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Historian and ethicist Nigel Cameron discusses his article, “C. Everett Koop’s fearless fight against the tobacco industry,” drawn from his biography of the former U.S. surgeon general. He recounts how C. Everett Koop, initially facing ridicule and expected to be ineffective, strategically used the 1982 Surgeon General’s report on smoking to dramatically reshape his public image and intensify the fight against Big Tobacco. Nigel details the pivotal press conference where Koop forcefully presented the report’s findings, overshadowing his superiors, declaring smoking “society’s chief cause of preventable death,” and refuting industry claims. This event marked a turning point, transforming Koop’s relationship with the press, establishing his “bully pulpit,” and escalating what Koop viewed as an “all-out war” against the tobacco industry’s “sleaze,” fundamentally altering the government’s stance on smoking.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Nigel Cameron. He’s a historian and ethicist, and he’s the author of the book, Dr. Koop: The Many Lives of the Surgeon General. There’s an excerpt from that book on KevinMD titled, “C Everett Koop’s fearless fight against the tobacco industry.” Nigel, welcome to the show.

Nigel Cameron: Great to be here.

Kevin Pho: All right, so just briefly share your story and tell us a little bit about the excerpt that you decided to share with us today.

Nigel Cameron: Obviously I’m British, you can still tell from my accent. I spent almost 30 years stateside. In the process, I got to know Koop back from the mid-eighties on, and so I ended up working on the book because I discovered just a few years before COVID hit that nobody was writing a biography. So that’s a quick version of how I came to be doing this.

What interested me in the book, of course, was partly the number of different things he got involved with: his many lives. But the excerpt about tobacco is very interesting because it was very deliberate.

In some ways he was politically naive, but sometimes he could be very smart. He was a curious sort. This was very smart. He was trashed by everybody when he was being confirmed as Surgeon General because he was conservative for life. He wasn’t a public health person; he was a pediatric surgeon.

The one thing the Surgeon General had to do, the only thing, was to sign off on the smoking report every year. He didn’t write it, but he signed off on it. And so he sat around working out how to use that to get himself back in the picture and get rid of all this negative press. And it worked because the press fell over him, because the press hated Big Tobacco. And so did he.

Kevin Pho: So give us the context in terms of the history behind just signing off on this legislation and the opportunity that this presented to Dr. Koop.

Nigel Cameron: When he was nominated, well, he was fingered for the job back in early 1981 after Reagan came into power. The actual confirmation took about nine months for various reasons. Finally, he was confirmed, interestingly, even with the majority of Democrats voting for him. But he was very unpopular, and the public health people were very much against his appointment.

And he’d inherited the Surgeon General’s job. Until the mid-1960s, it was enormously important. It’s astonishing looking back: he was in charge of the NIH, of CDC, of FDA. All that stuff was reporting to the Surgeon General. Under Lyndon Johnson, the role was stripped of all those responsibilities, and they were all made to report separately in HHS. The Surgeon General ends up with about five staff and a travel budget to go around making speeches.

Koop, when he’s first approached about the job, thinks he’ll be in the cabinet. The Surgeon General has never been in the cabinet. But he thinks this is a real big job and then discovers there’s not much to it. But the one thing that remained was the anti-smoking role. And so that was the one thing he really began to work on.

Kevin Pho: Tell us about the tobacco climate and the politics around it during that time in the early 1980s.

Nigel Cameron: For a long time the U.S. had earlier Surgeon Generals who had produced reports on tobacco. There was this feeling that tobacco should be constrained; it was a bad thing. And Koop himself was a pipe smoker into the seventies, so he wasn’t a natural anti-tobacco person.

He became persuaded. And yet Big Tobacco was enormously powerful, very powerful in Congress. Jesse Helms, who I call the patron saint of Big Tobacco, was one of whose major backers because he was also a social conservative. And tobacco smoking in the U.S. was somewhere in the mid-30 percent. It had been going down a little, but it was still high like that.

And there was a gentlemanly rivalry, as one writer put it, between Big Tobacco and the U.S. government on this issue. And that same writer went on to say that Koop turned that, through one press conference, into all-out war and really changed the dynamic of a major U.S. industry and its relation to the U.S. government.

Kevin Pho: Take us back in time to that press conference. You wrote that it’s on February 22nd, 1982. So tell us the events leading up to that historic press conference.

Nigel Cameron: Koop had only been confirmed for about three months. This was pretty new. And his boss, Brandt, who was the assistant secretary responsible for the FDA and NIH and all that, and who in fact had not really supported Koop’s nomination because he thought the job was an anachronism, it was really his deal. He came in and presented the report and then called on his subordinate, the Surgeon General, to make a follow-up speech, a sort of second toast.

