Document(s) 13 of 37

Differing views on the health question

During the 1920s, 1930s, and 1940s, more scientific evidence linking smoking and ill health was unearthed, but little reached the mainstream. What did reach the public was typically countered by views dismissing the health effects of smoking.

In 1924, Reader's Digest published an article entitled “Does Tobacco Injure the Human Body?” The author, Irving Fisher, concluded that “from every indication, it behooves the man who wishes to remain fit to omit tobacco from his daily schedule.”^[177]

In 1938, Science published the results of a study by Johns Hopkins University bio-statistician Raymond Pearl. After looking at the longevity of 6 813 men, Pearl concluded that 45% of smokers lived until age 60, compared with 65% of nonsmokers, and that a reduction in longevity was found at every age until age 60.^[462]

In 1940, the federal Department of Pensions and National Health produced “Smoking,” a booklet in a series of publications on health matters.^[142] The booklet was “not intended as a forthright condemnation, on all and every count, of a custom which is the solace of millions” but to give the “considered opinion of modern medical science on the effects of smoking” and to contribute to “public information on a matter of vital public health concern.”^{[142, p. 2]} Inhaling tobacco smoke was said to give rise to “stomach, teeth and eye trouble,” “smoker's breath,” and loss of “wind” for an athlete.^{[142, pp. 5, 14]} The booklet said that excessive smoking was blamed “for promoting nervous symptoms and circulatory disturbances.”^{[142, p. 5]}

Any research chemist knows that pure nicotine is twice as deadly as strychnine. . . . Practically every confirmed smoker is a walking, coughing example of the effect of tobacco on throat and voice.^{[142, p. 5]}

The booklet cited a study showing that smoking was associated with reduced life expectancy. Smoking by mothers was of concern because smoking damaged the blood supply, and babies depended on mother's blood supply for nourishment. The booklet said smoke from filtered cigarettes was no more beneficial than smoke from standard cigarettes. As for cancer, there was “no proof that smokers are more susceptible . . . than non-smokers.”^{[142, p. 10]} The booklet offered tips for giving up smoking and noted that “it is not undignified to decline gift cigarettes with the simple explanation that you no longer smoke.”[142, p. 13]

In 1941, retired world heavyweight boxing champion Gene Tunney, then head of the US Navy's physical fitness program, wrote an article in Reader's Digest entitled “Nicotine Knockout, or the Slow Count.”^[598] Tunney strongly criticized smoking, writing that “I can bluntly say that few things could be worse for physical fitness than promoting the cigarette habit.”^{[598, p. 23]} Tunney described tobacco advertising as a “national menace,” recalling that when he was a boxer, he declined an offer of US $15 000 to endorse a brand of cigarettes, politely saying that he did not smoke. He was then offered US $12 000 if he would agree to have his picture used with the statement that the brand “must be good, because all my friends smoke them.”^{[598, p. 23]} He declined this offer as well. The article prompted a report in the Globe and Mail, entitled “Tobacco deadly foe, says Gene Tunney.”^[74] Alfred H. Dunhill of London, UK, wrote a letter in reply to the Globe and Mail, stating that “the fact, of course, is that with smoking and drinking and many other pleasant habits, vice lies in excess. Nobody, for instance, defends the chain cigarette smoker.^[74] These events were reported in the Canadian Cigar and Tobacco Journal in an article entitled “Eminent American Physician Blasts Tunney for His Tirade on Tobacco.”^[74]

In 1943, Maclean's magazine carried an article entitled “This is the Truth About Tobacco.”^[170] Estimating that 60%–80% of adults smoked, clearly an overestimate if women were counted, the article dismissed almost all the health effects once said to be caused by tobacco. The only exceptions were said to be Buerger's disease (with 99% of the victims of this rare disease said to be smokers) and dimness of vision. The fact that life insurance companies no longer asked about smoking was cited as evidence that smoking did not lead to higher death rates. In 1948, an article in Saturday Night magazine appeared with the title “You May Puff Peacefully While Doctors Disagree.”^[105]

