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Congress did enact legislation to educate consumers about the hazards of smoking. In , the Federal Cigarette Labeling and Advertising Act of mandated the first Surgeon General's warning to appear on cigarette packages: This office was to play a key role in the development of the first 10 Surgeon General's reports — as well as development of national informational and educational programs about the risks of smoking. However, at the same time it prohibited FTC from taking any new regulatory action to control cigarette advertising for 4 years.
Contemporary observers explained that the tobacco industry had decided it was in their interest to accept the warning label in exchange for halting any regulatory efforts Drew However, subsequent analyses have shown how the tobacco industry used its connections within government to assure a weak bill and a weak warning label Brandt Subsequent government actions were largely focused around promoting public information about the risks of cigarette smoking and how they might be reduced. The Surgeon General convened another group of experts in to assess the importance of different constituents identified in cigarette smoke for disease risk; the group recommended that actions be encouraged to progressively reduce the tar and nicotine content of cigarette smoke Congressional Record Eventually, this disclosure became mandatory.
The pamphlet provided five suggestions: In the absence of any authority to mandate changes in the product, public education became the primary tool to reduce risk. However, one initiative that had a measurable impact on the prevalence of smoking was initiated by John F. Banzhaf III, a consumer lawyer. In , Banzhaf successfully petitioned the Federal Communications Commission FCC to apply the Fairness Doctrine 1 to cigarette advertising to counter the tobacco industry's advertising messages Banzhaf v.
FCC , F. After a court struggle, the national networks were forced to air antismoking advertising spots in prime time, giving tens of millions of dollars' worth of free airtime to antismoking efforts. In , 1, antitobacco messages were aired by the three major networks Lewit et al. These public service announcements may have contributed to a reduction of overall consumption; per capita cigarette consumption fell from 4, in to 3, in Figure 2. The effect was short-lived, however, as tobacco companies were mandated to take their ads off the airwaves in following the Public Health Cigarette Smoking Act of , which included a prohibition on broadcast advertising of cigarettes.
Consequently, the antismoking advertisements were no longer required under the Fairness Doctrine and cigarette consumption rose after they ended Warner From about the time of the report, per capita cigarette consumption began to decline in the United States Figure 2. Physicians and other health professionals had begun to accept the evidence and to stop smoking even before the release of the report.
Some had switched to smoking only a pipe or cigars, and many who continued to smoke had reduced the number of cigarettes they smoked. Ninety-three percent of the respondents supported antitobacco education efforts for youth, and those who did not said it was not because they doubted the harms of smoking, but because they doubted the effectiveness of educational efforts to change teenagers' behavior Snegireff and Lombard Surveys of physicians during the s continued to show decreasing prevalence of smoking and acceptance of the hazards of cigarette smoking Buechner et al.
Additionally, although many physicians had quit earlier, those who quit before were more likely to cite physical symptoms as the reason while, after , former smokers were more likely to cite scientific evidence of harm as their reason for quitting Meighan and Weitman The prevalence of smoking was also dropping rapidly among medical trainees and younger physicians.
Younger physicians were also more likely to report concern over the health effects of smoking on patients, to ask or advise patients about their smoking, and to agree that physicians should set an example by not smoking Coe and Brehm Appreciation of the health risks, and subsequent behavior change, was slow to follow among the general population. Gallup polls have surveyed Americans about their beliefs on the health effects of smoking since the s Gallup Organization Respondents were also specifically asked about lung cancer.
Instead, most cited a variety of non-life-threatening problems such as coughing, sinus irritation, nervousness, and fatigue Saad Even after the report, there was not a dramatic change in public beliefs about smoking. In general, although there was widespread awareness of reports of findings on smoking and health, including lung cancer, people were unsure whether to believe the results were conclusive.
This uncertainty may have reflected, at least in part, the doubt-creating strategies of the tobacco industry Proctor Some early studies hinted at the complexity of beliefs about health risks and the factors determining those beliefs. For example, having a higher education level among nonsmokers was associated with acceptance of statements that a link between smoking and health had been proven; but among smokers, the relationship was the opposite, and smokers with a higher education level were more likely to be skeptical of the evidence Cannell and MacDonald In another study, a survey found that male smokers were relatively optimistic about their chances of contracting cancer, while female smokers were not Toch et al.
And a study found that awareness of science reporting had little impact on smoking behavior, as many smokers were prone to doubt the scientific claims or exhibit fatalistic attitudes about health risks Robinson It was not until the s that a majority of Americans said smoking was a cause of lung cancer. Cigarette consumption was similarly slow to change.
Per capita consumption figures increased every year from to , with the exception of and , when there was the first widespread publicity on early laboratory animal and human cohort study findings Figure 2. Consumption decreased in and during all of the Fairness Doctrine years of — Since , every year for which data are available has seen declines in per capita adult cigarette consumption U. Department of Agriculture ; U. Census Bureau ; U. Department of the Treasury Although antismoking publicity and news reports did have an impact on beliefs and behavior over time, there were also forces working against this trend.
In particular, the tobacco industry's marketing efforts and organized campaign to promote doubt around smoking and health surely slowed the pace of change. Even as public knowledge about the link between smoking and lung cancer became widespread during the s and s, a FTC review concluded that many Americans still had very limited knowledge of the nature and extent of the health risks or how those risks applied to their own behavior FTC The nature of cigarette advertising also changed, apparently in response to adverse publicity, to obscure the extent of the danger.
