SMOKING HABITS HAVE CHANGED. IN 1964 OVER HALF OF ADULT AMERICANS SMOKED. WHEN I BECAME SURGEON GENERAL IN 1981, THE NUMBER HAD DECLINED TO 33 PERCENT. BETWEEN 1964 AND 1985 APPROXIMATELY THREE-QUARTERS OF A MILLION SMOKING-RELATED DEATHS WERE AVOIDED OR POSTPONED BY DECISIONS TO QUIT OR NOT TO START SMOKING. EACH POSTPONED DEATH REPRESENTED AN AVERAGE GAIN OF 2 DECADES OF LIFE EXPECTANCY. 26 NEARLY HALF OF ALL LIVING ADULTS WHO HAVE EVER SMOKED HAVE QUIT. FIFTEEN YEARS AGO, AT MEDICAL MEETINGS, WHERE DOCTORS SHOULD HAVE KNOWN BETTER, THE AIR WAS BLUE WITH SMOKE. NOW YOU RARELY SEE A PHYSICIAN SMOKE; 2/7 FEW THINGS BRINGS ME AS MUCH SATISFACTION AS THE DRAMATIC DECREASE IN SMOKERS DURING THE LAST 8 YEARS, FROM 33 PERCENT TO 26 PERCENT. AND IN MY FINAL YEAR IN OFFICE IT DROPPED ANOTHER 5 PERCENT. BUT THERE IS MORE TO DO. THERE IS STILL PLENTY OF BAD NEWS. 28 SMOKING IS STILL THE SINGLE MOST DEADLY "HABIT" ... ASSOCIATED WITH HIGHER MORTALITY AND ILLNESS THAN DRUGS, AUTOMOBILES, AND AIDS COMBINED. ALL THE AIDS PATIENTS WHO HAVE DIED SINCE WE KNEW ABOUT THE DISEASE, 8 YEARS, EQUALS THE SMOKING DEATHS OF ONLY 4 MONTHS. THE NUMBERS OF DEATHS ANNUALLY ATTRIBUTABLE TO SMOKING HAVE RISEN WITH EACH SURGEON GENERAL'S REPORT. 29 THE NEWEST STATISTICS, THE NEWEST STUDIES ARE GRIM. THEY DOCUMENT CONCLUSIVELY THE CAUSAL RELATIONSHIP BETWEEN SMOKING AND CANCER OF SEVERAL ORGANS. SMOKING IS A CLEARLY ESTABLISHED CAUSE OF CANCER OF THE LUNG, LARYNX, ORAL CAVITY, AND ESOPHAGUS. SMOKING ELEVATES THE DEATH RATES FOR CANCERS OF THE BLADDER, KIDNEY, PANCREAS, STOMACH, AND CERVIX. 30 FURTHERMORE, PASSIVE OR INVOLUNTARY SMOKING HAS BEEN ESTABLISHED AS A CAUSE OF LUNG CANCER IN NON-SMOKERS. PIPE AND CIGAR SMOKERS SUFFER HIGHER RISKS --SOMETIMES EXCEEDING THE RISKS OF CIGARETTE SMOKERS-- FOR CANCER OF THE ORAL CAVITY, LARYNX, PHARYNX AND ESOPHAGUS. THE DATA BASE FOR THESE CONCLUSIONS IS VOLUMINOUS AND UNASSAILABLE, TRACKING MORE THAN 2 MILLION INDIVIDUALS IN ALL 50 STATES. 31 THE EVIDENCE MAKES CLEAR THE INCREASED MORTALITY RISK FACTORS CAUSED BY SMOKING: MALE SMOKERS EXPERIENCE A 22-FOLD GREATER LUNG CANCER MORTALITY RISK THAN MALE NON-SMOKERS; AMONG WOMEN SMOKERS THE LUNG CANCER RISK IS 12 TIMES GREATER. FORMER SMOKERS ENJOY LOWERED MORTALITY RISKS, THOUGH NOT AS LOW AS NON-SMOKERS. WHILE THE STUDIES REVEAL A DOUBLED LUNG CANCER RISK FOR MALE SMOKERS, AND A 4-FOLD INCREASE LUNG CANCER RISK FOR SMOKING FEMALES, THE LUNG CANCER MORTALITY RATE FOR NONSMOKERS REMAINED UNCHANGED FOR BOTH MEN AND WOMEN DURING THE YEARS COVERED BY THE STUDIES. 