To commemorate the 60th anniversary of the Surgeon General’s Report, Alan Blum, professor and Gerald Leon Wallace, MD, Endowed Chair in Family Medicine at the University of Alabama, as well as the director of the Center for the Study of Tobacco and Society, will serve as a guest editor for the Cancer History Project this January. Blum is conducting a series of interviews with people who have been involved in the fight against tobacco since the report was published, and publishing a new online exhibit on the Center for the Study of Tobacco and Society website identifying the lost legacy of the Surgeon General’s Report on Smoking and Health. Blum will be giving a presentation to commemorate the report at the University of Alabama Jan. 11, 12:15-1:15 p.m. CT. Guests can also attend virtually via Zoom. Donald Shopland, an original member of the staff of the Advisory Committee to the Surgeon General upon its formation in 1962, will be giving a presentation on the Surgeon General’s Report Jan. 11, 5:30-7:00 p.m. CT. The presentation will be accessible via Zoom.
In 1964, the Office of the Surgeon General issued a report on smoking and health that ended a debate that had raged for decades—stating that cigarettes cause lung cancer and other diseases.
Sixty years later, Alan Blum, professor and Gerald Leon Wallace, MD, Endowed Chair in Family Medicine at the University of Alabama, as well as the director of the Center for the Study of Tobacco and Society, warns against celebrating the anniversary of the report.
“I should be clear that I would prefer to call this a commemoration,” Blum said in an interview with Donald S. Shopland, an original member of the staff of the Advisory Committee to the Surgeon General upon its formation in 1962. “A celebration would suggest everything is happy, because I think this is a more nuanced subject.”
This interview is available as a podcast through the Cancer History Project.
Since 1962, Shopland has served as an editor of 17 reports of the surgeon general on smoking and health, as interim director of the Office on Smoking and Health for two years in the 1980s, and as an advisor on smoking and health at NCI. He retired in 2014.
The process for choosing ten members who served on the Surgeon General’s Advisory Committee on Smoking and Health—who ultimately wrote and published the report—was quite complicated, Shopland said.
The Public Health Service, Federal Trade Commission, FDA, voluntaries, the American Medical Association—and two representatives from the tobacco industry—drew up the original criteria for the study.
“They said that they did not want anybody who really knew anything about the issue, or what they called taking a stand on the issue, which pretty much eliminated anybody who had done any work, any type of research on the [smoking and health,], because obviously that would’ve meant they had to take a stand,” Shopland said. “They also could not be part of any particular organization—this was the other criterion, nor could they have made any kind of a public statement either for or against smoking in health.”
The groups put together a list of 150 individuals, from which they selected 10 members to serve on the committee. Many of the final 10 committee members were cigarette smokers, he said.
“They weren’t familiar with the data, they weren’t experts, and here they had, sort of dumped in their lap, 7,000 studies that they now got to sift through,” he said. “And these guys didn’t know what to do with it. They actually spent the first two meetings trying to figure out what they were going to do.”
Members of the committee came in with a certain amount of bias, Shopland said.
“Like anybody else that was around at that time, if you were a smoker, you didn’t want to believe this stuff,” he said. “And they weren’t any different than the general public was, but it took them a good two months, or two committee meetings, before they actually got deep enough into some of the discussions about some of the data before they themselves decided that if they were going to answer this question, they were going to have to go a lot deeper than what the Public Health Services expected them to do, and come up with something a lot more detailed than something like the Royal College of Physicians.”
The committee’s goal was to issue a report that would end the controversy as to whether smoking was a health risk, Shopland said.
By this time, many studies had already demonstrated evidence that smoking was harmful, Shopland and Blum said. In fact, there was a long history of it.
In 1804, Benjamin Waterhouse gave a lecture to students at Harvard about the injurious effects of smoking.
“He was talking about cigar smoking and he was talking about stomach problems, but I think at least he was on the right track, but it took another 150 years or more for this committee to be established,” Blum said.
In 1900, early reports on the increase of lung cancer were reported, Blum said.
In 1928, a study by Herbert Lombard and Carl R. Doering—published in the New England Journal of Medicine—pointed to an association between smoking and lung cancer.
In 1941, Alton Ochsner and Michael DeBakey reported several hundred case studies of lung cancer and smoking.
More research was done too.
In 1950, Richard Doll and Austin Bradford Hill published their findings, which stated that smoking was an important cause of lung cancer. Other groups worked to study the association between smoking and cancer.
Ernst Wynder and Evarts Graham studied the incidence of lung cancer in physicians. American Cancer Society scientists, E. Cuyler Hammond and Daniel Horn conducted a cohort study in 1952, recruiting approximately 188,000 American men ages 50-69, across 10 states.
After following the group for approximately 20 months, Hammond and Horn found that men with a history of regular cigarette smoking had a considerably higher death rate than those who had never smoked or who only smoked cigars or pipes.
The study also pointed to lung cancer and other diseases in men who smoked.
Still, organizations such as the American Medical Association would not weigh in on the subject.
“For 15 years, from 1964 to 1979, the AMA was virtually silent on this issue because they were taking, what it turned out to be, $18 million from the tobacco industry to do more research,” Blum said.
Tobacco industry groups argued that more research was needed before anyone could weigh in on the controversy.
“It led up to the industry reacting to every one of these studies by saying, we need more research.’” Blum said. “To the point where the medical community, two thirds of whom smoked, including my father, were just not buying into this association.”
The Surgeon General’s Report on smoking and health was no small task. The fate of public opinion on smoking depended on it.
While the committee evaluated some 7,000 studies that existed on smoking and health at the time—there was one small hangup: The cancer chapter.
“Of all things,” Shopland said.
Walter J. Burdette, a well-known thoracic surgeon and geneticist, was in charge of writing the chapter about cancer.
“A lot of the cancer chapter, as he was approaching it, unfortunately, put too much emphasis on genetic and constitutional factors as they related to cancer etiology, particularly lung cancer etiology,” Shopland said.
As the report’s deadline neared in the late summer of 1963, the cancer chapter was in disarray, Shopland said.
Leonard M. Schuman, an epidemiologist at the University of Minnesota and another member of the committee, took 30 days off from work to re-work the chapter, “emphasizing the epidemiology of lung cancer as it related to cigarette smoking.”