During the s, there was an increased emphasis on ads that featured claims about tar and nicotine content, implying reduced exposures to cancer-causing agents NCI In the s, these health messages became more subtle, relying on imagery of active, healthy models Warner b. Additionally, the tobacco industry's power as a source of revenue for many print publications influenced the content of smoking and health media coverage USDHHS ; NCI After the broadcast advertising ban, cigarette advertising and marketing continued to grow, but shifted to print publications, outdoor billboards, sponsorship of sports, placement of brand implants in movies, and a number of other methods.
Some publications became highly dependent on this revenue. An article in the Columbia Journalism Review noted a trend: Although many individual physicians rapidly accepted the smoking and health findings, AMA, the leading professional medical organization, took more than two decades to take a clear stand on the issue.
At the time, AMA officials also opposed federal efforts to mandate warning labels, advertising restrictions, or other public education efforts around smoking Haseltine Historians have noted that AMA's position on smoking during the s and s was influenced by its need for support from congressional allies, particularly in southern tobacco-growing states, as well as its opposing Medicare and proposed national health insurance legislation during those years Kluger ; Rothstein ; Proctor Surgeon General Jesse L.
Steinfeld, appointed by President Richard M. Nixon in December , helped to bring public attention to the effects of smoking on non-smokers. Although he had more limited authority compared with his predecessors due to a reorganization within USDHEW, he made use of the public platform of the Office of the Surgeon General to advance public health. He reinvigorated the regular reports of the Surgeon General on smoking and health, involving dozens of outside experts as authors and peer reviewers to produce a page report in and the first report to address passive smoking in see Chapter 3.
The subsequent report was the first in the series to identify the exposure of nonsmokers to cigarette smoke as a health hazard USDHEW The review showed that levels of carbon monoxide in a smoke-filled room could reach concentrations equal to and even above standards for ambient air. The report also concluded the tobacco smoke was a source of discomfort for many people, but characterized the health risks of tobacco smoke in the air as unknown. Steinfeld continued to be outspoken and an advocate for smoking bans and, unlike his predecessors, he refused to meet with tobacco industry representatives Kluger A grassroots movement emerged in the early s to promote the interests of nonsmokers.
At the time, there was little data on the harms of exposure to secondhand smoke. However, an increasing number of nonsmokers viewed it as an annoyance in shared spaces, such as restaurants and airplane cabins. And the existence of a potential risk, however uncertain or small, was viewed in a fundamentally different way when it affected involuntarily exposed bystanders, some of whom might be susceptible to the effects Bayer and Colgrove Several were at the federal level. In , the Civil Aeronautics Board, which had jurisdiction, ordered domestic airlines to provide separate seating for smokers and nonsmokers.
In , Arizona became the first state to restrict smoking in some public spaces. In , Connecticut enacted the first statute to restrict smoking in restaurants. Minnesota followed in , requiring no-smoking zones in buildings open to the public. In , Berkeley, California, became the first city to pass an ordinance limiting smoking in restaurants.
At the same time, antismoking efforts in the United States began to develop into a more diverse movement, involving a broad constituency of volunteer health organizations, professional organizations, and newly created advocacy groups, such as Doctors Ought to Care created in USDHHS When lawyer Joseph A. Califano's actions did not develop in a vacuum, however.
They reflected a growing national agenda of public health advocacy against smoking National Commission on Smoking and Public Policy The Surgeon General's report, Smoking and Health , released under Califano, marked the year anniversary of the original report. The report included more than 1, pages and presented an enormous amount of data from now decades-long epidemiologic cohort studies, studies of mechanisms of disease, studies of behavioral and psychosocial influences on tobacco use, and the effectiveness of education programs and interventions. The report also reviewed the initial evidence on the health consequences of involuntary smoking, but called for more research without reaching any conclusions as to risks USDHEW In the Secretary's Foreword to the volume, Califano wrote: For one reason, because the consequences are not simply personal and private.
That is, smoking went beyond being a private medical concern to being a major public health problem that affected smokers and nonsmokers. At the same time, Califano acknowledged limits to government's role in regulating cigarette smoking in a free society and suggested that intervention would have to focus primarily on research, education, and persuasion. The report also brought a renewed focus to the need for understanding smoking behavior and how to help people who want to quit. Thirty million Americans, the report stated, had become former smokers since , and this figure gave encouragement that persuasion and education could have population-level impacts USDHEW The report also highlighted the effects of smoking for specific vulnerable or high-risk populations, including women, youth, minorities, the developing fetus, and certain occupational groups.
In this way, too, government intervention was seen as justified by the need to protect those who are most vulnerable or at increased risk. In his preface, Surgeon General Julius B. At this time, the scientific evidence on the health effects of exposure to secondhand smoke was limited. Studies starting in the late s had shown adverse effects of maternal smoking on the developing fetus and on children exposed to secondhand smoke in smoking households Comstock and Lundin ; Colley et al. However, it was not until the following decade that a critical mass of scientific evidence emerged linking exposure to secondhand smoke with cancer and other chronic health effects among nonsmoking adults.
Because the lung cancer investigations involved people who had experienced heavy exposure to smoke in the home over long periods of time, there were questions about whether, and to what extent, the data could be extrapolated to other enclosed public spaces. But over the next several years, additional studies gave weight to the argument that adult nonsmokers suffered harm by breathing the cigarette smoke of others and that smoking by parents adversely affected the respiratory health of their children.
In , two major scientific reviews were released in the United States—the U.
Baruch Spinoza
Measuring Exposures and Assessing Health Effects National Research Council —both concluding that secondhand smoke could cause lung cancer in healthy adult nonsmokers and respiratory symptoms in children. The report of the Surgeon General on involuntary smoking represents another landmark in the series of reports.