32 THE TOTAL NUMBER OF SMOKING-RELATED CANCER DEATHS WE CAN EXPECT IN 1990 WILL APPROACH 175,000. THIS AMOUNTS TO 35 PERCENT OF ALL CANCER DEATHS. THESE, TRAGICALLY, ARE "EXCESS" OR PREMATURE DEATHS. THESE 175,000 DEATHS WOULD NOT BE EXPECTED THIS YEAR IF TOBACCO USERS EXPERIENCED THE SAME DEATH RATES AS THOSE WHO DO NOT USE TOBACCO. 33 OF COURSE, CANCER IS NOT THE ONLY PROBLEM. CIGARETTE SMOKING ALSO LEADS TO DEATH FROM CORONARY HEART DISEASE, AND ALTHOUGH THE SMOKING-RELATED RISK FACTOR FOR CORONARY HEART DISEASE IS LOWER THAN THAT FOR CANCER, THE NUMBER OF SMOKING-RELATED CORONARY HEART DISEASE DEATHS IS LARGE SIMPLY BECAUSE CORONARY HEART DISEASE REMAINS THE GREATEST SINGLE CAUSE OF DEATH IN OUR SOCIETY. SMOKING ACCOUNTS FOR ABOUT 21 PERCENT OF THOSE DEATHS. 34 HOWEVER, THIS DARK CLOUD HAS A SILVER LINING. THE PRESENT CORONARY HEART DISEASE AGE-ADJUSTED DEATH RATE IS 50 PERCENT LOWER THAN IN THE 1960s; THE REDUCTION IN SMOKING IS A MAJOR FACTOR IN THIS DECLINE. QUITTING SMOKING REDUCES MORE SIGNIFICANTLY THE RISK FOR CORONARY HEART DISEASE THAN THE RISK FOR LUNG CANCER. FIVE OR TEN YEARS OFF CIGARETTES GIVES A RISK FACTOR SIMILAR TO THAT FOR THOSE WHO NEVER SMOKED. 35 THIS DECLINE HAS PROGRESSED TO THE POINT WHERE LUNG. CANCER, NO LONGER CORONARY HEART DISEASE, IS THE SINGLE LARGEST CAUSE OF EXCESS MORTALITY AMONG AMERICAN SMOKERS. CONTINUING OUR GOOD NEWS/BAD NEWS THEME, THAT GOOD NEWS --ABOUT LOWER RATES OF CORONARY HEART DISEASE BECAUSE PEOPLE HAVE STOPPED SMOKING-- IS FOLLOWED BY SOME NEW BAD NEWS, ESPECIALLY ABOUT WOMEN. 36 THE CONTINUING INCREASE IN LUNG CANCER AMONG WOMEN SMOKERS IS PARTICULARLY ALARMING BECAUSE THE MAGNITUDE OF THE RISK IS SURPRISING. WOMEN BEGAN TO SMOKE IN GREAT NUMBERS ABOUT THREE DECADES LATER THAN MEN, SO WE ARE SEEING ONLY NOW THE CONSEQUENT INCREASE IN SMOKING-RELATED ILLNESS. RECENT STUDIES REVEALED A DECLINE IN MORTALITY RATES FROM LUNG CANCER IN MALES UNDER 55, WHILE AMONG WOMEN THE RATE INCREASED BY 30 PERCENT. LUNG CANCER HAS NOW SURPASSED BREAST CANCER AS A CAUSE OF DEATH IN WOMEN. 