When I was in elementary school in the 1970s, I was friends with a boy who was considered hyperactive, which I vaguely understood to mean that he had excess energy and was therefore not supposed to eat sugar. He was occasionally disruptive in class and often had trouble focusing on group activities. My friend seemed to be constantly in motion, bouncing up from his chair during spelling tests and sprinting through the playground at recess, unable to keep still or remain quiet for any length of time. Another classmate, a girl, was a year older than the rest of us because she had been held back to repeat a grade for academic reasons. She was “slow,” a term we used at the time to refer to someone with a cognitive developmental disability.

If these two were growing up today, there’s a good chance they would be diagnosed with an attention disorder and medicated with a drug such as Adderall or Concerta. While A.D.H.D. has been around for awhile—it’s been listed in the Diagnostic and Statistical Manual of Mental Disorders in some form since at least 1968—its incidence in children has skyrocketed over the past few decades. As Alan Schwarz reported several months ago in the New York Times, the number of children taking medication for A.D.H.D. has increased from 600,000 in 1990 to 3.5 million today, while sales of stimulants prescribed for the condition rose more than fivefold in just one decade, from $1.7 billion in 2002 to nearly $9 billion in 2012. And researchers recently identified a new form of attention disorder in young people. Called “sluggish cognitive tempo,” it’s characterized by daydreaming, lethargy, and slow mental processing. It may affect as many as two million American children and could be treated by the same medications currently used for A.D.H.D.

This apparent epidemic of behavioral disorders in children highlights the convergence of a number of factors. In the late 1990s, changes in federal guidelines allowed the direct marketing of drugs to consumers, prompting increased awareness of disordered behaviors such as those which characterize A.D.H.D. Pharmaceutical companies routinely fund research into illnesses for which they manufacture drug therapies. As Schwarz (again) found, some of the chief supporters of sluggish cognitive tempo have financial ties to Eli Lilly; the company’s drug Strattera is one of the main medications prescribed for A.D.H.D. At the same time, overworked teachers in underfunded school districts lack the capacity to give special attention to rambunctious students, and instead urge parents to medicate them to reduce conflict in the classroom. Most important, the definition of what constitutes “normal” has narrowed. Thirty years ago, my unruly friend who wanted to run around during reading time and my absentminded classmate who forgot to write her name on her tests fell toward the extremes on the spectrum of normal behavior. Today they might be diagnosed with A.D.H.D. or sluggish cognitive tempo and given medication to make them less rowdy or more focused.

Normal childhood behavior these days means paying attention in class, answering all the questions on tests, turning in homework on time, and participating in classroom activities in a non-disruptive way. Children today, in short, are expected to be compliant. There will always be those who lack the ability to conform to an ever-constricting range of what constitutes normal behavior. For families with the access and the interest, pharmaceutical companies offer drugs designed to bring these young people within a threshold of what we consider acceptable.

Last week marked the fiftieth anniversary of the landmark 1964 publication of the U.S. Surgeon General’s report on smoking and health. The 386-page document detailed the link between cigarette smoking and a number of diseases, including emphysema, chronic bronchitis, and coronary heart disease. Crucially, it stated in unambiguous, unadorned language the causal link between cigarette smoking and lung cancer. The average smoker was nine to ten times more likely than a non-smoker to develop lung cancer; for a heavy smoker, the risk rose to twentyfold. Smoking, moreover, hastened death. “Cigarette smoking,” the report read, “is associated with a 70 percent increase in the age-specific death rates of males, and to a lesser extent with increased death rates of females.” The greater the number of cigarettes smoked, the higher the death rate.

I grew up in a time when smoking was both accepted and widespread. I remember pulling on the glass knobs of cigarette vending machines in restaurants, coughing my way through smoke-filled transatlantic flights, and catching a hazy glimpse of my junior high school English instructor taking a smoke break in the teachers’ lounge between classes. I surveyed the cigarette advertisements that filled the pages of magazines delivered to our house, pondering the rugged masculinity of the Marlboro Man and the self-conscious, flapper-era feminism of the Virginia Slims women. In the 1970s, my parents, both nonsmokers by that point, kept an ashtray in the living room for the convenience of any guests who wished to light up.