The report was released Jan. 11, 1964. Still, it stopped short of claiming that cigarette smoking was addictive.
One committee member, Maurice Seevers, who studied habit-forming drugs, followed World Health Organization criteria when it came to the question of addiction and smoking.
“[WHO] held at that time that it was not addictive, but it was habitual,” Shopland said. “That’s what he fell back on. That’s what he said the committee had to go to. That was the only criteria that they had at that time, was to use the WHO criteria. And they held that it was habituating and not addictive”
Sixty years later, Shopland said the report was the start of a series of Surgeon General’s Reports on smoking and health that have led to positive change.
“The real impact of those reports has been what I would call the constant drumbeat of more and more pronouncements that eventually, I think, more than anything else, undermine the behavior,” he said. “It undermined the social acceptability of smoking. And I think that particularly was true once we started documenting that it had an effect on the non-smoker.”
As of 2021,11.5% of U.S. adults (an estimated 28.3 million people) smoked cigarettes: 13.1% of men and 10.1% of women, according to CDC.
“But I’ll give the other side of that any day,” Blum said. “And that is, first of all, it took 60 years to do it.”
Subsquent Surgeon General’s Reports—those related to passive smoking, smoking addiction, and smoking in women, led to more significant change, he said.
“The passive smoking report led to a ban on smoking on airlines—the first federal effort on clean indoor air that I’m aware of,” Blum said. “There was not much federal legislation passed as a result of the Surgeon General’s Report.”
Transcript
Alan Blum: I have the honor today to be interviewing Don Shopland, someone whom I’ve known for really quite a few decades, and who I admire greatly. He’s a former 40-year employee of the Public Health Service, and the only one in the world who has worked on 37, I think it is, Reports of the Surgeon in the United States on Smoking and Health, and is the only one who can now say that he was there when the initial report was produced because he was on the staff—and the youngest member of that staff.
Welcome, Don. And your origins are in Maryland, is that correct?
Don Shopland: Yep. Grew up in Maryland.
And you were a student and an intern at the National Library of Medicine in 1962. And you had an interesting circumstance. And before you answer that question, I wanted to say that Cancer History Project associate editor Alexandria Carolan asked me to do this interview to share with our audience the origins of one of the landmark documents of the 20th century, Smoking and Health: Report of the Advisory Committee to the Surgeon General of the United States Public Health Service. And we’ll establish that, talk about the origins of the report, talk about its immediate impact, and then what it means today. And I should be clear that I would prefer to call this a commemoration. A celebration would suggest everything is happy, because I think this is a more nuanced subject. Let’s just leave it right now to commemorate an anniversary and hear some of the behind the scenes stories that Don Shopland can share with us.
DS: Well, of course I sort of fell into the work with the advisory committee, as you said. I just started working for the National Library of Medicine as an entry level library technician in September of 1962, which was right about the time I think that [Dr. Luther] Terry had announced the formation of the committee.
DS: Correct, Dr. Luther Terry.
DS: And so I was just out of high school and had just started working as a GS [General Schedule]-3, believe it or not. I think I made all of $55 a week or something like that.
The library had just opened up. They had been in a downtown area for a number of years and moved out to this huge, beautiful new facility on the NIH campus. And, of course, that’s where the advisory committee staff was located, and it’s where the advisory committee actually held almost all of its meetings except for the first one or two introductory meetings.
And initially I worked in the evenings and overtime when they needed someone to help pull a reader request for the advisory committee, photocopy requests as they were starting to sift through the data. And then it wasn’t until the summer of 1963 that I was assigned full-time to work for the committee.
And I didn’t find out until later that it actually was done at the request of Dr. Terry himself, which I didn’t know at the time. And so from August of ‘63 until the end of the project, I worked full-time on the committee as part of the staff.
DS: Her name was Mildred Bull. She was a very interesting person. I think she was probably 5’10 or 5’11. And she was a very important person to the project itself because a lot of people don’t know the story, but Peter Hamill, who was the medical coordinator and was the chief architect of the committee and the report, got sick right in the middle of the project and had to leave suddenly on the advice of his doctor.
They asked Dr. Eugene Guthrie to come in and take over. And Mildred was the person there who knew what was going on when Dr. Guthrie came in because there was no transition between Dr. Guthrie and Dr. Hamill.
DS: Well, she was a very smart lady. Peter Hamill almost resigned trying to get her a promotion in the middle of everything because she was only hired as his secretary initially. But she ended up almost being staff director for the project because she was just so darn good at what she did. And, he finally got her promotion. But Mildred was the glue that held that project together.
DS: Yeah, I wished I could say that I had this grand design as to what I wanted to be, but at the time that I joined the library, I had two job offers. I just graduated high school in that spring and I had two job offers. One was with the National Library of Medicine, and the other was with the NSA in Laurel, MD, which was a much longer drive, so I opted just to take the library job because it was closer and that was the only planning that went into it.
We’ll now join you with the committee and let’s take it back—really as far back as how we even had to have a committee to decide whether smoking was dangerous to health.
So we go back now, how far would you like to go back—to 1900, when the early reports on the increase of lung cancer were beginning to be reported? Or would you like to go to 1930, when we were beginning to see the early epidemiology coming out of Germany and the United States, one published in the New England Journal in 1928 by Lombard and Doering pointing to this association between smoking and lung cancer? Or would you like to go more toward the 1940s when DeBakey and Ochsner had reported their several hundred case studies of lung cancer and smoking?
DS: Well, you can start with almost any of those and you could make a case for the fact that they were the early studies that jump-started things. But I think if you look back and look at the events that really precipitated the movement in terms of trying to get the Public Health Service to look at this issue, you probably would have to start in the 1950s.
That was when the first case control studies were published, very early in the 1950s. And it was those studies that also got some publicity, if you know about some of the articles that were published by the Consumer’s Union and by the Reader’s Digest. Those were the things that started getting a lot more publicity for the issue itself. And then of course you had Dr. Leroy Burney, who asked the Public Health Service to establish a study group in, I think it was 1956, to take a look at the available evidence, which they did.
I think that study group was composed of six individuals, five of them were from the outside of the Public Health Service. And there was one investigator from the NCI who was in that study group. And they looked at 16 different studies and, as you know, concluded that they felt that there was a direct relationship between cigarette smoking and lung cancer.