37 WE MUST ENVISION A CATASTROPHIC EPIDEMIC OF LUNG CANCER AMONG WOMEN IN COMING YEARS. THIS EPIDEMIC IS AS PREVENTABLE AS IT IS PREDICTABLE. DISCOURAGING STUDIES INDICATE THAT SMOKING IS ACTUALLY INCREASING IN SOME SECTIONS OF THE FEMALE POPULATION, AND THAT OVER-ALL SMOKING PREVALENCE AMONG WOMEN MAY EXCEED THAT AMONG MEN WITHIN 5 YEARS. 38 A FINAL CONCLUSION OF THE NEWEST RESEARCH IS THAT SMOKING A MAJOR CAUSE OF STROKE (CEREBROVASCULAR DISEASE). WE ESTIMATE THAT SMOKING IS RESPONSIBLE FOR ABOUT HALF OF ALL STROKES OCCURRING IN PERSONS UNDER 65 YEARS OLD. SO, EVEN THOUGH WE'VE MADE PROGRESS, AS A SOCIETY WE'RE STILL BURDENED WITH THE TREMENDOUS AMOUNT OF SUFFERING AND HARDSHIP THAT GOES ALONG WITH ALL THESE DEATHS... 39 THE PEOPLE OF AMERICA ARE STILL BURDENED WITH THE ECONOMICS OF SMOKING. WE STILL HAVE TO COME UP WITH THE MONEY TO PAY THE ANNUAL SMOKING-AND-HEALTH BILL OF $39 BILLION. THAT'S FOR PERSONNEL AND MEDICAL TECHNOLOGY AND INSURANCE AND LOST WAGES...ALL THE REAL, BASIC COSTS LEVELLED AGAINST US ALL BY DISEASE AND DISABILITY. 40 SOME 30 MILLION AMERICANS STILL SMOKE, SO OUR EDUCATION CAMPAIGNS AND OUR SELF-HELP GROUPS MUST CONTINUE THEIR GOOD WORK. WE MUST GUARD AGAINST COMPLACENCY, AND INTENSIFY OUR EFFORTS TO ELIMINATE THE GREATEST CAUSE OF PREVENTABLE DISEASE AND DEATH AFFLICTING OUR SOCIETY. 41 AND THE TOBACCO INDUSTRY HAS NOT GIVEN UP. I DOUBT THAT YOU CAN FIND A MORE HEAVY-HANDED, OBTUSE, IMPOLITIC, AND UNTRUTHFUL GROUP OF CORPORATIONS IN AMERICAN PRIVATE ENTERPRISE. 42 ALMOST FROM My FIRST DAY IN OFFICE, THE INDUSTRY REMINDED ME AGAIN AND AGAIN -- AND NOT VERY SUBTLY EITHER -- THAT I OUGHT TO GET OFF MY ANTI-SMOKING "HOBBY- HORSE," AS ONE TOBACCO LOBBYIST CALLED IT, AND PAY ATTENTION TO OTHER, ALLEGEDLY MORE IMPORTANT PUBLIC HEALTH MATTERS. ECHOES OF THEIR COMPLAINTS WERE RELAYED TO ME FROM THE WHITE HOUSE, THE CONGRESS, AND EVEN FROM MEMBERS OF THE PRESS, WHO HAVE OFTEN BEEN THE GULLIBLE CARRIERS OF THE INDUSTRY'S DISASTROUS MESSAGE. 43 I ALSO READ THEIR DECEPTIVE, FULL-PAGE ADVERTISEMENTS THAT LIFTED MENDACITY AND HALF-TRUTHS TO A NEW AND HIGHER LEVEL OF FAUSTIAN ART. TO BE PERFECTLY HONEST, I DID NOT ASSUME THE POSITION OF SURGEON GENERAL WITH THE CLEAR INTENTION OF BEING SO PRO-ACTIVE AN OPPONENT OF TOBACCO AS I HAVE BEEN. BUT THEN I BEGAN TO STUDY IN SOME DEPTH THE INCONTROVERTIBLE TRUTHS ABOUT THE HEALTH HAZARDS OF SMOKING. 