Risk management and smoking


From Disease Treatment to Risk
Another possible reason for the delayed response
to the Surgeon General’s report was its less-thantraditional medical perspective. The report’s medical
researchers were reporting not the kind of traditional
clinical data that physicians were used to encountering in their literature but rather data from epidemiologic studies that indicated the risks of smoking.
Eventually, such data would be persuasive enough to
mark a perceptual shift to “a new kind of numeracy
among medical researchers and clinicians alike”
(Burnham 1989, p. 19). But in 1964, most physicians
were not prepared to understand—much less be persuaded by—the epidemiologic data represented in the
report, nor to incorporate a public health model into
their medical practice.
Accordingly, the medical profession did not
quickly jump on the smoking reduction bandwagon
that began rolling with the Surgeon General’s report. 

The American Medical Association Alliance House of
Delegates, in fact, refused to endorse the report when
it appeared in 1964 (Burnham 1989). Medical personnel increasingly warned people against smoking, but
this precept did not carry over into practice. In 1964,
smoking remained as acceptable in medical settings
as it was elsewhere. Moreover, although 95 percent of
physicians in that year saw smoking as hazardous, 25
percent continued to smoke (Burnham 1989); even by
the mid-1970s, nearly one in five physicians was a
smoker (Nelson et al. 1994). The AMA was criticized
by other health organizations for not taking a more
aggressive stance to reduce tobacco use. As late as
1982, for example, the association was faulted for helping prepare for Newsweek a 16-page “personal health
care” supplement, in which the only advice provided
on smoking was that a smoker should discuss the risks
with a personal physician and should refrain from
smoking in bed (Iglehart 1984). Soon thereafter, the
AMA had become an active advocate (see “Toward a
National Policy to Reduce Smoking,” later in this chapter). By 1990–1991, only 3.3 percent of physicians
smoked, although smoking rates among nurses were
significantly higher (Nelson et al. 1994).
Some social critics of the time tacitly welcomed
what they saw as a rare reluctance by the establishment to embrace a social movement. Sociologists and
other outside observers of American medicine had
noted a previous tendency of the establishment to
“medicalize” social problems, such as tobacco use and
alcohol abuse. From this perspective, medicine was
viewed askance as an “institution of social control,”
as a “new repository of truth, the place where absolute and often final judgments are made by supposedly morally neutral and objective experts” (Zola 1972,
p. 487).

 Implicit in this criticism was the fear that the
medical establishment was using its considerable
clout—its professional domination of the world of
facts—to translate all social ills into clinical terms that
could be treated in a clinical setting. One such critic,
medical sociologist Eliot Freidson, wrote that the physician who calls alcoholism a disease “is as much a
moral entrepreneur as a fundamentalist who claims it
is a sin” (Freidson 1974, p. 253).
But the medical establishment’s initial hesitancy
to join the movement to reduce smoking likely had
little to do with scruples about overstepping its purview. There is no dispute that cancer is a disease and
little dispute that the medical profession is the expert
social authority for defining and treating it. The “moral
entrepreneurship” of the Surgeon General’s 1964 report was not to declare cancer a medical problem but
rather to declare smoking a health risk—hence the central position of epidemiologic data in the report. 

Thus, while organized medicine followed slowly
and sometimes reluctantly in the wake, and while social skeptics worried about the Orwellian implications,
a battery of public health officials, politicians, and consumer advocates, armed with the findings of the Surgeon General’s report, moved against the persisting
social and medical problem of smoking. Ultimately,
the broad cultural current that distrusted medical moral
entrepreneurship embraced these efforts. The “demedicalizing” movement, which sought to make health
care both a personal matter and a political matter rather
than one wholly under the guardianship of physicians
(Starr 1982), supported a practice of medicine that took
a preventive stance instead of an exclusively therapeutic one. Preventive action—to prevent smoking, and
42 Chapter 2

Reducing Tobacco Use
thereby to prevent unnecessary illness and death from
smoking-related illnesses—was precisely the solution
called for in the epidemiologically based recommendations of the 1964 Surgeon General’s report.

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