Sixty years after the Terry Report certified the link between tobacco smoke and lung cancer| Tabaccologia

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On January 11, 1964, at the State Department in Washington, DC, U.S.A, at a packed press conference, in front of more than 200 reporters, Dr. Luther L. Terry, Surgeon General of the United States Public Health Service^*, presented what would become one of the most important and most quoted documents in the annals of medicine: the “Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service” (Figure 1) also known in short as the “Surgeon General Report on Smoking and Health” or “Terry Report” [1].

The document was born out of a request by U.S. President John F. Kennedy, who in 1962, after a press conference in which journalist L. Edgar Prina asked him for details about a report by the Royal College of Physicians reporting that cigarette smoking was a cause of lung cancer, asked the Surgeon General’s Public Health Service to review the issue and prepare a report on the subject.

The work of the 10-member committee lasted 14 months, and the results were unequivocal: smokers, compared with nonsmokers, had a 10-fold increased risk of developing lung and laryngeal cancer. Smoking was also linked to chronic bronchitis and emphysema, cardiovascular mortality, and low birth weight infants [1]. Dr. Terry observed that: “Few medical issues have aroused so much public interest or created so much scientific debate” and concluded that “Cigarette smoking is causally related to lung cancer... the magnitude of the effect far outweighs all other factors... and is a sufficiently important health risk to warrant appropriate corrective action”. Finally, Dr. Terry urged physicians, most of whom smoked, to quit and to advise patients to quit, as well as to use their leadership in urging public health decision makers to launch educational campaigns against smoking.

The Terry Report on the one hand triggered a series of reactions in the medical, media and political worlds in favor of greater tobacco control: Oregon Senator Maurine Neuberger, whose government activities focused on consumer, environmental and health issues, was the first member of Congress to take on the already politically powerful tobacco industry and its allies such as the American Medical Association (Figure 2). She spearheaded one of the first bills to require warning labels on cigarette packaging so much so that in 1964 Time described her as “a longtime crusader for labeling laws” [2]. But it would have to wait until 1984 for their actual introduction by another great surgeon, Charles Everett Koop, head of the U.S. Public Health Service from 1981 to 1989. The introduction of warnings on cigarette packs would mark the end of Big Tobacco’s negation strategy [3].

On the other hand, the Terry Report, stimulated multinational tobacco companies (Big Tobacco) to oppose tobacco control policies even more strongly and create the “strategy of doubt” [3]. Big Tobacco had already begun to worry in the early 1950s following the first studies on lung carcinogenicity from smoking. The mass media and public opinion began to be increasingly suspicious, to criticize and demonstrate aversion towards tobacco products and their manufacturers. Thus, on December 15, 1953, at the Plaza Hotel in New York City, the six major cigarette manufacturers gathered to cartel against the mounting scientific evidence on the link between tobacco smoking and lung cancer. There they created the tobacco industry’s Committee on Research, which was later renamed to the Council on Tobacco Research just in 1964 following the publication of the Terry Report. This Council (which offered lucrative employment to scientists willing to question the growing scientific evidence of the Association between cigarette smoking and disease) began an effective counter-information. In fact, on that occasion they drafted the “Frank Statement” on December 28, 1953. This was a document-press release from the major tobacco industries that appeared full-page in over 400 American newspapers and magazines on January 4, 1954, reaching some 43 million people. With this release, the tobacco industries wanted to counter the scientific evidence that had been produced up to that point on the harms of smoking and to reassure consumers. In fact, they publicly promised that they would conduct their own research (hence the importance of the Council on Research) to verify the actual Association between tobacco use and disease and that, if this association was confirmed, they would withdraw their products from the market [4].

Sadly, the Association between smoking and cancer, respiratory diseases, cardiovascular diseases, and a multitude of others has been confirmed by countless scientific evidence, extended to second- and third-hand smoke exposure, but tobacco products have not been withdrawn from the market, despite the fact that they kill half of all users.

In the 60 years since the publication of this historic smoking and health report, the percentage of Americans who smoke has steadily declined from a rate of about 42% of U.S. adults in 1965 to an unprecedented low of 11.5% in 2021, according to the U.S. CDC (Centers for Disease Control and Prevention) [5].

In Italy, prevalence also fell from 33% to 24% in the same years.

