December 1992 | Volume 43, Issue 8
In the past seventy years, while several major diseases have been eradicated, one has risen from obscurity to take its place among the nation’s leading killers
The patient at Barnes Hospital in St. Louis, in 1919, might have wondered during his last days why all the physicians were so peculiarly interested in his case. When the man died, Dr. George Dock, chairman of the department of medicine, asked all third-and fourth-year medical students at the teaching hospital to observe the autopsy. The patient’s disease had been so rare, he said, that most of them would never see it again. The disease was lung cancer.
Dr. Alton Ochsner, then one of the students, wrote years later, “I did not see another case until 1936, seventeen years later, when in a period of six months, I saw nine patients with cancer of the lung. Having been impressed with the extreme rarity of this condition seventeen years previously, this represented an epidemic for which there had to be a cause. All the afflicted patients were men who smoked heavily and had smoked since World War I. … I had the temerity, at that time, to postulate that the probable cause of this new epidemic was cigarette use.”
At the beginning of this century, most smokers chose cigars; the cigarette was seen as somewhat effete and faintly subversive. Smoking was an almost wholly male custom. In 1904 a New York City policeman arrested a woman for smoking a cigarette in an automobile and told her, “You can’t do that on Fifth Avenue!” Smoking by female schoolteachers was considered grounds for dismissal. At an official White House dinner in 1910, Baroness Rosen, wife of the Russian ambassador, asked President Taft for a cigarette. The embarrassed President had to send his military aide, Maj. Archie Butt, to find one; the bandleader obliged.
The commercial manufacture of cigarettes had been a cottage industry until 1881, when James A. Bonsack invented a cigarette-making machine. In 1883 James Buchanan Duke, who had inherited his father’s tobacco business in Durham, North Carolina, bought two of Bonsack’s machines. Within five years Duke’s company was selling nearly a billion cigarettes annually, far more than any other manufacturer.
Until World War I, cigarette production in America remained stable. But after the United States entered the conflict, in 1917, Duke’s company and the National Cigarette Service Committee distributed millions of cigarettes free to the troops in France, and they became so powerful a morale factor that General Pershing himself demanded priority for their shipment to the front. The war began to fix the cigarette habit on the American people: between 1910 and 1919 production increased by 633 percent, from fewer than ten billion a year to nearly seventy billion. Contemporary literature reflected the change. O. Henry’s carefully observed turn-of-the-century stories almost never mention cigarettes. But by the time of Ernest Hemingway’s expatriates in The Sun Also Rises , published in 1926, men and women alike smoke constantly.
It was the consequences of this growing habit that physicians began to notice in the 1930s. As the first cases of lung cancer began to appear, doctors struggled to find ways to cope with the disease. Surgery was the only effective treatment for major internal cancers, but at the beginning of the century no method existed to maintain a patient’s respiration under anesthesia when the chest was opened, so opening the chest almost alwavs meant immediate death.
The problem began to yield in 1904, when two German surgical investigators pioneered the use of enclosed chambers to maintain differential air pressure. One version enclosed the patient from the neck down, together with the surgical team, in a chamber with lower than normal atmospheric pressure; since the patient was breathing higher-pressure air from outside, his lung wouldn’t collapse when his chest was opened. The other researcher simplified the design by reversing it: his apparatus put the patient’s head in a pressurized chamber. The systems allowed the beginnings of modern chest surgery. Before long the chambers were superseded by a tube passed into the windpipe.
The first lobectomy—removal of a lobe of the lung—for lung cancer was accomplished in London in 1912. (The right lung has three lobes; the left, smaller to make room for the heart, has two.) The patient was a forty-four-year-old laborer with a chronic coueh and pain in his right chest wall. The record does not say whether he was a smoker, but X rays showed a rounded density at the base of the right lung, and the blood-tinged sputum he was coughing up contained malignant cells. His surgeon, Hugh Morriston Davies, removed the right lower lobe by a technique virtually identical to that used today. The patient did well at first, but without the hard-won experience of others to draw upon, Davies couldn’t know that the chest cavity must be drained after the operation. The patient died from an infection eight days later. Davies’s omission wasn’t corrected until 1929, when Dr. Harold Brunn of San Francisco began draining the chest cavity through a rubber tube, applying intermittent gentle suction to evacuate all air and fluid. Brunn reported six lobectomies with only a single death. (Only one of the six operations was for cancer)
Four years later the modern era in lung cancer treatment began. Early in 1933 James Lee Gilmore, a forty-nine-year-old Pittsburgh obstetrician suffering from a persistent cough and fever, consulted a physician friend who arranged for a chest X ray. It showed a small, rounded density in the left upper lobe. Dr. Gilmore went to Dr. Evarts A. Graham, a pioneer in chest surgery at the Barnes Hospital in St. Louis. There a biopsy showed the density to be a squamous-cell carcinoma, a type of tumor now known to be almost invariably the result of long-time cigarette smoking. Dr. Graham advised Dr. Gilmore to have it surgically removed, believing he could take out the upper lobe of the lung and save the rest. During the operation, however, Dr. Graham discovered that to get out the tumor he would have to remove the entire lung. No patient had ever survived that operation, but Graham felt he must proceed. As it turned out, Gilmore tolerated the operation well. At the time perhaps a half-dozen patients in the world had survived lobectomy for lung cancer. But now surgery for the disease became much more widely accepted.