And Koop, big guy, booming voice, immediately dominates the proceedings.

He makes this very powerful speech saying there will be irreparable loss to the U.S., huge economic damage, and so on, because of all these things that we can prove that tobacco does.

And of course, the tobacco industry had kept saying, “You can’t prove causal connections. It’s just correlations we don’t really know,” and so on. And Koop became contemptuous. And I think it was his contempt for the industry that has as much to do with his impact as the actual arguments he used.

And, as I say in the book, you look at the Washington Post or the New York Times for the next day: he’s on the front page. His picture’s all over the place. I think in one of them, his boss Brandt’s name isn’t referred to until three paragraphs down; in another one, it’s not until six paragraphs down. Koop is in. Koop really had changed the dynamic, not simply of the tobacco debate, but of the role of the Surgeon General within HHS. This person with this random little office was now a major player because, of course, politics is ultimately all about the press and perception.

Kevin Pho: Now, was this the first time that such a public figure had such a contemptuous, direct opposition to the tobacco industry in such a theatrical manner?

Nigel Cameron: I think the answer is yes, certainly in a theatrical manner. Earlier Surgeons General, and in fact several of them, had been quite active on this front.

People often forget how far back actual evidence of the harms of tobacco goes. In 1952, Reader’s Digest published a famous article called “Cancer by the carton.”

So this has been going for a long time, but it was gentlemanly. There were reports, there were debates, things were kept down. There are pictures of people writing Surgeon General reports all sitting around in conference rooms with ashtrays all over the table.

At one point, there are four officials testifying before Congress, NIH sort of people, every one of whom actually was a smoker, even if they were giving evidence against tobacco.

So it was a situation of a high degree of tolerance. Looking back, it seems strange, as these things do, but like looking back on the fifties and sixties, having no seat belts in cars; notions of risk were handled very differently.

And Koop, one of his greatest strengths, which runs throughout his life and throughout the book, ends up also as one of his greatest weaknesses: it is his ego. He had an enormous ego. And when you’re a pediatric surgeon, that really helps. When you get into politics, it maybe doesn’t, but sometimes it did.

And on this one occasion, this one hour in a press conference, Koop was really organized. He changed many things.

And of course, during his time in office, over around eight years, smoking dropped in the U.S. by almost 25 percent. You can track it decade by decade, and this was a far, far bigger drop than in earlier and following decades.

And the tobacco industry was huddling together, having their secret meetings to work out what to do about this. Because Koop really had made a difference. And it was his personality and his booming voice and his ego, which comes across in these accounts.

Kevin Pho: So you mentioned that the day after this historic press conference, he made the front page of the New York Times and the Washington Post. What was some of the public reaction to his press conference?

Nigel Cameron: There was shock. It was just shock. The press were delighted because they, for all sorts of reasons, were against Big Tobacco. Sure, these journalists were still smoking, but this was a target. This was big industry with a lot of issues of subvention, government underwriting, tobacco farmers, and so on. An obvious target for the generally rather liberal press. And so there was a deep concern that all of a sudden this industry was under threat.

And this industry, of course, was politically very powerfully connected. Interestingly, Koop says that Jesse Helms, who was their patron saint on the hill, actually he and Koop stayed very friendly on a personal level for quite a long time. This didn’t always happen. Koop could be very fractious and fall out with people. That relationship apparently survived.

Immediately the tobacco industry was under huge pressure. And then of course, you run through a few years and you have this effort to produce this big deal with them, which would have removed liability from the tobacco industry, and they would’ve paid a huge amount of money to the states to cover costs of Medicaid, Medicare, and so on. But of course, that would all be built into their pricing package, so it would’ve been a brilliant insurance deal for the industry. It finally didn’t work out then, but Koop had put the ball in play.

And then if you go forward eight, 10 years, he and Dave Kessler were running this committee called the Koop-Kessler committee, the two Ks, trying to do some sort of broad deal in which essentially Big Tobacco is on the outs of American public life.

Kevin Pho: So after this press conference, you said Big Tobacco huddled up, decided what to do next. So what eventually was their response?

Nigel Cameron: Interestingly, we have all these minutes of their secret meetings which I went into. First of all, they really wanted to go after people really hard who’ve come out taking his kind of view in the political realm.

At the same time, Koop said that he was more than once invited to a secret meeting to try and sound him out, seeing what his price was. We don’t have other evidence of that, but he said he had several approaches of that kind.

