Center for Tobacco and the Environment
April 30, 2024
This year the 60th anniversary of the first United States Surgeon General’s Report in 1964. These reports have been vital to informing Americans and the world about risks, harms, and costs of smoking and tobacco use. In honor of the anniversary of the first report, the Center for Tobacco and the Environment interviewed Tom Novotny, MD MPH, Professor Emeritus in the School of Public Health at San Diego State University, who has served in multiple roles for producing Surgeon General Reports, about his experience with them.
CTE: To get started, how many Surgeon General’s Reports did you work on, and what was your role with them?
TN: Let’s see, I was a senior editor for two, a managing editor for two, and I was a contributor to probably six and a reviewer of at least that many. I think it was in 1987 that I joined the Office on Smoking and Health under the Surgeon General, and then I worked on tobacco issues through most of my career with the CDC, which extended into 2002. After that, I was a contributor, reviewer, and writer of a couple of chapters for various Surgeon General’s Reports.
CTE: What is the process of creating a Surgeon General’s Report?
TN: It’s a very complicated process between the writing, which is by many contributors, and the extensive peer review process by multiple experts from a variety of disciplines, and then the very careful bureaucratic clearance process because of its status as an important government publication.
The senior editors compile all of the written contributions into a clearance draft, and they may write a lot of the content themselves as well. The Office on Smoking and Health and its contractors put it together for clearance through the Department of Health and Human Services and its Office of the Surgeon General. By the time it is printed, it’s a highly, highly reviewed, validated, and credible source of scientific information.
CTE: What would say is the main purpose of the Surgeon General’s Report?
TN: The Surgeon General’s Report is required by law to be produced regularly as one of the more persuasive, valid reviews of the scientific information about the single most important preventable cause of illness in this country, tobacco use. Cigarette smoking still causes 400,000 preventable early deaths every year, and that’s about 20% of all of our annual mortality. And so, smoking continues to be this incredibly important risk factor that requires good science to be able to not just inform people, but to support policy changes that benefit public health.
The Surgeon General’s Report serves as an official government resource to address the continued epidemic of tobacco-caused disease and how it must be addressed through research and policies. It makes recommendations that lead to policy change at national, state, and local levels.
The most important Surgeon General Report ever, of course, was the 1964 report, which announced officially that cigarettes, when used as directed, will likely kill you. That was an incredibly important message. The reason we know it’s so important is that if you plot out the consumption of cigarettes over time, you will see a bell-shaped curve, with commercial cigarette consumption increasing almost exponentially from 1900 onwards. At the top of that curve is the year 1965, and that’s when the consumption of cigarettes in the United States and elsewhere began a dramatic decline. In the 1950s, the prevalence of smoking among men was over 50% in the US; it is now down to about 12%. That Report and the efforts that followed can be cited as a turning point in the fight against tobacco-caused diseases.
What that report also did is standardize how we think about the causation of disease by risk factors such as tobacco use. This is an important concept because causality is not a word you can just toss around. You have to have a reason to say, “Yeah, it causes disease.” The preparation of the Surgeon General’s Report in 1964 provided a clear way of thinking about causality, a very nerdy epidemiologic concepts including biological plausibility, dose-response effects, reversibility of effects when risk factors are removed, and the consistency and strength of the evidence across different types of research studies. It laid out the evidence in such a way that scientists were very comfortable saying, “cigarette smoking causes lung cancer, causes heart disease, causes lung disease.” We could no longer ignore this important disease risk factor.
The first Surgeon General’s report that I worked on was also a very important one (1988). This report named nicotine as an addictive drug, and not just any addictive drug, but a more powerful addictive drug than morphine, heroin or cocaine. Even people who are addicted to these drugs admit that they have a harder time losing nicotine addiction than the other addictions. To be able to say that nicotine causes addiction and therefore tobacco use was another really important basis for public policy. That report was done under Surgeon General C. Everett Koop, who was perhaps the best-known Surgeon General and one of the more effective spokespersons for tobacco and other important issues such as HIV/AIDS. It was a great honor and a pleasure to work with him on that report.