The surgeon and his patient remained close friends. Dr. Gilmore eventually returned to Pittsburgh and resumed his practice for another quarter-century before he retired. Dr. Graham always regarded this operation as his greatest achievement, and lung cancer remained his leading interest. In 1950 Graham and a medical student named Ernst Wynder published a landmark study of the disease in the Journal of the American Medical Association . They found that practically all the victims had been long-time heavy cigarette smokers. An association between lung cancer and smoking had already been suggested by a number of other researchers, and a 1932 paper in the American Journal of Cancer had accurately blamed the tars in cigarettes for the formation of cancer. But this was the first major study to make the connection. In 1953 it was followed by the Sloan-Kettering Report, in which researchers at the Memorial Sloan-Kettering Cancer Center, in New York City, announced that they had produced skin cancers in mice by painting the tars from tobacco smoke on their backs.
Graham himself had been a cigarette smoker for more than twenty years, but he quit after his 1950 study and devoted himself after retirement in 1951 to research on the mechanisms of cancer production by tobacco tars. The remainder of the story is one of sad irony. In 1957 he was found to have lung cancer himself, of an especially malignant type called small-cell carcinoma. Graham died that same year; his patient Dr. Gilmore survived him by more than half a decade.
Long before the dangers of smoking became evident, cigarette companies were implying that it was actually beneficial. In 1927 the American Tobacco Company launched an advertising campaign claiming that “11,105 physicians” endorsed Lucky Strikes as “less irritating to sensitive or tender throats than any other cigarettes.” Physicians’ groups responded angrily, but they were more offended by the commercialization of professional opinion than by the specific claims involved.
In 1946 the R. J. Reynolds Tobacco Company launched its campaign featuring the “T-Zone Test” (“Taste and Throat”) with a claim that “more doctors smoke Camels than any other cigarette!” Of course, many more doctors did smoke then than now, and Camels were extremely popular. In 1949 Camel advertised its “30-day Test”with a group photograph of “noted throat specialists” who had found “not one case of throat irritation due to smoking Camels!” By the early 1950s, however, as medical studies began demonstrating close links between cigarette smoking and ill health, the manufacturers stopped claiming that smoking was healthful and began instead to insist that no connection with disease had been proved.
In the meantime, cases of—and deaths from—lung cancer among American men had begun a dizzying climb. In 1930 the death rate from lung cancer among men was less than 5 per 100,000 population per year. By 1950 it had quintupled to more than 20; today it is above 70. The numbers of new cases and of deaths have never been very far apart; even today not quite 10 percent of all lung-cancer patients can be cured. In 1989 there were an estimated 155,000 new cases of lung cancer in the United States and 142,000 deaths from the disease, making it far and away the leading cause of cancer deaths in our society, and cigarette smoking is responsible for an estimated 85 percent of the cases. The death rate still continues to rise, but there are definite signs that among men its rate of increase is diminishing, as more men give up smoking.
The rise of lung cancer among women lagged behind that among men by about thirty years. Heavy smoking remained relatively unacceptable socially for women until around World War II. Today women’s lung-cancer death rates are skyrocketing the way men’s did twenty or thirty years ago. A number of studies indicate that it may be harder for women to quit than for men, and it has been predicted that by the year 2000 more women than men will be dying of lung cancer.
World War II, like World War I, gave cigarette smoking an enormous boost. Cigarettes were sold at military-post exchanges and ships’ stores tax-free and virtually at cost—usually for a nickel a pack—and they were distributed free in the forward areas and were packaged in K rations.
The 1950s were the golden age of cigarettes on television. Arthur Godfrey would sign off at the end of his Chesterfield-sponsored variety show, saying, “This is Arthur ‘Buy-’em-by-the-carton’ Godfrey!” (The message was dropped in 1959 when Godfrey himself was found to have lung cancer. He underwent removal of the lung followed by radiation therapy, made a remarkable recovery, and lived for twenty-four years afterward.) When John Cameron Swayze anchored “The Camel News Caravan” in the early days of television, the sponsor required him to have a burning cigarette visible whenever he was on camera. Likewise, Edward R. Murrow was never seen on air without a cigarette; he died of lung cancer in 1965. But during the 1960s the tide turned against cigarettes on TV.