Following the approach of the report, it assembled the full body of evidence on exposure to secondhand smoke and health, reviewing the composition of tobacco smoke, dosimetry and toxicology, exposures, and the findings of epidemiologic studies USDHHS It interpreted that evidence within the context of what was already known about active smoking, treating exposure to secondhand smoke as resulting in a lower dose of tobacco smoke, compared with active smoking, but to the same toxic mixture from a health perspective.
The report had three overall conclusions, including its powerful first conclusion: Its second conclusion described the adverse effects of smoking by parents on the respiratory health of their children. Everett Koop, appointed by President Ronald W. Reagan in , used the visibility of the position to a greater degree than any of his predecessors and used the findings of the report to call for smoke-free public places. He was an outspoken public foe of tobacco, advocating a smoke-free environment by the year Although he was aware of the controversy surrounding the scientific evidence on secondhand smoke, further fueled by the tobacco industry's efforts to focus attention on the limitations of the data, he insisted that the data were sufficient for public health intervention.
He went on to argue, based on the report's third overall conclusion, that many of the measures that had been put into place in many states and communities were inadequate, such as creating separate nonsmoking sections with a common ventilation system did not eliminate exposure for nonsmokers. Between —, the number of communities around the country that had enacted laws restricting public smoking almost quadrupled, to over USDHHS In , Congress imposed a smoking ban on all U. Two years later, the ban was extended to flights of 6 hours or less, in effect banning smoking on all domestic flights.
Once these efforts gained momentum, new legislation spread rapidly. The recognition of exposure to secondhand smoke as a health risk to nonsmokers meant that the issue was no longer merely one of individual choice. People responded differently to risks that were imposed on them involuntarily. The existence of victims of cigarette smoking fundamentally altered the discussion about the right to smoke, and state and legal intervention was seen as entirely appropriate. There was also substantial public support for enacting restrictions on smoking in public spaces.
Additionally, the phenomenon may have been self-reinforcing, acting as a sort of contagion effect where actions on one locale influenced other locales Asbridge The attention to secondhand smoke was also aided by the growth in public concern over environmental pollutants during the s. In , under the Nixon Administration, both the U. The following years saw a wide range of new environmental and safety laws aimed at protecting the public from involuntary risks, including, for example, the Consumer Products Safety Act , the Safe Drinking Water Act , Amendments to the Federal Food, Drug, and Cosmetic Act of , and the Toxic Substances Control Act , creating new agencies and greatly expanding the regulatory authority of some existing agencies.
The emerging evidence on exposure to secondhand smoke and disease, particularly lung cancer, sparked a vigorous response from the tobacco industry that is now well documented Brandt ; Proctor The tobacco industry recognized the policy implications of evidence showing that exposure to secondhand smoke caused adverse effects among nonsmokers and initiated strategies to undermine the research findings, seeking to create doubt about the credibility of evidence that would drive policy-making United States v.
The first major study to link exposure to secondhand smoke to lung cancer, the cohort study carried out in Japan by Hirayama , was the target of an orchestrated campaign to undermine its findings. The tactics included arranging critical letters to the editor of the British Medical Journal , which published the paper, commissioned research with the intent of obtaining findings that would point to bias in the study, and even newspaper advertisements discrediting the findings. Such strategies were directed at the wider body of evidence on secondhand smoke and health; the industry and its consultants raised methodologic problems, such as uncontrolled confounding and exposure measurement error, in order to sustain doubt about the findings Kluger ; Proctor These same tactics and others were used to try and diminish the impact of the Surgeon General's report.
An attempt was made to engage some of the report's authors in a symposium that had undisclosed tobacco industry sponsorship. The report was characterized as political rather than scientific, and Surgeon General Koop's motives were questioned. The attack on the scientific foundation of the report intensified as well Proctor Some of these same strategies were used subsequently in an attempt to derail EPA's risk assessment of environmental tobacco smoke. An estimated 30 million people quit smoking in the decade following the report.
Additionally, throughout the s and s, the general understanding of smoking behavior and nicotine addiction was very limited. At the time, health scientists viewed smoking as primarily psychological and social, rather than pharmacological or biological. The report concluded that tobacco dependence should be characterized as a form of habituation rather than addiction USDHEW , drawing on a distinction established by WHO in That definition emphasized the physical effects of the drug, the compulsion to obtain it at any cost, and the habit's detrimental effects on the individual and society WHO The WHO Expert Committee on Addiction-Producing Drugs observed that for cigarette smoking, evidence was lacking at the time for a typical abstinence syndrome.
At the same time, because regular smoking was so widespread and socially accepted during the s, scientists were reluctant to portray smokers as addicts or as presenting a threat to society. Seevers, the only pharmacologist on the Surgeon General's Advisory Committee, had served on WHO's expert committee that produced the definition of addiction and was a longtime proponent of the view that an observable physical abstinence syndrome was a crucial defining feature of addiction Rasmussen and Seevers It would be another decade before federal research funders and public health scientists created an organized research program around smoking dependence and nicotine addiction.
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In the mids, scientists were beginning to compare tobacco smoking with other drug addictions. For example, Jerome H. Jaffe, who had promoted methadone treatment for heroin addicts as President Richard M. Nixon's drug czar from —, began to argue in favor of treating cigarette smoking as an addiction in the mids, maintaining that it did meet the appropriate criteria, including the presence of a withdrawal syndrome. By the late s, as smoking behavior was increasingly recognized as resembling that of other drug addictions, an organized research effort began Jarvik et al.