Uncovering the link between smoking and lung cancer

As early as 1912,^[5] scientific reports suggested that the rise in lung cancer might be attributable to cigarette smoking, but few offered hard evidence. A small-scale, seminal study published in Germany in 1939 found that patients with lung cancer were much more likely to smoke and to be heavy smokers than were healthy men of the same age.^[415]

The first large-scale study traces its origins to 1947, when Canadian physician Dr Norman Delarue was working in St Louis, Missouri, with Dr Evarts Graham. At that time Graham was depressed by his unsuccessful attempts to treat lung cancer with female hormones, on the premise that lung cancer was sex-linked. Few women at this time were getting lung cancer. A disgusted Graham asked that “someone please find out what is causing this epidemic.”^{[134, p. 431]}

In response, Delarue compared 50 patients with lung cancer and 50 patients hospitalized with some other disease. He found that more than 90% of the lung cancer patients had smoked, but only 50% of the other patients had any smoking history. Graham, a chain smoker, was unimpressed. He initially thought that the suggestion that smoking caused lung cancer was nonsense. Nonetheless, Delarue boldly proclaimed that by 1950 no one would be smoking.^[134]

Graham eventually changed his views. In 1950, Ernest Wynder (a medical student) and Graham co-authored the first large-scale smoking study providing scientific evidence of the relationship between smoking and lung cancer. The study, published in the Journal of the American Medical Association (JAMA),^[648] found that of 605 men hospitalized with lung cancer, only 1.3% had been nonsmokers throughout the preceding 20 years, whereas 51.2% had smoked more than 20 cigarettes a day over this period. In a control group of general hospital patients without cancer, 14.6% were nonsmokers and only 19.1% had been smoking more than 20 cigarettes a day. After this study, Graham successfully quit smoking in 1953, but it was too late. He died of lung cancer in 1957.

A second study published in the same issue of JAMA, this one by Morton Levin and others, found a statistical association between cigarette smoking and lung cancer.^[359] A study published in September 1950 in the British Medical Journal by Dr Richard Doll and Dr Bradford Hill examined the smoking patterns of lung cancer patients in 20 London hospitals and also found that lung cancer was associated with higher rates of cigarette smoking.^[147]

Resolution debated in Parliament

The evidence was mounting and in 1951 the House of Commons debated a resolution introduced by Liberal MP Daniel McIvor from Fort William, Ontario. The resolution read

That, in the opinion of this house, early consideration should be given to the advisability of appointing a special committee of the House to consider the entire cigarette problem; its effect on moral, mental and physical health, especially teenagers and unborn children; fire hazard and other related details.^[394]

Although the debate was short, references during the debate provided an interesting exposé of the state of affairs at that time. One reference was to the fact that there did not seem to be any effective organizations presenting information that smoking was bad for health. As well, some commercials were said to be coming over the air “almost as though cigarettes are a good thing for health,” sometimes with testimonials from a voice “you can imagine being the family physician.”^[221] An MP referred to a cigarette advertisement in a magazine published by the Health League of Canada. The ad included the words “Awarded the certificate of the institute of hygiene for quality and purity” without saying exactly what the institute was.^[222] One MP commented on the exceptionally high percentage of boys who smoked appearing before the courts.

The Health Minister, Paul Martin, Sr, voted against the resolution. Martin had suggested that the motion not be pressed “on the understanding that for the time being the matter could be given consideration at the departmental level.” However, the Cooperative Commonwealth Federation, forerunner to the New Democratic Party (NDP), forced a vote. The resolution was defeated.

The increase in smoking naturally increased the number of smoking-related fires. There was criticism in the House of Commons, including an accusation in 1950 that manufacturers saturated cigarette paper with chemicals to keep the cigarette burning.^[337] The matter of fires caused by cigarettes would be raised several times in subsequent years. In the 1950s, the industry initiated public education campaigns on fire safety but blamed smoking-related fires on negligent individuals instead of on cigarettes.

Industry offers reassurance

In November 1951, in a Canadian Cancer Society (CCS) newsletter, the Executive Director of the National Cancer Institute of Canada (NCIC) drew attention to the possible existence of a link between cigarette smoking and lung cancer.^[65] As time elapsed, more studies provided more evidence of the health consequences of smoking, and many studies made headlines. In 1954, the CMA issued its first public warning on the hazards of smoking. The same year, industry representatives met with NCIC and the CMA to discuss research. In 1954, the industry gave NCIC the first of three scheduled $100 000 grants to do research on lung cancer.

