Tobacco, Second-Hand Smoke, and the Campaign for a Smoke-Free America

The first person C. Everett Koop persuaded to stop smoking was his own father. John Everett Koop smoked three packs of cigarettes a day, developing a chronic cough that alarmed his wife. She shared her concerns with her son during one of his visits home from college. Koop agreed with her, but doubted that his father could muster the determination to quit. Overhearing his son's remark, John Koop walked quietly to an upstairs bathroom and flushed his cigarettes, never to smoke again.

No federal official before or since U.S. Surgeon General Koop has waged a more determined campaign against smoking, the leading cause of preventable death and disability in the United States. As a pediatric surgeon Koop had been dismayed to see the air at medical meetings filled with tobacco smoke, a common sight as late as the mid-1970s. Yet, he did not enter the office of the Surgeon General as an anti-smoking crusader; he had smoked an occasional pipe himself until he gave up the habit in the early 1970s. However, once he began to study smoking as a public health issue in preparation for releasing the congressionally-mandated annual Surgeon General's report on smoking and health, Koop became appalled by the deceptive advertising and aggressive lobbying of the tobacco industry. He devoted himself to the goal of alerting both smokers and non-smokers to the dangers of smoking--devoted, in fact, more time to the issue than to any other over the course of his eight years as Surgeon General. In 1981, the year of his confirmation, smoking took the lives of nearly 400,000 Americans, more than all deaths from alcohol, drug abuse, and automobile accidents combined. Koop's tireless warnings about the health risks of smoking helped reduce the number of smokers among Americans from 33 percent of the population in 1981 to 26 percent in 1989, even though the incidence of illness and death from smoking among women continued to rise.

Koop's first official act after his confirmation was to issue the 1982 Surgeon General's Report on Smoking and Health, the most authoritative statement to date on the connection between smoking and cancer of the lung, oral cavity, larynx, esophagus, stomach, bladder, pancreas, and kidneys. Thirty percent of all cancer deaths were attributable to smoking, the report stated. Reports issued by Koop in 1983, 1984, 1985, and 1988, respectively, showed that smoking caused even more deaths from heart disease than from cancer; that smoking was the major cause of illness and death from chronic obstructive lung disease in the United States; that smoking presented an even greater health hazard than exposure to workplace pollutants such as asbestos and coal dust, while at the same time increasing the lethality of such exposure; and that nicotine was an addictive substance. All of these findings were publicly contested by the tobacco industry.

Even though he was confirmed with the support of legislators from tobacco-producing states, most notably Jesse Helms, U.S. Senator from North Carolina, Koop was prepared to stand up to the powerful tobacco industry and its allies in Congress and in the administration of President Ronald Reagan. Koop castigated the tobacco industry for spending $4,000 on advertising for every dollar the U.S. Public Health Service spent on broadcasting anti-smoking messages. In 1982, he testified before Congress in favor of a series of rotating labels warning against the specific dangers of smoking (heart disease, cancer, emphysema, the risk to unborn children of pregnant women who smoke) in place of the current single generic label, "Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health." He continued to advocate rotating warning labels even after the Reagan White House withdrew its support under pressure from the tobacco industry. In 1986, he succeeded in having the Surgeon General's health warning placed on packages of smokeless tobacco--chewing and snuff tobacco--a product the tobacco industry suggested was a less harmful alternative to cigarettes. However, he failed to convince the Secretary of Defense to abolish discounts on cigarettes for sale to military personnel in commissaries, one of the major reasons for the dramatic increase in smoking after World War II.

The extensive coverage that the media gave the 1982 report demonstrated to Koop that moral suasion and publicity were effective ways to promote health causes in the absence of regulatory authority, which his office did not carry. He drew on the power of moral suasion again in 1984, when he launched what he called the Campaign for a Smoke-Free America by the year 2000 in pursuit of his goal to eliminate smoking in the United States altogether. Koop chose as the occasion the twentieth anniversary of U.S. Surgeon General Luther L. Terry's Report on Smoking and Health, issued on January 11, 1964. Terry's landmark study warned an unsuspecting nation that men who smoked had a higher mortality rate from coronary heart disease, chronic lung disease, and cancer than men who did not smoke. His report changed Americans' attitude towards what they had regarded as a sophisticated, glamorous recreational activity, and prompted Congress in 1965 to require health warning labels on cigarette packages and, in 1970, to outlaw tobacco advertising on television.

Koop commemorated Terry's report by launching a drive to enlist Americans in the fight against smoking. He laid out the goal of his Campaign for a Smoke-Free Society by the Year 2000, or SFS-2000, in a speech at the meeting of the American Lung Association in Miami in May of 1984, a speech Koop had discussed with only a handful of advisers for fear that it would be opposed by his superiors. Koop called on smokers to give up smoking voluntarily to preserve their health, and on non-smokers to insist on their right to be free from the nuisance and health threat of second-hand tobacco smoke. Smokers, he urged, should respect that right, and should not feel entitled to light up in the presence of non-smokers without first asking for their permission. If children were taught about the health risks of smoking and about their rights as non-smokers during every grade, Koop predicted, the United States could stamp out smoking by 2000, the graduation year of the first class of students who had received anti-smoking messages throughout their school career.

Over the next four years, Koop carried his SFS-2000 campaign to countless audiences across the country, in spite of resistance from such stalwarts of the tobacco industry as Senator Helms, who in 1988 called for an official investigation of the Surgeon General. Koop bolstered his campaign by issuing a report in 1986, entitled The Health Consequences of Involuntary Smoking, that portrayed second-hand smoke not simply as an annoyance but as a quantifiable health risk to non-smokers, especially children. By becoming the first public health official to stress that not just the smoker but also the bystander suffered health consequences from tobacco smoke, Koop helped to turn non-smokers into what he proudly called a "militant army" insistent on its right to breathe smoke-free air. He thus provided the American anti-smoking movement, the most successful anti-smoking movement in the world, with a broader scientific base and a renewed moral impetus that have since enabled it to secure a legal ban on smoking in federal buildings and on public conveyances nationwide as well as in offices, restaurants, and other work sites in a growing number of states.