The overall reduction in prevalence affects mortality: historical differences in the prevalence of consumption (very high in men and very low in women) and the long latency period between consumption and development of diseases, have led to the observation, for example, of a reduction in lung cancer mortality in men but not in women, as well explained by Lopez’s model [6].

The Terry Report initiated the process of awareness of the harms caused by tobacco and the implementation of measures that led to the reduction of its use, then the approval of the WHO Framework Convention on Tobacco Control (FCTC) in 2005 resulted in the successes we have observed in recent decades. Recently, we are witnessing a global slowdown in the decline of prevalence and, due to population growth, an increase in the total number of smokers. These are expected to increase further, unless effective tobacco control actions are taken, due to the expansion of the Tobacco Industry market in countries with low-to-middle Human Development Indexes and among women [7-9].

Cigarette smoking remains the leading cause of preventable disease, disability and death.

In 2019, tobacco use caused more than 8 million deaths worldwide, most (7 million) attributable to active smoking, the rest (1 million) to secondhand smoke [7].

The U.S. CDC has identified as many as 27 smoking-related diseases: many types of cancers (in addition to lung, cancers of the oral cavity and throat, esophagus, pancreas, colon, bladder, prostate, kidney, breast, ovary, and some leukemias); non-neoplastic respiratory diseases (chronic obstructive pulmonary disease (COPD), asthmatic episodes, recurrent respiratory infections); cardiovascular, renal, eye, male sexuality-related, female fertility-related diseases [10].

Dr. Terry’s historic indictment of cigarettes as the leading cause of lung cancer marked the beginning of the end of the Marlboro Man, but not of the tobacco industry, which remained extremely adept at enlisting new customers and keeping them active consumers through the nicotine addiction induced by its products.

The Terry Report continues to represent a milestone in the history of awareness of public health issues.

In 1995, for the New York Public Library’s 100 Books of the Century exhibition, the Terry Report was selected as one of the top 10 scientific works, along with, for example, Rachel Carson’s Silent Spring, James Watson’s The Double Helix and Albert Einstein’s The Meaning of Relativity, and on January 11, 2024, it was commemorated by the American weekly The Cancer Letter and the exhibition Blowing Smoke: The Lost Legacy of the Surgeon General’s Report on Smoking and Health.

The first is a weekly magazine, which focuses on cancer research (in fact, it was born in 1973 as a means of updating in the fight against cancer begun by Nixon’s National Cancer Act).

The second is an exhibit, available online, organized by Dr. Alan Blum, director of the University of Alabama’s Center for the Study of Tobacco and Society, which, by analyzing print and broadcast collections, examines the origins of and reactions to the release of the Terry Report by the media, medicine and the tobacco industry, thus delineating the context of one of the most important announcements made in the history of public health [11-12].

Figures and tables

Figure 1.Dr. Luther L. Terry and the first edition (1964) of the Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service.

Figure 2.Senator Maurine Neuberger (1962), who first proposed tobacco harm warning labels on cigarette packaging.

References

1. United States Department of Health, Education and Welfare. U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control: Washington; 1964.
2. Time. Tobacco: the washington hearings on cigarette labeling. 1964. Publisher Full Text
3. Fondazione AIRC per la Ricerca sul Cancro ETS. Quando la scienza capì che la sigaretta fa male. 2020. Publisher Full Text
4. Renzi D, Renzi AH, Giorni E, Cattaruzza MS. The Frank statement: the document that everyone should know. Tabaccologia. 2010; VIII(2):14-7.
5. CDC Smoking and tobacco use. Current Cigarette Smoking Among Adults in the United States.Publisher Full Text
6. Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in developed countries. Tobacco Control. 1994; 3:242-7.
7. GBD 2019 Tobacco Collaborators. Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet. 2021; 397:2337-60. DOI
8. Amram DL, Zagà V, Serafini A, Cattaruzza MS. Tobacco smoking and gender differences: epidemiological aspects. Tabaccologia. 2023; XXI(1):27-35. DOI
9. The Tobacco Atlas. The Tobacco Atlas 2022: seventh edition.Publisher Full Text
10. Ministero della Salute. I danni del fumo.Publisher Full Text
11. The University of Alabama. Blowing smoke: the lost legacy of the Surgeon General’s report on smoking and health.Publisher Full Text
12. The Cancer Letter. Exhibit: the 1964 Surgeon General’s report on smoking and health. 2024. Publisher Full Text