A substantial portion of the Surgeon General's report was devoted to behavioral aspects of smoking USDHEW ; indeed, of the 11 Surgeon General's smoking and health reports published between —, it was the first to include any mention of smoking behavior or dependence. The authors of the report sought to avoid using the term addiction, not because they believed it to be scientifically inaccurate, but because of its loaded meaning related to illicit drug use Henningfield and Zeller It was not until the report that the Surgeon General declared that cigarettes are addicting, similar to heroin and cocaine, and that nicotine is the primary agent of addiction USDHHS The focus on the behavioral and psychological aspects of cigarette smoking and addiction marked a substantial shift from the earlier science of smoking and health.
Researchers studying the health effects of smoking during the s and s were primarily epidemiologists, statisticians, and pathologists without expertise in studying addictive behavior. These researchers were focused on the consequences of smoking and not on why people smoked. During the s, scientists who had studied other drug addictions turned their attention to cigarette smoking, developing methods to measure nicotine intake and smoking behavior. A substantial body of evidence resulted.
The report of the Surgeon General, also released by Surgeon General Koop, reviewed this new evidence on smoking and addiction, concluding that: The third overall conclusion compared nicotine addiction to other addicting drugs, including heroin and cocaine. The report changed the view that smoking was just a habit. Cigarettes were now cast as addicting and as equally addictive as many illegal drugs.
The findings also had implications for treatment, pointing to the possibility of using nicotine replacement therapy to increase successful quitting of nicotine USDHHS For smoking initiation by youth, the finding that nicotine is addicting raised concern that adolescents and young adults might become addicted through experimentation; by , the pattern of initiation had moved to the teen years for both males and females USDHHS The Surgeon General's report on Preventing Tobacco Use Among Young People emphasized that tobacco use and addiction almost always begins before 18 years of age and that most adolescent smokers face the same challenges as adults in quitting smoking USDHHS Like the report, the report had profound implications for the tobacco industry, and the report also received great attention from the industry and its consultants.
The tobacco industry had information about the report when it was in development and was quick to criticize its findings after release. The finding that nicotine was addicting countered the argument that people became smokers by their own free choice. Efforts to discredit the report continued long after its publication, even though the industry's own documents show that it had long known that nicotine was addicting Proctor Beginning in the mids, per capita cigarette consumption began to decline more steeply than during the decade following the report Figure 2.
The scientific findings on tobacco smoke, summarized and transmitted to the health community and the population at large through the Surgeon Generals' reports and other channels, provided a basis for motivating effective action to control tobacco use. Underlying the decline was increasing public understanding of the dangers of cigarette smoking and increasing unacceptability of being a smoker; that is, the social norm around smoking changed from being completely acceptable and woven into day-to-day activities and interactions among people to becoming an increasingly unacceptable behavior.
Many factors contributed to this change, including the evidence on the dangers of exposure to secondhand smoke and the ever-increasing reluctance of nonsmokers to inhale tobacco smoke in their workplaces, public places, and eventually their homes USDHHS Advocacy at the local grassroots level played a critical role as non-smokers demanded smoke-free environments.
The need for using a battery of tobacco control measures was recognized and trials were carried out at the community level to assess the efficacy of combined approaches and their effectiveness in practice. The project was unique at the time for its scale and focus on studying the effectiveness of broad strategies for policy change.
The intervention led to a greater reduction in the prevalence of smoking in states participating in the ASSIST program than in non-ASSIST states, although the effect was modest, likely because of the general trend of declining per capita cigarette consumption over the years of the study Figure 2. State tobacco control programs also took a more aggressive approach during the s, moving beyond a focus on the harms of exposure to secondhand smoke to directly countering cigarette advertising efforts. As cigarette advertising linked smoking to glamour, vitality, and social success, some state programs, such as those in California, Florida, and Massachusetts, turned to explicit denormalization strategies USDHHS Initially, some of the funds from the MSA were directed to tobacco control, but the funding declined as states used the revenues for other purposes and only a few states ever reached the CDC's recommended funding levels Sloan et al.
Additionally, after decades of failed personal injury lawsuits against the tobacco industry for smoking-related harms, the climate for tobacco industry litigation transformed during the s. There was one major development with Cipollone v. The plaintiffs gained access to some internal tobacco company documents supporting claims that the industry had conspired to withhold information about harm from the public. But, it was during the s that far more complete access was gained to the industry's internal documents. Two major events made this possible.
First, an employee of a law firm that represented tobacco companies released documents to the public that exposed the tobacco companies' misconduct.
Second, class-action litigation and litigation on behalf of state governments allowed plaintiffs to combine their resources and expertise on a scale not before realized Miura et al. The litigation by the State of Minnesota and Blue Cross and Blue Shield of Minnesota resulted in the release of the industry's documents and their maintenance in two repositories, one in Minnesota for the U.
Under the MSA, the industry is required to continue to place its documents into a depository until From —, almost every state filed an action against the tobacco companies. The process ended with individual settlements with the states of Florida, Minnesota, Mississippi, and Texas, and the MSA with the remaining 46 states and the District of Columbia. The MSA did not just provide monetary relief to the states, but also placed restrictions on the tobacco companies that included ending cigarette billboard advertising, banning the use of merchandise with cigarette brand names, and limiting sponsorships.