The change had begun in 1955, when Surgeon General Leroy E. Burney invited representatives of the National Cancer Institute, the National Heart Institute, the American Cancer Society, and the American Heart Association to establish a study group to assess the mounting evidence of links between cigarette smoking and lung cancer. The group concluded that a causal relationship did indeed exist, and late in 1959 Dr. Burney published an article in the Journal of the American Medical Association stating the Public Health Service’s position: Cigarette smokine caused cancer.
The reports received little notice at the time, but as the 1960s got under way, agitation began to grow for the adoption of an official government position on smoking and health. In May 1962 an enterprising reporter pressured President John F. Kennedy on the subject at a press conference. The President plainly was caught off guard: “The—that matter is sensitive enough and the stock market is in sufficient difficulty without my giving you an answer which is not based on complete information, which I don’t have, and therefore perhaps we could—I’d be glad to respond to that question in more detail next week.”
Not long afterward Kennedy announced that he was assigning his surgeon general, Dr. Luther Terry, the responsibility for a study of smoking and health. He assured Dr. Terry that he expected an expert scientific review and would allow no political interference.
In July 1962 the surgeon general and his staff met with representatives of various medical associations and volunteer organizations, the Food and Drug Administration, the Federal Trade Commission, the Departments of Agriculture and Commerce, the Federal Communications Commission, the President’s Office of Science and Technology, and the industry-backed Tobacco Institute. The representatives were given a list of 150 eminent biomedical scientists, none of whom had taken a major public position on smoking; from this list they were to propose a committee of ten members and to strike any name to which they objected for any reason.
All of the first ten scientists contacted agreed to serve; three were cigarette smokers. They began meeting in November 1962 and worked for fourteen months before submitting their formal report, which was released at a press conference on January 11, 1964. Known ever after as the Surgeon General’s Report, it indicted smoking as a major cause of lung cancer in men and as a contributing cause of many forms of chronic lung disease.
After the report came out, the Federal Trade Commission issued the Trade Regulation Rules on Cigarette Labeling and Advertising, which, as of January 1,1966, required that all cigarette packages carry a warning (“Caution, Cigarette Smoking May Be Hazardous to Your Health”), that cigarette advertising not be directed at people under twenty-five or at schools or colleges, and that no claims be made for the healthfulness of filters or cigarette products.
The industry’s Tobacco Institute protested the new rules: “We respectfully submit that in these Trade Regulation Rules the Commission is … plainly legislating.” Few could deny the substance of the allegation, but a tradition of “delegated authority” had long been emerging between Congress and its administrative agencies, so the legal question became one of the limits of that delegation. It has largely been resolved in favor of the agencies.
The tobacco companies received a further blow in 1970, when after two years of lobbying, the Federal Trade Commission persuaded Congress to pass the Public Health Cigarette Smoking Act. The bill had two main provisions: a stronger warning was to appear not only on cigarette packages but in print advertisements as well (“Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health”), and all cigarette advertising was to be banned from radio and television. This time Congress itself issued the restrictive ruling. Challenged in the courts by the tobacco industry, the legislation was upheld by the Supreme Court in 1972. In 1984 the warning was made stronger again, establishing today’s four alternating messages: “Cigarette Smoke Contains Carbon Monoxide”; “Quitting Smoking Now Greatly Reduces Serious Risks to Your Health”; “Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight”; and “Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.”
In the summer of 1987 the First U.S. Circuit Court of Appeals in Boston ruled that these warnings on cigarette packages are sufficient to protect the tobacco companies against lawsuits claiming injury or death from smoking; the ruling dismissed the case of Palmer v. Liggett Group , filed in 1983 and seeking damages for $3 million for the death of Joseph C. Palmer from lung cancer in 1980. In the case of Cipollorte v. Liggptt Group, Lorillard, Inc., and Philip Morris, Inc. , concluded in New Jersey in 1988, the plaintiff herself was found “80 percent responsible” for her illness and its course, and the Liggett Group “20 percent responsible.” The verdict required Liggett to pay the plaintiff’s family an award of $400,000. The jury concluded that Liggett had failed to warn of health risks and had misled the public with its advertising slogans prior to 1966, when the first warning-label rule took effect, but the tobacco companies were exonerated of having conspired to misrepresent the dangers of smoking. The defense called the award “an expression of sympathy by the jury”; it was voided on appeal in January 1990, and then went to the United States Supreme Court. The Supreme Court ruled in June of this year that warning labels did not pre-empt all damage suits, and opened the way for a retrial of the Cipollone case. Moreover, by ruling that Congress had “offered no sign that it wished to insulate cigarette manufacturers from longstanding rules governing fraud,” the court threw the door wide open for future damage suits alleging that tobacco companies concealed information about the dangers of smoking or otherwise deceived smokers.
