Authors: Richard Kluger
A semi-official consensus now began to emerge in the professional medical and public-health community. It was first voiced in a 1957 report sponsored by the two federal agencies most closely linked to the smoking and health issue—the National Cancer Institute and the National Heart Institute—although neither was exactly a hotbed of agitation against the tobacco industry, along with their counterpart voluntary private agencies, the American Cancer Society and the American Heart Association. The four organizations had designated a seven-man ad hoc Study Group on Smoking and Health, composed of leading academicians like Abraham Lilienfeld who held six two-day conferences to review the swiftly growing body of literature on the subject. Their conclusion was that the “sum total of scientific evidence establishes beyond reasonable doubt that cigarette smoking is a causative factor in the rapidly increasing incidence of human epidermoid carcinoma of the lung.” The group called for intensified research, especially in the area, of heart disease, where evidence was more cryptic.
After he had helped frame the ad hoc Study Group’s report in March of 1957, NCI pathologist Michael Shimkin approached the nation’s nominally top health officer and chief medical advisor to the federal government, U.S. Surgeon General Leroy E. Burney, and urged him to speak out on the smoking problem. Burney, a conservative Indianan who liked to smoke, recognized the gravity of the matter. The Surgeon General, though, while he had line oversight of the Public Health Service and the National Institutes of Health (NIH),
derived his power entirely from the Secretary of Health, Education, and Welfare and so had to proceed with great caution in any matter that might prove politically explosive. Still, Burney was persuaded by the earnest Shimkin, whose outspokenness had not made him the darling of the NCI bureaucracy. “I knew I was dealing with an honest and candid man,” Burney recalled, and after obtaining several other advisory opinions on the smoking issue from people he trusted both within and outside the government, the Surgeon General asked Shimkin to draft an appropriate statement for him on the burning subject. The cautious statement Burney delivered in July of 1957, which marked the first official position on the question to be taken by any U.S. administration, noted that while the case against smoking was still “largely epidemiological in nature,” many past public-health advances were based on statistical data, and, at any rate, supporting biological findings had lately emerged so that “the weight of the evidence is increasingly pointing in one direction … that excessive smoking is one of the causative factors in lung cancer.”
The telltal cautionary words in that initial statement were “excessive” and “one”. What can “excessive smoking”? And if it was just one of several factors in causing the disease, what were the others that deserved mention at the same level of culpability?
NCI director John R. Heller, an irresolute careerist who ran his fiefdom for a dozen years with surpassing concern about offending powerful congressmen who might trim his agency’s budget, was even more cautious. Asked shortly after the release of Burney’s statement what he considered an “excessive” amount of smoking, the nonsmoking Dr. Heller replied two packs a day, leaving the inference that any smaller quantity was biologically tolerable. The truth was that nobody knew how many cigarettes of whatever strength any individual’s physical constitution could withstand. At the House subcommittee hearings chaired by Congressman Blatnik a few weeks later, Heller and Burney said it was premature to place health warning labels on cigarette packs, and called for further research before the government contemplated so rash a step.
Burney was emboldened to speak out more pointedly two years later by the intervening publication in the January 1959
Journal of the National Cancer Institute
of a thirty-page article that represented the culminating scientific paper of the decade on the smoking issue. Credited as lead author of the article in the alphabetical listing was Johns Hopkins’s highly regarded biostatistician Jerome Cornfield, who was joined in the effort by faculty colleague Abraham Lilienfeld, NCI’s William Haenszel and Michael Shimkin, Cuyler Hammond of the ACS, and Ernst Wynder from Sloan-Kettering—an all-star lineup of epidemiologists steeped in the subject. One by one, they shredded the arguments of skeptics, diehards, and the cigarette companies’ apologists.