Additionally, as a result of the Minnesota Settlement and the MSA, tens of millions of pages of internal memoranda, reports, and other tobacco company documents initially acquired through litigation were made available to the public USDHHS The tobacco industry was further discredited by congressional hearings and the litigation brought by the U.
FDA launched a large-scale investigation into the manipulation of nicotine levels in cigarettes and marketing to youth and, for the first time, asserted jurisdiction over cigarettes as drug delivery devices see Chapter At a hearing, seven tobacco company CEOs insisted that they believed nicotine was not addictive and not a cause of disease.
Photographs of the group holding up their right hands and being sworn in at the hearing, while denying what most members of the public knew to be true about cigarettes, turned them into objects of ridicule and further diminished the public's view of the tobacco industry Brandt In the DOJ litigation, the industry was found guilty of violating civil racketeering laws and lying to the public about the dangers of tobacco and its marketing to children.
The opinion by Judge Gladys Kessler focused on the representation of cigarettes with reduced machine yields of tar and nicotine as conveying lower risks and the industry's denial of the health effects of exposure to secondhand smoke United States v. Philip Morris et al.
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Momentum from the states' lawsuits also turned the political tide against the tobacco industry in the mids, and their influence in Congress weakened Sack Additionally, the characteristics of legislative debates on tobacco control measures at the state level changed from its prior focus on the sufficiency of scientific evidence of health effects during the s and early s to the impact of tobacco industry activities and marketing on children Jacobsen and Wasserman Evidence compiled by FTC and researchers demonstrated that the RJ Reynolds' Joe Camel marketing campaign had a measurable impact on smokers below the legal age and was accompanied by an increase in smoking initiation among youth DiFranza et al.
During this period, tobacco companies lost credibility in the eyes of the public. Attitudes around the engagement of scientists and physicians with the tobacco industry were also changing during the s. The tobacco industry had long funded researchers through the Council for Tobacco Research and later through the Center for Indoor Air Research Proctor Such funding became increasingly unacceptable, and universities began to implement policies that prohibited receipt of funding from the tobacco industry.
It had also recruited researchers as consultants, who were key in its doubt-creating initiatives. Engagement with the industry became increasingly unacceptable for researchers whose reputations were tarnished by their industry activities. At the same time, concerns about potential conflicts of interest among scientists increased, and disclosure of consulting activities to universities became the norm, making it more difficult for researchers to maintain secret ties to the tobacco industry.
By contrast, when the report was released, there was little concern that scientists' results would be influenced by their funding source. During the s, a number of tobacco control researchers and organizations began to speak out against tobacco industry funding of research at academic institutions. Some academic medical journals instituted policies refusing to accept papers for review if the research had been funded by the tobacco industry.
In , a number of academic medical centers, including Brigham and Women's Hospital, Massachusetts General Hospital, MD Anderson Cancer Center, Roswell Park Cancer Institute, and others, adopted policies barring their faculty and staff from accepting tobacco industry support. The biomedical research community was divided over the issue at the time, as some academic medical leaders objected that restrictions on funding from any particular industry would amount to a restriction on academic freedom.
However, tobacco control advocates countered that the tobacco industry's well-documented record of manipulating scientific information and the extent of the harms from cigarette smoking distinguished them from other industries Proctor Under Commissioner David A. In , almost one-half of U. Today, the overall prevalence of U. Opinions of the tobacco industry have fallen so low that it is now consistently ranked among the most distrusted of industries Harris Poll The industry has been found guilty in the courts as well.
Most notably, in , U. Phillip Morris , p. The tobacco industry is the only legal industry to have been pursued and convicted under federal racketeering statutes. The epidemic of smoking-caused disease in the twentieth century ranks among the greatest public health catastrophes of the century, while the decline of smoking consequent to tobacco control is surely one of public health's greatest successes.
Many premature deaths have been avoided because of tobacco control programs, but many more could have been avoided if smoking prevalence had dropped more rapidly when the early warnings of lung cancer risk were widely reported in The Surgeon General's report gave momentum to tobacco control; the authority of the Surgeon General, and the approach of the Advisory Committee to developing the report, gave unimpeachable credibility to the conclusion that smoking caused lung cancer in men.
That same authority has empowered the conclusions of subsequent reports that have covered involuntary smoking, addiction to nicotine, tobacco control interventions, smoking by adolescents and young adults, and other topics. Tobacco control programs proved more challenging than simply disseminating knowledge to the population of the dangers of smoking. This complexity, the addicting nature of nicotine, and the dynamic efforts of the industry to maintain its market, challenged initial efforts to curb tobacco use.
Over time, the need for broad interventions with multiple components was recognized, and cigarette consumption began to decline at a faster pace Figure 2. Several factors were particularly crucial in altering social norms around cigarette smoking in the United States, making it increasingly less acceptable: Other factors played a role in shaping attitudes and policies around cigarette smoking, including changes in political administrations, the development of a grassroots advocacy movement, the changing climate for litigation, and developments in the organization of public health research.
The production of the Surgeon General's report itself was a significant public health action, even if direct and immediate policy action seemed slow to follow. Additionally, the report was a pioneering step toward anticipating a much larger role for government, in collaboration with scientists, to use science to inform regulatory and other policies.
This approach is embodied in the Tobacco Control Act. Although early twentieth century antitobacco reformers appealed to moral and social concerns to support their cause, the report reinforced the central role of science as the primary authority to inform public health policy. Subsequent reports have maintained that position.
Because of the complexity of the factors involved, it is difficult to measure the degree to which particular interventions, following the report, influenced patterns of tobacco use. However, it is clear that tobacco control policies and actions need to draw on the full suite of interventions of proven efficacy. Grassroots activities and coalitions have played a critical role, as they supported smoking bans and had substantial impact in changing the social norm around smoking.
