The Surgeon Generals’ Reports and Respiratory Diseases. From 1964 to 2014

The 1964 report, Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service (generally referred to as the Surgeon General’s Report), has had lasting implications for clinical care and public health through its findings and methods (1). It is best known for the conclusion that smoking was a cause of lung cancer (in men), but it had other notable findings that anticipated conclusions of future reports (Table 1). Over time, many additional cancers were causally linked to smoking, as were cardiovascular diseases and diverse adverse effects of smoking on reproduction. Regarding respiratory diseases, the report found a causal association of smoking with “chronic bronchitis” and noted increased risk of death from influenza and pneumonia in smokers. Later reports concluded that passive smoking, a topic first considered in the 1972 report (2), caused diverse adverse respiratory effects for children and adults (Table 2). Table 1. Conclusions reached by the Advisory Committee to the Surgeon General in 1964 Table 2. Surgeon General’s report conclusions on active and passive smoking and various respiratory health effects Beyond these findings for smoking and health, the methodology used in the 1964 report was groundbreaking, becoming the foundation for evidence review, integration, and causal inference in subsequent reports of the Surgeon General (3). The approach of the 1964 report has also been widely used for evidence evaluation regarding causation in other domains (4). As described in the 2014 Surgeon General’s report, the committee developed and applied a transparent methodology for finding and evaluating research results and interpreted the evidence within a framework for causal inference that is still widely referred to as “the Surgeon General’s guidelines” or “criteria” (5). Surgeon General Luther Terry was not directly involved in the Advisory Committee’s discussions, and the Advisory Committee was composed of individuals without strong prior opinions on smoking and health. The report represents an early application of what is now referred to as systematic review; a similar approach had been taken in the 1959 evaluation of the evidence on smoking and lung cancer by Cornfield and colleagues (6). Although systematic review had long played a role in the synthesis of scientific evidence in other fields, the 1964 report is one of the first instances of its use for integrating findings of biomedical research. The reports of the Surgeon General on tobacco and health (including smokeless tobacco) have now been published for 50 years, a total of 33 reports. Over the 5 decades, the topics have spanned a broad range, reflecting the trends of emerging scientific evidence and the directions of tobacco control. The reports have captured the ever-expanding evidence base on tobacco and health and reached scientific conclusions that have often had powerful policy implications. With the inference of causation, prevention is possible through removal of the causal agent. As stated in the 2004 report: “A causal conclusion conveys the inference that changing a given factor will actually reduce population’s burden of disease…” (3, p. 19). For example, the initial finding that smoking caused lung cancer motivated follow-up action by the U.S. Congress, which passed the Federal Cigarette Labeling and Advertising Act of 1965. Over the 50 years since the first report, the possibility of prevention has become reality, as smoking prevalence declined and lung cancer incidence and mortality rates eventually followed. Falling smoking prevalence is also a major contributor to the dramatic decline in mortality from cardiovascular disease (7). This paper addresses how the Surgeon Generals’ reports have covered the topic of smoking and respiratory diseases over the 50 years from the first to the 2014 anniversary report. They have played a critical role in capturing the effects of smoking on the lung, serving as foundational documents for research and disease control. The reports have been the principal locus for synthesizing the evidence on smoking and respiratory diseases, much involving research performed by members of the American Thoracic Society. The conclusions of the reports chart the evolution of understanding of smoking and risk for respiratory diseases, drawing on findings of the reports over the last 50 years (Tables 2, E1, and E2).