For those clinging to the view, for example, that the disparity in lung cancer rates between men and women undermined the conclusion that smoking could
be causal in the formation of the disease, Cornfield
et al
. hammered at the hard data: in the over-fifty-five age category, where most lung cancer deaths occurred, only 0.6 percent of American women smoked more than a pack of cigarettes daily, compared with about 7 percent of men. Observation and interviews, moreover, had disclosed clearly, if with less explicit data, that women not only had smoked less for fewer years than men but also inhaled less deeply, did not smoke as far down the butt, and were more frequent users of filter-tip brands, reflecting a more health-conscious attitude generally than found among men. As the century wore on, the fact was, women’s lung cancer rate rose—to the point in the mid-1980s where it would surpass breast cancer as the most virulent form of the disease among women.
Cornfield and his co-authors waxed most ardent in countering the argument that it was “incredible,” as one critic had put it, that smoking should be held accountable as a prime causal agent in such a wide variety of diseases. “We see nothing inherently contradictory,” they replied, in such multiple causation, and noted, for example, how the Great Fog of London in 1952 had been linked causally with a measurable rise in both the respiratory and coronary disease rate; other public-health advocates had pointed out that unpasteurized milk had been found to host bacteria implicated in a number of infectious diseases. Given that tobacco smoke was such “a complex substance and consists of many different combustion products,” the Cornfield article argued, “[i]t would be more ‘incredible’ to find that these hundreds of chemical products all had the same effect than to find the contrary.” The authors concluded that if the collective findings that had to date incriminated cigarette smoke as a health peril had been made against a different agent “to which hundreds of millions of adults were not already addicted, and … which did not support a large industry, skilled in the arts of mass persuasion, the evidence for the hazardous nature of the agent would be generally regarded as beyond dispute.”
Later in the year, with the Cornfield demolition in hand, Surgeon General Burney offered a careful six-page statement in the name of the U.S. Public Health Service that reviewed the findings, which had grown substantially since his hedged comment two years earlier, and concluded, “The weight of the evidence at present implicates smoking as the principal etiological factor” in the increased incidence of lung cancer. But the Burney statement did not amount to a policy position or a call to action by the federal government. The most that could be said of the Eisenhower administration’s involvement with this pervasive and increasingly recognized public-health problem was that it did not force its chief medical officer to remain altogether silent on the subject.
If Burney’s position expressed less leadership on the smoking issue than a probable majority of public-health advocates thought appropriate, it also went further than conservative elements in the medical community liked. Two weeks after the Surgeon General’s statement appeared in
JAMA
, the journal
most widely read by U.S. physicians, an editorial in that magazine shocked Burney by insisting that there were not yet enough facts in the debate over smoking to “warrant the assumption of an all-or-none authoritative position” on causation. It went on to repeat the discredited arguments that lung cancer rates were higher among men than women “even when smoking patterns were the same,” and likewise were higher in urban than in rural areas, in disregard of the far more telling fact that smokers’ mortality rates were notably higher than those of nonsmokers no matter where they lived—and the more they smoked, the greater the disparity.
Many observers felt that the AMA and its medical journals were downplaying the smoking issue due to the need for allies to face the rising tide of national sentiment favoring publicly financed health care for citizens over sixty-five. Similar to the Social Security retirement benefits, a “Medicare” program was dreaded by a sizable portion of the medical profession as an unwelcome intrusion by the welfare state. Morton Levin, the top New York state health officer who had reported early on his findings regarding smokers’ elevated mortality rates, recalled attending an executive session of AMA eminences at the organization’s 1960 convention and hearing a powerful trustee insist that the AMA remain mute on the smoking issue because “the Senators from the tobacco states have threatened to vote against us on Medicare if we take any formal stand whatever—and, gentlemen, we simply cannot have Medicare.”
Foremost of the establishment groups on the other side of the smoking debate, and growing stronger now in its anticigarette position, was the American Cancer Society. The ACS leaders had long hesitated to antagonize millions of their contributors by denouncing their cherished smoking habit as arrant folly. Nor were the society’s chiefs anxious to tangle with a major U.S. industry, especially one with great influence over the media, which provided gratis vital publicity for the ACS’s fund-raising efforts. But it was the ACS that, however cautiously, had funded the crucial studies by Hammond, Horn, Auerbach, and, early on, Wynder. In the late ’Fifties, under the impetus provided by Howard Taylor, Jr., a Columbia professor of obstetrics and gynecology, and ACS executive director Mefford Runyon, the society began pushing doctors to take a more active role in discouraging their patients from smoking. “We are all looking for a breakthrough in cancer,” Taylor would evangelize, adding, “We already have it—through prevention we can control most of the lung cancer problem.”