The past half-century of public health experience with cigarette smoking, since the report, holds many important lessons for the future and for the actions that will follow from this report. Overall, this ongoing story illustrates the complexity of the factors involved and the need to consider cigarette smoking, not simply as an individual decision about behavior, but as a large-scale social and cultural phenomenon.
Despite the conclusive evidence of the harms of cigarette smoking presented in the report, as evaluated by an objective group of experts, the process of changing public beliefs, attitudes, and behaviors took decades, and the implementation of effective policies involved a lengthy process of intervention, evaluation, and surveillance. The tobacco industry's extensive campaign to counteract these forces through marketing, public relations, political influence, and creation of doubt about the scientific evidence on tobacco is now well documented through the industry's internal documents.
The industry used its influence to thwart public health action at all levels and fraudulently misled the public on many issues, including whether lower-yield cigarettes conveyed less risk to health and whether exposure to secondhand smoke harmed nonsmokers. Undoubtedly, these actions slowed progress in tobacco control.
An FCC regulation that required broadcasters to allot time to contrasting points of view on controversial topics. Turn recording back on. National Center for Biotechnology Information , U. Introduction Tobacco, a New World plant, was used by the native peoples of the Americas for millennia. Before the Report To understand the transformative consequences of the report for tobacco control, this chapter begins with a description of the developments in tobacco control before Scientific Judgment and the Report By the late s, the amassing evidence on smoking and lung cancer called for public health action.
Nicotine and Addiction An estimated 30 million people quit smoking in the decade following the report. Denormalization and the Tobacco Industry Beginning in the mids, per capita cigarette consumption began to decline more steeply than during the decade following the report Figure 2. Council for Tobacco Research Collection; Summary of the results of the April survey by the Gallup Organization Survey of Attitudes toward Smoking [news release].
American Lung Association; Sep 20, Facts You Should Know. Americans for Nonsmokers' Rights. Tobacco Industry Sound Bites and Responses. Americans for Nonsmokers' Rights; American Nonsmokers' Rights Association. Smokefree Laws April 5, Public place restrictions on smoking in Canada: Social Science and Medicine.
Notes from Tobacco Institute P. Bayer R, Colgrove J. Science, politics, and ideology in the campaign against environmental tobacco smoke. American Journal of Public Health. PMC ] [ PubMed: The FDA and graphic cigarette-pack warnings—thwarted by the courts. New England Journal of Medicine. Economic interests and the vindication of deviance: The cigarette, risk, and American culture. British American Tobacco Collection. Cigarette smoking behavior among Rhode Island physicians, — Smoking and lung cancer: Journal of the American Medical Association.
American physicians and tobacco use: Bulletin of the History of Medicine. Address by Joseph A. California Department of Health Services. A Model for Change: The California Experience in Tobacco Control. The impact of health news on attitudes and behavior. Centers for Disease Control and Prevention. State tobacco revenues compared with tobacco control appropriations—United States, — Morbidity and Mortality Weekly Report. The Managerial Revolution in American Business.
Harvard University Press; Clean Air Act Extension of Smoking habits of physicians and preventive care practices. Influence of passive smoking and parental phlegm on pneumonia and bronchitis in early childhood. Parental smoking and perinatal mortality. American Journal of Obstetrics and Gynecology. Strengthening the Cigarette Labeling Act. Congressional Record, July 27, Consumer Products Safety Act. Journal of the National Cancer Institute. Council for Tobacco Research. Hockett's Comments, March 5, Letter to Benjamin Sonenberg about filter type cigarettes.
Letter to Leslie Gould about three suggestions. A review of the statistical evidence on the association between smoking and lung cancer. Journal of the American Statistical Association. The Philadelphia area has hosted numerous other defunct basketball teams. Two franchises named the Bullets played in Camden and Cherry Hill in the s and s. The Philadelphia Kings played in the Continental Basketball Association in the league's — season.
The Philadelphia Rage moved from Richmond, Virginia in and played a year and a half in the American Basketball League before the league folded during the season. Philadelphia has been the home of numerous defunct professional soccer teams. The Philadelphia Phillies and other baseball clubs established the American League of Professional Football , the first professional soccer league in the United States. The league only played for one season in Arthur Irwin , the manager of the Phillies baseball team, served as the league president.
Walter Bahr , a Philadelphia native and the captain of the U. The KiXX won the championship in and , but disbanded in Philadelphia has also been home to defunct women's soccer teams. Philadelphia has had two defunct women's teams that played at the top level of the United States soccer pyramid. The Philadelphia Charge played in the Women's United Soccer Association from —, while the Philadelphia Independence played the and seasons in Women's Professional Soccer , reaching and losing in the championship game each year before the league folded in Philadelphia has not yet had a team play in the National Women's Soccer League , which is currently the top women's league in the United States.
The Wings take their name from another NLL franchise that previously played in the area. The Wings will play at the Wells Fargo Center. The original Philadelphia Wings won the NLL title six times, in , , , , , and They were the longest-tenured team in one location in the NLL, but relocated after the season to become the New England Black Wolves. Another lacrosse franchise, the Philadelphia Barrage , played in the Major League Lacrosse from — The team won the league championship in three out of the five years they played in Philadelphia, but the franchise folded after the season.