And then Dr. Burney himself issued a statement from that study that said the Public Health Service was on record of saying that cigarette smoking was one of the major factors in lung cancer—although I think he characterized it at the time, he said that excess cigarette smoking was a factor in lung cancer—and I’ve never understood where the “excess” or “excessive cigarette smoking” adjective came from because the study group didn’t say that.
I recall wondering that myself when I first heard him on film saying that. I want to step back one more time just to put smoking in its context. I don’t think many people realize that, if you stop and think about it, tobacco has been used for thousands of years.
We know that from archeological evidence of pipes. They were found in the Arctic or in the tropics. We think that tobacco was first cultivated in the Caribbean because there’s an island called Tobago, and there’s lots of indications that that’s where it began.
But through trade routes, tobacco, and presumably smoking, was all over the world. We don’t have the organic remnants of course, but we do have the pipes and other ceremonial objects that we believe were used. But something changed really in the late 19th century, certainly by the 20th century.
And that was this thing called lung cancer. And the earliest reports on the dangers of smoking were as far as I’ve been able to trace, not just King James I, the first who called the custom “loathsome to the spirit” or whatever, and he issued a “counterblast” against tobacco when Sir Walter Raleigh and others brought it over from America to England.
But really around 1804 when Dr. Benjamin Waterhouse gave his lecture to the students at Harvard about the injurious effects of smoking and the vinous spirits [alcohol]. He was talking about cigar smoking and he was talking about stomach problems, but I think at least he was on the right track, but it took another 150 years or more for this committee to be established.
And why? Because we were certainly arguing over the instance of lung cancer and smoking. And I just want to read from your and my subject today, it’s the remarkable Report on Smoking and Health of the Advisory Committee.
And in the very second paragraph of the foreword, Dr. Terry, who was the Surgeon General wrote: “Few medical questions have stirred such public interest or created more scientific debate than the tobacco health controversy. The interrelationships of smoking and health undoubtedly are complex. The subject does not lend itself to easy answers. Nevertheless, it has been increasingly apparent that answers must be found.”
So that was his charge. And we go back a bit in time. You’ve mentioned the reports of the epidemiologists. The ones that I’m familiar with were by Richard Doll and Austin Bradford Hill in 1950 in the British Medical Journal..
And then we had in this country, Ernst Wynder and Evarts Graham. Wynder was one of Graham’s students. Among the groups that they looked at were actually physicians and their incidence of lung cancer. And then we had Hammond and Horn working, I believe, for the American Cancer Society first and then ultimately with the Public Health Service. Is that correct? Those were the major epidemiologic groups.
DS: I think there were four studies that were published in 1950 itself.
DS: These were all what they called retrospective.
DS: I think they were all four case control studies. Right. And of course, those were the ones that got a little bit of the first publicity. But then if you remember that in addition to Hammond-Horn, and then you had the British doctor study, which was also one of the first, what we call the prospective cohort studies.
And then in this country, I think the first one that actually started before Hammond and Horn is the U.S. Veterans Study. The person that was head of that was Harold Dorn.
And I think their study preceded Hammond and Horn, or it could have been maybe Hammond and Horn as a few months before theirs. They were both initiated at the same time, but they were, at the time, two of the very largest prospective studies on anything, let alone on cigarette smoking.
And of course, both of them showed that, along with the British doctor study, that lung cancer among smokers was about 10- to 15-fold higher than among comparable non-smokers.
And those studies, when the results of those came out, they did generate a lot of publicity that got into the regular national press.
DS: And the veteran study was really important. I said it was one of the really largest studies around at the time until Hammond did his one million person study at the end of the decade.
Just to dot a couple of “i”’s—Raymond Pearl at Johns Hopkins in the 1930s was looking epidemiologically at smoking and found what he believed was conclusive results of the causation.
Well, certainly the association between cigarette smoking and lung cancer. And it was George Seldes, who is considered the greatest journalist of the 20th century, who almost single-handedly got this out into the public because the traditional media, the major newspapers of the day, and the radio stations, were all beholden to cigarette advertisers and they were not about to bite the hand that fed them.
DS: Well, and if I’m not mistaken, I think the Pearl study was one of the first ones that actually showed that there was an effect on overall mortality, not just lung cancer—but I think the Pearl study looked at overall mortality.
I guess the other thing about this while we’re doing this kind of warm up to getting into the report is that it didn’t come out of the blue. There had been discussions and debates over the decades.
I mean, I don’t know when the term “cancer sticks” was coined, but we were talking about smoking and cancer even before Dr. Alton Ochsner became the most outspoken critic of smoking in the late 1930s.
Just briefly, I had the privilege of meeting Dr. Ochsner and giving grand rounds at his hospital. And at 84, he never took an elevator. We climbed up and down the stairs all day long. He was a student at Washington University in St. Louis in 1919 when his pathology professor, George Dock, called him down to the morgue, said, “Take a look at this case. It’s called lung cancer. I don’t think you’re ever going to see another case like it.”
And he found himself 15 years later as a thoracic surgeon pulling out lungs almost every week of patients with lung cancer. And he made the deduction that most of these individuals were veterans of World War I, who had started smoking in World War I, thanks largely to free cigarettes given by the Red Cross, medical societies, and ladies auxiliaries.
And again, most were men who had started in World War I. And there was a lag time of 15 years, and he was the one who drew this deduction. He and DeBakey published an article about their first 400 cases of lung cancer by 1939.
But really, it led up to the industry reacting to every one of these studies by saying, we need more research. And you’re not telling the whole story and on and on, to the point where the medical community, two thirds of whom smoked, including my father, were just not buying into this association.
We had then, as you mentioned, Dr. Burney, the Surgeon General. We might want to define what the Surgeon General’s office is, and what your understanding was at the time that you began working for Dr. Terry.
DS: Well, at the time that I joined the Public Health Service, the Surgeon General was essentially the head of the entire Public Health Service. They were over all the different institutes of NIH. They were over CDC, they were over the FDA, and the Office of the Surgeon General was the management arm of the Public Health Service in terms of managing and administrating the entire health component of PHS.
A very big deal, which was probably why Dr. Terry, who was the Surgeon General under whom you worked, deferred very, very favorably to Dr. Burney.