CTE: How have Surgeon General’s Reports changed overtime, from the 1964 one to this 60th anniversary one?
TN: They haven’t changed very much in the way they are produced, but now the Reports try to segment out different parts of the tobacco epidemic and in order to focus attention on specific remedies and policies. For instance, Reports have addressed smoking among the young, minorities, and women. They have also addressed second-hand smoke, e-cigarettes, and smokeless tobacco.
Another Report I worked a great deal on was Tobacco and Health in the Americas (1992). We in the Office on Smoking and Health thought it appropriate to address the 500th anniversary of the so-called “discovery” of the “New World,” along with tobacco use, in 1492. That was the beginning of tobacco use as a global commercial, hedonistic activity. That report was also interesting because it was the first international focus for a Report. Working with the Pan American Health Organization (a WHO Regional Office headquartered in Washington DC), we were able to mobilize 35 countries across the hemisphere to report on tobacco use, health outcomes, and policies across the hemisphere. We also involved historians, agricultural specialists, and environmentalists who provided narratives on the history and on the impact of smoking and tobacco growing on the environment, including how hard it is on soils and how much deforestation is caused by tobacco agriculture. We also tried to describe the global tobacco epidemic an international threat to public health.
CTE: Looking ahead, how do you predict they will continue to advance in the future?
TN: I’ve had discussions with the Office on Smoking and Health, and I think they may be interested in a Report on the environmental impacts of tobacco. Maybe not in the next year or two, but there is a growing realization that the environmental issues are actually quite germane in terms of mobilizing new partnerships to address not only the public health issues caused by tobacco use but also the environmental consequences throughout the life cycle of tobacco growing, production, use, and disposal. Our new Center for Tobacco and the Environment may be able to be to contribute to that process in the future.
The other thing I think that may be even more important in the future is product regulatory activities. This is because in 2009, the Family Smoking Prevention Tobacco Control Act was passed and signed by President Obama, which gave regulatory authority to the Food and Drug Administration, which is a big deal. That was a consideration for a long time as David Kessler, who was the FDA commissioner back in the early ‘90s, tried to assert FDA regulatory authority over tobacco products. This effort was stopped until the US Congress passed specific authorizing legislation. That legislation set up the Center for Tobacco Products (CTP) at the FDA, which has had enormous influence on product regulation. The CTP has a Scientific Advisory Committee, and I was on that for a while. That committee has addressed such things as new tobacco products, flavorings, and menthol. It relies a great deal on evidence that’s provided in the Surgeon General’s Reports.
CTE: What was your favorite part of working on the Surgeon General’s Reports?
TN: My favorite part was seeing them finished because it’s such incredible, intense piece of work. At the same time, I got to know a lot of really great scientists and public servants, dedicated to getting the science right so that lives can be saved.
CTE: Why did you get into public health in the first place?
TN: The reason I went into public health relates to tobacco use. My first MD job was as a small town family doctor in Northern California. I had completed the Family Practice Residency program in Santa Rosa, and an administrator of the program was a 47-year-old woman who was asked me to be her doctor; she said she had been coughing. I did a chest x-ray, and she’s got this huge lung tumor. She had been smoking since she was 12 or 13 years old. This was a terminal diagnosis for her, as we had so few therapeutics back then. She died within six months, I think, and I took care of her during those difficult times. Now there’s somewhat better treatment and screening for lung cancer, but it is still the most common cancer in the US and almost 90% is attributable to smoking. The second most common cause is secondhand smoke exposure among non-smokers. Even people who don’t smoke are affected by it. Ask any family doctor what are the worst illnesses that they have to manage, and they are mostly preventable smoking-related diseases.
Dealing with my tobacco-using patients provoked me to think, “How can this horrible product continue to affect so many people?” As a doctor, you’re sort of at the tail end of a lot of disease risks and things that happen in people’s lives. In order to actually get upstream from those risks, public health seemed like a more reasonable pursuit for me. After six years of being a family doctor in a small town, I joined the CDC’s Epidemic Intelligence Service with the express purpose of working on smoking and health. That was in 1984. I’ve been able to pursue that interest ever since then, both as a public health service officer and as an academic.