In 1954, the Canadian Medical Association Journal published a report showing that the age-standardized lung cancer death rate in Canada had skyrocketed over the period 1932–54 from 3.0 to 17.0 deaths per 100 000 in males and from 1.6 to 3.7 in females.^[472] By 1958, the rate had further increased to 26.3 in males and to 3.8 in females. Thus in just 26 years, lung cancer mortality had jumped by a multiple of 8.8 in males and 2.4 in females.^[473]

In the 1950s, the sale of filtered cigarettes soared in response to all the media coverage of lung cancer. One well-known item was the 1952 Reader's Digest article “Cancer by the Carton.”^[452] Filters gave smokers the impression of health protection, and advertising enhanced this perception. Filters had another benefit for manufacturers: filter material cost less than tobacco as a cigarette component.

However, filters were sometimes too strong. In the United States, large sales of Kent filtered cigarettes followed the product's introduction in 1952. Advertising focused on the filter. However, after a while, smokers were finding that their nicotine craving was not satisfied. So in 1956, Lorillard, the manufacturer of Kent, changed the filter to allow more smoke, tar, and nicotine through. By 1958, Kent was satisfying consumers and was the fifth leading brand in the United States.^[629]

During the 1950s, much advertising addressed health issues. In 1958, Rothmans took out a series of full-page newspaper ads that discussed lung cancer and then pointed out that Rothmans King Size filtered cigarettes had lower tar intakes (at 18–20 mg) than other cigarettes. Figure 6 reproduces one of the ads in the series. This advertisement noted that

as a precautionary measure in the interest of smokers, . . . Rothmans Research Division accepts the statistical evidence linking lung cancer with heavy smoking [but that] the exact biological relationship between smoking and cancer in mankind is still not known and a direct link has not been proved.^[519]

The ad described the company's techniques to reduce tars in its cigarettes. Near the end of the text, Rothmans reiterated its pledge “to continue its policy of all-out research” and “to impart vital information as soon as available.” Rothmans concluded that “as with all the good things of modern living, Rothmans believes that with moderation smoking can remain one of life's simple and safe pleasures.”^[521] A different ad stated that the company had developed a filter that could filter “virtually 100% of the total solids in tobacco smoke” but that “such extreme filtration is unnecessary.”^[520]

In the United States, advertisements also reassured smokers with slogans such as “More doctors smoke Camels than any other cigarette!” and “Play safe — smoke Chesterfield.” A Philip Morris advertisement advised smokers to “Stop worrying about cigarette irritation” and proclaimed “The cigarette that takes the fear out of smoking!”^[339,628] During the 1950s, Ronald Reagan, Bob Hope, Bing Crosby, and other celebrities appeared in ads endorsing cigarettes.

In 1954, Canada's Department of National Health and Welfare decided to conduct its own study of smoking. Beginning in 1956, the Veterans Study followed the smoking behaviour and causes of death of Canadian veterans of the two world wars and the Korean War. Preliminary results released in 1960 showed that the group of cigarette smokers had 60% more deaths than the group of nonsmokers, that smokers who smoked more cigarettes had higher mortality rates, that smokers who quit reduced their risk of premature death, and that cigarette smoking was associated with an increase in lung cancer and heart disease.^[38] Further data released in 1963 essentially confirmed the preliminary evidence: the group of cigarette smokers had 52% more deaths than the group of nonsmokers. Of the excess deaths, 62% were attributed to heart and circulatory diseases and 33% to lung cancer and other forms of cancer.^[39]

Figure 6. A 1958 full-page Rothmans advertisement in the Toronto Daily Star.^[521]

In 1958, a special committee of NCIC concluded that

while it has not been established that cigarette smoking is a cause of lung cancer, statistical studies show that cigarette smokers have a greater risk of dying of lung cancer than have non-smokers and the risk increases with the amount smoked.^{[425, p. 568]}