The biggest change in cigarettes themselves since the 1964 Surgeon General’s Report has been the proliferation of low-tar, low-nicotine filtered cigarettes. Filters were first added to cigarettes long before there was public concern about the dangers of smoking. Viceroy advertised them in 1939: “ AT LAST … a cigarette that filter each puff clean! … No more tobacco in mouth or teeth.” After Wynder and Graham’s 1950 report and the 1953 Sloan-Kettering Report, filters came into progressively greater public demand, and by the 1960s they had practically taken over the market.
Unfortunately, the advantages of low-tar and low-nicotine “light” cigarettes have proven to be largely illusory for several reasons: first, while nicotine and tars can be reduced, carbon monoxide is a product of burning, and as long as cigarettes burn, they will produce it; second, confirmed smokers tend to increase their cigarette consumption after switching to lighter brands; and third, studies have found that the risk of heart attack increases with the number of cigarettes smoked per day and does not decline when milder ones replace full-strength brands.
Cigarette manufacturers counter by pointing out that a precise chain of events leading from smoking to cancer has never been established, and that no statistical study of smokers and cancer has been able to rule out every other possible variable—factors such as diet, environment, and alcohol consumption. The industry continues to maintain that its product does not harm its users’ health and that it provides pleasurable relaxation. This latter point, at least, is inarguable. Jean Nicot de Villemain, a French ambassador to Lisbon in the late sixteenth century, is said to have sent seeds of the tobacco plant to Catherine de Médicis, Queen of France, around 1556. The product had been brought to Europe from the New World first by Spanish and Portuguese explorers, but it was Nicot who presented it to Catherine and who later achieved immortality when Linnaeus used his name to christen the plant the seeds came from, Nicotiana tabacum . Later the active chemical alkaloid in its leaves was named nicotine.
This is the primary addicting substance in tobacco, and it is readily absorbed into the bloodstream from tobacco smoke in the lungs or from smokeless tobacco in the mouth or nose. Once in the blood, nicotine is rapidly distributed to the brain, where it binds to chemical receptors located throughout the nervous system to quicken the heartbeat, raise the blood pressure, relax skeletal muscles, and affect nearly all the endocrine glands. In regular tobacco users, nicotine levels accumulate in the body during the day and persist at declining levels overnight; as a result, users maintain some degree of exposure to the drug practically around the clock.
For decades there have been organizations that try to help smokers quit, but successive surgeon generals’ reports have found that most ex-smokers have quit spontaneously and on their own. A 1985 national survey estimated that of the 41 million Americans who quit smoking, 90 percent had done so without formal treatment programs or smoking-cessation devices.
Quitting requires motivation, an urgent reason for wanting to quit. Simply deciding that it’s a good idea is not enough, and smoking will always retain a powerful attraction. Surely we don’t smoke only because we are addicted. Smoking provides relaxation, mild euphoria, relief of tension, improvement in attention time and concentration. World War II memoirs often recall the pleasure of enjoying a cigarette after a long period of intense stress, and many surgeons who once smoked still remember the relief they felt when lighting up after a long, difficult operation. To what extent such relief and relaxation represent the alleviation of short-term withdrawal symptoms—fatigue, anxiety, irritability, and the like—is at least partly a matter of definition. In normal daily life, smokers develop a habitual pattern of motor activity that is familiar and reassuring, an ever-present support and a generally accepted way of reducing social tension.
Surgical removal of the lung, or an appropriate part of it, remains the only real potential cure for lung cancer, and then only when the cancer has not yet begun to spread. Unfortunately, spreading cancer cells may be impossible to identify before the operation and afterward can give rise to recurrence or metastasis, the transmission of the disease to a new site. As a result the surgeon can speak of having effected a cure only in terms of the passage of time. Lung cancer will generally recur within three years or less if it is to recur at all. Among all patients with a new diagnosis of lung cancer, not quite one in ten will live five years.
Of the other methods of treatment, radiation therapy retains a small potential for cure in selected cases where there has been no spread and when the tumor itself cannot be removed surgically. Of the four or five major types of lung cancer, one, small-cell carcinoma, is characterized by especially malignant behavior. Almost always widely spread when first discovered, it is usually not controllable by surgery but does respond to chemotherapy and radiation therapy, though only a bare few patients can be cured. The other types of lung cancer respond so poorly to chemotherapy that it is still not clear whether the treatment is of any benefit for them at all.
Probably no other human affliction besides AIDS depends so completely on prevention. Having risen from obscurity in our own century, lung cancer remains the number-one killer among all cancers. And despite all the sophisticated high-technology methods of treatment, the chances for today’s patient are really no different than they were for Dr. Gilmore sixty years ago.