Abstract
Tobacco use behaviors have changed significantly over the past century. After a steep increase in cigarette use rates over the first half of the 20th century, adult smoking prevalence rates started declining from their peak reached in 1964. Improved understanding of the health risks of smoking has been aided by the United States Surgeon General’s Reports, issued on a nearly annual basis starting in 1964. Among the many forces driving down smoking prevalence were the recognition of tobacco use as an addiction and cause of cancer, along with concerns about the ill-effects of breathing secondhand smoke. These factors contributed to the declining social acceptance of smoking, especially with the advent of legal restrictions on smoking in public spaces, mass media counter- marketing campaigns, and higher taxes on cigarettes. This paper reviews some of the forces that have helped change the public image of smoking, focusing on the 50 years since the 1964 Surgeon General’s report on smoking and health.
The United States over the past century has seen a dramatic shift in attitudes toward tobacco, which in turn has influenced the rise and fall of cigarette consumption and smoking related cancer deaths (1–4). This paper reviews some of the various forces that have helped change the public image of smoking, with a particular focus on the 50 years since the 1964 Surgeon General’s report on smoking and health.
Tobacco use and marketing before 1964
Cigarette smoking grew rapidly in America in the early part of the twentieth century, following the invention of automatic cigarette rolling machines and the rise of advertising and promotion on an unprecedented scale (4). Cigarette use grew despite opposition from temperance advocates and religious leaders concerned that smoking would lead to alcohol abuse and narcotic drugs, especially among youth (1, 4). During the first half of the century, however, neither the public nor most physicians recognized a significant health threat from smoking, even though the rise of lung cancer prompted epidemiological research beginning as early as the 1920s (1, 4). With the end of Prohibition (in 1933) and the decline of the temperance movement, advertising in the 1930s and 1940s was defined by campaigns which often included explicit health claims, such as “They don’t get your wind” (Camel, 1935), “gentle on my throat” (Lucky Strike, 1937), “play safe with your throat” (Phillip Morris, 1941), and “Fresh as mountain air” (Old Gold, 1946) (4, 5). Smokers of Camels were even encouraged to smoke a cigarette between every course of a Thanksgiving meal--as an “aid to digestion.” Except for a brief period around the Great Depression, per capita cigarette consumption increased steadily until 1953 (1, 4, 5), by which time 47% of American adults were smoking cigarettes (58% of males and 36% of females), and half of all physicians (6).
In the early 1950s evidence implicating smoking as a cause of lung cancer began to appear more frequently in medical journals and the popular press (1, 4). Cigarette sales declined in 1953 and the first part of 1954, but quickly rebounded as manufacturers rushed to introduce and market “filtered” cigarettes to allay health concerns. The emergence of the filter tip cigarette was a direct response to the publicity given to evidence linking smoking and cancer, and consumers reacted by shifting over to the new designs (4, 7). In 1952 filtered cigarettes accounted for less than 2% of sales; by 1957 this had grown to 40% and would surpass 60 % by 1966 (7, 8). The advertised benefits of filters were illusory, however, given that smokers of filtered brands often inhaled as much or more tar, nicotine, and noxious gases as smokers of unfiltered cigarettes (9–11). Filters were not really even filters in any meaningful sense, since there was no such thing as “clean smoke.” The industry had recognized this as early as the 1930s, but smokers were led to believe they were safer (4).
By 1957 the evidence implicating smoking as a causative factor in lung cancer had been established to a high degree of scientific certainty, leading to the first official statement from the US Public Health Service implicating smoking as a cause of lung cancer (12, 13). The tobacco industry also took notice of the emerging evidence, but instead of acknowledging what they knew to be true, hired a public relations firm (in December 1953) to implement a massive campaign to challenge the evidence (1, 4, 14). Medical doctors and academic scholars were hired to defend the industry’s claim that the evidence was “merely statistical” or based only on “animal evidence” (1, 4, 14). The public relations campaign -- which would extend for over 40 years -- was designed with the goal of reassuring the public, especially current smokers, that the question of whether smoking caused harm was an “open controversy” (1, 4, 14).
Tobacco use and marketing after 1964
The 1964 report of the Surgeon General’s Advisory Committee marks the beginning of a significant shift in public attitudes about smoking (1, 2, 4). Declining adult per capita cigarette consumption after 1964 followed increasing public appreciation of the dangers of tobacco use, accompanied by increasing efforts to regulate the use, sale, and advertising of tobacco products (15, 16). In the U.S. in 1965 approximately 42% of adults were current smokers (52% of men and 34% of women) (17). By contrast, in 2011 less than 20% of adults were current smokers, with significant variations from state to state (18). Also, a major defining characteristic of smoking prevalence today is socio-economic status with higher smoking rates found among the poor and less educated and also among individuals with mental health and substance abuse diagnoses (19). Adult per capita consumption has declined by about 70% since 1963, the year before the Surgeon General’s report (20). Total per capita consumption continued to rise until 1975, however, due in part to a significant increase in youth smoking (20).
Since 1964 there has also been a dramatic shift in the public’s knowledge and attitudes about smoking (2). In the mid-1960s it was still common to see doctors, athletes, and radio, movie and TV celebrities smoking or advertising different cigarette brands, and cigarette companies were major sponsors of popular shows on all three television networks (21). The Federal Trade Commission (FTC) in 1967 commented on how it was “impossible for Americans of almost any age to avoid cigarette advertising” (8), which is hardly surprising given the levels of money involved. In 2010, the US Surgeon General reported that from 1940 into 2005, an estimated $250 billion was spent in the U.S. on cigarette advertising (adjusted for inflation, in 2006 dollars) (22).
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