In 1962, a second report was far stronger:

the available statistical and epidemiological evidence of the association between smoking and lung cancer favours the conclusion that cigarette smoking is an important factor in the causation of lung cancer and is largely responsible for the dramatic and continuing increase in the recorded lung cancer death rates.^[426]

In 1960, the CMA voiced concern about a possible relationship between tobacco smoking and bronchitis, bronchiectasis, emphysema, and coronary heart disease. In 1961, the CMA accepted the “weight of evidence [implicating] cigarette smoking as the principal causal factor in the increased incidence of lung cancer in Canada.”^{[76, p. 690]}

In July 1961, the Canadian edition of Reader's Digest reported that Craven “A” had the lowest tar and nicotine of any Canadian cigarette. Afterward, Craven “A” sales “soared spectacularly,” according to Rothmans, the brand's manufacturer.^{[525, p. 11]}

In 1962, the Royal College of Physicians of London released a report on smoking and health. The report concluded that

cigarette smoking is a cause of lung cancer and bronchitis, and probably contributes to the development of coronary heart disease and various other less common diseases. . . . The number of deaths caused by diseases associated with smoking is large.^{[528, p. S7]}

As well, the report stated that “decisive steps should be taken by the Government to curb the present rising consumption of tobacco, and especially of cigarettes.”^{[528, p. S8]} The report listed seven possible measures:

• More education;
• More effective restrictions on sales to minors;
• Restrictions on advertising;
• Restrictions on smoking in public places;
• Tax increases;
• Information on tar and nicotine content for consumers; and
• A look at the value of antismoking clinics.

The report was followed by a decline in cigarette sales in Britain, a decline that lasted only 1 year.

In 1963, the CMA president urged doctors to stop cigarette smoking, at least during professional duties.^[76] Subsequently during the 1960s, the CMA publicly advocated measures, including legislation, to control smoking and was far more active than its American counterpart.

Canada's smoking and health program begins

On 17 June 1963, Canada's Minister of National Health and Welfare, Judy LaMarsh, made a landmark statement in the House of Commons acknowledging the harmfulness of smoking. “There is scientific evidence that cigarette smoking is a contributory cause of lung cancer, and that it may also be associated with chronic bronchitis and coronary heart disease,” she declared.^{[350, p. 1214]} A national conference would be held, and representatives of the provinces, health agencies, tobacco companies, and tobacco growers would be invited to attend. LaMarsh herself quit smoking.

Cabinet records now show that LaMarsh had planned a stronger statement but that her ministerial colleagues succeeded in getting her to tone down the words. The draft statement originally said that smoking was an “important contributory” cause of lung cancer, but this was changed to contributory. For chronic bronchitis and coronary heart disease, it was suggested that the words may also be replace the words is probably also to describe the association with smoking. Ministers urged her to be as “neutral and dispassionate” as possible “so as not to frighten people unnecessarily.” Interestingly, just 2 months before the statement, Cabinet had decided to permit smoking at its meetings.^[217]

Held in the Parliament buildings, the 1963 national conference was chaired by Minister LaMarsh. Ashtrays were scattered throughout the room, and the amount of smoking increased as the meeting went on. The conference was one of the few occasions when health organizations and the tobacco interests were brought together under one roof. Naturally, the perspectives were wildly different. Tobacco growers objected to some of the anti-smoking publicity of health charities, arguing that donations would be better spent on research. They objected to the “cancer stick” type of campaign, calling it “macabre.”

Tobacco manufacturers had a detailed written brief criticizing existing health studies and calling for more research. “The fact is,” asserted the industry,

that the ‘mounting evidence' consists of repetition of the same charges restated by different people. This ‘evidence' was and remains inconclusive no matter how often it is repeated and restated.^{[3, p. iv]}

The industry recommended that the difference in lung cancer rates between provinces be studied and explanations sought in terms of air pollutants, industry, population density, ethnic composition, climate, and smoking habits.

The briefs of health organizations tended to emphasize evidence supporting the scientific link between smoking and health. The Minister's June statement on the health consequences of smoking was affirmed by most health participants. Although some people at the conference supported a legislative approach, the consensus favoured health education and research.