In his own article that he wrote when I was editor of the New York State Journal of Medicine, he wrote what he called the behind the scenes account of this. And he credited Dr. Burney for the statement that Dr. Burney had issued in 1957 and the formation of that committee.
DS: Well, as you know, Dr. Burney issued a much lengthier statement in JAMA in November of 1959 in which he reviewed additional data from a newer study that had come out since the study group was formed.
And it was a very lengthy article. And the thing about that article is that he no sooner issued that article than the editor in chief of JAMA castigated Burney over taking such a strong stand, and essentially told Burney that he had better things to do than to attack cigarette smoking. And he did that in a published editorial.
Both of these articles are going to be in our exhibition about the Surgeon General’s Report. We’re updating what I did 10 years ago when you were one of our main speakers at the 50th commemoration here at the University of Alabama at Gorgas Library.
Dr. Burney himself wrote that the disappointment that he had by the AMA not taking a position in the 1950s on smoking was compounded by that highly critical editorial, by the editor of JAMA, John Talbott.
By the way, just an aside, I met Dr. Talbott in Miami when I was a resident. I had lunch with him because I wanted to meet all the other editors at JAMA. He was a rheumatologist by training. So I don’t know how he could weigh in on smoking, but he did. And one never questions the freedom of an editor, Dr. Burney wrote, to express his views.
But in the absence of any official AMA position on the hazards of cigarette smoking and lung cancer, an editorial by the editor in the official publication of the organization could very well lead the medical profession, the public, and the media to assume that the editor was in fact expressing the unspoken position of the AMA.
DS: Well, and the offshoot of that, of course, the AMA was back then, and is still now a very powerful health organization when you think about its hundreds of thousands of members.
And if you look back at that point in time, there were some people who were pushing the Public Health Service to do something education-wise about smoking. And one of the main reasons that they didn’t do it was because of Talbott’s editorial that all of the newspapers picked up.
If you go online and look at the tobacco documents, you can find pages and pages of newspaper clippings in response to that letter to the editor that Talbott wrote, and all of them pointed out that Talbott and the AMA said that Burney ought to have just minded his own business.
DS: I think if you do just a search and just say “tobacco documents,” it will show up.
That’s right. And this was initially worked on by UCSF in California, and now it’s quite a repository. I think frankly, just to put in a plug, our website here at the Center for the Study Tobacco Society is the perfect complement because although I don’t have as many internal tobacco documents, we were the first—actually back when Eric Solberg was running our group at Baylor College of Medicine in Houston, Eric was the first person to organize tobacco industry documents that we had obtained through some way.
I was entrusted with quite a few boxes of these. And Eric thought to organize them, and we let them go to the FDA, and Dr. Kessler was able to use these in his first attempt to regulate nicotine products in the 1990s.
That having been said, these documents today are fascinating. Our center supplements it with the original material that the industry said out loud in public, that few other people have saved.
So just to step back again to the 1950s, we both look at this as a lost opportunity to act on Hammond and Horn, Hill and Doll, Graham and Wynder, and to really take action.
They did not do that. But then you have the American Cancer Society, the American Heart Association, the National Tuberculosis Association, which was the forerunner of the American Lung Association. In your chronology, you noted that they sent a letter to the newly elected president, John F. Kennedy, requesting an advisory committee be established to determine once and for all whether Dr. Burney’s statement is what we should have as the official national position. Is that correct?
DS: That’s correct. They wrote a letter, I think it was dated June 1, 1961, asking him to appoint a commission to look at the entire issue of smoking and health.
And it’s my understanding that that letter went from the White House over to then what was called DHEW, Health Education and Welfare, and that an undersecretary in that office essentially drafted a reply that said that the appointment of a new commission, or a committee, by President Kennedy would be inconsistent with his campaign promise to eliminate a number of commissions and committees.
That was a response that went back to Ms. [Marion] Sheahan, who was the president of the APHA [American Public Health Association] at the time that essentially said that the president doesn’t think this would be a good thing to do, essentially because he’s trying to abolish these commissions and not have more appointed. From there, the issue sat for a number of months until the voluntary health organizations contacted Secretary [of Health, Education, and Welfare] Abraham Ribicoff at the time and asked that something be done.
At that time they had tried to contact Terry, and Terry had recommended to the secretary that a committee be established. But he said, if you did this, you need to check with the White House because there are certain things you need to be aware of politically.
It’s my impression that the secretary’s office sat on that request, and it never got forwarded to the White House. So after two attempts, nothing really happened. And then of course, you know the story about Kennedy being asked at his press conference.
There was one more, if I recall correctly. It was right after the Royal College of Physicians report came out, and Terry drafted a very lengthy memo to now Secretary Anthony Celebrezze at HEW, in which he listed seven reasons as to why this issue needs to be looked at again, one of which was new information, obviously, another was fact that there had been some legislation introduced in Congress.
Of course, the Royal College of Physicians had just issued a report in which it said that there was a relationship not only with lung cancer but with heart and probably bronchitis, emphysema as well. And so he listed those seven reasons as to why a new look at this should be undertaken. But again, that request sat in Celebrezze’s office and never went forward.
This is interesting for a couple of reasons. First of all, Dr. Burney, who was the Surgeon General in the 1950s under Dwight David Eisenhower, actually credits his Secretary of Health Education and Welfare, Marion B. Folsom, who had been an official of the Eastman Kodak Company, who gave him carte blanche, which I think is really interesting.
You think of the Democrat, progressive, Kennedy being more open, but it was Eisenhower’s administration that actually was more open to talking about it. Now, perhaps Eisenhower who smoked very heavily and had a well-known myocardial infarction, might have been more interested in this than Kennedy was.
But, certainly, we don’t get any sense that John Kennedy or Celebrezze had any interest in this issue, and were more interested in the politics. And just to take a step back, I forgot to mention the 300 years of American politics during which tobacco became, if not the number one income producer for taxes among, then among the very top income boosters in the whole United States. This was an economic pillar of society.
We couldn’t deny that tobacco employed many hundreds of thousands of people and was a mainstay of the economy of numerous states. So we’re not going to just sweep that under the rug. And then we got into the issue of personal freedoms and so forth, but it was clearly not the initial part of the Kennedy administration that was interested in this even after the Royal College of Physicians report that you mentioned that came out in 1962. That has its own story that we could go into at some point.
