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Later reports on smoking and health confirmed and extended the findings of the Terry report of 1964. Surgeon General William H. Stewart's three-part report, Health Consequences of Smoking, issued from 1967 to 1969, kept the issue before the public. A 1983 report maintained that cigarette smoking "should be considered the most important of the known modifiable risk factors for coronary heart disease in the United States." In 1988, a report on nicotine addiction brought certainty where the 1964 report had hedged, concluding that cigarette smoking is addicting, that the addiction is caused by nicotine, and that, in pharmacological and behavioral terms, tobacco addiction is equivalent to heroin and cocaine addiction. In regard to the effect of smoking on maternal and infant health, the 1969 report on Health Consequences of Smoking warned that smoking during pregnancy could lead to spontaneous abortion, stillbirth, and neonatal death. Health Consequences of Smoking for Women, published in 1980, declared that toxic substances in cigarette smoke, such as nicotine and hydrogen cyanide, "cross the placenta to affect the fetus directly" and retard fetal growth, resulting in a higher likelihood of Sudden Infant Death Syndrome (SIDS) and of impeded physical and possibly cognitive development. By 1980, lung cancer accounted for nearly as many deaths among women as breast cancer, and would soon account for more. An issue on which the 1964 report was silent, youth smoking, became a major and abiding concern of Surgeon General Julius B. Richmond with his report of 1979. Surgeon General Joycelyn Elders brought that message to the children directly, with SGR 4 Kids: The Surgeon General's Report for Kids about Smoking, prepared in magazine format.
The reports of the Surgeons General helped transform the cigarette from an icon of twentieth-century American individualism to a sign of personal disregard for health. Yet, this shift in the conception of smoking from social norm to social stigma did not end the debate over the health effects or the ethics of smoking. In the United States, smoking was still regarded as a matter of personal choice and private risk, not of communal good or public policy. In a society that has held individuals responsible for the risks they take--including health risks--the right to smoke was championed as part of the prerogative of all Americans to lead their own lives. Since the decision to smoke could only harm oneself, not others, smoking should not be regulated. In the absence of a national health care system, smoking advocates could argue that the cost of smoking was borne by the individual smoker, not the state or society at large, giving government no right to intervene when adults decided to smoke.
Anti-smoking forces, the Surgeon General prominent among them, changed the terms of this debate. Smoking, it was now maintained affected the health of millions of non-smoking Americans, mostly women and children, by exposing them to the dangers of involuntary smoking. While the 1964 report on smoking and health had shown authoritatively that smoking was a serious health threat to the individual, several Surgeon General's reports published in the 1970s and 1980s demonstrated the social cost of passive smoking. Surgeon General Jesse Steinfeld's 1972 report on the health consequences of smoking first raised concern. Reports published in 1979 and 1984, respectively, on smoking and cancer and smoking and chronic obstructive lung disease, went into greater detail on the issue, but stopped short of a definitive statement. However, Surgeon General C. Everett Koop's 1986 report, The Health Consequences of Involuntary Smoking, decisively portrayed second-hand smoke not just as an annoyance, but as a quantifiable health risk. Sustained exposure to second-hand smoke was equivalent to smoking about two cigarettes a day, a very moderate rate of cigarette consumption but one that nevertheless increased the risk of lung cancer and other diseases.
This finding provided an impetus for government regulation. For, even though the number of smokers had declined, the population at risk of exposure to environmental tobacco smoke--a term meant to invoke the specter of pollution--was large. About 70 percent of children in the United States shared a home with at least one smoking adult in the 1980s. The reports of the Surgeon General pointed to a causal connection between passive smoking and lung cancer and respiratory disease in children. Similar findings were posted for adults. According to some of the reports, passive smoking contributed to more than 50,000 deaths per year in the U.S. in the early 1990s.
While Americans consider it an aspect of their individual freedom to assume personal risks, they have little tolerance for risks that others impose upon them. In the wake of the 1986 report on involuntary smoking, Congress in 1987 banned smoking on all domestic flights of two hours or less, extending the ban to all domestic flights two years later. In 1992 the Environmental Protection Agency placed passive smoke on its list of major carcinogens, making it subject to federal workplace and other regulations. Grass-roots anti-smoking groups lobbied for the establishment of designated smoking areas in office buildings, restaurants, and sporting venues, and then for a general ban on smoking in public spaces. By the mid-1990s, more than 500 local communities and 40 states had enacted such measures.
The reports of the Surgeon General have stimulated a debate--one that has taken on an increasing urgency--on the dangers of smoking to non-smokers. In this way, the reports on passive smoking arguably have proven more influential than the original reports on the health risks of active smoking.