The federal government announced a 5-year, $600 000 antismoking budget starting in 1964: $200 000 for scientific and behaviourial research ($40 000 a year) and $400 000 for health education ($80 000 a year). This was the real beginning of Canada's smoking and health program. Before this, the federal government had an explicit policy of not being involved in any smoking-related education.^[407]

On 11 January 1964, the landmark report of the US Surgeon General's Advisory Committee on Smoking and Health was released.^[612] The Committee comprised 11 scientists, 5 of them smokers. Their report was much anticipated. January 11 was a Saturday, chosen because stock markets were closed. An auditorium in the State Department provided a location with excellent security. The report's contents had been a closely guarded secret. Even the White House did not get copies before 7:30 AM on the day of release. Media were allowed into the auditorium at 9:00 AM and “locked in,” unable to phone out until the media session was over.

The Committee's report concluded that cigarette smoking was a cause of lung cancer and laryngeal cancer in men, a probable cause of lung cancer in women, and the most important cause of chronic bronchitis. As well, the report stated that “cigarette smoking is a health hazard of sufficient importance in the United States to warrant remedial action.” The Committee based its conclusions on several thousand articles on smoking and health. The Canadian Veterans Study was one of seven prospective studies cited in the report.

The Committee's report received enormous press coverage. The credibility of the report was enhanced because the tobacco industry had been given the opportunity to vet all the Committee members before the work had begun. Thus, it was much more difficult for the industry to attack the report. Cigarette sales in both the United States and Canada dropped following release of the report but recovered after the initial impact wore off.[523,628]

In Canada, the Rothmans 1964 annual report tried to downplay the Committee report:

This report has created a further storm of controversy, since many eminent doctors, scientists and statisticians have questioned the conclusions reached in this report on the basis of the available scientific evidence. . . . The problems confronting the industry cannot be solved by charges and counter-charges in the press, but only by a continuing cooperative program between Government, the tobacco industry, and medical and scientific research.^{[523, p. 18]}

At the same time as the federal government was launching Canada's antismoking program, it was giving large amounts of assistance to tobacco interests: $120 000 for anti-smoking initiatives versus $575 414 for research on tobacco growing in fiscal 1964/65. Between 1954 and 1966, a total of $4.9 million was spent on tobacco-growing research.^[216] In 1965, the Department of Trade and Commerce appointed a commodity officer, who would be “exclusively responsible for serving the needs of the tobacco industry in relation to export market research and trade promotion.”^[215] Nonetheless, tobacco farmers were still upset at the mere existence of an antismoking program. To assuage the farmers the government asked the House of Commons Agricultural and Colonization Committee to initiate hearings on help for tobacco growers.

Clearly, the political environment in which the tobacco industry operated had changed, and the industry responded. In 1963, the four major companies formed the Canadian Tobacco Manufacturers' Council. The industry retained clout in high places, with former Liberal Prime Minister St Laurent as Chairman of Rothmans. For the new Liberal government considering measures for its antismoking program, St Laurent's position was powerful evidence of the industry's connections.

The goals of Canada's new antismoking campaign were threefold: to inform the public of the health risks, to encourage smokers to quit, and to dissuade nonsmokers from smoking. By today's standards, the efforts were relatively modest. The Department of National Health and Welfare prepared and distributed Smoking and Health Reference Book,^[139] which was sent to every doctor in the country, the Teacher's Information Kit, educational materials (primarily aimed at youth), and public service announcements for radio and television. The Drag, an educational film commissioned by the Department and produced by the National Film Board in 1967, was nominated for an Academy Award in the animated cartoon category. In 1965, the government conducted a national survey on smoking. To the surprise of many, the survey found that a bare majority of adults were nonsmokers (a majority of men, however, were smokers).^[141] In 1968, the Post Office introduced a cancellation mark with the slogan “The safe cigarette is the one you don't light.”