This was really the result of just two people. It was Sir George Godber who was one of the architects of the National Health System, the National Health Service in England, and who was the chief medical officer—probably the equivalent of the surgeon general. And he was very upset to be walking in the halls of Parliament and seeing everybody smoking in spite of all the epidemiologic evidence that was coming out.
And he decided that the government just wasn’t going to do anything. So he approached his friend Charles Fletcher, of the Royal College of Physicians, and said, let’s have lunch. And they thought maybe they could buy some ads and put up some billboards. They came with the idea for the College to issue a report?.
Dr. Fletcher pretty much wrote it single-handedly. And that report had an immediate impact in England. And it was a month or two later that Kennedy held a press conference. And Edgar Prina, a reporter for the Washington Evening Star, who had seen the report, posed a question that Kennedy wasn’t expecting to hear:
“There’s a recently published report on smoking and health in England that says they’re going to start doing a lot on smoking. What about your administration?”
And Kennedy tried to say, “Well, I don’t want to talk about it, because the stock market is open today, I’ll get back to you.” And what he did do was pretty much having that committee go forward—and that’s where you come in, and that’s where this committee comes in.
So what about this committee? How did it get formed, and what were the criteria for a committee member?
DS: Well, it was interesting. You could probably say maybe it was the brilliance of Luther Terry. When he had gotten the approval from both the Secretary and the White House, because both of them had to give him the go ahead, he decided to hold a planning meeting in which he invited all of the interested parties who had a stake in the game to this meeting to draw up the parameters of the study, as well as the criteria for who would be included, in terms of on this committee.
And of course, that meant that you had not only the players in the Public Health Service, the Federal Trade Commission, the FDA, all the voluntaries, and the AMA, but it also included the tobacco industry. And so at that meeting, you actually had two representatives from the tobacco industry.
One was George Allen who was president of the Tobacco Institute, and the other person was Clarence Cook Little, who was the director of the Tobacco Industry Research Committee. That later morphed into the Council for Tobacco Research. They were part of that planning. They were part of the group that actually drew up the criteria in terms of what the study would be. And that’s where they came up with the idea that there would be two phases.
One would be the first phase that would look at the magnitude and the nature of the health threat. And then the phase two study would be if they find that smoking was a health hazard, what would you now do about it? And that was what phase two was supposed to be about. And that group also drew up the criteria.
They said that they did not want anybody who really knew anything about the issue, or what they called taking a stand on the issue, which pretty much eliminated anybody who had done any work, any type of research on the issue, because obviously that would’ve meant they had to take a stand. And they also could not be part of any particular organization—this was the other criterion, nor could they have made any kind of a public statement either for or against smoking in health.
From that, it pretty much meant that any committee members that you were going to consider would have to be virgins, in a sense. They had to be people who didn’t really know anything about the issue. And so that group of, I think it was about a dozen different organizations represented around the table, they drew up an initial list of 155 individuals, and it was from that list that the eventual 10 committee members were chosen.
The unique thing about that process is that anybody could eliminate an individual to serve on the committee, or from that list, for any reason whatsoever. In fact, they didn’t have to even give a reason. They had complete veto power. It’s remarkable that out of that list of 155 people, we had 10 people who, essentially, the tobacco industry had approved by virtue of the fact that they did not eliminate any of the individuals who were chosen to serve on the committee.
As you know, we have written an unpublished manuscript about the 1964 report.
DS: It was myself and four other people who actually worked on the report. Two were committee members, which were Emmanuel Farber and Charles “Mickey” LeMaistre, and two of the senior PHS professionals, which were Dr. Guthrie and Dr. Hamill. The unpublished manuscript is, essentially, our attempt to put together a more complete narrative about the 1964 report.. But it also goes into a lot of the events that led up to it and including this selection, and who agreed to serve and who did not agree to serve as well.
DS: I never had a chance to talk to anybody about it. And of course, you’re now talking about the early 1960s and it was a very much of a male dominated movement, if you will, of society. I’ll be interested, I think the original list of 155, which by the way, five names were eliminated from that.
They really actually chose the 10 from a list of 150. We asked Peter Hamill about who was eliminated, and who was eliminated by the tobacco industry, and he said the tobacco industry never eliminated anybody. The five who were eliminated were eliminated by somebody else.
I don’t recall him talking about anybody other than the 12 or 15 that he contacted and wanted to actually serve. None of them were women either. I’d be interested to know if we went back to the archives and found the original list, as to whether there were any women actually listed.
Some aren’t listed because maybe more women had spoken out, like Senator Maurine Neuberger on smoking. But I’m just hypothesizing. In fact, we could talk about her for a whole hour. But she was the first elected official that I’m aware of, the senator from Oregon, to really blast the tobacco industry and call for remedial action, and do everything. A\s long as I brought her up, let me just mention a quote that I found in the introduction to her book Smoke Screen.
She cites—right after the publication of the Royal College of Physicians report that we were just alluding to, “A journalist writing in The Lancet, said, ‘Future historians will have views on our failure to find even a partial solution to the problem of smoking during the first 10 years after its dangers were revealed.’ Now, I don’t know whether they’re referring to the dangers having been revealed by, I think Hill and Doll, in 1950. The enormous and increasing number of deaths from smoker’s cancer may go down in history as a strong indictment of our political and economic ways of life.”
And then she adds, “Yet which segments of our society and which institutions will these future historians indict? The tobacco industry for its callous and myopic pursuit of its own self-interest? The government, for its timidity and inertia in failing to formulate a positive program for prophylaxis? The medical profession for abdicating its role of leader in this crucial area of public health? Or is the individual smoker and non-smoker alike incriminated by his failure to accept responsibility for his own and his society’s well being?”
She said that she thinks all of those folks are going to be blamed.
DS: You can check all of those boxes, I think.
DS: If you know who Peter Hamill is, he did a series of interviews for the J. F. Kennedy Oral History Project in 1969 and 1970, which isn’t too many years after the report came out. (And you can get these off their website by the way.) He goes into a lot. He was the one that Terry charged with actually selecting and vetting the committee members. He was a very young guy at the time. He was only 36 years old when he was tapped to serve as the medical coordinator to the committee.