44 AND I MUST TELL YOU THAT I WAS AT FIRST DUMBFOUNDED AND THEN PLAINLY FURIOUS AT THE TOBACCO INDUSTRY FOR ATTEMPTING TO OBFUSCATE AND TRIVIALIZE THIS EXTRAORDINARILY IMPORTANT PUBLIC HEALTH INFORMATION. HOW COULD THE TOBACCO INDUSTRY DARE TO DISMISS AS UNFOUNDED AND UNPROVEN THE ABSOLUTELY CLEAR CONNECTION BETWEEN SMOKING AND HEART DISEASE ... BETWEEN SMOKING AND DEATHS FROM STROKE ... BETWEEN SMOKING AND CANCER OF THE LUNG, THE MOUTH, THE ESOPHAGUS, AND OF THE STOMACH ... AND BETWEEN SMOKING AND A DOZEN OR MORE SERIOUS, DEBILITATING, EXHAUSTING, EXPENSIVE, AND HUMILIATING DISEASES? 45 HOW COULD THEY DARE TO DO THAT? I WONDERED. THE ANSWER WAS ... THEY JUST DID. AND THEY FLAUNTED THEIR ABILITY TO BUY THEIR WAY INTO THE MARKETPLACE OF IDEAS AND POLLUTE IT WITH THEIR FALSE AND DEADLY INFORMATION. REPRESENTATIVES OF THE TOBACCO INTERESTS ARE STILL WHINING THAT THE WORD "ADDICTION" IS INAPPROPRIATELY APPLIED TO SMOKING BECAUSE IT MAKES TOBACCO SEEM LIKE HARD DRUGS. 46 THEY KNOW THAT IT IS ADDICTIVE LIKE HARD DRUGS. THEY ARE AS SLEAZY AS EVER. THE 1988 SURGEON GENERAL'S REPORT OFFERED IRREFUTABLE EVIDENCE THAT NICOTINE HAD ALL THE ATTRIBUTES OF AN ADDICTIVE DRUG ... INOTHER WORDS, CONSTANT SMOKING WAS CLINICALLY AN ADDICTION. 47 POPULAR FOLKLORE HAD PREDICTED SCIENCE: FOR A LONG TIME PEOPLE HAD TALKED ABOUT GETTING "HOOKED" -- AS THE SAYING GOES -- ON CIGARETTES, AS THEY GET "HOOKED" ON HEROIN, COCAINE, MARIJUANA, AND ALCOHOL. . THE ADDICTION REPORT PRESENTS CONVINCING EVIDENCE THAT THE PHARMACOLOGIC AND BEHAVIORAL PROCESSES THAT DETERMINE TOBACCO (NICOTINE) ADDICTION ARE SIMILAR TO THOSE PROCESSES THAT MAKE COCAINE AND HEROIN ADDICTIVE. 48 THE DEFINITIONS USED IN THAT REPORT ARE NOT MINE. THEY ARE NOT IN ANY SENSE ARBITRARY. TOBACCO IS AN ADDICTIVE DRUG, ACCORDING TO THE STANDARD DEFINITION OF DRUG ADDICTION ADOPTED BY THE WORLD HEALTH ORGANIZATION, THE AMERICAN PSYCHIATRIC ASSOCIATION, AND THE A.M.A. 49 IN OTHER WORDS... * TOBACCO IS A "MOOD-ALTERING" SUBSTANCE ... * SMOKERS ARE COMPULSIVE IN THEIR USE OF TOBACCO ... * TOBACCO REWARDS THE USER -- IT IS, THEREFORE, A "REINFORCING" SUBSTANCE ... 7 SMOKERS BUILD UP A TOLERANCE TO NICOTINE AND, FROM TIME TO TIME, WILL REQUIRE HIGHER DOSE LEVELS TO GET THEIR NICOTINE "HIGH" ... 50