U.S. Public Health Service and Deputy Assistant Secretary for Health
U.S. Department of Health and Human Services
Presented at the Annual Convention of the Society of Behavioral Medicine
March 20, 1987
This conference had as its focus two of the most important concepts in public health today: Prevention and Cost containment.
The chair-person of the meeting, Dr. David Abrams, suggested that I speak on smoking, a behavior that was responsible at that
time for some $65 billion in direct health care costs and lost productivity each year.
Behavior is clearly the key to smoking prevention and cessation . . . and the prevention of smoking, quite frankly, is the
key to lower morbidity and morality rates across the spectrum of disease conditions. Hence, the prevention of smoking behavior
is one of society's most effective ways to reduce the cost of health care.
The assignment of smoking belonged to my office, but after being immersed in the data for a few years and watching how the
cigarette industry works I am keeping the assignment by choice. In addition to my own annual report on smoking to Congress,
I did announce the goal in 1984 of making United States a "Smoke-free Society by the Year 2000."
Smoking is a preventable burden of smoking related illness and death. Smoking is a personal choice. The scientific record
is clear on the relationship between cigarette smoking and about two-dozen serious disease conditions, most of them with high
I reviewed, very briefly, thirty years of biomedical research that had generated more than 50,000 studies on smoking and health
from more than 80 countries. With 2,000 more such reports being added each year. I cited a number that were in the area of
behavior and then went on to some of the descriptions of specific disease processes attributed to smoking.
I reviewed some of the Surgeon General's reports in aggregate and reported that the conclusion of each was unequivocal:
Smoking is a major contribution to the incidence of significance fatal disease in the population.
This talk was given shortly after Congress passed the law, which President Reagan signed, which in sum meant that the manufacturers
of cigarettes must issue new and stronger warnings on their packages and in all their advertising.
Let me digress here and tell a very interesting story about the tobacco industry. All this happened on my watch and as soon
as the cigarette industry learned that the Public Health Service was pushing Congress to enact legislature for new labels
to replace the old hackneyed one: "The Surgeon General has determined that smoking is detrimental to your health".
We were notified in many ways that they would fight us to the death on adding new warnings. Then suddenly, they made it clear
through these same channels that if we would drop one of the five warnings we had in mind, they would give us no trouble on
the other four. The one they wanted us to drop was: "Tobacco contains nicotine, which is an addictive drug." In those
days, when "habit forming" was a word people used instead of "addiction", the very use of the word addiction
in reference to smoking was an anathema to the whole cigarette industry. So much so that they were willing to take four other
labels, if we would get rid of the one they hated most. That was the kind of political compromise that people have to make
occasionally in government.
We essentially got what we wanted, and I had my crack at addiction in 1988 when my Report to Congress on Smoking and Health
was on that subject. It indeed did turn the table on the smoke industry.
The new warnings were not fancy. One spoke about smoking causing lung cancer, heart disease, emphysema, and complications
in pregnancy. Another warned that pregnant women who smoke risk fetal injury and premature birth. A third said that cigarette
smoke contains carbon monoxide. And the fourth said, "Quitting smoking now greatly reduces serious health risks"
Putting this all together the case of "The People versus Tobacco" is open and shut.
I then turned from main-stream smoke to side-stream smoke and pointed out on pages 13 through 16 of this lecture the price
that people pay for inhaling second-hand smoke. Perhaps the most surprising thing to audiences is that some of the toxic agents
found in main-stream smoke are found in greater concentrations in side-stream smoke. For example, the most carcinogenic agent
is 70 per cent more concentrated in side-stream smoke, carbon monoxide two and a half times greater in side-stream smoke,
nicotine 2.7 times greater, and ammonia 73 times greater.
I then went into other co-risk factors along with tobacco smoke that folks encounter every day on the jobs or other places
they frequent. And I finally, turned my attention to occupations that were relatively new and workplace hazards that were
still not well understood, citing especially the computer industry, the semiconductor industry, radio and television equipment
industry for starters. I ended with a plea to establish smoking cessation programs across the spectrum of American employment,
to work with management and with state and local governments to negotiate ordinances and agreements necessary to encourage
smokers to quit and protect non-smokers from the effects of side-stream smoke.
I closed expressing concern about the economics of smoking, the advertising attention that smoking gets, and that women are
such a target to advertisers. I took to task the editors and publishers of major women's magazines that carried lavish,
full-color cigarette ads, but decline to run life-saving, anti-cigarette articles that could save the lives of their readers.
Of course, I had to mention the barrage of advertising and promotion directed at young people and minorities, with specific
attention paid to the Black and Hispanic communities.
When I finally said that I didn't think that tobacco was a growth industry, people in the audience actually guffawed.
As I write this introductory page, the headlines in the papers are wondering about the solvency of Philip Morris and whether
or not they might face bankruptcy. Hurray!