He was the one that vetted all those guys. And in his interviews, he goes into a very lengthy discussion of who he was looking for, the types of talents, the disciplines he was looking for, what type of people they were, what kind of thinkers they were.
As I said in part of the introduction I wrote for our book, if we were looking at this today, we would say he was looking for people who thought outside of the box. He wanted people who weren’t afraid to mix it up in an argument. And even though they were going to be arguing about data or at least studies that they didn’t really have a lot of familiarity with, he knew that these were people that could do a good job of educating themselves during the process, and be willing to actually take on a debate in this committee if they felt strongly about certain issues. That was the type of people he was looking for. He wanted people who weren’t afraid to speak up.
DS: I don’t know about his earlier history at the time that he was chosen to be the medical coordinator. He was the chief epidemiologist for the Division of Air Pollution Control at PHS. This would’ve been the precursor that eventually morphed into the EPA by the end of the seventies. He was an epidemiologist by training as well. He was also a former Golden Gloves boxing champion.
DS: In the book, I cite him as being brilliant, intense—and he was really what I would call a Renaissance man. He was very highly educated, a very rounded education, and this comes through in his interviews with the Kennedy School, and he was a pretty smart cookie.
DS: Well, people lose sight of the fact when the committee was first established, Luther Terry and everyone thought that this could be done in six or seven months, because that’s the way that most other committees that worked on this kind of an issue did. They could do a report in five, six, seven months, but here you had a group of 10 guys that didn’t know anything about the issue.
They weren’t familiar with the data, they weren’t experts, and here they had, sort of dumped in their lap, 7,000 studies that they now got to sift through. And these guys didn’t know what to do with it. They actually spent the first two meetings trying to figure out what they were going to do. The November meeting and the January meeting is where they really started to try to grapple with how they were going to structure themselves, but more importantly, what type of methodology were they going to adopt in order to be able to issue a report that was going to end the controversy as to whether smoking was a health risk.
And a lot of these guys, as you know, were cigarette smokers. They came with a certain amount of bias in some cases. Like anybody else that was around at that time, if you were a smoker, you didn’t want to believe this stuff. And they weren’t any different than the general public was, but it took them a good two months, or two committee meetings, before they actually got deep enough into some of the discussions about some of the data before they themselves decided that if they were going to answer this question, they were going to have to go a lot deeper than what the Public Health Services expected them to do, and come up with something a lot more detailed than something like the Royal College of Physicians.
Let’s not forget, just to step back a little bit, even to the fifties and even back to the forties, there was a hearing of the Federal Trade Commission in the early 1940s about the outlandish health claims of cigarette advertising.
But of course, just like all these appeals we hear about certain figures about to be criminally charged, they kept delaying and delaying delaying, even though the FTC said, you can’t say that more doctors smoke Camels. It took them ten years to correct it.
You have the leading advertiser on radio and in newspapers, literally the leading advertiser, blocking any real convincing evidence because they’d always say there’s another side. They would always give the other side. And Burney himself writes that he gave the tobacco industry the courtesy of sending him his statement a couple of days before he issued it, saying there’s sufficient evidence to support the claim that there is a causal link between smoking and lung cancer. The tobacco industry released an attack on him at the same time as his statement.
That’s how they repaid his kindness, with a blistering attack. He said that you should never trust that industry in any way, shape or form. So we come to this pass, where I think this committee was aware of that. And then you point out in our earlier correspondence that one day they came into their meeting, and they were told they better get it done quickly.
DS: That’s correct. That happened at the May meeting.
DS: That would’ve been the fourth meeting.
DS: Correct. And James Hundley, who was the assistant surgeon general and chaired all the meetings of the advisory committee, or he either chaired or co-chaired. He essentially came in, went into an executive session, and said that, essentially you’ve all got to get the report out, and get the report out now.
And he gave them two options. You can either finish up where you are right now and issue the report, or you can let the PHS take it over and let them finish up the report for you. And of course, the committee went ballistic because just the meeting before in March, Hundley himself had drawn up a timeline for the report. It said it looks like given where we are, that probably the best we can probably do is have a report issued by the end of the year. And the committee agreed with it. They thought that was a logical timeline and one that they would then work toward. And now here at the next meeting, he’s saying, you’ve got to finish up the report and finish it up now.
DS: They simply threw him out of the room and they went into their own executive session and tried to make sense about what they thought was going on. They bantered back and forth about what they thought was the push behind all this.
They had pushed Hundley to find out whether Dr. Terry knew about it or was behind it. They wanted to speak to Dr. Terry. And Hundley essentially said that he wasn’t available, and he was non-committal about whether Terry knew anything. And they brought Hundley back in for another discussion about what was going on and pressed him some more. Hundley still really wasn’t giving up any information. They asked him to leave again, and at that point in time, they decided that they were going to take over the report, that the report was going to be theirs and theirs alone.
They decided that there would be no minority report on any issue, that everything that they would agree upon would be unanimous, which probably came back to haunt them in some cases, which we can discuss a little bit later on. And they essentially called Hundley back in and said, We’re going to do it our way. You all won’t be able to see the report. We will issue the report directly to the public. Neither you nor Dr. Terry, nor the department, nor the White House will be allowed to see this report until it’s made public.
DS: Well, I think they tried to tackle addiction, and let’s keep also something in mind as well. These guys weren’t addiction experts by any stretch of the imagination. But having talked to Mickey at some length about this—
DS: And Leonard Schuman, years ago, Len was the only epidemiologist on the committee, by the way.
DS: At least a card-carrying epidemiologist. They admitted that they really pushed the issue and really wanted to declare smoking addictive. Maurice Seevers was the person that pretty much held everything up, and he had been on the WHO committee that had established a lot of the WHO criteria for different substances including nicotine, and they held at that time that it was not addictive, but it was habitual. That’s what he fell back on. That’s what he said the committee had to go to. That was the only criteria that they had at that time, was to use the WHO criteria. And they held that it was habituating and not addictive.
But from my understanding, either all of the committee or most of the committee wanted to label it addictive. But again, this is where Seevers was the person who really knew the most about it, and he relied too much on the WHO criteria. Plus they knew they didn’t want to do a minority report.