Philadelphia is home to one of the league's teams, the Philadelphia Fusion. The Overwatch League differs from traditional eSports, with a set of permanent teams and regular season play, compared to the use of promotion and relegation commonly used in other eSports leagues. The Army-Navy football game — an annual college football game between the rival service academies , the United States Military Academy West Point and the United States Naval Academy Annapolis — has been held more often in Philadelphia which is located approximately midway between the two schools than in all other locations put together.
Eleven of the past fifteen Army—Navy Games have been held in Philadelphia. Temple, one of many schools that switched conferences in the early s , joined the American Athletic Conference in The school began playing football in , and has won two consensus national championships. The Penn Quakers first played in , and share a claim to six national championships. Villanova , which began playing football in , won the FCS national championship. Delaware 's football team began playing in ; the school won the FCS championship. Delaware State began playing football in , and the school lays claim to the black college football national championship.
Delaware and Villanova have played each other every year since in the Battle of the Blue , while Delaware and Delaware State have played every year since in the Route 1 Rivalry. Joseph's, Drexel, and most recently La Salle have all discontinued their football programs. Philadelphia also formerly had a bowl game: The bowl game moved to Memphis, Tennessee in Philadelphia enjoys a unique basketball rivalry among the Big 5 , a group of five local Division I universities: The Big 5 teams have played many of their games at the Palestra , Penn's venerable gymnasium.
The Big 5 rivalry is unique because each of the schools has a rich basketball history and each school is located within a fifteen-mile radius of all of the others. Villanova's victory over Georgetown in the championship game is widely considered one of the greatest upsets in NCAA basketball history. Joseph's in , and Jalen Brunson of Villanova in Temple joined the American Athletic Conference in all sports when the original Big East split into two leagues in it had joined Big East football a year earlier.
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Prior to the Big East split, Temple had been a member of the Atlantic 10 , and it still holds the most A Basketball Tournament championships. Drexel joined Division I in and makes up the City 6 in extramurals with the Big 5, and has its own basketball rivalry with Penn, known as the Battle of 33rd Street. The Drexel—Penn rivalry is geographically the closest in NCAA Division I; the two schools' campuses adjoin one another, and their basketball arenas are three blocks apart.
Drexel has never made the Final Four, but did reach the second round of the tournament. Delaware has made five NCAA tournament appearances, reaching the second round in Four Philadelphia schools field Division II teams: Women's basketball is another popular college sport in Philadelphia. Villanova has advanced further than any other area school, making the Elite Eight in The three championship teams were collectively inducted into the Basketball Hall of Fame in Philadelphia has several rugby teams in professional leagues.
The Philadelphia Whitemarsh RFC , a rugby union team, was founded in , the Philadelphia Fight , a semi-professional rugby league football team, was founded in , and the Northeast Philadelphia Irish, a team within the Eastern Pennsylvania Rugby Union , was founded in and has both men and women clubs. Numerous colleges in the area also offer club rugby teams, with most area teams competing as part of the Eastern Pennsylvania Rugby Union.
The Collegiate Rugby Championship has succeeded in drawing media attention, corporate sponsorships and attendance. Rowing has been popular in Philadelphia since the 18th century. Philadelphia hosts numerous local and collegiate rowing clubs and competitions, including the annual Dad Vail Regatta , the largest intercollegiate rowing event in the U. The regattas are hosted and organized by the Schuylkill Navy , an association of area rowing clubs that has produced numerous Olympic rowers.
In addition to basketball, football, and rowing, schools in the Philadelphia area offer other varsity sports. Temple, for example, fields varsity teams in lacrosse , soccer , volleyball , and several other sports. The schools also offer intramural sports. Rugby league is an increasingly popular sport in the Philadelphia area.
Aston, Pennsylvania is considered as the birthplace of rugby league in America. Rugby union is also an increasingly popular sport in the Philadelphia area. The club was founded in Media Rugby Football Club is a Division 1 rugby club that was founded in The team was formed in after the merging of the Philadelphia and Whitemarsh clubs.
The Northeast Philadelphia Rugby team, also known as the Irish, is a division 3 team in Philadelphia that was formed in There are several women's rugby union teams in Philadelphia and the surrounding suburbs.
Cricket has a long history of play in Philadelphia, and Philadelphia was one of the last bastions of cricket in the United States. The Philadelphian cricket team represented Philadelphia in first class cricket from —, and played against some of the top teams in the world. The Philadelphia Cricket Club was founded in Though it was disbanded in , it was revived in Other cricket clubs in Germantown , Merion , Belmont flourished during the late 19th and early 20th century.
Since , the city has been home to the annual Philadelphia International Cricket Festival , held during the first weekend in May, benefiting the Inglis Foundation. Each year, twelve teams, including five from the area and seven from across the United States or guest international sides, are invited to participate in the festival.
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The Philadelphia area has a long history of successful amateur soccer teams. The latter club helped found the United Soccer League of Pennsylvania. The Lighthouse Boys Club is a successful club whose history stretches back to the 19th century. The club is based in Southwest Philadelphia , and was founded in by West African immigrants, mainly from Liberia.
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The club has served as an affiliate of the Union since There are a number of Junior hockey teams in the area. The Flyers sponsor three teams: The Philadelphia Revolution also play in the area. Penn Jersey Roller Derby is a Philadelphia-based co-ed roller derby league, founded in They were one of the founding leagues of the Old School Derby Association. The Professional Inline Hockey Association has had several franchises in Philadelphia and the surrounding area, including the Philadelphia Growl. The Philadelphia Justice are a professional dodgeball team that has played in the National Dodgeball League since Due to a long history of Irish immigration, the Philadelphia area has hosted Gaelic games for over a hundred years.