The 1964 Surgeon General’s report was the work of a ten-member advisory committee made up of men from various medical fields. It included a surgeon, a pulmonary specialist, a bacteriologist, and a toxicologist. Appointed by Surgeon General Luther Terry, the group met at the National Institutes of Health in Bethesda, Maryland for over a year to review more than 7,000 articles on tobacco and disease. At the time, 42 percent of Americans smoked. Terry was so worried about the potential repercussions to the economy, given the report's negative findings, that he scheduled his press conference on a Saturday morning to minimize the effect on the stock market.

The association between smoking and disease documented in the report was not new. Epidemiologists had been exploring the link since the 1930s; their work established causal inference as an acceptable standard of proof and transformed what constitutes adequate knowledge in medicine and public health. In 1957, the previous Surgeon General, Leroy Burney, had noted the increasing implication of excessive cigarette smoking in the causation of lung cancer. But the comprehensiveness of the 1964 study and the overwhelming weight of the evidence were so convincing that Terry, a smoker himself, switched from cigarettes to a pipe in the months before the report was released, believing the latter to be less harmful. Another member of the committee quit altogether. A third, the heaviest smoker of the group, was diagnosed with lung cancer less than a year later and underwent surgery to remove a lung.

It was less the findings of the 1964 report than the publicity surrounding its release that catapulted the issue of tobacco use to the forefront of American public health. In the months following, smoking rates plummeted immediately—and temporarily—by 15 percent, a measure of the gravity with which the news was received. It raised the specter of lung cancer in the public consciousness, laying the groundwork for decades of legislation restricting the use, sale, and advertising of tobacco products. From the placement of warning labels on cigarette packages and constraints on television advertising to curbs on indoor smoking and limitations on sales to minors, it changed public opinion about smoking and generated pressure for politicians to act. It also strengthened the resolve of tobacco companies to create doubt about the link between smoking and serious disease. Until its dissolution under the terms of the Tobacco Master Settlement Agreement in 1998, the tobacco industry continued to dispute the scientific evidence by funding its own studies through its research arm, the Tobacco Industry Research Committee.

In my lifetime, I have seen the ways in which cultural attitudes toward smokers have shifted. No longer viewed as rebellious or sophisticated, the act of smoking has increasingly been vilified as smokers have been exiled from bars and shunted from entire offices to single rooms to the outdoors, where they huddle in doorways as they maintain their addiction. But while the luster and influence of the tobacco companies have dimmed, they have not disappeared. Today, 19 percent of Americans continue to smoke, or about 43 million people. Smoking remains the leading preventable cause of death and disease in the U.S., and rates are increasing in China and other parts of Asia as corporations search for new markets, preferably ones with fewer restrictions on the sale and advertising of their products.

Perhaps the most significant legacy of the 1964 report, in addition to the lives saved through anti-smoking measures, has been the promotion of an ideology of individual liberty regarding public health. After the U.S. began to require warning labels on cigarette packages, tobacco companies sought to portray smokers as adults whose freedom to indulge in the habit was being unfairly infringed upon. According to this line of thinking, the decision to smoke was a matter of personal choice, and the government shouldn’t be allowed to restrict someone’s ability to engage willingly in unhealthy behavior. If an individual knew the risks of smoking and still wanted to light up, then he should have the right to do so and bear whatever consequences might befall him. As public health agencies today struggle to enact laws limiting the size of sugary beverages and requiring calorie counts on restaurant menus, we can look to the previous fifty years of tobacco control for antecedents both to these attempts to regulate our behavior and to our understanding of their cultural meaning.

Sources:

Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: U.S. Department of Health, Education, and Welfare, 1964. Full text at http://profiles.nlm.nih.gov/ps/access/NNBBMQ.pdf.

Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America. New York: Basic Books, 2007.

Background on the 1964 report from the National Library of Medicine at http://profiles.nlm.nih.gov/ps/retrieve/Narrative/NN/p-nid/60.

Current statistics and other data on smoking from the Centers for Disease Control at http://www.cdc.gov/tobacco/data_statistics/index.htm.