He was the chair of pharmacology at the University of Michigan. His field was listed as pharmacology of anesthesia and habit forming drugs. I’ll just quickly review.
Dr. Schuman was professor of epidemiology at the University of Minnesota, and his field was health and its relationship to the total environment. LeMaistre was a professor of internal medicine at the University of Texas Southwest Medical School, and his specialty was internal medicine and pulmonary diseases and preventive medicine.
John Hickam, an internist, was a specialist in physiology of cardiopulmonary disease. Jacob Furth, professor of pathology at Columbia, was an expert in cancer biology. Louis Fieser, professor of organic chemistry at Harvard, was an expert in the chemistry of carcinogenic hydrocarbons. Emmanuel Farber was chairman of the Department of Pathology at the University of Pittsburgh, an expert in experimental and clinical pathology. William Cochran, professor of statistics at Harvard, with special application to biological problems. And two more, Walter Burdette, who was head of surgery at the University of Utah, was a geneticist and also a clinical experimental surgeon.
Lastly, Dr. Stanhope Bayne-Jones. Bayne-Jones, the eldest member of the committee, retired at that time, and a past president of the Society of American Bacteriologists, was an expert in the nature and causation of disease in human populations.
DS: Correct.
DS: Well, the cancer chapter.
DS: Of all things. When they sort of decided as to how they were going to divvy this up during the January meeting, it was between the November and January meetings, Burdette had agreed to take on the cancer chapter, which was logical. He had a background in it. He was a very well-known thoracic surgeon. And from what everybody talked about Burdette, is that he not only was brilliant, but everything he touched, he tended to be a real go-getter and could take on anything and get anything done.
Supposedly if you had a room full of people, he’d be declared the smartest guy in the room, so to speak. But he also was a geneticist. In fact, he had written several books about genetics, had a degree in genetics, and a lot of the cancer chapter, as he was approaching it, unfortunately, put too much emphasis on genetic and constitutional factors as they related to cancer etiology, particularly lung cancer etiology.
And it was very slow. I think the way that Mickey LeMaistre described it is that it was almost like pulling teeth, trying to get Burdette to put more emphasis on the epidemiology of cigarette smoking and cancer at different sites, and less emphasis on the genetic aspect of it.
By the time the late summer was coming on, the cancer chapter was still in pretty much disarray. A lot of stuff was there, I’d say the bones of the chapter was there. But they really were dissatisfied with how the chapter was shaping up. About this time was when Hamill was getting sick and was starting to take more and more treatments. He had a very painful neck condition.
And it was at that time that his physician said that he had to give up work immediately. And what Hamill did, is that he privately contacted Len Schuman and asked Len Schuman if he would take on the task of trying to incorporate the data from all the epidemiologic studies on lung and other cancers. Schuman agreed to do it.
In fact, what Schuman did is he took 30 days to leave from his post at the University of Minnesota and spent it at committee headquarters from the middle of August until the middle of September, completely rewriting a lot of the chapter, emphasizing the epidemiology of lung cancer as it related to cigarette smoking. And believe it or not, it was something that the other committee members knew nothing about.
When we were writing the book, John Harkness at the University of Minnesota pointed out to him all the work that Schuman had done, and Mickey didn’t know about it. I spent a full day at the University of Minnesota going through the archives collection up there.
Schuman had found all kinds of documentation for it, including his 30 day stay at the local hotel in Bethesda. And the fact that I do remember very distinctly, because that was the same time that I went to work for the committee, Len Schuman was there quite a bit, and I didn’t know who he was at the time, because as an 18-year-old kid, what did I know? And I told Mickey that. It all kind of dovetailed the fact that he actually spent a good part of his summer writing the cancer chapter, that if he had not done that, the report probably would’ve been delayed by at least a couple of months.
DS: He used his 30-day vacation time from the university and spent it at the headquarters in the basement of the National Library of Medicine, rewriting that chapter.
DS: It was a very sad day. The committee was coming in for a meeting that very weekend, and keep in mind, because these guys all had academic positions back at their home base, when they came in to meet as a committee, the meetings were always on the weekend so they could continue doing their normal work.
They would come in on a Friday and would spend Friday, Saturday, sometimes Sunday, sometimes Monday, depending on the workload. And that particular weekend they were supposed to meet. And as that happened, of course, Kennedy was assassinated in Dallas, and believe it or not, Mickey LeMaistre was called into Parkland Hospital to work on John Connally with one of his colleagues who was actually called over, and he took Mickey with him.
We actually had to contact Jacqueline Kennedy’s office, her secretary, to find out if we should even meet that weekend given the circumstances. And we got to go ahead and to work that weekend, even though it was a very—talk about a somber meeting.
DS: Well, we were at the point where they were writing the conclusions now, and writing a lot of the judgements that they were going to then make in terms of the different relationships, in anticipation that they may or may not meet one more time, which they eventually did. But that meeting went through Monday, and I think into Tuesday because of the circumstances.
Ironically, that night, that Friday night, the night of his assassination, the National Library of Medicine is right across the street from the National Navy Medical Center, and we were there when they brought Kennedy’s body in for an autopsy. It was right across the street from us. We were sort of on the tail end of that history when they brought his body in to be autopsied that weekend.
DS: Well, I don’t know of any effort that was made by anybody either at the department level, or the White House, to stop the report. If it happened, I was never aware of it. The person who would’ve known that would’ve been Gene Guthrie, who at that time now, had taken over for Hamill and was the medical director of the report, and was essentially in charge of it.
He has never mentioned that, and I’ve known Gene for a number of years. I knew him well after the report came out. He and I met several times and talked about the report and what went on. He never mentioned anybody interfering with the thing. I don’t know if that has any credibility that someone actually, like Abraham Fortas, or anybody else.
DS: You’ll have to, because I remember talking to Mickey at one point. I don’t recall what the genesis of the conversation was. I remember him saying that he had met Johnson in his office at one point, and Abe Fortas was there.
DS: And it was my impression, this was after the report was released in which Mickey had almost volunteered his time to Johnson to talk about implementation of something in terms of any kind of anti-smoking activity. And it was at that point that Mickey told me that he turned to Abe Fortas, and said that Abe Fortas was going to be his guy on that, or something to that effect. But it was my impression that was after the report was released.