At the same time, of course, the issue really was one of litigation.

In the states and in parallel with that, efforts to… obviously, we have the health warnings, which were already there. They were going to get more serious. There were big debates about advertising on television and whether that should be continued. At one point, rather curiously, because of the so-called fairness doctrine in the U.S. media: for every three ads that were shown by the tobacco companies, they had to show a free ad which was anti-smoking. And the dynamics of this piece worked their way through the system. And in fact, the tobacco companies ultimately agreed to withdraw from television advertising.

Partly, some suspect, because the anti-smoking ads which were required were doing damage to them, and they would prefer not to be exposed like that. But it was Koop who really ratcheted the whole thing up and put it on that level.

Kevin Pho: So now that Koop had this proverbial bully pulpit that now garnered so much attention, increased the power of the Surgeon General after that press conference and after his confrontation with Big Tobacco, how did he leverage that platform afterwards?

Nigel Cameron: He had a series of projects. One of the things Koop says is that because he spent so long waiting to be confirmed, he had a lot of time on his hands. He overdid it a bit because he was really quite busy. But think about what you can do as Surgeon General when you really have almost no actual power, but you could make speeches. And there’s a phrase we use in Washington: the power to convene. You can get people together, and that really can make a difference.

So he dreamed up this notion of what he called Surgeon General workshops. And Koop did everything with great flair. These were Surgeon General workshops. These basically were day-and-a-half, two-day conferences. And he did seven or eight of these over his time in office, and he just brought all the key players together.

So, for example, he obviously was getting into AIDS later on, but he was looking at disability issues. He was looking at domestic violence issues. Ultimately he was looking at drunk driving; he was pushed into that.

But he had this notion that you organize a meeting, you pull people together, you have some federal advisory group working on it. There’s a little cost involved, but not much. And you could have a press conference or, in one case at the end of the workshop, everybody went and testified on Capitol Hill.

And he put his imprimatur on these things. And so he could have these stories running which required not a lot in the way of staff support and funding, but because his name was on them, they would get press. And he bundled together a series of issues.

For example, this notion of self-help groups. He did a whole workshop on self-help groups. It’s worth looking at these stories because they show ways in which his soft power was put to really very good use as he assembled these groups.

And I think he was said, by one writer talking about the domestic abuse issue, basically it was Koop who turned this into a public health issue. It was simply regarded as a criminal issue, but it was also a public health issue because he framed the question and brought the players together.

Kevin Pho: So this event happened more than 40 years ago. As of talking to you now and learning about it, how should we remember this event in the proper historical context?

Nigel Cameron: One way to look at the significance of what Koop did exposing the tobacco companies was his honesty, the rigor of his thinking, and his scientific honesty. The story is that the Surgeon General would sign this thing. He didn’t write it; a big department at HHS wrote these documents. He wasn’t even in charge of it.

And so a guy called Don Shopland, who’s still around and recently edited a book about these debates, Shopland was the guy sent along to help him with the report and say, “This is where you sign.”

And he said he got into Koop’s office, and this big document, hundreds of pages, he annotated it page by page by page. He had questions. And Shopland said if there was ever a press conference where a speaker thoroughly knew his subject matter, it was that press conference.

So it was the thoroughness. It was his attention to detail, his scientific honesty in a political environment, which then, as now, is even more fraught. Typically people have briefing papers, they have talking points, everything is summarized. But Koop wanted to get to the facts. He was concerned about the detail. And it was partly because he knew his subject that he was taken so seriously.

That event set in motion the kind of role which really is extraordinary and of which there are few examples in American public life: a tiny office becoming highly significant. Towards the end of the eighties, pollsters said Koop was the second best known member of the U.S. government after Ronald Reagan.

Kevin Pho: We’re talking to Nigel Cameron. He’s the author of the book, Dr. Koop: The Many Lives of the Surgeon General. His excerpt from that book is on KevinMD, “C Everett Koop’s fearless fight against the tobacco industry.” Nigel, let’s end with some takeaway messages that you wanna leave with the KevinMD audience.

Nigel Cameron: Washington is in an interesting state at the moment. Notions of science, notions of integrity, notions of people cowering because of political pressures on them… Koop, partly because God gave him this ego, was protected from a lot of that.

And he was a man whose integrity was on the line every time and who was really quite fierce. And he would’ve happily lost his job rather than be made to do something he thought wasn’t right. And for a time that made him a very powerful figure in Washington. And we need people like that in public science.

Kevin Pho: Nigel, thank you so much for sharing your perspective and insight and thanks again for coming on the show.

Nigel Cameron: Good to be here.