The climactic clash within the upper strata of the ACS leadership over how activist a role the organization could risk taking on smoking occurred toward the end of 1959, as the board considered issuing an unequivocal indictment of smoking. At one stage in the heated intramural debate, ex-ACS president and longtime director Alton Ochsner took the floor and regaled his eminent colleagues
with a tale intended to disarm those still unpersuaded by the proof against smoking. There was a certain Russian count, Ochsner told them, who, suspecting his attractive young wife of infidelity, advised her that he was leaving their home for an extended trip, but in fact posted himself at a nearby residence to spy on her. The very first night after his leave-taking, the count watched by moonlight as a sleigh pulled up to his house, a handsome lieutenant from the Czar’s Guard bounded out, the count’s wife greeted the hussar at the door and led him inside, and in a moment the couple was seen through an upstairs bedroom window in candlelit silhouette as they wildly embraced; after another moment the candle was blown out. “Proof! Proof!” said the anguished count, smiting himself on the brow. “If only I had the proof!”
Ochsner’s colleagues got the message. In January 1960, the ACS board declared that, based upon all clinical, epidemiological, experimental, chemical, and pathological evidence, it was now “beyond any reasonable doubt” that smoking was
the
major cause of lung cancer and ought to be addressed as such. The society soon began producing pamphlets and filmstrips with titles like
Is Smoking Worth It?
for distribution to schools and any other interested organizations, and it placed further resources in the hands of Cuyler Hammond, who had launched a new investigation he termed a “cancer prevention study” which dwarfed his previous effort. Where his first prospective study had enlisted an all-male population sample of about 200,000, now he conscripted more than a million subjects, of both sexes, using 68,000 ACS volunteers in twenty-nine states. And instead of inquiring almost exclusively about their smoking habits, the far more intricate questionnaire sought some 300 pieces of information from each participant, covering their work, dietary, sleep, and exercise habits. Hammond was out to clinch his case.
The enormity of the stakes in the heated controversy over smoking was fully recognized at a two-day symposium on the subject held in September of 1960 at the New York Academy of Medicine. The conference chairman remarked, not without a hint of incredulity, that should the causation charge be substantiated, “it would indicate that cigarettes cause more deaths than any other recognized lethal agent, including all the known bacteria, known viruses, bullets, wild animals, chemical poisons, or even the American automobile.”
VI
IT
is instructive to contrast what the cigarette manufacturers did and what they said in the course of the ’Fifties as the health controversy intensified. The companies had three courses of action open to them, theoretically. They could have accepted the evidence against them as conclusive and gone out of business rather than further risking the public’s health. They could have
emphatically denied that their product was lethal and gone sullenly about their trade. Or they could have solemnly proclaimed their concern, decried any rush to judgment, and joined in the study of the problem, hoping that it would either exonerate their product or isolate the harmful agent. As prudent men purveying a legal, popular, and highly profitable product, they elected this third course, promising that if science could definitively identify a nasty ingredient that indisputably harmed smokers, their laboratories would remove it forthwith.
Meanwhile, the tobacco industry took action by offering many new brands with a filter tip. True, it was a largely cosmetic measure in most cases, but at the first real show of government concern and outcry in the print media, the industry reduced the strength of tobacco smoke reaching customers’ lungs. Nobody knew whether the reduction would make any difference, but since the studies were unanimous in finding a dose-response relationship—
i.e.
, the more smoke you consumed, the greater your risk—the logic of the measure was irrefutable. Yet the industry, other than Lorillard with its Kent brand, never said or would concede what it was in fact doing and why; to do so would have been tantamount to a confession that it was selling an inherently dangerous product. All it said about its product innovations was that it was offering smokers a wider variety of cigarette styles because that was what they seemed to want. If the industry had left it at that, it might reasonably have been accused of nothing more than disingenuousness.