Well, I’ll keep searching for that Holy Grail, but I think that what we’re doing now as we begin to wind down, we’re talking about the moment of the release, but then the aftermath.
One thing we do know for sure, that Lyndon Johnson never endorsed the report. He permitted it to go through, and I went to the LBJ Library where we had our exhibition that you saw 10 years ago. We had it also at the LBJ library.
I spent one day in the library and I asked them if they could produce their archive on anything to do with smoking under Johnson.
They gave me two little boxes with a bunch of letters from the public and there was literally nothing else. I kept saying, “No, no, I would like maybe some behind the scenes policy thing.”
No, they had nothing. He was not, as far as I know ever, even when he had his illnesses, Johnson smoked. But I don’t think it ever really came up. He was not a strong endorser of that report. I haven’t had a chance to ask Joseph Califano, who worked in the Johnson administration, whether there was anything else, but it just seems to me that Johnson did his good deed by letting it go forward.
DS: Name me one president that I would say was a big supporter of the smoking control movement.
DS: I don’t know of any.
This gets into the last point of it. What people will see on the website will be some of the videotape of the film of when Dr. Terry released it. We have some documentaries that were done by CBS and NBC that I got ahold of, and that’s going to be shown.
I think the Harry Reasoner documentary on Smoking and Health issued that April, three months after the report, is one of the best documentaries I’ve ever seen. He literally interviews the tobacco industry, man on the street, school kids, some members of the report. It’s riveting. And he introduced the advertising agencies, and David Ogilvy, who headed the first ad agency to decline cigarette advertising.
But in any event, your opinion then of the impact of the report immediately and then long-term, because you were the only one who was there from the outset to fully, until 2014, working on virtually every report of the surgeon generals. Did these subsequent reports that came out, did they have a major role compared to the initial report, or were they there to just reinforce it?
DS: It’s hard to say. There probably were a few reports in the series that had an immediate impact. I think the major impact of these reports is in their totality in terms of documenting the health risks that then permitted other people, especially, to do something about it, people like yourself, the voluntaries. Certainly once you got into the nicotine stuff and the FDA got more involved, but that was 30 years later, you could make a judgment that the report on nicotine addiction maybe pushed that further.
I think the real impact of those reports has been what I would call the constant drumbeat of more and more pronouncements that eventually, I think, more than anything else, undermine the behavior. It undermined the social acceptability of smoking. And I think that particularly was true once we started documenting that it had an effect on the non-smoker.
But I think all of those reports taken in total eventually moved the needle forward a little bit by a little bit. There were no big changes as you know, from year to year. And I think what we’re seeing now, even though it’s taken, what, 60 years, we’re now looking at the end result of that. If you go back to say before the report when you had close to 50% of the adult population smoking. Now, the latest figures that I saw come out of CDC for I guess it was 2022, is showing the adult rate now is at 11.2%. We’re almost getting down to single digits.
Teens, even lower than that. But I’ll give the other side of that any day. And that is, first of all, it took 60 years to do it. We didn’t start seeing a decline in lung cancer rates among men. It’s still not declining among women.
I think the three reports, if we want to talk about the positive steps forward that I would vote for, I think you and I have corresponded about this. I think the report on passive smoking, the report on addiction, and I would say the report on women—those were major earth-shaking headlines that did propel changes.
The passive smoking report led to a ban on smoking on airlines—the first federal effort on clean indoor air that I’m aware of. There was not much federal legislation passed as a result of the Surgeon General’s Report…
DS: I think that just bolsters my point. I think a lot of the successful anti-smoking steps that we’ve taken have been taken outside of government, by the activist or whoever, who are always ahead of the science to begin with, as you know. The science always comes later. The people out in the hinterland, if you will, are the ones that take the early action because they can.
DS: They were the only major medical entity in the country that has never endorsed the ’64 report.
DS: That’s Johnny-come-lately isn’t it?
Right. But let’s go back to Nov. 22, 1963, a fellow named Roy Ritts, who became chairman of immunology at Mayo, had been JFK’s personal physician at the Naval base. He had been lured by the AMA to come to Chicago to head up the AMA’s Education and Research Foundation (AMA-ERF). The day that he arrived on the job, I had the privilege of serving on a committee of the FDA with Dr. Ritts.
He arrived in Chicago on November. 22, 1963 to hear two points of news. Number one, that his patient, JFK, had been killed. And the second bad news he heard was told to him as good news: the AMA had just gotten $5 million to do more research. And he said $5 million—that was like $50 million today. And he said, “Really? That’s incredible!” And he said, “Who’s that from?” They said it was from the tobacco industry.
He practically quit right then and there. He was going to be the director of this—and he smoked by the way. They said, OK, you don’t have to work with that money.
Ritts didn’t last long at the AMA-ERF but he did relate to me his disappointment even back then. And he joked that, “The AMA did once issue a booklet that said if you smoke in bed, that might cause a fire.” But for 15 years, from 1964 to 1979, the AMA was virtually silent on this issue because they were taking, what it turned out to be, $18 million from the tobacco industry to do more research.
As we close, we look at the mantra, I think we’re still doing that today. University of Southern California, I heard last week got $20 million to study nicotine policy in pediatrics—$20 million to study what? In an age where we’re not regulating, we’re actually going backwards, we’re actually having less regulation these days.
DS: One of the ironies of almost any kind of a public health problem and not just smoking, I think there’s a lot of them, is that as you get the problem solved, you now find more money than you can deal with. Whereas back in the early days, when the problem was the greatest and they needed the most, we were dealing with nickels and dimes.
DS: There’s probably 100,000.
There are 356,000. At least that’s what it was in 2021 when I had a piece in The Lancet. And this is the sad part about our own culpability. We and the health professions really owed it to the public to act and not continue to study.
We love studying, but we’ve got to translate our research sooner than later.
I know that we could probably, and we’re going to have this opportunity in person, when on Jan. 11, we commemorate this report and we have the honor to host you at the University of Alabama.
I just can’t thank you enough for taking the time to talk with us. We really just scratched the surface. You are widely respected in your field as someone who’s been on the inside, who engages in respectful conversation and debate at every turn.
Lord knows we’ve disagreed on so many things, but you always take the high road.
