Surgeon General’s Report Chronicles 50 Years of Efforts to End Smoking

Health Letter, July 2014

By Jennifer Rubio

It has been a half-century since the first U.S. surgeon general’s report on tobacco changed the landscape for smoking and public health in the U.S. In January, the surgeon general issued a new report detailing the progress of past efforts and potential further action toward eliminating use of these unhealthy, addictive products. The report, “The Health Consequences of Smoking — 50 Years of Progress,” not only tracks tobacco use in the U.S. since the release of the initial report, it also presents new and sobering findings about tobacco’s impact on health.

At the time of the landmark 1964 surgeon general’s report, more than half of men and nearly a third of women were regular smokers. Smoking was generally widely accepted by the public, and there was not a great deal of awareness about the dangers of tobacco use. When the initial report was released, it garnered significant news coverage with its conclusions that smoking was associated with higher all-cause mortality rates in men, that it was a cause of lung cancer in men and a probable cause of lung cancer in women, and that it was the most important cause of bronchitis.[1]

The tobacco industry fought back with aggressive marketing and misinformation, but due to public health campaigns and new laws and policies implemented in the wake of the report, cultural views on smoking began to change. Progressively larger measures were launched at the federal, state and local levels, from warnings on cigarette packs to comprehensive indoor smoking bans. Smoking is now significantly less socially acceptable than it was 50 years ago, but tobacco use is still a significant problem. Since the release of the surgeon general’s report in 1964, 20 million people have died as a result of smoking, almost 2.5 million of them nonsmokers who died from secondhand-smoke-related illnesses.[2]

That number will continue to rise, warns the report, unless more aggressive action is taken to combat the health risks of smoking.

New health warnings

Smoking was already known to be linked to cancer, most notably lung cancer; chronic obstructive pulmonary disease (COPD); asthma; and cardiovascular disease. But the new report presents evidence tying smoking to a number of other illnesses, and expanding upon the known risks:

  • Smoking is a cause of liver and colorectal cancer.
  • Smoking worsens asthma, and smoke-free policies in workplaces have been tied to a reduction in hospital admissions of employees for respiratory diseases.
  • Smoking is a cause of Type 2 diabetes, increasing the risk of developing diabetes by 30 to 40 percent.
  • Sexual and reproductive problems, such as ectopic pregnancy, birth defects and erectile dysfunction, are attributable to smoking.
  • Smoking is a cause of age-related macular degeneration, an eye disease and a leading cause of blindness in people 60 and older.[3],[4]

The report also affirms that smoking adversely affects the immune system, causes ill health in general and is a major cause of premature death. The risk of premature death from smoking has more than doubled in men and more than tripled in women since the release of the first surgeon general’s report. Quitting smoking reduces this risk considerably, however — by about 90 percent if one quits by age 40, and about 40 percent if one quits by age 60.[5]

Some of the trends in the adverse health effects of using tobacco products have shifted in the 50 years since the initial report. New evidence shows the following changes:

  • Smokers in 2014 have a higher risk for lung cancer and COPD than smokers in 1964 did;
  • Lung cancer is now the leading cause of cancer-related death in the U.S. (the report suggests that changes in the composition of cigarettes may have increased the risk of lung cancer); and
  • The risk of COPD is rising, especially among women.[6]

A tobacco-free future

Despite the advances in science and increased public awareness of the dangers of smoking, barriers exist to the ultimate goal of eliminating tobacco use. These barriers include disparities in tobacco use among racial and ethnic groups, as well as other segments of the population; persistent media images promoting tobacco use; and, as always, the tobacco industry’s continued marketing to young people[7].

The surgeon general’s report identifies five techniques that it considers the most promising ways to overcome these barriers and move toward what it calls the “end game” of eliminating death and disease due to tobacco use:[8]

  • Raising the retail price of cigarettes and other tobacco products;
  • Instituting smoke-free indoor-air policies;
  • Sustaining high-impact media campaigns;
  • Granting full access to tobacco cessation treatments; and
  • Funding comprehensive statewide tobacco control programs.[9]

The report also mentions other actions that can be taken. In particular, it mentions tax collection on tobacco products through such tactics as a cigarette tax stamp and a national track-and-trace system to ensure that taxes are paid at certain points along the supply chain. It also points to attempts to change social norms, such as eliminating film portrayals of smoking in films rated as appropriate for children and young adults.[10]

In the future, when the U.S. is closer to that end game, the report suggests that other techniques may be helpful. These include reducing the nicotine content in cigarettes and placing greater restrictions on sales of tobacco products. The report suggests that alternative delivery methods for nicotine, such as e-cigarettes, may be helpful, but it cautions that questions remain about the effects and health risks of this newer technology.[11] (For more on the health risks of e-cigarettes, read Health Letter’s articles on the risks of poisoning from liquid nicotine and regulation of e-cigarettes.)

Currently, 42 million people in the United States smoke, including 3 million middle- and high school students.[12] Nearly a half-million people still die prematurely each year from smoking, and if current rates continue, 5.6 million of today’s Americans younger than 18 are projected to die prematurely from a smoking-related illness.[13] Thus, the report concludes, further action is needed in order to reduce and hopefully eliminate the burden of disease and death caused by the use of cigarettes and other tobacco products. The task is not an impossible one, though it will require systemwide change in terms of both government policies and social norms. The surgeon general’s report urges “not only … carrying forward the successful tobacco control efforts that have long been under way, but also expanding and accelerating those efforts in full recognition of the challenge that remains.”[14]


[1] Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. Executive Summary. 2014. Accessed May 22, 2014.

[2] Ibid.

[3] Ibid.

[4] Medline Plus. Macular degeneration. Accessed May 28, 2014.

[5] Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. Executive Summary. 2014. Accessed May 22, 2014.

[6] Ibid.

[7] Ibid.

[8] Ibid.

[9] Ibid.

[10] Ibid.

[11] Ibid.

[12] Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Fact Sheet. Accessed May 27, 2014.

[13] Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress. Executive Summary. 2014. Accessed May 22, 2014.

[14] Ibid.