. The most recent analyses of data from the impact of ASSIST have showed a greater reduction in smoking prevalence (the number of people who smoke) in states participating in the ASSIST program than in non-ASSIST states, but the effect seen has been modest.

The 1990s also realized a major political move by antismoking forces through successful ballot and legislative initiatives in several states designed to increase the cigarette excise tax and earmark funds for antismoking programs. California (which actually passed its ballot measure, Proposition 99, in 1988) was followed by similar initiatives in Massachusetts, Arizona, Florida, Alaska, and Oregon, where tax increase initiatives ranged from 25 cents per pack to over $1 per pack. But controversy and debate also arose in each state when the money became available for antismoking programs over how the funds should be spent. The funds in most states were, among other purposes, supposed to buy the best minds in advertising to counteract smoking through paid advertising campaigns. While some ad campaigns won awards (most notably in California and later in Florida), they lacked the frequency needed to make a more significant impact.

More recently, the Master Settlement Agreement (MSA) has been considered a landmark development in the antismoking movement, primarily for two reasons: 1) It established several restrictions of cigarette advertising and promotion to be phased in over several years; and 2) it provided substantial funding ($1.7 billion) for the establishment of a national foundation (later named the American Legacy Foundation) to develop a major antismoking initiative. There was also the promise by attorneys general and the private lawyers handling the state cases (also serving as settlement negotiators) that states receiving settlement funds would earmark an annual percent to fund state antismoking programs. However, state legislatures in a number of states have not stuck by their promises and have redirected money from the windfall settlement into programs other than antismoking efforts. The states, some activist charge, have become "addicted" to the cash flow from the settlements to close their budget deficits (the tobacco companies raised the price per pack to cover the expense). Meanwhile, some antitobacco advocates have warned that the dependence of public health programs on tobacco industry payments may divert organizations away from their primary public health mission.

See Also Advertising Restrictions; Air Travel; Litigation; Politics; Prohibition; Smoking Restrictions.

▌ ALAN BLUM
▌ ERIC SOLBERG

BIBLIOGRAPHY

Advisory Committee to the Surgeon General. Smoking and Health: A Report of the Surgeon General's Advisory Committee. U.S. Department of Health, Education and Welfare. Public Health Service. No. 1103, 1964.

Blum, Alan. "Medicine vs. Madison Avenue: Fighting Smoke with Smoke." Journal of the American Medical Association 242 (1980): 739–740.

——. "The Marlboro Grand Prix: Circumvention of the Television Ad Ban on Tobacco Advertising." New England Journal of Medicine 324 (1991): 913–916.

——. "Role of the Health Professional in Ending the Tobacco Pandemic: Clinic, Classroom and Community." Journal of the National Cancer Institute. Monograph No. 12. (1992): 37–43.

Blum, Alan, ed. "The World Cigarette Pandemic." New York State Journal of Medicine 83, no. 13 (December 1983): 1225–1381.

——. "The World Cigarette Pandemic, Part II." New York State Journal of Medicine 85, no. 7 (July 1985): 278–477.

Blum, Alan, Eric Solberg, and Howard Wolinsky. "The Surgeon General's Report on Smoking and Health 40 Years Later: Still Wandering in the Desert." The Lancet 363 (2004): 97–98.

Neuberger, Maureen. Smokescreen: Tobacco and the Public Welfare. Englewood Cliffs, N.J.: Prentice Hall, 1963.

Norr, Roy. "Cancer by the Carton." Reader's Digest (December 1952): 7–8.

Norr, Roy, ed. Norr Newsletter about Smoking and Health 1, no. 1–vol. 6, no. 3 (1955–1961). Available at the New York Academy of Medicine Library.

Smoking and Health. Report of the Royal College of Physicians of London. London: Pitman Medical, 1962.

Wolinsky, Howard, and Tom Brune. The Serpent on the Staff: The Unhealthy Politics of the American Medical Association. New York: G. P. Putnam's Sons, 1995.