Philadelphia's Franklin Field hosts the annual Penn Relays , the largest early-season track and field meet in the United States. One of the busiest streets in the city, Broad Street , is closed to traffic for the annual Broad Street Run , a mile race contested since The Philadelphia Marathon , founded in , is an annual marathon held on the third Sunday of November.
The city also hosts the Philadelphia Distance Run. Philadelphia has a rich history in boxing , with the sport having gained popularity in the s. The Blue Horizon was also a popular venue before it closed in Philadelphia has been the home of several prominent boxers. Though born in Beaufort, South Carolina , former world heavyweight champion and Olympic gold medalist Joe Frazier lived in Philadelphia. Frazier owned and managed a Philadelphia boxing gym before his death in Philadelphia native Bernard Hopkins is a former world middleweight and light-heavyweight champion.
Hopkins is perhaps best known for his incredible longevity, as he has remained active in the light heavyweight division well past his 40th birthday. Muhammad Ali and Sonny Liston also lived in Philadelphia during their boxing careers. Philadelphia does not currently host any professional automobile racing , but Philadelphia is in close proximity to Dover International Speedway and Pocono Raceway.
Midget car racing was popular during the s and s; the two major tracks were Yellow Jacket Speedway, which closed in , and National Speedway, which closed during World War II as a result of fuel rationing. Races were sanctioned by the American Automobile Association. Mario Andretti and other members of the Andretti family live in nearby Bethlehem, Pennsylvania. Horse racing became popular in Philadelphia in the mids, [19] and successful horses continue to be bred in the Philadelphia area. Riddle was named the horse of the century by The Blood-Horse magazine.
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Riddle also owned Triple Crown -winning horse War Admiral. The Atlantic City Race Course also hosts horse racing. The Manayunk area of the city is home to the annual Philadelphia International Championship bike race. The main feature of the race is the " Manayunk Wall ", an inclined street including all of Levering Avenue and a few blocks of Lyceum Avenue. The race may have helped promote a local economic revival, and cycling is a prominent theme of many of the shops and restaurants in the area. The women's Liberty Classic is held at the same time and over the same course.
Golf has a long history in Philadelphia; the Golf Association of Philadelphia is the oldest regional golf association in the United States. Merion Golf Club has hosted five U. Opens , most recently in Tennis is also a popular sport in Philadelphia. The Advanta Championships of Philadelphia were held in Philadelphia from —, while the Pennsylvania Lawn Tennis Championship was held in Haverford from —; it was briefly part of the Grand Prix tennis circuit.
Tilden was the first American to win The Championships, Wimbledon and was one of the most prominent sports figures of the first half of the 20th century. Mosconi is considered one of the greatest pool players in the history of the game. Philadelphia bid to host the , , and Summer Olympics but lost to Antwerp , London , Helsinki , and Melbourne respectively. Philadelphia has expressed interest in hosting other Olympic Games , including the Summer Olympics. Numerous notable athletes were born , raised, or attended college in Philadelphia and the Delaware Valley.
Since , many of the most accomplished Philadelphia athletes and sports figures have been inducted into the Philadelphia Sports Hall of Fame. As of , Philadelphia has the fourth largest media market in the United States, with almost three million television homes. It carries most Sixers and Flyers games, along with numerous college sports events. Sister channel The Comcast Network carries games when more than one team is playing at the same time. Philadelphia also has the sports radio station WTEL , as well as numerous other sports radio broadcasts.
The Philadelphia Sports Writers Association presents annual awards. Several films have depicted sports in Philadelphia. Most prominently, the Rocky film franchise follows the boxing career of Rocky Balboa. Broad Street Bullies is a documentary that chronicles the early history of the Philadelphia Flyers.
The film Pride follows swim coach Jim Ellis in s Philadelphia. The Mighty Macs depicts the s Immaculata College women's basketball team. The main character of the film Silver Linings Playbook is an Eagles fan who closely follows the Eagles season throughout the film. From Wikipedia, the free encyclopedia. Philadelphia Phillies and History of the Philadelphia Athletics. Sports in New York City.
List of college athletic programs in Pennsylvania and List of colleges and universities in Philadelphia. Philadelphia Sports Hall of Fame and Category: Sports portal Philadelphia portal. Of the predecessor institutions, only PhilaU had an athletic program. Retrieved June 5, Among those cities with teams in the four major sports not including metropolitan regions , only Philadelphia has reached championship rounds in all four in the new millennium. Philadelphia sports and the curse of the inauguration". Retrieved 7 November Ibanez hits grand slam to help clinch fifth straight NL East title".
Phillies Timeline s ". Retrieved 5 November Retrieved 8 April Look what they started on a ballfield in Philadelphia in ". The Yella Jackets Ruled". Retrieved March 7, Retrieved April 4, The Handy Hockey Answer Book. Retrieved 11 April Retrieved 9 April Retrieved 10 November Daily Record and Sunday Mail. Retrieved June 7, Retrieved 13 November Retrieved 6 November Retrieved 8 November Retrieved 11 November Most frequent playoff matchups".
United fosters a rivalry with expansion Philadelphia Union". A look at the rivalry". The Philly Soccer Page. Retrieved 28 February How the Country Roots for College Football". Retrieved 15 February Archived from the original on Retrieved 5 December Retrieved 9 November Pennsylvania Historical and Museum Commission. Retrieved 19 November Retrieved September 23, Retrieved 22 April Philly won't bid on summer Olympics after all".
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