CTE: What is one your proudest moments in your career?
TN: I managed to arrange one of my CDC jobs to be assigned to the University of California, Berkeley School of Public Health. The CDC had established Prevention Centers through grants to several different universities, and Berkeley didn’t have one. I helped to develop that Center while I was there from 1992 to 1997, and I got a bit of money from the Office on Smoking and Health to try to figure out what the economic costs of tobacco use were to the health care system. I got a statistician, a couple of analysts, and a grad student, and we accessed a great data set with longitudinal information on about 35,000 citizens including tobacco use, obesity and other risk factors, as well as payments for specific diagnoses through insurance coverage.
In other words, we were able to estimate what the medical care costs were that were specifically attributable to smoking, after adjusting for sociodemographics, other risk factors, and insurance coverage. In 1994, we published the results of that study in an article in the CDC’s Morbidity and Mortality Weekly Report, which is an official CDC journal. It gets extraordinary review as well because it is an official government document. The total cost for smoking-attributable disease in 1993 was about $50 billion a year, paid by the US health care systems.
After the press covered the publication, I was called by a lawyer in Mississippi named Richard Scruggs, who sued and successfully recovered damages from asbestos companies related to diseases caused by that exposure. He said, “I’d like to understand what you guys did with this estimation here.” He flies out to California, in his private Learjet – and brings his jury scientists with him – PhDs, behavioral scientists, and others. Over three days in Berkeley, we explained how we came up with these estimates. He went back to Mississippi and was deputized as an assistant attorney general by the attorney general of Mississippi. They then recruited several other state attorneys general who came together to sue the tobacco industry on behalf of the states attorneys general to recover the cost of medical care.
This lawsuit against the industry became quite contentious and was eventually addressed by the US Congress; it resulted in the Master Settlement Agreement. This settlement paid out billions of dollars from the major tobacco companies to all of the states. It also set up an NGO (the American Legacy Foundation), now called the Truth Initiative, in Washington, DC, and it in turn endowed the UC San Francisco Library of Truth Tobacco Industry Documents. This is a resource for numerous research studies on the tobacco industry that have exposed all the lies they have perpetrated over the years. That study was probably the most important thing I’ve done in my life.
CTE: Learning about Big Tobacco is wild. It’s just crazy.
TN: It’s all true. They’re horrible. They’re incredible. They’ve been cited for organized crime violations, RICO statutes, twice, actually. This was for lying about the addictive power of nicotine and about the false benefit of light and low tar cigarettes. They had to actually apologize for their lies through public service announcements on major media. We need to continue to confront them with their lies and to do all we can to counter their efforts to addict kids and keep people smoking; they’ve demonstrated their lack of concern for human health, and they are still in the same evil business as they have always been.
It might be interesting to look at Altria (Philip Morris Tobacco) and its newfound environmental consciousness. Their website says, “Our world is not an ashtray.” With this campaign, they are calling for volunteers to clean up the trash that it sells. Their answer to tobacco product waste is to focus on the downstream effort to clean up this stuff while they continue to sell cigarettes with useless plastic filters that end up in the environment as non-biodegradable toxic waste.
CTE: To wrap up here, what do you want people to know about tobacco and tobacco product waste?
TN: I think we need to continue to focus on preventing tobacco use because people are still dying in massive numbers due to cancer, heart disease, lung disease, and other tobacco-caused problems. Now, we know more about the environmental side of it, and I think it’s important to emphasize that filters are single-use plastics that have no health benefit. They’re only a marketing tool to make it easier to start smoking and to discourage people from quitting. We’re way behind on taking effective action, which would mean banning the sale of filtered cigarettes. We can do this. It can be done at the local level, it can be done at the state level, and it relates to other kinds of interventions that we know have been important, such as banning flavored cigarettes. It’s the same issue, actually: filters and flavors they make it easier to smoke. There’s no need for these things in tobacco products, and we should get rid of them. That to me right now, personally, is most important thing that we should strive to do with our environmental efforts – get rid of filtered cigarettes. By doing so, I think people will smoke fewer cigarettes, might not be as likely to start smoking, and might be encouraged to quit.