In 1965, a Canadian Youth Conference on Smoking attracted 70 teenage participants from the 10 provinces. The Department of National Health and Welfare organized the conference to learn first hand from youth about smoking issues. Many ideas for action were generated, including a suggestion to restrict tobacco advertising.^[140]

Support for Canadian legislation grows slowly

In 1964, the Canadian tobacco industry announced a voluntary code to restrict advertising, several months before the American industry announced its own code. Advertising was to be directed to adults, models were to be at least 25 years old, health claims in ads were restricted, athletes and celebrities were not to be used, and poster or bulletin-board advertising was not to be “immediately adjacent” to schools. No advertising was to “state or imply that cigarette smoking is essential to romance, prominence, success, or personal advancement.” Not surprisingly, the use of the word essential meant that this provision would be completely ineffective at curbing lifestyle advertising. The existing practice of not placing television commercials until after 9:00 PM was included in the code.^[286]

In the United Kingdom and the United States, there were some early legislative controls. The United Kingdom banned tobacco advertising on television in 1965. The same year, the US Congress adopted a law requiring a mild warning on packages: “Caution — Cigarette Smoking May Be Hazardous to Your Health.”

Through most of the 1960s, Canada was slow to consider legislative action against tobacco. The Department of National Health and Welfare emphasized an explicitly cooperative rather than confrontational attitude with the tobacco industry. Why? Tobacco growers and manufacturers represented a major industry. Memories of the failed attempt at alcohol prohibition lingered and discouraged the government from taking action. There was also a view that research and technology could find ways to make smoking safe, such as identifying the harmful substances in smoke and filtering them away. Another factor was that federal tobacco taxes made up fully 7% of all federal budgetary tax revenues.^[526] A 1970 National Health and Welfare publication recalled that “the Department of Finance was sharply conscious of the $400 million annual tax revenue which the tobacco industry provided.”[141, p. 2]

In the 1960s, more than 20 private-member's bills were introduced in the House of Commons. More than half were authored by Vancouver area MP Barry Mather (NDP), a tireless and visionary supporter of tobacco-control legislation. Mather persistently pressured the government to take action, and he dismissed arguments about the insufficiency of medical evidence:

Then it is sometimes said that they do not really know the cause of lung cancer. The same was once said of cholera and typhoid, which were brought under control long before the germs causing them were discovered. This was based on observation that drinking polluted water was associated with disease. If the provision of clean water had had to wait until the discovery of bacteria, thousands of preventable deaths would have occurred.^[388]

Mather's first bill, Bill C-75, was introduced immediately after LaMarsh made her 1963 statement. This bill would have given the government the authority to regulate the labeling, packaging, and advertising of cigarettes.^[387] Mather and other MPs presented proposals to place tobacco under the Food and Drugs Act, to restrict advertising, to require a warning on packages, and to limit tar and nicotine content. Other issues came up in Question Period, for example, tobacco sponsorship of skiing; and tobacco advertising on programs broadcast by the government-owned CBC.

Tobacco-belt MPs from southwestern Ontario led the parliamentary opposition to antitobacco legislation. In criticizing one of Mather's bills, tobacco-belt MP Jack Roxburgh proclaimed that “if this bill is passed it will be the first step toward doing away with everything for which democracy stands, from freedom of speech to the freedom of free enterprise.”^[527]

In the second half of the 1960s, health and medical organizations increased their support for a legislative approach. Inside the Department of National Health and Welfare, proposals to restrict advertising and require health warnings, with the support of officials like Harold Colburn, were actively considered.

Cabinet documents obtained under the Access to Information Act reveal that in May 1967 Cabinet approved a recommendation by National Health and Welfare Minister Allan MacEachen to have legislation prepared to require tar and nicotine levels on packages and in advertising and to prohibit advertisements “likely to create an erroneous impression regarding character, merit or safety of cigarettes or cigarette tobacco.”^{[204, p. 7]} Despite initial Cabinet approval, this legislation was never introduced.

The first World Conference on Smoking and Health was held in New York in September 1967, giving a boost to the movement. Also in 1967, the NDP and Conservatives were pressuring the government to restrict tobacco advertising. They were also calling on MacEachen to refer all existing private-member's bills on tobacco to the House of Commons Standing Committee on Health, Welfare and Social Affairs. Eventually, on 29 November 1968, the government agreed with this second alternative and referred the bills to Committee. This decision set in motion an unprecedented, comprehensive examination of tobacco issues in Canada.

Document(s) 13 of 37